Every finding on record at Manor, The

Based on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean and sanitary manner as evidenced by the following: On 6/16/25 at 10:01 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The slicer had food debris under the blade and on the food holder prongs. The FSD acknowledged and stated, it was not cleaned according to facility policy. 2. The walk-in freezer had two (2) boxes (one box of [NAME] and one box of Tilapia) that were open, unlabeled and not sealed. The FSD stated, the boxes should be sealed and labeled with an open and expiration date. The FSD acknowledged and stated they should be labeled according to policy, with name, date of opening and discard date. This will ensure that all the staff know when it expires and items should be sealed to maintain food quality, freshness and palatability. 3. The six-burner stove interior of the oven had food sediment and build up on the interior door. The catch tray that was lined with foil had burnt liquid, and food debris covering the entire tray and foil that was peeling. The FSD acknowledged and stated, it was not cleaned according to facility policy. 4. The griddle catch trays that were lined with foil had burnt liquid, and food debris covering the entire tray and foil that was peeling. The FSD acknowledged and stated, it was not cleaned according to facility policy. 5. A grey cabinet, labeled as a Utensil Cart, with multiple pull-out trays held cooking utensils. The pull-out trays had crumbs and debris on them with the utensils on top. The FSD acknowledged and stated, it was not cleaned according to facility policy. 6. The can opener blade had a metal chip on both sides, and brown substance on the blade. The FSD stated, I am not sure of the last time the blade was changed. I do not have any in the facility and will need to order it. She further stated, there wasn't a maintenance log in place to indicate when to replace the blade. On 6/16/25 at 12:10 PM, the surveyor interviewed the FSD, who stated, I acknowledged the surveyors finding and the equipment should have been cleaned and maintained in a sanitized way to prevent food borne illness and contamination for safety of our residents and staff. On 6/17/25 at 11:45 AM, the surveyor toured the unit kitchenettes with the Director of Nursing, (DON) and the Infection Preventionist (IP). During the tour, it was noted that both units ice machines, two of two units, had brown and black discoloration in the plastic grey shoot interior of the water dispenser and ice cube dispenser. The DON and the IP both acknowledge that the discoloration of sediment should not be in the interior aspect of the dispensers. On 6/18/25 at 12:05 PM, the surveyor interviewed the Maintenance Director (MD), who stated, I acknowledged the surveyors concerns after reviewing the pictures of the kitchen equipment. The equipment should be cleaned and maintained per policy, and I will contact our contracted company for them to come out and service. It is serviced three (3) times yearly that may need to be adjusted. On 6/19/25 at 10:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated, I acknowledged the surveyors concerns after reviewing the pictures of the kitchen equipment and ice machines on the units. The equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury. This ensures the safety of our residents and staff. On 6/19/25 at 11:10 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated, I acknowledged the surveyors concerns after reviewing the pictures of the kitchen equipment. The equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury. This ensures the safety of our residents and staff. On 6/24/25 at 10:18 AM, the survey team met with the LNHA, Assistant LNHA, Executive Director of facility, and the Director of Nursing (DON), who all acknowledged the surveyor's concerns. No additional information was provided. A review of the facility's, undated, Sanitation: Keeping food safe for guests and staff, included .food residue: cooking equipment residue may look harmless but can be a food source for microbes, insect and vermin .at the end of each shift or when you are finished with a stove/oven, wipe down equipment, replace aluminum liners and empty grease catch areas. A review of the Product dating and expiration policy, dated 9/2020, included . items removed from the original labeled cases are labeled with name/description of item, date opened, and last date or discard date. Items to be frozen are to be wrapped in plastic, then wrapped in foi and labeled with date it is frozen and the name. NJAC 8:39-17.2(g)

Based on interviews and review of pertinent facility documentation it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a peripherally inserted central catheter (PICC) (a tube inserted into a vein in the upper arm and threaded into a larger vein near the heart used for medications, fluids, and blood draws). This deficient practice was identified for 1 of 16 residents reviewed for care plans (Resident #49) and was evidenced by the following: On 06/18/25 at 11:47 AM, the surveyor observed the resident in the room in a chair. The resident showed the surveyor the PICC line in the upper arm. The surveyor reviewed the medical record for Resident #49. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; osteomyelitis (bone infection), congestive heart failure, and hypertension (high blood pressure). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 5/31/25, section C for cognitive patterns revealed the resident had a Brief Interview of Mental Status of 14, meaning the resident was cognitively intact. Section O of the MDS, special procedures indicated the resident was receiving intravenous antibiotic treatments on admission to the facility. A review of the physician orders showed an active order dated 5/25/25, for PICC line dressing change every Tuesday and Daptomycin (antibiotic) 350 mg intravenously one time a day for 25 days. A review of individualized comprehensive care plan (ICCP) initiated on 5/25/25 revealed no documented evidence to address the PICC line on the care plan. On 06/18/25 at 11:57 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of the 200 unit at the facility. The surveyor asked the RN/UM if a resident had a peripherally inserted central catheter would they be care planned for that and the RN/UM responded Yes. The surveyor asked who was responsible for initiating and updating care plans and she told the surveyor it was the Unit Managers. The RN/UM could not answer why the resident did not have the PICC line addressed on the care plan. On 6/23/25 at 10:20 AM, the surveyor reviewed the policy titled, Baseline Care Plans dated 11/18/24. The policy included that the resident's care plan was developed to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. Care plans will be based upon admission orders, information from the transferring provider and dissuasion with the resident. NJAC 8:39-27.1 (a)

Based on interview and record review, it was determined that the facility failed to follow professional standards of clinical practice by not obtaining a physician's order for hospice care. This was observed for 1 of 1 resident (Resident #12) reviewed for hospice and end of life care and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/18/25 at 9:50 AM, the surveyor reviewed Resident #12's electronic medical record (EMR). A review of the admission Record indicated that Resident #12 was admitted to the facility with diagnosis which included but was not limited to: chronic heart failure and chronic kidney disease. A review of the quarterly Minimum Data Set (MDS) (a comprehensive assessment tool) dated 4/2/25, indicated that Resident #12 had a Brief Interview for Mental Status Score (BIMS) of 13 out of 15 which indicated the resident was cognitively intact and that the resident was receiving hospice care. A review of the resident's Individualized Comprehensive Care Plan (ICCP) included a care focus area with an initiated date 9/23/24, indicating the resident had a terminal prognosis related to weight loss and congestive heart failure. The focus area included and intervention to have hospice care for the resident in the facility. A review of the physician order summary indicated a physician order dated 9/13/24, for hospice education and another order dated 9/13/24, for palliative consult. The physician orders did not include an order for hospice care. On 6/18/25 at 12:19 PM, the surveyor, in the presence of the survey team, reviewed Resident #12's physician's orders and hospice care with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). On 6/24/25 at 9:20 AM, the surveyor interviewed the DON who stated that residents who are enrolled to go on hospice need to have a physician's order indicating hospice care. On 6/24/25 at 9:44 AM, the DON, in the presence of the survey team, acknowledged that residents who go on hospice should absolutely have a specific order indicating hospice care. Further review of Resident #12's physician order summary indicated an order for hospice care with and ordered date of 6/18/25, after surveyor's inquiry. A review of the facility's Hospice Care Policy and Procedure with a recent date of 8/30/24, did not include the requirement to obtain physician's orders for hospice care prior to initiating hospice services. NJAC 8:39-11.2 (b)

Based on observation, interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to provide the necessary care and services for one (1) of 1 resident (Resident #11) reviewed for respiratory care and was evidenced by the following: Review of the admission Record (admission summary) reflected that Resident #11 was admitted to the facility with the diagnoses that included but was not limited to; emphysema (a chronic lung condition that causes shortness of breath) and chronic obstructive pulmonary disease (COPD) (a chronic lung condition that makes breathing difficult). A review of the admission Minimum Data Set (MDS), an assessment that facilitates a resident's care dated 5/30/2025, indicated that Resident #11 had a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated that the resident was cognitively intact. The MDS also indicated Resident #11 required partial to moderate assistance for activities of daily living (ADLs) and continuous and intermittent oxygen (O2) treatments. On 6/16/25 at10:52 AM, the surveyor observed Resident # 11 sitting in a wheelchair wearing O2 which was infusing at 2 liters/min via (by way of) nasal cannula (NC) [a medical device that provides supplemental O2 to people who have lower oxygen levels]. The surveyor observed that the O2 tubing was not dated or labeled. The surveyor also observed a nebulizer tubing (connects the nebulizer machine to the mask or mouthpiece, delivering medication directly to the lungs) set up on the bedside table not labeled or dated. On 6/17/25 at 10:45 AM, the surveyor entered Resident #11's room and observed that the O2 tubing and nebulizer tubing were still not dated or labeled. On 6/17/25 at 12:16 PM, the surveyor interviewed Resident #11 who was in their room eating lunch and reported having the diagnoses of COPD and required O2 continuously. Resident #11 stated that they did not remember when the O2 tubing or nebulizer tubing were changed, however felt that it was relatively new. The Resident stated that they had not had any respiratory infections since admission to the facility. A review of Resident #11's electronic medical record (EMR) revealed the following information: A review of the Order Summary Report (OSR) dated 5/23/2025, reflected a physician's orders (PO) to apply O2 at 2L via NC if SPO2 (the percentage of amount of oxygen in the blood), less than 90% every shift. A OSR dated 5/23/2025 contained an order for Albuterol Sulfate HFA inhalation Aerosol Solution 108 (90 Base) MCT/ACT (Albuterol Sulfate) 1 puff inhale orally every 8 (eight) hours for shortness of breath (SOB) or wheezing. A review of the OSR dated 6/16/2025, reflected an order to change nasal cannula every Sunday weekly on 11:00 pm to 7:00 am shift however, the order was not transcribed onto the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). There were no physician orders to change the nebulizer tubing. A review of Resident #11's Interdisciplinary Care Plan (ICP) dated 5/25/2025, indicated that Resident #11 had the diagnoses of COPD. The interventions included: give aerosol or bronchodilators as ordered, monitor and document any side effects and effectiveness and oxygen settings and O2 via nasal progs at 2L continuously. There were no interventions in the ICP that indicated that the nebulizer tubing or O2 tubing were to be changed weekly. On 6/17/25 at 12:10 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #11 was on O2 at 2 liters via nasal cannula. The LPN added that the resident had been on nebulizer treatments and O2 since admission to the facility. The LPN revealed that O2 and nebulizer tubing were to be changed every Wednesday by the 11:00 pm-7:00 am shift nurse and that staff were supposed to date and time the tubing. The LPN accompanied the surveyor to the room and confirmed that the O2 tubing and nebulizer tubing were not labeled and dated. The LPN then stated that it was important to change the tubing to maintain cleanliness and for infection control. On 6/23/25 at 12:46 PM, the surveyor interviewed the Director of Nursing (DON) who confirmed that O2 tubing and nebulizer tubing must be changed, labeled and dated every week. The DON stated that the nurses were responsible for ensuring that tubing was changed weekly on the 11:00 pm-7:00 am shift to prevent infection. A review of the facility policy dated 8/12/24 and titled, Respiratory Therapy Infection Prevention Policy and Procedure included that it was the policy of the facility to use this policy in the prevention of infection associated with respiratory therapy task and equipment. The policy specified that the O2 cannula and tubing were to be changed every 7 (seven) days or as needed and that the nebulizer set up was to be discarded every 7 days. NJAC 8:39-19.4(a)

2. On 6/16/25 at 10:33 AM, the surveyor observed Resident # 43 in bed. The surveyor reviewed the medical record for Resident #43. A review of the Face Sheet revealed the resident was admitted to the facility with diagnoses which included but not limited to, diabetes, congestive heart failure, paranoid schizophrenia, difficulty in walking, and hypertension. A review of the comprehensive admission MDS section C for cognitive patterns revealed the resident had a Brief Interview of Mental Status of 14 out of 15, indicating the resident was cognitively intact. On 06/18/25 at 09:24 AM, the surveyor reviewed the pharmacy consultant recommendations for Resident #43 which included: - Pharmacy consultant recommendations made by the consultant pharmacist on 4/2/25, 5/5/25, and 6/5/25, that Potassium Chloride should be mixed with 3 to 6 ounces of water or juice. The order at the time of surveyor review was for Potassium Chloride Oral Packet 20 MEQ (Potassium Chloride) Give 1 packet by mouth two times a day for supplement give with meal, mix 1 Packet of Phos-Nak in 75 milliliters (ml of water or juice, stir well and use promptly. - Pharmacy consultant recommendation made on 5/5/25, was for glucagon to have parameters. The current active order at time of surveyor review was as follows: Glucagon Emergency Injection Kit 1 mg (Glucagon (rDNA)) Inject 1 application intramuscularly as needed for HYPOGLYCEMIA GLUCAGON 1mg INTRAMUSCULAR INJECTION STAT. - Pharmacy consultant recommendation made on 5/5/25, to clarify loperamide, 2 mg ordered on the current orders, but medication discharge list read 4 mg. The current active order at the time of surveyor review was for Loperamide HCl Oral Tablet 2 MG (Loperamide HCl) Give 1 tablet by mouth two times a day for diarrhea. - Pharmacy consultant recommendation was to update Voltaren gel to indicate the dose in grams for each application. The recommended dose is 4 grams for lower extremity joints and 2 grams or upper extremity joints. The current active order at the time of surveyor review was for Voltaren Arthritis Pain External Gel 1 % (Diclofenac Sodium (Topical)) Apply to RT Knee topically two times a day for pain AND apply to left knee topically two times a day for pain. After review, it revealed that the orders were not changed to follow the pharmacy consultant recommendations. On 06/18/25 at 12:14 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of the 200 unit regarding pharmacy consultant recommendations. She stated The PC point out the recommendations and either the desk nurse or the Unit Manager follow up. Copies are left in a book, but if we need to, we will call the doctor to change the order. On 6/23/25 at 9:27 AM, a surveyor interviewed the facility PC. The PC stated that comments and recommendations were provided to the facility the next day after review. The recommendations were then emailed to the LNHA, DON, and Medical Director. The PC stated the facility should act upon the recommendations within one week. If the recommendation is significant if should be acted upon within 24 hours and the PC would verbally notify the nurse on the unit and the DON if available. If recommendations are not followed the PC would notify the DON and Medical Director if in the facility. The physician will sign the recommendations. On 06/24/25 at 09:40 AM, the surveyor interviewed the RN/UM regarding glycogen and need for parameters. The UM/RN stated that its only given if the blood sugar is below 70 or the resident doesn't have an intravenous access or unable to swallow. The surveyor asked if that would be part of the physician order and the RN/UM stated yes, it's always an order set. She then said whoever entered it did it wrong, it should be there. The surveyor then asked about the completed forms from the PC recommendations with the follow up and the RN/UM said that they were in the Electronic Medical Record (EMR) under the miscellaneous section, and it was the Unit Managers responsibility or the nurse. The surveyor asked if there was a book with the papers for review and she told the surveyor, No, they are just scanned in computer. On 06/24/25 at 10:03 AM, the surveyor reviewed the miscellaneous section of the EMR. The surveyor located one pharmacy recommendation follow-up dated 6/13/25, for the volataren gel recommendation that was not followed. No other recommendations were scanned into the miscellaneous section of the EMR at the time of surveyor review. A review of the facility policy titled Consultant Pharmacist's Medication Regimen Review (MMR), with a revised date of 6/8/24, included but was not limited to: the Consultant Pharmacist Medication Regimen Review shall be reviewed, noted, and acted upon by the facility nursing and/or medical staff to assist each elder to attain the highest practicable level of functioning or prevent or minimize adverse consequences related to medication therapy to the extend possible. Under the procedure section of the policy, it indicated the Unit Manger shall track physician responses to ensure that the recommendations are addressed in a timely manner. NJAC 8:39-29.3 Based on observation, interview and review of facility documentation it was determined that the facility failed to follow pharmacy consultant recommendations for 2 of 5 residents (Resident #6 and #43) observed for unnecessary medications and was evidenced by the following: 1. On 6/17/25 at 12:07 PM, the surveyor reviewed the medical record for Resident #6. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to, diabetes, malignant neoplasm of the liver (liver cancer), malignant neoplasm of the colon (colon cancer), and chronic kidney disease. A review of the comprehensive admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, section C for cognitive patterns revealed the resident had a Brief Interview of Mental Status of 14 out of 15, indicating the resident was cognitively intact. A review of Resident #6's pharmacy consultant recommendations for May and June 2025 indicated the following: - Pharmacy consultant recommendation was made by the pharmacist on 5/12/25, indicating missing indication for mild and severe pain with current PRN (as needed) pain orders. Please clarify or update orders so that all levels of pain are covered. - Pharmacy consultant recommendation made on 6/5/25, indicated to clarify the order for oxycodone (a controlled pain medication). Please indicate pain level for use vs APAP (acetaminophen - a non-controlled medication used to treat pain). A review of the physician's orders and medication administration record (MAR) indicated the following: A physician's order dated 5/23/25, for oxycodone 5 milligrams (mg) half tablet by mouth every six hours as needed for pain. A physician's order dated of 5/27/25, for oxycodone 5 mg to give a half tablet by mouth every 12 hours as needed for pain for 14 days. A physician's order dated 6/11/25, for oxycodone 5 mg half tablet by mouth every eight hours as needed for pain. After surveyor review, it was revealed that the orders were not changed to follow the pharmacy consultant recommendations to indicate pain level parameters for the administration of controlled pain medications. On 6/18/25 at 12:19 PM, in the presence of the survey team, the surveyor reviewed the pharmacy recommendations and corresponding physician's orders with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). On 6/23/25 at 9:27 AM, the surveyor interviewed the Pharmacy Consultant (PC) who stated that comments and recommendations were provided to the facility the next day after review. The recommendations were then emailed to the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and Medical Director. The PC further stated the facility should act upon the recommendations within one week. If the recommendation was significant it should be acted upon within 24 hours and the PC would verbally notify the nurse on the unit and the DON if available. If recommendations are not followed, the PC would notify the DON and Medical Director. The physician would sign the recommendations. On 6/24/25 at 9:24 AM, the surveyor interviewed the DON who stated that the facility reviewed pharmacy recommendations for order adjustments and acknowledged the surveyor's findings and stated that the orders regarding pain level for oxycodone were adjusted after the surveyor's inquiry. After surveyor inquiry, the physician's order was updated on 6/20/25, to include the following: oxycodone 5 mg give half tablet by mouth every eight hours as needed for moderate to severe pain.

Based on record review, and staff interviews, the facility failed to ensure Code Status was correct for one (Resident (R) R51) out of two residents reviewed for Advance Directives/Code Status. There was no documentation in the record to indicate the resident's Code Status (whether to initiate Cardiopulmonary Resuscitation (CPR) or not in the event the resident was found not breathing and/or without a pulse. Findings include: The facility's policies related to Code Status were requested from the facility on [DATE] at 4:30 PM. The facility provided a policy specifically related to Do Not Resuscitate (DNR) Status. However, the survey team was not provided with a policy related to the designation of Code Status prior to the survey exit on [DATE]. R51's Admission Record, found in the Electronic Medical Record (EMR) under the Profile Tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including infection following a medical procedure and long-term use of antibiotics. R51's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact). The assessment indicated the resident was receiving rehabilitation/therapy services. R51's Medication Review Report, (MRR) dated [DATE] and found in the EMR under the Orders Tab, indicated no orders related to the resident's designated wishes related to his Code Status. R51's undated comprehensive Care Plan, (CP) found in the EMR under the Care Plan tab was reviewed and indicated no documentation of the resident's wishes related to his Code Status. A review of R51's entire EMR indicated no documentation related to the resident's Code Status had been obtained by the facility since his admitted . During an interview on [DATE] at 11:24 AM, Registered Nurse (RN)1, confirmed there was no information related to R51's Code Status in his record and stated she would ask the resident what his wishes related to his Code Status were. She stated the expectation for every resident's Code Status was to be entered into his or her record upon admission to the facility. She stated the default Code Status was Full Code (perform CPR). During a follow-up interview on [DATE] at 11:28 AM, RN1 stated she had spoken with the resident and his wishes were to be Full Code. She stated she would update the resident's record to reflect his wishes and would call the doctor to obtain an order for Full Code. During an interview on [DATE] at 11:40 AM, the Director of Nursing (DON) stated his expectation was that every resident should have documentation related to their Code Status in their record upon admission to the facility or shortly thereafter. NJAC 8:,d+[DATE].6(a) NJAC 8:,d+[DATE].2(d)3

Based on observation, interview, and record review it was determined that the facility failed to follow facility policy and procedures regarding wander guards (a monitoring device, such as a bracelet used to help ensure safety of the resident at risk for elopement) for function. This practice was identified for 1 of 1 resident (Resident #50), reviewed for elopement. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: On 07/21/21 at 10:40 AM, during the initial tour of the facility, the surveyor observed Resident #50 walking in the hallway of the unit. The surveyor also observed that all the other residents' doors in the same hallway had stop signs on them with the word STOP printed in Spanish. At this time, the surveyor asked the Certified Nursing Assistant (CNA) on the unit what the signs were on each door for, and the CNA stated that it was to help deter the wandering resident from entering the other residents' rooms. The surveyor asked who the wandering resident was, and the CNA informed the surveyor it was the resident that was observed by the surveyor in the hall (Resident #50). The surveyor reviewed the medical record for Resident #50. A review of the Admission Record reflected that the resident was admitted to the facility in June of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), an assessment tool dated 6/29/21, reflected that the resident had a Brief Interview of Mental Status (BIMS) of 3 out of 15 which indicated severe cognitive impairment. A further review of the MDS in Section E. Behavior, reflected that the resident had a wandering behavior that occurred daily. A review of the Electronic Medical Record (EMR) behavior progress notes indicated that the resident would wander on the unit and walk into other resident rooms and the staff would redirect the resident out of the other resident rooms. On 07/22/21 at 12:10 PM, the resident was observed sitting at a table across from the nursing station having lunch. The surveyor observed a wander guard to the resident's right ankle. On 07/22/21 at 12:14 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding residents with wander guards. The surveyor asked the process for checking wander guards and the RN/UM informed the surveyor that we look at it every shift. The surveyor asked if the device was checked for function and the RN/UM stated that the devices were checked once before they go on the resident. The surveyor then asked the RN/UM if the devices were checked for function by any other staff member or supervisor at regularly scheduled intervals and the RN/UM responded no. On 07/22/21 at 12:57 PM, the surveyor continued to review the resident's medical record. A review of the resident's individualized care plan included a focus initiated on 6/22/21 for a risk for wandering/elopement. Interventions included to: clearly identify resident's room and bathroom; engage resident in purposeful activity; local county wander guard in place; and wander guard on right ankle. A review of the July 2021 Order Summary Report reflected a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The PO did not include to check wander guard function. A review of the resident's admission Elopement Evaluation dated 6/18/21, reflected that the resident had an elopement score of 2.0 which indicated the resident was an elopement risk and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 07/26/21 09:24 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding wander guards. The LPN informed the surveyor that, they are checked for placement every shift. The surveyor asked about checking the device for function and the LPN responded, when the resident goes near the door it would alarm. The surveyor asked if wander guards were checked at regular intervals and the LPN stated that, the Unit Managers are responsible for that, the nurses just check for placement. On 7/27/21 at 10:08 AM, the Director of Nursing (DON) in the presence of the facility's Administration and survey team, confirmed that staff should have been checking the function of the resident's wander guard every shift. A review of the facility's Resident Wandering Policy and Procedure dated 09/21/20, included under the procedure section of the policy that if assessment or behavior indicated need, implement the use of a Wander Guard for the resident, to be monitored every shift for placement and function. N.J.A.C. 8:39-27.1 (b)

Based on observation, interview, and record review, and review of other facility documentation, it was determined the facility failed to ensure the required Federal narcotic acquisition forms (DEA 222 form) were 1.) completed with sufficient detail to enable accurate reconciliation for 14 of 14 forms reviewed and 2.) dated and signed by the Medical Director as of the day it was submitted for filling for 4 of 4 forms provided. This deficient practice was evidenced by the following: 1. On 7/27/21 at 10:05 AM, a review of the facility's DEA 222 forms revealed an inconsistent pattern in regard to ordering the medication package size versus the number of packages being ordered. This inconsistency was identified on the following order forms: Order Form: # 6315, # 6316, # 6318, # 6319, # 6578, # 6579, # 6320, # 6321, # 6322, # 6325, # 0828, # 0830, # 0831, # 0832 On 7/27/21 at 10:21 AM, the surveyor interviewed the Director of Nursing (DON), who stated that one of the responsibilities of the DON was to complete the DEA 222 forms. The DON stated that she had looked back at previously completed forms and had followed those examples when completing the new forms. The DON stated the pills came in a zipped plastic bag and each individual tablet was in its own blister package, so the package size was one, and number of packages was the total number of individually packaged pills. She further stated she was never in-serviced on how to complete the newly revised DEA 222 forms by the provider pharmacy, but assumed they were filled out properly because the provider pharmacy never alerted her that they were filled out incorrectly. The surveyor stated the zipper locked bag was the one package and the package size was the total number of pills in that zipper bag. A review of the instructions for submission of the DEA 222 form located on the reverse side of the form included Part 1. Purchaser Information, 2. Only one item may be entered on a single line. Enter the number of packages, the size of the package, and the name of the item. Part 5. Controlled Substance Receipt 1. The purchaser fills out this section on its copy of the original form. 2. Enter the number of packages received and the date received for each line item. 2. On 7/27/21 at 10:19 AM, the surveyor requested from DON to review the facility's DEA 222 blank forms. The surveyor was handed four envelopes. Two envelopes were sealed, and two envelopes were opened. The two opened envelopes each contained two DEA 222 forms that had not been filled out but were already signed by the Medical Director. The identified forms were as follows: # 5572, # 5573, # 5574 and # 6314. At that time, the DON acknowledged the forms had been pre-signed by the facility's Medical Director. The DON stated she had been on leave and had the forms pre-signed in her absence for the acting DON to use. The DON further stated the Medical Director was in the facility at least three times a week and if needed, the acting DON could have reached out to the Medical Director if controlled substances needed to be ordered. On 7/27/21 at 11:35 AM, the surveyor interviewed the facility's Medical Director who stated he believed the facility policy for DEA 222 forms was for complete transparency. He stated that the facility's forms can only be sent to their provider pharmacy and that the provider pharmacy can only send the requested controlled substance medication to the facility. When the surveyor asked was there a possibility of drug diversion if the forms were pre-signed and the Medical Director acknowledged there was. The Medical Director further acknowledged that DEA 222 forms should not be pre-signed prior to completion of the controlled substance request. A review of the facility's Medication Ordering and Receiving from Pharmacy policy dated effective February 2019 included: D. The pharmacy dispenses medications listed in Schedules II, III, IV, and V in readily accountable quantities and containers designed for easy counting of contents. The policy did not include instructions for the proper completion of the DEA 222 form. N.J.A.C. 8:39-29.7(c)

Based on observation, interview, medical record review, and other facility documentation, it was determined that the facility failed to a.) identify all residents exposed to COVID-19 as persons under investigation (PUI), b.) implement mitigation strategies to prevent the transmission of COVID-19, and c.) create and implement a facility Contact Tracing Policy and Procedure to address the care of resident's who had been exposed to a COVID-19 positive individual. This deficient practice was identified for 25 out of 25 residents (Resident #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, and #32) reviewed for a known exposure to COVID-19 on 2 of 2 nursing units during a survey conducted on 1/05/21. On 12/28/20 the facility became aware that the 11:00 PM to 7:00 AM Certified Nursing Aide (CNA#1) tested positive for COVID-19. The surveyors reviewed CNA #1's 12/26/20 and 12/27/20 assignment and identified on 12/26/20 that CNA #1 had direct contact and provided care to 17 residents on the North unit. Resident #6 was considered PUI because his/her roommate had tested positive for COVID-19. The facility was utilizing Transmission Based Precautions (TBP) for Resident #6. Residents #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, and #23 were considered well, non exposed and were not on TBP. The facility failed to identify these 16 residents exposed to COVID-19 as Person Under Investigation (PUI). Upon known exposure to a COVID-19 positive staff member these residents were not placed on TBP to mitigate the spread of [MEDICAL CONDITION]. On 1/03/21 the facility became aware that the 7:00 AM to 3:00 PM CNA (CNA #2) tested positive for COVID-19. The surveyors reviewed CNA#2's 1/1/21 assignment and identified CNA#2 had direct contact and provided care to Resident #24, #25, #26, #27, #28, #29, #30, #31 and #32 who were considered well, non-exposed and were not on TBP. The surveyors reviewed CNA#2's 1/2/21 assignment and identified that CNA#2 had direct contact and provided care to Resident #24, #25, #26, #27, #28, #31, and #32 who were considered well, non exposed and not on TBP. The facility failed to identify these 9 residents who were exposed to COVID-19 as PUI. Upon known exposure to a COVID-19 positive staff member the facility failed to place these residents on TBP to mitigate the spread of [MEDICAL CONDITION]. During the survey conducted on 1/05/21, the surveyors observed six residents who were considered PUI. Five of these residents were observed residing on the North unit and one resident was observed residing on the South unit. These residents were identified as PUI by signage and Personal Protective Equipment (PPE) holders placed on their doors. Surveyor #1 further observed ten residents on the contained COVID-19 positive unit. Staff caring for the well non exposed residents were observed entering the resident's rooms wearing a KN95 mask, gloves, and a face shield or goggles. In addition, staff were unaware of the appropriate TBP or protocol that should have been implemented for exposure to [MEDICAL CONDITION]. The facility's failure to identify residents on the well non exposed nursing units as exposed to COVID-19 or implement strategies to prevent the spread of the COVID-19 virus, posed a serious and immediate threat to safety and well being of all well non exposed residents. This resulted in an Immediate Jeopardy (IJ) situation that began on 12/28/2020 when the facility was notified of the confirmed COVID-19 positive CNA#1. The facility's Administration was notified of the IJ on 1/05/2021 at 3:40 PM. The immediacy was removed on 1/06/2021 based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site revisit survey conducted on 1/07/21. The evidence was as follows: On 1/05/21 from 9:42 AM to 10:30 AM the surveyors conducted Entrance Conference with the Director of Nursing (DON), Administrator, Contracted Infection Preventionist (CIP), and Infection Preventionist in Training (IPT). The surveyors asked the Administrative staff what type of PPE the staff were required to wear when caring for the well non exposed residents. The DON stated that the staff would wear a KN95 face mask, face shield or goggles, and gloves when providing care to the well non exposed residents. The surveyors further asked what PPE the staff were required to wear when entering a resident's room that was COVID-19 positive or PUI. The DON further stated that the staff were required to wear full PPE which consisted of a N95 mask, face shield or goggles, gown, gloves, and a surgical mask over the N95 mask. The surveyors asked the Administrative team what they would do if they found out a staff member tested positive for COVID-19. The CIP stated that if the staff member was present in the facility, they would immediately be sent home. The CIP further stated that the residents who the positive staff member provided care to would be assessed for signs and symptoms of COVID-19 and tested for [MEDICAL CONDITION]. The CIP stated that the residents the positive staff members had taken care of were not placed on TBP as a preventative measure to address the spread of [MEDICAL CONDITION]. The DON agreed with the CIP's statement and stated that they would tell the staff that the residents were exposed but would not implement additional TBP for the residents. At that time, the CIP confirmed that staff members had recently tested positive for COVID-19 and the residents the staff cared for were not considered PUI or placed on TBP. The Administrator stated that employee health would perform contact tracing on the employees who tested positive but did not speak to contact tracing for the residents. At 10:52 AM, the surveyors toured the North unit (rooms 201 through 241) and observed five resident rooms that were considered PUI. These rooms were identified as rooms that required donning (putting on) of PPE to enter by a sign placed outside of the door that indicated enhanced barrier precautions. The sign further provided the staff with instructions for donning and doffing (taking off) PPE. The surveyors observed that the residents who resided in the PUI rooms had a container attached to the outside of their door with PPE equipment such as face shields, gowns, surgical masks, and gloves. At 11:01 AM, Surveyor #1 observed the call light outside of Resident #19's room was on. The surveyor observed the staff member enter the resident's room wearing a KN95 mask and goggles. There was no sign or PPE bin located outside of the resident's bedroom door. At 11:06 AM, Surveyor #1 interviewed CNA #3 who stated that she would know if a resident was PUI or COVID-19 positive by the signs and the PPE placed outside their door and by a shift report given by the management and nurses at the beginning of her shift. CNA #3 gave the example that a resident would be considered a PUI if their roommate had tested positive for COVID-19 and would require TBP. CNA #3 stated that for the well non exposed residents, the staff were required to wear a KN95 mask, goggles, and gloves before they entered the resident's room. CNA #3 further stated that if a staff member tested positive for COVID-19 the nursing staff would handle it and knew that the residents would be tested for COVID-19 again. The CNA #3 did not speak to the procedure if the well non exposed residents were placed on TBP. At 11:08 AM, Surveyor #2 interviewed Licensed Practical Nurse #1 (LPN#1) who was assigned to the North side. LPN#1 stated that if an employee tested COVID-19 positive, the employee was sent home immediately and everyone; staff and residents, were tested . LPN#1 stated that no changes were made if the resident had a negative test even if they were exposed to the COVID-19 positive employee. At 11:15 AM, Surveyor #2 interviewed LPN #2 who stated that she was assigned to the North Side which included rooms [ROOM NUMBERS]. Surveyor #2 asked LPN #2 why rooms [ROOM NUMBERS] both had signs on the door for enhanced precautions, LPN#2 stated that they both had roommates that tested positive for COVID-19. The roommates were moved to the COVID-19 unit and the remaining residents were placed as PUI because of the exposure. LPN #2 stated that enhanced precautions meant that a gown and gloves must be worn in addition to the N95, surgical mask and goggles when entering the room. LPN #2 stated that the increased precautions were so, nothing gets spread. She stated that if a direct care employee tested COVID-19 positive, all the staff and the residents were tested . Surveyor #2 asked what was done for the residents that the direct care staff had taken care of and LPN #2 stated that they were tested and monitored for signs and symptoms and vital signs were taken every shift but the residents were not placed on TBP unless they tested positive. At 11:18 AM, Surveyor #1 interviewed the Registered Nurse/Desk Nurse (RN/DN) who stated that the facility recently had an outbreak of COVID-19 before 12/25/2020. The RN/DN stated that the residents who resided on the unit who were on TBP were considered PUI because they had gone out for an appointment or recently had a roommate that tested positive for COVID-19. The RN/DN explained that the residents would be on TBP for 14 days to prevent the spread of infection. The surveyor asked the RN/DN what the facility's policy was if a staff member who cared for resident's had tested positive for COVID-19. The RN/DN stated that the facility would back track all the residents the staff member had contact with and re-test them for COVID-19. The RN/DN stated that if the resident did not test positive for COVID-19 they would not be placed on TBP. The RN/DN stated that the PPE that she wore when she entered the resident's rooms who were not on TBP consisted on a face mask, goggles, KN95 mask, and gloves. At 11:22 AM, Surveyor #1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who identified herself as the manager for rooms 201 through 241. The LPN/UM stated that the residents who were currently on TBP who resided on the North unit were considered PUI because they had recently left the facility for an appointment or had a roommate that tested positive for COVID-19. The LPN/UM stated that when staff entered a resident's room who was on TBP staff were required to wear a N95 mask, surgical mask over the N95 mask, gown, face shield or goggles, and gloves. The surveyor asked the LPN/UM what the facility would do if a staff member tested positive for COVID-19. The LPN/UM stated that they would do a PCR-test ([DIAGNOSES REDACTED]-CoV-2 test for genetic material that is specific to [MEDICAL CONDITION]) if the staff member had symptoms and would go back 24 hours to see what residents the staff member had contact with so the residents could be tested . Surveyor #1 asked the LPN/UM if any of the resident's the COVID-19 positive staff member had contact with would be placed on TBP. The LPN/UM stated, no. At 11:25 AM, Surveyor #2 interviewed the Director of Rehab (DR) who stated that if any employee tests COVID-19 positive they are made aware in the morning meeting or the shift report and then she updated her team. The DR stated if a resident had a negative test, they are not placed on TBP. At 11:29 AM, Surveyor # 2 interviewed CNA #4 who stated that the North side is her usual assignment. She stated that if there was a COVID-19 positive staff member the nurses tested all the residents. CNA #4 stated she was aware of COVID-19 positive staff members but was not made aware of the residents that had been exposed to those staff members. At 11:48 AM, Surveyor #2 interviewed CNA #5 who stated that she was aware of a positive staff member but was not made aware of the residents that were exposed to that staff member. She stated if a resident tested negative the required PPE was a N95 or KN95, surgical mask and goggles at all times. CNA #5 stated that the PUI residents had enhanced precautions sign on the door, requiring face shields/goggles, N95, surgical mask, gowns and gloves before entering the rooms. At 11:50 AM, the surveyors entered and toured the South unit (rooms 109 through 131) and observed one resident room that was considered PUI. This room was identified as a room that required donning (putting on) of PPE to enter by a sign placed outside of the door that indicated enhanced barrier precautions. The sign further provided the staff with instructions for donning and doffing PPE. The surveyors observed that the resident who resided in the PUI room had a container attached to the outside of his/her door with PPE equipment such as face shields, gowns, surgical masks, and gloves. At 11:57 AM, Surveyor #1 interviewed LPN #3 who stated that the resident on the South unit who was on TBP was considered a PUI because his/her roommate had tested positive for COVID-19. LPN #3 further stated that the staff was required to don full PPE when entering the resident's room. LPN #3 explained the PPE the staff was required to wear consisted of a N95 mask, surgical mask over, gown, gloves, face shield, or goggles. LPN #3 stated that all staff in the facility were tested for COVID-19 every 48 hours and that if a staff member tested positive all the resident's in the facility would be tested for COVID-19. LPN #3 stated that to her knowledge the resident's that had care provided by a staff member that tested positive for COVID-19 were not placed on TBP. LPN#3 stated that it could take a person a week to 14 days to test positive for COVID-19 after exposure to [MEDICAL CONDITION]. At 12:20 PM, Surveyor #1 toured the COVID-19 positive unit at the facility and observed ten resident's residing on the unit. The staff caring for the residents were observed wearing N95 masks covered by a surgical mask, gowns, gloves, face shields or goggles. Surveyor #1 observed that the unit was stocked with PPE. At 12:40 PM, Surveyor #2 interviewed the CIP and the IPT. The IPT stated that the PUI unit is rooms 201 to 212, the COVID unit is rooms 101 to 110, all other rooms were the well non exposed long-term care residents. The CIP stated that CNA #1 tested positive for COVID-19 before she started her shift on 12/28/20 and was immediately sent home. Staff was made aware that a staff member had tested positive and everyone in the building was tested for COVID-19. The CIP stated that CNA #1 worked 12/26/20 and 12/27/20, her assignment was rooms 228 to 241, on the long-term care unit. The CIP stated that they did not put all the exposed residents on TBP. She stated that the whole place should be placed on PUI at this point. The CIP stated that the importance of TBP was to prevent any further spread and prevent additional complications. At 1:08 PM, the IPT stated that CNA #2 tested COVID-19 positive on 1/3/21. He stated that CNA #2 worked 1/1/21 and 1/2/21. The IPT was unable to provide the surveyors with CNA #2's assignment of which residents he/she came in contact with. At 14:05 PM, Surveyor #2 reviewed the line listing (a table of information recorded for staff and resident's that identifies dates of exposure and signs and symptoms of [MEDICAL CONDITION] which is used as a tool for infection control tracking) in the presence of the IPT and CIP. Surveyor #2, CIP, and IPT confirmed that Resident #10, #11 and #16 had tested positive for COVID-19. These resident's were all on CNA #1's assignment on 12/26/20 and 12/27/20. At 15:50 PM, the surveyors conducted a final interview with the Administrator who stated that the Human Resource Department had a Contact Tracing Policy and Procedure, but believed it only addressed contact tracing for staff that tested positive for COVID-19 and not the care of resident's. Review of the facility outbreak line list indicated that CNA #1 tested COVID-19 positive on 12/28/20 using BINEX (a rapid test which detects the presence of protein [MEDICATION NAME] from [DIAGNOSES REDACTED]-CoV-2) testing procedures. CNA #1 was placed on quarantine and out of the facility on 12/28/20. Review of CNA #1 assignment sheets on 12/26/20 and 12/27/20 indicated that CNA #1 provided direct care to one PUI resident and 16 well non exposed residents. Out of 16 well non exposed resident's that CNA#1 provided care for on 12/26/20 and 12/27/20, three residents', (Resident #10, #11, and #16) tested positive for COVID-19 on 1/04/21. The remaining 13 well non exposed residents, (Resident #8, #9, #12, #13, #14, #15, #17, #18, #19, #20, #21, #22 and #23) remained negative and not on TBPs according to the facility's resident outbreak line list. Review of the facility's staff outbreak line list indicated that CNA #2 tested COVID-19 positive on 1/03/21 using BINEX testing procedures. CNA #2 was placed on quarantine and out of the facility on 1/03/21. Review of CNA #2's 1/1/21 assignment sheet indicated that CNA #2 provided direct care to nine well non exposed residents, (Resident #24, #25, #26, #27, #28, #29, #30, #31, and #32). These nine well non exposed residents remained negative and not on TBPs according to the facility's resident outbreak line list. Review of CNA#2's 1/2/21 assignment indicated that CNA#2 provided direct resident care to seven well non exposed residents, (Resident #24, #25, #26, #27, #28, #31, and #32). These seven well non exposed residents remained negative and not on TBPs according to the facility's outbreak line list. The IJ was identified on 1/05/2021 and the Administrator, DON, CIP, and IPT were notified of the IJ at 3:40 PM. A removal plan was accepted on 1/06/2021 which included that residents who were identified as coming into close contact with CNA#1 and CNA #2 remained in their rooms, were considered PUI, and were placed on TBP. A Contact Tracing Policy and Procedure was created by the facility and all licensed staff were in-serviced. The implementation of the removal plan was verified on-site on 1/07/21. On 1/07/21 at 9:52 AM, the surveyors toured the North and South units of the facility and verified through observations, interviews with facility staff, review of in-service education, facility documentation, and the Contact Tracing Policy and Procedure created on 1/05/21 that the Removal Plan had been implemented. Review of the facility's Pandemic Outbreak Policy and Procedure updated 12/9/20 indicated that when a Pandemic Influenza Outbreak was identified nursing services would isolate contaminated residents to minimize the spread of [MEDICAL CONDITION]. The Pandemic Outbreak Policy and Procedure did not address contact tracing for well non exposed residents who had been exposed to a COVID-19 positive individual or mitigation strategies to prevent the spread of infection by the implementation of TBP. The facility's Outbreak Policy and Procedure further indicated, The Administrator or designee shall be responsible for monitoring federal and state public health advisories and updating the Director of Nursing serving as the pandemic response coordinator. Review of the facility's Infection Prevention Control Policy and Procedure revised 3/5/20 indicated that it was the policy of the facility to follow national standards and guidelines to prevent the spread, recognize, and control the spread of infection. A review of the guidance of the New Jersey Department of Health/Communicable Disease Services (NJDOH/CDS) Considerations for Cohorting COVID-19 Patients in Post-Acute Care Facilities dated revised 10/22/2020 included that Group Cohort 2 COVID-19 negative, exposed consisted of both symptomatic and asymptomatic residents who tested negative for COVID-19 with an identified exposure to someone who was positive. These individuals should be quarantined for fourteen days from the last exposure, regardless of test results. The guideline further included that residents in Group Cohort 2 should be placed on TBP using the COVID-19 recommended PPE of a N95 mask, eye protection, gloves, and isolation gowns. NJAC 8:39-19.4 (a)(b)(c)(d); 27.1(a)

Based on observation, interview and record review, it was determined that the facility failed revise the fall care plan for a resident who sustained a fall. This deficient practice was identified for 1 of 1 resident reviewed for falls and was evidenced by the following: On 09/04/19 at 11:47 AM, the surveyor observed Resident # 8 at the lunch meal. The lunch meal was in front of the resident and the resident had his/her head faced downward and was not initiating self-feeding. On 09/04/19 at 12:48 PM, the surveyor interviewed the Certified Nurse Aide (CNA #1) assigned to provide care to the resident. CNA #1 stated that the resident was sleepy today and that the resident had a fall on Monday (09/02/19). She continued to state that if the resident was left alone, the resident can and will try to stand up and because of that reason the resident is kept at the nurses station. CNA #1 added that on the day the resident fell , the Unit Manager (UM) was not working. According to the Profile Face Sheet (an admission summary), Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Nursing Evaluation, dated 11/26/17, revealed an admitting [DIAGNOSES REDACTED]. A Risk Assessment for Falls, dated 11/26/17, revealed that the resident had a score of 30 and a resident receiving a score of ten or greater will be classified as a potential fall candidate. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate care dated 6/1/19, revealed that Resident #8 had a Brief Interview of Mental Status (BIMS) of 7 which indicated the resident was severely cognitively impaired. The MDS also revealed that the resident was not steady when moving from a seated to standing position and was only able to stabilize with staff assistance. On 09/05/19 at 8:25 AM, the surveyor observed the resident sitting in a wheelchair at a table located in front of the nurses station on the South side eating breakfast. Concurrently, the surveyor interviewed the UM who stated that the resident was at a high risk for falls, had a history of [REDACTED]. He continued to state that unfortunately he was not working on the Monday (09/02/19) that the resident fell . At that time, the surveyor reviewed Resident #8's Interdisciplinary Plan of Care (IDCP) with the UM. The IDCP, Potential For Falls, revealed that the document was a pre-printed care plan, updated on 12/18. Under the section Problems/Strength, Potential for falls related to: the following boxes were checked off: History of falls, Impaired balance, Impaired coordination, Unsteady gait, Desire to maintain independence and cognitive impairment. Underneath the problem list, there was a handwritten entry that reflected on 9-2-19 Found on floor at nurse's station. Under the Interventions/Approaches section on the IDCP, the following boxes were checked off: Keep call bell within reach, PT/OT (physical therapy/occupational therapy) as ordered, Keep area clutter free, Fall risk assessment, Bed in lowest potion as tolerated, Floor mat next to bet, Anticipate needs if unable to use call bell and under Provide appropriate assistive device, wheelchair was handwritten in. There were no new interventions identified on the IDCP for falls, nor was the intervention described by the UM and CNA #1, to leave the resident at the nurses station, listed on the IDCP. The UM confirmed that having the resident sit at the nurses station was not part of the IDCP for falls and acknowledged that the IDCP for falls was not updated with new interventions after the resident's recent fall. He continued to state that everyone knew that the resident should be watched, however, he could not offer an explanation as to why leaving the resident at the nurses station was not part of the IDCP for for falls, nor what should be done when the UM was not available to watch the resident. The surveyor reviewed two Fall Investigation Forms (FIF) for Resident #8. One was for a fall that occurred on 07/22/18 and one for a fall that occurred on 09/02/19. The FIF for the fall that occurred on 07/22/18 revealed that the resident was in front of the nursing station at a table and fell from his/her wheelchair. The document revealed that the fall was unwitnessed and the resident was found by a CNA who noticed that the resident was on the floor. The wheelchair was found on its side. The FIF for the fall that occurred on 09/02/19 revealed that the resident had an unwitnessed fall and was found lying on the floor in front of the nurses station and the wheelchair was found tipped over. The resident sustained [REDACTED]. Under recommendation, frequent monitoring to assist with needs was checked off and under other, continue with current fall prevention program was handwritten in on the form. On 09/05/19 at 1:00 PM, the surveyor, in the presence of the survey team, interviewed the DON regarding the IDCP for Falls for Resident #8. The DON stated that the resident was supposed to have intermittent supervision, although it is not on the care plan. Additionally, she acknowledged and confirmed that there were no new interventions in place to lessen the possibility of the resident falling again and it was expected that the nurses should have updated the IDCP immediately after the resident fell . She did not offer an explanation as to why the care plan interventions were not updated despite the resident sustaining two falls at the nurses' station. On 09/06/19 at 1:44 PM, the surveyor interviewed the UM regarding the presence of a facility fall program. The UM stated we don't have one. He continued to state we have interventions for each resident. The interview continued regarding the communication process for new interventions that may be added to the IDCP for a resident after a fall He stated that communication would occur in the morning, before the staff would begin an assignment. He further stated that there has been no new interventions added for fall prevention to Resident # 8. The surveyor reviewed the CNA Care Card for Resident #8 with the UM. The Care Card revealed under Safety & Fall Prevention, 1/2 side rails, Floor Mat and Low Bed and the resident was checked off as a high fall risk. There were no interventions or instructions regarding leaving the resident at the nurses' station. The Incident Accident Protocol Policy, revised 05/12/17, revealed,,Under section 4.3 and 4.3.3, that unwitnessed falls require a timely investigation with a 24 hour look back by the Administrator, DON, Charge Nurse or Supervisor. Under section 4.5 and 4.5.2, when conducting an investigation the administrator, DN or designee should initiate actions to prevent further incidents. On 9/09/19 at 10:40 AM, the Administrator stated that she had no additional information to provide other than the responses that were previously provided by DON in regards to Resident #8. NJAC 8:39-11.2(h)

Based on observation, interview, and record review, it was determined that the facility failed to 1.) follow a physician's order for a pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions) interrogation (a procedure that evaluate the programming of the pacemaker and confirms that the battery and wires are functioning appropriately) (pacemaker check) and 2.) follow the facility policy for completing neuro-checks. This deficient practice occurred for 2 of 21 residents reviewed for physician orders, Resident #23 and Resident #8 and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities with in the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. According to the Admission Record, Resident #23 was admitted to the facility on [DATE] and had medical [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/21/19, reflected that the staff assessed the resident as having moderately impaired decision making skills. On 09/03/19 at 9:52 AM, the surveyor observed Resident #23 sleeping in bed. On 09/04/19 at 12:25 PM, the surveyor reviewed the resident's medical record which revealed the following: Review of the (MONTH) 2019 Physician Order Sheet (POS) for Resident #23 revealed a physician's order, dated 07/16/17, for Pacemaker interrogation every 4 months (March, July, Nov). Review of the The (MONTH) 2019 Treatment Administration Record (TAR) reflected a corresponding physician order, dated 07/16/17, for pacemaker interrogation every four months (March, July, Nov). The surveyor also observed a handwritten FYI (for your information) that was documented in the hour section of the physician order and the remaining area in the TAR was blank. A specific date for the pacemaker interrogation was not documented on the TAR. Review of the (MONTH) 2019 TAR reflected the corresponding physician order, dated 07/16/17, for pacemaker check every four months (March, July, Nov). The surveyor observed a handwritten line under (MONTH) and a FYI was documented in the hour section of the physician order and the remaining area in the TAR was blank, A specific date for the pacemaker interrogation was not documented on the TAR. Review of the resident's Care Plan (CP), initiated on 06/11/18, revealed a Problem/Strength of potential for alteration in cardiac status secondary to pacemaker. The CP further reflected an intervention for scheduled pacemaker checks as ordered physician every four months. Review of the Nurses' Notes completed in (MONTH) 2019 and (MONTH) 2019 failed to reveal documentation that Resident #23's pacemaker interrogation was completed Review of the Pacemaker Follow Up Report, dated 12/27/18, revealed the last pacemaker interrogation was completed on 12/27/18. On 09/05/19 at 9:51 AM, the surveyor interviewed the Unit Manager (UM) regarding the completion of pacemaker interrogations for Resident #23 . The UM stated the last pacemaker check (interrogation) for the resident was completed in (MONTH) (YEAR). UM further stated Resident #23 was due to have a pacemaker check in (MONTH) 2019, but it was not completed. The UM continued to state that he documents the date in a calendar located at the nurses' desk and the nurses are supposed to check the calendar to see when the resident's pacemaker check was to be completed. The UM confirmed that Resident #23 did not have a pacemaker check completed in (MONTH) 2019. The UM also stated that the physician's order was documented on the (MONTH) 2019 and (MONTH) 2019 TARs as an FYI and confirmed that the date for the pacemaker check was not documented on the TAR. The UM further stated he would call the pacemaker check company and have Resident #23's pacemaker check completed. On 09/05/19 at 11:48 AM, the surveyor observed the UM transporting Resident #23 toward the nursing station. Upon interview, the UM stated he was taking the resident to get his/her pacemaker check completed. On 09/09/19 at 10:14 AM, the surveyor interview the Licensed Practical Nurse (LPN #1) who stated that the UM documents the pacemaker check dates in a calendar located at the nursing station. She stated the UM was responsible for completing the pacemaker checks and that the pacemaker checks are also documented on the TAR as an FYI; however, the dates were not documented. She further stated the nurse on duty is supposed to check the calendar and follow through with completing the pacemaker check if the UM was not present. On 09/09/19 at 10:45 AM, the surveyor interviewed the Director of Nursing (DON) who stated the pacemaker checks were documented as an FYI for Resident #23 and the regular nurse did not see it because the date was not blocked off on the TAR. The DON further stated the UM documented the dates for the pacemaker checks on a calendar and she and the Assistant Director of Nursing (ADON) were responsible when the UM was not present; however, she was unaware of where the calendar was located on the unit. The facility's Pacemaker policy, with an implemented date of 6/17, revealed that residents with cardiac devices should be routinely monitored as ordered by the physician. 2. On 09/04/19 at 11:47 AM, the surveyor observed Resident #8 during the lunch meal. The resident's head was down and was not initiating self-feeding. On 09/04/19 at 12:48 PM, the surveyor interviewed the primary Certified Nurse Aide (CNA #1) assigned to the resident. CNA #1 stated that the resident had a fall while seated in a wheelchair at the nurses' station on Monday (09/02/19). CNA #1 added after she washed and dressed the resident, she wheeled the resident to the nurses' station for supervision. She stated the resident stood up from the wheelchair and then fell and hit his/her head on the the back of the cabinet. On 09/04/19 at 1:18 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #8. The LPN stated that the resident was sleepy today and she did not know why. She stated that the resident had a fall two days ago (Monday, 09/02/19). The LPN stated that the resident tried to get up unassisted and fell at the nurses' station. She stated that when the resident fell , he/she hit her head on the back of a cabinet and had a bump on the back of his/her head. She continued to state that we did neuro checks (neurological assessment to determine level of consciousness) for 24 hours. Review of the Nurse Notes (NN), dated 09/02/19 at 9:25 AM, revealed that the resident sustained [REDACTED]. Review of the Physician Orders, dated 09/02/19 at 10:00 AM, revealed an order for [REDACTED]. On 09/05/19 at 8:25 AM, the surveyor interviewed the UM regarding the fall sustained by Resident #8. The UM stated the resident's physician had not yet come to evaluate the resident and that neuro-checks had been done for 24-hours after the fall. The UM stated that the physician does not write neuro-check orders. Review of a Fall Event Summary, dated 09/02/19, revealed documentation of bump on back of head noted and neuro checks initiated. Review of the Incident Accident Protocol Policy, revised 05/12/17, under 2.1.4 revealed, Any customer sustaining an injury to the head and/or has an unwitnessed fall which the customer is unable to describe, should be observed for neurological abnormalities by performing neuro-checks for 48 hours after the incident. The physician should be notified for abnormal findings. On 09/05/19 at 1:06 PM, the surveyor interviewed the DON regarding the policy for neuro-checks. The DON could not explain why the neuro-checks on Resident #8 were not completed for 48-hours, in accordance with the facility policy. NJAC 8:39-11.2(b), 27.1(a)

Based on observation, interview and document review, it was determined that the facility failed to a.) maintain potentially hazardous foods stored in a refrigerated unit at appropriate temperatures to prevent potential microbial growth, and b.) label and date potentially hazardous foods with a use by date, and maintain food service equipment intact. This deficient practice was evidenced by the following: On 09/03/19 at 9:00 AM, the surveyor completed an initial tour of the kitchen with the Dietary Director (DD) and observed the following: 1. In the walk-in refrigerator, there was a 1/2 pan with sliced lettuce and tomato with a slice of cheese, that was wrapped in plastic wrap, sitting on top of the vegetables. The plastic wrapped cheese contained a handwritten date of 9/1. The DD stated the dating policy was for two days after the food was prepped, it will be discarded. 2. A 1/2 pan of raw chicken breasts was not fully covered and contained liquid in the pan. The chicken did not contain a date. The DD stated the chicken should have been labeled with a pull date and use by date. 3. The chicken breasts were resting on top of a 1/2 pan containing a plastic bag, identified as chicken tenders by the DD. There was no label or date on the bag. 4. A rack, identified as containing clean equipment, contained three 8.75 gallon, large plastic bins. All of the bins had areas with broken corners and one of the corners fell off when the bin was lifted up. 5. A bag of feta cheese was opened, wrapped and dated 8/25. The bag did not contain a use by date. On 9/5/19 at 10:36 AM, the surveyor toured the kitchen with the DD. The Registered Dietitian (RD) joined the tour at 10:47 AM and the following was observed: 1. A refrigeration unit, located at the end of the resident tray line was opened on top to reveal varied cold cut items. The DD stated the unit was used at meal times to prepare sandwiches as needed. The top area contained a small pan of egg salad, tuna salad, ham that was prepared in three slice units and contained in a pan, and a small piece of wrapped Swiss and American cheese. The RD and DD confirmed that there was no thermometer located on top of the unit where the sandwich items were stored, nor was the temperatures of the food items monitored. The surveyor utilized a calibrated thermometer to check the temperatures of the the egg salad and three slices of ham. The egg salad was 42.7 degrees Fahrenheit (F) and the ham was 44 degrees F. The DD confirmed the food was out of the acceptable temperature range. Review of a Standards of Operation Policy for Dining Services, dated 06/18/18 revealed cold food items are maintained and served at 42 degrees or below. The policy reflected to tightly cover wrap all food items and to label and date. The policy also indicated that Dining Service Department participates in an ongoing preventive and corrective maintenance program. Small wares and equipment are checked routinely for service issues and repaired or replaced as needed. NJAC 8:39 17.2(g)

COMPLAINT: # NJ 0, NJ 8 Based on observation, interviews, and record review, on 12/03/2018 and 12/04/2018, it was determined that the facility nursing staff failed to follow physician's orders [REDACTED].#1 and Resident #4). The Facility also failed to implement Care Plan interventions for 1 of 7 sampled residents (Resident #3). The deficient practice was evidenced by the following: 1. According to the Facility's Profile Face Sheet, Resident #1 was initially admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 8/24/2018, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating Resident #1 was cognitively intact. The MDS also indicated the Resident required staff assistance for Activities of Daily Living (ADLs). A review of the physician's orders [REDACTED].#1 contained the following: [MEDICATION NAME] 175 microgram (mcg) tablet, for [MEDICATION NAME], give 1 tablet by mouth once daily for [MEDICAL CONDITION], dated 05/07/2018. [MEDICATION NAME] capsule 20 milligram (mg), for [MEDICATION NAME], give 1 capsule by mouth once daily [MEDICAL CONDITION](Gastrointestinal Reflux Disease), dated 10/05/2017. A review of Resident #1's Medication Administration Record [REDACTED] [MEDICATION NAME] 175 mcg, for [MEDICATION NAME]. Give 1 tablet by mouth once daily, on 12/01/2018 at 6:00 a.m. [MEDICATION NAME] capsule 20 mg, for [MEDICATION NAME]. Give 1 capsule by mouth once daily, on 12/01/2018 at 7:00 a.m. On 12/03/2018 at 10:25 a.m., the surveyor observed four med cups at Resident #1's bedside which contained ointments and creams, (two cups on the over-bed table and two cups on the bedside table). In addition, a bottle labeled [MEDICATION NAME] powder was also observed on the Resident's bedside table. 2. According to the Facility's Profile Face Sheet, Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Resident #4's MDS dated [DATE], the Resident had Short-term and Long-term Memory Problems, and was Moderately Impaired with Decision Making Skills. The MDS also included documentation that Resident #4 required extensive staff assistance for Activities of Daily Living (ADLs). A review of the PO's sheet for Resident #4 contained the following: [MEDICATION NAME] Shampoo 2%, ([MEDICATION NAME] Shampoo). Apply to hair twice a week on Tuesday and Friday, with a PO date of 6/4/2018. Wanderguard to right wrist. Check placement and function every shift, with a PO date of 4/11/2018. Evaluate pain level every shift with appropriate scale (while awake) dated 1/26/2018. A review of Resident #4's nursing notes dated 10/17/2018, indicated the nurse notified the physician that Resident #4 developed a blister to the left heel. The Nurse's Notes revealed the physician ordered the following treatment: Cleanse left heel blister with normal saline, apply [MEDICATION NAME], and cover with dry dressing daily, however, this order was not on the Physician order [REDACTED]. A review of Resident #4's TAR dated (MONTH) (YEAR), showed no documentation that indicated the following were administered as ordered. [MEDICATION NAME] Shampoo 2%, ([MEDICATION NAME] Shampoo). Apply to hair twice a week on Tuesday and Friday, on 10/30/18 on the 7:00 a.m. to 3:00 p.m. shift. Wanderguard to the right wrist, check placement and function every shift, 10/22/2018 on the 11:00 p.m. to 7:00 a.m. shift. Evaluate pain level every shift with appropriate scale (while awake), on 10/12/2018 on the 3:00 p.m. to 11:00 p.m. shift. Cleanse left heel blister with normal saline apply [MEDICATION NAME] and cover with dry dressing daily on 10/30/2018 on the 7:00 a.m. to 3:00 p.m. shift. 3. According to the facility's Profile Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Resident #3's MDS dated [DATE], Resident #3 had a BIMS score of 6/15, indicating severe cognitive impairment. The MDS also showed that Resident #3 required extensive staff assistance for ADLs. A review of Resident #3's CNA Care Log (Certified Nursing Assistance) for ADLs, dated (MONTH) (YEAR), under Staff Assist, category Bed Mobility (to and from lying, turning and positioning) revealed there was no documentation that indicated the task was completed on the following days: June 22, and (MONTH) 24, (YEAR) on the 11:00 p.m. to 7:00 a.m. shift. A review of Resident # 3's Care Plan (CP) dated 6/21/2017, under Problem, Impaired Skin Integrity,the CP showed that Resident #3 was admitted with a DTI (Deep Tissue Injury) of the sacrum. The CP goal listed: Potential for decline/further wounds will be minimized. Interventions listed on the CP included but were not limited to Turn and reposition Q (every) 2 hours. In addition review of Resident #3's CNA Care Log for ADLs dated (MONTH) (YEAR), under Staff Assist for Eating on (MONTH) 26, for the 3:00 p.m. to 11:00 p.m. shift revealed no documenting of initials indicating the staff assisted Resident #3 with the resident meals on the above date. During an interview on 12/03/2018 at 12:28 p.m., with the Licensed Practical Nurse (LPN), the LPN stated that he/she placed two of the four medication cups and the [MEDICATION NAME] powder at Resident #1's bedside at 8:30 a.m. on 12/03/2018. The LPN stated I don't know who put the other two cups there. The LPN explained the medications were left at the bedside because the LPN went to Resident #1's room to do the Resident's treatments. However, the Resident's morning care was not completed so he/she placed the medications on the table and asked the Certified Nursing Assistant (CNA) to notify the LPN when the care was completed. In addition, the LPN stated the medications are not supposed to be kept at the bedside, they are kept in the treatment cart. During the interview the LPN also identified the medications which were found at the bedside, by pointing to them on the TAR as: [MEDICATION NAME] cream, Risamine moisture barrier cream, and the [MEDICATION NAME] powder. During an interview with the Director of Nursing (DON) on 12/03/2018 at 3:52 p.m., the DON stated he/she will start in-servicing the nursing staff immediately on the Policy of Medication Administration and the in-service will be completed on 12/04/2018. The surveyor reviewed Resident #1's and Resident #4's Nurses Notes (NN) and there was no documentation in the NN for the above time frames indicating that the medications and treatments were administered as ordered. During a post survey interview with the Unit Manager (UM) on 12/11/2018 at 11:35 a.m., the UM stated, documentation should be signed by the end of the day. The UM also indicated signing the MARs and TARs was part of the nurses' responsibility. The UM stated if it was not signed it was not done. The UM also explained it was wrong to leave medication at the resident's bedside unless there was a Doctor's order to do so. The UM indicated if a resident was Care Planned to be turned and repositioned every two (2) hours and the CNA documentation was blank, this meant it was not done. Review of the Facility's Policy titled Administration of Medication with a revised date of (MONTH) 2014, under Medication Administration section 1. Medications are administered in accordance with written orders of the prescriber . Section 4. Medications are to be administered at the time they are prepared. Under Documentation section 4. The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for the specific medication, dose, administration, and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. N.J.A.C. 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to act upon recommendations made by the Consultant Pharmacist (CP). This deficient practice was identified for Resident #21, 1 of 24 residents reviewed and was evidenced by the following: According to the medical record, Resident #21 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. On 9/17/18 at 11:55 AM, the surveyor reviewed the Pharmacy Consultant Therapeutic Suggestions (PCTS) form dated 7/5/18 which reflected a notation that [MEDICATION NAME] eye drops (medication used to dilate the pupil) had not been approved for oral use, to evaluate the risk versus benefit for continued use, and to document in the progress note. The surveyor reviewed a second PCTS form dated 8/1/18 which reflected a notation that [MEDICATION NAME] eye drops had not been approved for oral use, to evaluate the risk versus benefit for continued use, and to document in the progress note. The surveyor reviewed the 7/20/18, 7/27/18, and 8/20/18 physician progress notes [REDACTED].#21 but made no notation about the [MEDICATION NAME] recommendations from the CP. A review of Resident #21's Nurse's Notes from 7/2/18 to 9/14/18 did not reveal documentation that the physician had been informed of the 7/5/18 and 8/1/18 [MEDICATION NAME] recommendations from the CP. When interviewed on 9/19/18 at 9:25 AM, the Unit Manager (UM) said he was responsible to follow up with the physicians with any new CP recommendations. The UM said, if the physician was unavailable, he would then file the PSTS form in the resident's chart for the physician to review at their next visit. At that time, the UM confirmed that the 7/5/18 and 8/1/18 [MEDICATION NAME] recommendations had not been addressed by the physician. Later on, at 12:45 PM, the UM informed the surveyor that he had informed the physician about the [MEDICATION NAME] CP's recommendations and had received an order to discontinue the [MEDICATION NAME] medication order. On 9/19/18 at 1:25 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the physician should have addressed the 7/5/18 and 8/1/18 CP's recommendations at the monthly visit. The DON further stated it was the responsibility of the UM to make sure that the CP's recommendations were addressed. When interviewed on 9/20/18 at 10:15 AM, the DON said the CP's recommendations were emailed to the UM. The DON stated that the PSTS forms were supposed to be filed in a CP recommendation binder for the physicians to address. The DON further stated that the UMs were supposed to monitor the CP recommendation binder and make sure the CP's recommendations were addressed in a timely manner. The surveyor reviewed the facility's Consultant Pharmacist's Medication Regimen Review (MRR) policy dated 2/4/17, provided by the DON. The policy indicated that the UM was responsible to forward the CP's recommendations to the physician indicated. The policy further revealed that the UM should track the physician's response to ensure the irregularities/recommendations were addressed in a timely manner. The policy also indicated that the UM should note the action for each irregularity/recommendation in a progress note and on the PSTS form within three business days. NJAC 8:39-29.3(a)(1)

Based on interview and record review, it was determined that the facility failed to a.) follow an active physician's order to re-evaluate the continued use of an as-needed (PRN) [MEDICAL CONDITION] medication, and b) consistently document the administration of a [MEDICAL CONDITION] medication on the Medication Administration Record (MAR). This deficient practice was identified for Resident #74, 1 of 5 residents reviewed for unnecessary [MEDICAL CONDITION] medications and was evidenced by the following: 1. According to the medical record, Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #74's Physician's Order Sheet (POS) dated 8/28/18 revealed a physician's order for Klonopin (an anti-anxiety medication) 0.5 milligram (mg) one tablet by mouth daily for 14 days as needed for anxiety. The August/September (YEAR) MAR revealed the corresponding physician order for [REDACTED]. The surveyor further reviewed a Controlled Drug Administration Record (decline sheet) received 9/9/18 for the Klonopin for Resident #74. The decline sheet revealed a 14-day Autostop and that the quantity of the Klonopin medication received was 14 tablets. The decline sheet revealed two doses were administered on 9/11/18 and 9/12/18, 2 days after the 14-day stop date. The surveyor reviewed the History and Physical dated 8/31/18 and the Physician's Progress Note dated 9/10/18. The History and Physical and Physician's Progress Note did not address the 14-day stop date for Klonopin. The surveyor further reviewed the POS for August/September (YEAR). The August/September POS did not reflect an order to renew the PRN Klonopin. On 9/18/18 at 10:28 AM, the surveyor interviewed the Unit Manager (UM) who stated that the facility was unable to locate the Klonopin order renewal in the medical chart. On 9/20/18 at 10:11 AM, the surveyor interviewed the Director of Nursing who indicated that the PRN Klonopin should have been discontinued after 14 days and that the physician should have been notified to reevaluate the necessity for the continued use of the medication. 2. The surveyor reviewed Resident #74's Controlled Drug Administration Record (decline sheet) for Klonopin received 8/28/18. The Klonopin decline sheet revealed a 14-day autostop and the quantity of medication received was 14 tablets. The Klonopin decline sheet revealed that three doses were administered on 8/30/18, 8/31/18, and 9/8/18. The surveyor further reviewed the August/Sepetember (YEAR) MARs for Resident #74. The MARs revealed that there were no nursing signatures that indicated that the Klonopin medication that was administered on 8/30/18, 8/31/18, and 9/8/18. On 9/18/18 at 9:47 AM, the surveyor interviewed the UM who explained that during a controlled drug administration, the nurse signs the PRN section of the MAR and also signs the decline sheet after giving the medication to the resident. At that time, the UM confirmed that a Licensed Practical Nurse (LPN), who was unavailable for interview, did not sign for the Klonopin on the 8/30/18 and 8/31/18 PRN MAR and stated, She should have. The UM further indicated that an agency nurse, who was unavailable for interview, did not sign for the Klonopin on 9/8/18 PRN MAR and indicated the nurse should have. On 9/18/18 at 10:23 AM, the surveyor interviewed the ADON who confirmed that the nurses should have been signed the MAR to match the decline sheet on 8/30/18, 8/31/18, and 9/8/18. The surveyor reviewed the Medication Administration policy, revised on 6/19/17, provided by the DON. The policy indicated the nurses should administer medications and treatments ordered by the physician according to the administration times that will provide the maximum benefit to the resident. The surveyor reviewed the PRN [MEDICAL CONDITION] Medication Policy and Procedure, dated 5/01/18, provided by the ADON. The policy reflected, under the procedure section, that the facility should ensure that PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. The policy also revealed that the duration could be extended if the physician believes it was appropriate for the PRN order to be extended beyond 14 days and the physician documented their rationale in the resident's medical record. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to monitor and follow physician's orders for pacemaker functioning. This deficient practice was identified for 1 of 3 residents, Resident #17, reviewed with pacemaker devices and was evidenced by the following: Resident #17 was admitted to the facility following hospitalization for heart failure. During this hospitalization a cardiac consult was completed that confirmed the [DIAGNOSES REDACTED]. Resident #17's discharge instructions included arranging a follow-up visit within two weeks with the cardiologist. The follow up visit was completed on 1/10/17. The recommendations were for the resident to follow up with the primary physician. A review of the resident clinical record on 6/26/17 and 6/27/17 did not include documentation that Resident #17's pacemaker was checked between 1/10/17 and 6/27/17. Further review of the clinical record revealed a physician's order dated 4/25/17 to check the pacemaker on 4/25/17 and every three months thereafter. An interview with the Unit Manager (UM) on 6/26/17 at 12:30 p.m. revealed that Resident #17 was not scheduled for a pacemaker reading. The surveyor reviewed the clinical record with the UM on 6/27/17 at 9:00 a.m. At that time, the UM noted the order for the pacemaker reading to be done on 4/25/17 and every 3 months thereafter. The order was not carried out. A review of the South Wing's pacemaker reading log revealed that Resident #17 had not had any pacemaker reading since 1/10/17. The facility was made aware of the above concerns on 6/26/17 at 2:30 p.m. On 6/27/17 at 11:00 a.m. the Director of Nursing confirmed that the pacemaker check was not done. NJAC 8:39-27.1 (a)

Based on observation, interview and medical record review, it was determined that the facility failed to develop a plan of care based on individual assessment for a resident with wandering behaviors who ingested a foreign substance. The deficient practice was identified for 1 of 20 residents, Resident #9, reviewed for care plan and was evidenced by the following: On 6/20/17 at 11:00 a.m., during the initial tour of the facility in the presence of the Unit Manager (UM), the surveyor observed Resident #9 ambulating independently through the South unit hallway while carrying a wall clock. The UM explained that the resident had a behavior of wandering throughout the locked unit. Resident #9 was wearing two Wanderguards, one belonging to the facility and the other provided by the county sheriff's department prior to admission that contained a GPS. On 6/23/17 at 9:00 a.m. the surveyor reviewed the resident's medical record which revealed that Resident #9 had a [DIAGNOSES REDACTED]. The Nurse's Notes, dated 10/11/16 at 4:00 p.m., described the event as follows: Resident noted by CNA eating a small bar of soap. Nurse made aware and tried to take the soap out of the resident's mouth but unable because resident already chewed the soap and swallowed the residual. Resident seen by MD, contacted poison center, new order received to monitor resident. The surveyor then reviewed the resident's care plan which did address wandering, but made no mention of eating non-food items. On 6/23/17 at 1:40 p.m. the Director of Nursing (DON) told the surveyor that she agreed that the resident's care plan should have been updated to reflect the behavior of eating a non-food object. Refer to F-323 NJAC 8:39-11.2(e)2

Based on observation, interview and record review, it was determined that the facility failed to thoroughly investigate an incident involving a resident consuming a non-food item. This deficient practice was identified in 1 of 3 residents, Resident #9, reviewed for behavioral symptoms as evidenced by the following: On 6/20/17 at 11:00 a.m., during the initial tour of the facility in the presence of the Unit Manager (UM), the surveyor observed Resident #9 ambulating independently through the South unit hallway while carrying a wall clock. The UM explained that the resident had a behavior of wandering throughout the locked unit. Resident #9 was wearing two Wanderguards, one belonging to the facility and the other provided by the county sheriff's department prior to admission that contained a GPS. On 6/23/17 at 9:00 a.m. the surveyor reviewed the resident's medical record which revealed that Resident #9 had a [DIAGNOSES REDACTED]. The Nurse's Notes, dated 10/11/16 at 4:00 p.m., described the event as follows: Resident noted by CNA eating a small bar of soap. Nurse made aware and tried to take the soap out of the resident's mouth but unable because resident already chewed the soap and swallowed the residual. Resident seen by MD, contacted poison center, new order received to monitor resident. On 6/23/17 at 12:00 p.m. the UM told the surveyor that he thought that Resident #9 ate the soap in the Activity Room. He added, I'll ask the Activities Director if there was an in-service about it. Then the UM told the surveyor he would, look to see if there was an investigation. On 6/26/17 at 10:35 a.m. the DON informed the surveyor that there was no investigation found for the incident when Resident #9 ate a bar of soap. On 6/27/17 at 11:37 a.m. the Activities Director showed the surveyor the locked closet in the beauty parlor where her donated prizes, including small soap bars, were kept. She stated that the other staff members assumed the soap came from their department. He might have gotten it from another resident's room. He never did anything like that again. There should have been an investigation. Refer to F- 279 NJAC 8:39-27.1 (a)

Based on observation, interview and record review it was determined that the facility failed to identify the causal factor and ensure that preventive measures were in place/implemented to prevent a resident at a high fall risk from experiencing additional falls. This deficient practice was identified for Resident #1, 1 of 6 residents, reviewed for falls and accidents and was evidenced by the following: The surveyor toured the 100 unit on 7/18/16 at 7:30 p.m., with the Charge Nurse. The nurse informed the surveyor that the resident was awake, alert and could be interviewed. At that time the surveyor observed the resident in a low bed positioned against the wall. On 7/19/16 at 9:15 a.m., the surveyor observed the resident in bed, in a low position, with a tab alarm attached to the bed. The resident responded to the surveyor's greeting but could not carry a conversation. The surveyor reviewed the resident's record on 7/19/16 at 11:30 a.m. The Admission Face Sheet indicated that Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated respectively 8/19/15, 11/19/15 and 2/19/16 reflected that Resident #1 required two person physical assist for toilet use. An Occupational Therapy Evaluation dated 5/9/15 indicated that Resident #1 required maximum assistance with toilet use. There were no other Occupational Therapy Evaluation in the medical record. The resident's Care Plan, initiated 5/8/15 and last revised 3/6/16, confirmed that the resident was assessed after a fall on 6/26/15 and required two person physical assist with toilet use. The resident's Care Card, last revised 6/20/16, indicated that the resident was to have two person physical assist with toilet use. According to the General Incident Form dated 9/07/15, 9/20/15 and 3/6/16 Resident #1 was assessed by the facility to be a high fall risk. On 7/20/16 at 10:30 a.m., the surveyor reviewed the Investigative Reports and Nurse's Notes provided by the facility and noted the following: - 8/14/15 13:15 p.m. (1:15 p.m): Resident was lowered to the floor when his/her feet started to slide out while being toileted. According to the Nursing Assistant Statement Falls provided by the facility, these current interventions were in place: a. Chair and bed alarm b. Frequent used items and call bell within reach c. Two staff for toileting. - 9/20/15 at 4:45 p.m.: Resident was being toileted in the bathroom. During transfer from toilet to wheelchair his/her legs buckled, lost balance and he/she was lowered to the floor bumping the left chin on the toilet paper dispenser and sustained mild swelling. - A review of a Nurse's Notes dated 3/6/16 8:45 a.m.: Resident #1 was lowered to the floor by the CNA in the bathroom. When assessed by the nurse, Resident #1 complained of left groin pain. The physician was notified and a X-Ray was ordered to rule out fracture. A review of the Radiology Report dated 3/6/16 19:58 p.m. (7:58 p.m.), indicated that the resident suffered a fractured left hip and that the resident suffered from osteopenia (a weakening of the bones). An interview with the Certified Nursing Assistant (CNA#1) who cared for the resident on 7/20/16 at 10:10 a.m., stated that the resident required two person physical assist for transfer. Another staff member who was more familiar with the resident's routine, indicated that the resident can be combative and was very forgetful. An interview with the Unit Manager on 7/20/16 at 10:30 a.m., revealed that the plan of care for each resident was discussed daily with the assigned CNA. The assigned CNA also received an assignment sheet that outlined the mode of transfer required by the resident. The Unit Manager further stated that a Care Card was posted in the resident's closet. The Unit Manager did not comment on the lack of implementation of the care plan for two person assist. On 7/22/16 at 10:30 a.m., the Director of Nursing (DON) informed the team that she could not locate any other Occupational Therapy Evaluation to verify the level of assistance required for activities of daily living. That same day at 11:05 a.m., the facility gave the surveyor a handwritten note dated 9/22/15 that indicated that the resident could be a one or two person assist depending on the level of participation. According to the DON the staff member was no longer employed by the facility. The facility's Accident Incident Protocol, implemented 2012, was reviewed. According to Section 4.5, when conducting an investigation the Administrator, DON or Designee should: 4.5.1 Make every effort to ascertain the cause of the incident. 4.5.2 Initiate actions to prevent further incidents. The facility failed to follow their own protocol. The plan of care was for the resident to have two person physical assist with toilet use. The resident sustained [REDACTED]. NJAC 8:39-27.1(a)

Based on observation and review of facility documentation it was determined that the facility failed to implement infection control practices based on Centers for Disease Control (CDC) guidelines for 1 of 2 residents (Resident #9). This deficient practice was evidenced by the following: On 7/21/16 at 9:25 a.m., the surveyor observed the Registered Nurse (RN) perform a wound treatment on Resident #9. On two seperate occasions, while the RN was gathering supplies, a wound treatment supply dropped onto the floor. The RN picked up the object with her bare hands, touched the lid of the garbage can to open it, and threw away the object. On both occasions, the RN continued to gather supplies without washing her hands. A review of the CDC Guidelines under When to Perform Hand Hygiene included: Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed); After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. On 7/21/16 at 9:55 a.m., the surveyor observed the RN washing her hands with soap under running water. A review of the CDC Guidelines on Techniques for Washing Hands with Soap and Water include but are not limited to; TheCDC Guideline for Hand Hygiene in Healthcare Settings recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds (not under running water), covering all surfaces of the hands and fingers. A review of the facility's Impaired Skin Integrity Policy did not state how hand hygiene should be performed. NJAC 8:39-19.4 (a)(1)

C# NJ & NJ CROSS REFERENCE TO F 323 Based on interview and record review, it was determined that the facility failed to accurately assess and develop a plan of care for 2 of 4 sampled residents (Resident # 1 and # 2) who had a history of [REDACTED]. Refer to F 323 Examples 1 and 2. NJAC 8:39- 11.1

C# NJ & NJ Based on interview and review of pertinent facility documentation, it was determined that the facility failed to provide adequate supervision, assess for, and implement safety interventions for 2 of 3 sampled residents with a history of falls (Resident # 1 and # 2). Subsequently both residents sustained un-witnessed falls in their rooms, resulting in hospitalization and pain management for fractured hip. This deficient practice is evidenced by the following: 1. Resident # 1 was admitted to the facility in January 2012 at 3 PM, with [DIAGNOSES REDACTED]. According to the Nurse's Notes (NN) on 1/16/12 at 4 PM, Resident # 1 was awake with periods of forgetfulness and required assistance from staff to complete activities of daily living (ADL's). A review of the resident's Admission Nursing Evaluation (ANE), dated 1/16/12 at 3 PM, indicated that Resident #1 had a history of [REDACTED]. Also, the Side Rail assessment dated [DATE], documented a history of falls in the last six months. The medical record lacked any documentation that a fall risk assessment and/or interventions to prevent falls was completed at the time of admission at 3 PM. On 1/17/12, the Department of Health and Senior Services received a Reportable Event Record/Report from the facility. The report revealed that on 1/16/12 at 10:45 PM, Resident #1 was found on the floor and complained of pain to the right leg. The right leg was also externally rotated and the resident was sent to the ER (emergency room ) and admitted with a fractured hip. The report also indicated that the resident was a fall risk related to dementia and had a past history of falls at home. A review of the NN dated 1/16/12 at 10:45 PM, revealed that the resident was found sitting on the floor and had attempted to toilet herself without assistance. The NN indicated that the resident was assisted up to the toilet and then transferred to a wheel chair and back to bed. At 11:30 PM, the resident complained of right groin pain. The Registered Professional Nurse (RN) pulled back the covers and noted that the right leg was externally rotated. The RN called the nursing supervisor to assess the resident. During an interview with the surveyor on 1/24/12 at 10:20 AM, the Director of Nursing (DON) confirmed that Resident #1 had a history of [REDACTED]. The DON also acknowledged that the RN failed to assess the resident prior to moving her off the floor and back to bed. The DON went on to say that Resident # 1 was admitted to the hospital with [REDACTED]. A review of Resident #1's medical record by the surveyor on 1/24/12, revealed that no nursing assessment was documented at the time of the fall and prior to lifting the resident off the floor. Review of the documentation on the facility General Incident Form, the action taken concurred with the 10:45 PM NN that the "Resident was assisted up from the floor and toileted per his/her request. Transferred back to bed via w/c (wheelchair). Upon complete assessment resident(s) right leg was noted to be externally rotated and verbalized c/o (complaint) (of) right groin pain...." Review of the personnel file for the RN involved revealed that the RN was terminated on 1/18/12, for failure to complete a fall risk assessment until after the resident fell . The RN did not initiate a care plan with fall precautions and interventions, such as an alarm, and failed to assess the resident after the fall, for range of motion before moving her off the floor, toileting, and into the wheel chair. According to the Hospital emergency room (ER) record, Resident #1 arrived at the hospital at 12:54 AM after a fall and hip injury. At the time of the nursing assessment the resident complained of pain on a pain scale of 7 out of 10, 0 of 10 being the pain goal. The resident received 1 milligram of Morphine Sulphate injection via intravenous (IV) push for pain at 2:08 AM. At 3:08 AM a CT Scan of both hips was done, the result was a right subcapital femoral neck fracture of the right hip. 2. Resident # 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].# 2 was alert with unsteady gait and had a fall risk score of 70 (51 or above is high risk for falls). According to the ANE dated 10/17/11 at 5:30 PM, Resident # 2 had a history of [REDACTED]. And a review of the New Jersey Universal Transfer Form dated 10/23/11 at 3 PM, indicated that the resident was transferred to the hospital with [DIAGNOSES REDACTED]. Resident #2 was readmitted to the facility on [DATE], with an unsteady gait and identified as a "fall risk". According to the ANE dated 10/27/11 at 1 PM, Resident # 2 had a history of [REDACTED]. A review of Resident# 2's Interim Care Plan dated 10/27/11, identified as a Goal to be free of injury related to falls. Interventions included call bell within reach and provide side rails for mobility. Subsequent safety measures were not documented until 11/4/11, after the resident fell and went to the hospital with a fractured hip. However, Resident #2 did not return to the facility. A review of the Plan of treatment for [REDACTED].#2 required extensive assistance with ADL's and supervision for ambulation inside his room. On 11/4/11 at 12:30 AM, nursing documented in the NN that Resident #2 was found on the floor near the bathroom. He had a laceration above his left eye and complained about not being able to bear weight. The physician was notified and ordered the resident to be sent to the ER in the morning. Nursing documented further that Resident #2 requested to use the bathroom, walked a few steps limping with staff assistance and verbalized pain to his left hip. The resident was assisted to bed, range of motion done to all extremities with tolerance except for a discomfort to the left hip. Resident #2 refused any medication at that time for pain. Review of the facility General Incident Form indicated that Licensed Practical Nurse (LPN) heard a large bang coming from the room of Resident #2. The LPN found Resident #2 on the floor in the bathroom doorway. Actions Taken included that the resident was helped back to the w/c with 2 person assistance and then put back to bed. There was no indication or documentation that this resident was assessed prior to being moved after the fall. At 5:20 AM, nursing documented that Resident #2 stated he was still in pain and why is he still waiting to go to the hospital. The ambulance was called and he was transported to the ER. At 3:35 PM Resident #2 was admitted to the hospital with [REDACTED]. Review of the hospital ER RN Triage record dated 11/4/11 indicated that Resident #2 was sent from the facility for evaluation of a fall while walking. A laceration over the left eye was noted and the resident complained of left hip pain. Additionally the MD (Medical Doctor) Chart showed that the resident's laceration was closed with 6 sutures. The results of an X-Ray of this resident's pelvis showed a left subcapital hip fracture. During an interview with the surveyor on 1/24/12 at 10 AM, the Unit Manager (UM) said that because he was alert and oriented they did not put an alarm on Resident #2. After we discussed the facility policy on falls, the UM agreed that with his history of falls, the facility should have placed an alarm on the resident. In an interview with the surveyor on 1/24/12 at 1 PM, another staff RN said that if a resident falls, they are not to be moved until assessed by a nurse. In addition, she said that any resident with a history of falls on admission is placed with an alarm right away and that an alarm is a nursing intervention. A review of the facility policy titled "Falls Prevention Program" indicated that "upon admission, all new residents will have a fall risk assessment completed and will be put on a program" and also indicated that if the fall risk assessment designates that a resident has a history of falls, an alarm will be placed on the resident. The policy also indicated that any resident who is readmitted from the hospital will be evaluated by the charge nurse/unit manager for placement on the list of residents at high risk for falls. NJAC 8:39-27.1(a)

C# NJ & NJ Based on interview and review of medical records and pertinent facility documents, it was determined that the facility failed to ensure implementation of facility policies concerning assessment and falls prevention for 2 of 3 sampled residents, (Resident # 1 and # 2). This deficient practice is evidenced by the following: Refer to F 323 Example 1 and 2. NJAC: 8:39- 27.1 (a)(b)