Every finding on record at Meadowview Nursing and Rehabilitation Center

Complaint #: NJ186394 Based on interviews, review of the medical records, and other facility documentation, it was determined that the facility failed to ensure staff provided safe transfers with a two person assist from chair to bed when on 05/08/2025, a Certified Nursing Aide (CNA #1) transferred a resident (Resident #1) with a Hoyer lift (mechanical lift used to transfer) with no additional staff, and the resident complained of pain with noted bruising to the inner thigh and a swollen knee, that an x-ray identified that the resident sustained a fracture of the distal femoral shaft (thigh bone). This deficient practice was identified for 1 of 3 residents reviewed for accidents and hazards (Resident #1), and was evidenced by the following: A review of an incident report for Bruise dated 05/09/2025 at 5:30 AM, revealed that around 5:30 AM, the assigned CNA reported to this supervisor that she found bruises on the resident's right leg. Upon assessment, the resident was seen with a bruise measuring nine centimeters by four centimeters (9 cm x 4 cm) on the back of their right lower leg, and an additional bruise on their right inner thigh measuring 7 cm x 4.5 cm. The resident was also noted with swelling and pain to their right knee. The report also included on 5/10/25, that staff spoke to the hospital and the resident was admitted with a fracture of the right femur .Documented on 5/18/25, that on 5/15/25, the resident still remained in the hospital and after multiple questioning sessions, CNA #1 admitted to not having assistance with the Hoyer lift transfer when transferring the resident from the geriatric (geri) chair (specialized chair for people with limited range of motion) to bed on 05/08/2025, which was against facility policy. On 05/22/2025 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) about Resident #1's incident report. The LNHA stated that the facility could not prove that CNA #1 broke Resident #1's leg, but CNA #1 did not follow the facility's policy and procedure. According to the LNHA, CNA #1 was dishonest during the investigation, and CNA #1 stated they had another aide (CNA #2) assist her with the use of Hoyer lift which CNA #2 denied. According to the admission Record face sheet (an admission summary), Resident #1 was admitted to the facility with diagnoses which included but were not limited to; contracture of muscle, bipolar disorder, dementia and pseudobulbar affect (a neurological condition characterized by uncontrollable episodes of laughing or crying). According to the Minimum Data Set (MDS), an assessment tool dated 02/25/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident's cognition was severely impaired. The MDS also indicated that Resident #1 required total care with all activities of daily living (ADLs) and was dependent with locomotion on and off the unit. A review of Resident #1's individualized comprehensive care plan (ICCP) included a focus area dated 06/24/2019, and revised on 05/11/2025, that the resident cannot do things by themselves anymore. The goals included that the resident would continue with physical therapy through the next review date. Interventions included: to transfer with the use of Hoyer lift only with two staff assistance for transfer and nursing restorative for passive range of motion to cervical/neck and bilateral lower extremities (BLE). On 06/05/2025 at 10:10 AM, the surveyor interviewed the Director of Nursing (DON) and the LNHA, who stated that on 05/08/2025 at 8:20 PM, the CNA #1 stated that they observed swelling to the resident's right knee while transferring Resident #1 from the geri chair to bed with the use of a Hoyer lift and Resident #1 had pain. CNA #1 further stated that Resident #1 verbalized and expressed pain by moaning during the transfer and they notified the License Practical Nurse (LPN #1), who assessed Resident #1, and medicated Resident #1 with Tylenol 325 milligrams for pain. The DON continued that LPN #1 notified the supervisor who did a change in condition and notified the physician (via a non-emergency fax was sent to physician). At 10:50 PM, the physician did not return the call. According to the LNHA, the facility's policy was if the physician did not respond, the staff should call a second time, and if no response, the Medical Director should be called. At that time, the DON and LNHA stated that on 05/09/2025 at 5:30 AM, CNA #2 reported to the supervisor that Resident #1's right knee had swelling, was painful to touch, and ecchymosis (bruise with skin discoloration). A review of the Progress Notes included a Plan of Care Note dated 05/09/2025 at 5:54 AM, authored by the Registered Nurse (RN) Supervisor, that they assessed the resident and found bruises on the back of their lower right leg that measured 9 cm x 4 cm, and another bruise on their right inner thigh that measured 7 cm x 4.5 cm. The RN Supervisor documented that at 5:50 AM, LPN #2 provided the resident Tylenol with relief. The RN Supervisor called the family and physician with no response and a message was left. A review of the Progress Notes included a Health Status Note dated 05/09/2025 at 8:29 AM, that LPN #3 documented Resident #1's right lower extremity was bent with their knee swollen and noted bruises. The physician was notified, and a stat (immediate) order was obtained for an x-ray. A review of the Radiology Result Report dated 05/09/2025 at 2:21 PM, indicated: Fracture of the distal femoral shaft with malalignment (a break in the lower part of the thigh bone). On 05/06/2025 at 12:11 PM, the surveyor interviewed CNA #2, who stated she received the report from CNA #1 that Resident #1's knee was swollen (unable to recall which knee) and to monitor the resident. CNA #2 further stated she went into the resident's room and observed swelling to their knee (unable to recall which knee) and left the room to finish her rounds. CNA #2 further stated that at 3:00 AM, she observed the resident sleeping and then at 5:30 AM, she went in the resident's room for incontinent rounds, and she observed bruising to the inner thigh (unable to recall which leg) that was painful to touch. CNA #2 stated the supervisor was made aware. The surveyor asked CNA #2 what the facility's policy for Hoyer lift transfers was, and CNA #2 stated a Hoyer lift was used to minimize the risk for a fall or injury to a resident. CNA #2 stated a Hoyer lift was used with two people, either nurses or aides, and one person guided, and the other person steered the Hoyer lift. On 05/06/2025 at 1:31 PM, the surveyor interviewed LPN #3, who stated they received a report from CNA #2 at approximately 6:50 AM, that [Resident #1's] leg was broken. LPN #3 stated she observed the back of Resident #1's right knee was swollen with bruising on their right inner thigh and discoloration. LPN #3 stated she notified the physician for a stat x-ray that was done at 1:16 PM, with the results were read at 2:27 PM, and the resident was sent to the hospital at 2:42 PM. On 05/06/2025 at 1:42 PM, the surveyor called the following facility staff to conduct interviews: the RN Supervisor, CNA #1, LPN #1, and the physician. The surveyor received no response or call back. On 06/05/2025 at 2:00 PM, the surveyor conducted a telephone interview with LPN #2, who stated she received a report from LPN #1 that Resident #1's right knee was swollen and the supervisor was aware. LPN #2 stated at 5:30 AM on 05/09/2025, CNA #2 informed the supervisor of resident's right leg bruising. On 06/05/2025 at 3:30 PM, the surveyor interviewed the Unit Manager (UM), who stated on 05/09/2025 at 6:50 AM, she received a report from the supervisor that Resident #1 had a bruise on their right leg and was observed with a swollen right knee, bruise to their inner thigh, the physician was notified by LPN #3, and an x-ray was ordered. The resident was transferred to the hospital after the results were read. On 06/05/2025 at 4:00 PM, the surveyor interviewed the LNHA, who stated the investigation regarding the incident revealed CNA #1 provided multiple names of staff that assisted her with the Hoyer lift transfer. The LNHA stated it was discovered during ongoing investigation that CNA #1 admitted to transferring Resident #1 with the Hoyer lift by herself. A review of the facility investigation statements on 05/15/2025 at 11:49 AM, revealed that the DON documented a second phone interview with CNA #1 in the presence of the LNHA was conducted. The DON asked CNA #1 if they used the Hoyer lift by herself to transfer Resident #1 to bed, and CNA #1 confirmed yes, I put [the resident] in bed by myself. The DON documented that she informed CNA #1, this is important information because in your last statement you did not mention that you transferred [the resident] by yourself with the Hoyer lift. And this is against our policy. You know there must be 2 people to operate the Hoyer lift. A review of the facility's policy titled Change in a Resident's Condition or Status. Under: Procedure revealed: The nurse will notify the resident's Attending Physician On-call when there has been a (an): discovery of injuries of an unknown source. 2. Notify the resident's Attending Physician or Physician On-Call to report Changes in a Resident's Condition (CIC). A. If no response from Physician after 20 minutes, a second attempt will be made by nursing; B. The Supervisor of Nursing is to be contacted if there is lack of response from Physician; and C. If no response received from the Attending Physician, the Supervisor of Nursing will notify the Medical Director regarding Changes in a Resident's Condition (CIC) and lack of response from resident's Attending Physician . A review of the facility's Lift (Hoyer, Mechanical Lifter) policy included under policy: It is the policy of the facility that two (2) persons must be used for a lifting, preparation, including transferring to and from one surface to another . NJAC 8:39-27.1 (a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following: On 02/24/2025 from 09:43 to 10:09 AM, the surveyor, accompanied by the Food Service Manager (FSM), observed the following in the kitchen: 1. On the wall next to the solo standup solo freezer, a wall mounted knife container contained two knives with wooden handles. The wooden handles of the knives were exposed to the surveyor. They appeared to be old and had fine cracks in the handles on visual inspection, which would allow bacteria to remain in the wooden handles.When interviewed the FSM stated, Ok. I know that. The FSM removed the wooden knives from the wall monted knife container/holder. 2. The high temperature dish machine was observed to be in use and actively washing dishware on 02/24/2025 at 10:01 AM. The surveyor asked the FSM to provide the surveyor the dish machine temperature log for observation. Review of the [facility name] Temperature Log revealed the following: No temperature was recorded for the breakfast meal on 2/24/2025 and the dish machine was observed to be in active operation at 02/24/25 10:03 AM. According to the FSM, staff should document the temperatures of the dish machine prior to dishwashing to ensure the machine is operating at the correct minimum wash and rinse temperatures to ensure proper cleaning and sanitizing of dishware. Further review of the dish machine temperature log revealed the following: No breakfast temperatures were recorded on the following dates for February 2025: 2/3/2025, 2/12/2025, 2/13/2025, 2/15/2025, 2/17/2025, 2/20/2025. The facility failed to record dish machine temperatures at lunch on the following dates: 2/6/2025, 2/7/2025, 2/9/2025, 2/10/2025, 2/11/2025, 2/12/2025, 2/13/2025, 2/14/2025, 2/16/2025, 2/19/2025, 2/10/2025, 2/21/2025. The facility failed to record dish machine temperatures for dinner in February 2025 on the following dates: 2/1/2025, 2/2/2025, 2/3/2025, 2/4/2025, 2/6/2025, 2/7/2025, 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025, 2/20/2025, 2/21/2025, 2/22/2025, and 2/23/2025. On 02/28/2025 from 09:03 to 09:17 AM, the surveyor, accompanied by the FSM, made the following observation in the dry storage room: 1. On an upper rack of a multi-tiered/rack canned good storage cart, a can of unsweetened applesauce had a significant dent on the bottom seam of the can. The FSM agreed and removed the can from the storage rack and to the designated dented can area. The surveyor reviewed the facility provided policy titled Dish Machine Cleaning, revised 1/21/2023. The following was revealed under the section PROCEDURE: Daily - Prior to loading the dish machine. 2. The wash temperature is to be at 160 or above and the rinse temperature is to be at 180 or above. 3. Document the date, and meal period, the wash and rinse temperatures and initials in the dish machine logbook. The surveyor reviewed the facility provided policy with the subject Food Storage, Policy Number: 5010. The following was revealed under PROCEDURE: 13. Storage areas are monitored by supervisory staff. Leaking, bulging or severely damaged cans or jars with leaky lids and other items identified as damaged or unusable are isolated and disposed of according to unit policy. N.J.A.C. 18:39-17.2(g)

Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 1 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #92). This deficient practice was evidenced by the following: On 02/27/2025 at 8:38 AM, the surveyor reviewed the SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #92 as follows: A review of the SNFBPNR for Resident #92 indicated a Medicare Part A start date of 11/27/2024 and last covered day was 01/10/2025 and Resident #92 remained in the facility. A further review of the SNFBPNR revealed under 1. Was a SNFABN, Form CMS-10055 provided to the resident? No was checked. If no explain why the form was not provided: was handwritten stayed in the facility. Under 2. Was a Notice of Medicare Non-Coverage (NOMNC) (CMS 10123) provided to the resident? There was nothing marked to indicate whether the resident received the NOMNC or not. During an interview with the surveyor on 02/27/2025 at 9:23 AM, Social Worker (SW #1), was questioned regarding Resident #92, who stayed in the facility after the provider initiated the discharge from Medicare Part A services without receiving the SNFABN and NOMNC. SW #1 said that Resident #92 did not these forms after staying in the facility following discharge from Medicare Part A services because she was unaware that these forms needed to be provided to Resident #92. During an interview with the surveyor on 02/27/2025 at 9:49 AM, the Director of Social Work (DSW) was questioned about Resident #92, who remained in the facility after the provider initiated the discharge from Medicare Part A services without receiving the SNFABN and NOMNC. DSW said that she recalls having a conversation with Resident #92 and their family regarding these forms, but she was unsure why they were not provided. NJAC 8:38-4.1(a)(7)

Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to develop and implement an individualized comprehensive care plan for a resident on antidepressant medication (medication used to treat clinical depression). This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #12) and was evidenced by the following: On 02/24/2025 at 10:16 AM, during the initial tour, Resident #12 was identified as being on antidepressant medication. A review of Resident #12's Electronic Medical Record (EMR) on 2/24/2025 at 2:01 PM, revealed the following: A review of the Admission Record reflected the resident had diagnoses that included history of falling and depression. A review of the most recent comprehensive Minimum Data Set, an assessment tool dated 1/7/2025, revealed that the resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. A further review of the MDS reflected use of antidepressant for Depression. A review of the Order Summary Report (OSR) with active orders dated 2/28/2025, revealed the following: Zoloft Tablet 50 milligrams; Give 2 tablets by mouth one time a day for Depression. A review of Resident #12's care plan did not include documentation that Resident #12 was on antidepressant medication. During an interview with the surveyor on 02/28/2025 at 08:30 AM, the Registered Nurse/ Unit Manager (RN/UM #2) stated that psychotropics (medications that affect the mind used to treat conditions such as depression) should have a care plan because of potential side effects. During an interview with the surveyor on 02/28/2025 at 09:11 AM, the Assistant Director of Nursing (ADON) stated that psychotropic medications needed to have a care plan. A review of the facility policy titled Psychotropic Policy (Behavior Management) with a reviewed date of 2/28/2025 revealed under Procedure #6: The goals of psychotropic medication . will be addressed in the resident's care plan. The care plan will also include the type of psychotropic drug(s) to be monitored for side effects daily, such as gait disorders, movement disorders, cognitive or behavior changes, discomfort (pain, constipation .), signs of hypotension . NJAC 8:39-11.2(e)

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to update a resident care plan, specifically for newly identified wounds, for 1 of 30 residents reviewed for comprehensive person-centered care plans, (Resident #63). This deficient practice was evidenced by the following: During the initial tour of the facility on 02/24/2025 at 11:00 AM, Resident #63 was observed lying in bed with air mattress in place on the bed and bilateral heel booties in place. A review of the EMR on 02/24/2025 at 11:37 AM, revealed the following: According to the Admission Record, Resident #63 was admitted to the facility with diagnoses including but not limited to: Palliative Care, Alzheimer's disease, and pressure ulcer left buttock stage 4. A review of the Quarterly Minimum Data Set, an assessment tool, dated 02/22/2025 revealed under section M Resident #63 had the following wounds; 1 stage 2, 1 stage 4 and 4 unstageable (Unstageable pressure ulcers are wounds that the bottom of the sore is covered by: slough, which is debris that appears tan, yellow, green, or brown in color or eschar that can be hard plaque that's tan, brown, or black in color) wounds. A review of the physician orders indicated active treatments to all identified wounds. According to the facility weekly wound observation tools completed by facility nursing staff revealed the resident had the following wounds: 1. previously identified pressure stage IV (4) left gluteus (commonly known as the buttocks) improving. 100% granulation (pink soft granular appearance on healing wound) tissue 2. on 01/17/2025 sacrum stage 2 and bilateral buttocks unstageable 40% slough; 60% granulation improving 3. on 02/08/2025 left ischium stage 2 100% granulation 4. on 02/15/2025 left lateral buttocks pressure unstageable improving 100% slough. A review of the current care plan showed a Focus area of; I have actual impairment to skin integrity of the left hip to gluteus related to poor circulation with initiated date of 09/20/2024. There was no care plan for the wounds on the sacrum, and bilateral buttocks, left ischium or the left lateral buttocks. During an interview with the surveyor on 02/28/2025 at 09:01 AM, Registered Nurse/Unit Manager (RN/UM#2) was asked who is responsible for doing care plans. RN/UM #2 responded we (nurses) initiate base line care plan upon admission and have 72 hours to complete. Since the person (residents) is here any one can adjust the care plan as needed. RN/UM #2 went on to say I am responsible to ensure the care plan is complete and accurate. All nurses can adjust the care plan. All disciplines are responsible to complete and update care plans. When asked what her expectations are of what would be on the care plan. RN/UM #2 replied ADL's (Activities of Daily Living), wounds, falls risk, infection, oxygen, anticoagulants, seizure, incontinence, and Foley. And whatever the system triggered based on resident needs and concerns. RN/UM #2 confirmed If there was a newly identified wound, the care plan should be updated to reflect new wounds and it should be myself, I should be capturing this. On 02/28/2025 at 01:23 PM, the surveyor requested a Comprehensive Care plan policy. The facility provided a Comprehensive Assessments and Care delivery Process policy that does not address when a care plan is to be revised and what should be included on the comprehensive care plan. During an interview with the surveyor on 02/28/2025 at 02:02 PM, the Assistant Director of Nursing (ADON) was asked what the expectations is for when a care plan needs to be revised/updated. The ADON replied absolutely a care plan should have updated at the time wounds were identified. The Nurse would have been responsible to update the care plan. When asked why is that important the ADON said So staff know the resident has a wound(s) and to follow the plan of care. NJAC 8:39-27.1(a)

Based on observation, interview, and review of the Electronic Medical Record (EMR), and review of other facility documents it was determined that the facility 1.) failed to perform a reweigh for a resident with greater than 5% weight loss in 30 day period for 1 of 3 residents investigated for nutrition (Resident #50) and 2.) failed to follow an order for wound vac dressing change for 1 (Resident #351) of 1 resident investigated for skin conditions. This deficient practice 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 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 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. 1. On 02/24/2025 at 11:01 AM, during the initial tour of the facility, Surveyor #1 observed Resident #50 lying in bed awake and alert, non-verbal. The Tube feeding was in progress providing Jevity1.5 (an enteral feeding providing 1.5 kilocalories per milliliter) at 50ml/hr (milliliters per hour). Resident #50 appeared well-nourished on visual observation. According to the Admission Record, Resident #50 was admitted to the facility with the following but not limited to diagnoses: Diffuse traumatic brain injury, cerebral infarction, seizures, and bed confinement status. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/21/2024, revealed that Resident #50 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated that Resident #50 is rarely/never understood. Section K of the MDS revealed that Resident #50 had no significant weight loss or gain over the past 30 or 180 days and received 51% or more of total calories and 501cc/day (cubic centimeters or more) of average fluid intake via feeding tube. A review of the Order Summary Report with active orders as of 02/28/2025 revealed Resident #50 had the following physician orders: Nothing by mouth diet. Water flush G-Tube (feeding tube) with 125 ml of water every 6 hours for hydration. Jevity 1.5 Cal (calorie) liquid (Nutritional Supplements) Give 50ml/hr via G-tube every day shift for Nutrition. 7-3 nurse will turn off machine when Total Volume achieved of 1000 ml and record amount achieved. A review of Resident #50's comprehensive care plan revealed a care plan Focus: I have the potential for NUTRITIONAL deficits r/t (related to) my need/dependence for artificial nutrition through feeding tube to meet my nutrition and hydration needs, being under hospice/comfort care I am NPO (nothing by mouth) - I rely on a tube feed to meet my nutrition needs. A review of the Interventions/Tasks section of Resident #50's comprehensive care plan did not include monitoring of weights. On 02/24/2025 at 12:21 PM Surveyor #1 reviewed Resident #50's weights via the EMR. On 02/01/2025, Resident #50 had a monthly weight of 139.6 pounds. Resident #50 had a weight of 148.4 pounds on 01/05/2025. Resident #50 had an 8.8 pound weight decline over a 30 day period, which was significant at - 5.93% over a 30 day period. On 02/25/2025 at 12:39 PM, Surveyor #1 reviewed the 12/27/2024 Interdisciplinary Care Conference Meeting via the EMR (electronic medical record). The following entry was observed under Section C Dietitian Summary: NPO, receives TF (tube feed) for nutrition support. BMI (body mass index/used to categorize whether a person is underweight, normal weight, overweight, or obese depending on what range the value falls between) is in healthy range. Likely meeting > (greater than)75% of est (estimated) nutrition needs with TF regimen. Continue w/current TF + flushes as ordered. Continue to monitor TF tolerance, hydration, weights, skin, meds, labs. Continue POC (plan of care) and follow up/reassess PRN (as needed). On 02/27/2025 at 01:22 PM, Surveyor #1 again reviewed the EMR under the weights/vitals tab section. There was still no reweigh performed. revealed that Resident #50 still did not have a re-weight conducted after an acute 8.8# weight decline over the past 30 days, as indicated by Resident #50's weight obtained on 2/1/2025. On 02/28/2025 at 08:38 AM, the surveyor reviewed the EMR for Resident #50. The EMR revealed that Resident #50 had not had a reweight performed as of 2/28/2025 for a weight decline of greater than 5 pounds in a 30 day period. This was a period of 27 days since the monthly weight was obtained on 02/02/2025. During an interview with Surveyor #1 on 02/28/2025 at 10:50 AM, the Registered Nurse/Unit Manager (RN/UM #3), was asked what the facility practice was concerning monthly weights and acute/significant weight changes. RN/UM #3 said that weights are done by CNA's (Certified Nursing Assistants) at the beginning of the month unless they are on weekly weights. Once the weights are recorded, they are entered into the EMR. RN/UM #3 further explained that a weight obtained that was five pounds less or more than the previous weight on record would require the nurse to reach out to the doctor and let him/her know right away. RN/UM #3 further explained that we try to get the weight first thing in the morning. Surveyor #1 asked if Resident #50 should have been reweighed due to the 8.8 pound weight decline that occurred between 02/01/2025 and 01/05/2025. RN/UM #3 replied I don't want to give you the wrong answer concerning Resident #50's re-weight. I would have to speak to the DON (Director of Nursing) to get the answer. On 02/28/2025 at 11:01 AM the surveyors met with facility administration. The surveyor asked the facility DON if Resident #50 should have been reweighed according to their facility weight policy. The DON told the surveyor, Yes, Resident #50 should have had a re-weight conducted for an 8.8# weight decline. A review of a facility policy titled [facility name] with the subject: Weights / Re-Weights, revised 6/29/21, revealed the following under Policy: Thereafter all residents are to be weighed monthly and reweighed if a loss or gain of 5 pounds is noted (or 3 pounds if resident weighs </= 100 pounds). In addition, the policy further revealed at Procedure/Responsibilities/Action at 2. The unit manager compares the monthly weights to the previous month's weights and requests re-weights for any weight discrepancies over or under 5 pounds (or 3 pounds if resident is 100 pounds or less). 51337 2. On 2/25/2025 at 8:39 AM, Resident #351 showed Surveyor #2 their wound dressing on the abdomen connected to the Wound VAC (Vacuum Assisted Closure a wound care treatment that uses negative pressure to promote wound healing). Resident #351 stated that it was not changed the previous day as scheduled. The surveyor observed the undated green dressing located in the resident's mid-abdomen stained with brownish material from the suction area downwards. On 2/25/2025 at 8:57 AM, a review of the EMR revealed the following: A review of the Admission Record reflected the resident had diagnoses that included surgical aftercare following surgery on the digestive system (the body's system that ingests, breaks down and absorbs food, and eliminates waste) and anemia (not having enough hemoglobin to carry oxygen to the body's tissues). A review of the most recent comprehensive MDS dated [DATE], reflected a BIMS score of 12 out of 15, which indicated an intact cognition. A further review of the MDS reflected the resident received surgical wound care. A review of the Clinical Physician Orders included a physician's order (PO) initiated on 2/7/2025 and reordered on 2/24/2025 for the following: Wound vac set at 125 mm/hg every shift for wound healing; Change dressing every Monday, Wednesday, Friday for wound healing .mid abdomen wound vac set at 125 mm/hg; Clean site with normal saline solution, pat dry, apply wound vac dressing. A review of the corresponding February 2025 Treatment Administration Record (TAR) revealed the resident's wound vac dressing was changed on 2/24/2025 by the registered nurse on duty. However, the registered nurse's skilled charting notes reflected the wound vac in place on the abdominal midline area and that dressing change was not required. There was no documentation in the EMR why the dressing change was not required. During an interview with Surveyor #2 on 2/26/2025 at 12:30 PM, RN/UM #2 stated that wound treatments had to be dated and labeled with the nurses' initials. RN/UM #2 further stated that if a dressing was not changed, then the nurse had to write #9 in the TAR which would be linked to a progress note where the nurse had to write the reason why a dressing was not changed. The RN/UM #2 acknowledged that the registered nurse on duty should not have checked the TAR as that meant that the wound dressing was changed. During an interview with Surveyor #2 on 2/28/2025 at 9:11 AM, the Assistant Director of Nursing (ADON) stated that wound treatments should be followed as ordered and that the nurses needed to sign and date the wound dressing as well as sign the TAR. The ADON further stated that if the nurses are not able to do the treatment, they need to call the doctors and put in a progress note. A review of the facility provided policy titled Medication and Treatment Orders dated 10/15/2019 did not include the process for documenting and completing physician's order for wound treatments. NJAC 8:39- 27.1(a)

Based on observation, interview and review of the electronic medical record (EMR), and review of other facility documentation, it was determined that the facility failed to consistently apply a hand splint as recommended by therapy. This deficient practice was identified for 1 of 1 resident reviewed for range of motion (Resident #1), and was evidenced by the following: During the initial tour on 02/24/2025 at 11:53 AM, the surveyor observed Resident #1 awake, non-verbal, lying in bed, with his/her right hand clenched in a fist position and pulled up toward the chest. There was no splint or hand roll in place at that time. The resident was cognitively impaired and was unable to provide health history or answer questions. On 2/25/25 at 1:23 PM, surveyor observed Resident #1 with no splint on right hand. On 2/26/25 at 9:29 AM, surveyor observed Resident #1 with no splint on right hand. A review of the Electronic Medical Record (EMR) on 02/24/2025, revealed the following: Resident #1 had a medical diagnoses that included but were not limited to: Intercranial Injury with paralytic syndromes, contracture of muscle, and encounter for fitting and adjustment of other specified devices. A review of the resident's most recent individual comprehensive care plan (ICCP) dated 12/18/24, revealed the following focus area: The resident has an ADL (Activity of Daily Living) self-care performance deficit related to limited ROM (Range of Motion), musculoskeletal impairment, hemiplegia (paralysis of one side of the body), activity intolerance, limited mobility, impaired balance and cognitive deficits. Goals included, The resident will maintain current level of function in all ADLs through the review date. Under Interventions included but were not limited to: Contracture Management: I wear a right-hand splint from 8am to 8pm. Make sure my skin is clean and dry with no skin issues. If anything is noticed, report to nurse right away. A review of the Occupational Progress Note/Discharge Summary dated 03/10/2020, revealed that Resident #1 was discharged from therapy on 03/9/2020. The Assessment Goals indicated that Resident #1 is on a Maintenance Program with staff for PROM (Passive Range of Motion) for RUE (Right Upper Extremity) and hand as tolerated during self-care. The Plan included, Patient discharged from therapy at this time. Resident sitting safely in a high back wheelchair with calf supports. Resident wearing Right Resting Hand Splint on 8 am and off 8 pm as tolerated with skin check during self-care. An Occupational Therapy Daily Note dated 06/17/2021 revealed, Patient provided with new WHFO (a wrist, hand, and finger orthosis medical device that supports and protects the wrist, hand and fingers) by orthotist on 06/16/2021. Follow up this day: Splint correctly donned. Patient with good wear tolerance and reports comfortable. During an interview with the surveyor, License Practical Nurse (LPN #3) when asked if Resident #1 used any adaptive equipment, LPN #3 stated she had to check. LPN #3 checked the EMR and identified under Task that Resident #1 wore a hand splint. LPN #3 was unable to provide any additional information at that time. On 02/26/2025 at 9:45 AM, during an interview with the surveyor, Registered Nurse/ Unit Manager (RN/UM#1), after reviewing the EMR, stated that Residents #1's Care Plan indicated that a right-hand splint was in use for contracture management. RN/UM #1 added that it is the responsibility of the Certified Nursing Assistant (CNA) to place and take off the hand splint. When the surveyor asked where the splint would be documented, RN/UM #1 stated that there is no place to document, just indicates it is care planned. Shortly after this interview, the surveyor and RN/UM #1 went to Resident #1's room. RN/UM #1 acknowledged that Resident #1 was not wearing a splint however, there was a rolled washcloth in the right hand. RN/UM #1 also acknowledged that there was no hand splint available in the resident's room. At that time, CNA #1 stated that the nurse (RN#2) just placed the washcloth in Resident #1's hand. When the surveyor inquired as to the use of the hand splint, CNA #1 stated that he/she recalled Resident #1 using a hand splint but was unable to determine how long ago it had been since Resident #1 had last worn it. On the same day at 1:17 PM, Resident #1 was observed at the nursing station wearing a right hand/wrist splint. On the same day at 1:33 PM during an interview with the surveyor, the Director of Therapy (DOT) stated that the nurse (LPN#2) called and stated that the resident was care planned for a hand splint and didn't have one. The DOT stated that therapy placed a hand splint on Resident #1 shortly after the call. The DOT was unable to state whether Resident #1 had a history of refusing the hand splint and that there was no documentation indicating refusal. The DOT added that Resident #1 was on Restorative Therapy that included Range of Motion (ROM) and skin checks. The DOT stated that the expectation for restorative therapy is that documentation would include tolerance of ROM and hand splint. The DOT confirmed that there was no documentation regarding the use of the hand splint. The DOT further stated that a new Plan of Care Note was added to apply splint handgrips to right hand topically every morning and remove at bedtime for contraction. During an interview with the surveyor on 03/03/2025 at 10:16 AM, the restorative CNA #2, stated that Resident #1 was not on her restorative therapy list. She added that Resident #1 is on Restorative Maintenance which is different than Restorative Therapy. Restorative maintenance is provided by the floor CNA's and involves doing ROM and adaptive devices during routine care. During an interview with the surveyor on 03/03/2025 at 11:10 AM, the Director of Nursing (DON) stated that a hand splint does not require a physician order. The DON added that the EMR was updated to provide an area to document the use of adaptive equipment by the CNA. On review of the facility policy titled, [facility name] Policy & Procedure, dated 07/22/2020, reflects the following: #7 Once restorative goals are achieved the resident will transfer to the Functional Maintenance/Restorative Program. #9 Any change in resident's status will be reported to the unit manager. The unit manager will re-evaluate to determine if resident needs to be evaluated by therapy for therapy services or rehabilitation/restorative service. NJAC 8:39-27.1 (a)

Based on observation, interview, review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to a.) ensure there was a physician order for the use of a Foley catheter and care plan, b.) ensure a resident with a catheter had the catheter bag in a privacy bag for dignity, and c.) failed to ensure a catheter bag did not come in contact with the floor to prevention possible contamination. This deficient practice was identified for 3 of 3 Residents reviewed for catheter use (Resident #6, Resident # 17, and Resident #348) and was evidenced by the following: On 02/25/2025 at 12:57 PM, Surveyor #1 observed Resident #17 lying in bed with their catheter bag hanging from the bed frame. The catheter bag was not in a privacy bag and was visible from the hallway. On 02/25/2025 at 03:14 PM, a review of the EMR revealed the following: According to the Admission Record, Resident #17 was admitted to the facility with diagnoses including but not limited to: Unspecified Dementia. A review of the quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident #17 had an indwelling catheter. A review of the most recent Admit/Readmit screener indicated that Resident #17 had a catheter. A review of the Order Summary Report with Active Orders as of 02/28/2025 revealed that there was no physician order for the use of the Foley, or the reason and care of the Foley. A review of the Comprehensive Care plan did not include the use and care of the Foley. During an interview with Surveyor #1 on 02/28/2025 at 10:24 AM, Licensed practical Nurse (LPN #1) was asked does a Foley catheter use require a physician order. LPN #1 responded yes, there should be a physician order for use and care of the catheter. During an interview with Surveyor #1 on 02/28/2025 at 10:34 AM, Registered Nurse/Unit Manager (RN/UM #2) was asked does a Foley catheter use require a physician order. RN/UM #2 replied Yes, there should an physician order for the Foley. When questioned if a resident has a Foley catheter, should there be a care plan. RN/UM #2 said Yes, there has to be a care plan for the Foley. During an interview with the Surveyor #1 on 02/28/2025 at 02:05 PM, the Director of Nursing (DON) was asked what the expectation is for a resident who is admitted to the facility with a Foley catheter. The DON replied it is necessary to have a care plan. The DON confirmed Yes there should have been a physician order. The DON also said it is important to have dignity bag for dignity and infection control. On 02/28/2025 at 12:01 PM, a review of a facility policy titled Indwelling Urinary Catheter Care did not include that the resident would need a physician order or care plan for the use of a Foley. On 02/28/2025 at 01:26 PM, a review of a facility policy titled Admission or Re-Admission updated 11/25/24, revealed under Procedure section 5. The RN or LPN will report and record all indwelling medical devices and obtain applicable order form the physician for instructed use (i.e. peripheral line, Foley catheters, ostomies). 51232 Upon initial tour of the facility on 2/24/2025 at 11:32 AM, Surveyor #2 observed Resident #6 lying in bed in his/her bedroom. The urinary drainage bag (a medical device used to collect urine) had no privacy cover and was visible from the hallway. On 02/24/2025 at 01:08 PM, Surveyor #2 reviewed the electronic medical records (EMR) for Resident #6 as follows: According to the Admission Record Resident #6 was admitted to the facility with various diagnoses, including but not limited to urinary retention (a condition where a person cannot fully empty their bladder) and paraplegia (characterized by the loss of sensation and motor function in the lower half of the body). A review of Resident #6's Order Summary Report indicated the following: start date 6/19/2024, ensure Foley catheter bag is below the bladder, off the floor and in a dignity cover bag. During an interview with Surveyor #2 on 2/26/2025 at 9:38 AM, the Infection Preventionist said that residents with a Foley should have privacy covers to maintain dignity and protect against contamination, such as preventing the Foley bag from touching the floor. During an interview with Surveyor #2 on 2/28/2025 at 2:08 PM, the DON said that residents with a Foley should have a privacy cover for dignity and infection control purposes. 51337 3. On 2/24/2025 at 10:09 AM, during the initial tour, Surveyor #3 observed Resident #348 in bed with an unsecured Foley catheter collection bag and tubing lying on the floor filled with urine visible from the hallway. On 2/25/2025 at 10:52 AM, a review of the EMR revealed the following: A review of the Admission Record reflected the resident had diagnoses that included Acute Kidney Failure (a decrease in kidney function that leads to accumulation of waste products in the blood) and Retention of Urine. A review of the most recent comprehensive MDS dated [DATE], revealed Resident #348 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. The MDS further reflected the resident used an indwelling catheter. A review of the Order Summary Report (OSR) with active orders as of 2/28/2025 revealed the following physician orders: A physician order with a start date of 02/11/2025, indicating use of urinary drainage bag with anti-reflux chamber every shift for proper drainage and storage. The order also included to ensure Foley bag is below the bladder, off the floor and in a dignity cover bag. During an interview with Surveyor #3 on 02/25/2025 at 12:51 PM, the Infection Preventionist stated the urine bag should not touch the floor and should be put in a dignity bag to prevent spread of infection. During an interview with the surveyor on 02/26/2025 at 12:28 PM, RN/UM #2 stated the drainage bag needed to be in a dignity bag and cannot be on the floor. RN/UM #2 further stated that the staff were educated on this. During an interview with the surveyor on 02/28/2025 at 9:12 PM, the Assistant Director of Nursing (ADON) stated that urine bag should be in dignity bag and cannot be on the floor. A review of the facility-provided policy titled Urinary Catheter Bags Care Maintenance dated 2/7/2025, indicated under section Procedure #15: Check to ensure the catheter drainage tube is not touching the floor and the drainage bag is covered. NJAC 8:39-19.4(a) 27.1(a)(b)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) administer oxygen therapy according to the physician's order, b.) ensure respiratory tubing, and nasal cannula were stored properly, and c.) obtain physician order for oxygen administration. This deficient practice was identified for 2 of 2 residents (Residents #75 and #349) reviewed for respiratory care according to the standard of clinical practice, and the facility's policy and procedure. The deficient practice was evidenced by the following: 1.) Upon initial tour of the facility on 02/24/2025 at 10:19 AM, Surveyor #1 observed Resident #75 using oxygen through a nasal cannula connected to an oxygen concentrator that provides extra oxygen to those who have difficulty breathing. However, the oxygen tubing was not labeled. Additionally, another nasal cannula was found resting on the seat of the resident's wheelchair, connected to a portable oxygen tank that was also unlabeled and exposed to the environment. On 02/25/2025 at 10:56 AM, Surveyor #1 reviewed the electronic medical records for Resident #75 as follows: According to the Admission Record Resident #75 was admitted to the facility with diagnoses, including but not limited to Chronic Obstructive Pulmonary Disease, (a progressive lung condition that leads to breathing difficulties due to airflow obstruction). A review of Resident #75's Order Summary Report indicated the following: start date 9/28/2024, check pulse oximetry (SPO2) (a non-invasive test that measures the oxygen saturation level in a person's blood) every shift if the oxygen saturation is below 92% and the resident is short of breath (SOB) administer oxygen at a rate of 2 liters per minute via nasal cannula, every 8 hours as needed for SOB. A review of Resident #75's Treatment Administration Record (TAR) revealed an order for monitoring SPO2 every shift if it drops below 92% and for administering oxygen at 2 liters per minute via nasal cannula every 8 hours as needed for SOB. However, there was no documentation in the TAR indicating that the as needed oxygen was being administered. During an interview with Surveyor #1 on 2/26/2025 at 9:38 AM, the Infection Preventionist (IP) said that if oxygen tubing is not in use, it should be stored in a plastic bag and not left open to the environment for infection control purposes. During an interview with Surveyor #1 on 2/26/2025 at 1:22 PM, the Registered Nurse/Unit Manager #1 said that oxygen tubing should have a physician's order, be changed and dated every Friday, and be stored in a plastic bag when not in use for infection control purposes. Additionally, any oxygen used as needed should be recorded on the TAR. A review of the facility provided policy, with a review date of 2/28/2025, titled, Oxygen Administration revealed under the section titled Procedure that, Every nasal cannula, will be changed once per week on a selective day labeled appropriately. When not in use, nasal cannula and tubing will be placed in plastic bag and tied to tank and/or concentrator. 51337 2. On 02/24/2025 at 10:13 AM, during the initial tour of the facility, Surveyor #2 observed Resident #349 in bed connected to an oxygen concentrator via nasal cannula (N/C) at 1 liter per minute (lpm). On 02/25/2025 at 8:25 AM, Surveyor #2 observed the resident in bed receiving continuous flow of 1 liter of oxygen per minute via nasal cannula connected to the concentrator. On 2/25/2025 at 11:00 AM, a review of the EMR revealed the following: A review of the Admission Record reflected the resident had diagnoses that included history of falling and generalized muscle weakness. A review of the Clinical Physician Orders active and discontinued as of 2/27/2025 at 12:47 PM, did not include a physician order for oxygen administration since admission. A review of the Resident #349's comprehensive care plan did not reveal a goal and interventions for the focus of resident having periods of shortness of breath initiated on 2/24/2025. During an interview with the Surveyor #2 on 02/26/2025 at 12:20 PM, the Registered Nurse/ Unit Manager (RN/UM #2) stated that oxygen administration should have a physician order. During an interview with the Surveyor #2 on 02/28/2025 at 9:10 AM, the Assistant Director of Nursing (ADON) stated that a physician order was absolutely needed for oxygen administration. A review of the facility provided policy titled Oxygen Administration dated reviewed 2/28/2025, did not include physician orders for oxygen administration. NJAC 8:39-27.1(a)

Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to ensure accurate accountability of controlled drugs to prevent loss or diversion. This deficiency was identified for 2 of 4 medication carts inspected. This deficient practice was evidenced by the following: On 02/26/2025 at 11:30 AM, the surveyor inspected F-Hall medication cart in the presence of the Registered Nurse/Unit Manager #1 (RN/UM #1). A review of the shift-to-shift Narcotic Record Controlled Count Sign Sheet (NRCCSS), which is used in healthcare settings to track the administration and accountability of controlled substances, revealed missing signatures for the following dates and shifts: 2/01/2025 for the outgoing nurse (7:00 AM - 3:00 PM), and 2/09/2025, for both the incoming and outgoing nurses (11:00 PM - 7:00 AM). On 02/26/2025 at 11:38 AM, the surveyor inspected E-Hall medication cart in the presence of the RN/UM #1. A review of the shift-to-shift NRCCSS revealed missing signatures on the following dates and shifts: 02/05/2025 for both incoming and outgoing nurse (3:00 PM - 11:00 PM), and 2/18/2025 for the outgoing nurse (7:00 AM - 3:00 PM). During an interview with surveyor on 02/26/2025 at 1:22 PM, the RN/UM #1 said that the nurses are required to sign the NRCCSS for accountability of narcotics. During an interview with surveyor on 02/28/2025 at 2:04 PM, the Assistant Director of Nursing said that the NRCCSS should be completed at the beginning and end of each shift to ensure accurate narcotic counts and prevent drug diversion. A review of the facility provided policy, with a review date of 2/28/2025, titled, Counting Controlled Drugs and Drug Diversion revealed under the section titled Procedure that, All controlled drugs will be counted in the start and end of each shift by two (2) license nurses. Both parties sign the count sheet indicating that each controlled drug count is correct. NJAC 8:39-29.7(c)

Based on observation, interview and review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to follow through on recommendations made by the Consultant Pharmacist (CP) during their monthly medication review regimen (MRR) in a timely manner. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident # 66) and was evidenced by the following: During the Initial Tour of the facility on 02/24/2025 at 10:57 AM, Resident #66 was observed in a high back wheelchair in his/her room clean and groomed. Resident requested and received a cup of coffee. A review of the EMR on 02/24/2025 at 10:00 AM, revealed the following: According to the Admission Record, Resident #66 was admitted to the facility with diagnoses including but not limited to: unspecified dementia with other behavioral disturbances. According to the most recent quarterly Minimum Data Set, an assessment tool dated 12/22/2024 revealed the resident had a Brief Interview for Mental Status of 6/15 MDS which indicated severe cognitive impairment. A review of the Order Summary Report revealed the following physician orders; Acetaminophen Tablet 325 MG (milligrams) Give 2 tablet by mouth every 6 hours for Pain Management ( mild pain 1-3). Do Not exceed 3000 mg of Tylenol per day give 2 tabs =650 mg with order date of 08/10/2024. Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for Temperature > (greater than) 100 Fahrenheit Do Not exceed 3000 mg of Tylenol per day dated 08/10/2024. A review of the CP Therapeutic suggestion form dated 8/30/24 revealed the following: Routine order of 2.6 gm's (grams)/day of acetaminophen noted. To avoid potentially going over maximum recommended daily dosing, consider decreasing the frequency of PRN (as needed) acetaminophen or d/c (discontinue) PRN acetaminophen. On 09/09/2024 the Advanced Practice Nurse (APN) hand wrote on the Therapeutic suggestion form to decrease acetaminophen dose to 650 mg po (by mouth) q (every) 8 hours prn for fever/pain. There was no documentation in the EMR that the facility followed up on the CP recommendations and the APN acceptance dated 9/9/24 until 12/22/2024. This was not addressed in 102 days. During an interview with the surveyor on 02/27/2025 at 10:24 AM, the Director of Nursing (DON) was asked what the process is when the CP has a therapeutic suggestion. The DON replied She comes in monthly and reviews all residents. She sends us a report after she leaves unless major issue that requires immediate attention. She then writes a note in chart she reviewed. If there is recommendation will document there is recommendation. She then emails and sends via regular mail the reports and the Unit Managers address them. When asked if there is a specific time frame of when the suggestion needs to be addressed. The DON replied If nursing recommendation we have to do it right away. If it is a physician we send it to them and wait for their response. The APN or MD send back to the unit and the nurse addresses the changes and then gets filed in EMR under miscellaneous tab. The UM is responsible to follow-up with physicians. The DON went on to say that she is not sure if there is a time frame in the policy. It should be done as soon as possible. On 02/27/2025 at 10:31 AM, a further review of the EMR under the miscellaneous tab indicated the therapeutic recommendations form was uploaded into the record on 09/10/2024, however the facility did not address what was written by the APN. During an interview with the surveyor on 02/28/2025 at 02:00 PM, the DON was asked what is the facility expectations of time frame for follow-up with cp recommendations and prescriber's orders. The DON replied as soon as possible. When asked if it was acceptable to wait 102 days to address the cp report, the DON said it is not acceptable to wait that long . On 02/27/2025 at 12:17 PM, a review of a facility policy titled Change of Status/Monthly Pharmacy Review with last reviewed date of 2/27/25, revealed under Procedure section 5. The Pharmacy Consultant recommendations will be reviewed with the attending physician. The policy did not include a specific time frame for addressing CP recommendations. NJAC 8:39-29.3(a)(1)

Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to follow enhanced barrier precautions (EBP), a set of infection control measures aimed at reducing the risk of transmitting infectious agents. This deficiency was observed for 1 of 1 resident (Resident #49) reviewed for EBP. This deficient practice was evidenced by the following: On 02/24/2025 at 10:38 AM, upon initial tour of the facility the surveyor observed the Home Health Aide (HHA#1) giving a bed bath to Resident #49 in their bedroom, while the resident was in bed, without wearing personal protective equipment (PPE), despite a sign on the outside of the door indicating EBP and the proper PPE required for contact. A review of Resident #49's Order Summary Report located in the Electronic Medical Record revealed an order to maintain EBP due to the presence of a urinary drainage tube, a medical device used to drain urine from the bladder and a history of Extended-Spectrum Beta-Lactamase (ESBL) in the wound, a bacteria resistant to many commonly used antibiotics. During an interview with the surveyor on 02/24/2025 at 10:40 AM, HHA #1 said that no one at the facility had informed her that PPE was required when performing a bed bath, though it should be worn for infection control purposes. During an interview with surveyor on 02/26/2025 at 09:38 AM, the Infection Preventionist said that EBP are implemented for residents with multidrug-resistant organisms which are bacteria or microorganisms resistant to multiple antibiotics, as well as for those with medical devices, such as a urinary drainage tube. Healthcare providers must wear PPE when performing tasks like bathing, wound care, or managing the medical device. A review of a facility policy, with a review date of 01/16/2025 titled, Infection Prevention Policy and Procedure Manual, revealed under definitions, that Enhanced Barrier Precaution: This is an approach using PPE (ie. gowns and gloves) during high contact resident care, design to reduce the transmission of colonized MDROs. N.J.A.C.8:39-19.4(a)

COMPLAINT #NJ00175651 Based on observation, interview, and record review, on 08/02/24, it was determined that the facility failed to notify a resident in writing of a resident room change for 2 of 2 residents (Resident #1 and Resident #2). This deficient practice was identified and was evidenced by the following: 1). On 08/02/24 at 11:45 A.M., the surveyor observed Resident #1 awake in bed, watching television. The surveyor asked how long the resident had been in this room and the resident stated that he/she had been there for about three weeks. The resident stated that the unit manager [of the previous unit] and the social worker informed his/her that the resident was moving due to, something to do with my kidneys. The resident further stated that he/she had not received anything in writing prior to the move. Review of Resident #1's Admission Record (AR) face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included, but were not limited to: hypertension, chronic kidney disease with heart failure, and type II diabetes. Review of Resident #1's annual Minimum Data Set (MDS), an assessment tool to facilitate the management of care, dated 07/13/24 reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Review of Resident #1's progress notes (PN) revealed a social worker note, dated 06/19/24 at 12:04 P.M., that indicated that the resident was transferred to another room and that written notification was provided. A further review of the electronic medical record did not reveal evidence of the required written notification of the room change. 2). On 08/02/24 at 11:33 A.M., the surveyor observed Resident #2 seated at the bedside in a wheelchair, watching television. The surveyor asked how long the resident had been in this room and the resident stated, Sometime in July, maybe three weeks. The resident stated that the social worker informed his/her that the resident was contagious and needed to be moved. The resident further stated that he/she had not received anything in writing prior to the move. Review of Resident #2's Admission Record (AR) revealed that the resident was readmitted to the facility with diagnoses that included but were not limited to: resistance to multiple antimicrobial drugs, kidney failure, and anxiety. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. Review of Resident #2's progress notes (PN) revealed a social worker note, dated 07/09/24 at 11:30 A.M., that indicated that the resident was transferred to another room and that written notification was not provided. A further review of the electronic medical record did not reveal evidence of the required written notification of the room change. During an interview with the surveyor on 08/02/24 at 12:42 P.M., the Director of Social Services (DSS) stated that she informed Resident #2 of the room change and that a notification was provided in writing to all residents. In a later interview, at 2:10 P.M., in the presence of the surveyor, the DSS reviewed a facility form titled, SUBJECT: Room Change, In-house. The DSS stated that residents received the form which informed them of the room changes; no form was provided to the surveyor for Resident #1 nor Resident #2. During an interview with the surveyor on 08/02/24 at 1:30 P.M., the Social Worker (SW) stated that she informed Resident #1 of the room change on the day of the move. She further stated that she had not provided the resident with a written notification. NJAC 8:39-4.1(a)

Complaint #: NJ163798, NJ166210 Based on interviews, medical records, and review of other pertinent facility documentation on 7/31/23 and 8/1/23, it was determined that the facility failed to thoroughly investigate an alleged staff-to-resident physical and verbal abuse allegation that involved the Certified Nursing Aide (CNA #2) and Resident #2. The facility also failed to ensure its policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property was implemented during the alleged abuse allegation. On 4/23/23 at approximately 8:00 P.M., Resident #2 reported to a family member that CNA #2 had grabbed the resident by the wrist and was rough and had called him/her fat during care. Resident #2's daughter reported the abuse allegation to the Registered Nurse/Evening Supervisor (RN/ES) that same day , however, CNA #2 continued to provide direct resident care for the rest of the shift on 4/23/23. The CNA also provided direct resident care on 4/24/23. On 4/25/23, CNA #2 was in-serviced by the Director of Nursing (DON) about abuse on that day. The facility' failed to follow its policies and procedures for abuse and remove the alleged staff member from direct resident care while the situation was being investigated. The facility continued to allow CNA #2 to continue to work after a alleged abuse violation was reported which placed other residents being cared for by this staff member in an immediate jeopardy (IJ) situation. This IJ was identified, and an IJ template was presented to the Administrator in the presence of the Director of Nursing (DON) on 8/8/23 at 5:00 P.M. The IJ began on 4/23/23 and continued through 4/25/23 when CNA #2 was in-serviced on the facility's Abuse, Mistreatment, Exploitation, Neglect, and Misappropriation of Property policy. On 8/15/23, the Surveyor verified the Removal Plan was implemented. The facility educated all staff on their revised Policy dated 8/8/23 titled Abuse, Mistreatment, Exploitation, Neglect, and Misappropriation of Property, So, the noncompliance remained on 4/25/23 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following: Review of the facility policy titled Abuse, Mistreatment, Exploitation, Neglect, and Misappropriation of Property Under Policy: include All residents at Meadowview Nursing and Rehabilitation Center have the right to be free from abuse, mistreatment, exploitation, neglect, and misappropriation of property. This included the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Under Definitions: include A. Verbal-any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability. C. Physical- hitting, punching, choking, slapping, pinching, kicking, etc. It also includes controlling behavior such as corporal punishment. Under Identification revealed A. Allegations of abuse may be made by anyone. Upon receiving such information, the nurse shall immediately ensure that the resident is in no imminent harm. The nurse will assess the situation; 2) immediately remove the alleged abuser from direct resident care until a thorough investigation of the allegation has been completed. The employee may be assigned to an area where there is no resident contact. 5. Investigation: Resident Abuse & Neglect: A. All reports or allegations of resident abuse and neglect are to be reported to the Administrator as above, the Director of Nursing, and the resident's family (or sponsor) within 24 hours of the occurrence such incident if abuse or neglect is suspected. The Department of Health and the Office of the Ombudsman shall be notified. If appropriate, the County prosecutor and the police shall be notified. B. The Administrator or designee shall begin an immediate investigation. Findings shall be reported to the administrator. According to the AR Resident #2 was admitted on with 3/28/2023 with diagnoses which included but were not limited Obstructive Sleep Apnea, Morbid (Severe) Obesity Due to Excess Calories, Difficulty Walking, and Anxiety Disorder, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 7/5/2023, Resident # 2 had a BIMS score of 15/15, which indicated the Resident #2 was cognitively intact. The MDS also showed Resident #2 needed total assistance and two-person physical assistance with most Activities of Daily Living (ADLs) and total dependence with locomotion on and off the unit. A review of the Resident's Care Plan (CP) initiated on 3/28/23 revealed under Focus: ADL deficit: I cannot do things by myself anymore without assistance due to physical decline. Under Goal, indicated, Occupational Therapy Short Term Goal: Resident will complete toileting with Mod A [moderate assistance]. Under Interventions, included: Dressing: Please help me get dress. I am totally dependent on the staff. Personal Hygiene/Oral Care: I am able to: wash my face and hands. I am dependent of my caregiver for all other hygiene. Toilet Use: I am not toileted. I prefer the bedpan and will need assistance of 2 people. During a phone interview on 8/7/23 at 11:55 A.M., CNA #2 stated Resident #2 requested to use the bedpan. She revealed to the Surveyor that she assisted 3 other staff members to provide care to the resident (Resident #2). CNA #2 stated, I did not call Resident #2 fat or shove him/her over the bed during care. While proving care, Resident #2 had a ribbon around his/her left wrist attached to the pull light. We [the staff] rolled Resident #2 over to the right side and the resident's (Resident #2) left arm jerked back when we roll him/her over. I will assume that's what they meant when he/she said that I grabbed their wrist and shoved them over their bed and called him/her fat. When asked by the Surveyor if she grabbed Resident #2's wrist and shoved them over their bed, and call the resident fat, CNA #2 stated: No, I did not. During the same interview, CNA #2 informed the Surveyor that she continued to work the rest of her shift after the allegation of abuse. During a phone interview on 8/7/23 at 12:45 P.M., the Certified Nursing Assistant (CNA #1) stated she was assigned to Resident #2 on the day of the incident. At approximately 8:00 p.m., she got three other staff members (2 CNA's and the LPN) to assist with the resident (Resident #2). We all went into the room to assist Resident #2 with care, he/she was afraid and said, before you guys start, give me my phone, I need to call my daughter and tell her what you guys are about to do to me. The LPN explained to Resident #2 that we were there to care for him/her. We started to care for the resident (Resident #2), when we turned the Resident #2 to the right, we didn't notice that his/her left hand was tied with a ribbon to the pull light. We turned Resident #2, his/her left arm jerked back. We than put Resident #2 on his/her back and immediately removed the ribbon along with the LPN. We completed proper care for the resident (Resident #2) and provided all his/her items within reach and left the room. At approximately 8:20 P.M., on 4/23/2023, Resident #2's daughter came in and he/she reported that we abused her during care and called him/her Fat. We were all called into Resident #2's room where he/she pointed to CNA #2 and said, she abused me. When asked by the Surveyor if she heard CNA #2 call Resident #2 fat or abuse them physically, she responded saying, No, I did not. During an interview on 8/7/23 at 1:12 P.M., the LPN informed the Surveyor saying, we (3 CNAs and myself) were in the room proving care to the resident (Resident #2), we turned the resident (Resident #2) to right side I believed, and he/she complained of pain at which time Resident #2 was turned on his/her back. When asked if anyone grabbed Resident #2's wrist, shove him/her and called him/her fat, the LPN said, No, we were not rough, no one called the resident (Resident #2) fat during care. No CNA #2 did not abuse the resident. It was a group effort to provide care for Resident #2. Resident #2's daughter came in shortly after we provide care and informed the RN/ES that the resident stated they were abused by the staff. The RN/ES called us[staff] in Resident #2's room, as the Resident #2 pointed to each staff stating we verbally abused him/her during care. The LPN also stated the RN/ES took each staff member individually to her office and questioned them about the allegation, at which time she informed the RN/ES saying, No one abuse the resident (Resident #2). During the same interview, the LPN stated, everyone [staff] continued to work after the incident, no one was sent home or removed from direct patient care., When asked if there was any in-service provided, the LPN said, No, there was no in-service provided after the incident. During an interview on 8/7/23 at 1:41 P.M., the Social Worker revealed Resident #2's daughter reported the abuse allegation to her. She further stated prior to 4/23/23 incident, I would usually send an email to the Director of Nursing (DON) and Administrator with family concerns. When asked if a thorough investigation was completed, she responded: No, there was no investigation done by me for 4/23/23 incident of alleged abuse. We were not allowed to complete the investigations as per the previous policy. The investigations had to be completed by the DON and Administrator. During the survey, the Surveyor was unable to reach the RN/ES for an interview. During an interview on 8/7/2023 at 2:38 P.M., the Administrator in the presence of the DON stated he received a phone call from the RN/ES on 4/23/23 at approximately 9:39 P.M., advising him of the incident that had occurred. I told the RN/ES that I would communicate with Resident #2's daughter. I told the RN that night to immediately obtain witness statements from the CNA's. I was off on Monday (4/24/2023) and returned on Tuesday (4/25/2023), I spoke with Resident #2's daughter on the phone in the presence of the DON on 4/25/23. I told her we [administration] had to complete an investigation about the incident. During the same interview, both the Administrator and DON acknowledge that the facility's policy on Abuse was not followed on 4/23/23 and that an investigation should have been initiated immediately by the RN/ES after the allegation. The DON stated she was informed by the RN/ES that Resident #2 daughter reported an allegation of abuse on 4/23/23. Stating CNA #2 grabbed their wrist and shoved them over their bed and called them fat. It turned out that Resident #2 s family had tied a ribbon on Resident #2's left wrist and attached it to the pull light. The DON further stated the RN/ES also informed her that during Resident #2's care, the CNA turned the resident (Resident #2) to the right side and caused a jerk back of the left arm. She further stated Resident #2 was repositioned on their back and the ribbon removed by the staff proving care. The DON also stated, from my understanding, CNA #2 was removed from Resident #2's hall on the night of the incident. The DON stated, CNA #2 was removed from resident care on 4/25/23 and in-serviced about abuse in my office prior to the start of her shift. She remained in my office on 4/25/23 until the investigation was completed and the allegation was not validated. The DON further stated, No, there was no in-service provided to the staff, there should have been an in-service provided immediately after the abuse allegation. She further stated, Yes, I should had provided the in-service immediately after the allegation. During the same interview, the Administrator stated, No, I do not expect a staff to continue providing direct patient care after an abuse allegation is made. Both Administrator and DON Acknowledged that that their policy on abuse was not followed on 4/23/23.When asked if the allegation was reported to the New Jersey Department of Health (NJDOH), the Administrator responded, No, we [administration] did not report the allegation. He continued to state, yes, the allegation should have been reported to the NJDOH by administration [Administrator/DON]. During a second interview on 8/8/23 at 12:09 P.M., the DON stated CNA #2 worked her regular shift on 4/24/23 because I did not have any details of the allegation of abuse. We [administration] did not speak to Resident #2's daughter until 4/25/23. After I interviewed all the staff on 4/25/23 by 5:00 P.M., it was decided that the complaint was not valid. The DON continue to state, the RN/ES only questioned the alleged CNA but didn't get a written statement from her all the other witnesses. The DON continued to say, Yes, the RN/ES should have gotten a written statement CNA #2 and follow the facility's abuse policy. I don't know why CNA #2 was not removed from direct patient care; I just know I followed the policy once I heard about the abuse allegation. The policy does not allow us [administration] to suspend a staff pending abuse allegation, but rather remove the staff from direct patient care. No, CNA #2 was not removed from direct patient care prior to the completion of the investigation. During the same interview, the Administrator acknowledged that he was informed about the abuse allegation by the RN/ES on 4/23/23. When asked if he instructed the RN/ES to remove CNA #2 from all patient care, he said: No, I did not tell the RN/ES to remove CNA #2 from all patient care on the day the abuse allegation was made. He continued to state, Yes, CNA #2 should have been removed from all resident's care, witness statements obtained, and a thorough investigation with summary conclusion completed by us [Administrator/DON] prior to CNA #2's return to patient care. N.J.A.C.:8.39-4.1 (a) (5)

Complaint #: NJ163793, NJ166210 Reference F610 Based on observation, interviews, medical record review, and review of other pertinent facility documentation during the on-site investigation on 8/7/23 and 8/8/23, it was determined that the facility's Licensed Nursing Home Administrator failed to ensure that the policies and procedures under the Abuse, Mistreatment, exploitation, Neglect, and Misappropriation of Property was implemented when Resident #2's family member reported he/she was grabbed by their wrist and shoved over their bed and called fat by the Certified Nursing Aide (CNA #2) on 4/23/23. The Administrator failed to report this incident along with an investigation to the New Jersey Department of Health. The Administrator also failed to ensure that all residents were free from abuse and a likelihood of harm when an alleged abuse allegation was made. The alleged CNA #2 continue to provide direct patient care after the allegation through the investigation period which was concluded on 4/25/23. The facility's failure to thoroughly investigate and follow its policies and procedures for abuse and allowing the alleged CNA to continue caring for residents placed other residents being cared for by this staff member in an immediate jeopardy (IJ) situation. This IJ was identified, and an IJ template was presented to the LNHA in the presence of the Director of Nursing (DON) on 8/8/23 at 5:00 P.M. The IJ began on 4/23/23 and continued through 4/25/23 when CNA #2 was in-serviced on the facility's Abuse, Mistreatment, Exploitation, Neglect, and Misappropriation of Property policy. On 8/11/23, the Removal plan was accepted and on 8/15/23, the Surveyor verified the Removal Plan was implemented. Resident #2 is no longer at the facility. The facility educated all staff on their revised Policy dated 8/8/23 titled Abuse, Mistreatment, Exploitation, Neglect, and Misappropriation of Property, the noncompliance remained on 4/25/23 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following: According to the AR Resident #2 was admitted on with 3/28/2023 with diagnoses which included but were not limited Obstructive Sleep Apnea, Morbid (Severe) Obesity Due to Excess Calories, Difficulty Walking, and Anxiety Disorder, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 7/5/2023, Resident # 2 had a BIMS score of 15/15, which indicated the Resident #2 was cognitively intact. The MDS also showed Resident #2 needed total assistance and two-person physical assistance with most Activities of Daily Living (ADLs) and total dependence with locomotion on and off the unit. A review of the Resident's Care Plan (CP) initiated on 3/28/23 revealed under Focus: ADL deficit: I cannot do things by myself anymore without assistance due to physical decline. Under Goal, indicated, Occupational Therapy Short Term Goal: Resident will complete toileting with Mod A [moderate assistance]. Under Interventions, included: Dressing: Please help me get dress. I am totally dependent on the staff. Personal Hygiene/Oral Care: I am able to: wash my face and hands. I am dependent of my caregiver for all other hygiene. Toilet Use: I am not toileted. I prefer the bedpan and will need assistance of 2 people. During an interview on 8/7/2023 at 2:38 P.M., the LNHA in the presence of the DON stated he received a phone call from the RN/ES on 4/23/23 at approximately 9:39 P.M., advising him of the incident that had occurred. I told the RN/ES that I would communicate with Resident #2's daughter. I told the RN that night to immediately obtain witness statements from the CNA's. I was off on Monday (4/24/2023) and returned on Tuesday (4/25/2023), I spoke with Resident #2's daughter on the phone in the presence of the DON on 4/25/23. The LNHA continue to state, I told her we [administration] had to complete a thorough investigation about the incident. During the same interview, both the LNHA and DON acknowledge that the facility's policy on Abuse was not followed on 4/23/23 and that a thorough investigation should have been initiated immediately by the RN/ES after the allegation. During a second interview on 8/8/23 at 12:09 P.M., the LNHA in the presence of the DON, acknowledged that CNA #2 should had been removed immediately from patient care until a thorough investigation was completed. The DON also stated, our policy does not require for a staff to be suspended after an abuse allegation, but rather remove from all residents care. The LNHA further stated, the investigation should have been completed by the administration (Administrator/DON). When asked by the Surveyor if the abuse allegation was reported to New Jersey Department of Health (NJDOH) and Ombudsman, the LNHA responded saying, No the abuse allegation was not reported, it should have been reported to NJDOH and Ombudsman. It is my responsibility to report incidents of abuse allegations to the NJDOH and Ombudsman. Review of the facility policy titled Abuse, Mistreatment, Exploitation, Neglect, and Misappropriation of Property Under Policy: include All residents at Meadowview Nursing and Rehabilitation Center have the right to be free from abuse, mistreatment, exploitation, neglect, and misappropriation of property. This included the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.Under Definitions: include A. Verbal-any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability. C. Physical- hitting, punching, choking, slapping, pinching, kicking, etc. It also includes controlling behavior such as corporal punishment. Under Identification revealed A. Allegations of abuse may be made by anyone. Upon receiving such information, the nurse shall immediately ensure that the resident is in no imminent harm. The nurse will assess the situation; 2) immediately remove the alleged abuser from direct resident care until a thorough investigation of the allegation has been completed. The employee may be assigned to an area where there is no resident contact. 5. Investigation: Resident Abuse & Neglect: A. All reports or allegations of resident abuse and neglect are to be reported to the Administrator as above, the Director of Nursing, and the resident's family (or sponsor) within 24 hours of the occurrence such incident if abuse or neglect is suspected. The Department of Health and the Office of the Ombudsman shall be notified. If appropriate, the County prosecutor and the police shall be notified. B. The Administrator or designee shall begin an immediate investigation. Findings shall be reported to the administrator. Review of the facility's Job Specification titled Nursing Home Administrator Under Definition: Under immediate direction of the appointing authority or governing board, administers directs, and coordinates all activities of a nursing home facility to carry out its objectives as to care of sick and/or disables, the furtherance of scientific knowledge, and participation in promotion of community health; does other related duties as required. N.J.A.C.: 8:39-13.1(a)

Complaint#: NJ163798, NJ166210 Based on observation, interview, and review of pertinent facility documents on 8/7/2023 and 8/8/23, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of abuse when a resident (Resident#2) reported to a familiy member that he/she was grabbed by their wrist and shoved over their bed and called fat by the Certified Nurse Aide (CNA) while providing care. This deficient practice was identified for 1 of 3 residents reviewed for reportable events. This deficient practice was evidenced by the following. During an interview on 8/7/2023 at 2:38 P.M., the Administrator stated he received a phone call from the RN/ES that night around approximately 9:39 P.M., advising him of the incident that had occurred between a CNA and Resident #2. I told the RN/ES that I would communicate with Resident #2's family member. The Administrator continue to state,I told the RN/ES that night to immediately obtain witness statements from the CNA's. I was off on Monday (4/24/2023) and on Tuesday (4/25/2023), I spoke with Resident #2's family member on the phone in the presence of the Director of Nursing (DON). I told her we [administration] had to complete a thorough investigation about the incident.During the same interview when asked if the allegation was reported to the New Jersey Department of Health (NJDOH), the Administrator responded, No, we [administration] did not report the allegation. He continued to state, yes, the allegation should have been reported to the NJDOH by administration (Administrator/DON). Review of the facility policy titled, Abuse, Mistreatment, Exploitation, Neglect and Misappropriation of Property with revised date of 6/12/21 revealed the following: Under Policy include: All residents at Meadowview Nursing and Rehabilitation Center have the right to be free from abuse, mistreatment, exploitation, neglect, and misappropriation of property. This includes facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. Under Procedure: #8. Reporting/response and Corrective Action: B. The results of the investigation shall be provided to the Office of the Ombudsman and the New Jersey Department of Health within five (5) working days of the incident. E. Should the investigation reveal that a false report was made/filed, the investigation shall cease. Residents, family, the Office of the Ombudsman, and the New Jersey Department of Health shall be notified of the findings. The facility couldn't provide documented evidence that the NJDOH was notified of this incident. NJAC 8:39-9.4

Complaint #: NJ163793, NJ166210 Based on observations, interviews, a review of the medical record, and other pertinent facility documents on 8/7/23 and 8/8/23, it was determined that the facility failed to provide documented evidence of care provided to a resident (Resident #2). The facility also failed to follow the Certified Nursing Assistant's job discreption and its policies titled, CNA Care Delivery, ADLs for 1of 3 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the AR Resident #2 was admitted on with 3/28/23 with diagnoses which included but were not limited Obstructive Sleep Apnea, Morbid (Severe) Obesity Due to Excess Calories, Difficulty Walking, and Anxiety Disorder, Unspecified. According to the Minimum Data Set (MDS), an assessment tool dated 7/5/23, Resident # 2 had a BIMS score of 15/15, which indicated the Resident #2 was cognitively intact. The MDS also showed Resident #2 needed total assistance and two-person physical assistance with most Activities of Daily Living (ADLs) and total dependence with locomotion on and off the unit. Review of Resident #2's ADL (Activity of Daily Living) Documentation, a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for September 4/23, showed blank spaces indicating the tasks were not completed as follows: Toileting on 4/2/23 and 4/22/23, on the night shift. On 4/2/23, 4/20/23, 4/22/23 and 4/26/23 on the day shift. On 4/2/23, 4/3/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23,4/27/23 and 4/28 on the evening shift. Eating on 4/4/23, 4/6/23, 4/8/23, 4/9/23, 4/11/23, 4/20,23, 4/22/23, and 4/26/23 on the day shift. On 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23,4/2/23 and 4/28/23 on the evening shift. Transferring on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Dressing on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23, 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23, 4/19/23, 4/20/23 through 4/28/23 on the evening shift. Personal Hygiene on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/26/23 through 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Bed Mobility 0n 4/22/23 on the night shift. On 4/2/23, 4/20/23, 4/22/23 and 4/26/23 on the day shift. On 4/2/23, 4/3/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the evening shift. Locomotion off the Unit on 4/2/23, 4/4/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Locomotion on the Unit on 4/2/23, 4/4/23, 4/6/23,4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/22/23, 4/26/23, 4/27/23 and 4/28/23 on the day shift. On 4/1/23 through 4/28/23 on the evening shift. Bathing on 4/2/23, 4/20/23, 4/22/23, and 4/26/23 on the day shift. On 4/2/23, 4/3/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/11/23, 4/12/23, 4/14/23, 4/15/23, 4/17/23, 4/18/23, 4/20/23, 4/21/23, 4/22/23, 4/23/23, 4/26/23, 4/27/23 and 4/28/23 on the evening shift. During an interview on 8/8/23 at 11:43 A.M., the Certified Nursing Assistant (CNA) stated, If the ADLs sheet is not signed off [not initialed], then I would assume the task was done, but it was just not documented. When presented with the printed copy of the ADLs sheets and asked if the ADL sheets should be signed, the CNA stated, Yes, the ADL sheets should be signed off every day by the CNA at the end of each shift. During an interview on 8/8/23 at 4:35 P.M., the Director of Nursing (DON) stated, The CNAs provide ADLs for the residents, and it is documented on the ADL (Activity of Daily Living) sheet at the end of each shift. She further stated, There should be no blank spaces on the ADL sheets. When presented with the printed ADLs sheets from the kiosk, the DON stated, Looking at the ADL sheets with the blank spaces, that means the tasks were not completed. Review of the facility's document titled Certified Nurse Aide Job Description reveals under Job Summary: Performs various nursing care activities and related nonprofessional services necessary to care for the personal needs and comfort of the residents. Under the supervision and direction of the staff nurse or unit manager, the certified nursing assistant functions in a cooperative effort with all treatment modalities for emotional, intellectual, physical, social and spiritual well-being of the resident, in accordance with acceptable practice standards and policies, procedures and philosophies of this facility. Review of the facility's policy last updated on 7/2021, titled CNA Care Delivery, ADLs under Policy Statement To assure that the facility continues to provide individualized care in response to each resident's standardized, comprehensive assessment (RAI), and to assure accountability and consistency by the primary caregivers in the deliver of this individualized care, each resident's specific care needs will be communicated to the aides through documentation maintain in the electronic Medical records (EMR). Under Procedure: 7. CNA will document in the EMR, ADLs provided and well as additional documentation specified by resident's plan of care. The CNAs uses the Point of Care (POC) Portal through Point Click Care (PCC). NJAC 8:39-35.2 (a)(g)1

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice occurred on 2 of 3-unit nourishment rooms (unit 1 and unit 2) and was evidenced by the following: On 12/6/2022 from 9:19 AM to 9:37 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM) observed the following on the 2nd unit nourishment room: 1. In an upper cabinet the surveyor observed (9) 4 oz (ounce) nectar thickened cranberry juices. The thickened cranberry juices had a best if used by date of 19 [DATE]. In addition, an upper cabinet above the microwave had (2) 46 Fl oz (fluid ounce) containers of orange juice concentrate. The orange juice containers had a use by date of 08/16/2022. On interview the LPN/UM stated that, Maintenance is responsible for monitoring the dates of foods in the nourishment room. 2. On 12/6/2022 at 9:37 AM, the surveyor conducted an interview with the Supervisor of Housekeeping, Laundry, and Maintenance (SHLM). When asked who is responsible for monitoring food dates in the nourishment rooms in the facility the SHLM responded, Housekeeping staff are responsible to stock the nourishment rooms and ensure that all products are monitored for use by dates. These items are going to be thrown in the trash because they are past the use by dates. On 12/6/2022 at 10:10 AM, the surveyor, accompanied by the Registered Nurse/Unit manager (RN/UM) observed the following on the first unit nourishment room: 1. On an upper shelf in the refrigerator the surveyor observed a resident provided bottle of French Dressing. The bottle was dated with resident name and dated 11/30/2022. The bottle had a manufacturer's best if used by date of [DATE]. The RN/UM stated, That is almost 1 month old. The surveyor reviewed the facility policy with Subject: Food Brought by Family/Visitors, dated 8/17/21. The policy revealed the following under the Procedure heading: 7. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 8. Staff is responsible for discarding perishable foods on or before the use by date. NJAC 8:39-17.2(g)

Based on interview and review of other facility documentation, it was determined that the facility failed to accurately track and document facility and contracted staff vaccination status to include primary series and boosters when eligible. This deficient practice was evidenced by the following: On 12/1/2022, during entrance conference, the facility was asked to provide documentation of their staff and contracted staff vaccination status. On 12/2/2022 the facility provided a spread sheet for the facility staff. A review of the facility staff vaccination spread sheet showed that 3 staff members were eligible/due for their booster in June of 2022. There was no documentation provided to indicate the boosters were received. On 12/5/2022 the facility provided a spread sheet for the contracted staff who provide services at the facility. A review of the spread sheet did not include documentation of the dates that 8 of the 12 Independent Licensed Practioners received the initial covid vaccines. The spread sheet also revealed that 2 of 21 Therapy Department, Dietician, Security, Entertainer, did not have any vaccinations documented as having been completed. 3 of 53 Hospice providers at the facility did not have documentation the initial series of vaccinations were administered. The spread sheet further revealed that 41 of the total contracted staff eligible/due for boosters did not receive the boosters. During an interview with the surveyor on 12/5/2022 at 10:21 AM, the Infection Preventionist (IP) said she is the facility IP and responsible for tracking all vaccinations. The IP said the majority of staff are boosted. When asked by the surveyor if any staff were not boosted, she replied, No, I have no one who hasn't been boosted. When surveyor questioned the IP regarding the four staff that are marked as unvaccinated on the Covid-19 Staff Vaccination Status Matrix, the IP said, Yes, they refused and are direct care staff. I have to look at why they are not unvaccinated. I don't want to misspeak. The surveyor also questioned why some of the contracted staff who were eligible for their 1st booster are not boosted despite the requirement that all healthcare workers were to have received the initial vaccination series and 1 booster. The IP stated she had to look at it and it (spread sheet) was not updated. On 12/05/2022 at 1:44 PM, the IP apologized to the surveyor and said she had more exemptions than she thought and the 4 she had as unvaccinated were in fact granted exemptions. During an interview with the surveyor on 12/6/2022 at 9:40 AM, the IP said it is me that is responsible to oversee the vaccine effort. She also said she is responsible to track vaccinations of facility staff and contracted staff at the facility. When asked what the process was to track vaccinations, the IP said, Most of the time staff get the vaccinations here and if elsewhere I have to chase them down, so it becomes more complex. This is for both covid and flu vaccinations. The IP went on to say when the contracted staff come into the building for the first time, they have to present their vaccination records and we make a copy. If this doesn't happen, we call the agency or office and get a copy. This is the same for hospice staff and security staff also. The surveyor asked if security were required to be vaccinated. The IP replied, Yes, security is also required to have 1 or 2 initial vaccine and 1 booster unless they have an exemption. The surveyor asked the IP if all the facility staff and contractors received their 1st booster if eligible. The IP said all the facility staff have received their vaccines and boosters, but I have not accurately tracked the contracted staff for their vaccination status. When asked if it was accurate to say she had not tracked both facility staff and contracted staff vaccinations/boosters the IP said, Yes, it is accurate to say I haven' been tracking staff and contracted staff vaccines and boosters. On 12/06/2022 at 10:40 AM, the IP provided the surveyor with an updated covid 19 staff matrix for vaccination numbers, and it still indicated (4) staff as being not vaccinated without exemption. When questioned as to who the 4 staff members are, the IP was unable to say and said, I will check and get back to you. The IP also said 9 total staff have either medical or religious exemptions. The Director of Nursing provided the surveyor with the current staff exemptions for surveyor review. While reviewing the exemptions, (1) staff had a physician note that indicated, Until issue resolved, would hold off on the booster.: There is no further documentation of the outcome of the delay. A 2nd staff member had a temporary medical exemption until 11/18/2022. There was no further documentation regarding the delay. During a follow up interview with the surveyor on 12/06/2022 at 12:41 PM, the IP said the four unvaccinated are staff members who had a reaction to the covid vaccines, and they are medical exemptions. That is where I screwed up. The staff who had a temporary delay for the vaccination until 11/18/2022 had a pending religious exemption. The IP said she will be following up with the staff who had a recommendation in April to hold off before getting the booster. A review of an undated facility policy titled Mandatory Employee Covid-19 Vaccination, revealed the following under the Policy section: All [facility name] employees including those who are not responsible for direct resident care, per diem (as needed) and contract employees are required to have at least the primary series and one booster. The policy further revealed Under the Procedure section: 3. Record Keeping- The facility must maintain a record of vaccinations, attestations and Exemption record for each employee and contract employees. NJAC 8:39-19.4(a)

Based on observation, interview, and record review and review of other facility documentation, it was determined that the facility failed to ensure the accurate assessment of a resident's feeding tube and a pressure ulcer was documented in the Minimum Data Set (MDS), an assessment tool. This deficient practice was identified for 2 of 21 resident's reviewed for MDS accuracy (Resident #85 and #71), and was evidenced by the following: A. On 12/1/2022 at 10:56 AM, during the initial tour of the facility, the surveyor observed Resident #85 in their wheelchair getting dressed. Resident #85 stated he/she had a feeding tube and they wanted it removed. The surveyor questioned if the resident was able to eat by mouth. Resident #85 responded, Yes. The surveyor asked how long the feeding tube had been in place. The resident responded, Too long. I want it out. A review of the Admission Record revealed that Resident #85 was admitted to the facility with the diagnoses including but not limited to: vascular dementia, and dysphagia, oropharyngeal phase (difficulty initiating a swallow). A review of the 8/24/2022 admission MDS revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating he/she was cognitively intact. Section G of the MDS revealed Resident #85 was independent with eating and section K revealed that Resident #85 received a mechanically altered diet. Section K did not have a feeding tube while not a resident or while a resident in the facility documented. Resident #85 had a quarterly MDS assessment completed on 11/24/2022. Section G revealed Resident #85 was an independent eater and section K revealed Resident #85 received a mechanically altered diet and did not include documentation of the resident having a feeding tube while not a resident or while a resident at the facility. A review of Resident #85's Order Summary report, dated 12/9/2022 revealed the following physician orders: G.I. (Gastroenterology) consult re: removal of peg tube one time only for removal of peg for 30 Days (11/18/2022). Enteral Protocol: Cleanse tube feeding site with soap and water, pat dry and cover with drain sponge every evening shift (9/5/2022). Enteral Protocol: Check Proper Placement of Feeding Tube every shift for Proper placement prior to tube feeding, flush or medication. (8/17/2022). every 6 hours 250 ml (milliliter) flush AND every shift ENTERAL PROTOCOL: Flush with 10 ml between medications and 50 ml at start and end of medication administration (8/17/2022). A review of the 12/1/2022-12/31-2022 Medication Administration Record (MAR) revealed that Resident #85 had received every 6 hour 250 ml water flush via feeding tube at 0000, 0600, 1200, and 1800 for the dates 12/1/2022 up to and including 12/9/2022 at 0600. A review of Resident #85's comprehensive care plan with a date initiated of 8/17/2022 revealed the following under the Focus section: I have a tube in my bellie (sic) for my feeding because of dysphagia. Under the GOAL heading the following was revealed with a revision date of 09/07/2022: My goal is to be able to eat a regular diet and swallow normal thin liquids within 90 days. Interventions and tasks included but were not limited to the following: Check for tube placement and gastric contents/residual volume per facility protocol. Notify MD (medical doctor) if residual is greater than 100 ml (milliliters). Dietitian to evaluate quarterly and as needed. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. On 12/9/2022 at 11:41 AM, the surveyor conducted an interview with the facility MDS Coordinator. The surveyor asked the MDS coordinator who is responsible for filling out the various sections of the MDS assessment tool. The MDS coordinator responded, Section K is filled out by the dietitian, section D and Q are filled out by Social Services and Section F is filled out by activities. I am responsible for filling out all the other sections, except section B which is filled out by the unit nursing managers. The MDS coordinator is responsible for checking accuracy prior to completion of the MDS. The surveyor went on to ask the MDS coordinator if Resident #85's Admission assessment, dated 8/24/2022 should have revealed that Resident #85 had a feeding tube on admission to the facility. The MDS coordinator explained, The MDS should have captured that the resident was on a feeding tube. That was an interim dietitian that was filling in for our regular dietitian. I should have corrected that on review. I am responsible for the accuracy of the assessment. On 12/09/2022 at 12:28 PM the surveyor conducted a telephone interview with the facility Registered dietitian (RD). On interview the RD revealed the following: He/she came to us (facility) with a feeding tube, but he/she was also able to eat orally. I am responsible for section K of the resident assessment. The surveyor asked the facility RD if he should have captured the presence of the feeding tube on Resident #85's admission assessment and subsequent quarterly assessment. The RD responded, The admission assessment I would say yes, it should be captured. I'm not sure that the feeding tube should be captured on the quarterly if he/she is not receiving fluids or enteral formula through the tube. The surveyor then made the RD aware that Resident #85 had a current order to receive a 250 ml water flush every 6 hours via the feeding tube. The RD responded that he was not sure how to code the MDS for the feeding tube in that situation. B. On 12/1/2022 at 11:05 AM, during the initial tour of the facility the surveyor interviewed Resident #71 in their room. Resident #71 was lying in bed and stated, I've lost a considerable amount of weight due to my sickness. A review of the Admission record revealed that Resident #71 was admitted to the facility with the following but not limited to diagnoses: Pressure ulcer of unspecified site, stage 4, osteomyelitis (an infection of bone), diabetes mellitus, paraplegia (paralysis of the legs and lower body). A review of the 10/18/2022 comprehensive admission assessment revealed that Resident #71 had a BIMS score of 15/15, indicating intact cognition. Section G revealed Resident #71 required total assist with all activities of daily living except eating, which he/she was independent. Section I of the MDS revealed an active diagnosis of pressure ulcer of unspecified site, stage 4. Section M that Resident #71 is at risk of developing pressure ulcers/injuries at M0150 and M0210 revealed that Resident #71 did not have one or more unhealed pressure ulcers/injuries upon readmission to the facility. A review of the Order Summary Report dated 12/9/2022 revealed the following orders for Resident #71: Measure sacral wound and complete wound assessment form every Wednesday 3-11. at bedtime every Wed for wound assessment every Wednesday 3-11. Order date 12/4/2022. Monitor wound vac machine for functioning & the placement to the sacrum every shift for wound care. Order date 10/12/2022. Wound vac set at 125 mm/hg (a unit of pressure based on an absolute scale) Change dressing every Mon, Wed, Fri for wound healing. Wound vac 1854: Cleanse sacral wound w/nss (with normal saline solution), apply Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas) to wound base, cover w/sponger (sic) & vac drape. Attached to -125 suction. M-W-F. Order Date: 12/4/2022. Collagenase Ointment (Santyl) 250 unit/GM (gram) Apply to sacral wound base topically every evening shift every Mon, Wed, Fri for sacral wound pressure area-cleanse with normal saline-apply Santyl to wound bed & cover with vac sponge - Skin prep to peri-wound cover with wound vac drape and attach suction at - 125 mm hcg (millimeters of mercury). Order date:12/5/2022. A review of Resident #71's comprehensive care plan, date initiated 10/16/2022 and date of revision on: 10/21/2022, revealed the following under Focus: Skin Intergrity: I Was admitted with a stage IV wound on my sacrum . On 12/9/22 at 11:49 AM, the surveyor conducted an interview with the facility MDS coordinator. The surveyor asked the MDS coordinator why Resident #71's comprehensive admission assessment/MDS did not indicate that Resident #71 was readmitted to the facility with a stage IV sacral pressure wound. The MDS coordinator explained, The admission assessment completed on 10/18/2022 does not indicate that resident #71 has a sacral wound. I missed it but I can make a correction. I have to make a modification correction and resend it to the state for both residents. Sometimes we make mistakes. Once I find a discrepancy, I will correct it and resubmit it to the state. On 12/9/22 at 1:39 PM the surveyor met with the Licensed Nursing Home Administrator and the facility Director of Nursing (DON). The facility DON stated, The MDS coordinator has already made the necessary corrections to those assessments that were coded incorrectly. NJAC 18: 39-11.1

Based on observation, interview and record review, it was determined that the facility failed to follow a prescribed care plan related to the transfer of a resident who had specific directions for transferring in and out of the bed/wheelchair. This deficient practice was identified for Resident #1, 1 of 7 residents reviewed for falls and accidents. Resident #1 during transfer, sustained a fracture to the right Tibia and Fibula (leg bones) and required intravenous pain medication. The evidence was as follows: The surveyor reviewed the medical record for Resident #1 on 3/6/14. The minimum Data Set (MDS), an assessment tool dated 1/16/14 and 10/25/13, indicated that Resident #1 was cognitively impaired, unable to walk and required two-person assistance for transfer out of bed or wheelchair. A review of the Certified Nursing Assistant (CNA) care plan indicated the resident was to be transferred with the use of two person assistance. The resident's Activities of Daily Living (ADL) care plan dated 8/31/13 indicated for staff to use two person assistance for transfer. According to the resident's Accident/Incident Report dated 2/15/14, Resident #1 sustained a leg fracture after the CNA attempted to transfer the resident herself. The surveyor reviewed the hospital record dated 2/15/14. It was documented on the History and Physical (H&P) report that the facility sent Resident #1 to the hospital because they were unable to control his/her pain. The report also showed that Resident #1 was given intravenous pain medication and the leg was splinted. (refer to F 323). NJAC 8:39-11.2(b)

CN# Based on observation, interview and record review, it was determined that the facility failed to follow a prescribed mode of transfer for a resident who had specific directions for transferring in and out of the bed/wheelchair. This deficient practice was identified for Residents #1, 1 of 7 residents reviewed for falls and accidents, who, during transfer, sustained a fracture to the right tibia and fibula (leg bones) and required intravenous pain medication. The evidence was as follows: The surveyor reviewed reportable complaint documentation and the medical record for Resident #1 on 3/6/14. The medical record indicated that Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The minimum Data Set (MDS), an assessment tool dated 1/16/14 and 10/25/13, indicated that Resident #1 was cognitively impaired, unable to walk and required two-person assistance for transfer out of bed or wheelchair. On 3/6/14 the surveyor reviewed the facility's Accident/Incident report dated 2/15/14. The documentation indicated that Resident #1 had sustained an ankle fracture. A review of the investigative protocol dated 2/14/14 revealed that a Certified Nursing Assistant (CNA) transferred Resident #1 "improperly on 2/13/14, did not follow CNA care plan to use two person assist for transfer." The surveyor reviewed the CNA care plan that directed staff to use two people to transfer Resident #1. The surveyor interviewed the Registered Nurse Unit Manager(RN/UM) on 3/6/14 at 11:30 a.m. She told the surveyor that Resident #1 had always required a two person transfer but that "it also depends on the aide and that it was up to the staff." The surveyor observed Resident #1 on 3/7/14 at 10:40 a.m. as two staff members assisted the resident during morning care. One staff member identified herself as the resident's CNA while the other stated that she was the Restorative Aide (RA). The surveyor observed that Resident #1 wore a splint to the right hand and a full leg cast on the right leg. Upon interview at this time, the CNA and the RA stated that Resident #1 was a two person transfer even with the use of the stand-up lift. When the surveyor inquired about the splint, the CNA told the surveyor that Resident #1 had contractures to the right hand and that it had been that way since she started taking care of the resident about seven months ago. The surveyor reviewed one employee accident statement which indicated that during rounds on the night of 2/13/14, the resident screamed and complained of leg pain when the employee attempted to provide care. A statement dated 2/15/14, written by an 11p.m.-7a.m. shift employee, indicated that Resident #1's right leg was swollen and that the resident "yelled ouch" in pain when the leg was touched. Resident #1 was given pain medication at that time. Another statement dated 2/15/14 indicated that Resident #1 complained of pain to the right leg during the 7a.m.-3p.m. shift morning care. The surveyor reviewed the hospital record dated 2/15/14. It was documented on the History and Physical (H&P) report that the facility sent Resident #1 to the hospital because they were unable to control his/her pain. The report also showed that Resident #1 was given intravenous pain medication and the leg was splinted. An X-ray report from the hospital revealed that Resident #1 sustained a tibia and fibula fracture and had pain with "any movement" of the leg. The hospital placed a long-leg cast to the resident's leg before discharging him/her to the facility. The surveyor reviewed Resident #1's Medication Administration Record (MAR) for December 2013, February 2014 and March 2014. This indicated that Resident #1 had a physician's orders [REDACTED]. The MAR showed that Resident #1 received Ultram 50 mg two times during the month of December. However, for the months of February and March 2014, the resident received Ultram three to four times per day due to pain. During an interview with the Administrator on 3/11/14 at 4 p.m., the Administrator acknowledged that the CNA did not follow the care plan. NJAC 8:39-27.1 (a)

C# NJ Based on complaint specifics, observation, interviews and a review of medical records and other documentation, it was determined that the facility failed to consistently ensure that 1 of 5 residents identified for wandering (Resident #1) was adequately supervised. Resident #1 self propelled the wheelchair (W/C) off the unlocked unit and into the Administrative area of the facility after administrative staff had left for the day. The Resident opened a fire door, fell down the stairs and sustained a closed head injury, thigh sprain and contusions of the hip. The evidence of this deficiency included: 1. The Resident Assessment Instrument (quarterly RAI) dated 5/29/12 indicated that Resident #1 had severe cognitive impairment with "fluctuating inattention", "disorganized thinking" and was known to "wander" in a W/C. The Resident also required extensive assistance of one person with most activities of daily living. A fall risk assessment dated [DATE] indicated a score of "18" (score of 10 or above indicate a high fall risk). The [DIAGNOSES REDACTED]. A Psychiatric Consultation dated 1/20/12 indicated [DIAGNOSES REDACTED]. The Interdisciplinary Care Plan indicated a review of 6/7/12 for use of a bed alarm and seat belt wheelchair alarm. Keep in common areas for visual monitoring by staff, check alarm often for functioning each shift. Also, every half hour observation while in "bed" and staff was to be close to Resident's room during hallway monitoring. The Psychotropic Drug Use (care plan) reviewed 6/7/12 indicated "Encourage physical mobility, exercise daily as tolerated." Also Resident "Needs to make indep (independent) decisions - strong willed" and was accustomed "to be in control (of) situations." There was no entry included in the care plan that indicated the Psychiatric [DIAGNOSES REDACTED]. A Wanderguard device was not identified as an intervention in the care plan. According to the investigative summary dated 7/6/12, for the incident that occurred on 7/1/12, Resident #1 "is out of bed to wheelchair and can mobilize self in the W/C by shuffling of her feet." The Resident has had previous falls and a buckle seat belt with alarm on her wheelchair which "she can open but not always at command." The Nursing Supervisor found that the Resident's alarm attached to the W/C was in the "off" position. The certified nurse aide #1 (CNA) gave the Resident a shower after dinner and placed the Resident in front of the nurse's station. The Resident was last observed by staff at "6:30pm." A housekeeping employee at "6:55pm to 7:00pm" heard a sound in the stairway from the Resident and notified the Supervisor. The summary further indicated that twenty minutes after Resident #1 was found, the Supervisor interviewed an unsampled resident that observed Resident #1 in front of the conference room (located in the Administrative area). The unsampled resident "stated that she observed Resident (#1) pass her "between 30- 40 minutes ago." The facility's Investigative Protocol Check List dated 7/1/12 indicated that the "Resident managed to leave unit in w/c, roamed to the administrative side of facility, exited through 2 double doors and doorway that leads to the stairwell. She was found by ... (housekeeper) who heard moaning. The alarm was found in the off position. Resident was returned to facility (from the hospital) with no injury." The Interdisciplinary Progress Notes (IPN) dated 7/1/12 written by the nursing supervisor, confirmed the investigative report and indicated that the "Resident propelled herself and was able to enter restricted stairwell, was found in prone position on landing between steps 1 & 2." The wheel chair was found on "steps #3 & 4 overturned." The Resident was alert, oriented to name and "complained of pain, "there was "no evident deformity noted," "no blood noted" and the Resident "denies loss of consciousness" and 911 was called. The Hospital Emergency Department (ED) indicated that prior to arrival on 7/1/12 at 8:00pm Resident #1 "... fell from a height, down approximately 3 stairs" and "appears in no apparent distress," was "uncomfortable", awake, alert, confused, obeys commands" and "moves all extremities." The Resident reported "pain in back, groin and left leg." Morphine 2 mg IM was given at 10:36pm. Also a prescription for Percocet 1 tablet as needed every six hours for pain. The [DIAGNOSES REDACTED]. Further review of the IPN dated 7/2/12 indicated the Resident returned to the facility via stretcher at 12:15am. The "Resident (was) awake, alert, in ... (no) distress". Multiple x-rays and cat scans were done in the hospital. A Percocet prescription was provided for severe pain, observation and neurological monitoring was provided. On 10/4/12 at 3:30pm CNA #3 (3-11 shift) stated that Resident #1 sometimes is "restless" and even when kept nearby, "minutes later" the Resident can change and is gone." CNA #3 indicated that the Resident has "been found across the bridge" in the Administrative area, "we redirect" and the Resident will "reluctantly return" to the unit. The Resident is now kept in a "group" activity from 3:00pm to 8:00pm and doesn't have opportunity to roam into the Administrative area. The Assistant Administrator indicated on 10/4/12 at 4:50pm that the fire door was a double door which led to the stairwell and was used mostly by housekeeping staff and the fire door emitted 2-3 short beeps when opened. She also stated that she closes the doors leading into the Administrative area when she leaves the unit at the end of the work day (6:00pm to 7:00pm). The Assistant Administrator did not work on 7/1/12, the day the Resident fell down the stairs. On 10/3/12 at 9:00am and 9:50am, the Surveyor observed the "bridge" that connected the resident's second floor unit to the second floor Administrative area. At the entrance to the Administrative area the Surveyor observed a seating area with a small sofa, chairs and plants. A few residents were observed in W/C's and ambulating about the area and along the main hall way of the Administrative area. A tour of the Administrative area of the building showed a short angled hallway that abutted the main hallway. The short hallway led to the fire door and stairwell which the Resident had entered and fallen down the stairs. Just before this fire door was a multi paneled portable privacy curtain that visually occluded the fire door. The Assistant Director of Nurses (ADON) stated on 10/3/12 at 9:55am that the privacy curtain was in place on 7/1/12 and that the Resident moved them to get to the door. On 10/3/12 at 1:35pm the Director of Nurses (DON) stated that she previously observed the Resident "cross over the bridge, into the Administrative area and redirected her" back to the unit. The Surveyor interviewed the Housekeeper on 10/3/12 at 1:40pm. The Housekeeper indicated that on 7/1/12 he had mopped the first floor area that was near the stairwell, placed the caution signs and left the area to dry for about 10 to 15 minutes. At about 6:50pm to 7:00pm he returned to "remove the signs" and "I heard a soft voice asking for help". "I followed where it came from and I found out it was in the stairway. When I looked in the glass panel of the exit door, I saw a foot on the stair. I hurriedly went to the security desk" and asked to have the Nursing Supervisor paged. The Housekeeper stated that he recognized the Resident and that he did not see her near the second floor fire door hallway in the Administrative area before the fall. He also stated that he did not hear any alarm, door beep or any commotion indicating a fall while going about his duties. The DON confirmed on 10/3/12 at 1:38pm that the investigation showed the W/C seatbelt alarm box was turned off and did not sound. The Nursing Supervisor stated on 10/3/12 at 1:10pm that "I was paged to the nurse office on the first floor (near the stairway) and went there right away and "heard a whimper at the fire door". The Supervisor opened the door and saw the Resident's "right foot caught in the railing with the leg" resting on the stair and her body was resting partially on a step and landing. The W/C was turned over midway down on the steps. The Resident appeared to have been propelled out of the W/C about half way down the stairs. The Resident was not moved and 911 was called immediately. There was no blood anywhere or any deformity of the limbs that might have indicated a fracture. The Supervisor went to the second floor and saw that one of the double fire doors was closed but the other was slightly ajar. The Supervisor felt that the Resident was "able to push the door open" and the "doors closed by itself." The Supervisor also stated that when the Resident was found, she wore a scarf that was knotted in the front of her head that may have insulated her head from the fall and there was "not a mark on her." The Resident was awake and alert and communicated with staff. The Supervisor and DON stated that the Resident had previously been seen in the main hallway of the Administrative area however they "never saw her (Resident) follow the path to that area (fire door stairway)." During further interview, the Supervisor indicated that sometimes the activity staff will have activities for the residents in the conference room at the end of the main hallway in the Administrative area. Also residents are known to visit the business office or other offices in the Administrative area. In an interview with CNA #1 on 10/3/12 at 2:55pm, she stated that the Resident "wandered a lot" and that the Resident would "look for children" and "goes thru the bridge and all over (Administrative area)". She also stated that the Resident was checked every half hour. The CNA indicated that the last time the Resident was observed was at 6:30pm sitting in the hallway. The CNA was unaware if the Resident ever went to the hall leading to the fire door stairway. During a post survey interview on 10/12/12 at 2:55pm CNA #2 confirmed that she assisted CNA #1 with the Resident's care after dinner. CNA #2 indicated that the Resident was calm after the shower and the doors to the unit's entrance were closed and the Resident was in the W/C near the nurse's station. CNA #2 stated that the Resident sometimes will push the doors open and self propel over the bridge toward the Administrative area and CNA #2 will bring her back to the unit. Resident #1 was observed on 10/3/12 at 9:40am sitting in a W/C near the nurses station with other residents. The Resident indicated no complaint of pain and was observed with a seat belt alarm that sounded when checked. The Resident Accidents & Incidents policy is "... to provide a safe environment to its residents and ensure accurate and timely reporting with appropriate intervention for all accidents/incidents of known and unknown origins." NJAC: 8:39-27.1(a)

Based on observation, interview, medical record review and review of data provided by the facility, it was determined that the facility failed to provide nutritional care and services to prevent a resident's severe weight loss of 23.8 pounds (lbs.) which was equivalent to 18% of her body weight, in 3 months and at one point the resident experienced a severe weight loss of 11 lbs. in 1 month. This deficient practice occurred to 1 of 12 residents sampled for nutritional concerns (Resident #20) and was evidenced by the following: The surveyor reviewed the medical record which noted that Resident #20 had a physician's orders [REDACTED]. On 7/30/10, Resident #20 was ordered by the physician to receive one can of Ensure Plus twice a day. According to the April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The surveyor noted that the plan of care concerning "Weight Loss Risk" for Resident #20 was revised by the Registered Dietician (RD) on 4/1/11. This revision added that the resident was to receive 2 nectar thick juices with each meal and 8 oz. of lactacid milk with her breakfast in addition to a lactose restricted, no added salt, pureed diet with nectar thickened liquids. The resident was also supposed to receive super cereal with breakfast, super mashed potatoes with lunch and dinner and a "soaked super cookie in [MEDICATION NAME] milk". A "super cookie" was a cookie that was high in calories. The plan of care also indicated that the amount of food that Resident #20 consumed would be monitored at each meal and her weights would be monitored weekly. A progress note written by the Advanced Practice Nurse (APN) on 2/4/11, did not include any documentation or interventions to address Resident #20's significant weight loss of 7.2 lbs. from 1/11 to 2/11. A progress note written by a physician on 2/23/11 did not include any documentation or interventions to address Resident #20's significant weight loss. A progress note written by a physician on 3/17/11 contained documentation that Resident #20 "seems to be losing weight". The physician recommended that a multivitamin be ordered for the resident. Review of the resident's hematology report, dated 11/19/10, revealed that the hemoglobin (Hgb) was low at 8.3. The "reference range" was 11.2 to 15.7. The resident's hemocrit (HCT) was low at 25.7. The "reference range" was 34.1 to 44.9. The hematology report, dated 1/4/11, indicated that Resident #20's Hgb remained low at 9.3 and the resident's HCT remained low at 28.9. The hematology report, dated 4/1/11, indicated that Resident #20's Hgb remained low at 10.5 and the resident's HCT remained low at 33.3. On 4/4/11 at 8:49 a.m., the surveyor observed a meal tray for Resident #20. According to the meal ticket that was on the tray, Resident #20 was to receive 8 ounces (oz.) of nectar thickened cranberry juice and 4 oz. of pureed french toast. "Super cereal" was handwritten on the meal ticket. The surveyor observed that Resident #20's meal tray had two 4 oz. containers of nectar thickened cranberry juice and pureed french toast. There was no super cereal observed on the tray. At 8:51 a.m. on 4/4/11, the surveyor observed a Certified Nursing Assistant (CNA) remove Resident #20's tray from the cart and serve it to the resident. The surveyor observed the CNA sit next to the resident and pour the thickened cranberry juice into a cup. The CNA then assisted the resident with drinking the juice. At this time, the surveyor asked the CNA if Resident #20 had received everything that the resident was supposed to receive on her breakfast tray. The CNA responded that the super cereal was not on the resident's tray and that she would need to call the kitchen. The CNA left the resident's room, went to a phone and called the kitchen for the super cereal. At 8:55 a.m., a bowl of super cereal was provided to Resident #20. When interviewed on 4/4/11 at 9:23 a.m., the CNA stated that the resident consumed both 4 oz. containers of cranberry juice and a spoonful of the french toast and a spoonful of the super cereal. The CNA also stated that Resident #20 was never a good breakfast eater, even when she was able to feed herself. The CNA added that the resident likes lunch and dinner. When interviewed, by the surveyor, on 4/4/11 at approximately 10:00 a.m., the RD stated that Resident #20 should have received the 8 oz. of [MEDICATION NAME] milk with breakfast and that super mashed potatoes would be provided at either lunch or dinner daily. The RD stated that the resident's meals were monitored and the amount consumed was documented on a meal monitoring form. A review of the only available meal monitoring form, which was dated for the "week of 3/20/11", revealed that there was no meal monitoring documented for Resident #20 until the dinner meal of 3/23/11. In addition, there was no documentation regarding the amount of the breakfast and lunch meals that Resident #20 consumed on 3/24/11 and 3/25/11. There was no documentation at all for any of the breakfast, lunch and dinner meals consumed by Resident #20 from 3/26/11 through and including 4/4/11. During this same interview, the RD stated that she did not know if the resident's weights were being monitored weekly. According to the medical record, Resident #20's weights were documented monthly not weekly as set forth in the resident's care plan. According to the weight sheet, Resident #20 weighed 130.2 lbs. in January of 2011 and 123 lbs. in February of 2011. This indicated a significant weight loss of 7.2 lbs. in 1 month. In March of 2011, Resident #20 weighed 112 lbs., which was indicative of a severe weight loss of 11 lbs. in one month. In April of 2011, Resident #20 weighed 106.4 lbs., which was indicative of a severe weight loss of 5.6 lbs. in one month. In total, Resident #20 experienced a severe weight loss of 18% (23.8 lbs.) in 3 months. An interdisciplinary note, dated 2/4/11 at 3:15 p.m., noted that the RD documented that Resident #20 had a 5% weight loss in one month and a 9% weight loss in 3 months. The RD wrote "meal monitoring indicated". The RD also documented that Resident #20 received 1 can of Ensure Plus, a supplement drink, at 9:00 a.m. and 6:00 p.m. and that the resident consumed only 0 to 25% of the 6:00 p.m. can. The RD wrote that she had suggested to the Unit Manager and "day shift nurses" that the resident's 6:00 p.m. can of Ensure Plus be changed to 2:00 p.m. because the resident may be full from dinner at 6:00 p.m. The RD also documented that Resident #20 was receiving [MEDICATION NAME] milk at each meal. A review of the meal tickets for these resident revealed that [MEDICATION NAME] milk was not being provided to the resident at any of her meals until the surveyor intervened after the breakfast meal on 4/4/11. A review of the resident's MARs for February 2011, March 2011 and April 2011, revealed that Resident #20 continued to receive her Ensure Plus at 9:00 a.m. and 6:00 p.m. The documentation on these 3 MARs indicated that the resident consumed 0% of the 6:00 p.m. supplement on most evenings. According to the RD's interdisciplinary note, dated 3/23/11 at 4:30 p.m., Resident #20 experienced an 11 lb. weight loss (9% loss) in one month. The RD documented to continue "meal monitoring" and to "resume weekly weights". The RD also documented that Resident #20 continues to consume "0-25%" of the 6:00 p.m. supplement. The RD wrote that the "care plan's in place for wt. loss and risk". When interviewed, by the surveyor, on 4/4/11 at approximately 10:00 a.m., the RD stated that Resident #20 did not consume much of her 6:00 p.m. Ensure Plus and would like to change the time to 2:00 p.m. The RD stated that the resident may not drink the Ensure Plus at 6:00 p.m. because she may still be full from dinner. The RD stated that she had spoken with the "hall nurses" about changing the times of Resident #20's Ensure Plus to 9:00 a.m. and 2:00 p.m. but had not pursued the change in times nor had she documented her additional discussions with the "hall nurses" regarding her recommendations to change the times of the supplement from 9:00 a.m. and 6:00 p.m. to 9:00 a.m. and 2:00 p.m. On 4/4/11 at 12:00 noon, the surveyor observed that Resident #20 was served a pureed vegetable lasagna souffle`, super mashed potatoes and pureed green beans. There were two 4 oz. containers of nectar thickened cranberry juice and a dish of pureed apple crisp dessert. There was no [MEDICATION NAME] milk or [MEDICATION NAME] soaked cookie on the tray as indicated on the resident's plan of care. When interviewed at this time, the RD stated that the [MEDICATION NAME] milk should be served on the resident's breakfast tray only and that the [MEDICATION NAME] soaked cookie would be served on the days that the resident did not receive the super mashed potatoes with the meal. When interviewed, by the surveyor, on 4/4/11 at 12:15 p.m., the Food Service Director (FSD) stated that he was told by his food service workers that milk was listed as a "dislike" for this resident and that the resident had refused the [MEDICATION NAME] milk so it was no longer on the meal ticket. Subsequently, Resident #20 did not receive the [MEDICATION NAME] milk at any meal. The FSD confirmed that the resident would receive the [MEDICATION NAME] soaked cookie as an alternate to the super mashed potatoes. The FSD added that there was a schedule for the meals that the resident would receive the super mashed potatoes and the [MEDICATION NAME] soaked cookie. This "schedule" was provided to the surveyor. When interviewed, by the surveyor, on 4/4/11 at 1:30 p.m., the FSD, in the presence of the RD, the Administrator (LNHA, the Director of Nurses (DON) and Assistant DON, stated that Resident #20 should get a super cookie soaked in [MEDICATION NAME] milk, however the super cookies are so "grainy" that the cookie would not dissolve in the [MEDICATION NAME] milk. Because the resident was ordered to receive a pureed diet, she could not receive the super cookie because it would not be at the proper consistency. The FSD stated that a "magic cup", a high calorie, ice cream type dessert and a milk shake were available but Resident #20 could not receive these items because they contain milk and the resident was lactose intolerant. The FSD stated that, for breakfast, Resident #20 should have received 8 oz. of nectar thickened cranberry juice, a carton of [MEDICATION NAME] milk, 6 oz. of super cereal and pureed french toast. The FSD confirmed that Resident #20 did not received all of these items at that morning's breakfast meal. The FSD stated that it was the responsibility of the dietary aides to monitor the trays prior to leaving the kitchen to ensure that the resident was receiving all of the items required for her diet. When interviewed by the surveyor on 4/4/11 at 1:30 p.m., the RD, in the presence of the FSD, LNHA, DON and ADON, stated that Resident #20 was receiving but not always consuming the Ensure Plus twice a day. The RD stated that she wasn't sure if Resident #20 had been receiving all of the high calorie food items listed on the plan of care when the resident suffered a significant weight lost of 7.2 lbs. from January 2011 to February 2011. The RD stated that when Resident #20 lost another 11 lbs. from February 2011 and March 2011, she did not change or implement any additional dietary interventions, like a calorie count, for the resident. The RD again stated that she wasn't sure if the resident was receiving all of the high calorie food items that were listed on the plan of care. The RD stated that when Resident #20 lost an additional 5.6 lbs. from March 2011 to April 2011, no new dietary interventions were implemented. When interviewed, by the surveyor, on 4/5/11 at 9:15 a.m., the LNHA stated that the facility staff had interviewed Resident #20's daughter, who told the facility staff that the resident developed a lot of "phlegm" when she drank milk so the daughter thought that this was a result of "lactose intolerance". The LNHA stated that they would still give the resident [MEDICATION NAME] milk. The RD, who was also present during this interview, stated that the resident would be receiving [MEDICATION NAME] tablets before her 3 meals, starting that day. The RD stated that since the resident would be receiving [MEDICATION NAME] tablets before her meals, the high calorie "magic cup" would be added to her diet. The RD added that, as of 4/4/11, the resident's Ensure Plus would be offered at 9:00 a.m. and 2:00 p.m. The LNHA stated that other interventions were now in place for Resident #20 in an attempt to prevent further weight loss. NJAC 8:39-17.4(a)(1 & 3) NJAC 8:39-27.1(a) NJAC 8:39-27.2(a)