Every finding on record at Merwick Post Acute

Complaint #: 3135062Based on observations, interviews, review of medical records, and review of pertinent facility documents on 08/13/26, it was determined that the facility failed to ensure a cognitively impaired resident (Resident #1) was protected from physical and verbal abuse.On 11/25/25 at 10:19 a.m., Resident #1's family representative reported to the facility an instance of physical and verbal abuse by the Certified Nursing Assistant (CNA) #1 against Resident #1. The resident's family representative then provided the facility with the recorded video camera footage that showed the abuse incident that occurred in the resident's room. CNA #1 continued to provide care to residents on 11/25/25 from 8:41 a.m., until 10:19 a.m., when the facility was made aware of the video evidence of the abuse allegation.The facility's failure to ensure that the resident was protected from abuse posed a likelihood that serious injury, harm, impairment, or death could occur to Resident #1 and other residents.The immediate jeopardy was removed, and the deficient practice corrected on 11/26/25, prior to the start of the survey and therefore Past Non-Compliance (PNC). This deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for abuse and was evidenced by the following:A review of the facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, with a revised date of April 2021, included under Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse [.]. Under Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff [.].A review of the Facility Reportable Event (FRE), submitted by the facility to the New Jersey Department of Health (NJDOH) on 11/25/25, included the date and time as 11/25/25 at 10:19 a.m. The FRE revealed that on 11/25/25 at 10:19 a.m., the resident's family representative made the facility aware of a physical abuse allegation by CNA #1 against Resident #1, which occurred while the CNA was transferring Resident #1.The surveyor reviewed the facility's Summary and Conclusion (S&C) report, which revealed that on 11/25/25, Resident #1's family representative provided the facility a video camera footage showing CNA #1 abuse Resident #1 while attempting to transfer the resident to the wheelchair in the resident's room. The S&C further revealed that after the facility reviewed the video footage, they determined that CNA #1's actions against Resident #1 were inconsistent with proper ADL (Activities of Daily Living) assistance for their residents; and that CNA #1's actions did not meet the facility's standards of safe and respectful care. The facility also concluded that CNA #1's actions constituted a violation of the facility's abuse prevention standards and that the facility terminated CNA #1's employment on 11/25/25.A review of Resident #1's Quality Assurance Report (QAR) dated 11/25/25, indicated that CNA #1 was observed in the video footage attempting to assist the resident out of bed in a rough and inappropriate manner, pulling the resident and causing them to end up on the floor.According to a Progress Note (PN) dated 11/25/25 at 9:21 p.m., Resident #1 was observed with a left upper extremity skin tear that measured 2.5 cm x1.5 cm. A PN labeled: post fall revealed the presence of discoloration on the resident's left arm and that the resident complained of pain at the site of the skin tear. The PN indicated that the resident's x-ray result was negative for fracture.The surveyor reviewed the video footage which was time-stamped for 11/25/25 at 8:41 a.m. and lasted 1 minute and 21 seconds. The video revealed:Resident #1 holding a blanket in their left hand. CNA #1 pulled the blanket out of the resident's left hand. Resident #1 resisted and held onto the blanket as CNA #1 continued to pull the blanket from the resident's hand. CNA #1 stated to the resident I am not fighting with you today; you have to get up. CNA #1 then pulled the resident's left arm to get the resident out of the bed. Resident #1 fell to the floor and CNA #1 left the resident's room. Further review of QAR indicated that CNA #1 went and reported to the Registered Nurse (RN #1) that Resident #1 fell to the floor while she was transferring the resident to the wheelchair. CNA #1 continued to provide care to residents until 11/25/26 at 10:19 a.m., when the facility was made aware of the abuse allegation by CNA #1.The QAR indicated that the facility suspended CNA #1 and then terminated her once they reviewed the video footage and determined that CNA #1 violated abuse policy.The surveyor reviewed the closed medical record of Resident #1.A review of Resident #1's admission record (AR), an admission record summary, revealed that the resident was admitted to the facility with medical diagnoses which included but were not limited to: Dementia, Adjustment Disorder, Chronic Respiratory Failure (a long-term condition where the lungs cannot maintain adequate oxygen level).A review of the Minimum Data Set (MDS), an assessment tool dated 09/23/25, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired. The MDS further revealed that the resident required staff assistance for transfer in and out of the wheelchair.A review of Resident #1's Care Plan (CP) initiated on 04/23/25, revealed under Focus, that Resident #1 used anti-anxiety medication related to anxiety disorder. Interventions related to this focus area included but were not limited to; providing the resident with a quiet space and reduced stimulus when anxious. On 8/11/26 at 11:19 a.m. the surveyor interviewed RN #1, who was the nurse on duty on the day of the abuse incident. He stated that CNA #1 informed him that Resident #1 ended up on the floor and that he went to the resident's room and saw Resident #1 on the floor. RN #1 also stated that he could not recall the details of the incident.On 08/13/26 at 1:19 p.m., the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated that the Unit Manager (UM) showed her the video footage of the abuse incident, and the video did not match what CNA#1 told RN #1. The DON stated that the video showed CNA #1 yanked Resident #1 out of bed. The DON also stated that CNA #1 was physically abusive with Resident #1; and that they terminated CNA #1 because it is physical abuse.On 8/13/26 at 1:31 p.m., the surveyor interviewed the LNHA in the presence of the DON. The LNHA stated that CNA #1 did not follow the facility's abuse policy. The LNHA further stated that in the video, CNA #1 showed actions that did not meet the facility's expectations regarding the type of care the staff were to provide for the residents.The facility addressed the situation by immediately suspending CNA #1 after being notified of the video footage, then terminated CNA #1 on 11/25/25.The facility also removed the immediacy of the F 600 IJ, and implemented the following: reeducated the facility staff on abuse policies and procedures, initiated 11/25/25 and completed 11/25/25; all new hires and agency staff will be trained prior to their first shift, initiated 11/25/25; all facility residents were interviewed unless cognitively impaired; skin assessments were completed on all cognitively impaired residents; a resident council meeting was held on 11/26/26 to review resident rights, abuse prohibition policy, and reporting mechanisms; a 30 day look back on all incident reports, grievances, and self-reports was initiated; reeducation was completed with supervisory staff on immediate investigation and reporting requirements; additional signage was placed throughout the facility reminding the residents and their families of the abuse reporting hotline and ombudsman contact information; audits were conducted by interviewing 15 random residents using a standardized abuse screening tool weekly for 90 days; audits were conducted on 10 new employee records weekly for documentation of abuse training completion; and audits were brought to Quality Assurance Performance Improvement (QAPI) committee monthly x 3 months.The IJ began on 11/25/25 at 10:19 a.m., when the facility became aware of the video footage that showed CNA #1 abuse Resident #1.The surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Regional Director of Clinical Services (RCS) of the F600 IJ and provided them with the IJ template on 8/13/26 at 4:05 p.m.The immediate jeopardy was removed, and the deficient practice was corrected on 11/26/25 prior to the start of the survey and therefore was Past Non-Compliance (PNC).The surveyor verified the implementation of the Removal Plan (RP) and corrective plan onsite on 08/13/26, and determined that there is sufficient evidence that the facility self-corrected the noncompliance on 11/26/25, and is in substantial compliance at the time of the current survey for the specific regulatory requirement for F600. N.J.A.C. 8:39-4.1 (a)5

Complaint: 3015011Based on interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by a) discharging a resident with a midline catheter (long, flexible catheter inserted into larger veins of the upper arm) in place without a physician order (PO) to do so; and b) removing a resident's midline catheter after the resident was discharged at the resident's home without a PO to do so. This deficient practice was identified for 1 out of 3 residents reviewed for the discharge process (Resident #2). 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 well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Resident #2 was no longer at the facility. The closed medical record for Resident #2 was reviewed. A review of the admission record face sheet for Resident #2 revealed that the resident was admitted to the facility with diagnoses including but not limited to: pleural effusion (collection of fluid around the lungs), heart failure (heart muscle not pumping blood as well as it should), type 2 diabetes mellitus (body cannot use insulin correctly causing sugar build-up in the blood), malignant neoplasm of an unspecified site of unspecified female breast (abnormal growth of cells that are cancerous), and elevated white blood cell count (increased number of blood cells that help fight infection, aid in healing, and assist in recovery from disease). A review of the discharge Minimum Data Set (MDS) an assessment tool dated 03/20/2026, revealed that Resident #2 had a Brief Interview for Mental Status Score of 15 out of 15, which indicated that the resident's cognition was intact. A review of the Infectious Disease Nurse Practitioner Note with an effective date of 03/11/2026 at 10:49 AM, revealed a recommendation that Resident #2 start Vancomycin (antibiotic used to treat bacterial infections that are resistant to other antibiotics) 750 milligrams (MG) intravenously (IV) daily and ertapenem (antibiotic used to treat bacterial infections) 1 gram (GM) IV daily for 7 days for a sacral (triangular bone at the base of the spine) pressure ulcer which was covered with slough (dead tissue within a wound) and surrounded by cellulitis (infection of the skin and the soft tissues underneath). A review of the health status note with an effective date of 03/11/2026 at 2:30 PM, revealed that Resident #2 was to have a midline inserted by an outside company. The PN further revealed that the midline was for antibiotic therapy with vancomycin and ertapenem. Review of the Order Summary Report (OSR) for Resident #2 revealed the following physician orders (POs): Please place midline. The order date was 03/11/2026. Ertapenem sodium injection solution 1GM, IV one time for wound infection once medication arrives from the pharmacy. The order date was 03/11/2026. The start date was 03/12/2026. Ertapenem sodium Injection solution 1GM, IV every 24 hours for cellulitis for seven days. The order date was 03/11/2026. Vancomycin IV solution 750 MG per 150 ML one time a day for seven days for cellulitis. The order date was 03/11/2026. The start order date was 03/11/2026. A review of the Medication Administration Record (MAR) for Resident #2 revealed that the resident received the prescribed dose of ertapenem on 03/12/2026 at 9:27 AM, and 7:39PM, on 03/13/2026, 03/14/2026, 03/15/2026, 03/16/2026, and 03/17/2026. The MAR further revealed that Resident #2 received the prescribed dose of vancomycin on 03/11/2026, 03/12/2026, 03/13/2026, 03/14/2026, 03/15/2026, 03/16/2026, and 03/17/2026. A discharge note written by physician (PHY) #1, dated 03/20/2026 at 6:31 AM, was reviewed. The PN revealed that Resident #2's scheduled discharge date was 03/20/2026. The PN further revealed that the resident's prescriptions were written, and discharge instructions reviewed with the resident. Further review of the OSR revealed an order that Resident #2 could be discharged home on [DATE]. The order date was 03/20/2026. The order start date was 03/20/2026. The OSR did not reveal an order for the resident's midline to remain in place or an order to remove the midline. A late entry PN written by Licensed Practical Nurse (LPN) #1, dated 03/20/2026 at 2:27 PM, and entered into the facility electronic medical record on 03/21/2026 at 2:37 PM, was reviewed. The PN revealed that a midline catheter was removed from Resident #2's right upper extremity without complication and the site was assessed and found to be clean, dry, and intact. The PN further revealed that Resident #2 was prepared for discharge and left the facility at 2:45 PM, via medical transport and was accompanied by a family member. An interview was conducted with LPN #1 on 05/19/2026 at 4:27 PM. LPN #1 stated that she was the nurse who discharged Resident #2 from the facility on 03/20/2026. LPN #1 stated that it was the usual practice to do a head-to-toe assessment on residents prior to discharging them. LPN #1 stated that she did not perform a head-to-toe assessment on Resident #2 prior to discharging the resident. LPN #1 stated that she did not know that Resident #2 had a midline in place when they were discharged . LPN #1 stated that on 03/21/2026, the day after Resident #2 was discharged , she was instructed by a manager to go to the resident's home to remove the midline. LPN #1 further stated that she and Nursing Supervisor (NS) #1 went to the resident's house on 03/21/2026 to remove the resident's midline. An interview was conducted with Unit Manager (UM) #1 on 05/19/2026 at 12:34 PM. UM #1 stated that residents should not go home with IV access without a PO. UM #1 further stated that nurses should obtain a PO to remove the IV access when treatment is finished. UM #1 stated that Resident #2 was discharged home on [DATE]. UM #1 stated that a family member of Resident #2 called her and informed her that the resident was discharged home with IV access in place. UM #1 stated that it was not safe to send a resident home with IV access without a PO and the family was not educated on the device prior to discharge. An interview was conducted with NS #1 on 05/19/2026 at 1:37 PM. NS #1 stated that the process when a resident is discharged includes obtaining a PO for discharge, completing a full assessment, and educating the resident and family. NS #1 stated that a Registered Nurse (RN) or an LPN was responsible for removing IV access prior to discharging a resident. NS #1 stated that she was informed that Resident #2 was discharged without a head-to-toe check being completed and that the resident was discharged home with IV access in place. NS #1 stated that a body check is done prior to discharge to look for any devices or abnormal findings and document them. NS #1 stated that she went to Resident #2's home with another nurse to remove the resident's IV access after the resident had been discharged from the facility. An interview was conducted with the Director of Nursing (DON) on 05/19/2026 at 2:05 PM. The DON stated that Resident #2 did not have a PO to remove their midline at discharge, nor did the resident have a PO to keep their midline in place at discharge. The DON stated that there were no arrangements for care of the resident's IV access after discharge. The DON stated that Resident #2 should not have had the IV access in place when they were discharged from the facility. An interview was conducted with physician (PHY) #1 on 05/19/2026 at 4:13 PM. PHY #1 stated that residents are not normally discharged from the facility with IV access. PHY #1 stated that the usual process was for facility staff to contact him for an order to remove IV access. PHY #1 further stated that he was not aware that Resident #2 was discharged from the facility with a midline in place. The facility policy Physician Orders with an updated date of January 2025 was reviewed. Under Policy Statement, the facility policy revealed that licensed nurses will obtain, document and provide care and services in accordance with orders received from the physician. Under Policy Interpretation and Implementation the facility policy revealed 4. Nursing staff will carry out the physician orders as directed by the physician. 5. The provision of care and services in accordance with the physician orders will be documented in accordance with professional standards of practice. The facility policy Peripheral IV Catheter Removal with a revision date of October 2024 was reviewed. Under General Guidelines the facility policy revealed 1. Evaluate the continued need for vascular access during provider visits and care planning. This section of the facility policy further revealed 2. Remove the peripheral/midline IV catheter if: a. vascular access is no longer clinically indicated. Under Documentation the facility policy revealed The following should be documented in the resident's medical record: 1. Date, time of procedure [ .]. NJAC 8:39-27.1 (a)

Complaint: 3015011 Based on interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to complete an incident report and thoroughly investigate after a resident was discharged from the facility with a midline catheter (long, flexible catheter inserted into larger veins of the upper arm) in place. This deficient practice was identified for 1 of 3 residents reviewed for the discharge process (Resident #2), and was evidenced by the following:Resident #2 was no longer at the facility. The closed medical record for Resident #2 was reviewed. A review of the admission record face sheet for Resident #2 revealed that the resident was admitted to the facility with diagnoses including but not limited to: pleural effusion (collection of fluid around the lungs), heart failure (heart muscle not pumping blood as well as it should), type 2 diabetes mellitus (body cannot use insulin correctly causing sugar build-up in the blood), malignant neoplasm of an unspecified site of unspecified female breast (abnormal growth of cells that are cancerous), and elevated white blood cell count (increased number of blood cells that help fight infection, aid in healing, and assist in recovery from disease). A review of the discharge Minimum Data Set (MDS) an assessment tool dated 03/20/2026, revealed that Resident #2 had a Brief Interview for Mental Status Score of 15 out of 15, which indicated that the resident's cognition was intact. A review of the Infectious Disease Nurse Practitioner Note with an effective date of 03/11/2026 at 10:49 AM, revealed a recommendation that Resident #2 start Vancomycin (antibiotic used to treat bacterial infections that are resistant to other antibiotics) 750 milligrams (MG) intravenously (IV) daily and ertapenem (antibiotic used to treat bacterial infections) 1 gram (GM) IV daily for 7 days for a sacral (triangular bone at the base of the spine) pressure ulcer which was covered with slough (dead tissue within a wound) and surrounded by cellulitis (infection of the skin and the soft tissues underneath). A review of the health status note with an effective date of 03/11/2026 at 2:30 PM, revealed that Resident #2 was to have a midline inserted by an outside company. The PN further revealed that the midline was for antibiotic therapy with vancomycin and ertapenem. Review of the Order Summary Report (OSR) for Resident #2 revealed the following physician orders (POs): Please place midline. The order date was 03/11/2026. Ertapenem sodium injection solution 1GM, IV one time for wound infection once medication arrives from the pharmacy. The order date was 03/11/2026. The start date was 03/12/2026. Ertapenem sodium Injection solution 1GM, IV every 24 hours for cellulitis for seven days. The order date was 03/11/2026. Vancomycin IV solution 750 MG per 150 ML one time a day for cellulitis. The order date was 03/11/2026. The start order date was 03/11/2026. A review of the Medication Administration Record (MAR) for Resident #2 revealed that the resident completed the prescribed dose of ertapenem on 03/17/2026. The MAR further revealed that Resident #2 completed the prescribed doses of vancomycin on 3/17/2026. A discharge note written by physician (PHY) #1, dated 03/20/2026 at 6:31 AM, was reviewed. The PN revealed that Resident #2's scheduled discharge date was 03/20/2026. The PN further revealed that the resident's prescriptions were written, and discharge instructions reviewed with the resident. Further review of the OSR revealed an order that Resident #2 could be discharged home on [DATE]. The order date was 03/20/2026. The order start date was 03/20/2026. The OSR did not reveal an order for the resident's midline to remain in place or an order to remove the midline. A late entry PN written by Licensed Practical Nurse (LPN) #1, dated 03/20/2026 at 2:27 PM, and entered into the facility electronic medical record on 03/21/2026 at 2:37 PM, was reviewed. The PN revealed that a midline catheter was removed from Resident #2's right upper extremity without complication and the site was assessed and found to be clean, dry, and intact. The PN further revealed that Resident #2 was prepared for discharge and left the facility at 2:45 PM, via medical transport and was accompanied by a family member. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 05/19/2026 at 4:27 PM. LPN #1 stated that she was the nurse who discharged Resident #2 from the facility on 03/20/2026. LPN #1 stated that she did not know that Resident #2 had a midline in place when they were discharged . LPN #1 stated that on 03/21/2026, the day after Resident #2 was discharged , she was instructed by a manager to go to the resident's home to remove the midline. LPN #1 further stated that she and Nursing Supervisor (NS) #1 went to the resident's house on 03/21/2026 to remove the resident's midline. An interview was conducted with Unit Manager (UM) #1 on 05/19/2026 at 12:34 PM. UM #1 stated that residents should not go home with IV access without a physician order (PO). UM #1 further stated that nurses should obtain a PO to remove the IV access when treatment is finished. UM #1 stated that Resident #2 was discharged home on [DATE]. UM #1 stated that a family member of Resident #2 called her and informed her that the resident was discharged home with IV access in place. UM #1 stated that she called the facility to follow up with NS #1, who was the NS on duty. UM #1 stated that she believed that facility staff went to the resident's home to remove the resident's IV access. UM #1 stated that it was not safe to send a resident home with IV access without a PO and the family was not educated on the device prior to discharge. UM #1 further stated that an incident report (IR) should have been completed if something was accidentally done and needed to be followed up on and rectified. UM #1 stated that she did not complete an IR related to Resident #2's discharge with IV access in place. An interview was conducted with NS #1 on 05/19/2026 at 1:37 PM. NS #1 stated that a Registered Nurse (RN) or an LPN was responsible for removing IV access prior to discharging a resident. NS #1 stated the day after Resident #2 was discharged , a family member called to inform NS #1 that the resident was discharged home with IV access in place. NS #1 stated that she requested that the family member take the resident to the emergency department to have the IV access removed but the family member declined. NS #1 stated that she was advised by facility management to go with another nurse to the resident's home to remove the IV access. NS #1 stated that she and another nurse went to Resident #2's home and removed the resident's IV access. NS #1 stated that this issue warranted an IR but she did not submit an IR and she was not sure if anyone had completed an IR. NS #1 further stated that the purpose of IRs was to follow up on incidents and to document actions that were taken to fix what happened. An interview was conducted with the Director of Nursing (DON) on 05/19/2026 at 2:05 PM. The DON stated that Resident #2 did not have a PO to remove their midline at discharge, nor did the resident have a PO to keep their midline in place at discharge. The DON stated that there were no arrangements for care of the resident's IV access after discharge. The DON stated that Resident #2 should not have had the IV access in place when they were discharged from the facility. The DON stated that if a resident was discharged with IV access in place without proper planning, it placed the resident at risk for bleeding, infection, or other negative repercussions. During the same interview the DON stated that she was not aware that Resident #2 was discharged with IV access in place, or that facility staff went to the resident's home to remove the IV access until the date of the survey (05/19/2026). The DON stated that she should have been called on 03/21/2026 when staff became aware of the issue. The DON stated that it was her expectation that an IR should have been completed related to Resident #2 being discharged with IV access in place. The DON stated that completion of an IR would have contributed to learning and preventing similar incidents from happening again. The facility policy Accidents and Incidents- Investigation and Reporting with a revision date of July 2017 was reviewed. Under Policy Statement the facility policy revealed that all accidents or incidents involving residents and employees occurring on the premises should be investigated and reported to the administrator. Under Policy Interpretation and Implementation the facility policy revealed 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: a. The date and time accident or incident took place; b. The nature of the injury/illness [.] c. The circumstances surrounding the accident or incident; [.] g. The time the injured person's attending physician was notified, as well as the time the physician responded and his or her instructions; [ .] 5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident; [ .] 7. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. NJAC 8:39-27.1 (b)

Complaint #:3015011 Based on interviews, record review, and review of pertinent documents, it was determined that the facility failed to ensure that the medical record accurately documented the care provided to a resident who was discharged home with a midline (long, flexible catheter inserted into larger veins of the upper arm) and had it removed in their home the next day by facility staff. This deficient practice occurred for 1 of 3 residents reviewed for discharge processes (Resident #2) and was evidenced by the following:Resident #2 was no longer in the facility. A closed record review was conducted. A review of the admission record face sheet for Resident #2 revealed that the resident was admitted to the facility with diagnoses including but not limited to: pleural effusion (collection of fluid around the lungs), heart failure (heart muscle not pumping blood as well as it should), type 2 diabetes mellitus (body cannot use insulin correctly causing sugar build-up in the blood), malignant neoplasm of an unspecified site of unspecified female breast (abnormal growth of cells that are cancerous), and elevated white blood cell count (increased number of blood cells that help fight infection, aid in healing, and assist in recovery from disease). Resident #2's discharge Minimum Data Set (MDS) an assessment tool dated 03/20/2026, was reviewed. The MDS revealed that Resident #2 had a Brief Interview for Mental Status Score of 15 out of 15, which indicated that the resident's cognition was intact. A late entry progress note (PN) written by Licensed Practical Nurse (LPN) #1 dated 03/20/2026 at 2:27 PM, and entered into the facility electronic medical record on 03/21/2026 at 2:37 PM, was reviewed. The PN revealed that a midline catheter was removed from Resident #2's right upper extremity without complication and the site assessed and found to be clean, dry, and intact. The PN further revealed that Resident #2 was prepared for discharge and left the facility at 2:45 PM, via medical transport and was accompanied by a family member. An interview was conducted with the Director of Nursing (DON) on 05/19/2026 at 2:05 PM. The DON stated that she became aware on the date of the survey (05/19/2026) that Resident #2 was discharged with a midline in their arm without a physician order to keep the midline in place; without having care arranged for the midline at the resident's home; and that facility staff went to the resident's home and removed the midline on 03/21/2026. During the same interview the late entry PN written by LPN #1, dated 03/20/2026 at 2:47 PM was reviewed with the DON. The DON confirmed that the PN did not reflect that the midline was removed from Resident #2's arm on 03/21/2026 at the resident's home. The DON stated that her expectation was for the PNs to reflect the care provided to the resident. The DON further stated that the PN dated 03/20/2026 at 2:47 PM was not truthful. An interview was conducted with LPN #1 on 05/19/2026 at 4:27 PM. LPN #1 stated that she did not know that Resident #2 had a midline when she discharged the resident. LPN #1 stated that Nursing Supervisor (NS) #1 informed her that the resident had been discharged with the midline and NS #1 and LPN #1 went to the resident's home to remove the midline on 03/21/2026. LPN #1 stated that she did not include in her PN that the midline was removed on 03/21/2026 at the resident's home. LPN #1 further stated that the PNs she writes should reflect what happened, and her PN dated 03/20/2026 does not reflect what happened with Resident #2. The facility policy Peripheral IV Catheter Removal with a revision date of October 2024 was reviewed. Under General Guidelines the facility policy revealed 1. Evaluate the continued need for vascular access during provider visits and care planning. This section of the facility policy further revealed that an IV catheter should be removed if vascular access is no longer clinically indicated. Under Documentation the facility policy revealed that the date and time of the IV device removal should be documented in the resident's medical record. The facility policy Charting and Documentation with a revision date of July 2017 was reviewed. Under Policy Statement the facility policy revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's condition should be documented in the resident's medical record. This section of the facility policy further revealed that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Under Policy Interpretation and Implementation the facility policy revealed, 2. The following information is to be documented in the resident medical record: [.] c. Treatments or services performed; [.] e. Events, incidents or accidents involving the resident; [ .] 3. Documentation in the medical record will be objective [.], complete, and accurate; [ .] 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided. NJAC 8:39- 35.2(d)16

Complaint #: 2680813Based on record review, staff interviews, and review of pertinent facility documentation on 12/3/2025, it was determined that the facility failed to ensure the individualized comprehensive care plan reflected a resident's current physician ordered diet. This deficient practice was identified for 3 of 3 residents (Resident #1, Resident #2, and Resident #4). The findings were as followed:1.According to the admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to: atrial fibrillation (irregular heart rhythm), dementia, and depression. According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 11/14/2025, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident's cognition was severely impaired. Resident #1 was no longer at the facility at the time of the survey.A review of Resident #1's Order Summary Sheet (OSR) with active orders as of 11/7/2025 revealed the following physician order (PO):Vegetarian diet, pureed texture, thin consistency with an order date of 11/7/2025.A review of Resident #1's Care Plan (CP) revealed a Focus with an initiated date of 11/10/2025, that Resident #1 is at risk of malnutrition r/t [related to] chronic disease, on mechanically altered diet, and low BMI [body mass index]. The CP further revealed an intervention with an initiated date of 11/10/2025, Provide and serve diet as ordered: Regular diet, pureed texture, thin consistency. Resident #1's CP did not reveal that the resident was on a vegetarian diet. 2.According to the AR, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: hypertension, depression, and weakness.According to the comprehensive MDS, an assessment tool dated 11/22/2025, resident #2 had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. A review of Resident #2's OSR with active orders as of 12/3/2025 revealed the following PO:Regular diet, chopped texture, thin consistency with an order date of 11/18/2025.A review of Resident #2's CP revealed a Focus with an initiated date of 11/18/2025, that Resident #2 is at risk of malnutrition r/t [related to] chronic disease, altered lab values, and on mechanically altered diet. The CP further revealed an intervention with an initiated date of 11/18/2025, provide and serve diet as ordered: Regular diet, regular texture, thin consistency.Resident #2's CP did not reveal that the resident was on a chopped texture diet. 3.According to the AR, Resident #4 was admitted to the facility with diagnoses which included but were not limited to: cerebral infarction (when blood supply to part of the brain is blocked or reduced), muscle weakness, and dementia. According to the comprehensive MDS, an assessment tool dated 11/26/2025, Resident #4 had a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #4's OSR with active orders as of 12/3/2025 revealed the following PO:Renal diet, pureed texture, nectar consistency with an order date of 12/1/2025.A review of Resident #4's CP revealed a Focus with an initiated date of 11/25/2025, that resident #4 has a nutritional problem r/t [related to] chronic disease, increased nutritional needs, need for supplements, on mechanically altered diet, on therapeutic diet, and altered labs. The CP further revealed an intervention with an initiated date of 11/25/2025, Provide diet as ordered: renal diet, ground texture, regular/thin consistency, nectar thickened liquids.Resident #4's CP did not reveal that the resident was on a pureed texture.On 12/3/2025 at 12:27 P.M., the surveyor interviewed the Registered Dietician (RD) who stated she was responsible for creating the nutritional care plan with help from speech therapy and nursing staff. The RD further stated the accurate diet for the resident should have been reflected on the care plans. The RD confirmed that Resident #1, Resident #2, and Resident #4 did not have the correct diets reflected on their care plans. The RD stated it was important to ensure the care plans were correct because the care plan tells the staff how to care for the residents. On 12/3/2025 at 1:11 P.M., the surveyor interviewed the Director of Nursing (DON) who stated that the dietary and nursing staff should ensure the accuracy of the resident's diet on the care plans. The DON further stated the resident's physician order for their diet should match the care plan. She stated this was important because a resident could choke. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered with a revision date of March 2002 revealed under Policy Interpretation and Implementation, 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.NJAC 8:39-11.2 (e) (1)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to a.) sanitize, store, and maintain kitchen equipment to prevent microbial growth, b.) store, label and date potentially hazardous foods to prevent food borne illness, and c.) discard potentially hazardous food past the use by date. The deficient practice was evidenced by the following: On 4/21/2025 from 9:36 AM to 10:05 AM, the surveyor, who was accompanied by the Assistant Food Service Director (AFSD), observed the following in the kitchen: 1. In the walk-in refrigerator, there was a 5-pound container of ricotta cheese with lid ajar and opened date of 4/8/2025. The packaging indicated to use within 7 days of opening. The AFSD confirmed it needed to be discarded. 2. In the walk-in refrigerator, there were 3 Styrofoam cups of brownish liquid covered with plastic lids with no label and use by date. The AFSD confirmed they were coffee and that they needed to be labeled and dated. 3. In the walk-in freezer, there were 2 Styrofoam cups of unlabeled and undated frozen whitish substance that the AFSD identified as ice cream. The cups were covered by plastic wrap. The AFSD confirmed they needed to be labeled and dated. 4. In the dry storage room [ROOM NUMBER], a dry spillage of whitish powder was noted on top of canned sliced peaches on the lowest shelf. Directly above the cans was a large carton box with whitish powder inside and outside the box. Inside the box was an unsealed plastic bag of whitish powder. The AFSD identified the powder as powdered thickener. The plastic bag was unlabeled and there was no opened or use by date. The AFSD stated that the powder should have been transferred to another container and the plastic bag sealed. The AFSD took the box out of the storage room. 5. In the dry storage room [ROOM NUMBER], a carton box containing four, 6-pound cans of chocolate pudding was directly on the floor. The AFSD stated that it should have been 6 inches from the floor. The AFSD transferred the box on top of other boxes sitting on a shelf. 6. In the dry storage room [ROOM NUMBER] on the active can rack, a 6-pound canned sliced apple was observed dented on the side from the upper to the lower seam. The AFSD confirmed it needed to be discarded. 7. In the dry storage room [ROOM NUMBER], a previously opened bag of dry pasta was observed with no opened date. The AFSD confirmed it needed to be discarded. 8. On the equipment table, a conveyor toaster not in use was observed with heavy buildup of reddish brown and black substance all over the catch tray. Underneath the conveyor was a heavy buildup of blackish debris. The outer edge of the toaster on the upper and left side had a buildup of greasy brownish substance. The AFSD stated it would be cleaned. 9. A vented rolling dish rack containing 14 inverted red reusable plastic cups with mouthpiece part down were stored on top of a floor drain underneath the dish machine conveyor. Dietary aide #1 stated that the staff have finished washing them and the cups were clean. On 4/22/2025 at 8:28 AM, the surveyor observed a vented rolling dish rack filled with inverted red reusable plastic cups with mouthpiece part down underneath the dish machine conveyor. The surveyor pointed them out to the Regional Food Service Director (RFSD) who stated that the cups would be washed again. On 4/22/2025 at 9:11 AM, the surveyor and the Licensed Practical Nurse/ Unit Manager (LPN/UM) #1 toured the nourishment room [ROOM NUMBER] and observed the following: 1. In the reach-in freezer, an unlabeled and undated frozen core power protein shake. The LPN/UM confirmed it needed to be discarded. 2. In the reach-in refrigerator, a big bottle of seltzer was unlabeled and with no opened date. 3. In the reach-in refrigerator, a tub of previously used sandwich spread was unlabeled and with no opened date. 4. In the reach-in refrigerator, a full-size container of ketchup was unlabeled and with no opened date. 5. In the reach-in refrigerator, two cups of cooked white rice were unlabeled and with no use by date. 6. In the reach-in refrigerator, one plastic bag of raw oatmeal was unsealed, unlabeled, and with no use by date. 7. In the reach-in refrigerator, one covered bowl of milk powder was unlabeled and with no use by date. On 4/22/2025 at 9:46 AM, the surveyor and LPN/ UM #2 toured kitchenette #1 and observed the reach-in refrigerator door hsignage that reflected, all food must be labeled and dated, after 3 days it will be thrown out. The following were also observed: 1. In the reach-in refrigerator, a container of butter was unlabeled and with no opened or use by date. The LPN/ UM #2 confirmed it needed to be discarded. 2. In the reach-in refrigerator, a plastic tumbler containing liquid with curdled brownish substance. The LPN/ UM #2 confirmed it needed to be discarded. On 4/22/2025 at 9:52 AM, the surveyor and LPN/ UM #3 toured kitchenette #2 and observed the following: 1. In the reach-in refrigerator, a plastic bag of bread that appeared to be hard to the touch, was unlabeled with no opened or use by date. 2. In the reach-in refrigerator, a plastic container with several cartons of milk was immediately taken by the LPN/ UM #3 who stated they needed to be discarded. 3. In the reach-in refrigerator, a take-out style plastic container with leftover food was unlabeled and undated. On 4/23/2025 at 8:51 AM, in an interview with the surveyor, the Food Service Director (FSD) stated that the dietary department was responsible for the refrigerators in the kitchenettes. The surveyor relayed to the FSD the observations from the initial and follow-up tours. The FSD stated that all foods need to be labeled and dated. The FSD stated that dented cans need to be discarded. The FSD stated that all items in storage need to be 6 inches from the floor. On 4/25/2025 at 9:30 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the the RFSD and the survey team, acknowledged the concerns. A review of undated facility-provided policy titled Food Storage included the following: - Under Procedure 7.b.) Food should be dated as it is placed on the shelves if required by state regulation. - Under Procedure 7.c.) Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (Time/ Temperature Control for Safety) food should be consumed, sold, or discarded. - Under Procedure 8.) Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. - Under Procedure 9.) Food will be stored a minimum of 6 inches above the floor . - Under Procedure 11.) Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2017 Federal Food Code. - Under Procedure 12.) Refrigerated food storage: f.) All foods should be covered, labeled, and dated. - Under Procedure 13.) Frozen Foods: c.) All food items should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. A review of undated facility-provided policy titled General Food Preparation and Handling included the following: - Under Procedure 2.) Food Storage: c.) Food in broken packages, swollen or dented cans with a compromised seal, or food with an abnormal appearance or odor will be discarded. - Under Procedure 4.) Food Service: d.) Leftovers must be dated, labeled, covered, cooled, and stored in a refrigerator. - Under Procedure 5.) Equipment: a.) All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. A review of undated facility-provided policy titled Handling Clean Equipment and Utensils included the following: - Under Procedure: 2.) Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. - Under Procedure: 3.) Glasses and cups will be stored in an inverted position on a clean sanitary surface. N.J.A.C. 8:39 - 17.2 (g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary and comfortable environment that helped prevent the development and transmission of communicable diseases and infections. This was identified for 7 of 32 residents reviewed for infection control. The deficient practice was evidenced by the following: 1.) On 04/24/2025 at 9:55 AM, upon tour of the second floor unit (Luxor 2), surveyor #1 observed Resident #158 in their bed with an Enhanced Barrier Precautions (EBP) sign along the doorframe. The surveyor further observed a black trash bin with self-closing lid inside the resident room next to the door. Inside the room, the surveyor observed the resident trash bin overflowing with personal protective equipment (PPE), specifically blue gowns. A review of Resident #158's electronic medical record (EMR) revealed a physician's order to maintain enhanced barrier precautions related to, but not limited to, tracheostomy status (a surgical hole in the windpipe that helps with breathing). On the same date at 9:57 AM, the surveyor observed Resident #322 in their bed with an Enhanced Barrier Precautions sign along the doorframe. The surveyor further observed a black trash bin with self-closing lid inside the resident room next to the door. Upon entering the room, the surveyor observed dirty gloves and a used deep suctioning catheter (a catheter that is placed deep into the airway to remove secretions from the lower respiratory tract) laying on top of used PPE gowns and gloves in the resident's trash bin. A review of Resident #322's electronic medical record (EMR) revealed a physician's order to maintain enhanced barrier precautions related to, but not limited to, tracheostomy status. During an interview with the surveyor on 04/24/2025 at 10:23 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) stated that any possible infectious material, including PPE and respiratory equipment, should be tied up in a plastic bag then disposed in the black PPE trash bin located at the doorway. During an interview with the surveyor on 04/24/2025 at 11:01 AM, the Infection Preventionist (IP) explained that staff are to contain any potentially infection material, including PPE and respiratory equipment, should be in a tied plastic bag then disposed properly. When asked if used suction catheters are to remain unwrapped and visible or if used PPE should be overflowing in resident trash bins the IP responded, no because it could spread infection. During an interview with the surveyor on 04/25/2025 at 09:40 AM, the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse, and Regional Operations acknowledged that PPE and infectious material should not have been placed in resident trash can. A review of the facility's undated Enhanced Barrier Precautions policy included the following under Policy Interpretation and Implementation: [ .]16. Staff are trained prior to caring for residents on EBP. A review of the facility's undated Suctioning the Tracheostomy Tube policy included the following under General Guidelines: [ .] 28. Disconnect catheter from tubing. Wrap Catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle. [ .] 32. Discard personal protective equipment in designated receptacles. A review of the facility's undated Personal Protective Equipment policy included the following under Policy Interpretation and Implementation: [ .] 5. Training on the proper donning (putting on), use and disposal of PPE is provided upon orientation and at regular intervals [ .]. On 04/22/2025 at 08:49 AM, surveyor #1 completed the Medication Administration Facility Task with Registered Nurse (RN#1) with Resident # 25. The surveyor observed as RN #1 washed their hands with soap and water without fully lathering under the flow of running water for ten seconds .The surveyor then observed RN #1 don (apply) gloves and continue to dispense medication from Resident #25's medication card by obtaining medication card from the cart, popping the medication through the foil backing, picking the pill out of the foil with the gloved hand, and placing in to the medication cup. Prior to administering the medication, RN #1 knocked on Resident #25's door, introduced self and surveyor, and advised that she will be administering their medications. RN #1 also informed the resident that their vital signs needed to be obtained. RN #1 applied the blood pressure cuff to the resident's arm and applied the pulse oximeter (a device that measures the oxygen levels in the blood). After providing Resident #25's medication and removing her gloves, RN #1 washed their hands with soap and water lathering under the flow of running water for five seconds. RN #1 exited the room and was observed quickly wiping the blood pressure cuff and pulse oximeter then roll the cuff upon itself. Surveyor #1 did not observe RN #1 saturate the blood pressure cuff as the cuff appeared to dry quickly, allow to air dry, and did not observe RN #1 wipe the monitor screen of the medical device. When asked how long hand washing should be completed, RN #1 confirmed that it should be 30 seconds with a full lather to ensure that all infections were removed. RN #1 acknowledged that hand washing was not completed for 30 seconds. RN #1 further acknowledged that she should not have used a gloved hand to touch the resident's medication. During an interview with the surveyor on 04/24/2025 at 10:23 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) confirmed that it was not best practice to wear gloves during medication pass and that a resident's medication should never be directly touched. The LPN/UM further stated that hand washing should last approximately 20 seconds with a full lather. During an interview with the surveyor on 04/24/2025 at 11:01 AM, the Infection Preventionist (IP) also that confirmed that it was not best practice to wear gloves during medication pass, a resident's medication should never be directly touched, hand washing should last approximately 20 seconds with a full lather, and that all areas of the blood pressure machine should be disinfected and set out to dry. A review of the facility's undated Handwashing/Hand Hygiene policy included the following under Washing Hands:[ .] 2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers [ .] A review of the facility's undated Administering Medications policy included the following under Policy Interpretation and Implementation: [ .] 25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precaution, etc.) for the administration of medications, as applicable. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. NJAC 8:39-33.1(b) 51232 2.) On 04/21/2025 at 10:17 AM, Surveyor #2 observed two urinals (containers used to collect urine) on Resident #133's bedside table. One of the urinals contained liquid. These were placed in close proximity to an actively running intravenous (IV) pump (a device used to deliver fluids and medications directly into the bloodstream) and an IV medication bag (a sterile bag containing liquid medication administered through an IV line), which was stored in an open plastic bag. On 04/21/2025 at 10:58 AM, Surveyor #2 observed Resident #49 lying in bed in the bedroom, with a bedside table positioned across the bed. On the table was a urinal containing urine, placed next to an open milk container and a cup of liquid with a lid. During an interview with Surveyor #2 on 04/24/2025 at 10:36 AM, the Registered Nurse/Unit Manager #1 said that urinals should never be placed on bedside tables, especially near food, beverages, or actively running IV medications, due to infection control concerns. During an interview with Surveyor #2 on 04/24/2025 at 11:00 AM, the Infection Preventionist said that urinals not in use should be stored away during meals, and those containing urine must be kept away from IV medications or infusion pumps to prevent cross-contamination. During an interview with Surveyor #2 on 04/24/2025 at 12:24 PM, the Licensed Nursing Home Administrator (LHNA) said that urinals should never be placed on bedside tables, particularly near food, beverages, or IV medications, due to infection control risks. A review of the undated facility provided policy titled, Resident Rights revealed that, under the section Policy Interpretation and Implementation, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity. NJAC 8:39-33.1(b) 49712 3.) On 04/21/2025 at 10:42 AM during initial tour of the building, surveyor #3 observed a nurse enter Resident #43's room and flush the residents Peripherally inserted central Catheter (PICC) line (a thin tube that's inserted through a vein in the arm and placed through the larger veins near the heart). The nurse was not wearing a gown. A review of Resident #'s 43 electronic medical record (EMR) revealed a physician's order to maintain enhanced barrier precautions related to wounds. On 04/22/2025 at 11:33 AM surveyor #3 observed the nurse doing vital signs on Resident # 37 in their room without a gown on. A review of Resident #37's EMR revealed a physician's order to maintain enhanced barrier precautions related to wounds. During an interview on 04/24/2025 at 10:01 AM with surveyor #3, The Licensed Practical Nurse said when performing direct care with residents on Enhanced Barrier Precautions they should be wearing gloves, a gown and sometimes a face shield. During an interview on 04/24/2025 at 11:02 AM with surveyor #3, the infection preventionist (IP) said that he does rounds everyday to make sure that staff are wearing the proper PPE when performing care. The IP said for residents on Enhanced Barrier Precautions staff should be wearing a gown and gloves when providing any direct care. When asked if vital signs and flushing a pick would require the nurse the wear a gown, the IP replied, yes. During a review of a facility provided policy titled Enhanced Barrier Precautions revealed, 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. NJAC 8:39-33.1(b) 41442 4.) On 4/21/25 at 10:08 AM during the initial tour of the facility, surveyor #4 observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in Resident # 70's room with a nasal cannula oxygen tubing (small flexible tube with two prongs that delivers oxygen into the nose) connected to the concentrator. The nasal cannula tubing was found on the floor under the bedside table. A review of the Admission Record, an admission summary, revealed that Resident #70 had medical diagnoses which included but were not limited to: Chronic Kidney Disease, contractures and hypoglycemia. A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 4/1/25, identified that the resident had a Significant Change, and included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was placed on Hospice 4/3/25. In addition, under section O Special Treatments, Procedures, and Programs, it was indicated that the resident was on oxygen. A review of the Physician Order Summary dated as of 4/24/25, revealed that Resident #70 was prescribed oxygen to be administered at two liters per minute (2 lpm) via a nasal cannula as needed for shortness of breath and to maintain a SpO2 (peripheral oxygen saturation) greater than 90 percent. During an interview with the survey team on 4/24/25 at 11:02 AM, the Infection Preventionist (IP) stated that she conducts infection control surveillance on the units. The surveillance process for monitoring respiratory equipment included checking the functioning of respiratory equipment, checking for appropriated labeling and storage of respiratory equipment. When asked how respiratory equipment should be stored when not in use, the IP stated that respiratory equipment should be dated and stored in a plastic bag when not in use. The IP added that oxygen tubing should be changed weekly. NJAC 8:39-33.1(b) 51337 5.) On 4/21/2025 at 10:38 AM, during the initial tour of the facility, Surveyor #5 observed a sign by the door of Resident #156 that the resident was on Enhanced Barrier Precautions (EBP) (an infection control practice designed to reduce transmission of multidrug-resistant organisms in nursing homes), and a Personal Protective Equipment (PPE) bin was outside the resident's room by the doorway. The sign had instructions for staff and visitors to wear gloves and gown during high-contact resident activities that included dressing, hygiene, toileting, transferring, bathing, changing linens, device care, and wound care. The surveyor observed 2 visiting staff from a vascular company inside the resident's room wearing gloves but no gown. Both visitors were observed repositioning the resident in bed, by touching their limbs and back, and pulling down their gown exposing the resident's abdomen and incontinence brief. Visitor #1 was observed operating the ultrasonography machine while Visitor #2 stayed by the bedside. When the two visitors concluded their visit, Surveyor #4 asked them if they should have worn gowns as indicated in the EBP signage. Visitor #1 stated they did not know that they had to wear gown. A review of the Admission Record revealed Resident #156 was admitted to the facility with diagnoses which included cellulitis of the lower limb (infection of the skin and underlying tissue) and heart failure. A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/21/2025, reflected the resident had a venous and arterial ulcer (open sores on the skin that result from compromised blood flow). A review of the Clinical Physician Orders active as of 4/21/2025 revealed an order for Enhanced Barrier Precautions for wounds every shift started on 3/28/2025. A review of the comprehensive care plans initiated on 3/28/2025, reflected a focus for EBP related to chronic wound. Interventions included the following: Staff will wear gown and gloves during high-contact care like dressing, bathing/ showering, transferring, providing hygiene, changing linens, assisting with toileting, device care, or wound care; Use of signage to identify resident that requires EBP. On 4/24/2025 at 11:01 AM, during an interview with the survey team, the Infection Preventionist (IP) stated that visitors like the staff from the vascular company who did an ultrasonography test on the resident need to observe EBP if they have close contact with a resident on EBP. A review of the facility-provided policy titled Enhanced Barrier Precautions revised in December 2024, included under Policy Interpretation and Implementation 7.a) Gloves and gown are applied prior to performing the high contact resident care activity. 8.) Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include .f.) providing bed mobility .h.) prolonged, high-contact with .resident's clothing or skin. N.J.A.C. 8:39 - 19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to treat each resident with respect and dignity in a manner that promotes his/her quality of life. This deficient practice was identified for 1 of 32 residents (Resident #123) reviewed for resident rights. Upon initial tour of the facility on 04/21/2025 at 11:15 AM, the surveyor was speaking with Resident #123 in their room with the door closed. While speaking with the resident, the door opened and Registered Nurse #1 (RN#1) attempted to enter. Resident #132 shook their head, looked at the surveyor, and stated no knock. This surveyor stated that they were speaking with the resident and RN #1 exited the room. Approximately 5 minutes later, RN #1 knocked, immediately entered the room, walked past the surveyor and began to set up wound care supplies. This surveyor explained that they were with the Department of Health and would like to speak with the resident. RN #1 stated that they had to set up for wound care. The surveyor requested RN #1 three different times to exit the room to allow privacy. During an interview with the surveyor on 04/21/2025 at 11:31 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) confirmed that RN #1 acknowledged she should have knocked, announced their presence, and stated their purpose when they entered the room. When asked what should have been done when the surveyor requested privacy, LPN/UM stated that RN #1 should have provided privacy and exited the room when requested. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Local infection of the skin, Colostomy Status, and Pressure Ulcer. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/22/2025, the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was cognitively intact. During an interview with the surveyor on 04/25/2025 at 09:40 AM, the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse, and Regional Operations acknowledged that residents have an expectation of privacy. A review of the facility's undated Resident Rights policy included the following under Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . NJAC 8:39-4.1 (a) 12

Based on observation and interview, it was determined the facility failed to maintain the resident's living environment in a clean, sanitary, and homelike manner that included a wall-mounted call device input (Resident #13) and soap dispensers (Resident #17 and #49). This deficient practice was identified for 2 of 4 nursing units observed for environment. This deficient practice was evidence by the following: 1. During the initial tour of the facility on 4/21/25 at 10:16 AM, the Surveyor #1 observed a call device input system taped to the wall above the resident's bed in room [ROOM NUMBER] bed #2. On 4/22/25 at 9:15 AM, the surveyor interviewed Resident #13's family member that stated that the call device input box had been taped to the wall for at least a month and that the Maintenance Department was aware of it and waiting on a new system to replace it. The family member confirmed that the call device had been functioning properly. During an interview with the surveyor on 4/24/25 at 12:34 PM, the Licensed Nursing Home Administrator (LNHA) stated that they are aware of the taped call device input box that was inherited from the previous management and that they are working on replacing the entire call device system. At that time, the surveyor expressed concern regarding the safety of the unsecured box. On 4/25/25 at 10:05 AM during a meeting with the facility administration, the LNHA stated that the call device input box had been secured to the wall by the Maintenance Department. A review of the undated facility provided policy titled, Homelike Environment, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment. N.J.A.C. 8:39-31.4(a) 51232 2. On 04/21/2025 at 10:17 AM, Surveyor #2 observed brown-colored debris on both the wall and floor in Resident #133's bedroom. On 04/21/2025 at 10:58 AM, Surveyor #2 observed that the wall-mounted soap dispenser's drip tray was detached from the wall in Resident #49's bathroom, located on the second floor of the Grace Garden Unit. On 04/22/2025 at 11:40 AM, Surveyor #2 observed that the wall-mounted soap dispenser's drip tray was detached from the wall in Resident #49's bathroom. On 04/22/2025 at 11:51 AM, Surveyor #2 observed that the wall-mounted soap dispenser's drip tray was detached from the wall in Resident #17's bathroom, located on the second floor of the Grace Garden Unit. On 04/23/2025 at 9:20 AM, Surveyor #2 observed that the wall-mounted soap dispenser's drip tray was detached from the wall in Resident #49's bathroom. On 04/23/2025 at 10:32 AM, Surveyor #2 observed that the wall-mounted soap dispenser's drip tray was detached from the wall in Resident #17's bathroom. On 04/24/2025 at 10:49 AM, Surveyor #2 observed that the wall-mounted soap dispenser's drip tray was detached from the wall in Resident #49's bathroom. During an interview with Surveyor #2 on 04/24/2025 at 10:31 AM, a facility maintenance staff member (MS) said that each morning, MS conducts daily rounds throughout the facility, including visits to the nursing stations on every unit to review the maintenance log and ask nursing staff if there are any maintenance issues that need attention. MS also said that he was unaware of the detached wall-mounted soap dispenser drip trays in the bathrooms of Residents #17 and #49. During an interview with Surveyor #2 on 04/24/2025 at 10:36 AM, Registered Nurse/Unit Manager #1 said that, to ensure a clean and homelike environment, the wall-mounted soap dispensers drip trays should be attached to the wall, and there should be no brown debris present on the walls or floors. During an interview with Surveyor #2 on 04/15/2025 at 12:24 PM, the Licensed Nursing Home Administrator said that the drip tray of the wall-mounted soap dispenser should be securely attached and functional, and no brown debris should be present on the walls or floors to maintain a clean and homelike environment. A review of the undated facility provided policy titled, Homelike Environment, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment. N.J.A.C. 8:39-31.4(a)

Based on interview and record review, it was determined that the facility failed to transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 2 of 2 residents reviewed for resident assessment (Resident #9 and Resident # 147). This deficient practice was evidenced by: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS no later than 14 days after assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. The following residents were identified that the MDS were not transmitted timely: 1. Resident #9: the discharge return anticipated MDS was completed on 12/21/2024 and was due to be transmitted no later than 01/04/2025. It was transmitted 04/23/2025. 2. Resident #147: the discharge return not anticipated MDS was completed on 12/20/2024 and was due to be transmitted no later than 01/03/2025. It was transmitted on 04/23/2025. 04/23/2025 12:18 PM, during an interview with the surveyor, the MDS Coordinator stated that MDS's should be transmitted within 2 weeks of completion. The MDS Coordinator acknowledged that Resident #9 and Resident #147 discharge MDSs were transmitted late. The facility provided policy titled, MDS Completion and Submission Timeframes, with a revision date of July 2017 reflected our facility will conduct and submit resident assessments in accordance with federal and state submission timeframes. NJAC 8:39-11.1

Based on observation, interview, and pertinent facility documentation, it was determined that the facility nursing staff failed to document on the Treatment Administration Record (TAR) to indicate that treatments were administered according to the Physician Orders (PO) and acceptable standards of clinical practice in accordance with the New Jersey Board of Nursing Statutes. The deficient practice was identified for 1 of 41 residents (Resident #49). 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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of the Admission Record revealed Resident #49 was admitted to the facility with diagnoses including but not limited to: quadriplegia, lack of coordination, and muscle weakness. A review of Resident # 49 's TAR dated 02/01/2025 - 02/28/2025, revealed the following PO: Offload heels off the mattress every shift for protection. A review of the TAR dated 02/19/2025, did not include documentation that the treatment was completed as ordered on 07/08/2020. Apply Remedy Z (protects and soothe irritated or compromised skin) to sacrum (back portion of the pelvis) every shift for prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease.). A review of the TAR dated 02/19/2025, did not include documentation that the treatment was completed as ordered on 07/16/2020. Air mattress every shift. A review of the TAR dated 02/19/2025, did not include documentation that the treatment was completed as ordered on 01/20/2021. Heel booties to bilateral feet while in bed every shift. A review of the TAR dated 02/19/2025, did not include documentation that the treatment was completed as ordered on 01/20/2021. Sacrum clean with normal saline (sterile solution of sodium chloride), apply zinc oxide (forms a protective layer on the skin to block moisture and irritants) to crease of buttocks open area every shift and as needed for moistened damage. A review of the TAR dated 02/19/2025, did not include documentation that the treatment was completed as ordered on 01/29/2024. Moisture barrier (skin protectant that forms a protective layer over the skin to prevent irritation and breakdown caused by moisture) to the sacrum, dry skin, and lower extremities every shift for skin care, clean sites and apply cream. A review of the TAR dated 02/19/2025, did not include documentation that the treatment was completed as ordered on 09/11/2024. On 04/23/2025 at 1:05 PM, Surveyor reviewed 02/2025 facility consultant pharmacist's medication regimen review for Resident #49, which noted blank entries on the Medication Administration Record (MAR). Further review of the resident's MAR and TAR for 02/2025 revealed undocumented treatments on the TAR for the evening shift of 02/19/2025, with no explanation in the EMR for the undocumented treatments. During an interview with Surveyor #2 on 04/24/2025 at 12:24 PM, the Licensed Nursing Home Administrator said that there should be no blank entries on the TAR, because blanks indicate that treatments were not administered. The facility was unable to provide a policy outlining procedures for documentation on the TAR. NJAC 8:39-11.2 (a) (b), 27.1 (b), 29.2 (a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to A). store oxygen equipment in a sanitary manner B.) develop a comprehensive care plan for a resident receiving oxygen therapy and a resident who self suctioned; C.) label and date oxygen tubing according to professional standards and failed to obtain a physician order for a resident receiving oxygen therapy. This deficient practice was identified in 3 of 4 residents (Resident #70; Resident #152; Resident #472) reviewed for respiratory care and was evidenced by the following: A.) On 4/21/25 at 10:08 AM during the initial tour of the facility, surveyor # 1 observed an oxygen concentrator (a device that enriches air with oxygen by removing nitrogen) in Resident # 70's room with a nasal cannula oxygen tubing (small flexible tube with two prongs that delivers oxygen into the nose) connected to the concentrator. The nasal cannula tubing was found on the floor under the bedside table. A review of the Admission Record, an admission summary, revealed that Resident #70 had medical diagnoses which included but were not limited to: Chronic Kidney Disease, contractures and hypoglycemia. A review of the Comprehensive Minimum Data Set (MDS), an assessment tool dated 4/1/25, identified that the resident had a Significant Change, and included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was placed on Hospice 4/3/25. In addition, under section O Special Treatments, Procedures, and Programs, it was indicated that the resident was on oxygen. A review of the Physician Order Summary dated as of 4/24/25, revealed that Resident #70 was prescribed oxygen to be administered at two liters per minute (2 lpm) via a nasal cannula as needed for shortness of breath and to maintain a SpO2 (peripheral oxygen saturation) greater than 90 percent. A review of the resident's individual comprehensive care plan (ICCP) did not include a focus area for respiratory care or oxygen. On 4/24/25 at 12:10 PM during a team interview with the administration of the facility, the Director of Nursing (DON) stated that oxygen administration should be care planned. A review of the facility's Comprehensive Care Plans policy, with a last revised date of 9/2022, included under #6: The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress . N.J.A.C. 8:39-27.1 (a) 45209 B.) Upon initial tour of the facility on 04/21/2025 at 10:55 AM, the surveyor #2 observed Resident #152 in bed sleeping. The surveyor observed that the resident's oxygen tubing was not labeled with the date in which the tubing was applied. On 04/24/2025 at 09:44 AM, surveyor #2 observed Resident #152 in bed sleeping. The surveyor observed that the resident's oxygen tubing was not labeled with the date in which the tubing was applied. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Pneumonia, Urinary Tract Infection, and Alzheimer's Disease. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/31/2025, identified that the resident was Severely Impaired in relation to Cognitive Skills for Daily Decision Making. A review of the resident's individual comprehensive care plan (ICCP) did not identify that the resident requires oxygen. A review of the Treatment Administration Record (TAR), dated as of 4/25/2025, included the following physician orders (PO): A PO, dated 1/28/2025, for [Oxygen] inhalation at 2 LPN (Liters Per Minute) via nasal cannula every shift for shortness of breath [ .]. A PO, dated 4/27/2024, to Change Oxygen Tubing, Humidifier, and clean filter weekly and as needed. Every night shift every Sunday. Date and Label Tubing and Humidifier. During an interview with the surveyor on 04/24/2025 at 10:05 AM, Licensed Practical Nurse (LPN #1) confirmed that resident's oxygen tubing was to be changed weekly on the Sunday overnight shift and it should be labeled/dated. LPN #1 explained that a resident care plan should have all the information needed to care for a resident. When asked if oxygen should be on a resident care plan LPN #1 stated, yes and it should have how many liters they are on. During an interview with the surveyor on 04/24/2025 at 10:23 AM, the Licensed Practical Nurse Unit Manager (LPN/UM) confirmed oxygen tubing was to be changed weekly and it should be labeled dated when changed. LPN/UM acknowledged Resident #152's oxygen dependence was not on the care plan. During an interview with the surveyor on 04/24/2025 at 11:01 AM, the Infection Preventionist (IP) also confirmed that oxygen tubing should be labeled and dated accordingly. During an interview with the surveyor on 04/25/2025 at 09:40 AM, the Director of Nursing, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse, and Regional Operations acknowledged oxygen is to be labeled/dated and should be on resident's care plans. A review of the facility's Comprehensive Care Plan policy, last updated 09/2022, included the following under Policy Interpretation and Implementation: The Comprehensive Care Plan will describe, at a minimum, the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being [ .] A review of the facility's Oxygen Administration policy did not identify label or dating of oxygen tubing. N.J.A.C. 8:39-27.1 (a) 51337 C.) On 4/21/2025 at 10:32 AM, during the initial tour of the facility, Surveyor #3 observed Resident #472 in bed. The resident was receiving oxygen (O2) via nasal cannula (NC) (a flexible tube with prongs that go inside the nostrils to deliver oxygen) at 2 liters per minute (lpm). The resident was also observed holding a Yankauer suction tube (a rigid device connected to a suction machine used to remove fluids from the airway) in their hands and suctioning themselves. The suction tube was attached to a canister located on the bedside table. The canister was half-filled with brown-tinged frothy liquid substance and connected to a wall-mounted suction machine. On 4/22/2025 at 10:52 AM, the resident was observed in bed receiving oxygen via NC at 2 lpm and holding a Yankauer suction device in their left hand. The suction canister was observed on bedside table containing whitish frothy liquid substance. On 4/24/2025 at 10:30 AM, a review of the electronic medical record (EMR) revealed the following: A review of the Admission Record reflected the resident had diagnoses that included acute and chronic respiratory failure with hypoxia (low level of oxygen in the body) and acute kidney failure. A review of the most current comprehensive Minimum Data Set (MDS), an assessment tool with target date of 4/26/2025 revealed that it was still in progress. A review of the Physician Order (PO) active and discontinued as of 4/24/2025 at 10:30 AM, did not reflect a physician order for oxygen therapy since admission to the facility. The PO did not also include an order for self-administration of the suction device since admission to the facility. A review of the Treatment Administration Record (TAR) for the month of April 2025 did not reflect oxygen administration and self-administration of the suction device since admission. A review of Resident #472's individualized care plan did not reveal a focus, goal, and interventions for the resident's oxygen use and self-administration of suction device. On 4/24/2025 at 12:08 PM, during an interview with the survey team and in the presence of the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) stated Yes when asked if a physician order was needed for oxygen administration and self-suctioning. The DON also stated Yes when asked if residents who receive oxygen therapy and residents who suction themselves needed to be care planned. A review of facility-provided policy titled Oxygen Administration revised October 2010 included under Preparation 1. Verify that there is a physician's order for this procedure .2. Review the resident's care plan to assess for any special needs of the resident. A review of the facility-provided policy titled Self-Administration of Medications revised February 2021 did not address self-administration of suction device. N.J.A.C. 8:39 - 27.1 (a), (c)(3)

Based on observation, interview, 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. The deficient practice was identified for 1 of 5 medication carts inspected. This deficient practice was evidenced by the following: On 04/23/2025 at 09:59 AM, the surveyor inspected the Luxor Unit medication cart in the presence of the Registered Nurse #1 (RN#1). A review of the shift-to-shift Narcotic and Controlled Drug Count Verification Record, (NCDCVR) which is used in healthcare settings to track the administration and accountability of controlled substances, revealed missing signatures for the following dates and shifts: 04/02/2025 for the outgoing nurse (11:00PM) 04/04/2025 for the outgoing nurse (11:00PM) 04/06/2025 for the incoming nurse (11:00PM) 04/07/2025 for the outgoing nurse (7:00AM) 04/09/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) 04/11/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) 04/12/2025 for the outgoing nurse (11:00PM) 04/13/2025 for the outgoing nurse (11:00PM) 04/14/2025 for the incoming nurse (11:00PM) 04/15/2025 for the incoming and outgoing nurse (11:00PM) 04/16/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) 04/17/2025 for the outgoing nurse (11:00PM) 04/21/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) 04/22/2025 for the incoming nurse (3:00PM) and outgoing nurse (11:00PM) During an interview on 04/23/2025 at 09:59 AM with the surveyor, RN #1 said that she was not sure why there were any blanks and that there should not be any blanks on the NCDCVR. During an interview on 04/23/2025 at 10:05 AM with the surveyor, the Unit Manager said that the NCDVR should be completed at the beginning and end of each shift to ensure accurate narcotic counts and there should not be any blanks. During an interview on 04/24/2025 at 12:07 PM with the surveyor, the Director of Nursing said when the nurses are coming on shift and leaving the shift, they should do an accurate narcotic count and sign off on the NCDVR. A review of the facility provided policy, with a revision date November 2022, titled, Controlled Substances revealed section Dispensing and Reconciling Controlled Substances that, 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing. NJAC 8:39-29.7(c)

Complaint # NJ00158378 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) follow a physician's order to obtain weekly weights for 1 of 5 residents (Resident #251) investigated for nutrition b.) notify a physician of a resident's medication refusal for 1 of 4 residents (Resident #254) investigated for accidents c.) follow a physician's order (PO) to notify if a resident's blood sugar fell below 100 for 1 of 30 residents (Resident #58) reviewed for medications d.) enter a progress note related to an unwitnessed fall for 1 of 4 residents (Resident #58), investigated for accidents and incidents and e.) document the administration of medication on the resident's electronic medication administration record (eMAR) for 1 of 30 residents (Resident #292) reviewed. 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 11/15/23 at 1:03 PM, the surveyor observed Resident # 251 seated in a wheelchair in their room. The resident stated they were newly admitted to the facility for rehabilitation. The resident further stated they were on a specialized diet and had spoken to both the kitchen and the dietician regarding their food preferences. The surveyor reviewed the medical record for Resident #251. A review of the resident's Admission Record indicated the resident was admitted to the facility in October of 2023 with diagnoses which included a fracture of the left humerus (bone of the upper arm that runs from the shoulder to the elbow), fracture of the right femur (thigh bone), muscle weakness and lack of coordination. A review of the resident's October 2023 Order Summary Report revealed a PO dated 10/20/22 that read for weight each Tuesday 10/24, 10/31, 11/7, 11/14 one time a day every 4 weeks on Tue. A review of the resident's October 2023 eMAR did not reveal a PO dated 10/20/22 that read for weight each Tuesday 10/24, 10/31, 11/7, 11/14 one time a day every 4 weeks on Tue. A review of the order details revealed when the PO was entered into the electronic medical record (eMAR) the nurse failed to indicate that documentation on the eMAR was required. On 11/17/23 at 12:39 PM, the surveyor interviewed the resident's Licensed Practical Nurse #3 (LPN #3) who stated residents on the subacute wing were weighed every Tuesday by the Certified Nurse Aides (CNAs). The CNAs would relay the weights to the nurses who would then enter the weights into the eMAR for each resident. The weights could be viewed on the dashboard section of the eMAR. On 11/17/23 at 12:47 PM, together with LPN #3 the surveyor reviewed the eMAR which revealed the resident's weight had been documented on two dates only 10/18/23 and 11/6/23. The LPN acknowledged there should have been weights documented on 10/24/23, 10/31/23, 11/7/23 and 11/14/23. LPN #3 then reviewed the order details for the PO dated 10/20/22 regarding acquiring weekly weights and acknowledged the order had been entered incorrectly and the required weight documentation did not carry over to the eMAR for scheduling. On 11/17/23 at 12:55 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM1) who stated residents were weighed on admission and every week on Tuesday. The RN/UM1 stated the CNAs used the daily census sheet as a guide to make sure no resident was missed. The weights are reviewed by nursing and the dietician for weight loss, gain, or any discrepancy usually on Wednesdays. The surveyor and the RN/UM1 then reviewed the resident's eMAR and she acknowledged the weights had not been recorded according to the PO. On 11/21/23 at 2:00 PM, the surveyor interviewed the Director of Nursing (DON) who stated the nurses should have followed the physician's orders for weekly weights. The DON further stated she had checked the nursing unit to ensure the resident's weights had not been recorded elsewhere and was unable locate any documentation the weights had been recorded according to the physician's order. A review of the facility's undated Weight Monitoring policy included . Weight can be a useful indicator of nutritional status . weights should be recorded at the time obtained. Suggested weight schedule . Newly admitted residents- weekly for four weeks . 2. On 11/15/23 at 12:22 PM, the surveyor observed Resident #254 in their room who stated they had been at the facility too long and was [mad] they were still there. The resident further stated they were at the facility for rehabilitation therapy. When asked the resident stated they would not smoke on campus but would occasionally when out of the facility with family. The surveyor reviewed the medical record for Resident #254. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in May of 2023, with diagnoses which included acute and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues), tachycardia (elevated heart rate), major depressive disorder, and anxiety. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 8/14/23, reflected a brief interview for mental status (BIMS) score of 11 out of 15, which indicated a moderately impaired cognition. A review of the individualized comprehensive care plan reflected a focus area initiated 8/23/23, indicating the resident was a smoker. Interventions included a nicotine patch had been ordered. A review of the Order Summary Report included a PO dated 8/23/23 for nicotine patch 24 hour, 14 mg/24hr (milligram per 24 hours) apply one patch transdermally one time a day for smoking cessation for 6 (six) weeks. A further review revealed a second PO dated 8/23/23 for nicotine patch 24 hour, 7mg/24hr apply one patch transdermally one time a day for smoking cessation for 2 (two) weeks. A review of the October 2023 MAR reflected the following: The medication order for nicotine patch 14mg/24hr was scheduled daily at 9:00 AM, from 10/1/23 until 10/4/23. On 10/1/23, 10/2/23 and 10/3/23 the nurse entered the code 5. According to the chart codes 5 indicated hold /see nurse notes. A review of the corresponding progress notes revealed the resident had refused the medication. The medication order for nicotine patch 7mg/24hr was scheduled daily at 9:00 AM, from 10/5/23 until 10/18/23. On 10/7/23, 10/8/23 and 10/12/23 the nurse entered the code 5. A review of the corresponding progress notes revealed the resident had refused the medication. A further review of the medication order for nicotine patch 7mg/hr, revealed on 10/5/23, 10/9/23, 10/10/23, 10/11/23 and 10/13/23 the nurse entered the code 2. According to the chart code 2 indicated drug refused. A review of the progress notes for October 2023 did not reveal documentation that the resident's physician had been made aware the resident had been refusing their nicotine patch administration. On 11/17/23 at 1:20 PM, the surveyor interviewed LPN #3 who stated that if a resident refused a medication, she would be prompted by the system to document in the progress notes the resident's refusal. She also stated if the resident refused a medication on multiple occasions, she would contact the physician for guidance. On 11/17/23 at 1:29 PM, the surveyor interviewed RN/UM #1 who stated the resident had the right to refuse a medication, but the nurse was responsible to document the refusal in the eMAR. If the medication was critical then the physician must be notified immediately. On 11/21/23 at 2:00 PM, the surveyor interviewed the DON who stated the nurses should reach out to the physician if a resident refused a medication. The DON acknowledged the nurses should have made the physician aware of the nicotine patch refusal. A review of the facility's Refusal of Treatment policy dated 2/2023 included . Documentation pertaining to a resident's refusal of treatment shall include at least the following .the resident's response and reason for refusal .the date the physician was notified as well as the physician's response . A review of the facility's Medication Administration policy dated revised 9/2023 included . Report and document . refusals . 3. The surveyor reviewed the closed medical record for Resident #292. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Type 2 Diabetes Mellitus (DM II), Morbid Obesity, and Heart Failure. A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 12/17/2023, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which demonstrated intact cognition. A review of Resident #292's Medication Administration Record (MAR) revealed the following: An order for Ammonium Lactate Lotion 12%. Apply to bilateral lower legs topically every day shift for skin care after cleansing with soap and water. The designated space for 11/9/2022 Day was blank, with no check mark or nurse's initials. An order for Farxiga Tablet 10mg. Give 0.5 tablet by mouth one time a day for Diabetes Give 05 (1/2) tablet daily (5mg). The designated space for 11/9/2022 at 0900 was blank, with no check mark or nurse's initials. An order for Ferrous Sulfate Tablet 325MG Give 1 tablet by mouth one time a day for supplementation. The designated space for 11/9/2022 at 0900 was blank, with no check mark or nurse's initials. An order for Metoprolol Succinate ER Tablet Extended Release 24 Hour 25 MG give 1 tablet by mouth one time a day for HTN please administer with meal. The designated space for 11/9/2022 at 0900 was blank, with no check mark or nurse's initials. An order for Plavix Tablet 75MG Give 1 tablet by mouth one time a day for DVT Prophylaxix. The designated space for 11/9/2022 at 0900 was blank, with no check mark or nurse's initials. An order for Apixaban Tablet 5MG Give 1 tablet by mouth two times a day for A-Fib. The designated space for 11/9/2022 at 0900 was blank, with no check mark or nurse's initials. An order for Florastor Capsule 250MG Give 1 capsule by mouth two times a day for Prophylaxis. The designated space for 11/9/2022 at 0900 was blank, with no check mark or nurse's initials. An order to evaluate for cough, shortness of breath (SOB), chills, headache, myalgia, sore throat, new loss of taste or smell, congestion or runny nose, nausea, vomiting, diarrhea, pneumonia, ARDS. Every shift for COVID-19, other s/s screening. The designated space for 11/9/2022 at DAY was blank, with no check mark or nurse's initials. An order for Gabapentin Capsule 100MG give 1 capsule by mouth three times a day for Neuropathy. The designated space for 11/9/2022 at 0900 and 1400 was blank, with no check mark or nurse's initials. An order to monitor every shift for SOB, edema, distended neck veins and abnormal breath sounds. The designated space for 11/9/2022 at DAY was blank, with no check mark or nurse's initials. An order for Insulin Lispro Solution 100unit/ML Inject as per sliding scale: if 150-200= 2 unit; 201-250= 4 unit; 251-300= 6 unit; 301-350= 8 unit; 351-400= 10 unit Call MD if Blood Sugar (BS) less than 70 or greater than 400, subcutaneous before meals and at bedtime for Diabetes. The designated space for BS 11/9/2022 at 0730 and 1130 was blank, with no check mark or nurse's initials. On 11/20/2023 at 10:42 AM, the surveyor interviewed Registered Nurse (RN #2), who stated that there should never be a blank space in a MAR. RN #2 continued to state that if a medication was not given then the physician should be contacted and explanation given in rogress notes. On 11/20/2023 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of Clinical Regional Nurse (CRN), who confirmed the presence of blank spaces throughout the MAR on 11/9/2022. The DON confirmed that there should not be blank spaces on the MAR. A review the facility's Documentation Policy/Procedure Policy, included .1.Pursuant to the Police and Procedure for the Interdisciplinary Progress Notes (IPN), all professional disciplines are to document accordingly . 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. A review the facility's Position Title: Licensed Practical Nurse responsibilities/Accountabilities: documentation, included . Dispenses medication and performs treatments, as requested, and in accordance with policies and procedures. 4. On 11/13/2023 at 11:37 AM, the Resident #58 was observed in the hallway in their wheelchair. The surveyor reviewed the medical record for Resident #58. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included Atrial Fibrillation, Asthma, and Type 2 Diabetes Mellitus (DM II). A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/13/2023, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which demonstrated intact cognition. A review of the PO identified that Resident #58 was ordered Insulin NPH (Human) (Isophone) Subcutaneous Suspension Pen-injector 100 unit/ML; Inject 20 unit subcutaneous every 12 hours for DM II. HOLD for Blood Sugar (BS) less than 100, call MD if BS readings less than 100. A review of Resident #58's eMar revealed that the resident's blood sugar returned as 92mg/dL on 11/12/2023 and 95mg/dL 11/13/2023. Underneath the resident's blood sugar results on 11/12/2023, a Chart Code of 11 was entered that identified No insulin Required. Underneath the resident's blood sugar results on 11/13/2023, a Chart Code of 5 was entered that identified Hold/See Nurse Note. A review of Resident #58's electronic medical record Progress Notes did not document that the resident's physician was contacted to notify of blood sugar below 100, as per the PO. Further review of Resident #58's electronic medical record Progress Notes identified a Plan of Care noted dated 11/7/2023 at 18:29 for an evaluation post fall, [status post] ER visit [ .] was sent to [emergency room ] last night post fall. Staff reports she hit her head on floor and was sent to [emergency department] for [computed tomography scan]. The surveyor did not observe a nursing note documenting the fall. On 11/20/2023 at 10:42 AM, the surveyor interviewed Registered Nurse (RN #2), who confirmed that if a physician sets parameters for a point of care test and the result returned below that number, the physician should be contacted, and a progress note should be entered documenting that conversation. RN #2 stated that after a fall, it was the responsibility of the nurse to enter the resident's assessment into the progress notes depicting the events of the incident. On 11/20/2023 at 11:08 AM, the surveyor interviewed Registered Nurse Unit Manager (RN/UM#2) who stated that if a physician enters an order to be contacted with blood sugar less than 100, then they were to be contacted and it should be documented under progress note. RN/UM #2 confirmed that there was no documentation of the physician being contacted for the blood sugars less than 100 on 11/12/2023 and 11/13/2023. RN/UM#2 confirmed that a progress note was required after a fall incident, which would include the narrative of the patient, pain and fall assessment, and vital signs. On 11/20/2023 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of Clinical Regional Nurse (CRN), who stated that physicians were to be contacted when any medication, including insulin, is withheld. The DON and CRN confirmed that there was no documentation of the physician being contacted for the blood sugars less than 100 on 11/12/2023 and 11/13/2023. The DON and CRN further confirmed that after a resident fell , the nurse was to document the incident in the progress notes because it was a change in patient's status. The DON and CRN confirmed that the fall was not documented in Resident #58's electronic medical record. A review the facility's Documentation Policy/Procedure Policy, dated 11/2022, included under policy . the resident's medical record will reflect- on a continuum- all events that substantiate the effectiveness of (or need for revision in) care planning. Moreover, documentation in the Interdisciplinary Progress Notes must reflect assimilation of communication amongst and between disciplines . 1. Pursuant to the Police and Procedure for the Interdisciplinary Progress Notes (IPN), all professional disciplines are to document accordingly .2. Documentation must address both new positive and negative events . A review the facility's Position Title: Licensed Practical Nurse responsibilities/Accountabilities: documentation, included . ensures that pertinent information is communicated to and from him/her and orders are taken correctly . Assesses each resident daily and implements a change in the course of action as needed NJAC 8:39-27.1(a)-29.2(d)

Complaint # NJ 154800, NJ 154946, NJ 158378 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents in a timely manner for 7 of 9 residents (Resident #3, #25, #103, #75, #48, #95, and #127) observed for incontinence care on 2 of 4 units ([NAME] and Luxor 1) and b.) provide nail care to residents that required extensive assistance from the staff for activities of daily living (ADLs) for 2 of 4 residents, (Resident #127 and #75) reviewed for ADLs. This deficient practice was evidenced by the following: 1. On 11/15/23 at 12:46 PM, during an interview with the surveyor, RN/UM #2 and LPN #2 identified residents as being dependent on staff for care. On 11/16/23 at 7:36 AM, the surveyor completed an incontinence tour on the [NAME] Unit and observed the following: a. On 11/16/23 at 8:00 AM, the surveyor accompanied by Registered Nurse (RN) #2 observed Resident #3 in bed. The surveyor observed that Resident #3's incontinence brief was saturated with urine. Licensed Practical Nurse (LPN) #1 entered the room to assist RN #2 who both acknowledged the brief was saturated with urine. A review of Resident #3's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, diabetes mellitus, hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body and dysphagia. A review of Resident #3's Admission Minimum Data Set (MDS) an assessment tool dated 9/8/23 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated Resident #3 had a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was always incontinent of bowel and bladder. b. On 11/16/23 at 8:22 AM, the surveyor accompanied by LPN #2 observed Resident #25 in bed. CNA #1 was in the resident's room and exposed Resident #25's incontinence brief which was saturated with urine. At that time when CNA #1 exposed the incontinence brief another incontinence brief was observed which also saturated with urine. The pad under the incontinence briefs used to protect the bed sheets also was saturated with urine. LPN #2 and CNA #1 both acknowledged the two briefs and pad were saturated with urine and they each stated that no residents should be wearing two incontinence briefs. A review of Resident #25's Admission Record revealed Resident #25 was admitted to the facility with diagnoses which included but not limited to Parkinson's Disease, diabetes mellitus, and cognitive communication deficit. A review of Resident #25's Quarterly MDS dated [DATE] revealed Resident #25 had a BIMS of 1 of 15 indicating a severe cognitive impairment. MDS further assessed Resident #25 was dependent on staff for personal hygiene and was frequently incontinent of bowel and bladder. c. On 11/16/23 at 8:30 AM, the surveyor accompanied by LPN #2 observed Resident #103 in bed. LPN #2 exposed Resident #103's brief which was wet with urine. At that time, when LPN #2 exposed the incontinence brief the surveyor observed another incontinence brief in place which was also wet with urine. LPN#2 stated that the resident's should not have two incontinence briefs in place. A review of Resident #103's admission record reflected Resident #103 was admitted to the facility with diagnoses which included but were not limited to aortic valve stenosis (heart valve disease), cerebral infarction (stroke) and end-stage renal disease with dependency on dialysis. A review of Resident #103's Quarterly MDS dated [DATE] revealed Resident #103 had a BIMS score of 12 of 15 which indicated the Resident had a moderate cognitive impairment. The MDS further reflected that Resident #103 required moderate assistance from staff for personal hygiene, was frequently incontinent of urine, and always incontinent of bowel movements. d. On 11/16/23 at 8:42 AM, the surveyor accompanied by RN/UM # 2 observed Resident #75 in bed, with the resident's permission the RN/UM asked to check the incontinence brief which was saturated with urine. Resident #75 stated, they don't have a lot of nurses here so I don't get the help and care that I need. A review of Resident #75's Admission Record revealed Resident #75 was admitted to the facility with diagnoses that included but were not limited to Parkinson's disease, need for assistance with personal care, and sarcoidosis (a condition where cells in the immune system form small, red and inflamed lumps.) A review of Resident #75's Quarterly MDS dated [DATE] revealed Resident #75 had a BIMS score of 13 of 15 which indicated that the resident was cognitively intact. The MDS further reflected that Resident #75 required staff assistance for personal hygiene and was continent of urine. e. On 11/16/23 at 8:52 AM, the surveyor accompanied by LPN #1 observed Resident #48 in bed. LPN #1, with the resident's permission exposed the incontinence brief which was saturated with urine and feces. LPN #1 stated, it doesn't look like it was changed this morning. A review of Resident #48's Admission Record revealed Resident #48 was admitted to the facility with diagnoses which included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), heart failure, and urinary incontinence. A review of Resident #48's Quarterly MDS dated [DATE] reflected that Resident #48 had a BIMS of 8 of 15 which reflected Resident #48 had a moderate cognitive impairment. The MDS further revealed the Resident required maximum assistance from staff for personal hygiene and was always incontinent of bowel and bladder. f. On 11/16/23 at 9:44 AM, the surveyor accompanied by CNA #2 observed Resident #95 in bed, unclothed, and observed their incontinence brief on the floor and was be saturated with urine. CNA #2 stated that he had just removed Resident #95's brief. The surveyor asked CNA #2 if it was acceptable to place the soiled brief on the floor. CNA #2 replied, You're just trying to make my job difficult. At that time, the Director of Nursing (DON) entered Resident #95's room and observed the soiled brief on the floor. The DON told CNA #2 that the soiled brief should not be on the floor. At that time, the DON stated to the surveyor that incontinence rounds should be completed every two hours, and that the above observations were unacceptable. A review of Resident 95's Admission Record revealed that Resident #95 was admitted to the facility with diagnoses which included but were not limited to Alzheimer's Disease, depression and anxiety. The Admission MDS dated [DATE] revealed Resident #95's cognitive skills for daily decision-making were severely impaired. The MDS further assessed Resident #95 required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. g. On 11/20/23 at 10:10 AM, the surveyor accompanied by CNA #5 observed Resident #127 in bed. CNA #5 asked Resident #127 is she could check his/her incontinence brief and the resident nodded their head. Resident #127 was wearing an incontinence brief which was saturated with urine. CNA #5 acknowledged the resident's brief was saturated. CNA #5 stated that it was the first chance she got to do incontinence care. A review of the Admission record reflected Resident #127 was admitted to the facility with diagnoses that included but were not limited to: diabetes mellitus, cerebral infarction (stroke) and a gastrostomy tube (a tube inserted into the belly that brings nutrition directly to the stomach). A review of the Quarterly MDS dated [DATE] revealed Resident #127 had short-term and long-term memory problems and that their cognitive skills for daily decision-making were severely impaired. Further review of the MDS revealed that the resident required extensive assistance from staff for personal hygiene and was always incontinent of bowel and bladder. During an interview with the surveyor on 11/16/23 at 10:28 AM, CNA #3 stated that she completed incontinence rounds every 2 hours starting at 7:00 AM, and continued all day long. CNA #3 stated that she never used double briefs because it could cause rashes and infections. During an interview with the surveyor on 11/16/23 at 10:31 AM, CNA #1 stated that she completes incontinence rounds on the residents every two hours and never used two briefs at one time. CNA #1 stated that she always did her last incontinence care rounds at 2:30 PM. During an interview with the surveyor on 11/17/23 at 7:14 AM, CNA #4 stated that she completed incontinence rounds every two hours and never put two briefs on the resident at the same time. The assigned 11 PM-7 AM CNAs (CNA #6, #7, and #8) for Resident's #3, #25, #103, #75, #48, #95, and #127 were unavailable to be interviewed. A review of the facility's Incontinence Care policy reflected .based on the resident's comprehensive assessment, all residents who are incontinent will receive appropriate treatment and services .to prevent infections and to restore continence to the extent possible. 2. On 11/16/23 at 8:42 AM the surveyor observed Resident #75 in bed. The surveyor observed the resident's fingernails to be long and soiled underneath. Resident #75 stated they would like to have their nails cleaned and trimmed. On 11/17/23 at 7:14 AM, the surveyor and CNA #4 observed Resident #75's fingernails appeared to be long and soiled underneath. Resident #75 stated they would like to have their nails cleaned and trimmed. On 11/20/23 at 10:10 AM, the surveyor accompanied by CNA #5 observed Resident #127 in bed. With the resident's permission, CNA #5 removed the sheet and exposed Resident #127's feet. Their toenails appeared to be long, and jagged and their feet were soiled, scaley, and dry. CNA #5 stated that she had told a nurse a long time ago that the resident's nails needed to be clipped but could not recall which nurse she had told. A review of the facility's policy ADL care with a revised date of 9/2023, reflected: It is the policy of this facility to provide ADL care to residents requiring such assistance to ensure all ADL needs are met on a daily basis. A review of the facility policy, Nail Care with a revised date of 9/2023, indicated .Nails will be cleaned daily and filed weekly or as necessary to keep nails clean. The nursing staff instructed on procedure will provide observation and care of nails. On 11/21/23 at 1:35 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant LHNA, Regional DON, Regional Infection Preventionist Nurse (RIPN), and DON to discuss the above observations and concerns. The DON stated that the podiatrist came to the facility every 90 days and the nurses and CNAs were responsible for putting the residents on the list to ensure those residents who needed to be seen would be seen. The DON further stated that the CNAs should be applying lotion to residents feet daily and fingernails should be cleaned and trimmed during care. On 11/22/23 at 9:33 AM, no further information was provided by the facility. NJAC 8:39-27.1 (a), 27.2 (h)

Complaint #NJ00155975; NJ00158378; NJ00154946; NJ154800 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide adequate staff to ensure all residents were provided with timely: a.) incontinent care, and b.) nail care for residents that required extensive assistance for activities of daily living (ADLs). This deficient practice occurred for 7 of 9 residents reviewed for incontinence care (Resident #3, #25, #103, #75, #48, #95 and #127 on 2 of 4 units ([NAME] and Luxor 1) and for 2 of 4 residents, (Resident #38 and #218) reviewed for ADLs and was evidenced by the following: Refer to F677E Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/21, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. The surveyor reviewed the staffing for dates 10/29/2023 through 11/11/2023 which revealed that the facility was deficient in Certified Nursing Assistant (CNA) staffing for residents on 14 of 14 day shifts and deficient in CNAs to total staff on 5 of 14 evening shifts as follows: -10/29/23 had 7 CNAs for 142 residents on the day shift, required at least 18 CNAs -10/29/23 had 8 CNAs to 19 total staff on the evening shift, required at least 9 CNAs. -10/30/23 had 10 CNAs for 142 residents on the day shift, required at least 18 CNAs. -10/31/23 had 13 CNAs for 142 residents on the day shift, required at least 18 CNAs. -11/01/23 had 10 CNAs for 142 residents on the day shift, required at least 18 CNAs. -11/02/23 had 12 CNAs for 142 residents on the day shift, required at least 18 CNAs. -11/03/23 had 9 CNAs for 142 residents on the day shift, required at least 18 CNAs. -11/04/23 had 10 CNAs for 147 residents on the day shift, required at least 18 CNAs. -11/05/23 had 9 CNAs for 147 residents on the day shift, required at least 18 CNAs. -11/05/23 had 6 CNAs to 19 total staff on the evening shift, required at least 9 CNAs. -11/06/23 had 9 CNAs for 147 residents on the day shift, required at least 18 CNAs. -11/07/23 had 13 CNAs for 144 residents on the day shift, required at least 18 CNAs. -11/07/23 had 9 CNAs to 22 total staff on the evening shift, required at least 11 CNAs. -11/08/23 had 11 CNAs for 144 residents on the day shift, required at least 18 CNAs. -11/09/22 had 12 CNAs for 144 residents on the day shift, required at least 18 CNAs. -11/09/23 had 11 CNAs to 24 total staff on the evening shift, required at least 12 CNAs. -11/10/23 had 10 CNAs for 144 residents on the day shift, required at least 18 CNAs. -11/11/23 had 9 CNAs for 143 residents on the day shift, required at least 18 CNAs. -11/11/23 had 8 CNAs to 20 total staff on the evening shift, required at least 10 CNAs. On 11/16/23 at 7:36 AM, surveyor #1 conducted an Incontinence tour on the [NAME] Unit. The surveyor was accompanied by one Licensed Practical Nurses (LPN) one Registered Nurses (RN) one Registered Nurse Unit Manager (RN/UM) and eight CNAs during the tour of nine residents for incontinence care. Of the nine residents the surveyor observed, seven (Resident #3, #25, #103, #75, #48, #95 and #127) were found with saturated incontinence briefs as well as multiple instances of double incontinence briefing. On 11/16/23 at 9:27 AM, surveyor #2 interviewed RN/UM on [NAME] Unit who stated there were two nurses, and two Certified Nurse Aides (CNA) working that day and the unit census was 27. This far exceeds the minimum staffing requirements required. On 11/16/23 at 8:42 AM, surveyor #1 observed Resident #75 in bed. Surveyor #1 observed the resident's fingernails were long and soiled underneath. Resident #75 stated they would like their nails cleaned and trimmed. On 11/20/23 at 10:10 AM, surveyor #1 along with a CNA observed Resident #127's feet, their toenails appeared long and jagged and their feet were soiled, scaley and dry. On 11/21/23 at 10:07 AM, surveyor #2 interviewed the facility staffing coordinator (SC) who stated she was aware of the minimum staffing requirements. The SC stated right now the facility met the staffing requirements but that ratios would change with staff call outs. On 11/22/23 the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team, stated she was aware of the minimum staffing requirements and were currently in the process of hiring more staff. A review of the facility Nursing Services and Sufficient Staff policy revised 9/2023 included . It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident .The facility will supply services by sufficient numbers . licensed nurses .including but not limited to nurse aides.

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate hand hygiene practices for 4 of 5 staff observed and b.) handle and store linens and resident's garbage in accordance with facility policy. This deficient practice was evidenced by the following: 1. On 11/13/23 at 1:50 PM, the surveyor observed Registered Nurse (RN) #1 don (put on) a disposable gown, and gloves and entered room [ROOM NUMBER] which had signage indicating the resident was on transmission-based precautions. On 11/13/23 at 1:55 PM, the surveyor observed RN #1 preparing to exit room [ROOM NUMBER], RN #1 doffed (took off) her gown and gloves and exited the room. The surveyor observed that RN #1 did not sanitize or wash her hands after she removed her gloves. On 11/16/23 at 7:57 AM, during incontinence rounds, the surveyor observed RN #2 enter room [ROOM NUMBER], and checked the resident's incontinence brief. Afterward, the surveyor observed RN #2 washed her hands for 5 seconds before placing her hands under the stream of water. RN #2 then used the same paper towel that she dried her hands with and turned off the faucet. On 11/16/23 at 8:00 AM, RN #2 entered room [ROOM NUMBER] during incontinence rounds and checked the resident's incontinence brief. Afterward, the surveyor observed RN #2 washed her hands for 13 seconds before placing her hands under the stream of water. RN #2 then used the same paper towel that she dried her hands with and turned off the faucet. On 11/16/23 at 8:13 AM, during incontinence rounds the surveyor observed RN #2 entered room [ROOM NUMBER]. Afterward, RN #2 washed her hands for 13 seconds before placing her hands under the stream of water. RN #2 then used the same paper towel that she dried her hands with and turned off the faucet. On 11/16/23 at 8:22 AM, Licensed Practical Nurse (LPN) #2 entered room [ROOM NUMBER] and checked the resident's incontinence brief. Afterward, LPN #2 washed her hands for 12 seconds before placing her hands under the stream of water. On 11/16/23 at 8:25 AM, LPN #2 entered room [ROOM NUMBER] and checked the resident's incontinence brief. Afterward, LPN #2 washed her hands for 5 seconds before placing her hands under the stream of water. On 11/16/23 at 8:30 AM, LPN#2 entered room [ROOM NUMBER] and checked the resident's incontinence brief. Afterward, LPN#2 washed her hands for 11 seconds before placing her hands under the stream of water. On 11/16/23 at 8:42 AM, during incontinence care rounds, the surveyor observed the Registered Nurse/Unit Manager (RN/UM) #2 entered room [ROOM NUMBER] and checked the resident's incontinence brief. Afterward, the surveyor observed the RN/UM #2 wash her hands for 9 seconds before placing her hands under the stream of water. During an interview with the surveyor on 11/16/23 at 1:30 PM, RN #2 stated that the process for handwashing included lathering hands together with soap for 15-20 seconds and the entire handwashing process should take one to two minutes. During an interview with the surveyor on 11/16/23 at 1:35 PM, LPN #2 stated that the process for handwashing included lathering hands together and that the entire process should take 20 seconds. The surveyor showed LPN #2 the handwashing instructions that were hanging on the wall which instructed to scrub hands for 20 seconds. LPN #2 acknowledged that she should wash her hands with soap for 20 seconds before placing her hands under the stream of water. On 11/17/23 at 7:14 AM, the surveyor observed Certified Nursing Assistant (CNA) #4 enter room [ROOM NUMBER] and the surveyor observed CNA #4 wash her hands for 9 seconds before placing her hands under the stream of water. CNA #4 applied gloves, provided care to the resident and afterward, the surveyor observed CNA #4 removed her gloves and washed her hands for 8 seconds before placing her hands under the stream of water. During an interview with the surveyor on 11/17/23 at 7:19 AM, CNA #4 stated that the process for handwashing included lathering hands together for 20 seconds before placing them under the stream of water. CNA #4 further stated that the reason she didn't lather her hands for 20 seconds was that she was rushing. During an interview with the surveyor on 11/17/23 at 7:22 AM, the RN/UM #2 acknowledged that the process for handwashing included lathering hands together for 20 seconds before placing them under the stream of water. During an interview with the surveyor on 11/21/23 at 9:31 AM, the RN #1 stated that she usually washed or sanitized her hands after she removed her gloves but that she must have been so focused on finding out when the resident's labs were going to be drawn that she forgot to lather for the full 20 seconds. 2. On 11/16/23 at 9:44 AM, the surveyor accompanied by CNA #2 observed Resident #95 in bed, unclothed, and observed their incontinence brief on the floor which appeared to be saturated with urine. The surveyor also observed two large clear plastic bags, one contained soiled gowns and linens and the other contained trash. CNA #2 stated that he had just removed Resident #95's brief. The surveyor asked CNA #2 if it was acceptable to place the soiled briefs, a bag of soiled gowns and linen, and a bag of trash on Resident #95's floor. CNA #2 replied, You're just trying to make my job difficult. At that time, the Director of Nursing (DON) entered Resident #95's room and observed the soiled diaper, bag of soiled laundry, and bag of trash on the floor. The DON told CNA #2 that the soiled brief, bag of soiled laundry, and bag of trash should not be in the resident's room on the floor. On 11/21/23 at 1:35 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant LHNA, Regional DON, Regional Infection Preventionist Nurse (RIPN), and DON to discuss the above observations and concerns. The DON stated that the staff should be washing their hands for 20 seconds before placing hands under the stream of water. A review of the facility's Hand Hygiene policy, revised 9/22 reflected .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Hand hygiene technique when using soap and water: Rub hands together vigorously for at least 20 seconds, away from the stream of water and covering all surfaces of the hands and fingers; use single-use towel to turn off the faucet. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. A Review of the facility's Infection Prevention and Control Program policy revised 5/19/23 included .the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures .soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. NJAC 8:39-27.1 (a); NJAC 8:39:19.4 (a)(n)

Complaint #NJ00156125 Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 5 residents reviewed for investigations and was evidence by the following: A review of Resident #296's Admission Record Face Sheet (an Admission summary) reflected that the resident was admitted to the facility with diagnosis which included ileostomy (surgery where the small intestines is diverted through an opening of the abdomen), multiple sclerosis (a chronic disease of the central nervous system) and depression. A review of Resident #296's Admission Minimum Data Set (MDS), an assessment tool, dated 6/16/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. On 11/20/23 at 1:15 PM, the surveyor reviewed a facility document dated 6/24/22 titled Resolution to Resident Grievance/Complaint Form for Resident #296. The grievance form revealed that on 6/17/22 that the resident felt threatened by the nursing supervisor and had called the police. Attached to the grievance form was an investigation dated 6/24/23 which revealed the facility concluded that there was no indication of abuse or threatening of Resident # 296. A review of the police incident report provided by the facility, dated 6/17/22, revealed Resident #296 had called the police on 6/17/22 and explained to the police that they felt harassed by the nursing supervisor and was not receiving the correct care. On 11/20/23 at 2:19 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding Resident #296's grievance and investigation. The LNHA stated when conducting that type of investigation, she would have reported an allegation of abuse to the NJDOH. The LNHA stated that she could not find documentation to confirm that the investigation was reported to the NJDOH. A review of the facility's policy reviewed a Policy labeled Abuse, Neglect and Exploitation which the most recent date of 9/2023, which included but was not limited to; section VII reporting/response: 1. reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies with specified timeframe's; a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. NJAC 8:39-4.1(a)(5)

Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan. This deficient practice was identified for 1 of 30 residents (Resident #124) reviewed for care plans and evidenced by the following: On 11/13/2023 at 12:47 PM, the surveyor observed Resident #124 with an unidentifiable mass on the forehead. The surveyor also observed that there was blood on the bedsheets. The surveyor reviewed the medical record for Resident #124: A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included displaced fracture of surgical neck of left humerus and schizophrenia. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 08/11/2023, reflected a brief interview for mental status (BIMS) score of 9 out of 15, which demonstrated moderately impaired cognition. A review of the individualized comprehensive care plan (ICCP) failed to include a focus area and interventions that identified Resident #124's forehead mass and picking behavior. A review of Resident #124's electronic medical record Physician Progress Note entered on 6/23/2023 identified that the resident declined dermatology on site to do any work up or treatment for black irregular lesion on [their] forehead. A subsequent Nursing Skin Evaluation entered on 10/11/2023, noted that the resident constantly scratches his forehead until it bleeds. On 11/17/23 at 10:55 AM, the surveyor interviewed Licensed Nurse Practitioner (LPN #2), who acknowledged that care plans are utilized to render care to residents based on their behaviors, personal preferences, and independence. LPN #2 confirmed that the resident's care plan should identify their unidentified mass and picking behavior. On 11/20/2023 at 11:08 AM, the surveyor interviewed Registered Nurse Unit Manager (RN/UM#2), who acknowledged that a care plan is a tool used to communicate the status and preferences of the resident needs to everyone involved in their care. RN/UM #2 stated that Resident #124's forehead mass, picking behavior, and refusal of evaluation should have been identified on the care plan. On 11/20/2023 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of Clinical Regional Nurse (CRN), who stated that a care plan was used to identify areas for patient review and improvement. The DON and CRN stated that Resident #124's forehead mass, picking behavior, and refusal of dermatology evaluation should be careplanned. A review the facility's Comprehensive Care Plan documentation, included [ .] 3. The comprehensive care plan will describe, at a minimum, the following .a- the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b-Any services that would otherwise be furnished ,but are not provided due to the resident's exercise of his or right to refuse treatment. A review the facility's Position Title: Licensed Practical Nurse responsibilities/Accountabilities: documentation, included: Under supervision of the Director of Nursing, the incumbent utilizes a general understanding of the principles of nursing and basic physical assessment skills in the development of and implementation of individualized nursing care plans to ensure that the needs of the resident are met [ .] formulates individualized nursing care plans utilizing the nursing progress. NJAC8:39-11.2(e) thru (i); 27.1(a), (d)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to consistently complete the dialysis communication form for one (1) of two (2) residents, (Resident # 239) reviewed for dialysis. This deficient practice was evidenced by the following: On 11/17/23 at 10:01 AM, the surveyor observed the resident seated in a wheelchair in their room. Resident #239 stated that he/she goes to dialysis on Mondays, Wednesdays, and Fridays. A review of Resident #239's admission record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: acute kidney failure, osteomyelitis of the vertebra (infection of the bone), and low back pain. A review of the Admission Minimum Data Set (MDS), an assessment tool dated 11/7/23 reflected a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated an intact cognition. A further review of the resident's MDS, Section O - Special Treatment and Procedures, reflected that the resident received hemodialysis services (a process of purifying the blood due to impaired kidney function). A review of the resident's individualized Care Plan revised on 11/3/23, reflected that Resident #239 was at risk for complications related to hemodialysis (HD -filtration of the blood by artificial equipment). A further review of the care plan revealed the intervention was to communicate with the dialysis center regarding medications, diet, and lab results; to coordinate care in collaboration with the resident's dialysis center. A review of the November 2023 Order Summary Report revealed that Resident #239 had active physician orders for the following: Monitor right chest wall Permacath (a special catheter inserted into a blood vessel for dialysis access) to prevent injury and observe for infection with a start date of 11/3/23. On 11/17/23 at 9:39 AM, the surveyor reviewed Resident #239's Hemodialysis Communication Record (HDCR) book which was located at the nurses' station. A review of the resident's HDCR book revealed individual forms that contained three separate sections to be filled out: the top section - to be completed by center licensed nurse for dialysis patient prior to HD treatment, the middle section - to be completed by dialysis nurse following dialysis treatment and to accompany patient on return to center post - HD, and the bottom section to be completed by center licensed nurse post - HD treatment. A further review of the HDCR forms reflected that the forms from 11/6/23 to 11/15/23 revealed the middle section was not consistently filled out and the bottom section was not filled out on 11/13/23 and 11/15/23. On 11/20/23 at 10:04 AM, the surveyor interviewed Resident #239 who stated upon arrival from dialysis the nurses assessed him/her. The resident stated the nurses checked his/her access site and checked their blood pressure. During an interview with the surveyor on 11/20/23 at 10:15 AM, the RN/UM stated that the nurse at the facility was responsible for filling out the top section of the HDCR and the dialysis center was responsible for completing the middle section and the facility nurses were responsible for filling out the bottom section of the HDCR. She further stated that if the dialysis center did not complete the middle section, then the nurses should follow up with the dialysis center to get a report. On 11/21/23 at 1:35 PM, the survey team met with the Administrator, Assistant Administrator, and Director of Nursing (DON) to discuss the above observations and concerns. The DON stated that the dialysis center should be filling out their section prior to the resident leaving the dialysis center. The DON then stated that if the dialysis center did not complete their section, the expectation of the nurses would be to call the dialysis center for a report. A review of the facility's policy, Dialysis, revised 9/2023 included . the following information will be documented in the resident's medical record: Monitoring for complications related to renal failure/dialysis, monitoring for signs and symptoms of infection, monitoring for patency of dialysis access, measures to protect dialysis access .A dialysis communication form will be sent with the resident to dialysis. Upon return from dialysis, the charge nurse will review and take note of any recommendations. NJAC 8:39-27.1(a)

COMPLAINT#: NJ164590 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to ensure a process was in place and followed to ensure untrained staff without sufficient competencies were meeting the health and/or safety needs of one or more residents. Hospitality Aides (HAs), which include (Certified Home Health Aides-CHHAs and Temporary Nurses' Aides-TNAs), were competent to provide Resident care by failing to ensure: a.) HAs were enrolled in a State-approved training and competency program, and b.) a system was in place to ensure all HAs received the appropriate training and were deemed eligible to provide resident care, which included, but was not limited to, assisting residents with toilet care, bathing and turning and repositioning residents. On [DATE] at 11:28 a.m., the Surveyor observed an HA (HA #1) assist a resident (Resident #2) from the bathroom with his/her walker and then transferred the Resident from a standing position to a sitting position into a chair in the corner of the room. During an interview on [DATE] at 11:29 a.m., the HA said she had 18 residents today, all total care, and she does the same duties as the Certified Nursing Assistant (C.N.A.). On [DATE] at 6:42 p.m., the Surveyor observed HA #2 assisted CNA #1 with bathing when she helped reposition a resident (Resident #7) in bed. The facility's failure to have a system in place to ensure that HAs were appropriately trained and certified to provide resident care placed all residents at risk for the likelihood that serious injury, serious harm, and death may occur, resulting in an Immediate Jeopardy situation (IJ). This placed all residents in an IJ situation. The IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (D.O.N.) on [DATE] at 8:00 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on [DATE] and continued through [DATE], when the facility removed all HAs from the floor. On [DATE], the Removal Plan was implemented. The facility implemented the Removal Plan, which included removing all uncertified aides [H.A.s] from the floor and educating all staff that uncertified aides [H.A.s] are not to be in resident care areas. So, the noncompliance remained on [DATE] as a level F for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 15 Hospitality Aides (H.A.s) reviewed that provided care on 4 of 4 resident units from [DATE] through [DATE] and was evidenced by the following: On [DATE] at 10:37 a.m., the Surveyor took a tour of the first-floor unit and requested the Assignment Sheet (AS) for the 7:00 a.m. - 3:00 p.m. shift. The AS revealed the unit 3 CNA Assignment with 3 names listed for each of the 3 hallways on the unit, including HA #1 with her own Assignment of 17 residents. At 6:23 p.m., the Surveyor took a 2nd tour of the unit and requested the AS for the 3:00 p.m.-11:00 p.m. shift for the 3 CNA Assignment, revealing 3 CNA names per hallway, to include HA #2 with her own Assignment of 20 residents. On [DATE] at 11:28 a.m., the Surveyor observed HA #1, as noted on her employee badge, provide assistance to a Resident (Resident #2) walking from the bathroom with his/her walker across the room and provided transfer assistance from a standing position into a sitting position to a chair in the corner of the room. On [DATE] at 6:42 p.m., the Surveyor observed HA #2 assisted CNA #1 with bathing when she helped reposition a resident (Resident #7) in bed. HA #2 was observed helping CNA #1 reposition the Resident up in bed by assisting with the chuck pad (sheet located under the Resident to help with movement) to move the Resident towards the head of the bed and also helped reposition his/her right leg during bathing. 1. According to the Admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Dysarthria Following Cerebral Infarction, Personal History of Transient Ischemic Attack (TIA) and Cerebral Infarction Without Residual Deficits and Other Abnormalities of Gait and Mobility. According to the Minimum Data Set (MDS), an assessment tool dated [DATE], Resident # 2 had a Brief Interview of Mental Status (BIMS) score of ,d+[DATE], which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance and one-person physical assistance with most Activities of Daily Living (ADLs), including transferring and toilet use. 2. According to the AR, Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorder, Generalized Muscle Weakness, and Need for Assistance With Personal Care. According to the MDS, an assessment tool dated Resident # 7 had a BIMS score of ,d+[DATE], which indicated the Resident was cognitively intact. The MDS also showed Resident #7 needed extensive, one-person physical assistance with most Activities of Daily Living (ADLs), including bed mobility and bathing. On [DATE] at 3:00 p.m., the Administrator provided a list of current Hospitality Aides (H.A.s) with 9 names. On [DATE] at 1:20 p.m., the Regional Human Resources Manager (RHRM) provided a 2nd list of Hospitality Aides/Hospitality Liaisons with 5 additional uncertified aides for a total of 14. A review of Daily Schedule Sheets (DSS) dated [DATE] through [DATE] revealed a total of 15 uncertified aides (H.A.s) were scheduled as Nursing Assistants with their own assignments of residents on all 3 shifts on all units to work as follows: HA #1 on the 7:00 a.m.-3:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. HA #2 on the 7:00 a.m.-3:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #3 on the 7:00 a.m.-3:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. HA #4 on the 7:00 a.m.-3:00 p.m. shift on [DATE]. HA #5 on the 7:00 a.m.- 3:00 p.m. shift on [DATE] and on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #6 on the 7:00 a.m.-3:00 p.m. shift and the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE] and 11:00 p.m.-7:00 p.m. on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #7 on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 11:00 p.m.-7:00 a.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. HA #8 on the 7:00 a.m.-3:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #9 on the 11:00 p.m.-7:00 a.m. shift on [DATE]. HA #10 on the 11:00 p.m.-7:00 a.m. on [DATE]. HA #11 on 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 11:00 p.m.-7:00 a.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #12 on the 3:00 p.m.-11:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on the 11:00 p.m.-7:00 a.m. on [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #13 on the 7:00 a.m.-3:00 p.m. shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. HA #14 on the 11:00 p.m.-7:00 a.m. shift on [DATE]. A review of a timesheet for HA #15 revealed Selected Range of Dates [DATE] - [DATE] included Under Date ,d+[DATE] and ,d+[DATE] Under Schedule 7:00 a.m.-3:30 p.m. Under In, 7:00 a.m. (a.m.) and Out, 3:30 p.m. (p.m.) and Under Daily revealed, 8.0 for both dates revealing Under Amount 23.5 [hours]. During an interview on [DATE] at 11:29 a.m., HA #1 stated, I'm a Certified Home Health Aide (CHHA). I have been working since April. I usually have 18 residents, all total care on my Assignment. When the Surveyor asked if she had done any CNA classes, she replied, I haven't done any CNA classes yet; I will do them soon. In the same interview, when the Surveyor asked her about her duties, HA #1 replied, I do the CNA duties, I provide incontinence care every 2 hours, and as [the] patient [Resident] needs it, I do showers for residents, I write my tasks on the Activities of Daily Living (ADL) sheet, I answer the call bell on this side [hallway], I provide meal assistance. I do everything a CNA does . During an interview on [DATE] at 11:49 a.m., the Unit Manager /Registered Nurse (UM/RN) stated today that she has HA (HA #1) who is going through training. The UM/RN further stated the HA has her own Assignment. She added that each aide has a hallway assigned. During an interview on [DATE] at 12:06 p.m., with the Nursing Supervisor (NS), in the presence of the Staffing Coordinator, she stated we use Temporary Nurses' Aides (T.N.A.s) on the floor; there are ADL Competency sheets [to be completed] and the goal is to [for them] to be enrolled in [a] CNA program. In the same interview, the NS stated, Most of the TNAs & Hospitality Aides (HAs) are home health aides, [they] have some training, and the Registered Nurse (RN) signs off [on the training]. Hospitality Aides serve water, pass trays, assist with care, and have passed some competencies. She continued, TNA can do as much as a CNA; TNA is never on the floor by themselves. Once the TNA passes competencies, [the] CNA does not need to be in the room with the TNAs; the TNA can have their own Assignment of residents once competencies are passed based on the Unit Manager. We [the facility] are following the guidance dated [DATE]. During an interview on [DATE] at 12:46 p.m., when asked if she assisted the TNA (HA #1) working on the floor today, CNA #2 working on the day shift on the 1st floor stated that she was told by the nurse the TNA (HA #1) has been here for a couple of months, so I don't provide assistance to her. During an interview at 12:57 p.m., CNA #3, the other CNA working on the day shift on the 1st floor, stated, Today, I did not provide assistance to the TNA (HA #1). During an interview on [DATE] at 1:17 p.m., when the Surveyor asked her if a TNA could work alone, the RN on the 1st-floor unit stated, Yes, if [a] TNA pass[ed] competencies, they can work alone, once passed, the nurse doesn't sign off on any paperwork, [but] offer[s] help if needed. During an interview on [DATE] at 1:57 p.m., the Unit Manager/Registered Nurse (UM/RN) stated, The nurse doesn't sign off on any competencies; the nurse educator is in charge of [the] competencies. She continued to say that the Administrator wanted [the] UM to train TNAs, but UMs had no time [to train]. The UM/RN further stated, I don't know if competencies are done; I had no idea of [a] CHHA/ [HA] on [the] floor. I thought TNAs were ready to go [work] when they arrived on the floor. Prior to the current staff educator, I don't know who trained the TNAs, [staff are] hired and [have] no official orientation to [the] company, go to [the]floor and learn on [the] floor. In the same interview, the UM/RN stated, I felt [the] TNAs needed to be trained; I was told there'd be a CNA training here through the school here, but [it was] not initiated yet. During an interview on [DATE] at 2:23 p.m., when asked about TNAs, the Regional Human Resources Manager (RHRM) stated, We shouldn't have any TNAs now; they should be in the CNA class or not working. Hospitality Aides (H.A.s) assist with ADLs, but no transferring. HA needs to have someone certified, CNA or nurse, with them to transfer. HA can pass trays and brush hair, but no feeding. The CHHAs are the HAs. The CHHAs need a certified person to work with them. We don't offer the CNA class here; I give the [phone] numbers to call. In the same interview, when the Surveyor asked about who verifies the staff has required certification and knows their job duties, the RHRM replied, The Supervisor, UM, Director of Nursing (D.O.N.), Assistant Director of Nursing (ADON) or Department Head, review the job description with [the] HA and both sign off on it, and it is kept in [their] file. The staff brings proof of their certification, and the nurses follow up with them. When the Surveyor asked about the TNA name badge, the RHRM replied, If there [was a] TNA on [the] floor, it would say TNA. If a CHHA was hired, [the] badge would say Hospitality Aide. The RHRM continued, H.A.s are supervisors, not hands-on care; they observe. During an interview on [DATE] at 2:44 p.m., the DON stated, We hire TNA. We are in the process of having a CNA class here. We train TNAs by following CNAs, and [they] do competencies. TNAs don't have an assignment, [they] answer call light, provide ice water and pass out trays during mealtimes. Hospitality Aides do the same duties as [a] TNA; HA wants to become CNAs. In the same interview, the DON stated, We do hire CHHAs, [they] are hired as Hospitality Aides (H.A.s) because [they] are not certified by the state to work independently. When the Surveyor asked how the nurse knew if the aide was a T.N.A. or a CNA, the DON stated, The nurse on the floor knows by the assignment sheet if the aide is a T.N.A. or CNA In the same interview, when the Surveyor showed the DON the 2 DOH memos dated [DATE], the DON stated, Yeah, these are [the] 2 memos followed by [the] facility. [The] State will probably extend it again, and we'll be in compliance. During an interview on [DATE] at 4:50 p.m., when the Surveyor asked her if a TNA could provide care, the Administrator replied, I believe not; TNA shadows a CNA. In the same interview, when the Surveyor asked about the duties of the HAs and CHHAs, the Administrator stated, HA don't provide care, only ice water, and I need to check if a HA can assist a resident to the bathroom; I think a certified person, a nurse or C.N.A. [is] to do care. CHHA and HA are the same. CHHA is a HA CHHA have [their] own license but don't provide care. NA (Nursing Aides) don't have skills; I let them go [from employment]. We created HAs. We are waiting to provide [CNA] classes here. In a second interview on [DATE] at 5:35 p.m., when the Surveyor asked the Administrator who ensures the TNA and HA receive the required training, the Administrator replied, The Nursing Staff Educator (NSE). The NSE was unavailable between March and May, so the Regional Corporate Clinical Nurse (RCCN) was responsible. During an interview on [DATE] at 5:40 p.m., the RCCN stated, The State extended deadlines; I provided education to TNAs on competencies for ADLs. After training, the TNA is buddied up [paired] with a CNA for ,d+[DATE] weeks; then, I would do another competency with the UM . TNAs are used after taking 8 hours of class and enrolled in a school, buddied up, doesn't stop until certified. I'm not sure if the TNAs are now enrolled in school; I have to check. Some were terminated if not [enrolled] in school. Prior to 2021, [TNA] took [s] [an] 8-hour class and enrolled in a CNA program. If they are unable to enroll in CNA school, we will switch them to HA, which will be a buddy system. There's no documentation of a buddy system; it's only on [the] staffing sheets. However, the RCCN could not provide evidence that the TNA was enrolled in an NJ State-approved training program. During the same interview, when the Surveyor asked her about the CHHA and HA, the RCCN stated, [The] CHHA don't do direct care. CHHAs are HAs, [they] are buddied up with CNAs as long as they are in [the] facility. The TNAs are called HAs [and] should not be doing direct care. During an interview on [DATE] at 6:32 p.m., CNA #1 stated, I'm working with the NA (HA #2). She passes trays and answers the call light. I only do care, not the NA. I'm with her the whole shift. During an interview on [DATE] at 6:35 p.m., when the Surveyor asked the NA (HA #2) her job title, she replied, CNA. In the same interview, when the Surveyor asked the NA (HA #2) about the care provided, she replied, Yes, I provided direct care. I work by myself. Then she walked away. This Surveyor observed HA #2 answer the call light and provided the Resident with ice. During an interview on [DATE] at 6:53 p.m., when the Surveyor asked about the AS sheet, the Licensed Practice Nurse (LPN #1) stated CNA #1 was not on the schedule; she came to help. During an interview on [DATE] at 6:55 p.m., the DON stated another CNA did not come into work with HA #2, so CNA #1 came from another floor to help. During a second interview on [DATE] at 6:58 p.m., LPN #1 stated, [The] CHHA is not supposed to provide direct care. I just go by the assignment sheet; if it says CNA Assignment, they are CNAs. I don't know why the facility hires CHHAs; I'm not involved with hiring. I didn't know HA #2 was a CHHA until the DON said it. [she is] on Assignment as CNA. On [DATE] at 12:30 p.m., the Administrator provided the Surveyor with copies of the 2 Department of Health (DOH) Memos dated [DATE]. A review of the first DOH Memo dated [DATE], Under To: Administrators of Long-Term Care Facilities Licensed Pursuant to NJAC 8:39, Under Subject: revealed [DATE] Temporary Feeding Assistant Training Revoked included: information during the COVID-19 pandemic, about Temporary Feeding Assistants completing a one-hour online training course, passing a [an] online written test and working as a Temporary Feeding Assistant under supervision, [the] waiver will be rescinded 90 days from [DATE] ([DATE]) . A review of a second DOH Memo dated [DATE], Under To: Licensed Inpatient Facility Administrators, Under Subject: revealed [DATE] Temporary Operational Waivers during a State of Emergency Revoked included: information during the COVID-19 pandemic the waiver applied to exceeding licensed bed capacity, bed additions staff qualification requirements waiver will be rescinded 90 days from [DATE]) [DATE]) On [DATE] at 7:52 p.m., the Surveyors provided a DOH Memo dated [DATE], to the Administrator revealed Under To: Nursing Homes . included: Re: (Reference) Temporary Nurse Aides (T.N.A.s) and the Public Health Emergency (P.H.E.) is expected to end on [DATE]. During a telephone interview on [DATE] at 12:33 p.m., the Medical Director (MD) stated she was unaware that uncertified aides, CHHAs, and HAs have been providing care. She continued, I knew the State gave [the] facility permission to use CHHA to provide assistance, but not hands-on care. It's very important for CNAs to be certified and trained to take care of the patient [Resident]; if not could result in mishaps and injury. In the same interview, when the Surveyor asked her about her expectation, the MD replied, The aides are to be certified, have ongoing education and training, renew their licenses, and be allowed to work in the facility. During an interview on [DATE] at 11:07 a.m., the RN stated, The nurse ensures the NAs or HAs are not doing direct care. NAs/[CHHAs]/HAs do answer the call light and get water. They can go into the patient's [Resident's] room, see what he/she needs, and tell the aide [CNA]. During an interview on [DATE] at 11:40 a.m., LPN #2 stated, Whatever nurse arrives on the floor first does the Assignment. When the Surveyor asked her what duties can the TNA/NA/HA allowed to do, LPN #2 replied, They are not to assist the Resident with the chuck pad on the bed, not to reposition or move the resident . TNAs can bring water and supplies . During a telephone interview on [DATE] at 12:30 p.m., when the Surveyor asked her about the HAs, the UM/RN stated, I assumed when the CNA/aide came to the floor [he/she] was a CNA. She continued, HA pass out water, deliver trays, make the bed, change the linens, provide water/ice, do simple tasks. [A] HA cannot physically move patients [residents], cannot assist CNA, even if present in the room, they observe, cannot touch [the] patient [Resident]. During an interview on [DATE] at 2:09 p.m., the RHRM stated, The Hospitality Aide is the same job description as the Hospitality Liaison. During an interview on [DATE] at 3:45 p.m., CNA #1 stated, The HA (HA #2) is [to] observe me, and I answer [their] questions. The NA (HA #2) is not supposed to touch [the] patient [Resident] or move his/her leg, or turn him/her. When the Surveyor asked her what happened with the NA (HA #2) during the care of Resident #7, she replied, I spoke to her after and [told her] she was supposed to watch me. A review of the updated facility policy titled Employee Care Partner Hiring Policy revealed the following: Under Our Purpose, included As a caring community, we believe in creating empowered care partner teams who will support our communities in creating meaningful relationships with all people who live and work in the homes. We will hire qualified candidates whose values and attitudes align with our core value of promoting honor, dignity, and respect for all care partners in the homes. Under Our Strategies included .5.All candidates must complete and sign a job application form. 6. The following criteria will be considered in determining whether an applicant is qualified for a particular job position: a. Ability to perform the essential functions of the job .c. Valid certifications and licenses. 7. Nursing Positions: Department Head, Nursing Services Mentor (Director of Nursing), and Community Mentor (Administrator) will interview candidates and discuss qualifications for potential hire .22. All policies, procedures, benefits, and conditions of employment must be reviewed with all new hires. All policies and procedures must be signed and dated by the new hire . N.J.A.C. 8:,d+[DATE].1 N.J.A.C. 8:,d+[DATE].2

COMPLAINT#: NJ164590 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to ensure a process was in place and followed to ensure untrained staff without sufficient competencies were meeting the health and/or safety needs of one or more residents. Hospitality Aides (HAs), which include (Certified Home Health Aides-CHHAs and Temporary Nurses' Aides-TNAs), were competent to provide Resident care by failing to ensure: a.) HAs were enrolled in a State-approved training and competency program, and b.) a system was in place to ensure all HAs received the appropriate training and were deemed eligible to provide resident care, which included, but was not limited to, assisting residents with toilet care, bathing and turning and repositioning residents. On [DATE] at 11:28 a.m., the Surveyor observed an HA (HA #1) assist a resident (Resident #2) from the bathroom with his/her walker and then transferred the Resident from a standing position to a sitting position into a chair in the corner of the room. During an interview on [DATE] at 11:29 a.m., the HA said she had 18 residents today, all total care, and she does the same duties as the Certified Nursing Assistant (C.N.A.). On [DATE] at 6:42 p.m., the Surveyor observed HA #2 assisted CNA #1 with bathing when she helped reposition a resident (Resident #7) in bed. The Administrator failed to ensure the facility policy titled Employee Care Partner Hiring Policy and the job description titled Administrator were followed. The facility's failure to have a system in place to ensure that HAs were appropriately trained and certified to provide resident care placed all residents at risk for the likelihood that serious injury, serious harm, and death may occur, resulting in an Immediate Jeopardy situation (IJ). This placed all residents in an IJ situation. The IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (D.O.N.) on [DATE] at 8:00 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on [DATE] and continued through [DATE], when the facility removed all HAs from the floor. On [DATE], the Removal Plan was implemented. The facility implemented the Removal Plan, which included removing all uncertified aides [H.A.s] from the floor and educating all staff that uncertified aides [H.A.s] are not to be in resident care areas. So, the noncompliance remained on [DATE] as a level F for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 15 Hospitality Aides (H.A.s) reviewed that provided care on 4 of 4 resident units from [DATE] through [DATE] and was evidenced by the following: On [DATE] at 10:37 a.m., the Surveyor took a tour of the first-floor unit and requested the Assignment Sheet (AS) for the 7:00 a.m. - 3:00 p.m. shift. The AS revealed the unit 3 CNA Assignment with 3 names listed for each of the 3 hallways on the unit, including HA #1 with her own Assignment of 17 residents. At 6:23 p.m., the Surveyor took a 2nd tour of the unit and requested the AS for the 3:00 p.m.-11:00 p.m. shift for the 3 CNA Assignment, revealing 3 CNA names per hallway, to include HA #2 with her own Assignment of 20 residents. On [DATE] at 11:28 a.m., the Surveyor observed HA #1, as noted on her employee badge, provide assistance to a Resident (Resident #2) walking from the bathroom with his/her walker across the room and provided transfer assistance from a standing position into a sitting position to a chair in the corner of the room. On [DATE] at 6:42 p.m., the Surveyor observed HA #2 assisted CNA #1 with bathing when she helped reposition a resident (Resident #7) in bed. HA #2 was observed helping CNA #1 reposition the Resident up in bed by assisting with the chuck pad (sheet located under the Resident to help with movement) to move the Resident towards the head of the bed and also helped reposition his/her right leg during bathing. During an interview on [DATE] at 4:50 p.m., the Administrator stated, The TNAs were already hired when I started; TNAs were to complete 8 hours of training, online training, and basically processes here were not in place. In the same interview, when the Surveyor asked about the TNAs providing care, the Administrator stated, I believe not, the TNA needs to do 80 hours of training of [per the] state regulation, and the TNA shadows a CNA. In the same interview, when the Surveyor asked about the duties of the HAs and Certified Home Health Aides (CHHAs), the Administrator stated, HAs don't provide care, only ice water, and I need to check if a HA can assist a resident to the bathroom, I think a certified person, a nurse or CNA [is] to do care. CHHA and HA are the same. CHHA is a HA. CHHA have [their] own license but don't provide care. NA (Nursing Aides) don't have skills, [so] I let them go [from employment]. If the NAs could not provide [the] course online, we [facility] created hospitality aides (HAs), we're awaiting [CNA] classes to be provided, I'd rather have some people to answer the call bell, get [a] glass of water. [The] HA would cover this, [be] a help on the floor w/CNAs and nurses. In a second interview on [DATE] at 5:35 p.m., when the Surveyor asked the Administrator who ensures the TNA and HA receive the required training, the Administrator replied the Nursing Staff Educator (NSE). The NSE was unavailable for the months between March and May, so the Regional Corporate Clinical Nurse (RCCN) was responsible. During an interview on [DATE] at 5:40 p.m., the RCCN stated, The State extended deadlines; I provided education to TNAs on competencies for ADLs. After training, the TNA is buddied up [paired] with a CNA for ,d+[DATE] weeks, then after I would do another competency with the UM .TNAs are used after taking 8 hours [of] class and enrolled in a school, buddied up, doesn't stop until certified. I'm not sure if the TNAs are now enrolled in school; I have to check. Some were terminated if not [enrolled] in school. Prior to 2021, [TNA] take[s] [an] 8-hour class and enroll in a CNA program. If they are not able to enroll in CNA school, we will switch them to HA, which will be a buddy system. There's no documentation of a buddy system; it's only on [the] staffing sheets. During an interview on [DATE] at 1:23 p.m., the Administrator stated, The HA/NA/TNA shadow the CNA, they pass water, answer the call bell and hand them [CNAs] the clothing, I don't know exactly, what [they] do, I need to look at the job description to clarify. During an interview on 6//,d+[DATE] at 11:04 a.m., the NSE stated, In the past, I don't know what happened. Once the CNA is assigned to another CNA, if lacking competencies, I re-educate, then the CNA can be released to do care. When asked about the HAs, the NSE replied: No, cannot do care. In the same interview, when the Surveyor asked about the hours needed for required training, the NSE continued to say, I do not know about the number of hours/modules the CNAs have to complete to become certified. I was not expected to know . A review of the undated Position Title: Administrator revealed Under Responsibilities/Accountabilities: included: .Interprets personnel practices within policy guidelines .is responsible for planning an is countable for all activities and departments subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents; .Oversees and guides department managers in the development and use of departmental policies and procedures; Review and evaluates the work performance assigned personnel as well as counsel/discipline assigned personnel according to established company personnel policy; .Implements facility objectives as determined and directed by the governing body; .Ensures the residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and rights; . A review of the updated facility policy titled Employee Care Partner Hiring Policy revealed the following: Under Our Purpose included As a caring community, we believe in creating empowered care partner teams who will support our communities in creating meaningful relationships with all people who live and work in the homes. We will hire qualified candidates whose values and attitudes align with our core value of promoting honor, dignity, and respect for all care partners in the homes. Under Our Strategies included .5.All candidates must complete and sign a job application form. 6. The following criteria will be considered in determining whether an applicant is qualified for a particular job position: a. Ability to perform the essential functions of the job .c. Valid certifications and licenses. 7. Nursing Positions: Department Head, Nursing Services Mentor (Director of Nursing), and Community Mentor (Administrator) will interview candidates and discuss qualifications for potential hire .22. All policies, procedures, benefits, and conditions of employment must be reviewed with all new hires. All policies and procedures must be signed and dated by the new hire . N.J.A.C. 8:,d+[DATE].1 N.J.A.C. 8:,d+[DATE].2

C#: NJ#159535, NJ#163626 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on 6/8/2023 and 6/9/2023, it was determined that the facility failed to a.) identify and address a significant unplanned weight loss of 7.5 % in one month, b.) implement and monitor weekly weights, and c.) comprehensively assess the resident after a significant weight change to prevent further weight loss for a resident with a history of weight loss, in a timely manner. The facility also failed to follow its policy titled Weight Management Protocol. This deficient practice was identified for 1 of 2 residents reviewed (Resident #15) for weight loss and was evidenced by the following: Reference: The Academy of Nutrition and Deititians, Position of the Academy of Nutrition and Dietitianss: Individualized Nutrition Approaches for Older Adults: Long-Term Care, Post-Acute Care, and Other Settings, dated April 2018. Position Statement It is the position of the Academy of Nutrition and Dietitians that the quality of life and nutritional status of older adults in long-term care, post-acute care, and other settings can be enhanced by individualized nutrition approaches. The Academy advocates that as part of the interprofessional team, registered Dietitian nutritionist assess, evaluate, and recommend appropriate nutrition interventions according to each individual's medical condition, desires, and rights to make health care choices. Nutrition and dietetic technicians, registered assist registered Dietitian nutritionists in the implementation of individualized nutrition care. Review of the facility's Weight Management Protocol policy, Rev 4/2014, reflected under Guidelines that monthly weights must be done the first week of each month completed by the 10th of the month and document in the medical record. The policy indicated that the threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria . a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. A re-weigh of residents within 24 hours, experiencing a significant unplanned and undesired weight loss/gain, should be witnessed and initialed by a licensed care partner for verification. The policy indicated the Dietician would be notified in the event of a verified weight loss or gain. The policy revealed that a. Meal intake will be monitored for each meal by the Nursing department, b. weight will be done x 4 weeks, or more frequently as needed, or until stable, c. The care plan (CP) will be updated based upon recommendation of the Interdisciplinary Care Partner team (IDCP) to reflect the weight loss/gain problem, the appropriate goal, and interventions. d. Interdisciplinary Notes will focus on weight problem, monitoring, interventions, and resident response; such as increased intake or weight gain/loss as desired. e. Resident's medication and lab values will be reviewed for possible cause of weight loss/gain. According to the Admission Record, Resident #15 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Alzheimer's disease, cerebral infarction, muscle weakness, and need for assistance with personal care. Review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/30/2022, revealed that Resident #13 had a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. The MDS also showed that the resident needed extensive to total assistance with all Activities of Daily Living (ADLs). Further review of the MDS showed that the resident had weight loss of 5% or more in the last month or a loss of 10% or more in 6 months, and that resident was not on a prescribed weight loss regimen. Review of Resident #15's Nutrition Note, (NN) written by the Registered Dietician (RD), on 4/29/2022 at 12:48 PM, indicated that the resident was seen for a quarterly review and triggered for significant weight loss of 14.6 lbs. or 13 % in six months. The NN revealed that the weight loss was unfavorable related to the resident having a BMI (body mass index) of 17, indicating that the resident was underweight, along with advanced age and disease progression. The RD documented that the were no new recommendations at this time and to continue with current plan of care. RD to follow and make changes as needed. Review of the NN, written by the RD, on 4/29/2022 at 12:54 PM, documented additional supplements of fortified cereals for breakfast and fortified mashed potatoes at lunch. Review of Resident #15's physician's Order Summary Report (OSR), for active orders as of 4/30/2022, revealed the following physician orders: 1. A physician order dated 1/3/2022 for Ensure Plus and to provide eight ounces three times a day for supplementation. 2. A physician order dated 4/29/2022 for super cereal in the morning with breakfast 3. A physician order dated 4/29/2022 for super mashed in the afternoon with lunch. Review of the Resident #13's 4/2022 Medication Administration Record (MAR) revealed the corresponding 1/3/2022 physician order for Ensure Plus three times a day for supplementation, with the discontinue date of 6/3/2022. The MAR included the administration times of 10:00 AM, 2:00 PM, and 7:00 PM. The MAR further revealed the corresponding 4/29/2022 physician order for super cereal in the morning with breakfast, with the discontinue date of 1/18/2023. The MAR included the administration time of 9:00 AM. The MAR also revealed the corresponding 4/29/2022 physician order for super mashed in the afternoon with lunch, with the discontinue date of 1/18/2023. The MAR included the administration time of 12:00 PM. Review of Resident #15's Care Plan (CP) revealed a Focus, initiated on 4/25/2018, that Resident #13 had a nutritional problem related to the diagnoses that included but were not limited to Alzheimer's, dementia, need for mechanically altered diet, need for assistance with meals, and history of significant weight loss. The goal, initiated on 2/4/2021, was for Resident #15's to not experience a significant, unfavorable weight change through the review date. Under Interventions, reflected to assist with meals, honor dietary preferences as able, provide and serve diet as ordered. Provide supplements as ordered: fortified cereal at breakfast and fortified mashed potatoes at lunch, healthy shakes with meals, and family to provide Ensure and [NAME] supplement as needed. Review of the facility provided, Weights and Vitals (weights), date range 2/1/2022 to 10/31/2022, revealed the following: 3/3/2022 a weight of 96.6 pounds. (lbs.); -10 % change [comparison weight 9/14/2021, 110 lbs., -12.2 %, -13.4 lbs.] 5/13/2022 a weight of 88.6 lbs; -5.0% change [comparison weight 4/14/2022, 95.8 lbs., -7.5 %, -7.2 lbs.]; -7.5% change [comparison weight 3/3/2022, 96.6 lbs., -8.3 %, -8 lbs.] and -10 % change [comparison weight 12/28/2021, 99 lbs., -10.5 %, -10.4 lbs.] There were no additional weights documented following the 5/13/2022 significant weight loss. The weights further reveal no documentation that Resident #15's weight was obtained for the month of June 2022. Review of the resident's Progress Notes (PN) from 5/13/2022 through 7/24/2022 revealed no documentation that Resident #15's physician was notified 5/13/2022 significant weight loss. The PN did not contain any additional notes from the RD and any assessment to determine the causal factor of Resident #15's 5/13/2022 significant weight loss. Review of the resident's late entry Physician Progress Note, with the effective date 6/20/2022 at 4:43 PM, revealed no documentation about Resident #15's 5/13/2022 significant weight loss. Further review of Resident #15's weights revealed a 07/1/2022 weight of 85.3 lbs.; -7.5 % change [comparison weight 1/20/2022, 96.4 lbs., -11.5 %, -11.1 lbs.] Resident #15 had lost an additional 3.3 lbs. from 5/13/2022. Review of Resident #15's NN, written by the RD, on 7/25/2022 at 2:36 PM, indicated that the resident was seen for a quarterly review and that there was no changed with the resident's chewing/swallowing status. The NN revealed that the resident triggered for significant weight loss of 10.5 lbs. or 11 % in three months and 11.5 % in six months. The NN revealed that the weight loss was unfavorable related to the resident having a BMI of 15.1, which indicated the resident was underweight, along with advanced age and disease progression. The NN further revealed that Resident #15's 7/12/22 laboratory results revealed an albumin level of 2.9. [The normal level is 3.4-5.4 low albumin level may indicate malnutrition.] The RD recommended to assist the resident will meals and to continue all other interventions. RD to follow and make changes as needed. Resident #15's BMI had decrease by 1.9 from the previous BMI of 17 that was documented in the 4/29/2022 NN, written by the RD. Review of Resident #15's physician's OSR, for active orders as of 7/31/2022, revealed a 7/25/2023 physician order for Active Liquid Protein Sugar Free (SF ALP) and to administer 30 millimeters (ml) one time a day for wound healing. Review of the Resident #13's 4/2022 MAR revealed the corresponding 7/25/2022 physician order, with the discontinuation of 12/14/2022, for SF ALP. The MAR included the administration time of 9:00 AM. During an interview on 6/8/2023 at 2:55 PM, the Licensed Practical Nurse (LPN) #1 stated that monthly weights were obtained between the first and the fifth of the month and that the nurses and Unit Manager (UM) were responsible for making sure the were obtained. The LPN added that the nurses and the Certified Nurse Assistants (CNA) could obtain a residents' weights and that the nursing staff were responsible for entering the weight into the electronic medical record (EMR.) The weights would then be reviewed by the UM and RD. During an interview on 6/8/2023 at 3:06 PM, the Registered Nurse/Unit Manager (RN/UM) stated that monthly weights were obtained by the nursing staff and inputted into the EMR for the RD to review. Th RD would review the weights and inform the nursing staff of any weight loss. The RD comes to the weight meeting with a spreadsheet of all the weight loss for the interdisciplinary team (team) to review. The team included the RD, Director of Nursing (DON), Unit Manager and sometimes the Licensed Nursing Home Administrator (LNHA). They would discuss the plan of care for the residents with significant weight loss, the physician would be notified, meal consumption would be monitored, and a referral to Speech Therapy for evaluation may be initiated. During an interview on 6/8/2023 at 3:20 PM, the RD stated her responsibilities included the monitoring residents' weights for weight loss, nutritional evaluation of newly admitted residents, and completing the quarterly and annual nutrition reviews. The RD added that weights were obtained by the 10th of each month and that she tracked to see which resident triggered for a significant weight loss in the past one month, three months, and six months. A 5 % or more weight loss in one month was considered significant and the resident would need to be reassessed. The resident's preferences and meal consumption would be reviewed and supplements and/or referral to speech therapy wound be initiated, if necessary. The RD added that any interventions would be documented in the resident's PN, and that nursing would notify the resident's physician and family of the weight loss. The UM would document the notification in the resident's PN. The RD stated Resident #15 was frail, required assistance with feeding, was on supplements, and that their family also provide additional supplements. When questioned about Resident #15's significant weight loss, the RD stated she would have to look into it and would follow up with the surveyor. During a follow-up interview on 6/9/2023 at 9:47 AM, the RD stated that Resident #15 never had a significant weight loss. The RD continued that she completed a NN noted on 4/29/2023 and that the resident had triggered for a significant weight loss for the prior six months. The RD further stated that she recommended Ensure three times a day, one scoop of [NAME] super energy and that the resident was eating 50 % to 100% of meals at that time. The RD added that the recommendations in place were appropriate and that they met Resident #15's needs. The surveyor questioned Resident #15's weight loss from April 2022 to May 2022. The RD reviewed the Resident #15's weights in the EMR and calculated the weight loss percentage for aforementioned months, in the presence of the surveyor. The RD stated that Resident #15 triggered for a significant weight loss of 7.2 lbs. which was 7.5 % weight loss in one month. The RD added that there was nothing in the resident's medical record that indicated that the resident was re-weighed. The RD further stated the next NN documented in the EMR was on 7/25/22 and that she recommended Active Liquid [SF ALP] for wound healing. When question if the physician was notified of the Resident #15's significant weight loss, the RD stated she was not sure if the physician was notified, and that the UM was responsible for notifying the resident's physician. The surveyor question if Resident #15's weight loss was assessed in June 2022, the RD stated there was no weight obtained for the resident for the month of June 2022. The RD added that there were difficulties with staff obtaining the residents' weights back then and that they were not being obtained in a timely manner. The RD continued that Resident #15's weight had stabilized in May 2022 and that the new weight had become his/her baseline. When questioned about the resident's July 2022 weight, the RD stated the resident had lost an additional few more pounds from May 2022 to July 2022. The RD explained the facility process when a significant weight loss is identified. The resident would be re-weighed, weekly weights would be initiated, meals would be monitored, the resident would be reassessed for new interventions, and the CP would be updated by the RD. The RD added that everything would be documented in the EMR. The RD stated that the May 2022 weight meeting was conducted on 5/13/22 and at the time, Resident #15's weight was still pending. The RD further stated that the June 2022 weight meeting was conducted on 7/1/2022 and that Resident #15 was not discussed during that meeting because the weight had not been obtained. The RD added that normally she would follow up with nursing for the weight and that in a week she would check again with nursing if the resident's weight had not been obtained. The RD added that Resident #15 had came back on the weight meeting list for the month of July 2022 and that the resident's significant weight loss was addressed at that time. The RD stated that Resident #15 was maintaining a weight of 85 lbs. to 88 lbs., and that the interventions in placed met their need. The resident was being assisted with meals, supplements were in place, and was eating 50 % to 100 % of meals. The RD explained that the UM was responsible for the documenting and monitoring the residents' weight in the EMR. She would then review the weights, generate a report with all the resident's weight by unit, and compare the weights by one month, three months, and six months. The RD stated that back then, the weights were imputed late and that she had additional responsibilities. The RD further stated that she did not know why the resident's weight was not obtained or assessed for the month of June 2022. Review of the 5/13/2022 Weight Meeting sheets revealed that Resident #15's May 2022 weight was pending. Review of the 7/1/2023 Weight Meeting sheets did not include documentation for Resident #15. Review of the 7/29/2023 Weight Meeting sheets revealed that Resident #15 had a 10 lbs. or 11 % weight loss times 3 months and a 11.1 lbs. or 11.5 % weight loss in six months. Under the Comments/Interventions, included the following interventions: unfavorable weight loss, regular pureed diet, fortified cereal, mashed potatoes daily, health shakes three times a day, SF ALP once daily, and assist with meals. During an interview on 6/9/2023 at 10:22 AM, the DON stated that residents' weights were monitored monthly to monitor for any weight loss or gain. If a significant weight loss was identified, the resident would need to be re-evaluated. The UM and RD are responsible for monitoring residents' weights in order to identify any significant weight loss or gain. The DON added that the EMR triggers a significant weight loss once inputted and that they try to get on top of it as soon as possible. The DON explained that the resident would be reweighted, reassessed, food preferences and medications would be reviewed, speech and or psychiatry evaluations would be initiated, if needed. The resident physician and family would be notified by either the UM or RD and the notification would be documented in the resident's EMR. The RD generates a report monthly for residents with either weight loss or gain and those residents are discussed during the monthly weight meeting. The team discusses new interventions and would monitor the residents with a significant weight loss closely. Inteventions wound include a calorie count to assess the resident's meal consumption. The RD would document any new interventions and notify the physician and family. The DON stated that any missing weight noted during the monthly weight meeting should be obtained right away and that it was important to obtain the weight because the team would not be able to identify if a significant weight loss had occurred. The DON continued that they would come together as a team and would take a holistic approach in order to come up with proper interventions for any resident with significant weight loss. The resident's family and physician would also be notified because they would have to be on board with everything. The DON added that a physician order for weekly weights would be obtained and documented on the resident's Treatment Administration Record. Review of Resident #15 May 2022, June 2022, and July 2022 revealed no physician order for weekly weights. During interview on 6/9/2023 at 1:00 PM, the LPN #2 stated that she used to be the UM for Resident #15's unit. LPN #2 further stated that resident's weights were reviewed monthly and the team would discuss the residents that with a weight loss or gain. LPN #2 added that the CNAs would obtain the weights, the nurses would document the weights in the EMR, and the Charge Nurse or UM would review them. The residents identified with a significant weight loss or gain would be discussed at the next weight meeting. The team would hold off discussing the residents with missing weights and they would try to obtain the weight as soon as possible. The weight would be obtained and given to the RD, who would then assess the resident and inform nursing of any new interventions. When questioned about Resident #15, the LPN stated that she could not recall the resident. The LPN review Resident #15's EMR, in the presence of the surveyor, and stated that she now remembered the resident. The LPN stated that Resident #15 was pretty good and required a lot of encouragement with meals. The LPN added that the resident had a poor appetite, needed to be assisted with meals, and was able to verbalize when he/she had enough food. During a follow-up interview on 6/9/2023 at 2:06 PM, the DON stated that he had no further information about Resident #15 significant weight loss from April 2022 to May 2022. The DON added that a significant weight loss would be considered as a change in condition and that it should be reported to the resident's physician and documented in the EMR. The DON further stated the physician's documentation would address the resident's weight loss and the intervention that were put in place. No further information was provided by the facility. Review of the facility's Change in Condition policy, rev 10/2019, revealed under Policy that the facility would ensure that changes in the resident's condition is communicated promptly to the licensed nursing staff to ensure prompt evaluation and management of such changes. Changes in condition will be communicated to the Attending Physician, resident and/or resident representative Care plan and medical records will be updated, as needed. Review of the undated Title: Registered Dietician revealed Under Job Function: included: . Completes comprehensive nutrition assessments . in accordance with federal and state regulatory guidance. Completes comprehensive assessments in accordance with current standards of practice. Consults with resident, family, or interdisciplinary team as needed regarding the plan of care for residents. NJAC 8:39-17.1(c)

C#: NJ#161374 Based on observations, interviews, medical records review, and review of other pertinent facility documentation on 6/5/2023, 6/6/2023, 6/7/2023, 6/8/2023, and 6/9/2023, it was determined that the facility failed to consistently follow resident's care plans, evaluate a resident's pain and ensure that pain medications were administered according to the physician's orders (PO's) for a resident who was experiencing pain. The facility also failed to follow its policies titled Pain Management and Medication Administration. This deficient practice was identified for Resident #13, 1 of 1 resident reviewed for pain management, and was evidenced by the following: Review of the facility's Pain Management policy, revised on 9/2022, indicated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standard or practice, the comprehensive person-centered care plan and the resident's goals and preferences. Under Treatment revealed .5. Pharmacological interventions should follow a systemic approach. Review of the facility's Medication Administration-Policy and General Guidelines, revised on 2/2023, indicated under that medications are administered, as prescribed, in accordance with good nursing principles and practices, and only by persons legally authorized to do so . Medications are administered in accordance with State and Federal regulations. The Purpose is to ensure the safe, accurate, and timely administration of medications. Under Procedure, indicated the Medication Administration Record (MAR) is electronically initialed by the person administering a medication immediately after administration of the medication. All routine Controlled Schedule II, III, IV, V medications are documented in the electronic MAR at the time of administration. All doses of Controlled Schedule II and PRN [as needed] III, IV, V medications are signed out in both the Controlled Substance Book and the electronic MAR at the time of administration. According to the Admission Record, Resident #13 was admitted to the facility on [DATE] with diagnoses which included but were not limited to low back pain, secondary malignant neoplasm of bone, and prostate. Review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/26/23, revealed that Resident #13 had a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had severe cognitive impairment. The MDS also showed that the resident needed extensive assistance with most Activities of Daily Living (ADLs) and received a scheduled and as-needed pain medication regimen. Further review of the MDS also showed that a pain assessment should be completed for the presence of pain, and the resident has pain occasionally with a pain intensity descriptor rating of moderate. A review of Resident #13's Care Plan (CP) revealed a Focus, initiated on 1/23/2023, that Resident #13 had acute/chronic pain related to depression and disease process. The goal was for Resident #13's to not have an interruption in normal activities due to pain. Under Interventions, reflected to anticipate the need for pain relief, respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions as needed. Review for compliance, alleviating of symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability, and impact on cognition. Identify and record previous pain history and management of that pain and impact on function. Identify and record previous pain history and management of that pain and impact on function. Identify previous responses to analgesia, including pain relief, side effects, and impact on function. Identify, record, and treat the resident's existing conditions, which may increase pain and or discomfort and cancer. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Review of Resident #13's physician's Order Summary Report (OSR) order date range 1/19/2023-2/25/2023, revealed a physician order dated 1/27/2023 for Morphine Sulfate Solution (a Schedule II narcotic used for relief of moderate to severe acute and chronic pain) (Morphine) 20 milligrams/milliliters (unit of measurement) (mg/ml) and to administer 0.5 ml [for a total dose of 10mg] every 4 hours for severe pain. Review of the Resident #13's 1/2023 MAR revealed the corresponding 1/27/2023 physician order for Morphine 20 mg/ml and to administer 0.5 ml every 4 hours for severe pain, with a discontinued date of 1/29/2023. The MAR included the administration times of 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The 1/2023 MAR revealed that Resident #13 had a pain level of 8 out of 10 on 1/28/2023 at 8:00 AM and that Morphine had been administered. Review of Resident #13's Individual Patient Controlled Substance Administration Record (declining sheet) (a narcotic medication sheet used to document the date and time the medication was removed, the nurse's signature and a declining count of the medication) for Morphine did not include documentation that the medication was removed for administration for the 1/28/23 8:00 AM dose. Further review of Resident #13's 1/2023 MAR revealed that Resident #13's pain level was a 4 out of 10 at 12:00 PM and had increased to a 10 out of 10 at 4:00 PM on 1/28/2023. Review of Resident #13's Progress Notes (PN) revealed no additional documentation about the resident's 1/28/2023 Morphine administration. Review of Resident #13's Progress Notes (PN) revealed a Medication Administration Note (MAN), with the effective date of 1/28/2023 at 7:24 PM, that indicated Resident #13 had refused vital signs due to pain. Review of Resident #13's OSR revealed a physician order, dated 1/29/2023, for Morphine 20 mg/ml and to administer 0.5 ml every 2 hours for severe pain. Review of the Resident #13' 2/2023 MAR revealed the corresponding 1/29/2023 physician order for Morphine 20 mg/ml and to administer 0.5 ml every 2 hours for severe pain, with a discontinued date of 2/12/2023. The MAR included the administration times of 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. The 2/2023 MAR revealed no documentation that Resident #13's pain level was assessed or that he/she received the physician ordered Morphine doses on 2/2/2023 at 6:00 PM and 10:00 PM. Review of Resident #13's declining sheet for Morphine did not include documentation that the medication was removed for administration for the 2/2/2023 6:00 PM and 10:00 PM doses. Further review of Resident #13's 2/2023 MAR revealed that Resident #13 had a pain level of 6 out of 10 on 2/2/2023 at 8:00 PM, which was the next administration time for Morphine after the missed 6:00 PM dose. The MAR further revealed that the resident's pain level had increased to a 9 out of 10 on 2/3/2023 at 12:00 AM, which was the next administration time for Morphine after the missed 10:00 PM dose. Review of Resident #13's PN revealed no additional documentation about the resident's 2/2/2023 Morphine administration. The 2/2023 MAR revealed that Resident #13 had the following pain levels and that Morphine had been administered: 1. A pain level of 8 out of 10 on 2/5/2023 at 8:00 AM. 2. A pain level of 8 out of 10 on 2/5/2023 at 2:00 PM. 3. A pain level of 6 out of 10 on 2/9/2023 at 2:00 PM. Review of Resident #13's declining sheet for Morphine did not include documentation that the medication was removed for the administration of the 2/5/2023 8:00 AM, 2:00 PM, and the 2/9/2023 2:00 PM doses. Further review of Resident #13's 2/2023 MAR revealed that, on 2/5/2023, Resident #13's pain level remained at an 8 out of 10. On 2/9/2023, the resident's pain level had increased to an 8 out of 10 at 4:00 PM, which was the next administration time for Morphine. Review of Resident #13's PN revealed no additional documentation about the resident's 2/5/2023 and 2/9/2023 Morphine administration. Review of Resident #13's Physician Progress Note (PPN), with the effective date of 2/11/2023 at 9:58 PM, revealed that the hospice registered nurse reported the resident as somnolent but still noted with facial grimacing. The PPN further revealed that the physician would increase the Morphine dose to 20 mg every two hours. Review of Resident #13's PPN, with the effective date of 2/12/2023 at 11:23 AM, indicated that nursing had initiated Morphine 20 mg every two hours that morning, and the resident was comfortable, with no facial grimacing noted and was sleeping. Review of Resident #13's OSR revealed a physician order, dated 2/12/2023, for Morphine 20 mg/ml and to administer 1 ml [for a total dose of 20 mg] every 2 hours for severe pain. Review of the Resident #13' 2/2023 MAR revealed the corresponding 2/12/2023 physician order for Morphine 20 mg/ml and to administer 1 ml every 2 hours for severe pain, with a discontinued date of 2/15/2023. The MAR included the administration times of 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. The 2/2023 MAR revealed no documentation that Resident #13's pain level was assessed or that he/she received the physician ordered Morphine dose on 2/12/2023 at 2:00 PM. Review of Resident #13's declining sheet for Morphine did not include documentation that the medication was removed for administration for the 2/12/2023 2:00 PM dose. Further review of Resident #13's 2/2023 MAR revealed the resident's pain level was 4 out of 10 on 2/12/2023 at 12:00 PM. Resident #13's pain level had increased to an 8 out of 10 at the 4:00 PM pain assessment, which was the next administration time for Morphine after the missed 2:00 PM dose. Review of Resident #13's PN revealed no additional documentation about the resident's 2/12/2023 Morphine administration. The 2/2023 MAR revealed that Resident #13 had the following pain levels and that Morphine had been administered: 1. A pain level of 3 out of 10 on 2/12/2023 at 6:00 PM. 2. A pain level of 7 out of 10 on 2/13/2023 at 6:00 AM. 3. A pain level of 5 out of 10 on 2/14/2023 at 12:00 AM. 4. A pain level of 9 out of 10 on 2/14/2023 at 2:00 AM. Review of Resident #13's declining sheet for Morphine did not include documentation that the medication was removed for the administration of the 2/12/2023 at 6:00 PM, 2/13/2023 at 6:00 AM, 2/14/2023 at 12:00 AM, and 2/14/2023 at 2:00 AM doses. Further review of Resident #13's 2/2023 MAR revealed the following: 1. The resident's pain level had increased to a 5 out of 10 on 2/12/2023 at 8:00 PM. 2. A pain level of 6 out of 10 on 2/13/2023 at 8:00 AM. 3. The resident's pain level had increased to a 9 out of 10 on 2/14/2023 at 2:00 AM. 4. The resident's pain level remained at a 9 out of 10 on 2/14/2023 at 4:00 AM. Review of Resident #13's PN revealed no additional documentation about the resident's 2/12/2023, 2/13/2023, and 2/14/2023 Morphine administration. During an interview on 6/6/2023 at 1:25 PM, the Registered Nurse/Unit Manager (RN/UM) who cared for Resident #13 stated the resident was very sick, on hospice, and required total assistance with ADLSs. The RN/UM stated that the resident experienced a lot of pain, had standing physician orders for pain medication, and was medicated as requested. Resident #13 was on palliative care, and that comfort measures were maintained. The RN/UM added that the resident had declined fast, was losing weight and muscle, and that she felt bad because the resident was in a lot of pain. The RN/UM stated there were family dynamics involved, the physician was in constant communication with both family members, and that care was administered per the physician's assessment and orders. During a follow-up interview on 6/7/2023 at 1:13 PM, the RN/UM explained the nursing practice when administering Morphine. The RN/UM stated the nurse measures out the physician-ordered amount in a syringe, record the date, time, amount removed, and their signature on the declining sheet. The nurse would administer the medication to the resident, and then returns to the medication cart to sign the medication as administered on the MAR. The RN/UM added that the MAR and the declining sheet should match and that Morphine was always available because extra bottles are kept in backup. The RN/UM stated that standing pain medications should be administered as ordered, and there should not be any blanks on the MAR. The RN/UM added that blanks on the MAR indicated that the nurse forgot to sign the MAR. When questioned about Resident #13's pain management, the RN/UM stated the resident was diagnosed with metastatic cancer (when cancer spreads from where it started to a distant part of the body) and was constantly in pain. The RN/UM reiterated that there was family dynamics involved. During a telephone interview on 6/7/2023 at 1:55 PM, the RN floor nurse explained the nursing practice when administering Morphine. The RN stated the nurse assesses the resident's pain level and administers the Morphine per the physician's order. The nurse is supposed to sign the declining sheet when the medication is removed from the bottle. The MAR is signed after the nurse administers the medication to the resident. During an interview on 6/7/2023 at 3:19 PM, the Director of Nursing (DON) stated the nurse should review the physician's order and follow the five rights when administering medication. The five rights include the right resident, right medication, right dose, right time, and right route. The DON stated that he expected the nurse to sign the declining sheet once they removed the dosage from the Morphine bottle. The nurses are expected to sign the MAR after administering the medication to the resident. The DON added that there should not be any blanks on the MAR. During an interview on 6/8/2023 at 9:50 AM, Resident #13's physician, who is also the facility's Medical Director (MD), stated the resident had an advanced cancer diagnosis, was malnourished when admitted , and that she assisted the family with end-of-life management and goals of care. The resident did not want to do further cancer treatments and just wanted to be comfortable. The MD added that family dynamics were involved and that the resident's sister did not want the resident on Morphine, while the resident's Power of Attorney (POA) wanted Morphine to be administered for pain management. The MD stated that she informed the resident's sister that the resident was not being overmedicated and that they were trying to keep him/her comfortable. The physician indicated that she had frequent communication with the resident's family, provided education about the resident's disease process and that the resident's pain needed to be managed . Due to the resident's lifestyle and medical history, he/she needed higher doses of Morphine for pain management. The MD added that Resident #13's appetite improved once the pain had been controlled. The MD stated that her goal was to control the resident's symptoms and that the Morphine dose was eventually lowered. The MD further stated that she expected the nurses to administer Resident #13's medication per the physician's order. During a follow-up interview on 6/8/2023 at 11:59 AM, the DON stated that he expected nurses to administer the resident's medication per the physician's order. The DON reiterated that there should be no blanks and that the medication should have been administered. The DON stated the MAR and declining sheet should match. The nurses are supposed to document all removal of narcotics on the declining sheet. The DON could not provide an answer as to why the nurses did not sign the MAR and/or the declining sheet on the aforementioned dates. During a follow-up interview on 6/9/2023 at 12:45 PM, the RN/UM, who was responsible for administering Resident #13's Morphine on 2/5/2023, stated that she would sometimes work the cart and that she administered the resident's medication per the physician order. The RN/UM added that the declining sheet should be signed when the medication is removed from the Morphine bottle. When questioned about Resident #13's 2/5/2023 medication administration, the RN/UM stated that she administered the medication as ordered but must have forgotten to sign the declining sheet. No further information was provided by the facility. Review of the facility's Controlled Substances Policy, revised on 1/2023, indicated under Policy that it was the policy of this facility to promote safe, high-quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The policy is revealed under General Protocols, 4. The Controlled Substance Administration Record (CSAR) [declining sheet] serves the dual purpose of recording both the narcotic disposition and patient administration. 5. The licensed nurse administering a controlled substance will document the administration in the patient's electronic medical record, i.e. Medication Administration Record [MAR] and/or Progress Notes. The policy further revealed under Documenting Administration Controlled Substances, that any facility nurse who administers a Controlled Substance (CS) to a resident will document on the resident's applicable declining sheet the date and time the CS was removed and the number of remaining doses. The nurse will also document the administration in the resident's MAR. N.J.A.C.: 8:39-27.1(a)

Based on observation, interviews, and record review, it was determined that the facility failed to ensure that a resident (Resident #60), who had a diagnosis of dysphagia (difficulty swallowing) and was at risk for silent aspiration (food or fluids that enter the lungs instead of the stomach without any outward, noticeable symptoms such as coughing, wheezing, or a hoarse voice), was given the correctly prepared liquid consistency in accordance with the resident's physician order for nectar-like thickness. The resident began to forcefully cough after drinking coffee that was prepared by an activity aide and not thickened to nectar-like consistency. This deficient practice was identified for Resident #60, 1 of 11 residents reviewed for altered consistency diets/liquids. There was a systemic failure when multiple facility staff failed to identify and provide the correct amount of nectar thickener to the resident's beverage. In addition, the Director of Nursing (DON) stated that all activity staff had not been trained to identify the correct consistency of food or thickening liquids. The facility's failure to ensure the resident, who had difficulty swallowing, had a history of silent aspiration and was at risk for aspiration, received the appropriate liquid consistency. Serving the wrong consistency constituted an immediate jeopardy to the resident's health and safety. According to the discharge facility's admission documents faxed to the facility, dated 10/11/19, prior to Resident #60's admission, revealed diagnoses including but not limited to: pneumonitis due to inhalation of food and vomit and dysphagia. The included history and physical (H&P), not dated, revealed the resident had developed aspiration pneumonia. The discharge facility paperwork included an endoscopic swallowing test, dated 10/08/19, that showed the resident was on Nectar Thickened Liquids (NTL); history of pneumonia likely due to aspiration; high risk for pneumonia with thin liquids; positive silent aspiration during the test and recommended to repeat the study prior to discontinuing use of thickened liquids secondary to silent nature of aspiration at times. The Universal Transfer Form, dated 10/17/19, which accompanied Resident #60 upon admission to the facility, revealed the primary diagnosis as pneumonitis due to inhalation of food and vomit and at-risk alert for aspiration. A review of the admission physician orders, dated 10/04/19, revealed thick liquids-nectar like/thick consistency. Maintain all previous diet recommendations. The Dining Preference Form, dated 10/17/19, indicated that the resident moved in from a rehab facility and the diet order was nectar thick liquids, controlled carbohydrates, and regular food texture. This Immediate Jeopardy (IJ) was identified on 01/07/20 at 12:10 PM after the surveyor observed an activity aide prepare an 8 ounce (oz) cup of coffee incorrectly and Resident #60 took a sip and began to forcibly cough. The IJ was relayed to the Administrator and the Director of Nursing (DON) on 01/08/20 at 11:22 AM and the removal plan was requested. The removal plan was accepted on 01/08/20 at 3:07 PM. The surveyors verified the implementation of the removal plan on 01/09/20 at 12:19 PM and throughout the remainder of the survey. This deficient practice was evidenced by the following: On 01/07/20 at 12:10 PM, the surveyor observed an activity aide pour half of a packet of Thick & Easy nectar thickening powder into an 8 oz cup filled with coffee and did not stir the thickening powder into the coffee. The surveyor observed the activity director pour the rest of the thickening packet into the 8 oz coffee without stirring it. Resident #60 stirred the coffee eight times. There were no other beverages and no food in front of the resident. The Registered Nurse (RN) came over and spoke in Resident #60's language. All three staff left without stirring the thickening powder or checking the consistency. Resident #60 poured two creamers into the coffee, stirred the coffee 21 times, immediately took a drink and began to forcibly cough at least three times and then began to loudly try to clear his/her throat. At that time, at 12:17 PM, the RN Unit Manager was called over by the surveyor and the RN acknowledged the coffee was not all the way thick. The Food Service Director (FSD) was present and measured the amount of coffee in the cup and verified there had been 8 oz of coffee. The thickening packet directions called for one packet per 4 oz. The RN Unit Manager acknowledged there had been one packet used but there should have been two packets used for 8 oz. Review of the Admission Record revealed Resident #60 was admitted on [DATE] with a diagnosis that included but was not limited to, Dysphagia, oropharyngeal phase. Review of the resident's comprehensive, admission Minimum Data set (MDS), an assessment tool dated 10/24/19, revealed the resident had a Brief Interview for Mental Status (BIMS) of 5 which indicated that the resident's cognition was severely impaired. The MDS also indicated that Resident #60 had non-Alzheimer's Dementia, dysphagia and was on a mechanically altered diet (change in food or liquids texture). Review of the Census List, dated 01/07/20 at 5:45 AM, revealed Resident #60 received nectar thick consistency liquids. Review of Resident #60's diet ticket, dated 01/07/20, revealed NECTAR THICK liquids. Review of the Thick & Easy nectar consistency food and beverage thickening powder instructions revealed, add one packet to 4 oz of liquid and stir for 15 seconds. Allow 1-4 minutes for the liquid to reach optimal thickness. Review of the Admission Summary, dated 10/17/19, revealed the resident was admitted to the hospital about three weeks prior with aspiration pneumonia and that the resident should only have thickened liquid. Review of the Nutritional Evaluation, dated 10/18/19, revealed the resident required nectar thick liquids; had dx [diagnosis]: aspiration pneumonia .Dysphagia; and that the endoscopic swallow evaluation and the diet recommendation was secondary to silent aspiration. Review of the Rehab Screen, dated 10/17/19, revealed that the resident was admitted with reg/NTL[regular/nectar thick liquids], and a recent study revealed the resident SILENTLY aspirated thin liquids. Review of the Physician Order Speech Therapy Form, dated 10/17/19 revealed to continue NTL. Review of the Baseline Care Plan, dated 10/23/19, revealed the diet order of nectar-thick liquids and risk for swallowing problems. Review of the Care Plan, with a focus dated 11/8/19, revealed resident has nutritional problem or potential nutritional problem related to aspiration pneumonia, dysphagia, diabetes, dementia, [CONDITION(S)], and high blood pressure with interventions that included but were not limited to monitor and report signs and symptoms of dysphagia and provide and serve diet as ordered. Review of the Medication Review Report, revealed the following: October 2019: thick liquids-NTL order date 10/04/19, active order status November 2019: NTL order date 10/17/19, active order status December 2019: NTL order date 10/17/19, active order status January 2020: NTL order date 10/17/19, active order status Review of the Medication Administration Record, dated October 2019, November 2019, December 2019, and January 2020, revealed diet Nectar consistency. Review of the ADL Flowsheets, dated 12/31/19, 12/05/19, 11/15/19, and 10/16/19 revealed diet Nectar thick fluid consistency. Review of the Physician Progress Note, dated 01/07/20 at 22:38 PM (10:38 PM), revealed dysphagia, oropharyngeal phase, resident on NTL for precaution with history of aspiration pneumonia. The resident had two chest x-rays as follow up of resolving aspiration pneumonia from several months ago, it showed improving lung change, but still having some residual infiltration. The resident tolerating the current regimen, will continue the same. Review of the nursing notes Skilled Evaluations, completed on 12/06/19-12/17/19, and 12/30/19, revealed: no cough noted, no signs/symptoms of a swallowing disorder, and on 12/28/19 and 12/29/19: no cough noted. During an interview with the surveyor on 01/07/20 at 12:31 PM, the activities aide stated she had worked at the facility for almost four years. The activity aide said she would look at meal tickets and stated she was aware Resident #60 was on nectar thick liquids. The activity aide stated the process was to put the thickening powder in the cup first or if she were busy, I let [the resident] do it. The activity aide said she didn't pay attention to how much goes into the cup but that the resident doesn't like it all so we cut the packet off at half. The activity aide stated if the resident had the wrong consistency drink, they could cough. The activity aide stated, I am trained once a month in a meeting where it is mentioned to check the meal ticket but I don't pay attention to how much. During an interview with the surveyor on 01/07/20 at 12:39 PM, RN #1 stated in the dining room the staff would check the diet sheets and that the nurses would verify the consistency but that she wasn't in the dining room at that time. RN #1 stated the purpose of the thickened liquid was so the resident would be able to swallow easier and that if the consistency was wrong, the resident could choke. During an interview with the surveyor on 01/07/20 at 12:45 PM, RN #2 stated she was there when the activity aide served fluid. RN #2 stated the activity aide put one packet of thickening powder in the coffee and that the activity aide would be the one responsible for seeing if the coffee was the correct thickness. RN #2 stated she didn't know the policy so she was not aware of how to check the nectar thick consistency. RN #2 stated it was an 8 oz cup of coffee but didn't know how much thickener should be added. RN #2 stated that Resident #60 was on thickened liquid for the prevention of aspiration and if it was the wrong consistency, it could be dangerous. RN #2 stated nursing staff was not trained on how to thicken liquid by the facility. During an interview with the surveyors on 01/07/20 at 12:51 PM, the activities director stated the diet list is in the dining room; thickened juices come already thickened. The activity director said the process was to put one packet of thickening powder in 6 oz of coffee. I have thickened before and we stir it and let it sit until thickened. The activity director stated if a resident had the wrong liquid consistency, they could choke. The activity director stated they have in-services on how to thicken liquids and that everyone was capable of thickening the liquids. During an interview with the surveyor on 01/07/20 at 1:20 PM, the RD stated the process was that the thickening packet would come from the kitchen and that the CNA, nurse or activities staff were able to thicken liquids and that they should have been in-serviced on how much to use. During a phone interview with the surveyor on 01/07/20 at 2:00 PM, the ST stated Resident #60 had been receiving thickened liquids upon admission and had a swallow test done prior to admission. The ST stated that the resident was on silent aspiration precautions which meant there may be no obvious response like coughing and that this is dangerous because it (fluid) could go right into the lungs without anyone knowing. During an interview with the surveyor on 01/07/20 at 2:19 PM, the DON stated the process in the dining room for altered diets/liquids was there is a list that is updated every day. The DON stated that the CNA, nurses, and activities staff were in-serviced how to thicken liquids quarterly by either the DON or ST. The DON further stated that the staff would be instructed how to identify the different consistency, no straws, the different cup sizes and always read the label when pouring the thickening packet because it could be a different packet per ounces and they (the staff) may have to use more than one packet. During an interview with the surveyors on 01/07/20 at 2:36 PM, the DON stated if a resident stops the staff from using the correct amount of thickening powder, the staff should educate the resident. The DON stated the staff should not walk away and leave the drink as is and the staff should check to ensure the liquid was thickened properly. The DON stated one of the nurses should be making the rounds to ensure that the liquids were the correct consistency. During an interview with the surveyors on 01/07/20 at 3:52 PM, the DON stated the Universal Transfer Form that comes in with the resident on admission was for the nurses' reference. The DON acknowledged the aspiration precaution on the Universal Transfer Form and stated if someone came with a modified diet on the precaution, they would have speech evaluate them. The DON stated the importance of the universal transfer form that indicated aspiration precautions, was to make nurses aware because it was important for nurses to know how to care for the resident. The DON stated the staff definitely would monitor for aspiration since the resident came in with aspiration pneumonia. On 01/07/20 at 4:03 PM, the DON informed the surveyors that there were no competencies for all staff regarding thickening liquids. During an interview with the surveyor on 01/08/20 at 9:45 AM, the DON stated the activity aide did not attend the training and that she looked back, and no education was found. The DON stated that the activity aides were not trained to identify the correct consistency of food or thickening liquids. The DON stated there were no paid feeding assistants and no RN who was qualified to teach the paid feeding assistant course. During an interview with the surveyor on 01/08/20 at 10:43 AM, the DON stated that the activity aide should not have been thickening liquids and that the way the activity aide thickened the NTL yesterday was not correct. The DON stated the activity aide (Life Enrichment Assistant) job description did not include learning to serve. The DON stated the purpose of the job description was to show what the employee will be performing and that the activity aides job description did not include that (thickening liquids or food) scope of practice. Review of the Thickened Liquids policy, dated 10/2019, revealed the facility provided thickened liquids as prescribed to residents who require them. Thickened liquids refer to liquids in which the consistency has been altered to facilitate safe oral intake. They are ordered as part of the treatment for a disease or clinical condition, such as dysphagia. Review of the Meal Supervision and Assistance Policy, dated 10/2019, revealed the resident would be prepared a meal and with adequate supervision and assistance to prevent accidents and that beverage consistency was given in accordance with the physician orders. Review of the Comprehensive Care Plans policy, dated 11/2019, revealed the comprehensive care plan would be reviewed and revised by the interdisciplinary team and it will include measurable objectives to meet the resident's needs as identified. NJAC 8:39-17.4(a)(1-2)

Based on observation, interview and review of the medical record, it was determined that the facility failed to consistently implement care plan interventions for residents with a history of pressures sores. This deficient practice was identified for Resident #1, 1 of 10 residents reviewed for pressure sores, as evidenced by the following: On 11/15/12 at 10:30 a.m., the surveyor reviewed the medical record of Resident #1 which revealed a [DIAGNOSES REDACTED]. On 11/15/12 at 11:00 a.m., the surveyor reviewed a Progress Record dated 7/27/12, which indicated that staff found a dark red area on the right lateral heel. The area was not measured and no wound tracking form was initiated. Review of the resident's care plan initiated on 6/20/12 and revised 7/27/12, revealed that the resident was to have pressure relief/reduction/ heel protection on admission. A review of the facility's Pressure Ulcer Prevention Management Policy revealed, "It is the policy of the facility to assess all residents upon admission, readmission, and quarterly thereafter, for risk factors associated with Pressure Ulcer development and the necessary precautions to prevent formation. Appropriate interventions will be utilized to prevent pressure ulcer development and to promote healing when pressure ulcers are present. " There was no documented evidence that the policy was consistently followed. On 11/15/12 at 12:30 p.m., the surveyor interviewed the nurse who revealed that the resident was provided with heel protectors on 7/27/12. A review of the Treatment Administration Record (TAR) revealed an order to offload the resident's heels on 7/27/12. A review of the Certified Nursing Assistant (CNA) Resident Care Plan Kardex failed to include any intervention regarding offloading the resident's heels on admission. There was no evidence that the facility consistently implemented the care plan. Refer to F 314. N.J.A.C.8:39- 11.2 (d)

Based on observation, interview and record review it was determined that the facility failed to consistently provide a pressure relief device for a resident who was identified to be at risk to develop pressure sores. The facility failed to ensure that treatments were completed and documented, and failed to document measurements when the resident developed actual skin breakdown, resulting in a resident developing an unstageable pressure sore to the right heel. This deficient practice and was identified for 1 of 10 residents (Resident #1) reviewed for pressure ulcers and was evidenced by the following: The surveyor reviewed the medical record of Resident #1 on 11/15/12 at 10:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. During the initial tour of the facility on 11/13/12 at 10:15 a.m. the Unit Manager Nurse (UMN) informed the surveyor that Resident #1 had a Stage III facility acquired pressure sore to the right heel area. The surveyor observed Resident #1 in bed; with his/her legs wrapped in a foam boot, and resting on the bed. On 11/15/12 at 11:30 a.m., the surveyor reviewed Resident #1's clinical record and care plan which revealed a physician's orders [REDACTED]. The care plan indicated the same. The Progress Record dated 7/27/12 indicated a "right heel with dark red area, skin prep ordered." No measurements were recorded. The Minimum Data Set ((MDS) dated [DATE] and 9/18/12, revealed that the resident's ability to perform activities of daily living (ADL) was impaired. The resident required total assistance of staff for bed mobility and transfer. A review of the Braden Scale for predicting pressure sore risk dated 6/20/12 revealed that Resident #1 was assessed as "15," or considered to be at mild risk for the development of pressure sores. The admission assessment sheet dated 6/20/12 revealed that the resident's heels were intact on admission. On 11/15/12 at 11:30 a.m., the surveyor asked the Unit Manager (UMN) for the wound tracking form and weekly skin assessment for review, but none was provided. The UMN informed the surveyor that no measurements were available. The UMN stated when the wound was found on 7/27/12, the Physician was informed and the resident was referred to the wound specialist. There was no documentation regarding the pressure area of the resident right heel until 8/9/12. A review of the Resident Care Plan Kardex initiated on 6/20/12, revealed no preventive measures were in place regarding pressure relief of the resident's heels until 7/27/12. On 11/16/12 at 11:30 a.m., the UMN confirmed that there were no preventive measures in place prior to 7/27/12 to protect the resident's feet. The UMN stated that the care plan was revised on 7/27/12 when the red dark area was identified. The UMN confirmed that the physician gave an order to offload the resident's heels on 8/9/12. On 11/16/12 at 12:30 p.m., the surveyor further reviewed the Progress Record from 8/16/12 to 11/15/12 which revealed the following: On 8/9/12 at 11:08 a.m., a full thickness wound of the right heel which measured 2.6 x 1.3 centimeter (cm), was documented. The documentation further indicated; "Plan: Unstageable pressure ulceration of the right heel, Evidence of [MEDICAL CONDITION] ( [MEDICAL CONDITION] ), continue repositioning in accordance with facility policy, off-load pressure on area, float heels off mattress." A Doppler study was done on 8/14/12 which revealed: "Mild macro vascular disease suggested bilaterally. At least moderate microvascular PAD suggested on the right. Wound healing may be delayed on the right." On 8/23/12 the right heel wound was measured as 4.8 cm x 6.2 cm. The wound specialist discontinued the heel protectors and ordered "Prevalon boots." The order to float the heels off the mattress remained in effect. The resident was observed throughout the survey from 11/13/12 to 11/20/12 with the Prevalon boots on, with his/her feet resting directly on the mattress. On 11/19/12 at 10:45 a.m., the surveyor observed the nurse perform wound care to Resident #1's right heel. The necrotic area had the following measurements: 5.8 cm x 4.0 cm. The surveyor observed at that time an open area on the right forefoot. The nurse told the surveyor that she/he observed a reddened area the previous day but did not assess it further. The nurse also stated that she forgot to inform the physician of the reddened area. The nurse proceeded to redress the resident's right heel, and left the open area untreated. The surveyor then asked the nurse to measure the open area, which measured 2.5 cm x 0.8 cm. The nurse completed the wound treatment, reapplied the Prevalon Boots and positioned the resident's feet directly on the mattress. The nurse did not float the resident's heels as ordered by the wound specialist. On 11/19/12 at 11:15 p.m., the surveyor asked the UMN about the open area on the resident's right forefoot. The UMN informed the surveyor that she was not aware of the wound. Later that same day, the UMN informed the surveyor that the causative factor for the wound might be from the cling (elastic bandage) being too tight. On 11/20/12 the physician ordered to wrap the right heel wound with Border gauze and discontinued the cling bandage. On 11/19/12 at 11:30 a.m., the surveyor interviewed the Certified Nursing Assistant (CNA) about the resident's care. The CNA informed the surveyor that the resident was dependent on staff for care. The CNA informed the surveyor that the resident had to wear the boots at all times. The CNA was not aware of the order to float the resident's heels off the mattress. The surveyor observed that the order was not entered on the Resident Care Plan Kardex, to ensure consistent implementation of the order. The nurse confirmed that the Prevalon boots had been ordered since 8/24/12 and did not realize that the resident's heels needed to be floated off the mattress. On 11/20/12 at 11:15 a.m., the Director of Nursing told the surveyor that Resident #1 should have had heel protectors in place on admission. Review of the facility Pressure Ulcer Prevention and Management Policy revealed, " For in house residents with a newly identified pressure ulcer the following forms will be initiated by the nurses who identified the Pressure Ulcer: a) Pressure Ulcer investigation Sheet. b) Unavoidable skin breakdown." The policy further stated that the Licensed Nurse was responsible to implement Pressure Ulcer Treatment, and a weekly Pressure Wound Tracking Report would be provided by the Unit Manager. These documents were not available to the surveyor for review during the Survey. There is no documented evidence this policy was consistently followed. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview and medical record review, it was determined that the facility failed to consistently implement measures to ensure residents' safety. The facility also failed to provide adequate supervision to a resident who was in the bathroom, which resulted in the resident, Resident #11, falling and sustaining a fractured humerus. This deficient practice was identified for 2 of 11 residents reviewed for falls, Resident #11 and #17, as evidenced by the following: 1. The surveyor reviewed the medical record of Resident #11 on 11/14/12 at 10:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. Review of an Interdisciplinary Progress note dated 5/7/12, revealed "Noted on floor in bathroom after CNA put (Resident) on the toilet as she stated she had to move her bowels. CNA noted her gown was wet, went to get a dry gown after telling (Resident) to wait there, she would be right back. (Resident) got up and fell ." The resident sustained [REDACTED]. An interview with the Unit Manager on 11/14/12 at 10:40 a.m., revealed that facility policy stated that "no resident should be left unattended in the bathroom." The Unit Manager provided the surveyor with the Facility Policy which stated Title: Fall Prevention/Management "Falling Stars," under Section I "All residents are not to be left unattended while on the toilet." There was no documented evidence this policy was consistently followed. 2. On 11/14/12 at 10:30 a.m., the surveyor reviewed the medical record of Resident #17, which revealed that the resident had [DIAGNOSES REDACTED]. During the initial tour of the facility on 11/13/12 at 10:00 a.m., the nurse identified the resident as " a high fall risk." On 11/14/12 at 10:15 a.m., the surveyor observed Resident #17 seated in a recliner chair in his/her room. A rolling walker was noted next to the recliner chair. Further review of the clinical record revealed a Quarterly Minimum Data Set (MDS), a resident assessment tool, dated 7/08/12 and 10/03/12 which indicated that Resident #17 was coded to require assistance with transfers. On 11/15/12 at 10:15 a.m., the surveyor reviewed the Progress Notes from 12/03/11 to 11/18/12, which revealed that Resident #17 sustained falls at the facility on 10/19/12, 10/21/12 and 11/14/12. The two prior falls occurred in the bathroom. On 10/19/12 the resident's roommate informed the staff of the fall. On 10/21/12 a housekeeping person informed the staff of the second fall in the bathroom. According to the incident report, there was no device in place to alert the staff of the falls. On 10/19/12 the resident's care plan was revised to include supervision and assistance with ambulation. The resident fell in the bathroom again on 10/21/12 and sustained three skin tears to the right hand. On 10/21/12 following the second fall, the care plan was revised to include a bed/ chair alarm. On 11/14/12 at 3:00 a.m., the resident fell in the room. A review of the Incident/Accident Report revealed that no protective equipment was in use at the time of the fall. The resident's roommate called and informed the staff that the resident was on the floor. On 11/15/12 at 12:30 p.m., the surveyor reviewed the Incident/Accident Report with the Director of Nursing (DON) who stated that the bed/chair alarm was implemented on 11/14/12. The care plan revealed an implementation date for the bed/chair alarm of 10/21/12. N.J.A.C. 8:39-27.1 (a) 31.2 (e)

C#NJ & NJ Based on interviews and review of medical records and other facility documentation, it was determined that the facility failed to ensure that medications and Intravenous Fluids (IVF) were accurately administered according to the physician's orders [REDACTED].#5 & #6). Resident #5 received a medication administered incorrectly and sustained eye irritation and bilateral Corneal Abrasions. Resident #6 received medication in IVFs which were ordered for another resident. This deficient practice is evidenced by: 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 casefinding, health teaching, health counseling, and provision of care supportive to restorative of life and well being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist." The medical records were reviewed by the surveyor on 3/5/12. 1. According to the medical record Admission and Discharge Summary, Resident #5 was admitted to the facility with medical [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 7/19/11 indicated the resident was alert and oriented with no cognitive deficits. A review of Daily Skilled Nurse's Notes, written by a Registered Nurse (RN) preceptor, dated 9/22/11 at 8:30 AM, reflected "Another RN (orientee) mistakenly instilled [MEDICATION NAME] ear drops to bilateral eyes instead of artificial tears." An RN immediately called the pharmacy and was told to flush the eyes immediately and repeat the flush in 5-10 minutes. The Nurse Practitioner was present and assisted an RN to flush the resident's eyes. The resident denied pain, burning or redness at that time and "stated she did not want or need it." An untimed physician's orders [REDACTED]. A subsequent Daily Skilled Nurse's Note, dated 9/22/11 at 3:00 PM, reflected that Resident #5's significant other stated the resident complained of eye pain. At 4:00 PM, Resident #5 was sent to the emergency room (ER) for "irritation to bilateral eyes." At 8:30 PM Resident #5 returned from the ER and denied pain or discomfort to the eyes and stated they feel a lot better." A physician's orders [REDACTED]. A review of an emergency room Record, dated 9/22/11, faxed to the Department of Health and Senior Services on 3/7/12, reflected Resident #5 had a [DIAGNOSES REDACTED]. The hospital Physician's History and Physical dated 9/22/11 documented the patient had ear drop medication "[MEDICATION NAME]" applied to eyes this morning by a nurse at the Nursing Home/Sub Acute facility...still complains of eyes feeling irritated with mild tearing, no visual changes, without headache, positive for sandy/gritty feeling in eyes, positive bilateral Corneal Abrasions." A review of Resident #5's physician's orders [REDACTED]. A review of Resident #5's physician discharge summary, dated 9/23/11, documented the resident "had [MEDICATION NAME] drops inadvertently to eyes, felt pain and was sent to ER, says some abrasions were noted, eyes irritated [MEDICATION NAME] prescribed. Still has some discomfort in the eyes." The Daily Skilled Nurse's Notes, dated 9/23/11 indicated the resident was discharged to home. A review of Resident #5's Physician order [REDACTED]. A POF and MAR, both dated 9/12/11 reflected a physician's orders [REDACTED]. The POF and MAR indicated [REDACTED]. During a post-survey telephone interview on 3/16/12 at 10:15 AM, the Director of Nursing (DON) stated the facility does not have a specific policy for the removal of medications from medication carts that have been discontinued by the resident's physician. The DON revealed "normally it's (discontinued medications) taken out of the cart (medication cart) that's a nursing standard of practice." In addition she stated "If the med (medication) is discontinued by the physician, you take it out of the med cart." A review of the facility's "Medication Error/Incident Report," dated 9/22/11, for Resident #5 revealed "[MEDICATION NAME] ear drops (insert in both eyes) instead of Artificial Tear drops @ (at)) 8:45 AM." The report reflected the resident's "reaction" was "burning in both eyes." A review of a statement, dated 9/22/11, from the orientee RN who was being observed by a preceptor documented "I didn't make sure to check labels. After LT (left) eye drop patient c/o (complained of) LT eye feel pain." There was no statement provided to the surveyor from the preceptor RN. The preceptor RN was no longer employed by the facility and was not available for interview. A review of the orientee RN's employee record reflected the nurse's date of hire was 9/7/11. When the DON was interviewed by the surveyor on 3/5/12 at 11:15 AM, she stated the orientee RN was on her last week of orientation and was being monitored by a preceptor RN during medication administration. The DON also stated the preceptor RN observed the orientee RN pour the medication and once the medications were poured correctly it was not necessary for the preceptor RN to follow into the room. The DON further stated Resident #5 complained of burning to the eyes after the administration of the medication. In addition, she revealed that during the investigation, both the [MEDICATION NAME] ear drops and Artificial Tear drops were on top of the medication cart and they were unable to determine if the [MEDICATION NAME] was administered into the eyes. However, the POF and MAR indicated [REDACTED]. During an interview on 3/5/12 at 11:45 AM, the 1st Floor Sub Acute RN/Unit Manager (UM) confirmed that the orientee RN "did administer" the [MEDICATION NAME] ear drops to Resident #5's eyes. She further stated the preceptor RN "should have verified the medication more closely and the preceptor must go with the orientee at all times." The RN/UM further stated there was "no policy on preceptoring, it is a nursing standard of practice that the RN will accompany the orientee into the room to observe the medication administration." A review of the Nursing Home Patient transfer form and Plan of Care dated 9/22/11, reflected ear drops "[MEDICATION NAME]" was applied to patient's eyes instead of ears. 2. According to the medical record Admission and Discharge Summary, Resident #6, was admitted to the facility with medical [DIAGNOSES REDACTED]. An "Admit Note" completed by the resident's physician, dated 11/20/11, indicated the resident had additional [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. A review of Resident #6's physician's orders [REDACTED]. There was no documentation which indicated IVF's of 0.45 NACL IV at 42 cc/hour was ordered for Resident #6. A review of Daily Skilled Nurse's Notes, dated 11/29/11 at 11:00 PM, documented IVF initiated at 9:00 PM. A subsequent note, not dated or timed, written by the 11:00 PM to 7:00 AM RN, reflected 0.45 NACL (Sodium Chloride) infusing well at 42 cc/hour. ABT (antibiotic) IV(intravenous) in progress. A review of the facility's "Medication Error/Incident Report" for Resident #6, dated 11/29/11, reflected during the 3:00 PM-11:00 PM shift "IVF 0.45 NACL with 20 meq of KCL (potassium)/L (liter) ordered for a different patient but hung and infused at 40 cc/hr (hour) till AM." The report further reflected the error was discovered by the UM in the morning during rounds. The physician was notified and [MEDICATION NAME] was given IV push for the morning dose. A review of a facility "Disciplinary Report Form" for the 3:00 PM to 11:00 PM RN who was on duty on 11/29/11, documented the RN failed to follow professional standards and committed a medication error by administering an unordered IV medication to the wrong patient. The RN was suspended pending investigation. The RN documented on the Disciplinary Report Form "Contributing factors that lead to my error-confusion during the report with the patient and labs of another patient, the patient that received the IV fluids did have an INT (intermittent access) and has received IV meds, the order sheet did not have a name on it and was flagged along with several other charts. And I was busy during the shift." A review of a statement obtained during the course of the facility's investigation, dated 12/2/11, from the 11:00 PM to 7:00 AM shift RN who was on duty 11/29/11-11/30/11, documented Resident #6 was received with IVF's of 0.45 NACL with 20 meq KCL/liter infusing at 40 cc/hour. The resident was a [MEDICAL CONDITION] patient on [MEDICATION NAME]. The RN further documented she looked for the order and was unable to locate the order for IVFs for Resident #6. In addition, the RN documented that later she located an order (for the 0.45 NACL with 20 meq of KCL at 40 cc/hr), but it was ordered for another resident. The 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shift RNs were not available for interview. A review of Resident #6's physician progress notes [REDACTED]. A review of Resident #6's POF and MAR, dated 11/30/11 reflected a physician's orders [REDACTED]. A review of Resident #6's BMP, dated 11/30/11 and 12/1/11 indicated the potassium level was within normal limits. During an interview on 3/5/12 at 12:25 PM, the 2nd floor Sub Acute RN/UM stated that during morning report the 11:00 PM to 7:00 AM shift RN informed her Resident #6 had IVF's of NACL infusing. The RN/UM revealed the resident was not ordered IVFs and immediately went to the room to check on the resident and removed the IVFs. A review of the facility's policy "Medication Administration," review date 10/10, reflected "All medications will be prepared and administered in a manner consistent with general requirements outlined in this policy and requirements outlined in the specific dispensing method." In addition, prior to medication administration, verify each time that the right medication is the right drug, at the right dose, the right route at the right date, at the right time, for the right customer and after administration, document necessary medication administration/treatment information, when medications are opened, when medications are given...on appropriate forms. NJAC 8:39-27.1 (a)