Every finding on record at Millville Center

Based on interviews, record reviews, and facility policy review, the facility failed to thoroughly investigate an allegation of staff to resident abuse and take action to prevent further potential abuse for 1 of 10 residents (Resident [R] #3) R#3 reviewed for abuse. R2 alleged that a Certified Nurse Aide (CNA) abused R3. The facility failed to follow its abuse and neglect policy titled OPS300 Abuse Prohibition, conduct a thorough investigation of the incident, and failed to remove the CNA assigned to R3 on the shift identified in the allegation. On 03/04/26, an Immediate Jeopardy (IJ) was identified at S483.12(c)2 and 483.12(c)3 related to the facility's failure to ensure a thorough investigation was completed after an allegation of staff to resident abuse was made on 02/10/26 and to prevent further potential abuse. On 03/04/26 at 8:20 PM, the Director of Nursing was notified of the IJ, which also constituted Substandard Quality of Care (SQC). The facility provided an acceptable Plan of Removal on 03/05/26 at 4:40 PM, which included staff training and suspension of staff. The IJ ran from 2/10/26 until 3/5/26 at 6:43 PM when the facility implemented an acceptable plan of correction.Findings include:Review of R2's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/15/26 and located in the electronic medical record (EMR) under the MDS tab, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment.Review of R3's quarterly MDS with an ARD of 03/02/26 and located in the EMR under the MDS tab, revealed R3 was unable to complete the BIMS due to the inability to speak or be understood.Review of the facility's LTC (Long Term Care) Reportable Event Survey, dated 02/10/26, revealed R2 reported that on Saturday (02/07/26), a CNA hit their roommate, R3, and pulled R3's hair. R2 stated the CNA cared for R3 but not for R2. At that time, R2 did not know the identification of CNA1.Review of the facility's Summary and Conclusion, dated 02/16/26, revealed R2 reported to the Social Worker (SW) that R2 observed R3's CNA, CNA1, the previous Saturday, or (02/07/26), punch R3 and pull their hair. R2 described the perpetrator as Caucasian, heavy, with brown hair and arm tattoos. R2 was shown headshot photos of three CNA staff (CNA1, CNA2, and CNA3) and denied that the staff involved was the person in the photos. R2 later complained that the faces were too small to correctly identify the perpetrator.Further review revealed there was no documentation of staff or thorough resident interviews. There was no documented evidence that CNA1, who was assigned to R3 and fit the description, was suspended during the investigation.During an interview on 03/04/26 at 4:22 PM, CNA1 (a Caucasian female, heavyset, with brown hair and tattoos on her arms, who fit the description) revealed that she was assigned to R3 on Saturday, 02/07/26. CNA1 stated she was completely unaware that R2 had made an allegation of abuse, and this was the first time she had been told about the abuse. CNA1 stated she was not interviewed by staff regarding an allegation and had never been suspended or removed from a shift pending the outcome of an investigation. She stated she was working on the 3-11 PM shift that day. CNA1 denied ever hitting either R2 or R3.During an interview on 03/04/26 at 5:10 PM, the SW stated R2 called the SW over during lunch in the dining room and told her there was a CNA abusing R3, who was R2's roommate at the time. The SW stated that R2 stated the CNA1 had punched R3 in the face, pulled R3's hair, and pushed them. R2 was unable to identify the CNA by name but said it was a white female who was heavy set with brown hair. The SW stated she informed the Director of Nursing (DON). The DON brought the SW and R2 into her office along with the Assistant Director of Nursing (ADON). The DON showed R2 pictures of staff, but the SW was unsure of whose pictures were shown because she could not see what was shown to R2. The SW stated R2 said no to all the photos, and she took R2 back to the unit and asked the resident if they saw the CNA in the surrounding area. R2 said no, they did not see the CNA, but the SW was unsure which staff were in the area. None of the CNAs present that day were interviewed. The SW stated she was unsure if any staff had been interviewed and did not interview any other residents. The SW further stated she assumed the DON would interview other staff.During an interview on 03/04/26 at 5:27 PM, the DON stated she was unsure who the facility's abuse coordinator was. The DON stated she was made aware of the allegation by the SW. The DON stated the SW, along with R2, came to her office, and R2 showed photos of all the staff that fit the description (CNA1, CNA2, and CNA3). The DON stated R2 could not distinguish the actual perpetrator from the photos. The DON stated she did not interview any CNA staff or other staff, as R2 could not identify the alleged perpetrator from the three photos shown. The DON stated that she ruled out all other staff based on the description. The DON shared the photos of CNA1, CNA2, and CNA3 that were shown to R2 with the surveyor. The photos were small, nail sized photos of only their faces and could only be slightly enlarged. The DON stated that no staff were suspended because R2 could not identify the perpetrator from the photos.On 03/04/26 during the 3-11 shift, CNA1 was observed providing care to residents.During an interview on 03/05/26 at 10:27 AM, R2 stated they saw the CNA, who was referred to as the fat one, pull R3's hair and hit them. R2 explained that it was a CNA they had seen before and since the incident, but they didn't know the CNA's name. R2 described the CNA as an obese, white female with brown hair and tattoos on her arms. R2 stated they told the SW what they saw and were shown some photos, but they could not recognize any of the faces in the photos.During an interview on 03/05/26 at 2:46 PM, CNA4 stated she worked the shift on 02/07/26 when the alleged incident occurred and was not interviewed by any staff. CNA4 stated she was unaware of any concerns that occurred during that shift. CNA4 stated that the given description matched the description of CNA1, and she did not know of anyone else who would fit that description.During an interview on 03/05/26 at 4:11 PM, CNA5 stated that on 02/07/26, she switched one of her assigned residents with CNA1 for R3. CNA5 stated they had done this several times in the past. CNA5 stated she was not interviewed about anything related to that shift or an allegation of abuse. CNA5 stated CNA1 was the only person who fit the description given by R2.Review of the facility policy titled, OPS300 Abuse Prohibition, updated 11/14/25, revealed, . physical abuse includes hitting, slapping, pinching, kicking . anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately regardless of the shift . The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation . immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will . initiate an investigation within 24 hours of abuse and . the investigation will be thoroughly documented within the Risk Management Portal. Ensure the documentation of interviews witnessed is included . NJAC 8:39-4.1(5) NJAC 8:39-13.4(c)(1)(i-iv).

Based on observations, record review, and interviews, the facility failed to ensure 1 of 3 residents (Resident [R] 1) reviewed for food allergies was not served foods to which the resident was allergic. R1 was noted to have food allergies to ketchup, vinegar, and mayonnaise. R1 was served two meals containing allergens. Serving residents foods to which they are allergic has the potential to lead to serious harm, injury, or death.The failure to follow its policy titled Allergies to ensure R1 was not served a food to which the resident was allergic placed this resident and all residents with food allergies at risk of serious harm, injury, or death. Immediate Jeopardy was identified on 03/03/26 at 12:20 PM when R1 was served mayonnaise and offered ketchup at the lunch meal. The Administrator was notified of the Immediate Jeopardy on 03/03/26 at 5:50 PM. The facility provided an acceptable removal plan on 03/04/26 at 5:33 PM.The removal plan included an audit of all resident diet orders and staff education on checking meal tickets and on not providing food items to residents to which they are allergic. The survey team validated implementation of the facility's IJ Removal Plan, and the IJ was lifted on 03/04/26 at 5:33 PM. Findings include:Review of R1's Census tab of the electronic medical record (EMR) revealed R1 was admitted to the facility with diagnoses included in the Diagnoses tab of bipolar disorder, gastroesophageal reflux, and anxiety.Review of the R1's Allergy tab in the EMR revealed they were allergic to dill, dill oil, mushrooms, ketchup, lactose, radishes, acetic acid (vinegar), and mayonnaise.Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/25 and located in the MDS tab of the EMR, revealed R1's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating R1 was cognitively intact.Review of R1's Care Plan, dated 12/18/25, revealed a focus problem of allergies to acetic acid (vinegar), dill, mushroom, ketchup, lactose, mayonnaise, and radishes. The goal was for the resident to have no allergic reaction over the next 90 days.Review of R1's Orders tab of the EMR revealed that allergies were listed as acetic acid, dill, mushroom, ketchup, lactose, and radishes.Review of the Diet Type report provided by the facility revealed that R1 was listed as having allergies to acetic acid, dill, dill oil, ketchup, mayonnaise, mushrooms, and radishes. Review of R1's tray card, provided by the facility, listed the same allergies.During an interview on 03/03/26 at 11:30 AM, R1 confirmed the food allergies, specifically to mayonnaise. R1 states they had talked with the Dietary Manager (DM) multiple times and continued to be served foods containing allergens. R1 stated that their mouth and tongue would swell when they consumed the allergens.During an observation of the noon meal service in the dining room on 03/03/26 at 12:20 PM, R1 was served the alternate menu items of a cheeseburger and potatoes. On the meal tray was a sealed packet of mayonnaise. Certified Nursing Assistant (CNA) 1 offered R1 ketchup, and the resident refused.During an interview on 03/03/26 at 12:15 PM, CNA1 confirmed she served R1's tray, confirmed she asked the resident if they wanted ketchup, and confirmed a mayonnaise packet was served with R1's meal. CNA 1 attempted to locate the tray card for R1 but was unable to do so.During an interview on 03/03/26 at 12:25 PM, the Dietary Manager (DM) stated she visited with R1 at least twice a week and was unaware that R1 had been served mayonnaise with her meal. The DM confirmed that R1 was allergic to ketchup and mayonnaise, and that the mayonnaise should not have been on the plate, and that CNA1 should not have offered the resident ketchup.During an interview on 03/03/26 at 2:30 PM, the Administrator confirmed the allergies listed on R1's EMR and confirmed that food allergies were listed on the diet ticket taken from physician orders, which the kitchen used to prepare resident meal trays. The Administrator confirmed R1's food allergies were noted on their tray slip, which dietary staff failed to utilize to ensure the resident did not receive and ingest food to which they were allergic.During an observation and interview in the dining room on 03/03/26 at 5:20 PM, R1 was served the evening meal prepared by the facility. R1 was served a cheeseburger, creamy coleslaw, cubed potatoes, and cookies. The coleslaw was not served in its own container and came into contact with the other foods on the plate.A review of the facility-made creamy coleslaw recipe provided by the facility revealed that mayonnaise and vinegar were used as ingredients. During an interview on 03/04/26 at 10:30 AM, the Registered Dietitian (RD) stated that allergies were in Meal Tracker and food items with the allergens did not appear on the resident's tray slip. The RD confirmed R1 received mayonnaise and creamy cole slaw on her tray last evening and that it was an error for R1 to receive those items.Review of the facility policy titled Allergies dated 03/03/26 directs staff some residents have allergies that can cause the residents to have an adverse reaction to said allergies. It is vital to the residents' safety that all meal tickets are checked for allergies by the dining department as well as the nursing department to ensure resident safety.NJAC 8:39-17.4(a)(1)(e)

Based on record review, staff interview, and facility policy review, the facility failed to ensure the resident and/or the resident representative (RR) were given a transfer notice/discharge notice at the time the resident was transferred/discharged to the hospital for seven of seven residents (Residents (R) 180, R181, R21, R22, R42, R89, and R56) reviewed for hospitalization of 30 sample residents. This created the potential for the residents or their RR to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: 1. Review of R180's electronic medical record (EMR) titled Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R180's EMR titled general Progress Notes located under the Prog (Progress) note tab, dated 02/20/25, revealed the resident sustained a change in mental status and was combative with staff threw water at the nurse and Certified Nurse Aide (CNA) and attempted to throw a telephone at the CNA. The resident was transported to the emergency room for evaluation and treatment. Review of R180's EMR failed to contain evidence that a transfer notice was sent with the resident and/or to the RR. 2. Review of R181's EMR titled Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R181's EMR titled Practitioner Note Progress Notes located under the (Prog) tab, dated 08/01/24, indicated R181 sustained a fall. The resident was assessed and then transferred to the emergency room for evaluation and treatment. Review of R181's EMR failed to contain evidence that a transfer notice was sent with the resident and/or to the RR. 3. Review of R21's Census tab located in the EMR revealed R21 was admitted on [DATE]. Review of the discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/25 located under the MDS tab of the EMR revealed R21 had a Discharge Return Anticipated MDS. Review of the Prog Note [Progress Note] tab in the EMR revealed a note, dated 01/27/25, that indicated R21 was sent to the hospital due to a change in mental status. Review of the EMR revealed no transfer notice for the hospitalization. 4. Review of R22's Census tab of the EMR revealed R22 was originally admitted on [DATE]. Review of the discharge MDS tab of the EMR with an ARD of 11/24/24 revealed R22 had a Discharge Return Anticipated MDS. Review of the Prog Note tab in the EMR revealed a skilled evaluation note, dated 11/24/24, that stated R22 was sent to the hospital due to coffee-ground emesis. Review of the EMR revealed no transfer notice for the hospitalization. 5. Review of R42's Census tab in the EMR revealed R42 was admitted on [DATE]. Review of the discharge MDS tab of the EMR with an ARD of 09/24/24 revealed R42 had Discharge Return Anticipated MDSs. Review of the discharge MDS tab of the EMR with an ARD of 09/30/24 revealed R42 had Discharge Return Anticipated MDS. Review of the Prog Note tab of the EMR revealed a note, dated 09/24/24, that stated R42 requested to go to the hospital due to not having a bowel movement in a week and for unrelieved pain in her left toe. Another note, dated 09/30/24, stated R42 was sent to the hospital due to stroke-like symptoms. Review of the EMR revealed no transfer notice for the hospitalizations. 6. Review of R89's Census tab of the EMR revealed R89 was admitted on [DATE]. Review of the discharge MDS tab of the EMR with an ARD of 01/27/25, revealed a Discharge Return Anticipated MDS. Review of the Prog Note tab of the EMR revealed R89 was sent to the hospital for a digressive change in status from the prior day. Review of the EMR revealed no transfer notice for the hospitalization. During an interview on 03/05/25 at 3:30 PM, the Director of Nursing (DON) stated she was still looking for the written transfer/discharge forms. The DON stated the facility notified the residents' family and the Long-Term Care Ombudsman regarding all hospital transfers. During a subsequent interview on 03/06/25 at 12:46 PM, the DON stated the residents were not provided with a written transfer/discharge notice. The Administrator was present during this interview. 7. Review of R56's admission Record located in the EMR under the Profile tab revealed an initial admission date of 01/06/21 and a hospital stay from 11/10/24 to 11/18/24. R56 returned from the hospital with diagnoses which included encephalopathy, acute kidney failure, and encounter for adequacy testing for hemodialysis. Review of R56's annual MDS with an ARD of 12/25/24 and located in the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. Review of R56's Prog Note tab of the EMR revealed an entry on 11/10/24 at 9:57 AM which stated, The nurse, MD [medical doctor], and [resident] were all in agreement that [resident] needed to go the ER [emergency room] for evaluation and treatment. A follow-up entry on 11/10/24 at 2:06 PM documented, [Resident] admitted to [hospital] with cystitis [bladder infection]. Review of R56's EMR and paper chart revealed no notice of transfer to the resident and resident's representative of the transfer to the hospital. During an interview on 03/03/25 at 3:29 PM, R56 stated he had been hospitalized for a urinary catheter issue, which caused pain. R56 could not recall receiving any paperwork from the facility regarding the transfer to the hospital. During an interview on 03/06/25 at 10:36 AM, Licensed Practical Nurse (LPN) 4 stated the paperwork sent to the hospital with the resident included only information for the hospital, about the resident, printed from the EMR. During an interview on 03/06/25 at 12:49 PM, the Administrator stated the transfer form does not exist for the facility, and the DON stated, the process existed but fell through the cracks. Review of the facility's policy titled, Discharge and Transfer, dated 11/15/22, indicated .For unplanned, acute transfers for patients must be permitted to return to the Center. Prior to the transfer, the patient and patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific information . The facility policy failed to address the following aspects: 1. The transfer notice must be in writing and in the language that the resident and/or the representative understands. 2. The transfer notice must identify the location and the reasons for the transfer. 3. If the facility has a resident with an intellectual disability or related disability, the transfer notice must include the name, mailing address, email address, and telephone number for the agency for the protection and advocacy of people with developmental disabilities. 4. If the facility has a resident with a mental disorder or a related disability, the transfer notice must include the name, mailing address, email address, and the telephone number for the protection and advocacy of people with mental illness. NJAC 8:39-4.1 (a) 32 NJAC 8:39-5.1(a)

Based on record review, interview, and facility policy review, the facility failed to initiate a new PASARR [Pre-Admission Screening and Resident Review] Level One for one of three residents (Resident (R) 22) reviewed for PASARR to reflect the admitting diagnosis of bipolar disorder of 30 sample residents. The failure to maintain a PASARR Level One that reflected the current diagnosis of R22 had the potential to delay or limit necessary assistance should R22 experience a bipolar episode that disrupted his daily life. Findings include: Review of R22's Census tab located in the electronic medical record (EMR) revealed R22 was originally admitted on [DATE]. Review of the Med Diag (Medical Diagnoses) tab located in the EMR revealed R22 had a diagnosis of bipolar disorder as of 02/02/23. Review of the Care Plan (CP) under the Care Plan tab of the EMR revealed R22 had a focus with interventions related to psychotropic drugs for targeted behaviors initiated on 02/10/23. Review of R22's PASARR Level One, dated 10/16/17 and provided by the Director of Nursing (DON) revealed R22 did not have bipolar disorder listed as an applicable diagnosis. PASARR Level One listed R22 as having no mental disorders or intellectual disabilities of any kind. During an interview on 03/05/25 at 3:02 PM, the Social Services Director (SSD) stated residents arrived with PASARRs from the hospitals they came from. She stated the PASARR should be recent and checked for accuracy. She verified PASARR Level One for R22 was conducted in 2017 and was not accurate. The SSD stated the PASARR should have been redone if it did not reflect the current diagnoses of residents. During an interview on 03/06/25 at 10:01 AM, the Admissions Director (AD) stated they used the prior PASARR and History and Physical from the previous facility [both dated 2017] which did not contain a psychiatric diagnosis. She stated the discrepancy should have been caught at admission and a new PASARR completed. She stated it was her error. Review of the facility's policy titled, SS105 Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients, revised 02/16/24, DON revealed Center Social Worker or designated staff will assure that all patients with Mental Disorders (MD) and/or Intellectual Disability (ID) receive appropriate pre-admission screenings according to federal and/or state regulations. The policy continued Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if .it is learned after admission that the Pre-Admission Screening and Resident Review (PASRR) was not completed or is incorrect. NJAC 8:39-5.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to develop a person-centered care plan related to dialysis when a resident started receiving hemodialysis for one of one resident (Resident (R)56) reviewed for dialysis of 30 sample residents. This had the potential for the residents to have unmet care needs. Findings include: Review of R56's Admission Record located in the electronic medical record (EMR) under the Profile tab revealed an initial admitted [DATE] and a hospital stay from 11/10/24 to 11/18/24. R56 returned from the hospital with diagnoses which included encephalopathy, acute kidney failure, and encounter for adequacy testing for hemodialysis. Review of R56's EMR under the Progress Notes tab revealed a General note, dated 11/13/24, Hospital Update- .Hospital is also setting up outpatient dialysis following the permacath placement . Another General note, dated 11/19/24, documented Patient is currently on dialysis mon-wed-and Fri . Review of R56's Order Summary Report located in the EMR under the Orders tab, revealed orders dated 11/19/24 for: Monitor hemodialysis site for signs/symptoms of complications . Notify the physician and dialysis center immediately with any urgent problems. Review of R56's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. R56 received dialysis. Review of R56's EMR under the Care Plan tab revealed the only mention of dialysis was an intervention dated 01/17/25, Staff will provide care and have [resident] ready to attend dialysis on Mondays, Wednesdays, and Fridays as scheduled, under the focus area of impaired renal function, revised on 01/10/24. All other interventions under the focus were dated 04/12/22, prior to dialysis starting upon R56's return from the hospital on 11/18/24. During a concurrent observation and interview on 03/03/25 at 3:21 PM, R56 was observed with a dressing over his right upper chest dialysis port. R56 reported going out to dialysis on a stretcher transport that the facility arranged. R56 reported waking around 3:15 or 3:30 AM on dialysis days, assisted by staff to get ready, and eating a light breakfast prior to leaving and a larger breakfast upon return. During an interview on 03/06/25 at 10:36 AM, Licensed Practical Nurse (LPN) 4 stated everything was in the Care Plan or Kardex for nurses and Certified Nurse Aides (CNAs) in detail of what to look for when caring for dialysis residents. During an interview on 03/06/25 at 11:08 AM, the Unit Manager, Registered Nurse (RN) 1 stated the unit managers were responsible for updating the care plans. RN1 stated the care plans were updated with MDS assessments and with any changes. RN1 stated the dialysis care plan should include anything needed to encourage, teach, or watch for. RN1 stated R56 was fairly new to dialysis, so we don't know his learning yet or his ins and outs. RN1 reported R56's Care Plan could definitely be updated and more comprehensive to include more information on how to care for him, his port, what to monitor, etc. During an interview on 03/06/25 at 12:53 PM, the Director of Nursing (DON) stated care plans were expected to include residents' specific dialysis information: where/when, type of line, program, any restrictions such as diet or fluid. The DON stated she expected more than the days of dialysis to be added to the care plan when dialysis started. Review of the facility provided, Dialysis Services Agreement, dated 03/05/25, revealed When a Center [skilled nursing facility] resident with renal disease requiring dialysis is authorized by Center [licensed provider of dialysis services] to receives services from Provider, Provider and Center shall jointly develop and agree upon the Center resident's care plan appropriate for management of end stage renal disease and pertinent to Services. Provider shall retain overall professional management responsibility for implementing and monitoring Services in accordance with the Center resident's care plan. Center shall be responsible for implementing non-Services portions of the Center resident's care plan, including but not limited to nutritional needs, . and monitoring aspects of the patient's condition and care pertinent to the nature of end stage renal disease. Review of the facility's policy titled, Person-Centered Care Plan, revised 10/24/22, revealed A comprehensive person-centered care plan must be developed for each patient and must describe the following: services that are to be furnished; . The care plan must be customized to each individual patient's preferences and needs . Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals . NJAC 8:39-11.2(e) thru (i) NJAC 8:39-27.1(a)

Based on interview, record review, and facility policy review, the facility failed to establish an antibiotic stewardship program to include protocols to monitor extended antibiotic use for one of two residents (Resident (R) 35) reviewed for antibiotics of 30 sample residents. This failure had the potential to affect resident safety related to antibiotic usage. Findings include: Review of a Centers for Disease Control and Prevention (CDC) website titled, Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/24 and located at https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html, indicated .Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice changes and track the impact of new interventions. Data on adherence to antibiotic prescribing policies and antibiotic use are shared with clinicians and nurses to maintain awareness about the progress being made in antibiotic stewardship. Clinician response to antibiotic use feedback (e.g., acceptance) may help determine whether feedback is effective in changing prescribing behaviors . Review of R35's electronic medical records (EMR) titled Face Sheet located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R35's EMR titled physician Orders located under the Orders tab, dated 03/14/23, indicated the resident was ordered doxycycline 100 milligrams (mg) to be administered twice a day for right shoulder septic arthritis. Review of a facility document titled, Medical Results, dated 03/31/23 and located under the Misc tab of the EMR, indicated the resident was seen and the document noted that R35 had a history of septic in his shoulder and was currently on suppressive therapy with doxycycline. During an interview on 3/06/25 at 8:57 AM, the Infection Preventionist (IP) stated her current electronic system did not permit the user to track resident prophylactic use of antibiotics. The IP stated she has never tracked the residents who were on an antibiotic prophylactically unless they were a new admission with a new antibiotic order. During an interview on 03/06/25 at 10:33 AM, the Medical Director stated all residents who were on an antibiotic prophylactically and long-term should be tracked. The Medical Director stated she was currently reviewing this issue this past week, but it had not been implemented prior to the recertification survey. The Administrator was present during this interview. Review of a facility's policy titled, Antibiotic Stewardship, dated 12/16/24, indicated . Centers will implement an Antibiotic Stewardship Program (ASP) as part of the facility's overall infection and control program. The Infection Preventionist (IP) is responsible for the Infection Prevention and Control program including ASP. The Administrator is ultimately responsible for the overall compliance with the ASP. The Director of Nursing (DON) and Medical Director are responsible for executing the ASP standards .Reviews antibiotic use data and ensures best practices are followed . There was no evidence in the facility's policies that addressed standards for extended antibiotic use for residents. NJAC 8:39-19.4(d)

Complaint #: 181226 Based on interviews and medical record review (MR) and other pertinent facility documentation on 12/11/24 and 12/12/24, it was determined that the facility failed to implement their Abuse Prohibition policy due to staff not reporting an allegation of staff to resident verbal abuse. This deficient practice was evidenced by the following: 1. During an interview with the Surveyor on 12/11/24 at 11:57 A.M., Resident #3 stated that they were not able to remember the exact date, but about a week ago, Resident #3 asked CNA (Certified Nursing Assistant) #1 to wash their hair twice. They stated that CNA #1 yelled and stated that she does not have time for that. Resident #3 stated that they then began to cry. Resident #3 stated that they reported the incident to the Social Worker. Resident #3 further stated that after the incident was reported to the Social Worker, CNA #2 yelled at them, and said that they were going to get people in trouble. According to the Admission Record (AR) Resident #3 was admitted with diagnoses including but not limited to left sided weakness and paralysis related to Cerebrovascular Accident (a medical emergency that occurs when blood flow to the brain is suddenly cut off), Hypertension (a chronic condition where your blood pressure is consistently too high), and Multiple Sclerosis (a neurological condition when your immune system attacks your nerves by mistake). A review of the Minimum Data Set (MDS), an assessment tool dated 9/25/24, revealed that Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #3 was cognitively intact, and was dependent on assistance with ADLs (Activities of Daily Living). The facility provided a Grievance Form dated 12/6/24, in addition to the Grievance Form, a statement obtained by the Social Worker 12/4/24, was also reviewed. The statement revealed that on 12/2/24 Resident #3 asked CNA #1 to wash their hair twice, and CNA #1 yelled, that she does not have time. Resident #3 stated CNA #1 continued to yell while she was helping the resident get dressed. The statement further revealed that CNA #2 yelled at Resident #3 on 12/3/24 and stated that she did not want CNA #1 to lose her job because of the incident that occurred on 12/2/24. No additional information was provided for surveyor review regarding the incident. 2. 12/12/24 at 2:18 P.M., Resident #6 observed going to activity in dayroom, declined to speak with Surveyor. According to the AR, Resident #6 was admitted with diagnoses including but not limited to Type 2 Diabetes Mellitus (a common condition that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), Depression (a serious mental health condition that can impact how a person feels, thinks, and acts) and Anxiety Disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that interfere with daily life). A review of the MDS dated [DATE], revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 14, indicating that Resident #6 was cognitively intact, and required supervision with ADLs (Activities of Daily Living). A review of the Private Resident Council minutes dated 10/24/24, revealed that under Nursing, residents pointed out that some Aides had attitudes or were rude towards them across all shifts. Additionally, under Additional concerns, Resident #6 stated feeling belittled by employees, and specified that it was across the building and not just nursing. There was no response documented for the concerns. During an interview with Surveyors on 12/12/24 at 10 A.M., the Social Worker (SW) for Long Term Care, stated that she advocated for the residents, and completed investigations for grievances. SW stated that her investigations involved collecting statements from residents, and for allegations that involved staff members, she would interview the resident making the allegation, then other residents on the staff member's assignment. She further stated that would formerly write up her investigation, and then turn her information into the Director of Nursing (DON), and the DON would proceed with investigating the employee. In the presence of the surveyor, the SW reviewed the statement from Resident #3 dated 12/4/24 and stated that she had given the statement to the DON. She further stated that she did not collect statements from other residents on CNA #1's and CNA #2's assignments. During an interview with Surveyors via telephone on 12/12/24 at 12:15 P.M., the Recreation Director (RD), stated that if there was a concern and if majority of the residents agreed with the concern, then the concern would be written in the minutes, and then a response would be signed and documented by the department heads. The RD stated that there was not a response to the 10/24/24 Private Resident Council minutes, and that there should have been a written response to the concerns expressed. RD stated that she would report any incident of abuse. The RD stated that belittling a resident is considered verbal abuse, however, this incident was not reported. During an interview with Surveyors on 12/12/24 at 1:08 P.M., the DON stated that an investigation entailed speaking to the resident, resident's roommate, resident's family members, and if the abuse involved staff, then the other residents on the staff's assignment. She further stated that belittling a resident was a form of verbal abuse and should be investigated. DON stated that she received a copy of all Resident Council minutes. She further stated that she was not made aware of the concerns in the 10/24/24 resident council minutes, and if she had been, she would have addressed the concern. During an interview with Surveyors on 12/12/24 at 1:56 P.M., the Assistant Director of Nursing (ADON) stated that in the absence of the DON, the council would ask her to sit in on meetings. She stated that when there was a concern, the department that the concern fell under, would respond to the concern on the response form. The ADON stated that the nursing department can either be notified verbally or in writing. She stated that she did not receive the minutes, nor was she informed of the 10/24/24 Private Resident Council meeting. During an interview with Surveyors on 12/12/24 at 2:31 P.M., the Administrator stated that examples of verbal abuse were calling someone out of their name, yelling and screaming at residents. In the presence of the Surveyors, Administrator reviewed the statement from the SW for Resident #3's grievance, she then stated that the incident should have been reported for abuse. A review of the facility's policy presented by the Director of Nursing (DON), titled Abuse Prohibition dated 7/1/13, reviewed and updated 10/24/22, included but was not limited to the following: under the heading for Policy, it states, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property and exploitation for all patients .Centers also to strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any reasonable suspicion of a crime against a patient. The Center will implement an abuse prohibition program through the following: .Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; protection of patients during the investigation. Under the heading for process, it states: 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than 2 hours after the allegation is made. N.J.A.C: 8:39-4.1 (a) 5, 12

Complaint #: 181226 Based on interviews and medical record review (MR) and other pertinent facility documentation on 12/11/24 and 12/12/24, it was determined that facility staff failed to report an allegation of staff to Resident abuse to facility Administration and New Jersey Department of Health (NJDOH) according to their Abuse Prohibition policy due to staff not reporting an allegation of staff to resident verbal abuse for 2 of 6 residents (Resident #3 and Resident #6). This deficient practice was evidenced by the following: 1. During an interview with the Surveyor on 12/11/24 at 11:57 A.M., Resident #3 stated that they were not able to remember the exact date, but about a week ago, Resident #3 asked CNA (Certified Nursing Assistant) #1 to wash their hair twice. They stated that CNA #1 yelled and stated that she does not have time for that. Resident #3 stated that they then began to cry. Resident #3 stated that they reported the incident to the Social Worker. Resident #3 further stated that after the incident was reported to the Social Worker, CNA #2 yelled at them, and said that they were going to get people in trouble. According to the Admission Record (AR) Resident #3 was admitted with diagnoses including but not limited to left sided weakness and paralysis related to Cerebrovascular Accident (a medical emergency that occurs when blood flow to the brain is suddenly cut off), Hypertension (a chronic condition where your blood pressure is consistently too high), and Multiple Sclerosis (a neurological condition when your immune system attacks your nerves by mistake). A review of the Minimum Data Set (MDS), an assessment tool dated 9/25/24, revealed that Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #3 was cognitively intact, and was dependent on assistance with ADLs (Activities of Daily Living). The facility provided a Grievance Form dated 12/6/24, in addition to the Grievance Form, a statement obtained by the Social Worker 12/4/24, was also reviewed. The statement revealed that on 12/2/24 Resident #3 asked CNA #1 to wash their hair twice, and CNA #1 yelled, that she does not have time. Resident #3 stated CNA #1 continued to yell while she was helping the resident get dressed. The statement further revealed that CNA #2 yelled at Resident #3 on 12/3/24 and stated that she did not want CNA #1 to lose her job because of the incident that occurred on 12/2/24. No additional information was provided for surveyor review regarding the incident. 2. 12/12/24 at 2:18 P.M., Resident #6 observed going to activity in dayroom, declined to speak with Surveyor. According to the AR, Resident #6 was admitted with diagnoses including but not limited to Type 2 Diabetes Mellitus (a common condition that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), Depression (a serious mental health condition that can impact how a person feels, thinks, and acts) and Anxiety Disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that interfere with daily life). A review of the MDS dated [DATE], revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 14, indicating that Resident #6 was cognitively intact, and required supervision with ADLs (Activities of Daily Living). A review of the Private Resident Council minutes dated 10/24/24, revealed that under Nursing, residents pointed out that some aides had attitudes or were rude towards them across all shifts. Additionally, under Additional concerns, Resident #6 stated feeling belittled by employees, and specified that it was across the building and not just nursing. There was no response documented for the concerns. During an interview with Surveyors on 12/12/24 at 10 A.M., the Social Worker (SW) for Long Term Care, stated that she advocated for the residents, and completed investigations for grievances. SW stated that her investigations involved collecting statements from residents, and that allegations involved staff members, she would interview the resident making the allegation, then other residents on the staff member's assignment. She further stated that would formerly write up her investigation, and then turn her information into the Director of Nursing (DON), and the DON would proceed with investigating the employee. In the presence of the surveyor, the SW reviewed the statement from Resident #3 dated 12/4/24 and stated that she had given the statement to the DON. She further stated that she did not collect statements from other residents on CNA #1's and CNA #2's assignments. During an interview with Surveyors via telephone on 12/12/24 at 12:15 P.M., the Recreation Director (RD), stated that if there was a concern and if majority of the residents agreed with the concern, then the concern was written in the minutes, and then a response is signed and documented by the department heads. The RD stated that there was not a response to the 10/24/24 Private Resident Council minutes, and that there should have been a written response to the concerns expressed. RD stated that she would report any incident of abuse. The RD stated that belittling a resident is considered verbal abuse, however, this incident was not reported. During an interview with Surveyors on 12/12/24 at 1:08 P.M., the DON stated that an investigation entailed speaking to the resident, resident's roommate, resident's family members, and if the abuse involved staff, then the other residents on the staff's assignment. She further stated that belittling a resident was a form of verbal abuse and should be investigated. DON stated that she received a copy of all Resident Council minutes. She further stated that she was not made aware of the concerns in the 10/24/24 resident council minutes, and if she had been, she would have addressed the concern. During an interview with Surveyors on 12/12/24 at 1:56 P.M., the Assistant Director of Nursing (ADON) stated that in the absence of the DON, the council would ask her to sit in on meetings. She stated that when there was a concern, the department that the concern fell under, would respond to the concern on the response form. The ADON stated that the nursing department can either be notified verbally or in writing. She stated that she did not receive the minutes or informed of the 10/24/24 Private Resident Council meeting. During an interview with Surveyors on 12/12/24 at 2:31 P.M., the Administrator stated that examples of verbal abuse were calling someone out of their name, yelling and screaming at residents. In the presence of the Surveyors, Administrator reviewed the statement from the SW for Resident #3's grievance, she then stated that the incident should have been reported for abuse. A review of the facility's policy presented by the Director of Nursing (DON), titled Abuse Prohibition dated 7/1/13, reviewed and updated 10/24/22, included but was not limited to the following: under the heading for Policy, it states, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property and exploitation for all patients .Centers also to strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any reasonable suspicion of a crime against a patient. The Center will implement an abuse prohibition program through the following: .Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; protection of patients during the investigation. Under the heading for process, it states: 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental, not later than 2 hours after the allegation is made. N.J.A.C: 8:39-4.1 (a) 5, 12

Complaint #: 181226 Based on interviews and medical record review (MR) and other pertinent facility documentation on 12/11/24 and 12/12/24, it was determined that facility failed to thoroughly investigate an allegation of verbal abuse for 2 of 6 residents (Resident #3 and Resident #6). This deficient practice was evidenced by the following: 1. During an interview with the Surveyor on 12/11/24 at 11:57 A.M., Resident #3 stated that they were not able to remember the exact date, but about a week ago, Resident #3 asked CNA (Certified Nursing Assistant) #1 to wash their hair twice. They stated that CNA #1 yelled and stated that she does not have time for that. Resident #3 stated that they then began to cry. Resident #3 stated that they reported the incident to the Social Worker. Resident #3 further stated that after the incident was reported to the Social Worker, CNA #2 yelled at them, and said that they were going to get people in trouble. According to the Admission Record (AR) Resident #3 was admitted with diagnoses including but not limited to left sided weakness and paralysis related to Cerebrovascular Accident (a medical emergency that occurs when blood flow to the brain is suddenly cut off), Hypertension (a chronic condition where your blood pressure is consistently too high), and Multiple Sclerosis (a neurological condition when your immune system attacks your nerves by mistake). A review of the Minimum Data Set (MDS), an assessment tool dated 9/25/24, revealed that Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, indicating that Resident #3 was cognitively intact, and was dependent on assistance with ADLs (Activities of Daily Living). The facility provided a Grievance Form dated 12/6/24, in addition to the Grievance Form, a statement obtained by the Social Worker 12/4/24, was also reviewed. The statement revealed that on 12/2/24 Resident #3 asked CNA #1 to wash their hair twice, and CNA #1 yelled, that she does not have time. Resident #3 stated CNA #1 continued to yell while she was helping the resident get dressed. The statement further revealed that CNA #2 yelled at Resident #3 on 12/3/24 and stated that she did not want CNA #1 to lose her job because of the incident that occurred on 12/2/24. No additional information was provided for surveyor review regarding the incident. 2. 12/12/24 at 2:18 P.M., Resident #6 observed going to activity in dayroom, declined to speak with Surveyor. According to the AR, Resident #6 was admitted with diagnoses including but not limited to Type 2 Diabetes Mellitus (a common condition that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), Depression (a serious mental health condition that can impact how a person feels, thinks, and acts) and Anxiety Disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that interfere with daily life). A review of the MDS dated [DATE], revealed that Resident #6 had a Brief Interview of Mental Status (BIMS) score of 14, indicating that Resident #6 was cognitively intact, and required supervision with ADLs (Activities of Daily Living). A review of the Private Resident Council minutes dated 10/24/24, revealed that under Nursing, residents pointed out that some Aides had attitudes or were rude towards them across all shifts. Additionally, under Additional concerns, Resident #6 stated feeling belittled by employees, and specified that it is across the building and not just nursing. There was no response documented for the concerns. During an interview with Surveyors on 12/12/24 at 10 A.M., the Social Worker (SW) for Long Term Care, stated that she advocated for the residents, and completed investigations for grievances. SW stated that her investigations involved collecting statements from residents, and for allegations that involved staff members, she would interview the resident making the allegation, then other residents on the staff member's assignment. She further stated that would formerly write up her investigation, and then turn her information into the Director of Nursing (DON), and the DON would proceed with investigating the employee. In the presence of the surveyor, the SW reviewed the statement from Resident #3 dated 12/4/24 and stated that she had given the statement to the DON. She further stated that she did not collect statements from other residents on CNA #1's and CNA #2's assignments. During an interview with Surveyors via telephone on 12/12/24 at 12:15 P.M., the Recreation Director (RD), stated that if there was a concern and if majority of the residents agreed with the concern, then the concern would be written in the minutes, and then a response would be signed and documented by the department heads. The RD stated that there was not a response to the 10/24/24 Private Resident Council minutes, and that there should have been a written response to the concerns expressed. RD stated that she would report any incident of abuse. The RD stated that belittling a resident is considered verbal abuse, however, this incident was not reported. During an interview with Surveyors on 12/12/24 at 1:08 P.M., the DON stated that allegations of abuse are investigated and reported. DON stated that an investigation entailed speaking to the resident, resident's roommate, resident's family members, and if the abuse involved staff, then the other residents on the staff's assignment. She further stated that belittling a resident was a form of verbal abuse and should be investigated. DON stated that she received a copy of all Resident Council minutes. She further stated that she was not made aware of the concerns in the 10/24/24 resident council minutes, and if she had been, she would have addressed the concern. During an interview with Surveyors on 12/12/24 at 1:56 P.M., the Assistant Director of Nursing (ADON) stated that in the absence of the DON, the council would ask her to sit in on meetings. She stated that when there was a concern, the department that the concern fell under, would respond to the concern on the response form. The ADON stated that the nursing department can either be notified verbally or in writing. She stated that she did not receive the minutes, nor was she informed of the 10/24/24 Private Resident Council meeting. During an interview with Surveyors on 12/12/24 at 2:31 P.M., the Administrator stated that examples of verbal abuse were calling someone out of their name, yelling and screaming at residents. In the presence of the Surveyors, the Administrator reviewed the statement from the SW for Resident #3's grievance, she then stated that the incident should have been reported for abuse. A review of the facility's policy presented by the Director of Nursing (DON), titled Abuse Prohibition dated 7/1/13, reviewed and updated 10/24/22, included but was not limited to the following: under the heading for Policy, it states, Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property and exploitation for all patients .Centers also to strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any reasonable suspicion of a crime against a patient. The Center will implement an abuse prohibition program through the following: .Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; protection of patients during the investigation. Under the heading for process, it states: 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental), not later than 2 hours after the allegation is made. N.J.A.C: 8:39-4.1 (a) 5, 12

NJ00170135 Based on interview, record review, and review of the facility's policy, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) immediately, but not later than two hours for one of 12 sampled residents reviewed for abuse/neglect and injuries of unknown origin (Resident (R)10). This deficient practice had the potential to allow residents of suspected abuse to go unreported to the SSA. Findings include: Review of facility's policy titled, Abuse Prohibition, revised 10/24/22, revealed . Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any reasonable suspicion of a crime against a patient. Reporting a reasonable suspicion of a crime only to an immediate supervisor does not meet the obligation to report. Retaliation in any form against an employee who reports a reasonable suspicion is strictly prohibited.7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.2 Report allegations involving abuse (physical, verbal- sexual mental) not later than 2 hours after the allegation is made. Review pf the facility's Internal Investigation report for an employee to resident verbal abuse involving R10 dated 01/23/24 revealed an allegation, Certified Nursing Assistant (CNA) 4 called R10 a liar. The investigation indicated the incident was not called in until 02/16/24. During an interview on 05/30/24 at 9:41 AM, R10 was asked how the staff treats her. R10 recalled, There was a time this woman was very rude to me, called me names, but I do not know her name. I told my daughter about it. During an interview on 05/30/24 at 11:41 AM, the Social Services (SS) staff was asked if she could recall the alleged abuse between CNA4 and R10. The SS stated, I remember [R10's Name] sitting at the doorway to his/her room, and he/she motioned for me to come over. The resident was highly upset because he/she and the aide had gotten into an argument the evening before about sandwiches and the resident stated the CNA called him/her a liar. I made the ADON (Assistant Direction of nursing) aware. During an interview on 05/30/24 at 12:30 PM, the ADON was asked about the investigation. The ADON stated, The Director of Nursing (DON) was on vacation at the time. I investigated the incident. The resident was upset and stated the CNA had been rude to her. I investigated it like a grievance. It was later the DON reported it to state as abuse. I think Corporate told her to report it. During an interview on 05/31/24 at 11:09 AM, the DON was asked why the allegation of abuse was called in a month after the incident occurred. The DON stated, It was after I spoke with the daughter that it was called in. It was reviewed as a grievance until then. The resident started to cry, and I figured it better be called in.

NJ00156215 Based on record review, and interview, and facility policy review, the facility failed to ensure a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided services according to accepted standards of clinical practice with medication administration for one resident (Resident (R) 2) out of 25 sampled residents. Findings include: Review of Review of R2's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of diabetes, cirrhosis of the liver, anemia, and dependence on dialysis. Review of R2's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/12/24, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. Review of the facility's investigation concluded on 07/13/22, revealed on 07/11/22, R2 was scheduled for dialysis and morning medications were due. The resident had previously stated that he did not want LPN1 as his nurse. LPN1 was the nurse on duty and had previously been educated to call for the nursing supervisor to administer the resident's medication per resident request. LPN1 stated that she called the unit where the supervisor was working but she did not answer. She also tried to call another nurse, but she did not answer the unit phone. Transportation to take the resident to dialysis was on the way to the facility so she asked CNA2 if she would check the resident's blood glucose, administer his insulin, and one oral medication. The nurse stated she stood outside the resident's door and observed the CNA administer the medications and she felt comfortable since the CNA was also a diabetic and administered his own finger sticks and insulin. Review of the July 2022 Medication Administration Record (MAR) revealed the medication was signed off by LPN1, even though she did not administer the medications. Review of the written statements by LPN1 and CNA2 confirmed the events that were included in the facility's investigation of the incident. Both staff were terminated from employment by the facility. Interview with LPN17 on 05/29/24 revealed that she would never ask a non-licensed employee to administer any medications to a resident especially insulin. She said she would report any concerns to her supervisor if she was aware of this happening. Interview with LPN27 on 05/29/24 at 4:40 PM revealed that if she was unable to administer any medications to a resident for any reason, she would contact her supervisor immediately or ask her unit manager. She would never ask a CNA to administer any medications to a resident. Interview with CNA28 on 05/31/24 at 11:15AM revealed she would never give a resident any medications. The CNA stated administering medications was not in her training. She would report the nurse to her supervisor if she was asked to. Interview with CNA30 on 05/31/24 at 11:45AM revealed she would not give any medications to any resident. If she was asked to, she would immediately report it to her unit manager or supervisor. During an interview with the Director of Nursing (DON) on 05/30/24 at 10:00 AM revealed after the investigation, she terminated both employees from the facility, initiated an action plan for delegation of duties for administration of medication, scope of practice for medications, interviewed other residents to make sure only nurses were giving them medication, and followed up weekly. She also stated the resident that was involved in the incident did not have any outcome and remained in the facility. Review is the facility's policy titled, General Dose Preparation and Medication Administration revised on 04/30/24 revealed, This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual (SOM) when administering medications.

NJ00171304 Based on observation, interview, record review, and facility policy review, the facility failed to ensure basic infection control practices were followed to prevent cross contamination for two residents of three residents reviewed for wound care (Resident (R) 2 and R24) out of a sample of 25 residents. The facility failed to ensure Enhanced Barrier Precautions were followed by wearing required PPE (Personal Protection Equipment) and wound supplies were placed on a protective barrier when performing wound care. These failures had the potential to cause the spread of infections. Findings include: 1. Review of R2's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of diabetes, cirrhosis of the liver, anemia, and dependence on dialysis. Review of R2's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/12/24, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The resident was identified as having a diabetic ulcer on his left foot and was at risk for developing pressure sores. During an observation of wound care for R2 on 05/30/24 at 2:20 PM, Registered Nurse (RN) 18 entered the resident's room and placed a box of disposable gloves, a box containing 4x4 gauze sponges, a bottle of Betadine solution, and two individual packets of Betadine swabs on top of the resident's bed. The nurse disinfected the resident's overbed table, placed a protective barrier to cover the table, removed the swabs from the box, and placed them on top of the barrier. The nurse did not put on a disposable gown prior to starting wound care. Using gloves removed from the box that was also on top of the resident's bed, the nurse cleaned the wound on the left lateral foot with saline and used the two Betadine swabs to paint the surface of the wound which was covered with eschar (a layer of hard, thick, blackened tissue). A 4x4 gauze pad and gauze wrap from the box on the bed were used to cover the resident's wound. After the wound care was completed, the nurse placed the box of supplies and box of gloves on top of her medication cart in the hallway. A sign announcing the resident was on Enhanced Barrier Precautions was not observed on the resident's door prior to and after the observation of wound care. During an interview with RN18 immediately after the observation, she stated that she did not know why she left the items on the resident's bed and only placed the Betadine swabs on the clean barrier. RN18 confirmed she should have cleaned and prepared the barrier before placing any of the supplies for wound care in the room and that she did not think to put on a gown prior to wound care. The RN also confirmed that a sign indicating Enhanced Barrier Precautions was not on the resident's door. She also stated that she should not have placed the box of supplies from the resident's room on her medication cart. 2. Review of R26's Admission Record located in the resident's EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with Stage IV pressure sore, congestive heart failure, hypertension, muscle contractures, dysphagia, heart disease, and Alzheimer's Disease. Review of R26's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an ARD of 04/21/24, revealed the resident was never understood therefore a BIMS assessment was not conducted. The resident was assessed with severely impaired cognitive status. R26 was also assessed as being at risk for developing pressure sores with the presence of a Stage IV pressure sore. During an observation on 05/30/24 at 2:00 PM, RN18 was preparing to conduct wound care on R26's Stage IV pressure sore on the resident's sacral area. She had the treatment supplies on a protective barrier on top of the overbed table. RN18 was not wearing a protective gown as she performed the treatment, only gloves. The wound was cleaned with a normal saline wash and a small square of calcium alginate placed on top of the wound bed and covered with a foam dressing. The nurse changed her gloves appropriately but failed to put on a gown at the beginning of the treatment. The door to the resident's room did not have a sign posted for Enhanced Barrier Precautions during the wound treatment. During an interview with RN18 immediately after the observation of wound care, she confirmed that she should have worn a protective gown when performing the treatment since the pressure sore is a chronic wound. She thought she did not have to since there was not a sign on the door at that time and the cart that was outside of the door had been moved to the room next door. In an interview with RN18 on 05/31/24 at 10:00 AM, she stated that she received training on Enhanced Precautions and basic infection control practices for wound care through her agency and working in medical facilities. During an interview with the Director of Nursing (DON) on 05/30/24 at 2:30 PM, the DON stated the facility had conducted an in-service for all nursing staff on Enhanced Barrier Precautions previously. RN18 was not here at the time. They expect all agency nurses to be trained on all infection control procedures. She confirmed that the nurse should have worn a gown during wound care and the supplies should not have been placed on the bed. The DON stated that according to staff, a sign had previously been on R26's door but for some reason was found in a drawer in her room. Review of the facility policy entitled, Enhanced Barrier Precautions revised on 01/08/24 revealed, In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used (when Contact Precautions do not otherwise apply) for novel or targeted multi-drug resistant organisms .Procedure: Enhanced Barrier Precautions, 1. Post the appropriate Enhanced Barrier Precautions sign on the patient's room door .PPE used for wound care.

Complaint#: NJ150408, NJ151017 Based on interviews, review of Medical Records (MR), and other pertinent facility documentation on 05/31/23 and 06/01/23, it was determined that the facility staff failed to a.) maintain a complete and accurate MR for documentation of a resident's treatments on the Treatment Administration Record (TAR), to show that the tasks were completed for 1 of 2 residents (Resident #2) reviewed for pressure ulcer and failed to follow its policy titled Nursing Documentation. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to contracture of muscle in the right and left lower legs, cerebrovascular disease, and anemia. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/29/21, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also showed that Resident #2 required extensive assistance for Activities of Daily Living (ADLs), had impairment to bilateral upper and lower extremities, and was at risk for pressure ulcers/injuries. Review of Resident #2's Medication Review Report (MRR), dated on or after 01/04/21, revealed a 12/03/20 physician order (order) for Patient to utilize blue foam wedge for l/es [lower extremities] for contracture management while supine in bed. Review of the January 2021, February 2021, and March 2021 TAR revealed the corresponding 12/02/20 order for the resident to utilize a blue foam wedge for lower extremities for contracture management while supine in bed, with the administration times of 9:00 a.m. and 9 p.m. The TAR was blank on 01/25/21 at 9:00 a.m., 02/07/21 at 9:00 a.m., 02/14/21 at 9:00 p.m., 02/25/21 at 9:00 p.m., 03/03/21 at 9:00 a.m., 03/04/21 at 9:00 p.m., and 03/15/21 at 9:00 a.m. Review of Resident #2's MRR, dated on or after 01/04/21, revealed an order, dated 10/23/20, to wear heel boots at all times every shift for DTI (deep tissue injury) wounds. Review of the January 2021, February 2021, and March 2021 TAR revealed the corresponding 10/23/20 order to wear heel boots at all times every shift for DTI wounds, with the administration times of day, evening, and night was blank on 01/08/21 night, 01/09/21 night, 01/15/21 night, 01/25/21 day, 02/07/21 day, 02/14/21 evening, 03/03/21 day, and 03/11/21 day. Review of Resident #2's MRR, dated on or after 01/04/21, revealed an order, dated 12/21/20, for 3-11 Wednesday and Sunday showers every evening shift, with a start date of 12/23/21. Review of the February 2021 and March 2021 TAR revealed the corresponding 12/21/20 order for 3-11 Wednesday and Sunday showers every evening shift was blank on 02/14/21 and 03/10/21. Review of Resident #2's MRR, dated on or after 01/04/21, revealed a Physician's Order dated 11/01/20 for Bengay Ultra Strength Cream to be applied to bilateral knees every evening shift for pain. Review of the February 2021 TAR revealed the corresponding 11/01/20 order for Bengay Ultra Strength Cream to be applied to bilateral knees every evening shift for pain was blank on 02/14/21. Review of Resident #2's MRR, dated on or after 03/25/21, revealed an order, dated 02/27/21, to perform foley catheter care every day and evening shift, with a start date of 02/28/21. Review of the March 2021 TAR revealed the corresponding 02/27/21 order to perform foley catheter care every day, and the evening shift was blank on 03/03/21 day and 03/15/21 day. During the same interview, the DON stated that treatment orders are documented in the TAR and that nurses document the completion of treatment by signing the TAR. The DON further stated that blanks on the TAR indicated the nurse may have forgotten to sign the TAR. The DON added that signing the TAR would indicate that the treatment was completed per the physician's order and that there should be no blanks on the TAR. The DON stated that signing the TAR was important for accountability and continuity of care. A review of the Resident's Care Progress Notes failed to provide documented evidence of why the dates and shifts on the TAR were blank. Review of the facility's NSG113 Nursing Documentation, revised on 05/01/23, revealed that nursing documentation would follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's condition, situation, and complexity. Nursing documentation will follow established policies and procedures and federal and state regulations. The Purpose is to communicate the resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Documentation of nursing care is recorded in the MR and is reflective of the care provided by nursing staff. The policy further indicated that each nursing role would document care delivered that is within the scope of their service. NJAC 8:39-35.2 (a)(g)1 NJAC 8:39-35.2(d)(9) 45622

Complaint#: NJ00150408 Based on interviews, review of the Medical Records (MRs), and review of other pertinent documentation on 05/31/23 and 06/01/23, it was determined that the facility failed to notify the resident's family of a new sacral skin issue. This deficient practice was identified for 1 of 8 residents (Resident #2) and was evidenced by the following: A review of Resident #2's Electronic Medical Record (EMR) was as follows: According to the Admission Record, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: contracture of muscle in the right and left lower legs, cerebrovascular disease, and anemia. Review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/29/20, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also showed that Resident #2 required extensive to total assistance for Activities of Daily Living (ADLs), was at risk for pressure ulcers/injuries, and was admitted without wounds. Review of the 10/29/20 Braden Scale, an assessment tool used to predict the risk for pressure sore development, revealed that the facility identified Resident #2 as being at moderate risk for developing a pressure sore. Review of Resident #2's December 2020 Progress Notes (PN) revealed a 12/18/20 Assessment note that a skin check was performed, and no skin injury/wound was noted. The PN revealed a 12/22/20 General note that wound rounds were completed with the wound consultant and that, per the wound consultant, the left buttock was noted with reopened scar tissue. Treatment changed to apply calazime (skin protectant that helps treat and prevent diaper rash and minor skin irritations) every shift. The PN further revealed a 12/22/20 wound consult note for the Chief Complaint of impaired skin integrity. The wound notes indicated that Resident #2 was seen on wound rounds for an open area on the buttocks/sacrum. The area of re-open scar tissue was 3 centimeters (cm) by 0.5 cm with an epithelial base. The wound consultant discussed with nursing and recommended calazime to the sacral region every shift and as needed. Review of Resident #2's December 2020 GHC Skin Integrity Report (skin report) revealed the resident had a Type of wound: Other- reopened scar tissue on the right buttocks noted on 12/22/20. The skin report indicated the wound measurements were 3 centimeters (cm) by 0.5 cm and that the surrounding tissues and wound edges were healthy. The physician was notified, and the resident's Care Plan (CP) was updated. The skin report further revealed that the reopened scar tissue was documented as resolved on 12/29/20. Review of Resident #2's Medication Review Report (MRR), dated on or after 01/04/21, revealed a 12/22/20 physician order (order) for Calazime Skin Protectant Paste. The order instructed to cleanse with soap and water and then apply to the buttocks topically every shift for the reopened scar tissue for 21 days. Review of Resident #2's Care Plan (CP) revealed a Focus, initiated on 12/22/20, that Resident #2 was at risk for skin breakdown related to immobility, contractures, and incontinence. Resident has actual skin breakdown L [left] buttocks reopened scar tissue (CLOSED 12/29/2020). The CP included interventions, initiated on 12/22/20, for diet as ordered, low air loss mattress, treatment as ordered, turn and/or reposition and check skin every 1-2 hours as determined by tissue tolerance, weekly skin checks, and weekly wound assessment to include measurements and description of wound status. During an interview with the surveyor on 06/01/23 at 11:38 AM, LPN #1, who cared for Resident #2, stated the resident had wounds when transferred to her unit. LPN #1 explained that the nurse would complete a change in condition documentation and notify the unit manager, physician, and the resident's family, for any new wounds or changes with the resident's skin. LPN #1 added that family notification was documented in the change in condition documentation and that the nurse would document the name and date of the family notified. During a telephone interview with the surveyor on 06/01/23 at 12:22 PM, the Assistant Director of Nursing (ADON) stated she was the Unit Manager that completed wound rounds with the wound consultant for Resident #2. The ADON stated the nurse is supposed to complete a change in condition documentation and notify the physician and the resident's family for any new wound identified. During an interview with the surveyor on 06/01/23 at 1:02 PM, the Director of Nursing (DON) stated nurses would assess the wound, inform the physician to obtain new orders, and notify the resident's family immediately for any new wound identified. The DON added that the nurse would document the family notification in the PN. Review of Resident #2's EMR revealed no documentation that the resident's family was notified of the reopened scar tissue identified on 12/22/20. On 06/01/23 at 1:30 PM, the surveyor attempted to conduct a telephone interview with the wound consultant but did not receive a return call. During a follow-up interview with the surveyor on 06/01/23 at 2:36 PM, the DON stated that she could not find any documentation that Resident #2's family was notified of the 12/22/20 reopened scar tissue. The DON stated the area was excoriated, not a wound, and was more of a MASD [moisture-associated skin damage] (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus.) Review of the 06/01/23 email, sent at 4:36 PM by the DON, included no additional documentation for Resident #2. Review of the facility's NSG122 Change in Condition: Notification of policy, revised 06/01/21, revealed the center must immediately inform the resident, consult with the physician, and notify the resident Health Care Decision Maker, where there is a need to alter treatment significantly, (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment.) The policy indicated the Purpose was to provide appropriate and timely notification about changes relevant to the patient's condition. N.J.A.C.: 8.39-13.1 (c)(d)

Complaint#: NJ155921 Based on interviews, medical record review, and review of other pertinent facility documents on 5/30/2023 and 6/1/2023, it was determined that the facility failed to develop and implement a Covid Care Plan (CP) for a resident (Resident #6) who tested positive for Covid-19, and failed to follow its policy titled Care Plans, Comprehensive, Person-Centered. This deficient practice was identified for 1 of 8 residents reviewed for CP and was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to the Admission Record (AR), Resident #6 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Essential Hypertension, Muscle Weakness, Dysphagia, and Unspecified Lack of Coordination. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/5/2023, Resident #6 had a Brief Interview of Mental Status (BIMS) score of 4/15, which indicated the resident was severely cognitively impaired. A review of Resident #6's progress notes dated 6/29/2022 by the Registered Nurse (RN) revealed: Pt [pateient] is covid positive, pt was coughing and sneezing this shift. Afebrile and no respiratory distress noted. Temperature 98.6, Respiration 20, O2 [oxygen saturation] 96% on R/A [room air], denies pain and discomfort. A review of Resident #6's CP initiated on 6/30/2022 did not reveal evidence of a Covid -19 positive CP being placed. During an interview on 5/31/2023 at 11:38 a.m., When asked by the Surveyor if Resident #6 should have had a Covid-19 CP in place, the Licensed Practical Nurse (LPN) stated, Yes, there should have been a CP for Resident #6's Covid-19 positive result. During an interview on 5/31/2023 at 1:02 p.m., the Director of Nursing (DON) stated, The purpose of the CP is to ensure continuity of care for the residents and that the proper care is provided to the residents. She stated that the Covid -19 CP should be initiated once a resident tests positive for Covid-19. When presented with Resident #6's CP, the DON stated, I don't see a CP for Covid-19 positive result; Yes, there should be a Covid-19 CP for every resident who test positive for Covid. A review of the facility's Care Plans, Comprehensive, Person-Centered revised 10/2022 under Policy: The Center must develop and implement a baseline person-centered care plan within 48 hours of admission/readmission for each patient/resident (hereinafter patient) that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care. Under: PURPOSE 1. To attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being. 2. To eliminate or mitigate triggers that may cause re-traumatization of the patient. 3. To promote positive communication between the patient, patient representative, and team to obtain the patient's and resident representative's input into the plan of care, ensure effective communication, and optimize clinical outcomes. Under: Practices and standards #7. Care plans will be: 7.1 Communicated to appropriate staff, patient, patient representative, and family; 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and as needed to reflect the response to care and changing needs and goals. N.[NAME].C.: 8:39-11.2(d)(2)

Complaint#: NJ151017 Based on observations, interviews, review of the medical record, and other pertinent facility documents on 5/30/2023 and 6/1/2023, it was determined that the facility failed to consistently document Activities of Daily Living care as being provided to a resident (Resident #7). The facility also failed to follow its Certified Nursing Assistant's job description and its policy titled Activities of Daily Living (ADLs) for 1 of 8 residents reviewed. This deficient practice was evidenced by the following: According to the Admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease, Essential Hypertension, Muscle Weakness, and Anxiety Disorder. A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/27/2021, Resident #7 had short-term and long-term memory problems. The MDS also indicated the resident had severe cognitive impairment and required 2-person physical assistance with ADLs and transfer. A review of Resident #7's Documentation Survey Report Version (v2)/ADL Sheet, a form utilized for documentation of ADLs care by the Certified Nursing Assistants (CNAs) for January 2022, showed blank spaces indicating the tasks were not completed as follows: Bed Mobility every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Transfer every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Walk-in the room every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Walk in the corridor every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Locomotion on the unit every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Locomotion of unit every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Dressing (includes braces/TEDS) every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and the 3:00 p.m. to 11:00 p.m. shift. Meal at 8:00 a.m., 12:00 p.m., and 6:00 p.m. on 1/2/2022, 1/4/2022, 1/7/2022, 1/15/2022, 1/16/2022, 1/22/2022, 1/23/2022, 1/29/2022 and 1/30/2022. Drink/Snack-other than with meals every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Toilet/Bladder/Bowel every shift on 1/15/2022, 1/29/2022, and 1/30/2022. Personal Hygiene every shift 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022. Bathing every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and on the 3:00 p.m. to 11:00 p.m. shift. Preventive skin care (protectors heel/elbow) every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022. Protective skin care lotions/cream-type every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022 on the 7:00 a.m. to 3:00 p.m. shift and 3:00 p.m. to 11:00 p.m. shift. Protective skin care pressure relieving device for bed and chair every shift on 1/2/2022, 1/15/2022, 1/29/2022, and 1/30/2022. A review of the resident's EMRs for Resident #7 showed no further evidence that the tasks mentioned above were completed. During an interview on 6/1/2023 at 11:15 a.m., the Certified Nursing Assistant (CNA) stated, If the ADLs sheet is not signed off [not initialed], then I would say the task was not completed that day. When presented with the printed copy of the ADLs sheets and asked if the ADL sheets should be signed, the CNA stated, Yes, the ADL sheets should be signed off every day by the CNA at the end of each shift. During an interview on 6/1/2023 at 1:02 p.m., the Director of Nursing (DON) stated, The CNAs provide ADLs for the residents, and it is documented on the ADL kiosk (an electronic medical device used to store patients' medical information) at the end of each shift. She continued, There should be no blank spaces on the kiosk. When presented with the printed ADLs sheets from the kiosk, the DON stated, Looking at the ADL sheets with the blank spaces, that means the tasks were not completed. She further stated, The blank spaces could also indicate the computer was down or the CNA forgot to complete their documentation. The DON stated, My expectation is for the documentation to be completed by the end of each shift. A review of the updated facility's document titled Certified Nursing Assistant Job Description reveals under Responsibilities/ Accountabilities: 1. Provide patient care in a manner conducive to safety and comfort. Patient care includes, but is not limited to: 1.1 Assists patient with or performs Activities of Daily Living (ADL); 1.3. Assist patients with ambulation and transfer. 1.4. positions patients in correct body alignment in and out of bed; 1.5 Applies adaptive equipment as ordered; 10. Record patient oral intake and output; 28. Perform other duties as requested. Perform all assigned tasks in accordance with our established policies and procedures and as instructed by your supervisors. A review of the facility's policy, last updated on 5/1/2023, titled Activities of Daily Living (ADLs) under Policy Based on a comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's activities of daily living (ADL) abilities are maintained or improved and do not diminish unless circumstances of the patient's clinical condition demonstrate that a change was unavoidable. Under Purpose, To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences. Under Practice Standards #4.2, A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral Hygiene. #5. Documentation of ADL care is recorded in the medical record and is reflective of the care provided by nursing staff. ADL care will be documented in real-time, as close to the time that care was provided and information obtained as possible. ADL care is documented every shift by the nursing assistant. NJAC 8:39-35.2 (a)(g)1

Complaint#: NJ00150408 Based on interview, review of medical records (MR) and pertinent facility documents on 05/31/23 and 06/01/23, it was determined that the facility failed to provide care for pressure ulcers in accordance with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for pressure ulcer care. The deficient practice was evidenced by the following: According to the Admission Record, Resident #2 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: contracture of muscle in right and left lower legs, cerebrovascular disease, and anemia. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/29/21, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also indicated that Resident #2 required extensive assistance for Activities of Daily Living (ADLs), had impairment to bilateral upper and lower extremities, was at risk for pressure ulcers/injuries, and had moisture associated skin damage (MASD) (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus.) Review of the 10/29/20 Braden Scale, an assessment tool used to predict the risk for pressure sore development, revealed that the facility identified Resident #2 as being moderate risk for developing a pressure sore. Review of the 01/22/21 Skin Check assessment revealed that Resident #2 had MASD to sacrum. Review of the 01/23/21 Change in Condition Evaluation-V 5.1 revealed that Resident #2 had a skin wound or ulcer. The resident had a significant change in macerated area on sacrum that was noted during AM care. The physician was notified on 01/23/21 at 12:00 PM and a new physician order (order) for medihoney (topical wound gel medication) to sacrum daily until healed was obtained. The open area to sacrum measured 8 cm [centimeters] x 5 cm x 0.1 [cm] depth. Review of Resident #2s January 2021 GHC Skin Integrity Report (skin report) revealed the resident had a Type of wound: Other- reopened scar tissue on the right buttocks noted on 01/23/21. The skin report indicated the wound measurements were 8 cm x 5 cm x 0.1 cm, the surrounding tissues were macerated (the softening of skin as part of the process of skin tissue breaking down,) and wound edges were excoriated. The physician was notified and the resident's Care Plan (CP) was updated. Review of Resident #2's MRR, dated on or after 02/01/21, revealed a 01/23/21 order for Medihoney wound/burn dressing gel. The order instructed to cleanse sacrum with normal saline and apply medihoney, 4 x 4 [gauze] and no tape. Review of Resident #2's Medication Review Report (MRR), dated on or after 01/04/21, revealed a 12/22/20 order for Calazime Skin Protectant Paste (Calazime.) The order instructed to cleanse with soap and water and then apply to buttocks topically every shift for the reopened scar tissue for 21 days. Review of the January 2021 Treatment Administration Record (TAR) revealed the corresponding 12/22/20 order for Calazime to be applied to buttocks every shift (day, evening, and night.) There was no documentation that the treatment was performed on 01/08/23 and 01/09/23 night shifts. Review of the February 2021 TAR revealed a 02/02/21 order for Santyl (topical medication that is used for removing dead skin tissue and aid in wound healing.) The order instructed to cleanse sacrum/buttocks with normal saline and apply nickel thick layer of Santyl and cover with dry clean dressing every day shift for unstageable [wound.] There was no documentation that the treatment was performed on 02/07/23 day shift. Review of Resident #2's MRR, dated on or after 03/25/21, revealed a 02/27/21 order for Negative Pressure Therapy (wound vac) to sacrum and to set unit to 125 mmHg (unit of measurement) continuously. The order instructed to cleanse wound with NSS [normal saline]/wound cleanser/ other, place black foam into wound, apply skin prep to intact skin around the wound, cover with occlusive dressing and secure tubing per manufacturer guide every day shift on Monday, Wednesday, and Friday, with a start date of 03/01/21. Review of the March 2021 TAR revealed the corresponding 02/27/21 order for wound vac to sacrum every day shift on Monday, Wednesday, and Friday, with a start date of 03/01/21. There was no documentation that the treatment was performed on 03/03/23 day and 03/15/23 day shifts. Review of Resident #2's Care Plan (CP) revealed a Focus, initiated on 12/22/20, that Resident #2 was at risk for skin breakdown related to immobility, contractures, incontinence. Buttock reopened scar tissue 1/24/2021. Sacrum/buttock reclassified as an unstaged [unstageable] pressure injury 2/2021. readmitted [DATE] Stage 4. The CP included an intervention of treatment as ordered, initiated on 01/25/23. The CP also included an intervention, initiated on 03/09/21, to Change Wound Vac dressing every Monday, Wednesday, and Friday. Review of the Resident #2's Progress Notes revealed no documentation that the treatments were completed on the aforementioned dates and shifts. During an interview with the surveyor on 06/01/23 at 1:02 PM, the Director of Nursing (DON) stated that treatment orders are documented in the TAR and that nurses document the completion of a treatment by signing the TAR. The DON further stated that blanks on the TAR indicated the nurse may have forgotten to sign the TAR. The DON added that signing the TAR would indicate that the treatment was completed per the physician's order and that there should be no blanks on the TAR. The DON stated that signing the TAR was important for accountability and continuity of care. Review of the facility's NSG113 Nursing Documentation, revised on 05/01/23, revealed that nursing documentation would follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's condition, situation, and complexity. Nursing documentation will follow established policies and procedures and federal and state regulations. The Purpose is to communicate resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Documentation of nursing care is recorded in the MR and is reflective of the care provided by nursing staff. The policy further indicated that each nursing role would document care delivered that is within the scope of their service. Review of the facility's NSG236 Skin Integrity and Wound Management, revised 02/01/23, revealed under Practice Standards, that the licensed nurse would 6.8 Implement pressure injury prevention for identified, modifiable risk factors and 6.13 Implement special wound care treatments/techniques, as indicated and ordered including, but not limited to Negative Pressure Wound Therapy. NJAC 8:39-27.1(e)

Based on observation, interview, review of clinical records and other pertinent facility documentation it was determined that the facility failed to: a.) provide adequate supervision for a resident identified as a high risk for falls, b.) implement appropriate fall prevention interventions for a resident after sustaining multiple falls with a major injury, c.) update the resident's Care Plan in a timely manner, d.) perform neuro-checks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) as per facility policy for a resident who had three falls resulting in head injuries. This deficient practice was identified for one of five residents, (Resident #193) reviewed for accidents. The resident had five (5) falls since 01/04/23, and three (3) out of 5 falls resulted in the resident sustaining head injuries. The deficient practice was evidenced by the following: On 01/20/23 at 10:56 AM, the surveyor was touring the 300 unit and observed the staff mechanically lifting Resident #193 into a geri-chair (specialized recliner) off the floor, in front of the nurse's station. The surveyor asked the Registered Nurse Unit Manager (RN/UM) what happened, and the RN/UM stated that Resident #193 fell out of the wheelchair in front of the nursing station. The Admission Record indicated that Resident #193 was admitted to the facility with the diagnoses which included but were not limited to metabolic encephalopathy (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function), unspecified falls, diabetes mellites (DM), and Dementia. The admission Minimum Data Set (MDS), an assessment tool used t0 facilitate the management of care dated 01/09/2023, indicated that the resident had short term and long-term memory loss and had impairments in cognitive decision making. The MDS also indicated that the resident required extensive assistance with activities of daily living and had a history of falls. On 01/23/23 at 11:07 AM, the surveyor observed the resident sitting in a specialized recliner at the nurse's station. The resident was unable to be interviewed due to cognitive impairments. The resident was quiet and resting. On 01/23/23 at 11:27 AM, the surveyor conducted a telephone interviewed the resident's responsible party (RP) who stated that Resident #193 had about 10 falls both at home and in the facility. The RP explained that the resident was experiencing falls at home and required more supervision than the family could provide and decided to admit Resident #193 to the facility for more supervision. The RP stated that Resident #193 had to be sent to the hospital a couple times due to falling in the facility. The RP further added that they did not know all the details regarding how Resident #193 had fallen. The RP requested the surveyor to inquire and review the Resident's medical record to find out how many times the resident fell . A review the resident's Care Plan (CP) dated 01/05/23, reflected Resident #193 was at risk for falls due to lack of safety awareness, decreased mobility, fatigue, anemia and diabetes mellitus. A review of the Progress Note (PN) dated 01/04/23 at 17:47 (5:47 PM) indicated that Resident #193 was admitted for the following reason(s): Status post fall and ambulatory dysfunction. On 01/25/23 at 11:25 AM, the facility provided the surveyor with incidents and accident reports for Resident #193 which indicated that Resident #193 had falls on the following dates: The surveyor reviewed the facility Fall Investigation Statement (FIS) dated 01/12/23 at 4:30 PM, written by Licensed Practical nurse (LPN#3) for fall #1. The FIS indicated that Resident #193 was observed lying on the floor on the right side next to the specialized recliner in front of the nurse's station. The fall was witnessed by the ward clerk. The Risk Management System form (RMS) #358 indicated that the resident did not bang or hit his/her head during the 01/12/23 fall. It also indicated that there were no injuries, and the RP and medical doctor (MD) were notified. The intervention on the RMS form indicated adding a non-skid mat to the cushion of the wheelchair to prevent the cushion from sliding. The CP further reflected that the intervention was not created until 01/24/23 but was initiated on 01/13/23. The surveyor reviewed the Risk Management System (RMS) form #359, dated 1/14/23 at 14:35 (2:35 PM) for fall #2 which reflected that Resident #193 was found on the floor in his/her room on his/her back, beside the wheelchair and verbalized pain to the back of their head. The nurse assessed the resident and observed a lump where the resident had complained of pain. According to the report, the resident was unable to explain what happened. The FMS indicated that a neuro-check was conducted, 911 was called and the resident was sent to the emergency room (ER). The FMS indicated that the resident had dementia, a lack of safety awareness and was impulsive. The FMS also indicated that the resident's son was visiting prior to the fall and left the resident alone in the room and did not inform nursing that he was leaving. A review of the PN dated 1/14/23 at 18:18 (6:18 PM,) indicated that the resident returned from the hospital to the facility around 5:00 PM. The PN further reflected while at the hospital the CT scan (several x-ray images) of the head and cervical x-rays were negative. The facility could not provide the surveyor with neurological checks for Resident #193 after falling and suffering a head injury on 01/14/23 at 2:35 PM. The surveyor reviewed the resident's CP which indicated interventions were not implemented on the resident's CP to prevent falls until 01/17/23, which was 3 (three) days after the resident fell and suffered a head injury. The intervention on the CP dated 01/17/23 indicated that staff were to remind family and visitors to inform staff when they were done visiting the resident. The FMS form #361 dated 1/14/2023 at 21:17 (9:17 PM), for fall #3 indicated that the resident was at the nurse's station after returning from the hospital after an un-witnessed fall. The resident continued to attempt to get up from the chair and walk and the nurse continued to reorient the resident that his/her lower extremities were weak and reminded the resident that he/she was unable to walk. The Licensed Practical Nurse (LPN #1) documented that she provided the resident with a coloring book with crayons. The nurse then had to leave the resident alone because another resident needed her care. During this time, another nurse called for her and she then found Resident #193 lying on the floor on right side. The resident's hands were covering his/her head and the resident had blood on his/her hands. The nurse applied gauze and pressure to the resident's head, another nurse called 911 and a third nurse came to clean and bandage the wound. The FMS form further indicated that the resident had a laceration to the back of his/her head and was sent to the ER. The FMS form indicated that the resident never lost consciousness. The surveyor could not find documentation that a neuro-check was performed on the resident after the resident had an unwitnessed fall and suffered a head injury. The FIS dated 01/14/23 at 6:00 PM and written by LPN#1 indicated that the resident was at the nurse's station accompanied by two nurses (LPN #1 and LPN #2) and a Certified Nursing Assistant (CNA #1). The statement indicated that the resident was attempting to walk, and the staff sat him/her in front of the nurse's station with a coloring book and crayons to redirect him/her. LPN#1 documented that she had to leave the nurses station to assist another resident when the resident got up and fell and was noted to be bleeding from the head. There was no documentation that a neuro-check was performed after the resident suffered a head injury or any further fall prevention interventions. The witness statement dated 01/14/23, from CNA #1 indicated that the resident was sitting at the nurse's station, and she had to answer another resident's light. When she came out from the other resident's room the resident was on the floor and was being sent to the hospital. The facility could not provide the surveyor with the statement from LPN #2, who was also identified as being at the nurse's station at the time the resident fell . The surveyor reviewed the CP and there were no interventions initiated after the third fall dated 01/14/23 at 6:00 PM and the resident sustained a laceration on the back of the head which required staples. Attached to the FMS #361 was a late entry progress note dated 01/16/23 at 18:48 (6:48 PM) that indicated that the interdisciplinary team (IDT) met to discuss Resident #193's fall of 01/14/23 and that the resident was receiving Physical Therapy (PT) and Occupational Therapy (OT) to work on transfers and ambulation. There were no new fall prevention interventions documented on the FMS form or on the CP regarding the resident's third fall at the nurse's station. On 02/02/23 at 11:10 AM, the surveyor interviewed the Rehabilitation Director (RD) who stated that Resident #193 received PT/OT from 01/5/23 through 01/24/23. The RD stated that the intervention for PT and OT services for the fall wasn't necessarily appropriate for the resident because the resident was already receiving services. The RD further explained that because the resident's cognitive status was limited, he/she wasn't benefiting from the PT/OT services provided and was discharged from services on 01/24/23 for that reason. A review of the PT Discharge Summary (DS) note dated 01/24/23, indicated that the resident was discharged from PT services due to reaching maximum potential. The DS note further revealed that the resident's performance varied depending upon level of alertness, arousal, and cognitive deficit. The PT discharge recommendations included the resident should be up out of bed daily, utilize a geri-chair for safety secondary to frequent falls, supervision when up out of bed, and use of a Hoyer lift due to fluctuations in the resident's performance. The surveyor reviewed the FMS #366 dated 01/16/23 at 20:58 (8:58 PM) for fall #4 which indicated that the resident was at the nurse's station and was provided with a coloring book, crayons, and towels for redirection; however, the resident was attempting to ambulate without assistance. The FMS indicated that the nurse sat with the resident for almost two hours along with other staff members because the resident had a history of falls. The FMS then indicated that Resident #193 was coloring and eating snacks when the nurse left the resident to take blood sugars for other residents. According to the FMS, when the nurse went into another resident's room, Resident #193, who was not being supervised, had fallen again at the nurse's station. The resident was sent to the hospital ER visit and three staples were applied to a laceration on the back of the resident's head. The PN dated 1/17/23 at 4:02 AM, indicated that Resident #193 returned from the hospital ER with staples to left side back of head and had no other injuries noted. The PN also indicated that the resident appeared in no pain and was in recliner chair at nurse station sleeping. The surveyor reviewed the PN and there was no documentation that fall prevention interventions were put in place immediately when the resident returned from the hospital after suffering a laceration to the scalp on 01/16/23. There were no neuro-checks documented or performed after the resident fell and hit his/her head and had a head injury. The surveyor reviewed the Resident's CP which was not updated until 01/17/23, to include new interventions to prevent the resident from falling. The fall interventions included the following: -Place the resident at the nurse's station for observation and safety -Staff to remind family/visitors to inform staff when done visiting. -When sitting in wheelchair, apply bilateral leg rest to aid in positioning -When sitting in the wheelchair, lock brakes. These interventions did not reflect that the resident continued to fall from a recliner while at the nurse's station and was not utilizing a wheelchair which was documented on the CP dated 01/17/23. The surveyor reviewed FMS #369 dated 01/20/23 at 11:06 AM, for fall #5 which indicated that Resident #193 fell from a wheelchair when in front of the nurses' station. The resident was assessed by the RN/UM, and it was determined that the resident had no injuries and no complaints of pain. Neuro-checks were initiated and completed. The FMS also revealed that fall prevention interventions for this fall were not initiated until 01/24/23, which was 4 (four) days after the fall. The CP reflected that on 01/24/23, fall interventions were put in place for this fall to include: -Scoop mattress -Fall matt next to bed -Staff to lay the resident down after meals -Toilet after meals On 1/26/23 at 8:35 AM, the surveyor observed Resident #193 in bed with two half side rails up at the top of the bed, bed in low position and a floor mat observed on the floor next to the door side of the resident bed. The resident was unable to be interviewed due to confusion and severe cognitive impairment. The surveyor interviewed CNA#2 who entered the resident's room. CNA#2 stated that the resident was very confused and was unsteady on his/her feet. She stated that the resident required extensive assistance with Activities of Daily Living (ADLs) but was able to feed himself/herself after setting up of tray. On 1/26/23 at 8:40 AM, the surveyor interviewed LPN #4 who stated Resident #193 was confused and had cognitive impairment. LPN #4 stated that sometimes the resident was verbal and sometimes not. He stated that Resident #193 required complete care with all aspects of ADL's and was frequently incontinent of bladder and bowel. He explained that at times, the resident requested to be toileted and could walk short distance with assistance. He stated that the resident wore incontinent briefs and was toileted every two hours. LPN#4 added that staff had to anticipate the resident's needs. He stated that the resident had fallen frequently since admission and was a risk for falls. He stated that when a resident had a witnessed fall, the staff performed a full assessment to include vital signs (VS), make sure the resident did not have any pain, injury, and perform neuro-checks for head injury or unwitnessed fall for 72 hours post fall. LPN#4 further stated that the staff were also were required to call the resident's primary care physician and the responsible party (RP). He stated that witness statements were obtained, and a Risk Management System Assessment (RMS) was completed along with a change in condition form and progress notes. He explained that when the staff fill out the RMS there was a section to put in a fall prevention intervention to prevent the resident from falling again. LPN#4 explained that an unwitnessed fall was the same process as a witnessed fall, but that it was the facility's protocol to initiate neuro-checks and complete them 72 hours post fall. He stated that if a resident hit their head or had head trauma, It's the physician's call to send the resident to hospital, but 90 percent of the time the resident is sent to the hospital for a head injury. LPN#4 stated that Resident #193 should have had neuro-checks for any unwitnessed fall or head injury however the neuro-check form was not in the resident chart and that the RN/UM must have the resident's neuro-check sheets in her office. He stated that the neuro-check sheets were usually completed and put into the resident hard copy of the chart, but that Resident #193's neuro-check sheets were missing and not in the resident's chart. He stated that the CP should be updated with interventions after a fall but that the LPNs did not have the access to update the CP. He further stated that interventions to prevent a fall should be done immediately post fall to prevent the resident form falling. On 01/26/23 at 10:20 AM, the Director of Nursing (DON) came into the conference room and handed the surveyor the neuro-check sheets for Resident #193's five falls since admission. The DON stated that the resident only had one neuro-check sheet completed for the fall which occurred on 01/20/22, and he/she did not have any other sheets to provide the surveyor. The DON stated that the nurses thought that if the resident went to the hospital, that neuro-check did have to be done. The DON stated the resident had fallen two times on 01/14/23, and once on 01/16/23, and suffered a head injury each time and there was no documentation that the resident had neuro-checks performed for 72 hours post fall as per the facility policy indicated. On 01/26/23 at 10:46 AM, the surveyor conducted a telephone interview with CNA #1 who stated that she remembered Resident #193 falling on 01/14/23, because she was the resident's primary care CNA that evening. CNA#1 added that she had written a statement regarding the fall. CNA#1 further stated that the resident fell right after her break. She explained that the resident's family member was visiting, and she asked the son to bring the resident to the nurse's station after the visit so that the resident could be supervised. When CNA#1 returned from her break, she had found out the resident had fallen in their room and had to go to the hospital. CNA#1 stated that the resident's first fall was on 01/14/23. CNA#1 then explained that when the resident returned from the hospital after the first fall, she performed PM care and the resident was placed at the nurse's station so that the staff could supervise the resident. She explained that the staff set the resident up with pen and paper to keep him/her occupied, but the resident wasn't using it. She stated that the pen and paper were just sitting in front the resident. She further added that the resident's attention span was not that long, and the resident would start using it and then lose interest quickly. CNA#1 further explained that she left the resident at the nurse's station so that she could answer another resident's call bell. She explained that there was a nurse at the nurse's station doing paperwork. She stated that when she returned to the nurse's station, all the nurses were surrounding the desk. She stated that LPN #2 was doing paperwork at the desk and couldn't get to the resident in time to prevent the resident from falling. She stated that the resident fell at the nurse's station and had sustained an injury to their head and there was a lot of bleeding, so the resident was sent to the hospital. On 01/26/23 at 10:51 AM, the surveyor attempted to telephone interview LPN #1 (Primary nurse for resident falls of 01/14/23) and did not get an answer. The surveyor left a message for LPN#1 to call back. On 01/26/23 10:57 AM, the surveyor telephone interviewed LPN #2 who was present on unit 300-unit on 01/14/23 and was sitting at the nurse's station doing paperwork when Resident #193 fell and suffered a head injury. LPN #2 stated that she worked on 01/14/23, completing admission documentation on the 300-unit. LPN #2 stated that she recalled when Resident #193 fell . LPN #2 stated, Yes. She did fall. She explained to the surveyor that the first fall happened on the 7:00 AM -3:00 PM shift in which Resident #193 fell and was sent to the hospital. She stated that herself and the primary nurse (LPN #1) were sitting at the nurse's station and LPN #1 was called to assist another resident in another room. She stated that while she was sitting at the nurse's station, her back was turned, and she was not facing the resident. LPN#2 stated that she was typing and looking in another direction and she did not observe the resident fall. She stated that she heard the fall. She added that the resident had blood all over because the resident was on a blood thinner, so they sent him/her back to the hospital. She stated that she didn't remember anyone asking her to write a statement even though she was present and at the nurse's station at the time the resident fell . She added that the resident was trying to stand up, so the staff gave the resident coloring books; however, the resident fell and hit his/her head. LPN #2 added that she was the only nurse sitting at the nurse's station at the time the resident fell because the resident's primary nurse (LPN#1) had gotten up to check on another resident. On 01/26/23 at 11:21 AM, the surveyor interviewed the Registered/Unit Manager, RN/UM who worked on the 300/400 units. The surveyor asked the RN/UM what the facility's process was for a witnessed fall and unwitnessed resident fall. The RN/UM explained that if a staff member witnessed a resident fall, then they would get a nurse and the nurse would immediately assess the resident and perform a head to toe assessment and obtain vital signs. If it appeared that the resident had no injuries, the staff would get the resident off the floor with an electric lift. She stated that if the resident had injuries, then they would call 911, the doctor, and the family or responsible party (RP). The RN/UM then stated that they would obtain witness statements from anyone that was involved with the fall, witnessed the fall or was in the area when the resident fell . She stated that the primary care CNA was responsible to fill out a statement even if they didn't witness the fall. She explained that the management would also get statements from anyone that was there and present in the area when the fall occurred. She indicated that a Risk Management System (RMS) form was completed and was given to the DON. The RN/UM explained that the IDT team consisted of nursing, therapy, recreation, and the interdisciplinary team would look at reasons why the resident could have fallen and think of things to do to prevent other falls from occurring. If a fall was an unwitnessed fall or if a resident suffered a head injury, then the staff would immediately initiate a neuro-check form. She stated that the nurse would be responsible for initiating the neuro-check form and that it was the responsibility of the RN/UM to make sure the neuro-checks were being conducted for the next 72 hours. The surveyor asked the RN/UM why Resident #193 did not have neuro-checks completed when the resident had suffered major head injuries on three different occasions (2 falls on 01/14/23 and 1 fall on 01/16/23). The RN/UM stated that the resident should have had neuro-checks done on the dates, however, did not have a response as to why the neuro-checks were not completed. The surveyor then asked the RN/UM why fall prevention interventions were not initiated or put on the CP until days later after the resident fell . The RN/UM explained that she did not implement the intervention for the CP because she was working on a medication cart that day. The surveyor reviewed the events that occurred regarding the two falls the resident had on 01/14/23 with the RN/UM. The RN/UM indicated that the first fall on 01/14/23 occurred at 1:27 PM. The RN/UM stated, We put [the resident] in front of the nursing station after returning from the hospital. The RN/UM stated that there was not a 3:00 PM - 11:00 PM supervisor to implement an intervention and the interventions were usually assessed by a RN/UM the next day. She stated, I don't want to say that they didn't do an intervention because they brought [the resident] in front of the nurse's station so someone could keep a better eye on [the resident] because the resident tried to get up on [his/her] own and walk and doesn't understand that [he/she] can't do that. The RN/UM further stated the resident could be supervised if they had the extra staff but that the intention of putting the resident in front of the nurse's station was to be supervised, however staff could not be at the nurse's station all the time because the nurses had to answer other residents call bells and had other duties and other residents to care for. The RN/UM stated that if a resident fell over the weekend, then interventions would not be updated on the CP until Monday. She stated that if a resident fell over the weekend, the nurses working over the weekend could put an intervention in place, however, it wasn't until Monday that the IDT would meet to discuss interventions for the resident and then the CP would be updated after the IDT discussed the event. The surveyor asked the RN/UM, When the resident fell two times on 1/14/23, were there interventions put in place immediately to prevent further falls? The RN/UM responded, No, the interventions were not updated until the 17th because the fall occurred on the 14th which was a weekend. The surveyor asked the RN/UM what interventions should have been put in place or would have been appropriate to prevent the resident from falling and getting injured again and the RN/UM replied that the staff gave the resident crayons and paper and sat next to him/her for over two hours. The RN/UM then added that the definition of supervision was when someone was sitting near the resident and being able to see them with their eyes. The RN/UM stated that the nurses and CNA could not always supervise the resident because they had other duties. The RN/UM revealed that from the moment the resident was admitted to the facility he/she was a fall risk and that was why his/her RP brought the resident to the facility. The RN/UM stated that she had suggested one to one supervision at the IDT meeting and was told by the team that they didn't have the staff to provide one on one supervision to the resident. She further stated that a 'one on one' meant that someone would be assigned to always supervise the resident. She also revealed that the social worker was trying to call a memory unit to see if a memory unit would be better suited for the resident. On 01/26/23 at 12:01 PM, the survey team interviewed the DON who stated that after any resident fell , the resident was assessed by the nurse to rule out any injury and the nurse would obtain vital signs. She stated that if it was determined that the resident had no injury, the staff would get the resident off the floor, collect statements from staff, complete the RMS, call MD and then call the family/RP. The DON further explained that interventions to prevent further falls and injury should be put in place at the time of the fall. She stated that she would expect that the staff would put an intervention to prevent further falls immediately after the fall to prevent the resident from falling again. The DON stated that the nurses all have access to the CPs and should have updated the care plan immediately to reflect new fall prevention interventions. The DON further stated that if a fall was unwitnessed or the resident had a head injury then neuro-checks should have been initiated. The DON told the surveyor that if the resident sustained a head injury as a result from a fall, and the resident could not be managed in the facility, then the resident would be sent to the hospital. The DON stated that after Resident #193 returned from the hospital on 01/14/23 and 01/16/23 and had suffered a head injury, neuro-checks should have been completed. The DON could not recall how long neuro-checks had to be done and had to refer to the facility policy. The DON confirmed that neuro-checks should have been completed for 72 hours after the resident fell and suffered a head injury on two falls that occurred on 01/14/23 and one fall that occurred 01/16/23, however the neuro-checks were not done. The DON added that the term supervision was attempting to watch a resident to the best of their ability. She added that supervision meant putting a resident in a common area. She further added that it was the facility's responsibility to put appropriate fall prevention interventions immediately in place to prevent further falls and injury. On 02/01/23 at 11:47 AM, the surveyor interviewed the DON in the presence of the survey team who stated that if the staff turned their back for 30 seconds, the resident would stand and still have a fall. The DON further stated that the resident would be appropriate for a facility with a specialized dementia unit and the facility was currently working on facilitating that for the resident. On 02/01/23 at 12:08 PM, the surveyor interviewed the facility's Administrator in the presence of the survey team who stated that the resident needed to be one-to-one supervision to prevent them from falling. The Administrator further stated that supervision meant that staff had to be present and observing the resident. The facility policy dated 10/24/22 and titled, Accidents and Incidents indicated that any resident fall resulting in a head injury, suspected head injury or an unwitnessed fall will be observed for neurological abnormalities by performing neuro-checks according to the Neurological Evaluation Policy and procedure after the accident occurs. Interventions to eliminate if possible and if not, reduce the risk of accident and incident have been identified and implemented. The facility policy dated 06/01/21 and titled, Neurological Evaluation indicated that neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluations will be performed: -Every 15 min times 2 hours then -Every 30 minutes times 2 hours then -Every 60 minutes times 4 hours then -Every 8 hours until 72 hours has lapsed. The purpose of neurological assessments was to monitor for neurological compromise. The facility policy dated 10/24/22 and titled, Person Centered Care Plan that the purpose was to attain the patient's highest practical physical, mental, and psychological wellbeing. NJAC 8:39-27.1(a)

43308 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain professional standards of nursing practice: a.) for not following a Physician's Order (PO) for the documentation of urine output on the Treatment Administration Record (TAR), b.) for not consistently documenting weekly skin assessments as ordered by the physician, and c.) for not signing the Controlled Medication Utilization Record (a narcotic declining inventory sheet that keeps a record of the amount of medication available) after the removal of the narcotic from inventory. This deficient practice was identified for two (2) of 26 residents, (Resident #7 & Resident #57) reviewed for following physician orders related to professional stands of nursing practice and for one (1) of four (4) medication carts, (300- unit back hall medication cart) during narcotic reconciliation related to medication storage. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: 1.) On 01/20/23 at 10:26 AM, the surveyor observed Resident #57 lying in bed watching the television. The resident stated that he/she was waiting to go to therapy. At that time, the surveyor observed an indwelling urinary catheter drainage bag (a bag that collects urine from your bladder) hanging on the side of the bed as well as a nephrostomy (a catheter that is inserted through your skin and into your kidney; the tube helps to drain urine from your body) bag next to the resident. Resident #57 stated that the staff emptied the urinary catheter bag as well as the nephrostomy catheter bag every shift. Resident #57 further stated that he/she had a Urinary Tract Infection (UTI) about a month ago, but that he/she was doing better. The surveyor reviewed the electronic medical record (EMR) for Resident #23. A review of the resident's Admission Record reflected that the resident was admitted to the facility January of 2022, with diagnoses which included, but were not limited to UTI, complications of nephrostomy catheter, hydronephrosis with renal and ureteral calculous obstruction (kidney swelling and blockage), benign prostatic hyperplasia (the flow of urine is blocked due to the enlargement of prostate gland). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the managemnt of care dated 11/09/22, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated an intact cognition. A further review of the resident's MDS, Section H - Bladder and Bowel reflected that the resident had an indwelling catheter. A review of the resident's individualized Care Plan revised 01/11/23, reflected that Resident #57 was at risk for infections related to history of UTI and required an indwelling catheter due to obstructive uropathy (blockage of urine flow). The interventions included to monitor urine for sediment, cloudiness, odor, blood, and amount. A review of the January Order Summary Report revealed that Resident #57 had active orders for the following: - Start date: 05/11/22 and discontinued 11/22/22: Record amount right nephrostomy tube every shift for percentage. - Start date 11/22/22: Record amount of drainage from right nephrostomy tube three times a day for percentage. - Start date 03/10/22: Empty catheter drainage bag at least once every eight hours to when it becomes half to two-thirds full every eight hours. - Start date 03/10/22: Empty catheter drainage bag at least every eight hours to when it becomes half to two-thirds full as needed. A review of the October 2022 TAR revealed there was no documentation for the following: - The percentage and the documentation of a chart code (completed or hospitalized ) for the PO, Record amount right nephrostomy tube were left blank on the following dates and times: * The day shift (7:00 AM to 3:00 PM) on 10/01/22, 10/02/22, 10/03/22, 10/13/22, and 10/28/22. * The evening shift (3:00 PM to 11:00 PM) on 10/11/22, 10/12/22, 10/13/22, 10/14/22, and 10/26/22. * The night shift (11:00 PM to 7:00 AM) on 10/02/22 and 10/14/22. - A chart code for the PO: Empty catheter drainage bag at least once every eight hours to when it becomes half to two-thirds full was left blank on the following dates and times: * 0600 (6:00 AM) on 10/03/22, 10/15/22, and 10/21/22. *1400 (2:00 PM) on 10/01/22, 10/02/22, 10/03/22, 10/13/22, and 10/28/22. *2200 (10:00 PM) on 10/11/22, 10/12/22, 10/13/22, 10/14/22, and 10/26/22. A review of the November 2022 TAR revealed there was no documentation for the following: - The percentage and the documentation of a chart code for the PO, Record amount right nephrostomy tube were left blank on the following dates and shifts: * The day shift on 11/01/22, 11/02/22, 11/04/22, 11/09/22, and 11/17/22. * The evening shift on 11/15/22 and 11/18/22. *The night shift on 11/02/22, 11/10/22, 11/11/22, and 11/21/22. - The milliliters (mls) and the documentation of a chart code for the PO, Record drainage amount from right nephrostomy tube were left blank on the following dates and times: *0600 on 11/24/22 and 11/25/22. *2200 on 11/22/22 - A chart code for the PO: Empty catheter drainage bag at least once every eight hours to when it becomes half to two-thirds full was left blank of the following dates and times: * 0600 on 11/03/22, 11/11/22, 11/12/22, 11/13/22, 11/24/22, and 11/25/22. *1400 on 11/01/22, 11/02/22, 11/04/22, 11/09/22, and 11/17/22. *2200 on 11/15/22, 11/17/22, 11/18/22 and 11/22/22. A review of the December 2022 TAR revealed there was no documentation for the following: - The milliliters (mls) and the documentation of a chart code (completed or hospitalized ) for the PO Record drainage amount from right nephrostomy tube were left blank on the following dates and times: *0600 on 12/16/22 and 12/19/22. *1400 on 12/08/22, 12/09/22, 12/10/22 12/20,22, 12/24/22, and 12/29/22. *2200 on 12/15/22, 12/16/22, 12/23/22 and 12/30/22. - A chart code for the PO: Empty catheter drainage bag at least once every eight hours to when it becomes half to two-thirds full was left blank of the following dates and times: * 0600 on 12/16/22 and12/19/22. *1400 on 12/09/22, 12/10/22, 12/24/22, and 12/29/22. *2200 on 12/15/22, 12/16/22, 12/23/22 and 12/30/22. A review of the January 2023 TAR revealed there was no documentation for the following: - The milliliters (mls) and the documentation of a chart code (completed or hospitalized ) for the PO, Record drainage amount from right nephrostomy tube were left blank on the following dates and times: *0600 on 01/02/23, 01/12/23, 01/14/23 and 01/21/23. *1400 on 01/02/23, 01/06/23, 01/08/23, 01/11/23, 01/12/23, 01/17/23, 01/18/23 and 01/22/23. *2200 on 01/03/23 and 01/19/23. - A chart code for the PO: Empty catheter drainage bag at least once every eight hours to when it becomes half to two-thirds full was left blank of the following dates and times: *0600 on 01/02/23, 01/12/23, 01/14/23, and 01/21/23. *1400 on 01/08/23, 01/11/23, 01/12/23, 01/13/23, 01/17/23, 01/18/23, and 01/22/23. *2200 on 01/03/23 and 01/19/23. A review of the Progress Notes from October 1, 2022 through January 22, 2023 revealed that there was no documentation to indicate the reason the urine output was left blank. On 01/26/23 at 10:54 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that the Certified Nursing Assistant (CNA) emptied the urine catheter bags. He further stated that the nurses documented the amount and if it was emptied in the EMR. LPN #1 concluded he was not sure if Resident #57 had a history of UTIs. On 01/27/23 at 09:51 AM, the surveyor interviewed CNA #1 who stated that both the CNAs and the nurses were responsible for emptying the urinary drainage bags. She stated that if the CNA emptied the urinary bag, then they would inform the nurse of the amount to be documented in the EMR. On 01/27/23 at 10:52 AM, the surveyor interviewed LPN #2 who stated that the nurses were responsible for documenting the urine output in the EMR if there was a PO for it. On 01/27/23 at 10:58 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that Resident #57 had an indwelling urinary catheter and a nephrostomy tube. The RN/UM stated she was not aware if the resident had a UTI recently because she was still learning all the residents. The RN/UM stated that the CNAs emptied both urinary bags and reported the amount back to the nurses to document in the EMR. At that time, the surveyor and the RN/UM reviewed the electronic TAR which revealed the blanks for the POs. The RN/UM stated that she believed it was a missed communication as the CNAs may have forgotten to inform the nurse or the nurses forgot to input the amount. The RN/UM acknowledged it was important to follow the POs and that there should be documentation corresponding to the blanks. On 01/27/23 at 11:01 AM the surveyor interview LPN #1 again who stated he cared for Resident #57 and that the CNAs informed him of the urine output from both the indwelling urinary catheter bag and the nephrostomy bag. LPN #1 stated that it was important to document the urine output and to know the amount because it assured the kidneys were functioning properly, there was no blockage and no infections. On 01/27/23 at 11:03 AM, the surveyor interviewed CNA #2 who stated she was responsible for emptying both the indwelling urinary catheter and the nephrostomy bag. She further stated that she reported the urine amount to the nurses and the nurses documented in the EMR. CNA #2 stated that it was important to keep track of the urine output because it ensured everything is flowing, and the kidneys are working properly. She further stated that the amount was reported per shift. CNA #2 stated that Resident #57 had a history of a UTI and that was the reason for the urinary catheters. On 02/01/23 at 11:18 AM, the DON in the presence of the Administrator, Consultant Pharmacist and the survey team stated that there was no facility policy to record the urine output for the nephrostomy. The DON stated the nurses are putting in the order as extra when they document the urine output. She then stated it was important to ensure the resident had urine output but that it was not a true I&O [intake and output] if staff was only documenting the output and not the intake. The DON stated that Resident #57 was hospitalized from 10/11/22 to 10/15/22 with a diagnosis of UTI. The DON acknowledged that there should not be blanks on the TAR. On 02/02/23 at 09:22 AM, the DON stated that staff were required to follow the physician's order. She further stated that the importance of documentation was for the continuity and quality of care for the resident. A review of the facility's policy, Catheter: Indwelling Urinary - Care of, revised 02/01/23, included 15. Empty the catheter drainage bag when it becomes 1/2 to 2/3 full 15.2 record output, if ordered 22. Document: 22.2 Amount of urine output if ordered. 2.) The Admission Record indicated that Resident #7 was admitted to the facility with the diagnoses which included but were not limited to pressure ulcer of the sacral region, unspecified stage, and multiple fractures of the pelvis. The admission MDS dated [DATE], indicated that the resident was cognitively intact and required extensive assistance with activities of daily living. The MDS also reflected that the resident had a stage 1 or greater pressure area over a bony prominence and was at risk for developing pressure ulcers. On 01/20/23 at 11:35 AM, the surveyor observed Resident #7 in the room sitting up in the wheelchair. The resident was well dressed and reading a newspaper. The surveyor interviewed the resident at that time who stated that he/she had swelling in the lower legs. The surveyor observed that the resident had plus three pitting edema (Pitting edema occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain) in both lower extremities. He/she pulled up his/her pant legs to show the surveyor. The resident stated that he/she didn't know if the doctor knew about the edema. Resident #7 also explained that he/she was receiving good care and that the facility was treating his/her wounds. The resident further stated that his/her wounds were not getting worse, they were healing, and that the facility were performing treatments. The surveyor reviewed Resident #7's clinical records which revealed that last skin check assessment that was documented in the assessment section of the EMR was recorded as being done on 12/07/23. The surveyor reviewed the January 2023 TAR which reflected the following physician's order dated 11/23/2022: -Skin checks on the 3:00 PM - 11:00 PM shift weekly every Wednesday for skin inspections document findings in PCC (the electronic medical record). The surveyor observed that there was a nurse's signature on the TAR every Wednesday on the 3:00 PM - 11:00 PM shift that indicated that skin checks were completed however, the skin check assessment form that the findings were documented on, were not completed since 12/07/22. On 01/23/23 at 12:51 PM, the surveyor interviewed the Registered Nurse (RN) who had been employed in the facility for [AGE] years and was caring for Resident #7, who explained to the surveyor that skin assessments were completed once a week and that there was a PO on the TAR. She stated that after the nurse completed the skin assessment the finding was documented on a form in the EMR called skin assessments. She added that if a nurse or Certified Nursing Assistant (CNA) discovered a new finding regarding the resident's skin, it should be documented as soon as it was found no matter what day it was. She continued to explain that the nurse would document any new findings such as pressure, skin tears, or bruising on the skin check form. She stated that edema (swelling) should be part of the resident's everyday assessment. She stated that the nurse or CNA should report edema and the physician should be notified so that they could be started on medication. The RN reviewed the TAR with the surveyor and confirmed that the nurse on the 3:00 PM -11:00 PM shift signed the TAR indicating that the skin assessment was done. The RN also confirmed that the weekly skin assessment was documented as being completed on the TAR however, the findings of the skin assessment had not been documented on the Skin Check assessment since 12/07/22. The RN also confirmed that the physician was made aware of the resident's lower extremity edema and that the resident was started on medication to manage the edema. On 01/23/23 at 01:09 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she was unsure why the nurses documented that they were performing the skin checks on the TAR but were not filling out the skin check assessments in the EMR. She explained that it would be important to document the finding on the skin check sheet to indicate if there were any changes in the resident's skin or if the skin remained the same or improved. She stated that the nurse signing off the skin assessments on the TAR should also be documenting the information about the resident's skin assessment on the skin check assessment in the EMR. The RN/UM confirmed that there were no skin checks assessments findings documented since 12/07/22. On 01/24/23 at 11:29 AM, the surveyor interviewed the facilities Registered Dietician who stated that he reviewed the skin check assessment sheets as part of the nutritional assessment to assess the proteins needs and nutritional needs for a resident that has skin breakdown. He further stated that the skin check sheets were an important factor during his nutritional assessments so that he would know if there were any changes in a resident's skin condition and if there was a change, he could adjust the nutritional needs of the resident to better aid in wound healing. On 01/24/23 at 11:43 AM, the surveyor interviewed the LPN #3 who stated that she was the facilities wound care nurse. LPN #3 explained that as a wound care nurse she always utilized the skin check assessment sheet in the assessment section of the computer to see if it matched her findings. She stated that when the wound check sheet was completed on admission, she checked the sheet the next day to make sure the documentation was accurate and reflected her assessment of the resident's skin. LPN #3 added that the weekly skin check assessments were completed by the nurses on the units and that it would be important that they were completed so the wound nurse could assure that adequate treatments were appropriate for the type of wound, and interventions were put in place to aid in healing. She stated that the nurse performing the skin check was responsible to sign the TAR that they completed the skin check but were also responsible to fill out their findings on the skin check form. On 01/24/23 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the skin check sheet in the assessment section of the EMR would show changes in the resident's skin condition and confirmed that the nurse should have completed the weekly skin assessment. The DON reviewed Resident #7's EMR and confirmed that there were no skin checks assessments findings documented for Resident #7 since 12/07/22. The surveyor reviewed the facilities policy dated 09/01/22 and titled, Skin Integrity and Wound Management indicated that the facility was to perform and document skin inspections on all admitted and readmitted residents and weekly thereafter and with any significant change on condition. The policy also indicated that the facility completed the wound evaluation upon admitted /readmission, new in-house acquired, weekly and with unanticipated decline in wounds. 43307 3.) On 01/23/23 at 12:03 PM, on the 300 unit, the surveyor inspected the back hall medication cart locked narcotic box with LPN #4 and observed that three Controlled Medication Utilization Records (CMURs) were not accurate. Resident #134's CMUR for Oxycodone (a pain reliever) revealed that there was documented a quantity of five pills and that the blister pack (a cardboard casing that stores the medication for dispensing) revealed a quantity of four pills. Resident #124's CMUR for Tramadol (a pain reliever) revealed that there was documented a quantity of 22 pills and that the blister pack revealed a quantity of 21 pills. Resident #58's CMUR for Percocet (a pain reliever) revealed that there was documented a quantity of 27 pills and that the blister pack revealed a quantity of 26 pills. LPN #4 stated that she had previously administered all of the medications and then proceeded to sign out the medications on each resident's CMUR in front of the surveyor. LPN #4 acknowledged that the medications should have been signed out at the time they were administered and stated that it was important that the resident's medications were monitored and that an accurate narcotic count was maintained. On 01/23/23 at 12:16 PM, the surveyor interviewed the Unit Manager (UM) for the 300 unit who stated that narcotics were signed out when they were removed from the narcotic drawer in the med cart prior to patient administration. The UM was informed LPN #4 acknowledged that she administered narcotics to three residents and did not sign the CMUR at the time of administration and that LPN #4 signed the CMURs in front of the surveyor. The UM confirmed from the electronic medical record documentation that each resident received the pain medication and stated that LPN #4 should have signed out the narcotics when she popped them out of the blister pack for resident administration and that she should have signed the narcotic book before she went to each resident's room. The UM further stated that it was important to document correctly for an accurate narcotic count and to confirm when a resident received the narcotic medication. On 01/23/23 at 1:15 PM, the surveyor interviewed the DON who stated that when a narcotic was administered that the nurse should have signed it out when the medication was popped out of the blister pack. The DON stated, You pop it in the container and sign in the narcotic book, do a triple check of the resident, then sign it out in the medication administration record. The DON further stated that it was important to document correctly for consistency and control and to make sure that the medication was given to the correct patient and at the correct time. On 01/24/23 at 12:39 PM, during an interview with the surveyors the Consulting Pharmacist stated it was best practice that narcotics were signed out immediately and that reconciliation was used as a backup. Review of the facility's policy, Omnicare, LTC Facility Pharmacy Services and Procedures Manual, Policy #/Title: 6.0 General Dose Preparation and Medication Administration, revised 01/01/22, revealed Procedure, 5.5 Document the administration of controlled substances in accordance with the Applicable Law. 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given .on appropriate forms. NJAC 8:39-27.1(a);29.2(a)

Based on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to consistently document blood sugars and administer diabetic medications in accordance with the physician order. This deficient practice was identified for one (1) of two (2) residents, (Resident #10) reviewed for diabetic medication administration and was evidenced by the following: On 01/20/23 at 10:10 AM, the surveyor observed Resident #10 standing up looking out their room's window. Resident #10 stated he/she was feeling fine. The surveyor reviewed the electronic medical record (EMR) for Resident #10. A review of the resident's Admission Record reflected that the resident was admitted to the facility August of 2022, with diagnoses which included: type two diabetes mellitus (DM) (high blood sugar), Alzheimer's disease, and chronic kidney disease. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/10/22, reflected a Brief Interview for Mental Status (BIMS) score of 08 out of 15, which indicated the resident had moderately impaired cognition. A further review of the resident's MDS, Section N - Medications revealed that the resident received insulin injections (a medication that helps sugar enter the body's cells). A review of the individualized Care Plan (CP) revised 09/01/22, reflected that Resident #10 had a diagnosis of DM with insulin dependence. A further review of the CP revealed the intervention included administer hypoglycemic medications as ordered. A review of the January Order Summary Report revealed that Resident #10 had active physician orders for the following: - Start date 08/24/23: Lantus (long-acting insulin )100 unit per milliliter (ml). Inject 12 units subcutaneously (under the skin) two (2) times a day for DM. - Start date 08/23/22: Humalog (fast-acting insulins)100 unit/ml. Inject four (4) units subcutaneously with meals for DM. Call the physician for less than (<) 70 or greater than (>) 400. - Start date 08/04/22: Humalog 200 unit/ml. Inject four (4) units subcutaneously at bedtime for DM. - Start date 08/05/22: Nateglinide (control high blood sugar) 120 milligrams (mg) tablet. Give one (1) tablet by mouth before meals for DM. A review of the Medication Administration Record (MAR) from November 2022 to January 2023 revealed the following: - On 11/09/22 at 11:30 AM, the Blood Sugar (BS) and the documentation of a chart code (administered or held) for Humalog four (4) units with meals were left blank. - On 11/13/22 and 11/14/22 at 6:30 AM, the documentation of a chart code for Nateglinide 120 mg before meals were left blank. - On 01/11/23, 01/12/23, at 01/13/23 for 11:30 AM the BS and the documentation of a chart code for Humalog four (4) units with meals were left blank. - On 01/13/23 at 7:30 AM, the BS and the documentation of a chart code for Humalog four (4) units with meals were left blank. - On 01/11/23, 01/12/23, and 01/13/23 at 11:30 AM, the documentation of a chart code for Natelinide 120mg before meals were left blank. - On 01/14/23 at 6:30 AM, the documentation of a chart code for Natelinide 120mg before meals was left blank. - On 01/19/23 at 2000 (8:00 PM), the documentation for a chart code for Lantus 12 units two (2) times a day was left blank. - On 01/19/23 at 2100 (9:00 PM), the documentation of a chart code for Humalog four (4) units at bedtime was left blank. A review of the resident's Progress Notes from November 1, 2022 through January 22, 2023 revealed that there was no supporting documentation to indicate the reason why the medications and blood sugars were blank on the MARs. On 01/25/23 at 10:47 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) for the 200 Unit who stated the nurses were responsible for checking the resident's BS. She further stated that depending on the results they would administer the insulin. The RN/UM stated the importance of checking the BS was to ensure that the resident was not hypoglycemic (low BS) or hyperglycemic (high BS). She further stated that the nurses should document in the EMR the BS as well as document if they administered or held the diabetic medications. The RN/UM stated that if there were blanks on the MAR, the staff would not know if the resident received the medication. On 01/25/23 at 10:57 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that the expectation was to check the BS and if it was in the appropriate range, then they would administer the insulin. LPN #1 stated that the nurses were responsible for checking the BS and documenting the number in the EMR. He then stated that the MAR should never be left blank because that was how the staff knew if it was done. On 01/25/23 at 11:09 AM, the surveyor interviewed LPN #2 who stated that the nurses were responsible for checking the resident's BS prior to the administration of insulin. She stated it was important to know the BS, because depending on the number they would either administer the medication or hold it. LPN #2 further stated if there was a space on the MAR to document the BS then it should be documented. She explained that the nurses should also document the location of the insulin injection or if the medication was not administered. LPN #2 stated that if there were blanks on the MAR that was an indication that the medication was not administered, or the BS was not taken by the nurse. On 01/25/23 at 11:37 AM, the surveyor interviewed the Director of Nursing (DON) who stated that checking the BS and administering medications were resident specific. The DON stated that the nurses should check the BS and administer the medication according to the physician's order. The DON stated that if there were blanks on the MAR then that indicated the resident wasn't in the building, the nurse forgot to sign it, or it was not done. The DON acknowledged that it was important to document so that everyone knew what was done. On 02/01/23 at 11:13 AM, the DON acknowledged in the presence of the Administrator, the consultant pharmacist and survey team that there should not be blanks on the MAR. The DON stated she spoke with the nurses involved, who stated they checked the BS and administered the medication to Resident #10 but, may have forgotten to sign the MAR. On 02/02/23 at 09:22 AM, the DON stated that staff were required to follow the physician's order. She further stated that the importance of documentation was for the continuity and quality of care for the resident. A review of the facility's policy, General Dose Preparation and Medication Administration, revised 01/01/22, revealed 6. After medication administration, facility should take all measures required by facility policy 6.1 document necessary medication administration/treatment information (e.g., . when medications are given, injection site of a medication, if medications are refused, PRN medications, applications sight) on appropriate forms. NJAC 8:39-27.1(a)

PART A Based on observation, interview and record review, it was determined that the facility Dietary Staff, who were ServSafe certified (an accredited certifying program for food service) failed to demonstrate knowledge of the proper procedure for cooling of cooked meats (4 of 4 roast beefs). On [DATE], the facility failed to follow proper procedures for cooling of cooked roast beef, a Potentially Hazardous Food (PHF), to within a safe temperature zone and time frame consistent with preventing a foodborne illness. These roast beefs were intended to be served on [DATE] during the lunch meal as a cold sandwich and were not intended to be re-heated prior to serving. This deficient practice was likely to affect all residents in the facility who were prescribed a diet to be eaten by mouth and prepared in the facility's kitchen. This deficient practice resulted in an immediate jeopardy situation for substandard food preparation and improper cooling of roast beef, which was identified on [DATE] at 12:35 PM and corrected on [DATE] at 3:25 PM after the facility submitted and implemented an acceptable plan of correction. This deficient practice was evidenced by the following sequence of events: On [DATE] at 11:43 AM the surveyor accompanied by the Food Service Director(FSD) observed a deep plastic container containing 4 whole and intact cooked roast beefs in their own juice on a shelf in the walk-in refrigerator. The surveyor observed the walk-in refrigerator temperature to be 42 degrees Fahrenheit at that time. The container was labeled with a date of [DATE] and was covered with plastic wrap and a hard plastic lid over top of the plastic wrap. The surveyor observed that the roasts were not dated. When questioned about the lack of a use-by date, the FSD stated the roasts were cooked this morning and they are going to be used for the lunch meal on Thursday. My cook should have labeled them with a use-by date. The surveyor then questioned the FSD as to when they had been placed in the refrigerator and the FSD stated around 8:30 AM. When interviewed by the surveyor on [DATE] at 12:35 PM, the Executive Chef who had cooked and prepared the roast beef that morning was unable to verbalize to the surveyor the policy/process utilized by the facility to cool cooked meats properly. The surveyor then requested the FSD to accompany the surveyor back to the walk-in refrigerator and take the temperatures of the 4 roast beefs in the plastic container. The FSD proceeded to take the temperature of the 4 roast beefs with the facility's digital thermometer. The thermometer registered Roast #1 = 95 degrees, Roast #2 = 84 degrees, Roast #3 = 84 degrees, and Roast #4 = 83 degrees Fahrenheit, respectively. Upon completion of the temperatures, the FSD stated these have been in the danger zone too long, I'm going to throw them away immediately. During further interview on [DATE] at 12:58 PM the surveyor requested a copy of the cooling temperature log sheet for the roast beef cooked that morning and the facility policy and procedure for the proper cooling of foods. The FSD provided the surveyor with a copy of GHC Cooling Chart. Upon review the surveyor observed that the GHC Cooling Chart noted that at 8 AM on [DATE], the temperature of the roast beef was 152 degrees. The temperature for the 1st Hr (hour) on the cooling chart noted the roast beef at 141 degrees. The subsequent columns for 2nd Hr, 4th Hr and 6th Hr had been marked out with white out and blank. When questioned about the white out, the FSD stated to the surveyor, I did not alter this in any way, it was already whited out when I looked at it earlier when you were here. When the surveyor asked the FSD who had altered the cooling chart, the FSD stated I don't know. During further interview at 12:58 PM the FSD stated that the policy at the top of the GHC Cooling Chart was their current policy that we utilize but my district manager is looking for a possible updated policy. The surveyor then asked the FSD, was this the policy in effect at the time the roast beef was cooked and cooled this morning? The FSD stated yes. The FSD then escorted the surveyor to a trash can located outside of the walk-in refrigerator and opened the lid to show that the 4 roast beefs had been thrown away. The surveyor requested and reviewed the policy and procedure for cooling and any in-services that may have covered proper cooling procedures. The policy and procedure for cooling, located on the top of the GHC Cooling Chart noted, Start recording temperature once the food reaches 135 F. Cool from 135 F to 70 F in 2 hours, then 70 F to 41 F or below for the remaining 4 hours. If product does not achieve cooling from 135 F to 70 F in 2 hours, it must be thrown out or reheated and then cooled again. The policy further noted, Tips for rapid cooling: Reduce size of food by removing from original cooking container, place in shallow containers, use ice bath or ice paddle. Do not seal during cooling process, to allow hot air to escape. On [DATE] at 2:28 PM the surveyors notified the facility's Licensed Nursing Home Administrator of the Immediate Jeopardy situation. On [DATE] at 3:10 PM, during further interview in the FSD office, the FSD provided the surveyor with a copy of the weekly menu for ,[DATE]-,[DATE] as requested. The menu noted that on Thursday [DATE] the lunch meal consisted of Roast Beef and Provolone on a roll with a lettuce and tomato garnish and mayonnaise. When the surveyor asked if the sandwich was to be served cold, the FSD stated yes. During further interview in regards to who had altered the cooling chart, the FSD stated it was the Executive Chef and he admitted it to the Administrator. The surveyor requested and received from the FSD copies of all ServSafe certified kitchen staff and inservices that would pertain to cooling of foods for the Executive Chef. Review of documents on [DATE] at 3:15 PM revealed that the Executive Chef received and provided a signature for an inservice titled Time and Temperature Control and Recording completed on [DATE]. During review of the inservice the surveyor observed that cooling was included as part of the signed inservice. The surveyor also observed that the Executive Chef was currently ServSafe certified, an accredited certifying program for food service, until [DATE], indicating that he was a certified food protection manager. On [DATE] at 3:25 PM a Plan of Correction (P[NAME]) was submitted by the facility and was accepted. The P[NAME] included the following: 1. Corrective action: All four roasts were immediately thrown away. 2. Identification of other residents or areas having the potential to be affected: All cooked foods and all residents that eat have the potential to be affected by not maintaining safe food temperatures and food storage procedures. 3. Measures put into place to prevent the recurrence: All dietary staff and cooks present were immediately in serviced on proper food temperatures and food storage procedures. Additionally all food service staff will be in-serviced on proper food temperature safety and procedures as they report to duty. In-service included cool down procedures as follows-Start recording temperature once the food reaches 135 F. Cool from 135 F to 70 F in 2 hours, then 70 F to 41 F or below for the remaining 4 hours. If product does not achieve cooling from 135 to 70 F in 2 hours, it must be thrown out or reheated and then cooled again. The Food Service Director or supervisor in charge in the kitchen will monitor when food comes out of the oven and cool down process and timely refrigeration process. The temperature log will be reviewed on a weekly basis by the Administrator & Food Service Director for trending and compliance. 4. Monitoring of corrective action: The Administrator and Food Service Director will review food temperature logs weekly and audit for trending and compliance. The findings will be submitted to the Quality Improvement committee monthly until the committee agrees the problem is corrected. 5. This Plan of correction is in effect immediately on [DATE] at 3:25 PM. The immediate Jeopardy that began on [DATE] at 2:28 PM was removed on [DATE] at 3:25 PM when the facility submitted the acceptable P[NAME]. PART B F812 s/s F The noncompliance continued at a level F as evidenced by the following: Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner. This deficient practice was evidenced by the following: On [DATE] from 8:25 AM to 9:25 AM the surveyor observed the following in the kitchen in the presence of the Food Service Director (FSD): 1. The Juice Refrigerator contained 6 trays of thickened and regular consistency beverages, none of which were dated. When interviewed at that time, the FSD stated they should have been dated. 2. In the cook's prep area, a plastic container containing clean utensils was left open, exposing the clean utensils to contamination. A spice rack located on the wall of the cook's prep area contained 19 plastic containers of various spices which did not have open dates. Located on a shelf below the cook's prep area, a bottle of Yellow Egg Shade Food Color was opened and dated [DATE]. When interviewed, the FSD stated that should be thrown away. On the same shelf, a bottle of opened Almond Extract had a date of ,[DATE]. The FSD could not identify in what year the bottle was opened. A can of Old Bay Seasoning was open and not covered, exposing the contents to the air. The FSD stated, that's trash. 3. There were three food scales located on a shelf in the cook's prep area that were determined to be clean by the FSD. Of the three, one scale was wrapped in plastic and two scales were not protected with plastic wrap. The FSD stated they should all be covered in plastic. 4. In the Cook's Refrigerator, a 1 gallon container of Creamy Caesar Dressing and a 4 pound container of grape jelly were open and had no open date. A clear plastic container of Ranch Dressing had a use-by date of [DATE], which was expired. 5. In the walk-in Refrigerator there was an opened container of cottage cheese and an opened container of Yoplait Vanilla Yogurt with no open dates. A bag of parsley in a plastic container had no received or use-by date. 6. There were two pans of deli sliced roast beef on the top shelf in the walk-in Refrigerator that were stacked on top of each other. The FSD stated they shouldn't be stacked like that. A metal tray of defrosting ground beef was covered with another metal pan, leaving the ground beef exposed to the air. The FSD stated they should have covered it with plastic wrap. A container of Thickened Dairy Milk was opened and did not have an open date. 7. In the walk-in Freezer, the surveyor observed trash on the floor beneath the shelves. A stack of 5 frozen pie crusts, located on an upper shelf, were not dated. On the same shelf, a bag of frozen bagels was undated and open to the air. The bagels were covered with ice crystals on visual inspection. 8. In the Dry Storage room, a personal container of opened Lipton Iced Tea was on a shelf. The FSD stated that shouldn't be in here. An open box of Styrofoam plates was exposed to the air. The FSD stated that should be closed. On [DATE] from 11:43 AM to 12:35 PM the surveyor observed the following in the kitchen in the presence of the FSD: 9. In the walk-in Refrigerator, a plastic container located on the shelf contained an opened deli turkey that had an expiration date of [DATE]. The FSD stated, that should be thrown away. Located on the back shelf, a plastic container covered with plastic wrap and a plastic lid contained 4 cooked roast beefs. The plastic wrap was dated ,[DATE]. The roast beefs did not contain a use-by date and further investigation revealed the roast beefs had been improperly cooled per facility policy and procedure. (noted above) The surveyor reviewed the facility's Food Handling policy which noted: 2. After opening .all items need an opened date and an expiration date. 3. All prepped items need 'today's date,' expiration date and the meal they were prepped for. 4. Poured beverages are to be individually dated w/ (with) labeling gun. NJAC 8:,[DATE].2(g)