Every finding on record at Morristown Post Acute Rehab and Nursing Center

Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to ensure implementation of interventions designed by the physical therapist to stimulate functional performance and prevent further decline. This deficient practice was identified for one (1) of three (3) resident reviewed for positioning and mobility (Resident #88) and was evidenced by the following: On 6/19/25 at 11:31 AM, during the initial tour of the second floor, the surveyor entered Resident #88's room. The resident was awake, alert, pleasant and had a breakfast tray in front of them with built up utensils (an adaptive eating utensils designed with molded plastic handles to assist individuals with limited or weakened grasping strength). No additional assistive device was observed on the resident. The surveyor reviewed the medical record for Resident #88. According to the admission Record, an admission summary, reflected that Resident #88 reflected diagnoses that included Parkinson's Disease (PD; a movement disorder of the nervous system that worsens over time) and plantar fascial fibromatosis (a noncancerous growth on the rubber band-like ligament that stretched from the heel to the toes). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/14/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had a moderately impaired cognition. A review of the resident's functional abilities reflected the resident was dependent for activities of daily living related to oral hygiene, toileting, shower/bathing, dressing, movement of sitting to lying, and surface transfer. Section I - Active diagnoses, included plantar fascial fibromatosis. A review of the Order Summary Report for that were active as of 6/25/25 included a physician's order for: Bilateral lower extremity multi podus (MPB; a boot that floats the heel, used for heel pressure relief and prevention of contracture) donned after AM care, and doffed to patient tolerance before PM care. The order was initiated on 6/7/23. A review of the individualized comprehensive care plan (ICCP) reflected a focus on the resident's contracture, bilateral multi podus and the resident's noncompliance, initiated on 5/5/23 and revised on 6/11/25. The interventions included to donn after AM care, and doff after pm care, initiated on 5/5/23, and did not reflect additional intervention to coincide with the revised focus on 6/11/25. A review of the electronic Medication Administration Record (eMAR), electronic Treatment Record where nurses documented offer and refusal or medication and treatments for April 2025, May 2025 and June 2025 did not reflect that the MPB were offered or declined. A review of the task list where the Certified Nursing Assistants (CNAs) documented care provided to the residents for April 2025, May 2025 and June 2025 did not reflect MPB as part of the tasks. On 6/23/25 at 8:51 AM, the surveyor passed by Resident #88's room and an assistive device was not observed worn by the resident. On 6/26/25 at 11:27 AM, in the presence of the surveyor and the Registered Nurse/Unit Manager (RN/UM), Resident #88 confirmed receiving morning care that morning. The RN/UM and the surveyor did not observe the MPB on the resident. The surveyor asked the RN/UM where the MPB was located. The RN/UM looked on the chair, in the closet, and all over the room then stated she could not find it. On 6/26/25 at 11:33 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) who was assigned to Resident #88 stated that residents with assistive device were verbally handed over to the next shift and stated she was not told anything that morning about Resident #88. The LPN also stated that she usually checked the eTAR which is another indicator she used to assure residents with assistive device offered/applied their treatment. At that time, the LPN confirmed the MPB was not on the eTAR and was not aware the resident required an MPB. On 6/26/25 at 11:38 AM, during a follow-up interview with the surveyor RN/UM, confirmed that the MPB could not be located and was not on the eTAR. The RN/UM stated it could not be determined when the MPB was offered/applied and declined. At that time, the RN/UM stated she would inform the rehabilitation department, the nurses and the Director of Nursing (DON) to evaluate the resident's status. On 6/26/25 at 11:42 AM, the surveyor, and the Director of Rehabilitation reviewed the rehabilitation notes for Resident #88 together. The DOR stated that the resident was discharge from physical therapy with a recommendation of the MPB, according to the discharge summary signed on 5/23/23. At that time, the DOR stated that the resident was referred to nursing on 10/8/24 by the nursing staff for decline in their activities of daily living unrelated to the MPB. The DOR stated that she was familiar with Resident #88 who was noncompliant, through refusal of the MPB. The DOR could not provide documentation of the attempt to apply the MPB daily and the refusal. At that time, the DOR stated that even though the resident refused, an attempt to offer should be made, documented and refusals should also be documented. The DOR acknowledged that the MPB should be accessible to the nurses and CNA for application. The DOR confirmed she was not aware that the MPB was missing or when it went missing. THe DOR stated that she should have been informed by nursing soon as they knew it was missing, and would have provided a replacement. The DOR could not recall when she last checked where the MPB was or if it was present during the last assessments. On 6/26/25 at 1:16 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Nurse and the Regional Administrator, the surveyor discussed the concerns regarding the missing MPB, the failure carry out the order and enable the nursing staff to consistently document daily the offer/refusal of the MPB on the medical record, and show consistent implementation of interventions designed by the physical therapist to increase functional mobility and prevent further decline . On 6/27/25 at 10:19 AM, during a meeting with the survey team, the DON, the Regional Nurse and the Regional Administrator, the LNHA stated that the resident was re-evaluated by the physical therapist after surveyor inquiry, the resident did not want MPB, and the therapist recommended manual intervention three times a week for four weeks to facilitate mobility improvement. A review of the provided facility policy for Resident Mobility, and Range of Motion dated/revised 1/2025, included that residents with limited mobility would receive appropriate services, equipment and assistance to maintain or improve mobility . NJAC 8:39-27.1(a), 27.2(m)

Based on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of five (5) residents (Resident #159) reviewed for unnecessary medications and was evidenced by the following: On 6/23/25 at 12:54 PM, the surveyor observed Resident #159 in bed and was reluctant to discuss their experience in the facility for fear of retaliation. The surveyor reviewed the medical record for Resident #159. According to the admission record, an admission summary, reflected that Resident #159 was admitted to the facility with diagnoses that included, major depressive disorder, mood disorder, anxiety disorder and (PTSD). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/28/25 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Section D for Mood reflected that an interview was conducted and was assessed; In the last two weeks of the assessment, the resident had not reported feelings of having little pleasure of doing things, feelings of being down, depressed and/or hopelessness. Section I. under active diagnoses, under psychiatric/mood disorder included anxiety, depression and PTSD. A review of the individualized comprehensive care plan (ICCP) did not include a focus, interventions and goals for the resident's diagnoses of PTSD from admission. A review of the most recent psychiatric progress note dated, 3/14/25 included that the resident reported poor sleep and was trailed on an antidepressant and the antipsychotic Abilify was discontinued as part of gradual dose reduction GDR. The assessment plan included supportive and individualized non-pharmacologic interventions, support/reassurance, comfort measures, reduced environmental stimuli. A review of the most recent psychotherapy note provided by a psychologist reflected a cognitive behavioral therapy (CBT; a psychotherapy that focuses on changing negative thought pattern and behaviors to improve mental health and well-being) was conducted on 1/13/25. The CBT note reflected a plan to continue emotional support and coping skills for grief/loss. The symptom frequency was identified as daily, and the goal was to reduce symptoms from 7 days a week to 4 days a week. Further review of the note revealed the therapeutic orientation used during the session was cognitive behavioral and person centered. Under follow-up reflected continued emotional support, and the change of treatment reflected as not applicable. No further CBT was found on the medical record . A review of the Social Services Notes from March 2025 to June 2025 did not reflect provision of CBT related to PTSD. On 6/24/25 at 1:30 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Chief Nursing Officer (CNO), Assistant Administrator (AA #1), (AA #2), Regional Nurse, Regional Administrator, the surveyor discussed the concern that Resident #159 who had an active diagnosis of PTSD, was not seen for CBT since 1/13/25 and no indication from the providers that the resident no longer required the service and the ICCP that did not included focus, interventions and goals for diagnosis of PTSD from admission. On 6/26/25 at 10:06 AM, in the presence of the survey team, the Regional Nurse, and the DON, the LNHA stated the resident was seen by a volunteer psychologist who stopped working in the area. The quarterly assessment screens from February 2025 and April 2025 reflected a mood interview of zero (no reported symptom). The psychiatrist performed a GDR, discontinued the antipsychotic, Abilify [no active diagnoses found], The LNHA also stated the assessment indicated no further need, however the resident was interviewed by the social worker (SW), and was placed back to receive services from the psychologist by the SW. No further information was provided. A review of the provided facility policy, Trauma Informed Care, dated/revised 1/2025 included under policy statement that the facility ensured that residents who are trauma survivors received culturally competent, trauma informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. NJAC 8:39-27.1 (a), 28.1 (c)

4. The surveyor interviewed Resident #134 on 6/19/25 at 12:16 PM. The resident was seated in an armchair at the bedside and told the surveyor they received hemodialysis three times a week. A review of the electronic medical record revealed the following information. The 4/19/25 admission MDS assessment tool indicated the resident had no cognitive deficits as evidenced by a BIMS score of 14 of a possible 15. The June 2025 Order Summary Report included a 4/14/25 physician's order for Midodrine oral tablet (medication used to raise blood pressure) 5 mg. twice a day for hypotension (low blood pressure) hold for SBP (systolic blood pressure) above 130 millimeters of mercury (mmHg). A review of the April, May, and June 2025 Medication Administration Records included documentation by the administering nurse that Midodrine was administered 10 times when the SBP was above 130 mmHg or when a blood pressure was not documented. The surveyor interviewed the Licensed Practical Nurse Unit Manager on 6/25/25 at 10:21 AM. She confirmed nurses must follow the parameters for Midodrine to be held when the SBP was above 130 mmHg. The surveyor discussed concerns regarding parameters not being consistently followed for the Midodrine physician order with the Administrator and the DON on 6/25/25 at 1:17 PM. A review of the facility's 2/5/25 policy titled Administering Medications indicated medications must be administered in accordance with the physician order. NJAC 8:39-11.2(b); 27.1(a) ), 29.2(a), 29.7(c) Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) documentation of removal, administration, maintenance of accountability and reconciliation of Resident #166's Morphine, a controlled dangerous substance (narcotic; with high potential for drug diversion) that resulted to 23 unaccounted doses, equaled to 115 milligrams (mg), identified during the medication storage inspection of 1 of 7 medication carts and 1 of 3 medication rooms, b.) administration of medication with parameters were administered in accordance with the physician's orders, identified for 1 of 3 residents reviewed for hemodialysis (Resident #134), c.) timely acquisition of medications, and were available for administration to Resident #494, identified for 1 of 35 residents reviewed for medication management. 1. On 6/26/25 at 10:37 AM, the surveyor and the Licensed Practical Nurse (LPN #1) began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box), located in the north side of the second floor. At that time, the surveyor observed the record of narcotic, barbiturate, abuse drug count log (a shift-to-shift accountability log, used by nurses to count each narcotic contained in the narcotic box) was signed daily. On 6/26/25 at 10:46 AM, in the presence of LPN #1, the surveyor observed Resident #166's Morphine 20 milligram (mg)/ 1 milliliter (ml) solution (soln) bottle (narcotic medication indicated for pain) contained 8 ml. At that time, LPN #1 confirmed the observation of 8 ml. A review of the Individual Patient Controlled Drug Record (IPCDR; a declining inventory log) for Resident #166's Morphine 20mg/ml soln indicated a count of 14.25 ml remained, was last signed dispensed and administered on 5/14/25 with a pharmacy label dated 12/6/24. Further review of the IPCDR reflected the following documentation by the nurses: -on 4/15/25 at 3:44 PM, a dose was signed removed. -on 4/20/25 at 8:13 AM, a dose was signed removed. -on 4/21/25 at 2:50 PM, a dose was signed removed. -on 4/30/25 at 2:25 PM, a dose was signed removed. At that time, the surveyor asked the nurse why the discrepancy was not identified during the shift-to-shift accountability check between her and the other nurse. LPN #1 had no response. A review of the shift-to-shift accountability log for Resident #166's Morphine 20mg/ml soln from December 2024 to June 2024 reflected the log was signed three (3) times daily. A review of the electronic Medication Administration Record (eMAR) from December 2024 to June 2025 reflected the following: -December 2024, no administration of Morphine was documented. -January 2025, no administration of Morphine was documented. -February 2025, no administration of Morphine was documented. -March 2025, no administration of Morphine was documented. -April included the following administration of Morphine: The 4/15/25 at 3:44 PM [reflected on the IPCDR] and 4/20/25 at 8:13 AM [reflected on the IPCDR]. Further review of the eMAR, reflected discrepancies on 4/17/25 at 1:33PM, which was not documented on the IPCDR as removed but was signed administered, and on 4/21/25 at 2:50 PM was signed removed from the IPCDR but was not signed as administered. -May 2025 reflected an administration on 5/15/25 at 11:28 AM [reflected on the IPCDR]. -June 2025, no administration of Morphine was documented. At that time, the surveyor asked the nurse why the discrepancy was not identified during the shift-to-shift accountability check between her and the other nurse. LPN #1 had no response. On 6/26/25 at 10:56 AM, during an interview with the surveyor, the Registered Nurse/ Unit Manager (RN/UM) stated she would inform the Director of Nursing (DON) of the discrepancies found on the second floor and begin the investigation. 2. On 6/26/25 at 10:47 AM, during the medication cart observation located in the north side of the second floor, the surveyor observed a sealed bottle of Morphine 100 mg/5ml (20 mg/ml) for Resident #50 without an IPCDR. LPN #1 confirmed the IPCDR could not be located. On 6/26/25 at 10:53 AM, during the medication room observation, located in the north side of the second floor, the surveyor observed two (2) sealed bottle of Lorazepam Oral concentrate 2 mg/ml from different pharmacy providers, for Resident #50 without an IPCDR. LPN #1 confirmed the IPCDR could not be located on the logbook on the cart. At that time, the surveyor asked the nurse why the discrepancy was not identified during the shift-to-shift accountability check between her and the other nurse. LPN #1 had no response. On 6/26/25 at 10:56 AM, during an interview with the surveyor, the Registered Nurse/ Unit Manager (RN/UM) stated she would inform the Director of Nursing (DON) of the discrepancies found on the second floor and begin the investigation. On 6/26/25 at 1:16 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Nurse and the Regional Administrator, the surveyor discussed the concerns regarding the 23 missing doses, equaled to 115 milligrams (mg), for Resident #166, the missed opportunity of identification when the discrepancy occurred when the Resident # 50's Morphine and Lorazepam that did not have an IPCDR to account and reconcile the presence or absence of the medication within the narcotic box in the cart and the refrigerator that was identified during the medication storage inspection. On 6/26/25 at 1:16 PM, the Regional Nurse informed the surveyors that 1 of 2 IPCDR for Lorazepam was found in the box [instead of the accountability logbook for the nurse be aware to account of the presence or absence of a narcotic medication]. The Regional Nurse confirmed that the IPCDR for the Morphine and the other Lorazepam could not be located at that time. On 6/27/25 at 10:19 AM, during a meeting with the survey team, the DON, the Regional Nurse and the Regional Administrator, the LNHA stated that a new IPCDR was received/made for Resident #50's Morphine and Lorazepam for accountability. On 6/27/25 at 12:50 PM, during a follow-up meeting with the survey team, the LNHA, the DON, the Regional Nurse, and the Regional Administrator, the Chief Nursing Officer (CNO) stated that they have identified a 6.25 ml discrepancy, five medication administration by the nurses, the progress notes were reviewed to rule out excessive dosing administration, interviewed 3 of the 5 nurses who administered the medication in April 2025 and May 2025, an education was provided to the nurses and the investigation was still in progress. A review of the investigation provided did not include the investigation of the June 2026, shift-shift log that was signed three times daily up to the first shift of June 26, 2026 (total of 76 signatures) or the prior months to determine when the discrepancy occurred. A review of the provided facility policy for Storage of Medications, dated/revised 1/2025 included that any discrepancies which cannot be resolved must be reported immediately .The DON, charge nurse or designee must also report any loss of controlled substances where theft is suspected to appropriate authorities . 3. On 6/24/25 at 1:56 PM, the Surveyor interviewed Resident #494, who stated that they did not recieve their medication Abilify on 6/18/25, 6/19/25 or 6/20/25, and the resident stated that they received a dose very early the morning of 6/21/25. The resident stated that they also did not receive a dose of their medication Lyrica on evening of 6/16/25. A review of Resident # 494's admission Minimum Data Set (MDS) (an assessment tool), dated 6/4/25, revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. A review of the resident's current Physician's Orders (PO) reflected that Resident #494 was precribed Abilify 30 milligram tablet, one time daily at 9:00AM and Lyrica 150 milligram capsule, one capsule three times daily. The residents' eMAR for the month of June 2025 revealed that Abilify was not adminsitered or the dates of 6/18, 6/19, and 6/20 and were marked 9. The eMAR for the month of June 2025 revealed that Lyrica was not adminsitered for the date of 6/16 at 1700 and was marked 9. According to the facility's eMAR key 9 code is revealed as meaning Other/see progress note. A review of the progress notes for these four opportunities indicate that facility was waiting for those medications to be delivered from pharmacy, and there was no indication of a provider notification or alternate orders. On 6/25/25 at 12:45 PM, the surveyor interviewed RN #2, who stated that she was not sure what happened on those dates for those medications and in those cases the facility should have checked the machine located inside the facility for medication availability, if it was not available in the machine, the manager or pharmacy should have been alerted. On 6/25/25 at 12:55 PM, the surveyor interviewed the RN Unit Manager (UM), who stated if the medications could not be obtained through the pharmacy or the facility's back up machine, the facility should have called the attending physician for further orders and document in a progress note. The RN UM stated that she did not know what happened on the dates marked 9. On 6/26/25 at 10:05 AM, the surveyor discussed the above concerns for Resident #494 with the LNHA and DON and they could not explain what had occurred. No further documentation provided to surveyor.

Based on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following: On 6/24/25 at 10:30 AM, the surveyor held the resident council meeting and 4 of 5 residents, who were in attendance, voiced that they did not know where the survey results were located. 1 of 5 of the resident's stated that they thought the survey results were at the receptionist desk. On 6/24/25 at 11:30 AM, the surveyor could not locate survey results near the receptionists desk and could not locate them throughout he facility and the receptionist stated that they did not know where the survey results were located. On 6/24/25 at 1:40 PM, the Surveyor met with Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and surveyor voiced concerns that previous years survey results could not be located. The LNHA stated the results were at the reception area desk and that they were oocate dbehind the receptionist desk. The LNHA acknowledged that the binder should be kept in an area that is accessible to residents and that residents should be able to access the book without asking for it. NJAC 8:39-9.4(b)(c)

Based on observation, record review, interview, and United States (U.S.) Food and Drug Administration (FDA) dish sanitation recommendations, the facility failed to ensure 1 of 1 dish machine and 1 of 1 three-compartment sink were utilized in accordance with FDA guidance to minimize the potential for foodborne illness. Specifically, the facility failed to ensure the low-temperature dish machine achieved recommended temperatures, failed to ensure sanitizer testing supplies were not expired, and failed to maintain the chemical concentration of sanitizer in the three-compartment sink. The failed practices had the potential to affect 194 residents who received meals from the dietary department out of a total census of 199 residents. Findings included: Chapter 4 of the U.S. FDA 2022 Food Code indicated, ,d+[DATE].110 Mechanical Warewashing Equipment, Wash Solution Temperature (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 49 C [Celsius] (120 F. [Fahrenheit]). The Food Code also specified, ,d+[DATE].114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation - Temperature, pH [potential of Hydrogen], Concentration, and Hardness. (A) A chlorine solution shall have a minimum temperature based on the concentration and the pH of the solution as listed in the following chart: For a concentration range of 25 to 49 milligrams per liter (mg/L), the chart indicated the minimum temperature was to be 49 degrees C or 120 degrees F. A continuous observation conducted on [DATE] from 2:30 PM to 2:42 PM revealed the following: Dietary Aide (DA) #21 was standing at the three-in-one compartment sink washing pots, pans, and serving utensils. Dietary #21 had the sanitizing portion of the sink filled with large baking pans submerged in a fuchsia-colored liquid. He indicated he did not know about the chemicals for the sink and had not checked them. Dietary Supervisor (DS) #23 walked over to the sink and stated she was responsible for checking the sanitizer. DS #23 used a chemical test strip to test the solution in the sanitizer. The test strip indicated 400 to 500 parts per million (PPM). DS #23 stated the concentration should be 200 PPM. DS #23 then accompanied the surveyor to observe the dish machine. The manufacturer of the machine was unable to be determined at this time. DA #20 was using the dish machine to run a rack of miscellaneous dishes off the metal table. The temperature gauge on the dish machine registered 110 degrees F. during the final rinse cycle. DA #20 indicated he had not checked the temperature, had not been taught to do so, and that the DS was responsible for checking the temperatures. DS #23 used a chlorine testing strip to check the chemical concentration following a rack of dishes being run through the dish machine. The first test strip indicated the concentration of the solution in the dish machine was zero. DS #23 obtained another chemical test strip and placed it in the dish machine, and the test strip continued to indicate zero. Following third test strip reading zero, the surveyor requested the container of chlorine test strips, which revealed the expiration on the package was [DATE]. DS #23 indicated she did not know how the strips could be expired considering how many of the strips they used and asked DS #22 to obtain a new package. DS #22 retrieved a new unopened container of test strips and handed it to DS #23. DS #23 obtained a test strip from the new container, ran a rack of miscellaneous dishes through the dish machine, then dipped the test strip into the liquid solution inside the machine. The new test strip continued to indicate zero. DS #23 was asked what she would do next, and she stated she did not know, because this had never happened before. DS #23 and the surveyor checked the chemical dispenser for the machine and noted there was very little product remaining in the container. During an interview on [DATE] at 3:45 PM, the Regional Director of Clinical Compliance (RDCC) stated she was unable to obtain any policies or competencies for the staff for the dietary department because the Dietary Manager (DM) was not in the facility at that time. During a telephone interview on [DATE] at 4:05 PM, the DM stated he was not certain of how to identify the manufacturer of the dish machine if the information was not listed on the machine. He indicated the machine should reach a minimum temperature of 135 degrees F. for the final rinse cycle. The DM stated at times, the water in the dietary department did not get hot enough and that this had been repaired before. He stated the dish machine chlorine test strips should read between 50 and 100 PPM. The DM stated the three-in-one compartment sink sanitizer should be changed every two hours and that if the chemical concentration was greater than 200, the sink should be emptied and the solution redone and rechecked. He stated he needed to contact the Director of Nursing (DON) or Administrator to tell them the facility needed to start using disposable dishes until the dish machine was fixed. The facility Diet Type Report, dated [DATE], indicated there were 194 residents who received meals from the kitchen. During an interview on [DATE] at 12:50 PM, the RDCC stated the Administrator would be unavailable for any interviews. At 4:23 PM, the RDCC stated she had looked all over the dish machine and had been unable to determine the manufacturer of the machine.

Based on observation, record review, interview, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and (&) Oversight Group (QSOG) memoranda, the facility failed to ensure CDC guidance and the facility's infection prevention and control (IPC) policies were promptly and consistently implemented, as evidenced by: 1) failure to ensure staff donned the appropriate personal protective equipment (PPE) while caring for 3 (Residents #1, #2, and #3) of 3 residents reviewed for enhanced barrier precautions (EBP. 2) failure to ensure staff donned the appropriate PPE when entering the room to deliver and set up a meal tray for 1 (Resident #4) of 3 residents reviewed for transmission-based precautions and failed to perform appropriate hand hygiene between delivering meals to Residents #4, #5, and #6. 3) failure to ensure a vaccination was promptly administered after consent was obtained for 1 (Resident #9) of 5 residents reviewed for vaccinations. 4) failure to ensure a resident who was symptomatic for respiratory syncytial virus (RSV) was promptly tested upon receipt of a physician order for testing for 1 (Resident #11) of 8 residents reviewed for RSV. 5) failure to correctly and consistently conduct and document contact tracing on residents and staff when 7 (Residents #12, #10, #14, #15, #16, #17, and #18) of 8 residents reviewed for COVID-19 tested positive for COVID-19. The failure to implement appropriate infection control measures had the potential to affect all 199 residents residing in the facility. Findings included: 1. QSOG Memorandum QSO-24-08-NH, Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024, indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The memo also specified, EBP are indicated for residents with any of the following: - Infection or colonization with a CDC-targeted MDRO [multidrug-resistant organism] when Contact Precautions do not otherwise apply; or - Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 1.a. An Admission Record indicated the facility admitted Resident #1 on 06/2018 and readmitted the resident on 07/2021. According to the Admission Record, the resident had a medical history that included diagnoses of obstructive and reflux uropathy, mechanical complication of nephrostomy catheter, and need for assistance with personal care. Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an indwelling catheter and was dependent on staff for bathing, toileting hygiene, and bed-to-chair transfers. Resident #1's Care Plan Report included a focus area revised 09/19/2024 that indicated Resident #1 was at risk for infection requiring enhanced barrier precautions related to a nephrostomy. Interventions directed staff to use a gown and gloves during high-contact activities, such as dressing, hygiene, transferring, bathing/showering, changing linens, device care, wound care, and therapy and to perform hand hygiene prior to and after providing care to the resident. Resident #1's Kardex revealed the resident required enhanced barrier precautions and directed staff to wear a gown and gloves during high contact activities, such as dressing, hygiene, toileting, transferring, bathing/showering, changing linens, device care, wound care, and therapy and to perform hand hygiene prior to and after providing care. Resident #1's Order Summary Report included an order dated 10/20/2024 for enhanced barrier precautions related to a nephrostomy. During an observation on 03/08/2025 at 9:26 AM, unidentified staff members entered Resident #1's room without donning PPE. At 9:30 AM, a follow-up observation revealed Certified Nurse Aide (CNA) #7 in Resident #1's room assisting the resident to transfer from the bed to a wheelchair. During an interview conducted when CNA #7 exited Resident #1's room on 03/06/2025 at 9:33 AM, CNA #7 stated she had just completed morning care for Resident #1, which included incontinence care, bathing, dressing, and transferring. CNA #7 stated she should wear a gown and gloves when providing care to a resident on EBP, but since there was no basket (clarified to mean PPE cart) outside the resident's room, the EBP signage that was posted should have been taken down. She acknowledged that Resident #1 had a nephrostomy tube in place but stated she had not been instructed that the resident required EBP. She again stated Resident #1 did not have a basket, so she did not wear a gown while providing care to the resident. During a telephone interview on 03/08/2025 at 1:00 PM, the Director of Nursing (DON) stated staff who were providing direct care to residents on EBP were required to wear a gown and gloves. The DON indicated CNA #7 should have donned a gown and gloves before providing morning care to Resident #1. During an interview on 03/08/2025 at 12:50 PM, the Regional Director of Clinical Compliance (RDCC) stated the Administrator would be unavailable for any interviews. 1.b. An Admission Record indicated the facility admitted Resident #2 on 04/2022 and readmitted the resident on 08/2023. According to the Admission Record, the resident had a medical history that included diagnoses of end stage renal disease and dependence on renal dialysis. Resident #2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance for bathing and bed-to-chair transfers and received dialysis while a resident. Resident #2's Care Plan Report included a focus area revised 01/02/2025 that indicated Resident #2 was at risk for infection requiring enhanced barrier precautions related to colonization with a targeted multi-drug resistant organism (MDRO). Interventions directed staff to use a gown and gloves during high-contact activities, such as dressing, hygiene, transferring, bathing/showering, changing linens, device care, wound care, and therapy and to perform hand hygiene prior to and after providing care to resident. Resident #2's Order Summary Report included an order dated 04/01/2024 for enhanced barrier precautions related to a central line. An observation on 03/06/2025 at 10:06 AM revealed that signage was posted outside Resident #2's room indicating enhanced barrier precautions were required and a gown and gloves were required for transfers. Certified Nurse Aide (CNA) #10 retrieved supplies from a linen cart outside Resident #2's room, and CNA #13 followed her into the room pushing a shower chair. Neither CNA donned a gown prior to entering the room. CNA #13 exited the room wearing a pair of gloves and retrieved additional linen from the linen cart in the hallway, then returned to the room. CNA #10 opened the door wearing gloves. Resident #2 was observed to be seated in the shower chair when the door was opened. CNA #10 proceeded to push the resident in the shower chair into the hallway, then propelled the resident down the hallway to the shower room. During an observation on 03/06/2025 at 10:32 AM, CNA #10 and CNA #13 returned Resident #2 to their room after giving the resident a shower. The CNAs donned gowns and gloves prior to assisting the resident further. During an interview on 03/06/2025 at 10:33 AM, CNA #10 stated she and CNA #13 had transferred Resident #2 from the bed to a shower chair wearing only gloves but would don a gown and gloves to put the resident back to bed and dress the resident. She stated since she was not providing any care other than transferring during the surveyor's initial observation, she did not need a gown just to transfer the resident from bed to the shower chair. She stated she had received training on EBP but did not realize transferring was included in the activities for which a gown and gloves would be required. CNA #10 observed the signage posted outside Resident #2's door and stated she should have donned a gown and gloves before transferring the resident. During an interview on 03/06/2025 at 10:58 AM, CNA #13 revealed she received training on EBP that directed her to don a gown and gloves during high contact care. CNA #13 acknowledged she did not wear a gown while transferring Resident #2 from the bed to the shower chair. CNA #13 stated she was not aware EBP required a gown for transfers. CNA #13 observed the EBP signage posted outside Resident #2's door and stated she should have donned a gown and gloves prior to transferring the resident. During an interview on 03/06/2025 at 10:20 AM, Licensed Practical Nurse (LPN) #8 stated the EBP signage posted for Resident #2's room was for Resident #2 due to the resident being on dialysis. During an interview on 03/06/2025 at 10:28 AM, CNA #9 stated Resident #2 required dialysis and was on EBP. She stated staff were to wear a gown and gloves while caring for Resident #2. During a telephone interview on 03/08/2025 at 1:00 PM, the Director of Nursing (DON) stated staff who were providing direct care to residents on EBP were required to wear a gown and gloves. The DON indicated CNA #10 and CNA #13 should have donned a gown and gloves before providing care to Resident #2. During an interview on 03/08/2025 at 12:50 PM, the Regional Director of Clinical Compliance (RDCC) stated the Administrator would be unavailable for any interviews. 1.c. A facility policy titled, Categories of Transmission-Based Precautions, revised 01/2025, included a section under each type of precautions that was titled, Resident Transport which indicated, If the resident is transported to another unit within Facility or to another facility, the Infection Control Coordinator (or designee) will notify the unit or facility of the type of precautions the resident is on and the resident's suspected or confirmed type of infection. Facility is also responsible for notifying transport staff of residents that require special care due to infectious conditions. An Admission Record indicated the facility admitted Resident #3 on 06/2012 and readmitted the resident on 06/2021. According to the Admission Record, the resident had a medical history that included diagnoses of end stage renal disease and dependence on renal dialysis. Resident #3's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2025, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required supervision or touch assistance for bed-to-chair transfers and received dialysis while a resident. Resident #3's Care Plan Report included a focus area revised on 02/28/2025 that indicated Resident #3 was at risk for infection requiring enhanced barrier precautions related to colonization with a targeted multi-drug resistant organism (MDRO), an indwelling catheter, and a chronic wound. Interventions directed staff to wear a gown and gloves during high-contact activities, such as dressing, hygiene, transferring, bathing/showering, changing linens, device care, wound care, and therapy and to perform hand hygiene prior to and after providing care to the resident. Resident #3's Order Summary Report contained an order dated 02/28/2025 for enhanced barrier precautions related to MDRO colonization, an indwelling catheter, and a chronic wound. An observation on 03/06/2025 at 10:45 AM revealed Medical Transport Staff (MTS) #11 and MTS #12 entering Resident #3's room with a stretcher to transport the resident to the dialysis center. The two staff transferred Resident #3 from the bed to the stretcher wearing a surgical mask, gloves, and no gown. Resident #3's door had signage posted indicating the resident required EBP and that a gown and gloves were required for transfers. During an interview on 03/06/2025 at 10:50 AM, Medical Transport #11 and Medical Transport #12 stated they were familiar with Resident #3 and transported the resident to dialysis every week. They stated they were not required to follow the posted EBP signage. Both staff observed and acknowledged the EBP signage outside Resident #3's room and stated they were only required to don PPE above what would be required for standard precautions if a resident was COVID-19 positive. During an interview on 03/08/2025 at 1:00 PM, the Director of Nursing (DON) stated staff who were providing direct care to residents on EBP were required to wear a gown and gloves. The DON indicated MTS #11 and MTS #12 did not work for him so were not required to wear the same PPE as his staff. During an interview on 03/08/2025 at 12:50 PM, the Regional Director of Clinical Compliance (RDCC) stated the Administrator would be unavailable for any interviews. ------ 2. A facility policy titled, Infection Control Guidelines for All Nursing Personnel, revised 01/2025, indicated Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. a. When transmission-based precautions are required, a sign will be placed at the resident's doorway directing individual to see the nurse before entering the room. Without violating HIPAA [Health Insurance Portability and Accountability Act] regulations, the nurse will ensure that any individual entering the room wears appropriate PPE. A facility policy titled, Categories of Transmission-Based Precautions, revised 01/2025, indicated, 1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. The policy also specified, Contact Precautions - In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy indicated, c. Gloves and Handwashing - (1) In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room and (3) Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent. The policy further indicated, Gown - (1) In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, non-sterile) for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's environment. A facility policy titled, Clostridium Difficile revised 01/2025 indicated 3. The primary reservoirs for C. [Clostridium] difficile are infected people and surfaces. Spores can persist on resident care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. 4. C. Difficile is transmitted by the fecal-oral route. Therefore, any resident care activity that involves contact with a resident's mouth when hands or instruments are contaminated may provide an opportunity for transmission. The policy also specified, 10. Residents with diarrhea associated with C. difficile (i.e. [that is], residents who are colonized and symptomatic) will be placed on Contact Precautions. a) Healthcare workers will wear gloves and gowns upon entering the room of a resident with C. difficile infection and will remove gown and gloves prior to exiting the room. and Hand washing with soap and water is superior to ABHR [alcohol-based hand rub] for the mechanical removal of C. difficile spores from hands. 12. Glove use when caring for residents with C. difficile, washing hands with soap and water upon exiting the room of a resident with C. difficile infection AND strict adherence to hand hygiene in general is considered best practice. An Admission Record indicated the facility admitted Resident #4 on 03/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of recurrent enterocolitis due to Clostridium difficile. Resident #4's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2025, revealed the resident's assessment was in progress. Section C of the assessment in progress indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Section I of the assessment in progress indicated Resident #4 had an active diagnosis of recurrent enterocolitis due to Clostridium difficile (C. diff). Resident #4's Care Plan Report included a focus area revised 03/05/2025 that indicated Resident #4 had a gastrointestinal (GI) infection related to C. diff. Intervention directed staff to maintain isolation precautions as indicated. Resident #4's Order Summary Report contained an order dated 03/05/2025 for transmission-based precautions (TBP)/contact precautions for C. difficile and for staff to wash hands prior to exiting the patient area. A continuous observation on 03/06/2025 from 11:27 AM to 11:33 AM revealed Hospitality Aide (HA) #16 delivering meal trays on a unit of the 500 Hall. HA #16 retrieved a meal tray from the service cart and entered Resident #4's room. Signage was posted outside the resident's room that indicated, Special Contact Precautions and that a gown and gloves were required to enter the room. Special instructions on the signage indicated hand hygiene must be performed using soap and water. Do not use hand sanitizer. HA #16 adjusted Resident #4's bedside table and set the meal tray in front of Resident #4 before exiting the room without washing her hands. HA #16 returned to the meal service cart without performing hand hygiene and retrieved Resident #5's meal tray, entered Resident #5's room, and placed the meal tray on the overbed table before exiting the room. Still without washing her hands, HA #16 returned to the service cart to retrieve Resident #6's meal tray, then entered Resident #6's room to deliver the resident's meal tray. Review of Resident #5's care plan and physician's orders revealed the resident was at risk for infection and required EBP related to a tracheostomy and PleurX catheter (a small tube inserted into the chest to drain fluid from around the lungs). Review of Resident #6's care plan and physician's orders revealed the resident was at risk for infection and required EBP related to a chronic wound. During an interview on 03/06/2025 at 11:28 AM, HA #16 stated she should have performed hand hygiene using alcohol-based hand rub (ABHR) when she exited Resident #4's room. She stated she did not need to wear a gown and gloves nor perform hand hygiene with soap and water before exiting the room because she was only delivering the meal tray. HA #16 then observed and acknowledged the signage posted outside Resident #4's door, which indicated staff were to don a gown and gloves before going into Resident #4's room and perform hand hygiene using soap and water when exiting. HA #16 also stated she should have performed hand hygiene using ABHR between delivering meal trays to Resident #5 and Resident #6. During an interview on 03/06/2025 at 11:34 AM, Licensed Practical Nurse (LPN) #14 stated Resident #4 was on special contact precautions for C. diff and that HA #16 should have donned a gown and gloves before entering the room and washed her hands with soap and water. LPN #14 also stated meal trays for residents on TBP were supposed to be delivered last. During an interview on 03/06/2025 at 11:37 AM, the Director of Nursing (DON) and Administrator were made aware of the observations concerning Resident #4. Both the DON and Administrator acknowledged Resident #4 was on special contact precautions and both stated HA #16 should have donned PPE according to the signage and washed her hands using soap and water when exiting the room. They both acknowledged that Resident #5 and Resident #6 were on EBP and stated HA #16 should have performed hand hygiene using ABHR between delivering their meal trays. ----- 3. A facility policy titled, Coronavirus, Prevention and Control, revised 03/05/2025, indicated Vaccination 1. Each resident and staff member will be educated about and offered an FDA [U.S. Food and Drug Administration]-approved COVID vaccine unless the immunization is medically contraindicated or the resident or staff member has already been fully immunized. The policy also specified, The resident's medical record will include documentation that indicates: a. That the resident or resident representative was provided education regarding benefits and potential risks associated with COVID vaccine. b. Each dose of COVID vaccine administered to the residents, or c. If the resident did not receive the vaccine due to medical contraindication or refusal. An Admission Record indicated the facility admitted Resident #9 on 04/2022 and readmitted the resident on 01/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of acute osteomyelitis. Resident #9's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2025, indicated Resident #9 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS revealed Resident #9's COVID-19 vaccine was not up to date. Resident #9's Vaccine Consent Form - Multi-Vaccines revealed a consent was signed by the resident on 10/23/2024. The form indicated the resident circled Yes to receiving a COVID-19 (2024-2025) vaccine and a Respiratory Syncytial Virus (RSV) vaccine. As of 03/07/2025, Resident #9's Immunization Record indicated the resident received the RSV vaccine on 10/24/2024 but did not receive the COVID-19 (Moderna Spikevax Vaccine 24-25) until 02/12/2025. During an interview on 03/07/2025 at 11:00 AM, the Infection Preventionist acknowledged the delay in administering Resident #9's COVID-19 (2024-2025) vaccine and stated she was unsure why the vaccine was not administered until four months after the consent was signed. She stated the vaccine should have been administered as soon as possible. During an interview on 03/07/2025 at 11:30 AM, the Director of Nursing (DON) stated he was not sure why Resident #9's COVID-19 vaccine was not administered after the consent was signed but thought it was related to multiple hospital admissions during that time (see hospitalization information below). The DON indicated vaccines should be administered as quickly as possible after consent was obtained. Regarding Resident #9's history of hospitalization s: - A Discharge-return anticipated MDS, with an ARD of 06/27/2024, indicated the resident was discharged to a short-term general hospital on 06/27/2024. - An MDS with an ARD of 09/23/2024 indicated the resident's reentry date was 07/08/2024. There were no further MDS assessments that indicated subsequent hospitalization s until 01/06/2025. - A Discharge-return anticipated MDS, with an ARD of 01/06/2025, indicated the resident's most recent reentry date was 07/08/2024 and that the resident was discharged on [DATE] to a short-term general hospital. An Entry Tracking Record MDS with an ARD of 01/25/2025 indicated the resident returned to the facility on [DATE]. During an interview on 03/08/2025 at 12:50 PM, the Regional Director of Clinical Compliance (RDCC) stated the Administrator would be unavailable for any interviews. ----- 4. A facility policy titled, Respiratory Syncytial Virus, Prevention and Control revised 01/2025 indicated 1. Residents who test positive for RSV infection should ideally be placed in a single person room. Limit transport and movement of the patient outside the room to medically essential purposes. 2. Residents who test positive for RSV infection should be placed on contact precautions for the duration of illness. The decision to discontinue transmission-based precautions should be made in consultation with infection preventionist and/or physician once symptoms have resolved. CDC online guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 01/08/2025 and available at https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html, indicated, Test and Treat - Develop plans to provide rapid clinical evaluation and intervention to ensure residents receive timely treatment and/or prophylaxis when indicated. The policy also indicated, ACTION: RESPOND when a resident or HCP [healthcare personnel] develops signs or symptoms of a respiratory viral infection. When an acute respiratory infection is identified in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility. While decisions about treatment, prophylaxis, and the recommended duration of isolation vary depending on the pathogen, IPC [infection prevention and control] strategies, such as placement of the resident in a single-person room, use of a facemask for source control, and physical distancing, are the same regardless of the pathogen. An Admission Record indicated the facility admitted Resident #11 on 12/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of end stage renal disease. Resident #11's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/20/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A Nursing Progress Note, dated 01/22/2025 at 7:06 PM, indicated Resident #11 complained of a cough and a loose bowel movement. According to the note, the resident was seen by the physician and new orders were received for a respiratory viral panel, COVID, and influenza testing. Resident #11's Order Summary Report included a physician's order dated 01/22/2025 to collect a swab specimen for a respiratory panel to rule out infection. There was no documentation in the medical record to indicate the ordered specimen was collected until 01/24/2025. A laboratory report revealed a respiratory viral panel was collected on 01/24/2025 at 3:40 PM, with the results reported the same day at 8:34 PM and confirming that Resident #11 was positive for RSV. During an interview on 03/07/2025 at 11:00 AM, the Infection Preventionist indicated the facility collected the swab specimens for the respiratory panel labs and stated that they should be obtained upon receiving the order from the physician. During an interview on 03/07/2025 at 11:30 AM, the Director of Nursing stated labs should be obtained when the orders were received from the provider. ------ 5. A facility policy titled, Coronavirus, Prevention and Control, revised 03/05/2025, indicated, Regardless of vaccination status, staff who have had higher-risk exposure to a positive COVID case will be tested for COVID as soon as possible, but no sooner than 24 hours following exposure, again 48 hours later, and again 48 hours later (Day 1,3, and 5). The policy also specified, 3) Asymptomatic residents who have had close contact with a COVID case will be encouraged to wear source control for 10 days following exposure. Testing will be conducted on Day 1, Day 3, and Day 5 following day of exposure (Day 0). If results are positive, no further testing is needed, and the resident is to be placed on transmission-based precautions. The policy also indicated, c. An outbreak is defined as a new SARS-CoV-2 infection in any HCP [healthcare personnel] or any nursing-home onset SARS-CoV-2 infection in a resident. d. In the event of an outbreak, the facility will initiate contact tracing to identify residents or staff who may have had close contact (> [greater than or equal to] 15 min [minutes] of exposure within 6 feet, cumulative over 24 hours) or higher-risk exposure with the positive individual during the 48 hours prior to symptom onset / specimen collection. The policy also indicated, When close contacts are identified, HCP with higher risk exposure to a COVID-positive individual and residents who had close contact with the COVID-positive individual will be tested immediately. Repeat testing will be conducted on Day 1 following exposure and again on Day 3 and Day 5. Review of laboratory results revealed the following: - A laboratory report dated 01/26/2025 indicated Resident #10 was positive for COVID-19. - A laboratory report dated 01/28/2025 indicated Resident #12 was positive for COVID-19. - A laboratory report dated 01/29/2025 indicated Resident #14 was positive for COVID-19. - A laboratory report dated 01/30/2025 indicated Resident #15 was positive for COVID-19. - A laboratory report dated 02/02/2025 indicated Resident #16 was positive for COVID-19. - A laboratory report dated 02/10/2025 indicated Resident #17 was positive for COVID-19. - A laboratory report dated 02/13/2025 indicated Resident #18 was positive for COVID-19. The facility's COVID-19 Outbreak Contact Tracing Log revealed the above COVID-19 outbreak started on 01/26/2025. Outbreak investigation #E-2025-30890 included contact tracing documentation for two residents and no staff. During an interview on 03/07/2025 at 11:00 AM, the Infection Preventionist indicated for contact tracing, she interviewed staff to find out if they wore a mask during care for residents who were positive for COVID-19 and determine if they needed to be tested . She stated most staff were determined by her not to be high-risk because they had not spent more than 15 minutes each time they encountered a COVID-positive resident. (This did not align with the facility's policy to consider high-risk exposure as greater than or equal to 15 minutes of exposure over a 24 hour period). The IP nurse stated and provided documentation that she conducted contact tracing for nurses assigned to the residents on the dates each resident tested positive, and on Days 3 and 5 after the exposure; however, she could not locate any documentation of contact tracing completed for the nurse aides and therapy staff who cared for the COVID-positive residents. During an interview on 03/07/2025 at 11:30 AM, the Director of Nursing indicated he had assigned the IP nurse to oversee all contact tracing and stated that to his knowledge, those items had been completed per guidelines. During an interview on 03/08/2025, the Regional Director of Clinical Compliance (RDCC) stated the Administrator would be unavailable for any interviews.

Complaint #: NJ00178715 Based on interview, record review, and review of facility's pertinent documentation on 11/06/2024, it was determined that the facility failed to obtain physician orders for laboratory services performed on 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for laboratory services and physician orders. The deficient practice was evidenced by the following: 1. According to Resident #1's Admission Record (AR), Resident was admitted to the facility with the following diagnoses that included but not limited to: Urinary Tract Infection, Hydronephrosis with Renal and Urethral Calculous Obstruction, Hypertension, Hyperlipidemia, Anxiety Disorder, Depression, Benign Prostatic Hyperplasia, and Congestive Heart Failure. According to the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 04/09/2024, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident's cognition was intact. The MDS further revealed in Section GG-Functional Abilities, Resident #1 required supervision to minimal assist in his/her completion of Activities of Daily Living (ADLs). A review of the Resident laboratory results from his/her electronic medical record revealed the following: a. Comprehensive Metabolic Panel (CMP) and CBC [Complete Blood Count] with Auto Differential - collected on 5/3/2024 at 12:00 [noon]. b. Glomerular Filtration Rate [GFR] - collected on 5/3/2024 at 13:52 [1:52 p.m./afternoon]. c. Comprehensive Metabolic Panel and CBC - collected on 5/22/2024 at 08:00 [morning]. d. Glomerular Filtration Rate- collected on 5/22/2024 at 12:02 [afternoon]. A review of Resident #1's Order Recap Report (ORR), a detailed list of the completed and discontinued physician orders, with Order Date: 03/01/2024-11/30/2024 indicated there were no documented Physician orders for the above-mentioned laboratory services performed on the Resident on the specified collection dates. 2. According to Resident #2's AR, Resident was admitted to the facility with the following diagnoses that included but not limited to: Other Diseases of Stomach and Duodenum, Acute Posthemorrhagic Anemia, Gastrointestinal Hemorrhage, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Heart Failure, and End Stage Renal Disease. According to the MDS, dated [DATE], Resident #2 had a BIMS of 15 indicating Resident's cognition was intact. A review of the Resident laboratory results from his/her electronic medical record revealed the following: a. Urine Culture and Urinalysis - with collection date of 10/31/2024 at 14:11 [2:11 pm/afternoon]. b. CBC [Complete Blood Count] with Differential; Comprehensive Panel Plasma; GFR, Estimated - with collection date of 10/03/2024 at 08:34 [morning]. c. Urinalysis with Reflex to culture-Urine Microscopic-Urine Culture -Organism 1 Sensitivities - with collection date of 09/27/2024 at 08:33 [morning]; Urine Culture - Organism 2 Sensitivities - with collection date of 09/26/2024 at 05:00 [morning]. A review of Resident #2's Order Summary Report (OSR), a detailed list of active, completed, and discontinued physician orders, with Order Date: 08/01/2024-11/30/2024 revealed there were no documented Physician orders for the above-mentioned laboratory services performed on the Resident on the specified collection dates. 3. According to Resident #3's AR, Resident was admitted to the facility with the following diagnoses that included but not limited to: Malignant Neoplasm of Bladder, Personal History of (Healed) Traumatic Fracture, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Urinary Tract Infection, Chronic Kidney Disease, and Rheumatoid Arthritis. According to the MDS, dated [DATE], Resident #3 had a BIMs of 15 indicating Resident's cognition was intact. A review of the Resident's laboratory results from his/her electronic medical record revealed the following: a. Urine Culture-Organism 1 Sensitivities - with collection date of 08/22/2024 at 14:30 [2:30 p.m./afternoon]. b. Comprehensive Panel Plasma-GFR; CBC - with collection date of 08/27/2024 at 08:37 [morning]. c. CBC - with collection date of 08/30/2024 at 06:31 [morning]. d. Lipid Profile - with collection date of 11/05/2024 at 11:50 [morning]. A review of Resident #3's ORR with Order Date: 08/01/2024-11/30/2024 indicated there were no documented physician orders for the above-mentioned laboratory services performed on the Resident on the specified collection dates. In an interview of the Surveyor with the Registered Nurse-Unit Manager (RN-UM) on 11/06/2024 at 11:23 a.m. [morning], the RN-UM stated, nursing staff after getting MD [physician] order for labs would carry out the order, call the labs and schedule pick up for the specimen especially for urinalysis and culture and once we get the results we relay to the doctor. RN-UM further stated there should be physician orders for labs ordered in the residents' charts. In an interview of the Surveyor with the Director of Nursing (DON) on 11/06/2024 at 3:08 p.m. [afternoon], DON stated they had transition of lab companies last January to February and stated he will check. DON provided Surveyor with ORR and OSR reports. Surveyor informed DON of missing Physician orders for lab services performed on Residents as shown. DON stated all residents' charts are purely electronic, no more paper, and physician lab orders might be queued in the electronic medical record of residents as during the transition the physicians can enter remote orders in the charts. At this point, the DON was unable to provide documented evidence of physician orders for the lab services performed for the Residents. A review of the facility's policy titled, Physician Orders under its Policy Statement: It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law .; under Procedure .3. In order to maintain resident/patient safety when a verbal and/or telephone order is taken from a healthcare Provider, the following must occur: a. The order must be documented on a physician order form or entered into the electronic health Record (EHR) . N.J.A.C. 8:39-27.1(a)

COMPLAINT # NJ176547 CENSUS: 192 SAMPLE SIZE: 3 Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate incontinence care and double diapering a dependent resident who required staff assistance. This deficient practice was identified for 1 of 3 residents reviewed for bladder and bowel incontinence (Resident #2) and 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: Traumatic Subdural Hemorrhage without loss of Consciousness, [NAME] Syndrome, Acute and Chronic Respiratory Failure with Hypoxia, Persistent Vegetative State, Cerebral Stroke Syndrome, Gastrostomy Status, Tracheostomy Status, Essential Primary Hypertension. According to the Minimum Data Set (MDS), an assessment tool dated 6/4/2024, Resident #2 had a Brief Interview for Mental Status (BIMS) of 99, indicating that Resident # 2's cognition was unable to be assessed. The MDS also identified that the Resident #2 was always incontinent of bowel and bladder and was dependent on staff. Review of Resident #2's Care Plan (CP) initiated on 6/15/2023, under Focus: Resident is Persistent vegetative state related to traumatic subdural hemorrhage. Under Goal: Resident will remain free from discomfort and have all needs met. Under Interventions: Anticipate and meet the resident's needs. A Care Plan (CP) initiated on 7/05/2022, included a focus that the resident is at risk for falls r/t [related to] Deconditioning, Incontinence, Unaware of safety needs. Interventions included but were not limited to: Assist with frequent changing. During a tour of the fourth floor with the Unit Manager (UM) on 8/30/2024 at 10:00 a.m., Resident #2 was lying in bed with eyes closed. Resident #2's incontinence brief was saturated with urine. During another observation at 11:09 a.m. with the assigned Certified Nursing Assistant (CNA), Resident #2 was lying in bed with eyes opened. Resident #2 had two incontinence briefs on, one blue closest to the skin and one yellow. Resident # 2 was soiled with feces and urine, and the urine was soaked all the way through to the bed pad. During interview at 12:14 p.m. with the assigned CNA, CNA indicated that his/her shift started at 7:00 a.m. and stated, I take it for granted that the previous shift changed the residents on their assignment on the previous shift. CNA stated that it was the first time Resident #2 was changed for this shift. CNA further stated that it was important to change residents when soiled to keep skin from breaking down. Interview with the UM at 11:16 a.m. revealed that incontinence care should be done three times per shift which is every two hours, and as needed. UM stated that the shift started at 7:00 a.m. UM further stated that it was not normal practice for Resident #2 to have two incontinent briefs on. Interview with the Director of Nursing (DON) at 1:47 p.m. revealed that the process for incontinence care was for it to be done frequently throughout the shift and as needed. DON further stated that it was not the expectation for a resident to have two incontinence briefs on. Review of the facility's policy titled Incontinence/Perineal Care with reviewed/revised date of 1/1/24, stated: It is the practice of this facility to provide to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection, to the extent possible, and to prevent and assess for skin breakdown. NJAC 8:39-27.2(h)

Based on interview and record review, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one (Resident (R) 23) of three sampled residents in a total sample of 42. This failure placed the residents at risk of not receiving necessary services. Findings included. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R23 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and major depressive disorder. The resident did not have diagnosis of Alzheimer and/or dementia. Review of the Medical Diagnosis list located in the Medical Diagnosis tab of the EMR revealed the following mental illness diagnoses were added after admission to the facility: Anxiety disorder, dated 05/14/19; and Schizoaffective disorder (a disorder characterized by or exhibiting symptoms of both schizophrenia and a mood disorder) dated, 04/28/23. Review of the Pre-Admission Screening and Resident Review (PASARR) Level I Screen located in the Miscellaneous tab of the EMR, dated 10/13/21, revealed R23 had one mental illness diagnosis which was listed as bipolar. The PASARR did not list the diagnosis of anxiety diagnosed on [DATE]. The level 1 screening was negative (did not require a level 2 screening which is a more in-depth screening). The PASARR had not been updated when new diagnoses of mental illness were identified after 10/13/21. Review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/05/23 revealed R23 had a Brief Interview of Mental Illness (BIMS) score of 15 out of 15 which indicated he was cognitively intact, had no behaviors, and was administered an anti-psychotic, and anti-anxiety, and anti-depressant medication during the observation period. During an interview on 01/03/24 at 2:50 PM, the Social Services Director (SSD) was asked if a new Level 1 PASARR had been submitted for the new diagnosis of schizoaffective disorder, as required. The SSD stated, No, not that I am aware of. I have only been in this position since October (2023). NJAC 8:39-5.1(a)

Based on interview and record review, the facility failed to ensure the PASARR (Pre-Admission Screening and Resident Review-a screening process for residents who have indicators of intellectual disability, related disability, or serious mental illness) was followed for one (Resident (R) 43) of three sampled residents in a total sample of 42. The facility failed to ensure a PASARR Level 1 was corrected to include serious mental illness to determine if a Level II (a more in-depth screening) was required. This failure placed the resident at risk of not receiving the mental health services needed and placed him at risk for a diminished quality of life. Findings included. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R43 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs.) and adjustment disorder with mixed anxiety and depressed mood. The resident did not have a diagnosis of Alzheimer or dementia. Review of the Level I PASARR located in the Miscellaneous tab of the EMR, dated 10/06/21 showed no diagnoses of serious mental illness had been documented on the Level I form therefore, no Level II screening (a more in-depth) screening was not performed. Review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/17/23 revealed R43 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 which indicated he was moderately impaired in cognition, had no behaviors, and was administered and anti-psychotic, and anti-anxiety, and anti-depressant medication during the observation period. During an interview on 01/04/23 at 8:30 AM, the Social Services Director (SSD) was asked about the missing diagnoses on R43's 10/06/21 PASARR Level 1. She stated, I wasn't here then, but I am supposed to ensure that they are correct. The MDS coordinator also checks, it must have been missed. NJAC 8:39-5.1(a)

Based on observations, interviews, record review, and review of facility policies, the facility failed to ensure one resident (Resident (R) 118)'s out of four residents' had appropriate fall prevention interventions to prevent potential accident hazards. Findings include: Review of an undated policy provided by the facility titled, Fall Risk Assessment indicated .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of R118's electronic medical record (EMR) titled, Admission Record, located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. Review of R118's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/23, located under the MDS tab indicated the staff was unable to determine the residents Brief Interview for Mental Status (BIMS) score and revealed the resident had short-and-long term memory problems. The assessment indicated the resident required the assistance of two staff members for bed mobility and transfers. Review of R118's EMR titled nursing Progress Notes located under the Prog [Progress] Notes dated 04/11/23 indicated the resident slipped off the bed while one staff member was performing personal care. The resident sustained a scrap on his scalp. Review of R118's EMR titled Morse Fall Scale, located under the Evaluations tab dated 04/11/23 indicated the resident was at high risk for falls and scored 75. Review of R118's EMR titled Care Plan located under the Care Plan dated 04/13/23 indicated the resident was to have two staff members present during bathing and changing. Review of R118's EMR titled nursing Progress Notes located under Prog Notes dated 06/03/23 indicated the resident was found on the side of his bed and sustained an unwitnessed fall. The resident had no injuries. The progress notes indicated the resident's bed was in a low position. Review of the R118's EMR titled Care Plan located under the Care Plan tab dated 06/03/23, indicated the resident had a referral made to physical therapy for evaluation. During an observation on 01/02/24 at 10:38 AM, R118 was in bed. The bed was in the lowest position. There was a wheelchair next to the left side of his bed when facing toward the bed. In addition, there was a chair with arms on the same side but up against the end of the bed. On the right side, facing the resident there was a chair up against the end of the bed. An attempt to interview the resident was made but it was not successful. The placement of the furniture did not During an observation on 01/03/24 at 10:00 AM, R118 was in bed and there were chairs touching each end of the bed on the left and right side when facing the resident. During an interview on 01/03/24 at 10:33 AM, Certified Nursing Assistant (CNA) 2 stated the chairs may have been placed up against R188's bed by a family member. During an observation on 01/04/24 at 5:42 AM, R118 was in bed. On the left side facing there were two chairs up close to the end of his bed. On the right side, facing the resident was one chair up close to the end of the bed. During an interview on 01/04/24 at 5:47 AM, CNA 1 stated she placed the chairs next to the resident's bed since he tends to try and get himself out of bed. CNA 1 stated even after she placed the chairs around the bed, the resident still attempted to get out of bed. During an interview on 01/04/24 at 5:52 AM, Licensed Practical Nurse (LPN) 2, who was also the night supervisor, entered R118's room and stated she was not aware of staff using chairs to create a barrier around the resident's bed. During an interview on 01/04/24 at 5:56 AM, LPN3 stated she has seen the chairs placed around R118 in the past and confirmed she has done nothing about the removal of the chairs. During an interview on 01/04/24 at 8:08 AM, LPN4, who was also the day supervisor, stated she was aware the family of R118 placed the chairs around the resident while he was in bed. LPN4 stated the resident was unable to get out of the bed on his own and had poor safety awareness. During an interview on 01/05/24 at 10:02 AM, the Director of Nursing (DON) stated there was no information the facility spoke with the family regarding placing chairs around R118 while he was in bed. The DON stated the resident had impaired dexterity when asked if the furniture was a potential accident hazard. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, the facility failed to ensure one (Resident (R) 15) of four sampled residents who were fed via a gastrostomy tube had the enteral feeding container labeled, dated, and timed, as required. This failure placed the resident at risk for having received expired and/or inaccurate enteral nutrition. Findings included. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE] with diagnoses that included a non-traumatic bleeding on the brain, one-sided paralysis, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of [DATE] revealed R15 had a staff assessed Brief Interview of Mental Status (BIMS) score of 2 out of 15 that indicated he was moderately impaired in cognition and was administered all of his nutrition via a gastrostomy tube. During an initial observation on [DATE] at 9:31 AM, the enteral feeding container was observed hanging on the pole. The container label was blank and did not show the date, time, rate, or initial of the nurse who hung the feeding container, as required. During an observation of the enteral feeding container on [DATE] at 6:20 AM, the enteral feeding container was observed hanging on the pole. The container label was blank and did not show the date, time, rate, or initial of the nurse who hung the feeding container, as required. During an interview on [DATE] at 6:21 AM, Licensed Practical Nurse (LPN) 7 was asked what information the enteral feeding container should contain. LPN 7 stated, It's supposed to have the date, time, rate and initials on the container. LPN7 confirmed the container did not contain this information. During an interview on [DATE] at 12:30 PM, LPN 5, who is also the unit manager for the floor, confirmed that the enteral feeding containers are to be labeled each time they are hung. NJAC 8:,d+[DATE].1(a)

Based on observation, interview, and record review, the facility failed to ensure infection control standards were performed during intravenous (IV) medication administration for one (Resident (R) 196) of one resident reviewed for IV antibiotic medications. The facility failed to ensure proper glove use was used during IV medication administration. This failure placed the resident at risk for cross contamination from infectious agents. Findings included. Review of the facility policy's titled, Infection Control (IC) Guidelines For All Nursing Procedures, dated 02/2023, revealed, .It is the policy of this facility to adhere to infection control (IC) guidelines to limit or prevent the spread of infection between residents and/or staff . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R196 was admitted to the facility on [DATE] with diagnoses that included a kidney infection, a urinary tract infection (UTI), was resistant to multiple antibiotics, and had a PICC line (an IV access for long-term antibiotic use). Review of the Order Summary located in the Orders tab of the EMR revealed a Physician Order, dated 12/27/23 for Piperacillin (an IV antibiotic) 4.5 grams to be administered every six hours for a complicated UTI. During a medication pass observation on 01/04/24 at 5:37 AM, Registered Nurse (RN) 1 applied gloves to administer a by mouth medication. RN1 then removed her gloves, used hand hygiene and without applying clean gloves, proceeded to open the port on the PICC line with her bare hands, administer a normal saline flush, and then connect the IV line to the PICC line for the antibiotic administration. During an interview on 01/04/24 at 5:48 AM, RN1 was asked why she did not use gloves during the administration of an IV medication. RN 1 stated, I should have used gloves for the IV and not the pill, I know to do that. During an interview on 01/04/24 at 9:22 AM, the Director of Nursing (DON) confirmed that gloves and hand hygiene are to be used during IV medication administration. NJAC 8:39-19.4(a)

Complaint # NJ00168549 and NJ00168552 Based on observation, interview, and review of pertinent facility documentation on [DATE], it was determined that the facility failed to implement its policy on Administering Medications and Physician Medication Orders for 4 of 4 resident residents (Resident #1, Resident #2, Resident #3, and Resident #4). This deficient practice was evidenced by the following: During the entrance conference on [DATE] at 9:40 a.m., the Licensed Nursing Home Administrator (LNHA) revealed that LPN #1 was the previous unit manager of XX floor and was currently acting as the facility's Infection Control Preventionist (ICP). During the tour of the XX floor on [DATE] at 9:59 a.m. the Surveyor interviewed LPN #1. LPN #1 introduced herself as the floor LPN/Unit Manager (UM) and the facility's ICP. LPN #1 revealed that she has been in the UM position since last year and 4 weeks for the ICP position. LPN #1 explained that as the floor UM, her job was to make sure that the residents were being taken care of, she also did daily rounds, took orders from the Doctors and the Nurse Practitioner (NP), and entered orders in Point Click Care (PCC). PCC is an online EHR (electronic health record) solution that provides services to the LTPAC (long-term and post-acute care) industry. One of PCC's Care Management is meant to aid care teams in prioritizing care for the patients. This module integrates other options such as secure conversations, practitioner management, nutrition management, skin and wound, point of care, and medication management. The UM stated that when a resident needed help, she would provide care to the resident. The UM stated that she does not administer medications or do the treatment, however, she admitted that a few weeks ago she administered medications because they were short-staffed. A review of LPN #1's employee file on [DATE] indicated that her license expired on [DATE] and her current status was Reinstatement Pending. 1. According to the ADMISSION RECORD (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: Unstable Angina and Presence of Cardiac Pacemaker. The Minimum Data Set (MDS) an assessment tool dated [DATE], indicated that Resident #1's cognition was intact and needed assistance from staff with Activities of Daily Living (ADL). A review of Resident #1's Telephone/Verbal Order Form (TVOF), from [DATE] through [DATE] revealed that LPN #1 transcribed an order in the PCC to indicate that an order was received from the PCP on the following dates and times. A verbal order was received. On [DATE] at 3:09 p.m. for Snacks at bedtime On [DATE] at 10:06 a.m. to obtain weight monthly. On [DATE] at 4:44 p.m. to Collect UA/CS (Urinalysis and Culture and Sensitivity). On [DATE] at 8:00 a.m. for Guaifenesin tablet Extended Release. On [DATE] at 2:34 p.m. for Metformin HCl Oral Tablet 500 milligram (mg). On [DATE] at 2:39 p.m. for Iron Oral Tablet 325 mg. On [DATE] at 09:42 a.m. for Nothing by mouth after midnight on [DATE] in preparation for the surgery. On [DATE] at 4:03 p.m. for Guaifenesin-DM Liquid ,d+[DATE] mg /5 millimeter (ml). On [DATE] at 4:36 p.m. for Budesonide Suspension 0.5 mg/2 ml via nebulizer. On [DATE] at 4:36 p.m. for Ipratropium-Albuterol Solution 0XXX,d+[DATE].5 (3) MG/3ML 3 ml inhale orally via nebulizer On [DATE] at 12:30 p.m. to Test for COVID-19. On [DATE] at 3:21 p.m., for Zaditor Ophthalmic Solution 0.025 %. On [DATE] at 4:53 p.m. for Guaifenesin Tablet Extended Release 12 Hour 600 mg. On [DATE] at 7:00 a.m. for Afluria Quadrivalent Suspension. A review of Resident #1's Medication Administration Record (MAR) for ,d+[DATE], revealed that LPN #1 administered 26 medications on [DATE] during the 7:00 a.m. to 3:00 p.m. shift. 2. According to the AR, Resident #2 was admitted to the facility on [DATE], with a diagnosis that included but was not limited to End Stage Renal Disease. The MDS dated [DATE], indicated that Resident #2's cognition was intact and needed assistance from staff with ADL. A review of Resident #2's TVOF, from [DATE] through [DATE] revealed that LPN #1 transcribed an order in the PCC to indicate that an order was received from the PCP on the following dates and times. A verbal order was received. On [DATE] at 3:09 p.m. for a snack at bedtime On [DATE] at 2:08 p.m. for a Chest x-ray On [DATE] at 1:23 p.m. Monitor the right upper chest Central Venous Catheter (CVC) for signs and symptoms of infection. On [DATE] at 1:24 p.m. Check Circulation left hand every shift. On [DATE] at 1:24 p.m. Monitor Arteriovenous Fistula site for infection. On [DATE] at 1:24 p.m. Monitor for bleeding. On [DATE] at 1:24 p.m. Monitor left arm fistula for bruit and thrill every shift. On [DATE] at 7:00 a.m. Afluria Quadrivalent Suspension On [DATE] at 7:00 a.m. monitor temperature and injection site for 24 hours. A review of Resident #2's MAR for ,d+[DATE], revealed that LPN # 1 administered 2 medications and monitored the Resident for signs and symptoms of COVID-19, infections to the right upper chest, pain, and obtained the Resident's vital signs on [DATE] during the 7:00 a.m. to 3:00 p.m. shift. 3. According to the AR, Resident #3 was admitted to the facility on [DATE], with a diagnosis that included but was not limited to Malignant Neoplasm. The MDS dated [DATE], indicated that Resident #3's cognition was intact and needed assistance from staff with ADL. A review of Resident #3's TVOF, from [DATE] through [DATE] revealed that LPN #1 transcribed an order in the PCC to indicate that an order was received from the PCP on the following dates and times. A verbal order was received. On [DATE] at 10:54 a.m., to check the Fentanyl Patch Placement. On [DATE] at a.m., Nystatin Powder to apply to the groin, breasts, and abdominal folds topically. On [DATE] at 10:00 a.m., to discontinue Vilazodone oral tablet check 40 mg. On [DATE] at 11:29 a.m., for Isolation for MDR UTI every shift. On [DATE] at 1:00 p.m., for Rapid Covid Swab. On [DATE] at 5:08 p.m., for a Midline Placement for IV antibiotics On [DATE] at 1:56 p.m., for CBC, CMP, Lactic Acid Serum. On [DATE] at 2:33 p.m., for Midline Placement. On [DATE] at 1:00 p.m., for Contact precautions. On [DATE] at 4:44 p.m., for the Cubicin Solution Reconstituted 500 mg for Leukocytosis. On [DATE] at 4:44 p.m., to discontinue Meropenem Solution Reconstituted 1 gm for bacterial infections. On [DATE] at 4:45 p.m., to discontinue Contact precautions. On [DATE] at 7:19 a.m., Afluria Quadrivalent Suspension, inject 0.5 ml intramuscularly. A telephone order was received on the following dates and times: On [DATE] at 1:27 p.m., for Oxycodone tablet 10 mg. On [DATE] at 10:32 a.m., for Duloxetine Capsule 30 mg. On [DATE] at 1:16 p.m., for Fluticasone Propionate Suspension. On [DATE] at 3:18 p.m., for Nystatin powder to apply to the right groin topically. On [DATE] at 10:07 a.m., for Vancomycin HCl Intravenous Solution 1000mg/10 ml On [DATE] at 10:14 a.m., for Piperacillin Solution Reconstituted ,d+[DATE].5 g. On [DATE] at 2:21 p.m., for Bupropion HCl Tablet 75 mg On [DATE] at 2:22 p.m., for Cubicin Solution Reconstituted 500 mg, use 500 mg IV. A review of Resident #2's Medication Administration Record (MAR) for ,d+[DATE] revealed that LPN # 1 administered medications on [DATE] and [DATE] during the 7:00 a.m. to 3:00 p.m. shift. 4. According to the AR, Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Hemiplegia and Hemiparesis. The MDS dated [DATE], indicated that Resident #4's cognition was intact and needed assistance from staff with ADL. A review of Resident #4's TVOF, from [DATE] through [DATE] revealed that LPN #1 transcribed an order in the PCC to indicate that an order was received from the PCP on the following dates. A verbal order was received on the following dates and times: On [DATE] at 2:21 p.m., for Contact droplet isolation for COVID On [DATE] 2:24 p.m., to hold Atorvastatin Calcium tablet 20 mg from [DATE] to [DATE] On [DATE] at 12:00 p.m., to Infused ,d+[DATE] NS. On [DATE] at 2:12 p.m., to discontinue Sodium Chloride Solution 0.9% On [DATE] at 5:57 p.m., to discontinue Infuse ,d+[DATE] (NS) On [DATE] at 12:49 p.m., to discontinue Contact /Droplet isolation COVID. On [DATE] at 12:50 p.m., for Afluria Quadrivalent Suspension (Influenza A telephone order was received on the following dates and times: On [DATE] at 1:30 p.m., for Bupropion 150 mg Depression. On [DATE] at 1:30 p.m., for Nystatin powder apply to the left breast topically. On [DATE] at 2:21 p.m., for Paxlovid oral tablet therapy pack 20 x 150 mg & 100 x 100 mg. A review of Resident #4's Medication Administration Record (MAR) for ,d+[DATE], revealed that LPN # 1 administered 14 medications on [DATE] and 14 medications on [DATE] during the 7:00 a.m. to 3:00 p.m. shift. In a follow-up interview with the LNHA on [DATE] from 12:20 p.m. through 1:47 p.m., the LNHA stated that since her license expired on [DATE] and was currently on Reinstatement Pending status. He further stated that LPN #1 was given a new position as the Assistant Director of Nursing (ADON). According to LNHA, the role of an ADON was an Administrative duty but not in the clinical aspect. He explained that the LPN should not be accepting and entering orders in PCC from the doctors and should not be administering medication to the residents because LPN #1 was not lawfully authorized because the LPN's license was not current. The Administrator revealed that LPN #1 was being supervised by the Administrator and by the Director of Nursing, however, he was not sure if the LPN was being supervised when she was accepting orders from the doctors and when she was administering medications on the aforementioned dates and times. A follow-up interview with LPN #1 on [DATE] at 2:32 p.m. The LPN revealed that her license expired and was in the process of reinstating. LPN #1 stated that on [DATE] she signed an agreement to continue to work as the facility's ADON and IP. As the ADON and IP, she has to remain on the floor to make sure that the residents are receiving the proper care. LPN #1 explained that she was not aware that she was not allowed to accept orders from doctors and or Nurse Practitioners and was not to administer medications. LPN #1 explained that on [DATE], she had to administer medications to the residents because there was a call out and there was no other nurse available at that time that could administer the medications. LPN#1 further explained that she made the decision to administer medications and did not call the DON and the Administrator. LPN #1 stated that the DON and Administrator were made aware a few days after [DATE]. A review of the job description for LPN Unit Manager indicated under Job Requirements: Licensed Nurse with a current state license. A review of the job description for Assistant Director of Nursing indicated under Summary: Manage administrative and functional areas or programs within the Nursing Department. Assist the Director of Nursing (DON) in the overall operation of the department in accordance with Company policies, and standards of nursing practices and government regulations, so as to maintain quality of care .Job Requirements: Minimum of three (3) years of nursing experience . A review of the facility policy titled Physician Medication Orders, dated ,d+[DATE], indicated POLICY STATEMENT Medication shall be administered only upon the written order of a person duly licensed .3. Verbal orders for drugs and treatments shall be received only by Licensed Nurses . A review of the facility policy titled Administering Medications, dated ,d+[DATE], indicated under Policy Interpretation and Implementation 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . NJAC 8:,d+[DATE].1(a) NJAC 8:,d+[DATE].2 (b) NJAC 8:,d+[DATE].2 (d) NJAC 8:,d+[DATE].2 (d)

Based on interview, record review, and review of facility policy, the facility failed to provide a transfer notice which contained all required information to four (Resident (R) 3, R4, R7, and R9) of four sampled residents reviewed for transfer notices. The notice failed to contain an explicit statement that the resident had the right to appeal against the transfer. The notice also failed to contain the name, address, and contact information for the correct state agency which handled these appeals. Findings include: 1. Review of a hard copy Admission Record, provided by the facility, revealed that R3 was admitted to the facility on [DATE]. The resident's diagnoses included adjustment disorder and bipolar disorders. Review of a Notice of Emergency Transfer, dated 05/08/22 and provided by the facility, revealed that the resident was transferred to another facility for a psychiatric evaluation Review of this Transfer notice revealed that it did not contain a statement that the resident had the right to appeal the transfer, nor did it give the name of the agency to whom such appeals should be submitted. The form did contain a statement saying, If the resident or his/her representative disagree with this transfer, the resident and/or representative may contact the following entity: NJ Long Term Care Ombudsman, and gave the contact information for the Ombudsman agency. 2. Review of a hard copy Admission Record, provided by the facility, revealed that R4 was initially admitted to the facility on [DATE]. Per the Admission Record, the resident's diagnoses included chronic obstructive pulmonary disease (COPD), dementia, and bipolar disorder. Review of hard copy Notice of Emergency Transfer forms, dated 06/28/22, 10/27/22, 01/03/23, and 04/07/23 and provided by the facility, revealed that that for each of the notices, R4 was sent to a hospital for acute care. Review of these four Transfer forms revealed they failed to state that the resident had the right to appeal the transfer. The forms failed to contain the name or contact information for the agency to whom the appeal should be addressed. Instead, each listed only the name and contact information for the Ombudsman's office. 3. Review of R7's Admission Record, located in the EMR under the Profile tab, revealed R7 was admitted to the facility on [DATE] with diagnoses that included sepsis, pressure ulcer, and adult failure to thrive. Review of R7's Notice of Emergency Transfer forms, provided by the DON with dates 08/29/22 and 11/14/22, indicated, . This notice is to confirm that . resident [R7] was transferred . on emergent basis . if the resident or his/her representative disagree with this transfer, the resident and/or representative may contact the following entity: NJ Long-Term Care Ombudsman . 4. Review of R9's Admission Record, located in the EMR under the Profile tab, revealed R9 was admitted on [DATE] with diagnoses that included pneumonia, atherosclerotic heart disease, acute kidney failure, and chronic obstructive pulmonary disease. Review of R9's Notice of Emergency Transfer forms, provided by the DON with dates of 06/22/22, 08/11/22, 08/30/22, 12/06/22, and 02/08/23, indicated, . This notice is to confirm that . [R9] was transferred . on emergent basis . if the resident or his/her representative disagree with this transfer, the resident and/or representative may contact the following entity: NJ Long-Term Care Ombudsman . Interview with the Corporate Representative on 06/21/23 at 1:47 PM revealed his belief that the information used on the Transfer notices was correct. He stated that the Office of the Ombudsman was the agency that residents should contact if they wanted to make an appeal, and there was no reason to list the Ombudsman's name and address twice on the form. (Federal regulation requires that, in addition to the name of the agency handling appeals, the notice must also contain contact information for the Office of the Ombudsman.) During an interview with a representative of the New Jersey (NJ) Long Term Care Ombudsman program by telephone on 06/22/23 at 9:15 AM, she stated, The Ombudsman is NEVER the appealing agency for transfers or discharges. She stated that after talking with the survey team on 06/21/23, she conferred with her supervisor who confirmed this information. The Ombudsman stated that they did not know who the correct agency was, but it was not them. During an interview with the Administrator on 06/22/2 at 12:11 PM, he was informed that the Transfer notices did not contain the correct agency responsible for appeals. When told that the Ombudsman's office denied being responsible for appeals, he stated that he did not know who the correct agency was and confirmed he would have to find that information. Review of the facility's Transfer or Discharge Notice policy, reviewed/revised 02/2023, revealed it did not identify the proper state agency to whom appeals should be directed. Review of the policy revealed, . The resident and/or representative (sponsor) will be notified in writing of the following information . A statement of the resident's rights to appeal the transfer or discharge, including:(1) the name, address, email, and telephone number of the entity which receives such requests;(2) Information about how to obtain, complete and submit and appeal form; and (3) How to get assistance completing the appeal process .

F657 E Based on interview, record review, and review of facility policy, the facility failed to ensure that four (Resident (R) 11, R4, R10, and R9) of four sampled residents reviewed for care plan involvement were provided the opportunity to participate in the development of their care plan. The residents and/or their representative/family members (FM) were not consistently invited to care plan meetings. In addition, the facility failed to explain/document if there was a reason that inviting the resident and/or their representative was not practicable. Findings include: 1. Review of a hard copy Admission Record revealed R11 was admitted to the facility on [DATE]. The resident's diagnoses listed on the Admission Record included dementia, mental disorder, and unspecified intellectual disabilities. The Admission Record listed a family member (FM11) as the resident's emergency contact. Per the resident's most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/23 and which was located in the electronic medical record (EMR) under the MDS tab, R11 had severe cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 5/15. Review of MDS tracking information revealed the resident had the following MDS assessments, which would trigger a care plan review/revision: 12/07/21 = Quarterly MDS, 03/08/22 - Quarterly MDS, 06/07/22 - Quarterly MDS 09/05/22 - Annual MDS, 12/06/22 - Quarterly MDS, 03/07/23 - Quarterly MDS, and 06/06/23 - Quarterly MDS. Review of a 06/19/23 Social Service Note, located under the tab for Progress notes in the EMR, revealed that a care plan conference was held in response to the 06/07/23 MDS, and FM11 attended via telephone. Further review of the entire EMR, including the Social Service Note records in the Progress Notes tag revealed no evidence that the resident or her FM were invited to any of the care plan conferences held after completion of the MDS assessments dated 12/07/21 through 03/07/23. In addition, a review of all Progress Notes during this time period revealed no explanation as to why the presence of the resident and/or their representative was not practicable for inclusion in care plan meetings. Interview with FM11 by phone on 06/20/23 at 4:45 PM revealed that when she attended the 06/19/23 care plan meeting, it was the first time that she had been invited to or attended a care plan meeting conducted after completion of an MDS. She confirmed that she never had a care plan meeting prior to 06/19/23, and had, in fact, had to call the facility herself and schedule a meeting on 04/18/23 because of concerns that needed to be reviewed. Interview with the Social Services Director (SSD) on 06/21/23 at 9:22 AM revealed that Social Services staff was the department responsible for inviting the resident and their representative to care plan meetings. She stated that the facility invites every alert and oriented resident to the meeting, as well as the family if the resident desires. The SSD stated if a resident was not alert and oriented, they invited the family/responsible party. She stated that these invitations should be sent every quarter. The SSD stated that she would review facility records and provide care plan meeting records for R11, as well as other requested residents. An additional interview with the SSD on 06/21/23 at 10:02 AM revealed that documentation regarding care plan conferences was maintained in the Social Service notes portion of the EMR Progress Notes. The SSD confirmed that she could only find evidence that R11's family member had been invited to one care plan conference - the one that took place two days earlier on 06/19/23. The SSD stated that due to R11's cognitive impairment, FM11 should be invited to all meetings. 2. Review of a hard copy Admission Record revealed R4 was admitted to the facility on [DATE]. Per the Admission Record, R4 had diagnoses including dementia and bipolar disorder. The Admission Record documented that the resident was her own responsible party, and three family members were listed as Emergency Contacts. Review of MDS tracking information in the EMR revealed it included the following MDS assessments, which triggered a care plan review/revision: 06/21/22 - Quarterly, 09/20/22 - Quarterly, 12/13/22 - Quarterly, and 03/07/23 - Annual. Review of the entire EMR, including the Social Service Note records in the Progress Notes tab, revealed no evidence that the resident or her family member were invited to care plan conferences held in response to these four MDS assessments. In addition, review of all Progress Notes during this time period revealed no explanation as to why the presence of the resident and/or their representative was not practicable for inclusion in these four care plan meetings. Interview with the resident on 06/20/23 at 12:17 PM revealed the resident, who was in her room, was pleasant but disoriented to time, and she did not express any concerns related to care planning. Interview with the SSD on 06/21/23 at 10:02 AM revealed that she could not provide evidence that R4, as well as her family/representative, were invited to every care plan meeting. 3. Review of a hard copy Admission Record revealed R10 was admitted to the facility on [DATE]. Per the Admission Record, R10 had diagnoses including vascular dementia, as well as hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The Admission Record documented that the resident's family member (FM 10) was the Power of Attorney (POA) for care, and she was also listed as Emergency Contact #1. Review of MDS tracking information in the EMR revealed it included the following MDS assessments, which triggered a care plan review/revision: 06/11/22 - Quarterly, 09/19/22 - Quarterly, 12/31/22 - Quarterly, and 03/31/23 - Annual. Review of the entire EMR, including the Social Service Note records in the Progress Notes tab revealed no evidence that the resident or her family member were invited to care plan conferences held in response to these four MDS assessments. In addition, review of all Progress Notes during this time period revealed no explanation as to why the presence of the resident and/or their representative was not practicable for inclusion in these four care plan meetings. An attempt to interview the resident in her room on 06/20/23 at 10:00 AM about care issues was unsuccessful, based on interference from FM10, who was also present. An attempt to interview FM10 about various issues, including care planning, was also unsuccessful. An additional attempt to interview R10 on 06/20/23 at 12:36 PM (without FM10's presence) revealed the resident answered basic demographic questions and did not report any care concerns. Review of R10's current MDS, a quarterly with an ARD of 06/09/23 which had not yet been signed, revealed the resident was severely cognitively impaired, based on a BIMS score of 4/15. Interview with the SSD on 06/21/23 at 10:02 AM revealed that she could not provide evidence that R10, as well as her family/representative, were invited to every care plan meeting. 4. Review of R9's Admission Record, located in the EMR under the Profile tab, revealed R9 was admitted on [DATE] with diagnoses that included pneumonia, atherosclerotic heart disease, acute kidney failure, and chronic obstructive pulmonary disease. Review of R9's MDS (Minimum Data Set) assessment schedule, located in the EMR under the MDS tab, indicated R9 had a quarterly/Medicare 5-day MDS assessment completed on 10/5/22 and a quarterly MDS assessment completed on 01/03/23. Review of the entire EMR revealed no documentation that the resident or resident's family member were invited to attend the Care Plan Conferences after completion of the two MDS. During a telephone interview on 06/21/23 at 3:00 PM, R9's family member (FM)1 stated, I was never invited to a Care Conference after he (referring to R9) was admitted in June 2022. I attended a Care Conference in June when he was admitted , and they never invited me to another one after that. Interview with the MDS Coordinator on 06/22/23 at 2:26 PM revealed that the care conferences used to be scheduled by the Social Services staff. The MDS Coordinator stated she made the schedule herself now. The MDS Coordinator clarified that by making the schedule, she meant that she set the dates and notified all members of the interdisciplinary team (IDT) about due dates for the assessment and care planning. The MDS Coordinator explained that after receiving the date for the care conference, Social Services (SS) was responsible for calling families and setting the care plan meeting. Interview with the SSD on 06/21/23 at 10:02 AM revealed that the facility had a new SS team, and it had been confirmed that residents and their families were not consistently being invited to the care plan meetings The SSD stated the SS team was working to ensure that this occurred for all future care plan meetings. Review of the facility policy titled, Resident Participation, Assessments and Care Plans, revised 02/2023, revealed, . 1. The resident and his or her legal representatives are encouraged to attend and participate in the . development of the resident's person-centered care plan. 2. Spouses and other members of the family may participate in the .development of the person-centered car plan with the resident's permission, 3. The resident/representative's right to participate in the development and implementation of his or her plan includes the right to: a. participate in the planning process . 4. The care planning process will facilitate the inclusion of the resident and/or representatives . 7. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. 8. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices, Notices include: a. the date, time, and location of the conference b, the name of each person contacted and date he or she was contacted. c. The method of contact (e.g., mail, telephone, emails, etc.) d, Input from the resident or representative if they are not able to attend e. Refusal of participation, if applicable; and f. The date and signature of the individual making the contact .

Based on interview, record review, and facility policy review, the facility failed to ensure that copies of resident records were provided within two working days for two (Resident (R) 2 and R11) of two residents reviewed for provision of records out of a sample of 11 residents. Requests for records from the residents' responsible parties and/or Power of Attorney were not acted upon in a timely manner, with delays exceeding two years in fulfilling the requests. Findings include: 1. Review of R2's hard copy Admission Record revealed R2 was admitted to the facility on [DATE] and was discharged from the facility on 11/02/20. Per the Admission Record, a family member (FM 2) was listed as both Emergency Contact #1, as well as R2's financial Power of Attorney (POA). Review of a request for R2's medical records revealed a letter was sent by an attorney and was dated 03/23/21. Attached to this letter was an Authorization for Release of Medical Records, signed by FM2, who was listed on the request for the records as the Durable POA. This form, signed by FM2 and dated 03/17/21, authorized the release of the resident's medical records to the attorney on behalf of the POA. The attorney's request for copies of the records noted the request was being made after the POA, himself, had made several requests for the records but they had not been provided. Review of R2's entire electronic medical record (EMR) revealed no evidence that the requested records were ever copied and delivered to the attorney/POA. An interview by telephone on 06/20/23 at 2:37 PM with the attorney revealed that he was representing the Durable POA. He confirmed that the initial request for the resident's medical records was made in 2021. He stated, It was over a year. We had to file a suit to get the records. They completely ignored us for ages. Further interview with the attorney revealed that even when records were eventually received, they were not complete, and the attorney had recently filed an order for the facility to produce the rest of the requested records. During this call, the attorney emailed a copy of this suit, dated 06/14/23. Review of the document confirmed that it was a request for additional information from R2's medical records which had still not been provided. Interview with the Regional Consultant on 06/20/23 at 11:39 AM revealed that when a POA sends a request for records, they must sign a consent form. The Regional Consultant added that if someone other than the POA requests the records, they ensure the POA has approved the request, and if the POA approves, the records can then be released. Interview on 06/20/23 at 2:06 PM with the Medical Records staff revealed that if the request is from the resident or family, once the request (Authorization form) is signed, it is usually 48 hours for the records to be copied/released. He stated that if the request was from an attorney, the request would go to Administration or Corporate staff for review to make sure the POA is OK with the request. Medical Records stated that for this type of request, it was two weeks max to get the records copied and sent out. When asked about R2's request, Medical Records stated, That was last year, two years ago, and the request was made due to litigation. Medical Records stated that the request was received when a different Administrator was working in the facility. He stated he needed to check to see what happened, and would return with any additional information he had. Interview on 06/20/23 at 1:26 PM with the Assistant Administrator revealed that neither he nor the current Administrator were working at this facility at the time that the initial request was made in 03/2021. The Assistant Administrator stated he thought the request came in during 2022 and, Once the lawyer reached out to me, there was back and forth on the phone, adding that, The issue was trying to find out exactly what he wanted. The Assistant Administrator stated that the records were finally sent out on 04/28/22. The Assistant Administrator stated, Per regulation, I understand records are to be sent out within 48 hours, confirming, So yes, this was late. A follow-up interview on 06/20/23 at 2:00 PM with Medical Records confirmed the copies were not sent to the attorney representing the POA until 04/28/22. He stated that he could find no record of the POA ever calling or sending in requests for copies and would continue to search for any relevant information. An additional interview with the Assistant Administrator was conducted on 06/20/23 at 5:15 PM. During this interview, the Administrator was also present. Interview with the Administrator confirmed that he was not working at the facility at the time the request for records was made in 2021 and had no direct knowledge of what occurred in 2021. Interview with both revealed they were unaware if the facility had a system for logging and tracking record requests. They stated that they would continue to look for any records which might show when the request was first received and the reason for the delay in sending out the copies. An additional interview was conducted with Medical Records on 06/21/23 at 10:34 AM. He stated that he had been the medical records staff since 2019 and had not really done medical records before being assigned to the position. Medical Records stated that he did not have a tracking system to show when record requests were received or completed and the facility had not been able to find any additional information about the request for R2's records. Medical Records confirmed that the submission of R2's copies was not timely, adding the records are supposed to be sent out in 48 hours. 2. Review of the hard copy Admission Record revealed R11 was admitted to the facility on [DATE]. Per the Admission Record, FM11, a family member, was listed as Emergency Contact #1. Review of a hard copy Authorization to Release Patient Information form, signed by FM11 and provided by the facility, revealed that FM11 had requested R11's medical and any bloodwork or x-rays on 11/15/22. At the top of this paper was a note that stated, Complete 2/15/23. Review of a copy of a letter addressed to the current administrator and sent via certified and regular mail on 04/29/13 by FM11 revealed, For the last two years and four months, I have requested but not received copies of her [R11] medical records. On 04/29/21, I received a record release form and the same date, completed, and mailed it to your facility. Your staff member [Medical Records] confirmed receipt of the signed document and informed me that he would send me [R11]'s medical records. Interview by telephone on 06/20/23 at 4:45 PM with FM11 revealed that she did not receive copies of R11's records until 2023. When asked to verify what she said, FM11 stated, That is correct - nothing from 2021 until 2023, adding, It was two years to get partial records. FM11 was asked to explain, and she stated, Even when they sent the records [in 2023], it wasn't everything. FMS stated she only received a partial set of copies, and these were not the records she requested, adding that what she received was assessments for Medicare/Medicaid. Further interview with FM11 revealed that the Medical Records staff had previously verified to her that the facility received her initial request for copies of the records on 02/15/21. She concluded by noting, I'm told it's my right to get these [copies] but no one will get the medical record to me. Interview on 06/20/23 at 1:55 PM with R11, who was in her bed, revealed she was pleasantly confused, and she stated she was unaware of any issues regarding a request for her medical records. Review of R11's most current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/23, revealed the resident was severely cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 5/11. Interview on 06/21/23 at 10:34 AM with Medical Records revealed that he stored record requests on his desk. He stated that when a request for copies comes in, he adds it to the stack on the desk in chronological order for him to work on, and once completed, the request is filed. He stated that he did not have a tracking mechanism to be able to verify when an initial request was first received, subsequent correspondence including sending the facility's Authorization form, or the final disposition of the request, including a date when all requested records were sent. Interview with Medical Records revealed that he did not remember confirming to FM11 that her initial request for records was received in 2021 and he could not find a copy of her initial request. However, Medical Records added that he had spoken back and forth with her after first receiving her request for copies of the record and stated, I had her fill out the Authorization to Release Patient Information. Medical Records stated the only record he could find was FM11's Authorization to Release Patient Information request for records on 11/15/22. During this interview, Medical Records confirmed that copies of records are supposed to be sent out in 48 hours. Medical Records stated that R11's records were sent out 01/15/23, rather than 02/15/23, explaining that the initial date written on the form was incorrect, and he had written over the date, changing the 2 for February to a 1 for January. Medical Record confirmed that the 01/15/21 submission of the copies was untimely, adding, It was quite some time [before the records were copied/sent] .I'm surprised about two years. Review of the facility policy titled, Release of Information, revised 02/20/23, revealed that, . All information contained in the resident's medical record is confidential and may only be released by written consent of the resident or his /her legal representative (sponsor), consistent with state laws and regulations . The policy further noted that . Requests will be honored only upon receipt of a written, signed, and dated request from the resident or representative . A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends or holidays) advance notice of such request .

Based on record review, interview, and facility policy review, the facility failed to ensure family representatives were immediately informed of a significant change in condition requiring transfer to the hospital for one (Resident (R) 9) of 12 sampled residents. Specifically, R9's family representative was not informed on two separate occasions when R9 was transferred to an acute care facility for severe pain. Findings include: Review of R9's Admission Record, located in the EMR under the Profile tab, revealed R9 was admitted on [DATE] with diagnoses that included pneumonia, atherosclerotic heart disease, acute kidney failure, and chronic obstructive pulmonary disease. Review of R9's Nurses Notes, located in the electronic medical record (EMR) under the Progress Notes tab and dated 08/12/22 at 9:12 PM, indicated, . Resident complained of pain due to muscle spasm . Dr. in to see patient . new order to send out to ER (emergency room ). Call placed to ER, patient admitted to D5 with diagnosis of back pain. There was no documentation R9's family representative was notified. Review of R9's Nurses Notes, located in the EMR under the Progress Notes tab and dated 02/08/23 at 1:08 AM, indicated, . At 09:55 PM Resident complained of pain from left shoulder extending to his left hip. Requested oxycodone [a pain medication] 5 MG (milligram). At 10:30 PM resident told writer that the pain was too severe, so he wanted to go to the hospital, writer called doctor and she recommended him going to the hospital. He left facility at 12:55 PM . There was no documentation R9's family representative was notified. Review of R9's Admission Record, located in the EMR under the Profile tab, indicated two emergency contact numbers and an email address where family representatives could be contacted. During a telephone interview on 06/21/23 at 3:00 PM, R9's family member (FM) 1 stated, I wasn't aware that he (referring to R9) went to the hospital for severe pain. I found out later when he called me from the hospital. During an interview on 06/22/23 at 12:15 PM, the Director of Nursing (DON) stated she could not find documentation in the EMR that the facility notified either of R9's family members on 08/12/22 or 02/08/23 when R9 was transferred to the hospital. The DON stated, The nurse who receives the order from the physician for transfer should have notified the family. Review of the facility's policy titled Change in Condition or Status, revised 1/2022, indicated, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical status . when it is necessary to transfer the resident to the a hospital/treatment center .

Based on observation, interview, and record review, the facility failed ensure one (Resident (R) 4) of 12 sampled residents received oxygen at the rate ordered by the physician and per the comprehensive care plan. Findings include: Review of the hard copy Admission Record revealed R4 was initially admitted to the facility on [DATE]. Per the Admission Record, R4's principal diagnosis was chronic obstructive pulmonary disease (COPD) with acute exacerbation. Additional diagnoses included chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), pulmonary edema, dementia, and need for assistance with personal care. Review of R4's current physician orders for 06/2023, located under the Orders tab in the electronic medical record (EMR), revealed that R4 was to receive O2 [oxygen] via nasal canula at 3L/min [liters per minute]. The current order was effective 04/12/23. Review of R4's current care plan, dated 06/03/23 and located under the Care Plan tab of the EMR, revealed that R4 has oxygen therapy r/t [related to] respiratory illness. It was documented R4 was to receive oxygen via nasal cannula at 3 L/min continuously. Observation on 06/20/23 at 12:17 PM revealed the resident was sitting in a wheelchair between her bed and the wall. The resident was receiving oxygen via nasal canula. The oxygen concentrator was behind the resident and the flow rate could not easily be seen, based on the positioning of the resident's chair. Interview with the resident at this time revealed her statement that she was receiving O2 at 4L/min, adding, It's always on 4. After receiving the resident's permission to move around to look at the concentrator, observation revealed that it was set between 4-5L/minute. Observation on 06/21/23 at 8:29 AM and 12:48 PM revealed R4 was asleep in bed, receiving O2 via nasal cannula. During each observation, the resident's O2 was set to 6L/minute. An additional observation was made on 06/21/23 at 12:54PM which showed the resident's O2 was still set at 6L/minute. Registered Nurse (RN) 1, who accompanied the survey team for this observation, confirmed that the oxygen concentrator was set to, and the resident was receiving oxygen at 6L/minute. An additional interview on 06/21/23 at 2:49 PM with RN1 revealed that after making the observation with the survey team, she checked the resident's record. She stated that upon review of the physician's orders, she found that the resident was supposed to receive O2 at 3L/minute, rather than 6L/minute. RN1 confirmed that the resident had been receiving O2 at the wrong rate, and in response, she changed the oxygen setting to the 3L/minute that was ordered. RN1 stated that although she could not be sure, it appeared the aides were setting the rate on the concentrator without knowing the ordered flow rate. Interview with the facility's Infection Preventionist (IP) on 06/22/23 at 12:13 PM revealed that the resident had a long history of respiratory issues, with exacerbations of COPD and a history of rounds of pneumonia. The facility's IP stated she was unaware that the resident had been observed receiving oxygen at a rate higher than prescribed. The IP stated that negative potential outcomes associated with too high a rate of oxygen in a resident with COPD included hypoxia. The IP confirmed that staff needed to follow the physician's orders and administer oxygen at the rate it was prescribed/care planned.

Based on observation, interview, record review, and review of facility policy, the facility failed to serve meals that reflected the resident's preferences for two (Resident (R) 4 and R10) of 10 residents reviewed for dietary services. The residents had identified foods that they disliked; however, these foods were served to the residents. Findings include: 1. Review of R10's hard copy Admission Record revealed R10 was initially admitted to the facility on [DATE]. Per the Admission Record, the resident's diagnoses included vascular dementia, unspecified protein-calorie malnutrition, reflux disease, Type II diabetes, and dysphagia. Review of a hard copy of R10's Food Preference Assessment revealed that the resident's dislikes included scrambled eggs, fried eggs, Spanish scrambled eggs, cheesy eggs, and Group - All Eggs. Observation on 06/21/23 at 8:39 AM revealed that Certified Nurse Aide (CNA) 4 was feeding R4 breakfast. In addition to french toast, cereal, milk and juice, the resident's meal included scrambled eggs (a listed dislike). Review of the tray card that came with the meal revealed that the resident should have received cereal, ground French toast and a fruit cocktail for the breakfast meal. There was nothing on the card to indicate that eggs were supposed to be served to the resident. 2. Review of R4's hard copy Admission Record revealed R4 was initially admitted to the facility on [DATE]. Per the Admission Record, the resident's diagnoses included dementia, bipolar disorder, chronic obstructive pulmonary disease (COPD), reflux, and diabetes, Review of a hard copy of R4's Food Preference Assessment, revealed that it included several Dislikes. The foods that the resident did not like included spinach and potato group. Observation on 06/21/23 at 12:51 PM revealed that CNA6 served the resident's meal tray and assisted her in self-feeding. In addition to a chopped pork sandwich, the meal tray contained two foods - spinach and mashed potatoes - that were identified as dislikes. Review of the resident's tray card revealed it listed spinach was to be served, even though this was one of the resident's dislikes. The tray card did not show that the resident was to receive a serving of potatoes; however, they were provided to the resident. Interview with the Director of Dietary (DOD) and the Dietary Supervisor (DS) on 06/21/23 revealed that either they or the Registered Dietitian (RD) obtained each resident's food preferences and documented them on the Food Preference Assessment. Additional interview with the DOD and DS on 06/21/23 at 1:22 PM revealed R10 was not supposed to be served eggs. They reviewed the tray cards against the preference lists and confirmed that, in addition to R10 not getting eggs, R4 should not have received spinach or potatoes. The DOD stated that it appeared that although food allergies were being listed on the tray card, the cards did not reflect the foods that the residents disliked. As a result, the staff serving the food did not know they should provide a substitute for the disliked food. Further interview with the DOD and DS revealed it appeared that even when foods which were disliked were omitted from the card, staff serving the meals still dished up these food items for the residents. A further interview with the DOD and DS on 06/21/23 at 2:00 PM revealed they had called for help with the computer system to fix the issue so that it would black out resident dislikes on the tray card. During this interview they also confirmed the need to ensure that dietary staff were following the tray cards and not giving food that was not listed (as in the example where R4 received potatoes, even though it was not listed as a food to be provided on the tray card. After the interview with the DOD and DS on 06/21/23 at 2:00 PM, observation and interview revealed that the facility had not corrected the system to ensure resident's preferences were honored: Review of R4's 06/22/23 tray card revealed the resident was to receive chopped kielbasa, chopped Oriental vegetable, and fruit cocktail for lunch. The tray card had no mention of potatoes on it. Observation on 06/22/23 at 1:13 PM revealed R4 had finished her lunch and was asleep in bed. Observation of her meal tray revealed the resident received potatoes for lunch for the second day in a row. Although the tray card showed potatoes were not listed as a food to be served during the lunch meal, an interview with CNA6 on 06/22/23 at 1:13 PM confirmed that R4 was provided potatoes for lunch. Review of the facility policy titled, Resident Food Preferences, reviewed/revised 02/2023, revealed, . Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team . Upon the resident's admission or within twenty-four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident's preferences .

Complaint #: NJ 047 Based on interview and record review it was determined that the facility staff failed to provide the necessary care and services to maintain the highest physical well being for 1 of 3 sampled residents, (Resident #1). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 required assistance of staff for all activities of daily living and one-on-one feeding assistance. Resident #1 had a physician order [REDACTED].#1 ate very slowly and that it would usually take 40 plus minutes to feed Resident #1 a meal. The Dietary Supervisor reported that there were no Dysphagia Advanced alternate meals made to order for the evening meal of [DATE], which would have included chopped brussel sprouts. The alternate dietary meal for a Regular Diet would have included whole brussel sprouts. The Director of Nursing (DON) reported that the Certified Nursing Assistant (CNA #1), who fed Resident #1 the evening meal on [DATE], remembered cutting up vegetables before she fed Resident #1. CNA #1 called for assistance when Resident #1 became unresponsive while being fed at approximately 6:40 p.m. A Registered Nurse (RN #1) responded and assessed Resident #1. Resident #1 was not breathing and RN #1 had difficulty finding a pulse. A Code Blue (Medical Emergency) was called as well as 911 and the attending physician for Resident #1. Resident #1 was transferred to the hospital by ambulance at 7:05 p.m. The surveyor observed documented in a statement by RN #2, that Resident #2 was admitted to the Medical Intensive Care Unit (MICU) with a [DIAGNOSES REDACTED]. This deficient practice is evidenced by the following: (All interviews were conducted on [DATE] unless otherwise documented.) According to the facility Admission Record, Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated [DATE], documented that Resident #1 had memory problems and was severely cognitively impaired. Resident #1 also required the assistance of staff for all activities of daily living (ADLs) and one-on-one assistance for feeding. The surveyor observed the following during medical record review: A physician order, dated [DATE], for a "Dysphagia Advanced Diet, allow regular scrambled eggs, ground meats and vegetables, continue thin liquids." A Nutrition care plan, dated [DATE] and revised [DATE], indicated "Provide diet as ordered." On the [DATE] "ADL Record", where the CNAs document care, the diet indicated was: "Dysphagia Advanced, allow regular scrambled eggs, ground meats." In a Nutrition note, written by the Dietician, dated [DATE]: "(Resident #1) Fed by staff. Intake ,[DATE]%. (Resident #1) remains on a Dysphagia Advanced diet (allow regular scrambled eggs, ground meat and vegetables." On further surveyor observation, a nurse's note, dated and timed [DATE] 20:40: "Resident #1 transferred to hospital for possible aspiration. Resident #1 was being fed by the assigned aide and (RN #1) was called into the room, noted that Resident #1 was turning blue, supervisor notified, Ambu-bag given and 911 (call) made. MD (doctor) and POA (power of attorney) made aware." The surveyor requested and reviewed the facility Resident/Patient Incident Report for Resident #1 dated and timed, [DATE] at 6:40 p.m. The description of incident was as follows: "Resident was in bed. CNA #1 reported that she was feeding Resident #1. All of a sudden Resident #1 started pocketing the food. When CNA #1 tried to remove the food from Resident #1's mouth, the resident refused to open his/her mouth, and that's when CNA #1 notified me. Resident #1 appeared unresponsive with bluish discoloration to mouth and fingers." On continued surveyor review of facility documentation, In-service Education on the "New Diet Manual" was provided staff on [DATE]. CNA #1 attended and signed the education program attendance sheet. Also, CNA #1 had documentation that showed clinical competency in the [MEDICATION NAME] Maneuver on [DATE]. The surveyor observed the facility policy on Diet Descriptions, dated [DATE]. The following was observed for the Dysphagia Advanced Diet: "Intended for individuals with mild chewing or swallowing difficulty. Chopped meats, fruit and vegetables are the size of a pea." At 1:00 p.m., the surveyor conducted an interview with both the DON and the Administrator. The Administrator reported: "Resident #1 was always on a dysphagia advanced diet. We looked back and CNA #1 had cared for Resident #1, 23 times in the last 3 months. Resident #1 was not new to her." The DON reported: "CNA #1 changed her story many times during the time that we interviewed her. Finally, she did admit to cutting up vegetables and said that she had fed them to Resident #1." At 2:00 p.m., the surveyor interviewed CNA #2 and asked what she would do if she observed someone coughing when being fed. CNA #2 replied: "I would stop feeding them. If they did not stop and they were choking, I would do the [MEDICATION NAME] Maneuver and call for the nurse." The surveyor then asked how the trays are delivered to the residents. CNA #2 then replied: "The nurses and aides deliver them. We look at the meal ticket and the food that is on the tray. If it is the wrong food, we report it to the nurse and not give it to the resident." At 2:22 p.m., the surveyor conducted an interview with the Food Service Director (FSD). The FSD reported: "The facility has a Tray Tracker program, where the diets and supplements ordered for residents are matched to a spread sheet. A tray ticket is produced and is placed on that specific resident's meal tray. No tray is prepared or delivered without a tray ticket. The trays are checked at the end of tray line, in the kitchen, before they are sent out to the floors, by the dietary supervisor." The surveyor asked how a resident would get an alternate meal if they so requested. The FSD then replied: "There are only 2 ways a person could get an alternate meal. One, if they had made out a Personal Choice Menu selection, which Resident #1 could not do. I know for a fact that Resident #1's family does not make them out either. And, two, if a resident decides during the meal delivery that they want something else. The staff then need to make a formal request to the kitchen, the kitchen Dietary Supervisor needs to review the request and if possible, then makes out a new meal ticket with the new food items on it." The surveyor then asked how Resident #1 could have been served regular brussel sprouts. The FSD replied, "Resident #1 probably was given the wrong tray." The surveyor requested and reviewed the hospital emergency room record for Resident #1 on [DATE]. The surveyor observed the following documentation in the emergency room physician notes: "(Resident #1) received to bed 1 not breathing, no pulse at 19:26 (7:26 p.m.) Resident #1 seen immediately on arrival because of high probability of imminent or life threatening deterioration in Resident #1's condition. CPR (Cardio-pulmonary Resuscitation) started immediately and continued for 8 minutes. Upon attempts to visualize the cords for intubation, large foreign body found to be obstructing the airway. Foreign body removed using McGill forcepts without difficulty, identified as an intact brussel sprout. After my evaluation in the Emergency Department, my clinical impression is [MEDICAL CONDITION] s/p (status [REDACTED]. Patient admitted to ICU." Documentation in the Facility Reportable Event of [DATE] stated that Resident #1 had died at the hospital that afternoon. NJAC 8:39 - 27.1 (a)

Complaint #: NJ The facility did not accomplish what their POC for F-309 set out to do. Based on observation, interview and medical record review, the facility failed to ensure that 1 of 3 sampled residents, (Resident #3), was appropriately monitored for choking/aspiration as designated by Speech Therapy. By not following implemented interventions in accordance with resident's needs, the facility placed Resident #3 at risk for not being able to maintain his/her highest practical level of well-being in accordance with the comprehensive assessment. On 4/29/2014 at 12:09 p.m., the surveyor observed Resident #3 sitting in a wheelchair, alone in his/her room, eating french fried potatoes in a rapid fashion, without taking time to thoroughly chew and swallow each one before inserting another one in his/her mouth. The surveyor brought this to the attention of the Registered Nurse (RN #1) who was caring for Resident #3. The surveyor showed RN #1 the meal ticket that was removed from Resident #3's lunch tray, which documented "feeder assist", and asked RN #1 if Resident #1 was to be assisted with feeding. RN #1 replied, "I'm not sure." RN #1 then went to the Unit Manager's (UM) office and asked the UM if Resident #3 was a feeder assist. The UM replied, "Yes." This resulted in an immediate jeopardy situation for Resident #3. RN #1 and the unit manager then proceeded to go to Resident #3's room and move Resident #3 to the unit dining room for supervision while completing his/her lunch. The surveyor met with the facility Administrator and Director of Nursing (DON) on 4/29/2014 at 2:30 p.m. The immediate jeopardy situation was identified on 4/29/2014 at 2:30 p.m. and lifted day of survey based on an acceptable plan of correction submitted to the surveyor at 4:33 p.m. This deficient practice is evidenced by the following: Observations, interviews, and medical record reviews were conducted on 4/29/2014, day of survey, unless otherwise noted. 1. According to a facility Admission Record, Resident #3 was admitted to the facility on [DATE]. A physician admitting order sheet, dated 4/22/2014, documented [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool, was not completed at the time of survey. The Nursing Admission Assessment (NAA), dated 4/22/2014, documented under General Comments, "Resident #3 alert with unclear speech, could not make needs known. Complete assistance with ADL's (Activities of Daily Living.) In the Neurologic/Cognition section of the NAA was documented "Confused, not oriented to person/place/time. Moderate alteration in judgement/insight." A physician order, dated 4/22/2014, documented a "Dysphagia Advanced" diet. At 10:20 a.m., while on tour of the 4th floor nursing unit with the Unit Manager (UM), a Registered Nurse, Resident #3 was observed sitting in his/her room asleep in a wheelchair. A medication was infusing via an infusion pump through a right antecubital PICC (Peripherally Inserted Central Catheter) line. The UM stated, "Resident #3 is on a Dysphagia Advanced diet and is working with speech therapy. Resident #3 is only in his/her room secondary to receiving the intravenous antibiotic therapy now. Resident #3 spends his/her time in day room and therapy." During medical record review, the surveyor observed the following documented in a nurse progress note dated and timed 4/23/2014 at 16:22 (4:22 p.m.): "Extensive assist of one with eating. Alert at times, but sleepy most of the day. (Family) stated that Resident #3 is always sleepy." According to a Post Acute Care physician progress notes [REDACTED]. A Speech Therapy Treatment Encounter Note, dated 4/28/2014, documented the following: "Resident #3 benefited from verbal cues for strong swallow and controlled rate/volume of intake." A meal tray ticket, observed by the surveyor, on Resident #3's lunch tray for 4/29/2014 documented Resident #3's diet as "Dysphagia Advanced" and "Feeding Assist." At 12:09 p.m., the surveyor observed Resident #3 sitting in a wheelchair alone in his/her room, eating french fried potatoes in a rapid fashion, without taking time to thoroughly chew and swallow each one before inserting another one in his/her mouth. The surveyor attempted to gain Resident #3's attention by calling his/her name, but Resident #3 kept his/her head down and continued to keep eating as described. At 12:10 p.m., the surveyor conducted an interview with RN #1 who was caring for Resident #3. The surveyor showed RN #1 the meal ticket that the surveyor had removed from Resident #3's lunch tray, which documented "feeder assist", and asked RN #1 if Resident #1 was to be assisted with feeding. RN #1 replied, "I'm not sure." At 12:11 p.m., RN #1 went to the Unit Manager's (UM) office and asked the UM if Resident #3 was a feeder assist. The UM replied, "Yes, don't tell me the state was there." At 12:13 p.m., the UM, RN #1, and the surveyor went to Resident #3's room and observed Resident #3 eating alone, without supervision. At 12:15 p.m., the UM and RN #1 removed Resident #3 from his/her room and took the resident to the dining room to complete the rest of the meal under supervision. At 12:17 p.m., the surveyor conducted an interview with Certified Nurse Assistant (CNA #1) who confirmed that she was the CNA taking care of Resident #3 that day and that she gave Resident #3 his/her lunch tray. The surveyor asked if Resident #3 required feeding assistance. CNA #1 replied, "Yes, Resident #3 is a feeder, but the speech therapist told me this morning that Resident #3 is okay to eat by him/herself if he/she is up in a chair. The surveyor then asked if the speech therapist told her that Resident #3 was okay to eat by him/herself independently, without supervision. CNA #1 replied, "I don't think she said to get Resident #3 out of the room." At 12:19 p.m., the surveyor conducted an interview with CNA #2, who was supervising the resident's lunch meal and asked what he would do if a meal ticket documented that a resident was a "feeder assist." CNA #2 replied, "I would stay with the resident." The surveyor then asked if he would be supervising Resident #3 until he/she was done with lunch. CNA #2 replied, "Yes." At 12:23 p.m., the surveyor conducted an interview with a Licensed Practical Nurse (LPN #1), and asked if he had given report to the CNA's this morning and to RN #1 when she arrived. LPN #1 replied, "Yes, I did give report to the CNA's for RN #1 this morning. RN #1 did not come in until about 9:00 a.m. or so. I told them Resident #3 is a feeder. I tell them that if they are not ready to feed them, do not leave the tray in the room, bring it in only when ready to feed." At 12:26 p.m., the surveyor conducted an interview with the speech therapist (ST #1) regarding Resident #3 and asked if she had spoken with CNA #1 this morning. ST #1 replied, "I said to CNA #1, if Resident #3 was out of bed and in the day room with supervision, he/she could eat by him/herself. Resident #3's alertness is the main reason he/she is on a Dysphagia Advanced diet. Resident #3 will fall asleep sometimes and needs to be prompted. For now, Resident #3 should be out of bed in a wheelchair and in the day room if he/she is to feed themself." A review of the facility's policy entitled, "Diet Descriptions", dated 4/13/2013 described the Dysphagia Advanced diet as "Intended for individuals with mild chewing or swallowing difficulty." At 2:30 p.m., the surveyor met with the facility Administrator and Director of Nursing (DON). The Administrator stated, "We have done so much education on this, I can't believe this happened." The immediate jeopardy to residents health and safety was identified and lifted day of survey based on an acceptable plan of correction submitted to the surveyor at 4:33 p.m. as evidenced by the following: 1. Resident #3 and all residents identified as requiring feeding assist will eat in the dining room or receive assistance 1:1 (one on one) in their room. 2. All residents have the potential to be affected by this practice. 3. Nursing staff were immediately educated on the meal delivery process for the residents that are identified on the tray tickets as requiring feeding assistance. 4. All residents identified as a "feeding assist" on their tray ticket will have their meal trays delivered on a separate food cart. A licensed nurse will oversee the delivery of the meal tray to the resident and ensure that the resident is supervised during the meal. 5. Routine on-going education will be provided regarding the meal delivery standard of practice. 6. Random audits will be conducted on the meals delivered to the residents who have "feeding assist" on their tray ticket to ensure compliance. 7. The results of these audits will be submitted and reported on at the monthly CQI (Continued Quality Improvement) Meeting by the DON or Administrator. NJAC 8:39 - 27.1 (a)

C#NJ Based on complaint specifics, interviews, and review of medical records and other facility documentation, it was determined that the facility failed to acquire and provide a medication for 1 of 4 sampled residents (Resident #1) as ordered by the physician. As a result, the resident had a seizure which required hospitalization and treatment. This deficient practice is further evidenced by the following: 1. According to an Admission Record Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, an assessment tool) dated 5/26/10 showed that the resident had an intact short term memory, long term memory problem, modified decision making skills, and required supervision with meals. A Facility Summary/Conclusion (no date noted) showed that on 5/28/10 Resident #1 had a seizure lasting a few minutes. Emergency care was rendered and he was sent to the hospital for care and treatment. Upon arrival to the emergency room , it was noted that his Phenobarbital level was 12 with a normal range being from 10-40. A review of the facility chart was conducted and it was noted the resident did not receive Phenobarbital dosing for two evenings. Phenobarbital was ordered and had not yet been received from the Pharmacy. Contact was made with Omnicare (Pharmacy) and the delivery arrived 5/28/10. A Care Plan dated 3/4/10 noted that the resident is a risk for falls with a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The comments on the back of the MAR indicated An Omnicare Refill Reorder Form showed that Phenobarbital 150mg was faxed to the pharmacy on 5/27/10 at 12:13 AM. A Nurses Note dated 5/28/10 at 2:41PM showed that the resident began having a seizure while in the wheelchair working with therapy. Convulsions lasted approximately 4-5 minutes. Afterwards the resident began a jerking with body and was not responding. The oxygen saturation rate was in the 80's, Oxygen was applied and it came up to 95%. The resident was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. A Hospital Record noted that the residents Phenobarbital was 12.1 on 5/28/10 with normal range between 15-40. An Attending Admission Note dated 5/29/10 noted that the resident presents with seizures and found to have sub therapeutic phenobarbital level. An Inpatient History and Physical (no date noted) showed that the resident missed two does of phenobarbital and subsequently developed a seizure. He was given 300mg of IV Phenobarbital but had a second seizure episode. A Progress Record dated 5/30/10 showed that the resident has a [DIAGNOSES REDACTED]. A Doctor's Progress Note dated 6/1/10 showed that the resident was transferred to the hospital for Seizures after missing doses of Phenobarbital and returned seizure free. A Clinical Practice Form dated 6/2/10 noted that the involved Registered Nurse (RN) had an identified knowledge deficit and required training that all medication is to be given as ordered. If medication is not available pharmacy and the supervisor are to be notified right away. A Facility Policy (revision date of 4/1/07) on General Medication Administration noted that if any discrepancies, including medication not available, notify physician and/or pharmacy as indicated. Resident #1 was interviewed by the surveyor on 10/12/10 at 10:00AM and he stated that he is familiar with the mediations he takes and he missed two doses of Phenobarbital. He further indicated that he informed the nurse for two consecutive evenings that he needs his Phenobarbital and she stated that the medication did not arrive from pharmacy. He stated that she should have notified the physician and the supervisor. He stated he had a seizure the following day and was admitted to the hospital. He stated that the physician in the hospital told him that the seizures occurred as a result of the two missed doses of Phenobarbital. He further verified that he has not had a seizure since he was admitted to the facility and has not had a seizure since the incident. When the RN Unit Manager was interviewed by the surveyor on 10/12/10 at 10:20AM she indicated that Resident #1 did not receive Phenobarbital for two nights. The nurse involved faxed over the refill to the pharmacy. The medication did not arrive. She followed up and called pharmacy the next day and they indicated they would send it. She checked the back up and it was not there. The RN verified that they do not have Phenobarbital in the back up. She stated the nurse should have notified the nursing supervisor that Phenobarbital was not available, she should have indicated to the 11PM-7AM nurse during shift report, she should have called the Unit Manager on the phone to make her aware, and she should have notified the Physician. She verified that the RN did not do any of that. She further indicated that she was present when Resident #1 had a seizure. She stated that it was a grand mal seizure that lasted a approximately 4-5 minutes. She further sated that the resident has not had a seizure since admission to the facility. She indicated that she spoke to the hospital Physician and he stated that the seizures occurred as a result of 2 missed doses of Phenobarbital. She further stated that Resident #1 is alert and oriented and is aware of what medications he receives. During a post survey interview with the Certified Occupational Therapy Assistant (COTA ) by the surveyor on 10/14/10 at 10:40AM, the COTA stated that Resident #1 was transferred to the wheelchair by the Certified Nursing Assistant (CNA) and was laughing and talking as usual. He made a high pitched noise which was out of character for him. She asked him if he was ok, he did not respond. The CNA stayed with the resident while she went to get the Unit Manager. When the Unit Manager arrived to the room, she indicated that she saw him shaking in his wheelchair as if he was having a seizure. An interview was conducted by the surveyor on 10/12/10 at 12:05PM and the Director of Nursing (DON) verified that a medication error occurred by a Registered Nurse who did not dispense a critical medication to Resident #1. The facility has an unwritten policy that indicates nurses are not allowed to borrow medications from another nurse. She verified that because Phenobarbital is a critical medication, she should have borrowed the medication from another resident and notified Administration about it. NJAC 8:39-29.6(a) NJAC 8:39-29.2(d)