Every finding on record at N J Eastern Star Home

Based on interview, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete reference checks for 2 out of 52 employees (Employee #4, #5); b.) complete background checks for 3 out 58 employees (Employee #1, #12, #13); and c.) complete license checks for 2 out of 58 employees (Employee #3, #8). This deficient was identified for newly hired employees reviewed since last survey from 9/27/2024 and was evidenced as follows:1.) A review of the employee personnel files revealed the following:For Employee #4, a Certified Nursing Assistant (CNA) with a start date of 6/28/25, there was no evidence of a reference check prior to the start of employment.For Employee #5, a CNA with a start date of 9/25/24, there was no evidence of a reference check prior to the start of employment.2.) A review of the employee personnel files revealed the following:For Employee #1, a housekeeper with a start date of 3/3/25, there was no evidence of a background check prior to the start of employment.Employee #12, activities support staff with a start date of 10/7/24, there was no evidence of a background check prior to the start of employment.Employee #13, a dietician with a start date of 11/20/24, there was no evidence of a background check prior to the start of employment.3.) A review of the employee personnel files revealed the following:Employee #3, a Registered Nurse (RN) with a start date of 10/27/25, there was no evidence of a license check prior to the start of employment. Employee # 8, an RN with a start date of 10/9/24, there was no evidence of a license check prior to the start of employment. On 1/22/26 at 2:01 PM, in the presence of the survey team, the surveyor made the Infection Preventionist (IP), Assistant Administrator (AA), and the Minimum Data Set Coordinator (MDS Coordinator) were made aware of the concerns regarding employee background checks, reference checks and license checks prior to hire. The AA acknowledged that the background checks, reference checks and license checks should be completed prior to hire in accordance with their abuse policy. The AA further stated that human resources complete the background check. The department head will complete the two reference checks. On 1/23/26 at 11:00 AM, the surveyor interviewed the Director of Administer Services and Human Resources, who stated that background checks, reference checks, and license checks should be completed prior to the employees hire. She further stated that the head of the department that the employee is hired will complete the reference checks. The human resources department will complete the background checks prior to hiring.A review of the facility's Abuse policy, revised 9/30/25.our facility will not knowingly hire any individual who has a history of abusing other persons. We will conduct employment background screening checks, reference checks and criminal background checks, as required, on all individuals who are offered employment within the New Jersey Eastern Star Home. Human resources (or other person as directed by the Administrator) will conduct employment background checks, 2 reference checks, and criminal conviction checks (including fingerprinting as required by law) on persons upon offer of employment.The appropriate professional licensing board will be contacted for any licensed individual who may have direct contact with residents to ensure there are no prior convictions for abuse or related offenses. A review of the facility's Comprehensive Recruitment and Hiring Policy, revised 8/14/25. Policy: the NJESH is committed to maintaining a comprehensive set of procedures for the recruitment and hiring of new employees to ensure efficiency and fairness in the selection process.All potential new hires must follow the process below: The HR manager will review the application and conduct a background check. Once the background check is completed and the potential new hire is cleared, the HR manager will advise the Department Head to schedule a physical and drug test. The Department of Head must contact at least 2 references and fill out the reference form . Once the new hire passes the physical/drug test and the reference checks have been done and if the new hire accepts the offer, then they must see the HR Manager for the new hire paperwork packet. The new hire cannot start until the HR manager receives the new hire paperwork packet and it's complete. This includes the reference checks from the Department Head.NJAC 8:39-9.3(b)

READY TO BE REVIEWEDBased on observation, interview, and record review, it was determined that the facility failed to document the code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 2 of 3 residents reviewed (Resident #30 and # 73) for advanced directives.This deficient practice was evidenced by the following:1.On 1/21/26 at 9:38 AM, during the initial tour, the surveyor observed Resident #30 in bed with their eyes closed. The resident did not respond to the surveyor.The surveyor reviewed Resident #30's electronic medical record (EMR).A review of the resident's admission Record Face Sheet (FS; an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), anemia (the lack of red blood cells resulting in reduced oxygen transport to organs) and urinary tract infection (a bacterial infection in the bladder, kidneys or urethra).A review of the resident's EMR revealed the following physician orders (PO) with the start date of 1/6/26: Hospice Eval and treatment with [Name Redacted] Hospice; Resident was evaluated and admitted to [Name Redacted] Hospice. Further review of the residents' EMR and hybrid paper chart did not reveal a PO for the resident's code status. A review of the resident's hybrid paper chart revealed a New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, dated 7/13/19. The POLST documented the resident had an advance directive that they desired do not attempt resuscitation/DNAR and Do not intubate (DNI). The form was signed by the resident and a physician. A review of the resident's Care Plan (CP) included a focus area which indicated I need comfort care related to terminal prognosis secondary to my current medical condition, preference for DNH (do not hospitalize)/DNR (do not resuscitate) code status and my enrollment to Hospice care program. The CP had an initiation date of 1/6/26.2.On 1/20/26 at 11:15 AM, during the initial tour, the surveyor observed Resident #73 sitting in their wheelchair.A review of the resident's FS revealed the resident was admitted to the facility with diagnoses which included but were not limited to; dementia, anemia and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities).A review of the resident's hybrid paper chart included a NJ POLST form, dated 11/15/22. The POLST documented the resident had advance directives that they desired do not attempt resuscitation/DNAR and Do not intubate (DNI). The form was signed by the resident representative and a physician.A review of the residents' EMR and hybrid paper chart revealed there was no PO for the resident's code status. A review of the resident's CP did not reflect a focus area to indicate resident's DNR/DNI code status.On 1/22/26 at 12:13 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) about code status (advance directives). The LPN stated if the resident's code status was a full code, there would not be any PO in the EMR. The surveyor inquired what if the resident had DNR/DNI code status. The LPN stated that there would be POs entered in the EMR, the code status would be reflected in the CP, and it would display in the dashboard (where you would see basic information about the resident). The LPN stated it was important to have a resident's code status in the EMR so that all the staff have same information in order to take care of the resident. In the presence of the surveyor, the LPN reviewed the EMR for Resident #30 and Resident #73 and acknowledged there were no POs for their code status, and their code status was not reflected in their dashboard. The LPN stated Resident #30 was receiving hospice services and the code status was not updated after the resident returned from the hospital. At that time, after reviewing Resident #73's EMR in the presence of the surveyor, the LPN stated, there is no DNR/DNI orders that means the resident is a full code. The LPN then reviewed the paper chart for Resident #73 and read the POLST form and further stated that the resident's code status should be DNR/DNI. The LPN further reviewed the CP for Resident #73 and acknowledged that the care plan was not updated with the code status and should have been updated.On 1/22/26 at 2:05 PM, the survey team met with the Assistant Licensed Nursing Home Administrator (Asst LNHA), Infection Preventionist (IP) and Minimum Data Set (MDS) Coordinator. The surveyor informed the administration of the above-mentioned concerns.On 1/23/26 at 9:49 AM, the Asst LNHA, IP and MDS Coordinator met with the survey team. The Asst LNHA stated the code status was reviewed for Resident #30 and Resident #73. The Asst LNHA acknowledged the POs should have been entered in EMR for both residents.A review of the facility provided policy titles, POLST signed and dated 3/11/21 indicated under Procedure: F. The DNI, DNR, DNH must be placed in the appropriate field in the EMR.N.J.A.C. 8:39-9.6 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was functioning properly and accurately setup according to the resident's weight in accordance with a physician's order for a resident who was previously identified to have had an alteration in skin integrity.This deficient practice was identified for 2 of 2 residents (Resident #15 and Resident #38) reviewed for pressure ulcers and was evidenced by the following:a.) On 1/20/26 at 10:58 AM and 12:09 PM, the surveyor observed Resident #15 lying in bed, sleeping, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 250 pounds.On 1/21/26 at 9:26 AM, the surveyor observed Resident #15 lying in bed, awake, eating breakfast, the air mattress pump was noted to be set to a weight of 250 pounds.On 1/22/26 at 9:27 AM, the surveyor observed the air mattress pump set to a weight of 250 pounds. The resident was in bed sleeping, at that time.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included but were not limited to; Alzheimer's disease (type of dementia that affects memory, thinking and behavior), dementia (loss of memory, language, problem-solving), polyosteoarthritis (degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement), and fusion of cervical spine (surgical procedure that permanently joins two or more vertebrae in the neck).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/16/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS, indicated that the resident was at risk to develop a pressure ulcer/injury, and on that date had two Stage 3 pressure ulcers (full-thickness skin loss) present. Additional review of the MDS, revealed the Skin and Ulcer/Injury Treatments section included a pressure reducing device for the bed and pressure ulcer/injury care. The resident's weight was noted to be 132 pounds.A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 1/16/24, the resident had a potential for skin breakdown development related to decrease mobility secondary to the disease process. Interventions included: pressure relieving/reducing device on bed and to reposition the resident in bed in a way that shearing is reduced. Another focus area dated 10/2/25, revealed that the resident had actual skin breakdown to the right buttock related to fragile skin. Interventions included: administer treatments per physician orders and monitor its effectiveness, provide the resident with preventive care. A record review revealed ongoing weekly wound assessment with recommendations by wound care consultants were completed, the wound showed improvement.A review of the Order Summary Report included the following physician orders (PO):A PO, dated 7/29/24, for moisture barrier to the sacral area topically every shift for prophylaxis.A PO, dated 9/15/25, for 30 milliliters (ml) of Protein Supplement two times a day for wound healing.A PO, dated 9/18/25, for a low air mattress, check placement and functioning every shift for wound healing. b.) On 1/20/26 at 11:03 AM, the surveyor observed Resident #38 lying in bed, sleeping, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 325 pounds (lbs).On 1/21/26 9:28 AM, the surveyor observed Resident #38 lying in bed, awake, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 325 pounds.On 1/22/26 9:29 AM, the surveyor observed Resident #38 lying in bed, awake, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 325 pounds. A review of the admission Record revealed the resident had diagnoses which included but were not limited to; dementia (loss of memory, language, problem-solving), primary generalized osteoarthritis (degenerative joint disease involving cartilage loss), and low back pain.A review of the resident's most recent comprehensive MDS, an assessment tool dated 12/10/25, included the resident was unable to complete the interview for BIMS, indicating the resident's cognition was severely impaired and their cognitive skills for daily decision making were moderately impaired. Further review of the MDS, indicated that the resident was at risk to develop a pressure ulcer/injury, and on that date had one unstable pressure ulcers (full-thickness skin and tissue loss where the wound's depth is hidden by slough) present. Additional review of the MDS, revealed that the Skin and Ulcer/Injury Treatments section included a pressure reducing device for the bed and pressure ulcer/injury care. The resident's weight was noted to be 148 pounds.A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 9/23/24, the resident had a potential for skin breakdown development related to decreased mobility secondary to the diagnosis. Interventions included: pressure relieving/reducing device on the bed and to reposition the resident in bed in a way that shearing was reduced. Another focus area dated 12/15/25, revealed that the resident had actual skin breakdown to the sacrococcyx (tailbone) related to pressure injury. Interventions included: administer treatments per physician orders and monitor its effectiveness, and to use pressure reduction mattress.A record review revealed ongoing weekly wound assessment with recommendations by wound care consultants were completed, the wound was noted to be chronic but in a stable state.A review of the Order Summary Report included the following POs:A PO, dated 10/4/24, for moisture barrier to the sacral area topically every shift for prevention.A PO, dated 9/10/25, for a low air mattress, check placement and function every shift for wound healing.A PO, dated 10/21/25, for 30 milliliters (ml) of Protein Supplement two times a day for wound healing.On 1/22/26 at 10:52 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding Resident #15's and Resident #38's mattress settings. The LPN stated an air mattress function was to offload pressure on their sacral wounds and to alleviate pressure for at-risk residents. When asked about the importance of assessing whether a mattress worked properly and maintained the correct air pressure, the LPN replied that the air mattress goes by the resident's weight because we don't want it to be too soft or too firm for the resident's skin integrity. He stated that if it was set to the wrong setting, then it would defeat the purpose of having an air mattress. The LPN further stated wound care recommends the air mattress, the nurse or vendor would set the air mattress up for the resident. The nurse was responsible for checking the air mattress setting when they complete their normal rounds every shift. At 11:01 AM, the surveyor and the LPN went to Resident #15's room. The surveyor asked whether the pump was set correctly for Resident #15's weight; the LPN stated that the resident weighed 129.6 pounds on 12/20/25 but the air mattress was set to 250 pounds. The surveyor and the LPN went to Resident #38's room. The LPN confirmed that Resident #38's weight on 12/20/25 was 142 pounds and the air mattress was set to 325 pounds. The LPN acknowledged that it should have been set according to the residents' weight and that he will check the settings for all residents on air mattresses to ensure they are on the correct weight.On 1/22/26 at 2:01 PM, in the presence of the survey team, the surveyor made the Infection Preventionist (IP), Assistant Administrator (AA), and the Minimum Data Set Coordinator (MDS Coordinator) aware of the concerns regarding Resident #15's and Resident #38's air mattress. The AA acknowledged that the air mattresses should be set according to a resident's weight to prevent skin breakdown.On 1/23/26 12:24 PM, the Charge Nurse/Licensed Practical Nurse (UM/LPN), stated that there were no facility policies on resident air mattresses. She further stated that moving forward the facility would implement a policy on air mattresses.A review of the manufacturers Operation Manual for the air mattress and pump provided to the surveyor by the facility states: Step 4.0 system package: Weight (lbs) simply press weight button to adjust patient, weight 100 lbs to 325 lbs according to patient weight.A review of the facility's Skin Integrity Program policy, reviewed 4/25/24, included. use pressure relieving devices such as special mattresses .NJAC 8:39-27.1(a)

Based on observations, interview, and review of facility policy, it was determined that the facility failed to appropriately label medications in accordance with professional standards of practice. The deficient practice was identified for 1 of 5 medication carts (the Subacute Rehab Side 2 medication cart) inspected during the Medication Storage task. The deficient practice was evidenced by the following:On 01/22/2026 at 9:40 AM, the surveyor inspected the Subacute Rehab side 2 medication cart with the Registered Nurse (RN) on D wing. The surveyor observed five syringes of Enoxaparin 30mg/3mL (a prescription drug used to prevent and treat blood clots, especially after surgery or serious illness) were lying in the third drawer, with no resident label or date and were not in a bag. The syringes were in their original packaging. The RN stated, I'm going to be honest, they are not stock, they should be labeled. The RN then disposed of the syringes in the sharps container on the right side of the cart. The RN stated the pharmacy checks the carts but did not know how often. The RN was unaware if nursing staff checked the carts. Further review of the cart revealed a bottle of liquid protein supplement was present in the bottom drawer. The bottle was opened and not labeled with the open date. The RN stated, they are good for 30 days.On 01/22/2026 at 2:10 PM, during a meeting with the survey team, the Assistant Licensed Nursing Home Administrator (ALNHA), Infection Preventionist, and MDS Coordinator were made aware of the above mentioned concerns. On 01/23/2026 at 12:40 PM, in a phone interview with the Pharmacy Consultant (PC), the PC stated the PC makes sure the facility is compliant with medication storage and labeling. If Enoxaparin is in the cart, it should have a patient specific label on it. If it is found without a label, I would inquire with nursing, find out who the resident was and put it in the labeled box. It is not stock and should not be floating unlabeled. The PC also stated he did a formal medication pass observation and medication cart check a couple of weeks ago.A review of the facility policy titled Cleaning and Disinfection of Medicine Carts, dated 03/15/2023 provided by the Assistant Licensed Nursing Home Administrator (ALNHA) revealed Policy Statement. Medication carts are considered shared medical equipment and shall be maintained in a clean, sanitary, and safe condition at all times. Scope: This policy applies to all licensed nursing staff, nursing supervisors, and the Infection Preventionist. N.J.A.C. S 8:39-29.4 (a) (h)

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure the required committee members, the Infection Preventionist (IP), was present for one of five Quality Assurance and Performance Improvement (QAPI) meetings. This deficient practice was evidenced by the following:On 01/20/2026 at 09:34 AM, during entrance conference, the surveyor requested the QAPI sign-in sheets from the last survey date of 9/27/2024 to present. On 01/23/2026 at 10:49 AM, the surveyor reviewed the QAPI Meeting Sign In Sheet dated 04/07/2025, which revealed the IP did not sign the sheet. On 01/23/2026 at 10:49 AM, during a meeting with surveyor, the Assistant Licensed Nursing Home Administrator (ALNHA) reviewed the QAPI Meeting Sign In Sheet dated 04/07/2026 and confirmed the IP did not sign the sign in sheet. The ALNHA stated in the absence of the IP, the Director of Nursing (DON) would review the IP information. On 01/23/2026 at 12:32 PM, a review of the QAPI Minutes dated 04/07/2025 at 10:40 AM revealed under the Nursing section skill competencies. Further review did not reveal infection control was not presented. On 01/23/2026 at 12:35 PM, in the presence of the survey team, the ALNHA acknowledged the QAPI Minutes provided were the full minutes, and there was nothing additional to add. A review of the facility's Quality Assurance & Performance Improvement (QAPI) policy dated 07/30/2025, revealed Purpose: New Jersey Eastern Star Home will participate in an effective, comprehensive, data driven QAPI process that focuses on systems of care, outcomes, and services for residents and staff.Facility governing body will ensure that the QAPI program is defined, implemented, and maintained, addressing identified priorities. Procedure: A. The QAPI committee is comprised of: .4) Infection Control/Preventionist. NJAC 8:39-33.1(b); 33.2(c)(7)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow physician orders (PO) for fall prevention as written on the Physician Order Summary. This deficient practice was identified for 1 of 3 residents (Resident # 2) reviewed for accidents and was evidenced by the following:On 1/21/26 at 9:56 AM, the surveyor observed Resident #2 with their eyes closed in their bed. The surveyor observed a floor mat (specialized pads placed beside a resident's bed to reduce injury severity from falls) folded up, leaning against the wall under the window. On 1/21/26 at 10:13 AM, the surveyor interviewed the Certified Nurse Aide (CNA) in the presence of the Licensed Practical Nurse (LPN#1). The surveyor inquired about the floor mat for Resident #2 and the CNA stated, it might be something new, and it is for nighttime. The surveyor reviewed the electronic medical record for Resident #2. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; displaced (bone fragments have moved out of their normal alignment) intertrochanteric fracture (a common type of hip fracture) of right femur (thigh bone), unspecified injury of left ankle, history of falling, and difficulty in walking. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/29/25, revealed a Brief Interview for Mental Status score of 9 out of 15, which indicated that the resident had moderate impaired cognition. Further review of the MDS indicated that Resident #2 was coded as Yes as having a fall history in the last month prior to their admission. A further review of section J revealed that the resident had fractures related to a fall prior to admission. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area of at risk for falls related to gait/balance problems secondary to diagnoses of right femur fracture, left ankle injury, fall, ambulatory dysfunction (a condition that makes it difficult or impossible to walk), dated 12/23/25. Further review of the ICCP reflected a focus area of the resident had a fracture of right hip related to diagnosis of fall, initiated on 12/23/25. A review of the Order Summary Report (OSR) reflected an active PO dated 12/26/25 for floor mat to left side of bed, monitor placement every shift for prevention. On 1/22/26 at 9:35 AM, the surveyor interviewed LPN#2, who stated that Resident #2 was a fall risk when the resident was admitted to the facility. LPN#2 also stated that the importance of the floor mat was for protection when the resident was getting out of bed without assistance in the evenings. On 1/22/26 at 2:10 PM, during a meeting with the survey team, the Assistant Licensed Nursing Home Administrator (ALNHA), Infection Preventionist, and MDS Coordinator were made aware of the above mentioned concerns. No additional information was provided. A review of facility's undated Fall Prevention Program policy, revealed. While the falls care plan may include potentially effective interventions, it is staff compliance that will reduce fall risk. A program's success or failure can only be determined if staff actually implement the recommended interventions. Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment. A review of facility's Physician Orders Policy, revised 2/10/25, revealed .Nursing supervisors or designees will audit orders periodically for accuracy, timeliness, and compliance. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure staff: a) performed appropriate hand hygiene (HH) during meal delivery services and b) removed soiled gloves upon exiting a resident room to prevent the potential spread of infection. This deficient practice occurred on 2 of 3 units, for 1 staff observed on 1 of 3 units and was evidenced by the following: a) On 09/25/2024 at 8:13 AM, Surveyor #1 observed the breakfast meal trays being delivered to residents on the B unit. Surveyor #1 observed two Certified Nursing Aides (CNA) delivering breakfast to residents without first performing HH or offering residents the opportunity to clean their hands. On 09/25/2024 at 8:49 AM, CNA #1 stated that there were only 2 CNAs on the B unit and confirmed he should have washed his hands after each resident interaction to prevent the spread of infection. CNA #2 was assigned to observe the dining area with the residents. On 09/25/2024 at 9:40 AM, during an interview with Surveyor #1, the acting Food service Director (FSD) revealed that the facility kitchen did not have or provide anything on the meal trays for the residents to cleanse their hands with. On 09/25/2024 at 8:06 AM - 8:17 AM, Surveyor #2 observed the breakfast trays being delivered to residents on the A unit. Surveyor #2 observed CNA #3 deliver trays twice into the same room without any HH performed or offering the residents HH, CNA #3 then pushed the tray cart down the hall, and without first performing HH, delivered a tray into another resident room and did not offer the resident HH. Next CNA #3 exited the room, and without performing HH, obtained another resident breakfast tray, delivered it and assisted opening foods and setting the resident up to eat without offering the resident any HH. CNA #3 asked CNA #4 to assist her in repositioning a resident in another room without either CNA first performing HH and then CNA #3 began to assist the resident with eating without first performing HH. During the same meal delivery on A unit, CNA #4 was observed delivering a meal tray to a resident without first performing HH or providing the resident with HH. CNA #4 exited the room, did not perform HH, then delivered 2 more meal trays without performing HH or offering the resident HH. CNA #4 exited again without performing HH and then delivered another meal tray without providing the resident with HH. CNA #4 then assisted CNA #3 to reposition a resident without performing HH first or after positioning. On 09/25/2024 at 8:21 AM, CNA #3 stated the correct process was to stop resident care, wash our hands, and deliver the trays to the residents. When asked about HH, CNA #3 stated the residents would have their hands cleaned during morning care and that she should have used HH in between delivering trays to each resident but had no reason as to why she did not. On 09/25/2024 at 8:32 AM, CNA #4 stated the process was to take the trays to each resident room and set the resident up to eat. She stated the residents were provided hand hygiene before meals. When asked what was used or how this was performed, CNA #4 stated we don't use anything because the residents were cleaned up in the morning. CNA #4 did acknowledge she should have used HH in between delivering the meal trays to the residents and had no reason as to why she did not. A review of the facility provided Sign in Sheet dated August 2024, included but was not limited to; a topic of HH. The sign in sheet indicated that CNA #1 had not signed that he had attended the education. CNA #3 was not listed as part of the nursing staff. CNA #4 had signed and dated on 08/08/2024, that she had attended the HH education. b) On 09/25/2024 at 8:30 AM, Surveyor #1 observed a contracted laboratory technician (LT) enter a resident room on the B unit. The LT donned (put on) gloves, drew the resident's blood sample, and left the resident room while still wearing the soiled gloves. The LT was observed in the hallway with the same gloves on, then collected a specimen from the nurse and began arranging specimens collected on the nursing desk countertop, before placing them into a collection bag. On 09/25/2024 at 8:33 AM, the LT stated that he had not disposed of the soiled gloves prior to exiting the resident room, and stated I should have put them [soiled gloves] in the trash. A review of the facility provided Handwashing Pledge undated, included but was not limited to; It is recognized as the single most important means of preventing the spread of infection. I understand that the only cost to me is the time it takes to wash, and the benefit of this pledge is a reduction of cross infection in my facility. A review of the facility provided policy, Handwashing/Hand Hygiene revised August 2019, included but was not limited to; This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene . 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections . 5. Residents, visitors . will be encouraged to practice hand hygiene . 7. Use an alcohol-based hand rub or soap and water for the following situations: b. before and after direct contact with residents; . j. after contact with blood or bodily fluids; . l. after contact with objects in the immediate vicinity of the resident; . o. before and after eating or handling food; p. before and after assisting a resident with meals . NJAC 8:39-19.4(a), 27.1(a) 38079

Based on observation, interview, and record review it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent potential urinary tract infections. This deficient practice was identified for 1 of 2 residents reviewed for indwelling urinary catheter (Resident #32), and was evidenced by the following: On 09/23/24 at 6:37 PM, the surveyor observed Resident # 32 in the room. At that time, the surveyor observed a used plastic bag tied to a handrail in the resident's bathroom. Inside the plastic bag was a used indwelling urinary catheter drainage bag dated 09/23/24. The urinary catheter drainage port was not capped, and was in direct contact with the plastic bag. On 09/24/24 at at 8:48 AM, the surveyor observed the resident resting in bed. The surveyor observed that the resident had an indwelling urinary Foley catheter (a flexible tube inserted into the bladder for urinary drainage) contained in a privacy bag and hung on the bedrail. On 09/24/24 at 12:06 PM, the surveyor observed Resident #32 sitting in a wheelchair at the bedside. The surveyor observed the Foley catheter drainage bag stored in a plastic bag in the bathroom. The drainage port was not capped. On 09/25/24 at 11:24 AM, the surveyor observed the Foley catheter drainage bag stored in a plastic bag in the bathroom, the drainage port was not capped. The Foley catheter drainage bag was dated 09/23/24. On 09/25/24 at 11:35 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who provided Resident #32's indwelling catheter care. The CNA stated that prior to switching the leg bag to the catheter drainage bag, he would wash his hands, don (put on) gloves and gown, remove the leg bag and applied the Foley catheter drainage bag. The CNA did not indicate that the drainage port was to be disinfected prior to apply the leg bag. On 09/25/24 at 11:45 AM, the surveyor interview the Licensed Practical Nurse (LPN) assigned to the Unit. The LPN stated that the leg bag and the Foley catheter drainage bags were scheduled to be changed every Sunday. The LPN stated that when an indwelling urinary catheter drainage bag was not in use, staff were required to clean the bag of any residual urine and store the Foley catheter drainage bag in a plastic bag in the bathroom. The LPN further stated that the CNAs received training on how to store the bags/ drainage /leg bag. The surveyor then inquired specifically regarding the storage of the Foley catheter drainage bag. The LPN stated that the Foley catheter drainage bag must be cleansed of any residual urine and stored in a plastic bag in the bathroom. On 09/25/24 at 11:50 AM, the surveyor interviewed the LPN who cared for Resident #32. The LPN stated that Resident #32 had a suprapubic catheter (tube inserted into the bladder to facilitate urinary drainage). The LPN added that Resident #32 wore a leg bag during the day and a Foley catheter drainage bag at bedtime. The Foley catheter drainage bag would be stored in a plastic bag in the bathroom when not in use. The surveyor accompanied the LPN in the bathroom and we both observed the Foley catheter drainage bag in a plastic type basin, not in a plastic bag, and the drainage port was not capped. The Foley catheter drainage bag dated 9/23/24. The LPN confirmed that both bags were to be changed on Sunday and as needed. The LPN observed there was no cap on the drainage port, the LPN donned gloves and placed the Foley catheter drainage bag in the plastic bag. On 09/26/24 at 9:05 AM, the surveyor observed the resident sitting in a wheelchair in the room. The surveyor went to the bathroom and observed that the Foley catheter drainage bag was dated 09/23/24 and stored in a the basin in the bathroom, the drainage port was not capped. On 09/26/24 at 9:30 AM, the surveyor accompanied the Registered Nurse Supervisor (RN/SON) to the room and we both observed the Foley catheter drainage bag in the plastic bag with visible amount of urine, stored in the bassinet. The drainage port was not capped. The Foley catheter drainage bag was dated 9/23/24. That same day during an interview with Registered Nurse, Supervisor of Nursing (RN/SON), she stated that the Foley catheter drainage bag should be stored in a clean plastic bag and the drainage port should be capped to prevent infection. When inquired about how this information was communicated to the staff, the RN stated , in services education were provided to inform the staff of what needed to be done. On 09/24/24 at 11:30 AM, the surveyor reviewed the medical record for Resident #32. According to the Admission Face Sheet, Resident #32 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, unspecified severity without agitation, benign prostatic hyperplasia with lower urinary tract symptoms and chronic kidney disease. The Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/4/24, reflected that Resident #32 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated a moderate cognitive impairment. A review of the September 2024 Order Summary Report, revealed an order with an original date of 09/22/2023, to change the Suprapubic Catheter (SP) monthly on the 22nd of the month every night shift starting on the 22nd and ending on the 22nd every month for Preventative Care. Use size SP tube 22 French (diameter size), order dated 08/03/21. Have the Catheter leg bag on in AM, OFF at Bedtime two times a day. A review of the resident's individualized Interdisciplinary Care Plan (ICP) revised on 3/10/22, included a focus area that the resident had bladder elimination dysfunction: use of indwelling Suprapubic catheter related to Neurogenic bladder. The goal of the ICP included that the resident will not show no signs/ symptoms of infection. Will be free from catheter related trauma. Will not develop Urinary Tract Infection (UTI). Interventions of the ICP included catheter care daily and as needed. Monitor for signs and symptoms of infection. On 09/26/24 at 11:40 AM, the surveyor reviewed the facility's policy and procedure on Foley Catheter Insertion and Care last revised 07/2019. The policy included to maintain Universal Precautions throughout procedure. Perform all manipulations of Foley system as clean procedure. Wipe the end of the Catheter with an alcohol pad. Wipe the connector on the new bag with the second alcohol pad. Cleaning the drainage bag Wash your hands thoroughly with soap and water. Rinse the bag with soap and cool water. Do not use hot water because it can damage the plastic equipment. Cap after one hour and place in plastic bag for storage. Plastic storage bag is to be changed daily. Foley bags are to be replaced weekly. NJAC 8:39-19.4(a)5

Based on observation, interview, record review and review of facility documentation, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. This deficient practice was identified during the medication administration observation for 1 of 2 nurses, 2 of 4 residents (Residents #12 and #48), and for 27 opportunities. This resulted in two observed errors which resulted in a medication administration error rate of 7.41 % and was evidenced by the following: 1. On 9/24/24 at 9:34 AM, the surveyor conducted the medication administration and observed a Licensed Practical Nurse (LPN) preparing to administer nine (9) medications which included one Aspirin chewable 81 milligram (MG) tablet to Resident #12. The LPN stated that the Aspirin was an over the counter (OTC) house stock medication (stock bottles that the facility purchased for any resident that had a physician's order for the medication). On 9/24/24 at 9:56 AM, the surveyor observed the LPN administer the Aspirin chewable 81 MG tablet to Resident #12. On 9/24/24 at 10:57 AM, during reconciliation for the medication observation, the surveyor reviewed the Order Summary report which revealed an active physician's order (PO) with a start date of 1/5/23 for Aspirin Enteric Coated (EC)(a coating that allows the tablet to survive intact as it passes through the acidic stomach and dissolve in the small intestine to be absorbed) tablet delayed release 81 MG (Aspirin) Give 1 tablet by mouth in the morning for coronary artery disease (CAD) (a condition that happens when the coronary artery struggles to supply the heart with enough blood, oxygen and nutrients). On 9/24/24 at 11:31 AM, the surveyor, with the LPN, reviewed the electronic medication administration record (eMAR) at the medication cart. The eMAR revealed the same PO as above. The LPN stated that the PO was for Aspirin EC and was able to show the surveyor an OTC house stock bottle of Aspirin EC 81 MG tablets that were stored in the medication cart. The LPN then stated that she had administered Resident #12 the Aspirin chewable 81 MG tablet and realized that she should have administered Aspirin EC according to the PO. The LPN added that both were the same drug but one was EC and one was chewable. The LPN also stated that she was an agency nurse and was not usually on this medication cart. The LPN acknowledged that the PO specified EC and that she had administered the chewable formulation. (ERROR#1) The surveyor reviewed the medical record for Resident #12. A review of the Admission Record revealed diagnoses which included, but were not limited to, dementia, gasto-esophageal reflux disease (heartburn) and atherosclerotic heart disease of native coronary artery (a disease of the coronary arteries having plaques of fatty material on their inner walls causing a struggle to supply the heart with enough blood, oxygen, and nutrients). On 9/25/24 at 8:32 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that the CP who had been servicing the facility was no longer employed but that he was the owner and could speak to any questions. The CP stated that the nurses were to follow the PO. The CP stated that the facility would have the records of any medication observations and in services that were completed. On 9/26/24 at 8:25 AM, the surveyor interviewed the Assistant Nursing Home Administrator (ANHA) who stated that the Infection Preventionist (IP) was the staff educator. The ANHA added that there were no medication administration observations completed for the LPN and would have to check if there were any in services completed. The ANHA added that the IP was covering for the Director of Nursing (DON) while the DON was temporarily not available. On 9/26/24 at 11:11 AM, the surveyor interviewed the IP who stated that she only completed medication administration observations if there was an issue or problem identified such as being late with medications. The IP added that the CP also did medication administration observations and in-services. On 9/26/24 at 11:28 AM, the surveyor interviewed the IP who stated that agency nurses were not observed for medication administration. On 9/26/24 at 11:31 AM, the surveyor, in the presence of the survey team, interviewed the ANHA and IP. The ANHA stated that the competency for agency nurses for medication administration was completed by the agency and would have to reach out to the agency for the records. On 9/26/24 at 11:43 AM, the surveyor was provided by the IP a Medication Pass in-service completed on 1/30/24 by the CP. A review of the Med Pass In-Service/Meeting sign-in sheet revealed that the LPN had not attended the in-service. A review of the in-service document used for the Medication Pass reflected the Five Rights which included but not limited to; 2. Right Medication: Review MAR for medication to be administered at the time ordered and Precautions. On 9/26/24 at 12:54 PM, the survey team met with the Licensed Nursing Home Administrator, ANHA and IP and reviewed the above concern. There was no further documentation provided. A review of the facility policy dated 2/23/2021 for Medication Administration Time provided by the ANHA revealed that the policy was for medications to be administered per physician order. In addition, the procedure reflected 11. Staff should verify each time a medication is administered that it is the correct medication, . 2. On 9/24/24 at 10:05 AM, the surveyor observed the LPN preparing to administer six (6) medications, which included one Glipizide Extended Release (ER) 5 MG tablet to Resident #48. On 9/24/24 at 10:09 AM, the surveyor observed the LPN address Resident #48 who was seated in a wheelchair in the hallway and explained to the resident that before they went to an activity that she wanted to administer the resident's morning medications. On 9/24/24 at 10:12 AM, the surveyor observed the LPN administer the Glipizide ER 5 MG tablet to Resident #48. On 9/24/24 at 10:17 AM, upon returning to the medication cart, the surveyor, with the LPN, reviewed the labeling on the package of the resident's Glipizide ER which revealed a sticker that specified Take this medication 1/2 hour before a meal. Read label carefully for how many times to take each day. The LPN stated that she was unsure when breakfast was served and could not speak to what time the Glipizide ER was to be administered. The LPN acknowledged that the time of administration on the eMAR was 8 AM. The LPN stated that she does go out earlier and tries to give medications before breakfast but was unaware of this medication. (ERROR#2) On 9/24/24 at 11:31 AM, the surveyor interviewed the LPN who stated that she was an agency nurse and was not usually on this medication cart. The LPN stated that she had administered insulin (a medication used to lower blood sugar) before breakfast but was unaware that the Glipizide had to be administered earlier. The LPN stated, I go down the line on my unit. The LPN explained that she went room to room with the eMAR administering medications in the morning. The surveyor reviewed the medical record for Resident #12. A review of the Admission Record revealed diagnoses which included, but were not limited to, diabetes (a long-term condition where the body has trouble controlling blood sugar). A review of the Order Summary Report revealed a PO with a start date of 7/24/21 for Glipizide ER tablet Extended release 24 hour Give 5 MG by mouth in the morning related to Type 2 Diabetes Mellitus without complications. A review of the eMAR reflected the above PO with a time of administration of 0800 (8AM). On 9/25/24 at 8:32 AM, the surveyor interviewed the CP via the telephone who stated that the CP who had been servicing the facility was no longer employed but that he was the owner and could speak to any questions. The CP stated that the nurses were to follow the PO and any cautionaries associated with a medication. The CP stated that the facility would have the records of any medication observations and in-services that were completed. The CP further explained that cautionary warnings were usually on the eMAR as well as on the packaging of the medication and that the nurses should be looking at the cautionary information and following it. The CP added that if the cautionary information was only on the packaging, then it was still the responsibility of the nurses to follow the information. On 9/26/24 at 8:25 AM, the surveyor interviewed the ANHA who stated that the IP was the staff educator. The ANHA added that there were no medication administration observations completed for the LPN and would have to check if there were any in-services completed. The ANHA added that the IP was covering for the DON while the DON was temporarily unavailable. On 9/26/24 at 11:11 AM, the surveyor interviewed the IP who stated that she only completed medication administration observations if there was an issue or problem identified such as being late with medications. The IP added that the CP also did medication administration observations and in-services. On 9/26/24 at 11:28 AM, the surveyor interviewed the IP who stated that agency nurses were not observed for medication administration. On 9/26/24 at 11:31 AM, the surveyor, in the presence of the survey team, interviewed the ANHA and IP. The ANHA stated that the competency for medication administration was completed by the agency that the nurse was from and would have to reach out to that agency for the records. On 9/26/24 at 11:43 AM, the surveyor was provided by the IP a Medication Pass in-service completed on 1/30/24 by the CP. A review of the Med Pass In-Service/Meeting sign-in sheet revealed that the LPN had not attended the in-service. A review of the in-service handout for Medication Pass reflected the Five Rights included but not limited to 2. Right Medication: Review MAR for medication to be administered at the time ordered and Precautions. And 4. Right Time: Medication can be given 60 minutes before the time on MAR or 60 minutes after is considered correct, Exception medication to be given with regard to meals, either before meals (AC) or after meals (PC) need to be given as such. Further review of the in-service handout for Medication Pass reflected for Administration of Medication 7. All Cautionary labeling must be followed (separation from meds or food/fluid parameters.) On 9/26/24 at 12:54 PM, the survey team met with the Licensed Nursing Home Administrator, ANHA and IP and reviewed the above concern. There was no further documentation provided. A review of the facility policy dated 2/23/2021 for Medication Administration Time provided by the ANHA revealed that the policy was for medications to be administered following best practices. In addition, the procedure reflected 11. Staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route at the correct rate, at the correct time, for the correct resident, as set forth in Medication Administration Times Schedule. A review of the Medication Administration Times Schedule that was part of the policy, reflected that AC hours of administration were 7:30 AM, 11:30 AM and 4:30 PM. In addition, with meals hours of administration were 8:00 AM, 12:00 PM and 5:00 PM. Additionally, the facility policy for Medication Administration Time reflected 19. Follow manufacturer medication administration guidelines. A review of the manufacturer specifications for Glipizide ER revealed for Patient Information to Take Glipizide extended-release tablets by mouth, 1 time each day with breakfast or your first meal of the day. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for residents who were receiving oxygen (O2) treatment according to standards of practice. This deficient practice was identified for three (3) of three (3) residents (Resident #10, #31, and #120) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/02/23 at 10:06 AM, the surveyor observed Resident #10 seated in a wheelchair in their room. The surveyor observed a nasal cannula (n/c; consisting of two hollow prongs projecting from a hollow face piece) O2 tubing attached to an O2 concentrator in Resident #10's room. The n/c O2 tubing was in a clear plastic bag and was dated 4/24/23. On that same date and time, the surveyor interviewed Resident #10. Resident #10 stated that he/she would use the O2 at night and that he/she had a problem with breathing after he/she had COVID-19. Resident #10 then added that he/she tried not to use it [oxygen] the during day. The surveyor reviewed the medical records of Resident #10. The resident's Admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Type 2 Diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), atrial fibrillation (an irregular and often very rapid heart rhythm) and history of COVID-19 (a highly contagious respiratory disease). A review of the 3/31/23 Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. The QMDS did not indicate that the resident was on oxygen. The Order Summary Report (OSR) dated 5/11/23, revealed an order for 02 at 2 (two) Liter via n/a as needed for SOB (shortness of breath). Further review of the OSR showed that there was no order for O2 tubing change. The resident's personalized care plan did not reflect that the resident was on 02 and there were no interventions for respiratory care for the use of PRN (as needed) 02. On 5/03/23 at 02:10 PM, the surveyor interviewed Licensed Practical Nurse#1 (LPN #1) regarding the process for storing and changing 02 tubing. LPN #1 stated that the 11-7 staff change the 02 tubing once a week and put it in a bag and label it with the date. At that same time, the surveyor showed LPN #1 the picture of Resident #10's 02 tubing that was observed on 5/02/23. LPN #1 confirmed that the 02 tubing should have been changed on 5/01/23. The surveyor asked LPN #1 if the staff documented when the 02 tubing had been changed. LPN #1 stated that she was not sure if it was documented. She further stated that there was no order on her shift (7-3) but that she would check if there was an order on the other shift. On 5/08/23 at 11:18 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the process for storing and changing 02 tubing. The IP stated that the 02 tubing should be changed every week on the 11-7 shift and that when it was not in use that the 02 tubing should be in a plastic bag. She added that there should be an order and that it was documented in the electronic Treatment Administration Record (eTAR). On 5/10/23 at 12:38 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Admissions and Marketing/Assistant Administrator (DoAM/AA) and Director of Nursing (DON), the findings about the 02 tubing. On 5/11/23 at 01:14 PM, in the presence of the survey team, LNHA and DoAM/AA, the DON stated that Resident #10 had a PRN order for 02 and that the next change was to be done on 5/01/23 but that the nurse acknowledged that they forgot. The DON added that changing the 02 tubing was a standard of practice and that the order had not been in the eTAR but that the facility was going to change the policy to reflect changing the 02 tubing in the eTAR and in the careplan. A review of the facility provided policy titled, Oxygen Use with a revised date of 8/08 included the following: 4. Nasal cannula, mask, tubing, humidifier bottles are all single resident use items and are changed and dated weekly and only used for one resident. 2. On 5/02/23 at 10:28 AM, the surveyor observed in Resident #31's room, a suction machine that contained a disposable suction canister that had approximately 175 milliliters of clear fluid in it. Attached to the canister was a suction tubing with a yankauer tip (an oral suctioning tool) attached to the other end of the tubing. The yankauer tip was laid on the top of the dresser. There was no protective covering over the yankauer to keep it clean. There was a bottle labeled sterile water for inhalation, next to the suction machine, which was dated 4/15/23. On that same day at 11:50 AM, the surveyor interviewed Resident #31 who was seated in a wheelchair in their room. Resident #31 stated that he/she had bronchitis and had been in the hospital recently and had phlegm (mucus, thicker than normal due to illness or irritation, coughed up from the respiratory tract) that was being suctioned. Resident #31 was not sure when was the last time the suction machine was used. The surveyor reviewed the medical records of Resident #31 and showed the following: The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing), asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and Type 2 diabetes mellitus. The 4/25/23 QMDS revealed a BIMS score of 10 out of 15, which indicated that the resident's cognition was moderately impaired. The OSR dated 5/11/23, revealed an order for suction machine at bed side-suction resident as needed for seizure precautions. On 5/03/23 at 02:16 PM, the surveyor interviewed the LPN #1 regarding the process for the suction machine equipment. LPN #1 stated that the equipment should be in a bag and if it is used the disposable portion should be discarded. She added that a new setup should be available for use. The surveyor asked LPN #1 the reason Resident #31 had the suction machine at bedside. LPN #1 stated that Resident #31 was on seizure precautions and that was the reason the suction machine was at the resident's bedside. The surveyor then showed LPN #1 a picture of the observed suction machine and disposable equipment. LPN #1 confirmed that the used disposable suction equipment should not have been left there and that it should have been discarded. On 5/08/23 at 11:19 AM, the surveyor interviewed the IP regarding the process for the suction machine equipment. The IP stated that the disposable suction equipment could be used for a week. She further stated that the yankauer tip should be stored in a plastic bag. On 5/10/23 at 12:39 PM, in the presence of the survey team, the surveyor notified the LNHA, DoAM/AA and DON the above findings about the improper storage of the disposable suction equipment. On 5/11/23 at 01:16 PM, in the presence of the survey team, LNHA and DoAM/AA, the DON stated that Resident #31 had been transferred to the hospital on 4/15/23 and the resident came back to that room on 4/28/23. The DON further stated that when the resident came back to the room a new suction machine and equipment was brought to the room and the nurse forgot to take out the old machine and used disposable suction equipment. At that same time, the surveyor asked the DON what the process was for the disposable suction equipment after it was used. The DON stated that the yankauer tip should be discarded right away [after use]. He added that it should all be in a bag and when not being used. A review of the facility provided policy titled, Suctioning with a revised date of 10/94, included the following: PURPOSE: To provide guidelines to help prevent nosocomial infections associated with suctioning and to decrease the spread of infections. PROCEDURE: .8. If using a multi-use bottle of sterile distilled water for source of water for flushing, mark bottle with resident's name, date, and your initials. Discard twenty-four (24) hours after opening or if contamination is suspected MISCELLANEOUS: .11. When suction equipment is designated for a particular resident for extended use, suction connecting tubing and suction collecting canister need not be discarded on a regular schedule, but should be cleaned and flushed as necessary when secretions are present. If the suction connecting tubing becomes visibly soiled with secretions that will not flush, new tubing may be attached. The suction collection canister should be emptied and cleaned daily and changed or decontaminated as necessary. 12.Disposable suction collecting canisters must be discarded after single resident use. The policy did not contain information about suction yankauer tip. 38327 3. On 5/02/23 at 11:16 AM, the surveyor observed Resident#120 laying on the bed with the head of the bed elevated. The surveyor observed that the resident had O2 in use at 4LPM (four liters per minute) via a n/c attached to an O2 wall with a humidified water bottle. At that same time, the resident stated that he/she had cancer and started on O2 use when he/she was hospitalized . The resident was not aware of how much O2 he/she should be on and stated I am comfortable right now with my O2. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included Secondary malignant neoplasm of the liver and intrahepatic bile duct (type of liver cancer), secondary malignant neoplasm of the unspecified lung (type of lung cancer), anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), essential hypertension (elevated blood pressure), unspecified abdominal pain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormones). The 5/05/23 Comprehensive MDS (CMDS) revealed a BIMS score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The CMDS reflected that the resident was on O2. A review of the April and May 2023 OSR revealed that there was an order dated 4/28/23 for O2 at 2 (two) liter via n/c PRN for SOB. There was no order for care of n/c tubing. The above order for PRN O2 was transcribed to the April and May 2023 eTAR. The April 2023 eTAR showed that the PRN O2 was signed as administered by the nurse on 4/29/23 at 0000 (midnight). The May 2023 eTAR reflected that there were no nurses' signatures that showed that the PRN O2 was administered. A review of the Progress Notes (PN) revealed that nurses documented on the following dates and times that the resident was on O2 use via n/c: 4/29/23 at 04:32 (4:32 AM) 4/30/23 at 18:47 (6:47 PM) 5/01/23 at 20:58 (8:58 PM) 5/02/23 at 04:40 (4:40 AM) 5/02/23 at 13:16 (01:16 PM) 5/02/23 at 21:11 (9:11 PM) 5/03/23 at 05:52 (5:52 AM) The personalized care plan did not reflect that the resident was on O2 and there were no interventions for respiratory care for the use of PRN O2. On 5/05/23 at 8:59 AM, the surveyor observed the resident seated on the bed with 2LPM via n/c. On 5/05/23 at 9:01 AM, the surveyor interviewed the assigned Certified Nursing Aide (CNA). The CNA informed the surveyor that it was the nurse's responsibility to take care of Resident #120's O2. She further stated that the resident was on continuous O2 since the resident was admitted to the facility because the resident was unable to breathe well without O2. On 5/05/23 at 9:48 AM, the surveyor interviewed Licensed Practical Nurse#2 (LPN#2). LPN#2 informed the surveyor that the staff nurse initiates the baseline care plan, and the nursing supervisors review and revise the care plan. LPN#2 stated that the O2 care plan should be part of the baseline care plan and care plan should include respiratory care like how often the O2 n/c to be changed, which in the facility, is once a week at 11-7 shift on a Saturday. On that same date and time, LPN#2 stated that for residents with an order for PRN or routine O2, the nurse must sign in the electronic Medication Administration Record (eMAR) or eTAR that it was administered and provided. She further stated that the care for n/c and change of n/c tubing must be signed in the eTAR. At that time, LPN#2 informed the surveyor that Resident #120 was alert and oriented to self, place, and people, with some confusion. LPN#2 stated that the resident required total assistance with activities of daily living (ADL), with incontinence, and pending hospice admission. She further stated that the resident was on O2 since admission at 2LPM. LPN#2 acknowledged that on 5/02/23 she was the assigned nurse of the resident and that the resident was on O2 but was unable to remember if she noticed that the O2 was at 4LPM at that time. LPN#2 further stated that you're maybe right, about the 5/02/23 O2 observation of the resident at 4LPM. She indicated that a family member visited on that day and probably, changed the amount of O2. In addition, LPN#2 stated that she should have signed the eTAR when the PRN O2 was administered and that there should have been a care plan for O2, and an order for n/c tubing care and changes according to the facility practice and policy. On 5/10/23 at 12:32 PM, the survey team met with the LNHA, DON, and DoAM/AA and were made aware of the above findings. On 5/11/23 at 01:03 PM, the survey team met with the LNHA, DON, and DoAM/AA. The DON informed the surveyor that according to LPN#2 on 5/02/23 the religious representative and a family member visited the resident and LPN#2 was not sure who changed it to 4LPM. Furthermore, the DON stated that there was no care plan and accountability for the nurse to change the n/c tubing. The DON further stated that the electronic medical record for the care plan did not have a pre-set O2 care plan and that he was not aware of how to modify it for him to be able to add O2 as part of the care plan. He acknowledged that there should be an order for n/c tubing care and a change in the eTAR. A review of the facility's Care Plan: Baseline and Comprehensive Policy dated 02/23/21 that was provided by the DON included that the facility will develop and implement a baseline care plan, followed by a comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. A review of the facility's Oxygen Use Policy revised 8/08 that was provided by the DON included that patients will be assessed for the need for respiratory services as part of the nursing assessment process; oxygen delivery via nasal cannula or mask will observe universal (standard) precautions; nasal cannula/mask/tubing/humidifier bottles are all single resident use items and are changed and dated weekly and only used for one resident; monitor resident for the effectiveness of oxygen administration and document in the medical record; and when oxygen is no longer required by the resident, dispose of all tubing, cannula, humidifiers, and clean/disinfect equipment. On 5/17/23 at 12:03 PM, the survey team met with the LNHA, DoAM/AA, and DON, and there was no additional information provided by the facility team. NJAC 8:39-11.2 (e)(1)(2)

Complaint # NJ00163437 Based on interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for one (1) of three (3) closed records reviewed for discharge (Resident #117). This deficient practice was evidenced by the following: On 5/04/23 at 01:27 PM, the surveyor reviewed the closed medical record for Resident #117 and revealed the following: The Admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; altered mental status (a change in mental function), hypertension (elevated blood pressure) and cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area). The Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/08/23, showed that the resident was discharged to the community (which includes private home/apt, board/care, assisted living, group home). A review of a Progress Note dated 12/08/23 showed a note written by nursing staff which included the following: Resident was discharged from the facility at approximately 2:45 PM, discharge papers with medication scripts were handed over to resident's responsible party. The Transfer/Discharge Report included Resident #117's diagnoses, last vital signs (included the date but not a time) and the date and time of discharge. The Transfer/Discharge Report did not include where Resident #117 was discharged to, a recapitulation of the resident's stay and the final status of the resident. The medical record revealed that there was no documented discharge summary which included the recapitulation of the resident's stay and a final summary of the resident's status. On 5/11/23 at 01:39 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Admissions and Marketing/Assistant Administrator (DoAM/AA) and Director of Nursing (DON), the findings that Resident #117's medical record did not include a discharge summary. On 5/16/23 at 12:48 PM, in the presence of the survey team, LNHA and DON, the DoAM/AA stated that Resident #117's physician left the medical practice and had not written a note but that another physician wrote a late entry. On 5/16/23 at 12:58 PM, in the presence of the survey team, DoAM/AA and DON, the LNHA confirmed that there was not a discharge summary written for Resident #117 until after surveyor inquiry. The surveyor then asked the LNHA if there should have been a discharge summary. The LNHA stated that there should have been a discharge summary. On 5/17/23 at 12:01 PM, the DoAM/AA provided the survey team a late entry Medical Progress Note which included a medical discharge summary. A review of the document indicated the note was created on 5/13/23, after surveyor inquiry. A review of the facility provided policy titled, Discharge Policy & Procedure dated 2/15/23, included the following: (2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services . 8. Discharge Summary a. A discharge summary will be completed upon discharge to include: a. A recapitulation of the residents stay in the facility (diagnoses, course of illness/treatment, therapy, lab, radiology and consultation reports) b. A final summary of resident status c. Medication reconciliation d. A post-discharge plan of care developed with the resident and resident representative. i. Location/Agency/Facility where resident will reside. ii. Arrangements for care, medications and services post-discharge. iii. Arrangements for follow-up communication post-discharge. A review of the facility provided policy titled, Discharge Planning-Physician's Responsibility dated 12/11/2020, included the following: I. Policy: It is the policy of that the medical care of each resident is supervised by a physician who assumes the principal obligation and responsibility to manage the resident's medical condition, including transfer and discharge . III. Process and Procedure: .C. Physician responsibilities Physicians are responsible for deciding whether the patient is safe for discharge, creating the discharge plan in conjunction with the rest of the team, and communicating instructions to the discharge nurse or designated discharge personnel . To facilitate a patient's safe discharge from an inpatient unit, physicians should: a. Determine that the patient is medically stable and ready for discharge from the treating facility . Physician responsibilities may include: .Provide appropriate documentation and other information that may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; . Provide pertinent medical discharge information within 30 days of discharge or transfer of the patient. N.J.A.C. 8:39-35.2(d)(16)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date the opened bulk dry food items and b) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a foodborne illness. This deficient practice was evidenced by the following: On 5/03/23 at 12:33 PM, during the second day tour of the kitchen, the surveyor and General Manager/Food Service (GM/FS) observed the following in the basement food storage area: 1. In the basement#1 refrigerator, the surveyor observed four (4) crates of 4oz (ounces) whole milk, one gallon of 2% milk, four boxes of individual creamers, six (6) crates of 2% 4oz milk. The inside bottom floor of basement#1 refrigerator had dried and liquid white substance residue covering almost half of the refrigerator. During an interview, the GM/FS informed the surveyor that the white substance was milk. The GM/FS stated that the refrigerator should be cleaned once a week and maintained to be clean. He further stated that there was no accountability log for the weekly cleaning of the basement#1 refrigerator. 2. In the dry storage room, the surveyor observed the unlabeled covered bin with black plastic inside with noticeable white and brown substances around it and papers at the bottom of the container. In addition, inside the container were two (2) opened bulky bags of sugar and flour with no date opened and a use-by date. At that time, the GM/FS informed the surveyor that as per facility policy and protocol, all opened food items must have a label, date opened, and use-by date. Furthermore, the GM/FS picked up and showed to the surveyor labels that were on the bottom of the container which revealed that three (3) out of four (4) labels that fell off were for the flour with dates: 4/15/21 (date open) and use by 6/25/21, 9/23/21 (date open) and use by 11/23/21, and 4/11/23 (date open) and use by 7/11/23. The other label was for the sugar with dates: 4/13/21 (date open) with use by 7/13/21. Furthermore, the GM/FS stated that the bag of sugar and flour contained 50 lbs (pounds) each and both had approximately 25 lbs remaining in each bag. He further stated that he did not know why the bag of sugar had no appropriate label. He acknowledged that the container of sugar and flour was not clean, with dust and residues of both flour and sugar visibly seen because of the black plastic. On 5/05/23 at 10:05 AM, the surveyor interviewed the GM/FS. The GM/FS informed the surveyor that according to their previous policy about the bulk items and following the 2017 Food Code, bulk sugar and other bulk food items once opened, should have an open date and use by date because, after two years, the sugar crystallized. The GM/FS stated that opened bulk flour and sugar should have been placed in a separate covered container with a label outside the container. On that same date and time, the GM/FS stated that in the process of receiving the delivery of milk every Monday, the Executive Chef (EC) who receives delivery should remove the old milk stock, clean and sanitize the reach in refrigerator (basement#1 refrigerator), check the new delivered milk temperature, then store the newly delivered milk. He further stated that it was a major oversight for me. A review of the undated facility's Bulk Product Procedure Policy that was provided by GM/FS included that all bulk products must have a receiving date upon delivery; once the product is open, it must be transferred in a clean and sanitized container labeled with product name, date opened, use by date (follow manufacturer's guideline), and employee initials; and products: bulk flour, bulk sugar, bulk rice, and bulk thickener. A review of the undated facility's Cold Storage Refrigeration and Freezers Cleaning and Sanitizing Policy that was provided by the GM/FS included that the reach-in Refrigerator and Freezer are weekly. On 5/10/23 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, and Assistant Administrator and were made aware of the above findings. NJAC 8:39-17.2(g)

Based on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to: a) follow up and act upon the Consultant Pharmacist's (CP's) recommendations for one (1) of 18 residents reviewed for Medication Record Review (MRR), Resident #118 and b) identify medication irregularity during the monthly MRR of the CP for one (1) of five (5) residents reviewed for unnecessary medications, Resident#120. This deficient practice was evidenced by the following: 1. On 5/02/23 at 11:08 AM, the surveyor observed Resident #118 seated in a wheelchair inside their room while watching television. The surveyor reviewed Resident #118's medical records. The Admission Record (AR or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included type two diabetes mellitus without complications (abnormal or elevated blood sugar level), essential hypertension (elevated blood pressure), and orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down). The Admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 4/12/23 showed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated that the resident's cognition was moderately impaired. The April and May 2023 electronic Medication Administration Record (eMAR) revealed a physician order (PO) dated 4/24/23 for Midodrine (medication that can treat a kind of low blood pressure that causes severe dizziness and fainting) 12.5 mg (milligram) to give one tablet by mouth every eight (8) hours (hrs) as needed (PRN) for hypotension hold for SBP (systolic blood pressure; the first number) more than 130. According to the 5/02/23 CP MRR for Resident#118, the CP recommended to change the PRN Midodrine to be given if SBP is less than 100 and obtain an order to check SBP every 8 hrs to determine if the order should be administered. Further review of the medical records and the eMAR showed that the above recommendation to change the parameter of Midodrine to SBP less than 100 was followed and was transcribed to May 2023 eMAR. The recommendation to obtain an order to check SBP every 8 hrs was not followed. On 5/05/23 at 9:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN informed the surveyor that the CP comes once a month to review the MRR of residents at the facility, and reports are submitted via email to the Director of Nursing (DON), and then the DON will give it to the Registered Nurse/Supervisor (RN/S) to follow up the recommendations and call the doctor. On 5/10/23 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Admissions & Marketing/Assistant Administrator (DoAM/AA), and DON and were made aware of the above findings. On 5/11/23 at 8:56 AM, the surveyor interviewed the RN/S in the presence of the survey team. The RN/S informed the surveyor that it was the facility's practice, policy, and procedure that the CP review resident's MRR every first week of the month, then a couple of days the written reports were sent via email to the DON. The RN/S stated that the DON will provide a copy to the RN/S, then the RN/S initiate to act upon the CP's recommendations, if it was not completed, it will then be delegated to the nurses in the unit and/or to the afternoon Nursing Supervisor. The RN/S further stated that the following day if the CP's recommendations were not completed, the RN/S will continue to follow up on the remaining recommendations that were not done. At that same time, the surveyor showed and notified the RN/S of the 5/02/23 CP's recommendation to obtain an order for SBP every 8 hrs was not followed. The RN/S stated that she was not sure who took care of the recommendations and why the recommendation for Resident #118 was not followed. On 5/11/23 at 01:03 PM, the survey team met with the LNHA, DoAM/AA, and the DON. The DON stated that he investigated what had happened and why the CP's recommendation on 5/02/23 was not followed. The DON further stated that it was the Registered Nurse (RN) who followed up on the CP's recommendation for a Midodrine order for SBP and the reason why the RN did not follow the recommendation to obtain an order for every 8 hrs to check SBP because all residents in the subacute where the resident was located had a standing order for vital signs check every shift. On that same date and time, the surveyor asked the DON what time every shift was plotted and the every 8 hrs plotted in the eMAR. The DON stated that every shift has no specific time and usually vital signs are checked during the first med pass at 8:00 AM for the 7-3 shift and 4:00 PM for the 3-11 shift. The DON further stated that every 8 hrs means it is 6:00 AM, 2:00 PM, and 10:00 PM. In addition, the DON stated that the RN should have called the doctor and obtained an order for every 8 hrs. Furthermore, the DON acknowledged that the CP's recommendation was not clear and should have been clarified as well. 2. On 5/02/23 at 11:16 AM, the surveyor observed Resident#120 laying on the bed with the head of the bed elevated. The resident informed the surveyor that he/she had a cancer diagnosis and with variable pain in the abdomen area that nurse administers pain medication. The resident further stated that he/she was satisfied with their pain medication regimen. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included Secondary malignant neoplasm of the liver and intrahepatic bile duct (type of liver cancer), secondary malignant neoplasm of the unspecified lung (type of lung cancer), anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), essential hypertension, unspecified abdominal pain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormones). The 5/05/23 Comprehensive MDS (CMDS) revealed a BIMS score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The CMDS reflected that the resident received PRN pain medications, with occasionally moderate pain for the last five (5 days). A review of the April and May 2023 eMAR revealed the following orders: 1. PO dated 4/28/23 at 1751 (5:51 PM) for Acetaminophen 325 mg to give 2 (two) tabs by mouth for a total of 650 mg every 4 (four) hrs PRN for mild pain. 2. PO dated 4/30/23 at 1530 (3:30 PM) for Oxycodone HCL (hydrochloride) oral 5 (five) mg to give one tab by mouth every 4 hrs PRN for mod-severe (moderate-severe) pain. 3. PO dated 5/02/23 at 1015 (10:15 AM) for Morphine Sulfate (concentrate) oral solution 20 mg/ml (milligram/milliliter), give 0.25 ml by mouth every 3 (three) hrs PRN for pain. The order for Morphine Sulfate was updated on 5/03/23 at 0645 (6:45 AM) to give 0.25 ml by mouth every 4 hrs PRN for pain. Furthermore, the above orders for PRN pain medications for April and May 2023 showed that the PRN Oxycodone was administered on 4/30/23 and 5/01/23 and the PRN Morphine was administered on 5/02/23, 5/03/23, 5/04/23, and 5/05/23. A review of the 5/02/23 MRR of the CP showed that there were no recommendations comments. In addition, the 5/02/23 at 1842 (6:42 PM) Progress Notes of CP in the electronic medical record revealed that MRR was completed. On 5/05/23 at 9:48 AM, the surveyor interviewed the LPN. The LPN stated that the resident was able to make needs known to staff, was constantly in pain, and was on multiple pain medication regimens as standing order and PRN. The LPN further stated that the physician and the responsible party were aware of the resident's condition. At that same time, the LPN informed the surveyor that there were times when the CNA will have to call the nurse to assess the resident because the resident had pain when repositioning. The LPN stated that even during morning rounds, the LPN noticed that the resident with a facial grimace and PRN pain medication being offered and the resident will decline. On that same date and time, the surveyor notified the LPN of the findings with regard to PRN pain medication Morphine with no indication of what level of pain to administer. The LPN stated that there should be a proper sequencing of PRN pain medications and it was probably an oversight on their part. She further stated that the CP should have pick up the irregularity and reported it to CP's monthly MRR. The LPN indicated that she will call the physician regarding the PRN Morphine order. On 5/10/23 at 12:32 PM, the survey team met with the LNHA, DON, DoAM/AA and were made aware of the above findings. On 5/11/23 at 8:56 AM, the surveyor interviewed the RN/S. The RN/S informed the surveyor that residents with multiple PRN orders for pain medications should have a sequenced order for mild, moderate, and severe pain, and it was the nurse's responsibility to clarify and obtain that order from the physician according to the facility's practice and policy. The RN/S stated that it was also the CP's responsibility to identify those irregularities and document and report it in the written MRR. She further stated that the nurse and the CP should have identified those sequencing irregularities for PRN Morphine for pain. A review of the facility's Medication Regimen Review (MRR) Policy that was provided by the LNHA with a revised date of January 2018 included that the CP performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. MRR also involves reporting findings with recommendations for improvement. MRR activities include but are not limited to evaluating medication orders to determine that the resident's orders represent optimal therapy for that individual that includes PRN orders that include indications for use. Recommendations are acted upon and documented by the facility staff and/or the prescriber. On 5/17/23 at 12:10 PM, the LNHA provided her phone with CP on the other line to discuss the PRN Morphine findings in the presence of the survey team. The CP stated that you are right, the Morphine should have been clarified and identified in the 5/02/23 MRR. The CP further stated that the nurse should have identified the irregularities as well. NJAC 8:39-29.3 (a)(1)

Based on observation, interview, and record review, it was determined the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a) expired medications were removed from the electronic emergency (back-up) supply for 1 (one) of 1 (one) back up machine, b) prescription medication for unsampled Resident #267 was removed from active inventory after being discontinued on October 2022, c) prescription medications were labeled, dispensed, and accounted, for 1 (one) of 2 (two) medication rooms inspected and 1 (one) of 3 (three) medication carts inspected. 21 CFR 1306.24(b) If the prescription is filled at a central fill pharmacy, the central fill pharmacy shall affix to the package a label showing the retail pharmacy name and address and a unique identifier, (i.e. the central fill pharmacy's DEA registration number) indicating that the prescription was filled at the central fill pharmacy, in addition to the information required under paragraph (a) of this section. 21 CFR 205.50(a)(3) a) Facilities. All facilities at which prescription drugs are stored, warehoused, handled, held, offered, marketed, or displayed shall: Have a quarantine area for storage of prescription drugs that are outdated, damaged, deteriorated, misbranded, or adulterated, or that are in immediate or sealed, secondary containers that have been opened . The deficient practice was evidenced by the following: 1. On 5/05/23 at 12:31 PM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) entered the medication room for the E wing (subacute unit). Located within the same medication room was the electronic back-up machine. At that time, the RN/UM stated that the supervisors on all shifts were responsible to monitor the inventory and did not have a written accounting that the task was being completed. On 5/05/23 at 12:37 PM, the RN/UM, in the presence of the surveyor began the cycle count for the back-up machine. The back-up machine had locked drawers that opened once the nurse entered their credentials. Each drawer contained several medications. On 5/05/23 at 12:53 PM, the surveyor, in the presence of the RN/UM observed two Ciprofloxacin (antibiotic medication used to treat various bacterial infections) 200 milligram (mg)/100 milliliter (ml) 5 % dextrose (D5W) injection, USP. The medication was labeled with an expiration date of 01/31/23. On 5/04/23 at 12:56 PM, the RN/UM confirmed the two Ciprofloxacin for injection were expired since 01/31/23. A review of the PAR (minimum and maximum quantity limits that was set for a certain medication) of the Ciprofloxacin D5W 200 mg/100 reflected a quantity of 2 (two). At that time, during an interview with the surveyor, the RN/UM stated expired medications should not have been contained within the electronic back-up machine. The RN/UM stated expired medications would not have been effective to treat the resident. At that time, the RN/UM stated, I recognize that we do not have an audit list and that could have helped with the accountability. The RN/UM stated she would remove the expired medications, notify the pharmacy to pick up, replace the medication and inform the Director of Nursing (DON). 2. On 5/11/23 at 9:34 AM, the surveyor in the presence of the Registered Nurse#1 (RN#1) began the unit inspection for the medication room for the D wing (unit 2). On 5/11/23 at 9:48 AM, the surveyor, in the presence of RN #1, observed a bottle of Lactulose (medication for encephalopathy) labeled for unsampled Resident #267 commingled with the over the counter (OTC; house stock) medications. At that time, RN#1 could not explain why the labeled medication bottle for Resident #267 dated 10/07/22 was in the same medication cabinet commingled with the OTC medications. The surveyor reviewed the medical records for Unsampled Resident #267. The Admission Record (AR; face sheet; admission summary) for Unsampled Resident #267 reflected the resident was admitted with diagnoses that included acute on chronic systolic (congestive) heart failure, cognitive communication deficit, and cerebral infarction (stroke). The Clinical Physician Orders for Unsampled Resident #267 reflected that Lactulose Solution had a start date of 10/07/22 and an end date of 10/12/22. A review of the Census List for Unsampled Resident #267 revealed the resident was discharged to the hospital on 10/12/22. On 5/11/23 at 9:56 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated discontinued medications should have been returned to the pharmacy provider for the resident to receive credit. On 5/11/23 at 10:02 AM, the LPN/UM stated the discontinued medication should have been separated from all the OTC medications in active inventory to avoid medication errors, We can't use someone else's medications and resident should receive the credit. 3. On 5/11/23 at 10:02 AM, the surveyor in the presence of RN#1 continued the inspection of the medication room and observed the following: -three sealed bottles of Lactulose with no pharmacy provider label -one box of Ondansetron (medication used to treat nausea and vomiting) 4 mg, quantity of thirty tablets with pharmacy provider label. At that time, during an interview with the surveyor, the RN/UM stated the pharmacy should not have sent prescription medications without a label. We do not know who the medications were indicated for, and this is not safe for the residents. On 5/11/23 at 10:22 AM, the surveyor began the medication cart inspection for the A and B wing (unit 1) in the presence of the Licensed Practical Nurse (LPN). On 5/11/23 at 10:31 AM, the surveyor observed an unlabeled box of Ondansetron 4 mg Oral Disintegrating tablets that contained 23. At that time, during an interview with the surveyor, the LPN stated that prescription back-up medications were also known as house stock. She further informed the surveyor that the Ondansetron was a house stock medication that they used. At that time, the LPN/UM explained the process for removal of back-up medications, we take out the dose of what we need for the resident. The LPN stated we should not have an unlabeled medication in our active inventory because medication error and drug diversion could occur. The LPN informed the surveyor that she would immediately remove the medication from the medication cart and give it to the RN/UM. On 5/11/23 at 01:05 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator (LNHA) and the Administrator in Training (AIT), the surveyor discussed the concerns regarding the expired medication, unlabeled medications and discontinued medication. At that time, the LNHA stated she followed up with the pharmacy provider. She stated that the pharmacy provider assured her that the expired medication would not show as available and would not be dispensed from the electronic back-up machine. At that time, the LNHA, presented an electronic mail (email) correspondence between her and the provider pharmacy. The email reflected that the electronic back-up machine was checked for outdated medications monthly and inventoried every 90 days. The individual tasked with the responsibility to was terminated in March. The correspondence further revealed that the expired medication in the machine was automatically quarantined and unavailable for removal. The LNHA acknowledged that the expired Ciprofloxacin D5W from 01/31/23 should have been removed. On 5/16/23 at 01:23 PM, the DON presented an email correspondence between him and the pharmacy provider. The email reflected that the Lactulose was a back-up supply and was labeled with the location on a different medication room. The pharmacy provider acknowledged that a unit dose medication would be best for the back-up supply and the bottles would be replaced with the unit dose medication. At that time, the DON and the LNHA stated that the medication that belonged on the back-up supply should have been in the same medication room and that they should have been informed. Both acknowledged it should not have been in a separate unit. On 5/17/23 at 11:40 AM, during a follow up interview with the surveyor, in the presence of the survey team, the DON stated that the previous medical director had ordered Ondansetron from a different pharmacy provider on 11/12/21 as a house stock. The DON stated the Ondansetron should not have been there. It should have been returned to the pharmacy or discarded. It was missed by nursing, the supervising nurses, and the consultant pharmacist (CP). On 5/17/23 at 11:54 AM, during an interview with the surveyor, in the presence of the survey team, the DON, LNHA and AIT, the CP stated that the unlabeled medications in a different unit from the back-up machine commingled with active OTC inventory was not inappropriate. The CP also stated the discharged resident's medication should have been removed and was overlooked. A review of facility policy provided; Medication Storage revised/reviewed 8/01/22 included under Policy: It is the policy that back up medication shall be kept in the [name redacted] provided by [name redacted]. A review of facility policy provided, Medication Storage in the Facility 2023 Edition included under section 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without closures are immediately removed from stock, disposed of according to the procedures for medication destruction and reordered from the pharmacy, if current order exits [exists]. NJAC 8:39-29.4 (c) (f) (g) (h)

Complaint # NJ00163437 Based on observation, the interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to: a) ensure there was a physician's order and physician documentation regarding discharge for one (1) of three (3) closed medical records reviewed for discharge (Resident #117) and b) ensure a physician's order for a diet order of nectar thick consistency for one (1) of five (5) residents were followed during Medication Pass Observation of Resident#1. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/04/23 at 01:27 PM, the surveyor reviewed the closed medical record for Resident #117 and revealed the following: The Admission Record (AR; or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; altered mental status (a change in mental function), hypertension (elevated blood pressure) and cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area). The Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/08/23, showed that the resident was discharged to the community (which includes private home/apt, board/care, assisted living, group home). A review of a Progress Note (PN) dated 12/08/23 showed a note written by nursing staff which included the following: Resident was discharged from the facility at approximately 02:45 PM, discharge papers with medication scripts were handed over to resident's responsible party. Further review of the electronic PNs showed a note written by the physician that included Resident #117's history and physical (H&P). The H&P did not include information about a plan for discharge. There was no other documentation written by a physician in the PN's. The Order Summary Report (OSR) dated 12/08/22, did not include a physician's order for discharge. A review of a copy of prescriptions written by the physician dated 12/07/22 did not include a physician's order for discharge. On 5/11/23 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) via phone, regarding the process of a resident's discharge. LPN #1 stated that the physician would usually write an order for discharge in the electronic medical record or would give a verbal order to the nurse and that the nurse would place the order in the electronic medical record. On 5/11/23 at 11:32 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process of a resident's discharge and a physician's order for discharge. The DON stated that there would be a physician's order for discharge and that it would be in the order section of the electronic medical record. The surveyor then asked the DON if Resident #117 should have had a physician's order for discharge in the electronic medical record. The DON stated that there should be a physician's order for discharge. On 5/11/23 at 01:39 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Admissions and Marketing/Assistant Administrator (DoAM/AA) and DON, the findings that Resident #117's medical record did not include a physician's discharge order and physician's documentation regarding discharge. On 5/16/23 at 12:58 PM, in the presence of the survey team, DoAM/AA and DON, the LNHA confirmed that there was no physician's order for discharge for Resident #117 prior to surveyor inquiry. The surveyor asked the LNHA if there should have been a physician's order for discharge. The LNHA stated that there should have been a physician's order for discharge. She added that an order could be in the electronic medical record, or it could be handwritten and uploaded to the electronic medical record. On 5/17/23 at 12:01 PM, the DoAM/AA provided the survey team a Clinical Physician Order which included the following: Discharge to ALF (Assisted Living Facility). A review of the document indicated the note was created after surveyor inquiry on 5/16/23. 2. On 5/05/23, at 8:53 AM, the surveyor began the Medication Observation Pass for Resident #1. LPN #2 began to prepare the medication for the resident. At that time, the surveyor observed an order on the electronic Medication Administration Record (eMAR) that indicated the resident had a nectar thick order. On 5/05/23 at 9:10 AM, LPN #2 confirmed with the surveyor that she was ready to administer the medications to Resident #1. On 5/05/23 at 9:11 AM, during the medication pass observation for Resident #1, the LPN stated she had pre-prepared the resident's nectar thickened liquid that morning. At that time, LPN #2 identified the liquid that was in a covered Styrofoam cup on the resident's sink was the liquid she had prepared that morning. At that time, Resident #1 stated she added a tea bag in the Styrofoam cup. The surveyor observed the LPN was about to administer the medications to the resident. At that time, the surveyor stopped the medication pass for Resident #1 to check the liquid in the cup. LPN #2 removed the Styrofoam cup from the resident's room. At that time, the surveyor and LPN #2 reviewed the liquid within the Styrofoam cup. The LPN informed the surveyor that the liquid in the Styrofoam cup was not nectar thick consistency. The surveyor reviewed the medical records for Resident #1. The AR reflected the resident was admitted with medical diagnoses that included, chronic obstructive pulmonary disease, hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction affecting unspecified side, and gastro-esophageal reflux disease without esophagitis. The quarterly MDS dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. Further review of the MDS under section K 0510 Nutrition approaches under subsection C. Mechanically altered diet - require change in texture of food or liquids (e.g., puree food, thickened liquids) indicated, yes. The OSR reflected the dietary order for No Added Salt diet, regular texture, nectar consistency with a start date of 12/29/21. Further review of the order summary report revealed an ST [speech therapist] recommendation: Thin/Free Water Protocol. Patient can be provided with regular thin water in between meals ONLY upon request and as tolerated. Adequate oral care and positioning OOB (out of bed) in wheelchair ONLY when provided with regular water with DIRECT SUPERVISION. Maintain aspiration precautions at all times and continue to monitor for aspiration (body temp; respiratory status). Medications to be provided with thickened Liquids. On 5/05/23 at 10:53 AM, during a follow up interview with the surveyor, LPN #2 informed the surveyor that she prepared a nectar thick liquid because she had an order for it. LPN #2 stated she used two (2) packets in a nine-ounce cup not filled to the brim and poured it into the Styrofoam cup. LPN #2 stated she was not sure why the liquid in Resident #1's room was not nectar thickened. The LPN #2 informed the surveyor that she did add ice into the resident's cup, and it may have changed the consistency. LPN #2 stated she should have double checked after mixing the liquid before placing the Styrofoam cup into the resident's room. On 5/10/23 at 12:04 PM, in the presence of the survey team, the DON, the LNHA and the DoAM/AA, the surveyor discussed the findings regarding the failure to follow the physicians order for nectar thickened liquid for Resident #1. On 5/11/23 at 12:07 PM, during an interview with the surveyor, the Rehabilitation Director (RD) stated Resident #1 was referred because the resident wanted an upgrade on their diet. The RD explained an upgrade/advance meant a less restrictive diet. On 5/11/23 at 12:08 PM, the surveyor and the RD reviewed the Speech Therapy Speech-language pathologist (SLP) Evaluation and Plan of Treatment. The evaluation reflected diagnoses that included dysphagia (swallowing difficulties). At that time, the RD stated that Resident #1's SLP recommended free water protocol with adequate mouth care and distant supervision. The RD clarified that medication must be administered with nectar thickened liquid. On 5/11/23 at 01:05 PM, the DON stated the resident was given instruction for free water protocol and in between meals. The DON also stated he had consulted with the consultant pharmacist and was told since the resident had order for free water protocol the nurse should have been able to administer the medication with thin liquid. The DON stated he would further research the order that indicated medication to be provided with thickened liquid. The DON informed the surveyors that education was given to LPN #2. A review of the facility provided policy titled, Discharge Policy & Procedure dated 2/15/23, included the following: POLICY It is the policy of this facility that residents will be assessed for their discharge goals, preferences and care needs to meet their goals. The assessment information will be used to develop a comprehensive discharge care plan .The care plan will be developed by the interdisciplinary team (IDT), including the resident's physician . OBJECTIVE OF THE DISCHARGE PLAN FACILITY POLICY The objective of the discharge plan policy and procedure is to provide a framework for the completion of relevant documents by the IDT and the residents and representative that will inform the discharge process and assist the resident to reach their discharge goals. The policy did not include information regarding physician order or documentation. A review of the facility provided policy titled, Discharge Planning-Physician's Responsibility dated 12/11/2020, included the following: I. POLICY: It is the policy of that the medical care of each resident is supervised by a physician who assumes the principal obligation and responsibility to manage the resident's medical condition, including transfer and discharge. II. STATEMENT: Physician involvement in nursing facilities is essential to the delivery of quality long-term care. Attending physicians should lead the clinical decision-making for patients under their care . III. Process and Procedure: .C. Physician responsibilities Physicians are responsible for deciding whether the patient is safe for discharge, creating the discharge plan in conjunction with the rest of the team, and communicating instructions to the discharge nurse or designated discharge personnel . To facilitate a patient's safe discharge from an inpatient unit, physicians should: a. Determine that the patient is medically stable and ready for discharge from the treating facility . Physician responsibilities may include: .Provide appropriate documentation and other information that may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; Give all orders needed at the time or prior to discharge from the facility . A review of the facility policy provided, Operational Manual, subject: Speech Therapy Policy revised/ reviewed 3/15/21 included under Procedure, B. The areas addressed by Speech therapist include, but are not limited to: 7. Diet consistency/textures A review of the facility policy provided, Nursing Policy Manual, subject Medication Administration dated 7/08 included under Policy: Medications are administered by licensed nurses per physician order, following all regulations and best practices. No further information was provided. NJAC 8:39-17.4 (a) 1(e), 27.1 (a) 45449

Complaint Intake: NJ 8 Based on interviews and record review, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 sampled residents reviewed for emergency care services. Specifically, the facility failed to ensure nursing staff requested emergency medical service timely when Resident #1 was exhibiting symptoms of a stroke. Findings include: 1. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required one-person physical assistant for bed mobility, dressing, personal hygiene, and locomotion; and two-person physical assistant for transfer and toileting. A review of Resident #1's medical record revealed a nursing note dated [DATE] at 5:45 PM which reported that Resident #1 readmitted after hospitalization for a calcaneal fracture. The note at 8:45 PM indicated Resident #1 remained alert with slurring of speech. The note further revealed the resident's hand grasp was poor on the resident's right hand. The resident's vital signs were obtained and recorded as follows: blood pressure (BP) ,d+[DATE]; pulse (P) 59; temperature (T) 97.3 degrees Fahrenheit (F), oxygen saturation (SPO2) 96% [record did not indicate whether on room air or with portable oxygen]; blood sugar 208 [unit of measurement omitted in original]. The record indicated the resident's attending physician gave order to send Resident #1 to the hospital. A review of the [NAME] Police Department Incident Report, # 036, revealed a 911 call to request for emergency service was placed at 9:38 PM. Although, the nursing note reviewed above did not explicitly document the time stamp for when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The details about the timeline which spoke to the initial observation made of Resident #1 exhibiting slurred speech by the resident's family member was not documented in the resident's medical record. A review of Resident #1 hospital admission record dated [DATE] revealed the resident's admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the personnel file of Registered Nurse (RN) #2 [nursing staff implicated in the allegation] revealed she was terminated on ground of an apparent error in nursing judgement about timing and urgency regarding the lag with calling 911. On [DATE] at 3:15 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) said they both were not employed with the facility at the time of the incident. The DON reviewed the record of file for the [DATE] incident with Resident #1 and reiterated the information on the file. Specially, the DON said the primary issue regarding the situation with Resident #1 was whether the nurse who took care of the resident called 911 in a timely manner, given that it had been identified by a relative who was on a video call with the resident when the resident started exhibiting symptoms and the nurse who assessed and verified the resident was exhibiting symptoms of a stroke. He clarified that the record lacked any rationale that led to more than 50 minutes delay before the nurse called 911. He said, with stroke, time was of essence in determining whether one lived, suffered irreversible brain damage, or died from a stroke. The DON said, Without any documented rationale in the record, it took too long for the nurse to call the emergency response. He said the facility had since adopted a standing order for nursing staff to send residents to the hospital on firsthand assessment which indicated a deviation from the resident's baseline and not having to wait on hearing back from the doctor. He expressed that the facility had continued to reinforce its emergency response training amongst staff, so they were efficiently reactive. New Jersey Administrative Code § 8:,d+[DATE].1(a)

Complaint Intake: NJ 8 Based on record review, interviews, and facility policy review, it was determined that the facility failed to investigate an injury of unknown source for 1 (Resident #1) of 3 sampled residents reviewed for injuries of unknown source. Findings include: 1. Resident #1 was readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required one-person physical assistant for bed mobility, dressing, personal hygiene, locomotion and two-person physical assistant for transfer and toileting. A review of Resident #1's medical record revealed a nursing note dated 03/10/2020 at 6:00 AM. The note documented no unusual findings with Resident #1 during the shift, it further reported that no pain or acute distress was noted with Resident #1. At 10:00 AM of the same day, the nursing note indicated Resident #1 complained of pain to the right foot. On assessment, it was noted that the resident had a bruise to the back of the right foot. The skin around the resident's right foot was reported as warm and swollen. At 11:00 AM, it was documented that the medical director (MD) was contacted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing note reported that the said X-ray result was received at 6:00 PM and it was positive for an acute calcaneal avulsion fracture, likely related to an Achilles injury. The note at 7:00 PM, read that Resident #1's family/responsible party was made aware of the injury and informed of the MD's directive to send Resident #1 to the emergency room (ER). On 03/10/2020 at 1:00 PM, it was reported that Resident #1 came back from the ER with a splint to the right foot. There was no documentation of a conclusive investigation to ascertain the cause/origin of the injury to Resident #1's right foot in the record. On 06/18/2021 at 02:30 PM, Licensed Practical Nurse (LPN) #1 said she would inform the nurse supervisor of any injury of unknown origin assessed on a resident. She said the nurse supervisor would tell the director of nursing who in turn started an investigation to ascertain the origin of the injury. On 06/18/2021 at 10:12 AM, the Director of Nursing (DON) reviewed Resident #1's medical record and verified the cause of the injury sustained by the resident to the right foot was undetermined. He concluded that there was no record on file which showed an investigation was conducted. The DON said when a nursing assessment identified an injury on a resident that was not consistent with what the resident admitted with, he immediately started an investigation. The DON stated he would interview the resident and any witness to get a clear account of how, where, and when the injury occurred. The DON said the MD and the resident's family/responsible party were notified. The DON said the next course of action was to launch an investigation to ascertain the root cause of the injury. The facility policy, Injury of Unknown Origin, dated 01/18/2021, indicated Injuries of unknown origin will be investigated. They will be reviewed at the safety committee meetings. New Jersey Administrative Code § 8:39-5.1(a)

Complaint Intake NJ 8 Based on record review, interviews, and facility policy review, it was determined that the facility failed to report an injury of unknown source to the state agency for 1 (Resident #1) of 3 sampled residents reviewed for injuries of unknown source. Findings include: 1. Resident #1 was readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required one-person physical assistant for bed mobility, dressing, personal hygiene, locomotion and two-person physical assistant for transfer and toileting. A review of Resident #1's medical record revealed a nursing note dated 03/10/2020 at 6:00 AM. The note documented no unusual findings with Resident #1 during the shift, it further reported that no pain or acute distress was noted with Resident #1. At 10:00 AM of the same day, the nursing note indicated Resident #1 complained of pain to the right foot. On assessment, it was noted that the resident had a bruise to the back of the right foot. The skin around the resident's right foot was reported as warm and swollen. At 11:00 AM, it was documented that the medical director (MD) was contacted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing note reported that the said X-ray result was received at 6:00 PM and it was positive for an acute calcaneal avulsion fracture, likely related to an Achilles injury. The note at 7:00 PM, read that Resident #1's family/responsible party was made aware of the injury and informed of the MD's directive to send Resident #1 to the emergency room (ER). On 03/10/2020 at 1:00 PM, it was reported that Resident #1 came back from the ER with a splint to the right foot. There was no documentation of a conclusive investigation to ascertain the cause/origin of the injury to Resident #1's right foot in the record. The record lacked information that revealed the facility reported a case of injury of unknown origin to the state survey agency (SSA). On 06/18/2021 at 10:12 AM, the Director of Nursing (DON) reviewed Resident #1's medical record and verified the cause of the injury sustained by the resident to the right foot was undetermined. He concluded that there was no record on file which showed that the SSA was notified. The DON said when a nursing assessment identified an injury on a resident that was not consistent with what the resident admitted with, he immediately started an investigation. The DON stated he would interview the resident and any witness to get a clear account of how, where, and when the injury occurred. The DON said the MD and the resident's family/responsible party were notified. The DON said the next course of action was to launch an investigation to ascertain the root cause of the injury. The DON clarified that, if the cause of the injury was undetermined, it was reported to the SSA as an injury of unknown origin. The Injury of Unknown Origin Policy, dated 01/18/2021, was provided by the nursing home administrator (NHA). It read in part, If the cause of the injury remains unknown, the injury will be reported to the department of Health. New Jersey Administrative Code § 8:39-5.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) maintain appropriate infection control practices for resident #58, 1 of 1 residents observed with an indwelling urinary catheter and b.) adhere to the accepted standards of infection control practices for the proper storage of respiratory equipment for Resident #269, 1 of 2 residents observed for respiratory care. This deficient practice was evidenced by the following: 1.) During the initial tour on 06/24/19 at 8:01 PM, the surveyor observed Resident #58 lying in bed with the head of the bed elevated. Resident #58 confirmed the use of an indwelling catheter. The surveyor entered Resident #58's private bathroom and observed a previously used catheter bag being stored in a clear plastic bag with a urine container. The catheter bag tip was uncapped, and a liquid yellow substance was observed at the bottom of the plastic bag. The catheter bag also contained a yellow substance. The surveyor did not see a date on the catheter bag, the urine container or the clear plastic bag. On 06/27/19 at 08:44 AM, the surveyor returned to Resident #58's bathroom and observed a previously used catheter bag stored in a clear plastic container. The catheter tip was uncapped, and a liquid yellow substance was observed within the catheter bag. The surveyor did not see a date on the catheter bag or the clear plastic bag. The surveyor interviewed Resident #58, who revealed a history of infections. Resident #58 revealed that the certified nursing assistants (CNA'S) usually cap the end of the catheter bag, but sometimes they're in a hurry. A review of the resident's medical record revealed [REDACTED]. A review of the quarterly Minimum Data Set (MDS), an assessment tool, reflected Resident #58's cognition was moderately impaired and was dependent on staff for toilet use. The surveyor reviewed the resident's ongoing Care Plan (CP) which identified a problem of Foley Catheter, [MEDICAL CONDITION] Bladder and [MEDICAL CONDITION] with the onset date of 7/25/18. The interventions included catheter care as per protocol. On 06/27/19 at 09:43 AM, the surveyor interviewed CNA #1, who revealed Resident #58 had gone to the hospital a couple of times since admission due to UTI's. CNA #1 revealed a way a resident could get a UTI is if a catheter leg bag was not properly cleaned when being changed with the bedside catheter bag. CNA #1 explained part of the process for switching the bags included rinsing the previously attached bag with water and storing the catheter bag in the bathroom in a plastic bag. After being prompted by the surveyor, CNA #1 further indicated that the tip of the catheter was cleaned with a moistened disposable washcloth and that the plastic storage bags were changed every other day on the morning shift, if drainage was observed in the plastic bag. CNA #1 indicated that nothing should be stored in the plastic bag with the catheter bag. In the presence of the surveyor, CNA #1 observed the catheter bag stored in the plastic bag in Resident #58's bathroom and indicated it was properly stored. When the surveyor asked if it should be stored with a cap on the tip, the CNA stated yes, she'd forgotten. On 06/27/19 at 10:05 AM, the surveyor interviewed the licensed practical nurse (LPN) #1 who revealed urinary catheter bags should be stored in the plastic bag in the bathroom after the bag was disconnected from a resident and rinsed thoroughly and the tip should be cleaned with an alcohol swab prior to being capped. LPN #1 indicated plastic storage bags were changed weekly. In the presence of the surveyor, LPN#1 observer Resident #58's urinary catheter bag stored in the resident's bathroom. LPN #1 indicated the urinary drainage bag should have been capped and didn't appear to have been rinsed thoroughly. The LPN indicated she has not watched the CNA's process for changing urinary catheter bags but stated the CNAs are in serviced. On 06/27/19 at 01:37 PM, the Director of Nursing (DON) revealed the tips of catheter bags should be cleansed with an alcohol pad and cap prior to storage after rinsing the bag. The DON further revealed plastic bags should be changed weekly and should be labeled. The surveyor reviewed the policy titled, Foley Catheter Insertion & Care with a revision date of (MONTH) 2019 which revealed drainage bags should be rinsed with cool water and capped after an hour prior to storage in a plastic bag. The policy further revealed plastic storage bags (page .SIC) should be changed daily. 2.) On 6/24/19 at 7:13 PM, during the initial tour of the facility, the surveyor observed Resident #269 seated in the resident's room conversing with people identified as family. The surveyor observed an oxygen concentrator at the head of the resident's bed, with oxygen tubing draped over the top of the concentrator. The oxygen concentrator was not turned on. When interviewed at the time, Resident #269 revealed the oxygen was no longer needed during the day, only at night. The surveyor made the same observations on 6/25/19 at 11:29 AM and 6/27/19 at 10:02 AM. A review of the resident's medical record revealed [REDACTED]. A review of the quarterly Minimum Data Set (MDS), reflected Resident #269's cognition was moderately impaired and required the use of supplemental oxygen therapy during the 14-day lookback period. The surveyor reviewed the resident's ongoing Care Plan (CP) which identified a problem of Foley Catheter, [MEDICAL CONDITION] Bladder and [MEDICAL CONDITION] with the onset date of 7/25/18. The interventions included catheter care as per protocol. On 06/27/19 at 10:02 AM, the surveyor interviewed CNA #2 who stated oxygen tubing should be dated and stored in a plastic bag when not in use. The CNA confirmed resident #269's oxygen was improperly stored on the top of the oxygen concentrator and revealed she could not locate a date on the tubing. On 06/27/19 at 10:05 AM, the surveyor interviewed LPN#1 who confirmed oxygen tubing should be dated and stored in a plastic bag when not in use. The LPN further revealed it was all the staff's responsibility to verify oxygen was stored properly. In the presence of the surveyor, LPN #1 observed the oxygen tubing and confirmed it was not stored properly. LPN #1 indicated the tubing should have been dated. On 06/27/19 at 1:25 PM, the DON confirmed oxygen tubing should be labeled with a date and properly stored in a plastic bag when not in use. The surveyor reviewed the policy titled, Oxygen Use with a revision date of (MONTH) 2019 which revealed oxygen tubing should be dated and stored in a plastic bag when not in use. NJAC 8:39 - 19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards of clinical practice with respect to: a.) not following physician orders [REDACTED].) assuring the application of compression stockings were in place before signing the Treatment Administration Record (TAR) and c.) assuring that preventive measures ordered to prevent skin injury were in place before signing the TAR. This deficient practice was identified for Resident #42, #216 and #4, 3 of 21 residents reviewed and was evidenced by the following: Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a licensed practical nurse is defined as performing task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) According to the physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) an assessment tool dated 5/22/19, indicated that the resident was cognitively intact and required limited assistance with activities of daily living (ADL's). On 06/25/19 at 10:32 AM, the surveyor interviewed Resident # 42 who stated that he/she was wearing a brace on the right lower leg until he/she fell at home on 11/9/18. The resident revealed that a doctor came in and examined his/her right knee in (MONTH) 2019. The resident also added that the physician was to come back in to measure his/her right knee for brace, but never did. According to the Physician order [REDACTED]. The TAR dated (MONTH) 2019 reflected an order for [REDACTED]. The TAR dated (MONTH) 2019 did not reflect a physician's orders [REDACTED]. On 06/26/19 at 9:00 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that Resident # 42 use to wear a right leg brace but had not been wearing it because his/her right leg was too swollen to put it on, so it was discontinued. On 06/26/19 at 9:05 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that Resident # 42 was not wearing a brace on his/her right lower leg because the resident had a right foot wound and the brace was not able to be applied until the wound was healed. The surveyor reviewed a Physical Medicine Consult dated 5/22/19, that reflected a consult by the facility Physiatrist (Rehabilitation Doctor) who ordered Resident # 42 a right knee brace for comfort due to the [DIAGNOSES REDACTED]. On 06/26/19 at 9:32 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that she was not aware Resident # 42 had a physician's orders [REDACTED]. The LPN/UM reviewed the (MONTH) 2019 POS in the presence of the surveyor and confirmed that there was a physician's orders [REDACTED]. The LPN/UM added that staff should have known that the brace was ordered because the physician wrote the order on the physician's orders [REDACTED]. [REDACTED]. I'm not sure why this order was missed, or the resident does not have the brace. I will have to investigate that. It must have dropped off the (MONTH) TAR somehow, but the resident should have had the brace by now because it's been a month and the brace is still not delivered. On 06/26/19 at 09:45 AM, the surveyor interviewed the Physical Therapy Director who stated that he was not aware and was not notified that Resident # 42 was ordered a right knee brace. On 06/26/19 at 10:00 AM, the surveyor interviewed the physiatrist (Rehabilitation Doctor) who stated that she ordered the right knee brace on 5/22/19 and called the orthotic company to come and measure the resident's right knee for the brace. She added that she did not follow up to assure that the orthotic company came in to fit the resident for the brace, because the nurses should by following up with the orders and if the nurse had issues obtaining the brace then she should have been notified. The psychiatrist revealed that she did not know that the resident still did not have the right knee brace that she ordered on [DATE]. On 06/26/19 11:00 AM, the surveyor interviewed the LPN #1 who stated that she worked on 5/28/19 and confirmed her signature was on the TAR dated 5/28/19. She added that a signature with a circle around it indicated that Resident # 42's right knee brace was not applied because it was not delivered from the company from which it was ordered, but I did not write that on the back of the TAR. I guess one of the nurses should have called to find out where the brace was after we noticed it wasn't here for a couple days. I really thought the nurse manager knew about the brace and was taking care of it. According to the Record of Employee Education dated 6/27/19, LPN #2 received education in regards to not transcribing the right knee brace onto the (MONTH) TARS, resulting in Resident # 42 order for the right knee brace not being carried out. On 06/27/19 at 11:26 AM, the surveyor interviewed the Director of Nursing and the Administrator who confirmed that Resident # 42's right knee brace was never ordered from the orthotic company and that the right knee brace order for Resident #42 was not carried out by the nursing staff. The Administrator added that they did not have a policy in place for braces, splints or adaptive equipment. 2. According to the Admission Record, Resident # 216 was admitted to the facility on [DATE]. There were MDS's completed at this time. According to History and Physical dated 6/18/19, the resident had the medical [DIAGNOSES REDACTED]. On 06/25/19 at 9:32 AM, the resident was observed sitting up in the wheelchair. The surveyor observed that the resident had regular black socks on. The resident was unable to be interviewed due to severe cognitive deficits. On 06/25/19 at 09:57 AM, the surveyor reviewed the POS dated 6/19/19, which reflected that Resident # 216 had an order for [REDACTED]. On 06/25/19 at 11:34 AM, the surveyor reviewed the TAR and the order for the [NAME] stockings was signed by the nurse on 6/25/19, which indicated that the [NAME] stocking were intact, however the surveyor did not observe the resident wearing the [NAME] stockings as ordered by the physician. On 06/25/19 at 12:57 PM, the surveyor interviewed the resident's Responsible Party (RP) who stated he/she visited daily for lunch and dinner with Resident 216 and never observed the resident wearing compression stockings. The RP stated (He/she) has not worn compression stockings while in this facility or while (he/she) was in the hospital. I'm here daily for lunch and dinner and never saw compression stocking on him/her. On 06/25/19 at 1:00 PM, the surveyor interviewed the CNA that stated the resident should be wearing [NAME] stockings and was not sure why she wasn't. In the presence of the surveyor the CNA could not find the [NAME] stockings in Resident #216's room. On 06/25/19 at 01:16 PM, the surveyor interviewed the Registered Nurse (RN) who admitted that Resident #216 did not have the compression stockings on at this time and that she signed the TAR indicating that the compression stockings were on but signed the TAR by mistake. The RN added that the compression stockings were ordered to prevent [MEDICAL CONDITION] due to the resident's decreased mobility. According to the TAR policy dated 07/08, treatments are to be administered by licensed nurses per physician's orders [REDACTED]. The physician must be notified for any refusal three or more times. N.J.A.C 8:39-11.2 (b), 27.1 (a) 3. During the initial tour of the facility on 6/24/19 at 7:00 PM, the surveyor observed Resident #4 in bed. The bed was against the wall, the resident was awake, his /her arms were visible, the right arm was covered with a Protective Guard. The surveyor returned to the room on 6/25/19 at 9:30 AM and observed that Resident #4 was in bed. An interview on 6/25/19 at 10:30 AM with the Certified Nursing Assistant (CNA#1) assigned to care for Resident #4 revealed that Resident #4 was non verbal and totally dependent on staff for care. The CNA further stated Resident #4 was mostly non verbal. The surveyor asked the CNA to see Resident #4's lower extremities. Resident #4 had a dressing to the right shin. Upon further inquiry the CNA revealed that Resident #4 sustained a skin tear during transfer. The surveyor reviewed Resident #4's clinical record on 6/25/19 at 12:30 PM. The Admission Face Sheet revealed that Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment (MDS) dated ,[DATE] revealed that Resident #4 was severely cognitively impaired, can never/rarely make decisions. A Physician order [REDACTED]. The surveyor returned to the room with the nurse on duty on 6/26/19 at 10:30 AM and observed Resident #4 in bed. Resident #4 had one Preventive Guard to the right arm, none was noted to the left arm. Resident #4 legs were rested directly on the mattress. The nurse removed the sheet and we both observed that Resident #4 had a dressing on the right shin. There was no Protective Guards to the lower extremities. On 6/27/19 at 9:30 AM the surveyor returned the room and observed the same. A second interview with CNA #2 on 6/27/19 at 9:45 AM revealed that Resident #4 was totally dependent on staff for care and was a sit to stand transfer. CNA #2 indicated that Resident #4's skin was intact. When prompted regarding the Protective Guard noted on the right arm, the CNA stated that Resident #4's skin was very thin(Fragile). She indicated that she did not know where the Geri-sleeves were. The CNA told the surveyor in the presence of the nurse on 6/27/19 at 10:00 AM that she was not aware that Resident #4 was to have Protective Guards on the lower extremities. The nurse told the surveyor that all pertinent information regarding Resident's care were on the Plan of Care Kardex. A review of Resident #4's Plan of Care Kardex with the nurse did not include for Resident #4 to have the Geri-sleeves or the Preventive Guards in place. A review of the TAR revealed that nurses had signed that the Preventive measures were applied even on the days that the surveyor observed that Resident #4 did did not have the Geri-sleeves or the Preventives Guards in place. Further review of the clinical record revealed that Resident #4 sustained skin tears and bruises at the facility on 9/6/18, 3/17/19, 5/21/19 and 6/20/19. N.J.A.C 8:39-11.2 (b), 27.1 (a)

Based on interview and review of medical records and other facility documentation, it was determined that the facility failed to monitor a staff member after a reported allegation of mistreatment of [REDACTED]. Additionally the facility failed to develop and implement a procedure for protecting residents from harm during an investigation of alleged mistreatment for 1 of 3 sampled residents (Resident #1). On 6/16/14 at approximately 7:45 p.m., Resident #1 reported to the facility Evening Supervisor/Licensed Practical Nurse (LPN) of "rough handling" by a Certified Nursing Assistant (CNA), CNA #1. At approximately 8 p.m. CNA #1 was removed from providing care to Resident #1 by the LPN, but continued to work on the unit, unsupervised while providing care to other residents' until the end of her shift at 11:00 p.m. CNA #1 was interviewed and suspended on 6/17/14 pending the outcome of the facility's investigation. The facility policy on abuse/mistreatment investigations, did not specifically state the disposition of the staff member pending the outcome of the facility's investigation. The facility failed to provide documentation to support that CNA #1 was being monitored while providing care to residents on 6/16/14 before the outcome of the investigation was determined. This deficient practice resulted in an immediate jeopardy situation for Residents under CNA #1's care until the facility investigation was completed on 6/18/14. CNA#1 was suspended on 6/17/14 for 1 day until the facility investigation was completed on 6/18/14, when the allegation of mistreatment was negated. The surveyor reviewed the medical record of Resident #1 on 6/23/14. The "Residents Information Sheet" dated 12/19/13, indicated that Resident #1 was admitted to the facility on [DATE]. The "Cumulative [DIAGNOSES REDACTED].#1 was admitted to the facility with [DIAGNOSES REDACTED]." A Minimum Data Set (MDS), an assessment tool, dated 5/9/14 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, indicating Resident #1's cognition was severely impaired. According to the MDS, Resident #1 had "trouble concentrating on such things as reading and watching television". She required staff assistance with Activities of daily Living (ADL's). On 6/23/14 at 2:00 p.m., the surveyor observed Resident #1 sitting in her wheelchair in the doorway of her room and conducted an interview with the resident in the privacy of her room. The surveyor questioned Resident #1 about the care the facility staff provided and if she had any concerns about being mistreated, while in the facility. Resident #1 stated: "I have to be helped to go to the bathroom. She grabbed my top, like this one, (pointing to a burgundy sweatshirt with a crew cut neckline only in green), so rough, pulling my arms up that it came inside out. It was tight around my neck, I felt like it was chocking me. It hurt me. I like to have my clothes taken off with one hand at a time. I don't think anyone should be treated this way. I did not like it and don't want her anywhere near me." On 6/23/14 at 3:15 p.m., the surveyor conducted an interview with the Supervisor/LPN who reported that on 6/16/14, at approximately 7:45 p.m., CNA #1 came out of Resident #1's room and stated "She is in a bad mood." The LPN then proceeded into Resident #1's room and noted resident sitting with her head down, visibly upset. The LPN comforted and completed the care for Resident #1, and placed her in bed. At approximately 8:00 p.m. the LPN spoke with CNA #1, informing her that she would have to report the incident, collected her statement and completed the incident report. CNA #1 continued to state "I didn't do anything". CNA #1's "assignment was changed at this time, so she would not provide any care for Resident" #1. As per the LPN, the facility rule was that "anytime an incident occurs, we take the staff involved off that assignment by changing to another assignment." The LPN then called the DON to report the allegation. The "DON did not pick up the phone." According to the LPN, she continued to monitor CNA #1's behavior for the remainder of the shift which ended at 11:00 p.m. The LPN stated that, "luckily she was in the same hall as my assignment. Most of the residents were in bed. She (CNA #1) changed some of the residents on her new assignment." As per the LPN, she was not able to monitor CNA #1 when she was providing care to other residents behind closed doors. "The CNA (CNA #1) looked like she was agitated for most of the remainder of the shift. She was standing at the nursing station, just rhailing off, I didn't do anything to her. After I spoke with her, she (CNA #1) eventually calmed down." During an interview with the Assistant Administrator (Assist Admin) on 6/23/14 at 4:10 p.m., she stated that the LPN/ Supervisor did appropriate handling of the situation. "I have to trust that the person we leave in charge can make a judgement when things occur". The Assist Admin stated that she was not called on the evening June 16, 2014 regarding the allegation of mistreatment. She learned about the incident on the next morning, (6/17/14) whereby a meeting regarding the incident was held at the facility. "CNA (#1) was suspended pending a more thorough investigation. We decided to take on a hard line with the CNA #1 and decided that we would do sensitivity training." As per Assist Admin, "being that the CNA #1 continued to be agitated for the remainder of the shift, I could see how it would have been better to suspend her then. She should have been sent home. The LPN would not be able to monitor CNA (#1) behind closed doors. The potential was there especially since, as per the LPN, the CNA (#1) continued to be agitated. I did not receive any phone calls that evening and am not aware that the DON was called and did not pick up the phone. I have changed the policy so now no matter, any allegation the staff will be suspended." The surveyor reviewed the facility policy titled "Safeguarding Residents from Abuse, Neglect and Misappropriation of Property". As per the policy, "If any alleged abuse is indicated, refer to the abuse and investigating policy and investigate incident. Investigate all allegations. Follow policy and procedures stated in separate policy title "Reporting and Investigating Resident Abuse, Neglect and Exploitation." The policy states: "Ensure the protection of residents through confidentiality of information and assign direct care staff to residents as appropriate, to meet resident needs and resident safety throughout the investigative process. Report all alleged violations and all substantiated incidents to the appropriate state office or agencies as required. Follow policy and procedures stated in separate policy titled Reporting and Investigating Resident Abuse, Neglect and Exploitation. Any employee found to be abusive, neglectful, exploitive or engaging in misconduct is subject to receive a recorded counseling, a recorded verbal warning, a written warning, suspension or termination. The action taken regarding the employee will be determined according to the employees' level of misconduct and investigative finding(s)." A revised version of same policy completed by the Assistant Administrator on the day of the survey, 6/23/14 at 4:45 p.m. indicated the following insertion to the current policy: "Any employee involved in a situation of alleged abuse will be questioned, interviewed and suspended from work immediately until further notice pending an investigation. If the option to terminate the employee is not exercised, then a plan will be developed for the employees continued employment and evaluation. This plan may include, but not be limited to: change in resident assignment, re-training, monitoring and re-evaluation." A review of the facility policy on 6/23/14 entitled "Reporting Resident Abuse or Exploitation" revealed the following: "Any supervisor who has been informed of abuse or who suspects or witnesses resident abuse or exploitation must report such to the Assistant Administrator, Director of Nursing or Administrator. The Assistant Administrator or designee will report the suspected or actual abuse to the resident's representative. An immediate investigation will follow." The Supervisor/LPN stated that she placed a call to the DON on 6/23/14 and she left a message on the DON's cell phone and on the DON's work voice mail. The DON did not pick up the call nor returned the call that same evening. The facility policy on abuse investigation did not state how the facility would protect residents from harm during an investigation when an employee has been reassigned pending the outcome of the abuse investigation. The facility failed to provide documentation that CNA #1 was monitored on 6/16/14 from the time of the allegation, made by Resident #1, at 7:45 p.m. until 11 p.m.. CNA #1 continued to provide care for residents according to the LPN/ Supervisor, after the CNA displayed agitated behavior." The facility staff failed to provide documentation of monitoring CNA #1 to ensure that the residents on the assignment were protected from potential harm. Consequently, this deficient practice jeopardized the health and safety for all residents cared for by CNA #1. The surveyor reviewed the employee file for CNA #1 which indicated that a written counseling was given to the CNA on 6/18/14. The written warning revealed that facility "has the responsibility in safeguarding residents from all forms of abuse." It further indicated the following: "As a result of your actions, you have received 1 day suspension 6/17/14, unpaid, a final written warning, 1 to 1 counseling/retraining on sensitivity with Director of Social Services (date to be determined). You will not be assigned to care for Resident (#1) until further notice. The DON and Supervisor will complete an Employee Monitoring Form to monitor/evaluate your interactions with residents and staff to ensure that all residents you care for are treated with respect and dignity. Any further infractions will result in termination." Review of the "Employee Monitoring Form" revealed the ongoing monitoring process included the following; "Supervisor/floor nurse will observe/interview/assess resident after the resident has been provided direct care by the above named employee (CNA# 1). Nursing personnel will evaluate assigned resident's demeanor 3 x per week for 4 weeks. Monitoring plan: Supervisor will interview/assess 2 alert and oriented and 2 confused non communicative residents each week for 2 weeks; evaluating resident's demeanor/behavior relating to the care provided by the above employee. Note agitation or relaxed, pleased with care or complaints. Supervisor will keep documented log of each resident interview. Log entries will be summarized on employee evaluation form." A review of the form indicated that on 6/18/14, (an unsampled) resident did not know CNA #1's name but stated she did her care well, no complaints. Another (unsampled ) resident wasn't sure of who she (CNA #1) was, voiced no complaints and stated "she did ok". On 6/19/14 an (unsampled) resident reported being pleased with the care provided by CNA (#1). Another (unsampled) resident stated that she was "pleased with care provided by CNA (#1) on evening shift. She takes her time with me." Two other residents on the evening of 6/19/14 were documented as smiling, pleasant, looking peaceful, no agitation noted after care was provided by CNA #1. Further review of CNA #1's file revealed multiple disciplinary actions, which included the following: On 8/4/13, The CNA (#1) was counseled for being "verbally abusive to resident."The written warning indicated that the CNA (#1) was allegedly accused by (an unsampled) resident as "being very rude to her and yelled at her about going to the bathroom at a certain time. She stated she was very upset and even made her cry. It was confirmed by the roommate who witnessed the encounter and stated that CNA (#1) yelled and cursed at her." The bottom of the form stated that, "This behavior is not to be tolerated and it is a form of abuse to the resident." CNA (#1) did not sign the written warning, denying the allegation. On 10/11/12, the CNA (#1) received written warning for "Sloppy Job". The written warning stated that the CNA (#1) was counseled due to "not locking the foley bag, fitted sheet was wet, garbage can full of diapers and chair next to window full of linen." On 1/25/13, the CNA #1 received written counseling for "refusal to do job as requested." The documentation further stated that "LPN asked CNA (#1) to assist in changing resident who was wet,(night clothes and bedding wet). She refused and went to start her car." Additional review of CNA #1's file revealed that the last performance evaluation for CNA #1 provided was 4/8/11. The immediate jeopardy to residents health and safety which began on 6/16/14, was identified on the day of the survey by the surveyor who notified the Assistant Administrator at 3:27 p.m. and a plan of correction was requested. The Immediate Jeopardy, which began on 6/16/14, continued ongoing until an acceptable Plan of Correction was accepted by the surveyor at 6:00 p.m. on 6/23/14, as evidenced by the following: 1. The Resident (#1) alleged "rough handling" by the aide (CNA #1) on June 16, 2014 as CNA (#1) was assisting the resident with taking off her jacket. CNA (#1) exited the resident's room stating to the Charge Nurse (LPN/Supervisor), "she must be in a bad mood". The Charge Nurse went into resident's room to asses what transpired. Resident (#1) was noted to be visibly upset and said, "Don't let her near me again. She's so rough. I shouldn't have to be treated like this". The Certified Nursing Assistant (CNA #1) was immediately taken off the resident's assignment. 2. All residents have the potential to be subjected to "rough Handling" by CNA (#1). 3. A revised policy and procedure has been put into place effective 6/23/14. This policy and procedure directs any and all supervisors to institute an immediate suspension of any employee allegedly accused of abuse. Following that suspension, notification must be made to the Director of Nursing and the Director of Social Work. The employee's suspension will remain in effect until a complete investigation of the incident has been completed. If the option to terminate the employee is not exercised, then a plan will be developed for the employee's continued employment. This plan may include: education, monitoring and re-evaluation. All employees will be notified of this policy change starting immediately and be completed by 6/30/14. Monitoring and performance evaluation have been formally structured with forms documenting the result of the monitoring and the evaluation. 4. The Administrator or her designee will be notified of all suspensions resulting from an alleged abuse. Each case, as it occurs, will be reviewed by the Administrator or her designee for a period of six (6) months. This will be called, "A Probationary Employment Plan". This plan will call for a re-evaluation of the employee to determine if the probationary period is complete, if the employee needs further assessment or if termination is deemed appropriate. 5. Completion Date: June 30, 2014. NJAC 8:39 - 13.4 (c) 2 i-vi

Based on observation, staff interview and review of the medical record, it was determined that the facility failed to provide adequate supervision and proper transfer for 2 of 7 residents reviewed. Resident #1 who was to be monitored and kept in sight fell and sustained a fractured hip requiring hospitalization and treatment. Resident #6 was improperly transferred and sustained skin tears requiring treatment. These deficient practices were evidenced by the following: 1. During the initial tour of the nursing unit on 6/15/11 at 10 a.m., the tour nurse told the surveyor that Resident #1 was confused at times with a history of multiple falls. She stated that the resident was to be placed by the nurses' station, in an activity or visits with his wife in an attempt to prevent falls. On 6/15/11 at 1:15 p.m., the surveyor observed Resident #1 seated in the hallway in wheelchair with the chair alarm applied. The surveyor reviewed the medical record for Resident #15on 6/15/11, which revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the "Integrated Progress Notes" dated 7/23/10 to the present indicated that the resident sustained [REDACTED]. The care plan dated 7/7/10 identified the resident to be at high risk for falls and interventions documented as : mobility monitor in and out of bed, needs assistance with all transfers, remind him to ask for help when using the bathroom, keep at nurses's, station, involved with activities of his choice or visiting with his wife as much as possible." The surveyor reviewed the investigation report that revealed on 7/23/10 at 2:30 p.m., that the Certified Nursing Assistance ( CNA) left the resident alone in the bathroom. The CNA was counseled and the staff was reminded that Resident #1 can not be left unsupervised. The surveyor reviewed the investigation report that revealed on 7/28/10 at 2:50 p.m., the resident was found on the floor in his room. The investigation further revealed that the wheelchair alarm was not attached to the resident at the time of the fall. The resident complained of left hip pain and was sent to the hospital where he was diagnosed with [REDACTED]. On 6/16/11, the surveyor reviewed the integrated progress notes in the medical record, that revealed on 9/23/10 at 6:45p.m., the resident was found sitting on the floor in another resident's room holding onto the sink. The wheelchair alarm did not sound. The fall investigation dated 9/23/10 failed to indicate why the chair alarm did not sound. On the same day, the surveyor reviewed the integrated progress notes in the medical record that revealed on 1/4/11 at 6:10p.m., the resident was toileted by a staff member and the resident requested privacy. The staff member left the resident on the toilet with the door open and went to assist another resident calling for help. At 6:15p.m., Resident #1 was found on the bathroom floor. The fall investigation dated 1/4/11 revealed that the resident is,"impatient, confused and disoriented most of the time. All must be aware of his whereabouts." The surveyor reviewed the integrated progress note in the medical record dated 4/12/11 at 3:15p.m., that revealed that the resident was found on the floor in the solarium by the housekeeper. The fall investigation dated 4/12/11, revealed that the activity had just finished and that there were no staff members present at the time of the resident's fall. The staff monitor was not present in the solarium. On 6/20/11 at 10a.m., the surveyor observed Resident #1 self propelling his wheelchair in the hall by the nurses' station. The resident's both eyes were observed to be black and blue. The nurse told the surveyor that Resident #1 fell out of bed on the weekend and sustained a nasal fracture. This incident occurred while the survey was in progress. On 6/16/11 at 1p.m., The surveyor interviewed the Director of Nursing and Assistant Administrator. They stated that the mobility alarms were checked for placement and function every shift and noted on the treatment administration record. They could not provide explanations as to the reasons the resident's chair alarm failed to sound and were not consistently in place at the time of his falls. 2. During the initial tour on 6/15/11 of the nursing unit at 10:30 a.m., the unit charge nurse stated that Resident #6 was blind and totally dependent on the staff for care. The surveyor observed the resident in the room, in bed with the curtain closed. On 6/15/11 at 12:55 p.m., the surveyor reviewed the medical record which revealed the resident was admitted to the facility with diagnoses, which include Depression, cognitive impairment and immobility. The surveyor reviewed the care plan dated 11/3/10 on 6/15/11 at 12:15 p.m., that identified Resident #6 required a 2 person assist with transfers since the resident does not bear weight. A review of Minimal Data Sets ((MDS) dated [DATE], 12/19/10, and 3/18/11, indicated the resident was a two person assist for transfer. On 6/17/11, the surveyor reviewed the month of June Plan of Care Kardex from 6/1/11 to the present, which indicated a 1 person assist to transfer the resident. On 6/17/11 at 10:30 a.m., the surveyor interviewed the Certified Nursing Assistant (CNA) responsible for Resident #6. She stated she had transferred Resident #6 from her bed to wheelchair and from wheelchair to bed by herself. On the same day at 12:20 p.m., the surveyor interviewed the Charge nurse who confirmed the 1 person assist for Resident #6 on the June Plan of Care Kardex, which indicated assigned staff should initial under designated day and shift on the Kardex. On 6/20/11 at 10:15 a.m., the surveyor interviewed the same CNA assigned to Resident #6 from the previous week. The CNA stated she had transferred the resident by herself this morning. The surveyor noted on the same day and the same time that the June Plan of Care Kardex was changed to a 2-person transfer on 6/17/11, however the area for staff to initial on 6/20 for 7-3 shift was blank . The Resident Incident and Accident Report dated 12/28/10 at 5 p.m., revealed that Resident #6 had a skin tear during a transfer . The CNA statement did not indicate a 2 person transfer . The Resident Incident and Accident Report dated 4/10//11 at 4:30 p.m. revealed that Resident # 6 had a skin tear during a transfer. The CNA statement did not indicate a 2 person transfer. NJAC 8:39-27.1(a)