Every finding on record at New Jersey Veterans Memorial Home at Paramus

Based on interviews, medical record reviews, and reviews of other pertinent facility documentation on 1/23/26, it was determined that the facility failed to implement the required residents' transfer assistance as instructed in the residents' individualized care plan. This deficient practice was identified for 2 of 3 residents reviewed (Resident #1 and Resident # 2).The evident is as follows: The evidence is as follows: On 1/23/26, the surveyor reviewed the Face Sheet (FS) for Resident #1, which revealed that Resident #1 was admitted to the facility with a diagnoses that included but not limited to, Parkinson's disease, depression, heart failure, and anxiety disorder.A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 1/12/26, revealed that Resident #1 had a Brief Interview Mental Status (BIMS) score of 15 out of 15, indicating that the resident was cognitively intact. Further review of the MDS revealed the resident was dependent on staff for toileting hygiene and required maximal assistance with toilet transfer and chair-to-bed transfers. A review of Resident #1's fall care plan, with an effective date of 1/14/26, and last revised on 7/31/24, indicated the resident required one-person assistance with transfers from bed to wheelchair and two-persons assistance for transfer from wheelchair to bed. Further review revealed the resident's Kardex, (a staff reference tool summarizing care needs), with an instruction for two-person assistance for transfers from toilet to wheelchair. A review of Resident #1's statement dated 9/22/25 revealed that Certified Nursing Assistant (CNA #1) transferred the resident from the wheelchair independently by lifting the resident out of the wheelchair to a standing position without the assistance of another staff member which caused near-fall for the resident. Reviewed of facility's Final Investigation document revealed that Resident #1 reported to the Social Worker (SW#2) that CNA#1 assisted them to stand in the bathroom using a grab bar. The document revealed that when the resident finished using the bathroom, CNA #1 assisted the resident to stand while she provided personal hygiene without the assistance of a second staff member. The facility investigation concluded that the Resident #1 required two-person transfer during the evening and evening shifts.Review of the Facility Reportable Event (FRE) revealed that the resident reported pain rate 5 out of 10. A mobile x-ray result for the lumbar spine indicated a fracture at L1. The resident was transferred to Hospital for further imaging and evaluation. Hospital imaging report dated 12/16/25 indicated no definite acute fractures is identified. On 1/23/26 at 11:01AM, the surveyor conducted an interview with CNA #2 who confirmed that staff are aware the resident's mode of transfer and the number of assistance required is on the assignment sheet and on the resident's care plan. The CNA provided the assignment sheet to the surveyor which confirmed the resident's transfer requirements. On 1/23/26 at 11:28 AM, the surveyor conducted an interview with Registered Nurse (RN #1) who stated that each resident is evaluated by rehabilitation staff who normally establish residents' transfer status and sends the order to the nurse to transcribe.On 1/23/26 at 11:56AM the surveyor conducted an interview with Resident #1, who stated that he did not recall this incident but knows they that he required two- staff assistance to transfer from the wheelchair to the bed. The resident further stated that two-person assistance was not consistently provided by staff. On 1/23/26 at 1:51PM, the surveyor conducted an interview with Social Worker (SW #2) who stated that she recalled Resdient#1 and the incident was reported to her by the resident. She further revealed that Resident #1 had stated that CNA # 1 attempted to transfer the resident independently, and had difficulty, which caused near miss of fall.On 1/23/26 at 3:04 PM, the surveyor conducted an interview with the Director of Nursing (DON) who stated it is important for nursing staff to follow the resident's care plan regarding transfer status to ensure resident's safety. The DON further stated the care plan served as a guideline for the provision of safe care. 2. On 1/23/26 the surveyor reviewed the Face Sheet (FS) for Resident #2, which revealed the resident was admitted to the facility with a diagnoses that included but not limited to, primary osteoarthritis of right hip, primary osteoarthritis of right knee, pain in right knee, Diabetes, hearing loss and history of falls.A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 11/24/25 revealed that Resident #2 had a Brief Interview Mental Status (BIMS) score of 14 out of 15, indicating that the resident was cognitively intact. MDS further revealed the resident was dependent on staff for bed-to chair transfer.According to Resident #2's care plan with an effected date of 2/24/25, the resident is at risk for falls related to a history of falls. The resident's care plan interventions included the use of a Hoyer lift for all transfers with the assistance of two staff members at all times as a safety precaution.A review of Resident #2's Kardex, (a staff reference tool summarizing care needs), revealed the resident required a Hoyer lift with 2-person assistance to transfer. On 1/23/26 at 10:29AM, the surveyor conducted an interview with Resident #2 who stated that 2 staff members assisted him toward the edge of the bed, they said 1,2,3 and both assisted him to transfer into the wheelchair without the machine. The resident further stated, They did what they wanted to do.On 1/23/26 at 1:16PM, the surveyor conducted an interview with SW #1 who stated that she interviewed Resident #2 and that the resident informed her that they were was transferred out of bed without a mechanical lift (Hoyer lift).The surveyor reviewed facility's investigation which stated: the facility was able to substantiate illegitimate transfer via the agency staff by way of investigation and correlation to the resident's initial interviewOn 1/23/26 at 11:28 AM the surveyor conducted an interview with the Registered Nurse (RN) #1 who revealed each resident was evaluated by rehabilitation to determine the transfer status. An order form was sent to the nurse to transcription, and the clerk updated the transfer status on the assignment sheet to reflect the new order.On 1/23/26 at 3:04 the surveyor interviewed the DON who stated that the expectation was for the staff to provide safe services by following the care plan.On 1/23/26 the facility's Activities of Daily Living (ADL) policy revised on 10/25, under policy statement it revealed that ADL assistance shall be provided in accordance with each resident's assessed needs, care plan, preferences, and applicable federal, state, and local regulation. NJAC 8:39-33.1(d)

Based on interviews, medical record reviews, and review of other pertinent facility documentation on 12/3/25, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation involving an injury of unknown origin for a resident. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #2), and was evidenced by the following: A review of the Facility Reportable Event (FRE) submitted to the NJDOH was dated 10/29/25, alleging an injury of unknown injury for Resident #2 occurred on 10/28/25.On 10/27/25, the Social Worker (SW#1), interviewed Resident #2 regarding an abrasion on their left knee that was discovered on 10/24/25. When SW#1, originally interviewed Resident #2 on 10/24/25, Resident #2 stated that they had hit their own knee causing the abrasion. On 10/26/25, Resident #2 told their Medical Power of Attorney (MPOA) that they had been dropped which prompted SW#1 to reinterview the resident regarding the injury of unknown origin.According to the Resident Face Sheet (RFS), Resident #2 was admitted to the facility with diagnoses which included but were not limited to sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) , hyperlipidemia (an abnormally high concentration of fats or lipids in the blood) , cortical age-related cataract (an age-related clouding of the eye's natural lens that starts in the outer layers (cortex) and spreads inward), and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance, such as from organ failure, severe infections, or drug toxicity, that leads to altered mental function).A review of the Minimum Data Set (MDS), an assessment tool dated 9/10/25, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 13/15, which indicated Resident #2's cognition was intact.A review of Resident #2's Care Plan (CP) revealed that the CP had been updated on 10/26/25 under Problems/Strengths, Resident #2 claimed that on 10/23/25, while being transfer back to bed, that he/she was dropped by 2 caregivers.A review of the Occurrence Journal from the facility numbered 696471 revealed that the facility was made aware of Resident #2's allegation of being dropped on 10/26/25 which led to an investigation by the facility.A review of the Electronic Mail (Email) between SW#1 and the Director of Nursing (DON), dated 10/27/25 at 11:53 AM., revealed that Resident #2 was alleging that their knee abrasion was caused by being dropped while being assisted into bed. On 12/3/25 at 9:39 AM., the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that if a resident were to fall that would be a reportable event and she would notify her supervisor. She further stated that if a resident had reported to a family member that they had been dropped because this was the resident's story the facility would treat it the same way as an actual fall.On 12/3/25 at 11:24 AM., the surveyor interviewed SW #1 who stated that she had been notified by the DON that there had been an unexplained injury regarding Resident #2 and that she had been instructed to interview Resident #2 regarding their unexplained injury. Resident #2On 12/3/25 at 12:25 PM., the surveyor interviewed the DON with the Licensed Nursing Home Administrator (LNHA) present, and she stated that the facility began looking into Resident #2's allegation on 10/27/25. At this time the surveyor requested both the DON and LNHA to look at the FRE and both the DON and LNHA confirmed the FRE was reported 10/29/25 to the DOH.On 12/3/25 at 12:34 PM., during the interview with the DON and LNHA, the DON stated the FRE date of 10/29/25 could have been a typo. The surveyor presented the email correspondence between the DON and SW#1 confirming that the DON was notified on 10/27/25 of Resident #2's allegation that they were dropped which caused their injury.The surveyor also presented Resident #2's CP to the DON and LNHA, which indicated that the CP had been updated 10/26/25 to include Resident #2's allegation of being dropped by caregivers. When asked who could have updated the CP on 10/26/25 both DON and LNHA could not answer the surveyor. When further questioned if there was a way to check who had changed the CP, both parties stated they could not.A review of the facility's policy titled Incident Reporting and Completion dated August 2023, included the following information under State Notification:Facility shall notify the New Jersey Department of Health and Senior Services immediately by the phone, Hot line [PHONE NUMBER], [PHONE NUMBER] (609-392-2020 after hours) the Office of the Ombudsman [PHONE NUMBER] and Veterans Administration [NAME].[NAME]-Lima@va.gov [PHONE NUMBER] ext.214647 for any of the following:1. Abuse-witnessed or suspected2. Neglect-willful deprivation of services or inadequate care resulting in injury3. Exploitation- using another's resources for personal gain4. Unexplained injuryNJAC 8:39-4.1(a)5

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team to address the implementation of fall interventions for 2 of 5 fall incidents, in 1 of 6 residents, (Resident #118), reviewed for accidents. This deficient practice was identified by the following: On 3/25/25 at 11:20 AM, the surveyor observed Resident # 118 seated in a wheelchair (w/c) inside the activity room with other residents. The surveyor reviewed Resident #118's medical records and revealed: A review of the Resident Face Sheet (an admission summary) reflected that Resident #118 was admitted to the facility with medical diagnoses which included but not limited to; type 2 diabetes mellitus without complications, vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), unspecified severity, with agitation, mood disorder due to known physiological condition, unspecified, major depressive disorder, recurrent, unspecified, and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing poor sleep quality, often leading to daytime fatigue and impaired function) unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 1/30/25, included a brief interview for mental status (BIMS) score of 3 out of 15, reflected that the resident's cognition was severely impaired. A review of the current Resident #118's personalized care plan (CP) reflected that the resident had multiple falls due to unsteady gait and balance and poor safety awareness secondary to dementia with an original date of 11/8/23, effective date of 2/5/25, and was revised on: -5/2/24 Actual fall -5/16/24 Lowered self to the floor -6/29/24 Actual fall -9/17/24 Actual fall -12/20/24 Actual fall Further review of the CP revealed interventions that included but were not limited to: Effective date of 6/20/24, one person assists with ADLs (activities of daily living) such as dressing, toileting needs and hygiene; one person assists with transfers. Effective date of 11/1/24: -W/c use for locomotion when out of bed (OOB). -Engage with diversional activities such as listening to music, religious gatherings, live entertainment in the dayroom . -Ensure that staff hold the resident's hand securely until the resident comfortably seated on a regular chair in the dayroom. -Assist the resident OOB and bring the resident to the dayroom when noted awake in the morning during rounds. -RNP (Restorative Nursing Program) ambulation program 3-5 x/week (3 to 5 times per week) as tolerated. Effective 1/13/25, magic cushion high back w/c when OOB. A review of the provided fall investigations by the Chief Executive Officer Secretary (CEOS) revealed that the two of five fall investigations new interventions and recommendations were not transcribed in the CP. The comprehensive CP was not reviewed and revised to reflect the new interventions and recommendations for the following fall investigations: -The 5/2/24 fall was investigated with a conclusion that the resident had an unwitnessed fall in the dayroom with no injury, which the resident stated that they were picking up something on the floor and the resident fell. The resident at that time was noticed with a piece of tissue paper near them and tried to pick it up. The recommendation: Staff will ensure dayroom floor is free of trash. The recommendation due date was 5/2/24, and date implemented 5/16/24. -The 6/29/24 fall was investigated with a conclusion that the resident during rounding, nurse noticed the resident walking in the room unsafely, and the nurse walked the resident to the dayroom with handheld assist. During the process to make the resident sit in the chair, the resident turned around suddenly and tripped on a chair and fell on their right side. There was no injury noted. CP was updated. Staff was instructed to use w/c to transport resident from room to dayroom for safety. The recommendation: Staff to provide w/c for locomotion. The recommendation due date was 6/29/24, and date implemented 7/5/24. A review of the Daily Note Summary of the Physical Therapist on 7/1/24 revealed that the resident had a fall, ambulating in the unit without any assistive device, thus, reiterated importance of safety. Resident's level of function fluctuating at this time due to observed episodes of lethargy. A review of the Physical Therapy (PT) Discharge summary dated [DATE], revealed that the resident ambulated 150 feet with rolling walker and contact guard assist with close w/c follow for safety. Further review of the medical records revealed that there was no documented evidence why the 5/2/24 and 6/29/24 recommendations for new interventions status post (s/p) falls were not documented in the resident's CP. On 3/27/25 at 12:25 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) in the Serenity nursing station, who informed the surveyor that it was the responsibility of the MDS person, Unit Manager, and Charge Nurse to initiate, update, and revise CP. She further stated that when the resident had fall incident, all new interventions and recommendations should be immediately put in the CP. On that same date and time, the surveyor asked the RN/UM to print the resident's fall CP. The surveyor also notified the RN/UM of the above concern regarding two fall investigations that the recommendations were not in the CP. The RN/UM stated that she had to call the MDS person to talk to the surveyor. On 3/27/25 at 12:30 PM, the surveyor interviewed the MDS Facilitator (MDSF) in the presence of the RN/UM. The MDSF informed the surveyor that they (RN/UM and MDSF) both could initiate, update and revise CP. The surveyor notified them of the above concern that the 5/2/24 and 6/29/24 fall investigations recommendations were not in the resident's CP. The MDSF stated that she would get back to the surveyor and check the records. On 3/27/25 at 12:38 PM, the MDSF confirmed to the surveyor that she did not find the CP interventions for new recommendations as part of investigations for the two fall incidents on 5/2/24 and 6/29/24. The MDSF acknowledged that the CP should have been updated of the new interventions for the two falls according to the recommendations. On 3/31/25 at 12:22 PM, the survey team met with the CEO (Chief Executive Officer, also known as the Licensed Nursing Home Administrator) and the Director of Nursing (DON). The surveyor notified the CEO and the DON of the above concerns and findings regarding the resident's CP. On 4/1/25 at 1:08 PM, the survey team met with the CEO, DON, Assistant Chief Executive Director-Clinical (ACED-C), and ACED-Clinical Support (ACED-CS). The ACED-C stated that the 5/2/24 fall intervention was initially put in the CP and in November 2024, there was a significant change and decline noted with the resident, and the 5/2/24 intervention was resolved that was why it was not active. The ACED-C further stated that the 6/29/24 intervention for w/c was given by therapy after evaluation on 7/1/24. On that same date and time, the surveyor asked the facility, was the 5/2/24 CP intervention that was resolved was the same intervention, and the DON acknowledged that the interventions in the CP for 5/2/24 that was resolved was not the same interventions on 5/2/24 fall investigation. The surveyor also asked where the CP was that on 7/1/24 to reflect that the w/c as part of intervention for the 6/29/24 fall, and both the DON and the ACED-C stated that they would get back to the surveyor. At that same time, the surveyor asked the DON, ACED-C and the ACED-CS should the interventions and recommendations for each fall reflected in the CP to prevent further fall, and the DON stated yes. A review of the facility's Care Planning Policy, with a revision date of 9/22, that was provided by the CEOS, revealed: Purpose: To ensure that interdisciplinary plans of care are developed, implemented, and evaluated to meet the individual needs of Resident. Practice: 7. CP are reviewed and updated quarterly and as needed. Decisions are recorded on the IDCP (interdisciplinary care plan) notes as to the progress towards goals and effectiveness of interventions . 9. When a goal is met, it is documented in the IDCP CP Notes and the CP is updated/revised . 12. At the case conference, the CP revision sheet will be generated by the Nurse Facilitator to indicate any changes in the Resident's plan of care from prior review .Nurse Facilitator will review goal revision sheet with the charge nurse weekly and when indicated. A review of the facility's Resident Fall Prevention and Management Policy, with a revision date of 12/24, that was provided by the CEOS, revealed: Purpose: 1. To identify Resident at risk for falls and develop an individualized CP . Procedure: 3. If Resident is re-admitted from the hospital, admitting nurse/MDSF needs to complete the fall risk assessment and initiate a CP. If Resident is high risk for falls any new intervention must be added to the CP and the CP revision sheet. 4. When a Resident experience a fall, a RN will conduct full body assessment prior to moving the resident, including range of motion, vital signs, neuro-check, accucheck, and urine dipstick if appropriate. The nurse/MDSF will add new appropriate interventions to the CP and the CP revision sheet . On 4/2/25 at 11:42 AM, the survey team met with the CEO, DON, ACED-C, ACED-CS, Central Office Director, and ACEO Non-Clinical for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-11.2(e) 2; 27.1(a)

Based on observation, interview, and record review, it was determined the facility failed to: a.) follow a physician's order for 1 of 37 residents, (Resident #162), and b.) provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 6 packages Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on 1 Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. 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 3/25/25 at 10:35 AM, the surveyor observed Resident #162 was not in their room. The Registered Nurse/Unit Manager (RN/UM) stated the resident was out to dialysis. The surveyor reviewed the medical records of Resident #162. A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate management of care, with an assessment reference date (ARD) of 2/14/25, indicated a Brief Interview Mental Status (BIMS) score of 13 out of 15, which reflected that the resident's cognition was intact. Resident #162 was documented with diagnoses that included, but were not limited to, End stage renal [kidney] disease, and hypertension (HTN; high blood pressure). A review of the physician's order (PO) dated 10/4/23, read: Metoprolol tartrate 25 milligram (mg) 1 tablet by mouth daily at 8 AM on Monday, Wednesday, Friday, and Sunday for HTN; Hold for systolic blood pressure (SBP) < [less than] 120 or heart rate (HR) < 70. A review of the Medication Administration Record (MAR) entries dated 1/9/25 to 2/5/25, revealed the nurses signed for the metoprolol tartrate medication (med) as administered 14 of 16 times when the med should have been held as per the parameters of the PO as follows: -On 1/10/25, the resident's documented HR was 62. -On 1/12/25, the resident's documented blood pressure (BP) was 118/61 and HR was 61. -On 1/13/25, the resident's documented HR was 65. -On 1/15/25, the resident's documented HR was 61. -On 1/17/25, the resident's documented BP was 112/56 and HR was 62. -On 1/19/25, the resident's documented HR was 61. -On 1/20/25, the resident's documented HR was 64. -On 1/22/25, the resident's documented BP was 116/61 and HR was 67. -On 1/24/25, the resident's documented HR was 63. -On 1/26/25, the resident's documented HR was 64. -On 1/31/25, the resident's documented HR was 66. -On 2/2/25, the resident's documented BP was 117/66 and HR was 64. -On 2/3/25, the resident's documented BP was 119/73 and HR was 63. -On 2/5/25, the resident's documented HR was 62. There was no documentation on the MAR that indicated the identified entries were held and not administered. A review of the MAR entries dated 2/6/25 to 3/5/25, revealed the nurses signed for metoprolol tartrate med as administered 9 of 16 times when the med should have been held as per the parameters of the PO as follows: -On 2/7/25, the resident's documented HR was 65. -On 2/9/25, the resident's documented HR was 62. -On 2/10/25, the resident's documented HR was 67. -On 2/17/25, the resident's documented HR was 64. -On 2/19/25, the resident's documented HR was 68. -On 2/23/25, the resident's documented HR was 63. -On 2/24/25, the resident's documented HR was 63. -On 2/26/25, the resident's documented HR was 64. -On 3/2/25, the resident's documented HR was 66. There was no documentation on the MAR that indicated the identified entries were held and not administered. Additionally, the following entries had a documented BP, and no documented HR as follows: -On 2/12/25 the written entry for indicated 123/66. The entry was signed as administered by the nurse. - On 2/16/25 the written entry indicated 122/67. The entry was signed as administered by the nurse. - On 2/21/25 the written entry indicated 139/80. The entry was signed as administered by the nurse. A review of the MAR entries dated 3/6/25 to 4/5/25, revealed the nurses signed for metoprolol tartrate med as administered 4 of 15 times when the med should have been held as per the parameters of the PO as follows: -On 3/7/25, the resident's documented HR was 61. -On 3/10/25, the resident's documented HR was 60. -On 3/24/25, the resident's documented BP was 114/88 and HR was 61. -On 3/30/25, the resident's documented BP was 109/65 and HR was 67. There was no documentation on the MAR that indicated the identified entries were held and not administered. On 4/1/25 at 11:17 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) about medications (meds) with parameters. The LPN stated that it was expected for nurses to follow hold parameters as per the PO. The surveyor reviewed with the LPN the metoprolol tartrate entries for Resident #162. The LPN confirmed there were entries in which the med should have been held as per the PO. The LPN stated if the BP or HR results were outside the parameters of the med order, the med should be held and not administered to the resident. The LPN explained if a med was not administered to the resident the nurses' circled their initials on the entry and on the back of the MAR documented why the med was not given to the resident. On 4/1/25 at 11:21 AM, the surveyor interviewed the RN/UM about meds with parameters. The RN/UM stated it was expected for nurses to follow the PO for meds with parameters. The surveyor reviewed with the RN/UM the MARs of Resident #162. The RN/UM acknowledged there were entries where the med should have been held and not administered to the resident as per the PO. On 4/1/25 at 11:37 AM, the surveyor interviewed the Director of Nursing (DON) about med orders with hold parameters, and the DON stated meds with parameters should be held as per the PO. The DON further explained that standards of practice were for the nurses to document the reason a med was held or not, and a prescribed order to be clarified with the physician as needed if the nurses had any concerns. At that same time, the surveyor notified the DON of the concern regarding the metoprolol tartrate med parameters not being followed per the PO for Resident #162. The DON acknowledged it was expected for the nurses to follow parameters for meds as ordered, and to document when a med was held. On 4/1/25 at 1:20 PM, the surveyor notified the Chief Executive Officer (CEO, also known as the Licensed Nursing Home Administrator), the DON, and the Assistant Chief Executive Director-Clinical (ACED-C) about the concern that the PO for Resident #162's metoprolol tartrate med with parameters was not being followed. On 4/2/25 at 11:20 AM, the CEO, the DON, and the ACED-C met with the survey team. The DON stated the Medical Director was informed of the identified concern, that it was determined there was no harm that occurred to the resident, the resident's meds were reviewed, and the metoprolol tartrate med was discontinued by the physician. The DON further stated that she was in the process of following up with the nurses from the identified entries and that the staff had previously received in-service education regarding meds with parameters. There was no additional information provided to the surveyor. A review of the facility's Administering Medications Policy, with a last revised date of 7/31/24, which indicated Medications shall be administered in a safe and timely manner, as prescribed. Under Policy Interpretation and Implementation of the policy revealed: 4. Meds are administered in accordance with prescriber orders, including any required time frame . 11. The following information is checked/verified for each resident prior to administering meds .b. Vital signs, if necessary . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the med shall initial and circle the MAR space provided for that drug and dose . 2. On 3/31/25, the surveyor reviewed a binder provided by the facility Chief Executive Officer's Secretary (CEOS), containing, but not limited to, facility DEA 222 Forms, copies of medical director state and federal controlled substance registration certificates, and packing slips associated with the DEA 222 Forms for controlled substance deliveries. A review of the facility DEA 222 Forms that were filled out and used to order controlled substances (CDS) revealed the following: DEA 222 Form with order form # 240136292 dated 8/30/24 for six packages of morphine 10 mg/0.5 ml (0.5 milliliters) syringes (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was not present. On 3/31/25 at 12:23 PM, the survey team met with CEO and DON to notify them of concerns with the DEA 222 forms. The surveyor showed the DON the DEA 222 form in question and asked if it should be filled in. The DON stated, yes, it should be filled out per the regulations, and she would correct it and obtain a packing slip. On 4/1/25 at 1:08 PM, the survey team met with the CEO and DON for concerns and responses to prior concerns. The DON provided the surveyor with a copy of the DEA 222 form in question with the blanks filled in and a copy of the associated packing slip obtained from the pharmacy, after surveyor inquiry. The facility offered no further pertinent information. The surveyor reviewed the instructions for completing the DEA 222 Forms located in the Code of Federal Regulations at 21 CFR1305.13. The CFR 1305.13 revealed at section (e) The purchaser must record on its copy of the DEA Form 222 the number of commercial or bulk containers furnished on each item and the dates on which the containers are received by the purchaser. A review of the facility's Medication Dispensing Controlled Substances Policy, Effective date January 2015. The policy reflected: I. Controlled dangerous substances are handled by the facility in a manner that promotes proper storage, security and compliance with applicable state and federal regulations. III. The DON is designated by the facility to be responsible for the control of such drugs. NJAC 8:39-11.2(b); 29.2(d); 29.7(c) 21 CFR 1305.13(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication for 1 of 5 medication carts inspected according to facility's policy and standard of clinical practice. 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/27/25 at 11:28 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following: The surveyor in the presence of the Licensed Practical Nurse (LPN), the surveyor inspected the med cart identified as the L Wing cart. The surveyor observed, in the 3rd drawer of the med cart a quantity of loose tablets and capsules on the bottom of the drawer. The surveyor counted the loose medications (meds) which amounted to seven items. The surveyor asked the LPN if they could positively identify any of the meds. The LPN stated they could not positively identify all of them, but what some could be. The surveyor asked the LPN if meds should be stored that way. The LPN stated no, they should be in the packaging they came in. At that same time, the surveyor observed the LPN disposed of the loose meds in the drug disposal device located in the bottom of the med cart. The surveyor also interviewed the Director of Nursing (DON) who happened to enter the nursing unit at that time. They surveyor asked the DON if meds should be loose in the med cart, The DON stated no, med should be kept in the packaging and the cart should be kept clean. On 3/31/25 at 12:23 PM, the survey team met with the Chief Executive Officer (CEO, also known as the Licensed Nursing Home Administrator) and DON to notify them of concerns with med storage. The DON affirmed that she was on the unit at the time of discovery and agreed that meds should be stored in proper packaging. On 4/1/25 at 1:08 PM the survey team met with the CEO and DON for responses to concerns. The DON provided education in-service attendance sheets that included but were not limited to checking med carts for loose meds. The DON also stated that the facility will be instituting new checks for the med carts every shift for loose or dropped meds and any compromised packaging. The facility did not provide any further pertinent information. A review of the facility's Medication Use, Medication Storage Policy, Effective date January 2015, revealed, meds will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the NJ Department of Health guidelines. The policy also reflected under PROCEDURE: 3. Meds will be stored in an orderly, organized manner in a clean area . 5. Meds will be stored in the original, labeled containers received from the pharmacy . NJAC 8:39-29.4(h)

Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate storage of disinfecting wipes and b.) disinfect the treatment area after use and follow appropriate infection control practices during the treatment pass observation of 1 of 2 nursing staff (Registered Nurse) to 1 of 2 residents, (Resident #68), reviewed for pressure ulcers, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), Disinfection and Sterilization Guideline, dated 12/7/23, included: 5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities: 5.a. Clean housekeeping surfaces (e.g., floors, tabletops) on a regular basis, when spills occur, and when these surfaces are visibly soiled . 5.c. Follow manufacturers' instructions for proper use of disinfecting (or detergent) products - such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal . Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. On 3/25/25 at 11:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who informed the surveyor that Resident # 68 had a facility acquired wound, stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) to buttocks. On 3/25/25 at 11:16 AM, the surveyor observed Resident # 68's room with an enhanced barrier precaution (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes, primarily through targeted gown and glove use during high-contact resident care activities) posted sign outside the resident's door and the resident was not inside the room. On 3/25/25 at 11:27 AM, the surveyor observed Resident # 68 seated in recliner wheelchair with padded arm rests and leg rest with chair cushion while attending activity with other residents. The surveyor reviewed the medical records of Resident #68 and revealed: A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia in other diseases classified elsewhere, unspecified severity, with agitation, muscle weakness, and age-related osteoporosis (a bone disease characterized by a decrease in bone density and mass, making bones weaker and more prone to fractures) without current pathological fracture. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 1/2/25, included a brief interview for mental status (BIMS) score of 3 out of 15, which reflected that the resident's cognitive status was severely impaired. A review of the physician's order dated 3/19/25, to cleanse stage 2 pressure ulcer to sacrum with normal saline (NS), apply zinc oxide 20% daily and cover with bordered gauze, remove zinc oxide with mineral oil prior to treatment changes x 14 days. A review of the provided wound timeline by the Director of Nursing (DON) revealed that Resident #68's sacral stage 2 pressure ulcer was a facility acquired wound that was discovered on 3/4/25. On 3/31/25 at 8:40 AM, the surveyor observed the Registered Nurse (RN) was assisted by the RN/UM for wound treatment of Resident # 68. The RN informed the surveyor while reading the orders in the Treatment Administration Record (TAR) that resident had an order for EBP, order for wound consultation, pain management, and that the resident was administered with Tramadol (a narcotic, can treat moderate to severe pain) prior to wound treatment. The RN also confirmed an order for stage 2 sacral ulcer with zinc oxide 20%, cleanse with mineral oil and NS covered with border gauze. Inside the room, the RN assessed the resident for pain and checked resident's identification. The RN performed handwashing inside the resident's room, donned (put on) gloves and gown, used the disinfecting wipes (purple top with 2 minutes contact time) for disinfecting the table, doffed (removed) off gloves, performed handwashing, donned gloves, placed a liner on top of dry table, and prepared supplies: 4 x 4 gauze (seven packets), NS container, two scissors, mineral oil poured over 4 x 4 gauze. At 9:00 AM, the surveyor observed the RN left the disinfecting wipes container open on top of the treatment cart in front of the room. The RN informed the surveyor that the contact time for the disinfecting wipes was two minutes. In the room, the surveyor observed the RN performed handwashing and donned gloves. The RN/UM entered room performed handwashing and put gloves and gown, drawn the privacy curtain and closed the door. The RN completed the wound treatment, disposed the garbage, left the room, signed the TAR, and informed the surveyor that she was done with wound treatment. The RN and the RN/UM left the resident's room without disinfecting the table that was used during wound treatment. The disinfecting wipes was left open. On 3/31/25 at 9:30 AM, the RN then pushed her treatment cart in the hallway, the surveyor stopped the RN for an interview. The surveyor asked the RN about the disinfecting wipes container that was left open from 9:00 AM up to this time, for total of 30 minutes, and the RN had no answer. The surveyor then asked the RN what the importance was of keeping the disinfectant wipes closed when not in use, and the RN responded that it should have been closed because it dries up and it contaminate. The surveyor asked the RN should she disinfect the table she used for treatment, and she responded yes it should be cleaned and disinfected after use. The surveyor asked why she did not disinfect the table after the wound care treatment, and the RN did not respond. On 3/31/25 at 10:20 AM, the surveyor asked the Chief Executive Officer Secretary (CEOS) of facility's policy and procedure for wound treatment, and she stated that she would get back to the surveyor. On 3/31/25 at 12:22 PM, the survey team met with the CEO (also known as the Licensed Nursing Home Administrator) and the DON. The surveyor discussed the concern with Resident #68's wound observation regarding storage of disinfecting wipes and not disinfecting the table after use. A review of the provided Infection Control Program, Non -Sterile Dressing Change Policy, that was provided by the CEOS, with a revised date of 3/13/24, revealed that there were no steps included to disinfect the table after treatment or after use of the table for wound treatment. A review of the Cleaning and Disinfection of Environmental Surfaces, with a revised date of 3/13/24, revealed that the environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration, a United States government agency within the Department of Labor, whose mission is to ensure safe and healthy working conditions for workers by setting and enforcing standards, and providing training, outreach, education, and assistance) Bloodborne Pathogens Standard . On 4/1/25 at 1:08 PM, the survey team met with the CEO, DON, Assistant Chief Executive Director-Clinical (ACED-C), and ACED-Clinical Support (ACED-CS). The DON stated that the RN was provided education with regard to the surveyor's concerns and will be monitored. On 4/2/25 at 11:42 AM, the survey team met with the CEO, DON, ACED-C, ACED-CS, Central Office Director, and ACEO Non-Clinical for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-19.4(a)(l)

Based on observation, staff interviews, record review, and facility policy review, it was determined the facility failed to maintain an error rate of less than 5%. There were two medication errors out of 30 opportunities which resulted in a 6% medication error rate. Medications given by Licensed Practical Nurse (LPN) #1 exceeded the time frame for medication administration. LPN #1 also failed to follow medication instructions by not giving medication with food as prescribed. Findings included: 1. A medication administration pass was observed on 10/18/2021 at 9:20 AM, with LPN #1. LPN #1 administered medication to Resident #56 which included [MEDICATION(S)]/[MEDICATION(S)] 25/100 milligram (mg) tablet and [MEDICATION(S)] 10 milliequivalents (MEQ) tablet. No food was administered at that time. Following the medication pass, a medication reconciliation (a review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders, dated 10/2021, indicated 1) [MEDICATION(S)]/[MEDICATION(S)] 25/100mg tablet to be given three times daily for [CONDITION(S)] at 7:30 AM, 11:30 AM, and 4:30 PM. 2) [MEDICATION(S)] 10 MEQ tablet to be given once daily with breakfast for supplement at 7:30 AM. On 10/18/2021 at 10:51 AM, an interview was conducted with LPN #1. The LPN stated he knew those two medications were given late, and the only reason was because of the number of residents the LPN had to pass medications to. The LPN stated the breakfast trays came to the floor at 7:30 AM. LPN #1 stated he did not know how much or what the resident had eaten for breakfast. On 10/18/2021 at 3:24 PM, an interview was conducted with Nursing Supervisor (NS) #1. The NS stated the breakfast trays came up to the floor at 7:30 AM, but if the medication was given later, then the resident should have been given something to eat with it. NS #1 stated she expected the LPN to call the physician if the medications were given late. On 10/19/2021 at 3:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated medications were to be given within a one-hour window of the ordered time. The DON stated she expected the nurse to give crackers or milk, which are on the medication cart, when a medication was ordered to be taken with food and the breakfast hour had passed. A review of the facility procedure, titled, Medication Pass Safety and Infection Control Reminders, undated, indicated, 14: Administer all medications within time frame (one hour before-to-one-hour after). New Jersey Administrative Code § 8:39-29.2(d)

C#: NJ 637 Based on interviews and record review, as well as review of pertinent facility documents on 8/12/21 and 8/13/21, it was determined that the facility failed to notify the physician and the resident representative (RR) of a change in condition for 1 of 4 residents (Res #3). This deficient practice is evidenced by the following: According to the Resident Face Sheet (RFS) Res #3 was originally admitted on [DATE] and discharge on 12/5/20, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool, dated 11/27/20, showed that Res #3's cognition was severely impaired and required total assistance with Activities of Daily Living (ADLs). The Plan of Care (POC) initiated on 11/17/20 showed that Res #3 had the potential for hypo/[CONDITION(S)] due to Type 2 Diabetes Mellitus and at Risk for Difficulty with intake related to poor dentition. Interventions included but were not limited to monitor oral tolerance, finely chopped diet and monitor for decline notify physician. Res #3's PN showed the following: On 12/1/20 at 9:00 pm, documented by Registered Nurse (RN #1) showed that Res #3 had poor appetite and was observed pocketing food in his/her mouth, no distress noted with oxygen saturation of 95 % on room air. On 12/3/20 at 9:00 pm, documented by RN #2 that the Resident was pocketing food while being fed, oxygen saturation 95%, will conitnue to monitor. The PN/medical records did not indicate that the Primary Physician (PP) and the RR for Res #3 were notified of the aforementioned change in condition. The surveyor conducted a telephone interview with the PP on 8/13/21 at 11:57 am. The PP stated that he was not notified of the Resident's pocketing of food and he should have been at that time. The PP stated that if he was notified , he would had ordered to keep the patient NPO (nothing by mouth) and to be evaluated by the Speech Therapist for safety due to potential for Aspiration Pneumonia. During staff interview Nurse Practitioner , Assistant Director of Nursing , Supervisor, Speech Therapist and Dietitian on 8/13/21 from 9:09 am to 11:55 am, they stated that pocketing of food was considered a change in physical condition and the PP/RR should have been notified. They agreed that RN#1 failed to notify the Physician and family member. The facility policy titled Change in a Resident's Condition or Status revised 5/2017, showed Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .d. significant change in the resident's physical .condition; e. need to alter the resident's medical treatment significantly .5 .notifications will be made twenty-four (24) of a change occurring in the resident's medical/mental condition or status. 6. Regardless of the resident's medical or physical condition, a nurse or healthcare provider will inform the resident of any changes in his medical care or nursing treatments . NJAC 8:39-13.1(c)(d) NJAC 8:39-27.1 (a)

Based on staff interviews, observations, review of facility policy, and record review, the facility failed to develop an effective procedure to identify presumptive positive COVID-19 residents from COVID-19 positive residents resulting in the nursing and housekeeping staff's failure to follow infection control guidelines in four of 12 sampled residents (Resident (R) 1, R2, R3, and R4). This failure had the potential to affect all 235 residents in the facility. In addition, the facility failed to cancel communal activities and dining on the dementia unit resulting in COVID-19 positive residents (R9, R10, R11, and R12) interacting with residents with an unknown COVID-19 status. The dementia unit had a census of 32 residents. On 04/21/20 at 3:40 PM, the Administrator, the Clinical Assistant Administrator, and the Non-Clinical Assistant Administrator were notified that the failure to develop an effective procedure to identify presumptive positive COVID-19 residents from COVID-19 positive residents resulted in the nursing and housekeeping staff's failure to follow infection control guidelines and the failure to cancel group activities and dining on the dementia unit constituted immediate jeopardy at F880. The facility presented an acceptable plan for removal of the immediate jeopardy at F880 on 04/22/20 at 6:15 PM. The removal plan included obtaining additional PPE, changing the signage to include a red STOP sign to indicate COVID-19 positive residents and a yellow STOP sign to indicate those residents with pending COVID-19 test results, and educating nursing, housekeeping, dietary, and environmental services staff on appropriate use of PPE and the color coded signage. To ensure all staff were educated, any staff that did not attend the in-services would be educated prior to the beginning of their shift. The removal plan included closing and sanitizing the dayroom on the dementia unit. Staff was educated on promoting social distancing for the residents who continued to wander out of their rooms. Housekeeping was educated to clean and sanitize high touch surfaces in the dementia unit. The facility provided a plan to monitor the burn rate of Person Protective Equipment (PPE) to assist in ordering an adequate amount of PPE. The removal plan was validated through observations, interviews of staff and record review of inservice records. Observations revealed the red and yellow STOP signs were placed on the residents' room doors according to the COVID-19 status of the residents. Observations were made of the amount of PPE on each nursing unit. Interviews of staff validated that the amounts of PPE available had improved and an understanding of the color-coded signage. Observations of the dementia unit validated that the dayroom was closed, most residents were in their rooms, those residents in the hall were monitored by staff for social distancing, and the residents were served their meals in their rooms. The survey team notified the Clinical Assistant Administrator that the immediate jeopardy at F880 was removed on 04/22/20 at 6:45 PM. Findings include: During the entrance conference on 04/19/20 at 10:45 AM, the Director of Nursing (DON) stated, Every unit has one wing for positive residents. Positive residents are moved to the designated unit. Their roommates are tested due to exposure. The residents that have pending test results stay on the other wing on the unit. The STOP sign on the door means the resident is positive. The DON stated that the nursing staff follows infection control procedures by providing care for the residents who are negative for COVID-19 first, then provides care to the residents awaiting test results, and lastly provides care to the residents who are positive for COVID-19. The DON stated that this procedure was to extend the use of PPE, in particular gowns, by providing care to the residents who are positive for COVID-19 last. During an interview on 04/19/20 at 2:00 PM, Registered Nurse (RN) 5 stated, This morning we handed out one blue (isolation) gown and one yellow poncho to each Certified Nursing Assistant (CNA) for the day shift. During an interview on 04/19/20 at 2:15 PM, the DON verified that each CNA was provided one isolation gown and one plastic poncho for their shift. During an interview on 04/20/20 at 10:00 AM, RN 6 stated, On one side (wing) of the unit are all COVID positive residents. The L side is COVID positive and K side is pending results. During an interview on 04/20/20 at 10:20 AM, RN8 stated, Both wings (L and K) have some positive COVID 19 and some pending. During an interview on 04/19/20 at 12:15 PM on the L-wing near the nurses' station, CNA 18, 19, 20, and 21 stated that the facility supplied them with one disposable gown and one plastic poncho to place over their gown per shift. These CNAs stated that the PPE provided by the facility was not enough to follow isolation precautions. The CNAs stated that all residents negative for COVID-19 were to have care first, then the residents who were presumptive (test pending or exposed) COVID-19, and last to have care were the residents who were positive for COVID-19 to help mitigate the spread of [MEDICAL CONDITION]. When asked how they would know which residents are pending test results and which residents are COVID-19 positive, the CNAs stated that the STOP sign on the residents' doors indicated that both residents were positive for COVID-19 or one resident was positive and the other had pending test results. The CNAs were unable to state which resident was positive and which was presumptive. The CNAs stated that they treat both residents with a STOP sign on the residents' bedroom door as positive increasing the exposure to COVID-19 to the resident awaiting test results. Continued interview on 04/19/20 at 12:45 PM, CNAs 17, 18, 20, and 21 revealed that once the last resident on their assignment received care, the plastic poncho would be discarded. The CNAs stated that they would wear the same isolation gown minus a poncho for the rest of the shift while providing care to the residents regardless if they are COVID-19 positive, presumptive, or negative. During an interview on 04/19/20 at 12:45 PM on the K wing, CNA17 stated that she was given one isolation gown and one plastic poncho per shift to wear while caring for the residents on her assignment. CNA17 stated her assignment includes both COVID-19 negative and positive residents. CNA17 stated that the STOP sign on the residents' bedroom doors indicated that both residents were positive for COVID-19 so it didn't matter which resident was given care first. During an interview on 04/19/20 at 1:00 PM on the M wing, CNAs 22, 23, and 24 stated that they are provided one isolation gown and one plastic poncho or apron as PPE for the shift. These CNAs were unable to state which residents in the rooms with the STOP sign were positive and which were presumptive. These CNAs stated that all residents in the rooms with the STOP sign were treated as positive during care. During an interview on 04/19/20 at 2:35 PM on the V wing, CNA25 stated that she was provided with one isolation gown and two plastic ponchos for the shift. CNA25 stated, I go to the negative residents first. I throw away the 'poncho' when all of the residents on my assignment have received their care. When I go back later to provide care, I use the second 'poncho.' I have only the gown to wear when caring for the residents. During an interview on 04/20/20 at 10:05 AM on the L wing, CNA21 stated that the STOP sign on the residents' bedroom door means all the residents in the room are positive for COVID-19. When asked which resident would receive care first in the room with the STOP sign CNA21 stated, I do the resident on the window side first then door side. When asked if it mattered if one resident is pending or one was positive when deciding to provide care, CNA21 stated, I treat both as positive. When asked who would receive care first in a room where there is a STOP sign on the residents' bedroom door, CNA21 stated, The window bed. Review of R2's paper medical record April 2020 physician's orders [REDACTED]. Review of R1's paper medical record April 2020 physician's orders [REDACTED]. R1's test results were pending as of 04/20/20. CNA21 verified that she provided care to R2 first based on her understanding that the STOP sign meant both residents were COVID-19 positive. Observation on the N wing on 04/20/20 at 10:30 AM, revealed CNA29 wearing an isolation gown with a thin plastic gown over it preparing to go into R3 and R4's room. The door of the room had a STOP sign. CNA29 stated that the STOP sign meant both residents are positive for COVID-19. CNA29 stated that since both residents in that room were COVID-19 positive, it did not matter which resident was provided care first. Review of R3's paper medical record April 2020 physician's orders [REDACTED]. Review of R4's paper medical record April 2020 physician's orders [REDACTED]. Observation on the L wing on 04/19/20 at 12:10 PM revealed housekeeping staff 30 was mopping the residents' rooms. Housekeeping staff 30 was asked if he mopped the rooms in any particular order, i.e. COVID-19 negative before COVID-19 positive rooms, and he stated, No. When asked what the STOP signage on the doors to the residents' rooms meant he stated, I have no clue. During an interview on 04/19/20 at 1:00 PM, the Assistant Director of Housekeeping stated, We are short-staffed. He (housekeeping staff 30) usually works in the laundry and on the weekends. I will reeducate him on the order to mop the floors with the COVID-19. Observation and interview on 04/20/20 at 7:30 PM on the secured dementia unit revealed 10 residents seated in the dayroom. The residents were not wearing face masks or social distancing. R9 was identified by the CNA26 as being positive for COVID 19. R9 was observed seated in a chair next to another resident who was identified as being COVID negative. CNA26 stated, What are we supposed to do? This a dementia unit and they (the residents) won't stay in their rooms or wear a mask. Review of R9's paper medical record Aril 2020 physician's orders [REDACTED]. Observation on 04/21/20 at 12:50 PM revealed approximately 15 residents seated in the dayroom on the secured dementia unit. Interview on 04/21/20 at 12:50 PM with CNA27 and CNA28, four of the residents (R9, R10, R11, and R12) in the dayroom were positive for COVID 19. These four residents were not wearing face masks. R9 was observed ambulating throughout the dayroom and was seated next to other residents with an unknown COVID 19 status. R10 and R11 were observed seated at a round table with a resident with unknown COVID 19 status. R12 was observed seated in a wheelchair placed at a rectangular table with three residents with unknown COVID 19 status. CNA27 stated, This is a dementia unit. We can't keep the residents separated because they wander. Review of R10's paper medical record April 2020 physician's orders [REDACTED]. Review of R11's paper medical record April 2020 physician's orders [REDACTED]. Review of R12's paper medical record April 2020 physician's orders [REDACTED]. Interview on 04/21/20 at 1:00 PM on the dementia unit, RN13 stated that the residents were unable to maintain social distancing, wear face masks, or stay in room due to their dementia. RN13 verified that the residents ate their meals and congregated in the dayroom. RN13 stated that the facility did not provide them with additional guidance or policies regarding infection control for the dementia unit. RN13 stated that as of 04/20/20 at 1:00 PM, all 32 residents residing on the dementia unit had been tested for COVID 19. Fourteen residents were COVID-19 positive and 17 residents' results were pending. During an interview on 04/21/20 at 3:00 PM, the Administrator verified that the staff on the dementia unit were educated concerning transmission-based precautions and communal activities following the same guidelines as the other units in the facility. Review of the facility's policy titled, COVID-19 Infection Prevention and Control Program-New Jersey Veterans Homes, dated 04/03/20, revealed . The VMH (Veteran's Memorial Homes) will maintain an active Infection Prevention and Control Program that includes all departments and contracted services, working to ensure the following infection prevention interventions are in place: Communal Activities: The Veterans Home shall cancel all group outings, group activities, communal therapies, and communal dining during the period of the COVID-19 pandemic . Make PPE available to care for residents on transmission-based precautions (as available) . Signage for staff regarding the use of PPE shall be posted in appropriate locations in the facility . Interview with the DON on 04/22/20 at 4:00 PM revealed that as of midnight on 04/21/20, the facility had a census of 239. Out of the 239 residents, 119 residents had been confirmed COVID-19 positive, 46 COVID-19 related deaths, and 148 residents with pending COVID-19 results. These numbers are since the first documented case of COVID-19 in the facility on 03/25/20.

Based on observation, interview, record review, review of the facility's documents, and review of the facility's policy, it was determined the facility failed to ensure resident's right to a dignified existence was promoted and enhanced for two of two sampled residents (Resident (R) 8 and R7). On [DATE], facility nursing staff incorrectly identified, pronounced deceased , and notified R8's family that he had expired; however, the resident who had expired was R7 and his family was not notified until five hours later. This failure placed all residents at risk for not having their rights honored. On [DATE] at 6:15 PM the Administrator, the Clinical Assistant Administrator, and the Non-Clinical Assistant Administrator were notified of the immediate jeopardy under the area of Resident Rights for a failure to correctly identify and make family notifications after a resident expired. The facility presented an acceptable plan for removal of the immediate jeopardy on [DATE] at 4:30 PM. The removal plan included all residents' ID bands, room name plates, medical records, and unit rosters were all checked and verified for accuracy. The facility started educating all nursing staff. To ensure all staff were educated, nursing staff could not begin their shift prior to receiving the education related to properly identifying residents. The removal plan was validated through observation, interviews and record review. Observations revealed all doors on the units were clearly identified with a D or a W to indicate if the resident was in the bed by the door or window. Observations also revealed all resident who were wore their ID bands on their person. Interviews were completed with staff related to identifying residents, specifically how they were instructed to identify residents who they were not familiar with their names. Record review revealed that staff had received inservice training regarding how to identify residents and the use of the ID bands on all residents in the facility. The facility was notified the facility that the immediate jeopardy was removed on [DATE] at 5:10 PM. Findings include: Review of the facility's undated form titled, Resident Rights, revealed, .each resident of the New Jersey Veterans Memorial Home (VMH) should be entitled to the following rights which included the right to a dignified existence . Review of the facility's policy titled, Death of a Veterans Home Resident, revised 2018, revealed, .the Division of Veterans Healthcare Services (DVHS) required that each of the New Jersey Veterans Memorial Homes (VMH) would establish a protocol assuring that the responsibility for the pronouncement of death was discharged in accordance with County or State Regulations, and in a [MEDICATION NAME], dignified , and expeditious manner. Continued review of the policy revealed when a VMH resident expired, the County Medical Examiner would be notified of the resident's death and would be provided with contact information for the resident's next of kin. The policy also revealed the VMH would promptly notify the Power of Attorney, guardian, or other designated person about a resident's death and the notification should be made at the time of the pronouncement of the resident's death, and the time between the pronouncement of the resident's death and the notification should not exceed one hour, unless the family member, guardian, or other designated person to be contacted provided other instruction as to when the required notification was to occur . Review of the facility's form titled, Final Investigation, dated [DATE] revealed for the section Fact Summary it was documented, Residents (R8 and R7's initials) were both residents from other units who were transferred to Valor Unit on [DATE]; and were cohorted in the same room for their Covid (sic)19 positive diagnosis. On [DATE] at approximately 10 AM (sic) while the wing nurse was passing meds (medications) in room V8, she administered (R8's initials) his medication, and then recalled that the night shift nurse had stated in the change of shift report that (R8's initials) had expired. The nurse immediately contacted the Supervisor and the DON (Director of Nursing). Upon investigation, it was noted that the night nurse and the night supervisor mistakenly contacted (R8's initials) family, documented in the wrong chart and also placed the wrong ID (identification) band on (R7's initials) when in fact it was (R7's initials) that had expired and not (R8's initials). Continued review of the Final Investigation revealed for the section Conclusions/recommendations, indicated, both residents' families were immediately contacted and notified of the error, both the night shift nurse and the supervisor were immediately contacted and corrected the documentation in the appropriate charts, night nurse who was working on [DATE], when (R7's initials) expired at 5 AM (sic), grabbed the chart looking at the name outside the door and that is why the error occurred, and in order to prevent this event from occurring again in the future, the following precautionary measures were taken. a. On all units, resident's ID (identification) bands, room name plates, and unit rosters were all immediately checked and verified for accuracy. c. All resident room name plates had been amended to show D or W to clearly demonstrate the resident's location in each room. Review of R8's undated Face Sheet, located in the resident's hard copy closed medical record, revealed the resident was admitted to the facility on [DATE]. Continued review of the face sheet revealed the resident's unit/room was documented as TV (Valor Unit) V008W (room V008 window). Review of R'8s quarterly Minimum Data Set (MDS), assessment with an assessment reference date (ARD) of [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Review of R8's undated Funeral Plan, located in the resident's hard copy closed medical record revealed the resident's chosen funeral home was (name of funeral home.) Review of R8's Interdisciplinary Progress Notes, dated [DATE] at 1420 (2:20 PM) (notes have a line drew threw them with initials) revealed a nursing progress note that stated the resident was transferred from the RS (Serenity Unit) to room V8W due to COVID-19 positive test result. Continued review of the Interdisciplinary progress notes revealed on [DATE] at 0500 (5:00 AM) nursing documented, Resident in bed unresponsive, pale, pupils dilated .no pulse, no respirations, no B/P (blood pressure) .called MD (medical doctor) and notified regarding death and RN (Registered Nurse) arrival and pronounced, MPOA (medical power of attorney) notified. I (nurse) will call funeral home. Further review of the Interdisciplinary progress notes revealed on [DATE] at 0730 (7:30 AM) nursing documented Body picked up at this time by name of funeral home. Review of R7's undated Face Sheet, located in the resident's hard copy closed medical record, revealed the resident was admitted to the facility on [DATE]. Continued review of the face sheet revealed the resident's unit/room was documented as TV (Valor Unit) V008D (room V008 door). Review of R7's admission MDS, with an ARD of [DATE], revealed the facility assessed the resident as having a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired. Review of R7's undated Funeral Plan, located in the resident's hard copy closed medical record revealed the resident's chosen funeral home was (name of a different funeral home.) Review of R7's Interdisciplinary Progress Notes, dated [DATE] at 1435 (2:35 PM) revealed a nursing progress note that indicated the resident was transferred from the RS (Serenity Unit) room R12D to room V8D due to COVID-19 positive test result. Continued review of the progress notes dated [DATE] at 0700 (7:00 AM) (line is drawn through documentation with initials) revealed the nurse documented, Tylenol given at 0630 am for increased temp of 99.8, fluids encouraged . no SOB (shortness of breath), HOB (head of bed) elevated . Further review of R7's progress notes dated [DATE] at 1505 (3:05 PM) nursing documented a late entry for [DATE] at 10:15 AM which revealed the nurse informed R8's POA (power of attorney) that his dad expired this morning (morning of [DATE]). The notification was made five hours after the resident had expired. Interview on [DATE] at 9:54 AM with Unit Clerk (UC) 38, who was assigned to the Valor Unit, revealed on [DATE] he received paperwork for R8 and R7 to come to the Valor Unit from the Serenity Unit. Continued interview with UC38 revealed per the paperwork, R8 was assigned to the Window side of room V8 and R7 was assigned to the door side of room V8. The UC stated he placed the resident's names outside the door of room V8 per the paperwork, updated the unit roster, and updated the residents' chart to show the same. The clerk also stated he did not know how R7 ended up in R8's bed by the window. The UC also stated he knew the residents were in the correct beds (R8 by window and R7 by the door) because the residents' social worker came to the room and checked on them both. Interview on [DATE] at 10:15 AM, Social Worker (SW) 34 stated that she was the social worker for both Serenity and Valor Units. SW34 stated that she was very familiar with R8 and R7. The SW stated that on [DATE] she became aware that both residents had been transferred from the Serenity unit to the Valor Unit, room V8. SW34 stated when she went into V8, R7 was in the bed by the door and R8 was in the bed by the window; and name plates outside the door indicated the same. Interview on [DATE] at 2:01 PM with Recreation Assistant (RA) 35 and RA36 revealed they were the ones who transported both R8 and R7 from the Serenity Unit to the Valor Unit on [DATE]. Both RAs stated they knew the residents very well. The RAs stated they first brought R8 to the Valor Unit and placed his bed in room V8 by the window and then brought R7 and placed his bed in room V8 by the door as instructed by the Valor unit's ward clerk. RA35 stated he remembers R8 talking and asking where he was being moved too. Interview on [DATE] at 10:10 AM, the DON revealed on [DATE] Licensed Practical Nurse (LPN) 33 assigned to room V8 called Registered Nurse Supervisor (RNS) 32 to come pronounce a resident as deceased . The DON stated LPN 33 reported to the RNS 32 the resident who had expired was R8 when in fact it was R7 who had expired. The DON also stated the RNS 32 identified the resident who she pronounced as R8 based on the identification name outside of the room's door and the residents hard copy medical record, which both had R8 as being in the bed by the window. The DON also stated LPN 33 assigned to the resident also failed to recognize the resident that was deceased was not the correct name and both the RNS 32 and LPN 33 were not familiar with either resident in room V8. Continued interview with the DON revealed neither resident wore ID bands since both residents came from the Serenity Unit. The DON stated that most residents on the dementia unit will frequently remove them. The DON further stated the facility's practice of correctly identifying residents was for staff to look at the ID bands on the resident and staff who were not familiar with the resident should have familiar staff verify who the name of the resident. When asked about picture identification, the DON stated pictures of residents were only located in the resident's Medication Administration Record [REDACTED]. When asked if staff have been re-educated since the event that took place on [DATE] when a deceased resident was not correctly identified, the DON stated she had not had the time to do any education yet. The DON confirmed the wrong resident was identified as deceased , and R7 went to the wrong funeral home and was almost cremated instead of buried per his wishes. Interview on [DATE] at 11:05 AM, with RN 12 revealed if she found a resident unresponsive, she would check the resident's ID band for the resident's name and if she was not familiar with the resident, she would call a staff person who was familiar with the resident to verify who the name of the resident. Interview on [DATE] at 11:15 AM, with LPN37 revealed if he was to find a resident unresponsive, he would check the resident's ID band to verify the resident's name and if he was unfamiliar with the resident, he would request someone familiar with the resident to come verify the name of the resident. Interview on [DATE] at 11:46 AM, LPN33 stated on the morning of [DATE] there was a lot of confusion related to the relocation of residents and that it was a very stressful shift. Continued interview revealed on the morning of [DATE], LPN 33 was notified by a CNA that the resident in room V8W may have passed away. LPN 33 stated that when he went into the room, he checked the name on the door and when he checked the resident for an ID band, the resident was not wearing an ID band. LPN 33 also stated that after he assessed the resident, he pulled the chart (hard copy medical record) for the resident in the bed by the window and the chart indicated the resident in the bed by the window was R8. LPN33 stated he notified the RNS 32 to come pronounce R8 deceased . LPN 33 stated that he made the resident a new ID band and placed it on the resident prior to the funeral home's arrival. When asked if he had looked in the resident's MAR indicated [REDACTED]. When asked had he received any education related to identifying residents, LPN 33 stated that he returned to work the next day and did not receiving any education regarding the identification of residents. Interview on [DATE] at 12:00 PM, RNS 32 stated that on [DATE], LPN33 notified her that R8 had expired. The RNS 32 stated that when she arrived at the Valor Unit, CNA 39 told her the resident was R8 in room V8W. RNS 32 stated that the sign outside of room V8W indicated R8 was in the bed by the window. RNS 32 indicated that the unit's roster also indicated that R8 was in the bed by the window. RNS 32 confirmed that the resident was not wearing an ID band. The RNS 32 stated that because the CNA confirmed the resident was R8, LPN 33 confirmed the resident was R8, the name outside the door indicated the resident in the window bed was R8, and the chart indicated the resident was R8, he did not look at the resident's picture in the MAR. Observation on [DATE] at 12:50 PM of the Serenity Unit revealed three residents in the day room did not have ID bands on their person. Continued observation revealed the residents' rooms were not marked with a D or a W by the names of residents to clearly identify the residents' bed location. Interview on [DATE] at 1:08 PM, RN 13 revealed that three residents in the day room were not wearing an ID bands, and that the residents had taken their ID band off and staff had placed the ID band in the resident's hard copy medical record. RN 13 confirmed that none of the residents' bedroom on the Serenity Unit were marked with a D or a W. Observation on [DATE] at 1:30 PM of the N Wing revealed rooms 102, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116 missing the W for window bed and that D was identified on the name plate outside of the residents' bedroom doors.

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to properly store food and provide equipment service to prevent the development of foodborne illness. This deficient practice was evidenced by the following: On 10/10/19 at 9:32 AM, in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. In Kitchen One: -Inside the steam table 5 of 5 of the heating elements were soiled with a layer of white/yellow film. The FSD stated that they are cleaned and descaled daily, and they should all be clean. -The reach in refrigerator was 44 degrees Fahrenheit (F). The FSD stated it should have been 41 degrees F or less and that the food would be relocated right away. -In the snack prep area there was a coffee carafe, in circulation for use, that was stored upright and with water pooled at the bottom. The FSD stated that it should have been dried and stored upside down. -There was a stack of 52 trays, in circulation for use, with water between them. The FSD stated they should be dried prior to stacking. -In the dish room, in the plate warmer, there was a stack of 60 plates, in circulation for use, with water between them. The FSD stated they should have been completely dried before stacking into the warmer. -The walk-in produce refrigerator was 46 degrees F. The FSD stated it should have been 41 degrees F or less and that the food would be relocated right away. -The glass doors on 4 of 4 convection ovens were soiled with dried drippings of a brown grease-like substance and food debris. The FSD stated they should be cleaned weekly on Sundays. However, he was unsure when they were last cleaned as they do not have a sign off sheet for task completion. 2. In Kitchen Two: -Inside the steam table 5 of 5 of the heating elements were soiled with a layer of white/yellow film. The FSD stated that they are cleaned and descaled daily, and they should all be clean. -The reach in freezer was 15 degrees F and the ice cream that was inside was soft. The temperature reading screen, on the outside of the unit, was blinking an error message. The FSD stated that something was wrong with the unit, the food would be moved, and the unit would be taken out of service until it could be serviced. -In the dish room, in the plate warmer, there was a stack of 50 plates, in circulation for use, with water between them. The FSD stated they should have been completely dried before stacking into the warmer. 3. In Kitchen Three: -Inside the steam table 5 of 5 of the heating elements were soiled with a layer of white/yellow film. The FSD stated that they are cleaned and descaled daily, and they should all be clean. -The reach in freezer had a large amount of ice buildup throughout the inside. The FSD stated that it should not have been built up like that and the unit would be de-iced right away. A review of the facility's policy for Food Storage revealed, under #2 the following: Refrigerator temperature will be maintained at 35-40 degrees F. A review of the facility's policy titled, Washing Pots and Pans revealed under #9 and #10 the following: washed items should be placed on racks to dry and should be completely dried from water before stacking or putting them away. In an interview on 10/16/19 at 1:32 PM, the Chief Executive Officer stated that the facility did not have a policy in place for frequency and accountability for steam table or oven cleaning, nor did they have a policy in place for freezer temperatures. NJAC 8:39-17.2(g)

Based on interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents co-signed the monthly Physicians Orders (PO) while working in collaboration with the Advanced Practice Nurse (APN). This deficient practice continued over a four month period reviewed for 35 of 37 residents (#21,#207, #34,#57, #79,#80, #170, #276, #235, #296, #297, #291, #105, #158, #299, #196, #110, #2, #130, #258, #184, #311, #203, #47, #32, #35, #38, #113, #128, #165, #194, #236, #280, #309, and #317) reviewed and was evidenced by the following: 1. On 11/27/18 from 10:00 AM to 12:00 PM, the surveyor reviewed Resident #21's POS, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly PO. There was no documentation that Resident # 21's primary physician had co-signed the monthly POS while working in collaboration with the APN. 2. On 11/30/18 at 8:48 AM, the surveyor reviewed Resident #207 PO, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly PO. There was no documentation that Residents # 207's primary physician had co-signed the monthly POS while working in collaboration with the APN. On 11/2918 and 11/30/18 all the Unit Managers were interviewed from the A/B, C/D, K/L, M/N, R/S and TV units and stated that the APN signs all the monthly PO's. On 11/30/18 at 10:00 the surveyor interviewed the APN who stated he signs all the monthly POS. 3. On 11/30/18 from 8:51 AM to 9:54 AM, the surveyor reviewed the monthly PO for Residents #34, #57, #79, #80, #170, #276, 296 and 235 that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly PO. There was no documentation that the primary physician had co-signed the monthly POS while working in collaboration with the APN. 4. On 11/27/18 from 10:45 to 11:30 AM, the surveyor reviewed Resident #297 and #291's POs, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly POs. There was no documentation that Resident #297 and #291's primary physician had co-signed the monthly POs while working in collaboration with the APN. 5. On 11/28/18 from 10:55 AM to 12:00 PM, the surveyor reviewed Resident #105, #158 and # 299's POs, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly POs. There was no documentation that Resident #105, 158 and #299's primary physician had co-signed the monthly POs while working in collaboration with the APN. 6. On 11/29/19 from 9:19 AM to 01:10 PM, the surveyor reviewed Resident #184, #196, #110, #2, #130, #258, #311, #203 and #47's POs that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly POs. There was no documentation that the residents primary physician had co-signed the monthly POs while working in collaboration with the APN. On 11/29/18 at 11:30 AM, the surveyor interviewed the APN for the AB and CD units who confirmed she signs and dates the monthly PO's for all the residents. 7. On 11/29/18 from 09:00 AM to 12:00 PM, the surveyor reviewed Resident #32, #35, #38, #113, #128, #165, #194, #236, #280 and #309's POs, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN signed and dated the monthly POs. There was no documentation that Resident #32, #35, #38, #113, #128, #165, #194, #236, #280 and #309's primary physician had co-signed the monthly POs while working in collaboration with the APN. 8. On 11/30/18 at 9:15 AM, the surveyor reviewed the discharged records for Resident #317. The surveyor reviewed the admission POs dated 8/21/18 which revealed no physician signature or APN signiture. On 11/29/18 at 1:53 PM, the surveyor spoke to the Administrator and Director of Nursing regarding physician visits for the residents mentioned above. The Administrator stated that they had contacted the physicians involved. There was no QI process provided to the surveyor during survey. On 11/30/18 at 9:30 AM, the surveyor interviewed the APN for KL, MN and RS and TV units who confirmed that he signs and dates the monthly POS for all the residents. NJAC 8:39-27.1

Based on interview and record review, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face to face visits and progress note documentation at least every 60 days if working in collaboration with an Advance Nurse Practitioner (APN). This deficient practice continued over several months for 10 of 37 residents (Resident #297, #291, #105, #158, #299, #196, #110, #2) reviewed. This deficient practice was evidenced by the following: 1. On 11/27/18 from 10:45 to 11:30 AM, the surveyor reviewed Resident #297 and #291's physician progress notes [REDACTED]. There was no documentation that Resident #297 and #291's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the APN's visits. 2. On 11/28/18 from 10:55 AM to 12:00 PM, the surveyor reviewed Resident #105, #158 and # 299's PPN section in the residents medical record, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN documented in the RPN that she performed the faced to face visits. There was no documentation that Resident #105, 158 and #299's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the APN's visits. 3. On 11/29/19 from 9:19 AM to 10:22 AM, the surveyor reviewed Resident #196, #110 and #2's PPN section in the residents medical record, that revealed from (MONTH) (YEAR) to (MONTH) (YEAR), the APN documented in the PPN that she performed the faced to face visits. There was no documentation that Resident #196, 110 and #2's primary physician had conducted alternating face to face visits with the resident while working in collaboration with the APN's visits. On 11/29/18 from 11:00 AM and 11:15 AM, the surveyor spoke to the Unit Managers (UM) on the AB and CD units who both stated that they were aware the residents physician was not documenting the face to face visits. They said it was the APN who documented. At 11:30 AM, the surveyor interviewed the APN who confirmed she does the monthly visits for the residents, signed the physician orders [REDACTED]. On 11/29/18 at 1:53 PM, the surveyor spoke to the Administrator and Director of Nursing regarding physician visits for the residents mentioned above. The Administrator stated that they had contacted the physicians involved. A review of the facility's policy Medical Services indicated under A 1. (d) A physician wishall examine each Resident within five days before or 48 hours after, admission and (e) A primary care physician shall see the Resident at least once every 30 days for thereafter. After 90 day period, alternate 30 day visits may be delegated by a physician to a New Jersey licensed physician assistant or advanced practice nurse, in accordance with VMH policies. NJAC 8:39-27.1

Based on observation, interview and record review, it was determined that the facility failed to: a.) properly store, label and dispose of medications in 6 of 12 medication carts inspected and 1 of 6 medication refrigerators inspected and b.) secure narcotic boxes in 6 of 6 medication room refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 9:42 AM, the surveyor inspected the L unit medication cart in the presence of a License Practical Nurse (LPN). The surveyor observed one unopened bottle of [MEDICATION NAME] eye drops that was not dated and was stored in the medication cart. The surveyor interviewed the LPN who stated that unopened bottles of [MEDICATION NAME] eye drops should be stored in the refrigerator. On [DATE] at 9:50 AM, the surveyor inspected the K unit medication cart in the presence of LPN #2. The surveyor observed an opened Breo inhaler that was not dated. The surveyor interviewed LPN #2 who stated that all opened Breo inhalers should be dated. On [DATE] at 9:55 AM, the surveyor inspected the K and L unit medication rooms in the presence of a Register Nurse (RN). The surveyor observed one expired [MEDICATION NAME] Inhaler stored with active medications. The surveyor interviewed the RN who stated that all expired medication should be stored separately from active medication. On [DATE] at 10:00 AM, the surveyor inspected the K and L unit medication room refrigerator in the presence of the RN. The surveyor observed a Narcotic box containing one opened bottle of [MEDICATION NAME] solution that was attached to a shelf that was not affixed to the refrigerator. The surveyor was able to pull the shelf with the Narcotic box attached from the refrigerator. The surveyor interviewed the RN who stated that the shelf containing the Narcotic box should be affixed to the refrigerator. On [DATE] at 10:10 AM, the surveyor inspected the M and N medication room refrigerator in the presence of RN #2. The surveyor observed one bottle of [MEDICATION NAME] Solution with an opened date of [DATE] that was expired and stored inside the narcotic box. The surveyor was able to pull the shelf containing the narcotic box out of the refrigerator. The surveyor interviewed RN #2 who stated that the expired [MEDICATION NAME] solution should have been removed from the refrigerator and that the shelf containing the attached narcotic box should be affixed to the refrigerator. On [DATE] at 10:15 AM, the surveyor inspected the C and D medication room refrigerator in the presence of LPN #3. The surveyor observed a shelf containing a narcotic box that was not affixed to the refrigerator. The surveyor was able to remove the shelf containing the narcotic box from the refrigerator. The surveyor interviewed LPN #3 who stated that the shelf containing the narcotic box should be affixed to the refrigerator. On [DATE] at 10:25 AM, the surveyor inspected unit B medication cart in the presence of LPN #4. The surveyor observed one Anoro Ellipta inhaler that was opened and not dated. The surveyor interviewed LPN #4 who stated that Anoro Ellipta inhaler when opened should be dated. On [DATE] at 10:30 AM, the surveyor inspected the Unit A medication cart in the presence of RN #3. The surveyor observed one opened [MEDICATION NAME]pen that was opened and not dated, one [MEDICATION NAME]vial that was opened and not dated, one [MEDICATION NAME] 160 inhaler that was opened and not dated and one [MEDICATION NAME] eye drops that was opened and not dated. The surveyor interviewed RN #3 who stated that an opened [MEDICATION NAME] pen, an opened [MEDICATION NAME] vial, an opened [MEDICATION NAME] Inhaler and an opened bottle of [MEDICATION NAME] should have been dated. On [DATE] at 10:35 AM, the surveyor inspected the A and B medication room refrigerator in the presence of RN #3. The surveyor observed a shelf containing an attached narcotic box not affixed to the refrigerator. The surveyor was able to remove the shelf containing the narcotic box from the refrigerator. The surveyor interviewed RN #3 who stated that the shelf containing the attached narcotic box should be affixed to the refrigerator. On [DATE] at 10:50 AM, the surveyor inspected the unit T medication cart in the presence of LPN #5. The surveyor observed one vial of Humalog that was opened and dated but contained no label with a resident's name. The surveyor interviewed LPN #5 who stated that all medication should contain a label with a resident's name. On [DATE] at 10:55 AM, the surveyor inspected the unit T and V medication room refrigerator in the presence of RN #4. The surveyor observed a shelf with an attached narcotic box that was not affixed to the refrigerator. The surveyor was able to remove the shelf containing the narcotic box from the refrigerator. The surveyor interviewed RN #4 who stated that any shelf that has an attached narcotic box should be affixed to the refrigerator. On [DATE] at 11:05 AM, the surveyor inspected the unit S medication cart in the presence of LPN #6. The surveyor observed one bottle of opened glucose test strips dated [DATE] which was expired and one opened bottle of [MEDICATION NAME] eye drops that was dated [DATE] and expired. The surveyor interviewed LPN #6 who stated that both the Glucose Test Strips and [MEDICATION NAME] eye drops were expired and should be removed from stock. On [DATE] at 11:15 AM, the surveyor inspected the R and S medication room refrigerator in the presence of LPN #6. The surveyor observed one shelf contained an attached narcotic box that was not affixed to the refrigerator. The surveyor was able to remove the shelf containing the narcotic box from the refrigerator. The surveyor interviewed LPN #6 who stated that the shelf with the attached narcotic box should be affixed to the refrigerator. A review of the Manufacturer's Specifications for the above medication revealed the following: 1. An unopened bottle of [MEDICATION NAME] Eye drops should be stored in the refrigerator. 2. Breo Inhaler once opened had an expiration date of 42-days. 3. Anoro Inhaler once opened had an expiration date of 42-days. 4. [MEDICATION NAME] solution once opened had an expiration date of 90-days. 5. [MEDICATION NAME] pen have an expiration date of 42-days. 6. [MEDICATION NAME]vial once opened had an expiration date of 28-days. 7. [MEDICATION NAME] eye drops once opened had an expiration date of 42-days. 8. [MEDICATION NAME] inhaler once opened had an expiration date of 90-days. 9. Glucose test strips once opened had an expiration date of 90-days. On [DATE] at 1:00 PM, the surveyor spoke to the Administrator and Director of Nursing regarding the unit inspection results. No additional information was provided. NJAC: 8;,[DATE].4 (a) (h) (d)

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan (CP) to address respiratory care needs for 2 of 3 residents (Resident #236 and Resident #165) reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 11/20/18 at 12:43 PM the surveyor observed Resident #236 in the dining room eating lunch independently. The surveyor reviewed Resident #236's medical records. Resident #236 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The surveyor reviewed Resident #236's physician's orders [REDACTED]. The resident's CP was initiated on 10/15/18. The resident was assessed as being at risk for shortness of breath and fatigue related to pneumonia. A review of the CP interventions revealed there was no intervention incorporating the use of Oxygen that was ordered on [DATE]. 2. On 11/21/18 08:22 AM, the surveyor observed Resident #165 sitting in a wheelchair in front of the nursing station. The surveyor reviewed Resident #165's medical record. Resident #165 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The surveyor reviewed Resident #165's physician's orders [REDACTED]. Resident #165 had a CP initiated on 9/30/18 for fever, cough, lethargy, and [MEDICAL CONDITION]. There was no documented interventions incorporating the use of Oxygen that was ordered on [DATE]. On 11/29/18 at 10:50 AM, the surveyor interviewed the Unit Manager (UM) who stated that all new physician orders [REDACTED]. On 11/29/18 at 1:53 PM, the surveyor spoke to the Administrator and Director of Nursing (DON). The DON stated the Oxygen orders should have been included in the CP. NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyor observed 5 nurses administer 30 doses of medication to 8 residents. The deficient practice was noted for Resident #113 resulting in 2 errors and a medication error rate of 6.67 %. This deficient practice was evidenced by the following: On 11/28/18 at 9:15 AM during the medication ad ministration pass, the surveyor observed the Unit T medication nurse omit two medications; Tylenol 325 mg and Vitamin C 500 mg for Resident #113. After administering Resident #113's medications the surveyor observed the medication nurse sign both Tylenol 325 mg and Vitamin C 500 mg as being administered in the Medication Administration Record. The surveyor interviewed the medication nurse who stated that she failed to administer both Tylenol 325 mg and Vitamin C 500 mg to Resident #113. NJAC 8:39-29.2 (d)

Based on observation, interview and review of documentation provided by the facility, it was determined that the facility failed to maintain: a.) maintain adequate sanitation during food preparation and b.) food equipment services to prevent the development of foodborne illness. This deficient practice was evidenced by the following: On 11/20 18 at 9:15 AM in the presence of the Food Service Director (FSD) the surveyor observed the following: 1. Three of three kitchens had multiple fiberglass meal trays chipped and cracked with sharp edges and the interior metal exposed. The FSD stated multiple meal trays were ordered about four months ago. 2. The underneath area of the shelf above the filled five bay portable steam table in the main kitchen and two empty five-bay steam tables in the 2nd and 3rd kitchens were soiled with caked on food debris in direct contact with ready-to-serve food. 3. An opened container of food thickener dated 11/20/18 had a plastic spoon stored inside. 4. Multiple wall tiles behind one of the storage racks in the kitchen located under the window were missing, as well as the area between the front and back hood. They were cracked and in poor repair. 5. One 12 inch fry pan located on the storage rack was highly soiled with a build-up of black, charred debris on the inside and outside of the pan. 6. No garbage pail was in the area of the hand wash sink behind the hood. 7. A build-up of dried food debris was located on top of the dish machine at the manifold. 8. A large number of dented cans was located outside the dry storage room. 9. Three (1) liter carafes in the 2nd kitchen were upright, covered and had standing water inside. 10. One of two hand wash sinks in kitchens #2 & #3 did not have a garbage recepticle. 11. The walk-in freezer located in kitchen #3 was stacked too high with food items and over-crowded which had inhibited proper air circulation, and multiple boxes and some boxes had fallen to the floor. On 11/26/18 at 2:00 PM, the surveyor informed the Administrator and Director of Nursing of the kitchen concerns. NJAC 8:39-19.7(g)

Based on observation, interview and record review, it was determined that the facility failed to maintain infection control practices that would prevent and reduce the spread of infection identified for two residents. Resident #22 who had a [DIAGNOSES REDACTED].#31 who had a [DIAGNOSES REDACTED]. Both residents required the use of a Glucometer for blood glucose checks by the staff. The Glucometers were for single use only were being utilized for 49 other residents with only the use of a surface wipe (which was not observed on the medication cart at the time) for cleansing and then put into the medication cart (not encased). There was also a stethoscope that was community use and a blood pressure machine that was mobile and used from resident to resident without observed cleansing. In addition, Resident #31 had an open wound which staff did not use complete PPE (used gloves only) during the wound treatment in accordance with the resident's care plan. There was no Personal Protective Equipment (PPE), no indications of precautions, and no consistent staff awareness/education as to how to protect themselves and others. The immediate jeopardy was identified on 10/10/17 at 1:00 p.m. and corrected on 10/10/17 at 4:05 p.m., based upon an acceptable plan of correction for immediacy which was verified by the survey team. This deficient practice was observed for 2 of 31 residents with infectious diseases residing in the facility, Resident #22 and #31 as evidenced by the following: On 9/29/17 at 10:05 a.m., the surveyor toured unit CD with the Charge Nurse (CN) of the unit. The CN informed the surveyor that Resident #22 was alert and oriented, received dialysis and was a double below the knee amputee. The surveyor observed that the resident had a private room. The surveyor inspected the unit's 2 medication carts which both contained Glucometers (a device to measure blood glucose levels) stored loose on top of the lancets (a device to obtain a small sample of blood from the resident's finger) used for blood glucose testing. On 10/10/17 at 10:01 a.m. the surveyor reviewed the records of Resident #22. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the resident's care plan dated 1/27/17 which documented Contact Precaution as an Intervention to the Problem: HIV positive and Monitor accuchecks (glucometer) as ordered as an Intervention to the Problem: Diabetes Mellitus. The resident's care plan was updated on 2/8/17, 5/16/17, 5/18/17, 5/23/17, 5/24/17, 6/25/17, 6/29/17, 7/6/17, 7/7/17 and 8/25/17 without any change to the Contact Precaution care plan. The surveyor reviewed the October 2017 physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) revealed the nurses used the Glucometer to test Resident #22's blood glucose level three times a day. HIV is found throughout all the tissues of the body but is transmitted via the body fluids of an infected person (semen, vaginal fluids, blood, and breast milk). HIV is the virus, which attacks the T-cells (CD-4 cells) in the immune system. HCV is a viral disease spread primarily through contact with the blood of an infected person. On 10/10/17 at 12:30 p.m., the surveyor observed Resident #22 in the resident's private room. The surveyor did not observe any signs that indicated the resident was on contact precaution or PPE was not observed at the resident's room. The surveyor interviewed the Unit Manager (UM) who was not aware that Resident #22 was on contact precaution. The UM stated there should be gloves in the room. The surveyor discussed the use of a shared Glucometer between Resident #22 and all other resident's of the unit. The UM stated that she could not guarantee that all nurses were properly cleaning the glucometer after each blood glucose check performed for Resident #22 and the other residents that are being tested . On 10/11/17 at 11:15 a.m. the surveyor interviewed the certified nursing assistant (CNA) who stated that there has been no PPE equipment in Resident #22's room. The CNA stated that when someone has an infection we use more precaution, have a stop sign and PPE (gloves, gown, mask) in the room. The surveyor interviewed the medication nurse who stated that if they need a protective gown it is stored in the clean linen supply room. On 10/11/17 at 12:00 the Assistant Chief Executive Officer (ACEO) provided the surveyor with the manufacturer specifications for the Glucometer device used in the facility. 2. On 10/10/17 at 10 a.m., the surveyor observed Resident #31 seated in a motorized wheelchair outside the dining room. The surveyor observed the resident's right lower leg a bandage. On 10/10/17 at 1:56 p.m., the surveyor interviewed the Unit Manager (UM) for resident's on the TV unit with infections that required precautions. The UM told the surveyor there was one resident. The resident was identified as Resident #31 who resided in a private room. The surveyor and the UM went to the resident's room and observed there was no PPE available in the resident's room. There was no sign outside the resident's room to alert staff and visitors to see the nurse before entering the room. The UM was unable to give an explanation for not having the PPE and signage available. At 2 p.m., the surveyor interviewed the CNA responsible for Resident #31's care. He told the surveyor that he knew the resident was on precautions and that he wears a gown and gloves when he provides care to Resident #31. The surveyor asked the CNA where the PPE is stored. He said the gowns are on the cart in the utility room behind the nurse's station. When the surveyor went into the utility room with the CNA there were no gowns. Then we went into the shower room where the CNA said the gowns are usually on a cart. However, when we observed the cart in the shower room there were no gowns. The CNA obtains the gloves from the box of gloves provided on the cart in the shower room. At 2:10 p.m., the surveyor interviewed the medication nurse (MN). The MN stated that he knew the resident was on precautions, but that he doesn't use the PPE because he only gives the resident medications. He did not know why the PPE was not readily available in the resident's room. At 2:12 p.m., the surveyor interviewed the nurse who was responsible for the treatment to Resident #31's right lower leg. He told the surveyor that he was aware that the resident was on precautions. The surveyor asked the nurse if he used PPE before providing the treatment for [REDACTED]. The nurse told the surveyor that he wears gloves. Further inquiry revealed that the nurse stated he does not wear a gown and he stated I should wear a gown. At 2:15 p.m. The surveyor interviewed the UM about the PPE. She was able to find a box of gowns in a locked store room. The UM could not explain why the PPE was not readily available for staff use and stated she was not sure what the facility's protocol was for precautions for Resident #31. At 2:20 p.m., the surveyor reviewed Resident #31's records. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the July 2017 physician's orders [REDACTED]. The accuchecks are obtained by pricking the resident's finger with a lancet (small device to obtain blood sample from the finger) and then inserting the lancet into the Glucometer to check blood sugar levels. The Glucometer that was used to obtain the blood sugar for Resident #31 was the same Glucometer that is used for other residents who required blood glucose testing. The surveyor reviewed the manufacturer device insert supplied by the facility which documented Do not allow cleaning solution to run into the meter through areas such as around the buttons or the meter's test-strip or data ports (area where the glucose blood strips are placed for testing). The package insert also documented For more information see: FDA Public Health Notification: Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogens: Initial Communication and CDC Clinical Reminder: Use of Fingerstick Devices on More than One Person Poses Risk for Transmitting Bloodborne Pathogens. On 10/12/17 at 11:20 a.m., the surveyor contacted the manufacturer for clarification of the information for the Contour Next EZ, the Glucometer used by the facility. The surveyor spoke with the manufacturer agent who confirmed that All of the meters we manufacture are for single use. We do not recommend using our machines for more than one person. The surveyor reviewed Resident #31's care plan dated 7/12/17 which revealed a care plan titled VHR (veteran home resident) is HIV positive with interventions that included the use of Personal protective equipment when handling the resident's body fluids and when giving care is very important. Further review of the resident's care plans revealed a care plan dated 10/5/17 for an open blister on the right calf which was documented as secondary to Vascular ulcer. The interventions included treatment as ordered and monitor for s/s (signs and symptoms) of infection such as drainage, [DIAGNOSES REDACTED], fever. On 10/11/17 at 9:30 a.m., the surveyor interviewed Resident #31 and asked the resident if the staff were wearing gowns and gloves while assisting the resident with personal hygiene needs and when the treatment to the right calf was performed. The resident said now they are. Resident #31 stated that no one wore a gown. A review of the facility's policy and procedure titled Infection control Standard of Practice Two Tier Isolation Precautions under Transmission Based Precautions was documented Special measures must be taken to prevent the spread of infection when a Resident is known to be, or carries a high risk of infection. In addition under Contact Precautions included Contact Precautions include the use of a private room, or shared room with a Resident who has a similar infection, or who is low risk (not confused, no wounds or invasive devices). Equipment should be dedicated solely for the Resident's use. On 10/10/17 at 2:30 p.m., the Administrator and ACEO were notified of the breach in infection control involving Resident #22 and #31 resulted in an Immediate Jeopardy (IJ) situation. The Immediate Jeopardy was corrected on 10/10/17 at 4:05 p.m. based on an acceptable Plan of Correction (P(NAME)) which included the following: 1. Re-Education of all staff: Re-HIV/HEP-C 2. Resident #22 and #31 were immediately provided with individualized equipment, including B/P (blood pressure) cuff/Apparatus, Glucometer, not to be used by another resident. 3. PPE, including gloves, mask, gown, eye shields (eye protector) and caviwipes appropriate wipes for the device (Disinfecting wipes) were placed inside resident (s) room. 4. Appropriate signage was be placed on Resident #22 and #31's door. 5. All residents have the potential to be affected by this deficient practice. Other residents identified were provided single use Glucometer for each resident use. 6. The Facility Infection Control Policy has been reviewed and revised to reflect [DIAGNOSES REDACTED]. 7. All Clinical staff, Engineering staff and Environmental staff have been re-in serviced/educated by Nurse Educator, Unit Managers, Supervisors and Department Heads on Standard Precaution to include the use of PPE and designated resident equipment and disinfecting. NJAC 8:39-19.4(a)

Based on observation, interview and record review, it was determined that the facility failed to notify the New Jersey Department of Health (NJDOH) of an allegation of staff to resident physical abuse and failed to report a resident to resident altercation for 2 residents (Resident #3 and #9) of 30 residents reviewed. This deficient practice was evidenced by the following: On 10/2/17 at 11:35 a.m., the surveyor observed Resident #3 seated in a wheelchair in the dining room during the noon meal. The surveyor reviewed Resident 23's medical record on 10/2/17. An Interdisciplinary Care Plan note dated 6/30/17 (no time) titled Special Meeting stated, Team met regarding the resident's report of certified nursing assistant (CNA) being rough while providing care. The surveyor asked the Assistant Chief Executive Officer (ACEO) for the investigation. On 10/4/17 at 10:20 a.m., the ACEO provided the surveyor with the Incident Case Report (ICR) form dated 6/30/17. The report indicated than the resident felt the CNA did not treat him/her with respect. The resident further stated, She throws me around like a rag doll. The accused CNA was immediately suspended and a complete investigation was completed. Under the section of the ICR form titled Reported to State Agency, the facility indicated, No. Under the area titled, Reason Not Notified the facility had an asterisk symbol (*). No other explanation for not reporting the incident to the NJDOH was identified in the report. 2. On 9/29/17 at 11:20 a.m., the surveyor observed Resident #9 seated in a wheelchair in the dining room. The UM informed the surveyor that Resident #9 was cognitively impaired and that the resident had a history of [REDACTED].#9 has a private room. The surveyor reviewed the resident's medical records on 10/3/17. The Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the resident's care plans. Resident #9 had a care plan documented Altercation with other resident dated 5/19/17 and another entry dated 6/29/17 that documented Unprovoked physical aggression towards (resident identifier redacted). A review of the investigation of both resident to resident altercations revealed that the facility had preformed an investigation of each incident. The surveyor noted that the incident dated 5/19/17 was reported to the NJDOH. However, the incident that occurred on 6/29/17 in which Resident #9 was observed striking another resident was investigated, but not reported to the NJDOH. A review of the facility's policy and procedure titled Resident Safety Policy and Procedure documented under Regulatory Agency Reporting Requirement; The New Jersey Memorial Home at Paramus requires all alleged and/or suspected incidents, events, or occurrences that may constitute abuse be reported to the appropriate Federal and State Agencies. On 10/4/17 at 1:30 p.m., the surveyor discussed the above concern with the Administrator, ACEO and Director of Nursing. The Administrator stated it was an oversite. NJAC 8.39-9.4(f)

Based on observation, interview and record review, it was determined that the facility failed to a.) store foods in a sanitary manner and b.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 9/29/2017 at 9:45 a.m., in the presence of the Assistant Food Services Supervisor (AFSS), the surveyor observed the following: 1. In the main kitchen #1, on a shelf in the dishwashing area the surveyor observed 4 stacked small sized steam table pans nesting together with water between them. The AFSS said these pans should have been completely air dried before stacking them. 2. In the basement dry storage area the surveyor observed a random sampling of dented cans which were in rotation for use. The facility does have an area set aside for dented cans in this dry storage area. The surveyor observed the following: - 1- 10 pound (lb) can of carrots with a 6 inch dent on the body of the can. - 1- 10 lb can of cranberry sauce with a 3 inch dent on the body of the can. - 1- 10 lb can of tomato paste with a 1 inch dent on the body of the can. The AFSS said that these should not have been on the shelf and should have been placed in the dented can area. 3. In kitchen # 2 on a shelf in the standing refrigerator # 43, the surveyor observed 2 trays, each with approximately 25 cartons of nutritional health shakes with no date indicating when the health shakes were pulled from the freezer to thaw. On 10/2/17 at 11:30 a.m., the surveyor received the Labeling of Prepared Food Items Procedure from the Administrator which stated: 1. Foods need to be labeled with a preparation/pulled date; Washing Pots and Pans Procedure which stated 10. Make sure the pots, pans and utensils are dried completely from the water before stacking them away and hanging the utensils up; and the Food Storage Procedure which stated 7. All dented, bulging, crushed and rusted cans must be separated from stock and placed on the designated rack for return to vendor. This is a repeat deficiency for failing to air dry the steam table pans and failing to remove dented cans from rotation. NJAC 8:39-17.2(g)

C# NJ Based on interviews and a review of medical records and other facility documentation, it was determined that the facility failed to provide adequate supervision in the Dayroom to prevent accidents/incidents, in accordance with facility policy and procedure, for 1 of 3 sampled residents (Resident #1) who was identified as a fall risk. On [DATE], Resident #1 was found lying on the floor in the Dayroom bleeding from her left temporal area/eyebrow with approximately a 2.5 cm laceration. She required an emergency room (ER) visit, received sutures to her laceration and was noted with an acute left-sided trimalar-type fracture deformity. A follow up visit to the hospital on [DATE] for a Computed Tomography (CT) scan post fall revealed a new parenchymal as well as subarachnoid hemorrhage in the left perisylvian region of her frontal temporal area. She required a hospital admission, pain management and was discharged on Hospice to the facility on [DATE] for comfort care. Subsequently, on [DATE], Resident #1 expired due to blunt head trauma secondary to a fall. This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on [DATE] revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool which was dated [DATE], reflected that the resident was cognitively impaired and required limited to total assistance with her activities of daily living, except for eating. A fall risk assessment, dated [DATE], identified the resident as a high risk potential for falls with a score of "14." An Interdisciplinary Resident Care Plan (IDCP), dated ,[DATE] to ,[DATE], identified the resident as a risk for falls and also identified the resident as having had an actual fall on [DATE]. Interventions included tab monitor at all times and to monitor the resident closely by nursing staff when in the Dayroom. Further review of the IDCP reflected that on [DATE], Resident #1 was on Hospice care for comfort/pain management. An Incident/Accident Report (IR), dated [DATE] at 9:25am, documented that Resident #1 was found lying on the floor on her left side. She was bleeding from the left outer eyebrow/temporal area with a laceration approximately 2.5 cm. Broken eyeglasses were on the floor and part of the eyeglass frame remained on the resident. She was unresponsive to verbal or tactile stimuli with her eyes closed tight. Further review of the IR, under Medical Comments, revealed that the fall was unwitnessed in the Dayroom. No neuro deficits. "Fracture on CT scan brain and left maxillary sinus with hemorrhage. Suture of left lateral periorbital area intact with ecchymosis and minimal edema." A final investigation from the facility, dated [DATE], concluded that the CNA assigned to the Dayroom was not present. The CNA was suspended pending the investigation. A preliminary conclusion from a related investigation, dated [DATE], documented that the Dayroom must not be unattended when residents are in the room. A review of the ,[DATE] day shift Nursing Dayroom Assignment (NDA) sheet for Resident #1's unit on [DATE], the day of the incident, had an assigned aide for the Dayroom from 8:30am to 3:00pm at every 30 minute intervals with the names listed of assigned staff. Further review of the NDA sheet documented that assigned staff must arrive on time, must remain in the Dayroom until relief arrives and, if unable to be on time, to notify the charge nurse or unit clerk in a timely manner. A written statement obtained by the facility from the CNA in question, dated [DATE], documented that she was assigned to the resident that fell . "I did not check the Dayroom schedule. Another resident put his light on stating that he would like to get dressed, so I went and did him, just as I was getting out of his room a nursing assistant saw me and told me that the resident fell ." It was further documented that the CNA forgot that the Dayroom schedule was changed since it was her first day to work for the week. During an interview by the surveyor on [DATE] at 9:36am with the CNA in question, who was assigned to the Dayroom when the resident sustained [REDACTED]. According to the CNA, she has worked in the facility for many years and does not have a permanent assignment (floater). On [DATE], she verbally received her assignment from the nurse that morning but did not print it since she knew who was on that assignment. According to the CNA, she went to feed residents for breakfast and was finished by 8:45am when she decided to check her Dayroom assignment. On her way to the Dayroom to check her assignment, she responded to a call light from one of the resident's rooms and assisted him with getting dressed. The CNA stated, "I forgot to look at my assignment." As she finished dressing the resident, another CNA came up to let her know that Resident #1 fell . When questioned by the surveyor regarding the practice of checking the Dayroom assignment, the CNA stated that it should be checked before starting to work. She also verified that without printing her nursing assignment or looking at the Dayroom assignment sheet, she would not know her Dayroom assignment. During an interview by the surveyor on [DATE] at 12:37pm with another CNA who found the resident on the Dayroom floor on [DATE], she stated that she responded to a tab alarm and found Resident #1 laying face down on the floor with no staff present. She proceeded to call for help and another CNA and a nurse responded. She went to check the assignment sheet to see who was assigned to be in the Dayroom at 9:25am and found the assigned CNA in another resident's room. The CNA also stated that the assigned CNA was not new to the facility and was not supposed to leave the Dayroom unattended. Additionally, she stated that assignments for the day should be checked prior to working and a CNA assigned to the Dayroom should not leave without coverage since the residents could get up, might need assistance and to prevent falls. During an interview by the surveyor on [DATE] at 11:20am, the RN/Unit Manager, who was familiar with the incident, stated that they always have assigned CNA's to cover the Dayroom and the residents should not be left without staff supervision. An Interdisciplinary Progress Note (IPN), written by Nursing and dated [DATE] at 9:25am, corroborated the IR documentation. It was further documented that the resident was sent to theER on the same day at 9:45am and returned at 4:20pm with 6 stitches on her left outer eyebrow. A physician note, dated [DATE], reflected that her sutures were intact with orders given including CT scan of the head. There was no further IPN documentation after [DATE] at 3:50pm. The facility could not locate further IPN notes. The resident was transferred and admitted to the hospital on [DATE], was readmitted to the facility on [DATE] and expired in the facility on [DATE]. During an interview by the surveyor on [DATE] with the Director Of Nursing (DON) regarding the missing medical records, she stated that their current medical records staff is on leave. They tried looking for the IPN from [DATE] but were unable to locate any additional IPNs. She will meet with the ward clerks to prevent further loss. A review of the Hospital Admission Form documented that Resident #1 was admitted on [DATE] at 9:29pm and discharged on [DATE] at 4:46pm. An Emergency Department Physician Documentation form, dated [DATE], reflected that the resident was at the hospital 2 days ago status [REDACTED]. A CT of the head was obtained which was read negative for an acute bleed but was positive for a left Trimalar fracture. A facial laceration was repaired and the resident was returned to the facility. The current visit was for a repeat CT which is "positive for a new parenchymal as well as subarachnoid hemorrhage." The CT of the brain, dated [DATE] from the hospital, documented, "Left perisylvian subarachnoid hemorrhage, unchanged since yesterday afternoon." A hospital discharge summary, dated [DATE], documented that the resident was being discharged back to the facility with Hospice. Final [DIAGNOSES REDACTED]. A review of the death certificate, dated [DATE] at 3:40am, documented that the cause of death was "blunt head trauma secondary to a fall." Facility policy, titled Activities/Dayroom Coverage, dated [DATE] and was last revised on ,[DATE], states that the purpose is "to promote a safe environment by providing continuous observation of residents in the Dayroom." The policy also states, "Nursing staff be assigned to dayroom at half hour intervals, unless otherwise designated by the charge nurse. This assignment displayed in the dayroom door will be posted so that it can be read by staff. Staff members assigned in the dayroom shall stay in close proximity to the residents in the dayroom especially those at risk for falls. Dayrooms are not to be left unattended while residents are present. Assigned aides are not to leave until their relief arrives." NJAC 8:,[DATE].1 (a) 8:,[DATE].1 (b)