Every finding on record at Parker at Somerset, Inc

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store food in a manner to prevent food-borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary and properly functioning manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 4/3/25 at 8:45 AM, the surveyor toured the main kitchen and four satellite kitchen areas with the Director of Dining (DD) and the Food Service Director (FSD) and observed the following: -A box of 4 -10 pound packages of defrosted chicken thighs in plastic type package and were inside of a box on a shelf in the walk in refrigerator. The box had a printed label that was dated 3/4/25 from the [NAME]. There was no pull date indicating when the chicken was removed from the freezer, and and no use by date. When asked what the dating policy was the DD stated that 5 days after the item was received or five days after the item was pulled from the freezer to defrost, the item must be used or discarded. The surveyor asked if the chicken was okay to use if the item did not have a use by date and the DD stated, no. -Another box on the shelf contained sixty pounds of defrosted beef eye of round in a plastic type package. The item sticker on the outside of the box was dated 2/5/25. A tour of the 1st floor Birch satellite kitchen revealed: - Debris underneath the refrigerator/ freezer and on the side of the cold cut refrigeration unit. The DD stated acknowledged the debris. - The fan above the stove had dark debris build up. - The ceiling vent in the food service area had visible debris. - At 9:25 AM, the under counter dish machine was observed in use by staff and the wash temperature was 143 F degrees Farenheight (F). - At 9:27 AM, the Dietary Staff (DS) again used the dish machine and the wash was 148 F. The DD and DS confirmed that the wash temperature should be 150 F. - The DS re-ran the cycle and the wash temperature was 148 F. The DS stated she had not been aware and the DD had the DS run the dish machine again. - At 9:33 AM, the wash cycle was 146 F and the DD contacted the repair company in the presence of the surveyor. The repair person stated that he probably needed to increase the temperature. The surveyor asked the DD if the dish machine could be used and the DD stated it can't be used. At 9: 42 AM, the surveyor toured the Dogwood satellite kitchen with the DD which revealed: -The under counter dish machine was in use and the wash temperature was 143 F. -The ceiling vent above the dish machine had visible debris. - The small vent above the stove had dark debris and a paper towel rubbed on the vent produced black debris. The DD confirmed it needed to be cleaned. At 10:01 AM, the surveyor toured the [NAME] Juniper satellite kitchen with the DD and the under counter dish machine wash temperature reached 137 F and the DS stated the machine was used in the morning. The DD stated the dish machine will not be used. On 04/04/25 at 7:45 AM, the surveyor conducted a follow-up interview with the DD regarding the above concerns. The DD stated the the chicken and beef were discarded. The surveyor asked what should have occurred and the DD stated that depending on if the items were received or pulled from the freezer, the items should have had either a pull date or a use by date which would have been 5 days. The DD stated the dish machine company increased the temperature for three of the under counter dish machines. The Food Labeling Policy, Dated 6/26/2022 revealed All food must be labeled properly upon delivery and after preparation. If food is not labeled properly, it will be discarded. 2. All items will be dated with the day it was received in the following manner: MM/DD/YY. The Dining Infection Control Policy Initial Date: 04/24/2020. Dish machine minimum Temperatures: Automatice Dishwashers Minimum temperature: Wash cycle: 150 F. NJAC 8:39-17.2(g)

C #: NJ 00184292 Based on interviews, and record review, as well as review of pertinent facility documents on 3/17/25 and 3/21/25, it was determined that the facility failed to ensure their policy on Medication Transcription was implemented for 1 out 5 residents (Resident #1). This deficient practice was evidenced by the following: According to the Admission Record, Resident #1 was admitted to the facility on ,d+[DATE], with diagnosis including but not limited to: Immune Thrombocytopenic Purpura (a bleeding disorder that keeps your blood from clotting). The Minimum Data Set (MDS), an assessment tool, dated 3/18/25, showed that the Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, showing resident had intact cognition. The form Medication Reconciliation History Form (MRHF), dated 2/27/25, revealed the medication reconciliation for Resident #1 was completed and signed by the first nurse and the physician on 2/27/25 at 3 P.M. The second nurse verification was signed on 2/28/25. During a telephone interview with LPN #1 on 3/18/25 at 10:32 A.M., she revealed that she works the 11-7 shift and is responsible for completing the 24-hour chart check. She stated that she accidentally signed the line for the 2nd nurse verification on the medication reconciliation form for Resident #1, she further stated that she is required to only sign the 24-hour chart check space in the admission packet, not the space for verifying nurse. During an interview with LPN #2 on 3/21/25 at 10:11 A.M., she revealed that she was aware of the process for medication reconciliation, and knew she was required to do the verification for the reconciliation, however, she did not complete the verification. During an interview with LPN #3 on 3/21/25 at 10:34 A.M., she revealed that she was aware of the medication reconciliation process and knew that a 2nd nurse was required to check the medications prior to putting them in the Electronic Medical Record (EMR), she assumed that the medication reconciliation check had been completed by LPN #2. During an interview with the Assistant Director of Nursing (ADON) on 3/17/25 at 2:48 P.M., she revealed, the MRHF was first to be completed by the initial nurse, which was the nurse that reconciled the medications with the provider, then the 2nd nurse was supposed to verify the medications to make sure there were no errors. She further stated that the verification for the MRHF for Resident #1 was not completed by the 2nd nurse but should have been done. The undated policy titled, Medication Transcription Policy, showed .#4. Double-check and Reconciliation: -A second licensed nurse should verify medications; -Compare new transcriptions with previous orders to prevent duplications or omissions . NJAC 8:39-27.1(b)

Based on interview and review of facility documents, it was determined that the facility failed to ensure that all Drug Enforcement Administration (DEA) 222 forms were completed with sufficient detail to enable accurate accountability and reconciliation for controlled medications for 5 of 8 DEA 222 forms reviewed in 1 of 1 back up controlled medication storage area. This deficient practice was evidenced by the following: On 11/5/20 at 11:14 AM, the surveyor reviewed all DEA 222 forms provided by the Director of Nursing (DON) for the past twelve months which revealed the following: 1. Review of a DEA 222 form dated 12/03/19, revealed that the portion of the form designated for signature of Purchaser or Attorney or Agent failed to contain a signature of authorization. Review of the attached Packing Slip that was signed by a Registered Nurse (RN) and dated 12/4/19, revealed that the pharmacy issued the facility the following controlled medications as requested on the unsigned DEA 222 form: Two packages of [MEDICATION NAME] 25 microgram (mcg) patches (an opioid medication used to treat pain), one package of [MEDICATION NAME] IR (Immediate Release) (an opioid medication used to treat pain) 15 milligram (mg) tablets (tab), three packages of [MEDICATION NAME] oral solution (5 mg/0.25 milliliter (ml) ), twenty packages of [MEDICATION NAME] (an opioid used to treat pain) IR 5 mg tab, and eleven packages of [MEDICATION NAME]/APAP (an opioid used to treat pain) 5/325 mg tab. 2. Review of a DEA 222 form dated 12/31/19, revealed that the area of the form designated to be filled in by the purchaser that detailed the number of packages received and the date received was blank. Review of the attached Packing Slip that was signed by a RN and dated 01/02/20, indicated that the facility was issued the following controlled medications as requested on the aforementioned DEA 222 form: One package of [MEDICATION NAME] 12 (12.5) mcg patches, three packages of [MEDICATION NAME] 25 mcg patches, two packages of [MEDICATION NAME] oral solutions 5 mg/0.25 ml, four packages of [MEDICATION NAME] ER (extended release) 10 mg tab, three packages of [MEDICATION NAME] IR 5 mg tab and six packages of [MEDICATION NAME]/APAP 5/325 mg tab. The number of packages received, and date received were not documented by the purchaser as required in the area allotted on the corresponding DEA 222 Form as required. 3. Review of a DEA 222 form dated 01/10/20, revealed that the area of the form designated to be filled in by the purchaser that detailed the number of packages received and the date received was blank. Review of the attached Packing Slip that was signed by an RN and dated 01/13/20, indicated that the facility was issued the following controlled medications as requested on the aforementioned DEA 222 form: Twenty packages of [MEDICATION NAME] IR 5 mg tabs, two packages of [MEDICATION NAME] 12 mcg patch and two packages of [MEDICATION NAME] Oral Solution 5 mg/0.25 ml. The number of packages received, and date received were not documented by the purchaser as required in the area allotted on the corresponding DEA 222 form as required. 4. Review of a DEA 222 form dated 01/27/20, revealed that the area of the form designated to be filled in by the purchaser that detailed the number of packages received and the date received was blank. Review of the attached Packing Slip that was signed by an RN and dated 01/27/20, indicated that the facility was issued the following controlled medications as requested on the aforementioned DEA 222 form: Six packages of [MEDICATION NAME] Solution 5 mg/0.25 ml and six packages of [MEDICATION NAME] IR 5 mg tab. The number of packages received, and date received were not documented by the purchaser in the area allotted on the corresponding DEA 222 form as required. 5. Review of a DEA 222 form dated 02/20/20, revealed that the area of the form designated to be filled in by the purchaser that detailed the number of packages received and the date received was blank. Review of the attached Packing Slip that was signed by an RN and dated 02/21/20, indicated that the facility was issued the following controlled medications as requested on the aforementioned DEA 222 form: Two packages of [MEDICATION NAME] 12 (12.5) mcg/hr. patch, four packages of [MEDICATION NAME] 25 mcg patch, 20 packages of [MEDICATION NAME]/[MEDICATION NAME] 5/300 mg tab (an opioid medication used to treat pain), nine packages of [MEDICATION NAME] 2 mg tab (an opioid medication used to treat pain), two packages of [MEDICATION NAME] solution 5 mg/0.25 ml syr., twenty packages of [MEDICATION NAME] IR 5 mg tab, and six packages of [MEDICATION NAME]/APAP 5/325 mg tab. The number of packages received, and date received were not documented by the purchaser in the area allotted on the corresponding DEA 222 form as required. The surveyor reviewed the Instructions that were printed on the back of all the DEA 22 forms which revealed the following: A person properly authorized by a power of attorney, on file at the registered location as set forth in 21 CFR 1305.5, may sign on behalf of the purchasing registrant. In such cases the officer or agent will indicate the capacity in which he signs, as Secretary, Agent, Attorney in-fact, etc. When items are received, the date of receipt and the number of items received must be recorded in the spaces provided on the triplicate copy. On 11/05/20 at 12:01 PM, the surveyor interviewed the DON who stated that the former DON was responsible for the completion of the DEA 222 forms prior to September 2020. She stated that when controlled medications were needed for the back up narcotic storage the DON was required to complete the DEA 222 form, obtain a signature from the Medical Director and fax the form to the Narcotic Department at the pharmacy. The DON stated that the Medical Director should have signed the DEA 222 form before the form was sent to the pharmacy. The DON stated the facility received confirmation of receipt of the DEA 222 form from the pharmacy. The pharmacy notified the facility of any irregularities noted on the form if applicable prior to processing. The pharmacy then sent for the DEA 222 form via courier and the order was filled within 24 to 48 hours. She further stated that when the delivery arrived the DON would compare the order received against the Packing Slip and confirm the quantity sent matched the amount requested on the DEA 222 form. The DON stated that the DON was the only responsible party at the facility who ensured that the DEA 222 forms were completed accurately. The DON was responsible to document the number of packages received and the date received on the DEA222 form. On 11/06/20 at 8:52 AM, the DON stated that the pharmacy admitted to the oversight regarding the DEA 222 form dated 12/03/20, which failed to contain the Medical Director's Signature. She stated that she spoke to the Director of Quality Assurance at the pharmacy who acknowledged the oversight and stated that the DEA 222 form was sent to the Drug Enforcement Agency (DEA) and the pharmacy was not questioned regarding the missing signature. She further stated that the pharmacy admitted the oversight on their part and the former DON was no longer employed by the facility. The DON stated that the number of packages received, and the dates received that were missing on the DEA 222 forms could be validated by the packing slips as proof of receipt. She stated that she documented the number of packages received and date received when the supervisor and another nurse put the controlled medications into the back up narcotic storage unit and the quantity was verified. The DON stated that the Consultant Pharmacist (CP) stopped coming into the facility in March 2020 due to the COVID-19 lock down and provided the surveyor with contact information. On 11/06/20 at 10:22 AM, the surveyor phoned the CP via speaker phone in the presence of the survey team with permission. The CP stated that she was at the facility in March 2020 right before the COVID-19 lock down. She further stated that she reviewed the DEA 222 forms when the facility was in the window for a State Survey and not on a routine basis. The CP was unable to recall when she last reviewed the DEA 222 forms. She further stated that she had not identified any issues with DEA 22 form completion at the facility. The CP stated that a physician signature was required to be documented on the DEA 222 form when it was sent to the pharmacy and should be sent back to the facility with an explanation if not completed correctly. The CP stated that the DEA 222 form needed to be signed and reviewed by the physician to ensure that he/she approved the medications that were ordered. The physician signature provided authorization for the order and receipt of controlled medications. The CP stated that the DON should document the date and quantity of controlled substances at the time the order was received. The purpose of the form was to order back up narcotics and the facility must keep the forms on file for accountability of narcotics. The CP stated that there was no issue with drug diversion at the facility. The surveyor reviewed the facility policy, Controlled Substances (revised January 1, 2018), which included the following: House Stock Controlled Substance Medications are medications which have not been ordered specifically for a resident (elder) but are kept on hand in limited quantities to administer in the event the medication is required before delivery of the controlled substance from the pharmacy. All house stock controlled substance medication is ordered by a form submitted to the pharmacy. Schedule II house stocks must be ordered using the specific DEA 222 Form. The Medical Director must sign and date at the bottom. N.J.A.C- 8:39-29.7 (C)

Based on observation, interview, and record review, it was determined that the facility failed to appropriately administer pain medication in accordance with a physician's orders [REDACTED].#91) for pain management in accordance to professional standards of 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 registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case-finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/30/2020 at 11:25 AM, the surveyor observed Resident #91 sitting in his/her room. The resident stated that he/she had just returned from therapy and had some pain so he/she had declined to speak with the surveyor. The surveyor reviewed the medical record for Resident #91. A review of the Admission Record (an admission summary), reflected that the resident was admitted to the facility in October of 2020 with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), an assessment tool to facilitate the management of care, dated 10/14/2020, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. A review of the resident's individualized care plan, dated 10/9/2020, indicated that the resident was at risk for acute pain related to recent surgery. Interventions included to administer as needed pain medications per physician order [REDACTED]. A review of the October 2020 Order Summary Report (OSR) reflected a physician's orders [REDACTED]. A review of the corresponding October 2020 electronic Medication Administration Record [REDACTED] On 10/19/2020 [MEDICATION NAME] was administered for a pain level of 7; which was effective. On 10/23/2020 [MEDICATION NAME] was administered for a pain level of 8; which was effective. On 10/25/2020 [MEDICATION NAME] was administered for a pain level of 7; which was effective. On 10/30/2020 tramdadol was administered for a pain level of 7; which was effective. A review of the electronic Progress Notes (ePN) had not reflected a nurse's note corresponding to these pain medication administrations. On 11/5/2020 at 10:39 AM, the surveyor interviewed the resident who stated that he/she received pain medications when needed. The resident stated that [MEDICATION NAME] (mild pain medication) was not effective for him/her, but the stronger medication he/she received was effective. At 10:40 AM, the surveyor interviewed the Registered Nurse (RN) who stated that the resident was on pain management post surgery. The RN stated that she could not recall the resident ever complaining of pain, but the resident received pain medications on both a routine and an as needed basis. The RN stated that pain medication was administered per PO. If the resident had pain greater than the level of the PO, the nurse called the physician. The RN stated that a resident who was alert and oriented (to person, place, and time) could request a specific medication, but that was documented in the ePN. At 11:35 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that residents on pain management had as needed pain medications based on a numerical pain scale. The pain scale was mild (1-3), moderate (4-6), and severe (7-10). The nurse administered the appropriate pain medication based on the corresponding PO and pain scale. If the pain level was greater than the prescribed medication, the nurse called the physician. On 11/6/2020 at 8:59 AM, the Director of Nursing (DON) stated that pain medication was sequenced based on a numerical pain scale of mild, moderate, and severe pain. An alert and oriented resident might have a pain level higher, but preferred the lower strength medication. The DON stated that the nurse documented in the ePN or the care plan of this. The DON stated that if the resident experienced pain greater than the level of medication prescribed, then the nurse contacted the physician. On 11/9/2020 at 9:46 AM, the DON in the presence of the Licensed Nursing Home Administrator and the survey team, confirmed that the nurse should administer pain medications per the PO. A review of the facility's Pain Management policy dated revised date 7/1/18 included that pain will be assessed using a pain scale prior to offering a resident an as needed or break through pain medication. Pain medication will be offered as prescribed by the physician, however if the resident requested milder pain medication not corresponding to the pain scale, the resident's request will be honored. NJAC 8:39-11.2(b)

Based on observation, interview and review of facility documentation it was determined that the facility failed to clean medical equipment between resident use, according to facility policy to prevent the spread of infection. This deficient practice was identified on 1 of 4 nursing units (Birch) and was evidenced by the following: On 10/30/20 at 10:36 AM, the surveyor observed Certified Nursing Aide (CNA #1) walk down the hallway on the Birch unit pushing a Hoyer lift, an assuasive device that allows people to be transferred between bed and chair. CNA #1 entered resident room [ROOM NUMBER] to assist the resident in 123-2 out of the bed to the wheelchair. On 10/30/20 at 10:49 AM, the surveyor observed CNA #1 exit resident room [ROOM NUMBER] with the Hoyer lift and placed the Hoyer in the hallway against the wall between resident rooms #122 and #123. CNA #1 was wearing the gloves they wore inside the room, then they walked back into resident room [ROOM NUMBER] and exited with two small bags of soiled linen. CNA #1 then walked down the hall to dispose of the two linen bags. CNA #1 then removed her gloves and performed hand hygiene with an alcohol-based hand rub, but never returned to clean the Hoyer lift. On 10/30/20 at 10:50 AM, the surveyor interviewed CNA #2 regarding the cleaning process for Hoyer lifts. CNA #2 told the surveyor that Hoyer lifts were brought to the shower area after use and they were cleaned and stored in the shower area. On 10/30/2020 at 10:55 AM, the surveyor observed CNA #1 take the same Hoyer lift used in resident room [ROOM NUMBER] from the hallway and entered resident room [ROOM NUMBER]-2 to assist a resident out of bed. On 10/30/20 at 11:34 AM, the surveyor observed CNA #1 exit resident room [ROOM NUMBER]-2 with the Hoyer lift and placed the Hoyer against the wall in the hallway between resident rooms #122 and #123 without cleaning the lift. At this time, the surveyor interviewed CNA #1 and asked the process for cleaning Hoyer lifts between residents. CNA #1 told the surveyor, I use wipes and I just cleaned it in the room. The surveyor entered resident room [ROOM NUMBER] with CNA #1 and asked to see wipes that were used to clean the Hoyer lift. The CNA #1 went through Resident #75's nightstand drawer looking for wipes and closed it without locating any wipes. CNA #1 then picked up a package of aloe hand cleansing wipes that were on top of a dresser in the room and said, I used these. The surveyor asked if they killed bacteria and if they were the wipes used to clean equipment and CNA #1 repeated, this is what I used, I used these. On 10/30/20 at 12:10 PM, the surveyor interviewed the unit Licensed Practical Nurse (LPN) regarding the process for cleaning Hoyer lifts between resident use. The LPN told the surveyor that Hoyer lifts were cleaned prior to going into a resident room. When the staff were finished using them, they could either clean it at the resident's room doorway or in the hallway. The LPN told the surveyor the Purple wipes (bleach wipes) that were stored in the blood pressure cuff machine were the wipes that were used to clean the Hoyer lifts. The surveyor asked if aloe hand wipes were used and the LPN said No. On 10/30/20 at 12:19 PM, the surveyor interviewed the Unit Manager/Registered Nurse (UM/RN) regarding the cleaning of the Hoyer lifts. The UM/RN said that Hoyer lifts were cleaned before and after each resident use. The UM/RN told the surveyor they needed to be cleaned before going in the room and then cleaned again either by the resident's doorway or in the hallway. The surveyor reviewed the medical record for Resident #75. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/29/20, reflected a Brief Interview for Mental Status (BIMS) could not be completed for the resident due to severe cognitive impairment. A further review of the MDS in Section G. Functional Status, reflected that the resident was a two plus person physical assist for bed mobility and transfers. The surveyor reviewed the medical record for Resident #95. A review of the most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 0 out of 0 which indicated severe cognitive impairment. A further review of the MDS in Section G. Functional Status, reflected that the resident was a two-person physical assist for bed mobility and transfers. On 11/15/20 at 10:45 AM, the surveyor interviewed the Director of Nursing (DON) regarding the cleaning of reusable resident equipment. The DON told the surveyor that any reusable equipment that goes from resident to resident would be cleaned both before use and after use. The DON told the surveyor that bleach wipes were provided to the staff and readily available. A review of the facility's Cleaning and Disinfection of Resident-care items and Equipment policy dated revised date of November 2019. The policy included under section #1, d. that reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, blood pressure cuffs, pulse oximeter, glucometer, point of care devices and other durable medical equipment). The policy also included under number 3, that durable medical equipment must be cleaned and disinfected before reuse by another resident. NJAC 8:39-19.4

Based on staff and resident interviews, it was determined that the facility failed to develop a process for notifying residents, their representatives and families by 5 PM the next calendar day each time a confirmed COVID-19 test result is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. The deficiency occurred during the COVID-19 pandemic. This deficient practice was evidenced by the following: An interview was completed with the Director of Nurses (DON) on 06/26/2020 at 7:20 PM. The DON was questioned about reporting COVID-19 related changes to residents and families. She said, For notifying residents and families, we report according to the timeline. On 06/26/2020 at 7:25 PM, a review of a provided document titled, Outbreak Response Plan, revised 6/19/2020, was completed. Under Communication, step 6 noted, Family and Residents communication according to timeline. There was no guidance on what the time frames were or what was to be reported. An interview was completed with the facility Administrator on 06/26/2020 at 7:35 PM. He stated, The timeline is the executive order that came out. It says you have to report within 24 hours, if there is a positive case (of COVID-19). We don't have that written anywhere, it's the leadership's responsibility to know what that is. When asked to clarify, the Administrator said that all the executive order said was to report new cases within 24 hours. It was not part of the facility's process to notify residents, their representatives and families by 5 PM the next calendar day each time a confirmed COVID-19 test result is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. NJAC: 8:39-13.1 (c)

Based on observation, interview and record review, it was determined that the facility failed to perform a rehabilitation screen and conduct an interdisciplinary meeting to reevaluate fall prevention interventions for a resident who sustained a fall, in accordance with the facility's policy. This deficient practice was identified for 1 of 1 resident reviewed for falls (Resident #28) and was evidenced by the following: On 11/21/19 at 11:49 AM, the surveyor observed Resident #28 seated in the dining room in a wheelchair with blue padding on either side of the resident. The resident was pleasant and was receiving feeding assistance by staff. The surveyor noted the resident had a large area of purple and yellow bruising over the left upper eye and forehead (periorbital). Review of the Admission Record revealed that Resident #28 was re-admitted to the facility on [DATE] after hospitalization with [DIAGNOSES REDACTED]. The document also indicated that the resident also had [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 09/03/19, identified that Resident #28 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated that the resident was severely cognitively impaired. The MDS also included that the resident required extensive assistance of two persons for physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). Review of a Change of Condition SPN, dated 11/04/19 at 4:56 AM, written by Registered Nurse (RN) #1, detailed that Resident #28 had an unwitnessed fall and was found on the floor laying on his/her left side, by the bed. The resident was assessed and was found to have a raised area on the left forehead and complained of a headache. The physician was notified and the resident was transferred to the hospital at 5:00 AM. Review of a Nurse Note (NN), dated 11/04/19 at 7:00 AM, revealed that RN #1 indicated that a thorough report regarding Resident #28's fall was given to the Supervisor/Unit Manager and the possibility of replacing the resident's bed side rails was discussed. Further review of the record revealed that the resident returned to the facility from the emergency room status [REDACTED]. Review of a NN, dated 11/06/19 at 10:29 PM, written by RN #2, revealed that at approximately 8:10 PM, Resident #28 stated, Mummy, please help me! RN #2 entered the resident's room and observed the resident lying on the floor on his/her left side. The resident reportedly explained that he/she tried to pull the curtain and rolled out of bed and hit his/her head. The resident's mattress was noted to be lifted and displaced partially on the frame. On assessment, the resident had a left upper eye periorbital contusion with bruising (purple discoloration) which was documented as swollen and painful to very light touch. The physician was notified and the resident was sent to the emergency room for imaging at approximately 9:00 PM. Review of a NN, dated 11/12/19, the resident was discharged from the hospital and received at the facility at 10:15 PM on 11/11/19. The NN also revealed that an air mattress and floor mats were in place. On 11/22/19 at 9:09 AM, the surveyor observed Resident #28 lying in bed on an air mattress with the head of the bed elevated. The resident was accompanied by Certified Nursing Assistant (CNA) #1 who provided the resident with feeding assistance. CNA #1 stated that the resident was impulsive and forgetful and thought that he/she could still walk independently. CNA #1 further stated and demonstrated that approximately two weeks ago, the facility implemented a wedge cushion (a triangular shaped foam cushion) that was placed on the bed against the resident's left side to prevent leaning. The facility also implemented side rails on both sides of bed, bed pad alarm and cushioned fall mats which were placed on the floor on both sides of the resident's bed. She further stated that prior to the resident's recent falls, the resident had smaller side rails. On 11/22/19 at 9:18 AM, the surveyor interviewed RN #3, who stated that she always knew Resident #28 to be impulsive since she started working at the facility two years ago. RN #3 stated that the resident previously had half rails and a bed pad alarm in place for safety to prevent falls but noted that they were discontinued prior to the resident's recent falls due to state regulations. RN #3 further stated that once the half rails were removed the air mattress was applied to the bed. On 11/25/19 at 9:28 AM, the surveyor interviewed the Social Worker (SW) who stated that Social Work was involved with care planning for falls. She further stated that since she began working at the facility in (MONTH) 2019, Resident #28 had a low bed, a fall mat on the right side of the bed, and both bed and chair alarms. The SW stated that the facility previously used half rails but struggled with them as they could be used as a restraint. She further stated that the facility was looking into alternatives that would give the resident something to hold onto. She did not believe that any interventions were discontinued. The SW concluded by stating that some families wanted side rails, but she wasn't sure about Resident #28's family. On 11/25/19 at 9:39 AM, the surveyor interviewed the Unit Manager (UM) who stated that on 11/04/19, Resident #28 slid off the bed and onto the left side and that was how the resident, got bruised up. She stated that the bed was in the low position and frequent room observations were in place. The UM further stated that a fall mat was not used on the left side of the resident's bed and that was why the resident had so much bruising. The UM explained that the resident's side rails and bed pad alarm were removed from the resident's bed not too long before the resident's first fall on 11/04/19 but was unsure of the exact date. The UM stated that a bed pad alarm may have alerted staff prior to the resident's second fall on 11/06/19, as the resident pulled the curtain and fell off the bed onto the left side. The UM added that both quarter rails and a bed pad alarm were added after Resident #28's second fall. The UM further stated that the facility policy mandated that at the time of a resident fall the assigned nurse and the supervisor discussed what was in place and how it happened, and the following day, the Interdisciplinary Team which consisted of the UM, Rehabilitation Department Head, Director of Nursing (DON) and Assistant Director of Nursing would meet to discuss the fall. The UM stated, after the first fall on 11/04/19, the DON may have met with Resident #28's family, but wasn't sure. The UM further stated that after the second fall the DON and the doctor met with the resident's family at the bedside. On 11/25/19 at 11:33 AM, in the presence of the survey team, the surveyor interviewed the DON who stated that on 11/11/19 both she and the physician met with the Resident #28's family to discuss interventions and goals of care. At that time, it was decided that resident would be removed from hospice care (end of life care) and opted for palliative care (relief of pain). The DON stated that side rails and a bed pad alarm were recently discontinued prior to both of the resident's recent falls on 11/04/19 and 11/06/19. The DON did not offer that once the side rails and bed alarm were discontinued prior to the first fall, that additional interventions were implemented in place of the side rails and bed pad alarm. The DON stated that on 11/06/19, Resident #28 rolled out of bed after he/she attempted to pull the curtain and that she realized after a Mock Survey was completed at the facility, a few weeks ago, that the facility was supposed to conduct an Interdisciplinary (IDT) Meeting immediately after a fall. The DON confirmed that an IDT meeting was not held after Resident #28's first fall on 11/04/19 but was completed after the second fall occurred on 11/06/19. On 11/25/19 at 11:54 AM, the surveyor met with the Rehabilitation Director (RD), who identified herself as an Occupational Therapist. The RD stated Resident #28 had a weak trunk and leaned to both the left and right and had cushions in place in the wheelchair to prevent leaning. The RD stated the facility had Risk Management Software that alerted therapy of falls and a post fall meeting would then be held to discuss interventions. The RD stated that she learned of Resident #28's fall on 11/04/19. She stated she did not assess the resident, but on 11/05/19, she recommended a positioning wedge which was provided to the resident on 11/12/19. Review of the resident's Care Plan (CP) revealed the resident was at risk for falls with a goal to be free from falls and injuries. The CP interventions included, but was not limited to: a. Keep bed in lowest position, low bed, initiated on 02/21/18. b. Staff to check on resident frequently, initiated on 02/28/18, revised on 11/12/19, and resolved on 11/12/19. c. Floor mat to both sides of the bed when the resident was in bed initiated on 11/06/19. d. Side rails applied to both sides of bed, initiated on 11/06/19. e. Bed alarm and chair alarm, initiated on 02/21/18, revised on 03/01/18, and resolved on 03/01/18. The bed alarm was dated at re-initiated on 11/12/19. f. Positioning wedge while in bed, initiated on 11/18/19. On 11/25/19 at 1:08 PM, the surveyor interviewed the Director of Social Work who stated she was not involved in a post fall meeting to discuss the falls that Resident #28 sustained and stated that was something that the facility planned to do going forward. On 11/26/19 at 9:23 AM, in the presence of the survey team, the surveyor interviewed the DON who stated on 11/04/19, Resident #28 slid out of bed onto the floor and was sent to the emergency room for an evaluation, and returned hours later. The DON stated it was decided that pillows would be placed on the side of the resident to prevent falls from bed. This intervention was not documented within the medical record. The DON stated that per facility policy a resident was supposed to be referred to therapy immediately following a fall. The DON could not speak to why therapy was not consulted after Resident #28's fall on 11/04/19. The DON stated that the facility realized that they needed to look at their interventions and care plans related to falls. The surveyor reviewed the facility policy, ACCIDENT/INCIDENT POLICY (Revised (MONTH) 1, (YEAR)) which revealed the following procedures for fall accidents: A comprehensive care plan for the resident at risk will be developed to include relevant environmental and resident risk factors, measurable goals, and person-centered interventions that may include needs for supervision and/or assistive devices as appropriate. The interdisciplinary team will review resident (elder) and/or representative preferences by considering the impact of these choices on individual well-being, other residents, and on the Home's obligation to protect resident (elders) from harm to develop a care plan in which staff honors the choice while mitigating risks. Interdisciplinary team members will conduct a systematic review of the event to eliminate or reduce the incidence of further falls. The interdisciplinary team will review and modify resident(s) elder(s) care plan interventions as indicated based on the findings of the systematic review. Post fall management may include interventions such as changes in the resident's (elder's) medications, environmental modifications, and/or additional staff training. A rehabilitation screen will be conducted after a fall to screen for the need for therapy to improve gait and balance. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to consistently complete ongoing records of communication between the facility and the [MEDICAL TREATMENT] center for 1 of 1 residents reviewed for [MEDICAL TREATMENT] (Resident #88). This deficient practice was evidenced by the following: 1. According to record review, Resident #88 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#88 received [MEDICAL TREATMENT] services three days per week at an offsite [MEDICAL TREATMENT] center. On 11/26/18 at 9:33 AM, the surveyor interviewed Resident #88 who stated that he/she went for [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday. The resident stated that he/she went to [MEDICAL TREATMENT] in the morning and returned to the facility after lunch. On 11/27/18 at 10:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the resident's [MEDICAL TREATMENT] schedule. The LPN stated that the resident went for [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday with a [MEDICAL TREATMENT] chair time of 10:00 AM. The surveyor questioned the LPN about how the facility communicated with the [MEDICAL TREATMENT] center and the LPN stated the facility used a communication form titled, [MEDICAL TREATMENT] Communication Record. The LPN further stated, The facility completed the top section of the form and sent the form to the [MEDICAL TREATMENT] center and the [MEDICAL TREATMENT] center filled out the second section of the form and returned the form with the resident. The bottom of the form was signed by the receiving nurse when the resident returned. The signature from the receiving nurse indicated that the form was returned and reviewed. The form was stored in the resident's [MEDICAL TREATMENT] binder. If the [MEDICAL TREATMENT] communication form was not completed on return, the facility would call the [MEDICAL TREATMENT] center to follow up and type the information into the progress notes. At that time, in the presence of the LPN, the surveyor reviewed Resident #88's [MEDICAL TREATMENT] Communication Records (DCR) completed on each [MEDICAL TREATMENT] day for the months of September, (MONTH) and (MONTH) (YEAR). The surveyor noted that the top portion of the DCR was completed by the facility nurse, the bottom portion of the DCR was to be completed by the [MEDICAL TREATMENT] nurse then returned with the resident to the facility, and the signature at the bottom of the DCR was to be completed by the facility on the residents return from [MEDICAL TREATMENT]. The surveyor noted the following omissions on the DCR: On 9/1/18, 9/4/18, 9/6/18, 9/8/18, 9/11/18, 9/13/18, 9/15/18, 9/18/18, 9/20/18, 9/22/18, 9/25/18, 9/27/18, 9/29/18, 10/2/18, 10/4/18, 10/6/18, 10/9/18, 10/11/18, 10/13/18, 10/16/18, 10/18/18, 10/20/18, 10/23/18, 10/25/18, 10/27/18, 10/30/18, 11/1/18, 11/3/18, 11/6/18, 11/8/18, 11/10/18, 11/13/18, 11/15/18, 11/17/18, and 11/20/18, the DCRs revealed the facility nurse did not entirely complete the top portion of the forms including, Room, Access Site, Access Condition- Palpable Thrill, +Bruit and Dressing, Diet, Time of Last Meal, Packaged Meal Sent With Resident, Residents General Condition, and Special Instructions. On 9/1/18, 9/4/18, 9/6/18, 9/8/18, 9/11/18, 9/13/18, 9/15/18, 9/18/18, 9/20/18, 9/22/18, 9/25/18, 9/27/18, 9/29/18, 10/2/18, 10/4/18, 10/6/18, 10/9/18, 10/11/18, 10/16/18, 10/18/18, 10/20/18, 10/23/18, 10/25/18, 10/27/18, 10/30/18, 11/1/18, 11/3/18, 11/6/18, 11/8/18, 11/10/18, 11/13/18, 11/15/18, 11/17/18, 11/20/18, and 11/24/18, the DCRs revealed the [MEDICAL TREATMENT] nurse did not entirely complete the bottom portion of the forms including, Pre Weight, Lab Work Done, Access Condition- Palpable Thrill, +Bruit and Dressing, Medications Given, Residents General Condition Post [MEDICAL TREATMENT], Intake and Output, and Change in Condition/Special Instructions. The 9/15/18 DCR revealed that the receiving nurse did not complete the PMC (Parker McCarrick) Nurse Acknowledging/Reviewing Post [MEDICAL TREATMENT] Communication Form signature portion of the form. On 11/27/18 at 11:23 AM, The Unit Manager (UM) acknowledged that some of the DCRs for Resident #88 were incomplete. The UM stated she would expect the nurse to call the [MEDICAL TREATMENT] center and the nurse should document the conversation with the [MEDICAL TREATMENT] center nurse in the nurse progress notes. The surveyor requested documentation for the dates of the incomplete DCRs. The UM was unable to locate further documentation or assessments related to incomplete [MEDICAL TREATMENT] forms on those dates. On 11/28/18 at 8:34 AM, the Director of Nursing (DON) confirmed the omissions on the DCRs and stated that she expected that the sheet (DCR) should be completed in its entirety. On 11/28/18 at 10:20 AM, the surveyor reviewed the resident's medical record including the interdisciplinary progress notes from September, (MONTH) and (MONTH) (YEAR). The record revealed there was no documentation of follow-up calls made to the [MEDICAL TREATMENT] center regarding incomplete information on the DCRs. The surveyor also reviewed the facility's policy titled, Receiving [MEDICAL TREATMENT], with an approved date of 6/25/18, that was provided by the DON. Under the procedure section, it revealed, Prior to leaving the facility to receive [MEDICAL TREATMENT] treatments, the nursing staff will complete the [MEDICAL TREATMENT] Communication Form. The policy also revealed,(NAME)at McCarrick will review the [MEDICAL TREATMENT] Communication Form upon return. NJAC 8:39 - 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently maintain an accounting of controlled medications stored in the facility's automated medication dispensing system (AMDS) located in the first-floor medication storage room. This deficient practice was identified on 64 of 89 days reviewed and was evidenced by the following: On 11/29/18 at 9:30 AM, the Registered Nurse/Unit manager (RN/UM) informed the surveyor that the facility utilized an AMDS for controlled and emergency medications for all residents. On that same day and time, the RN/UM stated that the facility performed an End of Shift Count of controlled medications (controlled medication reconciliation in the AMDS on a daily basis. The RN/UM stated that this is done once a day on the 3 PM-11 PM shift with the day shift charge nurse and the evening nursing supervisor. The RN/UM further stated, that the controlled medication reconciliation report (AMDS Inventory) was printed on a daily basis and stapled in the staffing notebook located at the nursing station and/or in the staffing office as their standard of practice. At that time, the RN/UM provided the surveyor with the staffing notebook for the first floor labeled Nov.12 3-11. The RN/UM stated that the notebook was the staffing schedule from (MONTH) 12, (YEAR) 3 PM-11 PM shift onward. The notebook revealed a daily staffing schedule for both nurses and Certified Nursing Assistants. The surveyor further observed printed AMDS Inventory sheets dated 11/12/18, 11/18/18, and 11/26/18 stapled to the notebook. On 11/29/18 at 12:33 PM, the surveyor interviewed the Charge Nurse (CN) of the First Floor unit. The CN stated that she routinely counted the controlled medication in the AMDS with the evening supervisor. A printed report was generated and she stapled it in the staffing notebook. The CN stated that the count was being done routinely on a daily basis. The CN stated that there were occasions where the AMDS did not produce a printed report and that she reported it to the supervisor. The CN added that she did not document the concerns elsewhere. On 11/30/18 at 8:53 AM, the DON presented the printed copy of the Omni Inventory report sheets for the month of September, October, and (MONTH) (YEAR) to the surveyor. The reports revealed that the printed daily controlled substances report sheets had not been done on the following dates: 09/01/18, 09/02/18, 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/07/18, 09/08/18, 09/09/18, 09/10/18, 09/11/18, 09/12/18, 09/13/18, 09/15/18, 09/16/18, 09/17/18, 09/18/18, 09/22/18, 09/24/18, 09/25/18, 09/26/18, 09/28/18, 09/29/18, 09/30/18, 10/02/18, 10/04/18, 10/06/18, 10/07/18, 10/09/18, 10/11/18, 10/12/18, 10/13/18, 10/17/18, 10/20/18, 10/21/18, 10/24/18, 10/25/18, 10/26/18, 10/30/18, 10/31/18, 11/01/18, 11/02/18, 11/03/18, 11/04/18, 11/05/18, 11/06/18, 11/07/18, 11/08/18, 11/09/18, 11/10/18, 11/11/18, 11/13/18, 11/14/18, 11/15/18, 11/16/18, 11/19/18, 11/20/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/27/18, and 11/28/18 At that time, the DON stated that she recognized the reports were not being done on a daily basis and that the expectation was to have the nurses complete the narcotic count, print the report from the ADMS and attach it to the notebook to account for any discrepancy. On 11/30/18 at 9:06 AM, the Administrator informed the surveyors in the presence of the DON that no one consistently monitored the controlled medication notebook for compliance. A review of the facility's undated policy on Controlled Substance Storage revealed 5. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed personnel and is documented. NJAC 8:39-29.4 (k)

Based on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe, consistent manner designed to prevent foodborne illness. This deficient practice was evidenced by the following: On 11/26/18 from 7:32 AM to 8:00 AM, the surveyor observed the following in the kitchen: 1. The surveyor interviewed the Food Service Worker (FSW) #1 at the dish machine who indicated that the dish machine specifications for adequate sanitization was a minimum wash water temperature of 160 degrees Fahrenheit (F) and a minimum rinse water temperature of 180 degrees F. On 11/26/18, the surveyor observed multiple dish machine cycles between 7:45 AM and 7:53 AM. The final rinse temperature gauge reached 162 degrees F. When interviewed, at that time, FSW#1 confirmed the dish machine was not reaching the proper temperature for adequate sanitation, turned off the dish machine, and notified the Cook. FSW#1 stated if the dish machine does not reach required temperatures, they are to, Notify supervisors who contacts maintenance. At that point, the surveyor reviewed the(NAME)Dishmachine Log (PDL) dated 11/25/2018-12/1/2018 with FSW#1. FSW#1 stated that based on the Wash and Final Rinse temperatures recorded at 7:00 PM on Sunday, 11/25/18, (the previous evening) by FSW#2, a supervisor should have been notified. The surveyor reviewed the PDL which reflected a wash temperature of 150 degrees F and a final rinse temperature of 170 degrees F. On 11/26/18 at 7:58 AM, the surveyor interviewed the Lead Cook (LC) who stated if the dish machine was not reaching the proper temperatures, maintenance should have been notified. On 11/26/18 at 11:50 AM, the surveyor interviewed FSW#2, who documented the wash and final rinse temperatures on the PDL on Sunday at 7:00 PM. The FSW #2 stated she checked the temperature of the dish machine and recorded them on the PDL after the dishes were completed. FSW#2 further stated that she forgot to document the temperature at the time when the dishes were being completed. On 11/26/18 at 11:55 AM, the surveyor reviewed the PDL's for the month of (MONTH) in the presence of the Dining Captain (DC), who was the acting manager for 11/25/18 Sunday evening shift. The DC stated, I was not told that there was a concern regarding the dish machine (last night). My job is to replace the (weekly) PDL on the weekend and to make sure all the blanks are filled in. If the machine is not the right temp, I contact maintenance after I troubleshoot. I'll notify them via Email. I should sign the bottom of the PDL's indicating I reviewed them; but I missed it. On 11/26/18 at 11:58 AM, the Food Service Director (FSD) stated maintenance was to be notified of concerns in the kitchen at the time of the concern via word of mouth. The FSD further revealed that PDL temperatures should be documented on prior to washing dishes. If the dish machine was not reaching the recommended temperature, the supervisor should notify maintenance and dishes should be run through after the temperature was made correct. The FSD indicated the LC or DC were responsible for monitoring and signing off the weekly log. The surveyor reviewed the PDL for the month of (MONTH) with the FSD. The PDL revealed low temperatures for 23 of the 44 logging opportunities. The FSD was not able to provide documentation which showed Maintenance was notified and the temperature was corrected prior to using the dish machine. The PDL further revealed that the supervisor failed to sign the dish machine log for 3 of 3 opportunities on the weekly PDL. On 11/27/18 at 12:26 PM, the Administrator confirmed that the temperatures for the wash should be 150 degrees F and the final rinse should be 180 degrees F. He further confirmed that he was not able to locate documentation regarding the dish machine not reaching temperatures on the dates indicated on the PDL. On 11/29/18 from 9:35 AM to 9:54 AM, the surveyor, accompanied by the Director of Support Services (DSS), observed the following in the kitchen: 2. A box of plastic spoons, a box of plastic forks, and a box of plastic knives were stored on a multi-tiered cart near the milk refrigerator. The boxes were uncovered exposing the contents inside. When interviewed, the DSS confirmed the surveyor's finding and stated that the boxes should have been covered. 3. A black plastic container containing forks was stored on a multi-tiered cart near the milk refrigerator. The forks were uncovered and exposed. When interviewed, the DSS confirmed the surveyor's findings and stated that the forks should have been covered. 4. In the walk-in freezer, a box of glazed carrots and a box of southern style chicken was stored directly on the floor. When interviewed, the DSS stated that the boxes were not supposed to be store directly on the floor of the walk-in freezer. 5. In the walk-in freezer, a bag contacting raw chicken, dated 11/27/18, was stored on a shelf. The surveyor observed the bag ripped and with the inside contents exposed. 6. The dish machine was in use for the breakfast meal clean up. The surveyor observed the Food Service Worker (FSW) remove a rack containing cups. The surveyor observed the cups in the upright position and filled with cloudy water. At which time, the DSS instructed the FSW to invert all the cups in the rack and run the rack through the dish machine for a second wash/rinse cycle. 7. The three-compartment sink was in use for the breakfast clean up. The surveyor observed multiple kitchen utensils partially submerged in the sanitizing liquid. When interviewed, the DSS confirmed the surveyor's findings and stated the kitchen utensils should have been completely submerged for proper sanitation. The surveyor reviewed the facility's Dishwashing policy with an updated date of 11/27/18, provided by the Food Service Director (FSD). The policy indicated Wash temperatures must be 150 degrees (F) or higher. Rinse temperatures must be 180 degrees (F) or higher. The policy further indicated that if the temperatures were not in the proper range to notify the supervisor. The policy also revealed the guidelines that should be followed when loading dish racks. The policy indicated that cups and glasses should be inverted. The surveyor also reviewed the dish machine manufacturer's (K-86 Series) recommendations with an updated date of 7-14, provided by the FSD. The manufacturer's water specifications indicated the minimum water temperatures for the wash tank was 150 degrees Fahrenheit and 180 degrees Fahrenheit for the final rinse. The surveyor reviewed the facility's Dry Storage policy with the effective date of (MONTH) 1, (YEAR), provided by the Administrator. The policy reflected all items must be in intact, closed containers. The surveyor reviewed the facility's undated Freezer Storage policy, provided by the Administrator. The policy revealed that all items must be at least six inches off the floor in the walk-in freezer. The policy further revealed no items were to be stored directly on the floor. NJAC 8:39-17.2(g)

Based on observation, interview and record review it was determined that the facility failed to a. prepare a clean surface for wound treatment supplies and b. demonstrate proper handwashing technique during a wound treatment. This deficient practice was identified for Resident #3, 1 of 5 residents reviewed for wound treatments, as evidenced by the following: On 8/21/17 at 10:25 a.m. during the initial tour of the facility, the Licensed Practical Nurse (LPN) told the surveyor that Resident #3 had an intact eschar (black scab) wound to the right ankle. On 8/23/17 at 9:30 a.m. at the resident's bedside, the surveyor observed the LPN perform a physician-ordered treatment to the resident's right ankle. The nurse donned gloves and laid out a chux pad (an absorbent disposable pad covered on 1 side with blue plastic) on the overbed table for a clean field. The nurse then placed all treatment supplies on the chux. The surveyor observed that the LPN did not clean the overbed table prior to setting up the wound treatment supplies. After the LPN set up the supplies on the overbed table, the surveyor observed the LPN wash her hands. The LPN wet her hands, applied soap to her hands and washed her hands with all of the friction under water for approximately 20 seconds. At 9:30 a.m. on the above date, the LPN told the surveyor that she should have wiped the over bed table surface with soap and water prior to setting up the supplies. The LPN further stated that she should wash her hands under running water for 20 seconds. At 12:15 p.m. the surveyor reviewed the undated facility policy for Hand Hygiene. The policy revealed that Hand hygiene is recognized as the most preventable measure to help reduce the spread of health-care associated infections. The policy further revealed that staff should follow the handwashing Procedure to wet hands under running water, using plenty of soap, work up a good lather and scrub hands and then rinse under running water. The surveyor further reviewed the undated facility policy titled Dressing Change. The policy revealed that staff should Place supplies at designated bedside table which has already been cleaned/prepped for use. NJAC 8:39-19.4 (a)

Based on observation, interview, and record review, it was determined that the facility failed to promote a resident's self worth and self esteem. This deficient practice was found for 1 of 23 residents (Resident #5) reviewed. The deficient practice was evidenced by the following: On 4/22/15 at 10:05 a.m. during a tour of the unit with the staff nurse, the surveyor observed Resident # 5 in bed in the resident's room with white socks covering both hands. On 4/23/15 the surveyor observed the resident between 9:10 a.m. and 12:10 p.m. in bed in the resident's room with white socks covering both hands. At 12:13 p.m. the surveyor observed the resident seated in the wheelchair the hallway across the nurse station with white socks covering both hands. Throughout the day, the surveyor observed that while the resident wore the socks, Resident #5 was able to pick things up and was not restrained from doing activities of daily living. At 1:50 p.m. the surveyor interviewed the staff nurse and asked about the resident being in the hallway with the socks on both right and left hands. The staff nurse said the resident goes into the hallway across the nurse station so staff can monitor the resident and so that staff/guests can greet the resident as well. The staff nurse said the resident wears the socks at all times, except for care, to prevent scratching. The surveyor asked if the use of socks to cover the resident's hands was appropriate, and the staff nurse said the resident had a doctor's order for the socks. On 4/24/15 at 9:05 a.m. the surveyor reviewed the resident's records. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the April 2015 Physicians Order Sheet (POS) indicated an order dated 2/18/15 to "Apply socks to hands to prevent scratching. Maintain at all times except for hygiene." A review of the Annual Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] indicated the resident's cognitive skills for daily decision making as being severely impaired. At 9:15 a.m. the surveyor observed the resident in bed and not wearing the socks. The surveyor reviewed the resident's physician's orders [REDACTED]. NJAC 8:39-4.1(a)12

Based on observation, interview and record review, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 3 of 23 residents (# 9, # 1, & # 4) reviewed. The deficient practice was evidenced by the following: 1. On 4/22/15 at 11:30 a.m., the surveyor reviewed the records of Resident # 9. The resident was admitted to the facility on [DATE] and readmitted on [DATE]. The surveyor reviewed the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE] which revealed a discrepancy with accuracy of the resident's height. A review of Resident #9's height on the Annual MDS dated [DATE] indicated the resident as being 71 inches tall and a review of the height on the Quarterly MDS dated [DATE] indicated the resident being 64 inches tall. 2. On 4/24/15 at 12:55 p.m., the surveyor reviewed the records of Resident # 1. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A reviewed the Admission MDS dated [DATE] and the Quarterly MDS dated [DATE] revealed a discrepancy with accuracy of coding for Hearing, Speech, and Vision; Cognitive Patterns; Mood; and Height. On the Admission MDS dated [DATE], the facility assessed the resident as being able to "Usually Makes Self Understood" and being able to "Usually Understand Others." On the Quarterly MDS dated [DATE], the facility assessed the resident as being able to "Sometimes Makes Self Understood" and being able to "Usually Understand Others." This area of assessment would be a key factor in determining if the resident interviews should be conducted. The surveyor observed that the facility assessed the resident under Cognitive status as being "rarely/never understood" and the resident Brief Interview for Mental Status (BIMS) interview was not attempted. A review of the Mood assessment indicated again that the resident was "rarely/never understood" and therefore, the resident mood interview was not attempted. A review of the Height on the Admission assessment dated [DATE] indicated the resident being 64 inches tall and a review of the Height on the Quarterly assessment dated [DATE] indicated the resident being 06 inches tall. On 4/28/15 at 10 a.m., the surveyor interviewed the MDS coordinator regarding the coding discrepancies on the MDS. The MDS coordinator said the interviews should have been attempted for the BIMS and Mood sections and coded 99 if the resident was unable to answer the questions. The MDS coordinator also said that the Height discrepancies were errors. 3. On 4/23/15 at 9:30 a.m. the surveyor reviewed the records of Resident #4. The resident was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. The surveyor reviewed the Annual MDS dated [DATE] and Quarterly MDS dated [DATE] that revealed a discrepancy with accuracy of coding for Hearing, Speech and Vision; Cognitive Patterns; and Mood. The facility assessed the resident as being able to "Sometimes Makes Self Understood" and being able to "Sometimes Understand Others." This area of assessment would be a key factor in determining if resident interviews should be conducted. The surveyor observed that the facility assessed the resident under Cognitive status on the Annual MDS as being "rarely/never understood" and the interview for the BIMS was not attempted. A review of the Mood assessment indicated again that the resident was "rarely/never understood" and therefore, the resident mood interview was not attempted. A review of the Quarterly MDS dated [DATE] revealed that the resident was assessed as being able to "Sometimes Makes Self Understood" and being able to "Sometimes Understand Others" and the BIMS interview was attempted However, the Mood assessment indicated that the resident was "rarely/never understood" and therefore, the resident mood interview was not attempted. On 4/28/15 at 10:10 a.m. the surveyor spoke to the Social Worker who said she was responsible for BIMS and Mood interviews and was not aware of the discrepancy. NJAC 8:39-11.2(e)1

Based on observation, interview and record review, it was determined that the facility failed to adjust the medication schedule to coordinate with a resident's [MEDICAL TREATMENT] schedule for 1 of 2 residents (#17) reviewed. The deficient practice was evidenced by the following: On 4/22/15 at 10:40 a.m. the surveyor observed the resident seated in the wheelchair on the unit. The staff nurse told the surveyor that the resident goes to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. She said the resident was picked up around 10:30 a.m. and returned between 4:30 p.m. - 5 p.m. On 4/28/15 at 10:45 a.m. the surveyor reviewed the records of Resident #17. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]." A review of the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. The medication nurse documented "LOA" (leave of absence), which indicated the resident was not present to administer the medication. At 11:35 a.m. the surveyor spoke to the medication nurse and the acting charge nurse (ACN) about the resident's medication schedule while the resident was out to [MEDICAL TREATMENT]. The medication nurse said she does not administer the medication and usually puts "LOA" in the MAR. The ACN said medications are always adjusted around a resident's [MEDICAL TREATMENT] schedule. NJAC 8:39-27.1(a)

Based on record review and interviews, it was determined that the facility did not ensure the legibility of physician handwriting for 2 of 12 resident records (Resident #5 and #16) reviewed for medication use and accuracy and was evidenced by the following: On 3/26/14 at 1 p.m. the surveyor reviewed the medical record for Resident #5 with regard to the use of an antipsychotic medication. The surveyor asked a staff nurse to read the consultations from the Psychiatrist regarding the medication. The five consultations dated 5/8/13, 6/5/13, 6/19/13, 9/25/13 and 1/8/14 were not legible to the staff nurse or the Registered Nurse Clinical Coordinator (RNCC). The surveyor interviewed the Director of Nursing (DON) on 3/26/14 at approximately 1:30 p.m. who also could not read the handwriting. The DON stated the facility previously discussed his handwriting with him many times before and "..he does okay for a while then goes back to writing illegibly." The RNCC faxed the five consults to the Psychiatrist's office on 3/26/14 and on 3/27/14 at 9 a.m., the RNCC provided the team with the five consults that were rewritten legibly by the doctor. The surveyor reviewed the medical record for Resident #16 on 3/27/14 at 1:35 p.m. The surveyor asked the nurse to read four Psychiatrist's consults dated 4/16/12, 10/23/13, 2/5/14 and 3/19/14. The nurse could not read the consults. The RNCC called the Psychiatrist's office again to get clarification of what was written on the consults. NJAC 8:39-16(g)

Based on observation, interview and review of medical record, it was determined that the facility failed to provide physician ordered Ted Stockings for Resident #2 and physician ordered skin protection devices for Resident #13, 2 of 21 residents reviewed for professional standards of practice. The facility also failed to sign the record to indicate medications were administered during the Medication Pass Observation on 3/27/14. This was identified for 2 of 2 nurses observed and was evidenced by the following: 1. During the medication pass on 3/27/14 at 9:36 a.m. the surveyor observed a nurse administer [MEDICATION NAME] 125 milligrams (mg) to Resident #23. Surveyor review of the Medication Administration Record [REDACTED]. 2. On 3/27/14 at 10:42 a.m. the surveyor reviewed the MAR for Resident #23 which indicated that the medication nurse had not signed the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. According to surveyor interview with a 1st floor Charge Nurse, the medication Nurse should have signed the MAR indicated [REDACTED]. N.J.A.C. 8:39 11.2 3. Resident #13 had a physician's orders [REDACTED].#13 on 3/26/14 at 9:36 a.m. and again at 11 a.m. in the day room without the Ted Stocking on. At 12:05 p.m.,the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for the resident and asked about the Ted Stockings. The CNA told the surveyor that she was not aware that Resident #13 had order for Ted Stocking. The surveyor reviewed the Treatment Administration record at 12:50 p.m. and noted that it had been signed as if the Ted Stocking was applied. 4. The surveyor reviewed the medical record for Resident #2 and noted that the resident had a physician's orders [REDACTED]. On 3/26/14 at 11 a.m. and at 12 noon, the surveyor observed Resident #2 in the day room without the skin sleeves. The surveyor asked a nurse who was in the day room to show the skin sleeves. The nurse went to Resident #2 and lifted both sleeves and told the surveyor that the sleeves were not on the resident. The nurse then went to the residents room and obtained the skin sleeves. Upon review of the TAR at 12:50 p.m., the surveyor noted that it had been signed as though the skin sleeves were applied. During interview with the facility administration on 3/31/14 at 10:30 a.m. The Director of Nursing told the surveyor that the Ted Stocking was not the CNA's care plan and that they had added it. 5. During medication pass observation on 3/26 at 9:45 a.m., the surveyor observed the medication nurse, a Licensed Practical Nurse (LPN), administer medications to Resident #13. The nurse then went to another resident and administered medications to that residents without signing for the medications she administered to Resident #13. When the surveyor asked about this, she stated that she forgot and went on to sign the MAR.

Based on observation, interview and the review of medical record, it was determined that the facility failed to attempt gradual dose reduction for a psychoactive medication which was ordered to be used before morning care. This deficient practice was identified for Resident #13, 1 of 5 resident reviewed for medication regime and was evidenced by the following: During the initial unit tour on 3/25/14, the Registered Nurse (RN) Unit Manager (RN/UM) told the surveyor that Resident #13 was confused, had agitation during care and received antianxiety medication prior to care. On 3/26/ at 9:36 a.m., the surveyor observed Resident #13 in the day room seated in a wheelchair with eyes closed during an activity program. The surveyor reviewed the medical record on the same day. This indicated that Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. Upon review of the physician's orders [REDACTED].#13 had a physician's orders [REDACTED]. The Surveyor reviewed the Medication Administration Record [REDACTED]. This indicated that Resident #13 was taking [MEDICATION NAME] for the [DIAGNOSES REDACTED]. At 12:05 p.m., the surveyor interviewed the Certified Nursing Assistant (CNA ) who cared for the resident. The CNA told the surveyor that she took care of Resident #13 on a full-time basis from October 2013 to January 2014. She stated that she was working part-time now with Resident #13 and that the resident was "nice" but upset at times for being in a nursing home and "doesn't like it." The CNA also told the surveyor that she usually provided morning care for the resident between 7:15 to 7:30 a.m. and didn't usually have a problem getting the resident up for morning care. On 3/27/14 at 11:22 a.m., the surveyor interviewed the resident's current CNA. She told the surveyor that she had been taking care of Resident #13 since January 2014 and that the resident was "sometimes nice and sometimes forcy," and curses at her. The CNA also stated that Resident #13 could be "nice or forcy" during the course of day when approached for care. The CNA added that she was usually able to talk to the resident and get the resident to allow for care to be provided. At 11:40 a.m., the surveyor interviewed the medication nurse. She told the surveyor that Resident #13 "can be combative especially during care, tries to curse and hit and sometimes angry at family" for putting him/her in a nursing home. The surveyor asked if the resident had this behavior daily, the nurse replied "no." When the surveyor asked why the resident received this medication on a routine basis without behavior, the nurse stated that it was dependent on the Psychiatrist's recommendation. At 12:25 p.m. the surveyor interviewed the RN unit manager. She told the surveyor that Resident #13's behavior was continuing and that was why they gave him/her [MEDICATION NAME] prior to care. She also stated that they did dose reduction every six months. There was no evidence of dose reduction since the medication was started, thirteen months ago. And no evidence that the facility attempted to provide morning care without the use of this medication. The surveyor reviewed the facility's Psych-pharm Drug policy dated 3/1/04. This indicated that facility would titrate psychoactive medication twice within a twelve month period. NJAC 8:39-27.1(a)

Based on observations on 5/7/13 in the presence of facility management, it was determined that the facility failed to store cylinders of compressed gas in a safe manner. This deficient practice was evidenced by the following: At 11:05 a.m., the surveyor observed that there was an H-tank of compressed Helium gas in the 2nd floor activities office that was not secured to prevent from tipping and rupture. Although there was a safety chain provided, it was not in use to secure the tank. NJAC 8:39-31.2(e) NFPA 99

Based on interview and record review it was determined that the facility failed to develop a plan of care based on individual assessment for residents with behaviors and pressure ulcers. This deficient practice was identified in 5 of 12 residents, Resident # 1, #8, #16, #18 and #19 as evidenced by the following: 1. On 3/22/12 at 9:30 a.m. the surveyor reviewed the medical record of Resident # 8 which revealed the following: The resident was admitted to the facility with [DIAGNOSES REDACTED]. An Interdisciplinary Progress (IDP) note of 3/19/12 revealed that the resident developed a stage II left buttock pressure ulcer which measured .5 centimeters round. Review of the 6/11 care plan identified the, "potential for pressure ulcer" related to incontinence, more sedentary, poor po intake, and a history of diabetes. Some of the identified interventions included; "weekly skin assessment, toilet q 2 h while awake, encourage adequate caloric intake, protein, and encourage ambulation." There was no documented evidence that the care plan addressed the pressure ulcer on the resident's left buttock. On 3/22/12 at 10 a.m. the surveyor along with the nurse observed the resident's skin. A stage II left buttock pressure ulcer was noted which measured .3 cm x .4 cm. On 3/22/12 at 10:30 a.m. the nurse stated that care plans were to be initiated when a problem was identified. She stated that this had not been done for the resident. 2. On 3/22/12 at 11:30 a.m. the surveyor reviewed the medical record for Resident # 19 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the IDP notes from 11/3/11 to 3/8/12 revealed the following behaviors: On 11/3/11 (11-7 shift) "The resident attempted to leave the building 2 times this morning around 6 a.m., he was brought back to the unit after he tried to hit the nurse. On 3-11 shift, the same day,".. the resident exhibited exiting seeking behavior to the elevator." On 12/20/11 "(The resident) continues to make remarks of a paranoid nature, always feels he is doing something wrong; (he/she) worries excessively about missing appointments." A 12/22/11 "Psych" note indicated that (he/she) had [MEDICAL CONDITION] about being in the navy and that homosexuals were trying to kill (him.) On 1/9/12 and 1/13/12 the resident wanted the police to be notified because (he/she) stated that someone was in his room stealing (his/her) things. On 2/6/12 the resident stated that, "people are banging on his door, knocking on (his/her) door and have orders to get (him/her.) Resident very concerned." On 3/5/12 at 10 a.m. "attempted to leave the building at front door- easily redirected." On 3/6/12 at 3:15 p.m. Resident #19 accused another resident of stealing (his/her) watch and (he/she) punched the other resident on the back. The watch was found in Resident #19's laundry hamper. On 3/8/12 (11-7 shift) the resident attempted to elope 2 times. Review of the 3/2/12 care plan identified the problem "Potential to wander out of building related to dementia, memory loss, disorientation." Some of the interventions included "place wanderguard on ankle; check placement of ankle alarm; hourly rounds; photo ID at front desk and redirect away from exit." The care plan was initiated 4 months after the elopement behavior had been identified. The care plan failed to address the resident's paranoid and delusional behaviors and there were no interventions identified to manage these behaviors. On 3/22/12 at 1:00 p.m. the Director of Nursing stated that care plans were to be initiated when problems were identified. She stated that it was the responsibility of the Interdisciplinary Team and not just one individual to initate and update the residents' care plans. 3. On 3/22/12 at 10:00 a.m. the surveyor reviewed the medical record of Resident #16 which revealed the following: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/22/12 at 12:30 p.m. the Unit Manager (UM) stated that the resident demonstrated behaviors of despondency, tearfulness, and repeatedly verbalized that (she/he) wanted to go home. She said the behaviors escalated later in the day due to sundowning syndrome. The UM stated that the resident was very anxious and cried inconsolably and was unable to be redirected. Review of the IDP (Interdisciplinary Progress) notes from 4/11 to 3/12 revealed the following behaviors: On 4/4/11 "anxiety and restlessness, tense expression, attempting to get up from the wheelchair." On 5/26/11 "resident with sun down is depressed and has [MEDICAL CONDITION]." On 6/14/11 "anxiety at sun downing, becomes restless." On 8/3/11 "tearful mid-afternoon, seeks family, difficult to redirect, needs to be supervised." On 9/27/11 "wants to go home, does not like to participate in large groups. Behaviors worsen at mid-afternoon, not easily directed." On 3/9/12 "increased agitation with crying." Review of the 2/16/11 care plan identified the problem "can be tearful misses family." Some of the identified interventions included: "escort to off unit activities, keep introducing her to staff and peers; Compliment her appearance; verbalize appreciation of her smile, nice clothing; and Call by name, approach with a smile and calm demeanor." The care plan did not address the resident's sundowning behaviors and there were no interventions identified to manage these behaviors. On 3/23/12 at 1:00 p.m., the surveyor interviewed the Director of Nursing (DON) who confirmed that the care plan failed to identify the resident's behaviors and there were no interventions identified to manage them. 5. On 3/21/12 at 10:00 a.m., the surveyor reviewed the medical record of Resident #1 which revealed the following: Resident #1 was admitted to the facility 7/6/05 with multiple medical [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress (IDP) notes revealed numerous behaviors of yelling and cursing at the staff and fell ow residents during care and at mealtimes as documented by the following: On 1/8/12 at 9 p.m., the resident was noted to be cursing at the Certified Nursing Assistant (CNA) during incontinent care. On 2/10/12 (7-3 shift) frequently noted throughout the shift, behaviors of yelling and cursing at the staff and fell ow residents during care and at mealtimes. On 2/13/12 9 p.m., the resident was verbally abusive during care, cursing and calling the CNA names. On 2/15/12 (7-3 shift) the resident was verbally abusive to staff during AM care, yelling and cursing at the CNA while being washed. On 2/15/12 (3-11 shift) the resident denied the need to receive care from others yelling at everyone to "Get out of here b----" On 2/16/12 the resident continued with verbal abuse to staff during care, spitting and trying to bite staff when teeth were being cleaned. On 2/18/12, 2/19/12, 2/21/12, 2/22/12 and 2/24/12 the resident was verbally abusive to staff during care. Review of the physician's orders [REDACTED]. Review of the Care Plan (CP) identified the resident's use of Psychoactive drugs for treatment of [REDACTED]. There were no target behaviors identified, interventions developed or goals to be met included in the CP. 6. On 3/22/12 at 10:00 a.m., the surveyor reviewed the medical record of Resident #18 which revealed the following: Resident #18 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Review of the Interdisciplinary Progress (IDP) notes revealed numerous behaviors of agitation, confusion, hallucinations and resisting care as documented by the following: On 12/8/11 (7-3 shift) resident was very agitated, screaming and yelling at the staff, refused snacks, stated "Just let me die." On 12/27/11 at 12 a.m. the resident attempted to get out of bed, complained of difficulty breathing but refused oxygen. The 1/20/12 Quarterly Summary revealed that the resident had frequent periods of increased confusion and agitation. On 1/20/12 at 12 a.m. the resident was confused, hallucinating, yelling and cursing. On 2/2/12 (11-7 shift) the resident was talking to herself, saying that there were dogs in the room and she did not want to live there anymore. On 2/11/12 "Everything is going upside down." On 2/16/12, 2/17/12 and 2/18/12 notations made of yelling and hallucinations. Review of the Care Plan (CP) identified the resident's use of Psychoactive drugs for treatment of [REDACTED]. The CP identified the side effects of the drug, to monitor the effectiveness of medications and write monthly nurses notes to evaluate the effects of the medication. There were no target behaviors identified, interventions developed or goals to be met included in the CP. During an interview on 2/23/12 at 9:30 a.m., the Director of Nursing (DON) confirmed that the residents' behaviors were not addressed on the care plan and there were no interventions identified to prevent recurrence. NJAC 8:39-11.2(e)2

Based on observation, interview and record review it was determined that the facility failed to attempt dosage reduction and/or to provide current evidence of contraindication for dosage reduction in the absence of behaviors. This deficient practice was identified in 1 of 11 residents, Resident #9 as evidenced by the following: Resident #9 was admitted from the hospital to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During the initial tour of the facility with the Unit Manager (UM) on 3/19/12 at 6:30 p.m, the UM stated that Resident #9 displayed behaviors of yelling, being "feisty" and received the antipsychotic medication-[MEDICATION NAME]. The UM also stated that the resident's daughter was actively involved in his/her care. The surveyor observed the resident on several occasions throughout the survey and there were no behaviors displayed at that time. On 3/21/12 at 9:45 a.m. the surveyor reviewed the medical record of Resident #9 which revealed the following: On 3/10/2011, 8/10/2011 and 1/17/2012 the Pharmacy Consultant had indicated, "per CMS guidelines, for residents receiving [MEDICATION NAME], a gradual dose reduction MUST be attempted in two separate quarters (with at least one month between the attempts), unless the clinical rationale has been documented in your progress notes." Each recommendation was signed by the doctor or Advanced Practice Nurse (APN) as accepted with a corresponding progress note which stated that taper trials of [MEDICATION NAME] in the past had failed. On 3/22/12 at 9:40 a.m. the Director of Nursing (DON) stated that Resident #9 was admitted to the facility on [DATE] on [MEDICATION NAME] 12.5 mg three times a day. The resident was hosptalized on [DATE] and returned to the facility on [DATE] and was no longer on [MEDICATION NAME]. The hospital had not continued the [MEDICATION NAME] for unknown reasons. The DON stated that behaviors of increased irritability and uncooperativeness returned and the resident was placed back on [MEDICATION NAME] 12.5 mg three times a day on 11/1/10. On 5/16/11 the Progress Notes indicated that Resident # 9 had increased irritability, was verbally abusive and more difficult to redirect. The DON stated that the [MEDICATION NAME] was increased on 5/25/11 to 25 mg at 8 a.m. and 8 p.m. and 12.5 mg at 2 p.m. During an interview on 3/21/12 the resident's daughter stated that Resident # 9 was combative at home and was placed on [MEDICATION NAME] for behaviors of resisting care. She further stated that the resident had been functioning much better at the facility. During an interview on 3/22/12 at 10:20 a.m. the APN stated that since the increase of [MEDICATION NAME] in May 2011, the resident has had some behaviors but none that were upsetting. She further stated that they" wouldn't rock the boat" and would leave the resident on it. The APN stated that the daughter had been educated about the black box warning prior to coming to this facility. The APN also stated that no further attempt at Gradual Dose Reduction (GDR) had been trialed since May. The failed attempt for GDR stated in the Progress Notes referred to the time the resident had returned from the hospital in October 2010 and was not placed on [MEDICATION NAME]. On 3/23/12 at 10:20 a.m. the DON and the UM were unable to provide documentation of discussions with Resident #9's daughter regarding the black box warning for [MEDICATION NAME] or attempting a GDR. They stated that the only discussion with the resident's daughter was in May 2011 when the dosage of the [MEDICATION NAME] had been increased. NJAC 8:39-27.1(a)