Every finding on record at Preakness Healthcare Center

Based on interviews and review of pertinent facility documents on 01/08/26, it was determined that the facility failed to provide the necessary care to ensure freedom from accidents to a resident (Resident #1) who required two person assistance for care and transfers resulting in the resident sustaining a fractured finger and multiple skin lacerations requiring stitches. This deficient practice was identified for 1 of 5 residents surveyed.This deficient practice was evidenced by the following: The surveyor reviewed the hybrid [paper and electronic] medical record of Resident #1. A review of Resident #1's admission Face Sheet Record (AFSR), an admission record summary, indicated the resident was admitted to the facility with the following diagnoses which included but were not limited to rheumatoid arthritis, fibromyalgia [chronic condition causing body pain], muscle weakness, neurocognitive disorder [condition causing decline in mental function], and hypertension. A review of the facility's Investigatory Summary Report and Conclusion (ISC) revealed that according to the Minimum Data Set (MDS), an assessment tool, dated 06/7/25, the resident had a Brief Interview of Mental Status (BIMS) score of 99 indicating Resident #1 was severely cognitively impaired. The ISC indicated under Summary of Incident revealed that on August 31, 2025 at approximately 8:00 AM Certified Nursing Assistant (CNA) #1 informed Registered Nurse (RN) #1 that the resident had a skin tear on the finger on their right hand. Upon assessment, RN #1 noted a 2 cm x 0.5 cm [centimeter] skin tear on the right hand with a small amount of bleeding and a laceration on the pinky finger measuring 1.4 cm x 0.5 cm with a small amount of bleeding. RN #1 cleaned the sites and applied sterile gauze reinforced with tape. The Assistant Nursing Supervisor (ANS) was notified and came to the unit at approximately 10 AM. Orders were received from the physician and the resident was sent out to the ER for further evaluation. The resident returned to the facility at 10:25 PM on 8/31/25 with their hand splinted and discharge instructions for laceration of finger and finger fracture. A review of the ISC under Investigation revealed the ANS interviewed CNA #1 and confirmed that they provided care to the resident alone and that CNA #2 had only assisted with the mechanical lift transfer. Under Conclusion, the ISC revealed that Resident #1 returned from ER with four stitches and a fracture of indeterminate (unknown) age to the fourth metatarsal [finger]. The ISC further stated that the resident had a physician's order for care by two staff and this was noted on the CNA Direct Caregiver Form (CF) and on the CNA assignments (CA) that the resident required care by two staff. When interviewed, CNA #1 stated that they were aware Resident #1 required two staff for care. A review of Resident #1's Physician's Order Form (POF) with a review date of 09/2025 revealed the following physician orders:Under Other Orders, Direct Care, a PO dated 07/12/2023, 2 Person Assist at all Times for SafetyUnder Other Orders, Restorative Nursing, a PO dated 05/13/2025, Mechanical Lift Transfers with 2 Person Assist for Safety using a Large Sling Pad. A review of Resident #1's CNA Direct Caregiver Form (CF), revealed the following: Direct Care, 2 person assist at all times for safety, dated 7/12/23, with a notation of FYIDirect Care, acknowledgement and understanding of all FYI's per shift dated 1/24 23. The 8/31/25, 7-3 shift box was not initialled.A review of the CA dated 8/31/25 for the 7:00 AM-3:00 PM shift revealed Resident #1 listed with the codes (HL) and (X2A) next to their name. Under the section CODES was listed Mechanical Lift Large-HL and Assist x2 - X2A. Resident #1 was included in CNA assignment #4 which was assigned to CNA #1. On 01/08/26 at 11:47 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who was the regular nurse on the unit. LPN #1 stated that CA reflected the resident care assignment (RCA) and that the nurses were the ones making the assignment. LPN#1 further stated on the CA, Resident #1 was a two person assist in care and HL for transfer, indicating the resident was a mechanical lift transfer which required a two person assist as well. LPN #1 said in the morning, before the start of the shift, the nurses make the assignment for the CNAs and endorsed this to the CNAs.On 01/08/26 at 1:26 PM, the surveyor interviewed Resident #1's regular CNA #3. CNA #3 stated stated Resident #1 was total care and required two person assistance during care and mechanical lift transfers [bed to chair/chair to bed]. CNA #3 said this was documented in the CF. CNA #3 further stated they receive regular education on care and transfers, like mechanical lifts, every year and as needed. On 01/08/26 at 4:34 PM, the surveyor interviewed the LNHA and the ADON. The LNHA stated CNA #1 stated they knew the resident was a two person assist for care but CNA #1 believed they could take care of the resident by themself. The LNHA further stated CNA #1 was in-serviced and had competency evaluation with a focus on two CNAs for care. A review of the facility's General Policy on Commitment to Care: Accountability Standards for Nurses and CNAs last revised 01/21/25, revealed under Scope: This policy applies to all licensed nurses (Registered Nurses [RNs], Licensed Practical Nurses [LPNs] and Certified Nursing Assistants [CNAs]) employed by the facility. Under Statement revealed: Each member is responsible for their actions, decisions, and the quality of care provided to the residents. Under Policy Guidelines, 2. Accountability for CNAs revealed, Resident Care, Personal Care Assistance: Provide residents with assistance in activities of daily living (ADLs) such as bathing, dressing, eating, and mobility .Resident Safety: Ensure the safety of residents by maintaining a clean and hazard-free environment and following infection control protocols. Team Collaboration, Support for Nurses: Assist nurses by carrying out delegated tasks efficiently and within the scope of practice.N.J.A.C 8:39-11.2(b)

Based on interviews, review of medical records, and review of pertinent documentation provided by the facility on 05/02/2025, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse and follow the facility's Resident Abuse policy. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for abuse and was evidenced by the following: A Facility Reported Event (FRE), a document used to report incidents, submitted to the New Jersey Department of Health (NJDOH) by the facility's Director of Nursing (DON) on 04/15/2025 was reviewed. The FRE revealed that on 04/15/2025 at 4:20 P.M., the facility's Executive Director (ED) listened to a voice message left by Resident #2 at 6:29 A.M., the same day. The voice message was described in the FRE as follows: [She/He] stated that [Certified Nursing Assistant (CNA) #1] beat the living hell out of [her/him], she is vicious and dangerous. Review of the facility's INVESTIGATORY SUMMARY AND CONCLUSION, written by the facility's DON about the allegation made by Resident #2 against CNA #1 was conducted. Under Investigation: the facility report revealed that the DON conducted interviews with Resident #2 and a resident that she/he was friendly with. Further review of the facility report revealed that interviews were conducted with CNA #1 and the Registered Nurse assigned to Resident #2 on day shift of 04/14/2025. The report contained no documentation that additional staff or resident interviews were conducted. Review of the admission Record (AR) revealed that Resident #2 was admitted to the facility with diagnoses that included but were not limited to: bladder neck obstruction (blockage that slows or stops urine flow out of the bladder), delusional disorder (condition in which a person cannot tell what is real from what is imagined), dysthymic disorder (mild, long-lasting form of depression that affects mood, body, and thoughts), and unspecified cord compression (pressure on the spinal cord, causing pain, numbness, weakness, and other problems). A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident's cognition was intact. During an interview on 05/02/2025 at 10:45 A.M., Resident #2 stated that she/he left a voice message for the ED in April, approximately two weeks ago. The resident stated that she/he left the voice message to let the ED know that staff was rough, and that her/his body was fragile. The resident further stated that she/he called to complain specifically about care received from CNA #1 on 04/14/2025. During an interview on 05/02/2025 at 12:04 P.M., CNA #1 stated that on 04/14/2025 she performed care for Resident #1, and she/he did not make any complaints. CNA #1 stated that on 04/15/2025 the DON called and informed her not to come to work for the overtime she was scheduled for on 04/16/2025. CNA #1 stated that on 04/18/2025 she provided a written statement about the incident to the facility's DON. CNA #1 stated that on 04/19/2025 she returned to the facility and received education related to abuse, resident rights, and transferring. During an interview on 05/02/2025 at 12:55 P.M., Resident #1 (who was cared for by CNA #1 on 04/14/2025) stated that she/he did not recall being interviewed recently by facility staff about rough treatment. During an interview on 05/02/2025 at 1:00 P.M an unsampled resident (who was cared for by CNA #1 on 04/14/2025) stated that no facility staff had interviewed her/him about rough treatment by staff in the last few weeks. During an interview on 05/02/2025 at 2:07 P.M., CNA #2 confirmed that he worked in the facility's 1-300 unit on day shift on 04/14/2025. CNA #2 stated that he had not given any statements or been interviewed about the incident on 04/14/2025 involving Resident #2 and CNA #1. During an interview on 05/02/2025 at 2:13 P.M., CNA #3 confirmed that she has worked in the facility's 1-300 unit regularly on day shift for approximately the last month. CNA #3 stated that she was not interviewed or asked to provide any statements about the incident on 04/14/2025 involving Resident #2 and CNA #1. During an interview on 05/02/2025 at 2:52 P.M., CNA #4 confirmed that she has worked in the facility's 1-300 unit on day shift routinely. CNA #4 stated that she was not asked to provide any statements or interviews about the incident on 04/14/2025 involving Resident #2 and CNA #1. During an interview on 05/02/2025 at 2:25 P.M., the DON stated that his investigation of the 04/14/2025 allegation by Resident #2 included an interview and statement from the nurse who cared for Resident #2 when the alleged incident occurred. The DON stated that his investigation also included interviews with CNA #1 and Resident #2. The DON stated that other residents were interviewed about the care they received from CNA #1 but a statement was documented from only one of those residents. The DON further stated that Resident #1 was the only resident in CNA #1's assignment that was assessed after the alleged rough treatment on 04/14/2025. During a follow-up interview on 05/02/2025 at 3:08 P.M., the DON stated that not following the facility's abuse policy could result in an abuser not being identified. The DON further stated that this could impact the mental and physical health of residents in every way. During an interview on 05/02/2025 at 3:19 P.M., The ED stated that she became aware of Resident #2's allegation against CNA #1 on 04/15/2025 at 4:20 P.M. The ED stated that an investigation of the allegation was started right away. During the same interview, the ED explained the expectations for investigation of an abuse allegation. The ED explained that statements should be taken from alert, verbal residents in the CNA's assignment. The ED stated that it was important to check the condition of non-interviewable residents in the CNA's assignment to ensure that there was not a bigger issue. The ED stated that this was not done. During a follow-up interview on 05/02/2025 at 5:07 P.M., the DON stated that he did not have documentation of any other interviews or statements from other residents in CNA #1's assignment on 04/14/2025. The DON further stated that he did not have documentation of statements from staff members, other than a nurse, who worked with CNA #1 on 04/14/2025. Review of the facility's policy Resident Abuse with a last reviewed date of 9/26/23, under DEFINITIONS: on page 1 revealed, Allegation- Is defined as a statement or a gesture made by someone (regardless of capacity or decision making ability) that indicates that abuse, neglect, exploitation or misappropriation of resident property may have occurred, and requires a thorough investigation to substantiate that it did or did not occur. The same facility policy revealed on page 6 under E. Investigation, Preakness Healthcare Center will investigate all incidents with injuries of unknown origin and all alleged violations. Allegations of abuse must be investigated by a professional, and, if applicable, in the primary language of the resident. The reports will include: [ .] f. Written statements from the resident (if able), possible suspect, eye witnesses and any circumstantial witnesses. [ .] h. any other information which may be helpful in the investigation as well as the protection of the resident. N.J.A.C. 8:39- 4.1 (a) (5)

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/15/25 at 9:24 AM, the surveyor in the presence of the Dietary Supervisor (DS#1) and the Registered Dietitian (RD) observed the following during the kitchen tour: 1. The surveyor observed in the dry storage room: a dented can of sliced potatoes in the regular rotation of non-dented canned goods; 3 boxes stored above 18 inches (in) from the ceiling, and the following items were observed opened without an open/use by label: one 3 pound (lb.) bag of tri-color pasta, 1 gallon container of white vinegar, one 32 oz (ounces) bottle of imitation vanilla, one 32 oz bottle of green food coloring, three 16 oz containers of chili powder, one 16oz container of ground thyme, one 16 oz container of Italian seasoning, one 16 oz container of oregano, one 16 oz container of sage, and one 32 oz bottle of egg yellow food coloring. Neither the DS#1 or RD could explain why the dented can was not placed in the dented can area or why the opened items had not been labeled with an open/use by labels. 2. The surveyor observed a four-shelf bread storage rack located outside the dry storage room with four opened bags of bread without an open/use by labels. The breads that were observed were: 1 bag of white bread, 2 bags of wheat bread, and 1 bag of rye bread. DS#1 stated the bags of bread should have been labeled once they were opened. 3. The surveyor observed in the combined walk-in refrigerator and freezer #1. The combined walk-in refrigerator fans was observed with a black colored debris on the fan cover and freezer #1 had multiple boxes stored above 18 in from the ceiling. 4. The surveyor observed in the combined walk-in refrigerator and freezer #2. Freezer #2 had multiple boxes stored above 18 in from the ceiling. 5. The surveyor observed the combined walk-in refrigerator and freezer #4. The combined walk-in refrigerator had 3 boxes stored above 18in from the ceiling. 6. The surveyor observed the cooking area with a double stacked steamer and a 3 standing dual ovens, all had a sticky brown colored substance on the top on the cooking equipment. DS#1 could not provide information when the equipment was last cleaned. On 1/16/25 at 10:52 AM, in the presence of the Dietary Supervisor #2 (DS#2) observed the following during the follow up kitchen tour: 7. The surveyor observed DS#2 and the Chef both wearing a large hooped earrings. The surveyor asked DS#2 and the Chef about dress code for the kitchen regarding jewelry. DS#2 stated the earrings that both DS#2 and the Chef were wearing were not allowed in the kitchen. 8. The surveyor observed the Chef checked the temperature of the pork chop without sanitizing the thermometer prior to use. The Chef stated they had sanitized the thermometer earlier but acknowledged once the thermometer was set down on the counter, the thermometer was considered contaminated and should be sanitized prior to use. On 1/17/25 at 12:09 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Assistant Director of Nursing (ADON) to review kitchen observation concerns. On 1/21/25 at 12:20 PM, LHNA provided the surveyor with multiple facility policies for the kitchen. A review of the Dented Cans policy with a revised date of 1/20/25, stated under the procedure section, 4. If any dented cans are observed, they will be deposited in a crate which will be labeled dented cans only, and Do Not Use. A review of the Spices policy with a revised date of 1/20/25, stated under the procedures section, 2. Once opened the spice container with be dated, closed, wiped cleaned, and place back on the shelf. 3. No more than one spice of the same kind will be opened and placed back on the shelf. A review of the Food Storage policy with a revised date on 1/20/25, stated under the procedure section on the policy, 5. Store food away from the walls and at least six inches off the floor and at a height of 18 or below the ceiling line. This applies to storage in storerooms, freezers, walk-in boxes/refrigeration. A review of the Large Kitchen Equipment Cleaning and Handling policy stated under the procedure section, Ovens, 4. Wipe down the outside of then oven with a clean washcloth wrung out with a detergent solution. Rinse and wipe dry. Refrigerator, 2. At least once a month or as needed, dust off compressor, condenser, coiled, motor and related areas. A review of the Dress Code for Food Service Workers policy with a revised date of 1/20/25, stated under the procedure section, Jewelry, [NAME] jewelry is not permitted except for a plain ring. Employees with pierced ears may wear small post earrings. A revie of the Food Thermometer Sanitization policy with a revised date of 1/21/25, stated under the procedure section, 1. Prior to thermometer use, ensure it is clean and free from any debris. Sanitize using an alcohol prep pad or an approved food-safe sanitizer. On 1/22/25 at 12:30 PM, the survey team met with the LNHA, DON, and ADON. The facility did not provide any further information. NJAC 8:39-17.2(g)

Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure reference checks were completed for 10 out of 10 newly hired staff (Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) prior to their start date of employment. This deficient practice was evidenced by the following: The surveyor reviewed 10 randomly selected new employee files for reference checks for 10 of the 10 new employees revealed the following: A review of Staff #1's file, a Recreation Activity Aide (RA), date of hire (doh) on 10/30/23, showed there were no reference checks in their file. A review of Staff #2's file, a Licensed Practical Nurse (LPN), doh on 1/29/24, showed there were no reference checks in their file. A review of Staff #3's file, a Registered Dietician, doh on 5/28/24, showed there were no reference checks in their file. A review of Staff #4's file, a LPN doh on 5/28/24, showed there were no reference checks in their file. A review of Staff #5's file, a RA, doh on 6/3/24, showed there were no reference checks in their file. A review of Staff #6's file, an Occupational Therapist, doh on 6/26/24, showed there were no reference checks in their file. A review of Staff #7's file, a Maintenance staff, doh on 7/29/24, showed there were no reference checks in their file. A review of Staff #8's file, a Food Service Worker, doh on 10/28/24, showed there were no reference checks in their file. A review of Staff #9's file, a Registered Nurse, doh on 12/23/24, showed there were no reference checks in their file. A review of Staff #10's file, a Physical Therapist, doh on 12/23/24, showed there were no reference checks in their file. On 1/17/25 at 12:09 PM, the surveyor notified the Executive Director (also known as the Licensed Nursing Home Administrator [LNHA]), Director of Nursing (DON) and Assistant DON (ADON) of the concern that there was no documentation of reference checks being completed for 10 of the 10 new hire files. The surveyor asked who was responsible for new hire files. The LNHA stated the Human Resources (HR) department which was located off the facility campus. The surveyor requested the contact number to speak with HR staff and the policy for new hire screening including reference checks. The LNHA provided the contact number for HR. On 1/17/25 at 12:53 PM, the surveyor interviewed over the phone with an HR Secretary (HRS). The HRS stated that the beginning of last year, the person responsible left and she temporarily took over the responsibility. The HRS further explained another staff was currently responsible and was not in the office at the time. The HRS stated new hires would list references on their application. The surveyor asked if references were called as part of the new hire process. The HRS stated HR did not follow up with references, criminal background checks were done prior to employment, and references were listed on the application if needed. The HRS referred the surveyor to the LNHA regarding any policy for new hire screening for the facility. On 1/21/25 at 12:23 PM, the LNHA, the DON, and the ADON met with survey team. The LNHA stated there were no references for the new hires as per the HR department. The surveyor asked about policy for new hire screening, and the LNHA replied that the facility referred to their Abuse prevention policy for new hire screening protocol and there was no separate policy. A review of the facility's Abuse Policy indicated that at least one reference should be obtained. The LNHA confirmed that it was the facility policy and acknowledged it was not completed for the new hires. A review of the facility's Resident Abuse Policy, with a last reviewed date of 9/26/23, under Procedure for Screening revealed, .4. Obtain references (one) employment reference of prospective employees from previous and/or current employers . N.J.A.C. 8:39-9.3 (a), (b)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with the federal guidelines. This deficient practice was identified for 17 of 17 system selected residents, Resident #2, #12, #34, #38, #46, #48, #69, #70, #139, #166, #199, #205, #209, #220, #233, #267, and #271) and was evidenced by the following: On 1/21/25 at 9:09 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS assessment. The MDS was a comprehensive tool that was federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. After transmission of the MDS, a quality measure will be transmitted to enable a facility to monitor the residents decline or progress. On 1/16/25 at 10:21 AM, the surveyor provided the MDS Consultant (MDSC) with the list of seventeen (17) system-selected residents who had not completed an MDS in over 120 days. The surveyor also requested a copy of the resident's final validation report (a report that generates after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). On 1/21/25 at 10:05 AM, the surveyor interviewed the MDS Coordinator (MDS/C) who stated that she was a Registered Nurse (RN) who reviewed the MDS assessments before transmitting them. The MDS/C also stated there was an RN who signed and completed the MDS's. On 1/21/25 at 10:15 AM, the surveyor interviewed the MDS/C, who stated that she was aware it was submitted late. The MDS/C added that she tried to submit it at least once every week. The MDS/C further stated that they followed the RAI (Resident Assessment Instrument, a tool that helps gather information about a resident's strengths and needs, which is used to create an individualized care plan) Manual. The surveyor and the MDS/C reviewed the 17 residents MDS assessments that were not submitted within fourteen days of completion as follows: 1. Resident #205 had a comprehensive assessment with an assessment reference date (ARD) of 9/13/24, that was signed as completed on 9/20/24 and was not transmitted until 10/15/24. 2. Resident #209 had a comprehensive assessment with an ARD of 9/15/24, that was signed as completed on 9/20/24, and was not transmitted until 10/15/24. 3. Resident #2 had a comprehensive assessment with an ARD of 9/15/24, that was signed as completed on 9/20/24, and was not transmitted until 10/15/24. 4. Resident #48 had a comprehensive assessment with an ARD of 9/10/24 that was signed as completed on 9/17/24, and was not transmitted until 10/15/24. 5. Resident #271 had a comprehensive assessment with an ARD of 9/12/24, that was signed completed on 9/19/24, and was not transmitted until 10/15/24. 6. Resident #38 had a quarterly assessment with an ARD of 9/13/24, that was signed completed on 9/17/24, and was not transmitted until 10/15/24. 7. Resident #199 had a quarterly assessment with an ARD of 9/13/24, that was signed completed on 9/20/24, and was not transmitted until 10/15/24. 8. Resident #69 had a quarterly assessment with an ARD of 9/12/24, that was signed completed on 9/19/24, and was not transmitted until 10/15/24. 9. Resident #34 had a quarterly assessment with an ARD of 9/14/24, that was signed completed on 9/20/24, and was not transmitted until 10/15/24. 10. Resident #220 had a quarterly assessment with an ARD of 9/10/24, that was signed completed on 9/17/24, and was not transmitted until 10/15/24. 11. Resident #267 had a quarterly assessment with an ARD of 9/15/24, that was signed completed on 9/20/24, and was not transmitted until 10/15/24. 12. Resident #233 had a quarterly assessment with an ARD of 9/12/24, that was signed completed on 9/17/24, and was not transmitted until 10/15/24. 13. Resident #46 had a quarterly assessment with an ARD of 9/10/24, that was signed completed on 9/17/24, and was not transmitted until 10/15/24. 14. Resident #166 had a quarterly assessment with an ARD of 9/13/24, that was signed completed on 9/19/24, and was not transmitted until 10/15/24. 15. Resident #139 had a quarterly assessment with an ARD of 9/15/24, that was signed completed on 9/18/24, and was not transmitted until 10/15/24. 16. Resident #12 had a quarterly assessment with an ARD of 9/15/24, that was signed completed on 9/20/24, and was not submitted until 10/15/24. 17. Resident #70 had a quarterly assessment with an ARD of 9/15/24, that was signed completed on 9/19/24, and was not transmitted until 10/15/24. A review of the facility's MDS 3.0 Policy, with a review date of 6/22/23, did not address the transmission of MDS data. On 1/21/25 at 12:29 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), and Assistant DON regarding the above concern. There was no further information provided. NJAC 8:39-11.1

REPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more during the medication administration, 4 nurses administered medications to 5 residents. There were 25 opportunities for error, 2 errors were observed which calculated to a medication administration error rate of 8%. This deficient practice was identified for 2 of 5 residents, (Resident #55 and Resident #122), that were administered medications by 2 of 5 nurses that were observed. The 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. 1. On 1/17/25 at 8:40 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications (meds) for Resident #55. The meds included an active physician's orders (PO) for the Divalproex (a medication [med] used for seizures in a dose form that can be taken as a capsule or opened and the contents placed on food) 125 mg (milligram) sprinkle give 2 capsules (caps) orally twice daily (AM [morning]-HS [bedtime]) for dementia with behavior disturbance. The LPN stated that the resident needs their meds crushed and given with pudding or applesauce to aid in swallowing. The surveyor observed the LPN appropriately open the caps but empty them in a pouch used for crushing meds with other meds. The LPN then proceeded to crush the contents of the pouch, including the contents of the Divalproex caps. The surveyor asked the LPN to check the cautionary warning under the med order. The LPN stated that it said swallow whole or sprinkle capsule contents on small amount of food but thought it meant not to crush the whole capsule. The surveyor completed the med pass observation. On 1/17/25, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and the Assistant Director of Nursing (ADON) to discuss the concerns with the med pass that the contents of the capsule should not be crushed or chewed per the cautionary warning on the Resident #55's Medication Administration Record (MAR). On 1/21/25, the survey team met with the LNHA, DON and ADON for responses to concerns. The LNHA stated that the nurses in question were observed for med pass and 1 of 2 did not pass. The facility did not provide any further pertinent information. The surveyor reviewed the facility policy manual titled: Dept: Nursing, Subject: Pharmacy Services, Last review date 6/14/16. The manual revealed, under page 1, Policy: 2. Med administered is free of significant error rate of 5% or greater. Page 6 II. A. Med Administration. 7. Meds should not be crushed unless the manufacturer allows it to be crushed 37791 2. On 1/17/25 at 8:25 AM, during the med administration observation, the surveyor observed the Registered Nurse (RN) preparing to administer meds to Resident #122. The surveyor observed the resident's MAR which reflected an order for Senna-Plus 8.6-50 mg (a combination of Sennoside, a natural vegetable laxative and Docusate Sodium, a stool softener), give 1 tablet (tab) by mouth every 12 hours for constipation. The surveyor observed the RN prepare 1 tab of Senna 8.6 mg for Resident #122. The surveyor observed the RN looked at the Senna 8.6 mg bottle and pointed to the MAR and stated that the resident was supposed to get 8.6 mg of Senna and that she pulled the correct med. The surveyor continued to observe the RN enter Resident #122's room and just prior to administering the med asked the RN if she could step outside of the resident's room with the med. The RN reviewed the resident's MAR and acknowledged that the resident had an order for Senna-plus 8.6-50 mg. The surveyor observed the RN pull out of the med a bottle of Senna 8.6 mg and a bottle of Senna-Plus from the med cart. The RN compared the ingredients of both bottles with the MAR and stated that she should have prepared Senna-Plus for Resident #122 instead of Senna 8.6 mg. On 1/17/25 at 1:30 PM, the surveyor discussed the above concerns with the LNHA and the DON. No further information was provided. A review of the facility's Med Administration Policy, with a revision date of 2/2023, and was provided by the DON revealed the following: 3. Nurse reviews each resident's MAR to determine which meds need to be administered at the given time. The nurse observes the six rights in administering each med; a. The right resident b. The right time c. The right med d. The right dose e. The right route of administration f. documentation. N.J.A.C 8:39-29.2 (d)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the foley urinary catheter drainage bag was stored in a manner to prevent Urinary Tract Infection (UTI) for 1 of 4 residents, Resident #77, reviewed for urinary catheter or UTI. The deficient practice was evidenced by the following: On 1/17/25 at 9:08 AM, the surveyor observed Resident #77's urinary catheter drainage bag hung from the bed's side rail that was in the up position and not in a privacy bag. The tubing leading to the drainage bag was above the bed. On 1/17/25 at 9:09 AM, the surveyor interviewed the Registered Nurse (RN) after the RN also observed Resident #77's urinary catheter drainage bag. The RN stated that the drainage bag and tubing should be lowered. She added that when she had done rounds that morning the resident was sleeping and had not checked that side of the bed and that the Certified Nurses Aide (CNA) on the night shift probably placed it there after emptying it. The RN then lowered the urinary catheter drainage bag to the bar that was under the bed. A review of Resident #77's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), neuromuscular dysfunction of the bladder (a condition that causes bladder control problems due to nerve damage), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). A review of Resident #77's most recent comprehensive Minimum Data Set (MDS), an assessment tool, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident's cognition was intact. Further review indicated the resident had an indwelling catheter. A review of Resident #77's Physician Order Form included an order for suprapubic cath (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen) french #24 for neurogenic bladder (a condition where normal bladder function is disrupted due to nerve damage). On 1/17/25 at 12:12 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Assistant DON (ADON) the concern that Resident #77's urinary catheter bag was observed hanging from the siderail that was up on the bed and the tubing was above the bed. On 1/21/25 at 12:22 PM, in presence of the LNHA and ADON, the DON stated that the staff were inserviced about the catheter placement. The facility did not provide any additional information. A review of the facility's Indwelling Catheters Policy with a reviewed date of 5/2019, included the following: 8. Prevention of Catheter-related complications . B. CNA will secure the catheter to facilitate the flow of the urine and the bag is below the level of the bladder . N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life specifically by ensuring staff able to communicate with the resident in the language that the resident understood and preferred according to plan of care. This deficient practice was identified for 1 of 2 residents, Resident #158, reviewed for communication. This deficient practice was evidenced by the following: On 1/17/25 at 9:40 AM, the surveyor observed Resident #158 laying on an air mattress (a specialized mattress) and the resident spoke Spanish. The surveyor also observed that there was no communication board (alternative communication methods designed to overcome communication barriers) at the bedside and the resident's television (TV) was on the English Channel. On 1/17/25 at 9:56 AM, the Licensed Practical Nurse (LPN) asked the Certified Nursing Aide (CNA) to help her reposition Resident#158 for the surveyor to observe the dressing in the sacrum. Inside the resident's room, the surveyor observed the CNA and LPN were unable to communicate with the resident in Spanish for the resident to comply with positioning. Both the CNA and the LPN were unable to understand the resident's request to change the TV channel to Spanish. The LPN confirmed that the resident spoke Spanish, and that the resident should have a communication board in the room as the facility's practice in order to understand the resident and respond to the resident's needs. The LPN further stated that she would notify the Maintenance department to assist the resident to have a Spanish channel. On 1/17/25 at 10:14 AM, the surveyor notified the Registered Nurse Supervisor (RNS) regarding the above findings and concerns. Both the surveyor and the RNS went inside the resident's room. The RNS informed the surveyor that Resident #158 spoke Spanish and should have a Spanish communication board inside the room as per the facility's practice. She further stated that she was unsure why there was no communication board inside the room. On that same date and time, the surveyor observed the RNS had difficulty communicating with the resident. The RNS stated that she was unsure what channel the Spanish channel was. The surveyor observed the RNS changed the channels multiple times to find a Spanish channel. The surveyor reviewed the medical records of Resident #158 and revealed: A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar levels) and essential hypertension (cases of high blood pressure in which the cause is unknown). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 10/2/24, reflected in Section A Identification Information that the resident's preferred language was Spanish and that needed or wanted an interpreter to communicate with doctor or health care staff. Section C Cognitive Patterns reflected that the resident's cognitive skills for decision-making were coded 3 as severely impaired cognition. A review of the provided Plan of Care by the Director of Nursing (DON) reflected that the resident had difficulty communicating because the resident speaks and understands, was created and updated on 10/2/24. The interventions included: provide a communication book and provide a translator if needed, were created and updated on 10/2/24. A review of the facility's Resident's Rights Policy, with a review date of 1/30/18 that was provided by the DON reflected that it was the facility's policy to protect and promote the rights of each resident, particularly those rights that pertain to a dignified existence, self-determination, and communication with access to persons and services within and outside the facility. On 1/21/25 at 12:19 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant DON. The LNHA stated Resident #158 should have a communication board. N.J.A.C. 8:39-4.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that due to a shortage of staff, the facility failed to a.) honor the resident's shower schedule for 1 of 5 residents, Resident #141 and b.) ensure residents were provided morning care in a timely manner for 2 of 5 residents, Residents #141 and #213 of Resident Council group. This deficient practice was evidenced by the following: On 1/17/25 at 11:01 AM, the surveyor conducted a resident group meeting with five residents who were alert and oriented and were selected by the facility to attend the group meeting. Resident#141 informed the surveyor that two weeks ago, not this past Monday (1/13/25), the resident did not get showered. Resident #141 did not mention the name of the Certified Nursing Aide (CNA) who told them that it was because of the shortage of staff which was why the resident did not get a shower. On that same date and time, Resident #141 informed the surveyor that there were concerns with short staff that affected the timeliness of care and caused the resident to be late for the Christmas lunch meal. Resident #141 stated that on 12/25/24, 7:00 AM-3:00 PM (7 AM-3 PM) shift, there was one staff in each wing on the 1st floor. Resident #141 further stated that they notified the Licensed Nursing Home Administrator (LNHA) about the concerns at that time, and the LNHA did not say anything about it. At that same time, Resident #213 informed the surveyor that the facility needed more CNAs because it affected care. Resident #213 stated that this weekend (1/11/25 and 1/12/25), morning care was late in their unit, and that there was a total of four CNAs for the entire 3rd floor. A review of Resident #141's most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 10/6/24, revealed a brief interview for mental status (BIMS) score of 15 out of 15, and reflected that the resident's cognitive status was intact. A review of Resident #213's most recent quarterly MDS, with an ARD of 10/2/24, revealed a BIMS score of 15 out of 15. On 1/17/25 at 11:50 AM, the surveyor asked the Director of Nursing (DON) for the last two weeks' and 12/25/24 CNAs' assignments and the DON responded that he would get back to the surveyor. On 1/21/25 at 9:35 AM, the surveyor asked Secretary #1 (S#1) for the 1st-floor unit showers for the last 2 months, and she stated that she would get back to the surveyor. On 1/21/25 at 10:01 AM, the surveyor interviewed the 1st floor Registered Nurse (RN) about the shower, and the RN stated that showers were given once a week and that if the resident requested more than once a week, it would be provided. The RN provided the surveyor unit's shower book for January 2025. The surveyor asked for the December and November shower book, and the RN responded that she would get back to the surveyor. On 1/21/25 at 10:07 AM, S#2 informed the surveyor that a shower was provided once a week and as needed if requested for more showers according to the resident's care plan. S#2 also stated that the other months' showers were filed in the resident's medical records. Both the surveyor and S#2 reviewed the medical records and found that the weekly Body Inspection paper for November 2024 had the 3rd-week missing signatures while December 2024 had the 3rd and 4th-week missing signatures for both CNAs and Nurses. On that same date and time, S#2 informed the surveyor that the Weekly Body Inspection paper should have been signed by nurses and CNAs when showers or bed baths were provided or refused as indicated in the paper. She further stated that she had to get back to the surveyor as to why there was no signature to reflect that showers were provided on those dates. On 1/21/25 at 11:28 AM, the surveyor interviewed CNA#1 who stated that she was the aide on 12/23/24 assigned to Resident#141. The surveyor notified CNA#1 of the above findings and concern that on 12/23/24, Resident #141 did not get a shower, and there was no documented evidence that the shower was provided. CNA#1 responded that on 12/23/24, the shower was probably not provided due to short staff. A review of the provided Nursing Home Resident Care Staffing Report revealed: Monday, 12/23/24 for the Day Shift, 7 AM-3 PM, revealed a ratio of 1 CNA:9.6 Residents. Saturday, 1/11/25 for the Day Shift, 7 AM-3 PM, revealed a ratio of 1 CNA:8.7 Residents. Sunday, 1/12/25 for the Day Shift, 7 AM-3 PM, revealed a ratio of 1 CNA:10 Residents. A review of the 7 AM-3 PM Unit 1-200 schedule for the date 12/25/24 revealed that CNA#2 had a total of 11 residents including Resident #141. On 1/21/25 at 12:19 PM, the survey team met with the LNHA, DON, and Assistant DON (ADON), and the surveyor notified the above findings and concerns. On 1/22/25 at 11:08 AM, the survey team met with the LNHA, DON, and ADON. The DON stated, I don't have anything for that except that Resident #141 was offered a bed bath, and there was no evidence it was given. A review of the facility's Residents Showers Policy with a review date of 4/19/18 that was provided by the DON revealed: Policy: All residents will receive showers at least once per week in accordance with resident's preference unless the resident declines a shower. Procedures: 5. Weekly skin assessment will be done by a nurse in the shower room and with the help of the CNA. Findings will be documented by the nurse on the Weekly Body Inspection Form . On 1/22/25 at 1:15 PM, the survey team met with the LNHA, DON, and ADON for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-25.2(b)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 7 residents, Resident #43. The deficient practice was evidenced by the following: The surveyor reviewed Resident #43's medical record (MR) and revealed the following: A review of Resident #43's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to acute kidney failure, (when the kidneys are damaged and can't filter blood the way they should) and urinary tract infection. A review of Resident #43's Minimum Data Set (MDS), an assessment tool, dated 1/20/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #43 was cognitively intact. A review of the resident's list of medications (meds) reflected a Physician's order (PO) for Ondansetron 4 mg (milligram), 1 tablet (tab) orally every 6 hours as needed (PRN) for nausea or vomiting with a date of 12/6/2023, and a PO for Tigan injection 100 mg/ml (milliliter) inject 2 mls (200 mg) intramuscularly every 6 hours PRN for nausea or vomiting, with a date of 5/16/2024. Further review of the MR, revealed a Medication Regimen Reviews (MRR) from the facility's Consultant Pharmacist (CP). The MRR reflected a recommendation by the CP to the physician (MD) dated 12/17/24, to discontinue both meds due to not being used in over 60 days. The MR reflected that the MD indicated on the CP recommendation disagree. There was no reason given on the sheet by the MD which revealed dates of 1/8/25 by the Registered Nurse (RN) and 1/12/25, by the MD signature. On 1/17/25 at 12:09 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and the Assistant Director of Nursing (ADON) to discuss the concerns with the duplicate meds. On 1/17/25 at 1:23 PM, the surveyor interviewed the RN on the unit where the resident resided. The surveyor asked the RN how they would tell which of the meds that both PRN for nausea or vomiting to give if the resident was experiencing those symptoms. The RN stated that he knows the resident. The surveyor asked what would happen if they were not there, or other staff that were not familiar with the resident were on duty and the resident required medication (med). The RN stated they would have to call the MD to clarify, so it might not be right away. The surveyor asked if the treatment would end up being delayed. The RN stated, yes, it was possible it could be. On 1/21/25 at 12:03 PM, the surveyor met with the CP in person to discuss the concerns with duplicate meds, and the CP stated that they were aware of the concern as the facility had contacted them. The CP was able to provide to the surveyor, evidence, that the CP had recommended to the MD, dated 7/16/24, a request to indicate how the meds should be given, which to administer first or second. The MR did not reflect any response by the MD to that recommendation. On 1/21/25 at 12:19 PM, the survey team met with the LNHA, DON and ADON, and the DON stated that the CP was called and informed of the concern and the MD was called and discontinued (d/c) the Ondansetron order. The surveyor reviewed the resident's MR that reflected a telephone PO to d/c the Ondansetron, dated 1/17/25, after the surveyor's inquiry. A review of the facility's Department: Nursing, Subject: Pharmacy Services Policy, last review date 6/14/16, under page 1, Policy: number 11. Each drug regimen must be free of unnecessary drugs. Page 5, L. Sequencing Med Orders, 1. When a resident has 2 or more med orders with the same indication of use (i.e. pain, constipation, nausea/vomiting, cough, etc,) indicate on each med order the specific instruction of use. The facility did not provide any further pertinent information. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to follow standards of clinical practice to ensure, a.) a physician's order (PO) for a heel booties 2 of 2 residents, Residents #72 and #158, were followed, and b.) a PO to document weekly vital signs for 1 of 5 residents was followed, Resident #88, reviewed for unnecessary medications. This deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 wellbeing, and executing a 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. 1. On 1/16/25 at 10:00 AM and 12:15 PM, the surveyor observed the resident in bed, the resident's feet were offloaded and was not wearing their bilateral heel float booties. A review of the Admission Record (AR, an admission summary) for Resident #72, reflected that the resident was admitted to the facility with diagnoses which included but not limited to; Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremor), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and fracture of the lower left femur. A review of the January 2025 Physician's Order Form revealed a PO, dated 5/19/24, for heel float booties on at all times. A review of the January 2025 Treatment Administration Record (TAR) reflected that the above PO for heel float bootties were transcribed and signed by nurses. The TAR revealed that a nurse signed that the resident was wearing their heel float booties on 1/16/25 during the 7am-3PM shift. On 1/16/25 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who acknowledge that the resident was not wearing their heel float booties. LPN#1 also stated that the resident was supposed to always wear their heel float booties due to issues with the resident's legs and according to the PO. On 1/17/25 at 1:30 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). A review of the facility's Pressure Injury Prevention and Management Policy that was provided by the DON, with a revision date 8/2020, which revealed the following: Under section F. Pressure Injury Preventive Devices; Float Gel Booties, good to prevent pressure injury on heels. Recommended for stage I, stage II and residents with high Braden scale (a validated tool designed to assess a patient's risk of developing pressure ulcers). Under Pressure Injury Documentation: d). Document resident choice or non-compliance, addressing the condition, treatment options, expected outcomes and consequences of refusing treatment or following an appropriate plan of care. Address resident's concerns and offer relevant alternatives. 46049 2. On 1/21/25 at 9:57 AM, the surveyor reviewed the paper chart and electronic medical record (EMR) of Resident #88. A review of the AR revealed that Resident #88 had diagnoses that included but were not limited to; hypertension (elevated blood pressure), history of transient ischemic attack (mini stroke), and urinary tract infection. A review of the PO dated 10/16/24, the order was to Monitor vital signs (VS, are useful in detecting or monitoring medical problems such as temperature, respiration, heart rate, and blood pressure) weekly. A review of the December 2024 and January 2025 Medication Administration Record (MAR) revealed the entry for monitoring VS weekly were blank and included no scheduled day or frequency. A review of the VS in the EMR, there were no entries for December 2024 and January 2025. On 1/21/25 at 10:26 AM, the surveyor interviewed LPN#2 who was assigned to care for Resident #88. The LPN stated routine monitoring of VS was done according to the PO and would be documented in the MAR. LPN#2 reviewed with the surveyor the resident's MAR and reviewed the weekly monitoring of VS entry. LPN#2 stated she was unsure why the entry was blank as it was her first time on the assignment and acknowledged that it should indicate when VS should be checked weekly and on which shift. On 1/21/25 at 10:28 AM, the surveyor interviewed the Registered Nurse (RN) working on the same unit. The RN stated it was expected for nurses to follow PO for routine monitoring of VS. The surveyor reviewed with the RN the MAR of Resident #88. The RN replied, the blank VS entry should have been clarified to indicate what day of the week and what shift VS were to be obtained. On 1/21/25 at 10:30 AM, the surveyor interviewed the RN Supervisor (RNS), about VS protocol. The RNS stated that it was expected for nurses to follow PO for VS. The surveyor reviewed with the RNS the MAR of Resident #88 and asked about the blank weekly VS entry. The RNS acknowledged the nurses should have clarified the entry to indicate the frequency and should not have left the entry blank. The RNS further stated she would clarify the order. On 1/21/25 at 11:09 AM, the surveyor interviewed the DON about VS protocol. The DON stated routine VS monitoring would be entered per PO. The DON further explained VS were documented in the MAR. The surveyor reviewed with the DON the MAR of Resident #88. The DON acknowledged it would be expected for the nurses to clarify the order as there was no frequency indicated and that the entry should have been completed as per PO. On 1/21/25 at 12:37 PM, the surveyor informed the Executive Director (ED, also known as LNHA), the DON and the Assistant DON (ADON) about the concern that the weekly VS entry were not completed for December 2024 and January 2025. The surveyor requested any policy regarding VS and PO. On 1/21/25 2:00 PM, the DON informed the surveyor that the weekly VS order was clarified with the physician for the weekly VS to be completed on Wednesday every 3:00 PM-11:00 PM shift. The DON stated there was no VS policy and that a policy for PO would be provided to the survey team. 38327 3. On 1/17/25 at 9:40 AM, the surveyor observed Resident #158 laying on an air mattress (a specialized mattress), covered with a blanket, and spoke Spanish. A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and elevated blood sugar levels) and essential hypertension (cases of high blood pressure in which the cause is unknown). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 10/2/24, reflected in Section C Cognitive Patterns that the resident's cognitive skills for decision-making were coded 3 as severely impaired. A review of the PO revealed an order dated 2/19/24, for heel booties at all times. On 1/17/25 at 9:56 AM, LPN#3 asked the Certified Nursing Aide (CNA) to help her reposition Resident#158 for the surveyor to see the sacral dressing. Inside the resident's room, the surveyor observed LPN#3 removed the blanket and Resident #158 had no bilateral heel booties in use. LPN#3 stated that she was unsure why the resident did not have bilateral heel booties. On 1/17/25 at 10:14 AM, the surveyor notified the RNS regarding the above findings and concerns. Both the surveyor and the RNS went inside the resident's room, and the RNS did not find the resident's bilateral heel booties. The RNS informed the surveyor that she would ask the Central Supply department to provide new heel booties to the resident. On 1/21/25 at 12:19 PM, the survey team met with the LNHA, DON, and ADON, and the DON stated that the facility developed a policy that both nurses and CNAs were responsible for heel booties after the surveyor's inquiry. A review of the facility's Prescribing and Ordering of Medications Policy and Procedure Manual (adapted from the pharmacy vendor's policy), revised on February 2023, that was provided by the DON, did not include information with regard to following PO. On 1/22/25 at 1:15 PM, the survey team met with the LNHA, DON, and ADON, and there was no additional information provided by the facility. NJAC 8:39-11.2 (b); 29.2(d); 29.4(a)(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain proper infection control practices during tracheostomy care. This deficient practice was identified for 1 of 1 resident observed for tracheostomy care, (Resident #92), and was evidenced by the following: On 1/15/25 at 10:46 AM, the surveyor observed Resident #92 in a reclined lounge chair in their room. The resident had a tracheostomy (trach, a surgically made hole through the front of the neck into the trachea (windpipe) with a tube placed through the hole to help the person breathe), which was attached to a ventilation system (a breathing machine that helps or breathes for a person). The surveyor reviewed the medical record for Resident #92. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility and had diagnoses that included tracheostomy, anoxia (absence of oxygen), brain damage, and dependence on respirator (ventilator) status. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 9/28/24, reflected that the resident was in a persistent vegetative state, indicating no signs of awareness. A further review of Section GG reflected that the resident was dependent on all activities of daily living (ADLs). A review of Section O reflected the resident received the following respiratory treatments: oxygen (O2) therapy, suctioning, trach care, and mechanical ventilation. A review of the Physician Order (PO)forms dated January 2025, included the following physician's orders (PO): A PO dated 7/17/19, trach care; to change gauze/dressing around the trach and the inner cannula (liner that fits into the trach tube) twice daily. A PO dated 5/18/20, to change trach ties (straps that hold the trach in place) twice weekly, on Mondays and Thursdays, and when dirty as needed. On 1/17/25 at 9:45 AM, the surveyor observed the Respiratory Therapist (RT) provide trach care for Resident #92 and observed the following: The RT gathered the trach supplies from the dresser in the room, which included a sterile trach clean and care tray, normal saline vials, four packages of drain sponge gauze, and the inner cannula, and placed them on top of the dresser. The RT performed hand hygiene: He turned on the water, wet his hands with soap, and lathered by rubbing his hands. Then, using his wet, bare hands, he turned the water faucet off and dried his hands with a paper towel. The RT donned (put on) a plastic gown and a pair of gloves, gathered the equipment, and placed it on the overbed table. The RT then used disinfecting cleaning wipes to wipe the table, moving the supplies on the table while wiping the table and placing the equipment back down on the table. The RT opened the sterile trach clean and care tray with the same gloved hands removed the sterile waterproof drape and placed the drape on the resident's chest under the vent tubing below the trach. The RT also untied the trach ties and removed the gauze between the trach and the neck with the same gloved hands. The RT opened the drain sponge gauze and moistened it with the normal saline vial, cleansing the right side of the resident's neck and trach area. Then, the same gauze was moistened with normal saline to cleanse the left side of the resident's neck and around the trach area. The RT retied the neckties and doffed (removed) the gloves and gown. The RT performed hand hygiene, using a 10-second lather and scrub with soap and water. He then rinsed his hands and turned the water off by touching the faucets with his bare hands. He then removed a piece of paper towel while touching the paper towel dispenser and dried his hands with a paper towel. The RT donned gloves and a plastic gown, returned to the overbed table, wiped the table with disinfectant wipes, opened two drainage sponges, and replaced the trach gauze dressing around the stoma. The RT disconnected the ventilation tubing, removed the inner cannula of the trach, opened a new inner cannula, and replaced it without changing gloves. The RT then secured the ties to the vent tubing. The RT moved the overbed table toward the window, used the bed controller, and then touched the wall switch to turn off the lights. The RT doffed his gloves and plastic gown and performed hand hygiene. He touched the faucets to turn off the water and touched the paper towel dispenser while removing a piece of paper towel to dry his hands. On 1/17/25 at 10:15 AM, the surveyor interviewed the RT, who stated that he should have used a paper towel to shut off the water and changed his gloves between cleansing the overbed table with the disinfectant wipes. The RT further stated that he believed he did not have to use different pieces of gauze when cleaning each side of the resident's trach area because the neck was one area. On 1/17/25 at 11:25 AM, the surveyor interviewed the Vent Program Manager (VPM), who stated that the RT should use an alcohol-based hand rub (ABHR) before entering the resident's room. The RT should have gathered the equipment and put on gloves, wiped the overbed table, removed gloves, used ABHR, put new gloves on, opened the kit, removed the drape, covered the table, and placed the inner cannula onto the drape. He further stated that the gloves that disconnected the trach tubing or the gauze that was removed made the gloves dirty, and that the RT should have used hand hygiene and changed the gloves after each time that would happen. The VPM further stated that when washing hands, the RT should not touch the faucets with bare hands and should use a paper towel to turn them off. The VPM stated that trach care should have been performed this way because of infection control and patient safety and acknowledged that the RT did not perform trach care correctly. On 1/17/25 at 12:10 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) of the concerns with trach care observation. On 1/22/25 at 9:39 AM, the surveyor interviewed the Registered Nurse Infection Preventionist (RN/IP), who stated that he was disappointed the RT would have performed trach care that way. The RN/IP further stated that trach care was not performed that way, that the staff were given in-services and with demonstrations return demonstrations from the staff, and that the RT was in-serviced on the proper trach care techniques to prevent the spread of infections. A review of the facility's RT Practice Resource Guide, Tracheostomy and Transtracheal Care document dated 6/2013, included . the staff should use proper hand washing technique and don personal protective equipment. A review of the Clinical Competency Validation Tracheostomy care form, revised on 1/23, included that the RT met all the critical elements, including cleansing hands and maintaining standard precautions on 12/10/24. A review of the facility's Handwashing/Hand Hygiene policy with a revision date of 8/19/24, included .the facility's staff follow the handwashing/hand hygiene procedures to prevent the spread of infections to other staff, residents, and visitors . facility staff must perform hand hygiene .before and after direct contact with residents, before handling clean or soiled dressing, gauze pads, before and after removal of gloves, and before and after aseptic procedures .when washing hands .use a new dry paper towel to turn off the faucet .never turn off the faucet with clean, washed hands . NJAC 8:39-25.2(b), (c)4

Based on observation, interview, and record review, it was determined that the facility failed to properly a.) label, dispose and secure medications in 3 of 9 medication carts inspected and b.) store medication for 1 of 4 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 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. 1. On 1/17/25 at 10:45 AM, the surveyor inspected the 2-300 medication (med) cart A in the presence of the Registered Nurse (RN). The surveyor observed an opened and undated vial of Novolog insulin that had a pharmacy date of 12/31/24, and was stored in the med cart. The surveyor also observed an opened bottle of blood glucose test strips that was undated. At that time, the surveyor interviewed the RN who acknowledged that both the Novolog insulin vial and a bottle of blood glucose test strips should have been dated once opened. On 1/17/25 at 11:00 AM, the surveyor inspected the 2-300 med cart B in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened and undated bottle of blood glucose test strips. At that time, the surveyor interviewed LPN#1 who stated that once a bottle of blood glucose test strips was opened that it should have been dated. A review of the manufacturer's specifications for the following medications (meds) revealed that the bottle of blood glucose test strips had an expiration date of 90 days once opened and Novolog Insulin Pen had an expiration date of 28 days once opened. On 1/21/25 at 1:30 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Infection Preventionist to discuss the above concerns. There was no additional information provided. A review of the facility's Med Storage Policy that and a revision date of 2/2023, and was provided by the DON revealed that the meds will be stored in a manner that maintains the integrity of product, ensures the safety of the customers, in accordance with state department of Health guidelines and are accessible only to be licensed nursing and pharmacy personnel. 49078 2. On 1/17/25 at 10:20 AM, the surveyor began to inspect selected med storage areas in the facility. The surveyor observed the following: The surveyor in the presence of LPN#2, the surveyor inspected the med cart identified as Cart A located on the 1-300 Unit. The surveyor observed a box containing a foil package of Arformoterol inhalation solution (an inhaled med used to open lung passages) that did not reflect a date when the foil was originally opened. The manufacturer labeling on the box reflected: Store unopened pouched unit-dose vials in a refrigerator. Unopened pouched unit dose vials can also be stored at room temperature (temp) for up to 6 weeks. Do not use past the expiration date or after 6 weeks storage at room temp, whichever is sooner. Keep refrigerated or store at room temp for up to 6 weeks. The surveyor asked LPN#2 if the box or foil should have a date when it was opened on it. LPN#2 stated, yes we usually date nebulizer solutions. The surveyor asked LPN#2 if there was no date on it, could it be easily determined how long it was in the cart. LPN#2 stated not, not really. The surveyor also observed, in the 2nd drawer of the med cart a quantity of loose tablets and capsules on the bottom rear of the drawer along with scraps of papers. The surveyor counted the loose meds which amounted to 14 items. The surveyor asked LPN#2 if they could positively identify any of the meds. LPN#2 stated they could not. The surveyor asked LPN#2 if meds should be stored that way. LPN#2 stated, no they should be disposed of. The surveyor observed LPN#2 disposed of the loose med in the drug disposal device located in the bottom of the med cart. On 1/21/25 at 1:30 PM, the surveyor met with the LNHA, DON and ADON for responses related to concerns with med storage. The DON stated for the storage of meds that were not dated and opened and the loose meds, we are just going to inservice the staff and move forward with that. The facility did not provide any further pertinent information. A review of the facility's policy manual titled: Dept: Nursing, Subject: Pharmacy Services, Last review date 6/14/16. The manual revealed, under POLICY: 7. Drugs and biologicals used in the facility must be labeled in accordance with the currently accepted professional principles and include the appropriate accessory and cautionary instructions and expiration date when applicable. A review of the facility's Policy and Procedure Manual, revised February 2023, page 84, Section 6.8 Med Storage. Which reflected under: Med Storage, Policy, A. Meds will be stored in a manner that maintains the integrity of the product, ensures the safety of the customers, in accordance with the state Department of Health guidelines and are accessible to only licensed nursing and pharmacy personnel. Procedure: C. Meds will be stored in an orderly, organized manner in a clean area. E. Meds will be stored in in the original, labeled containers received from the pharmacy. G. Meds will be stored at the appropriate temp in accordance with the pharmacy and/or manufacturer labeling. NJAC 8:39-29.4 (a)(d)(g)(h)

Based on observation, interview and record review, it was determined that the facility failed to; a) complete the Hemodialysis Communication Record (HCR) to include a signature by the facility nurse that acknowledged review of the HCR for 14 of 14 days reviewed; b) document a complete assessment of vital signs and/or disposition of access site post dialysis treatment in the medical record; c) follow a recommendation for a change in medication; and d) had a diet order for 1 of 3 residents, Resident #169. This deficient practice was evidenced by the following: On 1/15/25 at 10:52 AM, the surveyor observed Resident #169 lying in bed, who stated that they were going to dialysis today and that they had a communication binder (binder for HCRs) that they took with to dialysis. A review of Resident #169's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dependence on renal dialysis (a state of chronic dependence on a machine and medical professionals to maintain life when the kidneys are no longer able to function properly), hyperlipidemia (condition in which there are high levels of fat particles (lipids) in the blood), and anemia (a blood disorder that occurs when the body doesn't have enough healthy red blood cells or hemoglobin, which carries oxygen throughout the body). A review of Resident #169's most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #169's was cognitively intact. Further review of the MDS indicated the resident received dialysis. On 1/17/25 at 9:29 AM, the surveyor interviewed the Registered Nurse (RN) regarding the process for a resident that received dialysis services. The RN stated that the HCR was filled out by the facility nurse prior to going to dialysis and that when the resident returned the HCR should be reviewed and should be signed by the facility nurse. He added that vital signs were taken and the dialysis site was checked and documented in the medical record. On 1/17/25 at 10:03 AM, the surveyor reviewed Resident #169's binder that contained the HCR's which indicated the following: HCRs dated 1/15/25, 1/13/25, 1/10/25, 1/8/25, 1/6/25, 1/3/25, 12/31/24, 12/29/24, 12/27/24, 12/24/24, 12/22/24, 12/20/24, 12/18/24 and 12/16/24, did not have a facility nurse signature to acknowledge that the HCR was reviewed. The HCR did not have a section on the form for an assessment of vital signs and disposition of dialysis site post dialysis. Further review of the HCR's reflected the following: 12/16/24 HCR included we do not give epogen (medication used to treat anemia (low red blood cell count) in people with long-term serious kidney disease), anymore. Medication (med) changed to mircera (used to treat anemia in people with long-term serious kidney disease) 30 mcg (microgram) every 2 weeks. 12/22/24 HCR included under med: given mircera 30. A review of Resident #169's Physician Order Form (POF) and Med Administration Record reflected an order for Epogen inject 1 ml (milliliters) (10000 Unit) IVP (Intravenous push) three times weekly (Monday, Wednesday, Friday) at dialysis. Further review of the POF did not have a diet order. A review of Resident #169's progress notes (PN) in the electronic medical record indicated the following: 12/27/24, did not include vital signs or disposition of dialysis site upon return to the facility from dialysis. 12/24/24, did not include disposition of dialysis site upon return to the facility from dialysis. 12/20/24, did not include vital signs or disposition of dialysis site upon return to the facility from dialysis. 12/18/24, there was no note post dialysis. 12/16/24, there was no note post dialysis. On 1/17/25 at 10:53 AM, the surveyor interviewed the Registered Nurse Supervisor (RNS) regarding HCRs. The RNS stated that the resident would bring the binder with HCRs to dialysis and that dialysis would write in it vital signs and any recommendations. She added if anything urgent they would call us. The RNS stated that the nurse would review the HCR. The RNS was not sure if there was a section post dialysis for the facility to write the assessment but that the nurse would document the vital signs and site check in the medical record. The surveyor showed the RNS Resident #169's HCRs that did not have a facility nurse signature. The RNS stated that there should be a signature for accountability that it was reviewed. On 1/17/25 at 11:04 AM, the surveyor interviewed the Registered Dietician (RD) regarding Resident #169's diet. The RD confirmed that there was no diet order on the POF and that there should be an order for the resident's diet. On 1/17/25 at 12:10 PM, the surveyor notified the Licensed Nursing Home Administrator(LNHA) , Director of Nursing (DON) and Assistant DON (ADON) the concerns that Resident #169's HCRs were not signed as reviewed, there was no documented evidence that the vital signs and/or dialysis site was assessed upon return to facility on 4 days of the 14 days reviewed, that a recommendation for a med change was not followed and there was no diet order on the POF/POS. On 1/21/25 at 12:21 PM, in the presence of the survey team, LNHA and ADON, the DON stated that they inserviced all nurses on the policy when a resident returned from dialysis to check the HCR and carry out any recommendations. The facility did not provide any additional information. A review of the facility's Dialysis Care of Resident on Hemodialysis with End Stage Renal Disease (ESRD) Policy, with a reviewed date of 4/18/23, included the following: Procedure: 6. The nurse updates the attending physician of any new recommendation from dialysis center and obtains the physician's orders from the dialysis center to the P.O.S. (Physician Order Set) and implements accordingly. Care of Resident with ESRD 4. Obtain and document vital signs pre and post dialysis in the medical record on dialysis days. 5. Observe the access site post dialysis and document results in the Interdisciplinary PN of the Medical Record. Dialysis Progress Notes Binder 1. Daily Communication PN Binder is sent will all residents to Hemodialysis. 2. When the resident returns from hemodialysis, the receiving nurse must review the Dialysis Communication PN for any recommendations and sign to acknowledge that the notes have been reviewed. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the resident receive care and treatment in accordance with professional standards of practice by developing and implementing a comprehensive person-centered care plan (CP), and the resident's choices that included refusal of care. This deficient practice was identified for 1 of 39 residents, (Resident #262), reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 wellbeing, and executing a 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 1/15/25 at 10:48 AM, the surveyor observed Resident #262 sitting in the chair, alert and oriented. The resident stated that they did not feel like going to dialysis today. Resident #262 added that they did not like the food served in the facility and sometimes they ordered food outside. On 1/15/25 at 10:58 AM, the surveyor interviewed the Registered Nurse (RN), who confirmed that the resident did not attend dialysis today. RN#1 stated that Resident #262 was non-compliant with care, including dialysis, medication (med), food preference, and the resident ordered food from outside. On 1/21/25 at 10:46 AM, the surveyor reviewed the medical records of Resident #262, which revealed the following: A review of the Admission Record (an admission summary) reflected that Resident #262, was admitted to the facility with diagnoses that included, but were not limited to, end-stage renal disease (ESRD; a condition in which the kidney loses the ability to remove waste and balance fluids). A review of the quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date of 11/17/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Section O-Special Treatments, Procedures, and Programs-dialysis-while a resident was checked. A review of the December 2024 Physician's Order form for Resident #262, reflected a Physician Order (PO) dialysis order dated 6/20/24, for Hemodialysis for ESRD on Monday-Wednesday-Friday at 5:30 PM pick up at 4:45 PM. A review of the Progress Notes in December 2024 revealed that Resident #262, documented a refusal to attend dialysis four times, refused to eat breakfast, lunch, and dinner five times, ordered food outside, and refused med. A review of Resident #262's CP did not reflect a CP for the refusal of care, med, and non-compliance with dialysis and diet. On 1/21/25 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident refused care and was non-compliant with diet. The LPN added that that refusal should be documented and added in the CP. On 1/21/25 at 12:29 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), and Assistant DON (ADON) to discuss the above concern. No additional information was provided. A review of the facility's MDS 3.0 Policy with a reviewed date of 6/22/23, given by the ADON on 1/22/25, stated under Procedure: 12. Any changes in the resident's status will be reflected in the Interdisciplinary CP as necessary . NJAC 8:39-27.1(a)

Based on interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 4 of 4 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on three 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 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. On 1/17/25, the surveyor reviewed a binder provided by the Director of Nursing (DON), 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 # 2317211189 dated 5/5/24, for one package of 20 morphine sulfate 10 mg (milligram)/0.5 ml (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 present. DEA 222 Form with order form # 231721190 dated 7/25/24, for one package of 20 morphine sulfate 10 mg/0.5 ml syringes 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 present. DEA 222 Form with order form # 2317211182 dated 9/4/24, for one package of 30 oxycodone 5 mg/325 mg (a schedule II-CDS used for pain) and one (1) package of 10 oxycontin 10 mg (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 present, On 1/21/25 at 11:15 AM, the surveyor met with the facility Consultant Pharmacist (CP) to discuss the concerns with the completion of the DEA 222 forms. The CP stated the facility must have missed those and they do know how to fill them in since they did so on others. On 1/21/25, at 12:15 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant DON (ADON) to discuss the concerns with the DEA 222 forms. The DON acknowledged that Part 5 on the forms were not filled in and should be completed when the items were received. On 1/22/25 at 11:08 AM, the survey team met with the LNHA, DON and ADON, and the DON stated that the incomplete information will be addressed and agreed that the forms should be completed per the instructions, but there were packing slips showing delivery attached. The facility offered no further pertinent information. A review of the instructions for completing the DEA 222 Forms located in the Code of Federal Regulations at 21 CFR1305.13, revealed the following: 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 Policy and Procedure Manual, revised February 2023, revealed: 5. Prescribing and Ordering of Medications 5.6 Controlled Dangerous Substance Inventory for Backup Box and Emergency Kits. The policy reflected under section 5.6, Policy, A. (Provider Pharmacy name redacted) and the facility will properly distribute, maintain and dispense controlled substances that are stored within the backup box and emergency kit. All CDS are dispensed and handled in accordance with state and federal regulations. The policy also reflected under Procedure, A. CDS Inventory in Back Up Supply- Schedule II CDS: 1. The DEA form 222 must be completed to obtain the par level quantity of Schedule II CDS in back up supply. Upon signature of the Medical Director or his/her designee, the facility makes a copy then sends the original to the pharmacy to the attention of the Pharmacist In Charge. NJAC 8:39-29.3(a)6, 29.4(g), 29.7(c) 21 CFR 1305.13(e)

Based on observation, interview, and record review, it was determined that the facility failed to maintain the prior year's Federal and State of New Jersey (State) inspection results and post the location of those results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. On 1/16/25 at 8:29 AM, the surveyor observed a binder in the reception desk for Licensure Reports (survey results) which the Security Staff (SS) confirmed that the survey results were for date 8/12/21. On 1/16/25 at 11:08 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the facility's most recent Federal and State surveys were from 2023. He further stated that it was the facility's practice that the survey results should be at the reception desk by SS and that the 2023 survey results should always be available to residents, staff, and visitors. At that time, the surveyor notified the DON of the above findings and concerns. The DON stated that he was not sure why the survey results that were posted was from 2021, and it should be for 2023. The DON further stated that he would get back to the surveyor about the policy for posting survey results. On 1/16/25 at 12:57 PM, the DON informed the surveyor that the facility had no policy about posting survey results. He further stated that they do follow the regulation that the facility had to post the most recent survey results at the reception desk, which was from 9/8/23. On 1/22/25 at 1:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant DON, and there was no additional information provided by the facility. NJAC 8:39-9.4(a, b)

Complaint # NJ00 181747 Based on interview, medical records (MR) review, and review of pertinent facility documents on 01/14/2025, it was determined that the facility failed to develop and implement a care plan (CP) focus to include behaviors for residents who were on psychoactive medications. The deficient practice was found in 2 of 4 residents, (Resident #1 and #2), reviewed for behavior monitoring and comprehensive care planning and was evidenced by the following: 1.According to the admission Face Sheet Record (AFSR), Resident #1 had diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypothyroidism, Essential Hypertension, and Hyperlipidemia. A review of Resident #1's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 09/21/2024, under Section C showed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 08 indicating Resident's cognition was moderately impaired. The MDS further revealed in Section GG-Functional Abilities and Goals that Resident required maximal assistance in his/her completion of Activities of Daily Living (ADLs). The Resident's MDS further showed under Section N- Medications that Resident was taking antipsychotic medication (class of drugs that treat mental health conditions) and an indication (a diagnosis) was noted. A review of the Resident #1's Physician's Order Form (POF) with Review Date of 12/2024 indicated an order originally dated 09/16/2024: OLANZAPINE TAB 5MG For Zyprexa, 1 TABLET ORALLY AT BEDTIME FOR DEMENTIA/DELIRIUM. A review of Resident #1's Medication Administration Record (MAR) Routine Medications dated from months of September 2024 to December 2024 indicated a medication order entry of: OLANZAPINE TAB 5MG (RP: ZYPREXA) 1 TABLET ORALLY AT BEDTIME FOR DEMENTIA/DELIRIUM with HOUR [of administration] at 8:30pm [evening]. The MAR revealed the medication OLANZAPINE on the aforementioned months were signed and initialed by staff indicating the medication was administered to the Resident. A review of the document PSYCHIATRIC ASSESSMENT/EVALUATION FORM (PA/EF) dated on 9/21/24 and signed by Psychiatrist #1 [name] under History of Present Illness: 81 y/o/w [widow] .She has been on Zyprexa [Olanzapine] for hallucinations and delusions .; under Current Psychotropic Meds: Olanzapine 5 mg hs [bedtime]; Diagnosis (Justification per Med): Dementia with hallucinations; Target Behavior (per med): hallucinations. A review of the PA/EF dated 12/28/24 signed by Psychiatrist #1 [name] under History of Present Illness: Staff still reports intermittent episodes of hallucinations and paranoia. No side effects to .; under Current Psychotropic Meds .Diagnosis (Justification per Med): Dementia with delusions; Target Behavior (per med): paranoia. A review of Resident #1's document titled Psychotropic Use Review (PUR) dated 12-04-2024 revealed under Target behavior: Hallucinations delusion affecting primary daily activities - # of Episodes: 6. A review of Resident #1's CP with CP Reference Date of 06-10-24 did not indicate a Focus [Problem Area] addressing the Resident's Target Behaviors as mentioned above in the PA/EF and PUR. The CP furthermore did not indicate a corresponding Goal and Interventions to address the target behaviors. 2.According to the admission Face Sheet Record (AFSR), Resident #2 had diagnoses which included but were not limited to: End Stage Renal Disease, Paroxysmal Atrial Fibrillation, Anemia, Essential Hypertension, and Type 2 Diabetes Mellitus. A review of Resident #2's Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities, dated 10/23/2024, under Section C showed Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 15 indicating Resident's cognition was intact. The MDS further revealed in Section GG-Functional Abilities and Goals that Resident required maximal assistance in his/her completion of Activities of Daily Living (ADLs). The Resident's MDS further showed under Section N- Medications that Resident was taking an antianxiety medication (type of medication used to treat anxiety and related conditions) and an indication (a diagnosis) was noted. A review of the Resident #2's Physician's Order Form (POF) with Review Dates of 09/2024, 10/2024, 11/2024, and 12/2024 indicated an order with original date of 09/18/2024: ALPRAZOLAM TAB 0.25MG For: XANAX, 1 TABLET ORALLY THREE TIMES WEEKLY MON-WED-FRI (30 MIN BEFORE HD [hemodialysis] FOR ANXIETY. A review of Resident #2's Medication Administration Record (MAR) Routine Medications with dates of September 2024, October 2024, November 2024, December 2024, and January 2025 indicated a medication order entry of: ALPRAZOLAM TAB 0.25MG (RP: XANAX) 1 TABLET ORALLY THREE TIMES WEEKLY MON-WED-FRI (30 MIN BEFORE HD [hemodialysis]) FOR ANXIETY with HOUR [of administration] at 10:30am [morning]. The MAR revealed the medication ALPRAZOLAM on the aforementioned months were signed and initialed by staff indicating the medication was administered to the Resident. A review of Resident #2's document PSYCHIATRIC ASSESSMENT/EVALUATION FORM (PA/EF) dated on 10/8/24 and signed by Psychiatrist #2 [name] under History of Present Illness: 67 y/o/w AAF [alert, awake, female] .On Dialysis .Anxiety while attending Dialysis; Prescribed Xanax [dose] 30 min before dialysis .can be fidgety and easily frustrated .under Current Psychotropic Meds: Xanax [dose] 30 min before dialysis; with Updated Diagnosis: Generalized Anxiety Disorder, Adjustment Disorder. A review of Resident #2's Progress Notes (PN) dated 10-17-24 11:20 am [morning] documented by Registered Nurse (RN #1), 7:10am [morning] Resident noted screaming inside her/his room asking for help .resident in no distress noted .assessment done claimed that [Resident] was given a shower this morning and that she/he was having a very bad experience .8am [morning] resident noted yelling again saying that her/his heart is about to explode resident noted anxious .assessed resident, no tachycardia [abnormal heart rate] .10:45am [morning] pick up for therapy went down to rehab .Resident will be seen by Psychiatrist tomorrow, will continue to monitor resident . Further review of Resident #2's PN revealed that on 10-29-24 and as documented by RN #1, 12:45pm [afternoon] resident noted screaming in the room & crying, saying she wants to go home .talked to resident regarding her condition and she was redirected .continue to monitor behavior. A review of Resident #2's CP with CP Reference Date of 09-16-24 did not indicate a Focus [Problem Area] addressing the Resident's Behaviors [Anxiety while attending dialysis] was initiated as mentioned in the PA/EF and PN on the above-mentioned dates. In the interview of the Surveyor with the Executive Director [Administrator], Director of Nursing (DON), and the Assistant Director of Nursing (ADON) on 01/14/2025 at 11:59am [morning], the DON and ADON stated the nurses do psychotropic charting every month and a psychiatrist follows up the residents with psychotropic medications regularly. When asked regarding the absence of Care Plan on the behaviors of residents with psychotropic medications, the DON and ADON were unable to provide statements. A review of the facility's Policy Manual under Subject: Psychotropic Drug Use; under Objective: 1) To assure that all behavior problems are assessed properly and that every alternative to the use of psychoactive medications has been attempted to eliminate problem behaviors; 3) To assure that all residents receiving psychoactive medications are monitored daily for target behaviors, adverse side effects, and drug reactions; 4) The IDCP [inter-disciplinary care plan] assess, monitor, evaluate the resident's behavior and the use of psychoactive medications .under Procedure: .3) Upon completion of behavioral assessment the nurse will initiate an interdisciplinary team meeting to implement non-pharmacological interventions .These interventions will be entered onto the Interdisciplinary Careplan and the Care Needs Form, and the twenty four hour report .6) If psychoactive medications are initiated .c) The interdisciplinary team must initiate a care plan for psychoactive medications and update the behavioral care plan. N.J.A.C: 8:39-11.2 (d)(e)1,2

Complaint#: NJ00179720 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to follow the Medical Emergency Response policy for a resident (Resident #2) in respiratory distress. This deficient practice was identified for 1 of 3 residents reviewed for medical emergency response procedures. The facility also failed to provide the needed emergency transportation services to manage the acute respiratory symptoms of Resident #2, which resulted in the Resident's failure to improve. In addition, the facility failed to develop a policy and procedure for the staff to follow to determine the use of emergency or non-emergency transportation services based on residents presenting symptoms. The facility's failure to implement its Medical Emergency Response policy and to develop a policy and procedure for the staff to follow to determine the use of emergency or non-emergency transportation services based on residents presenting symptoms placed Resident #2 and all other residents in an immediate jeopardy (IJ) situation related to the State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. This IJ was identified and reported to the facility's Executive Director (ED) and Director of Nursing (DON) on 11/21/2024 at 5:52 PM. The ED was presented with the IJ template that included information about the issue. The IJ began on 11/15/2024 and continued through 11/25/2024 when the facility submitted an acceptable Removal Plan (RP)the New Jersey Department of Health. On 11/26/2024, the Surveyor verified the Removal Plan was implemented, which included educating all staff on the Non-Emergent Medical Transportation Policy and the revised Emergency Medical Response Policy. The staff interviewed revealed knowledge of what a medical emergency is and the protocol for using 911 vs non-emergent transport for medical emergencies. The staff indicated that the Certified Nursing Assistance or nurse who identified the Resident in distress would first call 911, ensuring EMS services were dispatched as soon as possible. So, the noncompliance remained on 11/26/2024 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings included the following: On 11/21/2024, the Surveyors reviewed the following in the electronic medical record (EMR): According to the Admission Record, Resident #2 was readmitted to the facility with diagnoses that included but was not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory, and heart failure. The annual Minimum Data Set (MDS), an assessment tool, dated 11/15/2024, indicated Resident #2 was cognitively intact, required substantial/ maximal assistance with Activities of Daily Living (ADLs), and depended on transfers. According to the progress note (PN) dated 11/15/2024 at 2:50 PM, written by the Licensed Practical Nurse (LPN) #1, at 9:25 AM, Resident #2 was found to be lethargic but was responsive to staff. The Resident's oxygen level was 96% (percent), but the Resident was using his/ her accessory muscles (use of muscles other than those typically used for breathing to take in and expel air) while breathing. The PN further showed the RN/ANS (Registered Nurse/Assistant Nursing Supervisor) assessed Resident #2 and r/t (Respiratory Therapy) assisted with re-applying the Resident's bi-pap machine (bilevel positive airway pressure machine, which is a noninvasive breathing machine that helps people with breathing difficulties). Resident #2's temperature (T) was 98, heart rate (HR) was 84, respirations (RR) were 20, blood pressure (BP) was 157/81, and the oxygen level (SPO2) was 100 %, while the Resident was wearing a bi-pap machine. In addition, the PN revealed that at approximately 9:30 AM, the nurse called the doctor and was waiting for the return call. At 9:52 am, the Nurse Practitioner (NP) returned the call to the facility. After she was given an update on Resident #2's status by LPN #1, the NP gave an order to send the Resident to the emergency room (ER) for evaluation for Acute Respiratory Distress. LPN #1 notified the RN/ANS of the order and received assistance from LPN#2 by calling the Pulse ambulance service and notifying the ER of the transfer. At 10:57 AM, Pulse ambulance representatives arrived to pick up Resident #2 for transport and were given a report of Resident #2's status. Resident #2 waited from 9:52 AM to 10:57 AM for transport to the hospital with symptoms of Respiratory Distress. A review of the New Jersey Universal Transfer Form (a document prepared by the facility for the Resident's transfer to the hospital), dated 11/15/2024 and timed at 10:45 AM, revealed the Resident's vital signs were BP 157/81, HR 84, RR 28, T 98, SPO2=100% with BiPAP. A review of the Physician's Orders for Resident #2 revealed an untimed telephone order from the NP dated 11/15/24 to send to [Acute care hospital] ER for evaluation of Acute Respiratory Distress . A review of the ED Nursing Note from 11/15/2024, signed at 4:43 PM, revealed, 1100 pt (patient) brought in via BLS (Basic Life Support) to ED from [Nursing Facility] for c/o (complaint of) AMS (Altered mental status). On arrival to ED pt was found to be in respiratory distress with agonal breathing, (an abnormal breathing that's characterized by gasping, labored breathing, and strange vocalizations, usually a symptom of a medical emergency). Pt (patient) on NRB (Non-rebreather) at 10L (Liters) by BLS. Pt intubated (a procedure that involves inserting a tube into the trachea (windpipe) to help a person breathe) by MD. RT at bedside to adjust ventilator along with this RN . During an interview with the Surveyor on 11/19/2024 at 1:04 PM, the RN/ANS stated he was the Supervisor on the day Resident #2 was sent to the ER. He said that, around 9:30 AM, he received a call from Resident #2's nurse, who stated that Resident #2 was short of breath and wanted to be placed back on the bi-pap machine. RN/ANS stated that he assessed Resident #2 and ruled out a cardiovascular accident (CVA), but Resident #2 appeared weak, was breathing rapidly, but calmed down after receiving his/her medication. The RN/ANS stated that respiratory therapy was called to put the BiPAP back on the Resident and that LPN #1 called the doctor because Resident #2 was short of breath. RN/ANS stated he went back to see Resident #2 around 9:45 AM, and the Resident had a bipap back on and appeared calmer. He further stated that while re-assessing the Resident, the doctor called back and ordered him to send the Resident to the hospital. The RN/ANS further stated that LPN #1 and LPN #2 gathered the paperwork to send to the Resident and called the ambulance, ER, and Resident #2's family. In addition, RN/ANS stated that if a resident is stable, the protocol is to send them out using Pulse ambulance service. He explained that if they cannot stabilize the Resident or the ambulance cannot come in less than one hour; they call 911. According to the RN/ANS, they did not call 911 because there was no code blue, 911 would need to be called for code blues. RN/ANS stated that Resident #2 appeared stable and had normal vitals. During an interview on 11/19/2024 at 1:43 PM, LPN #2 stated LPN #1 asked her to look at Resident #2. LPN #2 stated that the Resident had a glazed look on his/ her face and was staring; it appeared that the Resident wasn't focusing. She further stated that Resident #2 did not look or act normal, but all the vitals were normal. LPN #2 also stated that Resident #2 was usually more interactive and would communicate and tell you if he/ she needed anything. LPN#2 said she was unsure if the NP specified which transport to call. She explained that 911 would be called for an emergency such as respiratory distress. The Surveyor and LPN#2 reviewed the NP's order to send Resident #2 to the ER for evaluation of Acute Respiratory Distress. LPN #2 stated that she was unaware that the NP's order stated to send the Resident out for evaluation of Acute Respiratory Distress. During an interview with the Surveyor on 11/19/2024 at 1:54 pm, the NP stated they received a call at 9:50 AM from the nurse (LPN #1) taking care of Resident #2. The LPN stated Resident #2 was in distress. The NP said she requested Resident #2 to be sent to the hospital and recalled the order for Acute Respiratory Distress. The NP stated they should have called 911 if the vital signs had changed. On 11/19/2024 at 3:19 PM, the Director of Nursing (DON) and Executive Director (ED) were interviewed. The DON and the ED stated that the administration is notified when a resident is transported to the hospital. The ED stated security sends an email notification each time a resident enters and leaves the building for census purposes. The DON stated that the Nursing Supervisors also notify them when a resident is transported to the hospital during report. The ED and the DON stated they use Pulse, Life Ride, and TLC for stable residents requiring transport and 911 for emergencies. According to the DON, a nurse does not need to call a Supervisor to call 911; they can use their nursing judgment in an emergency. The DON further stated that he is familiar with Resident #2 and was notified by the RN/ANS of the Resident being transported to the ER for issues with their respirations after the Resident had left the building. According to the DON, he was informed that the Resident's breathing had improved and was not aware of Resident #2's condition at the time of pick up. The DON stated that if the vital signs change at any time while waiting for transport to the hospital, he expects the staff to call 911. During an interview on 11/21/2024 at 1:31 PM, the Assistant Director of Nursing (ADON) stated that if the transport did not have an ambulance or if the wait was too long, they would call 911. She said that 2 hours would be too long of a wait time for an ambulance to pick up any resident for transport for evaluation, and in that situation, 911 would be called for the Resident to be transported. The ADON further stated that if the Resident's status changes, 911 should be called instead of waiting for medical transportation. She also stated that if a resident is experiencing respiratory distress, then the Resident should be sent to this hospital via 911. During an interview on 11/21/2024 at 2:12 pm, LPN#1 stated she recalled the day Resident #2 was sent to the hospital. She stated while she was doing her rounds around 8 am, the Resident's bipap was removed, and a nasal cannula (a device to deliver oxygen through nostrils) was applied to the Resident through respiratory therapy. She stated that when she returned to give Resident #2 their medication, the Resident did not appear to be focusing and appeared to be using his/ her abdominal muscles while breathing. She stated she called the Supervisor to assess the Resident because the Supervisor was able to speak to Resident #2 in Spanish. While Resident #2 spoke with the Supervisor, the Resident requested that the bipap machine be placed back on. She informed the Supervisor that she would call the Resident's doctor. LPN #1 stated that the NP returned her call and told her to send the Resident out for respiratory evaluation. She stated that she called the family and completed the paperwork, and LPN #2 called the ER and for the ambulance. During a telephone interview on 11/21/2024 at 3:23 pm, the Medical Director (MD) stated that staff should assess the Resident and provide clinical information to the doctor to discuss what orders are needed. For instance, if the Resident needs stat (immediate) orders or if they need to go out to the hospital. She explained that if a resident is unstable and their vital signs are abnormal, they should be transported to the hospital via 911. If a resident is in Acute Respiratory Distress, she expects the staff to call 911. The MD further stated that anyone on oxygen or bipap should be transported by paramedics, which should be a standard of care, and anyone on a ventilator, trach, or bipap should be transported by 911. Review of the facility's Policy titled Code Blue Medical Emergency Response, with a last revised date of 12/9/2020, revealed the following: Under Policy: (The Facility) will utilize standard procedure in responding promptly to a medical emergency. Definitions included: Medical Emergency- Examples include but not limited to: An unconscious person; a person in respiratory distress; a person who is choking; a person who us having seizures; a person with severe bleeding; a person who falls which leads to a serious injury. Procedure: Medical Emergency Response 1. A person in a medical emergency is identified and code blue is initiated. 2. Identify code status of a resident. NOTE: The medical record will also be checked to verify the code status of the Resident. If you are the first responder in an emergency situation: - Check the person for responsiveness, breathing and pulse. - Page Code Blue (x6164) and direct staff to call for ambulance and paramedics. NJAC 8:39-27.1(a)

Complaint #: NJ171754 Based on observation, interview, record review, and review of other facility documentation on 3/1/2024, it was determined that the facility failed to notify and obtain a physician's order to change the form of a medication from liquid to tablets. The Physician order for this medication could not be filled by the Pharmacy because this medication did not come in liquid form. The facility failed to follow its policy titled Prescribing and Ordering of Medications. The deficient practice was identified for 1 of 4 residents( Resident #2) reviewed for medication administration, and was evidenced by the following deficient practice: 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. A review of the Admission Record reflected that the resident was admitted to the facility with diagnoses that included but not limited to Diabetes Mellitus (a disease in which the body does not produce enough or respond normally to insulin), Pressure Ulcer of the Left Buttocks, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors) A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/1/2024, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact. The MDS also revealed the resident had a diagnosis of Parkinson's Disease. A review of the resident's Physician Order Sheet (POS) revealed a telephone order dated 2/16/2024 for Baclofen 50 mg(milligram)/5 ml (milliliter) Po (by mouth) q (every) 8 hrs. (hours). Dx (diagnosis) Muscle Spasm. Another review of the resident's POS dated 2/19/2024 revealed: D/C Baclofen 50 mg/5 ml. Start: Baclofen tablet 20 mg give 2 tablets total of 40 mg Po q 8 hrs. Dx: Muscle Spasm, give at 12:30 a.m., 8:30 a.m., and 4:30 p.m. Baclofen tablet 10 mg give 1 tablet Po q 8 hrs Dx: Muscle Spasm, give at 12:30 a.m., 8:30 a.m., and 4:30 p.m. (TORB (telephone order read back) indicated that RN received the order from the Physician. Review of Resident #2's February 2024 Medication Administration Record (MAR) revealed the aforementioned order. The MAR also revealed on 2/20/2024, the 12:30 a.m. dose was initialed by the Nurse. During an interview with the Surveyor on 3/1/2024 at 1:15 p.m., the Registered Nurse (RN#1) stated on 2/16/2024, Resident #2 returned from their Neurologist appointment with written recommendation for Baclofen 50 mg/5 ml Po every 8 hours for muscle spasm. He further stated the above recommendation was reviewed with the covering MD and faxed to the pharmacy. During the same interview, the Surveyor asked what is the process for a medication that is unavailable at the pharmacy in the form initially ordered by the MD. RN #1 stated if the pharmacy calls and said a medication was unavailable or does not come in the form ordered by the MD, the nurse is responsible to call the MD, make them aware that the medication is unavailable or does not come in the form ordered. The Surveyor asked if a nurse is allowed to write an order or change the form of a medication without speaking with the MD and the RN #1 replied No. During an interview on 3/1/2024 at 1:43 p.m., RN #2 said the above order was unavailable on the morning of 2/19/2024 during her scheduled work shift. She called the pharmacy to follow up on the delivery and was informed by the Pharmacist that the medication was unavailable in the liquid form and the order needed to be changed to tablet. She said the Pharmacist gave instructions that the order should be written as: Baclofen tablet 20 mg give 2 tablets total of 40 mg Po Q 8 hrs Dx: Muscle Spasms, give at 12:30 a.m., 8:30 a.m., and 4:30 p.m. Baclofen tablet 10 mg give 1 tablet Po Q 8 hrs Dx: Muscle Spasms give at 12:30 a.m., 8:30 a.m., and 4:30 p.m. to equal a total of Baclofen 50 mg. RN #2 said she wrote a telephone order for the above order and faxed to the pharmacy. When asked if she notified the MD that Baclofen liquid was unavailable at the pharmacy as previously ordered, RN #2 said No, I did not call or speak with the MD prior to writing the new order to change the form of Baclofen liquid to Baclofen tablet. Yes, I should have notified the MD that Baclofen liquid was unavailable, and as per the Pharmacist, Baclofen was available in tablet form. RN #2 continued to state, I just wanted the resident to have their medication, I did not change the route, dose, or time of the medication, I only change the form from liquid to tablet. During an interview on 3/1/2024 at 2:54 p.m., the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) stated a nurse should not change the form of a medication as ordered by the MD. A nurse needs a physician's order to change the form of a medication. He further stated RN #2 should have called the MD, notify him that Baclofen was unavailable in liquid form, and obtain an order to change the order from Baclofen liquid to Baclofen tablets. A review of the facility's Policy and Procedure Manual Section V: Prescribing and Ordering Medications under Policy revealed: Medications will be dispensed and administered only upon the writing or verbal order by individuals that are legally authorized, duly licensed, and granted clinical privileges by the facility. Under Procedure revealed: A. No medications or biological's are dispensed or administered except upon the order of a person lawfully authorized to prescribe for and treat human illness. NJAC 8:39-11.2 (b), 29.2 (d)

Complaint #: NJ 899 Based on record reviews, interviews, and facility policy review, it was determined the facility failed to ensure Emergency Medical Services (EMS) was called immediately when a resident went into cardiopulmonary arrest to ensure potentially life-saving interventions were administered. This affected one (Resident #4) of three residents reviewed for Code Blue procedures. The facility failed to have a policy that ensured EMS services were utilized during a Code Blue life-threatening emergency. The facility identified 242 residents that were a full code, indicating the residents desired to have cardiopulmonary resuscitation performed in the event of cardiopulmonary arrest. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. On [DATE] at 4:31 PM, the Executive Director (ED) was informed of the Immediate Jeopardy situation, and a Removal Plan was requested. Findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had significant memory impairment. The resident needed minimal assistance to get out of bed and was able to self-propel a wheelchair. During a review of the clinical record, Registered Nurse (RN) #1's progress note dated [DATE] at 8:07 AM revealed the following, At 4:15 AM nebulizer treatment was going, when I suddenly heard resident yelling help me. I quickly rushed to the room, there I found resident gasping. I noted bluish discoloration to [gender] lip. The situation I found [Resident #4] prompted me to initiated CPR [cardiopulmonary resuscitation] and called Code Blue. Crash Cart and AED was brought to the room to resuscitate the resident. All the effort initiated to resuscitate the resident could not bring [gender] back to life. Nurses from other floors and the supervisor were present, initiated continuous CPR for more than an hour. At 5:30 AM, paramedics pronounced the resident dead. Resident was cleaned, dressed, and placed in [gender] bed. Supervisor notified the resident's family of [gender] death. ,d+[DATE] nurse notified of the resident death. On [DATE] at 6:29 AM, RN #1 was interviewed via telephone. RN #1 stated prior to giving Resident #4 the nebulizer treatment, he took the resident's pulse oximeter (blood oxygen saturation level), and it was at 96%. He gave the resident the nebulizer treatment and said he would return. He stated about 10 minutes later the resident cried out help me, help me and he returned to the room. He found that the resident's lips were blue. RN #1 yelled out to call a Code Blue. He stated he stayed with the resident and started CPR. He was unable to say how long it took for the paramedics to arrive because he was so focused on the resident. On [DATE] at 6:07 PM, the Executive Director (ED) was interviewed. The ED stated [name of town] did not allow the facility to call 911. A private ambulance company was to be called if advanced life support was needed. On [DATE] at 6:47 AM, RN #2 was interviewed. RN #2 was the overnight supervisor the night Resident #4 went into cardiopulmonary arrest (coded). RN #2 could not recall the time but stated a certified nursing assistant (CNA) called her in her office sometime after 4:00 AM to overhead page a Code Blue. RN #2 called the Code Blue then went to the resident's room. She stated upon her arrival to the room, other employees informed her that EMS had not been called. RN #2 placed a call to Ambulance Company #1, a private contracted ambulance company. RN #2 explained the ambulance company was a private ambulance company and the first company to call if there was a medical emergency. She stated if this ambulance company was not available, then there was another company they could try to call. If they needed paramedics, then Ambulance Company #1 would call to have them dispatched. Regarding Resident #4, RN #2 stated she had to call back the ambulance company to make sure they were on their way. She believed she waited approximately ,d+[DATE] minutes. RN #2 stated the average time for the ambulance company to arrive at the facility was ,d+[DATE] minutes. RN #2 had designated herself to make the phone calls and copy the paperwork needed for the ambulance. She stated she had looked back into the room and observed the nurses doing continuous CPR. The interview with RN #2 was continued about calling a code. RN #2 stated every nurses' station had a sheet called, Calling the Code. The sheet walked through all the steps of a Code Blue - Medical Emergency and other Codes. For a Code Blue, the first step was to announce the code over the facility's paging system or dial 0 for the operator/security and have them overhead page the code and location. The next step was to call one of two different ambulance companies. The Code Blue sheet indicated, If unable to contact the ambulance: Call the [name of city] Police Department. The last line revealed, If emergency is a visitor or employee: Call 911 and stay on the line with the 911 operator. RN #2 stated only the nurses were trained on calling a code and not the CNAs. Regarding the code on [DATE], RN #2 stated she did not document when she called the family or called for an ambulance. She stated, I assumed [RN #1] would have documented, but I should have done it myself. On [DATE] at 2:18 PM, RN #3 was interviewed. RN #3 stated the nurse supervisors were supposed to bring her the AED report sheet after the AED was used in a code. RN #3 stated the two night nurse supervisors from the Code Blue on [DATE] did not remember filling out the form. The information from the AED was never downloaded. On [DATE] at 3:38 PM, the Director of Staff Development (DSD) was interviewed. The DSD stated the facility did not do competencies on running a code. She stated there was no system in place to evaluate if the nursing staff ran a successful code. She recalled having a mock code in 2019. On [DATE] at 4:10 PM, the Operations Supervisor from Ambulance Company #1 was interviewed. The Operations Supervisor stated they offered Basic Life Support (BLS) transportation services. She stated if a facility, such as Preakness, was to call for an ambulance, then they would call for the paramedics. She stated she did not know why the facility had a policy to not call 911. The Operations Supervisor stated at night, the company had been short staffed and there were times when they had to quote an arrival time of 40 minutes to an hour. The facility should call whoever could accommodate the facility, but I believe codes would be a call to 911. On [DATE] at 7:41 AM, RN #4 was interviewed. RN #4 was one of the two nurse supervisors during the Code Blue for Resident #4 on [DATE]. She recalled being at the employee entrance when the code was called. She stated employees began arriving to work at 4:00 AM, therefore, it had to be sometime after that, but she was not able to state what time the Code Blue was called. RN #4 stated it would take her approximately two to three minutes to get to the resident's room from the nurse's office and about four to five minutes from the employee entrance. When she arrived at the resident's room, the AED was being applied and RN #2 stated she was going to call the ambulance. RN #4 stated the nursing staff performed CPR for a minimum of 40 minutes but was not sure because she never looked at the time. Three out of four security guards on duty the night of [DATE] documented on the Security Officer Daily Log form hearing the overhead page for a Code Blue for Resident #4 at 4:50 AM. Information obtained from Ambulance Company #1 revealed no record of a call on [DATE] from the facility. Records obtained from Ambulance Company #2 revealed a call was received from RN #2 on [DATE] at 4:58 AM. They indicated the call was disconnected/dropped. The dispatcher made multiple attempts to contact the caller but was unable to do so until 5:05 AM due to the phone extension not being answered or going to other areas of the facility. Upon receipt of call information, an ambulance from Ambulance Company #2 was dispatched while online with the caller, in addition to local paramedics being contacted for an ALS (Advanced Life Support) unit to be dispatched. On [DATE] at 11:30 AM, the ED stated since RN #1 documented the code four hours after the event and he does not recall the exact time, that it may have been a typo in his progress note. According to the nurse's note, the resident went into cardiopulmonary arrest on [DATE] at 4:15 AM and CPR was started. According to the documentation, a Code Blue was announced at 4:50 AM, and the first call was made to Ambulance Company #2 at 4:58 AM. The facility spoke with Ambulance Company #2, and an ambulance was dispatched at 5:05 AM. According to the documentation, the facility staff did not speak with Ambulance Company #2 until 50 minutes after the resident went into cardiopulmonary arrest. Ambulance Company #2 arrived at 5:30 AM and pronounced the resident deceased . 2. On [DATE] at 6:07 PM, the Executive Directive (ED) was interviewed. She stated about a year ago, a meeting was held with [name of city]. The meeting was held with assisted living and nursing home facilities in the area. Her understanding was [name of city] did not want the facilities calling 911 and they were to contract with private ambulance services for all transport and emergency services. On [DATE] at 6:47 AM, Registered Nurse (RN #2) was interviewed. She stated the facility's policy was not to call 911 for residents. The nurses were instructed to call the private ambulance companies. We call [Ambulance Company #1] first and if they are not available or will take too long, we go down the list and call another company. After we try all the ambulance companies, we can call the [local] police department and then they can call 911. On [DATE] at 10:50 AM, the Medical Director (MD) was interviewed. The MD indicated she was involved in the development of all the medical policies for the facility. She stated she was technically not involved in the development of the Code Blue policy because she understood it to be a directive from [name of city]. Her understanding of the policy was as follows: The facility was not allowed to call 911. They were to try one of the private ambulance companies first; and then the private ambulance company would call for paramedics, if needed. On [DATE] at 11:57 AM, a telephone interview was conducted with the Chief of the [name of city] Volunteer First Aid Squad. The Chief stated that approximately a year ago, there was a meeting at the Mayor's office with the local assisted living and nursing homes to discuss how to best utilize the volunteer first aid squad. The Chief explained as an all-volunteer Basic Life Support (BLS) squad, they were lucky if they had one ambulance available for a timely dispatch at any given time. The purpose of the meeting was to ask the assisted living and the nursing homes to have contracts with private ambulance companies for routine transports (dialysis, doctor appointments) and not put an extra taxing on the volunteer squad. The Chief stated they recommended facilities call the private ambulance companies first, but if they need paramedics for a life-threatening event, they should call 911. If 911 was called, the [name of paramedics] unit would be dispatched. On [DATE] at 3:29 PM, a telephone interview was conducted with the [name of city] Assistant to the Mayor (Mayor's office). The Mayor's office stated the meeting was to ask the assisted living and nursing home facilities to utilize their contracted private ambulance companies for non-emergent needs only. Per the Mayor's office, there was no directive stating 911 should not be called. The Mayor's office felt the 911 system should be utilized to reach paramedics for a timely dispatch. The facility's policy for Code Blue Medical Emergency Response, dated [DATE] and revised on [DATE], was reviewed. It read, in part, as follows: Procedure: Medical Emergency Response 1. A person in a medical emergency is identified. 2. Identify code status of a resident. NOTE: The medical record will also be checked to verify the code status of the resident. If you are the first responder in an emergency situation: - Check the person for responsiveness - If unconscious, send first staff encountered to call for Code Blue - If you are alone, dial the operator/security desk, ask for Code Blue to be announced with the exact location of the person in need of immediate medical attention. - Return to the person, If unconscious, open the airway and check for breathing. If breathing, place in the recovery position (not used for suspected head injuries or fractures), and monitor breathing and pulse. - If unable to give breaths, begin procedure for obstructed airway. - If no pulse, start chest compressions. 3. The following will be responsible to the Code Blue announcement. - Nursing Supervisory staff/nurse. - Nurse Practitioner and physician - CPR Trained personnel - A nurse with a crash cart, AED, and Emergency meds box. - Security if patrol is available. 4. Nursing personnel arriving on the scene will evaluate the emergency. 5. A nurse will take charge. The staff not needed to participate in the emergency will be directed to return to their units or to help monitor residents who may be in the area. The nurse will: - page for more assistance if needed. - If the person is a resident: Resident - any nurse responding to the emergency will assess resident and can call and ambulance if needed. DO NOT CALL 911, if paramedics were notified, call and alert security that ambulance or paramedics is on the way. - If non-resident (visitor or employee) call 911. - Have security guard secure an elevator to be available for the emergency. On [DATE] at 11:13 AM, the ED was informed the IJ Removal Plan had been accepted by the New Jersey Department of Health. The facility's Removal Plan read as follows: IJ Removal Plan [DATE] This response to findings outlined in the immediate jeopardy template was the facility's credible allegation of compliance. Preparation and/or execution of this response does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Immediate Jeopardy template. The response was prepared and/or executed solely because it was required by the provisions of federal and state law. The facility respectfully denies these findings, notwithstanding the following actions have been taken: Element One Resident #4 no longer resides at the facility. An investigation into the events of [DATE] surrounding the care of Resident #4 was initiated by the Executive Director and Director of Nursing (DON) on [DATE]. Staff were interviewed and statements were obtained from those involved in the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital paramedics notes were requested for review but were not provided. Executive Director was verbally informed by Director at [name of paramedic] that his staff were told that the resident was unresponsive at 4:30 AM and it was noted that CPR was in progress when the paramedics arrived. Paramedics were dispatched at 5:12 AM as per his record. The AED manufacturer [name of manufacturer] was contacted on [DATE] by the MIS Nurse [RN #3] with a request to retrieve AED data for review with company representative confirmation that results will be sent before COB (close of business) on [DATE]. On [DATE], the Product Support Engineer of [name of manufacturer] provided documentation that the AED was used on [DATE]. He explained that because the AED (FRx) uses a sequential chronometer and not a clock that keeps trace of current day and time, the actual time of the event cannot be estimated. He documented that this was the only event recorded on that date. The facility investigation was concluded on [DATE]. Staff involved in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Forty-two nurses were re-educated by the Assistant Nursing Supervisor and the Staff In-service Instructor (DSD) on [DATE] and [DATE] on Code Blue Medical Emergency Response and how to properly document actions and responses. On [DATE], the ADON re-educated nursing supervisors on Code Blue, medical emergency response and documentation, AED use. Element Two All Residents who require CPR have the potential to be affected by this practice. Element Three The Code Blue Medical Emergency Response policy was reviewed and revised on [DATE] by the Medical Director (MD) and Executive Director (ED) to specify announcing and responding to a code, assessing the resident, calling 911 for EMS and requesting paramedics if necessary, use of AED, documentation requirements, further clarification of role responsibilities and documentation of all actions and responses during a Code Blue with accurate times, actions taken during the code and resident outcome. The Calling the Code posting that is posted on each resident unit was revised to direct that 911 is to be called for EMS and paramedics. In-service that began on [DATE] is in progress for all nursing staff, including licensed nurses, nursing management, nursing supervisors and certified nursing assistants by the DON, ADON, Staff Inservice Instructors (DSD) and Assistant Nursing Supervisor on the revised Code Blue Medical Emergency Response policy to include a thorough review of the revised Code Blue policy and procedures to follow. The 42 staff re-educated on [DATE] and [DATE] before the policy revision will be educated by the DON, ADON, Assistant Nursing Supervisor and Inservice Instructors on the revised policy. Education includes announcing and responding to a code, assessment of the resident, actions to take based on assessment findings, process to initiate CPR if required, use of the defibrillator as appropriate, process for contacting EMS by calling 911, and documentation of all actions taken in the medical record with the time of each action at the conclusion of the code. Education includes review of all Code Blue documents including the revised policy and procedure with the additional documentation requirements, the Code Blue Checklist, Code Blue worksheet, AED Incident Report form, and Code Blue sample progress note with timelines of actions taken and outcomes. As of 7:00 PM on [DATE], 63 nursing staff were educated. Education will continue the 11 PM to 7 AM shift on [DATE] and will continue [DATE]. Any nursing staff requiring re-education who are not on the current work schedules will receive re-education at the start of their next scheduled work shift. Nursing supervisors received re-education regarding their role when a Code Blue was called to ensure the facility procedures were followed and to ensure Code Blue response, Code Blue actions are properly implemented and when required contact with EMS was timely. Education also included supervisory review of all Code Blue documents including the revised policy and procedures with the additional documentation requirements, the Code Blue Checklist, Code Blue worksheet, AED Incident Report form, and Code Blue sample progress note with timelines of actions taken and outcomes. Element Four The DON/designee will review all Code Blue actions and documentation for the next three months to ensure all proper procedures and protocols were followed during any Code Blue. Findings from these reviews will be analyzed and reported to the Executive Director and Medical Director and in the aggregate at the monthly QAPI meeting by the DON/designee and serve as the basis for action as appropriate. Based on the findings, the QAPI committee will determine if additional audits are required. The Executive Director is responsible for the implementation of the removal plan. Completion Date - [DATE] The Plan of Removal was signed by the ED on [DATE]. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On [DATE] between the hours of 12:00 PM and 3:26 PM, 15 interviews were conducted to verify in-service training had been completed on the facility's new Code Blue documents, including the revised policy and procedures with the additional documentation requirements, the Code Blue Checklist, Code Blue worksheet, AED Incident Report form, and Code Blue sample progress note with timelines of actions taken and outcomes. Of those interviewed, five were Certified Nursing Assistants (CNAs), two were Licensed Practical Nurses (LPNs), four were Registered Nurses (RNs), one day shift RN Supervisor, two evening shift RN supervisors, and one night shift RN Supervisor. The staff interviewed revealed knowledge of the protocol to call 911 immediately. The staff indicated that the nurse who identified the resident in distress would inform the first person to arrive at the resident's room to call 911, therefore ensuring EMS services were dispatched as soon as possible. The interviews revealed a consistent message that they call 911 directly to have paramedics dispatched in the event of a life-threatening medical emergency. The CNAs indicated their training included the ability to call the Code Blue on the overhead paging system and 911. The licensed nurses indicated the new forms for the Code Blue checklist, Code Blue worksheet, and AED incident Report Form would ensure all items were appropriately documented during a Code Blue incident. NJAC 8:,d+[DATE].1(a)

Complaint # NJ 839 Based on observation, interview, medical record review and review of other facility documentation on 7/21/14 and 7/22/14, it was determined that the facility failed to consistently provide adequate supervision for residents identified as a fall risk. This deficient practice was for 1 of 4 sampled residents (Resident #4). Resident #4 fell out of a chair and required staples to a laceration on the head. This deficient practice was evidenced by: According to the medical record, Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 5/28/14, reflected that the resident had severe impairment in cognition. The MDS also reflected that the resident required total assistance for transfers and total care with all aspects of activities of daily living (ADL's). A facility Reportable Event Record/Report (FRE) and associated investigative documents, faxed to the Department of Health (DOH) on 5/27/14, indicated that on 5/3/14, Resident #4 was in the activity room with other residents and fell from the "Broda" chair. The FRE also indicated that the Recreational Therapy Aide (RTA) witnessed the resident falling from the chair while interacting with other residents. The resident fell , hitting his head and sustained a laceration that required 6 (six) staples. The facility conclusion to the investigation reflected that the resident slid out of the chair due to poor truck control. According to the FRE the facility interventions included; Physical Therapy evaluation of the resident's positioning in the Broda chair and that the nursing staff will assign a Certified Nursing Assistant (CNA) to monitor resident in the activity room on all shifts. The "Fall Risk Assessment" dated 4/4/13, indicated a score of "6", which indicated that Resident #4 was in the range of moderate risk for falls. The "Care Plan" dated 2/26/13, reflected that Resident # 4 was at risk for falls due psychotropic medication usage and the resident required a mechanical lift for transfers. The surveyor reviewed an "Employee Statement" written by the RTA, dated 4/3/14. The RTA stated in an interview with the surveyor on 7/22/14 at 10:00 a.m., that the date was written wrong on the statement, "It should have been 5/3/14." In this statement, the RTA indicated that there wasn't a CNA in the room with her at the time that Resident #4 had fallen. The RTA also stated that there is supposed to be an assigned CNA in the recreational room at all times when residents are in that room. "I don't know where the CNA was, but they are supposed to be in the recreation room to monitor the residents." The surveyor conducted an interview on 7/22/14 at 10:05 a.m., with the 7a.m.- 3p.m. Licensed Practical Nurse (LPN). The LPN stated that a CNA was to be assigned to the recreational therapy room at all times for resident monitoring. At that time, the surveyor observed the recreational room and there was no CNA in the room, nor was there a CNA assigned to the recreational therapy room. The surveyor observed approximately seven residents in the room. The LPN then stated that there is usually no one assigned to the recreational therapy room in the morning, and that there is usually someone assigned to the recreation therapy room during the afternoon and change of shift. The LPN also stated that there should be a CNA in the recreational room when residents were in there. The surveyor conducted an interview on 7/22/14, at 11:00 a.m. with the 3 p.m.- 11 p.m. Registered Nurse (RN) assigned to Resident #4 on 5/3/14. The RN indicated that a CNA should have been assigned to the recreational therapy room, however, there was not a CNA in there when Resident #4 fell . The RN stated, " There is supposed to be a CNA assigned to the recreation room when residents are in there, I don't know why there wasn't." The surveyor conducted an interview on 7/22/14, at 12:15 p.m. with the 3 p.m.-11 p.m. RN supervisor. The RN supervisor stated she was notified that Resident #4 had fallen in the recreational therapy room. The RN stated that a CNA was not assigned to the recreational therapy room at the time that Resident #4 had fallen and she does not know why. "It is the facility practice that a CNA is assigned to that room while residents are in there. The CNA is assigned in there to make sure residents are monitored to prevent falls." The surveyor interviewed the DON on 7/22/14, at 12:50 p.m. The DON stated that a "CNA should be assigned to the recreation therapy room at all times while residents are in there. The CNA's are assigned in the recreation therapy room to monitor residents. There is no written policy on recreational room monitoring." The form titled, "Assignment 3-11 Shift" dated 5/3/14, reflected a CNA was not scheduled to monitor the activity room at the time of Resident #4's fall. The same assignment sheet indicated that all residents were to be removed from the activity room after 3:30 p.m. The FRE faxed to the DOH on 5/27/14 indicated that Resident #4 fell from the "Broda" chair in the recreation therapy room on 5/3/14, at 3:55 p.m. An interview was conducted by the surveyor on 7/22/14, at 1:10 p.m. with the Recreation Therapy Aide (RTA). The RTA stated that on 5/3/14, there was about 20 residents in the recreation room watching a movie and that the movie ran past 3:30 p.m. "The CNA's were supposed to take the residents out of the recreation room at 3:30 p.m. even when the movie was on. They usually take the confused residents first, that are not participating in the activity. The practice is that a CNA should be assigned to the recreation room with me as long as there is residents in there." A review of the facility 3p.m.- 11p.m. assignment sheet dated 5/3/14, indicated that a CNA was assigned to the activity room. NJAC 8:39-27.1 (a)