Every finding on record at Preferred Care at Hamilton

Based on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to maintain complete and accurate medical records. Specifically, the facility did not have physician's orders and a care plan in place for the use of bilateral hearing aids. This deficient practice was identified for 1 of 1 resident (Resident #117) reviewed for communication and sensory needs. This deficient practice was evidenced by the following:On 5/6/2026 at 11:06 AM, the surveyor observed Resident #117 on the North Wing hallway self-propelling in his/her wheelchair and not wearing bilateral hearing aids. The bilateral hearing aids were observed on the resident's bedside dresser drawer. The surveyor said hello to the resident, and the resident did not respond to the surveyor. On 5/7/2026 at 11:34 AM, the surveyor observed the resident in his/her bedroom sitting in their wheelchair watching television and not wearing bilateral hearing aids. The bilateral hearing aids were observed on the resident's bedside dresser drawer. The surveyor said hello to the resident, and the resident did not respond to the surveyor. A review of the admission Record (an admission summary) revealed diagnoses including, but not limited to, hearing deficits (decreased hearing ability). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/7/2026, included a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. A review of the Individual Comprehensive Care Plan (ICCP), dated 4/1/2026, did not include a focus area or interventions to address the resident's hearing deficits or the use of bilateral hearing aids. A review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated May 2026, did not include a physician order for bilateral hearing aids. During an interview with the surveyor on 5/7/2026 at 11:38 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM), who has worked at the facility for two years as the North Wing UM, stated that the resident should have a physician's order and care plan addressing bilateral hearing aids to ensure staff were aware the resident used hearing aids and to guide the plan of care. During an interview with the surveyor on 5/12/2026 at 9:30 AM, the Director of Nursing (DON) stated that other residents have physician orders for hearing aids because they required staff assistance with application and removal for accountability purposes. The DON further stated that Resident #117 does not require assistance with applying or removing hearing aids, therefore, a physician's order was not necessary. The DON also noted that bilateral hearing aids should be included on the care plan because it helped guide the resident's care. A review of the facility's Hearing Aide policy, dated January 2026, included This facility supports residents in the use and routine care of their hearing aids, including keeping devices clean, properly stored, and protected from damage or loss when not in use. Residents will be encouraged to independently apply, remove, and care for their hearing aids whenever able, with staff providing assistance as needed to promote safety, dignity, and maintenance of functional independence. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to properly label and date the oxygen nasal cannula (NC) (a device used to deliver oxygen through tubing) for 1 of 1 resident (Resident #129) reviewed for respiratory care. This deficient practice was evidenced by the following: On 5/6/2026 at 11:12 AM, the surveyor observed Resident #129 in his/her bedroom lying in bed watching television, with the head of the bed elevated to approximately 90 degrees, receiving oxygen through a NC at two (2) liters per minute (LPM). The NC was not labeled or dated. On 5/7/2026 at 11:33 AM, the surveyor observed the resident in his/her bedroom sitting in their wheelchair watching television and receiving oxygen through a NC at 2 LPM. The NC was not labeled or dated. A review of the admission Record (an admission summary) revealed the resident had diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that blocks airflow and makes breathing difficult), Congestive Heart Failure (CHF - a condition in which the heart cannot pump blood effectively, leading to fluid buildup in the lungs), and respiratory conditions due to smoke inhalation (a condition in which the lungs are damaged or irritated from breathing in smoke). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/26/2026, included a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. A review of the Individual Comprehensive Care Plan (ICCP), dated 4/17/2026, included a focus area indicating that Resident #129 received oxygen therapy. Interventions included: administering oxygen as ordered. A review of the Treatment Administration Record (TAR), dated May 2026, included the following physician orders (PO):PO dated 5/6/2026: Oxygen 2 LPM via nasal cannula every shift. During an interview with another surveyor on 5/7/2026 at 10:08 AM, the Infection Preventionist (IP) stated that oxygen tubing should be labeled, dated, and changed weekly for infection control purposes. During an interview with the surveyor on 5/11/2026 at 11:53 AM, the Director of Nursing (DON) stated that Resident #129's oxygen tubing should have been labeled and dated for infection control purposes. A review of the facility's Oxygen Administration policy, dated February 2026, included Date and initial tubing and humidifier bottles when started and weekly. Store tubing when not in use in a clean plastic bag. N.J.A.C. S 8:39-19.4(a)

Complaint #175979 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) implement interventions to prevent the development of a stage 3 (full thickness wound) facility acquired pressure injury; b.) ensure individualized comprehensive care plan interventions were implemented to prevent a facility acquired pressure injury wound from worsening; c.) ensure daily observation during wound care was documented according to professional standards of nursing practice to follow continuity of care; and d.) ensure that the physician evaluated and assessed the resident's medical issues related to skin care. This deficient practice occurred for 1 of 2 residents reviewed for pressure ulcers (Resident #167). Resident #167 was identified as having moisture associated skin damage (MASD) and dermatitis (inflammation of the skin) on the right buttocks measuring 2 centimeters (cm) x 1.5 cm x 0.1 cm on 5/29/24, which progressed to a stage 3 pressure injury on 6/5/24, of the right buttocks measuring 2.8 cm x 1.5 cm x .2 cm and MASD on the sacrum measuring 2 cm x 0.7 cm x 0.1 cm. The evidence was as follows: A review of the Admission Record face sheet (admission summary) indicated that Resident #167 was admitted to facility with the diagnoses that included but not limited to; Parkinson's disease and protein calorie malnutrition. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/10/24, indicated that Resident #167 had moderate cognitive impairment and required partial to moderate assistance with activities of daily living (ADLs). The MDS also indicated that the resident was at risk for developing pressure ulcers/injuries. A review of the Resident Evaluation-V2 dated 4/7/24, reflected that Resident #167's skin was intact at the time of admission to the facility and the Braden Scale (used to predict pressure ulcer risk) reflected that the resident's score was 15, which indicated that the resident was at risk for skin breakdown. The surveyor was unable to interview or observe Resident #167 as the resident was longer a resident in the facility. A review of Resident #167's individual comprehensive Care Plan (ICCP) dated 4/7/24, reflected that the resident was at risk for skin breakdown related to bladder incontinence and immobility. Interventions included to: turn and reposition every two to four hours; inspect skin during provision of care and bathing activities; labs as ordered; limit out of bedtime to two hours per session; provide pressure relieving cushion; report any skin breakdown to the nurse; suspend or float heels as able; apply moisture barrier cream and needed for protection after each incontinent episode. A review of the Treatment Administration Record (TAR) dated 4/7/24, reflected a physician's order to apply peri-guard external ointment (skin protectants, miscellaneous) to the coccyx (tailbone) topically every shift for skin protection and/or healing. The order was subsequently discontinued on 4/8/24. The ICCP was not updated to reflect that the resident was not receiving a moisture barrier cream for preventive protective skin care. On 1/29/25 at 10:34 AM, the surveyor interviewed the Licensed Practical/Nurse Unit Manager (LPN/UM #1), who stated that Resident #167's skin was assessed on admission to the facility and was intact. LPN/UM #1 stated that skin checks were ordered on admission and were scheduled to be conducted on the resident's shower days. LPN/UM #1 added that skin checks were documented on the Medication Administration Record (MAR) and the nurses assigned to the resident were required to sign that the skin check was performed. LPN/UM #1 stated that he thought the condition of the resident's skin was documented in the resident's progress notes but was not sure. A review of the MARs for April, May, and June of 2024, included a physician's order dated 4/7/24, for skin checks to be done on shower days every evening shift on Tuesday and Friday for monitoring. There was no weekly documentation of skin checks describing the resident's skin condition until the resident developed moisture associated skin damage on 5/29/24. A review of the Wound Observation Progress Note (WOPN) dated 5/29/24 at 5:30 AM, indicated that the resident had developed a facility acquired skin injury on the right buttocks measuring 2 cm x 1.5 cm x 0.1 cm. The wound was described as moisture associated skin damage (MASD) and dermatitis (inflammation of the skin). A review of the resident's ICCP revealed that the ICCP was not updated to reflect that the resident had developed actual skin impairment, and no new interventions were initiated to prevent further deterioration of the skin after the resident developed an impairment on 5/29/24. A review of the Wound Care Consultant Report (WCR) dated 5/29/24, reflected that the resident developed MASD on the right buttocks. The WCR indicated that the Wound Care Consultant (WCC) recommended honey gel with a border foam dressing as the treatment to the resident's right buttocks. According to the report, the WCC performed a treatment to the wound using honey gel with a border foam dressing on 5/29/24. The WCC also recommended preventative interventions to promote wound healing such as: alternating pressure mattress with turning and repositioning; a specific type of gel (roho) cushion to be applied to the resident's wheelchair (to reduce pressure); and to encourage the resident to perform seat lifts every 15 minutes. The ICCP was not updated to reflect these interventions. A review of the Physician Order Report (POR) dated 5/30/24, reflected a wound treatment to start on 5/31/24, and to cleanse the area with normal saline solution (NSS), apply Medihoney wound/burn dressing external gel (wound dressings) to the right buttock topically everyday shift for wound care and to cover with a bordered foam dressing daily. The treatment was started two days after the WCC recommended the treatment to start on 5/29/24. A review of the May 2024 TAR revealed that Resident #167 did not have a treatment done on 5/30/24. The TAR revealed that the treatment was not performed until 5/31/24. A review of the MAR dated 5/31/24, had a nursing signature indicating that a skin check was performed for Resident #167. There was no further documentation regarding the condition of the resident's skin. A review of the Nurse Practitioner Note (NPN) dated 6/2/24, indicated that the Nurse Practitioner (NP) documented that the resident had no wounds, rash, or lesions and that the skin turgor/texture was within normal limits (wnl). A review of the NPN dated 6/4/24, indicated that the NP documented that the resident had no wounds, rash, or lesions and that skin turgor/texture was wnl. A review of the primary care physician (PCP) notes dated 5/31/24 at 5:01 PM, 6/2/24 at 10:12 PM, and 6/4/24 at 10:29 PM, did not address the resident's MASD that developed on their right buttocks. A review of the TAR dated 6/4/24, included a nursing signature that indicated a skin check was performed for Resident #167. There was no further documentation regarding the condition of the resident's skin. A review of the WOPN dated 6/5/24 at 8:38 PM, reflected that Resident #167 had developed a stage 3 pressure ulcer of the right buttocks measuring 2.8 cm x 1.5 cm x .2 cm and MASD of the sacral area measuring 2 cm x 0.7 cm x 0.1 cm. The resident had a weekly skin check done on 6/4/24, and there was no documentation regarding the resident's skin condition. A review of the WCR dated 6/5/24, indicated that the resident's skin condition had worsened. The documentation reflected that the resident's right buttocks wound had deteriorated to a stage 3 pressure injury measuring 2.8 cm x 1.5 cm x 0.2 cm and developed MASD of the sacral area measuring 2 cm x 0.7 cm x 0.1 cm. The WCR indicated that the resident had a bedside sharp debridement (a surgical procedure used to remove dead (necrotic) tissue from wounds) of the right buttocks wound and the resident tolerated the procedure well. The WCR specified that the resident was to be offloaded (method applied to reduce pressure) utilizing an alternating pressure mattress. The resident's ICCP did not reflect that the resident was utilizing the mattress as recommended by the WCR. A review of the subsequent PCP note dated 6/8/24 at 4:30 PM, the physician did not address that the resident had a new stage 3 pressure injury on the right buttocks. The NP nor the PCP documented and addressed that the resident had developed a facility acquired stage 3 pressure ulcer until 6/11/24. On 1/29/25 at 11:27 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that weekly skin assessments were ordered on admission and performed on the resident's shower days. The IP explained that skin checks were ordered weekly as a preventative measure to prevent skin breakdown and the checks were documented on the MAR when it was completed. The IP stated that she was not sure where the actual skin check was documented regarding the condition of the residents' skin. At that time, the IP reviewed the resident's medical record and stated that she could not locate where the nurses were writing what the resident's skin actually looked like, but would find out where the information was located. The IP stated that the facility completed a RMS (Risk Management System-incident) report which was the WOPN when a resident developed a wound. The IP reviewed the resident's ICCP with the surveyor and confirmed that the ICCP was not updated to include actual skin breakdown with interventions after the resident developed skin breakdown on 5/29/24. On 1/30/25 at 10:01 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the nurses were required to sign the MAR after completing a weekly skin check. The DON stated that weekly skin checks were documented by exception, meaning that the nurses only documented if there was an issue with the resident's skin. The DON stated that she would have expected the nurses to write a description of the resident's skin when they performed a weekly skin check after the resident had developed a skin impairment on 5/29/24. The DON did not have an explanation as to why the treatment order was not obtained when the resident developed skin breakdown on 5/29/24. The DON reviewed the TAR in the presence of the surveyor and confirmed that the treatment order was not received until 5/30/24, but was not completed until 5/31/24. The DON did not have an explanation as to why Resident #167's ICCP was not updated to reflect the WCR recommendations for additional offloading interventions after the wound development on 5/29/24. The DON explained that the facility did not need an order for periguard ointment because the Certified Nursing Aide (CNA) applied it to the resident's buttock during care for skin protection. On 1/30/25 at 1:20 PM, the surveyor interviewed the WCC, who stated that he saw Resident #167 on 5/29/24, and that treatment recommendations and offloading interventions were given to the nurse on the that day. The WCC stated that the nurses were responsible to get the treatment orders from the providing physician and to update the ICCP with the new offloading interventions to aid in skin healing. On 2/3/25 11:44 AM, the surveyor conducted a telephone interview with the resident's PCP, who stated that he left the recommendations for wound care up to the wound care team. The PCP stated that he did not write the notes on 6/2/24 or 6/4/24, that Resident #167's skin was intact. The PCP stated a Nurse Practitioner (NP) documented those notes, and that he did not work with the NP. The PCP added that the NP was hired by the facility and he did not follow-up or supervise the NP. The PCP did not have a response as to why there was no documentation from the PCP or NP that addressed that the resident developed a facility acquired stage 3 pressure ulcer until 6/11/24. On 2/3/25 at 12:01 PM, the surveyor interviewed the Medical Director (MD), who stated that there were two groups of NPs that came to the facility and saw the residents. The MD stated that the NPs were contracted and they had their own physicians. The MD also stated that the NP should have been reporting to the attending physician (PCP) and the MASD wound should have been reported to and addressed by the physician. The MD stated that the NP who documented that the resident's skin was intact when in fact it was not, did not work at the facility anymore, but he would have to address with the PCP that it was not documented until 6/11/24, that the resident had a new wound. A review of the facility's Skin Assessment Policy dated 1/3/25, included it was the policy to perform a full body assessment as part of our systematic approach to pressure injury prevention and management .documentation of skin assessments with any skin impairment will be noted in the patients' medical record . A review of the facility's Pressure Ulcer/Wound Treatment Management policy dated 2/1/24, included that the facility was to provide evidence-based treatments in accordance with current standards of practice and physician's orders .wound treatments will be provided in accordance with physician's orders and in the absence of treatment orders, a licensed nurse will notify the physician to obtain treatment orders . A review of the facility's Care Plan Process policy dated September 2024, included that the resident's care plan (CP) will be developed was appropriate for each resident's needs and/or wishes based on the assessment and reassessment process with the required timeframes .the plans of care have key areas, may include but were not limited to health maintenance and daily care needs .the CP would include problem statements to include medical problems for which the resident was on significant medications (i.e., hypertension, diabetes etc.). The policy indicated that a CP would include: identified problem; onset date; related risk factors; build on the resident's strengths; reflect treatment goals and objectives; interventions and approaches. A review of the facility's Pressure Ulcer/Wound Treatment Management policy dated 2/1/24, included the facility was to provide evidence-based treatments in accordance with current standards of practice and physician's orders .wound treatments will be provided in accordance with physician's orders and in the absence of treatment orders, a licensed nurse will notify the physician to obtain treatment orders . A review of the facility's Resident Care Consultants and Referrals policy dated June 2024, included the nurse would inform the attending physician of the consulting physician recommendations for appropriate follow-up and physician orders if indicated . A review of the facility's Service Agreement - Advance Practice Nursing dated 6/5/18, included the facility had a contract with [name redacted] to provide advanced practice nurses (APN). The APNs were expected to follow all facility policies and procedures. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/28/25 at 10:00 AM, during initial tour of the kitchen, the surveyor, accompanied by the Food Service Director (FSD) and the Licensed Nursing Home Administrator (LNHA) observed the following: Upon entering the kitchen, the FSD washed her hands at the hand washing sink, and lathered with soap outside the flow of running water for 14 seconds. The LNHA then washed his hands lathering with soap prior to rinsing for a total of 13 seconds. The surveyor used a digital stopwatch to record the time. The [NAME] had a long beard with a beard net that was worn under his chin and not covering his beard hair while he actively worked in the kitchen. At that time, the FSD confirmed it should not have been worn that way. A plastic bin of powdered mashed potatoes and a bin of flour both had the scooper stored inside the bin hanging off the edge. The scoopers caused the lids to remain slightly open. At that time, the FSD confirmed it should not have been stored that way and could allow rodents to get in. One 16-ounce (oz.) container of dried parsley flakes, one 16 oz container of bay leaves, and one 16 oz container of dried thyme which were opened and not dated with an opened date. The ice scooper bin was mounted on the wall above seven uncovered racks of clean coffee mugs and soup bowls. The mugs and bowls had water on them. The FSD stated that the ice scooper bin had been there forever meaning above the spot where racks of clean supplies were stored. In the walk-in freezer was one pie, identified by the FSD as an apple pie, covered with plastic wrap and not labeled or dated. Next to the walk-in refrigerator were two racks of clean dessert bowls that were uncovered with an exterior exhaust fan cage above it. The fan was covered with a thick layer of gray dust-like material. Next to the two racks of clean dessert bowls was the refrigerator's cooling system/motor which was also covered in a thick layer of gray dust. On the drying rack were two red and two white cutting boards which were pitted and had deep cut marks. On 1/30/25 at 11:15 AM, during a follow-up tour of the kitchen, the surveyor observed the following: The [NAME] went to the hand washing station, wet his hands, dispensed foam soap into his hands, and immediately began to rinse his hands with no lather time. Following the Cook, a Dietary Aid (DA #1) washed his hands lathering with soap for 16 seconds prior to rinsing The usrveyor used a digital stopwatch to record the time. DA #2 was observed at the steam table leaning over a large tray of mashed potatoes as he used a large whisk to mix the potatoes. The surveyor observed DA #2 with a large amount of sweat drops on his face and running down his nose, dripping into the tray of mashed potatoes as he mixed. At that time, the surveyor approached the Regional Food Service Director (RFSD) and informed him of that observation. The RFSD approached DA #2, observed the sweat on his face, and acknowledged the concern. On 1/31/25 at 11:46 AM, the surveyor interviewed the Infection Preventionist (IP) in the presence of the LNHA and the Director of Nursing (DON). The IP stated that she provided infection control education including hand hygiene to all facility staff including kitchen staff and administration. The IP stated that the required minimum time for lathering with soap when washing hands for infection control was 20 seconds. At that time, the LNHA added that he was also educated on the proper amount of time to lather with soap when washing his hands and acknowledged the surveyor's observation of him not meeting the minimum 20 seconds. The IP further stated that anyone who entered the kitchen was required to wear proper hair and beard nets appropriately and that those items were readily available at the kitchen entrance. The IP stated that having beard hair and any other hair outside of the hair net posed an infection control risk. On 2/3/25 at 10:13 AM, in the presence of the survey team, the LNHA acknowledged that personal hygiene when preparing food, appropriate hand hygiene, and proper use of hair and beard nets should have been followed appropriately in the kitchen. The LNHA also acknowledged that kitchen supplies and equipment should have been maintained in a sanitary manner, and that all items should have been labeled and dated appropriately. A review of the facility's Hand Hygiene policy with a most recent created date of 8/1/24, included all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. This applies to all staff working in all locations within the facility .hand hygiene technique when using soap and water: a. wet hands with water. avoid using hot water to prevent drying of skin. b. apply to hands the amount of soap recommended by the manufacturer. c. rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. rinse hands with water . A review of the facility's dietary Dating policy with a reviewed date of 8/2023, included all fresh and frozen foods must be dated with the date it was received into the kitchen, unless it has a purveyor shipping label on it. Make sure to not date over or cover up the manufacturer's expiration date on the product . A review of the facility's Personal Hygiene policy with a reviewed date of 8/2024, included cover hair and facial hair with restraint (hairnet, cap, beard net or hat). Mustaches and beards must be well trimmed . A review of the facility's Kitchen Supplies: Storage policy with a most recent created date of 6/2024, included all food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of . A review of the facility's Food Prep Hygiene policy with a last revised date of 6/2024, included during food preparation, maintain appropriate distance and body posture from food prep area to avoid possible contamination . NJAC 8:39-17.2(g)

Based on observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medication. This deficient practice was identified for 1 of 5 residents reviewed for psychoactive medication used (Resident #85), and was evidenced by the following: On 1/30/25 at 12:07 PM, the surveyor observed Resident #85 sitting up in the wheelchair reading a book. The resident was very pleasant and stated they were having a good day and had no complaints. The surveyor reviewed the medical records for Resident #85. A review of the Admission Record face sheet (an admission summary) reflected that Resident #85 was admitted to the facility with the diagnoses which included but not limited to; chronic respiratory failure and diabetes mellitus (DM). A review of the comprehensive Minimum Data Set (MDS), an assessment tool, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident was dependent on staff for activities of daily living (ADLs) and received psychoactive medications. A review of the Medication Administration Record (MAR) revealed that the resident was on the following psychotropic medications: A physician's order (PO) dated 7/26/24, for trazodone hydrochloride (HCl) oral tablet 150 milligrams (mg); give 75 mg by mouth at bedtime for depression targeting insomnia. A PO dated 12/24/24, for lorazepam oral tablet 0.5 mg; give 1 tablet by mouth two times a day for anxiety. A PO dated 1/29/24, for buspirone HCl oral tablet 7.5 mg; give 1 tablet by mouth two times a day for anxiety. A PO dated 9/11/24, valproic acid oral solution 25 mg/5 milliliters (ml), anticonvulsant, give 5 ml by mouth every 12 hours for mood disorder. A review of the individual comprehensive Care Plan (ICCP) which included the following focus areas: A focus area dated initiated 4/19/24, that Resident #85 had the potential to express mood issues related to recent admission to the facility and history of depression. Interventions included: monitor, record, report to the medical doctor (MD) as needed (prn) acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate; change in psychomotor skills; and monitor, record, report to MD prn mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. A focus area dated initiated 4/19/24, that the resident had the potential to be verbally abusive (i.e. screams/curses at staff/residents) related to (r/t) cognitive impairment, dementia, ineffective coping skills, and delusional behaviors. Resident #85 was noted to be incontinent of bowel and bladder and refused frequently to allow incontinence care, refused frequently to get out of wheelchair and sit and/or lie down in bed, refused labs, refused to sleep in the bed often despite verbalization of understanding with continuous education. Interventions included to: monitor behaviors every shift; document and observed behavior and attempted interventions. A focus area dated initiated 4/18/24, Resident #85 used antidepressant medication trazodone r/t depression and anxiety, delusions, anxiousness, verbally aggressive with staff. Interventions included to: administer antidepressant medications as ordered by physician, monitor and document side effects and effectiveness; monitor, document, report prn adverse reactions to antidepressant therapy: change in behavior, mood, or cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. loss, nausea and vomiting, dry mouth, dry eye. A Review of Resident #85's MAR and the Treatment Administration Record (TAR) did not include documentation that the facility was monitoring the resident's behavior for the use of psychotropic medications. On 1/31/25 at 9:50 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated that Resident #85 required complete care with ADLS. The CNA stated that the resident was incontinent of bladder and bowel and wore incontinent briefs. The CNA stated that the resident was able to feed themselves and became anxious at times. The CNA stated that the resident became very confused and thought they were leaving the facility. The CNA stated that the resident did not become verbally or physically aggressive when she provided them care. On 1/31/25 at 9:55 AM, the surveyor interviewed Resident #85's Licensed Practical Nurse (LPN), who stated the resident required complete care with activities of ADLs. The LPN explained that Resident #85 could be sweet one minute and then could be cursing and screaming at the staff the next minute. The LPN explained that the resident usually exhibited behaviors during the evening shift and during sundown hours. She stated that the resident usually calmed down on their own and apologized for the behaviors. The LPN stated that if the resident had behaviors, the behaviors were documented in the Progress Notes. The LPN reviewed Resident #85's medical record, and confirmed that the resident did not have physician's orders for behavior monitoring or monitoring for side effect from psychotropic medication use. The LPN stated that she had seen other residents that had orders for that, and she was not sure why some residents on psychotropic medications had orders for side effects and behavior monitoring and some did not. On 1/31/25 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who explained that when residents started a new psychotropic medication or any changes in medications, the resident was monitored for 14 days. The LPN/UM stated that medication monitoring was documented in the Progress Notes. The LPN/UM stated that behavior monitoring and side effect monitoring for the use of psychotropic drugs was done on a case-by-case bases. The surveyor and the LPN/UM reviewed the resident's ICCP which specified that the resident's behavior was to be monitored every shift for the use of psychotropic medications, and the LPN/UM stated that she did not know the facility's behavior monitoring protocol. On 1/31/25 at 10:37 AM, the surveyor attempted to call the Resident's Representative (RR), but the phone number documented in the medical record was the wrong number. A review of the facility's policy Behavior Management, Intervention and Monitoring policy dated 7/1/24, indicated that the facility was to monitor specific behavior for resident's receiving psychotropic medications and that a licensed nurse would monitor and document drug side effects of all psychotropic use daily and will note in the resident medical record for behavior and side effects observed. On 2/3/25 at 10:14 AM, the surveyor interviewed the Director of Nursing (DON), who stated that behaviors were documented by exception, meaning only when the resident exhibited behaviors. The DON stated that the facility only documented and monitored the resident when a resident was being gradually dose reduced (GDR) from a psychoactive medication. The DON stated that monitoring was only done daily if the resident was started on a new psychotropic medication or if there was a change in the psychotropic medication. The DON could not speak to why the policy specified that a licensed nurse would monitor and document drug side effects and all psychotropic medication used daily and would note in the medical records for behavior and side effects. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. The deficient practice was identified for 1 of 24 residents reviewed for professional standard of practice (Resident #12). 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. The evidence was as follows: On 1/28/25 at 10:26 AM, the surveyor observed that Resident #12 had a bag attached to intravenous tubing line. The resident revealed a PICC located in the left chest wall. The surveyor observed the dressing was not labeled or dated. On 1/29/25 at 10:10 AM, the surveyor observed the undated and unlabeled dressing on Resident #12. On 1/29/25 at 10:37 AM, the surveyor interviewed Resident #12, who stated that the dressing had not been changed since it was inserted. The resident continued that the medication bag was changed every eight (8) hours. On 1/29/25 at 10:57 AM, the surveyor reviewed the medical record for Resident #12. A review of the Admission Resident face sheet (an admission summary) reflected Resident #12 was admitted to the facility with medical diagnoses which included but was not limited to; acute and/or chronic congestive heart failure (CHF). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/8/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated a cognitively intact cognition. A review of the Order Summary Report included physician's orders (PO) with a start date of 1/17/25, for milrinone lactate in dextrose intravenous solution (IV) 40-5 milligrams (mg)/200 milliliter (ml), 16.85 micrograms (mcg) every shift continuous for heart failure. The PO did not reflect any orders for PICC line observation or dressing changes. A review of the corresponding Medication Administration Record (MAR) dated, 1/1/25-1/31/25, revealed the nurses were electronically for the milrinone lactate in dextrose IV three times a day at 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM) since 1/17/25. The Mar did not include orders for PICC line observation or dressing changes. A review of the Treatment Administration Record (TAR) dated, 1/1/25-1/31/25, did not reflect any orders for PICC line observation or dressing changes. A review of nursing progress notes from since the start of the PICC line did not include any documentation for the PICC line dressing changes or measurements of the external portion of the catheter. On 1/29/25 at 12:08 PM, the surveyor interviewed the Infection Preventionist (IP), who stated upon admission, the nurse conducted an initial assessment and contacted the physician for orders. The IP stated a PICC line data set should have been discussed with the physician and the orders should be placed in the electronic medical record (eMR) that distributed the orders to the correct forms (MAR or TAR). The IP stated the forms allowed the nurse to acknowledge, perform, and document accordingly. The IP acknowledged that the facility process was not followed and since the dressing was unlabeled and undated she could not tell me when it was last changed. On 1/31/25 at 12:35 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged the facility process was not followed by staff. On 2/3/25 at 10:16 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, IP, and the Regional Nurse, who all acknowledged the surveyor's concerns. A review of the facility's PICC /Midline/CVAD Dressing Change policy, dated 1/2025, which included a policy statement; .change peripherally inserted central catheter (PICC) .dressing weekly or if soiled in a manner to decrease the potential for infection or cross contamination .measure external length of catheter from hub to skin entry to ensure that it has not migrated .secure the catheter with engineered stabilization device .label the dressing with date and time and your initials. A review of the facility's Infection Control IV policy, dated 1/3/2025, change IV site according to physician orders or facility policy . NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure appropriate monitoring of pain with adequate assessment prior to administration for a resident who was prescribed pain medication. This deficient practice was identified for 84 of 131 doses administered for pain management to Resident #42, and was evidenced by the following: On 1/28/25 at 11:25 AM, during initial tour of the facility, the surveyor observed Resident #42 resting in bed wearing a back brace belt and watching television. The resident told the surveyor that they were dealing with back pain. On 1/29/25 at 12:27 PM, the surveyor observed the resident as they had completed their lunch in the main dining room and were walking out of the dining room, wearing a back brace belt and using a cane. The resident stated they were being managed for pain. On 1/29/25 at 1:10 PM, the surveyor reviewed Resident #42's medical record. A review of the Admission Record face sheet (an admission summary) indicated that the resident was admitted to the facility with diagnosis which included but was not limited to; thoracic discitis (inflammation of the spinal discs) and cervical spondylopathy (disease or disorder of the spine in the neck region). A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/12/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS further indicated that the resident received regularly scheduled pain medication. A review of the resident's Individualized Comprehensive Care Plan (ICCP) included a care focus with initiated 10/22/24, for pain. Interventions included but not limited to: administer pain medications as ordered. A review of the resident's physician's orders (PO) included an order with a start date of 10/22/24, and end date of 11/7/24, for morphine sulfate half a tablet (a controlled pain medication) of 15 milligrams (mg) to be given as needed every six hours for moderate to severe pain ranging from 4-10 on a scale of 0-10. A second PO dated 11/20/24, for morphine sulfate tablet 15 mg to be given as needed every six hours for moderate to severe pain ranging from 4-10. A review of the November 2024, December 2024, and January 2025 Medication Administration Record (MAR) indicated morphine sulfate was administered as ordered with no documented pain level assessment conducted prior to administering the following doses: November: 11/20 (one dose), 11/21 (two doses), 11/22 (one dose), 11/23 (two doses), 11/24 (two doses), 11/25 (one dose), 11/26 (three doses), 11/27 (two doses), 11/28 (two doses), 11/29 (two doses), 11/30 (two doses). There were a total of 20 doses administered with no pain level assessments. December: 12/1 (two doses), 12/2 (two doses), 12/3 (one dose), 12/4 (two doses), 12/5 (two doses), 12/6 (one dose), 12/7 (two doses), 12/8 (two doses), 12/9 (two doses), 12/10 (two doses), 12/11 (two doses), 12/12 (two doses), 12/13 (two doses), 12/14 (one dose), 12/15 (two doses), 12/16 (two doses),12/ 17 (two doses), 12/18 (two doses), 12/19 (two doses), 12/20 (one dose), 12/21 (two doses), 12/22 (two doses), 12/23 (two doses), 12/24 (two doses), 12/25 (two doses), 12/26 (one dose), 12/27 (one dose), 12/28 (two doses), 12/29 (one dose), 12/30 (two doses), and 12/31 (two doses). There were a total of 55 doses administered with no pain level assessments. January: 1/1 (one dose), 1/2 (one dose), 1/3 (one dose), 1/4 (two doses), 1/5 (two doses), 1/6 (two doses). There were a total of nine doses administered with no pain assessment. On 1/30/25 at 1:56 PM, the surveyor interviewed the Director of Nursing (DON), who reviewed the MAR for the resident's pain medication and confirmed that a pain level assessment was not documented for each pain medication administered. The DON further stated there was a separate order for a pain level assessment every shift, but acknowledged that the pain level at the time of the assessment may not have been the same pain level at the time the pain medication was administered. The DON acknowledged that a pain level assessment should have been documented at the time the pain medication was administered. On 1/31/25 at 11:21 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that when administering pain medication, nurses were expected to assess the resident's level of pain on a scale from 0-10, and document that level on the MAR at the time the medication was administered. The LPN reviewed Resident #42's MAR with the surveyor, and confirmed that the portion requiring a pain level assessment for each administered dose of pain medication was marked with an X, which indicated there was no pain level assessments documented for those doses. On 1/31/25 at 11:31 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM), who reviewed the MAR with the surveyor for Resident #42 and stated based on the documentation provided, there were no pain assessments done for the doses administered that had an X indicated for the pain level. On 2/3/25 at 10:13 AM, in the presence of the survey team, the DON acknowledged that Resident #42 received pain medication without properly documented pain assessments. A review of the facility's Pain Management policy with a most recent created date of 11/2024, included .the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .pain management .recognition, assessment, treatment and monitoring of pain . NJAC: 8:39-27.1(a)

Complaint # NJ 182108 Based on observation, interview, and review of other pertinent facility documentation it was determined that the facility failed to: a) ensure that soiled linen and soiled incontinent briefs were properly stored in a sanitary manner and b) ensure soiled medical equipment was sanitized prior to storage to prevent cross contamination and the spread of infection. This deficient was identified on 1 of 2 nursing units observed (South Unit) and 1 of 2 medication storage rooms observed (North Unit), and it was evidenced by the following: 1. On 1/28/25 at 12:00 PM, the surveyor was conducting a dining observation on the South Unit. The surveyor entered Resident room [ROOM NUMBER] and observed one bag of dirty linen and one bag of trash which contained dirty protective briefs, on the floor in the room. On 1/28/25 at 12:30 PM, the surveyor returned to Resident room [ROOM NUMBER] on the South Unit and observed a Certified Nursing Assistant (CNA #1) feeding the resident in bed B (near window). There were two bags of dirty linen and trash now moved in the front of the resident's bed while the CNA #1 continued to feed the resident. The surveyor interviewed CNA #1 at that time, and asked the CNA what the two bags were, and the CNA stated that the one bag contained resident dirty incontinent briefs, and the other bag contained dirty linen. CNA #1 then revealed that she utilized the same bags of dirty linen and briefs going from resident room to resident room because she did not want to waste bags so used the same bag for all residents she cared for. On 1/28/25 at 12:35 PM, the surveyor interviewed the License Practical Nurse (LPN #1) for the South Unit, who stated that CNA #1 should not be taking bags of dirty linen and briefs room to room after she performed resident care. LPN #1 stated that after resident care, CNA #1 should be utilizing individual bags for each resident for dirty briefs and dirty linen. LPN #1 stated that after caring for the resident, the linen and trash should immediately be removed from the resident's room and placed in the soiled utility room. LPN #1 accompanied the surveyor to Resident room [ROOM NUMBER] and observed the dirty linen in front of the residents' bed while CNA #1 was feeding the resident. LPN #1 stated that this should not have occurred and that if was an infection control issue. LPN #1 stated that going room to room with dirty briefs and linen could cause cross contamination. On 1/28/25 at 12:37 PM, the surveyor interviewed the LPN/Unit Manager (LPN/UM #1), who went to Resident room [ROOM NUMBER], and immediately removed the bag of linen and briefs. LPN/UM #1 stated that this was gross and a dignity issue. LPN/UM #1 stated, If I was a resident I would not want to eat in my own toilet. LPN/UM #1 then stated that this was an infection control issue and dirty bags of linen and briefs should not be going from resident room to resident room. On 1/30/25 at 08:27 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that during meal service, dirty linen and briefs should be bagged and taken to the soiled utility room. The IP stated that the staff should never be taking dirty trash or linens from room to room; that it could pose an infection control issue related to cross contamination. The IP stated that the staff should never be feeding residents with dirty linen and dirty briefs in bags in the resident's rooms. On 2/3/2025 at 9:30 AM, the Director of Nursing (DON) stated that the facility took this matter seriously and education was provided to the staff regarding proper handling and disposal of soiled linens, particularly during resident care activities. A review of the facility's Linen Handling policy dated 6/2024, included it was the policy of the facility to handle, store, process and transport clean linen and sanitary method to prevent contamination of the linen which could lead to infection .contaminated linen was linen that was soiled with blood or other potentially infectious materials .clean linen should be stored separately from soiled and that linen could become contaminated with pathogens from contact with intact skin or body substance, or from environmental contaminants or contaminated hands . 45208 2. On 1/30/25 at 8:49 AM, the surveyor, in the presence of LPN/UM #1, toured the North Medication Storage Room. The surveyor observed; one soiled oxygen (O2) concentrator with a humidification bottle that was half-way filled with a liquid substance that was still attached and three soiled tube feeding pumps stored in the medication room. At that time LPN/UM #1 stated, the soiled equipment should have been placed in the soiled utility room so housekeeping could process the equipment. LPN/UM #1 acknowledged that the soiled equipment should not be in the medication room; it could cause cross contamination to the sterile supplies and medication preparation area. On 1/30/25 at 9:31 AM, the surveyor interviewed the IP, who stated that soiled equipment should never be placed in the medication room; there was a soiled utility room that used equipment should be placed in. The IP stated it ensured housekeeping cleaned it, and when equipment was cleaned, a clear bag was placed on the equipment so that staff were aware, and it could go back into circulation. On 1/31/25 at 12:35 PM, the surveyor interviewed the DON, who stated that the facility's process for soiled equipment was to remove the equipment from the resident's room when it was no longer needed and placed it in the dirty utility room. The DON stated housekeeping cleaned the item and covered it with a clear plastic bag signifying it had been cleaned. A review of the facility's Cleaning and Disinfection of Nursing Equipment policy with a revised date of 3/2024, included .Policy; Equipment are to be free of soil and contamination with infectious organisms and product . clean and disinfect all highly technical/sensitive equipment (pumps, etc ) per manufacturer's recommendations . NJAC 8:39-19.4

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified in 1 of 1 kitchen garbage dumpster areas, and was evidenced by the following: On 1/28/25 at 10:38 AM, during initial tour of the kitchen, the surveyor, in the presence of the Food Service Director (FSD) and the Licensed Nursing Home Administrator (LNHA) observed the kitchen's garbage dumpster area. The surveyor observed food debris including: bread slices and other unidentifiable disposed food and disposable gloves scattered on the ground. The surveyor also observed a half full garbage compactor which had the door wide open and was not actively being used by staff. At that time, the FSD stated that the dumpster area should have been maintained and cleaned; that leaving the garbage compactor open and having food debris on the ground was disgusting and could promote rodents. On 2/3/25 at 10:13 AM, in the presence of the survey team, the LNHA acknowledged that the dumpster area should have remained clean, and the garbage containers should have remained closed when not in use. A review of the facility's Dumpster Area policy with a revised date of 11/2024, included .the trash area should be clean, odor-free, and free from pest infestation. Trash containers should be sealed, leak proof, and covered at all times to prevent exposure to waste .all trash shall be placed inside the dumpster . NJAC 8:39-19.3(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) provide pharmaceutical services in accordance with professional standards of practice and b) accurately document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts reviewed for medication storage. This was evidenced by the following: On 1/30/25 at 1:03 PM, the surveyor in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM #1), reviewed the Middle Cart North medication cart. A review of the cart revealed the Individual Patient Controlled Substance Administration Record sheet (declining inventory) for Resident #21's morphine extended release (ER) 60 milligram (mg) tablets was not signed by the nurse who administered the medication on 1/30/25. The declining inventory sheet revealed there should be a tablet count of 10 and the medication card revealed 9 tablets. A review of the cart revealed the declining inventory sheet for unsampled Resident #47's morphine ER 100 mg tablet was not signed by the nurse who administered the medication on 1/30/25. The declining inventory sheet revealed there should be a tablet count of 30 and the medication card revealed 29 tablets. At the time of observation, the surveyor interviewed LPN/UM #1, who stated, there should be no missing signatures and acknowledged that there were missing signatures on the narcotic declining inventory sheet. LPN/UM #1 acknowledged the narcotic tablet count was incorrect. On 1/30/25 at 11:45 AM, the surveyor in the presence of LPN/UM #2, reviewed the A-Hall South medication cart. A review of the cart revealed the declining inventory sheet for unsampled Resident #71's oxycodone immediate release, (IR) 10 mg tablet was not signed by the nurse who administered the medication on 1/30/25. The declining inventory sheet revealed there should be a tablet count of 30 and the medication card revealed 29 tablets. At the time of observation, the surveyor interviewed LPN/UM #2, who stated, there should be no missing signatures and acknowledged that there were missing signatures on the narcotic declining inventory sheets. LPN/UM #2 acknowledged the narcotic tablet count was incorrect. On 2/3/25/25 at 9:48 AM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that the individual declining inventory sheets should be completed and filled out for each narcotic dose dispensed immediately at the time the medication was removed from inventory. A review of the facility's Medication Administration policy dated revised 1/2025, included .Medications are administered by licensed nurses .in accordance with professional standards of practice .if medication is a controlled substance, sign narcotic book . NJAC 8:39-29.7(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a) label, date, and store respiratory equipment in a manner to prevent contamination for infection control and b) develop a individualized comprehensive care plan (ICCP) for use of oxygen. This deficient practice was identified for 2 of 3 residents reviewed for respiratory care (Resident #45 and #85), and was evidenced by the following: 1. On 1/28/25 at 10:30 AM, during the initial tour of the facility, the surveyor observed Resident #45 lying in their bed watching television. The surveyor observed an oxygen concentrator (device that delivers oxygen) with nasal cannula (device that delivers additional oxygen through the nose) tubing placed on the oxygen concentrator unbagged and exposed to the air. On 1/29/25 at 1:14 PM, the surveyor reviewed the medical record for Resident #45. A review of the Admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; anxiety disorder (feelings of worry and fear), acute embolism and thrombosis of unspecified deep veins of left lower extremity (blood clot forms and breaks off traveling to the lungs), and encephalopathy (impairment of brain function). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/6/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating a cognitively intact cognition. A review of the Order Summary Report included a physician's order (PO) dated 1/20/25, for oxygen at 3 liters per minute (lpm) via nasal cannula every shift. Further review revealed a physician's order for oxygen at 3 lpm via nasal cannula due to shortness of breath or decreased pulse oxygenation as needed to maintain oxygen saturation (SPO2; percent of oxygen in a person's blood) 90% or greater. A review of the ICCP did not include a focus area for respiratory. The ICCP did not include interventions to administer oxygen. On 1/29/25 at 1:44 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN #1), who stated that oxygen tubing should be stored in a bag when not in use. UM/LPN #1 further stated that the tubing should be stored in a bag for infection control purposes. On 1/30/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that oxygen tubing was changed once a week and as needed. The IP further stated that oxygen tubing should be stored in a bag when not in use to ensure it does not become contaminated. On 1/31/25 at 10:30 AM, the surveyor presented the Director of Nursing (DON) and IP pictures of the oxygen concentrator with the oxygen tubing unbagged and exposed to air. The DON and IP acknowledged that oxygen tubing should be stored in a bag and not exposed to air when not in use for infection control purposes. On 2/3/25 at 10:14 AM, the DON, in the presence of the IP, Regional Director of Nursing, Licensed Nursing Home Administrator (LNHA), and the survey team, confirmed that oxygen tubing should be stored in a bag and not exposed to air when not in for infection control purposes. The DON also confirmed that Resident #45's ICCP did not include oxygen and it should have. 33106 2. On 1/28/25 at 10:26 AM, during the initial tour, the surveyor observed Resident #85 sitting up in the wheelchair (w/c) with oxygen (O2) being infused via a nasal cannula at 4 lpm. The O2 tubing and the humidification bottle (add moisture to the breathing gases for administration of O2) was not labeled or dated. The resident was pleasant and had no complaints. Resident #85 when asked, was unsure when the O2 tubing was changed or when the humidification bottle was changed. On 1/29/25 at 10:00 AM, the surveyor reviewed the medical record for Resident #85. A review of the Admission Record face sheet reflected that Resident #85 was admitted to the facility with the diagnoses which included but not limited to; chronic respiratory failure and diabetes mellitus (DM). A review of the most recent comprehensive MDS indicated that the resident had a BIMS score of 7 out of 15, which indicated severely impaired cognition. The MDS also indicated that the resident received O2. A review of the physician Order Summary Sheet reflected a physician's order (PO) dated 7/30/24, for the resident to be administrated O2 at 4 lpm via nasal cannula. A review of Resident #85's ICCP did not include the administration of the resident's oxygen. On 1/29/25 at 12:49 PM, the surveyor observed Resident #85 sitting up in the w/c and O2 was infusing via nasal cannula at 4 lpm. The resident was pleasant and stated they were having a good day. The surveyor observed the O2 nasal tubing had a piece of tape on it with illegible writing and the humidification bottle was not labeled or dated. On 1/30/25 at 11:38 AM, the surveyor was accompanied by LPN #1 to Resident #85's room to observe the O2 tubing and the humidification bottle. LPN #1 confirmed that there was no labeling on the humidification bottle and the date on the O2 tubing was illegible. LPN #1 stated that the tubing should be changed weekly and that the 11:00 PM-7:00 AM (11-7) nurse was responsible to date the O2 nasal cannula and humidification bottle but must have forgotten. On 1/30/25 at 11:42 AM, the surveyor interviewed UM/LPN #1, who stated that the 11-7 nurse had just changed all the respiratory tubing on the South unit on Tuesday (1/25/24). UM/LPN #1 stated that she was not sure if the humidification bottles should be labeled with a date or initialed, but the date written on the O2 tubing must have smeared. The surveyor reviewed the Treatment Administration record (TAR) that included a PO dated 7/30/24, for oxygen tubing to be changed and to date the tubing and respiratory bag weekly every night shift on Tuesday. The TAR indicated that the tubing was changed 1/28/25, but the date on the tubing was illegible. There was no physician's order to change or date the humidification bottle. On 2/3/25 at 10:14 AM, the surveyor interviewed the DON, who stated that the O2 nasal cannula and the humidification bottle should be dated and initialed and confirmed that a ICCP was not developed for Resident #85 when the physician ordered Resident #85 to be administered O2. A review of the facility's Oxygen Administration policy dated revised 7/1/24, included oxygen tubing would be dated and initialed when started each week .humidification bottle needed to be changed weekly or when empty if it was a week before it was completed .The policy did not include labeling or dating the humidification bottle of the storage of oxygen tubing when not in use. A review of the facility's Care Plan Process policy dated revised September 2024, included .that the resident's CP (care plan) will be developed was appropriate for each resident's needs and/or wishes based on the assessment and reassessment process with the required timeframes .the plans of care have key areas, may include but were not limited to health maintenance and daily care needs .CP would include problem statements to include medical problems for which the resident was on significant medications (i.e., hypertension, diabetes etc.) .a CP would include identified problem, onset date, related risk factors, build on the resident's strengths, reflect treatment goals and objectives, and interventions and approaches . NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to revise an individual comprehensive care plan for a resident with a history of falls who used a fall mat. This deficient practice was identified in 1 of 5 residents reviewed for falls (Resident #17) and was evidenced by the following: On 1/28/25 at 11:02 AM, during the initial tour, the surveyor observed Resident #17 in bed with eyes closed. The resident had a fall mat on the floor next to the bed and the right side of the bed was pushed up against the wall. On 1/29/25 at 1:24 PM, the surveyor reviewed incidents and accidents for Resident #17. The report reflected that on 11/17/24, the resident was observed on the floor sitting with their back against the bed frame. It was documented that the resident sustained no injuries from the fall and on the following day an interdisciplinary team meeting was held. A review of the Admission Record face sheet (an admission summary) reflected Resident #17 was admitted to the facility with diagnoses which included but were not limited to; failure to thrive, hypertension (high blood pressure), chronic pain, and anxiety. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/30/24, reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 4 out of 15, meaning the resident had severe cognitive impairment. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated on 6/23/21, that the resident was at risk for falls. The care plan focus area was updated on 11/17/24, following a fall. Interventions included frequent room checks, side rails, encourage resident to ask for assistance, call light within reach, bed in low position, well lit room and a clutter free environment. Interventions did not include fall mats and bed against the wall. On 1/30/25 at 9:15 AM, the resident was observed in bed with eyes closed. The bed was against the wall and a fall mat on the floor next to the side of the bed. On 1/31/25 at 11:55 AM, the resident was observed in the bed. The bed was against the wall and a fall mat in place. There was a Certified Nursing Assistant (CNA) with the resident providing care. The surveyor asked the CNA if the resident had history of falls, and she said yes and pointed to the fall mat. On 2/3/25 at 10:45 AM, during a meeting with the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), the Regional Director of Nursing (RDON), and the Infection Preventionist (IP), the surveyor asked if the resident should have been care planned for fall mats and having the bed against the wall. The DON replied yes, it should have been on the care plan. A review of the facility's Fall Policy dated 1/2024, included .the care plan would be reviewed and updated following a resident fall . A review of the Care Plan Process policy dated 9/2024, included the purpose was to ensure a care plan will be developed that is appropriate for each resident's needs and/or wishes based on the assessment and the reassessment process with required timeframes . NJAC 8:39-27.1(a)

Based on interview and record review, it was determined the facility failed to conduct a new Preadmission Screening and Resident Review (PASRR) level one assessment after a resident was newly diagnosed with a mental illness. This deficient practice was identified in 1 of 2 residents reviewed for PASRR (Resident #17) and was evidenced by the following: On 1/28/25 at 11:02 AM, during the initial tour the surveyor observed Resident #17 in bed with eyes closed. On 1/28/25 at 11:26 AM, the surveyor reviewed the medical Record for Resident #17. A review of the Admission Record face sheet (an admission summary) reflected the resident was initially admitted to the facility in 2021, with diagnoses which included but not limited to; failure to thrive, hypertension (high blood pressure), chronic pain, and anxiety. Further review showed a new diagnosis of psychosis in 12/2022. A review of Resident #17's PASRR level one in the Electronic Medical Record (EMR) dated 6/2021. A review of section one of the PASRR which asked if the resident had a mental illness diagnosis, no was marked. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/30/24, reflected the resident had a Brief Interview of Mental Status (BIMS) score of 4 out of 15, meaning the resident had severe cognitive impairment. A review of section I of the MDS titled active diagnoses revealed the resident had a diagnosis of anxiety and psychotic disorder. On 1/29/25 at 8:50 AM, the surveyor interviewed the Social Worker (SW) regarding the PASRR for Resident #17. The SW was able to provide the surveyor with the level one PASRR, completed prior to admission, but not a level two. The surveyor asked if a level two was completed when the resident developed a new mental illness diagnoses, and the SW stated she would complete it now because it was missed. The surveyor asked how a new diagnosis would be communicated to her, and she said that the psychiatrist told the nurse of a new diagnosis, and the nurse let the social worker know. On 2/3/25 at 12:30 PM, during a meeting with the Director of Nursing (DON), she acknowledged the PASRR should have been completed and told the survey team the SW was educated. A review of the facility's Resident Assessment-Coordination with PASRR Program policy dated 7/2024, included . any resident who exhibits a newly evident or possible serious mental disorder will be referred promptly to the state mental health or intellectual disability authority for a level two resident review . NJAC 8:39-27.1(a)

Complaint # NJ 182108 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 nursing units (South Side) reviewed for environmental concerns, and was evidenced by the following: On 1/28/25 at 10:30 AM, the surveyor observed the South side nursing unit and identified the following concerns: In Resident room [ROOM NUMBER]-B had one bag of dirty linen on the floor near the resident's dresser. In Resident room [ROOM NUMBER]-A had a cracked trash can with no liner. In the bathroom the surveyor observed the toilet which had a brown substance splattered in the toilet and around the rim. The surveyor also observed a clear bag tied to the handrail filled with used Foley catheter leg bags. On 1/20/25 at 12:57 PM, the surveyor observed in Resident #1's bathroom a clear bag tied to the hand grab bar. The surveyor observed used Foley catheter leg bags in the clear bag. At that time, the surveyor asked Resident #1 if they tied the clear bag to the handrail. Resident #1 stated no, the [facility]; the resident does not use it. At that time, the Unit Manager/Licensed Practical Nurse (UM/LPN) observed Resident #1's bathroom, and she acknowledged that the bag had used Foley catheter leg bags in it. The UM/LPN stated it should not be hanging on the handrail for infection control reasons, and she was not sure who tied it to the handrail and removed the bag and discarded it. Resident #1 then stated, It's just dirty. On 1/31/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Infection Preventionist (IP), who stated that soiled linen should be bagged and taken to the soiled utility room immediately. The DON further stated it should not be left on the resident's floor. The IP stated it should not be left in the resident's room for infection control purposes. The surveyor presented the photos of the soiled bagged linen, the trash can with no liner, and bathroom to the DON and IP. The DON and the IP acknowledged that the toilet should have been cleaned and the trash can should not be cracked and should have a liner in it. On 1/31/25 at 10:38 AM, the surveyor interviewed the Environmental Services Director (ESD), who stated that the housekeepers had a daily schedule that they followed. The ESD further stated that if a resident had an accident, the Certified Nursing Aide (CNA) should have notified the housekeeping department so that the toilet seat could have been cleaned right away. The ESD acknowledged the surveyor's concerns with the toilet seat, trash can, dirty linen, and the bag with used Foley catheter leg bags. On 2/3/25 at 10:14 AM, the DON, in the presence of the IP, Licensed Nursing Home Administrator (LNHA), Regional Director of Nursing, and survey team acknowledged the surveyor's environmental concerns. A review of the facility's Linen Handling policy dated revised 6/2024, included .It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection .linen can become contaminated with pathogens from contact with intact skin or body surfaces, or from environmental contaminants or contaminated hands . A review of the facility's Routine Cleaning and Disinfection policy dated created 1/2025, included .routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge .routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to .toilet seats . NJAC 8:39-31.4(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to promote and maintain resident dignity a.) while providing feeding assistance and b.) for a resident with a urinary catheter. This deficient practice was identified for 4 of 16 residents reviewed for dignified dining (Resident #11, #51, and #72) and 1 of 2 residents reviewed for urinary catheters (Resident #52). The evidence was as follows: 1. On 1/29/25 at 12:15 PM, the surveyor observed resident dining in the North Wing resident dining room. The surveyor observed a Licensed Practical Nurse (LPN) actively feeding Resident #72, while standing alongside the resident at the resident's table. There were five empty and available chairs near the LPN while she remained standing over the resident who was seated in a geriatric chair at the table. On 1/29/25 at 12:20 PM, the surveyor interviewed the Certified Nursing Aide (CNA) who was in the dining room, who stated that staff should have been seated alongside the resident while providing feeding assistance. On 1/29/25 at 12:23 PM, the surveyor observed the CNA replace the LPN with assisting Resident #72 with feeding. The LPN walked away from the table, and at that time the surveyor interviewed the LPN, who stated that the proper way to assist a resident with feeding was to sit alongside the resident to maintain eye contact and dignity. On 1/30/25 at 1:48 PM, the surveyor reviewed Resident #72's medical record. A review of the resident's Admission Record face sheet (an admission summary) indicated the resident was admitted to the facility with diagnosis which included but was not limited to; dementia and mood disorder. A review of the resident's physician's Order Summary Report indicated the resident had a ground texture regular diet. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool dated 1/7/25, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated severe cognitive impairment. A further review of the MDS reflected the resident required partial to moderate assistance with eating. On 1/31/25 at 12:00 PM, the surveyor interviewed the Director of Nursing (DON) and the Infection Preventionist (IP), who both stated that when assisting residents with feeding/eating, staff should be seated alongside the resident and not have been standing over them for dignity concerns. On 2/3/25 at 10:13 AM, the DON, in the presence of the survey team acknowledged that staff should always be seated when assisting residents with meals. 2. On 1/30/25 at 11:36 AM, during a follow-up kitchen inspection, the surveyor observed three meal trays being prepared by the kitchen staff with individual resident meal slips placed on them. Upon closer review of the meal slips, it was observed for each slip to have Resident #11, #51, and #72's names on each slip with the term Feeders printed below each resident's name. The surveyor continued to monitor and followed the meal trays which each still had the resident's meal slip on them as they were delivered to the main dining room. Staff then passed the trays out to the individual residents and the meal slips remained on the tray on the table in front of the residents. On 1/30/25 at 1:48 PM, the surveyor reviewed Resident #11's medical record. A review of the resident's Admission Record face sheet indicated the resident was admitted to the facility with diagnosis which included but was not limited to; dementia and dysphagia (difficulty swallowing). A review of the resident's quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 5 out of 15, which indicated severe cognitive impairment. A further review of the MDS reflected the resident required substantial to maximal assistance with eating. On 1/30/25 at 1:48 PM, the surveyor reviewed Resident #51's medical record. A review of the resident's Admission Record face sheet indicated the resident was admitted to the facility with diagnosis which included but was not limited to; Alzheimer's Disease and dysphagia. A review of the resident's quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 1 out of 15, which indicated severe cognitive impairment. A further review reflected the resident was dependent on staff for assistance with eating. On 1/30/25 at 1:48 PM, the surveyor reviewed Resident #72's medical record. A review of the resident's Admission Record face sheet indicated the resident was admitted to the facility with diagnosis which included but was not limited to; dementia and mood disorder. A review of the resident's quarterly MDS dated [DATE], indicated that the resident had a BIMS score of 1 out of 15, which indicated severe cognitive impairment. A further review reflected that the resident required partial to moderate assistance with eating On 1/31/25 at 9:35 AM, the surveyor interviewed the Regional Food Service Director (RFSD) and the Food Service Director (FSD), who stated that they were unsure as to how the term feeders was put on the meal slips. On 1/31/25 at 12:00 PM, the surveyor interviewed the DON and the IP, who both stated that staff and the facility should not refer to residents or use terms such as feeders because that would be considered undignified. On 2/3/25 at 10:13 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team acknowledged that the meal slips containing the term feeders was an error and should have been caught by the facility. A review of the facility's Dining and Meal Assistance policy with a last revised date of 6/2024, included all residents will be encouraged to eat in the dining room. facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: not standing over residents while assisting them with meals . avoiding the use of labels when referring to residents (e.g., feeders) . 49094 3. On 1/28/25 at 10:30 AM, during the initial tour of the facility, the surveyor observed Resident #52 lying in their bed awake. The resident stated they had a suprapubic catheter (type of indwelling catheter that drains urine from the bladder into a bag). The surveyor observed the indwelling catheter drainage bag secured to the bed frame, not placed in a privacy bag exposing the contents (urine) in the bag. The surveyor was able to observe the urine in the resident's catheter drainage bag from the hallway. On 1/29/25 at 10:45 AM, the surveyor reviewed the medical record for Resident #52. A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included but not limited to; retention of urine, type two diabetes (body does not use insulin properly), neuromuscular dysfunction of bladder (nerves controlling bladder function are damaged), and cystostomy status (surgical creation of an opening into the bladder). A review of the most recent comprehensive MDS, an assessment tool dated 12/9/24, indicated the resident had a BIMS score of 15 out of 15, indicating a cognitively intact cognition. A review of the Order Summary Report included a physician's order (PO) dated 12/2/24, for a catheter: maintain 20 french (Fr; size of the indwelling catheter) catheter with a 10 cubic centimeter (cc) balloon (balloon inflated to keep catheter in place) for a diagnosis of neurogenic bladder (bladder function are damaged) and attach urinary drainage bag and maintain it below the level of the bladder every shift for catheter management. A review of the individual comprehensive care plan (ICCP) included a focus area dated 12/8/24, that the resident had a suprapubic catheter due to neurogenic bladder. Interventions included but not limited to; check and place catheter in privacy bag each shift and secure catheter per facility protocol. On 1/29/25 at 1:44 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated that catheter drainage bags should be located below the resident's bladder, hooked on the resident's bed frame, and placed in a privacy bag. The UM/LPN further stated the importance of the catheter drainage bag to be in a privacy bag was for the resident's dignity. On 1/30/25 at 1:04 PM, the surveyor interviewed the Infection Preventionist (IP), who stated that catheter drainage bags should be placed in a privacy bag, positioned below the bladder, and should not be touching the floor. The IP also stated that privacy bags were used for the resident's dignity. On 1/31/25 at 10:30 AM, the surveyor presented the Director of Nursing (DON) and IP a picture of the resident's catheter drainage bag that was seen during initial tour. The DON and IP acknowledged that the catheter drainage bag was not in a privacy bag at that time. The DON stated it should have been in a privacy bag for dignity reasons. On 2/3/25 at 10:14 AM, the DON, in the presence of the ADON, Regional Director of Nursing, Licensed Nursing Home Administrator (LNHA) and the survey team, confirmed that the catheter drainage bags should be maintained in a privacy bag for dignity reasons. A review of the facility's Urinary Catheters policy dated reviewed 11/1/24, did not include storing Foley catheter bags in a privacy bag. NJAC 8:39-4.1(a)(12)

Based on document review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days after completion of the MDS for six of 11 sampled residents (Resident (R) 10, R41, R57, R72, R79, and R85) reviewed for MDS transmission. Findings include: Review of the RAI Manual dated October 2023 revealed the Comprehensive Assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. Review of the facility's MDS transmission verification document provided by the facility revealed that the following MDS assessments had not been transmitted: 1.10's Annual MDS with an assessment reference date (ARD) of 10/09/23; 2.41's Quarterly MDS with an ARD of 10/10/23; 3.57's Quarterly MDS with an ARD of 10/08/23; 4.72's Quarterly MDS with an ARD of 10/10/23; 5.79's Quarterly MDS with an ARD of 10/10/23; 6.85's Quarterly MDS with an ARD of 10/10/23. During an interview on 12/13/23 at 2:15 PM the MDS Coordinator confirmed the above six MDSs had not been transmitted. NJAC 8:39-11.2(e)

C# : NJ 893 Based on observation, interviews, and medical record review, as well as review of pertinent facility documents, it was determined that the facility failed to maintain a safe environment for 2 of 3 residents (Resident #1 and Resident #2) observed during Environmental tour. This deficient practice is evidenced by the following: 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses that included but were not limited to the following: Dementia and Muscle Weakness. The Minimum Data Set (MDS), an assessment tool dated 8/11/21 showed that Resident #1 was moderately impaired and required extensive assistance from the staff with Activities of Daily Living (ADL). 2. According to the AR, Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included but was not limited to the following: [CONDITION(S)]. The MDS, an assessment tool dated 8/11/21 showed that Resident #2's cognition was intact and required extensive assistance from the staff with ADL. The medical records for Resident #1 and Resident #2 showed that they were both transferred to room xx5 on 11/2/21. During the tour on 11/10/21 at 9:44 am, the surveyor observed a portable electric heater (PEH) inside room xx5 (room of Resident #1 and Resident #2). The PEH (warmwave model) was plugged into the electric wall and in use. The PEH was at low setting heat during the tour. The surveyor did not observe any flammable material/substance inside room xx5. The Housekeeping Director (HD, also overseeing maintenance department) entered the room and checked the room temperature which was at 76.6 degrees Fahrenheit. The surveyor conducted an interview with Resident #2 on 11/10/21 from 9:44 am to 9:50 am. Resident #2 stated that when they moved them in room xx5, the room was cold and it feels uncomfortable. Resident #2 reported it to the staff (unable to recall the name) and he brought in the PEH and plugged it into the electric wall. Resident #2 revealed that staff (nurses, CNAs, housekeeping) knew about it because they come in and out of room xx5. The surveyor conducted an interview with the multiple staff (including Administrator and HD) on 11/10/21 from 9:50 am to 12:45 pm. The staff could not explain who brought in the PEH in room xx5. The Administrator stated that portable electric heaters are not allowed in the facility especially in resident/s rooms. The Warmwave 24 inches, 1500-[NAME] Electric Portable Heater under product overview showed .Ceramic Heater spreads heat for maximum heating comfort . The facility's policy titled Space Heaters revised on 8/2021, under Protocol: 1.) Portable Heaters are not allowed in all areas of the facility. Maintenance, Housekeeping and Administration will monitor during daily rounds to ensure that there are no portable heaters in the facility. 2.) Staff will report any heaters found in the facility to administration. NJAC 8:39-31.7 (f)

Complaint Intake: NJ 2 Based on record reviews, interviews, and review of facility policy, it was determined that the facility failed to report an unwitnessed injury for one of three residents (Resident #1) reviewed for an injury of unknown origin. Findings included: 1. The facility originally admitted Resident #1 on 10/02/2002 and readmitted the resident on 07/02/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident's cognition was severely impaired. The resident was totally dependent on staff for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The resident required extensive assistance for eating. Resident #1 had a discharge MDS assessment for 06/27/2021 and 07/16/2021 (discharged to the hospital due to an elevated [MEDICATION(S)] level). A review of the nurse's notes written by Licensed Practical Nurse (LPN) #6 dated 07/16/2021 revealed LPN #6 placed a call to the hospital and an emergency room nurse stated Resident #1 was admitted for [MEDICATION(S)] toxicity. A review of the care plan, updated on 07/11/2021, revealed Resident #1 had actual impairment to skin integrity due to fragile skin and usage of blood thinners (aspirin and [MEDICATION(S)]). Resident #1 had a bruise to the left eye on 07/11/2021. A further review of Resident #1's care plan revealed the following interventions were put in place: Identify/document potential causative factors and eliminate/resolve where possible. Padding to siderails. Place Resident #1's personal care items such as cell phone within easy reach. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. A review of Resident #1's incident report, dated 07/11/2021, revealed Temporary Nurse Aide (TNA) #1 observed a dark reddish-purple discoloration with no swelling on the outer corner of Resident #1's left eye. The TNA immediately informed Licensed Practical Nurse #4 of the bruising. LPN #4 assessed the resident. The resident denied pain or discomfort. No injuries were observed at the time of the incident. Resident #1 was able to get things from the bedside table located on the left side. Resident #1 used hand motions to show they were reaching for the phone and accidentally hit their eye on the bed rail. [Per an interview with the Director of Nursing (DON) on 09/26/2021 at 2:00 PM, the resident was nonverbal but able to use hand motions to indicate what happened or express needs.] The phone was found on the floor next to Resident #1's bedside table at the time of the incident. The presentation of the bruise was vertical, consistent with hitting the edge of the side rail. The bruise had extended around the eye by the next day. The resident was on two blood thinners (aspirin and [MEDICATION(S)]) and was predisposed to bruising easily. A review of the nurse's notes written by LPN #4 dated 07/11/2021 revealed TNA #1 called LPN #4 to Resident #1's room where LPN #4 observed a dark reddish-purple discoloration to Resident #1's outer left eye with no swelling or pain. There were two small water bottles and a phone on the floor next to the bed and bedside table. When questioned, Resident #1 was unaware of how the discoloration occurred. LPN #4 observed Resident #1 lying in the center of the bed. Resident #1 was observed attempting to reach with the resident's left hand towards the bedside table on the left side of the bed while being asked questions regarding the discoloration. No items were on the table at this time. A review of the nurse's notes written by the Director of Nursing (DON), dated 07/12/2021, revealed the Interdisciplinary Care Team discussed that day the bruise was found on Resident #1's left eye. Further investigation and interview of staff who were assigned to Resident #1 care was conducted. TNA #1 observed Resident #1 with a reddish bruise/discoloration in the outer aspect of the resident's left eye with no open lesion. TNA #1 and LPN #4 stated that during the start of the shift, they did not observe bruises on Resident #1's eye while the resident was in bed. Upon further investigation, staff observed that Resident #1's phone was found on the floor next to the bedside table located on Resident #1's left side. Resident #1 may have reached out for the phone and accidentally bumped the side of their eye on the edge of the side rail. The presentation of the bruise was consistent with hitting the edge of the rail. Resident #1 was on multiple blood thinners and was predisposed for easy bruising. Based on the investigation, there was no evidence to suspect abuse or neglect. LPN #4 was on vacation and unavailable for interview. During an interview on 09/26/2021 at 2:00 PM, the DON stated that Resident #1 was nonverbal but able to point to the siderail and the cell phone, so an injury of unknown was ruled out. During an interview on 09/27/2021 at 12:57 PM, the Administrator stated that Resident #1 was nonverbal, and Resident #1 pointed to the siderail when asked what happened to the area near their eye. The Administrator further indicated the facility ruled out that it was an injury of unknown because Resident #1 was able to point to where they hit their eye. The Administrator stated that since this incident was not an injury of unknown, it was not reported to the State Agency. During an interview on 09/27/2021 at 2:03 PM, TNA #1 stated that she noticed Resident #1 had a bruise the size of a pea near the left eye on 07/11/2021. TNA #1 further indicated that she was going in Resident #1's room to feed the resident their dinner. TNA #1 indicated that she immediately told LPN #4 about the bruise. TNA #1 said the next day the bruise had spread around Resident #1's eye. She indicated that Resident #1 did not seem to be in pain. She indicated that Resident #1 was nonverbal but able to point at the side rail when the nurse asked what happened to the resident's eye. TNA #1 further indicated that there were two bottles of water and the telephone on the floor next to the bed on the left side. TNA #1 indicated that Resident #1 could have been reaching for the phone and bumped the area near the resident's eye on the side rail. A review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 05/17/2019, revealed, Definitions of abuse and neglect: g. Injuries of unknown origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: i. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; ii. The injury is suspicious because of the extent of the injury of the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. G. Reporting and Response: Abuse Policy Requirements: It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. New Jersey Administrative Code S 8:39 - 5.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to consistently follow facility policy to document refused medications. This deficient practice was identified for 1 of 21 residents reviewed for professional standards of nursing practice (Resident #18) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of the April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 04/11/21 5:00 PM Cranberry capsule 450 milligram (mg) (a dietary supplement) 04/11/21 5:00 PM Artificial tears (a medication to relieve dry eyes) 04/20/21 5:00 PM and 9:00 PM all ordered medications 04/21/21 5:00 PM and 9:00 PM all ordered medications 04/23/21 5:00 PM and 9:00 PM all ordered medications 04/24/21 5:00 PM and 9:00 PM all ordered medications A review of the April 2021 progress notes and April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 05/29/21 9:00 PM [MEDICATION(S)] 1 mg (an antianxiety medication) 05/30/21 9:00 PM [MEDICATION(S)] 1 mg A review of the May 2021 progress notes and May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 06/05/21 9:00 AM and 5:00 PM Artificial tears 06/07/21 9:00 PM [MEDICATION(S)] 50 mg (an antipsychotic for depression with psychosis) 06/07/21 9:00 PM [MEDICATION(S)] 15 mg (an antidepressant for depression) 06/07/21 9:00 PM [MEDICATION(S)] 5 mg (an antidepressant for depression with psychosis) 06/07/21 9:00 PM [MEDICATION(S)] 100 mg (a medication to for constipation) 06/07/21 9:00 PM [MEDICATION(S)] 10 mg (a medication for dementia) 06/07/21 9:00 PM [MEDICATION(S)] 10 mg (an allergy medication) 06/07/21 9:00 PM [MEDICATION(S)] 1 mg A review of the June 2021 progress notes and June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 07/03/21 9:00 AM [MEDICATION(S)] 1 mg 07/03/21 9:00 PM all ordered medications 07/04/21 9:00 AM and 9:00 PM [MEDICATION(S)] 1 mg 07/04/21 9:00 PM [MEDICATION(S)] 10 mg 07/05/21 9:00 AM [MEDICATION(S)] 1 mg 07/11/21 9:00 AM all ordered medications 07/11/21 1:00 PM Saline Nasal Spray (a medication to relieve dry nose symptoms) 07/17/21 9:00 AM Saline Nasal Spray A review of the July 2021 progress notes and July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the surveyor on 07/20/21 at 11:48 AM, the Licensed Practical Nurse (LPN) stated that if a resident refused their medications, the LPN reattempted to administer the medications at a later time. If the resident continued to refuse, the LPN would circle his/her initials when signing the MAR; and on the back of the MAR, document the refusal and the reason why the resident refused. If the resident refused for 3 days, the LPN called the physician for new orders. During an interview with the surveyor on 07/20/21 at 12:27 PM, the Infection Preventionist (IP), who sometimes filled in as the Unit Manager, stated that she educated the nurses to write on the back of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a follow up interview with the surveyor on 07/20/21 at 12:41 PM, the IP provided to the surveyor a nursing in-service dated 04/07/21 regarding documenting medication refusals by residents. The IP stated that she verbally reminded nurses to make sure that they were documenting on the reverse side of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the surveyor on 07/20/21 at 12:52 PM, the Director of Nursing (DON) stated that if a resident refused a medication, the nurse would document the refusal on the reverse side of the MAR. For Resident #18, the nurses documented medication refusals in the chart, as the resident's behavior was to refuse medications. During a follow up interview with the surveyor on 07/21/21 at 10:15 AM, the DON stated that he reviewed the MARS and progress notes for documentation of Resident #18's medication refusals. The DON stated that some documentation was there, and some was not. During an interview with the surveyor on 07/21/21 at 10:24 AM, the Corporate DON stated that the nurses were interviewed, and they stated that they would have to document all of the refused medications on the back of the MAR. At that time, nurses were educated to document that, for example, all 9 AM medications refused and to document the reason why. The Corporate DON stated that it is best practice to document medication refusals on the back of the MAR. The Corporate DON further stated that for the month of April, the majority of the medication refusals were documented in the progress notes and the nurses should have documented the medication refusals on the MAR. A review of the facilities current Medication Administration Procedures undated policy reflected If a resident refuses medication, document refusal on MAR [Medication Administration Record] or TAR [Treatment Administration Record]. and or in resident medical record. NJAC 8:39-27.1 (a)

Based on interviews, record review and review of pertinent facility documents on 4/23/2021, It was determined that the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimal Data Set (MDS), an assessment tool dated 1/26/2020, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating the Resident's cognition was moderately impaired. The MDS also indicated that Resident #2 needed extensive assistance with Activities of Daily Living (ADLs). Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Vital signs and pulse oxygen (ox) every shift x (times)5 days, then blood pressure and pulse weekly. O2 (Oxygen) at 3L (Liters) NC (Nasal Cannula) continuous. Review of Resident #2's Skilled Evaluation form were as follows: Under Respiratory #5a. Oxygen Volume 2L/M (Liters per Minute), dated 1/23/2020. Under #14. O2 found to be temporarily off, dated 1/24/2020. Under Respiratory #5a. Oxygen Volume 2L/M (Liters per Minute), dated 1/25/2020. Review of Resident #2's Medical Record (MR), revealed no vital signs were taken for the 7:00 a.m. to 3:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts on 1/25/2020. During an interview on 4/22/2021 at 10:34 a.m., the Unit Manager (UM) stated, every nurse is responsible for ensuring O2 liters are correct. The UM further stated, I do rounds and check O2 liters. During an interview on 4/23/2021 at 9:50 a.m., the Certified Nurses Aid (CNA) stated, it is the CNAs responsibility to ensure the O2 tanks are full. We would put them on the concentrator until we get a new one that is filled. The nurses do the vital signs. During an interview on 4/23/2021 at 10:12 a.m., the Director of Nursing (DON) stated we document vitals for the first 5 days, they did not follow doctor's orders for the day shift. Vitals are missing for the 7:00 a.m. to 3:00 p.m. shift for 1/25/2021. The DON further explained only the temperature was taken for the 7:00 a.m. to 3:00 p.m., and again at 10:00 p.m., no other vitals were taken. The DON further stated, there should have been. Review of the facility's policy titled Physician Medication Orders, undated, indicated the following: Under Policy Statement: Medication shall be administered only upon written order of a person duly licensed and authorized to prescribe such medications in this state. Under Policy Interpretation and Implementation: a. No drugs or biological's shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. b. All drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order . Review of the facility's policy titled Medication Administration dated 5/ , indicated the following: Under Purpose: To administer the following: .Right dose Right documentation . Right time. Under Procedure: #10 Verify that any further medication identifiers match the label and the medication #11. Verify the correct medication, expiration date, dose, dosage form, route and time again by comparing to the MAR before administering. Review of the facility's policy title Oxygen Administration undated, indicated the following: Under Policy: Oxygen will be administered as per MD order to aid in breathing . Under Procedure: #9. Document initiation of oxygen in nursing notes including time, flow, indication and method: cannula or mask and in the TAR. Document use and resident reaction to oxygen. N.J.A.C. 8:39-29.2(d)

Based on observation, interview and record review it was determined that the facility failed to provide: a.) care and services for the prevention of pressure sore development and the deterioration of a pressure sore once it developed, and b.) weekly documented measurements to track the progression of wounds. This deficient practice was identified for 2 of 4 residents, Resident #'s 1 and 14, reviewed for pressure sores and was evidenced by the by the following: 1. On 5/4/15 beginning at 10:50 a.m. the surveyor observed Resident #1 in bed with a Hospice Certified Nurses Assistant (CNA) in the room providing care. Resident #1 had a dressing to the left foot and was on a low air loss mattress. Resident #1 was admitted to the facility in 12/2012 and had [DIAGNOSES REDACTED]. According to the most current significant change Minimum Data Set (MDS an assessment tool) dated 3/25/15, Resident #1 was dependent on staff for all activities of daily living, was nonverbal and unable to answer questions. On 5/5/15 at 8:45 a.m. the surveyor reviewed the medical record of Resident #1. The surveyor was unable to find wound assessments for the left heel. The surveyor then asked the Unit Manager (UM) for wound assessments and tracking process of the wound. The UM stated that she would find the information and provide it to the surveyor. Later that day at 1:20 p.m. the UM provided the surveyor with a form titled "Order Sheet-NJ" under the subheading of "Nurse's Treatment Notes" which indicated that on 2/10/15 and on 2/24/15 the 3pm-11pm shift documented a left heel blackened area. The form did not indicate a measurement of the area and there was no corresponding nurses note in the medical record. During an interview with the Administrator on 5/5/15 at 1:30 p.m. she stated that they were unable to locate additional information and that she had looked through the chart herself. On 5/7/15 at 9:20 a.m. the Director of Nurses (DON) provided the surveyor with a form titled "PRESSURE ULCER RECORD (ONSITE)" which indicated that the left heel Deep Tissue Injury (DTI) wound measured 8.0 centimeters (cm) x 5.0 cm. Per interview with the DON at that time she stated that the next time the wound was measured was 4/22/15 and it was 4.5 cm x 5.5 cm and per surveyors request on 5/7/15 the left heel was measured and was 5 cm x 3 cm. According to facility policy and procedure titled Weekly Skin Assessment, "All residents in facility must have a weekly skin assessment done by a Nurse. " Additionally the facility policy and procedure titled WOUND CARE AND MANAGEMENT GUIDELINES indicated that the staff are to "Document what the wound actually looks like..." There was no documented evidence this policy was consistently followed. 2. On 5/6/15 at 9:30 a.m. the surveyor observed Resident #14 in a wheelchair in the resident's room. The surveyor reviewed the record which indicated that Resident #14 was admitted to the facility in April of 2015 with [DIAGNOSES REDACTED]. The Nursing Admission Baseline Data form indicated that the resident was admitted with a Stage II pressure ulcer of the sacrum which measured 1.0 cm (cm) x 0.1 cm. The Braden Scale dated April 2015 indicated the resident was at high risk for the development of pressure ulcers due to the existence of a pressure ulcer. There was a physician's orders [REDACTED]. The resident was on the "Wound Management List" to be seen by the wound doctor on 4/24/15 but was not seen until 5/1/15. Per a staff nurse reponsible for caring for Resident #14, she stated "I don't know he comes on Fridays and 4/24/15 was a Friday, and (the resident) was on the list but wasn't seen until 5/1/15. I don't know why." The surveyor reviewed the facility's Pressure Ulcer Record on 5/6/15 which indicated that Resident #14 had a Stage II wound of the medial sacral area which measured 1.0 cm x 0.1 cm. The treatment as of 4/23/15 was for the use of Z Guard. According to manufacturers recommendation and interview with the Director of Nurses on 5/7/15 at 9:50 a.m., the product is used in the prevention of a wounds up to Stage 1 or redness. The same record also indicated that on 5/1/15 the treatment was changed to [MEDICATION NAME] cream to the sacrum. There was no description of the wound and no corresponding Nurse's note which described the wound. During surveyor interview with the Unit Manager (UM) regarding the lack of documentation of the sacral wound, the UM stated that there were no wound measurements available and that she would call the wound doctor who saw the resident on 5/1/15 to inquire about documentation. Later that day on 5/6/15 the UM provided a "Wound/Vascular Assessment Note" from the wound doctor's office. The form indicated that Resident #14 was seen on 5/1/15 and at that time the wound measured 3.5 cm x 1.5 cm x 0.3 cm. The physician changed the care of the wound from Z Guard to [MEDICATION NAME] (a cream which can be used to treat Stage II - IV pressure sores per manufacturers recommendation). On 5/7/15 at 9:50 a.m. the surveyor observed a wound treatment by the resident's nurse. The wound measured 4.0 cm x 3.0 cm then a small area 1.0 cm x 1.5 cm. According to surveyor interview with the nurse who measured the wound during the treatment, she stated that the wound looked as though it were two wounds because the center had healed. On 5/7/15 at 11 a.m. the surveyor reviewed the facility's policy on "Consultations (request for)" there were no time frames listed. Per surveyor's continued interview with the DON regarding the standard treatment for [REDACTED]. This is a repeat deficiency of the standard survey of 5/28/14. N.J.A.C. 8:39-27.1 (e)

Based on observation, interview and record review it was determined that the facility failed to provide adequate pain management for 2 of 2 residents observed for the management of pain. Resident #1 was cognitively impaired, experienced pain during the treatment to an unstageable left heel wound and Resident #11, who was alert and oriented, verbalized pain during treatments to a Stage II wound on the sacrum and an unstageable wound on the left heel. This deficient practice was evidenced by the following: 1. On 5/3/15 at 4:20 p.m. during the initial tour of the facility, the Unit Manager (UM) stated that Resident #11 was alert and oriented and had two pressure ulcers. When interviewed at that time, the UM informed the surveyor that Resident #11 had a stage II ulcer on the sacrum (left buttock) area and an unstagedable ulcer on the left heel. The UM also stated Resident #11 required total assistance from staff for all activities of daily living. On 5/5/15 at 10:40 a.m. the surveyor observed a facility nurse as she provided wound care treatments and dressing changes to the above mentioned ulcers for Resident #11. A Certified Nursing Assistant (CNA) was at the resident's bedside to assist the nurse. Prior to the start of the treatments the nurse stated to the surveyor that Resident #11 was not in pain. At 11 a.m. the nurse began the treatment to the sacral area by cleansing the wound with Normal Saline Solution (NSS). As the nurse cleansed the wound, Resident #11 moaned and told the nurse that he/she had pain. The Nurse then stated that she would give the resident pain medication after she finished treatments. She continued and completed the sacral wound treatment and dressing change. At 11:10 a.m. the nurse started the wound treatment for [REDACTED]. The CNA elevated the resident's left leg for the nurse to provide treatment to the left heel. The CNA also told the nurse that the resident complained of pain when she elevated the leg. The nurse told Resident #11 that she would give something for pain later. The nurse continued unwrapping the old dressing and cleansed the wound with NSS. Resident #11 started to moan in pain. Again, the nurse stated to the resident that she would give the resident something for pain after she finished the treatment. At 11:30 a.m. the nurse administered [MEDICATION NAME] 5-325 milligram (mg) to Resident #11. On 5/5/15 at 12:10 p.m. the surveyor reviewed Resident #11's medical record that included a 3/19/15 annual Minimum Data Set (MDS an assessment tool) which indicated that the resident had no deficits in cognition or decision making and occasionally experienced moderate pain. There were current physician's orders [REDACTED]. The surveyor reviewed the facility's policy and procedure for "PAIN MANAGEMENT" revised 12/2013 which indicated under the heading 'Purpose', "To promote the health, safety and welfare of residents by ... monitoring and management of pain." On 5/6/15 at 1:30 p.m. the Director of Nursing (DON) stated the the nurse should have stopped the wound care and should have given pain medication when Resident #11 was complaining of pain. 2. Resident #1 was admitted to the facility in 12/2012 and had [DIAGNOSES REDACTED]. According to the most current significant change Minimum Data Set (MDS an assessment tool) dated 3/25/15, Resident #1 was dependent on staff for all activities of daily living, was nonverbal and unable to answer questions. On 5/4/15 at 12:59 p.m. the surveyor observed a facility nurse perform a treatment and dressing change to Resident #1's left heel with an unstageable ulcer. The nurse stated that she had medicated Resident #1 with [MEDICATION NAME] 50 milligrams at 12 noon. The nurse removed the dressing which had adhered to the wound and Resident #1 screamed. The nurse continued with the treatment and began to cleanse the wound with normal saline solution. The nurse then patted the wound to dry the normal saline solution then applied the clean [MEDICATION NAME] and Kling; Resident #1 continued to scream after each procedure. According to surveyor review of the Medication Administration Record, [REDACTED]." The treatment nurse failed however to assess Resident #1's continued need for pain management during the treatment and dressing change when the resident moaned throughout. On 5/6/15 at 10:13 a.m. the Hospice CNA stated that earlier that day the resident had screamed when turned. The Hospice CNA also stated that whenever the left leg was moved, the resident screamed. She would report it to the nurse who usually gave the resident something for pain. The Hospice CNA had been responsible for caring for Resident #1 since March of 2015. The surveyor reviewed the facility policy and procedure "PAIN MANAGEMENT." The policy stated that both verbal and nonverbal pain assessments would be utilized. For resident's with dementia who were unable to describe the pain, "The pain assessment utilized will be chosen based upon the Nurse's assessment of the resident's cognitive abilities." The policy continued and indicated that "...pain assessments will include Intensity/Severity, Frequency/Pattern, Precipitating Factors and Responses to Treatment." The surveyor reviewed Resident #1's Physician order [REDACTED]. However, parameters and indication for use were not indicated for all of the medications which left the decision subjective in the nurse's decision as to which medication to give during a specific pain event. Refer to F281, Example 2. N.J.A.C. 8:39-27.1 (a)

C/O # NJ Based on interview, medical record review and review of other facility documentation, it was determined that the facility failed to provide adequate supervision to 1 of 4 Resident's (Resident #3), reviewed for risk of elopement. The Resident had been placed on a 1:1 supervision on 4/5/15 at 7 PM due to Resident's continued wandering and trying to escape. The 1:1 aide, Certified Nurses Aide (CNA) #2, who was covering for the assigned 1:1 CNA, left Resident #3 unsupervised and the result was that Resident #3 eloped on 4/6/15 at approximately 5 am. The insufficient supervision created an Immediate Jeopardy (IJ) situation for Resident #3. The IJ which began on 4/6/15 was lifted the day of survey 4/13/15. The Administrator and Director of Nursing were notified of the IJ on 4/13/15 at 10:40 am. This deficient practice is evidenced by the following: According to the "Admission Record" Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. A review of the Treatment Record (TAR) dated April/May 2015, indicated that the order was signed as completed by the Nursing staff on all shifts consistently for the duration of the Resident's stay at the facility from 4/3/15 until discharge on [DATE]. According to the "Daily Skilled Nurse's Note" Resident #3 was independent for Activities of Daily Living (ADL's) to include ambulation. An "Elopement Assessment Screen" dated 4/3/15 documented a score of 6. The form stated that a score of 5 or greater equals a high risk. Under the score total was written W/G placed on admission. A review of an "Interdisciplinary Progress Note" dated 4/3/15 and timed at 11 PM, documented that the Resident verbalized unhappiness about being at the facility instead of at home. Documentation included that the Resident was constantly moving out of the room and in the hallways. A further review of the medical record documented in an "Interdisciplinary Progress Note" dated 4/4/15 and timed at 6 am revealed that the Resident was wandering and exit seeking. A review of a "Daily Skilled Nurse's Note" dated 4/6/15 and untimed, documented that the Resident was pacing during the night, Nurses, Supervisor and CNA's were aware and were monitoring the Resident. The note included that the wander guard was on and functioning. The note went onto document that Resident #3 was not seen at 5:10 am in the room or in the hallway. The note further documented that the Resident was brought back by Supervisor. A review of a computer generated Care Plan, dated 4/3/15 documented that the Resident was a potential elopement risk related to exit seeking behaviors, wandering/pacing, wants to go home. Under interventions/approaches "apply wander guard and check for placement q shift and function daily." In addition provide 1:1 hand written. The hand written entry was undated. During a tour of the facility on 4/13/15 at 11:35 am with the Director of Maintenance, the surveyor observed that there are 12 exit doors in the facility and that 5 of the exit doors are on the wander guard system. The other 7 doors are fire exit doors that are also alarmed but not on the wander guard system. On 4/13/15 at 12:45 PM during an interview with the nursing Supervisor, who was on duty at the time of the elopement, the Supervisor stated that the Resident was placed on 1:1 supervision when the shift began on 4/5/15 at 7 PM, due to the Resident continuously wandering and trying to escape. The Supervisor stated "I told the staff not to leave the Resident alone." The Supervisor also stated that CNA #1 went on break and had another CNA, CNA #2, cover the 1:1. The Supervisor further stated that CNA #2 went to answer a call bell and left Resident #3 unsupervised and that was when the Resident eloped. The Supervisor went on to say that the exit door alarmed and staff responded to the alarm. The Supervisor stated that " the staff did a room to room search in the building and I went outside with another employee to do a perimeter search." The Supervisor stated "I reset the alarm the night of the elopement." A review of a "Reportable Event Record/Report" dated 4/6/15, sent to the Department of Health (DOH) by the facility, documented that at approximately 5 am CNA #2 went to assist another Resident and when the CNA came out of the room Resident #3 was not there. The report further documented that room searches and a perimeter search were done immediately by the staff. The report went on to document that while the Supervisor was outside, a police officer brought the Resident back to the facility at 5:20 am. The report further documented that the Resident was found by an off duty Police Officer 1 1/2 blocks away lying in the grass. The report further documented that the Physician and family were notified. A review of the investigation provided to the surveyor documented an interview with CNA #2 stating that CNA #2 went to assist another Resident. It further stated that CNA #2 believed that CNA #1 would be back momentarily. CNA #2 went on to say upon exiting the room of another Resident, Resident #3 was missing at approximately 5 am. The investigation further documented that CNA #2 received disciplinary counseling immediately by the Supervisor and was re-inserviced on the responsibilities of 1:1 assignment. In an interview with the Administrator and Director of Nursing (DON), on 4/13/15 at 10:40 am the Administrator and DON stated that the facility assumed the Resident eloped through the fire exit door by Resident #3's room. The Administrator stated that the door was alarmed but is not on the wander guard system. The Administrator and the DON stated that the alarm went off the night of the elopement. The DON stated that the Maintenance Director checked all the alarms and doors on 4/6/15 and all alarms were functioning. In an interview with CNA #2 who stated that "I did not hear an alarm sound but I was in a room with another Resident providing care." CNA #2 went on to say "If an alarm sounds at night there is an announcement overhead as to what door is alarming and when the alarm is cleared." In a telephone interview with the Registered Nurse (RN) #1 on 4/23/15 at 10:18 am, who was on duty the night of the elopement, the RN stated that "An alarm did go off the night the Resident eloped. I don't remember hearing an announcement but I was in a room with a Resident." The RN went on to say that "We do announce alarms overhead at night as to where the door is alarming, we check the Residents and someone goes to the alarming door. After we make sure all the Residents are here the alarm is cleared." During an interview with the North Wing Unit Manager (UM) the UM stated that the receptionist has the main wander guard alarm panel. The Receptionist works 8 am-8 PM. The UM went on to state that when a door alarm goes off the receptionist makes an overhead page to let staff know what door is alarming. The UM further stated that after 8 PM the staff is responsible to announce the door alarms. The UM also stated that there are alarm panels by the Nurses station on the North and South wings. When an alarm goes off the light will blink on the alarm panel next to the door that is alarming. In an interview with the UM from South wing the UM stated that only the South wing and receptionist have the ability to reset the alarms. A review of a form with company name of "Current Technologies Electronics" titled "Work Order" dated 4/10/15 documented under work performed: "Inspected all doors with maintenance for locking and key pad capabilities. All working correctly at this time." A review of a facility policy titled "Policy and Procedure for Wandering Resident" documented that For new admissions with a history of elopement or Residents who have been noted to elope from the facility a wander guard transmitter will be placed on the Resident's wrist or ankle. The Immediate Jeopardy to Resident #3's health and safety, which began on 4/6/15 was lifted and deficient practice corrected on 4/13/15 at 3:16 PM, when the facility provided an acceptable Plan of Correction (POC) to the Department of Health. Resident #3 was discharged to home with family on 4/6/15. The POC stated the following: 1." All alarms were checked by our maintenance director and found to be in working order. Resident #3 was determined to go home and family and Physician were agreeable. Discharge order was received and Resident was discharged . APS ( Adult Protective Services) was also called by our Social Worker. Electrician was called and rechecked alarms and all were in good working orders (sic). 2. Re-inservicing will be completed with all staff upon hire and annually. Staff were re-inserviced after the event compliance date 4/13/15. 3. Whenever a patient/Resident is placed on a 1:1 the nursing supervisor will re-inservice the staff members who will be assigned to the 1:1 and will audit that staff is compliant and has a good understanding of the responsibilities. Supervisor or designee will monitor the 1:1 every 15 minutes times 4 then hourly times 4 hours. The results will be reported to the DON who will then report to the Administrator the results who will report to QA (Quality Assurance) committee quarterly. 4. QA (Quality Assurance) will review results and make further recommendations." "Date of Compliance: 4/13/15" NJAC 8:39-27.1 (a)