Every finding on record at Preferred Care at Old Bridge, LLC

Complaint NJ#'s 420827, 2636492Based on observation, interviews, record review and review of pertinent facility documents it was determined that the facility failed to provide appropriate assistance with toileting needs and personal hygiene care for 4 of 6 residents (Residents #5, #8, #9, and #4) reviewed for Activities of Daily Living (ADL). This deficient practice was evidenced by the following:1. On 10/23/25 at 8:45 AM, Surveyor #1 observed Resident #5 sitting in a chair by the bedside on the South Unit. Resident #5 was disheveled and unkempt. Their sneakers were heavily soiled and stained. Their facial area was covered with yellow and white flakes. Resident #5's lower extremities were swollen, covered with yellow flaky and discolored areas. The residents fitted sheet on the bed was heavily soiled and yellow stained. Resident #5 informed the Surveyor #1 that they used the sink to wash themselves daily. And further stated, that they had not had a shower. The resident stated, I make my bed, they don't do it. Surveyor #1 reviewed the Electronic Medical Record (EMR) for Resident #5. A review of the admission Record (an admission summary) reflected that Resident #5 was admitted to the facility with diagnoses which included but were not limited to, muscle weakness, major depressive disorder and anxiety disorder. A review of the Care Plan Report for Resident #5 included a Focus dated 12/2/20, for assistance with ADL functions. Interventions dated 4/27/22 included: I require staff assistance by one staff to provide bath/shower; requires one staff assistance with dressing. On 10/23/25 at 1:00 PM, Surveyor #1 interviewed the Licensed Practical Nurse (LPN) / Unit Manager (UM) regarding Resident #5's care. The LPN/UM #1 stated that Resident #5 preferred to stay in their room and staff were to assist Resident #5 with care. On 10/23/25 at 1:05 PM, Surveyor #and LPN/UM #1 went to Resident #5's room and observed the linen condition, soiled and discolored. He confirmed that the bedding had not been changed. Surveyor #1 then inquired regarding the shower schedule for Resident #5. The LPN/UM #1 stated that Resident #5 was scheduled to have a shower on Tuesday and Friday during the 7:00 AM to 3:00 PM shift. Surveyor #1 reviewed the plan of care with the Certified Nurses Aide (CNA) #1 and could not locate that the resident has had a shower or refused a shower on Tuesday 10/21/25. On 10/23/25 at 1:10 PM, Surveyor #1 interviewed LPN/UM #1 regarding the process followed when a resident refused care or a shower. The LPN/UM #1 stated that the CNA should report this to the nurse and the nurse should then document in the progress notes that the resident refused their shower. Surveyor #1 reviewed the progress notes in the EMR from 10/2/25 to 10/23/25 and could find documented evidence that Resident #5 refused a shower. On 10/23/25 at 1:20 PM, the LPN/UM #1 informed Surveyor #1 that the unit had a shower log where the nurses would document the skin assessment performed on every shower day. Surveyor #1 reviewed the shower log for October and verified that staff initialed the shower log to indicate that Resident #5 had a shower on 10/7/25, 10/14/25 and 10/28/25 (5 days from now). Surveyor #1 reviewed the shower log with LPN/UM #1, he did not have any comment. On 10/23/25 at 2:05 PM, the surveyor interviewed CNA #1 who was assigned to Resident #5. CNA #1 stated that she observed the resident in the room this morning and was informed that Resident #5 was independent with care. When asked if she changed the bed linen this morning, she stated, No. When asked if she changed the linen yesterday on 10/22/23, she stated, I was not assigned to the unit, but based on the condition of the sheet, the linen had not been changed. On10/23/25 at 9:30 AM, Surveyor #1 entered the North Unit. While approaching the nursing station a foul and strong urine odor permeated the hallway. On 10/23/25 at 9:52 AM, Surveyor #1 located the smell in the hallway of the North Unit in Resident #8's room. Surveyor #2 informed surveyor #1 that she toured the North Unit at 8:20 AM and noted a similarly strong urine smell outside of that same room (door was closed at that time). Surveyor #1 then entered Resident #8's room, along with CNA #2. Both observed Resident #8 lying in bed, the bedspread was folded, and the resident's gown was visibly soaked with urine. CNA #2 asked the resident if she could check the incontinence brief, and the resident agreed. The bedding was observed as being yellow stained, and Resident #8 was wearing an incontinence brief which was bulging from the back and was visibly soaked with urine. The surveyor observed that there was no urinal at the bedside. Resident #8 stated in the presence of CNA #2, I have not been changed since last night around 12:00 AM. On 10/23/25 at 10:00 AM, Surveyor #1 interviewed CNA #2 who stated that early this morning she was alerted by LPN/UM #2 to check on Resident #8 due to the odor in the hallway. CNA #2 further stated she was unable to attend to Resident #8 in a timely manner since she had been caring for another resident. Surveyor #1 reviewed the EMR for Resident #8. A review of the admission Record for Resident #8 reflected the resident was admitted to the facility with diagnoses which included, but were not limited to, muscle weakness, benign prostatic hyperplasia with lower tract symptoms (an enlarged prostate affecting the flow of urine). A review of a Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/15/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident had a moderately intact cognition. It also reflected that Resident #8 required partial/moderate assist for toileting. A review of the Care Plan Report dated 05/09/25, had a Focus for I require assistance with ADL functions. Interventions dated 5/9/25 included, I require extensive assistance of one person for toilet use. On 10/23/25 at 11:37 AM, Surveyor #1 interviewed LPN/UM #2 regarding incontinence care. She stated that the nurses and the CNAs were to make rounds at the start of the shift to ensure all residents were safe. She further stated that she did not round this morning. The surveyor inquired where the CNA would document the care provided to each resident. The LPN/UM #2 stated that the care provided was documented on the Point of Care (PoC) Kiosk (computerized system) used by the CNA. On 10/23/25 at 11:45 AM, Surveyor #1 reviewed the PoC Kiosk for Resident #8 and there was no documented accountability for care provided to the resident from the 11:00 PM (10/22/25) to 7:00 AM (10/23/25) shift. On 10/23/25 at 11:15 AM, Surveyor #1 interviewed CNA #2 who stated she was aware of the strong urine odor when she entered the unit, but she did not know that was from Resident #8's room. On 10/23/25 at 1:45 PM, Surveyor #1 interviewed LPN/UM #2. She stated that residents were dependent on staff for incontinence care, and residents should be checked every two hours and before meals. Surveyor #1 inquired if Resident #8 was checked and provided with incontinence care on 11:00 PM (10/22/25) to 7:00 AM (10/23/25) shift. She stated, based on the observation reported by staff, incontinence care was not provided. 3. On 10/23/25 at 9:30 AM, Surveyor #1 performed an incontinence care observation with a random CNA on the South Unit. Resident #9 was soaked with urine. On 10/23/25 at 10:30 AM, Surveyor #1 interviewed CNA #3 who was assigned to Resident #9. CNA #3 stated that she was taking care of other residents and did not have time to provide incontinence care to Resident #9 prior to breakfast. Surveyor #1 reviewed the EMR for Resident #9. A review of the admission Record reflected Resident #9 was admitted to the facility with diagnoses which included but were not limited to, unspecified Atrial Fibrillation, unspecified convulsions and unspecified dementia. A review of a Quarterly MDS dated [DATE], reflected the resident had a BIMS score of 13 out of 15, which reflected the resident had an intact cognition. The MDS also reflected the resident was frequently incontinent of bowel and bladder. A review of the Care Plan Report dated 6/18/16, included the resident had a physical functioning deficit related to self-care impairment. There was a goal for staff to assist with care. Interventions included, provide personal hygiene assistance. 4. On 10/23/25 at 8:37 AM Surveyor #2, with Surveyor #1 present, observed an open door to a resident room on the South unit. Resident #4 looked out into the hallway and stated, Come in. Resident #4 was lying in bed awake and alert. Resident #4 stated, You can't get anything done around here. You have to wait for everything. Resident #4 stated they had to go to the bathroom but did not know where their call bell was. On 10/23/25 at 8:41 AM, Surveyor #1 observed CNA #4 in the hallway. Surveyor #1 requested CNA #4 join her and Surveyor #2 in Resident #4's room. CNA #4 entered Resident #4's room with the surveyors and acknowledged the resident's call bell was out of sight and out of reach. The resident then stated to CNA #4 that they needed to go to the bathroom. CNA #4 stated, OK and left the room at 8:43AM. On 10/23/25 at 8:49 AM, Surveyor #2 observed CNA #4 walking in the hallway. The surveyors returned to Resident #4's room. Resident #4 stated that they had not yet been taken to the bathroom. The surveyors left the room. Surveyor #1, in the presence of Surveyor #2, approached and interviewed CNA #4. He stated that when a resident tells you they need to go to the bathroom, you take them. He acknowledged that Resident #4 stated they needed to go to the bathroom. He acknowledged that he did not go back to Resident #4's room to assist them. CNA #4 stated this resident was not on their assignment and he was in the hall trying to find out which CNA was assigned to Resident #4. He acknowledged that any CNA could take any resident to the bathroom. CNA #4 acknowledged that he did not take Resident #4 to the bathroom although he should have, stating it was an error. Surveyor #2 reviewed the EMR for Resident #4. A review of the admission Record reflected that the resident was admitted with diagnoses that included but were not limited to unspecified sequelae of cerebral infarction (complications that resulted from a stroke), urinary tract infection, retention of urine, and generalized muscle weakness. A review of a Quarterly MDS dated [DATE], reflected the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. The MDS also reflected that Resident #4 had an indwelling urinary catheter, and was frequently incontinent of bowels. A review of the Physicians Orders (PO) reflected a PO dated 9/25/25, to remove the indwelling urinary catheter. A review of the Care Plan Report for Resident #4 included a Focus dated 8/21/25, that the resident required assistance with ADL functions. Interventions dated 8/21/25, included, Toileting: I am totally dependent on (1) staff for toilet use. A review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, last revised 1/2025, indicated the following: Policy: Residents will be provided with care, treatment and services as appropriate to maintain their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services, necessary to maintain good nutrition, grooming and personal and oral hygiene. Procedure Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s)demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. The policy was not being followed. NJAC 8:39-27.2 (d)(h)(i)

Complaint NJ# 420827Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that a.) resident's call bells were within reach and could be activated for assistance with their needs, and b.) resident's needs were met in a timely manner once the call bell was answered. This deficient practice was identified for 3 out of 9 residents (Resident's #4, #6 and #7) reviewed for reasonable accommodation of needs. This deficient practice was evidenced by the following: 1. On 10/23/25 at 9:20 AM, the surveyor observed Resident #6 in bed. When the surveyor inquired about the residents call bell, they stated, I do not have a call light. The resident further stated that if they required assistance, they used their wheelchair to go to the hallway to find/alert staff. The surveyor reviewed the electronic medical record (EMR) for Resident #6. A review of the admission Record reflected that Resident #6 had diagnoses which included but were not limited to, unspecified dementia without behavioral disturbances and chronic obstructive pulmonary disease. A review of a Quarterly Minimum Data Set (MDS) dated [DATE], a tool used for the management of care, reflected a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated cognitive impairment. A review of the Care Plan Report dated 8/25/25, had a Focus for falls related to poor safety awareness, unsteady gait, and diagnosis of convulsions. Interventions included ask for assistance when attempting to transfer; and Keep call light within easy reach. On 10/23/25 at 11:30 AM, the surveyor accompanied the Licensed Practical Nurse (LPN) / Unit Manager (UM) #1 to Resident #6's room. The LPN/UM #1 confirmed the residents call bell was not accessible. In the presence of LPN/UM #1, the surveyor asked Resident #6 if they could activate the call bell. The resident stated that they did not have a call bell. The call bell was not visible nor accessible. The LPN/UM #1 traced the call bell from the wall and observed that the call bell was tied underneath the mattress on the bedframe. The surveyor then asked the LPN/UM #1 if Resident #6 could activate the call bell, the UM stated, No. The surveyor then asked the LPN/UM #1 who was responsible to ensure residents call bells were accessible and within easy reach. The LPN/UM #1 stated the Certified Nursing Assistant (CNA) and the nurses were responsible. She stated that she verbally reminded the CNAs daily to ensure residents call bells were within reach prior to exiting the room after they provided care. On 10/23/25 at 11:50 AM, during an interview with the CNA assigned to Resident #6, she stated that she was not aware that the resident did not have their call bell within reach. 2. On 10/23/25 at 8:37AM, the surveyor observed Resident #4 lying in bed. Resident #4 was awake and alert. The call bell cord was observed coming from the wall jack and going behind a privacy curtain gathered against the wall. The resident stated they had to go to the bathroom but did not know where their call bell was. On 10/23/25 at 8:41AM, the surveyor, in the presence of a second surveyor, requested CNA #1 to accompany the surveyors to Resident #4's room. CNA #1 acknowledged that Resident #4's call bell was behind the privacy curtain and was out of sight and out of reach. CNA #1 lifted the call bell cord and guided the button end of the cord to Resident #4's bed. CNA #1 laid the call bell button on the bed on the resident's left side near their upper arm. The resident stated Where is it? I still can't reach it. I can't see it. I have a blind spot on my left side. CNA #1 then moved the call bell button to the resident's right hand. The resident told the CNA they needed to go to the bathroom. CNA #1 said OK and left the room at 8:43AM. On 10/23/25 at 8:49AM, the surveyor, in the presence of a second surveyor, returned to Resident #4's room. Resident #4 stated that nobody had taken them to the bathroom. The surveyor interviewed CNA #1 who stated that when a resident tells you they need to go to the bathroom, you take them. CNA #1 acknowledged that Resident #4 stated they needed to go to the bathroom and acknowledged he did not take the resident. CNA #1 further stated that Resident #4 was not on his assignment. The surveyor reviewed the EMR for Resident #4. A review of the admission Record reflected that Resident #4 was admitted with diagnoses that included but were not limited to unspecified sequelae of cerebral infarction, urinary tract infection, retention of urine, and muscle weakness (generalized). A review of the admission MDS dated [DATE], included a BIMS score of 13 out of 15 which indicated Resident #4 was cognitively intact. A review of the Care Plan Report reflected a Focus dated 8/21/25, which indicated the resident required assistance with ADL functions. In addition, the care plan report reflected the intervention keep call light within easy reach dated 8/21/25. 3. On 10/23/25 at 8:52AM the surveyor, in the presence of a second surveyor, observed Resident #7 in their room with the door open. Resident #7 looked in the hall, waved and told the surveyors to come in. Resident #7 stated that when staff responded to their call bell they would turn the call bell off so it stops ringing. But they leave and never come back to do what you needed. The surveyor reviewed the EMR for Resident #7. A review of the admission Record reflected that Resident #7 was admitted with diagnoses that included but were not limited to unilateral primary osteoarthritis left knee, and hereditary and idiopathic neuropathy, unspecified. A review of a Quarterly MDS dated [DATE], included a BIMS score of 15 out of 15 which indicated Resident #7 was cognitively intact. A review of the Care Plan Report revealed a Focus dated 11/6/20, which reflected the resident required assistance with ADL functions. In addition, the care plan report reflected the intervention keep call light within easy reach dated 11/6/20. On 10/23/25 at 12:45 PM, the surveyor interviewed CNA #2 who stated that the call bell system alerts as a light above the residents room and a sound that can be heard in the hallway. She further stated that the residents room and bed number could also be seen on a monitor at the nurses' station. CNA #2 stated that upon entering the resident's room, the call bell was turned off and if it was her resident, she would see what they needed. CNA #2 also stated, If it's not my resident I go and get the aid. In addition, CNA #2 stated the CNAs should respond to the resident right away. On 10/23/25 at 12:50 PM, the surveyor interviewed LPN/UM #2 who stated that the process for answering call bells was to ask what the resident needs; then either do it or leave to get the staff that can do it. For example, if a resident needs pain medicine the CNA would get the nurse. LPN/UM #2 stated that staff should then go back to the resident to tell them someone was coming. LPN/UM #2 stated that everybody can answer a call bell. Sometimes they can do what the patient needs, but sometimes they have to get someone else. LPN/UM #2 stated that call bells needed to be in reach at all times, which meant the resident was able to press it with their dominant side or whatever's easiest. A review of the facility's policy titled, Call Bell last revised 1/2025 revealed the following: Purpose Residents will have a functioning call bell to alert staff of their needs. Procedures #1 Call bell functioning will be checked on a regular basis by Nursing and Maintenance. #7 When making beds and tidying resident rooms, call bell will be left in a standard place in all rooms: attached to a partial side rail or the top of the bed. The Nursing Assistant leaving the room must ensure that the call bell is in place regardless of the residents' ability to use it. #9 The Nursing Assistants will ensure that the call bell is within the resident's reach before leaving the room. NJAC 8:39-31.8(c)(9)

Complaint#: NJ187513, NJ187972Based on interviews, closed medical record review, and review of other pertinent facility documents on 7/10/2025, it was determined that the facility failed to develop an elopement risk care plan (CP) for a resident (Resident #5) who was identified as an elopement risk. This deficient practice was identified in 1 of 4 residents reviewed for elopement risk. This deficient practice was evidenced by the following:The surveyor reviewed the closed medical record for Resident #5.According to the admission Record (AR), Resident #5 was admitted to the facility with diagnoses which included but were not limited to Diabetes, Anemia, Hyperlipidemia (high cholesterol). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/11/2025, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. A review of Resident #5's Elopement Risk Evaluation form dated 6/20/2025 revealed Resident #2 was at risk for elopement.A review of Resident #5's Care Plans (CP) revealed no elopement risk care plan for Resident #5.During an interview on 7/10/2025 at 3:30 PM with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), the DON stated that if a resident was an elopement risk they should have a care plan in place. The DON further indicated that it was important for nursing staff to update the care plan so that all staff know how to care for the resident. The DON confirmed that there was no elopement risk care plan for Resident #5. The DON stated that the nursing staff had 14 days to update the resident's care plan according to the facility policy. The DON further stated the resident was discharged prior to the 14-day period the staff had to update the care plan. A review of the facility's policy titled Care Plan Revisions Upon Status Change revised on 3/2025 revealed under Policy Explanation and Compliance Guidelines, 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: d. The care plan will be updated with the new or modified interventions within 14 days.NJAC 8:39-27.1 (a)

Based on interviews, medical record review, and review of other pertinent facility documentation on 7/10/2025 it was determined that the facility failed to follow their protocol and policy to prevent the elopement of a safety awareness impaired resident (Resident #2) who exited the facility from the rear entrance when an incoming family member entered the facility and held the door for Resident #2 to leave the facility and return to their home with staff failing to adequately supervise resident and ensure safety of its residents. This REQUIREMENT is NOT MET as evidenced by:Complaint#: NJ187513, NJ187972Based on interviews, medical record review, and review of other pertinent facility documents on 7/10/2025, it was determined that the facility failed to follow their protocol and policy to prevent the elopement of a safety awareness impaired resident (Resident #2) who exited the facility from the rear entrance when an incoming family member entered the facility and held the door for Resident #2 to leave the facility and return to their home with staff failing to adequately supervise resident and ensure safety of its residents. This deficient practice was evidenced by the following:According to the admission Record (AR) Resident #2 was admitted to the facility with diagnoses which included but were not limited to: hypertension, altered mental status and vascular dementia.A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/28/25. Resident #2 had a Brief Interview of Mental Status (BIMS) score of 4 out of 15, which indicated the resident had moderate cognitive impairment.According to the facility reportable event (FRE) dated 6/17/2025, the FRE indicated that on 6/16/2025, Resident #2 was able to tell facility staff member that at approximately 6:30 PM resident chose to go home and arranged his/her own transportation. At approximately 7:15 PM facility staff received a phone call from the resident family member, asking why resident had gone home. The surveyor reviewed Resident #2's nurses (NN) dated 6/17/25 at 12:57 PM. The NN revealed that writer last checked Resident #2 around 6:00 PM in his/her room sitting in a chair. Around 7:15 PM, a call was received from family member stating can you explain to me how my (resident) got home when he/she is supposed to be at your facility. Writer went to resident room and resident was not there. All resident rooms were checked on the unit, resident was not located. On 7/10/2025 at 11:15 AM, the surveyor interviewed RN #1 who stated around 5 PM when she went into the room to give Resident #2's roommate medication, she saw Resident #2 sitting in a chair. RN #1 left the room to perform other duties and returned to resident room around 6 PM to check his/her blood pressure. Resident was observed to be sitting in same chair. RN #1 left the room to return to the nurses desk. At around 7:15 PM the phone rang with resident family member was on the phone asking how he/she got home. On 7/7/2025 at 2:25 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Administrator. The DON stated that Resident #2 had no key to get into his/her home. He/she went to the neighbor next door to get the spare key. Afterwards, the neighbor called the family member to alert them that resident had asked for the key to get in and was at home. A review of the facility's policy titled Elopement Prevention and Management revised 10/24 revealed under Policy: The facility defines elopement as follows:, When a cognitively impaired resident/patient leaves the facility grounds unattended and without staff knowledge.NJAC 8:39-33.1(d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 3/26/25, the surveyor observed three (3) nurses administer medications to five (5) residents. There were 32 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.25 %. This deficient practice was identified for one (1) of five (5) residents, (Resident #79), that were administered medications by one (1) of three (3) nurses. The deficient practice was evidenced as follows: On 3/26/25 at 8:10 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) preparing to administer the morning medications to Resident #79. LPN #1 stated that according to the electronic medication administration record (EMAR), the resident had a physician's order (PO) for Insulin Lispro (a fast-acting insulin-a medication used to lower blood sugar) but had looked through the medication cart and could not find the resident's Insulin Lispro. LPN #1 stated that he would have to check the backup supply. LPN #1 then stated that he was going to administer the morning medications that were in the cart first. On 3/26/25 at 8:20 AM, the surveyor with the LPN #1, observed the resident in bed with a breakfast tray on the overbed table. The breakfast tray had an uncovered plate with part of an egg omelet remaining and an empty bowl with cereal residue. LPN #1 stated that the resident spoke another language but was able to understand that medications were being administered. The surveyor observed LPN #1 obtain a blood sugar (BS) result of 279 from Resident #79. Then, the surveyor observed LPN #1 administer seven (7) oral medications that had been crushed and placed in applesauce to the resident. On 3/26/25 at 8:30 AM, the surveyor with LPN #1, went to the medication room on the unit to look for the backup supply of Insulin Lispro. LPN #1 was joined by the Nurse Supervisor/Registered Nurse (NS/RN), and they were unable to find a backup supply of Insulin Lispro. The NS/RN stated that she would go to another unit to find the backup supply of Insulin Lispro. On 3/26/25 at 8:44 AM, the surveyor observed the NS/RN give a vial of Insulin Lispro to LPN #1. The NS/RN stated that she had retrieved the Insulin Lispro from the backup supply on the Rehab unit. On 3/26/25 at 8:52 AM, the surveyor observed LPN #1 administer six (6) units (U) of Insulin Lispro subcutaneously to the right abdomen of Resident #79. At that time, the breakfast tray was no longer observed in the room. On 3/26/25 at 8:53 AM, the surveyor interviewed LPN #1, at the medication cart, who stated that there were no other morning medications to administer to Resident #79. LPN #1 verified that the EMAR reflected a 9 AM time of administration for Insulin Lispro. LPN #1 stated he had 1 hour before and 1 hour after to administer the medication and was on time. LPN #1 also verified that breakfast was usually delivered to the floor between 7:30 AM and 8:00 AM and that the resident had eaten breakfast before administering the Insulin Lispro. (ERROR #1) LPN #1 could not speak to why the Insulin had an administration time of 9 AM which would be after breakfast was finished. The surveyor reviewed the electronic medical record for Resident #79. A review of the resident's Admission Record reflected that the resident had diagnoses, which included but not limited to; Type 2 Diabetes Mellitus (DM) (a diminished response to insulin causing inadequate control of glucose blood levels, hyperglycemia (high blood sugar) and dementia (a decline in cognitive abilities). A review of the most recent comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 2/23/25, reflected the resident had a brief interview for mental status (BIMS) score of three (3) out of 15, indicating that the resident had a severely impaired cognition. A review of the resident's Order Summary Report (OSR) reflected a PO with a start date of 3/3/25 for Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-Injector 100 Unit (U)/ML (milliliter) (Insulin Lispro), Inject as per sliding scale: if 150-200 =2 U; 201-250 =4 U; 251-300 = 6 U; 301-350 = 8 U; 351-400 =10 U, subcutaneously (SC) three times a day for DM call MD(physician) if BS greater than 400 or less than 70. A review of the EMAR reflected the same PO as the above OSR with a time of administration of 9 AM. Further review of the EMAR revealed that the PO was discontinued on 3/26/25, after the medication administration observation and the same PO was entered on 3/26/25 with different times of administration for 7:30 AM, 11:30 AM and 4:30 PM. Further review of the EMAR, during reconciliation of the medications observed during the medication administration observation, revealed a PO dated 9/4/24 for Insulin Glargine (a long-acting insulin) Solution 100 U/ML, Inject 18 U SC in the morning for Diabetes, Rotate Sites, give after breakfast. The EMAR had a time of administration of 8:30 AM and was signed on 3/26/25 as being administered by LPN #1. A review of the resident's individualized Care Plan Report had a focus area of Has Diabetes Mellitus with an initiated date of 8/9/22 and interventions, which included but not limited to, Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness and Fasting Serum Blood Sugar as ordered by doctor. On 3/26/25 at 11:36 AM, the surveyor interviewed LPN #1, who stated that he had changed the administration time of the Insulin Lispro from 9 AM to 7:30 AM because that was standard protocol. LPN #1 could not speak to the meaning of standard protocol. LPN #1 then verified that he had not administered the Insulin Glargine during the medication administration observation because he had administered that Insulin before the surveyor had joined him. LPN #1 then reviewed the PO for Insulin Glargine and acknowledged that the PO indicated a time of administration of 8:30 AM with instructions to give after breakfast. LPN #1 was unable to speak to why he had administered the Insulin Glargine before breakfast. (ERROR #2) On 3/26/25 at 1:49 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone, who stated that he was the owner and could speak to any questions. The CP stated that the time of administration of insulins should depend on the mealtime. The CP added that the recommendation was that fast-acting insulins should be administered 15 minutes before eating a meal. On 3/27/25 at 8:10 AM, the surveyor interviewed the Director of Nursing (DON), who stated insulin administration was coordinated according to the mealtimes of 7:30 AM, 11:30 AM and 4:30 AM. The DON added that insulin administration could be dependent on blood sugars and eating habits. The DON also stated that Resident #79 had a specific time of administration for insulin at 9 AM because they were not an early riser and woke up between 8 and 8:30 AM and tended to eat breakfast late. The DON also stated that physician's orders were to be followed. The DON acknowledged the insulin supply for current orders should have an adequate supply on hand. A review of an Inservice Attendance Sheet dated 3/3/25, provided by the DON revealed the topic of the inservice was Resident #79 and the subject was Resident prefers to sleep in until 8 AM and should have breakfast after that time. There was no documentation from the physician reflecting the BS be taken after breakfast and insulin administration to be administered after the meal. On 3/27/25 at 10:17 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that she was familiar with the care of Resident #79 and had fed the resident on the morning of 3/26/25. CNA #1 stated the resident was a diabetic and she had to make sure that the resident ate in the morning. She stated the resident required assistance and encouragement to eat. CNA #1 added that she brings the breakfast tray into the resident in the morning and the resident was able to indicate whether they were ready to eat breakfast. CNA #1 also stated that she remembered on 3/26/25 that the resident was up when she brought the tray in which she thought was after the breakfast trucks were usually delivered to the floor but was unsure of the exact time. CNA #1 added that she remembered the resident ate all their cereal and approximately half of the egg omelet. CNA #1 stated that she does not tell the nurses when the resident was ready to eat but she tells the nurse the percentage the resident ate after they finished the meal. On 3/27/25 at 12:29 PM, the surveyor interviewed LPN #2, who stated that she was the medication nurse for Resident #79 for the day. LPN #2 stated that she checked the resident's blood sugar before the resident ate breakfast and lunch and then administered the Insulin Lispro because it was a fast-acting insulin and should be administered right before a meal. LPN #2 added that the Insulin Glargine was administered in the morning after the resident finished their breakfast. LPN #2 could not speak to why there was a time of administration of 9 AM indicated on the EMAR for the Insulin Lispro. A review of an unsigned Medication Pass Observation for LPN #1 provided by the DON that had been completed on 9/18/24, revealed that there was no observation of insulin administration observed during that med pass. On 3/27/24 at 2:00 PM, the surveyor interviewed the DON, who stated the 9/18/24 Medication Pass Observation was completed by a nurse who no longer worked at the facility and that med passes were performed yearly for the nurses. The DON added that an inservice was performed immediately after the med pass with the nurse if there were any discrepancies noted. A review of a Med Pass Inservice completed by the CP on 2/10/24, revealed an attendance sign in sheet that was not signed by LPN #1. The Medication Pass Inservice information sheets that the CP reviewed during the inservice revealed that one of the five rights was Right Time: Medication can be given 60 minutes before the time on MAR or 60 minutes after is considered correct, Exception medication to be given with regard to meals either AC (before meals) or PC (after meals) need to be given as such. In addition, another information sheet reviewed during the inservice Medications Administration with Regards to Meals revealed that Insulin Lispro was to be administered before a meal. On 3/31/25 at 10:41 AM, the survey team met with the Licensed Nursing Home Administrator, Administrator in Training, DON and Regional DON. The DON stated that she had spoken with the family representative and the physician, and both agreed that they were more concerned with the resident exhibiting hypoglycemia (low blood sugar) and wanted to make sure the resident had eaten breakfast before getting insulin. The DON acknowledged that the standard protocol for a fast-acting insulin was to be administered prior to a meal and that the PO had not indicated different instructions for the time of administration. A review of the facility policy dated as reviewed January 2025 for Medication Administration provided by the DON reflected Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. In addition, Administer medication as ordered in accordance with manufacturer specifications. A review of the facility policy dated as reviewed January 2024 for Insulin Administration Policy provided by the DON reflected All insulin will be administered in accordance with physician's orders. In addition, Insulin administration will be coordinated with mealtimes and bedtime snacks unless otherwise specified in the physician order. The policy also reflected, For current insulin orders, an adequate supply of insulin will be maintained for each resident. The manufacturer specifications for Insulin Lispro revealed Administer Insulin Lispro by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) identify and address a severe weight loss of 7.6 pounds (lbs.) and 5.3% in one week from 9/15/22 through 9/22/22, and obtain a reweight for 1 of 4 residents, (Resident #97), b.) ensure that a resident identified as at risk for malnutrition or malnourished was comprehensively evaluated and assessed for 2 of 4 residents, (Resident #38 and #97), and c.) provide the recommended supplements to residents that experienced weight loss for 3 of 4 residents, (Resident #33, #38 and #97) reviewed for nutrition. The evidence was as follows: 1. On 3/2/23 at 11:25 AM, the surveyor observed Resident # 97 awake and seated in a wheelchair in front of the North nursing unit. At that time, the resident stated that he/she was aware of his/her weight loss. The surveyor reviewed the electronic and paper medical record for Resident # 97. Review of the Admission Record (an admission summary), included that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), hemiplegia and hemiparesis (weakness of one side of the body) following cerebral infarction affecting the right dominant side, and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/13/22, included a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated that the resident had an intact cognition. Review of the March 2023 Order Summary Report (OSR) indicated a physician order (PO) dated 8/15/22, for a Regular diet *Regular texture, Thin consistency. Review of the August 2022 through March 2023, electronic Medication Administration Record (eMAR) reflected the above corresponding PO. Review of the resident's weights included the following: 9/15/22 145.6 lbs. 9/22/22 138 lbs. Review of Nutrition Assessment -V2 dated 8/22/22, indicated that the Registered Dietitian (RD) #1 observed the resident consume > 50% of the breakfast meal. It further indicated that the resident's food preferences, diet, and weight history were obtained. It also included nutritional interventions for a super cereal (a nutritionally fortified hot cereal) at breakfast and a four ounce (oz) mighty shake for breakfast, lunch, and dinner to provide 200 calories and 6 grams of protein per four oz portion. There was no documented evidence in the resident's hybrid (electronic and paper) medical records that the above RD's recommended nutritional supplements were given, accepted, or consumed by the resident. Review of the resident's progress notes from the hybrid medical records from 9/22/22 through 2/22/23, reflected no documented evidence that the resident's severe weight loss was identified and addressed by the RD, Nursing, Attending Physician (AP) or the Nurse Practitioner (NP). Review of the Mini Nutritional assessment dated [DATE] which was completed by RD #2, indicated that the resident was identified as Malnourished, had a moderate decrease in food intake, and had a weight loss greater than 6.6 lbs. There was no documented evidence that RD #2 reassessed the resident and recommended nutritional interventions. Review of the resident's comprehensive care plan (CP), a nutrition CP initiated on 8/29/22 included interventions for .supplements as rx'd [prescribed]; monitor weight, labs, skin integrity, hydration status; honor food preferences; meds as rx'd. There was no documented evidence of a revised CP that addressed the severe weight loss. Review of the resident's meal tickets (documentation of what was provided on a meal tray for breakfast, lunch, and dinner) provided to the surveyor by the Food Service Director (FSD), in the presence of the Regional FSD on 3/2/23 at 10:08AM, did not reflect the RDs recommended nutritional supplements. Review of the Nursing Quality Assurance Performance Improvement Plan Monthly Review (NQAPIPMR) forms dated 9/22/22, 10/20/22, 11/28/22, and 1/26/23, included a Weight Variance Report that addressed residents who experienced weight losses. Resident #97 was not included. On 3/2/23 at 11:36 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN). She stated that the DON, RD, and UMs conducted monthly weight meetings and discussed those residents who experienced weight loss. She stated that the DON retained the weight meeting documentation records. She acknowledged that she was aware of the resident's severe weight loss and recently discussed this with the RD. The UM/LPN stated that the RD told her that maybe the original weight documentation was incorrect, but she was not sure if this was documented in the resident's medical record. On 3/2/23 at 11:52 AM, the surveyor interviewed the Certified Nursing Aide (CNA) #1 who was familiar with the resident. She stated that residents were weighed by CNAs monthly or sometimes twice weekly. She was not aware of the Resident #97's weight loss. The CNA could not speak to whether the resident received nutritional supplements on his/her meal trays. On 3/2/23 at 12:20 PM, the surveyor interviewed the DON who stated that she, the RD, and UMs conducted monthly meetings to discuss residents who experienced weight loss. She further stated that the content of the meetings were documented on the NQAPIPMR forms. The DON provided copies to the surveyor. On 3/2/23 at 1:04 PM, the surveyor reviewed the NQAPIPMR forms which indicated a list of residents and their calculated weight loss. The report indicated whether the weight loss was desired, undesired, planned or unplanned. It further included nutritional interventions and the date the CPs were revised. Resident #97 was not included. On 3/2/23 at 1:24 PM, the surveyor interviewed the DON in the presence of the survey team. She stated that RD #1 worked from November 2021 through December 31, 2022, RD #2 was employed from January 2023 through February 10, 2023, and RD #3 would be working as an interim from February 11, 2023, to present. On 3/2/23 at 2:04 PM, the surveyor interviewed RD #3 in the presence of the survey team. RD #3 confirmed the above statement from the DON regarding her employment timeline in the facility. She stated that she documented comprehensive nutritional assessments for new admissions and then initiated a comprehensive nutrition care plan and provided dietary recommendations. Furthermore, RD #3 also stated that she revised care plans quarterly, annually and on an as needed basis. She stated that we always update the care plans. RD #3 further stated that if she recommended nutritional supplements, she would complete a Dietitian Recommendations communication form. She stated that she then presented the form to the nurse who signed it and relayed the information to the physician. She stated that a copy went to the FSD, and a copy remained in the chart. She stated that the form was utilized to communicate initiation or discontinuation of nutritional supplements. She acknowledged that the RD and AP should have been notified of a resident's 5% or more weight loss in one week and that weekly weight monitoring should have been conducted. During the interview, RD #3 stated that the RDs reviewed residents' weekly or monthly weights depending on the status. She further stated that after she reviewed the weights, she conducts a nutritional assessment which would be documented in the medical record. She acknowledged that if a resident had a significant weight loss, she would request a re-weight to confirm the weight loss. She stated that if a significant weight loss was confirmed, she would conduct a root cause analysis to determine whether the weight loss was intentional or unintentional, make nutritional recommendations, and revise the care plan, all of which would be documented in the resident's medical record. On 3/3/23 at 10:25 AM, the surveyor had a follow up interview with Resident #97. The resident stated that he/she had not received mighty shake supplements. The resident further stated that he/she was just recently offered a vanilla mighty shake, but he/she refused it and stated it was too sweet. Resident #97 informed the surveyor that he/she never liked any kind of cereal, and the staff were aware of his/her food preferences. The resident also stated that the staff did not offer him/her other alternatives to choose from. On 3/3/23 at 10:33 AM, the surveyor conducted a follow up interview with the UM/LPN in the presence of a second surveyor. The UM/LPN informed the surveyor that the residents were weighed monthly by the CNAs. She stated that she would review the weights for discrepancies to confirm significant weight loss. She further stated that if a significant weight loss was confirmed, she or the nurse would document this in the resident's electronic medical records, and she would notify the RD. She stated that the RD would document a nutritional assessment and then communicate recommendations with the Dietician Recommendations form. The UM/LPN stated that she would sign the recommendation form in acknowledgement, then the RD would alert the kitchen of the nutritional supplements that needed to be provided to the resident. She further stated that the RD also notified her for any discontinuation of nutritional supplements and that the RD would directly speak to the kitchen staff to communicate the discontinued recommendations. During the interview, the UM/LPN stated that she would notify the AP and that the AP usually agreed to the RD recommendations. The UM/LPN stated that she only documented in the resident's medical records when the AP disagreed with the recommendations. The UM/LPN acknowledged that the resident received mighty shakes and super cereal on his/her meal trays in the past. She further acknowledged that the resident did not prefer the nutritional supplements and that the RD was notified of this. However, the UM/LPN could not speak to whether the RD reassessed the resident, updated his/her preferences and made new recommendations. The UM/LPN stated that she relied on the RD for weight calculation to determine weight loss. She further stated that she expected the RD to identify and address significant weight loss and provide nutritional interventions. On 3/3/23 at 12:55 PM, the LNHA and DON met with the survey team. The DON acknowledged that the CNAs obtained weights. She stated if there was a weight discrepancy, a re-weight should be obtained to confirm significant weight loss. She further stated that she expected the nurse to notify the RD of the confirmed weight loss, and that the RD should have addressed the weight loss with a nutritional assessment, revised CP, and provided nutritional interventions which may include supplements. Furthermore, the DON stated that nutritional supplements were provided with the resident's meal and acknowledged that there was no documented evidence to account for the administration and recorded consumption of the mighty shakes and super cereal. On 3/6/23 at 9:41 AM, the surveyor attempted to call the resident's AP in the presence of the survey team, but the AP was not available at that time. The AP's office manager (OM) informed the surveyor that the AP would be in the office at 3:00 PM. On 3/6/23 at 10:33 AM, the surveyor interviewed the DON in the presence of the survey team. She stated that she reviewed Resident #97's paper medical records and acknowledged that there was no documented evidence from the AP and RD that addressed the residents severe weight loss, and she stated, I did not see any. On 3/6/23 at 12:20 PM, the LNHA, LNHA in training, and DON met with the survey team. The DON acknowledged that the resident's AP was aware of the resident's significant weight loss but did not address it. She further acknowledged that the RD was also aware of the resident significant weight loss, but the RD failed to document this in the resident's medical records. The DON stated that the resident had resolved edema which could have contributed to the resident's weight loss, and then acknowledged that there was no documented evidence related to when that occurred. The DON acknowledged that she was unable to correlate the resolved edema and the weight loss. During the interview the DON stated that the Mini Nutritional Assessment form was utilized to assess whether a resident was malnourished or at risk for malnutrition. The DON stated that she expected the RD to act upon when a resident was identified as malnourished or at risk with a documented comprehensive nutritional assessment and a revised CP to include dietary interventions. The DON informed the survey team that the Mini Nutritional Assessment was new to them, and she had never seen that form prior to surveyor inquiry. On that same date at 3:36 PM, the surveyor reattempted to conduct a telephone interview with the AP, but the OM stated that the AP was unavailable to speak to the surveyor. 37791 2. On 2/22/23 at 10:15 AM, the surveyor observed Resident #38 seated in a wheelchair and listening to the radio. The resident appeared thin and did not respond to surveyor inquiries. On 2/27/23 at 12:15 PM, the surveyor observed the resident eating lunch independently. The resident meal consisted of a sweet potato, roasted pork and Brussel Sprouts. There was also a dessert and a low-fat milk on the tray. The resident stated that he/she consumed most of the roasted pork and sweet potatoes, and few of the Brussel sprouts. On 2/27/23 at 12:39 PM, the surveyor observed both the CNA #2 and an LPN in the resident's room encouraging the resident to consume more food. The surveyor observed that the resident consumed 0% of the lemon meringue pie dessert. In addition, there was no mighty shake or magic cup (supplements) observed on the resident's lunch tray or on the overbed table. The surveyor reviewed the electronic and paper medical record for Resident #38. Review of the Admission Record reflected that the resident was admitted to the facility with diagnoses which included but not limited to; malignant neoplasm of prostate (prostate cancer), major depressive disorder (mood disorder that causes a persistent feeling of sadness and a loss of interest), neutropenia (condition of few neutrophils, a type of white blood cell that fights infection), and anemia (condition that causes a lack of healthy red blood cells to carry adequate oxygen to body tissues). Review of the quarterly MDS dated [DATE], included that the resident had a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. Review of the March 2023 OSR POs indicated a PO for a Regular diet, Regular texture, and thin consistency with a start date of 3/5/21. It also included a PO dated 8/6/22, for Remeron 15 milligrams (mg) one tablet by mouth at bedtime as an appetite stimulant. Review of the September 2022 through March 2023 eMAR, reflected the above corresponding PO. Review of the resident's weights included the following: 8/11/22 96 lbs. 9/5/22 93 lbs. 10/3/22 97 lbs. 11/10/22 95 lbs. 12/9/22 95 lbs. 1/6/23 94 lbs. 2/1/23 92.6 lbs. Review of the resident's progress notes from the hybrid medical record from 9/1/22 through 02/22/23, included the following documentation related to the resident's nutritional status: Review of the nutritional progress note dated 9/8/22, indicated that the resident experienced a 9.7% weight loss over the last 90 days. It also indicated that the resident had a mildly depleted albumin (protein in the blood) level of 3.4 dated 7/8/22. RD #1 documented that she observed the resident consume less than 50% of breakfast that day and added the following supplements: a four oz mighty shake at lunch and dinner, which provided an additional 200 calories and six grams of protein per four oz portion, and a four oz magic cup at lunch and dinner, which provided an additional 290 calories and 9 grams of protein per four oz portion. There was no documented evidence in the resident's hybrid medical records that the above RD's recommended nutritional supplements were given, accepted, or consumed by the resident. Review of the Mini Nutritional Assessment completed by RD #2 and dated 1/9/23, identified Resident #38 as being at risk for malnutrition. There was no further documented evidence of a comprehensive nutrition assessment or revised nutritional interventions to address the risk for malnutrition, prior to surveyor inquiry. Review of the nursing progress notes from 9/1/22 until 2/22/23, did not include documented evidence that the resident received or refused the mighty shake and magic cups at lunch and dinner. Review of the resident's paper chart did not include Dietitian Recommendations (the communication form utilized by the RD to inform the nursing staff, the physician and the Food Service Department for the recommended nutritional supplements) forms. Review of the CP date initiated 9/8/22, included the following interventions, Diet, supplements, snacks, fortified foods as rx'd [prescribed]; honor food preferences; meds as rx'd; weight, labs, hydration status, diet counseling/education as needed. The CP did not include that the resident was at risk for malnutrition and there was no evidence of revisions, or additional interventions related to the identification of risk for malnutrition dated on or after 1/9/23, until to surveyor inquiry. Review of the resident's meal tickets provided to the surveyor by the FSD, in the presence of the Regional FSD on 2/27/23 at 10:00AM, did not include a mighty shake or magic cup for lunch or dinner. On 3/6/23 at 12:30 PM, the surveyor interviewed the DON, in the presence of the LNHA and the survey team. She acknowledged that the 1/9/23, Mini Nutritional Assessment identified the resident at risk for malnutrition. She further stated that the RD should have documented a follow up comprehensive nutritional assessment and revised the care plan. 40042 3. On 2/22/23 at 12:13 PM, the surveyor observed Resident #33 in his/her room seated in a wheelchair in front of the lunch tray on an overbed table. The resident stated that he/she had not eaten lunch yet and the plate was covered with a domed lid. There was no mighty shake observed on the tray. On 2/24/23 at 12:53 PM and on 3/2/23 at 1:15 PM, the surveyor observed the resident in his/her room seated in a wheelchair in front of the lunch tray on an overbed table. There was no mighty shake observed on the tray. The surveyor reviewed the electronic and paper medical record for Resident #33. Review of the Admission Record reflected that the resident was admitted to the facility with diagnoses which included but not limited to; dysphagia (difficulty swallowing) and Alzheimer's disease, unspecified. Review of the Admission MDS dated [DATE], reflected that the resident had a BIMS score of 12 out of 15, which indicated that the resident had a slightly impaired cognition. It further reflected that the resident was holding food in mouth/cheeks or residual food in mouth after meals, was 65 inches tall, weighed 125 lbs., experienced a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and Yes, not on a physician-prescribed weight-loss regimen, and was on a mechanically altered diet-require change in texture of food or liquid . Review of the March 2023 OSR indicated a PO dated 11/7/22, for a Mechanical Soft Chopped meats texture. Review of the November 2022 through March 2023 eMAR, reflected the above corresponding PO. Review of the resident's weights included the following: 9/29/22 139 lbs. 11/2/22 125 lbs. Review of the Nutrition Assessment -V2 dated 11/7/22, included that the resident experienced a 10% weight loss x 60 days and that RD #1 observed the resident consumed > 50% of the lunch meal. It further indicated that the RD initiated a care plan. The RD further documented nutritional interventions which included a four oz mighty shake twice a day at lunch and dinner to provide 200 calories and 6 grams of protein per four oz portion. There was no documented evidence in the resident's hybrid medical records that the above RD's recommended nutritional supplements were given, accepted, or consumed by the resident. Review of the CP did not reflect documented evidence of a nutritional status CP that included the resident's weight loss, nutritional goals or interventions. Review of the resident's paper chart did not include Dietitian Recommendations forms. Review of the resident's meal tickets provided to the surveyor by the FSD, in the presence of the Regional FSD on 3/2/23 at 10:08AM, did not include a mighty shake for lunch or dinner. On 3/03/23 at 10:18 AM, the surveyor interviewed Resident #33, who stated that he/she had never received a mighty shake on the lunch or dinner tray. The resident stated that they came yesterday to ask about it. On 3/03/23 at 11:02 AM, the surveyor interviewed the residents regularly assigned CNA #3 who stated that she had not observed a mighty shake on the resident's lunch tray. On 3/03/23 at 1:20 PM, the surveyor interviewed the DON in the presence of the LNHA and the survey team. She stated that when the RD assessed a resident and made recommendations, she assumed the RD would follow up. On 3/03/23 at 1:44 PM, the surveyor interviewed the DON in the presence of the LNHA and the survey team. The DON acknowledged that there was no documented evidence that mighty shakes were provided to the resident. She further stated that if the RD discontinued the mighty shakes there should have been follow up documentation with a rationale. On 3/06/23 at 12:00 PM, the surveyor interviewed the LNHA in the presence of the DON, the LNHA in training and the survey team. The LNHA stated that RD #1 worked consistently throughout the entire year of 2022. On 3/06/23 at 12:53 PM, the surveyor conducted a phone interview with RD #3. She stated that the Mini Nutritional Assessment form was a screening tool used to identify a resident as malnourished or at risk for malnutrition. She stated that this tool was not considered a comprehensive nutrition assessment. She further stated that the RD should have completed a comprehensive follow up evaluation and assessment, and even if supplementation was not indicated, there should have been supporting documentation. RD #3 also stated that if the RD discontinued nutritional supplements, there should have been supporting documentation as well. On 3/6/23 at 1:34 PM, the survey team met with the LNHA, LNHA in training, and DON. There was no additional information provided. Review of the facility policy Weight Taking and Recording with a revised date of 5/2022, reflected that the policy was to . strive to prevent, monitor, and intervene for undesirable weight loss for our residents. In addition, it included to . to monitor weight changes. It also included the following: The dietitian will review the weight and will make recommendations as necessary . Any weight change of 5 lbs. +/- or more since the last weight assessment will be taken for confirmation with the license nurse. If the weight is verified the dietitian will be notified . The Unit Manager and the Dietitian will review the completed monthly weights . The threshold for significant unplanned and undesired weight loss will be based on the following criteria . 1 month - 5% weight loss is significant; greater that 5% is severe . The dietitian will review the weekly weight and will make necessary recommendations as necessary. Review of the facility policy Nutritional Management with a revised date of 10/22/22, included the following: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status . Acceptable parameters of nutritional status refer to factors that reflect that an individual's nutritional status is adequate . such as weight, food/fluid intake, and pertinent laboratory values . A systematic approach is used to optimize each resident's nutritional status: a. Identifying and assessing each resident's nutritional status and risk factors, b. Evaluating/analyzing the assessment information, c. Developing and consistently implementing pertinent approaches, d. Monitor the effectiveness of interventions and revising them as necessary . A comprehensive nutritional assessment will be completed by a dietitian on all admission, annual, and upon significant change in condition . The assessment shall clarify the resident's current nutritional status and individual risk factors . The dietitian shall use data gathered from the nutritional assessment to estimate the resident's calorie, nutrient and fluid needs and whether intake is adequate to meet those needs . Care plan implementation: a. The residents' goals and preferences regarding nutrition will be reflected in the resident's plan of care. b) Interventions will be individualized to address the specific needs of the resident . Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis . The care plan will be updated as needed, such as when a resident's condition changes . interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified . The physician will be notified of significant changes in weight, intake, or nutritional status . The comprehensive care plan should describe any interventions offered but declined by the resident or resident's representative. NJAC 8:39-11.2(e)(2) (i), 17.1(c), 17.4(a)(3), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the physician addressed severe weight loss for 1 of 4 residents (Resident #97) reviewed for nutrition. The evidence was as follows: On 3/2/23 at 11:25 AM, the surveyor observed Resident # 97 awake and seated in a wheelchair in front of the North nursing unit. At that time, the resident stated that he/she was aware of his/her weight loss. The surveyor reviewed the electronic and paper medical record for Resident #97. Review of the Admission Record (an admission summary) included that the resident was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (stroke), hemiplegia and hemiparesis (weakness of one side of the body) following cerebral infarction affecting the right dominant side, and dysphagia (difficulty swallowing). Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/13/22, included a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated that the resident had an intact cognition. Review of the resident's weights included the following: 9/15/22 145.6 lbs. (pounds) 9/22/22 138 lbs. Review of the Mini Nutritional assessment dated [DATE], indicated that the resident was identified as Malnourished, had a moderate decrease in food intake, and had a weight loss greater than 6.6 lbs. Review of the resident's progress notes from the hybrid medical records from 9/22/22 through 2/22/23, reflected no documented evidence that the resident's severe weight loss was identified and addressed by the Attending Physician (AP) or the Nurse Practitioner (NP) prior to surveyor inquiry. On 3/6/23 at 9:41 AM, the surveyor attempted to call the resident's AP in the presence of the survey team, but the AP was not available at that time. The AP's office manager (OM) informed the surveyor that the AP would be in the office at 3:00 PM. On 3/6/23 at 10:33 AM, the surveyor interviewed the DON in the presence of the survey team. She stated that she reviewed Resident #97's paper medical records and acknowledged that there was no documented evidence from the AP that addressed the residents severe weight loss, and she stated, I did not see any. On 3/6/23 at 12:20 PM, the LNHA, LNHA in training, and DON met with the survey team. The DON acknowledged that the resident's AP was aware of the resident's significant weight loss but did not address it in the resident's hybrid medical records. On 3/6/23 at 1:34 PM, the survey team met with the LNHA, LNHA in training, and DON. There was no additional information provided. On 3/6/23 at 3:36 PM, the surveyor reattempted to conduct a telephone interview with the AP, but the OM stated that the AP was unavailable to speak to the surveyor. NJAC 8:39-23.2 (b)

Based on interview and record review, it was determined that the facility failed to timely transmit a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with federal guidelines. This deficient practice was identified for one (1) of 28 residents, (Resident #87) reviewed for the timely transmission of MDS's and was evidenced by the following: The MDS is a comprehensive federal mandated process for clinical assessment of all residents that has to be completed and submitted to the Quality Measure System. The facility must electronically transmit the MDS up to 14 days of the assessment being completed. After transmitting of the MDS, it will generate a quality measure to enable a facility to monitor the residents decline and progress. According to the latest version of the Center for Medicare/Medicaid Services (CMS) - Resident Assessment Instrument (RAI) 3.0 Manual (updated October 2019) page 2-33, 05. Quarterly Assessment (A 0310 A = 02) .The MDS completion date (item Z 0500 B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days). On Page 2-17 indicates, Transmission Date no later than .MDS completion date +14 calendar days. On 3/1/23 at 10:18 AM, the surveyor reviwed the survey's Facility Assessment Task which includes a review of designated residents' MDS Assessments. Resident#87 was triggered under the survey facility task as MDS record over 120 days old. On that same date at 10:20 AM, Resident #87 had a Quarterly MDS with an Assessment Reference Date (ARD) of 1/23/23, that was completed on 2/6/23, and was Accepted on 2/27/23. The MDS should have been transmitted no later than 2/20/23. On 3/2/23 at 10:20 AM, the surveyor reviewed the MDS submission report which revealed that the resident's 1/23/23, MDS assessment was submitted on 2/27/23, and indicated Record Submitted Late: The submission date was more than 14 days after Z 0500 B . On that same day at 12:47 PM, the surveyor spoke to the Registered Nurse (RN)/MDS Coordinator in the presence of the survey team regarding the above finding. She acknowledged that the MDS assessments must be electronically transmitted up to 14 days of the assessment completion date. The RN/MDS Coordinator further acknowledged that the assessment was not submitted timely in accordance with the federal regulations, until after the surveyor's inquiry when she ran the MDS transmission reports. On that same day at 3:15 PM, the surveyor discussed the above finding with the Licensed Nursing Home Administrator (LNHA), LNHA in training, and the Director of Nursing (DON) in the presence of the survey team. On 3/6/23 at 1:34 PM, the LNHA, LNHA in training, and the DON met with the survey team. No additional information was provided. NJAC 8:39-11.1

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to develop a comprehensive, person-centered care plan for residents with nutritional concerns, weight loss and malnutrition. This deficient practice was identified for 2 of 27 residents reviewed for comprehensive care plans (Resident #33 and #264), and was evidenced by the following: 1. On 2/22/23 at 12:13 PM, the surveyor observed Resident #33 in his/her room seated in a wheelchair in front of the lunch tray on an overbed table. The resident stated that he/she had not eaten lunch yet and the plate was covered with a domed lid. The surveyor reviewed the electronic and paper medical record for Resident #33. Review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing) and Alzheimer's disease, unspecified. Review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/8/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated that the resident had a slightly impaired cognition. It further reflected that the resident was holding food in mouth/cheeks or residual food in mouth after meals,was 65 inches tall, weighed 125 pounds, experienced a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and Yes, not on a physician-prescribed weight-loss regimen, and was on a mechanically altered diet-require change in texture of food or liquid . In addition, the Care Area Assessment (CAA) Worksheet which was completed and signed by the Registered Nurse (RN) MDS Coordinator on 11/14/22, included Will Nutritional Status - Functional Status be addressed in the care plan? Yes and reflected that the overall objectives included improvement, slow or minimize decline and maintain current level of functioning in the area of nutritional status. Review of the resident's weights included the following: 9/29/22 139 pounds (lbs.) 11/2/22 125 lbs. Review of the Nutrition Assessment -V2 dated 11/7/22, included that the resident experienced a 10% weight loss x 60 days and that the Registered Dietitian (RD) observed that the resident consumed >50% of the lunch meal. It further indicated that the RD initiated a care plan. The RD further documented nutritional interventions which included a four-ounce mighty shake twice a day at lunch and dinner to provide 200 calories and 6 grams of protein per four-ounce portion. Review of the comprehensive care plan (CP) did not reflect documented evidence that the resident's nutritional status, weight loss, nutritional goals and interventions were included or addressed. 2. On 2/22/23 at 11:55 AM, the surveyor observed Resident #264 in his/her room seated in a wheelchair in front of an overbed table. The resident appeared thin. The resident's lunch tray arrived, and he/she was able to feed themselves and began to consume the lunch meal. The surveyor reviewed the electronic and paper medical record for Resident #264. Review of the Admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified protein-calorie malnutrition (protein calorie malnutrition happens when you are not consuming enough protein and calories), dementia, dysphagia and adult failure to thrive (can occur when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of an Admission MDS dated [DATE], reflected that the resident had a BIMS score of 14 out of 15, which indicated that the resident had an intact cognition. It further reflected that the resident had a diagnosis of Malnutrition (protein or calorie) or at risk for malnutrition. It also reflected that the resident was holding food in mouth/cheeks or residual food in mouth after meals,was 62 inches tall, and weighed 112 lbs. In addition, the Care Area Assessment (CAA) Worksheet which was completed and signed by the RN MDS Coordinator on 2/16/23, included Will Nutritional Status - Functional Status be addressed in the care plan? Yes and reflected that the overall objectives included improvement, slow or minimize decline and maintain current level of functioning in the area of nutritional status. Review of the Mini Nutritional assessment dated [DATE], reflected that the resident had a moderate decrease in food intake, experienced a weight loss of 2.2 to 6.6 lbs. during the last three months, had a Body Mass Index (BMI) [measure of body fat based on height and weight that applies to adult men and women] of 19 to less than 21 and was assessed as malnourished. Review of the Medical Nutrition Therapy assessment dated [DATE], reflected to Proceed with POC [plan of care]. Review of the CP did not reflect documented evidence that the resident's nutritional status, nutritional goals and interventions were included or addressed. On 3/02/23 at 12:47 PM, the surveyor conducted a phone interview with the RN MDS Coordinator in the presence of the survey team. She stated that a nutrition care plan should have been initiated for Resident #33 and #264. On 3/03/23 at 1:20 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team. The DON stated that she expected the RD to initiate a nutrition care plan on admission and update the care plan periodically for quarterly reviews and significant changes. On 3/03/23 at 1:44 PM, the surveyor interviewed the DON in the presence of the LNHA and the survey team. The DON acknowledged that there was no nutrition care plan for Resident #33 and #264. In addition, the DON stated that the MDS Coordinator and the team were responsible to ensure that the residents comprehensive care plans addressed the CAA's. On 3/06/23 at 12:53 PM, the surveyor conducted a phone interview with RD #3 who stated that if the CAA's triggered for nutritional status, the RD should have initiated a care plan. On 3/6/23 at 1:34 PM, the survey team met with the LNHA, LNHA in training, and DON. There was no additional information provided. Review of the facility policy Nutritional Management with a revised date of 10/22/22, included the following: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status . A comprehensive nutritional assessment will be completed by a dietitian on all admission, annual, and upon significant change in condition . Care plan implementation: a. The residents' goals and preferences regarding nutrition will be reflected in the resident's plan of care. b) Interventions will be individualized to address the specific needs of the resident . Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis . The care plan will be updated as needed, such as when a resident's condition changes . interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified . The comprehensive care plan should describe any interventions offered but declined by the resident or resident's representative. Review of the facility policy Comprehensive Care Plans with a revised date of 4/1/22, included the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . The comprehensive care plan will be developed withing 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care . The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . The comprehensive care plan will describe at a minimum, the following: a.) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: .A registered nurse with responsibility for the resident . A member of the food and nutrition services staff . The RAI [Resident Assessment Instrument] coordinator . Review of the facility policy Resident Assessment - RAI with a revised date of 10/22/22, included that The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual. NJAC 8:39-11.2(d), (e)(2), (i), 27.1(a)

Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure the safe and appetizing temperatures of food and drink served to the residents. This deficient practice was identified by 4 of 5 residents, who during the 2/27/23, Resident Council group meeting stated that hot foods were received cold, and confirmed during the lunch time meal service on 3/3/23, on 1 of 3 nursing units (South) tested for food temperatures by two surveyors, and was evidenced by the following: On 2/22/23 at 9:54 AM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD). During the tour, the surveyor observed that the department had a functioning plate warmer and a method to heat the plate liners to assist in maintaining hot food temperatures during tray delivery to the residents. Towards the end of the tour, the FSD stated that he conducted test tray audits (a tool that evaluates how long it takes to deliver resident trays, meal appearance, taste, portion sizes, tray accuracy and acceptable food temperatures) and resident meal satisfaction surveys. He presented the binders for the completed forms to the surveyor and further stated that there were no concerns regarding food temperatures or meal satisfaction. On 2/27/23 at 11:27 AM, the surveyor met with the five residents for the Resident council meeting. Four out of five residents stated that they were displeased with food temperatures and that hot foods were received cold. On 3/03/23 at 11:50 AM, the surveyor observed the second South unit enclosed food truck delivered to the unit. On 3/03/23 at 11:54 AM, the surveyor calibrated (calibration ensures that the thermometer is accurate and precise for the measurement of food temperatures) a state issued digital thermometer to 31.7 degrees Fahrenheit (F) via the ice bath method in the presence of a second surveyor and a Licensed Practical Nurse (LPN). On 3/03/23 at 12:05 PM, the last tray was delivered to the residents. At that time, the surveyor obtained food and fluid temperatures in the presence of a second surveyor and the Registered Nurse (RN)/Unit Manager (UM) who acknowledged each of the temperature readings. The temperatures were as follows: Seafood oriental (chopped w/ sauce): 117 degrees F Rice (was scooped in a tight ball): 119.3 degrees F Broccoli (chopped): 124 degrees F Four-ounce cardboard container of skim milk: 53 degrees F Coffee: 141.5 degrees F On 3/03/23 at 12:25 PM, the surveyor interviewed the Regional FSD who stated that both methods for maintaining hot food temperatures during tray transport to the residents were working properly. He also stated that the department placed cold beverages in the freezer a half hour before meal service to help maintain cold temperatures during tray transport to the residents. He also acknowledged that he delivered the second South unit lunch food truck at 11:50 AM. On 3/6/23 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with copies of Test Tray forms which indicated that the Acceptable Temp for Serving included the following criteria; hot foods should be served above 135 degrees F, cold foods should be served below 45 degrees F, hot beverages should be served above 135 degrees F, and cold beverages should be served below 45 degrees F. On 3/06/23 at 11:00 AM, the surveyor interviewed the FSD in the presence of the Regional FSD, who acknowledged and confirmed that the Serving Temp referred to the temperatures taken after the last tray was served on the nursing unit. On 3/6/23 at 1:34 PM, the survey team met with the LNHA, LNHA in training, and the Director of Nursing (DON). There was no additional information provided. Review of the facility policy Food Temperatures with a revised date of April 2022, included that All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit . All cold food items must be stored and served at a temperature of 41 degrees or below. Review of the facility policy Meal Distribution with a revised date of May 2022, included that Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. NJAC 8:39-17.4 (a) 2, (e)

Based on record review, interviews, and facility document and policy review, the facility failed to report the results of all alleged violation investigations, to the New Jersey Department of Health (NJDOH) Health Facility Survey and Field Operations (HFSFO) and, within prescribed timeframes. Findings included: On 07/13/2022 at 1:35 AM, the Administrator stated the facility received a letter dated 05/25/2022 from the NJDOH through the United States Postal Service (USPS) on 05/30/2022. Per the Administrator, the facility was made aware the NJDOH received a letter from an anonymous facility staff member alleging Housekeeper (HSK) #1's used racial verbiage against people of color and in front of residents at the facility, which allegedly occurred approximately two months prior to the survey. Review of the letter by the surveyor revealed that it was dated 5/25/2022. However, the letter was signed by the NJ Department of Health and Senior Services' Coordinator Complaint Program not by the NJ DOH/HFSFO. The NJ DOH/HFSFO is the state survey agency where nursing facilities report incidents, including, but not limited to; injuries of unknown origin/allegations of abuse. The Administrator stated she did not make any observation of such interactions involving HSK #1 or any other staff in the facility. The Administrator added that she formed a surveillance panel with members of top management staff at the facility who monitored HSK #1's interactions with staff and residents across the facility with no evidence corroborating the allegation uncovered during their surveillance. The Administrator added that she interviewed all staff and raised the allegation during the June 2022 Resident Council meeting, and each one of the employees and Resident Council members denied the occurrence of the allegation. Per the Administrator, regardless of the facility's investigative findings, she made HSK #1 write a statement acknowledging that the facility had zero tolerance for such interactions and that HSK #1 understood that if she were observed to conduct herself in such a manner, her actions would be met with severe consequences. The Administrator added that the facility conducted a facility wide in-service on the subject matter. During a follow-up interview with the Administrator on 07/27/2022 at 9:51 AM, she stated she did not report the allegation to the NJDOH/HFSFO. The Administrator clarified that lack or failure to report the allegation to the NJDOH/HFSFO was due to the facility receiving the complaint allegation from the NJDOH itself. 2. A review of Resident #3's admission Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #3's cognitive status using a Brief Interview for Mental Status (BIMS) assessment, for which the resident scored 3 out of 15 indicating the resident was severely impaired in his/her cognitive function. The facility also identified the resident needed extensive assistance for most activities of daily living (ADL) and was totally dependent on staff for toileting and dressing. A review of Resident #3's Care Plan, dated 04/18/2022, revealed that, on 04/22/2022, Resident #3 had swelling of the left eye with a self-inflicted scratch. A review of an Investigational Summary, dated 04/22/2022, indicated Resident #3 was found with periorbital [CONDITION(S)] and a scratch under the left eye at breakfast time. The facility concluded Resident #3 sustained a self-inflicted scratch to the area below his/her left eye. An interview with the Administrator was conducted on 07/27/2022 at 3:12 PM. The Administrator stated the facility investigated the findings for Resident #3 and found no evidence to support that the origin of Resident #3's injuries were unknown. The Administrator reported that he believed the incident did not need to be reported to the NJDOH. A review of a facility policy titled Reporting Reasonable Suspicion of a Crime in Long Term Care, last documented as reviewed in January of 2021, was conducted. The document revealed in part: In accordance with federal guidelines, it is our duty to report any suspicion of any crime against a resident who resides in our facilities. This includes mistreatment, neglect, verbal, mental, sexual, and physical abuse, injuries of unknown source and misappropriation or exploitation of resident property. As an employee, you may report any reasonable suspicion of crime without retaliation from our facility or your supervisors. If you do experience retaliation for reporting a crime, you may file a complaint with the state survey agency. Under the title Abuse, Prevention and Prohibition Program, the document noted, All allegations of abusive conduct will be fully investigated and reported to the Administrator, State Agency, law enforcement and other agencies as required within timeframes specified. New Jersey Administrative Code S 8:39-9.4(f)

Based on observation, interview and record review, it was determined that the facility failed to: a.) administer breakthrough pain medication in a timely manner when a resident visually and verbally exhibited signs of unmanaged pain during movement, b.) ensure the same resident was appropriately assessed and pre-medicated for breakthrough pain prior to performing wound care and activities of daily living, and c.) place a pressure-relieving gel seat cushion to the chair when out of bed to offload pressure and reduce pain associated with the resident's full thickness tissue loss pressure ulcer. This deficient practice was identified for 1 of 3 residents reviewed for pain management (Resident #25). The evidence was as follows: On 3/2/21 from 11:28 AM to 11:57 AM, the surveyor observed that Resident #25 was in bed on an air mattress. The resident's eye's were closed and the room was darkened. The surveyor interviewed the resident's roommate who stated that Resident #25 was very sick. The surveyor asked the roommate how he/she knew Resident #25 was very sick and he/she replied that Resident #25 would shout out but the roommate was unable to elaborate further. The surveyor reviewed the medical record for Resident #25. A review of the Admission Record face sheet (an admission summary) reflected that the resident had [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/22/20 reflected that the resident had a brief interview for mental status score of 11 out of 15 indicating an intact cognition with moderate forgetfulness. The MDS assessment included that the resident had no behaviors in the last seven days of rejecting care, or physical or verbal behaviors. It further included that the resident required an extensive two person physical assist for bed mobility and personal hygiene, and only transferred out of bed 1-2 times in the last seven days. The assessment indicated that the resident had a functional limitation in range of motion affecting one side of the upper extremity and one side of the lower extremity. The resident's pain was further assessed at that time to reflect that he/she had occasional pain level of 5 out of 10 on a pain scale, a moderately distressing pain, that did not impact sleep or day to day activities. The MDS reflected that the resident received a scheduled opioid pain medication 7 out of the last 7 days, and in addition received pain medication as needed (PRN). A review of the resident's individualized comprehensive care plan initiated on 9/20/19 reflected that the resident needed pain management due to multiple conditions including but not limited to [MEDICAL CONDITION] disc disease of the lumbar spine, gout, episodes of on and pain to the left lower abdomen related to an aortic aneurysm, a history of [MEDICATION NAME] pain, [MEDICAL CONDITION] (a condition that causes weak and brittle bones), [MEDICAL CONDITION] (weakness, numbness, and pain from nerve damage usually in the hands and feet), and a history of a surgical incision on the inguinal area. The goal indicated that the resident will maintain an adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress, or verbalizing satisfaction with level of comfort. Interventions included to Administer medication as ordered .Evaluated characteristics and frequency/pattern of pain .evaluate what makes the patient's pain worse .monitor swelling/pain of joints and Notify MD (Medical Doctor). The care plan initiated on 8/19/20 further reflected that the resident had acute/chronic pain from his/her medical conditions and that he/she had range of motion limitations due to immobility. The goal for managing the resident's pain was revised on 2/20/21 and included that the resident will have an acceptable pain level one hour after intervention was initiated with a goal date of 6/20/21. Interventions included to: Avoid pressure on the areas of pain; Complete pain assessment; Distracting activities; Evaluate the effectiveness of pain medications, Give pain medications; Re-position for comfort. (The care plan addressed neither the resident's acceptable numeric level of pain nor any precipitating factors that were known to cause him/her increased pain). Further review of the resident's individualized comprehensive care plan dated 10/26/2020 revealed that the resident had a behavior sometimes of refuses to get OOB (out of bed) but it did not specify why the resident refused to get out of bed. A review of the Certified Nursing Aide Kardex for Resident #25 included to complete pain assessment as needed .ROHO Cushion to wheelchair when OOB (out of bed). A review of the most recent Wound Consult report dated 3/3/21 reflected that Resident #25 also had a Stage III (full thickness tissue loss) pressure ulcer to the sacrum that was improving. The wound measured 2 centimeters (cm) x 1.5 cm x 0.3 cm and was draining a moderate amount of serous (clear) drainage. The Wound Consult report indicated that the wound bed was covered in 30% slough (yellowing dead tissue), which was debrided (removed the dead tissue) using a blade and [MEDICATION NAME] 20% spray (a topical anesthetic) without complications. The Wound Consultant/Advanced Practice Nurse (WC/APN) recommended to perform a wound dressing change daily to the sacral ulcer by applying Santyl (a [MEDICATION NAME] agent) in a nickel-thick amount to the wound, apply collagen powder and calcium alginate cut to fit the size of the wound base and cover the wound with a bordered foam dressing. An additional Order included to avoiding position directing pressure to Wound site .continue use of ROHO cushion (a seat cushion to relieve pressure and allows for more comfort while sitting for longer periods of time). The resident's care plan initiated on 9/20/19 did not specifically address that the resident had a Stage III pressure ulcer to the sacrum. Interventions in the care plan for Impaired Skin Integrity dated 8/20/20 only included vague descriptions of the resident's skin including that the resident had a skin issue, open areas, area monitored but it did not specify a sacral ulcer or the implications of pain related to a Stage III pressure ulcer to the sacrum. An intervention dated 12/9/2020 included to use a ROHO cushion to wheelchair when out of bed. Interventions did not address assessing or pre-medicating the resident prophlyactically for pain prior to daily wound treatments. A review of the physician's orders [REDACTED]. 1.) a PO dated 11/25/20 for a narcotic [MEDICATION NAME] (HCl). The order specified to administer one tablet of 5-milligrams (mg) by mouth every eight (8) hours around the clock for pain management. The eMAR was plotted for the [MEDICATION NAME] HCl to be administered at 6 AM, 2 PM and 10 PM. 2.) a PO dated 9/30/20 for Tylenol 325 mg (an [MEDICATION NAME] that treats minor aches and pains). The order specified to administer two tablets to equal 650 mg every four (4) hours as needed for mild pain (numeric pain scale of 1-3). The eMAR was plotted for the Tylenol to have a Pain Level numeric assessment documented with the PRN dose. 3.) a PO dated 10/22/20 to administer the schedule-IV controlled opioid [MEDICATION NAME] HCl tablet. The order specified to administer 100 mg by mouth every eight (8) hours as needed for moderate to severe pain with numeric levels of 4-10 on a pain scale of 0 to 10. The eMAR was plotted to be administered PRN. 4.) a PO dated 12/9/20 to apply [MEDICATION NAME] Ointment (a topical numbing cream) 5% to the sacral area topically every 24 hours as needed for numbing prior to the wound treatment, and that it may be used less than or equal to four times daily. The eMAR was plotted for the ointment to be applied PRN. The Order Recap Report for March 2021 further reflected a PO dated 9/30/20 for [MEDICATION NAME] Cream 1-2.5% for rectal inflammation to be applied topically every 6 hours PRN, and a PO dated 11/14/20 for a daily scheduled medication used to treat gout ([MEDICATION NAME] 100 mg). There were no other physician orders [REDACTED]. The surveyor continued to observe and conduct interviews with facility staff. The following was revealed: On 3/9/21 at 10:40 AM, the surveyor observed Resident #25 in bed on an air mattress. The resident was awake and the resident's assigned Certified Nursing Aide (CNA) was in the resident's room. The CNA stated that she had finished providing morning care to Resident #25. The surveyor asked the resident in the presence of the CNA if he/she could show the surveyor their hands from under the blanket, and the resident just stared at the surveyor. At that time, the CNA slowly removed the resident's blanket that was covering his/her body and began to gently touch and open the resident's right and left hand. There was no visible acute swelling to either the left or right arm. As the CNA opened the resident's left hand, the surveyor observed the resident quickly pulled back the left arm and make a facial grimace as though he/she had pain. The CNA acknowledged the resident's discomfort in moving his/her upper left extremity. The CNA then showed the surveyor the resident's feet from under the blanket. The surveyor observed that both legs were elevated on a single pillow and the left leg had more swelling that the right leg. The resident's left foot was in a plantar flexion (when the top of the foot points away from the leg) and the left leg was laterally rotated. The resident's left heel was in direct contact with the resident's lateral right ankle. There was no positioning devices in place. The CNA separated the resident's left and right leg from touching, and the resident immediately flinched and grimaced. The CNA then covered the feet with a blanket. At that time, the resident's cell phone rang and the CNA assisted the resident with the phone call by holding the phone to the resident's ear. The surveyor observed that the resident was not verbally communicating back with the caller. After the CNA terminated the call after several minutes of the resident not verbally engaging, the surveyor interviewed the CNA. The CNA stated that Resident #25 was alert and oriented and in the past could usually make his/her needs known without an issue, but in the last two months the resident has had a decline in cognition and function. The CNA confirmed that the resident was not verbally responding to the caller and that his/her cognition and ability to communicate would wax and wane. The CNA continued that she now had to anticipate all of the resident's needs because he/she was dependent on staff for all activities of daily living and required at least two people to provide care because the resident was unable to turn in bed or hold a phone to the ear anymore. The CNA elaborated that the resident would wear specialized boots when out of bed, but that Resident #25 would often refuse to get up or accept showers on shower days anymore. The surveyor asked the CNA why the resident refused to get out of bed or allow for showers anymore, and the CNA stated that it may be because (he/she) had pain. The CNA added that she thought it was because of pain because the resident cries when I wash him/her. The CNA acknowledged that on gentle touch or movement of the left arm and leg in the presence of the surveyor, the resident exhibited signs of discomfort. The CNA stated that movement would often increased the resident's pain, so when the resident would cry during care, she would immediately stop and get the nurse and the nurse would administer pain medication to the resident. She stated that she would return to finish care after about 30 minutes so the medication could take effect. The CNA stated that the resident could usually say if he/she was in pain or if he/she didn't want to eat, but it depended on the day. The CNA stated that the resident had a little open wound on the buttock that the nurse puts a treatment on everyday. The CNA stated that she thought the resident developed the wound in the hospital. The CNA wasn't sure if the resident received pain medication prior to care, adding that the surveyor would have to ask the nurse that question. On the same day 3/9/21 at 11:03 AM, the surveyor interviewed the resident's assigned Licensed Practical Nurse (LPN). The LPN stated that this was her first day with Resident #25 because she was an agency nurse. The LPN stated that she was orienting with a Registered Nurse (RN) but the RN was also new and had only been working at the facility for about three to four weeks herself. She stated that she couldn't speak to much about the resident. The surveyor asked what information she received on the shift to shift report about Resident #25, and neither the LPN nor RN could speak to the information they received on report about Resident #25. The LPN stated that she did just finish a wound treatment with the RN for Resident #25 around between 9:30 AM and 10:00 AM this morning. The surveyor asked the LPN about how the resident tolerated the wound dressing change, and the LPN stated that the resident didn't complain of any pain in the moment. The surveyor inquired about the pain assessment done prior to the wound care, and the LPN stated that the resident did not give her a numeric pain scale number, so she didn't need the pain meds at the time. The LPN stated that she did not pre-medicate the resident for any pain because the resident did not complain of pain. The surveyor asked how she assesses for pain and she stated that she asks for a numeric number and depending on the number she will medicate for pain. She added that I typically give pain meds before a dressing change but that she did not do it today. The LPN stated that she did the wound care with the RN today. At 11:15 AM, the surveyor interviewed the RN who stated that the resident had a pressure ulcer to the sacrum about the size of a nickel and that it was not draining. The surveyor asked the RN if she had conducted a pain assessment prior to the wound care, and the RN stated that she asked the resident are you in pain? and the resident reported that the pain was a 2-3 out of 10, but she didn't need to give the resident any medication because the resident had already received a dose of [MEDICATION NAME] HCl at 6 AM. The RN confirmed that a wound treatment performed between 9:30 AM and 10:00 AM was between 3 to 3.5 hours since the last dose. The RN did not speak to the administration of Tylenol for mild pain of 1-3, or the order for the [MEDICATION NAME] cream to be applied PRN prior to wound care. At 11:21 AM, the LPN/Unit Manager (LPN/UM) overheard the surveyor interviewing the LPN and the RN, and the LPN/UM stated that she was there also during the wound treatment this morning with the resident because the resident needs assistance with turning and the resident was new to the nurses. The LPN/UM stated that the resident didn't say a word and that the resident was not moaning. The LPN/UM stated that had she seen the resident flinch in pain, moan or scream, she would stop or have the nurses stop and medicate the resident for pain and return. The surveyor asked why they would wait until the resident was in pain to medicate him/her, instead of offering a prescribed medication (Tylenol, [MEDICATION NAME], or [MEDICATION NAME] as ordered by the physician) prophlyactically to prevent any pain. The LPN/UM acknowledged that it was easier to prevent pain than to treat pain, but kept insisting that the resident did not even flinch in pain. The surveyor asked the LPN/UM about the resident's pain management, and the LPN/UM stated that the resident has a history of generalized pain mostly to the lower extremities and that he/she would sometimes just lay in bed and scream. She added that when the resident gets out of bed he/she screams also and therapy was working with the resident. She stated that medications were adjusted and whatever (he/she) is getting now is effective. The surveyor asked the LPN/UM what makes the pain worse for Resident #25, and she stated that if someone goes to change the resident just touching him/her the resident will yell Oww! Oww! as though in pain. She elaborated that repositioning makes the pain worse, and because the resident will sometimes scream without anyone even touching him/her, it's more of a behavior and not necessarily pain. The LPN/UM continued to state that despite the resident's history of flinching when changing him/her, or touching and repositioning causing the resident to report signs of pain, that this did not occur during the wound treatment that morning. The LPN/UM confirmed that the resident did not get pre-medicated prior to the wound treatments. The surveyor reviewed the resident's eMAR for March 2021 together with the LPN, the RN and the LPN/UM who confirmed that there was no record of administration of any pain medication administered including the Tylenol, [MEDICATION NAME], or the [MEDICATION NAME] numbing ointment given prior to the wound care in accordance with the physician's orders [REDACTED].>The surveyor reviewed the Individual Patient Controlled Drug Records for the [MEDICATION NAME] 5 mg and the [MEDICATION NAME] 100 mg order in the presence of the LPN, the RN, and the LPN/UM. The declining inventory record revealed that the last dose of [MEDICATION NAME] 5 mg was removed from inventory on 3/9/21 at 6 AM that morning and the last dose of [MEDICATION NAME] was removed on 3/2/21 at 9:42 AM. At 11:30 AM, the RN stated to the surveyor that it was a standard of practice to give a pain medication prior to treatment. The RN stated that because the pain medication doses were PRN and not routinely scheduled, and because it didn't look like the resident was in any pain, it wasn't needed. The LPN and RN both stated that they would only chart by exception that if a resident exhibited pain during a wound treatment than they would document how the resident tolerated the procedure, but otherwise they wouldn't need to document how he/she tolerated the dressing change. The LPN/UM further expressed that the resident had a psychiatric consult on 2/19/21 for evaluation of a gradual dose reduction of his/her [MEDICAL CONDITION] medications, and the [MEDICAL CONDITION] medications were subsequently discontinued. The LPN/UM stated that the resident's calling out in pain was sometimes behavioral and we had to determine if the resident was really in pain or if it was a behavior. She stated that they thought it might be behavioral because the resident would receive pain medication and after it was effective, the resident would continue exhibit signs of pain. The surveyor asked how she knew the pain medication given was effective if the resident was showing or verbalizing pain, and the LPN/UM stated that it was because the resident was already medicated. The LPN/UM confirmed that it could also mean that the medication was not effective if the resident continued to exhibit signs of pain. She acknowledged that pain was subjective and tolerance to pain can vary between individuals. She was not aware of the resident's numeric acceptable pain level. The surveyor asked to see any Psychiatric consults, Physiatrist Consults or any other Physician notes that addressed the resident's verbalizations of pain as being a behavior. The LPN/UM stated that she would get back to the surveyor. On 3/9/21 at 11:54 AM, the surveyor and the LPN entered the room of Resident #25 who was in bed with eyes closed. The LPN attempted to move the resident's left leg and the resident pulled back the leg and grimaced. The LPN stated that this was indicative of pain and that he/she could receive pain medication now. She stated that the resident appears comfortable until moving him/her. She confirmed that avoiding movement can be an alleviating factor for pain, and assessment for pain involves more than just looking at a resident. She confirmed pain assessment should include how the resident responds to normal activities of daily living, repositioning, touching and other visual cues of pain, and not just when looking at a resident at rest. She could not speak to if the resident responded in the same way during the wound treatment that morning between 9:30 AM and 10:00 AM. The LPN stated that she would give the resident pain medication now. A review of the eMAR's for February 2021 and March 2021 did not reflect documented evidence that the resident received the PRN [MEDICATION NAME] ointment to the sacrum prior the dressing change. The eMAR's were also blank to reflect the resident did not receive any doses of Tylenol PRN for mild to moderate pain of 1-3 out of 10 on the pain scale. The eMAR for February 2021 further reflected that the resident only got [MEDICATION NAME] 100 mg on 2/5/21 at 9:35 AM for a pain of 5 out of 10 on the pain scale; on 2/12/21 at 9:10 PM for a pain of 4 out of 10 on the pain scale; 2/19/21 at 9:36 AM for a pain of 5 out of 10 on the pain scale; and on 2/20/21 at 11:00 AM for a pain of 7 out of 10 on the pain scale. The [MEDICATION NAME] was documented as effective on those dates. There was no documented evidence that these doses of [MEDICATION NAME] were given prophlyactically prior to wound care of the Stage III pressure ulcer to the sacrum. A review of the eMAR for March 2021 conducted on 3/9/21 reflected that the resident received [MEDICATION NAME] on 3/1 at 11:30 AM for a pain of 5 out of 10 on the pain scale which was effective; on 3/2/21 at 9:43 AM for a pain of 4 out of 10 on the pain scale which was effective, and on 3/9/21 at 12:00 PM for a pain of 4 out of 10 on the pain scale. On 3/9/21 as of 1:32 PM, there was no documented evidence that the resident had been re-evaluated for the effectiveness of the 12:00 PM dose of [MEDICATION NAME] given on 3/9/21. Further, there was no documented evidence that these doses of [MEDICATION NAME] were given prophlyactically prior to wound care of the Stage III pressure ulcer to the sacrum. A review of the Physical Medicine and Rehabilitation Follow up notes dated 10/26/20 reflected that the resident had good pain control status [REDACTED]. Extremities were noted to have gross [MEDICAL CONDITION] .not tenderness to the right knee at this time, continues to have left knee tenderness to palpation with no swelling . The Plan was to use Tylenol PRN and [MEDICATION NAME] PRN . the MD performed a steroid injection to the left knee. A review of the most recent Physical Medicine and Rehabilitation Follow up note dated 12/3/20 reflected that the resident was seen for a chief complaint of generalized weakness and [MEDICAL CONDITION] and denies any acute issues at that time. Range of Motion assessment revealed right lower extremity was impaired at the knee. The left lower extremity was impaired at the hip, the right upper extremity was impaired at the shoulder and elbow, and the left upper extremity was within functional limits. The Plan for pain included Tylenol PRN and [MEDICATION NAME] PRN, and otherwise as per eMAR, and to monitor for side effects and efficacy. Medical team to follow up. The next day on 3/10/21 at 8:38 AM, the surveyor observed Resident #25 awake in bed on an air mattress. The surveyor attempted to interview the resident about his/her pain and the resident verbally responded to the surveyor. The resident stated that he/she had pain in the back-side. The resident was only able to elaborate on the location of the pain, and not the type, severity, duration or other possible causes of the pain. The resident stated that he/she got pain medication that morning, and when asked if the medication was effective at relieving the pain, the resident replied, No. The resident continued to state that not only did he/she have pain to the back-side but also had pain that also went up higher and the resident kept repeating that the pain was across the shoulders, too. At 8:43 AM, while the surveyor was interviewing Resident #25, the Licensed Practical Nurse (LPN) assigned to care for Resident #25 entered the resident's room. The LPN was not the same LPN as assigned to the resident on 3/9/21. The surveyor observed that the LPN was holding a medicine cup filled with apple sauce. The LPN stated that a Certified Nursing Aide (CNA #2) had reported to her that Resident #25 was experiencing pain during morning care. The LPN stated that the Tylenol that she gave that morning around 7 AM was not effective and therefore she was going to administer a PRN dose of [MEDICATION NAME] for breakthrough pain. The surveyor observed the LPN put two whole tablets of the [MEDICATION NAME] into the resident's mouth at one time using a cup of apple sauce, and gave the resident a cup of water with a straw. The resident did not drink through the straw, so the LPN used the teaspoon from the apple sauce to collect water from the drinking cup and attempted to give the resident water using a spoon-feeding method with two teaspoons of water. The LPN encouraged the resident to swallow the medication, but the resident pocketed it and then spit out both of the tablets and the remaining applesauce from his/her mouth. At that time the LPN confirmed that the resident spit out the two tablets of [MEDICATION NAME], and she accessed a brown paper towel and wiped the resident's mouth with the paper towel. The surveyor observed the LPN roll up the two whole [MEDICATION NAME] tablets into the paper towel, and crumpled it into a ball. She then removed her gloves over the brown paper towel with the [MEDICATION NAME] tablets inside it and threw it all in the resident's regular trash can at the door. The LPN exited the resident's room and stated that she was going to get another dose of [MEDICATION NAME] and crush it up this time, so the LPN returned to the medication cart. The surveyor observed the LPN open the Narcotic book and access the resident's Individual Patient's Controlled Drug Record (a declining inventory sheet used for the accountability of controlled drugs) for the [MEDICATION NAME] tablets. The drug record reflected the [MEDICATION NAME] tablets were white oblong in color and shape. The LPN turned to the back of the drug record which was used for signing Destroyed/Wasted Medication Doses. The LPN filled out the form reflecting that tablets number 16 and 17 had been wasted because resident spit out. The LPN signed for the destruction of the [MEDICATION NAME]. The LPN then signed out two additional tablets (Tablet 14 and 15) of [MEDICATION NAME] from the resident's Individual Patient's Controlled Drug Record, removed the two tablets from the the medication card, and proceeded to crush them into fine granules and put it into a cup of applesauce for ease of swallowing. At approximately 8:57 AM, the LPN spoon fed the two tablets of crushed [MEDICATION NAME] into the resident's mouth, and upon the medication sitting in the resident's mouth, the resident began to grimace and repeating, I don't like that, I don't like that. At 8:59 AM, the resident stated that he/she was going to throw up and the resident began to spit out the crushed up [MEDICATION NAME] tablets in the presence of a Registered Nurse (RN) and the surveyor. The LPN stated that the resident was not able to take the [MEDICATION NAME] after two attempts, so she collected the crushed [MEDICATION NAME] granules that the resident spit out, put it back into the medicine cup and brought it to the medication cart. She then opened the Narcotic book and returned to the resident's Individual Patient Controlled Drug Record for the [MEDICATION NAME], and on the back of the form she began to fill out the destruction/wasting of [MEDICATION NAME] dose 14 and 15, but she didn't fully record a reason for why the tablets were not given. At 9:01 AM, the LPN informed the surveyor that because the two attempts to administer [MEDICATION NAME] was ineffective and that he/she spit them both out, that she was going to call the Medical Doctor (MD) to get an order for [REDACTED]. On the same day on 3/10/21 at 9:15 AM, the LPN showed the surveyor the [MEDICATION NAME] 5% ointment from the treatment cart. The ointment tube was designated for Resident #25 and had a delivery date of the day before on 3/9/21 and an open date of 3/10/21, and the tube appeared to have been used. The LPN confirmed that the [MEDICATION NAME] was delivered yesterday or last night. She could not speak to if they had the [MEDICATION NAME] had been available prior to yesterday or if there was any housestock. She stated that the Wound Consultant had made rounds at approximately 6:30 AM that morning and that she had done the wound treatment for [REDACTED]. On 3/10/21 at 9:17 AM, the surveyor interviewed the Rehab Director/Physical Therapist (PT). The PT stated that the resident received Occupational Therapy (OT) services from 10/1/2020 until 11/20/2020, and Physical Therapy services form 10/1/2020 until 12/4/2020. She stated that she had worked with the resident on and off during his/her time receiving Physical Therapy. She stated that the resident had been hospitalized in September 2020, and was readmitted to the facility with weakness and required a maximum assistance for bed mobility and transfers. She stated that the resident was also evaluated for the use of positioning boots because of identified plantar flexion of the foot, and that the boots were necessary to stabilize and prevent further contractures of the feet. She stated that the resident was tolerating the multipodus boots for up to three hours while in bed upon discharge from rehab services. The surveyor asked the PT about the resident's pain during rehab services, and the PT stated that the therapists performed active range of motion exercises with the resident during therapy services and used positioning wedges for the left leg due to the left hip that was rotated causing the resident pain. She stated that the resident would say no at times to things such as sitting up in the chair because he/she could not tolerate it due to discomfort. At the time the resident was able to articulate any pain the exercises or plan for the day were adjusted to meet the resident's needs and tolerance levels. She added that the resident was not able to tolerate sitting in a chair and that the rehab team offered the resident maximum encouragement but the resident would sometimes clearly say no. She stated that the rehab team would make sure the resident was pre-medicated for pain prior to therapy in order to prevent pain. She confirmed that pain would be voiced during movement specifically with the left leg due to hip flexion, foot drop and formation of contractures (shortening of muscles and soft tissues caused by immobility) to the left hip and ankle. The PT could not speak to if the resident had a decline in the bilateral lower extremities, since she had not seen the resident for services since 12/4/20. The surveyor requested a copy of all in-service records provided by the PT regarding caregiver training for Resident #25. The PT stated that she would have to get back to the surveyor because it was filed and not easily accessible. The PT stated the rehab department had provided caregiver training for the Certified Nursing Aides and the LPN/UM upon discharge from rehab services and that the Resident #25 had not been referred back to therapy since discharge on 12/4/20. The PT could not speak to the resident's current tolerance to pain or if he/she had any further decline that could impact pain perception. A (TRUNCATED)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) a medication used to treat low blood pressure ([MEDICATION NAME]) was administered in accordance with the hold parameters prescribed by the physician which occurred for 19 different nurses over a period of six months, and b.) the accurate documentation of a resident's skin condition in accordance with professional standards of nursing practice. This deficient practice was identified for 3 of 22 residents reviewed for professional standards of practice (Resident #10, #25, and #77). 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. The evidence was as follows: 1. On 3/10/21 at 9:03 AM, the surveyor observed Resident #10 in bed awake. At that time the surveyor interviewed Resident #10 regarding his/her medication regimen. The resident expressed that he/she had no concerns. The surveyor reviewed the medical record for Resident #10. According to the Order Summary Report for March 2021 in the electronic medical record (EMR), Resident #10 was admitted with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/18/21 reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated the resident had intact cognition. It further reflected that the resident required extensive assistance with most activities of daily living, including bed mobility, transferring, dressing and toileting. A review of the medications on the Order Summary Report for March 2021 indicated a physician's orders [REDACTED]. The order specified to administer one (1) tablet by mouth every eight (8) hours (three times a day) for [MEDICAL CONDITION] (low blood pressure). Further, the order included parameters to hold the medication if the systolic blood pressure (SBP; top number of a blood pressure reading) was greater than 120. A review of the electronic Medication Administration Record's (eMAR) from 9/1/2020 to 3/10/2021 revealed the following: -The eMAR for September 2020 for the dates 9/1/20 to 9/30/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters six (6) times out of 90 opportunities by three (3) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 9/3/20 at 6 AM for a SBP of 126 by License Practical Nurse (LPN) #9. 9/19/20 at 6 AM for a SBP of 127 by LPN #4. 9/22/20 at 6 AM for a SBP of 130 by LPN #4. 9/23/20 at 2 PM for a SBP of 130 by Registered Nurse (RN) #7. 9/28/20 at 6 AM for a SBP of 128 by LPN #4. 9/29/20 at 6 AM for a SBP for 127 by LPN #4. -The eMAR for October 2020 for the dates 10/1/20 to 10/31/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters five (5) times out of 93 opportunities by four (4) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 10/1/20 at 6 AM for a SBP of 130 by LPN #4. 10/2/20 at 10 PM for a SBP of 122 by LPN #5. 10/3/20 at 10 PM for a SBP of 136 by LPN #7. 10/21/21 at 6 AM for a SBP of 125 by LPN #9. 10/27/20 at 2 PM for a SBP of 133 by LPN #5. On 10/28/20 the 2 PM dose was blank. -The eMAR for November 2020 for the dates 11/1/20 to 11/30/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters two (2) times out of 90 opportunities by two (2) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 11/1/20 at 6 AM for a SBP of 122 by LPN #7. 11/15/20 at 2 PM for a SBP of 124 by LPN # 10. -The eMAR for December 2020 for the dates 12/1/20 to 12/31/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters six (6) times out of 93 opportunities by four (4) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 12/13/20 at 6 AM for a SBP of 125 by LPN #13 12/13/20 at 2 PM for a SBP of 130 by RN #7. 12/19/20 at 10 PM for a SBP of 125 by an Agency Nurse (AN #6). 12/22/20 at 6 AM for a SBP of 126 by LPN #4. 12/25/20 at 6 AM for a SBP of 128 by LPN #4. 12/29/20 at 6 AM for a SBP of 128 by LPN #4. -The eMAR for January 2021 for the dates 1/1/21 to 1/31/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters four (4) times out of 93 opportunities by four (4) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 1/13/21 at 2 PM for a SBP of 130 by AN #5. 1/15/21 at 6 AM for a SBP of 129 by LPN #6. 1/20/21 at 6 AM for a SBP of 125 by LPN #7. 1/25/21 at 6 AM for a SBP of 155 by LPN #8. -The eMAR for February 2021 for the dates 2/1/21 to 2/28/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters seven (7) times out of 84 opportunities by six (6) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 2/9/21 at 10 PM for a SBP of 121 by AN #2 2/10/21 at 10 PM for a SBP of 128 by AN #3. 2/12/21 at 2 PM for a SBP of 135 by RN #6. 2/16/21 at 10 PM for a SBP of 130 by AN #2. 2/17/21 at 6 AM for a SBP of 148 by LPN #6. 2/17/21 at 10 PM for a SBP of 129 by RN #5. 2/27/21 at 6 AM for a SBP of 130 by AN #4. -The eMAR for March 2021 for the dates 3/1/21 to 3/10/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters three (3) times out of 30 opportunities by three (3) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 3/4/21 at 10 PM for a SBP of 121 by AN #1 3/6/21 at 6 AM for a SBP of 138 by LPN #4. 3/9/21 at 10 PM for a SBP of 128 by LPN #11. A review of the electronic Progress Notes (ePN) from September 2020 to March 2021 did not reflect documented evidence as to why the [MEDICATION NAME] was signed as given without regards to the hold parameters on the dates identified. On 3/10/21 at 1:03 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated the expectation of the nurses when a medication error occurs was to notify the primary physician. The DON further stated that all medication errors were documented on a medication error form, the physician gets notified, and the nurses are re-educated about the medication error. On 3/11/21 at 8:33 AM, the surveyor interviewed RN #8 regarding the process for administering medications specifically [MEDICATION NAME]. RN #8 stated prior to administering [MEDICATION NAME] she checks the resident's BP and then she checks the PO to verify the parameters, adding that she did not because [MEDICATION NAME] was only to be given when the BP is too low. She further stated, if the SBP was less than 120 she would administer the medication. However, if the SBP was above 120 it would be too high and therefore she would not administer the [MEDICATION NAME]. RN #8 concluded if she did not administer the the medication, she wrote a progress note under the hold medication option in the eMAR. On 3/11/21 at 8:39 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM stated the DON provided her a copy of the Consultant Pharmacist's (CP) monthly recommendations to be reviewed and she notified the physician of the recommendations. The surveyor and LPN/UM together reviewed the Consultant Pharmacist's monthly recommendations for November 2020, December 2020 and January 2021. The LPN/UM stated a check mark on the January 2021 CP recommendation for Resident #10 meant she notified the physician and addressed the recommendation. For the November and December 2020 CP recommendations for Resident #10 there were initials. The LPN/UM stated the initials handwritten on the CP recommendations represented the nurse that had made the medication error, and it was subsequently addressed. The LPN/UM explained both she and the DON would conduct in-service educations with the staff that made the medication errors. She stated the training included that all nurses should read the entire PO prior to administering the medication. The LPN/UM stated when the [MEDICATION NAME] medication error kept repeating for Resident #10. she discussed it with the resident's physician. She emphasized the physician would be notified of the medication error on the same day she received the CP recommendations. She further stated the physician would have nursing assess and monitor Resident #10 after any medication error. The LPN/UM concluded the medication errors were not documented in the progress notes or in the electronic medical record but documented on the medication error sheet which the DON kept in an internal document file. On 3/11/21 at 8:48 AM, the surveyor interviewed LPN #12. LPN #12 stated [MEDICATION NAME] had parameters and if the SBP was above 120 then she would hold the medication and if it was below 120, she would administer the medication. She explained if she held the medication and clicked no, a progress note box opens and then she would document the reason she held the medication. She stated that she would document the reason it was held such as elevated SBP. She then stated every resident may have different parameters for [MEDICATION NAME] which was why nurses have to read the entire PO for each resident. She elaborated that the nurses sometimes have to take the extra step to click on the more link within the order if you can not see the entire order on the screen. She explained when you click more in the eMAR it showed the entire order and the instructions including the hold parameters. She continued to explain that in the eMAR, if she administered a medication it would show a check mark and if she did not administer the medication she wrote the progress note and documented a numeric code which had specific meanings such as 4 which meant vital signs not in parameters or 5 which meant hold see nurses notes. She stated that both numeric codes meant the medication was not administered to the resident. A review of the Individual Inservice Record provided by the DON reflected continuing to violate the policy of Preferred Care in the above listed matter is subject to disciplinary action The surveyor reviewed the electronic Medication Administration Record's (eMAR) from 9/1/2020 to 3/10/2021 for nurses who administered [MEDICATION NAME] more than once without regard to the hold parameters for Resident #10; LPN #4 had eight (8) medication errors with the [MEDICATION NAME], and LPN #5, LPN #6, LPN #7, LPN #9 and the AN #2 had two (2) errors administering the [MEDICATION NAME] without regard to the hold parameters. The surveyor reviewed multiple Individual Inservice Record for LPN #7 and LPN #13 for [MEDICATION NAME] administered outside of the hold parameters. A review of the Medication Administration Error/Medication Documentation dated 1/4/21 indicated, LPN #4 and LPN #13 did not follow the PO for [MEDICATION NAME]. The LPN/UM educated LPN #4 and LPN #13 the same day regarding not reading the entire order prior to administration of the medication. A review of the Medication Administration Observation Quality Improvement Program dated 1/7/21 reflected LPN #13 observed the LPN/UM conduct the critical elements of medication administration including, .MAR is read prior to preparing medications A review of an in-service sign in sheet provided by the DON dated 1/26/21 for Medications with hold parameters indicated the DON presented an in-service to the nursing staff which covered [MEDICATION NAME] order - read thoroughly for hold parameters. A review of the Medication Administration Error/Medication Documentation dated 1/31/21 indicated, LPN#6, LPN # 7, LPN #8, AN #5 did not read instructions adequately for the medication [MEDICATION NAME] and the medication should have been held for Resident #10. A review of the Individual Inservice Record dated 2/2/21 reflected the LPN/UM conducted an inservice with LPN #6, LPN #7, LPN #8, and AN #5 regarding the medication error. A review of an in-service attendance sheet provided by the DON dated 2/12/21 and 3/3/21 for Medication pass and medication error reduction presented to the nursing staff reflected Nurses must read the entire medication order before administration. Be mindful of medications with hold parameters especially, [MEDICATION NAME], blood pressure medications .and document in the MAR 2. On 3/4/21 at 2:15 PM, the surveyor observed Resident #77 in his/her room. The resident stated that he/she had just returned from the [MEDICAL TREATMENT] center. The resident also stated that the nurses gave him/her medications without an issue. The surveyor reviewed the medical record for Resident #77. A review of the Admission Record indicated that the resident had a readmission date of [DATE] with [DIAGNOSES REDACTED]. A review of the resident's current interdisciplinary care plan revealed a focused area of an altered cardiovascular status as related to [MEDICAL CONDITION] (low BP) with an initiation date of 9/14/2020 and an intervention of [MEDICATION NAME] use. A review of the readmission MDS dated [DATE] reflected that the resident had a BIMS score of 12 out of 15, indicating that the resident had intact cognition. A review of the medications on the Order Summary Report for March 2021 revealed that Resident # 77 had a physician's orders [REDACTED]. The order specified to administer one (1) tablet by mouth three times a day for orthostatic [MEDICAL CONDITION]. Further, the order included parameters to hold the medication if the systolic blood pressure was greater than 120. A review of the eMAR from February 2021 and March 2021 revealed that the medication [MEDICATION NAME] was plotted to be administered at 9 AM, 1 PM and 5 PM on non-[MEDICAL TREATMENT] days and 6 AM, 1 PM and 5 PM on [MEDICAL TREATMENT] days. A review of the eMAR for February 2021 for the dates of 2/1/21 to 2/28/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters three (3) times out of 76 opportunities by three (3) nurses. The EMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: On 2/12/21 at 5 PM for a SBP of 121 by AN#7. On 2/22/21 at 9 AM for a SBP of 126 by LPN#5. On 2/25/21 at 1 PM for a SBP of 121 by RN#5. The eMAR for March 2021 for the dates of 3/1/19 to 3/11/19 reflected that the medication [MEDICATION NAME] was administered outside of the physician ordered parameters one (1) time out of 31 opportunities by one (1) nurse. The eMAR reflected that on 3/5/21 the nurse signed for the administration of the [MEDICATION NAME] without regard to the hold parameters as follows: on 3/5/21 at 5 PM for a SBP of 132 by AN#1. On 3/11/21 at 8:34 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #18) who was assigned to administer medications to Resident #77. She stated that Resident #77 was at [MEDICAL TREATMENT] and had a PO for [MEDICATION NAME]. The LPN reviewed the eMAR with the surveyor which indicated a PO for [MEDICATION NAME] with a requirement to Hold if SBP is greater than 120. She explained that if the blood pressure is greater than 120 she would click on N for not administered in the computerized order and then have to enter the BP that was obtained. In addition, the LPN stated that she would have to write a progress note as to why the medication was not administered. On 3/11/21 at 8:38 AM, the surveyor interviewed LPN #19, who was administering medications. She stated that any medication with Hold parameters was noted on the eMAR in the physician's orders [REDACTED]. The LPN added that [MEDICATION NAME] usually had to be held if the SBP was higher than 120 or whatever the physician indicated in the PO. The LPN added if the SBP was greater than the PO indicated she would click on N in the computerized order indicating not administered and would then be able to enter the numeric code 4, which according to the Chart Codes on the eMAR, indicated vitals outside of parameters. She added that she would then be able to enter the exact SBP that was obtained from the resident to show that the blood pressure was outside of the parameters verifying the reason the medication was not administered and this documentation would be reflected in the progress notes. A review of the progress notes from 2/1/21 to 3/10/21 for Resident #77 reflected documentation of dates and times when [MEDICATION NAME] administration was held with regard to the BP. There was no documented evidence as to why [MEDICATION NAME] was administered without regard to the hold parameters on 2/12, 2/22, 2/25 and 3/5. On 03/11/21 at 8:44 AM, the surveyor interviewed UM/LPN #2 who stated that she received the Consultant Pharmacist (CP) report from the DON. The UM/LPN #2 added that she would work on the recommendations that were made and return the report to the DON when she had finished. On 03/11/21 at 10:28 AM, the surveyor with UM/LPN #2 reviewed Resident #77's eMAR for February with regard to the [MEDICATION NAME] administration. The UM stated that the DON was aware of the incorrect administration of [MEDICATION NAME] and there had been education with the nurses that had administered the [MEDICATION NAME] in error. The UM added that the CP usually sends a report which would indicate that there was an error. On 3/11/21 at 11:28 AM the Licensed Nursing Home Administrator (LNHA), DON and Regional Nurse met with the survey team. The DON stated that the CP emails their report and then she distributes the section of the report to the corresponding UM of each wing. The DON added that the UM will work on the recommendations and return the completed report within 7 to 14 days. The DON also stated that Individual Inservice Reports were completed for each nurse that a medication error reported. In addition, the DON stated that the primary physicians were notified and a review was requested of the need to continue the use of the [MEDICATION NAME]. The DON also added that she had noticed looking through the CP reports of the repeated incidents of [MEDICATION NAME] being administered incorrectly and a QAPI was started at the end of January 2021. The DON added that she had requested at the end of January that the CP restart on-site medication pass observations. The DON stated that she felt the reasons for the errors were that the nurses were not reading through the order, being hasty and not realizing what the medication is being used for. In addition, the DON stated that staffing has required agency nurses to be used and the facility has hired new nurses which has also contributed. The DON stated that the nurses were inserviced specifically on [MEDICATION NAME] and understanding the usage and reading the parameters that are noted on the eMAR. The DON stated that she felt there was a reduction in February 2021 and the goal was to have zero errors. The DON stated that neither Resident #10 and Resident #77 had any adverse events associated with the [MEDICATION NAME] being given for elevated SBP. She stated that the residents were monitored by the nurses vital signs were being taken every shift. On 3/11/21 at 2:06 PM, the surveyor conducted a phone interviewed the Consultant Pharmacist. The CP stated that he was not the CP who had completed the drug regimen reviews but could speak to the content of the reviews and the services provided to the facility. The CP stated that drug regimen reviews were completed remotely and a report was emailed to the Director of Nursing (DON). The CP added that an on site visit was performed once a month for unit inspections only. The CP verified that repeat findings regarding the inaccurate documentation on the electronic medication administration record for the administration of [MEDICATION NAME] by the nursing staff was on the reports. The CP added that those findings were noted on the report for the specific resident and noted as a Medication Error. The CP added that when repeat findings were noted on the reports, the CP would have a conversation with the DON as part of company practice. The CP added that there was a discussion with the DON regarding the [MEDICATION NAME] medication errors and that the DON was going to follow up by performing a quality assurance improvement plan which included educating and inservicing the nursing staff. The CP also stated during the month of February the DON had requested from the CP to reinstitute performing on-site medication pass observations with the nurses. The CP could not speak to whether there was improvement noted. A review of the February CP Summary Report that was emailed to the facility indicated that on 2/26/21 a Med Error was noted for Resident #77 regarding the [MEDICATION NAME] administration and the report was assigned to Administration. There was no CP report completed for March as of 3/11/21. The surveyor reviewed the facility undated policy for Medication Administration Procedures provided by the DON which included, as part of the five (5) rights of medication administration which are to be reviewed three (3) times before administration of any medication, to check the order and check for vital signs or monitoring parameters ordered to be done prior to medication administration. A review of the facility's policy, Medication Error created 6/15/2020 included, the facility shall ensure that residents are free of medication error rates of five (5) percent or greater .medications shall be administered according to physician's orders [REDACTED]. a medication error report will be completed by the license nurse .The resident will be monitored NJAC 8:39-11.2(b), 29.2(a), 29.2(d), 29.3(a)(5) 3. On 3/10/21 at 8:38 AM, the surveyor observed Resident #25 awake in bed on an air mattress. The resident stated to the surveyor that he/she had pain in the back-side. The resident was only able to elaborate on the location of the pain, and not the type, severity, duration or other possible causes of the pain. The resident stated that he/she got pain medication that morning, and when asked if the medication was effective at relieving the pain, the resident stated, No. The resident was unable to speak to if he/she had a wound to the back-side. The surveyor reviewed the medical record for Resident #25. A review of the Admission Record face sheet (an admission summary) reflected that the resident had [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment dated [DATE] reflected that the resident had a brief interview for mental status score of 11 out of 15 indicating an intact cognition with moderate forgetfulness. The MDS assessment included that the resident had moisture-associated skin damage (MASD; inflammation and excoriation to the skin that is caused by prolonged exposure to moisture), and that he/she was receiving ointments to the affected area. A review of the electronic Progress Notes (ePN) dated 11/23/20 at 2:35 PM reflected that Resident #25 was noted with an open area on the sacrum that appears red and pink with a scant amount of blood noted. The open area measured 4 centimeters (cm) x 5 cm x 0.1 cm, and the physician was made aware and ordered [MEDICATION NAME] wound gel (a [MEDICATION NAME] ointment) to be applied to the wound with calcium alginate (an absorbent dressing) and cover it with a dry dressing. The family was made aware of the new wound. A review of the physician's orders [REDACTED]. A review of the resident's individualized care plan reflected it was updated on 11/23/20 that Resident #25 developed MASD on the buttocks and interventions included, treatment orders for Medicated Honey and calcium alginate will be initiated and area monitored for improvement. A review of the electronic Treatment Administration Record (eTAR) for November 2020 did not reflect the corresponding physician's orders [REDACTED]. A review of the electronic Medication Administration Record (eMAR) for November 2020 reflected that the nursing staff were signing in the eMAR instead of the eTAR during the 3 PM-11 PM shift that they were cleansing the sacral wound with normal saline solution, patting it dry and applying [MEDICATION NAME] gel and a calcium alginate dressing on the wound for 11/23/20, 11/24/20 and 11/25/20. A review of subsequent ePN's dated 11/24/20, 11/25/20, 11/26/20 and 11/27/20 did not address follow-up assessments on the resident's skin breakdown, nor did it accurately reflect the current condition of the resident's skin despite signing in the eMAR and the eTAR that a wound treatment was being performed to the resident's sacrum. The ePN dated 11/24/20 at 6:30 PM reflected that evening care was provided and the resident was kept clean and dry with No acute changes noted. The ePN 11/25/20 at 2:33 PM, 11/26/20 at 1:35 PM, and 11/27/20 at 3:19 PM reflected skin warm and dry to touch but it did not address the resident's skin breakdown or how the resident tolerated the wound dressing change. A review of the Skilled Evaluation for nursing dated 11/24/20 at 2:24 PM, 11/25/20 at 2:33 PM, 11/26/20 at 1:35 PM, and 11/27/20 at 3:19 PM reflected that the resident's skin was warm/dry with skin turgor normal and no surgical sites. The assessment question that asked are there any current skin impairment(s)? The nurses marked No for each assessment. The narrative notes that corresponded with the evaluation assessments did not address the resident's skin breakdown and the nurse documented Skin warm to touch . no acute changes noted . incontinent of bowel and bladder. On 3/10/21 at 8:06 AM, the surveyor interviewed the resident's assigned Licensed Practical Nurse (LPN) who confirmed that the resident had a wound on the sacrum and that the treatment had been done by the Wound Consultant at approximately 6:30 AM that morning. She and the surveyor reviewed the eTAR together and saw that the treatment had not yet been signed for as completed. The LPN acknowledged that the eTAR wasn't signed yet, and that she didn't know who was responsible to sign it if the Wound Consultant performed the treatment and not the nurse, adding that she did not know because she only worked per-diem. On 3/10/21 at 11:05 AM, the surveyor observed Resident #25 in bed. Two Certified Nursing Aides (CNA's) were positioning the resident on a mechanical lift pad. During the positioning, one CNA showed the surveyor a wound dressing on the resident's sacrum with initials and a date written on it: 3/10/21. Both CNA's confirmed that the resident had a wound to the sacrum. On 3/10/21 at 1:02 PM, the Director of Nursing (DON) stated in the presence of the survey team that the Wound Consultant does rounds with the Unit Manager, but if the Wound Consultant arrived before the UM, than she would do rounds with the 11 PM to 7 AM shift (night) nurse and the night nurse would sign for the accountability of the wound treatment. The surveyor discussed the findings with the DON and the Licensed Nursing Home Administrator (LNHA) regarding the accuracy of the skin assessments for four days from 11/24/20- 11/27/20, when the resident was receiving a wound treatment in accordance with the physician's orders [REDACTED].>On 3/11/21 at 11:39 AM, the DON acknowledged that the documentation was not accurate in the Skilled Nursing notes or the ePN and that nurses should have been accurately documenting in the notes to reflect that there was current skin breakdown in accordance with the resident's skin condition. The DON acknowledged that because the nurses were signing for the application of a sacral wound treatment in the eMAR on the dates in question, would suggest that the resident's skin was not intact at the time the Skilled Nursing notes were written on 11/24/20, 11/25/20, 11/26/20 and 11/27/20. The DON confirmed that the sacral wound that started as MASD on 11/23/20 had not yet healed but was improving in size. The DON confirmed that the ePN's did not reflect the breakdown of the skin on those dates either. NJAC 8:39-3.2(a), (b); 11.2 (b); 27.1(a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) the application of a positioning wedge in accordance with a resident's Physical Therapy recommendations and the individualized care plan, b.) the application of multipodus boots in accordance with a resident's discharge physical therapy recommendations, restorative mobility program and physician orders, c.) the individualized care plan had a measurable goal for the resident's range of motion limitations and that the care plan was developed for the resident's Restorative Nursing Program with the multipodus boots. This deficient practice was identified for 1 of 2 residents reviewed for restorative programming (Resident #25). The evidence was as follows: On 3/2/21 at 11:57 AM, the surveyor observed Resident #25 in bed on an air mattress. The resident's eye's were closed and the room was darkened. The surveyor observed a pair of multipodus boots (a boot that supports the ankle and foot and is typically used to prevent foot drop contractures due to a lack of immobility) on the resident's night stand. The surveyor reviewed the medical record for Resident #25. A review of the Admission Record face sheet (an admission summary) reflected that the resident had [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment dated [DATE] reflected that the resident had a brief interview for mental status score of 11 out of 15 indicating an intact cognition with moderate forgetfulness. The MDS assessment included that the resident had no instances of rejecting care in the last seven days. It further included that the resident required an extensive two person physical assist for bed mobility and transfers, and had a functional limitation in range of motion affecting one side of both the upper extremity and the lower extremity. The assessment further reflected that the resident had been discharged from physical therapy services on 12/4/2020, and that in the last 7 days, the resident had had 0 days of a Restorative Nursing Program (RNP) with at least 15 minutes a day of restorative exercises and 0 days of splint or brace assistance. A review of the Physical Therapy Discharge Summary signed on 12/9/20 reflected that the resident was discharged from physical therapy (PT) on 12/4/20. The Discharge summary reflected to Establish RNP to maintain current level of function. The summary reflected that previously on 11/23/20 an Inservice done with staff in terms of proper wedge placement under LLE (left lower extremity) to help with proper positioning of LLE, will initiate training with multipodus boots. The Discharge Summary for 12/4/20 included that an Inservice done with staff in terms of proper wedge placement under LLE to help with proper positioning of LLE, and also with multipodus boots BLE (bilateral lower extremities). Tolerating for 3 hours, educated for skin checks pre and post application, RNP established for donning and doffing the boots and rolling in bed. The PT Discharge Summary further reflected a goal that the resident will be able to tolerate multipodus boots to the bilateral lower extremities for 4 hours when in bed for proper positioning of legs and prevent contractures. At baseline on 11/17/21, the resident was able to tolerate 1 hour and 30 minutes of the multipodus boots and the wedge on the LLE to prevent rotation of LLE when in bed. Inservice done with nursing staff, orders initiated. On 11/23/20 the resident was able to tolerate 2 hours of the multipodus boots and upon discharge on 12/4/21 the resident was able to tolerate 3 hours with no abnormal response noted. Inservices done. Recommendations included that the resident will continue to use the wedge under LLE for proper positioning of leg and also use of multipodus boots for 3 hours, in-service done, skin checks to be done pre and post application. RNP established. Recommended OOB (out of bed) to regular chair with proper positioning .and use of foot hugger (foot rest support board used when out of bed). The Summary included that RNP was necessary to facilitate patient maintaining current level of performance and in order to prevent decline . The Rehab Director/Physical Therapist signed the Discharge Summary on 12/9/20 and the Medical Doctor (MD) electronically signed the PT Discharge Summary in agreement with the plan on 12/10/20 at 11:44 AM. A review of the resident's individualized comprehensive care plan initiated on 9/20/19 reflected that the resident was at risk for falls related to impaired mobility and needs assistance for activities of daily living. Interventions initiated 12/11/2020 included for Nursing, CNA's and Occupational Therapy to apply a wedge under the left lower extremity when in bed for proper positioning of left leg. Skin checks to be performed pre-and post application and Q (every) shift. The care plan also reflected that the resident had a physical functioning deficit related to mobility impairment and range of motion (ROM) limitations initiated on 9/20/19. The Goal was revised on 2/20/21 to reflect that the resident will maintain his/her current level of physical functioning and ROM. There was no measurable goal and the care plan inappropriately reflected further that the resident required moderate independence with transfers and that he/she was very capable of ironing (his/her) clothes safely. Interventions included to monitor and report changes in physical functioning ability and monitor and report changes in ROM ability. The care plan did not address the resident's multipodus boots or that he/she was on a Restorative Nursing Program. A review of the Order Recap Report with physician's orders [REDACTED]. In addition there was another order dated 12/9/20 which read: Late order 12/04 Patient to use Multipodus boots when in bed for 3 hours to help with proper foot positioning. Skin checks to be performed pre and post application. (This order did not specify what shift was responsible for the application of the multipodus boots). Further there was a physician's orders [REDACTED]. There was no corresponding progress notes to reflect why it was discontinued when the resident had just been using it as part of the Physical Therapy discharge plan which was signed on 12/9/20. The care plan was not updated to reflect that the order for the wedge had been discontinued on 12/11/20. The surveyor attempted to review the Restorative Nursing Program accountability logs from December 2020 to March 2021, but there was no evidence of a Restorative Nursing Program accountability logs in either the electronic Medical Record or the hybrid medical chart. A review of the electronic Treatment Administration Record (eTAR) and electronic Medication Administration Record [REDACTED]. On 3/9/21 at 10:40 AM, the surveyor observed Resident #25 in bed on an air mattress. The surveyor observed the same pair of multi podus boots on the resident's night stand. At that time, the resident's assigned Certified Nursing Aide (CNA) assisted the resident with a phone call. The CNA held the phone to the resident's ear, but the resident was not verbally communicating back with the caller. After the CNA finished assisting the resident, the surveyor interviewed the CNA. The CNA stated that Resident #25 was alert but has had some increased moments of confusion lately. The CNA confirmed that the resident was not verbally responding to the caller, but stated that the resident has had a decline in the last two months. The CNA stated that the resident was fully dependent on staff for activities of daily living (ADL) and that the resident needed at least two people to provide care because the resident was unable to turn in bed. She stated that while she was not always assigned to the resident, she has known him/her for a long time. The surveyor asked the CNA about the multi podus boots on the night stand, and the CNA stated that Resident #25 only wears the boots when (he/she) gets out of bed. She stated that most days when she was assigned to the resident, the resident refuses to get out of bed, and therefore the boots would not be worn on her shift. The CNA further added that she elevated the resident's feet on pillows when in bed. At that time, the CNA showed the surveyor the resident's feet by removing the blanket. The surveyor observed that the resident's left foot was in a plantar flexion (when the top of the foot points away from the leg) and the left leg was laterally rotated. The resident's left heel was in direct contact with the resident's lateral right ankle. There was no wedge in place. The CNA repositioned the resident's left and right foot to avoid pressure points, and covered the feet back up with a blanket. The resident's left leg continued to be rotated laterally. She could not speak to the use of the multi podus boots any further and did not address any other positioning devices that the resident uses, including the wedge in accordance with the resident's care plan. On 3/9/21 at 11:54 AM, the surveyor observed Resident #25 in bed. The multipodus boots were still on the night stand. The resident's assigned Licensed Practical Nurse (LPN) entered the resident's room and the LPN showed the surveyor the resident's bilateral feet. The resident's left foot was in the plantar flexion and was rotated laterally on a pillow and his/her left heel was back in direct contact with the resident's lateral right ankle. There was no wedge in place in accordance with the resident's care plan and the resident was not wearing the multipodus boots. On the next day on 3/10/21 at 8:38 AM, the surveyor observed the resident in bed awake. The resident's multi podus boots were on the night stand. The surveyor attempted to interview the resident regarding the use of the wedge and the multi-podus boots for the feet, but the resident kept repeating the location of his/her pain. From 8:43 AM to 9:06 AM, the resident's assigned LPN attempted to administer pain medication twice to Resident #25, but was unsuccessful. The LPN stated to the surveyor that she would call the Physician to order a pain medication that could be dissolved under the tongue or given through a suppository route, one that the resident would not need to swallow. At 9:08 AM, the surveyor interviewed the LPN regarding positioning devices, multipodus boots and the RNP for Resident #25. The LPN stated that she only works [MEDICATION NAME] and does not apply the multipodus boots nor does she need to sign to account that the multipodus boots are on during her shift. She stated that if she had to sign, it would be in the electronic Treatment Administration Record (eTAR) for electronic Medication Administration Record [REDACTED]. The surveyor reviewed the physician's orders [REDACTED]. The LPN read the physician's orders [REDACTED]. Skin checks to be performed pre and post application. The LPN confirmed that the order was for the resident to wear the multipodus boots in bed but she could not speak to when the three hours were supposed to start and end. She stated that the order would have to be clarified with the physician. The surveyor asked who was responsible for clarifying orders, and the LPN stated any nurse assigned to the resident or the LPN/Unit Manager. She stated that the Rehab Director/Physical Therapist entered the physician's orders [REDACTED]. On 3/10/21 at 9:17 AM, the surveyor interviewed the Rehab Director/Physical Therapist (PT). The PT stated that the resident received Occupational Therapy (OT) services from 10/1/2020 until 11/20/2020, and Physical Therapy services form 10/1/2020 until 12/4/2020. She stated that she had worked with the resident on and off during his/her time receiving Physical Therapy. She stated that when the resident had been hospitalized , he/she returned with weakness and required maximum assistance for bed mobility and transfers. She stated that the resident was also evaluated for the use of multipodus boots because of identified plantar flexion of the foot, and that the it was necessary to stabilize and prevent further contractures of the feet. She stated that the resident was tolerating the multipodus boots for up to three hours while in bed. She stated that the resident was supposed to get the boots for three hours a day as part of his/her restorative nursing program. The surveyor asked the PT to look at the physician's orders [REDACTED]. She stated that therapy can get the physician's orders [REDACTED]. She stated that it was then up to the nurse when to put it on but stated that they were doing it during the day. She stated that the nurses are supposed to sign for the accountability of the multipodus boots in the eTAR. She stated that as far as she knew the resident was tolerating the multipodus boots for 3 hours a day. If the resident was not tolerating it, she would have a referral to evaluate for alternative modalities. She acknowledged she did not receive any updated referral since his/her discharge date on 12/4/20. The PT further stated that the LPN/UM was aware of the multipodus boots for the resident and that she had attended the training with two other CNA's. The PT acknowledged that the order she entered did not specify when the multipodus boots were supposed to be applied, but that nursing could make that decision when they would be applied. The PT stated that they performed active range of motion exercises with the resident during therapy services and used positioning wedges for the left leg due to the left hip that was rotated causing pain. She stated that the resident would say no at times to things such as sitting up in the chair because he/she could not tolerate it. The PT could not speak to if the resident had a decline in the bilateral lower extremities, since she had not seen the resident for services since 12/4/20. The surveyor requested a copy of all in-service records provided by the PT regarding caregiver training for Resident #25. The PT stated that she would have to get back to the surveyor because it was filed and not easily accessible. On 3/10/21 at 9:43 AM, the surveyor interviewed the LPN/UM who stated that the facility had a full time Restorative CNA (R/CNA) but that he was not available today for an interview. The surveyor asked about the use of the multipodus boots and the LPN/UM could not speak to when or if the resident wore them. The LPN/UM stated that she believed that the R/CNA would come to her at times to tell her that the resident did not want to wear the multipodus boots, but she could not speak to where they gets documented. She reviewed the physician's orders [REDACTED]. The surveyor asked who was responsible for the accountability of the boots and the LPN/UM stated that there was no accountability for the boots. She confirmed that it was not on the eTAR or eMAR for the nurses to sign. The surveyor asked if there was an RNP accountability form, and the LPN/UM confirmed she was not aware of any accountability for the boots. The surveyor asked how she knew if the resident was wearing them or tolerating them if there was no accountability, and the LPN/UM could not speak to it. At 11:10 AM, the surveyor interviewed two Certified Nursing Aides (CNA's) who were preparing to get the Resident #25 out of bed using a mechanical lift. Both CNA's confirmed that the resident does not wear the multipodus boots during their shift. One of the CNA's stated that while she was not assigned to the resident today, she was assigned to the resident all last month and that the resident never wears those boots. The surveyor asked what they were for and why the resident never wore them, and the CNA was not sure. She stated that wasn't told that she ever had to apply them, so it wasn't something she had to do or sign for. She stated that the resident was very sensitive to pain when touched and that may be why. The other CNA stated that she didn't have to apply the boots but that she would put them on when the resident got out of bed to the gerichair. At 11:39 AM, the surveyor observed the resident's assigned CNA apply the multipodus boots to the resident's feet while in the gerichair in the presence of the LPN/UM. As the CNA lifted the resident's legs to apply the boots one at a time, the resident began to grimace and moan. Once each boot was on and the foot was placed back on the pillow, the resident stopped moaning and grimacing. At 12:05 PM, the surveyor observed Resident #25 in the day room positioned in a gerichair still wearing the multipodus boots. At approximately 12:30 PM, the PT provided the surveyor a copy of one In-Service Form with caregiver training dated 11/17/20 which was 17 days prior to discharge from Physical Therapy Services. The In-service form reflected that the Physical Therapy Assistant and Certified Occupational Therapy Assistant provided training that included proper positioning in chair with foot board/hugger and multipodus boots to be worn in bed in AM 2-3 hours or as tolerated. skin checks pre and post application. The training did not address the wedge for the left leg. The PT confirmed this was the only in-service training record available. The caregivers in attendance included an LPN, the LPN/UM, and two CNA's. Neither of the CNA's that attended the caregiver training were the designated R/CNA. On 3/11/21 at 12:15 PM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The DON stated that the R/CNA was putting the multipodus boots on the resident and signing in a Restorative Nursing Program log. The DON provided the surveyor a copy of a handwritten Restorative Nursing Flow Sheet for Resident #25. The DON could not speak to why the assigned LPN and the LPN/UM was unaware of the Restorative Nursing book. The Regional Nurse stated that the LPN/UM should have known about the Restorative book where the R/CNA signs for it. They confirmed it was not in the resident's medical record and all the months were kept in a separate binder. The surveyor reviewed the December 2020 Restorative Nursing Flow Sheet which reflected a goal of Proper Application of multipodus boots to bilateral lower extremities to be worn in bed 3-4 hours with skin checks. The RNP was inappropriately plotted to be done on two eight hour shifts: 7 AM to 3 PM shift and the 3 PM to 11 PM shift. The Certified Nursing Aides on both shifts were signing that the resident refused the boots 12 times during the day shift, and 15 times during the evening shift. It was further signed to reflect that during the day shift the resident would only have the multipodus boots on for 5 minutes and up to 25 minutes, and not for 3-4 hours as prescribed. In the evening shift, the resident would only wear the multipodus boots from 5 minutes to 15 minutes maximum. There was no accountability for the application of the wedge from 11/24/20 until 12/11/20 when the order for the wedge was discontinued by the MD. A review of the January 2021 Restorative Nursing Flow Sheet reflected that the multipodus boots were not worn for the 3-4 hours in accordance with the RNP but it was documented that they were worn for 5-20 minutes during the day shift with 18 day shifts out of 31 that the resident refused them. The evening shift reflected that the resident wore the boots from 10-20 minutes for 15 out of 31 evening shifts. This did not correspond with the physician's orders [REDACTED]. A review of the February 2021 Restorative Nursing Flow Sheet for the multipodus boots reflected that the resident wore the multipodus boots for 5-30 minutes maximum and refused 13 day shifts out of 28. The RNP was signed to reflect that during the evening shift the multipodus boots were worn for 5-15 minutes maximum, but had refused it 8 evening shifts out of 28. This did not correspond with the physician's orders [REDACTED]. A review of the March 2021 reflected that the resident refused the Multipodus boots during the day shift 5 day shifts out of 9 days, and 5 evening shifts out of 9 days and resident only wore the boots for 15-20 minutes and not the 3-4 hours as ordered by the physician. At 12:17 PM, the surveyor continued to interview the LNHA who stated that the R/CNA was not available for an interview today. The surveyor asked who was responsible for reviewing the RNP Flow Sheets and the DON confirmed the LPN/UM. The surveyor asked why the CNA's were signing for 5-30 minutes of the multipodus boots at a time when the order was for 3-4 hours, and the DON acknowledged she could not answer if it was because the resident was not tolerating it beyond 30 minutes or if it was because the CNA's and R/CNA was not signing to reflect they were accurately following the physician order. The DON stated that the resident has had a recent decline in status prior to the implementation of the multipodus boots, and that there was no evidence that the resident had further decline as a result of only receiving the boots up to 30 minutes at a time. The DON was unable to provide any other documentation regarding notification of physician that resident refused the multipodus boots or a screening from therapy to address the resident's refusals and decreased use of the boots from the PT Discharge baseline of 3 hours. The DON was also unable to provide documented evidence that the refusals were addressed in the care plan. The DON provided the surveyor a copy of the CNA's Kardex with an effective date of 3/11/21. The Kardex reflected to apply a wedge under the left lower extremity when in bed for proper positioning of the left leg (which according to the physician order [REDACTED]. According to facility policy Restorative Nursing: Splint Use, reviewed on 2/10/2020, included the following: A splint is a support that is used to rest an extremity or joint in an optimum position, relieve swelling, an/or (sic) allow continuing function despite a painful joint, or to correct/prevent deformities . 1. Follow the therapist instructions for the application, time periods for use, and care of the splint. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that the Consultant Pharmacist recommendations regarding the use of a medication to treat low blood pressure ([MEDICATION NAME]) were acted upon in a timely manner when the medication was identified to not be administered in accordance with the physician prescribed hold parameters for a period of six (6) months. This deficient practice was identified for 2 of 6 residents reviewed for Consultant Pharmacist reviews (Resident #10 and #77), and was evidenced by the following: 1. On 3/10/21 at 9:03 AM, observed Resident #10 in bed awake, at that time the surveyor interviewed Resident #10 regarding his/her medication regimen. The resident expressed that he/she had no concerns. The surveyor reviewed the medical record for Resident #10. According to the physician's Order Summary Report for March 2021 in the electronic medical record (EMR), reflected that Resident #10 was admitted with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/18/21 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident had an intact cognition with mild forgetfulness. A review of the medications on the Order Summary Report for March 2021 indicated a physician's order (PO) dated 7/27/2020 for a medication to assist in raising the blood pressure (BP), [MEDICATION NAME] (HCL) tablet 5 milligrams (mg). The order specified to administer one (1) tablet by mouth every eight (8) hours (three times a day) for [MEDICAL CONDITION] (low blood pressure). Further, the order included parameters to hold the medication if the systolic blood pressure (SBP; top number of a blood pressure reading) was greater than 120. A review of the electronic Medication Administration Record's (eMAR) from 9/1/2020 to 3/10/2021 revealed the following: -The eMAR for September 2020 for the dates 9/1/20 to 9/30/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters six (6) times out of 90 opportunities by three (3) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 9/3/20 at 6 AM for a SBP of 126 by License Practical Nurse (LPN) #9. 9/19/20 at 6 AM for a SBP of 127 by LPN #4. 9/22/20 at 6 AM for a SBP of 130 by LPN #4. 9/23/20 at 2 PM for a SBP of 130 by Registered Nurse (RN) #7. 9/28/20 at 6 AM for a SBP of 128 by LPN #4. 9/29/20 at 6 AM for a SBP for 127 by LPN #4. -The eMAR for October 2020 for the dates 10/1/20 to 10/31/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters five (5) times out of 93 opportunities by four (4) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 10/1/20 at 6 AM for a SBP of 130 by LPN #4. 10/2/20 at 10 PM for a SBP of 122 by LPN #5. 10/3/20 at 10 PM for a SBP of 136 by LPN #7. 10/21/21 at 6 AM for a SBP of 125 by LPN #9. 10/27/20 at 2 PM for a SBP of 133 by LPN #5. 10/28/20 the 2 PM dose was blank. -The eMAR for November 2020 for the dates 11/1/20 to 11/30/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters two (2) times out of 90 opportunities by two (2) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 11/1/20 at 6 AM for a SBP of 122 by LPN #7. 11/15/20 at 2 PM for a SBP of 124 by LPN # 10. -The eMAR for December 2020 for the dates 12/1/20 to 12/31/20 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters six (6) times out of 93 opportunities by four (4) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 12/13/20 at 6 AM for a SBP of 125 by LPN #13 12/13/20 at 2 PM for a SBP of 130 by RN #7. 12/19/20 at 10 PM for a SBP of 125 by Agency nurse (AN) #6. 12/22/20 at 6 AM for a SBP of 126 by LPN #4. 12/25/20 at 6 AM for a SBP of 128 by LPN #4. 12/29/20 at 6 AM for a SBP of 128 by LPN #4. -The eMAR for January 2021 for the dates 1/1/21 to 1/31/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters four (4) times out of 93 opportunities by four (4) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 1/13/21 at 2 PM for a SBP of 130 by AN #5. 1/15/21 at 6 AM for a SBP of 129 by LPN #6. 1/20/21 at 6 AM for a SBP of 125 by LPN #7. 1/25/21 at 6 AM for a SBP of 155 by LPN #8. -The eMAR for February 2021 for the dates 2/1/21 to 2/28/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters seven (7) times out of 84 opportunities by six (6) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 2/9/21 at 10 PM for a SBP of 121 by AN #2 2/10/21 at 10 PM for a SBP of 128 by AN #3. 2/12/21 at 2 PM for a SBP of 135 by RN #6. 2/16/21 at 10 PM for a SBP of 130 by AN #2. 2/17/21 at 6 AM for a SBP of 148 by LPN #6. 2/17/21 at 10 PM for a SBP of 129 by RN #5. 2/27/21 at 6 AM for a SBP of 130 by AN #4. -The eMAR for March 2021 for the dates 3/1/21 to 3/10/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters three (3) times out of 30 opportunities by three (3) nurses. The eMAR reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: 3/4/21 at 10 PM for a SBP of 121 by AN #1 3/6/21 at 6 AM for a SBP of 138 by LPN #4. 3/9/21 at 10 PM for a SBP of 128 by LPN #11. On 3/10/21 at approximately 10 AM, the surveyor reviewed Consultant Pharmacist (CP) Recommendations in the EMR. A review of the progress notes section revealed that on 9/29/20, 10/27/20, 11/30/20, 12/29/20 and 1/31/21, the CP wrote: Medication Regime Review (MRR) completed - Recommendations sent to facility. There were no other entries by the CP on either the EMR or the resident's hybrid chart. On 3/10/21 at 10:14 AM, the surveyor conducted a phone interview with the CP. The CP stated that he was not the CP who had completed the drug regimen reviews but could speak to the content of the reviews and the services provided to the facility. The CP stated the drug regimen was reviewed remotely and the CP entered a progress note into the EMR, and that all the recommendations were emailed to the Director of Nursing (DON). On 3/10/21 at 12:36 PM, the License Nursing Home Administrator (LNHA) provided the surveyor with the CP's Medication Regimen Review (MRR) for Resident #10 since September 2020. A review of the Consultant Pharmacist's monthly Summary Report for November 2020, December 2020, and January 2021 reflected repeated recommendations to address that the [MEDICATION NAME] was being given without regard to the SPB hold parameters for Resident #10. The comments specifically stated .Medication error - [MEDICATION NAME] signed for as administered with SBP above hold parameter of 120 .please review, correct and report as per facility policy. The September 2020, October 2020 and February 2021 CP report did not address the errors with the [MEDICATION NAME]. On 3/10/21 at 1:03 PM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team. The DON stated the expectation of the nurses for when a medication error occurs was to notify the primary physician. The DON further stated that all medication errors were documented on a medication error form, the physician gets notified, and the nurses get re-educated about the medication error. On 3/11/21 at 8:39 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM).The LPN/UM stated the DON provided her a copy of the CP monthly recommendations to be reviewed and she notified the physician of the recommendations. The surveyor and LPN/UM reviewed together the Consultant Pharmacist's monthly recommendations for November 2020, December 2020, and January 2021. The LPN/UM stated a check mark on the January 2021 CP recommendation for Resident #10 meant she notified the physician and addressed the recommendation. For the November 2020 and December 2020 CP recommendations for Resident #10 there were initials. The LPN/UM stated the initials that were handwritten on the CP recommendations represented the nurse that had made the medication error, and it was subsequently addressed. The LPN/UM explained both her and the DON would conduct in-service educations with the staff that had the medication errors. She stated the training included that all nurses should read the entire PO prior to administering the medication. The surveyor continued to interview the LPN/UM regarding the medication error protocol. The LPN/UM stated when the [MEDICATION NAME] medication error kept repeating for Resident #10 she discussed it with the resident's physician. She emphasized the physician would be notified of the CP recommendations on the same day she received the CP recommendations. She further stated the physician would have the nursing assess and monitor Resident #10 for any effects related to not following the hold parameters. The LPN/UM concluded the medication errors were not documented in the progress notes or in the electronic medical record but documented on the medication error sheet which the DON kept in an internal document file. The LPN/UM confirmed there were 33 instances of not following hold parameters for Resident #10 since September 2020 until present. On 03/11/21 at 11:29 AM, the surveyor interviewed the DON in the presence of the survey team. The DON stated the facility had a lot of agency nurses and several new nurses. However, she had completed inservices on medication administration and medication errors, specifically for [MEDICATION NAME] and holding the medication in accordance with the hold parameters. She further stated that on 1/22/21 she started a Quality Assurance and Performance Improvement (QAPI) project on the [MEDICATION NAME] medication errors because she felt either the nurses were not reading the entire PO or not understanding the PO. The DON expressed she felt the inservices were effective because there was a reduction in occurrences from one month to the next, but that it was still an ongoing issue particularly with agency nurses. She confirmed it was not yet been fully corrected because the goal was to have zero medication errors with the [MEDICATION NAME], but that Resident #10 did not have any adverse effect from the [MEDICATION NAME] being given when the SBP was over 120. The DON stated if a nurse had multiple medication errors then disciplinary actions would occur. A review of the Consultant Pharmacist's expectations of the facility for the administration of medications, undated included, Review Medication Administration Record [REDACTED]. review cautionaries A review of the facility's policy, Medication Administration Procedures, undated included, .check for vital signs, other tests to be done during/prior to medication administration obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration .and document in the MAR . A review of the facility's policy, Medication Error created 6/15/2020 included, the facility shall ensure that residents are free of medication error rates of five (5) percent or greater .medications shall be administered according to physician's order in accordance with accepted standards and principles which apply to professionals providing services . 2. On 3/4/21 at 2:15 PM, the surveyor observed Resident #77 in his/her room. The resident stated that he/she had just returned from the [MEDICAL TREATMENT] center. The resident also stated that the nurses gave him/her medications in accordance with the [MEDICAL TREATMENT] schedule. The surveyor reviewed the medical record for Resident #77. A review of the Admission Record indicated that the resident had a readmission date of [DATE] with [DIAGNOSES REDACTED]. A review of the resident's current interdisciplinary care plan revealed a focused area of an altered cardiovascular status as related to [MEDICAL CONDITION] (low BP) with an initiation date of 9/14/2020 and an intervention of [MEDICATION NAME] use. A review of the readmission MDS dated [DATE] reflected that the resident had a BIMS score of 12 out of 15, indicating that the resident had an intact cognition. A review of the medications on the Order Summary Report for March 2021 revealed that Resident # 77 had a physician's order (PO) dated 2/2/21 for [MEDICATION NAME] (HCL) (a medication to raise the blood pressure) tablet 10 mg. The order specified to administer one (1) tablet by mouth three times a day for orthostatic [MEDICAL CONDITION]. Further, the order included parameters to hold the medication if the SBP was greater than 120. A review of the eMAR from February 2021 and March 2021 revealed that the medication [MEDICATION NAME] was plotted to be administered at 9 AM, 1 PM and 5 PM on non-[MEDICAL TREATMENT] days and 6 AM, 1 PM and 5 PM on [MEDICAL TREATMENT] days. A review of the eMAR for February 2021 for the dates of 2/1/21 to 2/28/21 reflected the medication [MEDICATION NAME] was administered outside of the physician ordered parameters three (3) times out of 76 opportunities by three (3) nurses. The eMAR further reflected that on the following dates and times the nurses signed for the administration of the [MEDICATION NAME] without regard to the hold parameters: on 2/12/21 at 5 PM for a SBP of 121 by AN#7. on 2/22/21 at 9 AM for a SBP of 126 by LPN#5. on 2/25/21 at 1 PM for a SBP of 121 by RN#5. The eMAR for March 2021 for the dates of 3/1/19 to 3/11/19 reflected that the medication [MEDICATION NAME] was administered outside of the physician ordered parameters one (1) time out of 31 opportunities by one (1) nurse. The eMAR reflected that on 3/5/21 the nurse signed for the administration of the [MEDICATION NAME] without regard to the hold parameters as follows: on 3/5/21 at 5 PM for a SBP of 132 by AN#1. On 3/11/21 at 8:34 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #18) who was assigned to administer medications to Resident #77. She stated that Resident #77 was at [MEDICAL TREATMENT] and had a PO for [MEDICATION NAME]. The LPN reviewed the eMAR with the surveyor which indicated a PO for [MEDICATION NAME] with a requirement to Hold if SBP is greater than 120. She explained that if the blood pressure is greater than 120 she would click on N for not administered in the computerized order and then have to enter the BP that was obtained. In addition, the LPN stated that she would have to write a progress note as to why the medication was not administered. On 3/11/21 at 8:38 AM, the surveyor interviewed LPN #19, who was administering medications. She stated that any medication with Hold parameters was noted on the eMAR in the physician's order and would have to be followed. The LPN added that [MEDICATION NAME] usually had to be held if the SBP was higher than 120 or whatever the physician indicated in the PO. The LPN added if the SBP was greater than the PO indicated she would click on N in the computerized order indicating not administered and would then be able to enter the numeric code 4, which according to the Chart Codes on the eMAR, indicated vitals outside of parameters. She added that she would then be able to enter the exact SBP that was obtained from the resident to show that the blood pressure was outside of the parameters verifying the reason the medication was not administered and this documentation would be reflected in the progress notes. A review of the progress notes from 2/1/21 to 3/10/21 for Resident #77 reflected documentation of dates and times when [MEDICATION NAME] administration was held with regard to the BP. There was no documented evidence as to why [MEDICATION NAME] was administered without regard to the hold parameters on 2/12, 2/22, 2/25 and 3/5. On 03/11/21 at 8:44 AM, the surveyor interviewed the UM/LPN #2 who stated that she received the Consultant Pharmacist (CP) report from the DON. The UM/LPN #2 added that she would work on the recommendations that were made and return the report to the DON when she had finished. On 03/11/21 at 10:28 AM, the surveyor with the UM/LPN #2 reviewed Resident #77's EMAR for February with regard to the [MEDICATION NAME] administration. The UM stated that the DON was aware of the incorrect administration of [MEDICATION NAME] and there had been education with the nurses that had administered the [MEDICATION NAME] in error. The UM added that the CP usually sends a report which would indicate that there was an error. On 3/11/21 at 11:28 AM the Licensed Nursing Home Administrator (LNHA), the DON and Regional Nurse met with the survey team. The DON stated that the CP emails their report and then she distributes the section of the report to the corresponding UM of each wing. The DON added that the UM will work on the recommendations and return the completed report within 7 to 14 days. The DON also stated that Individual Inservice Reports were completed for each nurse that a medication error was identified. In addition, the DON stated that the primary physician's were notified and a review requested of the need to continue the use of the [MEDICATION NAME]. The DON also added that she had noticed looking through the CP reports of the repeated incidents of [MEDICATION NAME] being administered incorrectly and a Quality Assurance Improvement Plan (QAPI) was started at the end of January. The DON added that she had requested at the end of January that the CP restart on site medication pass observations. The DON stated that she felt the reasons for the errors to continue were that the nurses were not reading through the order, being hasty and not realizing what the medication is being used for and in addition, staffing has required agency nurses to be used and the facility has recently hired new nurses. The DON stated that the nurses were inserviced specifically on [MEDICATION NAME] and understanding the usage and reading the parameters that are noted on the EMAR. The DON stated that she felt there was a reduction in February and the goal was to have zero errors. A further review of the nurses identified as administering the [MEDICATION NAME] without regard to the parameters revealed that after education and inservicing had repeated the error as follows: on 2/22 LPN #5 had repeated the error. on 2/25 RN #5 had repeated the error. on 3/5 AN#1 had repeated the error. The DON could not speak to why there were nurses that repeated the error in the month of February 2021 after education and inservicing had been done. The DON stated that there were no repercussions after a repeat medication error. There was no documentation provided of the physician's rationale for continuing the Midodorine with the same parameters. On 3/11/21 at 2:06 PM, the surveyor interviewed the CP via telephone. The CP stated that he was not the CP who had completed the drug regimen reviews but could speak to the content of the reviews and the services provided to the facility. The CP stated that drug regimen reviews were completed remotely and a report was emailed to the DON. The CP added that an on site visit was performed once a month for unit inspections only. The CP verified that repeat findings regarding the inaccurate documentation on the electronic Medication Administration Record [REDACTED]. The CP added that those findings were noted on the report for the specific resident and noted as a Medication Error. The CP added that when repeat findings were noted on the reports, the CP would have a conversation with the DON as part of company practice. The CP added that there was a discussion with the DON regarding the [MEDICATION NAME] medication errors and that the DON was going to follow up by performing a quality assurance improvement plan which included educating and inservicing the nursing staff. The CP also stated during the month of February the DON had requested from the CP to reinstitute performing on-site medication pass observations with the nurses. The CP could not speak to whether there was improvement noted. A review of the February CP Summary Report that was emailed to the facility indicated that on 2/26/21 a Med Error was noted for Resident #77 regarding the [MEDICATION NAME] administration and the report was assigned to Administration. There was no CP report completed for March as of 3/11/21. A review of the facility policy dated 6/15/20 for Medication Errors provided by the DON included that the policy explanation and compliance guidelines were that medications shall be administered according to physician's orders and in accordance with accepted standards and principles which apply to professionals providing services. In addition, the policy included that a medication error report would be completed by the nurse and reported to the primary physician. There was no documentation provided that addressed a procedure for repeated medication errors. NJAC 8:39-29.4(d)(3)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) the appropriate disposition of a Scheduled-IV controlled drug ([MEDICATION NAME]), and b.) appropriately sign for the destruction of the [MEDICATION NAME] for 2 of 2 opportunities for medication destruction for 1 of 8 residents reviewed for medications management (Resident #25). This deficient practice was identified for 2 of 2 nurses on 3/10/21, and was evidenced by the following: On 3/10/21 at 8:38 AM, the surveyor observed Resident #25 awake in bed on an air mattress. The resident stated to the surveyor that he/she had pain in the back-side. The resident was only able to elaborate on the location of the pain, and not the type, severity, duration or other possible causes of the pain. The resident stated that he/she got pain medication that morning, and when asked if the medication was effective at relieving the pain, the resident replied, No. At 8:43 AM, while the surveyor was interviewing Resident #25, the Licensed Practical Nurse (LPN) assigned to care for Resident #25 entered the resident's room. The LPN was holding a medicine cup filled with apple sauce. The LPN stated that a Certified Nursing Aide (CNA) had reported to her that Resident #25 was experiencing pain during morning care. The LPN stated that the Tylenol that she gave that morning around 7 AM was not effective and therefore she was going to administer [MEDICATION NAME] (a scheduled-IV controlled drug). The LPN added that she had two tablets of [MEDICATION NAME] in the medicine cup, and the surveyor observed two medium sized white oblong pills in the applesauce in addition to at least one other unidentified small round pill. The LPN put the two tablets into the resident's mouth at one time, and gave the resident a cup of water with a straw. The resident did not drink through the straw, so the LPN used the teaspoon from the apple sauce to collect water from the drinking cup and attempted to give the resident water using a spoon-feeding method with two teaspoons of water. The LPN encouraged the resident to swallow the medication, but the resident pocketed it and then spit out both the tablets and remaining applesauce. At that time the LPN confirmed that the resident spit out the two tablets of [MEDICATION NAME], and she accessed a brown paper towel and wiped the resident's mouth with the paper towel and used the same paper towel to collect the two tablets of [MEDICATION NAME]. The surveyor observed the LPN roll up the two whole [MEDICATION NAME] tablets into the paper towel, and crumpled it into a ball. She then removed her gloves over the brown paper towel with the [MEDICATION NAME] tablets inside it and threw it all in the resident's regular trash can at the door . The LPN exited the resident's room and stated that she was going to get another dose of [MEDICATION NAME] and crush it up this time. The LPN returned to the medication cart. The surveyor observed the LPN open the Narcotic book and access the resident's Individual Patient's Controlled Drug Record (a declining inventory sheet used for the accountability of controlled drugs) for the [MEDICATION NAME] tablets. The drug record reflected the [MEDICATION NAME] tablets were white oblong in color and shape. The LPN turned to the back of the drug record which was used for signing Destroyed/Wasted Medication Doses. The LPN filled out the form reflecting that tablets number 16 and 17 had been wasted because resident spit out. The LPN signed her name for the destruction of the [MEDICATION NAME]. At 8:52 AM, the LPN called upon the LPN/Unit Manager (LPN/UM) who was walking down hallway and requested her to sign her name as the witness for the destruction of the [MEDICATION NAME]. Without requesting to see the tablets of [MEDICATION NAME] or witnessing them being destroyed/wasted, she proceeded to sign her initials as the witness. The LPN/UM asked the LPN if there was a drug buster (a drug disposal system) in the medication cart and the LPN replied, No and so the LPN/UM went down the hallway and returned with a drug buster and put it into the medication cart. At 8:55 AM, the LPN then began to put the one small round pill that was still in the medicine cup with the apple sauce into the drug buster in the presence of the LPN/UM and surveyor. As she putting the pill into the drug buster, the LPN stated to the LPN/UM that the one small round tablet was the [MEDICATION NAME]. The LPN/UM proceeded to walk down the hallway. The LPN then signed out two additional tablets (Tablet 14 and 15) of [MEDICATION NAME] from the resident's Individual Patient's Controlled Drug Record, removed the two tablets from the the medication card, and proceeded to crush them into fine granules and put it into applesauce for ease of swallowing. At approximately 8:57 AM, the LPN spoon fed the two tablets of crushed [MEDICATION NAME] into the resident's mouth, and upon the medication sitting in the resident's mouth, the resident began to grimace and repeating, I don't like that, I don't like that. At 8:59 AM, the resident stated that he/she was going to throw up and the resident began to spit out the crushed up [MEDICATION NAME] tablets in the presence of a Registered Nurse (RN) and the surveyor. The LPN stated that the resident was not able to take the [MEDICATION NAME] after two attempts, so she collected the crushed [MEDICATION NAME] granules that the resident spit out, put it back into the medicine cup and brought it to the medication cart. She put the cup of the crushed [MEDICATION NAME] into the bottom drawer of medication cart and stated that she would get someone to sign for wasting the medication later. She then opened the Narcotic book and returned to the resident's Individual Patient Controlled Drug Record for the [MEDICATION NAME], and on the back of the form she began to fill out the destruction/wasting of [MEDICATION NAME] dose 14 and 15, but she didn't record a reason or her initials or get another nurse to witness for the wasting at the time the drug was spit out. At 9:06 AM, the surveyor interviewed the LPN. The surveyor asked the LPN if the [MEDICATION NAME] was a small round pill, and the LPN stated that what she put into the drug buster with the LPN/UM was the [MEDICATION NAME]. The surveyor asked what she threw away in the brown paper towel in the resident's trash can and she stated that there were no pills in there. The LPN went to the trash can to retrieve the brown paper towel stored inside the pair of used gloves that she had thrown away. Upon opening the brown paper towel, there were the two white oblong tablets. The LPN then acknowledged the tablets that were in the paper towel were actually the two [MEDICATION NAME] tablets. The surveyor observed the LPN independently open the medication cart and put the two tablets of [MEDICATION NAME] into the drug buster. There was no witnessing nurse present. The LPN neither requested to have the LPN/UM return to observe the [MEDICATION NAME] get wasted once it was identified in the paper towel, nor did she request any other nurse to witness the tablets being destroyed. The LPN confirmed that a witnessing nurse was supposed to watch as any controlled drug was destroyed into the drug buster and confirmed that she had not properly done that. She could not speak for why the LPN/UM would sign as a witness of drug destruction, if she did not visualize the [MEDICATION NAME] tablets getting destroyed. At 9:43 AM, the surveyor interviewed the LPN/UM regarding how controlled drugs were to be properly destroyed with a witnessing nurse. The LPN/UM stated that drugs were supposed to be destroyed by placing the pill into a drug buster. The LPN/UM stated that this was why she went to get one for the LPN when it was not available in the medication cart. She confirmed that medications, especially unused controlled drugs, should not go inside the regular trash can in the resident's room. The surveyor asked when witnessing nurses are supposed to sign for the destruction of a wasted controlled drug, and the LPN/UM acknowledged that witnessing nurses are supposed to sign after they observe the drug get wasted and not before. The surveyor asked if she saw the LPN waste the [MEDICATION NAME], and the LPN/UM stated that she assumed that the small round pill that the LPN was putting in the drug buster in the presence of the surveyor, was the [MEDICATION NAME]. She acknowledged that [MEDICATION NAME] was not small and round but a white oblong tablet, and that the resident had two tablets that were being wasted when she signed. The LPN/UM was not aware that the LPN had thrown the [MEDICATION NAME] into the resident's trash can and could not speak to why the LPN would discard the [MEDICATION NAME] in that manner. The surveyor reviewed the medical record for Resident #25. A review of the Admission Record face sheet (an admission summary) reflected that the resident had [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment dated [DATE] reflected that the resident had a brief interview for mental status score of 11 out of 15 indicating an intact cognition with moderate forgetfulness. The next day on 3/11/21 at 11:00 AM, the surveyor returned to review the resident's Individual Patient Controlled Drug Record for the [MEDICATION NAME]. The declining inventory record revealed that the LPN had signed out two tablets of [MEDICATION NAME] on 3/10/21 at 9 AM, but had never signed with a witnessing nurse that those tablets which were crushed in applesauce were wasted when the resident had spit them out in the presence of the surveyor. The LPN had only signed for dose 14 and 15 as being destroyed/wasted, but there were no nurse signatures or a listed reason. On 3/10/21 at approximately 1:05 PM, the surveyor discussed the findings with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. At 11:07 AM, the surveyor interviewed the LPN/UM who confirmed that she was aware that the [MEDICATION NAME] dose signed out for 3/10/21 at 9 AM was wasted, and confirmed that there were no witnessing signatures. She could not speak to who or if anyone had witnessed the wasting of the medication. The surveyor and a Registered Nurse looked inside the drawers of the medication cart where the surveyor had observed the LPN to place the medicine cup with the crushed [MEDICATION NAME] that the resident had spit out on 3/10/21, and it was not in the medication cart. The LPN/UM and the RN confirmed it was not there and that the LPN must had thrown it out yesterday at the end of her shift. They could not speak to who wasted it with her, if there was no signature. On 3/11/21 at 12:00 PM, the surveyor interviewed the DON and LNHA who were unable to speak to if [MEDICATION NAME] doses 14 and 15 had been witnessed as wasted if the form had not been signed as wasted with a witnessing nurse on 3/10/21. They confirmed that the LPN did not follow the protocol for the destruction of medication, and that the LPN and LPN/UM should not have signed for the wasting of the medication if it was not observed by both nurses. The DON stated that this issue had not come up as a problem in the past and she provided the surveyor a copy of the facility's policy on drug destruction. According to facility policy Discarding and Destroying Medications, revised October 2014, included the following: 2. Controlled and Non-controlled medication will be disposed of in accordance with state regulations and federal guidelines regarding disposition of medications . 5. c. Both controlled and non-controlled substances may be disposed of in the collection receptacle . 6. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses. d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least two witnesses .13. Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for a medication. NJAC 8:39-29.4(h)

COMPLAINT # NJ 1, NJ 1 Based on observation, interviews, and review of Medical Records (MR), and other pertinent facility documentation on 2/18/2020 and 2/20/2020, it was determined that the facility failed to provide appropriate incontinence care, and failed to follow the Facility Policy titled Incontinent Care for 1 of 4 sampled Residents (Resident #4). This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 12/5/2019, Resident #4 had a Brief Interview for Mental Status (BI[CONDITION]) score of 6/15, indicating Resident #4 had severe cognitive impairment. The MDS also indicated the resident needed extensive assistance for Activities of Daily Living (ADLs) and was frequently incontinent of bowel and bladder. Review of the Care Plan (CP) for Resident #4 with an initiated date of 7/07/2014, included the following problem: .at risk for alteration of elimination of bowel and bladder, at risk for constipation due to impaired mobility, and incontinence. Under Interventions/Tasks included but was not limited to: Resident's family/POA wants resident to be double diapered at all times. Risks have been explained to family and resident. The CP revision date was 2/18/2020. During a Care Tour on 2/18/2020 at 10:10 a.m., accompanied by the Unit Manager (UM) and the Director of Nursing (DON), it was observed that Resident #4 had 2 disposable diapers in place. The outer diaper was yellow which was dry, the inner diaper was blue, which was wet and had a urine odor. Resident #4's skin was observed intact. During an interview on 2/18/2020 at 10:11 a.m., the UM stated, the Certified Nursing Assistants (CNAs) should not be double diapering residents here. In addition, she stated she was not sure why they doubled diapered this resident. During an interview on 2/18/2020 at 10:12 a.m., the DON stated, the resident should not have 2 diapers in place because we do not double diaper here. During an interview on 2/18/2020 at 10:18 a.m., CNA #1, who was assigned to Resident #4 that day, stated she had not changed the resident since starting her shift at 7:00 a.m., and she did not put 2 diapers in place. I guess the night shift double diapered him/her. In addition, the CNA stated, the Policy states to change incontinent residents every 2 hours to prevent skin problems and she was never instructed to double diaper Resident #4. During an interview on 2/18/2020 at 2:44 p.m., the DON stated, if we find a resident double diapered we talk to the staff and check with the family to see if they requested it. We try to encourage the family not to request it. It's a dignity issue. In addition, the DON stated Resident #4 was CP for double diapering. The Assistant Director of Nursing (ADON) added it to the CP today because she just remembered a conversation she had with the POA a month ago. During an interview on 2/18/2020 at 3:15 p.m., the ADON stated she was reviewing the CP today and realized she never CP the double diapering the POA requested after having a conversation with her a month ago. The ADON also stated it had nothing to do with the survey today. In addition, the ADON stated the risks were explained to the family member and she still wanted him/her double diapered. The ADON was unable to explain why the family member wanted the resident double diapered. During an interview on 2/20/2020 at 9:59 a.m., CNA #2 stated, when Resident #4 was on his assignment about a month ago and a family member was in the room when the resident was being changed and she insisted, I put 2 diapers on the resident. CNA #2 also stated, I said it isn't policy here, however, he spoke with the ADON about it and was told to put 2 diapers in place. During a post survey telephone interview on [DATE] at 10:18 a.m., Resident #4's family member stated, she makes all the decisions for him/her and is the Power of Attorney (POA). The POA stated she never spoke to anyone at the Facility regarding putting 2 diapers in place on Resident #4, and never requested double diapering. In addition, she stated the staff never spoke to her about double diapering and the risks. Review of the Facility's progress notes on 2/18/2020 and 2/20/2020, did not include any documentation by the staff regarding a conversation with the POA of Resident #4 about double diapering or incontinence care. In addition, the DON was unable to provide any documentation/progress note by the staff regarding conversation with the POA requesting 2 diapers. The DON was unable to provide a policy on double diapering. Review of the Facility Policy titled Incontinent Care undated, under Policy: Residents who are incontinent will be checked on a regular schedule and kept dry. Under Objective: To keep the resident as clean and dry as possible. To prevent skin irritation and/or breakdown. To facilitate personal hygiene. N.J.A.C. 8:39-27.2 (h)

Complaint # NJ 9 Based on interviews, review of the Medical Record (MR), and other pertinent facility documentation on 10/25/2019, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) as well as follow their own facility policy Abuse Reporting and Investigation for 1 of 3 sampled residents (Resident #2). This deficient practice is evidenced by the following: 1. According to the Admission Record, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 9/5/2019, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating that Resident #2 had intact cognition. The MDS documentation indicated that Resident #2 required staff assistance for Activities of Daily Living (ADLs). During an interview on 10/25/2019 at 09:39 a.m., Resident #2 stated that a nurse made her very angry a couple of weeks ago. Resident #2 stated that a nurse on the 3-11 shift (3 p.m. to 11 p.m.), (Licensed Practical Nurse #1) stuck her tongue out at me during an argument. Resident #2 further stated that the 3 to 11 supervisor was standing right there and said she did not see it. During a telephone interview on 10/25/2019 at 12:55 p.m., the 3-11 Nursing Supervisor stated I was on the unit, I don't remember what the nurse and Resident #2 were talking about but Resident #2 said to me did you see that she just stuck her tongue out at me? (Referring to LPN #1). The Supervisor responded to Resident #2 by saying No I didn't see anything. The 3-11 Nursing Supervisor further stated that he/she prevents abuse by reporting it. The 3-11 Supervisor further stated that she didn't tell anyone or do anything about it because she didn't see it and when she looked at the nurse accused of sticking out her tongue, LPN #1 stated I didn't do anything. During an interview on 10/25/2019 at 1:13 p.m., the Director of Nursing (DON) verified that sticking your tongue out at a resident is considered abuse, and abuse should be reported immediately to the Supervisor, call the Administrator, Regional Office, and State. Review of a facility policy titled Abuse Reporting and Investigating updated 4/26/2017, Under Verbal Abuse revealed : Verbal Abuse is defined as the use of oral, written, or gestured language that willingly includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Under Reporting revealed: All incidents of abuse must be reported to the Administrator/Designees, as well as to the resident's representative (sponsor). An investigation must be made and the findings of such investigations must be reported to the Administrator/Designee. The individual suspected of the alleged abuse is suspended until the investigation is complete. The policy further revealed under New Jersey Reportable Events : According to the Department of Health and Senior Services licensing standards of health care facilities require that facilities notify the Department's Assessment and Survey Unit of reportable events in accordance with all applicable State and Federal Regulations. It indicates that every facility should notify the Department of Health : Immediately . after business hours followed by written confirmation within 72 hours for the following but not limited to any suspected case of resident abuse or exploitation, which have been reported to the State of New Jersey. NJAC 8:39- 9.4

Complaint # NJ 9 Based on interviews, review of the Medical Record (MR), and other pertinent facility documentation on 10/25/2019, it was determined that the facility failed to investigate an allegation of abuse, as well as follow their own facility policy Abuse Reporting and Investigation for 1 of 3 sampled residents (Resident #2). This deficient practice is evidenced by the following: 1. According to the Admission Record, Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 9/5/2019, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating that Resident #2 had intact cognition. The MDS documentation indicated that Resident #2 required staff assistance for Activities of Daily Living (ADLs). During an interview on 10/25/2019 at 09:39 a.m., Resident #3 stated that a nurse made her very angry when a couple of weeks ago a nurse on the 3-11 shift (3 p.m. to 11 p.m.), (Licensed Practical Nurse #1) stuck her tongue out at her during an argument. Resident #2 further stated that the 3 to 11 Supervisor was standing right there and said she did not see it. During a telephone interview on 10/25/2019 at 12:55 p.m., the 3 -11 Supervisor stated I was on the unit, I don't remember what the nurse and Resident #2 were talking about but Resident #2 said to me did you see that she just stuck her tongue out at me? (Referring to LPN #1). The Supervisor responded to Resident #2 by saying No I didn't see anything. The 3-11 Nursing Supervisor further stated that he/she prevents abuse by reporting it. The 3-11 Supervisor further stated that she didn't tell anyone or do anything about it because she didn't see it and LPN#1 said I didn't do anything. During an interview on 10/25/2019 at 1:13 p.m., the DON verified that sticking your tongue out at a resident is considered abuse, and that abuse should be reported immediately to the Supervisor, call the Administrator, Regional Office, and State, and should be investigated anytime it is reported. An Investigation was done by the facility on 10/25/2019, it was determined that the incident occurred on 10/4/2019 at around 3:30 p.m. Review of a facility policy titled Abuse Reporting and Investigating updated 4/26/2017, under Investigation revealed: An investigation report will be conducted to identify the incident, identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting results to the proper authorities. The policy further revealed under New Jersey Reportable Events: According to the Department of Health and Senior Services licensing standards of health care facilities require that facilities notify the Department's Assessment and Survey Unit of reportable events in accordance with all applicable State and Federal Regulations. It indicates that every facility should notify the Department of Health immediately .after business hours followed by written confirmation within 72 hours for the following but not limited to any suspected case of resident abuse or exploitation, which have been reported to the State of New Jersey. NJAC 8:39- 9.4

C# NJ 0 C# NJ 1 Based on interview, review of Medical Records (MRs), and review of other pertinent documentation, it was determined that the facility failed to accurately document skin assessments on the Treatment Administration Record (TAR) according to the physicians order for 3 of 4 sampled residents (Resident #1, Resident #2, Resident #3). This deficient practice was evidenced by the following; 1. According to the facility Admission Record (AR), Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated 7/25/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severely impacted cognition. Review of Resident #2's Nursing Note (NN) on 5/8/19 at 11:30 p.m. indicated the following; .Skin evaluation reveals current skin breakdown/ skin conditions; refer to the completed evaluation and physician orders [REDACTED]. Review of a document titled; Resident Evaluation- V2, dated 5/8/19 at 23:30 (11:30 p.m.) indicated that Resident #2 had the following skin alterations on admission; Coccyx- red blanchable skin; Other- below left knee old skin abrasion; other- buttocks creasse (crease); Small bruises to the right and left arm; left heel DTI (deep tissue injury; right heel redness . Review of Resident #2's Care Plan (CP) initiated 5/8/19, indicated; Focus; Impaired skin integrity left heel necrotic area, redness to buttocks .noted on admission. A review of an Order Summary Sheet/Physicians Order Sheet (POS) dated 5/1 through 7/31/19 revealed the following order, initiated 5/21/2019; Weekly skin observations every evening shift every Tue (Tuesday) 0-No skin breakdown, 1-Previously identified wound 2- Newly identified wound. The 5/2019, 6/2019 and 7/2019 Treatment Administration Record (TAR) confirmed the aforementioned order and was transcribed to be completed weekly. Review of the 5/2019, 6/2019, and 7/2019 TAR revealed that for 11/11 opportunities, (5/10, 5/21, 5/28, 6/4, 6/11, 6/18, 6/25, 7/2, 7/9, 7/16 and 7/23/19) the weekly skin observation was documented as 0 which indicated that the resident had no skin breakdown or was checked off as completed but with no numerical value documented. Review of the Weekly Skin Assessment Form (WSAF) for Resident #2, which corresponded with each weekly skin observation on the TAR, indicated that the skin was not intact for all 10/10 opportunities. During an interview with the surveyor on 9/6/19 at 1:15 p.m. the Director of Nursing (DON) verified that documenting a 0 on the TAR would indicate that Resident #2 had no skin breakdown. The DON reviewed the documentation and explained that documenting a 0 for Resident #2 was not correct, and should have been documented as a 1 which would indicate a previously identified wound. 2. According to a facility AR, Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE], revealed a BIMS score of 6, which indicated severely impacted cognition. Review of Resident #3's NN dated 6/21/19 at 3:01 p.m. revealed the following .pt (patient) c/o (complained of) pain in sacral area. Broken skin and redness noted to scaral (sacral) area . Review of Resident #3's CP indicated the following Focus; 6/24/19 Open wound to Sacral Area . Interventions included but were not limited to weekly skin checks as ordered. A review of Resident #3's 7/2019 POS revealed the following order, initiated 6/11/2019; Weekly skin observations every evening shift every Tue (Tuesday) 0-No skin breakdown, 1-Previously identified wound 2- Newly identified wound. The 6/2019 through 8/2019 TAR confirmed the aforementioned order and was transcribed to be completed weekly. Review of the 6/2019 through 8/2019 TAR revealed that for 9/9 opportunities, (6/25, 7/2, 7/9, 7/16, 7/23, 8/6, 8/13, 8/20 and 8/27/19) the weekly skin observation was documented as 0 which indicated that the resident had no skin breakdown Review of the WSAF for Resident #3, which corresponded with each weekly skin observation on the TAR, indicated the following on 6/25/19 and thereafter 4. Integrity: Not Intact. Review of the weekly would consultation forms from 6/24 through 9/2 indicated that Resident #3 had a sacral pressure ulcer. On 9/6, the surveyor observed Resident #3 had a pressure ulcer to the sacrum that was dressed and dated. During an interview with the surveyor on 9/30/19 at 2:35 p.m., the DON verified that documenting a 0 on the TAR would indicate that Resident #3 had no skin breakdown. The DON explained that documenting a 0 for Resident #3 was not correct, and should have been documented as a 3 on 6/25/19 which would indicate a newly identified wound. The following weekly skin observations should have been documented as a 2 which would have indicated a previously identified wound. 3. According to a facility AR, Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of an MDS dated [DATE], revealed a Cognitive Skills for Decision Making score of 3, which indicated severe impairment of the residents ability to make decisions regarding tasks of daily life. Review of a 7/1/2019 Wound care round documentation revealed that Resident #1 had an existing arterial pressure ulcer located on the right medial ankle measuring 2 cm (centimeters)( in length) x (by) 2 cm (in width) x (by) 0.2 cm (in depth). In addition, Resident #1 also had a existing right heel arterial ulcer measuring 2 cm x (by) 2 cm x (by) 0.2 cm. Review of Resident #1's CP indicated the following Focus; (Resident #1) has actual open areas to her . right heel and right medial ankle rt (related to) immobility, contractures, (and) arterial disease diagnosis. Review of the POS [REDACTED] 0- No skin breakdown, 1- Previously identified wound 2- Newly identified wound. A review of Resident #1's TAR revealed the following order, initiated 2/16/19; Weekly skin observations every evening shift every Tue (Tuesday) 0-NO skin breakdown, 1-Previously identified wound 2- Newly identified wound. This order had a start date of 2/16/2019. The 7/2019 TAR confirmed the aforementioned order and was transcribed to be completed weekly. Review of the 7/19 and 8/19 TAR revealed that for 5/8 opportunities (7/10/19, 7/17/19, 7/24/19, 8/21/19 and 8/28/19) the skin breakdown was documented as a 0, which would indicate that the resident had no skin breakdown. On 7/3 the skin breakdown was not documented, which would indicate that the skin check was not completed. Review of the weekly would consultation forms from 6/24 through 9/2 indicated that Resident #3 had a sacral pressure ulcer. Review of the weekly would consultation forms from 7/1 through 8/19 indicated that Resident #3 had a right medial ankle arterial ulcer and a right heel arterial ulcer. During an interview with the surveyor on 9/30/19 at 2:35 p.m., the Director of Nursing (DON) verified that documenting a 0 on the TAR would indicate that Resident #1 had no skin breakdown. The DON explained that documenting a 0 for Resident #1 was not correct, and should have been documented as a 1 on the 7/2019 and 8/2019 TAR which would indicate a previously identified wound. A policy titled Daily Review of physician's orders [REDACTED].Process: Each nurse taking a physicians order is responsible for noting the order correctly and completely. Noting the physician order [REDACTED].Reviewing the order to the treatment administration record (ETAR) . N.[NAME][NAME]C. 8:39-27.1 (a)

Based on observation, interview and record review it was determined that the facility failed to implement and revise comprehensive care plans for 3 of 24 residents, Residents #8,#15, and #18. Resident #15 was care planned for combative behaviors and sustained an injury during a transfer. The deficient practice was evidenced by the following: 1. On 2/19/16 at 10 a.m., during the initial tour, the nurse stated that Resident #15 had a fall four days ago and sustained a laceration to their scalp. She stated the fall occurred when the resident was being toileted by a CNA and the resident became combative and fell . The nurse told the surveyor that the resident had a history of [REDACTED]. On 2/24/16 at noon, a family member spoke to the surveyor that they were upset regarding an incident that occurred on 2/15/16. They said the facility told them that the resident fell in the bathroom while being toileted by the CNA. They said that the resident had a laceration on the back of the head and was sent to the emergency room and received staples to the area. They added that they thought that the resident required a two person assist. At 1:25 p.m., the surveyor requested the investigative report of Resident #15's fall and hospitalization . The investigation indicated that the resident was treated at the hospital for a 3.0 cm laceration to the head requiring five staples. The investigation included that the resident had a history of [REDACTED]. Also, the investigation documented the resident required assistance with all activities of daily living and transfers. The interventions taken to prevent reoccurrence were 2 caregivers at all times, re-approach resident at a later time when resident is combative after ensuring safety and non-skid strips to the resident's bathroom floor. On 2/24/16 at 1:00 p.m., the surveyor reviewed the electronic record for Resident #15. The resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the progress notes revealed that from 11/12 through 2/14/16, the nurse documented that the resident had combative behaviors towards staff during care. The surveyor then reviewed the following care plans for Resident #15: A) Needs assistance with all ADL's (activities of daily living), was initiated on 11/20/10. Interventions for this problem included: 1) 2 caregivers at all times, if resident becomes combative stop, make sure resident is in a safe environment and notify nurse, date initiated: 3/16/14, 2) Assist of two staff if indicated, 2 people for bed positioning. Talk to resident calmly explain what you are doing, was initiated on 3/15/11 and revised on 3/16/14 and 3) Provide incontinence care as necessary, was initiated on 11/20/10. B) I sometimes have behaviors which include yelling during care, refusing care, combative during care, striking out at others, use of racial slurs toward staff, and cursing at others was initiated on 1/13/11 Goals included, My behaviors will not interfere with my care and my needs will be met, initiated on 1/13/11 and revised on 12/2/15. The target date for the goal was 3/2/16. Interventions for this focus area included: speak to resident unhurriedly and in a calm voice; 2 staff members for bed positioning; talk to resident calmly explain what you are doing and resident often refuses care. Reapproach at at later time; Notify nurse. date initiated 2/27/11 and revision on 10/15/14. C) Resident is a risk for falls related to poor safety awareness and limited mobility, initiated on 11/20/10. The goal for no falls with injury had a target date of 3/2/16. Interventions included: Assist with transfers as needed. D) On 2/15/16, a separated care plan for falls was initiated which indicated a focus area of At risk for falls related to Fall 2/15/16. Interventions included: Activity Programming; Bed in lowest position; Call light or personal items available and in easy reach or provide reacher; Assess that the wheelchair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, antitippers; and keep environment well lit and free of clutter. The resident's care plans were not revised and or implemented to include recommendations made by the Interdisciplinary team to address/prevent reoccurrence of a fall with injury. Refer to F323 2. On 2/19/16 at 10 a.m., the DON stated that Resident #8 was confused and had no recent falls. On 2/23/16 at 10:25 a.m., the surveyor reviewed the resident's record. The resident has [DIAGNOSES REDACTED]. The Order Summary Report for active orders as of 2/1/2016 revealed an order for [REDACTED]. On 2/23/16 at 10:30 a.m., the surveyor went to the resident's room. The surveyor observed one blue floor mat between the two beds in the middle of the room. The surveyor then reviewed the resident's current care plan. The fall care plan, dated 3/28/14, had an intervention for mats to both sides of the bed. On 3/1/16 at 10:15 a.m., the surveyor interviewed the resident's CNA. She stated that when she got the resident dressed and out of the bed, there was only one mat in between the two beds. The surveyor asked the CNA how she knew how to deliver care to the resident. She said that it was in the resident's closet. The surveyor and the CNA went to the resident's closet and observed the resident's care card. Under the Fall Precautions area it indicated Floor Mats x 2. At that time, the DON walked by the resident's room. The surveyor showed the DON the care card and asked if there was another mat in the room. She was unable to locate another mat and stated she would call maintenance for another one. 3. On 2/19/16 at 9:45 a.m., the DON stated that Resident #18 was confused and had a history of [REDACTED]. On 2/24/16 at 3:10 p.m., the surveyor reviewed the electronic record for Resident #18. The resident had multiple care plan for at risk for falls and for actual falls. The fall risk care plan dated 7/9/2015 had and intervention dated 1/3/2016 for floor mats to both sides of the bed every shift. On 1/4/16 another care plan for falls was initiated for at risk for falls related to: fell in the past 30 days, fell on [DATE]. An intervention was initiated on 1/4/16 for mat beside bed. On 1/12/16 another fall care plan was initiated after the resident fell with an intervention mat beside bed dated 1/13/16. The surveyor reviewed the Order Summary Sheet for active orders as of 2/1/16. There was a current order for floor mats to both sides of the bed. On 2/25/16 at 1:15 p.m., the surveyor reviewed the inconsistent care plan interventions that were documented for Resident #18 with the DON. NJAC 8:39-11.2(e)

Based on observation, interview and record review it was determined that the facility failed to provide adequate supervision consistent with a resident's needs to prevent an accident with injury for 1 of 9 residents, Resident #15. This deficient practice occurred during a transfer by a Certified Nursing Assistant (CNA) in the resident's bathroom. The resident sustained [REDACTED]. The evidence was as follows: On 2/19/16 at 10 a.m., during the initial tour, the nurse stated that the resident had a fall four days ago and sustained a laceration to their scalp. She said that the fall occurred when the resident was being toileted by a CNA and the resident became combative and fell . The nurse told the surveyor that the resident was confused and had a history of [REDACTED]. On 2/24/16 at noon, a family member complained to the surveyor that they were upset regarding an incident that occurred on 2/15/16. They said the facility told them that the resident fell in the bathroom while being toileted by the CNA. They said that the resident had a laceration on the back of the head and was sent to the emergency room and received staples to the area. They added that they thought that the resident required a two person assist because of their behaviors. At 1:25 p.m., the surveyor requested the investigative report of Resident #15's fall and hospitalization . The investigation indicated that the resident was treated at the hospital for a 3.0 cm laceration to the head requiring five staples. The investigation included that the resident had a history of [REDACTED]. Also, the investigation documented the resident required assistance with all activities of daily living and transfers. The interventions taken to prevent reoccurrence were 2 caregivers at all times, re-approach resident at a later time when resident is combative after ensuring safety. Non-skid strips to the resident's bathroom floor. On 2/24/16 at 1:00 p.m., the surveyor reviewed the electronic record for Resident #15. The resident was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor reviewed the following Progress Notes: On 11/12/15 at 10:41 a.m., the nurse documented in the progress notes, resident is noted to have outbursts at staff and curses at staff. Resident also noted to refuse care and treatment. On 11/17/15 3:05 p.m., the Social Worker (SW) documented that the resident was monitored for being combative with care, cursing, derogatory name calling, hitting/smacking/banging the wheel chair/walls/tables, and agitation. On 12/3/15 at 10:41 a.m., the nurse documented a Care Plan Note which indicated; two caregivers at all times due to combative behavior. On 1/30/16 at 6:16 a.m., the nurse documented that the resident is uncooperative at times calling caregivers racial slurs (not of new origin). On 2/14/16 at 8:27 p.m., the nurse documented the resident requires extensive assist with care, resident at times uncooperative with care, refers to caregivers using the N word on occasion. On 2/15/16 at 12:40 p.m., the nurse documented in the progress notes, while CNA was transferring resident from wheel chair to toilet became combative and fell to the floor. Hitting head on floor. At 1:00 p.m., the nurse documented, resident transported via stretcher to hospital emergency room . The Universal Transfer Form completed by the nurse dated 2/15/16 at 1:00 p.m. indicated assist times 2 with transfers. At 7:46 p.m., the nurse documented that the resident was transferred back into the facility from the emergency room visit post fall, laceration to scalp, received 5 staples. The surveyor then reviewed the following care plans for Resident #15: A) Needs assistance with all ADL's (activities of daily living), was initiated on 11/20/10. Interventions for this problem included: 1) 2 caregivers at all times, if resident becomes combative stop, make sure resident is in a safe environment and notify nurse, date initiated: 3/16/14, 2) Assist of two staff if indicated, 2 people for bed positioning. Talk to resident calmly explain what you are doing, was initiated on 3/15/11 and revised on 3/16/14 and 3) Provide incontinence care as necessary, was initiated on 11/20/10. B) I sometimes have behaviors which include yelling during care, refusing care, combative during care, striking out at others, use of racial slurs toward staff, and cursing at others was initiated on 1/13/11 Goals included, My behaviors will not interfere with my care and my needs will be met, initiated on 1/13/11 and revised on 12/2/15. The target date for the goal was 3/2/16. Interventions for this focus area included: speak to resident unhurriedly and in a calm voice; 2 staff members for bed positioning; talk to resident calmly explain what you are doing and resident often refuses care. Reapproach at at later time; Notify nurse. date initiated 2/27/11 and revision on 10/15/14. C) Resident is a risk for falls related to poor safety awareness and limited mobility, initiated on 11/20/10. The goal for no falls with injury had a target date of 3/2/16. Interventions included: Assist with transfers as needed. D) On 2/15/16, a separated care plan for falls was initiated which indicated a focus area of At risk for falls related to Fall 2/15/16. Interventions included: Activity Programming; Bed in lowest position; Call light or personal items available and in easy reach or provide reacher; Assess that the wheelchair is of appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety, antitippers; and Keep environment well lit and free of clutter. The resident's care plans were not revised and or implemented to include recommendations made by the Interdisciplinary team to prevent reoccurrence of a fall with injury. On 2/24/16 at 12:30 p.m., the surveyor spoke with the nurse regarding Resident #15's fall on 2/15/16. The nurse stated, I was called to Resident #15's room by a CNA, the CNA said during transfer, the resident became combative and fell . The surveyor then reviewed the Minimum Data Set (MDS), an assessment tool, dated 8/18/15. The MDS indicated that the resident required an extensive assist of 2 persons for bed mobility dressing, transfers, toileting, and personal hygiene. It also indicated that Resident #15 did not ambulate and was always incontinent of bowel and bladder. Under the area of Balance During Transitions and Walking, the resident was assessed to not be steady, only able to stablilize with staff assistance when moving from seated to standing position. Under the section, moving on and off toilet, the MDS indicated that this activity did not occur. The MDS, dated [DATE], indicated that the resident required an extensive assist of 2 persons for transfers, extensive assist of one person for bed mobility, toileting and personal hygiene. The resident remained incontinent of bowel and bladder. There was no change under the area of Balance During Transitions and Walking. The surveyor again reviewed the progress note titled, Care Plan Note dated 12/3/15. There was no explanation provided in the note regarding the difference in assistance provided during that assessment period. On 2/24/16 at 1:20 p.m., the surveyor requested records for the Care Tracker, an electronic documentation used by the CNA to record level of care provided during ADL's, for the time period of 12/11 through 2/14/16. The DON provided a copy of the ADL Flow Sheet Log. It revealed that there was an inconsistent number of caregivers during transfers, which was documented as requiring 2 persons in the MDS dated [DATE] and 11/16/15. In the area of toilet use the CNA's documented between one and two person transfers. The surveyor then reviewed the ADL Flow Sheet Log from 2/15/16 through 2/24/16, which again revealed, that there was an inconsistent number of care givers provided assistance with transfers and toilet use. This was not in accordance with the recommendations of 2 care givers at all times to prevent reoccurrence documented in the Investigative Report for the fall dated 2/15/16. On 2/25/16 at 10:35 a.m., the surveyor observed the resident seated in a high back wheelchair at a table in the day room on the unit. There was a sensory activity in progress. When the activity aide asked Resident #15 a question, the resident threw the activity pad across the table towards the aide. At 11:15 a.m., the surveyor spoke to CNA #1, who was caring for Resident #15 on 2/25/16. CNA #1 stated that he had worked in the facility part time for about five years and was familiar with the resident's care. He stated that he would get information from the nurse and the Care Tracker on how to care for the resident. CNA#1 stated that the resident was a two person assist for awhile, at least for about six months. On 2/25/16 at 1:30 p.m., the surveyor spoke to CNA #2, who was assisting the resident at the time of the fall. She stated that that was the first time she was assigned to the resident and that she was not employed by the facility but from the agency staffing provider. The surveyor asked CNA #2 how she knew how to care for the resident. CNA #2 showed the surveyor the Care Tracker and how she documented the information in the system for Resident #15. She stated that she enters in the level of assistance she provided. The survey then questioned CNA #2 how she knew how many staff members were needed to care for the resident. She stated that the information was located on the back of the closet door in the resident's room. The surveyor then asked CNA #2 about the fall on 2/15/16. She stated that the resident had soiled their clothes after eating lunch. CNA #2 stated that she brought the resident back to their bathroom and began to undress them. She stated that she sat the resident on the toilet and took off their shirt, no problems. Then, she stood the resident up to change the resident and the resident's hands were on the grab bar. The resident started calling her names, swinging their arms, and then fell . CNA #2 stated she left the room and got the nurse. The surveyor reviewed the CNA care card located in Resident #15's closet. It had been revised on 2/15/16 for 2 care givers at all times. On 2/25/16 at 2:05 p.m., the surveyor again spoke to CNA #1. He stated that when he is going to give care to Resident #15, he asks another CNA for assistance. He stated that the resident can hold on to the grab bar to stand but can,fight you when they are being changed. He said that the resident tries to hit and calls you names. That's why he has someone else to assist him. On 2/25/16 at approximately 2:15 p.m., the surveyor asked the DON regarding the inconsistent level of assistance provided to the resident according to the documentation and the MDS. She stated that the MDS was documented as to the capability of the resident. She added that the resident only required one assist, but that two staff were needed when the resident was combative. The surveyor again reviewed the progress note titled, Care Plan Note dated 12/3/15. There was no explanation provided in the note regarding the difference in assistance provided during that assessment period. On 2/29/16 at 11:15 a.m., the surveyor interviewed the nurse who wrote the care plan note. She stated that the note was written after a review of the care tracker and the level of care that was provided was 2. On 2/29/16 at 11:30 a.m., the surveyor reviewed the following Physician Assistant's (PA) notes from 9/18/15 through 1/25/16. The PA documented that the resident was very aggressive; does not like to be touched or fed and swings and bangs arms on the wall. On 1/25/16, the PA documented that Resident #15 continues with disorientation, confusion, agitation calling staff names, refusing care does not like to be touched, fed, does not ambulate, requires assistance with all ADLs. On 2/23/16, the PA documented that the resident was confused, disoriented, combative, does not like to be spoken to or touched requires maximum daily assistance, 5 stitches to the scalp. The surveyor then reviewed the physician's orders [REDACTED]. On 2/29/16 at 11:00 a.m., the surveyor spoke to the SW. The SW stated that Resident #15 had a lengthy history of banging on walls and railings, uses racial slurs and cursing, resists care, can be combative, randomly swings. On 2/29/16 at 11:30 a.m., the surveyor interviewed CNA #3. CNA #3 stated, the resident can be quiet and in an instant become verbally abusive - can swing their arms too. The resident calls the staff black n-----r, get away from me, then starts swinging their arms. On 3/1/16 at 10:20 a.m., the surveyor again interviewed CNA #3. He stated that he cared for the resident that morning (3/1) performing a.m. care with the help of another staff member. He added that the resident became combative and scratched him. He said in the afternoon, when the resident needs assistance to be changed, he places the resident back to bed because you never know when they can become combative. On 3/1/16 at 2:18 p.m., the surveyor spoke to the 3-11 CNA. She stated that she has the resident on a steady basis and sometimes assists the resident with care by herself. She said that when she delivers care to the resident, she places the resident in bed for safety. The surveyor asked if all staff members assisted the resident in bed. She said she didn't know, but would mention it to the nurse. NJAC 8:39-27.1(a)

Complaint #s: NJ & NJ Based on observation, interview and record review, it was determined that the facility failed to implement care plan interventions for fall safety and maintaining skin integrity. Resident #14 was not transferred according to the care plan and sustained a skin tear and deep laceration to the leg. This deficient practice was identified for 2 residents (Resident #14 and Resident #1) of 19 residents reviewed for care plan implementation. This deficient practice was evidenced by: 1. During the initial tour conducted on 2/25/14, the Unit Manager (UM) stated Resident #14 was alert and confused. The UM stated Resident #14 had fragile skin and sustained a skin tear. At this time, the surveyor observed Resident #14 who was lying in bed. During an interview conducted on 2/27/14 at 12:10 p.m., the Director of Nursing (DON) stated to the surveyor that the skin tear occurred when a Certified Nursing Assistant (CNA) transferred Resident #14 from a chair to the bed alone. The DON revealed that there should have been two people transferring the resident. The DON also stated the CNA had received disciplinary action for the improper transfer and the incident was reported to the Department of Health. The Minimum Data Set (MDS) an assessment tool dated 2/1/14, indicated Resident #14 was alert and oriented with mild memory impairment. In addition, the MDS revealed the resident required extensive assistance from two staff for turning from side to side while in bed and for moving from the bed and into a chair. The resident's care plan both when initiated on 10/1/2012 and revised on 2/27/14 after the fall, reflected the resident required two person assistance with all transfers with nurse supervision. There was no evidence in this instance that the care plan interventions were consistently implemented. Refer to F323 2. On 2/27/14 at 9:00 am the surveyor reviewed the medical record for Resident #1. Resident #1 had [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. The care plan dated 3/26/13 included this intervention, as reflected in the physician order, was initiated on the care plan on 1/14/14 and continued on the current care plan when revised on 3/4/14. On 2/25/14 at 12:00 p.m. the surveyor observed the resident in the dayroom without Geri sleeves in place to protect the skin of the upper extremities. On 2/27/14 at 9:00 a.m., the surveyor observed the resident seated in a wheelchair at the nursing station. The resident did not have the Geri sleeves on. The same observations were made on 3/4/14 at 9:05 a.m. On 2/28/14 at 9:30 a.m., the surveyor reviewed the electronic Progress Notes dated 2/19/13 to 1/28/14 which revealed the resident had multiple incidents of skin tears and bruises. The following incidents were documented: 3/26/13 at 12:30 p.m. skin tear to left hand. 4/17/13 at 23:30 p.m., skin tear to left leg. 5/9/13 bruise to left hand. 10/01/13 at 8:30 p.m. bruise to right upper inner thigh. 10/07/13 at 7:00 p.m. bruise to right forearm. 10/08/13 at 7:05 p.m. bruise to right arm. 11/25/13 at 2:48 p.m. skin tear to left arm and elbow area. 11/26/13 at 10:00 bruise on left hand. 12/31/13 at 10:58 p.m., skin tear to left elbow. 01/15/14 at 9:20 a.m. bruises to right arm and right thigh. On 2/27/14 at 12:30 p.m., the surveyor reviewed the electronic Treatment Administration Record (eTAR) and noted that the nurse had signed the eTAR to indicate that the Geri sleeves were applied on the following dates: 2/25/14, 2/26/14, 2/27/14 and 3/4/14. The surveyor interviewed the nurse that same day at 1:15 p.m. who revealed the Certified Nursing Assistants (CNA) are responsible to apply the Geri sleeves. On 3/4/14 at 10:30 a.m., the surveyor interviewed the CNA who cared for the resident. The CNA indicated that the resident did not have the Geri sleeves on. The surveyor went to the room with the CNA and observed the Geri sleeves folded at the bottom of the resident's night stand drawer. The CNA told the surveyor she could not recall the last time the resident had the Geri sleeves on. N.J.A.C. 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to provide a restorative ambulation program to improve or maintain a resident's ambulation ability for 1 of 19 residents reviewed for a restorative program (Resident #8). This deficient practice was evidenced by: During the initial tour conducted by the surveyor on 2/25/14 at approximately 10:30 a.m., the Unit Manager (UM) stated Resident #8 was alert and oriented. She stated the resident was able to make needs known to staff. At this time, Resident #8 was observed lying in bed. When interviewed the resident stated that he/she felt terrible. On 2/25/14 at noon, the surveyor reviewed Resident #8's medical record. According to the Admission Face Sheet the resident was admitted to the facility with [DIAGNOSES REDACTED]. The surveyor observed the resident who was in a wheelchair on: 2/25/14 at noon, 2/26/14 at 9:50 a.m. and 12:30 p.m., and 2/27/14 at 9:15 a.m. A review of a Minimum Data Set (MDS), an assessment tool dated 8/5/13 revealed Resident #8 was alert and oriented. The MDS indicated the resident was able to move from side to side while in bed, and from the bed and into a chair with only supervision. The MDS also revealed Resident #8 could ambulate inside the room and corridors with assistance of one staff member. A review of another MDS dated [DATE] revealed Resident #8 now required extensive assistance for moving from side to side while in bed and for moving from the bed to the chair. According to the MDS the resident could no longer ambulate. A review of a form titled, Rehab Alert Form, dated 11/15/13 revealed Resident #8 was referred to a Functional Maintenance Program (FMP) for ambulation. According to the form, the restorative aides were to ambulate Resident #8 from the bed to the bathroom and from the room to the nurse's station daily. This task was to be completed with the assist of one staff member. During an interview conducted on 3/4/14 at 11:00 a.m. with the surveyor, the UM stated that when residents were discharged from Physical Therapy the nursing department received a Rehab Alert Form. These forms were used to alert the nursing staff of the resident's FMP. The UM stated Resident #8 was not on an FMP and that she did not recall ever seeing the resident ambulate. The UM added that in the absence of a restorative aide (RA) it was the responsibility of the CNA to assist the residents with the FMP. The RA was also interviewed at that time who stated that she started serving in the position in November 2013 and Resident #8 was not on a FMP. The RA stated that she did not recall ever seeing the resident ambulate. A review of the Rehab Alert Form dated 11/15/13 in the presence of the RA revealed the RA's signature. The RA stated that she never provided ambulatory services to Resident #8. At that time, the RA stated that she did not know what happened. During an interview with the surveyor on 3/4/14 at 11:20 a.m., the CNA stated that when there was no RA serving in the position, the resident's FMP was not done. The CNA stated they had "a lot" of work to do and they just could not get it all done. A review of Resident #8's restorative record from 11/1/13 through 2/2014 in the presence of the UM was noted to be blank. During a subsequent interview on 3/4/14 conducted at 11:45 a.m., the UM stated that the FMP request for the resident was not entered into the computer. The UM told the surveyor that she was responsible for entering this information into the computer and did not. Further, the UM stated that the CNAs would not have known to provide FMP services to Resident #8. NJAC 8:39-27.1(a)

Complaint #s: NJ & NJ Based on observation, interview and record review, it was determined that the facility failed to: consistently provide adequate supervision to residents at risk for falls; implement specific and individualized interventions to address accidents; and consistently follow safe transfer techniques. Resident #14 was improperly transferred and sustained a skin tear and deep laceration to the leg requiring an emergency room visit and treatment. This deficient practice was identified for 2 of 12 residents reviewed for falls and accidents (Resident #1 and Resident #14) and was evidenced by: 1. During the initial tour conducted on 2/25/14, the Unit Manager (UM) stated Resident #14 was alert and confused. The UM stated Resident #14 had fragile skin and sustained a skin tear. At this time, Resident #14 was observed lying in bed. During an interview conducted on 2/27/14 at 12:10 p.m., the Director of Nursing (DON) stated to the surveyor that the skin tear occurred when a Certified Nursing Assistant (CNA) transferred Resident #14 from a chair to the bed alone. The DON revealed that there should have been two people transferring the resident. The DON also stated the CNA had received disciplinary action for the improper transfer and the incident was reported to the Department of Health. On 3/4/13 the surveyor reviewed Resident #14's medical record. The Admission Face Sheet indicated Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment tool dated 2/1/14, indicated Resident #14 was alert and oriented with mild memory impairment. In addition, the MDS revealed the resident required extensive assistance from two staff for turning from side to side while in bed and for moving from the bed and into a chair. The resident's care plan both when initiated on 10/1/2012 and revised on 2/27/14 after the fall, reflected the resident required two person assistance with all transfers with nurse supervision. A review of an investigation report dated 2/22/14 at 3:30 p.m. revealed that a CNA had removed Resident #14 from the corridor and into the room. The CNA transferred the Resident #14 from a chair into the bed. While doing this, the CNA saw blood on the resident's pants and called the nurse to the room. According to the Verification of Investigation dated 2/22/14, Resident #14 had a history of [REDACTED]. The skin tear was identified as being 8 centimeters (cm) by 4 cm, and the laceration measured 4 cm by 3 cm by 1.2 cm which had a moderate amount of blood present. The nurse administered first aide treatments to the leg. Resident #14 was sent to the hospital for treatment. The nurse Progress Notes dated 2/22/14 at 15:30, confirmed a skin tear was found to the resident's right lower leg which measured 8 c.m. by 4 c.m. with a "deep laceration" that measured 4 c.m. by 3 c.m. by 1.2 c.m. A review of the hospital Discharge Summary dated 2/22/14, indicated the resident was prescribed oral antibiotics for this injury. During a wound care treatment observation conducted on 3/5/14 at 9:00 a.m., Resident #14 was observed lying in bed. The UM removed the dressing from the resident's right lower leg. When interviewed at this time, the UM identified Resident #14's injury as a large laceration. A review of an Employee Memorandum dated 2/22/14, the CNA transferred the Resident #14 by herself and the resident required maximum assistance of two, which was stated on the care card. The CNA refused to sign the form. A review of a facility written summary reflected the CNA informed the nurse that she transferred the resident by herself. In addition, the CNA did not check the resident's care card. 2. The surveyor reviewed the medical record of Resident # 1 on 2/26/14 at 9:40 a.m. which revealed the resident had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A review of the electronic Progress Notes and the post falls investigation summary revealed the following: On 03/21/13 at 13:00 the resident was noted with a hematoma to the right side of the head 3.4 centimeter (cm) by 3 cm. The resident was sent to the emergency room for evaluation. The resident was diagnosed with [REDACTED]. On 03/31/13 at 16:10 the resident tipped forward and landed on the floor and sustained bruises to the right forehead. On 03/31/13 at 18:45 p.m. the resident slipped forward and fell to the floor. On 05/06/13 at 19:15 p.m. the resident was found on the floor laying on the right side. The resident was noted to have a large hematoma to the right side of the head. The resident was sent to the emergency room for evaluation and returned the same day. On 10/13/13 at 12:00 p.m. the resident was found on the floor in front of the wheelchair. On 10/19/13 at 18:00 the resident was found on the floor with the head rested on the dinner cart and seated on the footrest. On 01/27/14 at 16:00 the resident fell from the bed and sustained a skin tear to the right forearm. The resident was noted to be incontinent of bowel. On 02/04/14 at 08:45 a.m. the resident was found seated on the footrest of the wheelchair. A review of the post fall investigation summaries provided by the facility revealed the resident fell while seated at the nursing station for four of the seven falls. One fall occurred in the resident's room. A review of MDS dated [DATE] and 12/27/13, revealed Resident #1 was cognitively impaired and required extensive assistance from staff with Activities of Daily Living. A review of the Resident Assessment Protocol Summaries (RAPS) dated 9/27/13 documented that falls triggered for Resident #1 and that falls were referred to the comprehensive care plan. The resident received a score of 15 on the Fall Risk Assessment, which indicated "high fall risk." A review of the care plan for falls initiated 4/1/13, addressed the problem of "At risk for fall related to history of falls." Interventions in place at time of the fall included, bed and chair alarm, bed in lowest position, floor mats on both sides of the bed. On 2/25/14 at 12:00 p.m., the surveyor observed Resident #1 seated in a wheelchair at the Nursing station. Six others residents were observed in the area, no staff was present. On 02/27/14 at 10:25 a.m., the surveyor interviewed the CNA who cared for the resident. The CNA told the surveyor that the resident was dependent on staff for care, slept late at times and can make her needs known. During an interview with the nurse that same day at 11:30 a.m., she stated that the resident can be very anxious and was kept in the hallway for supervision. The nurse could not indicate who was responsible to supervise the resident while in the hallway. The surveyor asked the nurse what interventions were put in place after each fall to prevent further incident, the nurse indicated the interventions were added to the care plan and the resident was kept at the nursing station for close supervision. On 02/28/14 at 10:30 a.m., the surveyor reviewed the fall investigative report with the nurse who indicated that fall interventions will be on the care plan. The care plan was not revised to include the line of supervision required by the resident for safety. A review of Resident #1's care plan showed that no interventions were added after the falls regarding the line of supervision required to prevent further accident. The facility was aware and documented that the resident was able to remove the lap buddy. NJAC 8:39-27.1(a)