Every finding on record at Runnells Center for Rehabilitation & Healthcare

Based on interviews and review of pertinent facility documentations on 4/13/26, 4/16/26, and 4/17/26, it was determined that the facility Social Worker (SW) failed to review an electronic mail (email) message dated 4/10/26 about an alleged verbal abuse. The deficient practice was identified for 1 of 5 residents (Resident #1) reviewed for abuse and neglect and was evidenced by the following: A review of the Minimum Data Set (MDS), an assessment tool dated 2/25/26, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident's cognition was moderately impaired. The MDS further revealed that the resident required assistance from staff for completion of their activities of daily living (ADLs). On 4/16/26 at 12:18 PM, the surveyor interviewed Resident #1 concerning the 4/9/26 incident. Resident #1 stated that it was nighttime and 2 female nurses, described as one with black hair and the other with reddish dark hair, pointed their fingers and swore at me. The resident denied staff being rough with their PEG tube cleaning or causing pain. (Percutaneous Endoscopic Gastrostomy tube, a tube surgically placed through the abdominal wall into the stomach to provide long-term nutritional support or decompression). Resident #1 stated that staff only used swear words at them. The resident did not report this incident to staff but told a family member about it the next day. On 4/16/26 at 1:56 PM, surveyor interviewed the SW who stated that Resident #1's CC emailed her Friday, 4/10/26, regarding care concerns, as well as somebody yelling at the resident. The SW stated that she returned to work on Tuesday 4/14/26 and that day in morning clinical meeting she made the clinical team aware of the email. The SW was unable to say if the allegations were investigated. The surveyor requested grievances for the month of April 2026. A review of the email from Resident #1's CC to the facility SW dated 4/10/26 at 4:21 PM revealed allegations of rough care and verbal abuse by staff who were cursing loudly at Resident #1.On 4/16/26 at 1:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) together with the Regional Clinical Director (RCD). The LNHA and the RCD stated that they did not know about the alleged abuse until 4/16/26 when the SW handed the CC's email to the LNHA. A review of the facility's policy, Abuse, Neglect, Misappropriation Prevention Policy and Procedure, revised 8/29/19, under Verbal Abuse revealed, includes the use of oral, written or gestured language that willfully 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 Identification revealed, 4.Staff members must report to his/her immediate supervisor, department head or the administrator any suspected, actual or allegations of abuse, neglect or mistreatment.N.J.A.C. 8:39-27.1(a), 39.4(g),(i)

Complaint #: 2728562, 2728912 Based on interviews, medical record review, and review of pertinent facility documents on 1/27/26, 2/2/26 and 2/4/26, it was determined that the facility failed to ensure that a resident was free from significant medication error. This occurred on 1/23/26, when a Licensed Practical Nurse Unit Manager (LPN/UM) incorrectly used a medication list belonging to another resident (Resident #6) to reconcile Resident #5's medications. Review of Resident #5's January 2026 Medication Administration Record (MAR) revealed incorrect medications were listed and the staff administered the wrong medications to Resident #5 on these dates as follows: -Furosemide (medication used to treat excess fluid in the body) 20 mg tablet daily (Administered on 1/24/26, 1/25/26, and 1/26/26).-Lithium Carbonate Extended Release (a mood stabilizer used to treat bipolar disorder) 450 mg tablet daily (Administered on 1/24/26, 1/25/26, and 1/26/26).-Trazodone (an antidepressant/anxiety) 100 mg tablet at bedtime (Administered on 1/23/26, 1/24/26, and 1/25/26).-Clonazepam (treats seizure disorder) 0.5 mg twice daily (Administered on 1/23/26, 1/24/26, 1/25/26, and 1/26/26).-Risperidone (antipsychotic medication) 3 mg tablet twice daily (Administered on 1/23/26, 1/24/26, 1/25/26, and 1/26/26).Resident #5's Universal Transfer Form (UTF) dated 1/26/26 at 2:20 PM, included Resident #5 was transferred to the hospital for further evaluation for [Altered Mental Status]. The facility's failure to ensure that a resident was free from significant medication error placed Resident #5 and all other residents at risk for serious harm, injury/or death and resulted in an IJ situation.The IJ began on 1/23/26 at 4:04 PM, when the wrong medications were transcribed onto Resident #5's MAR and administered to resident, until 1/26/26 at 1:40 PM when the facility stopped administering the wrong medications after the resident's family informed the facility that the medications on the resident's list of medications were not accurate, and also informed the facility that the resident was not completing their sentences. The facility was notified of the F760 IJ and was provided the IJ Template on 2/2/26 at 4:05 P.M. The facility submitted an acceptable Removal Plan (RP) on 2/3/26 at 12:41 PM. The survey team verified the implementation of the RP on-site on 2/4/26 at 2:01 PM.This deficient practice was identified for 1 of 3 residents reviewed (Resident #5) for medication reconciliation and was evidenced as follows:A review of the facility's policy titled Medication Regimen Reconciliation - Admission/re-admission dated 5/25/25 included Policy Statement: Medication Reconciliation Review (MRR) would be completed within 24 hours to prevent medication errors and potential resident harm. Procedure: 1. The licensed nurse will obtain, verify, and document with the attending physician the resident's current prescription and over the counter medications [.] 6. The primary purpose of MRRs is to help [the facility] maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately.A review of the facility's policy titled Identifying and Managing Medication Errors and Adverse Consequences dated 5/25/25, indicated that staff would strive to prevent medication errors.1. Resident #5 was not at the facility at the time of the survey; a closed record review was conducted and revealed the following:According to the admission Record (AR), Resident #5 was admitted to the facility with diagnoses which included but were not limited to: influenza, depression, cerebral infarction, hyperlipidemia, hypertension, and cardiac arrhythmia.A review of the Facility Reported Event (FRE) dated 1/28/26, revealed the following:On 1/26/26 at 1:40 PM, a medication error was identified following a medication review with Resident #5's Representative (RR), after the RR informed the facility that Resident #5 was not completing [their] sentences. The FRE further stated that after the MRR, the facility determined that a wrong medication list (Resident #6's list of medications) was utilized to reconcile Resident #5's medications during their admission process at the facility.A review of Resident #5's progress notes (PN) revealed an admission summary note written by Licensed Practical Nurse (LPN #1) on 1/23/26 at 3:17 PM, which stated that Resident #5 arrived at the facility at 1 PM and that LPN #1 conducted the admission assessment. A review of Resident #5's Medication Administration Record (MAR) for January 2026 included the following medications:-Clonazepam 0.5 mg tablet twice daily, Administered on: 1/23/26 at 5 PM, 1/24/26 at 9 AM & 5 PM, and 1/25/26 at 9 AM & 5 PM, and 1/26/26 at 9 AM.-Risperidone 3 mg tablet twice daily, Administered on: 1/23/26 at 5 PM, 1/24/26 at 9 AM & 5 PM, and 1/25/26 at 9 AM & 5 PM, and 1/26/26 at 9 AM.-Trazodone HCl 100 mg tablet at bedtime, Administered on: 1/23/26 at 9 PM, 1/24/26 at 9 PM, and 1/25/26 at 9 PM.-Furosemide 20 mg tablet daily, Administered on: 1/24/26 at 9 AM, 1/25/26 at 9 AM, and 1/26/26 at 9 AM.-Lithium Carbonate Extended Release 450 mg tablet daily, Administered on: 1/24/26 at 9 AM, 1/25/26 at 9 AM, and 1/26/26 at 9 AM.A review of Resident #5's Order Summary Report (OSR) revealed corresponding actives order dated 1/23/2026 for the above-mentioned medications. A review of Resident #5's medication list from the transferring facility did not include any of the above-mentioned medications. Further review of the medical record revealed that the above medications belonged to Resident #6 and not Resident #5.A statement dated 1/23/26, written by the Licensed Practical Nurse/Unit Manager (LPN/UM) indicated that LPN/UM reviewed Resident #5's admission packet and the medication list. The LPN/UM further stated that while transcribing the medication list that was on multiple pages, the LPN/UM failed to verify that each page was for Resident #5 which led to the entering of medications prescribed for Resident #6 into Resident #5's list. 2. Resident #6 was not at the facility at the time of the survey, and a closed record review was conducted and revealed the following:According to the AR, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: schizoaffective disorder, heart failure, and hypertension.A review of Resident #6's Medication List showed the same medications that were transcribed and administered to Resident #5, which included the following medications:-Furosemide 20 mg tablet daily-Lithium Extended Release 450 mg tablet, every twelve hours-Trazodone 100 mg tablet, at bedtime-Clonazepam 0.5 mg, twice daily-Risperidone 3 mg tablet, twice dailyDuring interview on 2/2/26 at 11:29 AM, LPN #1 stated that it was the role of the Unit Manager (UM) or the Nursing Supervisor (NS), depending on the shift, to complete the MRR, contact the physician and obtain appropriate orders. LPN #1 stated that upon the arrival of Resident #5 to the unit, LPN #1 completed the initial nursing assessment and stated that all paperwork was given to the LPN/UM. LPN #1 confirmed that the wrong medications were administered as noted in the EMR system after LPN/UM entered them into the MAR.During a joint interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 2/2/26 at 12:25 PM, the DON stated that when a resident is admitted on day shift, it was the responsibility of the UM to review the admission packet which included the resident's medication list. The DON further stated that once the packet was reviewed, the UM would notify the physician so that the orders could be obtained. DON stated that if the physician was not in the building, the UM would contact the provider (physician) through the phone. The DON stated that the UM was required to review resident's demographics, discharge summary and the medication list with the provider, so that the provider could make decisions regarding whether to continue with the plan, discontinue, and/or alter the plan at their discretion. The DON further stated that once the UM received verbal order confirmation from the provider, the UM would then enter medications into the resident's Electronic Medical Record (EMR). LNHA stated that on 1/26/26, she was informed by the facility's Infection Preventionist (IP) that Resident #5's family reviewed the resident's medication list and expressed concern because they believed that Resident #5 was not supposed to be on the medications on the list. The DON and the LNHA both stated that upon discovery of this information about wrong medications, the facility initiated an investigation immediately and determined that an error was made in the medication transcription process. LNHA and the DON further stated that after speaking with the LPN/UM and review of the documentation, they determined that LPN/UM did not use the correct medication list, and that she provided inaccurate information to the provider when she obtained the verbal order for the medications.During an interview with the Medical Director (MD) on 2/2/26 at 2:43 PM, the MD stated that he was not sure what happened in this case, and that it was expected that residents should only be prescribed medications from their own lists. He further stated that he was not sure how Resident #6's paperwork wound up together with Resident #5's.During a telephone interview with the Attending Physician (AP) on 2/2/26 at 3:43 PM, the AP stated when not at the facility, a nurse will call and provide the new admission's demographics, including what medications are listed. The AP stated that he expects that the person providing the information has already confirmed that the demographics are correct prior to calling to obtain orders. The AP further stated that any mixing up of those lists could cause a danger to any resident. The AP stated not being aware of this incident until the facility called and informed them on 1/29/26.During a follow-up interview with the DON and the LNHA on 2/4/26 at 12:42 PM, the surveyor asked about a signed job description for the LPN/UM, the DON stated at the time of the incident the LPN/UM was covering as the UM as they were considering them for that position. The DON stated that the LPN/UM's current role was as a night shift Nursing Supervisor (NS). The DON provided the surveyor with a copy of the signed job description dated 3/5/25, which indicated that NS were responsible completing chart audits on all admissions and it listed steps that the NS was to take when contacting a physician for admission orders. Those steps included reconciling medications, reading back and verifying telephone orders, and transcribing the orders.The facility submitted an acceptable Removal Plan (RP) on 2/3/26 at 12:41 PM, indicating the action the facility would take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice as follows:On 1/26/26 Resident #5 was assessed and monitored for any adverse reaction including vital signs, and level of consciousness. Neurological checks were initiated and maintained until the resident was sent out for further evaluation. An investigation into the incident was also initiated and the identified LPN/UM was suspended pending the outcome of the investigation.On 1/26/26 an audit was initiated by the Director of Nursing (DON)/Designee of all new admissions from 1/23/26/ to 1/26/26. discharged medication reconciliation records for all new admissions and re-admissions from 1/23/26 to 1/26/26 to ensure accuracy, proper transcription, physician orders, and compliance with the facility's admission protocol. Re-education was initiated for licensed nursing staff on the facility's admission process, medication reconciliation requirements, nurse accountability and resident identification procedures. On 1/26/26 the DON educated licensed nursing staff on a new protocol requiring two-nurse verification for: Transcription and review of hospital discharge medication lists, and use of two resident identifiers prior to medication transcription and administration.The surveyor verified the implementation of the RP on-site on 2/4/26 at 2:01 PM and determined that the IJ for F760 was removed as of 1/26/25. NJAC 8:39-27.1(a)

Complaint # 2723777 Based on interviews and record review it was determined that the facility failed to allow a resident with an infectious diagnosis that required Enhanced Barrier Precautions to return after being hospitalized despite the facility's ability to provide that care. This deficient practice was identified for 1 of 2 residents (Resident #2) reviewed for discharges.This deficient practice was evidenced by the following:According to Resident #2's admission Record (AR), the resident was admitted with diagnoses including but not limited to: compartment syndrome (increased pressure in an area of the body that compromises blood flow and tissue function), unspecified, subsequent encounter; paraplegia (impairment or loss of motor and sensory function in the lower half of the body), unspecified; muscle weakness (generalized); and need for assistance with personal care. According to the Minimum Data Set (MDS), an assessment tool dated 12/27/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed that Resident #2 was frequently incontinent of bowel and had a urinary catheter. Review of a Progress Note (PN) dated 12/30/2025 at 4:47 PM, revealed that Resident #2 was transferred from the facility to an acute care hospital due to altered mental status, hypotension (low blood pressure), and diarrhea. A PN dated 12/31/2025 at 2:30 AM, revealed that Resident #2 was admitted to the hospital for septic shock (a life-threatening, advanced stage of sepsis caused by severe infection, leading to critically low blood pressure, dangerous circulatory, cellular and metabolic dysfunction, and multi-organ failure). An interview was conducted with the Infection Preventionist (IP) on 01/27/2026 at 2:37 PM. The IP stated that he was not involved in decisions about re-admitting Resident #2 because the resident had negative cultures for candida auris (CA). The IP stated that as far he knew, the facility had the ability to care for residents with CA. The IP stated that CA required contact isolation and the facility had adequate personal protective equipment (PPE) and the staff was educated on putting on and removing it. An interview was conducted with the Director of Nursing (DON) on 01/27/2026 at 3:06 PM. The DON stated that the facility was notified that Resident #2 was positive for CA on 01/15/2025 or 01/16/2025. The DON stated, We are not a C. Auris facility, and that this was based on an internal facility document. The DON further stated, C. Auris is highly contagious, that is why we do not accept it. This was a decision made by upper management. An interview was conducted with the Admissions Director (AD) on 01/27/2026 at 3:36 PM. The AD stated that during the first or second week of January, Resident #2's family member informed her that the resident was diagnosed with CA. The AD stated that she informed the resident's family member that the facility generally did not accept residents with CA. The AD stated that the facility had never accepted a resident with CA because of the facility's clinical capabilities. The AD stated that the facility's clinical capabilities was a list supplied by Corporate that states which conditions the facility can and cannot manage. The Surveyor requested to view the facility's clinical capabilities document. A follow up interview was conducted with the DON on 01/27/2026 at 5:03 PM. The DON stated that the facility did not have a document which indicated that residents with CA were not to be admitted . Resident #2 was not readmitted to the facility. NJAC 8:39-4.1(31)

Complaint # 2638227 Based on observation, interview, and record review it was determined that the facility failed ensure staff consistently documented care/services provided to residents in accordance with professional standard. This deficient practice was identified for 2 (two) of 3 (three) residents (Resident #1 and #3) reviewed for reviewed for accident/incident, and was evidenced as follows:This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.1.) On 10/29/25, the Department of Health conducted a complaint survey at the facility. The surveyor reviewed Resident #1's closed medical record (MR) which reflected the resident was admitted to the facility with diagnoses which included Alzheimer's disease, dementia with psychotic disturbances, and type 2 diabetes (high blood sugar).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/24/25, reflected a brief interview for mental status (BIMS) score of 2 out 15, which indicated a severely impaired cognition. Section E - Behavior reflected the resident had behavioral symptoms (such as hitting or scratching self, pacing, rummaging.).Section GG Functional Abilities indicated the resident was independent for eating, required supervision or touching assistance for safe performance or better quality of oral/toilet/personal hygiene, shower/bathing, upper/lower body dressing, and for putting on/ taking off footwear. A review of the individualized comprehensive care plan (CP) initiated on 3/21/25, included a focus that Resident #1 was a wanderer who exhibited behaviors of urinating in the hallway and other resident's room. Further review of the CP reflected the resident exited the unit on 4/6/25, bit another resident on 7/10/25, and was pushed by another resident that resulted in a fall on 9/19/25. The intervention initiated on 3/21/25 was to identify patterns of wandering. On 7/10/25 another intervention was included to analyze, the times of day, places, circumstances, triggers and what de-escalates behavior and document. The CP also revealed the resident required safety rounds of at least every 2 hours initiated on 8/4/25.A review of the Documentation Survey Report (the report of the electronic point-of-care system (POCS) where the Certified Nursing Assistants (CNAs) electronically document patient care activities) revealed the following:-From 7/1/25 to 7/31/25, reflected there were 46 out 93 shifts, that reflected charting blanks for behavior monitoring that included wandering.-From 8/1/25 to 8/31/25, reflected there were 21 out of 93 shifts, that reflected charting blanks for behavior monitoring that included wandering.-From 9/1/25 to 9/30/25, reflected there were 25 out of 90 shifts, that reflected charting blanks for behavior monitoring that included wandering. 2.) The surveyor reviewed the medical record for Resident #3.A review of the admission Record, (an admission summary) reflected the resident was admitted to the facility diagnoses that included dementia (memory loss) with other behavioral disturbances.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/8/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident had a severely impaired cognition. The resident had no indicators of psychosis. Section GG, Functional Abilities reflected the resident was dependent on a helper for mobility that included: rolling left to right, sit to lying, for transfers from chair to bed, toileting and showering.A review of the individualized comprehensive care plan (CP) included a focus that Resident #3 was high risk for falls, initiated on 6/3/25. The interventions included to offer toileting to the resident prior to bed and rounding at least every two (2) hours at night, initiated on 6/20/25.A review of Resident #3's POCS from 06/01/25 to 06/30/25, reflected the following: -There were 21 out of 90 shifts, charting blanks for bowel and bladder elimination monitoring. - There were 22 out of 90 shifts, that reflected charting blanks for behavior monitoring that included wandering.On 10/31/25 at 11:50 AM, in the presence of two surveyors, the Assistant Director of Nursing (ADON) stated that they did not document anywhere the 2-hour monitoring for Resident #1 and the 2-hour monitoring at night, for Resident #3 as it was their standard of practice to often see their residents. The ADON could not provide evidence that this individualized care plan intervention was implemented. At that time, the ADON acknowledged and confirmed the CPs should be individualized. On 10/31/25 at 12:50 PM, in the presence of a surveyor, the Assistant Administrator (AIT), the ADON, the Regional DON, and the assisting Administrator of the Behavioral Health (LNHA), the surveyor discussed the concerns with the charting blanks on the POCs and the missing documentation to show that both resident's were monitored every 2-hours as part of the CP intervention.No further information was provided.A review of the facility provided policy, titled, Nursing Documentation, dated/revised 5/5/25, included to document all pertinent psychosocial, medical and nursing observations. The plan of care and response must be included. NJAC 8:39-27.1 (a)

Complaint #2585508 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) an injury of unknown origin and implement facility's policy for accidents and incidents by not thoroughly updating the care plan after an assessment. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed for accident/incident, and was evidenced as follows: On 10/31/25 at 9:00 AM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) informed the surveyor that there were no reportable events (report filed with the NJDOH) found on file for Resident #3.The surveyor reviewed the medical record for Resident #3. A review of the admission Record, (an admission summary) reflected the resident was admitted to the facility with diagnoses that included dementia (memory loss with cognitive decline) with other behavioral disturbances.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 6/8/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident had a severely impaired cognition. The resident had no indicators of psychosis. Section GG, Functional Abilities reflected the resident was dependent on a helper for mobility that included: rolling left to right, sit to lying, for transfers from chair to bed, toileting and showering.A review of the nurse's Progress Note (NPN) dated 6/11/25 at 1:25 PM, reflected the resident was sent seen with redness on the right eye. During the shift, the right eye became bruised, and a bruise on the right arm was also observed. The physician was notified, who ordered a hold on the administration of Aspirin, the resident to be monitored and neuro-checks (an assessment for potential head injuries and monitored changes over time).A review of the facility provided a soft file for the Unknown incident on 6/11/25 when the unilateral right-side bruising was reported to the nurse. The file included witness statements. CNA #1 signed a statement on 6/10/25, that the resident's bruises were present at the start of her 3PM to 11PM. A review of CNA #2 undated witness statement reflected that she reported the skin redness to the nurse, while knowing that the nurse was aware of the unilateral bruise on the right eye and right arm. Further review of the soft file revealed the interdisciplinary team met on 6/13/25 [no specified time] revealed that the individualized comprehensive care plan (CP) was updated and floor mats on either side was implemented from 6/1/25. According to the facility investigation of the bruise of unknown origin the unilateral bruise on the right eye and the right arm was attributed to the resident's anticoagulant or due to poor safety awareness and disease process of dementia. A definitive root cause of the right eye and right arm bruises were not reflected. On 10/31/25 at 11:59 PM, during an interview with the surveyors, the Assistant Director of Nursing (ADON) confirmed that a reportable was not filed with the NJDOH when a unilateral bruise on the right eye and the right arm was found, that was investigated in the facility as a bruise of unknown origin. The ADON stated that the unilateral bruises found on the resident's right eye and arm were caused by the aspirin.A review of the CP did not reveal a focus, and intervention was made for the anticoagulant, the right arm bruise and dementia.On 10/31/25 at 11:59 PM, during an interview with the surveyors, the Assistant Director of Nursing (ADON) confirmed that a reportable was not filed with the NJDOH when a unilateral bruise on the right eye and the right arm was found, that was investigated in the facility as a bruise of unknown origin. The ADON stated that the unilateral bruises found on the resident was caused by the aspirin. At that time, the surveyor and the ADON reviewed the CP together. The ADON confirmed the Aspirin, should have been care planned.On 10/31/25 at 12:50 PM, in the presence of a surveyor, the Assistant Administrator (AIT), the ADON, the Regional DON, and the assisting Administrator of the Behavioral Health (LNHA), the surveyor discussed the concerns with not reporting the injury of unknown source and the individualized care plan that was not thoroughly updated to include, Aspirin, the right arm bruise and for diagnosis of dementia and its associated interventions.No further information was provided.A review of the facility provided policy for Accident and Incident - Investigation A review of the facility provided policy for Interdisciplinary Care Planning Policy and Procedure dated 8/1/25 included that individualized interdisciplinary [ID] interventions will be planned by each discipline to correct problems identified during IDCP conference. NJAC 8:39-4.1(a)(5)

Complaint # 2638227 Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to ensure the accuracy of a resident's weight and monitor the resident's food intake in accordance with the resident's care plan. This deficient practice was identified for 1 of 3 closed records reviewed (Resident #1) and was evidenced by the following: The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included Alzheimer's disease, dementia (memory loss with cognitive decline) with psychotic disturbances, and type 2 diabetes (high blood sugar).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/24/25, reflected a brief interview for mental status (BIMS) score of 2 out 15, which indicated a severely impaired cognition. Section E - Behavior reflected the resident had behavioral symptoms (such as hitting or scratching self, pacing, rummaging.).Section GG Functional Abilities indicated the resident was independent for eating, however required supervision or touching assistance for safe performance or better quality of oral/toilet/personal hygiene, shower/bathing, upper/lower body dressing, and for putting on/ taking off footwear.A review of Weight and Vital Summary report located in electronic Health Record (eHR), revealed the following:On 6/4/25, the resident weighed 162 pounds (lbs; standing). On 7/4/25, the resident weighed 158.4 lbs (standing).On 8/8/25, the resident weighed 154.4 lbs (standing).On 8/20/25, the resident weighed 147.0 lbs (standing) was crossed off on 9/3/25 by the RD who documented incorrect documentation.A review of the electronic Progress Note (ePN) included a Nutrition/Dietary Note (NDN) dated 6/23/25, which was a quarterly review and indicated the resident's weight was 162.0 and to continue plan of care. No further review was documented until 8/20/25.A review of the NDN dated 8/20/25, which reflected the resident's monthly weight was 147 lbs an 11.4 lbs weight loss and was below the UBW usual body weight. The RD also documented speaking with the resident's family representative, added a nutritional supplement, Glucerna 8 ounces per day, recommended monitoring of acceptance of Glucerna, weights and appetite. A review of the Order Recap Report (ORR) reflected Glucerna was ordered on 08/20/25 as recommended by the RD.On 10/28/25 at 12:55 PM, during a telephonic interview with the surveyor, the Registered Dietician (RD) stated that on admission, the nursing department obtained the weights and entered the data into the electronic medical record (eMR). The weekly and monthly weights were also obtained by nursing but were reviewed and entered by the RD. At that time, the surveyor and the RD reviewed the eMR together. The RD stated that the 8/20/25, weight was struck out by her because there was no need for the resident's weight at that point. I thought the weight was an error based on the weight that came in September, which was more consistent, and that weight appeared to be an outlier. At that time, the RD stated she did not document re-weights in the eMR. The RD also stated that she may have the weight and re-weight in her office, but she was not in the facility, that day and nobody else had access to her records.On 10/28/25 at 12:40 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated they had a weight binder in the unit, within the binder was a weight form with a list of resident's names who needed weights provided by the RD. The Certified Nursing Assistants (CNAs) obtained the weight and wrote into the weight form. The LPN also stated that the RD provided the list of re-weights needed. On 10/28/25 at 12:45 PM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) confirmed and acknowledged that a soft file was not part of the medical record. The ADON stated that weights and re-weights should have been available for review in the eMR allowing ancillary providers access to the information of the weight variance and evidence that the variance was thoroughly investigated. A review of the individualized comprehensive care plan included a focus area for nutrition, initiated on 3/21/25. The interventions included to monitor oral intake as needed that was also initiated on 3/21/25.A review of the Documentation Survey Report (the report of the electronic point-of-care system (POCS) where the Certified Nursing Assistants (CNAs) electronically document patient care activities). The POCS revealed the following:-during the resident's stay on July 2025, 16 of the 62 shifts the CNAs documented the percentage of meal that was eaten by the resident. There were 46 charting blanks.-during the resident's stay on August 2025, 6 of the 62 shifts the CNAs documented the percentage of meal that was eaten by the resident. There were 56 charting blanks.On 10/28/25 at 4:14 PM, in the presence of a surveyor, the Assistant Administrator (AIT), the ADON, the Regional DON, and the assisting Administrator of the Behavioral Health (LNHA), the surveyor discussed the concern that the evidence of a re-weight was not present in the medical record to ensure the weigh variance was investigated prior to interventions were made and the concern with the monitoring of the resident's consumption as indicated within the care plan.A review of the provided Dietary Intake policy dated 8/1/25, reflected that dietary intake would be monitored by the CNA assigned to a particular resident for breakfast, lunch and supper. A review of the provided Weights policy, dated 8/1/25, reflected that the licensed nurse will evaluate all weights obtained . and determine if re-weight is necessary. The licensed nurse will be responsible for transcribing the weight in the re-weight box on the weight record. NJAC 8:39-27.1(a),27.2(a)

Based on observation, interview, and policy review, the facility failed to ensure one of one Licensed Practical Nurse (LPN) (LPN 4) and one of one Certified Nursing Assistant (CNA) (CNA 13) used proper glove technique when providing wound care and personal care for one of one residents (Resident (R) 18) observed for wound care of 35 sample residents. This practice placed the resident at an increased risk for infections.Findings include:Observation on 08/12/25 at 10:34 AM of CNA13 as she provided personal care to R18. CNA13 entered R18's room and washed her hands and then put on a protective gown and two pairs of gloves. CNA13 retrieved her cell phone from the supply cart outside of the door and looked at her phone while a basin was filled with soapy water. R18 was handed a soapy washcloth, and he washed his own face. CNA13 took another cloth and washed his chest, abdomen, underarms, hands, and back. CNA13 then dried those areas with a towel, applied lotion and deodorant. CNA13 then provided perineal care to the front and used a towel to wash his legs. CNA13 removed the first layer of gloves. She then used another washcloth to cleanse his bottom. CNA13 removed the remaining gloves after dumping basin and washed her hands.Observation on 08/12/25 at 11:04 AM of LPN4 in R18's room revealed she had placed a package of 4 X 4's, a package of t-gauze, and a border dressing on the top of the wound cart. LPN4 left to retrieve a spray bottle of wound cleanser and 2 x 2 gauze in an open package. LPN4 entered the room and placed the dressing supplies on top of his bedside table, washed her hands, put on four layers of gloves, and a protective gown. LPN4 put a barrier on top of the overbed table and then placed the dressing supplies on the top of the table. LPN 4 removed the first pair of gloves and used the wound cleanser with the 2 x 2 gauze and cleansed the wound like that two times. LPN4 removed the second pair of gloves, put a layer of Triad paste (wound dressing) inside and around the outer border of the wound with her gloved hand and covered it with a border dressing. LPN4 removed the third pair of gloves, removed her protective gown, the last pair of gloves, and then washed her hands.Interview on 08/12/25 at 11:30 AM with LPN4 and CNA13 about the use of multiple gloves revealed CNA13 stated it saved time when going from a soiled task to another clean task. LPN4 stated that was how she was taught in nursing school.During an interview on 08/12/25 at 4:00 PM, the Infection Preventionist (IP) stated the practice of wearing multiple gloves did not follow the policy and procedure for the use of gloves. The IP said one pair of gloves should have been used with hand hygiene between each glove change.Review of the facility's Handwashing/Hand Hygiene'' policy, revised 06/03/25, revealed no information on putting on multiple layers of gloves. The policy indicated that employees must wash hands after removing gloves. NJAC 8:39-19.4(a), 27.1(a)

Based on observation, interview, and policy review, the facility failed to ensure proper glove use and hand washing was used during one of one meal services observed. One of one cook (Cook (C) 1) and two of three dietary aides (DA) (DA2 and DA4) touched ready-to-eat foods and the inside of coffee cups without performing hand hygiene when moving between tasks. The failure to ensure proper hand washing and glove use could contaminate the food served to the residents.Findings include:Observation on 08/13/25 at 10:30 AM in the kitchen revealed DA4 placing Styrofoam coffee cups with his gloved hands onto a tray. He put his fingers inside of each cup as he placed the cup on the tray. DA4 then filled a large pitcher with coffee and filled each coffee cup. When DA4 had filled the tray of coffee cups with coffee he carried it to a heated cart. DA4 opened the cart with the same gloves and then returned to fill another tray, again touching the inside of each cup. DA4 never changed his gloves during this process.Observation on 08/13/25 at 10:45 AM in the kitchen revealed C1 had gloves on and was pureeing rice, touching the three compartment sink multiple times in the process. After he completed pureeing the rice he placed the container in the steamtable. C1 removed the covers off of the other containers already in the steamtable. Without changing his gloves, he removed hamburger and hot dog buns from the bag and placed them on a plate. He then went to get some plastic wrap to cover the buns. Before tray service started C1 identified the food was not at the correct temperature for service. C1 removed each container of food from the steamtable and placed them on the stove top to ensure they were at the correct temperature. C1 never changed his gloves during this process. During the tray service, C1 dished all the food, retrieved the buns with his hands, and placed cooked hamburgers and hot dogs on the buns with his hands while wearing the same gloves.Observation on 08/13/25 at 11:55 AM of DA2 revealed she was preparing ham and cheese sandwiches to be grilled later. DA2 was wearing gloves. DA2 touched the handle to the walk-in cooler, retrieved cheese and ham, and returned to the prep area. DA2, while wearing the same gloves, picked up bread and placed it on a flat pan. DA2 then put a slice of cheese and then a slice of ham on the bread.During an interview on 08/13/25 at 12:30 PM, the Food Service Director who was covering from another facility agreed C1 and DAs 2 and 4 had not changed their gloves after they had touched other surfaces. She confirmed she had also observed the above incidents.Review of the facilities 2019 Bare Hand Contact with Food and Use of Plastic Gloves policy revealed Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed.NJAC 8:39-17.2(g), 19.7(d)

Based on observations, interviews, and record review, the facility failed to ensure that one of one residents (Resident (R) 16) reviewed with contractures out of 35 sample residents received a splint on her hands per the care plan. Failure to use the hand splints has the potential for the resident to develop skin breakdown in the palms of her hands.Findings include:Review of R16's Face Sheet located in the electronic medical record (EMR) under the admission tab documented that the resident was admitted to the facility on [DATE] with diagnoses of traumatic brain injury (TBI) and contracture of muscle of right and left hands.Review of R16's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/11/25 located in the resident's EMR under the MDS tab revealed the resident had persistent vegetative state (a severe brain disorder where a person is awake but unaware of themselves or their surroundings), functional limitation in range of motion bilaterally in upper and lower extremities, and was dependent of staff for all personal care.Review of R16's TBI Care Plan, located in the EMR under the Care Plan tab and dated 06/17/25, revealed the resident was totally dependent on the staff for her care, had contractures of both hands, and was to continue to wear her left hand splint and right grip orthosis to be applied after morning care, and removed before evening care. Review of R16's Physician Orders dated 08/01/25 found in the EMR under the Orders tab revealed no order for R16 to wear a splint to either hand. A review of R16's Nursing Notes dated 07/01/25 through 08/12/25 located in the EMR under the Progress Note tab did not reveal any documentation related to R16's splints.An observation on 8/11/25 12:49 PM revealed R16 sitting in her room in her chair. R16 had contractures on both hands and although R16 had splints on her feet, she had no splints on her hands. An observation on 08/12/25 at 12:26 PM revealed that R16 was sitting in her chair in her room and although R16 was wearing feet splints, she had no splints on her hands.During an interview on 08/12/25 at 12:20 PM, the Family Member (FM) 1 said although R16 was to wear splints on both of her hands, the staff had not been placing the splints on her hands. F1 stated she wanted some type of device on R16's hands to prevent her nails from rubbing and causing irritation to her hands.During an interview on 08/12/25 at 4:35 PM, Certified Nursing Assistant (CNA) 8 and CNA4 stated they were ready to transfer R16 back to bed. CNA8 and CNA4 said although they had removed R16's feet splints, R16 had no hand splints on her hand to remove. CNA4 said although she always observed feet splints on R16, which she removed prior to transferring back to bed, she never observed hand splints on R16. During an interview on 08/13/25 at 12:00 PM, CNA12 said she was assigned to provide care to R16 on 08/11/25 during the day shift. CNA12 said she was not told in report that R16 required hand splints, was not aware R16 wore splints to her hand, and therefore, did not place splints on her hands. During an interview on 08/13/25 at 2:16 PM, Licensed Practical Nursing Supervisor (LPNS) 2 said she was assigned as the nurse on R16's unit during the day shift on 08/13/25. She said she was not aware R16 was to wear splints on her hands.During an interview 08/13/25 at 8:04 AM, 1 [NAME] Unit Manager (WUM) said he had been on vacation the past week. He said R16's splints were in her room; she was to wear hand splints when out of bed and did not know why the staff were not placing splints on her hands. 1WUM said residents were to have a physician's order for splints and he was not aware R16 did not have a physician order for the hand splints.During an interview on 08/13/25 at 9:00 AM, the Director of Rehabilitation stated during her last quarterly assessment during the week of 08/03/25, R16 had splints on both hands and had no decrease in her range of motion. She stated she was not notified that R16 had any issues with her hand splints and had not been wearing the splints, which were part of her plan of care.During an interview on 08/13/25 at 5:30 PM the Director of Nursing (DON) confirmed an order was required for a resident to wear splints. The DON stated she was not aware R16 no longer had a physician order for hand splints. The DON further stated she was not aware the staff were not placing splints on R16's hands and had not been following the care plan.Review of the policy titled Contracture Management dated 06/03/25 documented: .Utilizing aids like splints, as recommended by healthcare professionals, can help maintain proper joint alignment and prevent progression of contractures . All interventions, including assessments, care plan implementation, and the resident's response to treatment should be meticulously documented .Review of the policy titled Making, Application and Care of Splints dated 06/03/25 documented: A physician's written order for a splint is required. NJAC 8:39- 27.1(a), 27.2(m)

Based on observation, interview, and policy review, the facility failed to ensure three of three residents (Resident (R) 172, R204, and R218) rights to a dignified dining experience. The residents were unable to protect their right to dignity due to their impaired cognitive status creating the potential for feeling of embarrassment or frustration.Findings include:Review of R172's electronic medical record (EMR) annual Minimum Data Set (MDS), located under the MDS tab, with an Assessment Reference Date (ARD) of 06/10/25 revealed her Brief Interview for Mental Status (BIMS) score was nine out of 15, this score revealed she had moderate cognitive impairment.Review of R204's EMR revealed an annual MDS, located under the MDS tab, with an ARD date of 06/04/25 revealed his BIMS score was four out of 15, this indicated he had severe cognitive impairment.Review of R218's EMR quarterly MDS with a ARD of 08/05/25, located under the MDS tab, revealed her BIMS score was zero which indicated she had severe cognitive impairment.Observation on 08/12/25 at 9:20 AM in the 3W unit dining room, revealed Certified Nursing Assistant (CNA) 2 was standing beside R172 and helping her to eat her breakfast. R172 is blind and was seated in a high back wheelchair. CNA2 fed R172 her entire breakfast this way. Other residents were present in the dining room. At 9:30, R204 was loudly saying he was still hungry. CNA2 took a bowl of hot cereal off of R218's breakfast tray and gave it to R204. CNA2 did not ask R218 if she was done eating or if she was still hungry.During an interview on 08/13/25 at 3:10 PM, CNA2 revealed she was aware she should sit by a resident when helping them to eat. CNA2 had hurt her back so sitting for too long and reaching up to help a resident sometimes would make her back hurt. CNA2 since R218 had not touched her hot cereal, she thought it was alright to give it to R204. CNA2 stated the cover was still on it. CNA2 agreed she had not observed R218 at all times to know if she had not taken the cover off, if she had taken a spoonful out and then put the cover back on.During an interview on 08/13/25 at 4:00 PM, the Director of Nursing (DON) agreed that staff should not stand beside a resident to help them to eat. The DON stated CNA2 was on light duty, but she was not aware she could not sit to help a resident with eating. The DON confirmed taking food off of one resident's tray and giving to another resident should not have been done. The DON stated if the resident was still hungry she should have requested a new bowl of cereal for R204.Review of the facility's Quality of Life - Dignity policy, dated 06/03/25, revealed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. 'Treated with Dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. NJAC 8:39- 4.1(a)12

Complaint NJ #165993 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the number of episodes, behavioral interventions, and its outcomes for the use of psychotropic medications (mood altering medications) in accordance with facility policy. This deficient practice was identified for one (1) of six (6) residents (Resident #656) reviewed for abuse in a resident-to-resident interaction, and was evidenced by the following: A review of the reportable event record/report (FRI; Facility Reported Incident) that was called in on 7/23/23 at 1:10 PM. The FRI occurred on 7/23/23, at approximately 11:22 AM, and was reported an incident of a resident-to-resident abuse. The event description included the following: At around 11:22 AM on 7/23/23, the Licensed Practical Nurse (LPN) was in the hallway by her medication cart when she witnessed Resident #656, and Resident #657 passed each other on opposite sides of the hallway. The LPN witnessed Resident #656 walked up to, then strike Resident #657 twice in the face. The LPN called out for help and immediately separated both residents . A review of Resident #656's Admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to unspecified dementia (impairment of memory loss and judgment), with other behavioral disturbance, and major depressive disorder. A review of Resident #656's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 9/11/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated that Resident #656's cognition was severely impaired. Additionally, section E. Behavior revealed the resident was not delusional. A review of the Order Summary Report contained Physician Orders that were active orders for June 2023 which included the following: -Ativan 1 milligram (mg), give one (1) tablet by mouth every 8 hours for anxiety with a start date 2/20/23. -Behavior Monitoring for medication: Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23. -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give five (5) capsules by mouth every 12 hours for mood stabilizer with a start date of 5/26/23. -Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23. A review of the Progress Notes from June 1, 2023, to June 30, 2023, revealed behaviors were observed, but did not indicate whether the behavior was for anxiousness or for explosive aggressive behavior for the following dates: 1) 6/1/23 at 9:54 PM 2) 6/7/23 at 12:48 PM 3) 6/7/23 at 12:49 PM 4) 6/8/23 at 12:35 AM 5) 6/8/23 at 12:35 AM 6) 6/12/23 at 12:29 AM 7) 6/12/23 at 12:29 AM 8) 6/13/23 at 12:28 AM 9) 6/13/23 at 12:28 AM 10) 6/14/23 at 1:54 PM 11) 6/14/23 at 1:54 PM 12) 6/16/23 at 12:38 PM 13) 6/16/23 at 12:39 PM 14) 6/18/23 at 12:26 PM (not reflected on the eMAR) 15) 6/19/23 at 2:57 PM (not reflected on the eMAR) 16) 6/19/23 at 2:57 PM (not reflected on the eMAR) 17) 6/25/23 at 12:11 PM 18) 6/25/23 at 12:11 PM 19) 6/26/23 at 2:50 PM 20) 6/30/23 at 12:07 AM 21) 6/30/23 at 12:07 AM 22) 6/30/23 at 7:00 PM 23) 6/30/23 at 7:00 PM A review of the electronic Medication Administration Record (eMAR) for June 2023 included the following orders: -Ativan 1 milligram (mg), give one (1) tablet by mouth every eight (8) hours for anxiety with a start date 2/20/23 and end date of 7/24/23. -Behavior Monitoring for medication (BMFM): Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates: 1) 6/7/23, for the day shift (7:00 AM to 3:00 PM) 2) 6/7/23, for the night shift (11:00 PM to 7:00 AM) 3) 6/11/23, for the night shift 4) 6/12/23, for the night shift 5) 6/14/23, for the day shift 6) 6/18/23, for the day shift 7) 6/18/23 for the night shift 8) 6/29/23, for the night shift -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give five (5) capsules by mouth every 12 hours for mood stabilizer with a start date of 5/26/23. -Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates: 1) 6/7/23 for the day shift (7:00 AM to 3:00 PM) 2) 6/7/23 for the night shift (11:00 PM to 7:00 AM) 3) 6/11/23 for the night shift 4) 6/12/23 for the night shift 5) 6/14/23 for the day shift 6) 6/18/23 for the night shift 7) 6/26/23 for the day shift 8) 6/29/23 for the night shift A review of the Order Summary Report contained Physician Orders that were active orders for July 2023 which included the following: -Ativan 1 milligram (mg), give one (1) tablet by mouth every 8 hours for anxiety with a start date 2/20/23. -Behavior Monitoring for medication: Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23. -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give six (6) capsules by mouth every 12 hours for mood stabilizer with a start date of 6/23/23. -Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23. A review of the Progress Notes from July 1, 2023, to July 31, 2023, revealed behaviors were observed, but did not indicate whether the behavior was for anxiousness or for explosive aggressive behavior, on the following dates: 1) 7/5/23 at 1:41 PM 2) 7/5/23 at 1:42 PM 3) 7/8/23 at 9:52 PM 4) 7/8/23 at 9:52 PM 5) 7/15/23 at 2:07 PM 6) 7/15/23 at 2:07 PM 7) 7/17/23 at 12:52 PM 8) 7/17/23 at 12:53 PM 9) 7/20/23 at 11:40 PM 10) 7/20/23 at 11:44 PM 11) 7/23/23 at 11:42 PM 12) 7/23/23 at 11:43 PM 13) 7/24/23 at 12:43 PM 14) 7/24/23 at 12:43 PM 15) 7/28/23 at 12:19 AM 16) 7/28/23 at 12:20 AM 17) 7/29/23 at 12:10 AM 18) 7/29/23 at 12:10 AM 19) 7/30/23 at 6:36 PM 20) 7/30/23 at 6:36 PM A review of the electronic Medication Administration Record (eMAR) for July 2023 included the following orders: -Ativan 1 milligram (mg), give one (1) tablet by mouth every eight (8) hours for anxiety with a start date 2/20/23 and end date of 7/24/23. -Behavior Monitoring for medication (BMFM): Lorazepam (antianxiety), target behavior of anxiousness with a start date of 2/20/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates: 1) 7/4/23, for the night shift 2) 7/8/23, for the evening shift -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium), give six (6) capsules by mouth every 12 hours for mood stabilizer with a start date of 6/23/23. -Behavior Monitoring for medication: Depakote, target behavior of explosive aggressive behavior with a start date of 5/24/23. The BMFM reflected that behaviors were documented without the number of episodes, without an intervention (non-pharmacological), and without the outcome of the intervention on the following dates: 1) 7/4/23, for the night shift 2) 7/20/23, for the night shift 3) 7/23/23, for the night shift 4) 7/24/23, for the day shift 5) 7/27/23, for the night shift 6) 7/28/23, for the night shift 7) 7/31/23, for the night shift A review of the Psychiatric Follow-Up Form dated 5/26/23 included the following: Patient presented with agitation/aggressive behavior. Patient was seen in peer's room. The peer was noted with bloody lips .start Depakote Sprinkle 750 mg every 12 hours and discontinue Depakote Sprinkle 500 mg every 12 hours. Notify Psych NP if patient becomes agitation/aggressive. Continue non drug interventions . A review of the Psychiatric Follow-Up Form dated 6/14/23 included the following: No drug changes. Continue to monitor the patient's mood, behavior, and non-drug interventions . On 4/8/24 at 10:43 AM, during an interview with the surveyor, the [NAME] President of Clinical Services could not explain why the behaviors under the progress note was not specific to the behavior, the number of episodes, interventions made were not specified, and the outcome of a non-pharmacological intervention(s) were not reflected on certain dates on June 2023 and July 2023 of the eMAR. The concerns were communicated with the VPCS. On 4/8/23 at 12:37 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that she had reviewed the eMAR for the discussed concerns with the VPCS and interviewed four (4) nurses who had indicated Yes for behavior on the eMAR without documentation of the number of episodes, interventions made, and the non-pharmacological intervention outcome. At that time, the DON informed the surveyor that the nurses who had marked yes, on the eMAR meant that they had administered the medication to the resident and did not understand how to properly use the BMFM. The DON acknowledged that the order was for behavior monitoring, not administration of the medication and the documentation on the BMFM was incorrect. At that time, the DON stated that a facility wide in-service/education for behavior monitoring documentation would be conducted to increase the nurses' understanding. A review of the undated facility provided policy, Behavioral Assessment and Monitoring included the following: Policy Statement Problematic behaviors will be identified and managed appropriately with minimal complications using non-pharmacological and/or pharmacological approaches as appropriate. Monitoring 1. Exception charting will be used to document the occurrence of any problematic behaviors, interventions implemented, and the resident response to interventions when these behaviors occur. N.J.A.C. 8:39-27.1 (a)

Based on interview and record review, it was determined that the facility failed to ensure that the primary physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 35 (Resident #658) reviewed for physician visits and was evidenced by the following: On 4/4/24 at 12:40 PM, the surveyor reviewed the closed paper and electronic medical record for Resident #658. The Admission Record (a summary of important information about a resident) documented that Resident #658 had diagnoses that included but were not limited to, generalized anxiety disorder and major depressive disorder. A review of physician progress notes revealed the following: On 9/12/22, a medical visit note was completed by the resident's primary physician. On 10/4/22, a medical visit note was completed by the Nurse Practitioner (NP). On 11/1/22, a medical visit note was completed by the Nurse Practitioner (NP). On 11/28/22, a medical visit note was completed by the Nurse Practitioner (NP). On 12/6/22, a medical visit note was completed by the Nurse Practitioner (NP). There was no documented evidence that the primary physician visited and examined Resident #658 at least every 60 days. On 4/4/24 at 1:50 PM, the surveyor interviewed the VP of Clinical Services about the physician progress notes for Resident #658. The VP of Clinical Services acknowledged physicians were to conduct face-to-face visits at least every 30 days or at least every 60 days when alternating visits with an NP. On 4/8/24 at 10:07 AM, the surveyor interviewed the Director of Nursing (DON) about the physician visits and documentation for Resident #658. The DON stated there should be documentation by the primary physician for the resident and would look to provide further information. On 4/8/24 at 11:18 AM, the surveyor called to speak with the primary physician over the phone and left a message with the office for a call back. On 4/8/24 at 12:21 PM, the surveyor received a return telephone call from the NP who worked in collaboration with the resident's primary physician. The NP informed the surveyor that she visited the residents at least monthly. The NP stated when alternating with the physician, the physician would be required to visit quarterly, every three months. On 4/9/24 at 11:50 AM, the survey team met with the Licensed Nursing Home Administrator, DON, IP, VP of Clinical Services, and regional staff. The surveyor informed the facility of the concern of the physician conducting face-to-face visits at least every 60 days when alternating with an NP. There was no additional information provided by the facility. A review of the provided facility policy titled Physician Visits, under Policy Interpretation and Implementation read: After the first ninety (90) days, if the Attending Physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule for visits may be established, but not to exceed every sixty (60) days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulation . NJAC 8:39 - 23.2 (d)

NJ #165993 Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 35 residents, Resident #200 and #655 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 4/02/24 at 09:33 AM, the surveyor interviewed Resident #200 in their room. Resident #200 stated they take an antidepressant medication and have for a few years. On 4/4/24 at 9:10 AM, the surveyor reviewed Resident #200's hybrid (paper and electronic) medical records. The Admission Record (AR) documented the resident had diagnoses that included but were not limited to, adjustment disorder with depressed mood, schizoaffective disorder depressive type, bipolar disorder, and generalized anxiety disorder. A review of a Annual MDS assessment, dated 1/22/24, indicated in Section N-Medications, under N0415. High-risk Drug Classes: Use and Indication, Resident #200 was not coded for taking an antidepressant. A review of the Order Summary Report included a physician's order dated 7/6/2022 which read, Sertraline HCL Tablet 100 milligrams (MG), Give 2 tablets by mouth one time a day for depression for a total dose of 200mg. On 4/08/24 at 11:48 AM, the surveyor interviewed Registered Nurse/MDS Coordinator (MDSC), who stated all resident who are taking an antidepressant medication should have that coded in their MDS. The surveyor reviewed with MDSC the annual MDS assessment of Resident #200. MDS coordinator #1 stated the coding was a data entry error. MDSC stated the MDS assessment would be corrected. According to the latest version of the Center for Medicare/Medicaid Services - Resident Assessment Instrument 3.0 Manual (updated October 2023) on Chapter 3-page N7-9- N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0415C2. Antidepressant: Check if there is an indication noted for all antidepressant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). On 4/9/24 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyors with a facility policy titles, Electronic Transmission of MDS with a revision date of December 2010. The policy stated under the policy interpretation and implantation section, The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. On 4/9/24 at 11:30 AM, the survey team met with the LNHA and Director of Nursing (DON) to discuss the MDS coding error. The DON acknowledged the errors and stated they would fix errors that were discovered. No further comment made. 45449 2. On 4/3/23 at 12:30 PM, the surveyor requested for the reportable, incidents, and accidents for Resident #655 from the [NAME] President of Clinical Services. A review of the incident and accident report (Risk Management Assessment form (RMA; used to document, identify, and control risks) for Resident #655 included the following: On 8/14/23 at 10:52 PM, the Resident was found sitting on the hallway by the Certified Nursing Assistant (CNA #1). The resident informed the CNA that he/she wanted to get ice water. The resident was educated to consistently request for assistance. On 8/20/23 at 6:57 PM, the Resident informed CNA #2 that he/she fell on his/her right hip next to the bed and lifted himself/herself onto the bed. The resident was educated and redirected. The physician was informed, who then ordered another X-ray (to produce images of the internal tissue, bones, and organs). The X-ray showed good alignment and no injury was reflected on the result. On 8/30/23 at 3:41 PM, an Unsampled Resident reported to the Licensed Practical Nurse (LPN) that while outside, he/she observed Resident #655 walk out of the electric sliding door and fall in the presence of the resident's sister. After returning to the facility, the family member did not report the resident's fall. The resident was assessed upon return, and the LPN documented that there were no apparent bruises. At that time, the sister was interviewed and stated that the resident barely fell , the resident's knee bent and did not touch the floor. The sister was educated to inform the facility of any incident. On 9/4/23 at 7:24 AM, the resident was found on the floor by LPN#2. The resident informed LPN#2 that he/she went to the rest room, and while trying to get back onto the bed, he/she slid off the bed onto the floor. The Director of Nursing documented that the resident was receiving rehabilitative services and the resident continued to be non-compliant with assistive device. The surveyor reviewed Resident #655's hybrid medical record. A review of Resident #655's Admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to unspecified intellectual disabilities (a condition that limits intelligence, and adaptive behavior), anxiety disorder, and major depressive disorder. A review of Resident #655's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 11/7/23, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #655's cognition was intact. Further review of section J.1800, Any falls since Admission/Entry or Re-entry or Prior Assessment, whichever is more recent reflected 0 which indicated No. On 4/8/23 at 9:30 AM, during an interview with the surveyor, the MDSC stated that the quarterly MDS information was based of the nurses' progress notes (PN). The qMDS for 11/7/23, encompassed information from 8/12/23 to 11/7/23. At that time, the surveyor asked the MDSC why the documented falls on the PN that occurred on 8/14/23, 8/20/23, 8/30/23 and 9/4/23, were not reflected on the qMDS dated [DATE]. At that time, the MDSC stated that she had signed the qMDS for 11/7/23, for completion however the MDS Nurse (MDSN) who completed and signed section for J.1800 for that qMDS should have included the data. At that time, the MDSC informed the surveyor that MDSN was not in the facility that day but would reach out for more information as to why it was not included. At that time, the MDSC stated that the accuracy of the MDS was important for care plan and other assessment for their residents. A review of the resident's Care Plan reflected focus, goal and interventions for the falls that occurred on 8/14/23, 8/20/23, 8/30/23, and 9/4/23. On 4/8/23 at 11:53 AM, the [NAME] President of Clinical confirmed with the surveyor that section J.1800 of the qMDS for 11/17/23, was missed, and informed the surveyor that the qMDS for 11/17/23, would be revised for correction after surveyor inquiry. A review of the facility policy provided, Electronic Transmission of the MDS revised December 2010, included the following: Policy Statement All MDS assessments .will be completed electronically encoded into our facility's MDS information system and transmitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Policy Interpretation and Implementation 6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. NJAC 8:39-11.1, 11.2(e)(1)

Based on record review, staff interviews, and policy review, the facility failed to protect the right of two (Resident (R) 11 and R7) of four residents reviewed for abuse to be free from physical abuse by another facility resident. R11 experienced physical abuse by R24 resulting in facial injury requiring hospitalization and R7 experienced physical abuse by R23 resulting in facial injury requiring hospitalization and surgical intervention. The failure resulted in harm to R11 and R7. Findings include: 1. A. Review of R24's Profile tab in the electronic medical record (EMR) revealed he was admitted to the facility's secure unit on [DATE] with diagnoses, according to the Medical Diagnoses tab of the EMR, of metabolic encephalopathy with altered mental status, muscle weakness and difficulty walking, and heart failure. R24 was discharged from the facility on [DATE]. Review of R24's [DATE] hospital Discharge Summary, located in the Miscellaneous tab of the EMR, revealed the resident was brought to the emergency room for increased confusion and disorientation. He was diagnosed with metabolic encephalopathy (brain dysfunction). R24's documented behaviors included wandering and trying to stand though he was at risk of falling. There were no aggressive behaviors documented. Review of R24's five-day Minimum Data Set (MDS), assessment, with an assessment reference date (ARD) of [DATE], revealed he scored zero out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R24 required extensive assistance with transfers and locomotion, and he was ambulatory but unsteady on his feet. Review of R24's [DATE] Care Plan, located in the Care Plan tab of the EMR, revealed, [R24] has metabolic encephalopathy/dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] cognitive deficits. The interventions included: All staff to converse with [R24] while providing care . [R24] needs assistance/escort to activity functions . [R24's] preferred activities are looking [at] magazines, books, and walking around . Encourage ongoing family involvement. Invite [R24's] family to attend special events, activities, meals . [and] Introduce [R24] to residents with similar background, interests, and encourage/facilitate interaction. Review of R24's [DATE] to [DATE] Notes, located in the Notes tab of the EMR, revealed the resident had one incident of attempting to hit staff during care on [DATE]. No additional aggressive behaviors were documented. Review of R24's [DATE] 1:38 AM Occurrence [sic] Note, located in the Notes tab of the EMR, revealed, Around 10 PM, resident physically abuse [sic] his roommate [R11] with his chair and his fist. His roommate sustained severe injuries to his face, all parties were notified. Order obtained to send him to [emergency room ]. Resident was picked [up] by 911 at 10:45 PM. B. Review of R11's Profile tab in the EMR revealed the resident was admitted the facility on [DATE] with diagnoses, according the Medical Diagnoses tab of the EMR, of Alzheimer's disease with behavioral disturbance, muscle weakness, and difficulty walking. R11 was discharged from the facility on [DATE]. Review of R11's five-day MDS assessment, with an ARD of [DATE] and located in the MDS tab of the EMR, revealed R11 scored five out of 15 on the BIMS, indicating severely impaired cognition. R11 required limited assistance with bed mobility, transfers, and locomotion and was able to ambulate. R11 occasionally exhibited physical behaviors directed towards others and wandering. Review of R11's Care Plan, located in the Care Plan tab of the EMR and dated [DATE], revealed, [R11] is physically aggressive (Hitting staff) r/t [related to ] anger, dementia, [and] poor impulse control. The interventions included: The resident's triggers for physical aggression are (hitting staff). The resident's behaviors is [sic] de-escalated by redirecting . Analyze times of day, places, circumstances, triggers, and what deescalates behavior and document . Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain, etc. [and] When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. The Care Plan also documented, [R11] is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness. The approaches included: identify pattern of wandering: is wandering purposeful, aimless, or escapist? is resident looking for something? does it indicate the need for more exercise? intervene as appropriate . Monitor location every 15 min. Document wandering behavior and attempted diversional interventions in log . [and] Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Review of R11's [DATE] Occurrence [sic] Note, located in the Notes tab of the EMR, revealed, Resident physically abuse [sic] by his roommate with a chair and his fist as a result resident sustained severe injuries to his nose and face around 10 PM [on [DATE]]. I was trying to take the chair from him; he chased me trying to hit me too. I called for help, all the CNA [certified nurse aides] came and helped. All parties involve [sic] were notified, order obtained to send resident to [emergency room ]. Resident picked up by 911 at 10:30 PM. Review of R11's [DATE], 6:18 AM Orders - General Note from eRecord, located in the Notes tab of the EMR, revealed, [R11] arriver [sic] at the facility at around 2:20 AM via emergency transportation, he was brought to the unit at 2:30 AM in a stretcher by two emergency personnel . very agitated, will not stay still in the stretcher, he was dropped off at the TV and will not sit still, chair was offered to him but he would not sit down, walking around the hall, had to be monitored 1:1 [one-to-one]. Review of R11's [DATE] Care Plan, located in the Care Plan tab of the EMR, revealed, [R11] was a receiver of physical aggression. Punched by another resident in the face. The approaches included: Separate the two residents. Call 911, police, and transfer to ER [emergency room ] for evaluation. Apply ice pack to the nose bridge until transferred out to ER. Provide emotional support . Upon readmission: monitor any injuries to [the] facial area and follow any treatment orders if applicable. Provide with psychology services to allow him ability to vent any concerns he may have related to incident. Encourage his wife to visit as often as possible for support. Social services to visit weekly as well to assist with adjustment period. C. Review of the facility's [DATE] Reportable Event Record/Report, provided on paper, revealed on [DATE] at 9:30 PM, a resident-to-resident abuse incident occurred, and was reported to the state agency on [DATE] at 10:00 PM. The narrative documented, On [DATE] at approximately 9:30 PM, both residents were sitting talking with each other in the dayroom witnessed by staff as they were also roommates. Suddenly [R24] picked up a chair and before staff could get to him, he proceeded to hit [R11] with the chair and punched him in his face ,d+[DATE] times with his closed fist. Causing [R11] injuries to his face in 3 different areas as well as a bloody nose. As staff where [sic] attempting to grab [R11] away, [R24] started swinging and throwing chairs at the staff as well. Supervisor spent some time calming down [R24] enough for him to sit and relax, while the other staff were tending to the injuries of [R11] and calling 911. Police arrived with paramedics and transferred both residents separately to [the hospital.] [R24] was sent for a psych evaluation and [R11] was sent to be evaluated for his injuries. [R11] was later sent back to the facility, stable with no facial fractures, no pain, and didn't understand what happened. [R24] is currently inpatient involuntary psych commitment and will be placed in a facility better suited for his needs. The police, Ombudsman, both residents' physicians, and both residents' responsible parties were notified. The facility conducted an investigation which included interviews with multiple staff members. The investigation revealed R24 had no history of aggressive behaviors and staff could not determine why he became aggressive with R11. In an interview on [DATE] at 3:37 PM, Licensed Practical Nurse (LPN) 4 stated on the evening of [DATE], she witnessed R11 and R24, who were roommates, sitting and talking with each other in the day room. She stated, All of a sudden, [R24] grabbed a chair and kept hitting [R11]. I called for help . We separated the residents. LPN4 stated she did not witness an argument or any behavior preceding the event that would cause R24 to hit R11. She stated R24 admitted to her that he hit R11 but did not state a reason to her. LPN4 stated, R11 suffered facial lacerations and a bloody nose that required emergency medical transport to the emergency room for evaluation. She stated, It was horrific, there was blood everywhere. In an interview on [DATE] at 3:52 PM, the Director of Nursing (DON) stated in the event of resident-to-resident abuse resulting in serious injury, the incident should be reported to the state agency and police department within two hours. She stated this incident of resident-to-resident physical abuse resulted in serious injury for R11. She stated the incident was reported on [DATE] within a half hour of the occurrence. 2. A. According to R23's Profile tab of the EMR, the resident was admitted to the facility on [DATE] with diagnoses, per the Medical Diagnoses tab of the EMR, of schizoaffective disorder and anxiety. Review of R23's [DATE] Pre-Admission Screening and Resident Review (PASRR) Level I Screen, located in the Miscellaneous tab of the EMR, revealed R23 was in a psychiatric hospital and had a diagnosis of schizophrenia, which significantly impaired his functioning. A primary dementia exclusion was requested. Review of R23's [DATE] PASRR Level II Psychiatric Evaluation, located in the Miscellaneous tab of the EMR, revealed dementia/major neurocognitive disorder was confirmed by the psychiatrist; however, R23 did not meet the conditions for a primary dementia exclusion. The psychiatrist documented, Pt [patient] became noncompliant w/ [with] treatment at his residence. Pt was noted to be internally preoccupied. Paranoid. Poor ADLs [activities of daily living], talking to self, w/ neurocognitive deficits. Pt kept asking if he could fight people while off meds [medications], this behavior has stopped. Nursing home placement was recommended and the rationale was, Pt. needs supervision taking medications [and] with most needs - when compliant with assistance he is psychologically stable . [he] needs assistance with meals [and] showering. The evaluation documented R23 did not have an active psychosis, had a serious mental illness and treatment needs that could be met in a nursing facility, and did not need specialized services. Review of R23's [DATE] Care Plan, located in the Care Plan tab of the EMR, revealed, [R23] has Level II PASRR determination with mental health treatment needs related to Mental Illness. On [DATE], the Care Plan documented, The resident is (dependent on staff) for meeting emotional, intellectual, physical, and social needs r/t [related to] intellectual deficits. The approaches included: All staff to converse with resident while providing care . [and] establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary . The resident uses psychotropic medications (antipsychotics) r/t disease process (schizophrenia) . Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness [every shift]. Review or R23's Notes, under the Notes tab of the EMR, did not reveal any documented behaviors since admission until an incident on [DATE]. Review of R23's [DATE] Occurance [sic] Note, located in the Notes tab of the EMR, revealed, [R23] is observed leaving [R7's] room with bloodied hands and blood stains on both of his cheeks. [R23] showed no aggression prior and after the incident. Supervisor . was made aware . [physician] is informed and ordered may use restraints. A cut was noticed on the back of his right hand around the ring finger. Resident denies any pain. When asked what happened, [R23] states, I punched him in the face. When asked again 30 minutes later in the presence of . [police officer], [R23] reiterated, I punched him in the face! Resident was immediately removed from [R7's] room and redirected inside his room . 911 is called. Officers . arrived around 4:30 PM and interviewed both [residents] separately. [R23] is asked to wash his hands. A cut/laceration was noted on the back of his right ring finger. Resident denies any pain. Bacitracin is applied after being cleansed with normal saline and patted dry. Approximately after 5 PM [sic], [R23] is escorted out via stretcher by two EMS [emergency medical service] personnel and sent to [hospital]. B. Review of R7's Profile tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses, according to the Medical Diagnoses tab of the EMR, of shoulder fracture, seizures, weakness, schizophrenia, bipolar disorder, depression, and anxiety. R7 was discharged from the facility on [DATE]. Review of R7's admission MDS assessment, with an ARD of [DATE] and located in the MDS tab of the EMR, revealed he scored five out of 15 on the BIMS, indicating severely impaired cognition. R7 experienced hallucinations but no additional behavioral symptoms. He required extensive assistance with bed mobility, transfers, and locomotion. Review of R7's [DATE] Care Plan, located in the Care Plan tab of the EMR, revealed, The resident uses psychotropic medications (lithium and haloperidol) r/t [related to] behavior management. The approaches included, Monitor/record occurrence of for target behavior symptoms (SPECIFY: hallucination and agitation) and document per facility protocol. Review of R7's [DATE] Occurance [sic] Note, located under the Notes tab in the EMR, revealed, At approximately 4:15 PM while giving medications to one of my patient [sic], the nursing assistant while standing in front of the patient's room, called for my attention. As I raced into [R7's] room, [R23] was seen walking away from inside the room with blood on his hands and blood splattered on his face. [R7] was found bleeding from both nostrils and a lateral cut (2.5 cm [centimeters]) on the bridge of his nose with both eyes bleeding and right cheek swollen. When asked what happened, [R7] states the guy (pointing at [R23]) hit me! At approximately 4:20 PM, 911 was immediately called. Treatment was provided. Wounds were cleansed with normal saline, patted dry. Pressure applied to the nose to prevent further bleeding. [R7] is advised and educated not to blow his nose. Supervisor . is notified. Officers . arrived at around 4:30 PM and interviewed both residents. [Physician] and POA [Power of Attorney] were made aware. Approximately 5:15 PM, resident is taken to [Hospital] via stretcher escorted by two EMS [emergency medical service] personnel. Review of R7's [DATE] No Type Specified note, located in the Notes tab of the EMR, revealed, Called [Hospital] . informed writer that [R7] is in stable condition, awaiting transfer to an eye specialist [surgeon] in University Hospital in [NAME]. C. Review of the [DATE] Reportable Event Record/Report revealed an incident of resident-to-resident abuse occurred on [DATE] at 4:45 PM, and the incident was called in to the state agency on [DATE] at 5:44 PM. The narrative documented, On [DATE] at approximately 4:45 PM, a nursing aide observed [R23] in the room of another resident, [R7]. [R23] had, what appeared to be, blood on his hands and proceeded to walk out of [R7's] room, heading towards his own room. The nursing aide entered [R7's] room and observed [R7] sitting on the couch with lacerations to his face and a bloody nose. The nursing aide called for the nurse and another aide called for the nursing supervisor. [R23] was placed on 1:1 [one-to-one] monitoring in his room and [R7] was assessed by the nurse and his injuries treated. 911 was called at 4:48 PM. Two officers from the [NAME] Heights Police Department arrived at approximately 4: 55 PM. An ambulance arrived at 5:15 PM and [R7] was transported to [the hospital] for evaluation of his injuries. Another ambulance arrived at 5:25 PM and [R23] was transported to [the hospital] for crisis [evaluation]. The police, Ombudsman, both residents' physicians, and both residents' responsible parties were notified. The facility conducted an investigation which documented, A nursing aide on the unit had observed [R7] lying in bed at approximately 4:00 PM. This same aide also observed [R23] ambulating on a different hall of the unit at that same time. Another nursing aide, who was assigned to [R7], saw the resident in bed at 4:30 PM and provided him with water. When she exited [R7's] room, she observed [R23] down the hall at the nursing station. At approximately 4:45 PM, this same nursing aide observed [R23] in the room of [R7] with blood on his hands and injuries to [R7's] face. Upon questioning, [R23] repeated several times, l hit him but could not elaborate any further. When [R7] was questioned about the incident, he answered, He hit me!' He, also, was unable to provide any further information. No other staff member on the unit heard any noises indicative of a physical altercation taking place . It appears that a resident-to-resident altercation occurred between [R7] and [R23], facility is unable to substantiate abuse as there is no evidence as to what may have caused the altercation or which resident was responsible for initiating the altercation; it is unclear if the resident acted willfully or in self-defense. In an interview on [DATE] at 4:10 PM with LPN3, she stated she did not witness an altercation between R7 and R23; she was called to the room by the nurse [Registered Nurse (RN) 1] and recalled seeing a trail of blood on the floor to R23's room and R23 with blood on his hands, and found R7 with a bloody nose. LPN3 stated when she spoke with R23 after the incident, R23 reported R7 had called him the N-word and he had reacted by hitting R7. In an interview on [DATE] at 12:33 PM, CNA3 stated she had just seen both residents about 15 minutes prior to the incident and had not witnessed any aggression or fighting. She stated she found R23 leaving R7's room with blood on his hands, and R7 with blood on his face. In an interview on [DATE] at 2:35 PM, RN1 stated he did not witness the incident between R7 and R23; he was called to R7's room by the CNA. RN1 stated R23 stated he had hit R7, but he could not recall if he stated anything had happened to cause the aggression. In an interview on [DATE] at 3:52 PM, the DON stated in the event of resident-to-resident abuse resulting in serious injury, the incident would be reported to the state agency and police department within two hours. She stated this incident of resident-to-resident physical abuse resulted in serious injury for R7 and was reported to the state agency within an hour of incident on [DATE]. Review of the facility's Prohibition of Resident Abuse & Neglect policy, dated [DATE] and provided on paper, revealed, Our facility practices ZERO tolerance of resident abuse, neglect, mistreatment, exploitation or misappropriation of property by anyone including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, vendors, or any other visitors or individuals . Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish . Instances of abuse of all residents, irrespective of mental or physical condition, cause physical harm, pain, or mental anguish . Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. NJAC 8:,d+[DATE].1 (a) 5

C# 160500 Based on interviews, record review, and review of other pertinent documents on 1/13/23, it was determined that the facility failed to ensure that residents were consistently provided quarterly statements of their Personal Needs Account (PNA) for 3 of 3 residents (Residents #3, #4 and #5) reviewed for PNA records. This deficient practice is evidenced by the following: 1. According to the Admission Record (AR), Resident #3 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 12/6/22, revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated that the Resident's cognitive status was moderately impaired. During an interview with surveyor on 1/13/23 at 9:25 AM, Resident #3 stated that he/she did not receive quarterly PNA statements for 2022. 2. According to AR, Resident #4 was admitted to the facility on [DATE]. The MDS dated [DATE], revealed a BIMS score of 13 which indicated that the Resident's cognitive status was intact. During an interview with surveyor on 1/13/23 at 12:15 PM, Resident #4 stated that he/she did not receive PNA statements every quarter for 2022. 3. According to AR, Resident #5 was admitted to the facility on [DATE]. The MDS dated [DATE], revealed a BIMS score of 15 which indicated that the Resident's cognitive status was intact. During an interview with the surveyor on 1/13/23 at 12:35 PM, Resident #5 stated that the facility used to provide PNA statements every quarter but not this year. The Resident explained that he/she received a quarterly PNA statement once in 2022 but could not confirm which quarter. The surveyor conducted a telephone interview with the Director of Social Services (DSS) on 1/13/23 at 3:07 PM, who stated that the business office handles resident's PNA accounts and statement distribution. During an interview with the surveyor on 1/13/23 at 11:28 AM, the Business Office/HR Manager (BO/HRM) stated that the facility receives quarterly PNA statements from a contracted company that manages residents' accounts, but she was unsure how the statements are distributed to residents. She explained that she is responsible for recording the resident's cash-out receipts and reconciling them with the contracted company. However, she could not confirm if she is responsible for the timely distribution of quarterly PNA statements to the residents. During the exit conference with the Director of Nursing (DON) and Regional VP of Nursing (RVPN) on 1/13/23 at 4:24 PM, they stated that every quarter the administrator and social worker would distribute and review the PNA statements with the residents, then the residents would sign an area on the statement to acknowledge receipt, and a copy of the signed statement is retained afterwards. The DON and RVPN stated that residents should have received their PNA statements every quarter for 2022 but they were unable to provide documented evidence to the surveyor during the survey. During a telephone interview with the Assistant Administrator (AA) on 1/17/23 at 2:43 PM, he stated that the BO/HRM is now responsible for distributing quarterly PNA statements to residents. He explained that residents should have received their PNA statements every quarter for 2022 because the former administrator and administrator in training distributed the PNA statements, however, the AA was unable to provide documented evidence to the surveyor. Additionally, the AA was unable to provide a policy for PNA accounts and stated that the facility refers to the regulation. A review of the job description titled Director of Human Resources/Business Office Manager, undated, under Responsibilities/Duties, indicated monitors, categorizes and distributes all correspondence regarding resident finances, including but not limited to PNA .distributes quarterly PNA statements jointly with Social Services Department. NJAC 8:39-4.1 (a) 9

Based on interviews and record review, as well as review of pertinent facility documents on 8/9/22 and 8/10/22, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) a staff to resident allegation of abuse and follow the facility policy ABUSE REPORTING for 1 of 2 residents (Resident #3) reviewed for incident and accident. This deficient practice is evidenced by the following: During the tour with the Unit Manager (UM #1) on 8/9/22 at 11:15 am, she stated that Resident #3 was interviewable. During an interview with Resident #3 on 8/9/22 at 11:26 am, Resident #3 revealed that on 7/13/22 during 11:00 to 7:00 am, a female aide (no name) put feces into his/her face and male aide (Certified Nursing Assistant #1) punched him/her on the right thigh and had called the police. He/she further added that the aforementioned incident was reported to the Director of Nursing (DON) on the same day (unable to recall time). Resident #3 further stated that he/she felt violated and abused. According to the ADMISSION RECORD (AR) form, Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool dated 6/15/22, showed that Resident #3's cognition was intact required extensive assistance from staff in Activities of Daily Living (ADL). The Care Plan (CP), initiated on 6/14/22 and revised on 7/19/22, showed that Resident had behavior problem of accusatory in nature related to Paranoid [CONDITION(S)]. The CP further showed that on 7/13/22 at 6:30 am, Resident #3 reported to the Residents Representative (RR) that a male aide scratched his/her rectum and hit him/her on the right thigh, and a female aide wiped his/her face with the dirty towel that was used to wipe his/her rectum. The Progress note (PN) dated 7/13/2022 at 07:23 am, Licensed Practical Nurse (LPN #1) documented the assigned nurse to Resident #3 during 11:00 pm to 7:00 am shift. The PN documentation indicated that at 6:45 am, LPN #1 heard that Resident #3 was yelling. LPN #1 entered Resident #3's room, the Resident reported that the two aides were rough during care. The PN further indicated that on 7/13/22 at 5:17 pm, LPN #2 documented the assigned nurse to Resident #3 during 7:00 am-3:00 pm shift. LPN #2 documented that around 11:10 am, the police arrived at the facility because Resident #3 reported that the overnight staff hit him/her on the right hip. Resident #3's skin had no bruises or redness during the assessment. Futhermore, the PN showed that on 7/20/22 at 2:13 pm, documented by the Director of Nursing (DON), the PN showed that the office of ombudsman was made aware of Residents #3's behavior of accusing staff of abuse and calling 911. The Medical record (MR) showed no documented evidence to indicate that the aforementioned incident was reported to the NJDOH. LPN #2 was interviewed on 8/9/22 at 12:50 pm, she confirmed the aforementioned incident, an allegation of abuse on 8/9/22 involving Resident #3. LPN #2 stated that she reported the incident to UM #1 and to the DON on the aforementioned date (unable to recall time)because it is consider an allegation of abuse. UM # 1 was interviewed on 8/9/22 at 1:11 pm, she confirmed the aforementioned incident, an allegation of abuse on 7/13/22 involving Resident #3. UM #1 stated that she reported the incident to the DON on 7/13/22 because it was an allegation of abuse. She further added that she did not further investigate because she reported the aforementioned incident to the DON. Vice President Clinical (VPC) was interviewed on 8/9/22 at 1:33 pm, VCP stated that the aforementioned incident was not reported to NJDOH which was not according to the facility. The VPC further added that any allegation of abuse had to be investigated and reported to the NJDOH. The surveyor conducted a telephone interview with the DON on 8/10/22 at 11:02, she confirmed the aforementioned incident invoving Resident #3 was reported to her, however, she did not report to the NJDOH. The facility's policy titled Your Rights and Protections as a Nursing Home Resident, undated, showed .Be Free from Abuse and Neglect .You have the right to be free from verbal, sexual, physical, and mental abuse. Nursing Homes can't keep you apart from everyone else against your will. If you feel you have been mistreated (abused) .report this to the nursing home .local Long-Term Care Ombudsman, or State Survey Agency. The nursing home must investigate and report all suspected violation .within 5 working days of the incident to the proper authorities . The facility's policy titled ABUSE REPORTING, dated 1/4/21, showed .When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility Administrator, or his/her designee, will notify the following persons or agencies of such incident asap [as soon as possible] but not longer than 2 hours; a. State Licensing and Certification Agency. b. Ombudsman .5 .d. Physical abuse is defined as hitting, slapping, pinching, kicking .9. A completed copy of the initiated abuse investigation and written statements from witnesses, if any, must be provided to the Administrator within twenty-four (24) hours of the occurrence of such incident. NJAC 8:39-9.4 (f)

Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) document and carry out a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) notify the resident's physician that staff was unable to obtain the urine and stool sample. This deficient practice was identified for 1 of 35 residents, (Resident #84) reviewed for quality of care and was evidenced by the following: On 1/05/22 at 11:44 AM, the surveyor was approached by an alert and oriented resident, Resident #34 who was the roommate of Resident #84. Resident #34 stated that his/her roommate was recently admitted to the hospital. Resident #34 stated that he/she was very close with his/her roommate and they looked after one another like family. Resident #34 further stated that his/her roommate, Resident #84 had become delirious in the middle of the night and when that happened, the resident was sent out to the hospital by facility staff. The surveyor reviewed the medical record for Resident #84. A review of Resident #84's Admission Record (an Admission Summary) reflected that that resident was a long term care resident at the facility and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/21/21 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A review of the resident's Progress Notes (PN) dated 12/23/21 and timed at 23:10 (11:10 PM) written by the Registered Nurse (RN) reflected that the resident had two episodes of vomiting. The RN called the resident's physician to notify him of the change in resident's status and received new orders for a urinalysis and a stool culture to test for ova (eggs) and parasites. A review of the resident's January 2022 Order Summary Report (OSR) did not reflect a PO for the urinalysis or stool culture. A review of the resident's laboratory results, did not indicate that urine or stool was obtained from the resident and sent to the lab for processing. A review of the Laboratory Requisition Form dated 12/23/21 reflected that the RN put in a request for a urinalysis and culture to be obtained for the resident. The urine was never obtained and sent to the laboratory. A review of an additional Laboratory Requisition Form dated 12/23/21 reflected that the RN made an additional request for a stool culture to test for ova and parasites be obtained for the resident. The stool culture was never obtained and sent to the laboratory. A review of the resident's PN from 12/23/21 to 12/30/21 did not indicate that the resident's physician was made aware that the urine or stool sample was not obtained for the resident. This reflected a seven-day delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A further review of the resident's January 2022 OSR reflected a PO dated 12/30/21 for urinalysis and culture. A further review of the resident's PN's dated 12/30/21 and timed at 22:28 (10:28 PM) written by the Licensed Practical Nurse (LPN) indicated that the resident was in no distress. The 12/30/21 PN indicated that the Nursing Supervisor attempted to obtain urine via straight catheterization (inserting a flexible tube into the bladder to collect urine) and was unable to do so. The PN further indicated that the resident would be provided with fluids to drink and the nurse would try to obtain the urine later in the shift. A continued review of the resident's PN from 12/30/21 to 1/2/22 did not reflect that urine or stool was obtained or that the resident's physician was notified that the Nursing Supervisor was unable to obtain urine by way of straight catheterization for the Resident #86. A review of the resident's Care Plan (CP) revised 12/13/21 indicated a focus area that the resident had high blood pressure related to [CONDITION(S)] and was at risk for stoke. The goal of the resident's CP was that the resident would remain free from signs and symptoms of high blood pressure through the next review date. The interventions in the resident's CP indicated to monitor and document abnormalities in urinary output and report significant changes to the resident's physician. On 01/10/22 at 10:44 AM, the surveyor interviewed the resident's Registered Nurse/Unit Manager (RN/UM) who stated that the resident's primary nurse was not working that day. The RN/UM stated that the resident was alert and oriented and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN/UM told the surveyor that the resident was sent out to the hospital because the resident's blood pressure was low, and the resident became confused which was different from his/her baseline. The RN/UM stated that prior to being sent to the hospital the resident had been complaining of nausea and vomiting. The RN/UM stated that she thought the resident's physician ordered a stool and urine sample for culture, but the staff was unable to obtain the urine. The RN/UM did not mention if the stool was ever obtained. The RN/UM further stated that she was unsure of why the staff were unable to obtain the urine sample and would have to find out. The RN/UM stated that if the physician ordered labs, they were usually done the following morning and if the nurse was unable to obtain the physician ordered urine and stool sample, the physician should have been notified and it should be documented in the resident's medical record. At 11:53 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident was alert and oriented, very social, non-compliant with care, and made smoking his/her priority. The DON further stated that prior to the resident's hospitalization the resident became weak and lethargic. The DON told the surveyor that when a physician ordered laboratory work to be done, the expectation was to follow the PO. The DON stated that if the staff was unable to obtain the physician ordered lab specimen, the staff would have to let the physician know and then document that the physician was notified in the resident's medical record. On 01/11/22 at 11:46 AM, the surveyor interviewed the Vice President of Clinical Operation (VP) who stated that it wasn't until 12/30/21 that the resident's urine was attempted to be obtained. The VP did not speak to the stool sample or notification of the physician. At 11:49 AM, the DON stated that when labs were ordered for a resident, the nurse would write a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further stated that it was the nurses working at the facility's responsibility to obtain the urine and stool samples, not the laboratory technicians. At 1:02 PM, the surveyor placed a call to the RN who wrote the PN dated 12/23/21 and timed at 23:10 (11:10 PM) for the urine and stool culture after speaking with the resident's physician, but the RN was unavailable for an interview. At 1:24 PM, the surveyor conducted an interview with the resident's physician over the telephone who stated that if he gave orders for laboratory specimens to be obtained, it was his expectation that they would be done for the resident. The physician further stated that he expected the nurses would notify him of the laboratory results and he further expected to be notified if the labs were unable to be obtained. The resident's physician further stated that he did not recall being notified that the resident's urine or stool were not obtained as ordered. A review of the facility's Physician Notification of Change in Resident/Patient Condition Policy and Procedure dated 12/20/21 indicated, Our facility shall promptly notify the resident, his or her attending physician, and the representative (sponsor) of changes in the resident's condition and/or status. NJAC 8:39-27.1(a)

Based off observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) place a splinting device on a resident who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was identified for 1 of 4 residents, (Resident #43) reviewed for position and mobility. The deficient practice was evidenced by the following: On 01/04/22 at 10:02 AM, the surveyor observed Resident #43 glide to the front of the nurse's station on the 3 West unit in his/her motorized wheelchair. The surveyor further observed that the resident had a splinting device secured around on his/her left hand. The surveyor attempted to interview the resident; the resident softly told the surveyor his/her name. On 01/05/22 at 12:21 PM, The surveyor observed the resident lying in bed in his/her room. The surveyor observed a trapeze bar over the resident's bed. The surveyor further observed that the resident was not wearing a splinting device on his/her left hand. On 01/06/22 at 10:53 AM, the surveyor observed the resident sitting upright in bed watching television. The surveyor observed that the residents left hand was not placed in a splinting device. The resident's left hand was observed to be formed in a fist and was placed at the resident's side. At 1:36 PM, the surveyor observed the resident in bed watching television. The surveyor observed that the resident was not wearing his/her left-hand splint. The surveyor attempted to interview the resident and asked the resident where his/her hand splint was. The surveyor could not understand the resident when he/she spoke. The resident pointed and showed the surveyor that his/her left-hand splint was located on the dresser next to the resident's bed. The residents left hand remained curled in a fist. On 01/10/22 at 10:03 AM, The surveyor observed the resident in his room, lying in bed. The surveyor observed the resident's left hand under a sheet. The resident's left-hand splint was observed laying on the floor by the resident's closet. At 10:23 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident wore a splint on his/her left-hand. The CNA told the surveyor that she got the resident up out of bed on Monday's and Wednesday's and on those days, she would put the splint on the resident's left hand. The CNA further stated that on the days she did not put the splint on the resident, the therapist would. The CNA never mentioned that the resident would remove the hand splint. At 10:55 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that she regularly took care of the resident and she never put the splinting device on the resident. The LPN stated that the resident was alert and oriented, did not speak clearly, had [CONDITION(S)] (decline or loss in the ability to express speech), and could make needs known by speaking very slowly. The LPN was unsure if the resident had a contracture upon surveyor inquiry and stated that the resident did not wear a split to his/her left hand. The LPN further stated that if the resident wore a hand splint, there would be a PO for the use of the hand splint. The LPN reviewed the POs for the resident in the presence of the surveyor and identified that there was a PO for the use of the left-hand splint. The LPN further reviewed the January 2022 Treatment Administration Record in the presence of the surveyor and identified that there was no place for her to sign for the use of the left-hand splint. At 11:25 AM, the surveyor interviewed the Registered Nurse/Unit Manager who stated that the resident was alert and oriented, had a contracture to his/her left hand, and wore a splinting device. The RN/UM further stated that it was the CNA's or the nurse's responsibility to place the splinting device on the resident and then the nurse would sign for the application of the device on the TAR. The RN/UM stated that sometimes the resident would put the left-hand splint on himself/herself. The RN/UM told the surveyor that the therapy department was not responsible for putting the hand splint on the resident but would educate the nursing staff on how to apply it if needed. The RN/UM never mentioned that the resident would remove the hand splint. At 11:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the person responsible for putting the splinting device on the resident was the restorative nursing aide and the primary nurse would sign for the accountability of putting the hand splint on the resident in the TAR. The DON did not speak to who would place the hand splint on the resident when the restorative nursing aide had off from work. At 12:20 PM, the surveyor interviewed the Director of Rehab (DR) who stated that Resident #43 wore the splint to his/her left hand, and it was the restorative nursing aide's responsibility to put the left-hand splint on the resident in the morning and document that she put it on and took it off the resident. The DR further stated that the resident would sometimes remove his/her left-hand splint. At 12:33 PM, the surveyor asked the Administrator if the restorative nursing aide was available for an interview and was told that she had off from work. The Administrator stated that she was unsure who was responsible for putting the hand splint on the resident when the restorative nursing aide was off from work, but she would find out. At 12:40 PM, the Administrator stated that it was the nurse's responsibility to put the hand splint on the resident when the restorative nursing aide had off work The surveyor reviewed the medical record for Resident #43. A review of the resident's Admission Record (an Admission Summary) reflected that the resident had resided at the facility for several years and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/5/21 indicated that the resident had unclear speech and was usually able to be understood when expressing himself/herself. A further review of the resident's MDS indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A review of Section G0400 - Functional Limitation in Range of Motion indicated that the resident had limited range of motion in one upper extremity. A review of the resident's January 2022 Order Summary Report (OSR) reflected a PO dated 01/10/22 for resting hand splint on left hand. ON after AM care. Off at PM care. A review of the November 2021 TAR and December 2021 TAR did not reflect a PO for the nurses to sign for the accountability for the resting hand splint. A review of the January 2022 TAR reflected a PO dated 01/10/22 for nurses to sign for the accountability of the resting hand splint to be applied after AM care and removed after PM care. A review of the resident's November 2021 Restorative Nursing Program Sheet indicated hand splint to prevent contracture on after AM care, off before PM care. A further review of the November 2021 Restorative Nursing Program Sheet reflected that the restorative nursing aide did not sign for the use of the hand splint on 11/6/21, 11/7/21, 11/13/21, 11/14/21, 11/18/21, 11/20/21, 11/21/21, 11/27/21, and 11/28/21. A review of the resident's December 2021 Restorative Nursing Program Sheet indicated hand splint to prevent contracture on after AM care, off before PM care. A further review of the December 2021 Restorative Nursing Program Sheet reflected that the restorative nursing aide did not sign for the use of the hand splint on 12/4/21, 12/5/21, 12/11/21, 12/12/21, 12/13/21, 12/18/21, 12/19/21, 12/25/21, and 12/26/21. A review of the resident's January 2022 Restorative Nursing Program Sheet indicated hand splint to prevent contracture on after AM care, off before PM care. A further review of the January 2022 Restorative Nursing Program Sheet reflected that the restorative nursing aide did not sign for the use of the hand splint on 01/1/22, 01/2/22, 01/6/22, 01/7/22, 01/8/22, 01/09/22, and 01/10/22. A review of the resident's undated Care Plan (CP) reflected a focus area that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal of the residents CP was for the staff to continue to provide the resident with help and the resident would not sustain injuries or feel unsafe. The interventions for the resident's CP included that the resident had a left-hand grip orthosis splint to be put on after AM care and removed after PM care to prevent further joint limitations and pain. The resident's CP did not reflect that the resident would remove his/her left-hand splint. On 01/11/22 at 11:27 AM, the surveyor interviewed the Vice President of Clinical Operations who stated that she interviewed the resident and the resident stated that sometimes he/she would remove the hand splint during the day and the residents care plan was updated to reflect that the resident had this behavior. A review of the facility's undated Cast/Splint/Brace/Immobilizer/Sling Care Policy indicated, Cast/Splint/Brace/Immobilizer/Sling Care monitoring is performed on residents. The facility's Cast/Splint/Brace/Immobilizer/Sling Care Policy did not reflect who was responsible for putting the splint on the resident or how the splinting device was monitored or accounted for while in use for a resident. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to: a.) receive a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) plot medications to be administered according to the resident's [CONDITION(S)] schedule. This deficient practice was identified for 1 of residents, (Resident #15) reviewed for [CONDITION(S)] and was evidenced by the following: On 1/04/22 at 10:26 AM, the surveyor observed Resident #15 lying in bed. The resident closed his/her eyes when the surveyor entered the resident's side of the room. The surveyor asked the resident if he/she went to [CONDITION(S)] and the resident stated, no. The surveyor did not attempt to further interview the resident because the resident's body language indicated that he/she did not want to further communicate with the surveyor. The surveyor reviewed the medical record for Resident #15. A review of the resident's Admission Record (an Admission Summary) reflected that the resident resided at the facility for approximately half a year and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's most recent significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/15/21 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. A further review of the resident's MDS, Section O - Special Treatments, Procedures, and programs reflected that the resident was on [CONDITION(S)]. A review of the resident's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/10/22 at 10:11 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that for the past two weeks, the resident's [CONDITION(S)] schedule had changed for him/her to be picked up from the facility at 2:30 PM, instead of 5:30 AM on Tuesday's, Thursday's, and Saturday's. The LPN told the surveyor that as of tomorrow (01/11/21), the resident would be going back to his/her regular scheduled [CONDITION(S)] schedule of 5:30 AM. The LPN stated that when the resident went to [CONDITION(S)] early in the morning, he/she would return to the facility around 11:30 AM. This indicated the resident was out of the facility for approximately six hours. The LPN stated that when the resident left for [CONDITION(S)] at 2:30 PM, she was done with her shift at 3:00 PM, so she did not know when the resident was returning to the facility. The LPN stated that the resident's medications should be scheduled to be administered according to the resident's [CONDITION(S)] schedule. The LPN was unaware if the resident's medication times had changed to reflect the change in the resident's [CONDITION(S)] schedule. At 11:21 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident's [CONDITION(S)] schedule had changed because the resident had tested positive for COVID-19. The RN/UM further stated that she assumed the resident's medications were changed according to the resident's [CONDITION(S)] schedule. At 11:50 AM, the surveyor interviewed the Director of Nursing (DON) who stated that medications should be plotted when the resident was in the building, not when the resident was at [CONDITION(S)]. The DON further stated that if a resident's [CONDITION(S)] schedule changed, the medication times should also be changed. A review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This indicated that the resident was COVID-19 positive and needed additional infection control measures in place. A further review of the resident's December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered the [MEDICATION(S)] medication at 1700 (5:00 PM) on Thursday 12/23/21, Saturday 12/25/21, Tuesday 12/28/21, and Thursday 12/30/21. A further review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the medication [MEDICATION(S)] 10 mg at 1700 (5:00 PM) on Thursday 12/23/21 and Saturday 12/25/21. A further review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the medication [MEDICATION(S)] 2.5 mg at 1700 (5:00 PM) on Thursday 12/23/21, Saturday 12/25/21, and Tuesday 12/28/21. A further review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The supplement was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the Nephro 8 oz supplement at 1700 (5:00 PM) on Thursday 12/23/21, Saturday 12/25/21, Tuesday 12/28/21, and Thursday 12/30/21. A review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered the Vitamin C 500 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/04/22, and Saturday 01/8/22. A further review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered [MEDICATION(S)] 220 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/04/22, and Saturday 01/8/22. A further review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 1700 (5:00 PM). The nurses had signed that the resident was administered [MEDICATION(S)] 25 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/04/22, and Saturday 01/8/22. A further review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 0900 (9:00 AM) and 1700 (5:00 PM). The nurse signed that the medication [MEDICATION(S)] 2.5 mg was administered at 1700 (5:00 PM) on Saturday 01/01/22. A further review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The supplement was plotted to be administered at 0900 (9:00AM) and 1700 (5:00 PM). The nurses had signed that the resident was administered the Nephro 8 oz supplement at 1700 (5:00 PM) on Saturday 01/1/22, Thursday 01/06/22, and Saturday 01/8/22. A further review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was plotted to be administered at 1100 (11:00 AM), 1700 (5:00 PM), and 2100 (9:00 PM). The nurses had signed that the resident was administered the Calcium Acetate 667 mg at 1700 (5:00 PM) on Saturday 01/1/22, Tuesday 01/4/22, and Saturday 01/8/22. The resident's [CONDITION(S)] chair time had changed to 2:30 PM pick up from the facility on Tuesday's, Thursday's, and Saturday's, this indicates the resident would not have been back at the facility for approximately five to six hours (7:30 PM to 8:30 PM). Therefore, Resident #15 would not have been in the facility at 5:00 PM to have been administered his/her medications. A review of the resident's undated Care Plan (CP) indicated a focus area that the resident was on [CONDITION(S)] related to renal (kidney) failure. The goal of the resident's CP was the resident would have immediate intervention if complications from [CONDITION(S)] occurred and the resident would show no complications from [CONDITION(S)] through the next review date. The intervention on the resident's CP did not include scheduling the resident's medication according to [CONDITION(S)] times. On 01/11/22 at 11:30 AM, the surveyor conducted a follow up interview with the DON who stated that on 12/23/21 the resident tested positive for COVID-19 and his/her [CONDITION(S)] chair time changed to 3:30 PM. At 11:33 AM, the surveyor interviewed the Vice President of Clinical Operations (VP) who stated that when the resident's [CONDITION(S)] chair time changed, there was no PO to reflect the change in time, and she was unaware of when the resident went back to his/her normal schedule of 5:30 AM pick up from the facility. The VP further stated that the facility had no policy and procedure for residents on [CONDITION(S)]. A review of a typed statement provided by the DON indicated that the resident, was diagnosed covid + on 12/23/21. [CONDITION(S)] center asked to keep [gender redacted] days the same and change chair time to 3:30 PM. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate pharmaceutical services which included ensuring accurate administering and reconciliation of all drugs, in accordance with professional standards. This deficient practice was identified for 3 of 4 residents (Resident #47, #156 and #812) during the medication administration observation with 2 of 2 nurses during the medication observation pass. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1. On 1/6/2022 at 10:42 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor with the Licensed Practical Nurse (LPN #1). The surveyors with the LPN #1 observed on the electronic Medication Administration Record (eMAR) for Resident #812 a single order for [MEDICATION(S)] ([MEDICATION(S)])150 milligram (mg; an antipsychotic medication). LPN #1 removed two (2) bingo cards (a method of packaging medication doses within clear or light resistant bubbles or blister pack done by the provider pharmacy) from the medication cart with the resident's name on the top right-hand corner. One (1) of the bingo cards for Resident #812 was for [MEDICATION(S)] 100 mg and the other bingo card was for [MEDICATION(S)] 50 mg. Each bingo card had a supplementary note that read 150 mg = 100 mg + 50 mg. The PO had no supplementary instructions. On 1/6/22 at 11:22 AM, the surveyor interviewed LPN #1 who stated that she administered one (1) tablet of 100 mg and one (1) 50 mg tablet to make the dose of 150 mg. LPN #1 acknowledged that the PO should match what was being administered. LPN #1 added that there should be two (2) PO; one for [MEDICATION(S)] 100 mg and one for 50 mg that she would sign on the eMAR to reflect the medications she was administering. LPN #1 stated she would inform the Unit Manager (UM) to reconcile the discrepancy between the PO and the medication being administered. On 1/6/2021 at 12:01 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the night nurse received the medications from the pharmacy and reconciled those medications with the PO. The RN/UM further stated if the PO does not match the medication being sent by the pharmacy then they called the pharmacy or the physician and clarified the PO. The RN/UM added that the nurse passing the medication should also call the pharmacy if the PO does not match with the medications being administered. The RN/UM stated that sometimes the pharmacy called when the medication sent was different from the order and instructed the nurse to correct the PO with the physician. The RN/UM confirmed that medications must be administered as ordered. The surveyor reviewed the medical record for Resident #182 A review of the resident's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included [CONDITION(S)] disorder and anxiety. A review of the current Order Summary Report (OSR) reflected an order dated 12/27/21 with a start date of 12/28/21, for [MEDICATION(S)] ([MEDICATION(S)]) 150 mg; give 150 mg by mouth one time a day. There were no supplementary notes associated with the PO. On 1/10/22 at 11:00 AM, the surveyor conducted an interview with the Assistant Director of Nursing (ADON) who stated that medications being administered must match the PO on the eMAR. The ADON further stated that the physician can be contacted to clarify the PO to reflect the medication being dispensed by the provider pharmacy. On 1/10/22 at 2:30 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated that PO must match what was being administered by the nurses. CP further stated if a PO was for [MEDICATION(S)] 150 mg and the pharmacy sent 100 mg and 50 mg and the label indicated to administer both to equal 150 mg; then the PO should be changed to match the medication that was being dispensed from the pharmacy and administered by the nurses. On 1/11/22 at 12:16 PM, the Director of Nursing (DON) acknowledged that LPN #1 should have administered the medication as prescribed by the physician. On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team interviewed the Licensed Nursing Home Administrator (LNHA), DON, and Vice President Clinical (VPC). The VPC stated that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further clarified that if there was a discrepancy between the PO and the bingo card, then the physician should be called to clarify the PO. 2. On 1/6/22 at 11:03 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor with LPN #1. The surveyors with LPN #1 observed on the eMAR for Resident #47 a PO for losartan ([MEDICATION(S)]) 25 mg (a medication to reduce high blood pressure); give 1 tablet by mouth one time a day. LPN #1 removed a bingo card from the medication cart with the resident's name on the top right-hand corner for [MEDICATION(S)] 50 mg tablets that were cut in half. The bingo card had a supplementary note for [MEDICATION(S)] which indicated 25 mg = ½ TABS and ½ tablets were dispensed. The PO had no supplementary instructions. On 1/6/22 at 11:22 AM, the surveyor and LPN #1 reviewed the eMAR which revealed a PO dated 7/27/21, for [MEDICATION(S)] 25 mg; give 1 tablet by mouth one time a day. LPN #1 stated that the pharmacy had already cut the [MEDICATION(S)] 50 mg tablets to make the 25 mg dose. The surveyor asked LPN #1 if the PO and eMAR should match the medication being administered to Resident #47. LPN #1 acknowledged that the PO and eMAR should match the medication administered. LPN #1 stated that she would inform the UM to reconcile the discrepancy between the PO and the medication being dispensed and administered. On 1/6/2021 at 12:01 PM, the surveyor interviewed the RN/UM who stated the night nurse received the medications from the pharmacy and reconciled those medications with the PO. The RN/UM further stated if the PO does not match the medication being sent by the pharmacy then they should call the pharmacy or the physician and clarify the PO. The RN/UM added that the nurse passing the medication should also call the pharmacy if the PO does not match with the medications being administered. The RN/UM confirmed that medications must be administered as ordered. The surveyor reviewed the medical record for Resident #47. A review of the current OSR reflected an order dated 7/27/20 and a start date of 7/28/20, for [MEDICATION(S)] 25 mg; give 1 tablet by mouth one time a day for hypertension. There were no additional supplementary notes associated with the medication order. On 1/10/22 at 11:00 AM, the surveyor interviewed the ADON who confirmed that medications being administered must match the PO on the eMAR. The ADON stated that the physician should be contacted to clarify the PO to reflect the medication being dispensed by the provider pharmacy. On 1/10/22 at 2:30 PM, the surveyor interviewed the CP via telephone who confirmed that PO must match what is being administered by the nurses. On 1/11/22 at 12:16 PM, the DON acknowledged that LPN #1 should have administered the medication as prescribed by the physician. On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team interviewed the LNHA, DON, and VPC. The VPC stated that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further stated that if there was a discrepancy then the physician should be called to clarify the PO. 3. On 1/10/22 at 9:09 AM, the surveyor conducted a medication pass observation in the presence of a second surveyor with LPN #2. The surveyors with the LPN #2 observed on the eMAR for Resident #156 a PO for Vitamin D3 (a dietary supplement) 5,000 international units (IU) tablet; give one tablet by mouth once daily for supplement. LPN #2 removed a bottle of Vitamin D3 5,000 IU capsules from the medication cart to administer to Resident #156. LPN #2 stated that the Vitamin D3 5,000 IU capsule was an over the counter (OTC) medication and was obtained by the facility as a house stock product. On 1/10/22 at 10:30 AM, the surveyors with LPN #2 reviewed the eMAR for Resident #156 which revealed a PO with a start date 6/16/2020, for Vitamin D3 5,000 IU tablet; give one tablet by mouth once daily for supplement. LPN #2 stated the capsule formulation was the only available item in his cart. LPN #2 acknowledged the PO indicated to administer Vitamin D3 5000 IU tablets and that he had administered the capsule. LPN#2 also acknowledged that the PO should match the medication administered. LPN #2 stated that he would have to call central supply to see if they had the tablet formulation. LPN #2 stated that he could also call the prescriber to request for a change of formulation to the capsule because the resident was able to swallow the capsules. On 1/6/2021 at 12:01 PM, the surveyor interviewed with the RN/UM who stated that OTC medications were the facility's house stock medications and can be ordered from central supply. The RN/UM added that for house stock medications, the nurses can check other medication carts for availability. The RN/UM further stated that the physician can be contacted, and a request made for an alternative medication if a medication was not available. The surveyor reviewed the medical record for Resident # 156. A review of the resident's Admission Record reflected that the resident was admitted to the facility with diagnoses which included Vitamin D deficiency, [CONDITION(S)], extrapyramidal and movement disorder (involuntary or uncontrollable movements, tremors, or muscle contractions). A review of the current OSR reflected an order dated 6/15/2020 with a start date of 6/16/2020, for Vitamin D3 5,000 IU tablet; give 1 tablet by mouth one time a day for supplement. On 1/10/22 at 11:00 AM, the surveyor interviewed the ADON who confirmed that medications being administered must match the PO on the eMAR. The ADON further stated that the physician should be contacted to clarify the PO to reflect the medication being dispensed by the provider pharmacy. On 1/10/22 at 2:30 PM, the surveyor interviewed the CP via telephone who confirmed that PO must match what was being administered by the nurses. A review of the house stock item list provided by the LNHA revealed that Vitamin D3 5,000 IU tablet was on the list and Vitamin D3 5000 IU capsule was not on the list. On 1/11/22 at 12:16 PM, the DON acknowledged that the nurses should administer a medication as prescribed by the physician. On 1/11/22 at 1:52 PM, the surveyor in the presence of the survey team interviewed the LNHA, DON, and VPC. The VPC stated that when the nurses received a medication from the pharmacy, they were to make sure that the medication matched what was ordered by the physician. The DON further clarified that if there was a discrepancy between the PO and the bingo card, then the physician should be called to clarify the PO. A review of the facility's Medication Administration Policy dated revised 12/20/21, included prior to administering the first dose of a new medication, the nurse will verify the order was correctly transcribed by comparing with the physician's order .check the transcribed order on MAR for the dose, time and route of administration .compare medication order on the MAR three (3) times with label on medication (taking out of drawer before opening and compare label again). A transcription of medication policy was requested, but the facility was unable to provide a policy. NJAC 8:39-11.2(b); 29.2(a)(b)(d); 29.4(b)

Based on observation, interview and record review, it was determined that the facility failed to provide effective interventions to maintain skin integrity and prevent shearing for a staff- dependent resident. Resident #10 developed facility-acquired Stage II sacral pressure ulcers. The facility also failed to provide proper wheelchair positioning for another staff-dependent resident. Resident #21, developed an unstageable pressure ulcer on the right elbow. These deficient practices were evidenced for 2 of 10 residents reviewed for pressure ulcers as evidenced by the following: 1. During the initial tour of the facility on 5/16/13 at 10:30 a.m., the tour nurse identified Resident #10 with a recurrent stage II sacral pressure ulcer. The tour nurse stated that the resident was non-verbal and staff dependent for all activities of daily living. The tour nurse further stated that the resident required the assistance of 2 staff members for bed mobility and mechanical transfers since Resident #10 was a "big man" and had recently gained weight. On 5/16/13 at 12:30 p.m. the surveyor reviewed the medical record of Resident #10 which revealed the following: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, of 9/19/12, 12/4/12, and 2/27/13 indicated that the resident required the assistance of 2 staff members for bed mobility and transfers. A review of the "Braden Scale- For Predicting Pressure Sore Risk" of 12/4/12 and 2/27/13 indicated that the resident had a "potential problem" with "friction and shear." A review of the "Long Term Care Interdisciplinary Progress Notes" revealed the following: On 8/15/12 "repositioned x 1 assist." On 9/24/12 "Skin is intact. Stage II sacral breakdown has healed." On 10/29/12 at 10:00 a.m. "Sacral wound reopened." On 11/15/12 at 10 a.m. "Healed intact sacral tissue." On 11/30/12 11p.m.-7a.m. "Repositioned x 1 assist." On 1/27/13 at 8:00 a.m. "Bed mobility with assist of 1." On 3/2/13 Monthly summary "repositioned x 1 assist." On 4/13/13 at 4:00 p.m. "Right hip reopened with 2 small open area approximately measuring 0.4 x 0.2 and 0.3 x 0.3 and superficial depth." "Sacrum reopened measuring 8.5 x 7 with multiple open areas." On 4/1/13 at 10:30 a.m. the wound nurse evaluated the resident and documented the following: "skin- sacral-intact; right great toe - unstageable; 4 x 3 centimeters (cm) plantar aspect, dark tissue intact." On 4/16/13 at 9 a.m. the wound nurse documented the following: "Sacral- 7 x 6 cm. abraded tissue, pink superficial multiple open areas." "Sacral-shearing; R hip -stage II; Use 2 staff to lift and reposition in bed." On 4/24/13 at 9 a.m. "Resident positioned with lift after shower. Will trail new slide sheet for next positioning." On 4/27/13 at 8 a.m. "Sliding sheet works well but time consuming to apply." On 5/13/13 at 10:30 a.m. the wound nurse documented the following: "sacral 4 x 4.5 cm. superficial pink areas-multiple; Healed -right great toe, right hip; sacral- superficial area R/T shearing, incontinence and pressure (stage 2)." A review of the Certified Nurses' Aide (CNA) daily "Assignment Sheets" from 5/11 to 5/15/13 which directed the care that the staff provided for the resident, revealed that Resident #10 required the assistance of 1 staff member with positioning. This contradicted the tour nurse's statement and the MDS which stated the resident required a 2-person assist for positioning and transfers. A review of the daily "ADL Flow Records" from 9/10/12 to 5/16/13 which indicated the care that was provided by the staff for the resident revealed that the resident was not consistently assisted by 2 staff members with bed mobility. The CNA that provided the care to the resident along with the nurse initialed the flow records daily. A review of the 1/27/13 "Pressure Ulcer Care Plan" identified the problem - risk for pressure ulcer related to hx of pressure ulcer, immobility, incontinence of bowel and bladder." Some of the identified interventions included: "roho mattress; gel cushion; heelzup; pillow between knees and reposition with 2 people assist q 2 h when in bed." On 4/1/13 the care plan was revised and identified the problem- "R great toe black discoloration" with the intervention to "wrap R great toe to cushion as protector daily." The care plan did not address/identify the resident's recurrent sacral stage II pressure ulcers or shearing as a problem. There were no interventions identified to prevent recurrence. On 5/17/13 at 10:30 a.m. the Patient Care Coordinator (PCC) stated to the surveyor that care plans were revised as issues were identified. The PCC further stated that this had not been done for the resident. The PCC was not aware that the "Assignment Sheets" did not identify that the resident required the assistance of 2 staff members for positioning. The PCC was also not aware that the "ADL Flow Sheets" did not consistently reflect that the resident received the assistance of 2 staff members with bed mobility. On 5/17/13 at 10:45 a.m. the surveyor in the presence of the PCC, Wound Nurse and CNA observed the resident's skin. There were numerous sacral Stage II skin openings which measured 4 cm x 4.2 cm. The Wound Nurse stated to the surveyor that "shearing" may be a causal factor. The CNA and PCC stated to the surveyor that a causal factor may be from repositioning/moving the resident in bed since the resident was a "big man." The CNA further stated that a "sliding sheet" was utilized to move the resident up in bed. However, it was not used to turn the resident from side to side. The PCC further stated to the surveyor that she had not observed the staff reposition the resident in bed. On 5/17/13 at 1:30 p.m. the Director of Nursing (DON) stated to the surveyor that the care plans were revised as issues were identified. The DON also stated that the nurse initialed the "ADL Flow Sheets" to ensure that proper care was provided by the CNA. The DON was not aware that the "ADL Flow Sheets" were initialed daily by the nurse, but did not consistently reflect that the resident received the assistance of 2 staff members with bed mobility. A review of the facility's "Pressure Ulcer Prevention and Care" policy dated 7/17/2009 revealed the following: "Implement care plan interventions; Ensure interventions are in place as noted on the care plan. FRICTION/SHEAR- Prevent shearing forces by lifting resident/patient. Raise HOB (head of bed) 30 degrees during positioning. Monitor bed and wheelchair position." While the survey was in progress, the facility drafted an updated revision to the above policy to ensure that causal factors and recommended interventions be identified with facility acquired pressure ulcers. 2. On 5/20/13 at 11 a.m. the surveyor observed Resident #21 seated in a reclining high back wheelchair in the activity area. The resident's right arm was slightly flexed and an elbow pad was applied to the resident's right elbow. The resident's right arm/elbow was wedged/positioned snuggly against/under the right arm bolster that was attached to the right arm of the resident's wheelchair. On 5/20/13 at 11:30 a.m. the surveyor reviewed the medical record of Resident #21 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (assessment tool) of 2/9/13 and 5/9/13 revealed that the resident was staff dependent for activities of daily living, including bed mobility and transfers. A review of the "Long Term Care Interdisciplinary Progress Notes" revealed the following: On 1/6/13 "noted new pressure ulcer to the right elbow measuring 0.5 x 0.3 centimeters (cm) with superficial depth- weakness to right upper extremity remains." (healed 1/22/13). On 4/30/13 at 10 a.m. the wound nurse documented "Requested to assess right elbow- 1x 1.2 cm x 0.2 cm, dark, discolored tissue, dry, periulcer intact with slight inflammation- positive right elbow contracture." " Unstageable right elbow R/T pressure, decreased weight, MS, contracture." The recommendation at this time was "No pressure on area, keep pressure off with pillows in bed, heelbow type when in wheelchair." A review of the therapy notes revealed that the resident was last evaluated by the physical therapist in Novemeber 2012 with regards to transfer status. The resident was last evaluated by the Occupational Therapist (OT) on 2/24/12. However, no additional occupational therapy notes or evaluations were provided to the surveyor upon request. Review of the 1/6/13 care plan identified the problem of "Stage II on R elbow" with the intervention "elbow pad to R elbow." However, the elbow pad was discontinued (no date) when the ulcer healed. On 4/30/13 the care plan was revised with the problem "unstageable to R elbow" with the intervention "R elbow pad when OOB in W/C." On 5/16/13 the care plan was revised and identified the problem "Stage IV pressure ulcer on R elbow." Some of the identified interventions included: "Reposition Q2h when in bed; R elbow pad when out of bed and Cushion on w/c right arm rest." On 5/21/13 at 9:05 a.m. the surveyor in the presence of the nurse and wound care nurse observed the skin on the resident's right elbow. A Stage III pressure ulcer was noted on the right elbow which measured .8 cm x .8 cm. On 5/21/13 at 9:30 a.m. the CNA and the nurse stated to the surveyor that they were not aware when the right arm bolster had been applied to the resident's wheelchair. They both stated that it had been there for "quite some time." At 9:45 a.m. the Patient Care Coordinator (PCC) stated to the surveyor that the right elbow pad should not have been discontinued when the ulcer had healed in January. The PCC further stated that the right arm bolster had been applied to the residents wheelchair "a long time ago." The PCC stated that the OT usually applied bolsters to the wheelchairs for positioning. However, the PCC was unable to provide documentation to support her statements. The PCC further stated that the previous therapy department had been replaced by a new therapy department last June or July 2012. On 5/21/13 at 10 a.m. the OT stated to the surveyor that the resident had never been evaluated for wheelchair positioning. The OT further stated that there was no documentation to identify when the right arm bolster had been applied to the resident's wheelchair. On 5/21/13, while the survey was in progress, the resident was evaluated by the Occupational Therapist and wheelchair modifications (removal of the bolster /changing right arm of the wheelchair) were made to allow for pressure relief to the resident's right elbow. NJAC 8:39-27.1(e)

Based on interview and record review, it was determined that the facility failed to develop care plan interventions to prevent shearing incidents for a staff dependent resident. The facility also failed to identify interventions to protect the skin of a staff dependent resident with a recent history of a pressure ulcer on the right elbow. These deficient practices were evidenced for Residents #10 and #21, 2 of 10 residents reviewed for pressure ulcers. Resident #10 developed facility acquired recurrent stage II sacral pressure ulcers. Resident #21 developed a new facility acquired unstageable pressure ulcer on the right elbow. Theses deficient practices were evidenced by the following: 1. During the initial tour of the facility on 5/16/13 at 10:30 a.m., the tour nurse identified Resident #10 with a recurrent stage II sacral pressure ulcer. The tour nurse stated that the resident was staff dependent for all activities of daily living and required the assistance of 2 staff members for bed mobility and mechanical transfers. On 5/16/13 at 12:30 p.m. the surveyor reviewed the medical record of Resident #10 which revealed the following: The resident was admitted to the facility with [DIAGNOSES REDACTED]. A review of the "Braden Scale- For Predicting Pressure Sore Risk" of 12/4/12 and 2/27/13 indicated that the resident had a "potential problem" with "friction and shear." A review of the "Long Term Care Interdisciplinary Progress Notes" from 9/24/12 to the present revealed that the resident had recurrent Stage II pressure ulcers on the sacrum and right hip. On 4/16/13 at 9:00 a.m. the wound nurse documented the following: "Sacral- 7 x 6 cm. abraded tissue, pink superficial multiple open areas." "Sacral-shearing; R hip -stage II; Use 2 staff to lift and reposition in bed." On 5/13/13 at 10:30 a.m. the wound nurse documented the following: "sacral 4 x 4.5 cm. superficial pink areas-multiple; R/T shearing, incontinence and pressure. (stage 2)." A review of the 1/27/13 "Pressure Ulcer Care Plan" identified the problem - risk for pressure ulcer related to hx of pressure ulcer, immobility, incontinence of bowel and bladder." The identified interventions included: "roho mattress; gel cushion; heels up; pillow between knees and reposition with 2 people assist q 2 h when in bed." On 4/1/13 the care plan was revised and identified the problem- "R great toe black discoloration" with the intervention to "wrap R great toe to cushion as protector daily." The care plan did not address/identify the resident's recurrent sacral stage II pressure ulcers or shearing as a problem. There were no interventions identified to prevent recurrence. On 5/17/13 at 10:30 a.m. the Patient Care Coordinator (PCC) stated to the surveyor that care plans were to be revised as issues were identified. The PCC further stated that this had not been done for the resident. On 5/17/13 at 1:30 p.m. the Director of Nursing (DON) confirmed what the PCC had stated to the surveyor, that the care plans were to be revised as issues were identified. The DON was not aware that this had not been done for the resident. 2. On 5/20/13 at 11:30 a.m. the surveyor reviewed the medical record of Resident #21 which revealed the following: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (assessment tool) of 2/9/13 and 5/9/13 revealed that the resident was staff dependent for activities of daily living, including bed mobility and transfers. A review of the "Long Term Care Interdisciplinary Progress Notes" revealed the following: On 1/6/13 "noted new pressure ulcer to the right elbow measuring 0.5 x 0.3 centimeters (cm) with superficial depth- weakness to right upper extremity remains." (healed 1/22/13). On 4/30/13 at 10 a.m. the wound nurse identified a facility acquired unstageable right elbow pressure ulcer which measured 1x 1.2 cm x 0.2 cm. The recommendation at that time was "No pressure on area, keep pressure off with pillows in bed, heelbow type when in wheelchair." Review of the 1/6/13 care plan identified the problem of "Stage II on R elbow" with the intervention "elbow pad to R elbow." However, the elbow pad was discontinued (no date) when the ulcer had healed. There were no additional interventions identified to protect the skin integrity of the resident's right elbow. On 4/30/13 the care plan was revised with the problem "unstageable to R elbow with the intervention "R elbow pad when OOB in W/C." On 5/16/13 (2 weeks later) the care plan was revised and identified the problem "Stage IV pressure ulcer on R elbow." Some of the identified interventions included: "Reposition Q2h when in bed; R elbow pad when out of bed and Cushion on w/c right arm rest." On 5/21/13 at 9:05 a.m. the surveyor, in the presence of the nurse and the wound care nurse, observed the skin on the resident's right elbow. A Stage III pressure ulcer was noted on the resident's right elbow which measured .8 cm x .8 cm. On 5/21/13 at 9:45 a.m. the Patient Care Coordinator (PCC) stated to the surveyor that the right elbow pad should not have been discontinued when the pressure ulcer had healed in January. The PCC further stated that interventions to protect the skin of the resident's right elbow, as well as the recommendations made by the wound nurse, should have been identified on the care plan. The PCC stated that this had not been done for the resident. Refer to F 314 NJAC 8:39-11.2(e)(2)