Every finding on record at Sunnyside Manor

Based on observation, interview and document review, it was determined that the facility failed to maintain the kitchen environment and equipment in a clean and sanitary manner prevent contamination from foreign substances and potential for the development of foodborne illness. This deficient practice was evidenced by the following: On 09/09/2025 at 8:33 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: The large ice machine was observed with with visibly blackened areas on the exterior of the baffle (the component that directs the flow of ice into the storage bin). The FSD removed the baffle which exposed various blackened mold like in appearance areas inside of the ice machine. The FSD stated, that is not good, then turned off the ice machine.The large blue ice scoop was affixed to the wall in a holder, and not protected from potential contamination.The metal slats inside of the cooking hood where shiny in appearance with visible grease ton them, and one fire suppression nozzle had visible dust like debris stuck to it.The white plastic type cutting board, attached to the food service steam table was stained with visible grooved areas.Items stored underneath the cutting board, including partitioned plates were stored upright with visible debris observed inside the plates. At 8:56 AM, the surveyor accompanied the FSD to the kitchen service pantry while the breakfast meal was in progress. The surveyor observed that the specialized refrigerator with the lift up lid contained chicken salad, egg salad, ham and other items in containers that the FSD stated were used for the lunch meal. The heat from the breakfast meal service area was felt by the surveyor in the area of the refrigeration unit. The surveyor asked the FSD to take the temperature of food items, and the FSD utilized the a digital thermometer and placed it in the chicken salad wih the following temperature reading: 47.2, 46.9, then 45.7 degrees Fahrenheit. The surveyor asked the FSD if the items were potentially hazardous foods and he confirmed that they were.On 9/9/25 at 9:20 AM, the surveyor alerted the Licensed Nursing Home Administrator (LNHA)of the food temperature concerns and debris in ice machine. On 09/09/25 at 9:45 AM, the FSD stated the repair company addressed the ice machine, and the ice machine required a goop filter. The surveyor reviewed the copy of the repair invoice dated 9/9/25 which revealed a a slime eliminator was needed, and the coil was cleaned in the refrigeration unit because the temperature was dropping. A review of the Kitchen Cleanliness Policy and Procedures, undated revealed: Policy: To maintain a safe and sanitary kitchen environment that complies with health regulations and promotes the well-being of residents. Procedures : 1. General Cleanliness: All food preparation and serving areas must be cleaned and sanitized daily. Surfaces, equipment, and utensils should be free from food debris and spills at all times. NJAC8:39-17.2 (g)

Based on observation, interview and record review it was determined that the facility failed to ensure: a) a timely nutritional assessment was completed after admission, b) identified nutrition interventions were implemented, and c) nutritional interventions were revised for a resident who experienced a significant weight loss. This deficient practice was identified for 1 of 2 residents reviewed for nutrition (Resident #4) and who was identified as being at nutritional risk, and at risk for pressure ulcers and was evidenced by the following:On 09/09/2025 at 12:44 PM, the surveyor observed Resident #4 in the living room on the main floor and was sitting in a wheeled recliner. Resident #4 was watching television with other residents. Upon staff interview, staff stated the resident had fed self and consumed 100% of stuffed shells and broccoli, and did not eat dessert since they did not like sweets. On 09/11/2025 at 9:34 AM, the surveyor reviewed the electronic medical record for Resident #4 which revealed diagnoses which included, but were not limited to: history of falling, displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, and hypothyroidism. The Nursing admission Screening dated 6/14/25, revealed the resident had a history of Dementia, was confused and had right hip edema, and it was checked off as 0 for pitting (pits occur when applying pressure). Skin: A surgical incision and bruising were identified at the right hip and MASD (moisture associated skin damage) on the coccyx. The height and weight under vital signs were left blank. A review of the Weight Summary report for Resident #4 revealed the following weights:6/15/25- 151 pounds (#) admission Weight6/18/25- 147# (Recorded by the Registered Dietitian-RD)6/25/25- 146#7/9/25- 146#7/16/25- 145#7/23/25-140# (Recorded by the RD)8/6/25- 138# (Recorded by the RD) [8 # weight loss -5% X 1 month]8/25/25-139# (Recorded by the RD) 9/6/25- 135# - 9/10/25 at 14:55 (2:55 PM) the weight was struck out and documented as incorrect documentation by the RD. The surveyor calculated from the admission weight -151# to 9/6/25 weight, 135 #, Resident #4 sustained a 15 # (10%) weight loss in less than 3 months.The Nutritional assessment dated [DATE] (completed 33 days after admission) and locked 7/25/25, by the RD revealed under Relevant Medical Conditions, No Edema; Weight status trends revealed 4.1% weight loss X 1 month and 1.4% X 1 week. The Food and Fluid Intake/Diet History Data revealed: 7/21/25, intake 50% noon meal. states feels full easily. Skin Issues: MASD-coccyx (moisture associated skin damage is the general term for inflammation or skin exposure caused by prolonged exposure to a moisture source such as urine). Nutritional Concern and Nutritional Diagnosis: Inadequate oral intake due to poor appetite as evidenced by weight decline 3.5 % X less than 2 weeks .Increased nutrition risk for pressure ulcer. The Nutritional assessment dated [DATE] and locked 8/11/25 by the RD revealed: Most recent weight 138 #, 8/6/25. Nutritional Assessment: . 8/8/25 RD reassessment [due to] weight change . Goals/Intervention: Increased nutrient needs [due to skin issue, weight loss, [as evidenced by] [stage] III [pressure ulcer] sacrum (full thickness skin loss that extends into the subcutaneous tissue), [weight loss] 5% times 1 month and increased nutrition risk for [pressure ulcer]. Nutritional interventions: HNS [House Nutritional Supplement 1 X daily, increase Prostat to 30 ML twice daily .A Weight Change Note, documented by the RD on 8/8/25 at 15:42 [3:42 PM], revealed: Note Text: Weight Warning: Value 138: Date 8/6/25, (5.5%, 8.0)-7.5% Change (8.6%, 13.0) RD reassessment initiated; 3 Day intake monitor requested.A review of the Care Plan for Resident #4 revealed: Resident has nutritional problem result to increased nutrient needs [due to] skin issue, weight loss [as evidenced by] [Stage III Pressure Ulcer Sacrum], weight loss 5% X 1 month, Anemia, Increased nutrition risk for [pressure ulcer], Date Initiated 8/11/25. The Goal Date Initiated: 8/11/25 The resident will maintain adequate nutritional status as evidenced by maintaining weight >135#, no [signs/symptoms] of malnutrition, and consuming at least 60% of meals and 100% supplements daily through review date. The Interventions, Initiated 8/11/25: included: Provide and serve regular diet as ordered, Provide and serve supplements as ordered ., RD to evaluate and make diet change recommendations [as needed] and the resident needs a calm, quiet setting at meal times with adequate eating time. The resident prefers to sit in the 1st seating in the [main dining room]. Encourage the resident's socialization and interaction with table mates during meals. Although, Resident #4 was identified on 7/16/25 as having inadequate oral intake due to poor appetite as evidenced by weight decline 3.5 % X less than 2 weeks .Increased nutrition risk for pressure ulcer, there was no nutrition Care Plan initiated until 26 days later, and after Resident #4 sustained additional weight loss. The 3 Day intake monitor requested that was documented in the 8/8/25 RD note was also not included in the Care Plan.On 09/11/2025 10:08 AM, the surveyor interviewed the RD in the presence of the survey team. The surveyor asked the RD about the weight that documented on 9/6/25 at 135 #, and there was a Strike Out Date/Strike Out By/Strike Out Reason dated 9/10/25 at 14:55 (2:55 PM), Incorrect Documentation. The RD stated that Resident #4 was on weights and I crossed it out because it did not corroborate with the 130# weight which the RD stated was documented in the weight book, and was not documented in the electronic medical record. [This would have indicated an additional 5-pound weight loss] The RD also confirmed that there was no reweight completed to determine if the weight documented in the weight book was accurate. The surveyor asked what the Nutrition Goal was for Resident #4 and the RD stated for weight stabilization, and Resident #4 would be weighed that day. When asked what the facility reweight policy was, the RD stated, if there was a 5# change, the resident would be reweighed within two days. The surveyor asked it was policy to cross off a weight from the medical record if it was not confirmed it was an error, the RD stated, no, it was an error. The RD stated Resident # 4 would be weighed today and when asked if the weight loss was significant the RD stated, now the weight loss is significant.On 09/11/2025 10:47 AM, the RD informed the surveyor that Resident #4 was weighed and weighed 128#, which indicated the resident lost an additional 11# (7%) since 8/25/25. The surveyor asked the RD what nutrition interventions were implemented upon admission, and upon identifying the weight loss for Resident #4, the RD stated the first Nutritional Assessment, the Resident's weight was 151#. The RD stated that Resident #4 was at increased risk for a pressure ulcer upon admission due to Anemia. The RD stated, since it was post- operative anemia, she stated she chose to monitor the weekly weight and encourage the resident to eat for the nutrition interventions. The RD stated the second weight obtained was 147 # and weight was taken 3 days after admission. The surveyor asked what nutrition interventions were implemented at that time and the RD stated, at that time, I didn't implement any interventions and just completed the admission Assessment. The surveyor asked if the resident had edema upon admission and the RD stated per the admission notes there was no edema. The RD stated the next weight was 146 #, and additional 1 # weight loss from the previous week and the RD stated she reevaluated the resident's nutritional status on 7/17/25. On 09/11/2025 at 10:59 AM, the surveyor asked the RD about the 3-day intake monitor requested (documentation of all the foods that are eaten to determine nutritional intake) that was documented in the 8/8/25 RD note. The RD stated that she did not notify the nurses of her recommendation for the 3-day intake monitoring and confirmed it was not completed. When asked when specific interventions were implemented to prevent weight loss, the RD stated she implemented interventions, including a house supplement on 8/11/25.On 09/11/2025 at 12:32 PM, the surveyor interviewed the Minimum Data Set Coordinator (MDS-an assessment tool) about Resident #4. The surveyor asked who was included in the Interdisciplinary Team (IDT), and the MDS stated the Nurse, RD, Social Worker, Therapy and Activities. The surveyor asked if the IDT was aware of the weight loss, and if the IDT was going to proceed with a significant change MDS, and the MDS stated that the first time she was made aware of the weight loss for Resident #4 was on 9/10/25 and the resident did not decline in two areas. The surveyor asked if the resident was admitted with a pressure ulcer and the MDS stated, not a pressure ulcer, dermatitis, and it developed into a Stage III pressure ulcer, The surveyor asked if the facility had met with the family and the MDS stated there was a care conference held on 6/18/25 with the family and the IDT. The surveyor reviewed the Care Conference documentation, dated 6/18/25 which revealed: Resident is followed by the RD. Family requested to incorporate nutritional supplements. Weekly weights ongoing .On 9/12/25 at 11:22 AM, the survey team met with the Director of Nursing (DON) and Licensed Nursing Home Administrator during the exit conference. In response to the surveyor requesting, on 9/11/25, a timeline of the weight loss with interventions the DON provided the following: Resident admitted [DATE]; On 7/16/25: RD reassessment: Began process for interdisciplinary plan of care due to weight changes which included Prostat (Protein Supplement) and a multivitamin . 8/8/25 Care Plan Updated add, Mighty Shake added (liquid nutritional supplement). A review of the undated Resident Nutritional Assessments policy revealed: Nutritional Assessment: the consultant dietitian on each resident completes a nutritional assessment within 14 days of admission.NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to adhere to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 1 of 2 residents reviewed (Resident # 35). The deficient practice was evidenced by the following: On 9/09/25 at 10:21 AM, the surveyor observed Resident #35 seated in a recliner chair in the room. Resident #35 had a Nebulizer machine and a Nebulizer mask (used for breathing treatments) with white stains and was directly placed on top of the nightstand. The Nebulizer mask also touched the Nebulizer machine and was in close proximity of the resident's phone and toiletries items.On 09/9/25 at 12:35 PM, the surveyor returned to the room after the resident had been assisted with care, received morning medication, and observed the Nebulizer mask on the nightstand face down and in direct contact with the surface, was not protected. The mask was not dated. The surveyor attempted to interview the resident, but the resident could not proceed with the interview.On 09/10/2025 at 8:20 AM, the surveyor observed the resident in bed. The Nebulizer mask was noted on the nightstand as observed the day before and not protected.On 9/10/25 at 9:50 AM, the surveyor accompanied the Registered Nurse (RN) to the room where we both observed the Nebulizer mask, with white stained areas, that was on the nightstand in the same position as observed on 9/9/25 and was in closed proximity of other items and was not protected. The RN stated that the mask should not have been on the table. When asked to elaborate on how the mask should be stored, the RN stated if the treatment was a standing order the mask would be kept at the bedside. If the Nebulizer treatment was ordered as needed, the mask would be discarded.On 9/11/25 at 10:30 AM, the surveyor reviewed the medical record for Resident #35. The admission record reflected that Resident #35 was admitted to the facility with diagnoses which included, but were not limited to; muscle weakness, hypertension, and unspecified congestive heart failure. A review of the nurse's progress notes dated, 8/27/25 timed 12:18 PM, revealed the following: Noted increased in chest congestion, seen and evaluated by hospice, diminished lung sounds noted with upper chest congestion, [02] Oxygen saturation] 92 %, (Normal 95% to 100%). No difficulty breathing noted. New recommendation noted for DuoNeb (breathing treatment) 1 vial [QID] four times a day x 1 week. (MD) physician aware and new order noted reflecting recommendation. A review of the Order Summary Report for September 2025, revealed the following orders for Resident #35: Ipratropium-Albuterol inhalation Solution 0.5-2.5(3) MG (milligrams)/ML (milliliter) Ipratropium-Albuterol 1 vial inhale orally four times a day for chest congestion for 7 days. Start Date: 08/27/2025A review of the Medication Administration Record (MAR) reflected that Resident #35 received the Nebulizer treatment on 8/27/25, 8/28/25, 8/29/25, 8/30/25, 8/31/25, 9/1/25 and 9/2/25 as scheduled: 0900, 1300 (1:00 PM), 17:00 (5:00 PM and 21:00 PM (9:00 PM). The order was a standing order for 7 days.The surveyor requested the facility's policy for storage of respiratory care equipment.On 9/10/25 at 11:07 AM, the Director of Nursing (DON) provided the undated facility policy's titled, Administration Medication through a Metered Dose Inhaler (Nebulizer) . Purpose: The purpose of this procedure is to provide guidelines for safe administration of oropharyngeal inhaled medications:The following were noted under Administer medication: Rinse the mouthpiece with warm water to remove medication residue.Discard all disposable items into designated containers. The DON confirmed that the mask should have been discarded. NJAC 8:39-19.4 (K)

Based on observation, interview, record review and review of pertinent facility documents it was determined that the facility failed to treat a resident's pain to the extent possible in accordance to current professional standards of practice. The deficient practice was identified for 1 of 2 residents (Resident # 38) investigated for Pain. The deficient practice was evidenced by the following: A review of Resident # 38's Significant Change Minimum Data Set (MDS; an assessment tool) dated 05/08/2024 revealed under section J. that he/she received as needed and scheduled medications for pain. A review of Resident # 38's Order Summary Report located in the Electronic Medical Record (EMR) revealed that he/she was receiving oxycodone-acetaminophen (medication used to treat pain) oral tablet 5-325 mg (milligrams) one time a day for pain management prior to care. The order was started on 03/27/2024. Further, the Order Summary revealed an order for Resident # 38 to wear a cervical neck brace at all times. A review of Resident # 38's Diagnoses located in the EMR revealed that he/she was diagnosed with but not limited to Unstable Burst Fraction of First Cervical Vertebra (bone in the cervical spine area crushed in all directions). A review of Resident # 38's Care Plan located in the EMR revealed that Resident # 38 had a focus of chronic pain related to arthritis, neuropathy (Weakness, numbness, and pain from nerve damage) and acute pain related to the cervical fracture. A review of the April, 2024 Medication Administration Audit Report revealed that the oxycodone-acetaminophen oral tablet 5-325mg was scheduled to be given at 9:00 AM. However, the report revealed the following dates an times of the actual administration of the oxycodone-acetaminophen: On 04/06/2024, the medication was administered at 11:03 On 04/09/2024, the medication was administered at 10:26 On 04/12/2024, the medication was administered at 10:21 On 04/13/2024, the medication was administered at 10:55 On 04/14/2024, the medication was administered at 10:37 On 04/21/2024, the medication was administered at 10:46 On 04/28/2024, the medication was administered at 11:02 A review of the facility-provided, undated policy titled, PAIN ASSESSMENT & MANAGEMENT revealed, 11. Medicate the resident as the physician ordered. A review of the facility-provided, undated policy titled, Administering Pain Medications revealed on the second page to, Administer pain medications as ordered. On 05/08/2024 at 12:58 PM during the initial tour of the facility, the surveyor visited Resident # 38 in his/her room. At that time, Resident # 38 stated he/she has neck pain and bilateral leg pain. He/She also had a cervical neck brace on. On 05/10/2024 at 10:43 AM during an interview with the surveyor, Registered Nurse # 1 confirmed that Resident # 38 received oxycodone-acetaminophen 5-325mg and that it was scheduled for 9:00 AM. On 05/13/2024 at 9:41 AM during an interview with the surveyor, Registered Nurse # 2 said We [nurses] have to give them [medications] within the hour. If they are scheduled, they have to be within the hour. On 05/13/2024 at 11:34 AM during an interview with the surveyor, the Director of Nursing confirmed she would consider a medication administered as late an hour after an administration time. Further, the DON stated, If it is a standing order, Yes. If it was given at ten and scheduled for nine, then yes. when the surveyor asked would she considered a nine AM scheduled opioid for pain management given after ten AM or eleven AM, a late medication. S 8:39-27.1 (a)

Based on interviews and review of medical records it was determined that the facility failed to complete and electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of the resident's discharge. This deficient practice was identified for 1 of 1 resident, (Resident # 27) reviewed in the Resident Assessment Task for MDS record over 120 days old. On 05/08/2024 the surveyor reviewed the MDS history in the electronic medical record which revealed: Resident #27 was discharged on [DATE]. The surveyor was unable to locate a discharge MDS in Resident #27's electronic medical record. On 05/09/2024, the surveyor interviewed the MDS Coordinator (MDSC), who stated that the discharge MDS on Resident #27 should've been completed within 14 days of discharge date . She also stated, I missed it. On 05/14/2024 the surveyor noted that the discharge MDS was completed on 05/10/2024 and transmitted on 05/13/2024 (completion was due by 1/22/2024 and transmission was due by 02/05/2024). When the surveyor asked for a policy regarding MDS completions, the MDSC stated they did not have a policy for MDS discharge assessments and that they follow the RAI manual. According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2023, page 2-17, discharge return-not anticipated must be completed no later than the discharge date + 14 calendar days with the transmission date no later than MDS completion date +14 days. On 05/13/2024, the surveyor interviewed the Director of Nursing who stated that the MDS should have been completed before now. NJAC 8:39-11.2 (e) 3

Based on observation, interview, and record review, it was determined that the facility failed to implement, reassess and/or discontinue a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice was identified for 1 of 2 residents (Resident #35) reviewed for accidents. 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: On 8/3/22 at 11:25 AM, during the initial tour, the surveyor observed Resident #35's room. The resident was not in the room and the surveyor observed a clean room, bed made, call bell was on the resident's bed, and no observed crash pads in the room. The surveyor reviewed the medical record for Resident #35. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility on in July of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS), an assessment tool dated 7/15/22, reflected the resident had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated severely impaired cognition. The MDS further revealed in Section J. Health Conditions, the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Order Summary Report included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Progress Notes included an Alert Note dated 7/9/22 at 10:24 PM, that the resident transferred him/herself to wheelchair independently; was assisted to the bathroom by writer; education given but resident not able to verbalize understanding; call bell placed in reach; new orders for crash pads to be placed bedside to decrease fall risk; will continue checks for duration of shift. A review of the Interdisciplinary Team (IDT) Care Conference Notes dated 7/19/22 did not include an assessment of the crash pad ordered by the physician. A review of the resident's comprehensive care plan did not include a focused area or intervention for a crash pad. A review of Resident #35's Kardex (a system in which nursing staff was given a brief overview of individual resident care needs) did not include the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/4/22 at 9:55 AM, the surveyor observed Resident #35's room. The resident was not in the room and the surveyor observed the resident's room was clean, bed made, call bell on the bed, and no crash pads observed in the room. On 8/5/22 at 9:54 AM, the surveyor observed Resident #35's room. The resident was not in the room and the surveyor observed the resident's room was clean , bed made, call bell on the bed, and no crash pads observed in the room. On 8/5/22 at 10:07 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who confirmed her assignment included Resident #35 and that the resident did not have a crash pad. On 8/8/22 at 10:14 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who confirmed her assignment included Resident #35. The LPN also confirmed the resident was a fall risk and did not have a crash pad. On 8/8/22 at 10:30 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who confirmed Resident #35 was a fall risk. At this time, the surveyor and ADON reviewed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor and the ADON then reviewed the comprehensive care. The ADON acknowledged the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor and the ADON then reviewed the IDT Care Conference Note dated 7/19/22, and the ADON confirmed the note did not include an assessment of the crash pad. On 8/8/22 at 10:54 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who acknowledged that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN/UM also confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at 10:26 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), ADON, and survey team stated that the crash pad was a nursing intervention and that the crash pad was not appropriate since Resident #35 was able to ambulate. The DON acknowledged there was an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged that the nurse on duty failed to communicate to the fall team or IDT team the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged physician order's should be carried out or reassessed by the nurses and discontinued if not appropriate because it was a professional standard of practice. A review of the undated facility provided physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .verbal orders must be signed by the prescriber at his or her next visit . NJAC 8:39-27.1

Based on interview and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set (MDS) - Discharge Assessments in accordance with federal guidelines. This deficient practice was identified for 5 of 8 residents reviewed for Resident Assessment (Resident #1, #3, #4, #5, and #7) and was evidenced by the following: On [DATE] at 11:02 AM, the surveyor reviewed the MDS assessments, an assessment tool used to facilitate the management of care, in the electronic medical record (record) for five system-selected residents. A review of the MDS history revealed the following for the five residents: 1. Resident #1 was discharged to the community on [DATE]. The record revealed that the discharge MDS was not completed by the facility and was 166 days overdue. 2. Resident #3 was discharged to the community on [DATE]. The record revealed that the discharge MDS was not completed by the facility and was 144 days overdue. 3. Resident #4 was discharged to the community on [DATE]. The record revealed the discharge assessment-return not anticipated MDS was completed on [DATE] for the resident's discharge date of [DATE]. 4. Resident #5 was discharged to the community on [DATE]. The record revealed that the discharge MDS was in progress and was 100 days overdue. 5. Resident #7 expired in the facility on [DATE]. The record revealed that the facility did not complete a death in facility tracking record and was 87 days overdue. During an interview with the surveyor on [DATE] at 12:07 PM, the MDS Coordinator stated she was responsible for completing the MDS assessments at the facility. The MDS Coordinator stated she had 14 days from the discharge date to complete a discharge MDS. The MDS Coordinator further stated she had seven days to complete the death in facility MDS for a resident who expired in the facility. During an interview with the surveyor on [DATE] at 09:15 AM, the Director of Nursing stated that Residents #1, #3, #4, #5, and #7 MDS assessments were processed on [DATE] and provided the surveyor with the CMS Submission Report MDS 3.0 NH Final Validation Report (validation report). A review of the validation report for Residents #1, #3, #4, and #5 revealed that the MDS assessments were completed late. The validation report further revealed that the MDS assessments were more than 14 days after the Assessment Reference Date (discharge date ). The surveyor reviewed Resident #7's validation report which reflected that the death in facility tracking record was submitted late. The validation report further revealed that the submission date was more than 14 days after the discharge date . NJAC 8:39 - 11.2

Based on observation, interviews and review of pertinent facility documents on 12/1918 and 12/21/18, it was determined that facility staff failed to secure the treatment cart and medication for an un-sampled resident. This deficit practice was evidenced by the following: On 12/19/18 at 9:35 a.m., a tour was conducted on the 'Low End' hall of the facility accompanied by the Assistant Director of Nursing (ADON). During the tour the surveyor observed an unlocked treatment cart with a prescribed medication Silver Sulfadiazin Cream on top of the cart. During an interview on 12/19/18 at 9:55 a.m., with the ADON, the ADON stated that the carts are normally locked. The ADON further explained that the prescribed medication Silver Sulfadiazin Cream should be locked up, in the cart. During an interview on 12/19/18 at 10:00 a.m., with a Licensed Practical Nurse (LPN), the LPN stated normally the treatment cart is always locked, I'm unsure why it's unlocked. In addition the LPN stated Silver Sulfadiazin Cream should be in the cart locked. During an interview with the Director of Nursing (DON) on 12/19/18 at 2:40 p.m., the DON stated that medications are kept in the medication / treatment cart or within eyeshot of the cart. A review of the facility's policy titled Disposition of medications / Medication Storage dated 11/10, showed the following: Medications will be stored safety and securely in accordance with all state and federal guidelines and as per manufactures recommendations. Under section (3) indicated, all medication should be secured in a locked cart, cabinet, or room. NJAC 8:39-27.1(a)

REVISED COMPLAINT NJ # 7 Based on observation, interviews and record review on 12/19/18 and 12/21/18, it was determined that the facility nursing staff failed to document physician's orders [REDACTED].#6). In addition, the facility nursing staff failed to consistently implement Care Plan (CP) interventions, for 1 of 6 sampled residents (Resident #6), as well as failure to follow the facility's policy titled Urine Output/Measuring Policy, for 1 of 6 sampled residents (Resident #6). This deficit practice was evidenced by the following: 1. According to Resident #6's physician's orders [REDACTED].#6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 8/26/18, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating Resident #6 was cognitively intact. The MDS further indicated the Resident required staff assistance for Activities of Daily Living (ADLs), and had a Foley catheter. A review of Resident #6's CP dated 5/30/18, indicated the resident had an indwelling Foley catheter. Interventions included but not limited to Monitor and document intake and output as per facility policy. A review of Resident #6's PO sheet dated 12/05/18, revealed a PO for Foley catheter care every shift. A second PO dated 12/5/18, indicated Skin Protective Cream to sacrum and buttocks every shift. A review of Resident #6's urinary output documentation sheet indicated urinary output was not documented on: 12/7/18, 12/13/18, and 12/14/18, for the 7:00 a.m. to 3:00 p.m. shift, 12/13/18, 12/14/18, and 12/19/18, for the 3:00 p.m. to 11:00 p.m. shift, 12/8/18, and 12/17/18, for the 11:00 p.m. to 7:00 a.m. shift. A Review of Resident #6's Progress Notes (PN) did not reveal documentation of urinary output for the above dates. A review of Resident #6's Treatment Administration Record (TAR), revealed no documentation of administration of skin protective cream to the sacrum and buttocks every shift on: 12/18/18, for the 7:00 a.m. to 3:00 p.m. shift, 12/7/18, and 12/18/18, for the 3:00 p.m. to 11:00 p.m. shift, 12/7/18, for the 11:00 p.m. to 7:00 a.m. shift. A review of the facility's policy titled Urinary Output/Measuring Policy, undated, revealed the following: The purpose of this procedure is to accurately determine the amount of urine that a resident excrete in a 24-hour period in accordance with the 'Medical Doctor' (MD) orders. Under the section titled Procedures #3, indicated Be sure that the intake and output record is available as needed. A review of a second policy titled Long-Term Care Facility/Administering Medications, specified that Topical medications used in treatments must be recorded on the residents treatment record. N.J.A.C. 8:39-27.1(a)

Based on observation, interview and the review of the medical record and facility documentation, it was determined that the facility failed to provide comprehensive assessments regarding the use of side rails. This deficient practice was identified for 4 of 4 residents reviewed for side rail use (Residents #41, #43, #54 and #35) and was evidenced by the following: 1. During the initial tour on 1/8/18 at 10:48 a.m. the surveyor observed Resident # 41 ambulating slowly in his/her room without difficulty. On 1/11/18 at 8:50 a.m. the surveyor observed the resident lying in bed with closed eyes and one half side rail raised, while the other rail was in the lowered position. On 1/11/18 at 11:00 a.m. the surveyor reviewed the resident's medical record which revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the Admission Resident assessment dated [DATE] and under the Safety Awareness section the facility circled no for Siderails used. The January 2018 physician's orders [REDACTED]. The resident had a Fall Risk Assessment evaluation on 8/17/17 with a score of 20 and re-assessed on 11/21/17 with a score of 25. Both scores identified Resident #41 as being at a moderate risk for falls. Review of the resident's current Plan of Care indicated that it did not address the use of side rails. Review of the Minimum Data Set (MDS) assessment tool revealed an initial assessment completed on 8/28/17, with a Brief Interview for Mental Status (BIMS) score of 6. A quarterly MDS, dated [DATE] included a BIMS score of 5. Both these scores indicated the resident had a severe impairment in cognitive function. Both of these MDS assessments indicated the resident required one person assistance for bed mobility and transfers. Upon further review of the medical record, the surveyor reviewed a Restraint Consent form, dated 1/2/18, for the use of half side rails for positioning. There was no documented evidence that the facility assessed other alternatives prior to initiating the use of a half side rail, assessed the resident for the need of a side rail or for the risk of entrapment prior to installation of the side rails and prior to obtaining a consent. On 1/16/18 09:20 a.m. the Licensed Practical Nurse (LPN) told the surveyor during interview that Resident #41 needed supervision when getting in and out of bed and was not able to release the side rails. 2. On 1/08/18 at 10:27 a.m. the surveyor observed Resident # 43 in a low bed with eyes closed. The bed had bilateral upper side rails in the up position. At 10:30 a.m. the resident stated that he/she was not independent with transfers and could not lower the railing. The resident also told the surveyor that he/she doesn't know why the facility staff placed them on the bed. On 1/10/18 at 10:24 a.m. the surveyor reviewed the medical record of Resident #43 which revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An initial MDS dated [DATE] assessed the resident's BIMS level at 15, which indicated that the resident's cognition was intact. The MDS also indicated that Resident #43 required extensive help of one staff member for bed mobility and transfers, used a wheelchair, had limited range of motion to one upper extremity and had not fallen since admission. The surveyor reviewed the Admission Resident assessment dated [DATE] and under the Safety Awareness section the facility did not indicate yes or no for Siderails used or Education needed. The resident had a Fall Risk Assessment evaluation, dated 12/23/17, with a score of 44 which was identified the resident as being a significant risk for falls. Further review of the medical record revealed that on 1/2/18 the facility obtained a physician's orders [REDACTED]. Review of the resident's current Plan of Care did not include the use of side rails. There was no documented evidence that the facility assessed other alternatives prior to initiating the use of half side rails, assessed the resident for the need of side rails or for the risk of entrapment prior to obtaining a consent and installation of the side rails. 3. On 1/10/18 at 10:51 a.m. the surveyor observed Resident #54 in a low bed with eyes closed. There was a floor mat on one side of the bed. There were bilateral half upper side rails raised on the bed. On 1/11/18 at 8:45 a.m. the surveyor again observed the resident in a low bed with one floor mat next to the bed. The half side rails were in the up position and a Licensed Practical Nurse (LPN) was at bed side talking to the resident. The LPN then stated that this resident needed assistance with bed mobility and transfers. On 1/11/18 at 9:38 a.m. the surveyor reviewed the resident's medical record which revealed the resident was admitted on [DATE] from an Assistive Living facility with medical [DIAGNOSES REDACTED]. The resident's initial MDS was completed on 12/11/17 and indicated that a BIMS evaluation could not be conducted because the resident was rarely/never understood. The MDS confirmed that the resident was dependent on staff for bed mobility and transfers and had a functional limitation in range of motion of one side of their lower extremities. Resident #54 used a wheelchair for mobility. Review of the POS [REDACTED]. The facility obtained verbal consent on a Restraint Consent dated 1/2/18 from the Office of Public Guardian, the resident's representative. The resident's current Plan of Care did not identify the use of side rails as an intervention for any of the identified focus areas. Further review revealed there was no documented evidence that the facility had assessed other alternatives prior to initiating the use of side rails, assessed the resident for the need of side rails or for the risk of entrapment prior to obtaining a consent and installation of the half side rails. 4. On 01/10/18 at 10:06 a.m. the surveyor observed Resident #35 in bed with two half side rails up. The resident's hospice aid was in the room. On 1/11/18 at 9:37 a.m. the surveyor again observed Resident #35 in bed with bilateral half side rails partially raised about eight inches above the resident's mattress. At that time, the resident was alone and stated that he/she liked the rails up a few inches because it helped to move in bed .to pull himself/herself up and to change position. Resident #35 then demonstrated this use of the side rails for bed mobility for the surveyor. 01/11/18 at 11:30 a.m. the surveyor reviewed the resident's medical record which revealed that he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Admission Resident Assessment indicated that the resident/family had been educated on the potential for negative outcomes in the use of side rails and he/she understood the usage of the side rails. The Side Rail consent form had been signed on admission by the Resident's responsible party. The resident's initial MDS, dated [DATE], included a cognitive assessment with BIMS score of 9, which indicated that the resident had a moderately impaired mental status. The MDS also indicated that the resident required extensive assistance of one person for bed mobility and that he/she was involved in the activity. The Care Plan for Resident #35 did not address the use of side rails. On 1/12/18 at 12:22 p.m. the surveyor interviewed the ADON who stated that Resident #35 was alert and oriented. She could not find any assessment that addressed bed rails other than the brief Safety Awareness section of the Admission Resident Assessment. There was no documented evidence that the facility assessed other alternatives prior to initiating the use of half side rails, assessed the resident for the need of bed rails or for the risk of entrapment prior to installation of the side rails and prior to obtaining a consent. 5. On 01/11/18 at 11:37 a.m. the Director of Nurses (DON) provided the surveyor with copies of the Policies and Procedures for Proper Use of Side Rails which revealed the facility's policy statement that included will attempt to use appropriate alternatives prior to installing a side or bed rail. The Procedure included the following items: #4. An assessment will be made prior to installation to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility, ability to transfer between positions, to and from bed or chair, to stand and toilet, and risk of entrapment. #5. The use of side rails as assistive device will be addressed in the resident care plan. #6. Less restrictive interventions will be considered. On 1/12/18 at 10:05 a.m. the Administrator told the surveyors that the facility had removed all of the side rails from the residents' beds in November of 2016, when they became aware of the proposed bed rail regulation and we replaced them as needed and as per resident request. On 1/16/18 at 9:00 a.m. the Director of Nursing (DON) stated that she thought their assessment on the Admission Resident Assessment in each resident's medical record was adequate to meet the new regulation. She then presented to the surveyor an expanded assessment form for the use of side rails to use in the future. Refer to F656 N.J.A.C. 8:39-11.1

Based on observation, interview and review of the medical record and review of other facility documentation, it was determined the facility failed to develop care plans for the use of bed rails as an intervention. This deficient practice was identified for 4 of 4 residents reviewed for side rail use (Resident's #35, 41, 43 and #54) as evidenced by the following: 1. During the initial tour on 1/8/18 at 10:48 a.m. the surveyor observed Resident # 41 ambulating slowly in his/her room without difficulty. On 1/11/18 at 8:50 a.m. the surveyor observed the resident lying in bed with closed eyes and one half side rail raised, while the other rail was in the lowered position. On 1/11/18 at 11:00 a.m. the surveyor reviewed the resident's medical record which revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The surveyor reviewed the Admission Resident assessment dated [DATE] and under the Safety Awareness section the facility circled no for Siderails used. The January 2018 physician's orders [REDACTED]. The resident had a Fall Risk Assessment evaluation on 8/17/17 with a score of 20 and re-assessed on 11/21/17 with a score of 25. Both scores were identified as a moderate risk for falls. Review of the Minimum Data Set (MDS), an assessment tool, revealed an initial assessment completed on 8/28/17, with a Brief Interview for Mental Status (BIMS) score of 6. A quarterly MDS, dated [DATE] included a BIMS score of 5, which indicated that this resident had a severe impairment in cognitive function. Both MDS assessment dates indicated the resident required one person assistance for bed mobility and transfers. Upon further review of the medical record, the surveyor reviewed a Restraint Consent form, dated 1/2/18, for the use of half side rails for positioning. There was no documented evidence that the facility assessed other alternatives prior to initiating the use of a half side rail, assessed the resident for the need of a side rail or for the risk of entrapment prior to installation of the side rails and prior to obtaining a consent. Review of the resident's current Plan of Care indicated that it did not address the use of side rails. 2. On 1/08/18 at 10:27 a.m. the surveyor observed Resident # 43 in a low bed with eyes closed. The bed had bilateral upper side rails in the up position. At 10:30 a.m. the resident stated that he/she was not independent with transfers and could not lower the bed rails. The resident also told the surveyor that he/she doesn't know why the facility staff placed the rails on the bed. On 1/10/18 at 10:24 a.m. the surveyor reviewed the medical record of Resident #43 which revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An initial MDS, dated [DATE], assessed the resident's BIMS level at 15, which indicated that the resident's cognition was intact. The MDS also indicated that Resident #43 required extensive help of one staff member for bed mobility and transfers, used a wheelchair, had limited range of motion to one upper extremity and had not fallen since admission. The surveyor reviewed the Admission Resident assessment dated [DATE] and under the Safety Awareness section the facility did not indicate yes or no for Siderails used or Education needed. The resident had a Fall Risk Assessment evaluation, dated 12/23/17, with a score of 44 which was identified as a significant risk for falls. Further review of the medical record revealed that on 1/2/18 the facility obtained a physician's orders [REDACTED]. Further review of the medical record revealed that on 1/2/18 the facility obtained a physician's orders [REDACTED]. Review of the resident's current Plan of Care revealed that it did not include the use of side rails. 3. On 1/10/18 at 10:51 a.m. the surveyor observed Resident #54 in a low bed with eyes closed. There was a floor mat on one side of the bed. There were bilateral half upper side rails raised on the bed. On 1/11/18 at 8:45 a.m. the surveyor again observed the resident in a low bed with one floor mat next to the bed. The half side rails were in the raised position and a Licensed Practical Nurse (LPN) was at bed side talking to the resident. The LPN then stated that this resident needed assistance with bed mobility and transfers. On 1/11/18 at 9:38 a.m. the surveyor reviewed the resident's medical record which revealed the resident was admitted on [DATE] from an Assistive Living facility with medical [DIAGNOSES REDACTED]. The resident's initial MDS was completed on 12/11/17 and indicated that a BIMS evaluation could not be conducted because the resident was rarely/never understood. The MDS confirmed that the resident was dependent on staff for bed mobility and transfers and had a functional limitation in range of motion of one side of the resident's lower extremities. Resident #54 used a wheelchair for mobility. Review of the POS [REDACTED]. The facility obtained verbal consent on a Restraint Consent dated 1/2/18 from the Office of Public Guardian, the resident's representative. The resident's current Plan of Care did not identify the use of side rails as an intervention for any of the identified focus areas. 4. On 01/10/18 at 10:06 a.m. the surveyor observed Resident #35 in bed with two half side rails up. The resident's hospice aid was in the room. On 1/11/18 at 9:37 a.m. the surveyor again observed Resident #35 in bed with bilateral half side rails partially raised about eight inches above the resident's mattress. At that time, the resident was alone and stated that he/she liked the rails up a few inches because it helped to move in bed .to pull himself/herself up and to change position. Resident #35 then demonstrated this use of the side rails for bed mobility for the surveyor. 01/11/18 at 11:30 a.m. the surveyor reviewed the resident's medical record which revealed that he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Admission Resident Assessment indicated that the resident/family had been educated on the potential for negative outcomes in the use of side rails and he/she understood the usage of the side rails. The Side Rail consent form had been signed on admission by the Resident's responsible party. The resident's initial MDS, dated [DATE], included a cognitive assessment with BIMS score of 9, which indicated that the resident had a moderately impaired mental status. The MDS also indicated that the resident required extensive assistance of one person for bed mobility and that he/she was involved in the activity. The Care Plan for Resident #35 did not address the use of side rails. 5. On 01/11/18 at 11:37 a.m. the Director of Nurses (DON) provided the surveyor with copies of the Policies and Procedures for Proper Use of Side Rails which revealed the facility's policy statement that included will attempt to use appropriate alternatives prior to installing a side or bed rail. The Procedure included the following items: #4. An assessment will be made prior to installation to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: bed mobility, ability to transfer between positions, to and from bed or chair, to stand and toilet, and risk of entrapment. #5. The use of side rails as assistive device will be addressed in the resident care plan. #6. Less restrictive interventions will be considered. On 1/12/18 at 10:05 a.m. the Administrator told the surveyors that the facility had removed all of the side rails from the residents' beds in November of 2016, when they became aware of the proposed bed rail regulation and we replaced them as needed and as per resident request. On 1/16/18 at 9:00 a.m. the Director of Nursing (DON) stated that she thought their assessment on the Admission Resident Assessment in each resident's medical record was adequate to meet the new regulation. The DON also stated that the facility had started an assessment process for side rails for all residents and that Care Plans have been addressed. N.J.A.C 8:39-11.2 (e)

Based on observation, interview and review of medical records and facility documents, it was determined that the facility failed to follow fall prevention interventions as written on the resident's plan of care. This deficient practice was identified for 1 of 3 residents (Resident # 16) reviewed for falls and accidents and was evidenced by the following: The surveyor reviewed the medical record which showed that Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the annual Minimum Data Set (MDS), an assessment tool dated 4/15/17, reflected that Resident # 16 required extensive assistance of two for transfers. Subsequent quarterly MDS's dated 7/14/17 and 10/13/17 also reflected that the resident required assistance of two for transfers. On 01/09/18 at 11:42 p.m., the surveyor reviewed the nurses notes dated 08/23/17 that reflected a Certified Nursing Assistant (CNA) attempted to assist the resident on the sit to stand when the resident began to slip off the side of the bed, so the CNA assisted the resident to the floor. On 01/09/18 at 12:32 p.m., the surveyor reviewed a facility Incident/Accident Report dated 8/23/17 that indicated a CNA attempted to transfer the resident to the sit to stand and the resident began to slip off the side of the bed and the CNA lowered the resident to the floor. The CNA notified the nurse. The resident was assessed and had no complaints of pain. A small red mark was noted on the resident's back on assessment. The facility Incident/Accident Report also reflected that the CNA was educated not to start the transfer process until two person assist was available. On 01/10/18 at 10:35 a.m., the surveyor reviewed the resident's care plan dated 2/3/16 which reflected that the resident required max assistance of two staff members for transfers. On 01/11/18 at 10:49 a.m., the surveyor interviewed Registered Nurse Assistant Director of Nursing (RN/ADON) who stated that the CNA involved with this incident was no longer employed by the facility. The RN/ADON also stated, The CNA should have had another staff member assisting with the transfer. On 01/12/18 10:30 a.m., the Director of Nursing (DON) and Administrator did not provide any additional information. NJAC 8:39-27.1 (a)

Based on observation, interview and record review on 2/22/17 in the presence of facility management, it was determined that the facility failed to maintain their resident room built-in Heating and Air Conditioner units in safe and effective operating condition by allowing excessive amounts of dust and debris to accumulate in the filters which could cuase the motors to overheat. This deficient practice was evidenced by the following: From 10:45 a.m. to 1:45 p.m., the surveyor observed clogged and dirty filters in the following resident rooms. 146, 145,144, 140, 143, 150, 154, 158, 163. In resident rooms 174 and 184 the filters in the heating units were so heavily clogged with dust and debris that the motor of the heating unit forced the filter off of its track and into the unit itself. An interview was conducted with the Maintenance Director at the time of the observations and he agreed that the filters should not be like that in the facility. An air filter maintenance log was provided and dated 9/7/16, more than 5 months ago. NJAC 8:39-31.2(e)

Based on observation, interview and record review, it was determined that the facility failed to provide evidence for the continued need of psychoactive medication, including documentation of the rationale when the therapeutic goals were not met. The facility also failed to accurately document target behaviors to match the information in the Nurse's Notes. This deficient practice was identified for Resident #9, 1 of 1 residents reviewed for psychoactive medication and was evidenced by the following: During the initial unit tour on 2/22/17, the unit Licensed Practical Nurse (LPN) told the surveyor that Resident #9 was confused and non-verbal. The surveyor reviewed the medical record which showed that Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. On 2/24/17 at 11:40 a.m., the surveyor observed the resident seated in a geri-chair in a common area with eyes closed. The surveyor reviewed the February 2017 Medication Administration Record [REDACTED]. There was also an order [REDACTED]. Upon review of the Psychoactive Monthly/Quarterly Evaluation (PM/QE), the surveyor noted the facility's identified target behaviors for the use of the [MEDICATION NAME] were: sad mood,withdrawn behaviors for the month of 9/2016. For August and July 2016, the facility included yelling as part of the target behavior. A review of the PM/QE from 5/2016 to 1/2017 reflected that Resident #9 did not exhibit the above behaviors. There was also no rationale given for continuing to give the medications in the absence of behaviors. On 2/28/17, the facility faxed Nurses' Notes dated 3/29/16 to 6/4/16. This showed that Resident #9 had behaviors of yelling at times and also was anxious at times. This was conflicting information as the PM/QE indicated that there were no such behaviors. In addition, the Nurse's Notes reflected that the resident still had the same behaviors even with the use of [MEDICATION NAME]. The surveyor reviewed Nurse's Notes for August and September 2016 and Interdisciplinary notes for October and November 2016. Both reflected that Resident #9 still had the same behavior of yelling at times. There was no documented evidence that the interdisciplinary team evaluated if the current medication was effective or appropriate or should be reduced, changed, or discontinued. NJAC8:39-29.3(a)

Based on observation, interview and record review, it was determined that the facility failed to provide physician-ordered thickened liquids for a resident at risk for choking due to difficulty swallowing. This deficient practice was identified for Resident #10, 1 of 2 residents reviewed for altered liquid consistency diet and was evidenced by the following: During the initial unit tour on 2/22/17 at 10 a.m., the Assistant Director of Nurses (ADON) stated that Resident #10 was oriented to self and required thickened liquids. On 2/23/17 at 9:40 a.m., the surveyor observed the Licensed Practical Nurse (LPN) administer medications during medication pass observation. The surveyor observed the LPN prepare Resident #10's medications and then poured an 8-ounce cup of unthickened apple juice in a cup and inserted a straw. The LPN then took the medication and the cup of apple juice and entered the resident's room. Just before she gave the resident the medication and juice, the surveyor stopped her and asked the LPN to step out of the room and return to the medication cart. The surveyor instructed the LPN to read the Medication Administration Record [REDACTED]. The LPN stated that she knew that the resident received thickened liquids but did not explain why she went to give the resident thin liquid. The surveyor observed the LPN read the instructions on the can of powder thickener. She then opened the lid of the apple juice and added 1 tablespoon of thickener in the apple juice. The LPN placed the lid back on the juice cup and was about to go into the resident's room when the surveyor stopped her again and asked her to re-read the the directions on the can of thickener. According to the the directions, the nurse was to add two tablespoons of the thickener for an 8 oz. of apple juice in order to make nectar consistency liquid. The nurse only added 1 tablespoon. Upon interview, the LPN stated, you really have to read the fine print. At 10:20 a.m., the surveyor reviewed Resident #10's medical records which reflected that Resident #10 had a [DIAGNOSES REDACTED]. The surveyor also reviewed the resident's Physician order [REDACTED]. The POS showed that the resident's diet order was pureed diet with nectar thick liquids. The surveyor reviewed a form labeled Speech Therapy Discharge Summary dated 1/9/17. The form also reflected that Resident #10 was supposed have nectar thick liquids for safe nutritional intake. On 2/24/17 at 1 p.m. the Administrator and the Director of Nurses both agreed that the LPN should have been aware that the resident's liquids needed to be thickened. NJAC8:39-27.1(a)

COMPLAINT # NJ Based on interviews, review of medical records and other pertinent facility documentation on 7/14/16, it was determined that the facility failed to ensure that Resident medical records were maintained in their entirety and safe from loss for 1 of 5 sampled Residents, (Resident #1). This deficient practice was evidenced by the following: Reference : New Jersey Hospital Association Provider Resources Section 6: The NJ Universal Transfer Form (UTF) must be used by all licensed healthcare facilities and programs when a patient is transferred from one care setting to another. 1. According to the Medical Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 4/1/16, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating that Resident #1 had moderately impaired cognition. The MDS documentation included that Resident #1 required staff assistance for Activities of Daily Living (ADLs). A review of the Physician order [REDACTED]. A review of the Nurses Notes (NN) dated 1/20/16, timed 11-7 (shift), indicated that Resident #1 complained of chest pain radiating to the left side of the body. The NN further revealed that Resident #1's attending Physician was notified and ordered the Resident to be sent to the hospital. There was no documentation that the family/Responsible Party was notified of Resident #1's change in condition requiring a transfer to the hospital. The facility was unable to provide a Universal Transfer Form (UTF), for Resident #1. During an interview with the Assistant Director of Nursing (ADON) on 7/5/16 at 12:40 P.M., the ADON stated I can't find the UTF for Resident #1. NJAC 8:43 E-13.4 (d)

COMPLAINT # NJ Based on interviews, review of medical records and other pertinent facility documentation on 7/5/16 and 7/14/16, it was determined that the facility failed to follow their own policy for the documentation of Incidents/Accidents for 1 of 5 sampled Residents, (Resident # 2). This deficient practice was evidenced by the following: 1.According to the Resident Inquiry Form Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 4/11/16, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS documentation included that Resident #2 required staff assistance for Activities of Daily Living (ADLs). A review of a facility Incident/Accident Report dated 6/24/16 timed at 12:40 A.M., revealed that Resident #2 was found on the floor next to the bed. The report went on to indicate that the Resident was assessed and the attending Physician and family were notified of the incident. A further review of the same report dated 6/24/16, revealed under the Statements of Caregivers from previous 24 hour period. Include current shift as starting point, 3-11 Date/Time section, signed by the Director of Nursing (DON) included the following; 6/23/16 Certified Nursing Assistants (CNAs) reported to the writer while showering in main shower room residents knees buckled and resident needed to be lowered to the ground The section further indicated that The Resident was examined and there were no body marks. A review of the Nurse's Notes (NN) for Resident #2 did not include documentation of the 6/23/16 incident of lowering the Resident to the ground or an assessment post incident. During an interview with Licensed Practical Nurse (LPN #1) on 7/5/16 at 12:30 P.M., LPN #1 stated that I don't think lowering a Resident to the floor is considered a fall. I guess you would document the incident in the medical record. During an interview with the Assistant Director of Nursing (ADON) on 7/5/16 at 12:40 P.M., the ADON stated If a Resident is lowered to the floor the Nurse is alerted, an Incident report is done and this is considered a fall . The family and Physician are notified and we follow the Physician instructions. This is charted in the medical record for 3 days post incident. During an interview with the DON on 7/5/16 at 12:42 P.M., the DON stated Yes, lowering to the floor is a fall. They (the Nursing staff) asked me if they had to do an incident report and I said no. I got the statement from 3-11 shift and the Residents falls were within a few hours of each other and I felt they could be put together on one (1) report. During a telephone interview with CNA #1 (one of the CNAs in the shower room during the incident) on 7/14/16 at 10:28 A.M., CNA #1 stated that the incident happened around 4 P.M. and I called the Nurses and they all came in and checked the Resident. The Resident ate his dinner and had no complaints through the rest of my shift. During a telephone interview with CNA #2 (in the shower room at the time of the incident) on 7/14/16 at 10:48 A.M., CNA #2 stated I called the Nurse and they checked the Resident. There were no injuries and the Resident had no complaints of pain or that anything else was wrong. During an interview with the DON on 7/14/16 at 11:55 A.M., the DON stated I was there when the Resident was lowered to the floor in the shower room and I assessed him and there were no injuries. The next day I saw an Incident report from the night shift fall (6/24/16) and there was no incident report from the 3-11 shift for the Resident being lowered to the floor. I added the 6/23/16 incident under the 3-11 shift section of the 6/24/16 Incident report. The DON went on to say Yes, there should have been a separate Incident report for the Resident being lowered to the ground. I would have the Nurses notify the family and Physician. It is my expectation to have documentation of incidents in the progress notes. A review of an undated facility policy titled, Policy: Incident/Accident, revealed under the Policy section Facility staff will document all incidents and accidents, . on an Incident/Accident Report Form. The policy further indicated under the Procedure section 2. The reporting nurse will document the occurrence, the residents condition, the action taken and a follow-up evaluation of the resident in the interdisciplinary clinical progress notes. NJAC 8:39-27.1 (b)

COMPLAINT # NJ Based on interviews, review of medical records and other pertinent facility documentation on 7/5/16 and 7/14/16, it was determined that the facility failed to notify the Family/Responsible Party of a Residents transfer to the hospital for 1 of 5 sampled Residents, (Resident #1). This deficient practice was evidenced by the following: 1.According to the Medical Record, Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 4/1/16, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating that Resident #1 had moderately impaired cognition. The MDS documentation included that Resident #1 required staff assistance for Activities of Daily Living (ADLs). A review of the Physician order [REDACTED]. A review of the Nurses Notes (NN) dated 1/20/16, timed 11-7 (shift), indicated that Resident #1 complained of chest pain radiating to the left side of the body. The NN further revealed that Resident #1's attending Physician was notified and ordered the Resident to be sent to the hospital. There was no documentation that the family/Responsible Party was notified of Resident #1's change in condition requiring a transfer to the hospital. Reference : New Jersey Hospital Association: The facility was unable to provide a Universal Transfer Form, (a form that must be completed by all licensed healthcare facilities and programs when a patient transfers from one care setting to another that provides pertinent patient information) for Resident #1. During an interview with the Assistant Director of Nursing (ADON) on 6/28/16 at 12:40 P.M., the ADON stated that The family/Responsible party is to be notified of a Residents change in condition requiring transfer to a hospital as this goes along with a change in condition. During an interview with the Director of Nursing (DON) on 7/14/16 at 11:55 A.M., the DON stated It is our policy to call familys if there is a change in condition. The DON went on to say that I would expect documentation that a family was notified of transfer to a hospital. A review an undated facility policy titled, Change in a Resident's Condition or Status, revealed under the Policy section, Our facility shall promptly notify the Resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status . The policy further indicated that the Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. NJAC 8:39-13.1(c)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that residents were free from significant medication errors. This deficient practice was identified for Residents #2 and #4, 2 of 14 residents reviewed and was evidenced by the following: 1. On 1/6/16 at 9:55 a.m., the surveyor observed Resident #2 in bed, dressed. At 1:35 p.m., the surveyor reviewed the medical record for Resident #2. Review of the physician order [REDACTED].#2 was prescribed an antibiotic, [MEDICATION NAME], for right leg [MEDICAL CONDITION] (leg infection). The PO indicated to give [MEDICATION NAME] 500 mg 1 tablet by mouth every day for 7 days. On 1/8 at 12:50 p.m., the surveyor reviewed the current January 2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. After the resident had received eight doses of the antibiotic [MEDICATION NAME] over a four day period, the medication error was identified by the facility. The manufacturers' recommendations for the administration of [MEDICATION NAME] included: do not take more than one dose in a day. On 1/11 at 11:05 a.m., the surveyor interviewed the Director of Nursing (DON) who acknowledged that the [MEDICATION NAME] was administered twice a day in error over a four day period. 2. On 1/5/16 at 11:30 a.m. during the initial tour, the surveyor observed Resident #4 in his/her wheelchair in the lobby. The Assistant Director of Nursing (ADON) stated that the resident had multiple behavioral disturbances and was on antipsychotic medication. On 1/6 at 11:30 a.m., the surveyor reviewed the medical record for Resident #4 who had a history of [REDACTED]. According to the medical record, Resident #4 was re-admitted to the facility on [DATE] following hospitalization . Review of the re-admission (POS) dated 1/4/16 included a PO for an as needed antipsychotic medication, [MEDICATION NAME]. The order stated to give [MEDICATION NAME] 5 mg/ml intramuscularly twice a day as needed for increased agitation. The PO of 5 mg/ml was the concentration of the liquid medication and not the dose to be administered. The facility did not clarify this order till surveyor inquiry. On 1/7 at 12:10 p.m., the surveyor interviewed the Unit Licensed Practical Nurse (LPN). She stated that she believed the medication dose was the same as the concentration of the medication. The surveyor asked the nurse for the vial of the [MEDICATION NAME]. This showed that the concentration of the [MEDICATION NAME] was 5 mg/m. A review of the corresponding MAR for January 2016 reflected that Resident #4 received the [MEDICATION NAME] on 1/5/16 at 12 p.m. On 1/11 at 11:05 a.m., the surveyor interviewed the DON who confirmed that the dose for the [MEDICATION NAME] was not stated within the PO, and that the order should have been clarified prior to administration to the resident. NJAC 8:39-29.2 (d)

Based on observation, interview and record review, it was determined that the facility failed to store and maintain the closed urinary drainage system of an indwelling catheter (a flexible tube used to collect urine directly from the bladder) in a manner to prevent Urinary Tract Infections [MEDICAL CONDITION], and failed to provide documented evidence of changing the urinary leg bag according to physician orders [REDACTED].#6. The facility also failed to ensure that a urinary drainage bag was kept off the floor according to the facility policy for the prevention of UTI. This deficient practice was identified for Residents #6 and #11, 2 of 2 residents reviewed for urinary catheters use. The findings were as follows: 1. On 1/5/16 at 11:45 a.m. during the initial tour, the Assistant Director of Nursing (ADON) stated that Resident #6 had an indwelling urinary catheter due to a history of [MEDICAL CONDITION]. On 1/6/16 at 9:40 a.m., the surveyor observed Resident #6 in bed with his/her eyes closed. The surveyor observed a large urinary drainage bag attached to the resident's bed frame. At that time, the surveyor observed the storage of the urinary leg bag (a small urinary drainage bag that secures to the leg when out of bed) in the bathroom. The leg bag was stored in a large open white plastic bag which was tied to a grab bar. The leg bag's connection port used to secure to the indwelling urinary catheter was not capped, causing cross-contamination. At 1 p.m., the surveyor reviewed the medical record for Resident #6 who was admitted to the facility with a history of [MEDICAL CONDITION] bladder and [MEDICAL CONDITION] requiring the use of an indwelling urinary catheter. At 2:20 p.m., the surveyor observed the storage of the large urinary drainage bag inside the bathroom. The drainage bag was in the white plastic bag hanging from the grab bar in the bathroom. There was some urine residue in the bottom and sides of the white plastic bag. The tubing's connection port was not capped and the drainage port used to empty urine from the bag was not secured to the large drainage bag. On 1/7 at 9:10 a.m., the surveyor observed the resident in bed with the TV on. The surveyor observed the storage of the small urinary leg bag in the bathroom. The leg bag was stored in a white plastic bag hanging from the grab bar. Inside the plastic bag was a urinal and the leg bag. There was some urinary residue on the bottom and sides of the white plastic bag and inside of the leg bag. The leg bag's connection port was not capped. At 9:35 a.m., the surveyor observed Resident #6 in bed, as two Certified Nursing Aides (CNA's) prepared the resident for a shower. The CNA removed the large urinary drainage bag from the indwelling catheter and laid the catheter port in the resident's incontinent brief. At that time, the CNA went to the sink to clean the large drainage bag and placed it in the large white plastic bag in the bathroom. The CNA did not cap the connection port of the large drainage bag before placing it in the white plastic bag. The CNA then returned to the resident's bedside and transferred the resident from the bed onto a shower chair with the assistance of another CNA. The CNA did not attach a urinary drainage bag to the urinary catheter, but placed the exposed port of the catheter between the resident's legs and wheeled the resident to the shower room. At 9:45 a.m., the surveyor interviewed the CNA. The CNA confirmed that she was assigned to Resident #6 regularly and stated, I always shower the resident without a drainage bag, that way the straps don't get wet in the shower. At 10:15 a.m., the surveyor reviewed the Physician order [REDACTED].#6 who had a physician order [REDACTED]. The PO was pre-printed in the Treatment Administration Record (TAR) for November and December 2015. The TAR was not signed to reflect that the leg bag had been changed per PO for all of November and December 2015. On 1/11/16 at 11:15 a.m., the surveyor interviewed the Director of Nursing (DON). The DON provided the facility's policy and procedure which stated, Never disconnect the catheter drainage system. and Ensure that there is no disconnection or leaking of urine from the system (except into the drainage bag). The DON acknowledged that the CNA did not provide proper technique according to the facility's policy in caring for Resident #6 who had an indwelling urinary catheter in order to prevent a UTI. The DON also could not provide documented evidence that the leg bag was changed according to PO for November and December 2015. 2. On 1/5/16 at 11:50 a.m. during the initial tour, the ADON stated that Resident #11 was admitted to the facility with an indwelling urinary catheter due to [MEDICAL CONDITION]. On 1/6 at 10:10 a.m., the surveyor observed Resident #11 in bed awake as the CNA exited the room. The resident's bed was in a very low position. The large urinary drainage bag had a privacy flap that was attached to the bed frame but the urinary bag was resting directly on the floor. The drainage port was not secured to the bag and was also touching the floor's surface. At 1:25 p.m., the surveyor again observed Resident #11 in a very low bed with the large urinary drainage bag resting on the floor with an unsecured drainage port touching the surface of the floor. At 1:30 p.m., the surveyor reviewed the medical record for Resident #11 who was admitted to the facility on [DATE] with an indwelling urinary catheter due to a [DIAGNOSES REDACTED]. On 1/7 at 9:20 a.m., the surveyor observed Resident #11 in bed, with the bed in a low position. The large urinary drainage bag was observed attached to the bed frame and resting on the floor. On 1/11 at 11:00 a.m., the surveyor interviewed the DON who acknowledged that according to the facility policy, the catheter tubing and drainage bag were to be kept off the floor for the prevention of UTI's. NJAC 8:39-19.4 (a) 27.1 (a)