Every finding on record at Willow Springs Rehabilitation and Healthcare Cente

Based on observation, interview and policy review, the facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, and dishes were stacked dry. These failures had the potential to affect 153 residents who consumed food prepared by the kitchen.Findings include:Observations of the kitchen on 01/05/26 at 10:16 AM, revealed dust and debris were visible on the top of the dishwasher that included a rusted spring and dirty knife. The tile wall next to the grill had dust and stains scattered throughout the surface. The floor behind the oven and stove had a layer of black substance against the floorboard and under the three-compartment sink. The oven and stove top had built up grease and black debris. Also, the plate warmers had debris and dust on top of them and there were plates in the warmer that had water on them stacked on top of each other. During an interview on 01/05/26 at 10:45 AM, the Regional Dietary Director (RDD) confirmed the areas during the initial tour of the kitchen, stating they were not clean. The RDD also confirmed the water on the plates should not be there because they could carry bacteria and cause an infection.During an observation on 01/07/26 at 10:50 AM, the RDD was observed to bring in four boxes of pasta and put them on the prep table. The RDD collected five plates of food from breakfast and took them to the dirty area of the dishwasher. The RDD then went to the refrigerator and pulled on the handle without washing his/her hands from the time of entrance.On 01/07/26 at 10:55 AM, the Regional Director of Dietary Services (RDDS) was asked if staff should wash their hands when entering the kitchen. The RDDS stated yes. Observations on 01/07/26 at 11:09 AM, revealed the plate warmer had debris on top and the plates were visibly wet and were placed on the trays that were going out to residents. On 01/07/26 at 11:33 AM, the Food Service Director (FDS) was observed washing hands and walking away with the paper towels and then using the same paper towels to wipe his/her face and threw the towels away. The FDS then pulled out gloves from the box and put them on. The FDS went to the stove and continued cooking. During an interview on 01/07/26 at 12:10 PM, the RDDS was asked about the plates that were stacked on each other and placed on trays. The RDDS looked at it and started pulling the wet plates and stated the plates should be dry because it was called wet nesting and it could cause bacteria to grow. The RDDS pulled out 16 more wet plates. Continued observations on 01/07/26 at 12:24 PM, revealed Dietary Aide (DA)2 walked away from the serving line and went to the door where an unidentified staff member gave him/her a dietary ticket. After taking the ticket in the gloved hand, DA2 went back to the serving line and began to set up trays. During an interview on 01/07/26 at 12:28 PM, the RDDS was asked about staff walking away from the serving line doing a different task then returning to the line wearing the same gloves. The RDDS stated the gloves should have been disposed of and the hands washed before coming back to the line. The RDDS was also asked about the FDS wiping his/her face with the paper towel and then putting gloves on afterward. The RDDS stated the hands should have been washed again. During an observation on 01/07/26 at 1:01 PM, DA3 was observed to his/her wash hands at the sink and finished by drying his/her hands with the disposable paper towels. DA3 lifted the lid of the trash can which contaminated the hands. The trash can had a working foot peddle. During an interview on 01/07/26 at 1:10 PM, the RDDS was asked about using hands to lift the lid of the trash can after washing hands. The RDDS stated the trash can had a foot pedal, so the lid did not have to be touched. During an interview on 01/07/26 at 1:13 PM, DA3 was asked about using his/her hands to lift the lid when the trash can had a foot pedal. DA3 stated, I did not think about it.Review of the undated facility policy titled, General Sanitation of Kitchen, revealed, Policy: Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Review of the undated assignment sheet titled, Daily Cleaning Assignments revealed, on Sunday the AM [NAME] should clean the plate warmer and the PM [NAME] should clean the stove. On Sundays and Thursdays clean outside dishwasher, Saturdays PM#3 clean three sink area.Review of the undated facility policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, revealed, Policy: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from food handlers' hands to the food product being served. 4. Hands are to be washed when entering the kitchen and before putting on the single use gloves and after removing single use gloves. 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. b. After handling garbage or garbage cans. Wash hands after removing gloves. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) when entering a room with a resident on transmission-based precautions, droplet precautions, and while providing direct care to a resident on enhanced barrier precautions (EBP) for two of five residents (Resident (R)40 and R89) reviewed for infection prevention and control out of a total sample of 49 residents. This failure placed staff and residents at risk of infection from cross-contamination.Findings include:.1. Review of R89's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R89 was admitted to the facility on [DATE], with diagnoses that included stroke, non-Alzheimer's dementia, aphasia (difficulty speaking), and a feeding tube.Review of R89's undated Physician Orders, located under the Orders tab of the EMR, reflected the following orders: Enteral Feed Order four times a day. Give Jevity 1.5 Bolus Feeding of one container (237 mLs) [milliliters], four times daily as listed and crush medications per manufacturer recommendations (do not crush enteric coated or extended-release medications, or those not approved by manufacturer) and mix in 5mL warm water each. Confirm placement, flush with 30 mL of warm water, administer medications individually flushing with 15 mLs of warm water in between, and with 30 mLs of warm water after all meds are given.During an observation on 01/07/26 at 11:30 AM, Licensed Practical Nurse (LPN)1 was observed administering a bolus feeding to R89 who was on EBP. LPN1 did not wear a gown. A sign was posted outside R89's room that indicated EBP were in place and that providers and staff must wear gloves and a gown for the following high-contact resident care activities, device care, or use, which included a feeding tube.During an interview on 01/07/26 at 11:53 AM, LPN1 indicated that he/she forgot to put on a gown before accessing the resident's feeding tube. LPN1 said staff were required to wear a gown and gloves whenever direct care was provided to a resident on enhanced barrier precautions.During an interview on 01/08/26 at 2:18 PM, the infection preventionist (IP) stated that the facility followed the Centers for Disease Control and Prevention (CDC) guidelines for EBP. The IP said that he/she provided education to staff and ensured appropriate signs were posted at resident rooms within line of sight and placed PPE bins at the doorway for PPE access before entering room. The IP said that staff must ensure they properly put on the appropriate PPE before entering the room.During an interview and record review on 01/08/26 at 4:30 PM, the Assistant Director of Nursing (ADON) said that he/she completed competency assessments during new hire on-boarding, skills fairs, and annual reviews. The ADON presented a PPE Donning/Doffing Checklist Competency form for LPN1 dated 11/04/25, that reflected LPN1 met donning and doffing of PPE requirements. The ADON signed and dated the form on 11/04/25.Review of the facility's policy titled, Personal Protective Equipment dated October 2018, revealed, 1. Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge.3. Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required for a task is based on: (a) the type of transmission-based precaution;(b.) the fluid or tissue to which there is a potential exposure; (c.) the likelihood of exposure; (d.) the potential volume of material; (e.) the probable route of exposure; and (f.) the overall working conditions and job requirements.5. Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals.2. Review of R40's electronic medical record (EMR) revealed an undated admission Record, located under the Profile tab with an admission date of 12/23/25, with diagnoses of wedge compression fracture, atherosclerotic heart disease, and muscle wasting.Review of the R40's Physician Orders, located in the EMR under the Orders tab revealed on 12/31/25, flu place resident in droplet isolation.During an observation on 01/06/26 at 10:37 AM, a sign was posted on R40's door stating droplet precautions and it had pictures of a gown, gloves, mask, and eye wear.During an observation on 01/06/26 at 11:19 AM, Certified Nursing Assistant (CNA)2 put on a gown, gloves and mask and went into the room.During an interview on 01/06/26 at 11:22 AM, CNA2 was asked to look at the sign to see if everything that should have been worn was worn. CNA2 stated that the eye wear was not worn. CNA2 also stated that no personal care was provided.During an interview on 01/08/26 at 9:44 AM, the Director of Nursing (DON) was asked what the expectations were when droplet isolation was put into place. The DON stated the expectation was for the staff to follow the sign and guidance. During an interview on 01/08/26 at 3:19 PM, the IP was asked about expectations for following the precautions. The IP stated all PPE indicated on the sign should be worn for droplet precautions. Review of the facility policy titled, Personal Protective Equipment revised October 2018, revealed, Policy Statement: Personal protective equipment appropriate to specific task requirements is available at all times. NJAC 8:39-19.4

Based on observations, record review, and interviews, the facility failed to promote a dignified dining experience by standing to feed two of 15 residents (Resident (R)42 and R101) reviewed for dignity while dining on the Memory Care Unit. This failure had the potential to negatively impact the quality of life for the affected residents.Findings include:1.Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R42 was admitted on [DATE], with diagnoses including dementia with anxiety, aphasia, and dysphagia.Review of the modified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/25, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R42 was severely cognitively impaired.2.Review of the admission Record, located in the EMR under the Profile tab revealed R101 was admitted on [DATE], with diagnoses that included Alzheimer's disease and aphasia. Review of the quarterly MDS with an ARD of 09/18/25, revealed a BIMS score of three out of 15 which indicated R101 was severely cognitively impaired.An observation of the assisted dining room on 01/07/26 at 12:20 PM, revealed 15 residents waiting for lunch. Residents were observed talking, asking to eat, yelling out, and were encouraged to sit down when standing. Six staff members were in the dining room at the time of the observation. At 12:20 PM, the first meal cart arrived to be delivered to the residents who chose to eat in their rooms. At 12:47 PM, the tray cart for the assisted dining room arrived. R42's lunch tray was not on the cart. R101 was served his/her meal and was eating with verbal encouragement from staff as they were passing trays. R42 was observed to reach for R101's food as he/she had none. A certified nursing assistant (CNA3) observed R42 attempting to eat R101's food, obtained a container of yogurt for R42, and encouraged him/her to eat the yogurt as his/her tray had not arrived. At 12:56 PM, CNA3 was observed standing next to R42, assisting him/her to eat the yogurt. CNA3 was asked if he/she should stand to assist a resident to eat or sit next to them. CNA3 stated, We're waiting for the next cart. I know I'm supposed to sit. R42's tray arrived at 1:08 PM. At 1:05 PM, Registered Nurse (RN3) was observed standing next to R101 and assisting him/her to drink his/her juice. When asked if he/she should stand to assist a resident to eat or sit next to them, RN3 stated, Oh yes, I should have gotten a chair. During an interview on 01/08/26 at 9:31 AM, the Unit Nurse Manager, Licensed Practical Nurse (LPN3) said, Staff are expected to sit to assist residents to eat. I should have gotten chairs for them.During an interview on 01/08/26 at 12:15 PM, with the Administrator, Director of Operations, and the Director of Nurses (DON), the Administrator stated, they should sit next to residents, when assisting a resident with their meals.Review of the facility's policy titled, Assistance with Meals dated 03/22, revealed, Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example, not standing over residents while assisting them with meals. NJAC 8:39-4.1(a)12

Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure a Significant Change Minimum Data Set (MDS) assessment was completed within 14 calendar days after one of one resident (Resident (R) 36 elected hospice benefits out of a sample of 33 residents. This failure could potentially place the resident(s) at risk for unmet care needs being addressed, coordination of hospice care, and care planning of the resident.Findings include:Review of the RAI Manual, dated 10/01/2019, indicated under Section A0310A=04 Significant Change in Status Assessment (SCSA) The SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change in guidelines for either major improvement or decline.An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program.and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election.An SCSA must be performed regardless of whether as assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place.During an observation and interview on 01/05/26 at 10:00 AM, R36 was observed in his/her room and confirmed he/she was receiving hospice services.Review of R36's facility Physician orders, dated 08/25/25, and located under the Orders tab in the electronic medical record (EMR) indicated, Admit to [name of hospice agency].Review of R36's [name of hospice agency] documentation located in a white hospice binder at the nurse's station indicated R36 was admitted to hospice services on 08/22/25, for a terminal diagnosis of malignant neoplasm of overlap sited of bronchus and lung.Review of R36's significant change MDS with an ARD of 09/21/25 and located in the residents EMR under the MDS tab revealed R36 was currently receiving hospice services. Further review of the significant change MDS revealed it was not completed within 14 days from when R36 elected hospice benefits. The significant change MDS section regarding hospice services revealed it was not signed as being completed by the MDS Coordinator until 09/24/25. This was 33 days after receiving the hospice physician order to be placed on hospice services.During a phone interview on 01/07/26 at 10:26 AM, the Hospice Clinical Director with the [name of hospice company] stated R36 has been receiving hospice services since 08/22/25, and has not come off hospice services.During an interview on 01/07/26 at 11:56 AM, when reviewing R36's EMR with the MDS Coordinator (MDSC)1, he/she confirmed R36 went onto hospice services on 08/22/25. The MDS Coordinator then stated, Whenever there is a significant change, the sig [sic] change MDS has to be put in within 14 days of that change. The MDS Coordinator confirmed that he/she completed the hospice section of the significant change MDS and signed it as being completed on 09/24/25. When asked why it was not completed within the required 14 days, she stated, I don't know why. I just missed it.During an interview on 01/07/26 at 12:16 PM, when reviewing R36's EMR with the Director of Nursing (DON) regarding the timeliness of significant change MDS, the DON confirmed R36 went onto hospice services on 08/22/24. The DON stated, I'm also seeing the sig [sic] change portion for hospice services was signed and completed by the [name of the MDS Coordinator] on 09/24/25. The DON confirmed it was not completed within the required 14-day requirement and stated, It would be my expectation that we are completing the documentation within the required timeframe.During an interview on 01/07/26 at 4:24 PM, when reviewing R36's EMR with the Regional MDS Coordinator regarding the completion of the significant change MDS for R36, he/she confirmed the sig [sic] change MDS was not completed within 14 days of coming on hospice services and stated, It was not done when it should have been within the 14 day requirement. NJAC 8:39-11.2(i)

Based on observations, record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for two of 33 sampled residents (Residents (R) 9 and R36) receiving hospice services. Failure to ensure the accuracy of the MDS for residents receiving hospice services could lead to inaccurate assessment, place the residents at risk for unmet care needs being addressed, and care planning of the residents.Findings include: Review of the RAI Manual, dated 10/01/2019, indicated under Section J1400 Prognosis: indicated Definition: Condition or chronic disease that may result in a life expectancy of less than 6 months; In the physician's judgement, the resident has a diagnoses or combination of clinical conditions that have advanced or will continue to advance to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgement should be sustained by a physician note.Steps for Assessment: 1. Review the medical record for documentation by the physician that the resident's condition of chronic disease may results in a life expectancy of less than 6 months, or that they have a terminal illness. 2. If the physician states that the resident's life expectancy may be less than 6 months, request that he or she document this in the medical record.3. Review the medical record to determine whether the resident is receiving hospice services. Coding Instructions: Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the patient is terminally ill; or 2) the resident is receiving hospice services.'Terminally ill' means that the individual has a medical prognoses that his or her life expectancy is 6 months or less if the illness runs its normal care; Code residents identified as being in a hospice program for terminally ill persons.1.During an observation on 01/06/26 at 9:30 AM, R9 was observed in his/her room lying in bed. R9 was also observed to be non-interviewable at this time.Review of R9's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date to hospice services on 02/17/23, with medical diagnoses that included dementia with behavioral disturbances.Review of R9's Physician order, dated 02/17/23, and located under the Orders tab in the EMR revealed hospice eval [evaluation] and tx [treatment]. Review of R9's Care Plan, located in the EMR under the Care Plan tab and initiated on 02/21/23, indicated, I have a terminal prognosis r/t [related to] Alzheimer's. Interventions indicated, I 'am receiving hospice services through [name of hospice agency].Review of R9's [name of hospice agency] most recent hospice physician face-to-face encounter note located in a [name of hospice company] white binder located at the nurses station and dated 11/10/25 indicated, I certify the patient is terminally ill with a life expectancy of six (6) months or less if the disease process runs its normal course.Review of R9's [name of hospice agency] physician orders located in a [name of hospice company] white binder located at the nurses station dated 11/25/25, indicated Patients medical prognosis is that their life expectancy is 6 months or less and the terminal illness is running its normal course as evidenced by following clinical findings: Alzheimer's disease and senile degeneration of the brain.Review of R9's quarterly MDS, with an Assessment Reference Date (ARD) of 12/02/25, and located in the resident's EMR under the MDS tab revealed Section J1400 Prognosis was completed by the MDS Coordinator on 12/08/25. It further indicated the MDS was coded as No to the question of does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS further indicated that R9 was receiving hospice services when the MDS was completed.During a phone interview on 01/07/26 at 11:04 AM, the Hospice Registered Nurse (RN)4 with the [name of hospice company] confirmed the terminal diagnoses of R9 and stated R9 has been on hospice services since 02/21/23. RN4 further stated that R9 has never come off hospice services.During an interview on 01/07/26 at 11:56 AM, when reviewing R9's EMR with the MDS Coordinator (MDSC)1, he/she confirmed that he/she completed R9's quarterly MDS sections for terminal illness and hospice services on 12/08/25. The MDS Coordinator confirmed that he/she coded the terminal prognosis of R9 as no and further coded R9 as receiving hospice services as a yes. The MDS Coordinator stated, I just missed it, I guess. It should have been coded as yes for the terminal prognoses.During an interview on 01/07/26 at 12:16 PM, when reviewing R9's EMR with the Director of Nursing (DON), the DON confirmed R9 began receiving hospice services on 02/21/23. When reviewing the quarterly MDS for R9 and the inaccuracies between the section of terminal prognosis of less than 6 months and hospice services, the DON was asked what her expectation would be for accurate coding of the MDS, she stated, I would assume they review the records when completing their sections of the MDS and make sure we are reviewing all documentation. I'm seeing the coding was not accurate. It would be my expectation that when completing the MDS, they are being coded accurately. During an interview on 01/07/26 at 4:24 PM, when reviewing R9's EMR with the Regional MDS Coordinator, he/she stated, According to the RAI manual, which is what we would follow, it would be the expectation that both sections (referring to the terminal prognosis and hospice services of the MDS) match. I can see that the section for terminal illness is marked as no, and I see he/she has been receiving hospice services since 2023. It would be an error on our part as they should match.2. During an observation and interview on 01/05/26 at 10:00 AM, R36 was observed in his/her room and, he/she confirmed that she was receiving hospice services.Review of R36's facility Physician orders, dated 08/25/25, and located under the Orders tab in the EMR indicated, Admit to [name of hospice agency].Review of R36's [name of hospice agency] documentation located in a white hospice binder at the nurse's station indicated R36 was admitted to hospice services on 08/22/25. The hospice documentation indicated on 08/27/25, the physician certified that the patient's prognosis is six months or less if the disease runs its normal course. The terminal diagnosis was Malignant neoplasm of overlap sites of bronchus and lungs.Review of R36's [name of hospice agency] Hospice Physician Narrative, for certification benefit period of 08/22/25 to 11/19/25 [located in the white hospice binder at the nurse's station] indicated an admission to hospice services on 08/22/25. It further indicated, Prognosis given the ongoing cognitive and functional decline and recent infections life expectancy is estimated to be less than 6 months.Review of R36's [name of hospice agency] Hospice Certification and Plan of Care, with a certification benefit period of 08/22/25 to 11/19/25 [located in the white hospice binder at the nurses station] indicated the terminal diagnoses, and also signed by the physician on 09/02/25 indicating I certify/recertify the patient is terminally ill with a life expectancy of six (6) months or less if the disease process runs its normal course.Review of R36's Hospice Physician Orders, located in the [name of hospice agency] white hospice binder at the nurse's station and dated 11/05/25 indicated, Terminal Diagnosis of malignant neoplasm of overlap sites of bronchus and lung. Patient continues to meet eligibility for hospice services.Review of R36's [name of hospice agency] Hospice Physician narrative, for certification benefit period of 11/20/25 to 02/17/26, located in the white hospice binder at the nurses' station indicated, Prognosis given the ongoing and functional decline, poor nutrition status and recent infections, life expectancy is estimated to be less than 6 months.Review of R36's significant change MDS, with an ARD of 09/21/25, and located in the residents EMR under the MDS tab revealed Section J1400 Prognosis was completed by the MDS Coordinator on 09/24/25. It further indicated the MDS was coded as No to the question of does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS further indicated that R36 was receiving hospice services when the MDS was completed.Review of R36's quarterly MDS, with an ARD of 12/22/25, and located in the residents EMR under the MDS tab revealed Section J1400 Prognosis was completed by the MDS Coordinator on 12/31/25. It further indicated the MDS was coded as No to the question of does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS further indicated that R36 was also receiving hospice services when the MDS was completed.During a phone interview on 01/07/26 at 10:26 AM, the Hospice Clinical Director with the [name of hospice company] stated that R36 has been receiving hospice services since 08/22/25, and had not come off hospice services.During an interview on 01/07/26 at 11:56 AM, when reviewing R36's EMR with theMDSC1 he/she confirmed that he/she completed R36's significant change MDS sections for terminal illness and hospice services on 09/22/25. He/she also confirmed he/she completed R36's quarterly MDS on 12/31/25. The MDS Coordinator confirmed he/she coded the terminal prognosis of R36 as no and further coded R36 as receiving hospice services as a yes on both the significant change MDS and quarterly MDS. He/she then stated, I just missed it. During an interview on 01/07/26 at 12:16 PM, when reviewing R36's EMR with the DON, the DON confirmed R36 began receiving hospice services on 08/22/25. When reviewing the significant change MDS and the quarterly MDS for R36 and the inaccuracies between the section of terminal prognosis of less than 6 months and hospice services, the DON stated, It would be my expectation they are completed accurately. NJAC 8:39-33.2(d)

Based on interview, record review, and facility policy review, the facility failed to ensure two of 33 sampled residents (Resident(R)7 and R174) received a baseline care plan within 48 hours of admission into the facility. This deficient practice had the potential to allow residents not to receive the instructions for a person-centered care plan after admission. Findings include:1.Review of R7's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R7 was admitted to the facility on [DATE], with diagnoses of muscle wasting, heart failure, and falls.Review of the Progress Notes, located in the EMR under Progress Notes revealed an Initial Navigation Guide Meeting note dated 10/15/25, revealed the review of the baseline care plan was completed13 days after R7's admission.2.Review of R174's admission Record, located in the EMR under the Profile tab revealed R174 was admitted to the facility on [DATE], with diagnoses of trauma ischemic muscle, type two diabetes, and hypertension.Review of the Progress Notes, located in the EMR under Progress Notes revealed an Initial Navigation Guide Meeting note dated 12/31/25, revealed the review of the baseline care plan was completed five days after R174's admission. During an interview on 01/08/26 at 9:54 AM, the Director of Nursing (DON) stated the baseline care plan should be discussed with the resident and family and should be completed within 48 hours after admission. [NAME] an interview on 01/08/26 at 10:15 AM, the Social Service Director (SSD) was asked about the baseline care plan being discussed within 48 hours of admission. The SSD stated the team of social services and nursing meet with the family and/or residents within 48 hours to discuss the baseline care plan. When asked about the date of 10/15/25, for R7's meeting the SSD stated there should have been a meeting within 48 hours and that was not met. The SSD was asked to review R174's meeting date. The SSD stated the resident came in late on a Friday evening, so it was probably done on the following Monday after the weekend. When the SSD reviewed the day, the SSD stated it was on a Wednesday, and the care plan should have been done before then. Review of the revised facility policy titled, Care Plan- Baseline, dated March 2022, revealed Policy Statement: A baseline plan of care to meet resident's immediate health and safety needs developed for each resident within forty-eight (48) hours of admission. NJAC 8:39-11.1;11.2

Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure a person-centered comprehensive care plan was developed for one of one resident (R36) receiving hospice services out of a total of 33 sampled residents. This deficient practice placed the resident at risk for unmet resident care needs.Findings include:During an observation and interview on 01/05/26 at 10:00 AM, R36 was observed in his/her room and confirmed that he/she was receiving hospice services.Review of R36's facility Physician orders, dated 08/25/25, and located under the Orders tab in the electronic medical record (EMR) indicated, Admit to [name of hospice agency].Review of R36's [name of hospice agency] documentation located in a white hospice binder at the nurse's station indicated R36 was admitted to hospice services on 08/22/25 with a terminal diagnosis to include malignant neoplasm of overlap sites of bronchus and lungs.Review of R36's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/25, and located in the residents EMR under the MDS tab revealed R36 was receiving hospice services.Review of R36's Care Plan, and located in the EMR under the Care Plan tab initiated on 11/12/25, indicated, I have a terminal prognosis r/t [related to] cancer of the lung. Further review of R36's EMR revealed there was no additional care plan implemented prior to 11/12/25, regarding hospice services and/or a terminal diagnosis with measurable goals and interventions related to hospice services.During a phone interview on 01/07/26 at 10:26 AM, the Hospice Clinical Director with the [name of hospice company] stated that R36 had been receiving hospice services since 08/22/25, and had not come off hospice services.During an interview on 01/07/26 at 11:56 AM, when reviewing R36's EMR with the MDS Coordinator (MDSC)1, he/she confirmed R36 went on hospice services on 08/22/25. MDSC1 further confirmed that the comprehensive care plan was not developed or initiated until 11/12/25, by stating, I'm seeing it was not done.During an interview on 01/07/26 at 12:16 PM, when reviewing R36's EMR with the Director of Nursing (DON) regarding the comprehensive care plan for hospice services, the DON stated, I would assume and it would be my expectation that the staff complete the comprehensive care plan around the time he/she [referring to R36] went on hospice services. The DON confirmed the comprehensive care plan was not implemented for R36 regarding hospice services until 11/12/25.During an interview on 01/07/26 at 12:30 PM, when reviewing R36's EMR with the Registered Nurse (RN)2 regarding the comprehensive care plan, he/she confirmed that he/she initiated R36's comprehensive care plan for terminal illness on 11/12/25. He/she stated, I was fairly new to the facility and when I started working here in October, and I started going through the care plans to see which ones were not done or updated. This was one of them.During an interview on 01/07/26 at 4:24 PM, when reviewing R36's EMR with the Regional MDS Coordinator he/she stated, The Care plans are opened the day after the ARD of the MDS is done and when I reviewed the chart. I also saw the comprehensive care plan was not completed for hospice services until 11/12/25.Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission. NJAC 8:39-11.2(e) thru(i)NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure feeding tube placement was verified prior to administering a nutrition supplement for one of two residents (Resident (R) 89) reviewed with feeding tubes out of a total sample of 33. This failure had the potential to place residents at risk of aspiration and hospitalization.Findings include:Review of R89's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R89 was admitted to the facility on [DATE], with diagnoses that included stroke, non-Alzheimer's dementia, aphasia (difficulty speaking), and a feeding tube.Review of R89's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/25, and located under the MDS tab of the EMR, revealed R89 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R89 was cognitively intact.Review of R89's undated Physician Orders, located under the Orders tab of the EMR, reflected the following orders: Enteral Feed Order four times a day. Give Jevity 1.5 Bolus Feeding of one container (237 mLs), four times daily as listed and crush medications per manufacturer recommendations (do not crush enteric coated or extended-release medications, or those not approved by manufacturer) and mix in 5mL warm water each. Confirm placement, flush with 30 mL of warm water, administer medications individually flushing with 15 mLs of warm water in between, and with 30 mLs of warm water after all meds are given.During an observation of medication pass on 01/07/26 at 11:25 AM, Licensed Practical Nurse (LPN)1 administered Jevity 1.5 bolus feeding. LPN1 did not verify placement before administering the nutrition supplement.During an interview on 01/07/26 at 11:53 AM, LPN1 indicated that he/she forgot to verify the gastric tube placement before administering the bolus feeding. LPN1 said that tube placement was verified by pulling back gastric residual in a syringe. LPN1 stated that the risk of not verifying gastric tube placement was aspiration.During an interview and record review on 01/08/26 at 4:30 PM, the Assistant Director of Nursing (ADON) said that he/she completed competency assessments during new hire on-boarding, skills fairs, and annual reviews. The ADON presented an Enteral Tube Feeding Continuous Pump Competency Assessment for LPN1 dated 11/05/25, that reflected LPN1 demonstrated competency in enteral feedings following general guidelines. The ADON entered his/her initials as the observer next to each task, checked yes that competency was demonstrated, signed, and dated 11/05/25.Review of the facility's policy titled, Maintaining Patency of a Feeding Tube (Flushing), revealed . 5. Confirm placement of tube.6. For intermittent feeding, flush with warm purified water before and after the feeding. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen (O2) concentrators had filters or were free of dust for one of one sampled resident (Resident (R)66) out of a sample size of 33. This failure had the potential for residents to have an increased chance of unnecessary respiratory treatments and/or infection.Findings include:During an observation on 01/05/26 at 2:19 PM, R66 was wearing an oxygen canula connected to an O2 concentrator. The cabinet filter had a layer of dust and lint.During an observation on 01/07/26 at 9:12 AM, R66 was wearing an oxygen canula connected to an O2 concentrator. The cabinet filter had a layer of dust and lint.During an observation and interview on 01/08/26 at 9:41 AM, The Director of Nursing (DON) was shown the filter, and the DON confirmed the filter had lint that should not be there. The DON stated they were just out here servicing the concentrators. Review of R66's electronic medical record (EMR) located under the Profile tab was an undated admission Record, with an admission date of 11/26/25, with diagnoses of chronic obstructive pulmonary disease (COPD) and atelectasis. Review of R66's Physician Orders, located in the EMR under the Orders tab revealed on 11/28/25, intermittent oxygen as needed at 2 liters per minute to keep saturation greater than 90%. Additional orders dated 11/28/25, revealed change oxygen tubing, humidifier and clean filter weekly on Tuesday 11/7 shift and as needed for soiling or damage.Review of the revised November 2011 facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revealed Purpose: the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment.9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. NJAC 8:39-27.1(a)

Based on observation, policy review, and interviews, the facility failed to remove expired medications stored in two of three medication carts (Cedar Unit - High Side and Cedar Unit - Low Side Medication Carts) observed for medication storage and labeling. This failure had the potential for reduced effectiveness or ineffective treatment of medical issues and was at risk for bacterial growth.Findings include:Observation of the Cedar - High Side medication cart on 01/07/26 at 10:09 AM, with Licensed Practical Nurse (LPN)4 revealed the following expired (over the counter (OTC) medications:Zinc 50 mg (milligrams) tablets - expiration date 08/2025; opened 10/06/24Dairy Aid tablets - expiration date 08/2025; opened 11/20/24Folic Acid 800 mcg (micrograms) tablets - expiration date 09/2025; No open dateFish Oil 1000 mg softgels - expiration date 12/2025; No open dateFish Oil 1200 mg softgels - expiration date 11/2025; No open dateDuring a continued observation of the medication cart on Cedar - High Side on 01/07/26 at 10:14 AM, with LPN4 four Potassium chloride extended release (ER) 10 milliequivalent (mEq) (750 mg) tablets in daily dose packs were not labeled for an individual resident and one bottle of OTC Advil liquid gels with a resident's name written on the bottle who had been discharged from the facility were observed. During an interview on 01/07/26 at 10:45 AM, LPN4 said that the nurses, who worked on the medication carts, were responsible for checking the cart for expired medications. LPN4 said that the pharmacist consultant also checked the carts when on-site for expired medications and compliance with pharmacy services. LPN4 said that she checked the OTC medications expiration date before medications were administered to a resident. LPN4 said the appropriate procedure was to remove the medication from the cart and place it in the medication room for disposal.Observation of the medication cart on Cedar - Low Side on 01/07/26 at 10:55 AM, with LPN5 revealed a vial of Tuberculin Purified Protein Derivative (Mantoux) Test dose that must remain refrigerated, was stored in the top drawer. The box the vial was placed in had a label that read, discard opened product after 30 days. There was no open date.During an interview on 01/07/26 at 10:59 AM, LPN5 said that the Tuberculin Purified Protein Derivative (Mantoux) Test was administered to residents and the multi-dose vial should be dated and refrigerated. LPN5 could not state when the vial was opened or how long the vial had been in the medication cart.During an interview on 01/07/26 at 11:15 AM, the Director of Nursing (DON) said that the nurses and Unit Manager were responsible for checking the medication carts for expired medications and removing the expired medications. OTC and prescription medications should be checked for expiration dates before they are administered to residents. The DON said that the pharmacy consultant also audited the medications carts every two to three months to ensure that the facility was complying with policies and procedures. The DON said that all expired medications must be removed from the active supply and destroyed in accordance with facility policy, regardless of the amount remaining.Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, revealed .3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secure location. Medications are stored separately from food and are labeled accordingly. NJAC 8:39-29.4

Based on observation, record review, and interviews, the facility failed to pharmacy implement processes for receiving controlled substances (CS) for two (Cedar Unit - High Side and Cedar Unit - Low Side Medication Carts) of three medication carts observed for medication storage and labeling. This failure had the potential to create a risk of drug diversion, theft, improper handling of returns, all impacting patient safety and compliance.Findings include:Observation of the medication cart on Cedar - High Side on 01/07/26 at 10:09 AM, with Licensed Practical Nurse (LPN)4 revealed the following controlled substance inventory log sheets of the logbook for controlled medications located on the medication cart, were missing all required components such as the Rx number (a unique identifier assigned to your specific prescription by the pharmacy), Rx date (date controlled substances were issued by pharmacy), and/or the controlled substance label directions:Page (pg) 147 - no Rx numberPg 148 - no Rx number, no Rx datePg 154 - no Rx number, no Rx datePg 155 - no label directionsPg 156 - no Rx number, no Rx date, no label directionsPg 169 - no Rx number, no Rx datePg 172 - no Rx number, no Rx dateDuring an interview on 01/07/26 at 10:45 AM, LPN4 said that the nurses, who received the narcotics and controlled substances, from the pharmacy were responsible for transcribing the resident's name, prescribing doctor, directions for medication administration as printed on the label, the Rx number, and the Rx issue date on the inventory sheet. LPN4 said that the pharmacist consultant also checked the inventory logbooks when on-site to audit the medication carts. LPN4 said that he/she did not ensure the inventory sheets were complete before logging controlled medications that he/she removed for administration.Observation of the medication cart on Cedar - Low Side on 01/07/26 at 10:55 AM, with LPN5 revealed the following controlled substance inventory log sheets of the logbook for controlled medications located on the medication cart, were missing all required components such as the Rx number, Rx date, and/or the controlled substance label directions:Pg 45 - no label directionsPg 58 - no label directionsPg 65 - no label directionsPg 67 - no Rx numberPg 70 - no Rx numberPg 72 - no Rx numberPg 72 - no Rx number, no Rx date, no label directionsPg 79 - no label directionsDuring an interview on 01/07/26 at 10:59 AM, LPN5 said he/she did not notice the inventory sheets were incomplete when he/she documented medications were removed from the narcotic drawer. LPN5 said incomplete sheets without the label directions could place residents at risk for harm if not administered correctly. He/she also stated the poor record-keeping could cause the narcotic count to be incorrect. During an interview on 01/07/26 at 11:15 AM, the Director of Nursing (DON) said that the nurses and Unit Manager were responsible for overseeing procedures that prevented drug diversion such as monitoring the inventory log sheets and actual narcotic count. The DON said that the pharmacy consultant also audited the medication carts every two to three months to ensure that the facility complied with policies and procedures. The DON said that he/she would ensure that the logbook for controlled medications was completed following the facility process.Review of Consultant Pharmacist Services Med Room and Med Cart Audit forms provided by the DON, dated 12/10/25, revealed an audit of the Cedar Unit was conducted by the Consultant Pharmacist. The results in the Controlled Drugs section, reflected Receipt of Controlled Substances: Is Rx Number, Date, Drug, Dose, Amount Received and Directions complete in the logbook (spot check sample of 10 pages per book) was answered no. A comment followed, Rx number, Rx date and directions must be included in logbook for each drug.A request for a specific facility policy about Controlled Substances was made on 01/07/26 at 11:30 AM and 01/08/26 at 4:00 PM. This was not received before the survey exit. NJAC 8:39-29.7(c)

Complaint # 180991 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 12/09/2024, it was determined that the facility failed to administer medications according to the acceptable standards of nursing practice for 1 of 4 residents (Resident #1). The facility also failed to follow its policy titled Administering Medications. 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 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. According to the Admission Record (AR), Resident #1 was admitted to the facility with diagnoses which included but were not limited to, Cellulitis (a bacterial infection that affects the skin and underlying tissues), Essential Hypertension (high blood pressure), Heart Failure (condition that occurs when the heart can't pump enough blood to meet the body's needs, Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Acute Kidney Failure (when your kidneys suddenly stop working properly). According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with a date of event of 11/23/2024 revealed that the Licensed Practical Nurse (LPN#1) allegedly left medications at Resident #1's bedside. A review of the Quarterly Minimum Data Set (MDS), an assessment tool dated 11/08/2024, reflected that the Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was cognitively intact. A review of the Order Summary Report (OSR) Active Orders for Resident #1 dated 11/21/2024 included the following Physician's Orders (Pos): Tramadol HCL Oral Tablet 50 MG give 1 tablet by mouth every 6 hours as needed for pain. A review of the 11/1/2024-11/30/2024 Medication Administration Record (MAR) revealed documentation by LPN #1 that Resident #1 received one dose of Tramadol 50 mg on 11/23/2024 at 9:08 A.M. A review of the facility's investigation report for the 11/23/2024 incident revealed that after thorough investigation, it was found that after Resident #1's shower, the Certified Nursing Assistant (CNA #1) informed the resident that their medication was on the bedside table. The resident asked CNA #1 to hand him/her the medication and CNA #1 handed them to him/her. After thorough investigation, the primary nurse does not recall leaving the medications at the resident's bedside. The Interdisciplinary Care Team (IDCP) believed the nurse left the as needed (PRN) Tramadol at Resident #1's bedside while the resident was in the shower after the resident requested it. No harm came to the resident. During an interview with the Surveyor on 12/09/2024 at 12:35 P.M., the Assistant Director of Nursing (ADON) stated she was told by the Director of Nursing (DON) on 11/25/2024 that on 11/23/2024 CNA #1 brought Resident #1 back from taking a shower and Resident #1 could not reach the medication that was on the resident's bedside table. Resident #1 asked CNA #1 to push the bedside table closer so he/she can take the medication. The ADON stated that she began an investigation and went to every resident's room and searched each room to see if any medications were left at other resident's room. She did not find any other medications left at the bedside in other resident's room. The ADON stated the expectation was not to leave medications unattended in a resident's room. The ADON further stated the expectation was for the nurse to ensure residents took their medications before leaving the resident's room. The ADON stated that leaving medications at the resident's bedside unattended could put residents in danger because another resident could take the medication instead. During an interview with the Surveyor on 12/09/2024 at 12:52 P.M., LPN #1 stated that she was aware that it was reported that she left Resident #1's medications on Resident #1's bedside table. She stated that she does not remember leaving medications at Resident #1's bedside table. LPN #1 also stated that if a resident was not in their room, then she would come back with the resident's medication. LPN #1 stated she would not leave a resident's room without ensuring medications were taken by a resident. LPN #1 further stated that it was important to observe a resident take their medication to ensure that the resident took them. The Surveyor attempted to contact CNA #1 on 12/09/2024 at 1:04 PM but CNA#1 was not available for an interview. During an interview with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) on 12/09/2024 at 2:05 P.M., the DON stated that on 11/25/2024 she was informed by CNA #1 that she had returned to Resident #1's room after giving the resident a shower and noticed a cup with medication on the resident's bedside table on 11/23/2024. The DON stated that she was told by CNA #1 that Resident #1 asked her to move the bedside table closer so they can take the medication and CNA #1 moved the table closer as Resident #1 requested. The DON stated that she did not recall if CNA #1 stated if Resident #1 took the medication that was on the bedside table. The DON stated that an investigation was initiated, and the investigation concluded that LPN #1 did leave Tramadol at Resident #1's bedside although LPN #1 does not recall leaving the medication at Resident #1's bedside. The DON stated that she was not able to interview Resident #1 because the resident was transferred to the hospital on 11/25/2024. The DON further stated that she was not able to confirm what medication was in the medicine cup found at Resident #1's bedside. The DON stated that it was the facility's policy that medications were not left at the resident's bedside table. The DON stated, if medications are left unattended at the bedside, another resident could come and take the medications. The DON further stated that the expectation was that when a nurse gave a resident their medication, the nurse should stay in the room and ensure the resident takes the medication. A review of the facility's policy titled Medication Administration with a revision date of April 2019 revealed under Policy Statement: I. Medications are administered in accordance with prescriber's orders, including required time frame. II. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. NJAC 8:39-29.2(d)

C/O # NJ163363 Based on interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to: a) assess a resident (Resident #534) in a timely manner by a Registered Nurse (RN) who had an unwitnessed fall which resulted in the resident experiencing pain and a right hip fracture. Resident #534 fell on [DATE] at approximately 6:00 PM, and was not assessed until the next day at approximately 10:15 AM (over 12 hours) by the Medical Doctor. This deficient practice was identified for 1 of 4 residents reviewed for falls; and b) failed to ensure that there was a physician order for the use and monitoring of a safety device (Wander Bracelet) used to prevent residents from elopement (leaving a specified area without permission or supervision) in place. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #107). This deficient practice was evidenced by the following: A review of an undated facility provided policy titled, Assessing Falls and Their Causes revealed under Steps in the Procedure, After a Fall: 1. If a resident has just fallen or is found without a witness to the event evaluate for possible injuries to the head, neck, spine, and extremities. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. The policy also revealed, under Documentation, that When a resident falls, the following should be recorded: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. 1) According to the Admission Record, Resident #534 was admitted to the facility with diagnoses including but not limited to: Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). According to the Minimum Data Set (MDS), an assessment tool used to facilitate care dated 02/12/2023, Resident #534 had a Brief Interview for Mental Status (BIMS) score of 02/15, indicating severely impaired cognition. Section GG indicated that Resident #534 was independent with walking in the corridor. A review of the Progress Notes revealed the following: a) On 04/17/2023 at 8:10 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM#2) was alerted by staff that Resident #534 had fallen on 04/16/2023 at about 6:00 PM. LPN/UM #2 went to check on the resident who was still in bed. Resident #534 stated he was in pain while pointing to his right hip which was externally rotated. Resident #534 was unable to move their right lower extremity without pain. LPN/UM #2 called the Nurse Practitioner and received orders for x-rays of right hip, pelvis, and lower extremity and pain medication. The Medical Doctor (MD) was asked to consult. b) On 04/17/2023 at 10:15 AM, the MD assessed Resident #534. The resident stated his right hip pain was 10/10 (10 being the highest level on the pain scale). c) On 04/17/2023 at 10:16 AM, the MD ordered the resident to be sent to ER (emergency room ) for a possible right hip fracture. d) On 04/17/2023 at 11:19 AM, the resident was transported to the ER. e) On 04/17/2023 at 18:08 PM (6:08 PM), Resident #534 was admitted to the hospital with a closed fracture of the right hip (a fracture that does not break the skin). A review of the facility investigation titled Full QA (Quality Assurance) Report dated 4/17/2023, revealed the following under the Summary: Resident # 534 had an unwitnessed fall resulting in an injury. The resident fell in front of the nursing station. Certified Nursing Assistant (CNA #2) heard the resident fall and went to check on the resident. CNA #2 then notified the assigned Licensed Practical Nurse (LPN #2). The resident was brought back to their room and further assessed for injury. LPN #2 said the resident had no visible redness or bruising injuries noted and was observed without any complaints of pain. LPN #2 failed to follow the facility policy and standard of practice for unwitnessed falls and failed to notify the Registered Nursing (RN) supervisor to conduct a full body assessment. In addition, LPN #2 also failed to complete a risk report, document in the medical record, endorse the incident to the following shift, and notify primary medical doctor and the resident's family. On 04/17/2023, at approximately 8:00 AM, CNA #2, who was present the night before when the fall happened, approached LPN/UM #2 inquiring about how Resident #534 was doing. LPN/UM #2 immediately assessed the resident who complained of pain to their right hip area, was unable to move their right lower extremity when asked and the right leg was noted to be externally rotated. Vitals were obtained, neurological checks initiated, ice was applied to right hip area and Tylenol was administered. The Director of Nursing (DON), Administrator, Advanced Practical Nurse (APN), and the resident's family were notified of incident. New orders were given for x-rays of right hip, pelvis, and lower extremity; and for Tramadol 50 milligrams twice day for pain. The Physiatrist (Rehabilitation physician) was in the facility at the time and staff requested a consult. An assessment was completed and new orders were received to send the resident to the ER for further evaluation. Resident #534 was admitted with a diagnosis of a closed right hip fracture. The resident did not return to the facility. During an interview with the surveyor on 07/10/2024 at 10:01 AM, CNA #2 who originally reported the fall stated, I don't really remember that night, it was a long time ago. When asked what would you do if you found a resident on the floor, CNA #2 replied, I would call for the nurse and stay with the resident until the nurse got there. During an interview with the surveyor on 07/10/2024 at 12:05 PM, LPN/UM #2 stated, I don't remember that incident. The surveyor asked LPN/UM #2 when should a resident be assessed after a fall. LPN/UM #2 told the surveyor that Residents should be assessed immediately after a fall by the RN supervisor. During an interview with the surveyor on 07/10/2024 at 01:12 PM, the DON replied Yes, when asked if LPN #2 should have notified an RN to assess Resident #534 after the fall. The DON also replied Yes, when asked if LPN #2 should have reported the fall at that time. The DON also stated, The resident should have been assessed right away. 41442 A review of the facility policy titled, Wander Management and Elopement Prevention, updated March 2022 revealed: 2. The staff will implement a wander management system device, if recommended, as a part of the plan of care. 3. Resident care plans will include resident specific interventions to ensure safe wandering and prevent elopement. 4. The wander management system device will be used in conjunction with other resident-specific interventions for the management of unsafe wandering. 2) According to the Admission Record, Resident #107 was admitted with diagnoses that included but were not limited to; Senile Degeneration of the Brain, Alzheimer's Disease, and Dementia. During the initial tour on 07/09/2024 at 09:22 AM, Resident #107 was observed in their room eating breakfast. At that time, a Wander Bracelet (a device that would alarm and lock doors to prevent a resident from leaving an area attended) was fastened to their right ankle. A review of Resident #107's Physician Orders did not include a physician order for a Wander Bracelet monitoring device. A review Resident #107's Care Plan did not include a focus area for the Risk for Elopement and no indication that a Wander Bracelet was placed to the right ankle. A review the most recent MDS dated [DATE], revealed Resident #107 had severe cognitive impairment. Under Section P-Restraints and Alarms, there was no documentation that a Wander/Elopement alarm was used. A review of a Quarterly Evaluation dated 04/12/2024, under the Elopement/Wandering Risk Evaluation section, indicated that Resident #107 was assessed and found to have at risk behaviors including wandering aimlessly and had actual/potential risk for elopement. Included in the interventions was a Wander Bracelet. During an interview with the surveyor on 07/10/2024 at 12:45 PM, LPN/UM #2 verified that Resident #107 did not have a Physician Order or Care Plan for a Wander Bracelet. At that time, LPN/UM #2 indicated that she would get working on it. During an interview with the surveyor on 7/11/2024 at 01:11 PM, the DON stated that the process for assessing for risk of elopement is done on admission and as needed. The DON stated that if a resident was indicated to be at risk and a Wander Bracelet was recommended, the Physician would be notified and an order for a Wander Bracelet would be obtained. In addition, the family is notified and the Care Plan is updated. NJAC 8:39 - 27.1 (a)

Complaint # NJ00168248, NJ00168274 Based on interviews, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: A review of the Facility Assessment revealed under the Staffing Guidelines that the facility created a staffing pattern to ensure their residents needs are met on a consistent basis. The assessment went on to indicate that Our facility staffing pattern provides a base to ensure that the facility has a sufficient number of qualified staff to meet the needs of the residents. We incorporate the State of New Jersey's regulatory requirements for ratios of direct care staff members to residents into our staffing baseline. A review of the Nurse Staffing Reports revealed the following: 1.For the 2 weeks of Complaint staffing from 01/08/2023 to 01/21/2023, the facility was deficient in Certified Nursing Assistant (CNA) staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -01/08/23 had 9 CNAs for 138 residents on the day shift, required at least 17 CNAs. -01/09/23 had 10 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/10/23 had 11 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/11/23 had 11 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/12/23 had 11 CNAs for 137 residents on the day shift, required at least 17 CNAs. -01/13/23 had 11 CNAs for 136 residents on the day shift, required at least 17 CNAs. -01/13/23 had 9 total staff for 136 residents on the overnight shift, required at least 10 total staff. -01/14/23 had 11 CNAs for 136 residents on the day shift, required at least 17 CNAs. -01/15/23 had 12 CNAs for 136 residents on the day shift, required at least 17 CNAs. -01/16/23 had 10 CNAs for 136 residents on the day shift, required at least 17 CNAs. -01/17/23 had 11 CNAs for 138 residents on the day shift, required at least 17 CNAs. -01/18/23 had 11 CNAs for 138 residents on the day shift, required at least 17 CNAs. -01/19/23 had 12.5 CNAs for 138 residents on the day shift, required at least 17 CNAs. -01/20/23 had 11.5 CNAs for 138 residents on the day shift, required at least 17 CNAs. -01/21/23 had 11 CNAs for 141 residents on the day shift, required at least 18 CNAs. 2. For the week of Complaint staffing from 02/05/2023 to 02/11/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 1 of 7 overnight shifts as follows: -02/05/23 had 11 CNAs for 137 residents on the day shift, required at least 17 CNAs. -02/05/23 had 9 total staff for 137 residents on the overnight shift, required at least 10 total staff. -02/06/23 had 12 CNAs for 136 residents on the day shift, required at least 17 CNAs. -02/07/23 had 11 CNAs for 133 residents on the day shift, required at least 17 CNAs. -02/08/23 had 13 CNAs for 133 residents on the day shift, required at least 17 CNAs. -02/09/23 had 12 CNAs for 131 residents on the day shift, required at least 16 CNAs. -02/10/23 had 10 CNAs for 130 residents on the day shift, required at least 16 CNAs. -02/11/23 had 10 CNAs for 130 residents on the day shift, required at least 16 CNAs. 3. For the week of Complaint staffing from 04/16/2023 to 04/22/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -04/16/23 had 10 CNAs for 137 residents on the day shift, required at least 17 CNAs. -04/17/23 had 12 CNAs for 137 residents on the day shift, required at least 17 CNAs. -04/18/23 had 13 CNAs for 137 residents on the day shift, required at least 17 CNAs. -04/19/23 had 12 CNAs for 137 residents on the day shift, required at least 17 CNAs. -04/20/23 had 10 CNAs for 142 residents on the day shift, required at least 18 CNAs. -04/21/23 had 10 CNAs for 142 residents on the day shift, required at least 18 CNAs. -04/22/23 had 12 CNAs for 142 residents on the day shift, required at least 18 CNAs. 4. For the week of Complaint staffing from 10/08/2023 to 10/14/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -10/08/23 had 11.5 CNAs for 133 residents on the day shift, required at least 17 CNAs. -10/09/23 had 10 CNAs for 130 residents on the day shift, required at least 16 CNAs. -10/10/23 had 12 CNAs for 128 residents on the day shift, required at least 16 CNAs. -10/11/23 had 11 CNAs for 126 residents on the day shift, required at least 16 CNAs. -10/12/23 had 10 CNAs for 126 residents on the day shift, required at least 16 CNAs. -10/13/23 had 11 CNAs for 125 residents on the day shift, required at least 16 CNAs. -10/14/23 had 12.5 CNAs for 124 residents on the day shift, required at least 15 CNAs. 5. For the 2 weeks of Complaint staffing from 12/17/2023 to 12/30/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -12/17/23 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -12/18/23 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -12/19/23 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -12/20/23 had 11 CNAs for 118 residents on the day shift, required at least 15 CNAs. -12/21/23 had 12 CNAs for 118 residents on the day shift, required at least 15 CNAs. -12/22/23 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs. -12/23/23 had 12 CNAs for 119 residents on the day shift, required at least 15 CNAs. -12/24/23 had 9 CNAs for 119 residents on the day shift, required at least 15 CNAs. -12/25/23 had 12.5 CNAs for 119 residents on the day shift, required at least 15 CNAs. -12/26/23 had 8 CNAs for 120 residents on the day shift, required at least 15 CNAs. -12/27/23 had 12 CNAs for 120 residents on the day shift, required at least 15 CNAs. -12/28/23 had 10 CNAs for 120 residents on the day shift, required at least 15 CNAs. -12/29/23 had 12 CNAs for 123 residents on the day shift, required at least 15 CNAs. -12/30/23 had 14 CNAs for 123 residents on the day shift, required at least 15 CNAs. 6. For the week of Complaint staffing from 01/21/2024 to 01/27/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -01/21/24 had 10 CNAs for 130 residents on the day shift, required at least 16 CNAs. -01/22/24 had 13 CNAs for 130 residents on the day shift, required at least 16 CNAs. -01/23/24 had 11 CNAs for 129 residents on the day shift, required at least 16 CNAs. -01/24/24 had 12 CNAs for 129 residents on the day shift, required at least 16 CNAs. -01/25/24 had 11 CNAs for 129 residents on the day shift, required at least 16 CNAs. -01/26/24 had 11 CNAs for 128 residents on the day shift, required at least 16 CNAs. -01/27/24 had 13 CNAs for 128 residents on the day shift, required at least 16 CNAs. 7. For the week of Complaint staffing from 02/25/2024 to 03/02/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -02/25/24 had 13 CNAs for 132 residents on the day shift, required at least 16 CNAs. -02/26/24 had 11 CNAs for 132 residents on the day shift, required at least 16 CNAs. -02/27/24 had 10 CNAs for 132 residents on the day shift, required at least 16 CNAs. -02/28/24 had 9 CNAs for 132 residents on the day shift, required at least 16 CNAs. -02/29/24 had 11 CNAs for 135 residents on the day shift, required at least 17 CNAs. -03/01/24 had 9 CNAs for 135 residents on the day shift, required at least 17 CNAs. -03/02/24 had 9 CNAs for 135 residents on the day shift, required at least 17 CNAs. 8. For the 2 weeks of Complaint staffing from 05/12/2024 to 05/25/2024, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -05/12/24 had 10 CNAs for 146 residents on the day shift, required at least 18 CNAs. -05/13/24 had 10.5 CNAs for 144 residents on the day shift, required at least 18 CNAs. -05/14/24 had 14 CNAs for 143 residents on the day shift, required at least 18 CNAs. -05/15/24 had 14 CNAs for 142 residents on the day shift, required at least 18 CNAs. -05/16/24 had 15 CNAs for 142 residents on the day shift, required at least 18 CNAs. -05/17/24 had 11 CNAs for 142 residents on the day shift, required at least 18 CNAs. -05/18/24 had 14 CNAs for 142 residents on the day shift, required at least 18 CNAs. -05/19/24 had 12.5 CNAs for 142 residents on the day shift, required at least 18 CNAs. -05/20/24 had 12 CNAs for 139 residents on the day shift, required at least 17 CNAs. -05/21/24 had 11 CNAs for 139 residents on the day shift, required at least 17 CNAs. -05/22/24 had 12 CNAs for 139 residents on the day shift, required at least 17 CNAs. -05/23/24 had 10.5 CNAs for 139 residents on the day shift, required at least 17 CNAs. -05/24/24 had 10 CNAs for 139 residents on the day shift, required at least 17 CNAs. -05/25/24 had 13 CNAs for 135 residents on the day shift, required at least 17 CNAs. 9. For the 1 week of staffing prior to survey from 06/30/2024 to 07/06/2024, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts as follows: -06/30/24 had 9.5 CNAs for 144 residents on the day shift, required at least 18 CNAs. -07/01/24 had 12 CNAs for 144 residents on the day shift, required at least 18 CNAs. -07/02/24 had 12 CNAs for 144 residents on the day shift, required at least 18 CNAs. -07/03/24 had 14 CNAs for 144 residents on the day shift, required at least 18 CNAs. -07/04/24 had 13 CNAs for 144 residents on the day shift, required at least 18 CNAs. -07/05/24 had 11 CNAs for 146 residents on the day shift, required at least 18 CNAs. -07/06/24 had 12 CNAs for 144 residents on the day shift, required at least 18 CNAs. During the initial tour on 07/08/2024 at 08:12 AM, the surveyor asked for census and current staffing for the Birch Unit. Licensed Practical Nurse/Unit Manger (LPN/UM #1) said there are 56 residents, 2 nurses and 4 CNA's. During an interview with the surveyor on 07/08/2024 at 09:45 AM, Resident # 99 said that on weekends they seem short staffed. During an interview with the surveyor on 07/10/2024 at 11:10 AM, CNA #1 who said we have a heavy workload. I average 15 residents for my shift, and it depends on call outs. Even if we have 5 aides, I still have 12 residents. During an interview with the surveyor on 07/10/2024 at 12:33 PM, the Director of Human Resource said I also do staffing and payroll. When asked if she was aware of the minimum staffing requirements for CNA's she stated 1:8 for CNA for 7a-3p shift, 1:10 3p-11p, 1:14 for 11p-7a shift. She went on to say when I do the schedule, I try to meet it, but when there are call outs, it puts a damper on the schedule. I do the schedule for the week, if there are call outs we try to call per diems. The Director of Human Resources said that not all the time meeting the staffing ratio requirements. During an interview with the surveyor on 07/11/2024 at 09:12 AM, the Director of Nursing (DON) was asked What is your current staffing pattern that you use for each unit for each unit? The DON relayed the following: Cedar unit Day shift- 2 nurses, 1 Unit Manager (UM), and we try to have 3rd nurse depending on census to help. For CNA's depends on census and we try to follow CNA ratios per New Jersey Department of Health (NJDOH), of 1-8 and try to go for 5 CNA's. Evening shift- 2 nurses, 1 Registered Nurse (RN) or Licensed Practical Nurse (LPN) supervisor. There is always an RN in the building on all shifts. We try to follow 1-10 CNA guidelines. The DON gave no specific number of CNA's. Night shift- 1 nurse, 1 RN or LPN supervisor to help with morning med pass depending on census. CNA's 1-14 ratio and we try to make sure we have that in place. Applewood Unit Days shift- 2 nurses, 1 UM, and follow state guidelines for CNA's as well. Evening shift-2 nurses, supervisor for house, 1-10 ratio for CNA's. Night shift- 1 nurse, CNA's 1-14 ratio per state guidelines. Birch Unit- Day shift- 2 nurses, 1 UM, CNA's 1-8 based on state guidelines. Evening shift- 2 nurses, 1 supervisor for house RN or LPN, CNA's 1-10 based on state guidelines. Night shift- 1 nurse, 1 supervisor for house RN or LPN and CNAs based on state guidelines 1-14. The surveyor questioned what about supervisors? The DON said, 1 supervisor on evenings and night shift either RN or LPN, but we always have an RN in the building. The DON was asked if there was any difference on the weekends? And the DON replied the only difference is the UMs are not here on weekends so there is a supervisor on 7-3, 3-11 and 11-7. During a follow-up interview with the surveyor on 07/11/2024 at 09:23 AM, the DON said we do our best to meet the state requirements and do our best to fill the call outs and if we need to the Assistant Director of Nursing, DON, UM, and Infection Preventionist are to assist and to support staff. We staff the best we can, and I don't really think weekend call outs are any different then weekday. During an interview with the surveyor on 07/11/2024 at 12:47 PM, CNA #3 said she has 12 residents today. When asked if she feels as though she can take care of residents properly when she has 12 residents CNA #3 stated, Not all the time. During an interview with the surveyor on 07/11/2024 at 01:34 PM, the DON confirmed the minimum requirement for CNA is 7-3 shift 1-8 ratio, 3-11 shift is 1-10 ratio, and for 11-7 shift is 1-14. We do the best that we can to meet the ratios. The DON again said I don't feel weekends are any worse that weekday. NJAC 8:39-5.1(a), 27.1(a)

Resident #122 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure specific target behaviors were monitored prior to the administration of an anti-psychotic medication for a resident who received an anti-psychotic medication (Seroquel) since May of 2024. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #122), and was evidenced by the following: On 7/8/2024 at 9:45 AM, the surveyor observed Resident #122 in the dayroom seated in a wheelchair. The resident stated they had woken up early and had just come from therapy and stated his/her mood was fine. The surveyor reviewed the medical record for Resident #122. A review of the Admission Record (an admission summary) reflected the resident was admitted to the facility with diagnoses which included heart failure, chronic kidney disease, restless and agitation, and dementia. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 6/3/2024, reflected that Resident #122 had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated severely impaired cognition. A further review of the MDS indicated Resident #122 had behaviors of rejection of care occurred one to three days and had received anti-psychotic medications on a routine basis during the seven day look-back period. A review of the individualized comprehensive care plan included a focus area initiated 5/29/2024, and a target date of 8/28/2024 that the resident used anti-psychotic medication related to behavior management, and behavior disturbances related to dementia with a goal to show effectiveness of medication use as evidenced by a reduction in behavior/mood symptoms by the review date. Interventions included to administer anti-psychotic medication as ordered. Observe for effectiveness and side effects including sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction (involuntary movements related to side effects that can be caused by certain drugs), tardive dyskinesia (condition caused by long term antipsychotic medication use that may cause uncontrollable jerky movements of the face and body, weight gain, edema, sweating, loss of appetite and urinary retention; consult with physician to consider dosage reduction when clinically appropriate; monitor/record occurrence of target behavior; provide redirection from inappropriate behaviors; educate me/family/caregivers about the risks, benefits, and side effects of medication being given. A review of the July 2024 Order Summary Report (OSR) included the following physician's orders (PO): A PO dated 5/28/2024, for Seroquel 12.5 milligram (mg) oral tablet; give 12.5 mg by mouth at bedtime for behavioral disturbances related to dementia. A review of the corresponding July 2024 Medication Administration Record (MAR) reflected that the resident received 12.5 mg of Seroquel on 7/1/2024; 7/2/2024; 7/3/2024; 7/4/2024; 7/5/2024; 7/6/2024; 7/7/2024; 7/8/2024; and 7/9/2024. A review of both the July 2024 OSR and the corresponding July 2024 MAR did not reveal an order to monitor the behaviors associated with the use of Seroquel or the monitoring of the potential side effects that may be caused using Seroquel. A review of Resident #122's Nursing Progress Notes since admission did not reflect nurses were documenting the presence of or lack of behaviors or side effects associated with the use of Seroquel for behavior disturbances related to dementia. On 7/10/2024 at 11:51 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN #1) who stated the resident had dementia but was alert with some confusion and was taking Seroquel for dementia with behavioral disturbances. LPN #1 further stated she had not witnessed any adverse behaviors on her shift nor on any other shifts that she knew of. LPN #1 stated residents on medications like Seroquel should be monitored for side effects and behavior disturbances every shift. When asked by the surveyor, LPN #2 could not recall if Resident #122 had an order to monitor for behaviors or side effects associated with the use of Seroquel. On 7/10/2024 at 11:55 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM #3) who stated the resident had been taking Seroquel since they were admitted to the facility and had not exhibited any behaviors associated with dementia. LPN/UM #3 stated all residents on psychotropics (drug or substance that affects how the brain works and causes changes in mood, thoughts, feelings, or behavior) were monitored every shift for behaviors and side effects. On 7/10/2024 at 12:10 PM, the surveyor, LPN/UM #3 and LPN #1 reviewed the resident's July 2024 MAR and POS. Both LPN/UM #3 and LPN #1 acknowledged there were no physician's orders to monitor for side effects related to the use of Seroquel or to document/monitor behaviors associated with the resident's dementia with behavioral disturbances diagnosis. LPN/UM #3 and LPN #1 confirmed there should be orders for both. On 7/10/2024 at 12:20 PM, the surveyor and LPN/UM #3 and LPN #1 again reviewed the resident's POS and there was a new order entered for the resident to be monitored for behaviors and side effects associated with the use of Seroquel. When the surveyor asked LPN/UM #3 if she had contacted someone to enter a new order, she acknowledged she had. LPN/UM #3 stated she had contacted the Assistant Director of Nursing (ADON) to obtain an order for monitoring and further acknowledged there had not been prior to surveyor inquiry. On 7/10/2024 at 1:03 PM, the surveyor interviewed the ADON who stated resident's prescribed antipsychotic, antidepressant, and anti-anxiety medications should be monitored for the target behaviors and side effects of those medications every shift for the entire duration the resident was prescribed the medication. The ADON confirmed there should have been physician's orders for monitoring when the Seroquel order was initiated, and that monitoring was important to ensure the resident was not taking medications unnecessarily or experiencing unnecessary side effects. A review of the revised July 2024 OSR included the following new physician's orders: A PO dated 7/10/2024, for Behaviors/Intervention, monitor for agitation, Intervention codes: 1. redirection; 2. (1:1); 3. activity; 4. toilet; 5. food/fluid offered; 6. position change; other interventions (specify in progress notes); 8. medication; every shift for monitoring. A PO dated 7/10/2024, Side Effects, monitor for side effects of Anti-psychotic medications every shift which may include but is not limited to sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention (specify in progress notes) every shift for monitoring Side Effects codes: Y = Yes, N = No, document side effects in progress notes. On 7/12/2024 at 10:47 AM, the survey team met with Facility Administration including the facility Director of Nursing (DON) who stated the nurse was responsible to ensure physician's orders for all psychotropic medications included orders for behavior monitoring, side effect monitoring, there was a care plan in place and consent for use was obtained from the resident or their Power of Attorney. The DON acknowledged there should have been orders for Resident #122's behavior monitoring associated with the use of Seroquel as well as monitoring for side effects. The DON further acknowledged that until surveyor inquiry there were no orders for monitoring. A review of the facility's Behavioral Assessment, Intervention and Monitoring policy, dated revised March 2019, included the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .the facility will comply with regulatory requirements related to the use of medication to manage behavioral changes .the nursing staff will identify, document, and inform the physician about specific details regarding changes in the individual's mental status, behavior, cognition, including: a. onset, duration, intensity and frequency of behavioral symptoms .interventions will be individualized and part of overall care environment .non-pharmacological approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. When medications are prescribed for behavioral symptoms, documentation will include: rationale for use; potential underlying causes of behavior; other approaches and interventions tried prior to use of antipsychotic medications; potential risk versus benefits of medications; specific target behaviors and expected outcomes; dosage; duration; monitoring for efficacy and adverse consequences . NJAC 8:39-27.1(a)

Complaint # NJ 160656 Based on interview, record review, and review of other facility documents, it was determined that the facility failed to ensure medications, treatments, and Enteral feedings were administered within the required time frame consistent with professional standards and facility policy. This deficient practice was identified for 1 of 7 residents (Resident # 234) reviewed for medication, treatment, and Enteral feedings administration. The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. A review of Resident # 234's Admission Record revealed diagnoses which included but were not limited to; retention of urine, other symbolic dysfunctions (a breakdown in communications), and dysphagia (difficulty in swallowing). A review of the most recent comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate resident care dated 11/08/2022, included but was not limited to; Section G documented the resident required staff assistance for Activities of Daily Living (ADLs), and Section K0510 that the resident required a feeding tube while a resident at the facility. A review of the Order Summary Report, active orders as of 11/30/2022, included but were not limited to; Enteral Feed . every shift [name redacted] via feeding pump at 65 ml (milliliters) per hour X 18 hours or until total volume infused: total volume = 1200 ml; Enteral feeding via bolus every 4 hours, 5 times a day; Apixaban 5 mg (milligram) 1 tablet via PEG-tube (a tube inserted directly into the stomach) two times a day; Metoprolol 50 mg give 1 tablet via PEG-tube two times a day; Phos-NaK (phosphorus, sodium, potassium) 280-160-250 mg give 1 packet via G-tube before meals and at bedtime; active liquid protein 30 ml two times a day; Ipratropium-Albuterol 0.5-2.5 mg/3 ml inhale orally four times a day; tamsulosin Capsule 0.4 mg give 2 capsules via PEG-tube in the evening; and Nystatin suspension 1000000 unit/ml give 5 ml by mouth every 6 hours. On 11/08/2022, an order for Augmentin 500-125 mg give 1 tablet via G-tube three times a day for infection until 11/09/2022. A review of the Medication Admin (Administration) Audit Report dates run 11/01/2022 through 12/02/2022, identified the following as being administered 2 or more hours late: Enteral Feeding [name redacted] either via pump or bolus 16 times on 11/02/2022 x 1; 11/03/2022 x 2; 11/04/2022 x 2; 11/05/2022 x 1; 11/06/2022 x 1; 11/07/2022 x 2; 11/16/2022 x 2; 11/22/2022 x 2; 11/25/2022 x 1; 11/28/2022 x 1; and 11/30/2022 x 1. Apixaban 22 times on 11/02/2022; 11/03/2022; 11/04/2022; 11/07/2022 through 11/13/2022; 11/16/2022; 11/17/2022; 11/18/2022; 11/21/2022; 11/22/2022; 11/23/2022; 11/24/2022; 11/25/2022; 11/27/2022; 11/28/2022; 11/29/2022; and 11/30/2022. Augmentin 1 time on 11/08/2022. Metoprolol 6 times on 11/03/2022; 11/08/2022; 11/13/2022; 11/18/2022; 11/24/2022; and 11/28/2022. PhosNaK 13 times on 11/02/2022; 11/03/2022; 11/04/2022; 11/07/2022; 11/08/2022; 11/09/2022; 11/10/2022; 11/11/2022; 11/12/2022; 11/13/2022; 11/18/2022; 11/19/2022; and 11/28/2022. Active Liquid Protein 4 time on 11/17/2022; 11/23/2022; 11/24/2022; and 11/30/2022. Ipratropium-Albuterol 16 times on 11/02/2022; 11/03/2022; 11/04/2022; 11/07/2022; 11/08/2022; 11/09/2022; 11/10/2022; 11/11/2022; 11/16/2022; 11/22/2022; 11/23/2022; 11/24/2022; 11/25/2022 x 2; 11/28/2022; and 11/29/2022. Tamsulosin 11 times on 11/03/2022; 11/04/2022; 11/08/2022; 11/09/2022; 11/12/2022; 11/14/2022; 11/17/2022; 11/22/2022; 11/23/2022; 11/24/2022; and 11/28/2022. Nystatin suspension 7 times on 11/08/2022; 11/09/2022; 11/13/2022; 11/23/2022; 11/24/2022; 11/26/2022; and 11/28/2022. A review of the Progress Notes failed to document medications, treatments, or Enteral feedings being administered late or the physician and family notification. On 07/09/2024 at 10:42 AM, during an interview with the surveyor, a Licensed Practical Nurse (LPN) stated the process for Enteral feedings was to gather the supplies, prime the feeding tube, use a stethoscope to ensure correct placement of the feeding tube, flush the tube with water, and hook up and start the feeding or medication administration. She further stated that the dressing would be changed daily, and that staff were to provide continuous feedings and bolus feedings as close to the ordered time as possible. The LPN stated that the staff would only have an hour before or after the ordered times to administer feedings, treatments, and medications. On 07/10/2024 at 8:37 AM, the Registered Dietitian (RD) stated it was important to administer tube or bolus feedings in a timely fashion, and that it was vital to see if the resident could be eating orally and if they still need the bolus. She further stated, you don't want to cram it [the enteral feedings] if you are late which it shouldn't be, and that staff would have to check for residuals (Enteral feed that had not been absorbed and left in the stomach). When inquired if an Enteral feeding was administered two or more hours late, the RD stated, That's a big stretch and it should be documented why it was late. When asked about Resident #234, the RD stated she was not the RD at the facility at that time. On 07/10/2024 at 12:12 PM, during an interview with the surveyor, a second LPN stated the process for administering a feeding or medications via a PEG tube. She stated that the staff should flush the tube, and check for residual and placement. She stated that she was caring for a resident who had a G-tube and was being administered bolus feedings which would be done via gravity. On 07/10/2024 at 1:04 PM, the Director of Nursing (DON) stated the nurses should be documenting as they are administering Enteral feedings, medications, and treatments. She stated the best practice was to check off the medication or treatment at the time it was administered. When asked about the Medication Admin Audit Report, the DON was unable to provide additional information as to why the medications, treatments, and Enteral feedings were documented as being administered two or more hours late. A review of the facility provided policy, Enteral Nutrition revised 2018, included but was not limited to; Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered. A review of the facility provided policy, Administering Medications undated, included but was not limited to; Medications are administered in a safe and timely manner, and as prescribed. Policy: 4. medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR (Medication Administration Record) space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to provide the necessary care and maintenance of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident #6). This deficient practice was evidenced by the following: During initial tour on 07/08/2024 at 8:08AM, the surveyor observed Resident # 6 oxygen tubing not labeled, and the bag that held the tubing when not in use was also not dated. On 07/09/2024 at 09:11 AM during an observation of Resident #6, the Oxygen tubing was not labeled or dated. On 07/10/24 at 10:12 AM during an observation of Resident #6, the oxygen tubing and bag were not labeled or dated. According to the Admission Record, Resident #6 was admitted to the facility with diagnoses including but not limited to, Respiratory Failure with Hypoxia and Asthma. A review of the Order Summary Report revealed a physician order initiated date of 01/24/24 for oxygen at 2 liters/minute via nasal canula (a device that delivers extra oxygen through a tube into the nose) every shift continuous. In addition, for the care of the respiratory equipment; Change Oxygen Tubing, Humidifier, and clean filter weekly on Fridays 11-1 shift, and as needed, date and label tubing and humidifier bottle. During an interview with the surveyor,on 07/09/2024 at 12:00 PM, LPN/UM #2 stated that the respiratory equipment is maintained by nursing. She added that respiratory equipment is changed weekly on Fridays night shift. When equipment is changed, it should be documented in the Electronic Record and that the equipment should be dated and initialed. During an interview with the surveyor on 07/11/2024 at 12:10 PM, the Infection Preventionist stated that during infection control rounds on the units, he checks that respiratory equipment is properly dated and changed weekly and Oxygen tubing should be dated. During an interview on 07/11/2024 at 01:28 PM, the Director of Nursing (DON) stated that all oxygen equipment is to be changed weekly on Friday night shift. She added that the tubing and storage bag should be dated with the last change date. A review of a facility policy titled, Oxygen Administration, with a revised date of 10/2010, revealed, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. N.J.A.C.8:39-27.1(a)

Complaint #: NJ156378, NJ157304, NJ157715, NJ158101, NJ159337, NJ159347, NJ159775, NJ160752 Based on observation, interview, and review of facility documentation, it was determined that the facility failed to ensure the personal privacy of a resident's body during an incontinence care check. This deficient practice was identified for 1 of 1 residents reviewed for privacy (Resident #14) and was evidenced by the following. According to the Admission Record (AR), Resident #14 was admitted to the facility with diagnoses which included but were not limited to, Diabetes (high blood sugar levels), Depression (a mood disorder that causes persistent sadness and loss of interest), and Unspecified Epilepsy (a neurological disorder that causes seizures). 1.) On 07/03/2024 at 9:59 A.M., the Surveyor observed Resident #14 in bed with head of bed elevated at 45 degrees. The Surveyor observed that the Licensed Practical Nurse/Unit Manager (LPN/UM) did not pull the privacy curtain during the incontinence care check. During an interview with the Surveyor on 07/03/2024 at 10:24 A.M., the LPN/UM stated that she does not know why she did not pull the privacy curtain. N.J.A.C. 8:39 - 4.1(a) (16)

Complaint#: NJ159347 Based on observations and interviews, it was determined the facility failed to maintain a clean and homelike environment for 1 of 3 nursing units (Applewood Unit). The deficient practice was evidenced by the following: The surveyor toured the Applewood Unit on 07/03/2024 and observed the following: 1.) On 07/03/2024 at 9:05 A.M., upon entering the unit, the Surveyor noted a strong urine odor on the unit. The Surveyor observed the Housekeeper on the unit during the tour. 2.) On 07/03/2024 at 1:55 P.M., the Surveyor returned to the unit and as soon as the doors to the unit were opened, the Surveyor noted a strong pungent odor. The Surveyor noted a strong odor of feces while on unit. The Surveyor did not observe any dirty linens on the cart during the tour. Incontinence care was not being provided during that time. The surveyor toured the Applewood Unit on 07/05/2024 and observed the following: 1.) On 07/05/2024 at 9:40 A.M., upon entering the unit, the Surveyor noted a strong urine odor on the unit. The Surveyor observed 2 Housekeepers cleaning the unit. 2.) On 07/05/2024 at 10:42 A.M., the Surveyor returned to the unit and noted a urine odor. During an interview with the Surveyor on 07/05/2024 at 10:43 A.M., the Licensed Practical Nurse/Unit Manager (LPN/UM) of the Applewood Unit stated the dirty linens were causing the urine odor. The LPN/UM further stated, Laundry picks up the dirty linen every 2 to 3 hours. The LPN/UM confirmed the presence of urine odor on unit. The LPN/UM stated the unit was cleaned in the morning. The LPN/UM further stated, the [NAME] does the floors, and the Housekeeper cleans the rooms twice a shift. The LPN/UM stated,all staff are responsible for controlling odors on the unit. During an interview with the Surveyor on 07/05/2024 at 12:38 P.M., the Housekeeping Director (HD) stated that rooms were cleaned twice a day. The HD further stated, I check the rooms to see if they are cleaned. The HD stated the Certified Nursing Assistants (CNAs) were responsible for changing the linens. The HD stated the odor was brought to his attention by one of the nurses. Review of the undated facility policy titled Work Schedules, Environmental Services revealed under Policy Interpretation and Implementation 3. Cleaning schedules are developed and implemented to assure that each area of our facility is maintained in a safe, clean, and comfortable manner. NJAC 8:39-4.1(a) (11)

Complaint #: NJ159337 Based on interviews and records review on 07/02/2024, 07/03/2024 and 07/05/2024, it was determined that the facility failed to ensure a resident (Resident #19) was free from a medication error for 1 resident of 3 residents (Resident #19) reviewed for medication administration and follow their policy titled Medication Administration. Resident #19 received medication in error that was not prescribed to be administered to the resident. This deficient practice was evidenced by the following. According to the Admission Record (AR), Resident #19 was admitted to the facility with diagnoses which included but were not limited to Major Depressive Disorder (Mood disorder that causes a persistent feeling of sadness), Constipation (problem passing stool), Unspecified Dementia (impaired ability to remember, think or make decisions), Abnormal Gait and Dysphagia (difficulty swallowing). According to the Quarterly Minimum Data Set (MDS), an assessment tool dated 10/21/2023, Resident #19 had a Brief Interview of Mental Status (BIMS) score of 0/15, which indicated the Resident was severely cognitively impaired. According to the facility's form titled Incident report, dated 11/1/2022 at 2:30 p.m., under type revealed: Medication Incident, location: Applewood Unit. Review of Resident #19's Electronic Medical Record under allergies revealed: No Known Allergies. According to the facility's form titled Individual Statement Form dated 11/1/2022 at 2:30 p.m., location: Applewood Unit revealed the following information. I administered an antibiotic to the wrong patient (Resident #19) during medication pass. I was educated afterwards on the 7 rights of medication administration: right patient, right drug, right dose, right time, right route, right reason, and right documentation. During an interview on 07/05/2024 at 1:55 p.m., the Regional Director of Specialty Program (RDSP) revealed that the process of medication administration included following the 5 rights of medication administration, give the medication and document. She continued to state, it is the right of the resident not to receive the wrong medication and I would expect the nurse to follow the physician's order and regulations about medication pass. During this survey, the Surveyor was unable to reach the nurse who administered the wrong medication to Resident #19. A review of the facility's policy with revision date April 2019 titled Administering Medications under Policy Statement revealed: Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation #9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services. NJAC 8:39-29.2 (d)

Based on observation, interview and medical record review, it was determined that the facility failed to revise a falls Care Plan for Resident #2 to include individualized interventions to maintain the resident's safety. The resident had a history of [REDACTED]. This deficient practice was identified for Resident # 22, 1 of 22 residents reviewed for comprehensive care plans as evidenced by the following: During the initial tour of the facility on 7/30/2014 at 10:30 a.m. the Unit Manager (UM) stated Resident #2 was confused and had behaviors of crying and being resistive with care. At this time Resident #2 was observed seated in a wheelchair in the room. On 7/30/14 at 11:50 a.m. the surveyor observed Resident #2 eating lunch in the Dining room. The resident was sitting in a regular chair. A Certified Nursing Assistant was seated next to the resident. On 7/30/14 at 12:30 p.m. the surveyor reviewed Resident #2 's medical record. The Admission Face Sheet indicated Resident #2 had [DIAGNOSES REDACTED]. The resident required assistance from staff for bed mobility and transfer. Further review of the Progress Notes and the post fall investigation summaries provided by the facility revealed the resident fell at the facility on the following dates: On 10/29/13 at 7:00 p.m. the resident was found seated on the floor in the bathroom. The resident attempted to use the bathroom unassisted, slipped and fell . The intervention added to the Care Plan after the fall was to toilet the resident every two hours. On 12/23/13 at 8:10 p.m. the resident fell and sustained a skin tear to the right forearm with the following measures 2.5 centimeters (cm) x 1. 5 cm. There were no interventions added to the Care Plan at that time. According to the Incident Accident Report dated 12/23/13 the resident was last seen around 6:30 p.m. The resident indicated he/she needed to use the bathroom. The resident left the dining room and went to the room to use the bathroom. On 2/19/14 at 12:45 p.m. the resident was observed on the floor in the bathroom in a supine position. The resident attempted to toilet him/herself and fell in the bathroom. The resident sustained [REDACTED]. The resident was not assisted to the bathroom after meals. Again the Care Plan intervention was to toilet the resident every two hours. On 3/2/14 at 5:45 p.m. the resident fell from the wheelchair. The intervention was for the staff to escort the resident from the dining room after meals and be toileted. On 3/25/14 at 6:50 p.m. the resident was found on the floor in the bathroom. A review of the fall summary dated 3/25/14 indicated that the resident wheeled him/herself from the dining room and attempted to toilet him/herself. The resident slipped and fell in the bathroom. According to the investigation Summary dated 3/25/14 the resident was not assisted to the bathroom after dinner. The facility indicated that the Care Plan was appropriate. No revision was made on the Care Plan at that time. On 5/13/14 at 7:45 a.m. the resident was observed on the floor. According to the investigation summary dated 5/13/14, the call bell was attached to the bed but was not on. The resident complained of right hip pain and the resident's left leg was slightly rotated outward. The resident stated that he/she was going to the bathroom. The resident was transferred to the hospital and admitted with a left [MEDICAL CONDITION]. The resident underwent [REDACTED]. On 8/5/14 at 12:40 p.m. the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for the resident. The CNA stated the resident required extensive assistance from staff with bed mobility and transfer. The CNA also stated that over a year ago the resident became dependent on staff for care. The CNA revealed that before the fall with the fracture the resident could not ambulate independently. A review of Resident #2 's Care Plan related to falls, effective as of 10/30/13, revealed no evidence that the resident was assisted to the bathroom after meals. There was no documented evidence that the resident was being monitored closely by staff. The resident had a care plan for falls initiated 11/22/10. The same intervention was noted after each fall since 10/29/13 as follows: "Toilet every two hours." The Care Plan did not include additional interventions to keep Resident #2 safe until after the fall which resulted in a fracture. The Care Plan did not address supervision of this confused resident. There was no documented evidence that the Interdisciplinary Team met and revised the Care Plan and implemented interventions after each fall to keep the resident safe. Refer to F323 NJAC 8:39-11.2

Based on observation, interview and record review, it was determined that the facility failed to: provide adequate supervision to residents at risk for falls; implement specific and individualized interventions to address accidents and; ensure that assistive devices to alert staff of falls were in place and functional for Resident #2, #6 and #11. Resident #2 sustained a fall with a fractured hip resulting in hospitalization for a surgical repair of the fracture. This deficient practice was identified for Residents # 2, # 6, and # 11, 3 of 9 residents reviewed for falls as evidenced by the following: 1. During the initial tour of the facility on 7/30/14 at 10:45 a.m. the surveyor observed Reisdent #2 in the room with a Certified Nursing Assistant (CNA) at the bedside providing care. The nurse touring with the surveyor stated that Resident #2 was confused , had a history of [REDACTED]. On 7/30/14 at 12:30 p.m. the surveyor observed the resident seated in the Dining room in a regular chair. A CNA was seated close to the resident. On 7/30/14 at 1:30 p.m. the surveyor reviewed Resident # 2's medical record. The Admission Face Sheet indicated Resident # 2 had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The Minimum Data Set ( MDS ), an assessment tool, dated 5/30/14 indicated Resident # 2 had severe cognitive impairment. The resident received a score of 3 on the Brief Interview for Mental Status. A score of 0 - 7 indicated severe cognitive impairment. The MDS also revealed the resident required extensive assistance from staff for bed mobility and transfer. A review of a form titled, "Resident Nursing Instructions", dated 10/30/13, indicated the resident required one person physical assist with transfer prior to the fall. A review of the electronic medical record revealed progress notes and the post falls investigation summaries which included the following: On 10/29/13 at 7 p.m. the resident was found sitting upright on the bathroom floor. According to the investigation summary, the resident attempted to toilet him/herself and fell on to the floor. The intervention was to toilet the resident every 2 hours. On 12/23/13 at 8:10 p.m. the resident was observed on the floor near the doorway. The resident sustained [REDACTED]. The Incident Investigation Summary indicated the resident was last seen at 6:30 p.m. in activity room. The intervention again was to toilet the resident every two hours. On 2/19/14 at 12:45 a.m. the resident was found in a supine position on the bathroom floor. The resident sustained [REDACTED]. The resident stated he/she went to the bathroom and slipped coming back. Measures established to minimize risk to the resident in the future was to offer toileting every two hours. On 3/2/14 at 5:40 p.m. the resident fell from the wheelchair, the roommate alerted the staff of the fall. On 3/25/14 at 6:50 p.m. the resident fell again in the bathroom. According to the Incident Investigation Summary of 3/25/14 the resident was not toileted immediately after meals. The resident stated he/she wheeled herself from the dining room to the bathroom because he/she needed to use the bathroom. On 5/13/14 at 7:45 a.m. the resident was found on the floor in his/her room. The corresponding Incident Investigation Summary revealed the following:" Staff heard cry for help. Entered the room and observed the resident lying on the floor on the left side. The resident complained of pain to the left hip. The resident's left leg was noted to be rotated outward. The call bell was attached to the bed but was not on." The resident was transferred to the hospital and admitted with a left hip fracture. The resident underwent [REDACTED]. The Incident Investigative Summary further indicated that the care plan would be reviewed and revised at that time. A review of the Resident Assessment Protocol Summary (RAPS) dated 5/30/14 documented that falls triggered for Resident #2 and that falls were referred to the comprehensive care plan. The resident received a score of 7 on the Falls Assessment Risk dated 2/19/14. A review of the care plan for falls initiated since 2010 and last revised 6/13/14 addressed the problem of falls related to advanced age, forgetfulness, history of falls and poor safety awareness. Interventions in place as of 10/30/13 consisted of assisting the resident with toileting and assist back to room after meals and toileting. On 8/4/14 at 12:10 p.m. the surveyor interviewed the CNA who cared for the resident. The CNA stated that the resident was confused and dependent on staff for care. The CNA further stated that prior to the fall the resident required one person physical assist for bed mobility and transfer. The CNA also stated the resident did not have any alarms in place prior to the fall of 5/13/14. The surveyor interviewed the Unit Manager at 12:35 p.m. who confirmed that the resident was provided with a bed alarm and a motion sensor upon return to the facility on [DATE], after the fracture. There was no documented evidence that the facility revised/ implemented individualized interventions after each fall to keep the resident safe. On 8/6/14 at 10:30 a.m. the Director of Nursing (DON) stated that falls were identified as being a concern for Resident #2. The DON further stated that specific measures were being considered to reduce falls including to monitor the resident. The DON also stated that the Interdisciplinary Team met on 4/7/14 to discuss Resident #2's frequent falls. At that time it was decided that the resident would be provided with a bed and a sensor alarm. The recommended interventions were not implemented or added to the falls Care Plan until 5/18/14, after the fall of 5/13/14 which resulted in a fractured the left hip. 2. During the initial tour on 7/30/14 at 9:30 a.m. the surveyor observed Resident #11 seated in a wheelchair. The Unit Nurse Manager (UM) stated the resident was alert and had periods of confusion. The UM revealed the resident had a fall and sustained a fractured femur. On 7/30/14 at 12:30 p.m. the surveyor observed Resident #11 in the main dining room, seated in a wheel chair at a table with three other residents eating their lunch meal. On 7/31/13 the surveyor reviewed Resident #11's medical record. The Admission Face Sheet indicated Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool dated 5/16/14, indicated Resident #11 was alert and oriented, was non-ambulatory and required one person physical assistance with transfers, bed mobility and toileting. The resident's care plan, initiated on 5/29/13 and revised on 5/27/14 after a fall reflected the resident required extensive assistance from one person with all transfers. A review of an Incident Report dated 11/12/13 and untimed, revealed Resident #11 had a fall and complained of left leg pain. At the time, the resident told the nurse that he/she had lost his/her balance while getting dressed. A review of another Incident Report dated 2/27/14 at 3:45 a.m. revealed Resident #11 was found sitting on the floor. At this time, the resident told the nurse that he/she was " trying to fix the bed", slipped and fell to the floor. According to the report, the intervention implemented to minimize the risk of falls for Resident #11 was to use a "call bell bed alarm" while in bed. The alarm was connected to the call bell system and would alert staff at night if the resident was out of bed. A review of an Incident Report dated 5/4/14 at 4:25 a.m. revealed that a nurse found Resident #11 on the floor and lying on his/her back. A statement obtained from the Certified Nursing Assistant (CNA) who was caring for the resident revealed that at 4:00 a.m. the CNA toileted the resident. Then at 4:30 a.m. the CNA heard someone yelling for help and entered the resident's room and found the Resident #11 lying on the floor. A nurse was present with the CNA. A review of a Progress Note dated 5/4/14 at 4:55 a.m. revealed Resident #11 was found lying on the floor and complained of right leg pain and the resident also told the nurse that he/she had hit his/her head. According to this note, the resident's right leg was positioned underneath his/her left leg. The resident was sent to the hospital for an evaluation and admitted with a [DIAGNOSES REDACTED]. A review of a form titled "Tracking Record for Improving Patient Safety" revealed that a bed alarm was in place but did not sound. According to the documentation on the Fall Investigation form Resident #11' s bed call light alarm was in place but was found to have had a faulty wire and therefore the alarm did not trigger the nurse call system. During an interview conducted by the surveyor on 8/5/14 at 9:55 a.m., the Director of Nursing (DON) stated that the nurse call bell alarm was a new device that the facility was using to aid in decreasing resident falls. The DON stated that there was no accountability system in place at that time to monitor the alarms for proper functioning. On 8/6/14 at 10:30 a.m. in presence of the surveyor the UM tested Resident #11' s bed alarm. The alarm failed to trigger the nurse call bell located at the nurses station. The UM returned to the resident's room, adjusted to bed alarm pad and retested the alarm. At that time the bed alarm did sound at the nurses station. 3. During the initial tour conducted on 7/30/14 at 10:30 a.m. the surveyor observed Resident #6 seated in a wheelchair at the nurse's station. The Licensed Practical Nurse stated that the resident was alert and confused. The LPN also stated that the resident was a high risk for falls. On 7/31/14 the surveyor reviewed Resident #6 's medical record. The Admission Face Sheet indicated that the resident was admitted to the facility with [DIAGNOSES REDACTED]. According to a progress note, written on 7/18/14, the resident was found on the floor at the bedside. According to the Incident/Accident Report, the resident had been in bed prior to the unwitnessed fall. At that time a bed alarm was implemented for the resident's safety. On 8/5/14 at 9:15 a.m. the surveyor and the LPN entered Resident #6 's room. The resident was in bed and alone in the room. In the presence of the surveyor the LPN tested Resident #6 's bed alarm. The bed alarm did not sound when tested and was found not to be in working order. At that time the LPN reported the information to a supervisor and the resident 's alarm was changed. NJAC 8:39-27.1 (a)