Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living specifically by not turning the resident in bed every two hours to prevent skin deterioration. The deficient practice was identified for 2 of 5 residents (Resident # 179, 152) investigated for Activities of Daily Living. The deficient practice was evidenced by the following: A review of Resident # 179’s Minimum Data Set (MDS; an assessment tool) dated 9/15/2024 revealed under section “GG” that he/she has lower extremity impairment on both sides. Further, the MDS revealed under section, “M” that he/she is at risk of pressure ulcers/injury. A review of Resident # 179’s Care Plan revealed a focus of an Activity of Daily Living (ADL) Self Care Performance deficit related to deconditioned status post hospitalization, pain, and weakness. The Care Plan revealed an intervention for “Bed Mobility” that Resident # 179 requires the assistance of one staff member and a sheet for turning and repositioning. The intervention was dated 4/14/2025. A review of the Physician’s Orders located in the Electronic Medical Record (EMR) revealed an order to, “Turn every 2 hours for turning schedule” with a start date of 4/01/2024. A review of the Treatment Administration Record (TAR) located in the EMR revealed blanks in the documentation area for the order to turn every two hours. The blank areas were identified for the following dates and times: 4/5/2024 – 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM. 4/13/2024 – 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM 4/20/2024 – 12:00 PM, 2:00 PM, 6:00 PM, 8:00 PM, 10:00 PM On 8/01/2025 at 12:05 during an interview with the surveyor, the Director of Nursing (DON) replied, “After investigation and following up with the nurse, I would make that determination.” After the surveyor asked if there are blanks on the Treatment Administration Record and no progress notes referring to the administrations, would you consider that completed. The DON said rotating residents in bed is important because it helps with skin integrity prevention or maintenance. A review of the facility policy titled, “Activities of Daily Living (ADL), Supporting” revised April of 2025 revealed that, Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.” NJAC § 8:39-27.1 (a) A review of Resident # 152’s Minimum Data Set (MDS) an assessment tool dated 05/07/2025 revealed in the Brief Interview for Mental Status (BIMS) that the resident scored a 15 indicating that the resident is cognitively intact. The MDS also revealed in section GG that the resident has bilateral lower extremity impairment and requires substantial/maximum assist with showering. A review of Resident # 152's Care Plan revealed a focus for Activity of Daily Living (ADL) Self-Care Performance deficit related to activity intolerance. The Care Plan revealed an intervention for “Bathing” that Resident # 152 requires the assistance of1 staff with bathing. The intervention was dated 10/15/2024. A review of the ADL record documentation sheet located in the Electronic Medical Record (EMR) revealed blanks in the documentation area for showering evening shift. The blanks were identified for: 07/14/2025 3-11 07/17/2025 3-11 07/21/2025 3-11 07/28/2025 3-11 A review of Resident # 152’s grievances revealed that on 05/10/2025 the resident filed a grievance regarding his/her shower schedule. The resolution was a shower schedule hung on the residents closet door. On 07/01/25 at 9:30 A.M. during an interview with the Administrator regarding blanks on the ADL record regarding showers and would they be considered performed. The Administrator stated that the resident “may have refused it.” A review of the facility policy titled, “Bathing and showering” revised February 19, 2024, revealed that “the interdisciplinary team will develop bathing/showering schedules with resident and/or representative,” It further revealed that “Provision of refusal of showers and/or tub baths will be documented in the medical record by the certified nursing assistant and/or licensed nurse.” A review of the facility policy titled, “Activities of Daily Living (ADL), Supporting” revised April of 2025 revealed that “Residents are provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out services of daily living independently received the services necessary to maintain good nutrition, grooming, and personal and oral hygiene, NJAC 8:39-27.1(a)

Complaint # NJ00172812Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide access to the call system while a resident was in bed. The deficient practice was identified for 2 of 8 residents investigated under the Environment Task. (Resident # 2 and Resident # 77)On 07/29/2025 at 10:29 AM, during the initial tour of the facility, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On the same date at 10:37 AM, the surveyor observed Resident # 77 awake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/30/2025 at 10:29 AM, the surveyor observed Resident # 77 wake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/31/2025 at 09:40 AM, the surveyor observed Resident # 2 asleep in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On the same date at 09:42 AM, the surveyor observed Resident # 77 wake in bed. At that time, the surveyor observed the handheld call device on the floor adjacent to the bed.On 07/31/2025 at 09:43 AM, during an interview with the surveyor, the Certified nursing assistant (CNA) # 1 said that when residents are in bed the handheld call device should be attached to their sheet within their reach.On 08/01/2025 at 09:58 AM, during an interview with the surveyor, the Registered Nurse Unit Manager (RNUM) #1 said that the handheld call system should be clipped to the resident's blanket and within reach when residents are in their bed. The RNUM #1 replied, no when asked if the handheld call device should be on the floor.On 08/01/2025 at 01:01 PM, during an interview with the surveyor, the Director of Nursing (DON) replied, No when asked if the handheld call device should be on the floor when residents are in bed.A review of the facility policy titled, Answering the Call Light dated April 2016 revealed under General Guidelines number 5., When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. N.J.A.C. S 8:39-31.8

Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/23, included the resident had a Brief Interview for Mental Status score of 6, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident exhibited wandering behavior daily. Review of the Care Plan, initiated 08/17/23, included a focus of, I have a behavior problem. I like to go 'shopping in other resident's rooms.' I like to wander in and out of resident's rooms. I believe another male resident is my husband and initiated oral sex with him, with an intervention to, intervene as necessary to protect the rights and safety of others. Review of a Progress Note, written by Licensed Practical Nurse (LPN) #1 on 01/06/24 at 12:19 AM, revealed, Resident was observed by staff kissing another resident on the lips, while that resident was asleep out in community requiring [Resident #103] to be redirected earlier in shift. The kiss was reported to manager. An hour or so later [Resident #103] was observed attempting to kiss resident again by this nurse and coworker but was able to interseed [sic]. Resident continues to be bizarre, confused, forgetful with inappropriate behaviors and with very poor safety awareness. Wanderguard in place to LLE [left lower extremity] and functioning well. The surveyor requested all Facility Reportable Events (FRE) related to Resident #103. On 01/16/24 at 10:59 AM, the Director of Nursing (DON) provided FRE's dated 08/21/23 and 10/07/23 and stated there were no additional FRE's for Resident #103. During an interview with the surveyor on 01/16/24 at 12:31 PM, the Certified Nursing Assistant (CNA) stated Resident #103 was a wanderer and that staff monitor and redirect the resident. During an interview with the surveyor on 01/16/24 at 12:35 PM, LPN #2 stated Resident #103 had a history of sexually inappropriate behaviors and that staff frequently monitor and redirect the resident. LPN #2 further stated that when abuse was witnessed or suspected, staff reported the incident to the nursing supervisor and the DON. During an interview with the surveyor on 01/16/24 at 12:38 PM, LPN #3 stated Resident #103 had sexually inappropriate tendencies and that staff monitor and redirect the resident. LPN #3 further stated that when abuse was witnessed or suspected, staff immediately reported the incident to the nursing supervisor and the DON who then report it to the NJDOH in a timely fashion. During an interview with the surveyor on 01/16/24 at 12:47 PM, the Registered Nurse/Unit Manager (RN/UM) stated Resident #103 had a history of being sexually inappropriate and that staff monitor and redirect the resident. The RN/UM further stated that when abuse was witnessed or suspected, staff notify the UM, the ADON, the DON, and the Licensed Nursing Home Administrator (LNHA). On 01/16/24 at 1:52 PM, the surveyor attempted to call LPN #1 who wrote the Progress Note on 01/06/24. The surveyor left a message for the LPN to call the surveyor back. During an interview with the surveyor on 01/16/24 at 2:14 PM, the DON stated that sexual abuse included any sexual act that the resident reports was ill intent, including intercourse, kissing, and inappropriate touching. The DON explained that when abuse was witnessed or suspected, the facility ensures the residents are safe and staff report the incident to the immediate supervisor, the DON, and the LNHA. The DON further stated that the incident was reported to the NJDOH within two (2) hours. When asked about the incident documented in Resident #103's Progress Notes on 01/06/24, the DON stated she recently came across that progress note today (01/16/24) and was planning to report the allegation to the NJDOH, Long Term Care Ombudsman, and the police. The DON further stated that the incident should have been reported to the NJDOH on 01/06/24 when the incident was documented. During an interview with the surveyor on 01/16/24 at 3:25 PM, LPN #1 stated that on 01/05/24, she worked the 3:00 PM to 11:00 PM shift and that at the beginning of her shift, she overheard LPN #2 report to the RN/UM that Resident #103 kissed Resident #23 who was seated in front of the nurse's station. LPN #1 further stated that about an hour after that, LPN #1 witnessed Resident #103 approach Resident #23 and bend over towards the resident, but that she was able to intervene before Resident #103 touched Resident #23. When asked about reporting the incident, LPN #1 stated she reported the incident to the RN/UM and was instructed to monitor the resident and document the incident in a progress note. LPN #1 further stated the Progress Note was dated 01/06/24 at 12:19 AM, because she documented the incident at the end of her 3:00 PM - 11:00 PM shift. During a follow-up interview with the surveyor on 01/17/24 at 9:38 AM, the DON, in the presence of the LNHA, stated the RN/UM should have reported the incident to the DON and the LNHA who would then make the final decision on reporting the incident to the NJDOH. During a follow-up interview with the surveyor on 01/17/24 at 10:30 AM, LPN #2 stated she did not recall the incident on 01/05/24. During a follow-up interview with the surveyor on 01/17/24 at 10:49 AM, the RN/UM stated that on 01/05/24, LPN #2 reported to her that Resident #103 kissed Resident #23 on the cheek. The RN/UM further stated she should have reported the incident to the DON and the LNHA because Resident #23 had a diagnosis of dementia and was unable to consent to the kiss from Resident #103. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated October 2022, included, Investigate and report any allegations within timeframes required by federal requirements. NJAC 8:39-9.4 (f)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 residents (Resident #103) reviewed for abuse. This deficient practice was evidenced by the following: On 01/16/24 at 10:25 AM, the surveyor observed Resident #103 ambulate into the day room and begin conversing with the other residents. At that time, the Assistant Director of Nursing (ADON) entered the day room and redirected the resident. According to the admission Record, Resident #103 had diagnoses which included, but were not limited to, encephalopathy (condition that causes brain dysfunction), unspecified dementia with agitation, depression, cognitive communication deficit, anxiety, and insomnia. Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/08/23, included the resident had a Brief Interview for Mental Status score of 6, which indicated the resident's cognition was severely impaired. Further review of the MDS included the resident exhibited wandering behavior daily. Review of the Care Plan, initiated 08/17/23, included a focus of, I have a behavior problem. I like to go 'shopping in other resident's rooms.' I like to wander in and out of resident's rooms. I believe another male resident is my husband and initiated oral sex with him, with an intervention to, intervene as necessary to protect the rights and safety of others. Review of a Progress Note, written by Licensed Practical Nurse (LPN) #1 on 01/06/24 at 12:19 AM, revealed, Resident was observed by staff kissing another resident on the lips, while that resident was asleep out in community requiring [Resident #103] to be redirected earlier in shift. The kiss was reported to manager. An hour or so later [Resident #103] was observed attempting to kiss resident again by this nurse and coworker but was able to interseed [sic]. Resident continues to be bizarre, confused, forgetful with inappropriate behaviors and with very poor safety awareness. Wanderguard in place to LLE [left lower extremity] and functioning well. The surveyor requested all incident/accident investigations related to Resident #103. On 01/16/24 at 10:59 AM, the Director of Nursing (DON) provided incident reports dated 08/21/23 and 10/07/23 and stated there were no additional incident reports for Resident #103. During an interview with the surveyor on 01/16/24 at 12:31 PM, the Certified Nursing Assistant (CNA) stated Resident #103 was a wanderer and that staff monitor and redirect the resident. The CNA further stated that when abuse is witnessed or suspected, the staff are required to fill out a written statement. During an interview with the surveyor on 01/16/24 at 12:35 PM, LPN #2 stated Resident #103 had a history of sexually inappropriate behaviors and that staff frequently monitor and redirect the resident. LPN #2 further stated that when abuse is witnessed or suspected, staff complete an incident report and obtain written statements from the staff. During an interview with the surveyor on 01/16/24 at 12:38 PM, LPN #3 stated Resident #103 had sexually inappropriate tendencies and that staff monitor and redirect the resident. LPN #3 further stated that when abuse is witnessed or suspected, staff complete an incident report and obtain written statements from the staff. During an interview with the surveyor on 01/16/24 at 12:47 PM, the Registered Nurse/Unit Manager (RN/UM) stated Resident #103 had a history of being sexually inappropriate and that staff monitor and redirect the resident. The RN/UM further stated that when abuse is witnessed or suspected, staff complete an incident report which opens up an investigation that the DON and Licensed Nursing Home Administrator (LNHA) are involved in. The RN/UM added that staff statements are also collected and a summary of investigation is written. On 01/16/24 at 1:52 PM, the surveyor attempted to call LPN #1 who wrote the Progress Note on 01/06/24. The surveyor left a message for the LPN to call the surveyor back. During an interview with the surveyor on 01/16/24 at 2:14 PM, the DON stated that sexual abuse includes any sexual act that the resident reports is ill intent, including intercourse, kissing, and inappropriate touching. The DON explained that when abuse is witnessed or suspected, the facility ensures the residents are safe and staff report the incident to the immediate supervisor, DON, and Licensed Nursing Home Administrator (LNHA). The DON further stated that the nurse completes an incident report and the DON and LNHA obtain statements from staff and residents. The DON added that the investigation should be completed within five days. When asked about the incident documented in Resident #103's Progress Notes on 01/06/24, the DON stated she recently came across that progress note today (01/16/24) and was currently in the process of investigating the incident. The DON further stated that since the Progress Note was written on 01/06/24, investigation into that incident should have been started the same day the note was written. During an interview with the surveyor on 01/16/24 at 3:25 PM, LPN #1 stated that on 01/05/24, she worked the 3:00 PM to 11:00 PM shift and that at the beginning of her shift, she overheard LPN #2 report to the RN/UM that Resident #103 kissed Resident #23 who was seated in front of the nurse's station. LPN #1 further stated that about an hour after that, LPN #1 witnessed Resident #103 approach Resident #23 and bend over towards the resident, but that she was able to intervene before Resident #103 touched Resident #23. LPN #1 added that she reported the incident to the RN/UM and asked if she should complete an incident report, however, the RN/UM instructed her to monitor the resident and document the incident in a progress note. LPN #1 stated she was never instructed to complete an incident report or provide a written statement. LPN #1 further stated the Progress Note was dated 01/06/24 at 12:19 AM, because she documented the incident at the end of her 3:00 PM - 11:00 PM shift. During a follow-up interview with the surveyor on 01/17/24 at 9:38 AM, the DON, in the presence of the LNHA, stated the RN/UM should have reported the incident to the DON and LNHA who would then make the final decision regarding the incident. During a follow-up interview with the surveyor on 01/17/24 at 10:30 AM, LPN #2 stated she did not recall the incident on 01/05/24. During a follow-up interview with the surveyor on 01/17/24 at 10:49 AM, the RN/UM stated that on 01/05/24, LPN #2 reported to her that Resident #103 kissed Resident #23 on the cheek. The RN/UM further stated she should have reported the incident to the DON and LNHA because Resident #23 had a diagnosis of dementia and was unable to consent to the kiss from Resident #103. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated October 2022, included, Investigate and report any allegations within timeframes required by federal requirements. Review of the facility's Accidents and Incidents - Investigating and Reporting policy, dated July 2017, included, All accidents and incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator, and, The nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. Further review of the policy included, The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. NJAC 8:39-4.1(a)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified resident behavior and preferences. This deficient practice was identified for 1 of 36 residents (Resident #45) reviewed for care plans and evidenced by the following: On 1/10/24 at 10:44 AM, the surveyor observed the resident lying in bed, but permitted the surveyor to enter. The surveyor observed the bottom of the room's radiator unit broken, open and exposed. The surveyor located the resident's call bell in the bottom, closed nightstand drawer. The surveyor also observed a sign that depicted a call bell on Resident #45's closet door that stated, press the red button for help from nurse. On 1/11/24 at 11:08 AM, the surveyor observed Resident #45's call bell in the bottom, closed nightstand drawer and the bottom of the radiator was broken, open and exposed. On 1/12/24 at 11:22 AM, the surveyor observed Resident #45's call bell in the bottom, closed nightstand drawer and the bottom of the radiator was broken, open and exposed. On 1/12/24 at 11:31 AM, the surveyor interviewed the Certified Nursing Assistant (CNA#1) and brought them to room [ROOM NUMBER]. The surveyor inquired about the radiator and call bell. CNA#1 described Resident #45 as a fixer and that they like to put things away. On 1/17/24 at 11:43 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1), who described a resident's individualized comprehensive care plan (ICCP) as an outline of the basic needs for the resident. LPN#1 stated that nurses could review the ICCP but could not access it. LPN#1 reported that the RN Supervisor or Unit Manager were in charge of the ICCP, but nursing staff could monitor the care plan for accuracy and updates. LPN#1 also confirmed that the care plan should have identified resident preferences and any behaviors that the resident may have exhibited. On 1/18/24 at 11:04 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM#1), who stated that the purpose of an ICCP was to make everyone aware of the areas a resident may have needed help. RNUM#1 further stated that a care plan should have been personalized to the resident. When asked what type of things should be identified on a ICCP, RNUM#1 stated, falls, room preferences, dietary needs, and behaviors. When asked if Resident #45's care plan should have identified their preference to have the call bell stored in the nightstand drawer and the Resident's tendency to disassemble equipment, RNUM#1 confirmed. On 1/23/24 at 12:03 PM, the surveyor interviewed the Director of Nursing (DON), who confirmed that the expectation for Resident #45 was that the care plan identified the behavior to take apart items and the preference to have the call bell in the drawer. The surveyor reviewed the medical record for Resident #45: A review of the admission Record face sheet (an admission summary) reflected that the resident had diagnosis that included, but was not limited to, unspecified dementia, major depressive disorder, and unspecified mood disorder. A review of the most recent Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 12/15/23, reflected a brief interview for mental status (BIMS) score of 99, which indicated that the resident was unable to complete the assessment. A review of Resident #45's individualized comprehensive care plan (ICCP) had focus areas that identified behaviors but did not identify the Resident's behavior of taking items apart or their preference to keep the call bell in a closed drawer of the nightstand. A review of the facility's undated policy, Homelike Environment included . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. NJAC8:39-11.2(e) thru (i); 27.1(a), (d)

Complaint NJ #: 168814 Based on interview, record review, and review of facility documents, it was determined that the facility failed to address recommendations from the Wound Care Consultant (WCC) in a timely manner for 1 of 5 residents (Resident #502) reviewed for pressure ulcers. This deficient practice was evidenced by the following: According to the admission Record, Resident #502 had diagnoses which included, but were not limited to, COVID-19, diabetes mellitus, and dementia with anxiety. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/12/23, included the resident's Brief Interview for Mental Status score was 14, which indicated the resident's cognition was intact. Further review of the MDS included the resident had three unstageable - deep tissue injury (DTI) pressure ulcers that were present upon admission to the facility. Review of the Care Plan, initiated 10/12/23, included a focus of, the resident has a pressure ulcer development r/t [related to] immobility, with an intervention for, Nutrition/Dietitian consult as needed. Review of the WCC report, dated 10/18/23, included the resident was seen for an initial evaluation of a DTI to the left buttock and an unstageable pressure ulcer to the right buttock. Further review of the WCC report included nutrition recommendations of, Recommend increasing dietary protein intake, and, Recommend obtaining prealbumin, albumin, and Vitamin D-25 level. The WCC added, Will suggest increase in protein intake to improve healing and BW [bloodwork] to evaluate protein levels (albumin/prealbumin/vitamin d/total protein). Review of the resident's Electronic Medical Record (EMR) revealed there were no evaluations or progress notes completed by the Dietician or labs results for prealbumin, albumin, and Vitamin D-25 level for the time period of 10/18/23 through 10/25/23. Review of the WCC report, dated 10/25/23, included the resident was seen for a follow-up evaluation for the left and right buttock pressure ulcers which were improving. Further review of the WCC report included nutrition recommendations of, Recommend Dietician consult, Recommend increasing dietary Protein intake, and, Recommend obtaining prealbumin, albumin, and Vitamin D-25 level. The WCC added, Will again suggest increasing protein intake to improve healing and BW to evaluate protein levels (albumin/prealbumin/vitamin d/total protein) - will consult RD [Registered Dietician]. Review of the resident's EMR revealed there were no evaluations or progress notes completed by the RD or labs results for prealbumin, albumin, and Vitamin D-25 level for the time period of 10/25/23 through 11/01/23. Review of the WCC report, dated 11/01/23, included the resident was seen for a follow-up evaluation for left and right buttock pressure ulcers which were improving. Further review of the WCC report included chemistry recommendations for prealbumin, albumin, and Vitamin D-25. Review of the resident's EMR revealed there were no evaluations or progress notes completed by the RD after the WCC report dated 11/01/23, but there were lab results, dated 11/03/23, for albumin, prealbumin, and Vitamin D-25. Review of a progress note, dated 11/04/23, revealed the resident was discharged from the facility. During an interview with the surveyor on 01/22/24 at 10:43 AM, the Licensed Practical Nurse (LPN) stated that the WCC visited the facility once a week and submited the WCC report to the Unit Manager (UM). The LPN further stated that the any recommendations made by the WCC should be implemented as soon as they were received to ensure the wounds are getting better. During an interview with the surveyor on 01/22/24 at 10:52 AM, the Registered Nurse/Unit Manager (RN/UM) stated that she started working at the facility in November 2023. When asked about the WCC, the RN/UM stated the WCC emailed her the WCC report with any recommendations and that the RN/UM put the orders in that night. The RN/UM further stated that if there was a nutrition recommendation, she would email the Dietician to let her know. The RN/UM added that WCC recommendations should be implemented within 24 hours to promote wound healing. During an interview with the surveyor on 01/22/24 at 11:42 AM, the Dietician stated that the WCC visited the facility weekly and if there were any recommendations related to nutrition, the UM would put in for a nutrition consult that same week. The Dietician further stated that after she evaluated a resident, she would either document under the progress notes or evaluations in the resident's EMR. When asked about Resident #502, the Dietician stated that she started working at the facility the last week of October 2023 and did not recall the resident because she was not involved with the WCC reports until November 2023. The Dietician added that if there was a nutrition recommendation made on 10/18/23, the Dietician at that time should have been notified by the UM and followed-up with the resident. During an interview with the surveyor on 01/22/24 at 1:07 PM, the Director of Nursing (DON) stated that the WCC visited the facility weekly and emailed the WCC report within 12 to 24 hours after the visit to the UMs and DON. The DON further stated the UM reviewed the WCC report, notified the physician, and implemented the recommendations once approved by the physician. The DON added that she was unsure of the timeframe that recommendations from the WCC should have been implemented, but that it was important to follow-up on WCC recommendations for continuity of care. At that time, the surveyor notified the DON of Resident #502's WCC nutrition recommendations that were not addressed on 10/18/23 and 10/25/23. During a follow-up interview with the surveyor on 01/23/24 at 12:45 PM, the DON stated she reviewed Resident #502's WCC reports and stated that when the nutrition recommendation was made on 10/18/23, the UM should have followed up with the physician to address the recommendations. Review of the facility's Nutrition Assessment policy, dated October 2017, included, The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission . and as indicated by a change in condition that places the resident at risk for impaired nutrition, and, Increased need for calories and/or protein - onset or exacerbation of diseases or conditions that result in a hypermetabolic state and an increased demand for calories and protein (e.g . wounds). NJAC 8:39-27.1(a)

Deficiency Text Not Available

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed a.) conduct quarterly Interdisciplinary Care Plan (ICP) meetings and b.) to consistently maintain documentation showing that the resident's representative (RR) was invited or attended ICP meetings in accordance with the facility practice and policy. This deficient practice was identified for two (2) of 36 residents (Resident #67, #81) reviewed, and was evidenced by the following: On 01/22/23 at 10:30 AM, the surveyor reviewed the admission Record (AR) for Resident # 67 which reflected that the resident was admitted to the facility with diagnoses that included but was not limited to dementia with mood disturbances, major depressive disorder, recurrent and cognitive communication deficit. It further reflected that resident had a Power of Attorney (POA) with contact information listed on the AR. The surveyor reviewed Resident #67's medical record which revealed the following information: A review of Resident #67's Care Plan Meeting Review (CPMR) form dated 01/31/23, reflected that the Resident Representative/Power of Attorney (RR/POA) did not attend the care plan meeting on this date. The CPMR dated 10/24/23, indicated that Resident #67's RR/POA attended the care plan meeting. The facility could not provide the surveyor with any additional CPMRs. There was no documentation found in the medical record that the POA was contacted, invited, refused, or attended the care plan meeting on 01/31/23. The surveyor could not find any other care plan meetings that were conducted in 2023. A further review revealed that the care plan meetings should have been conducted in April of 2023 and July of 2023 for Resident #67. On 01/23/23 at 9:14 AM, the surveyor reviewed the AR for Resident # 81 which reflected that the resident was admitted to the facility with diagnoses that included but was not limited to unspecified dementia, behavioral disturbances, depression, and cognitive communication deficit. It further reflected that resident has a POA with contact information listed on the AR. The surveyor reviewed Resident #81's medical record which revealed the following information: A review of the CPMRs for Resident #81 dated 06/05/23 and 07/17/23 indicated that both were conducted for a comprehensive (Annual, Admission, and Significant (Sig) change) care plan meeting. The surveyor could not locate any other care plan meeting documentation that was completed that year. Further record review revealed that the care plan meetings should have been conducted in March of 2023 and October of 2023 for Resident #81. On 01/23/24 at 10:50 AM, the surveyor interviewed the Director of Nursing (DON) regarding care plan meetings and the process on how the meeting were conducted and who was in attendance. The DON stated that care plan meetings were to be completed quarterly and attendance was documented on either the CPMRs or in a separate progress note in the electronic medical record (EMR). The DON further stated she did not know why the care plan meetings were not completed quarterly on Resident #67 and Resident #81 and confirmed that there was no documentation showing that either resident POA/RR were consistently contacted or invited to attend care plan meetings. On 01/23/24 at 11:40 AM, the surveyor interviewed the Social Worker (SW) regarding the facility process when conducting care plan meetings. The SW stated that care plan meeting were to be completed quarterly. The SW also stated that family, RR and POA were to be contacted to attend and to arrange a time and date for the meetings. The SW stated that multiple attempts were made to contact resident representatives, and this was documented under progress notes in the EMR system. He explained that if the RR or POA attended meetings it would be documented under the evaluation's tab/care plans in the EMR. The SW elaborated further to include that care plan meetings were important in facilitating communication, making sure that the residents' families were informed from a holistic approach by keeping them up to date of any resident changes. Reference: New Jersey Statutes Annotated, Title 8. Chapter 39 Subchapter 12(a)(b). Advisory resident Assessment and care plans states:(a) The resident care plan is developed at a meeting held by an interdisciplinary team that includes professional and/or ancillary staff from each service providing care to the resident. (b) The facility makes care planning meetings available at mutually agreeable times, including evenings and weekends, for the convenience of families and significant others. Reference: New Jersey Statutes Annotated, Title 8. Chapter 39 Subchapter 13.2(a) Mandatory resident communication services states: Residents and their families shall be given the opportunity to participate in the development and implementation of the care plan, and their involvement shall be documented in the resident's medical record. The facilities undated policy labeled Resident Rights with a reference number of 483.10 under 1(k) indicated that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: appoint a legal representative of his or her choice, in accordance with state law. The policy specified that residents were to be informed of and participate on his or her care plan meeting. The facility policy statement labeled Care Plans, Comprehensive Person -Centered version October 2022, indicated under item #5 that the resident is informed of his or her right to participate in his or her treatment and is provided advance notice of care planning conferences. Under item #6 it further indicates, that the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. Item #12 of the policy, indicates that the interdisciplinary team reviews and updates the care plan; (a) when there has been a significant change in the resident's condition;(b) when the desired outcome is not met;(c) when the resident has been readmitted to the facility from the hospital stay; and (d) at least quarterly, in conjunction with the required quarterly MDS assessment. Item #13 of the facility policy, indicated that the resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. NJAC 8:39 -12(a)(b) NJAC 8:39-13.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for one (1) of four (4) units ([NAME] Glen) was evidenced by the following: The surveyor conducted a tour of the [NAME] Glen Unit on 1/10/24 at 9:52 AM. The surveyor interviewed Registered Nurse/Unit Manager (RN/UM #1) who explained that the [NAME] Glen Unit was comprised of dementia (cognitively impaired) residents and some residents that had behavioral disturbances related to dementia. RN/UM #1 informed the surveyor that Housekeeping was responsible for cleaning/maintaining the resident rooms and daily touch surfaces and the certified nursing assistants (CNAs) were responsible for making beds, changing bed linens, and general cleanliness of the rooms. During the tour the surveyor identified the following: 1.) In room [ROOM NUMBER], beneath the window, brown drippings/splatter was observed on the wall. 2.) Towards the end of Hallway B, near the fire exit, brown smudges, which presented as handprints, was observed on the handrail. 3.) Hallway C's linen cart, located in between rooms [ROOM NUMBERS], had brown stains/residue/drippings on the sides and debris across the top of the blue mesh cart cover. The handrail next to the linen cart was observed to have brown residue. 4.) In room [ROOM NUMBER], the bottom of the radiator unit was broken open and exposed. In the bathroom, the toilet was observed to have dried brown brown substance, which appeared as feces, on the toilet seat. On 1/12/24 at 11:31 AM, the surveyor interviewed CNA#1 who stated that unit cleanliness was approached as a team and everyone was responsible to ensure that the unit was clean/sanitary. CNA#1 reported that the housekeepers each take a hallway and were responsible for cleaning the resident rooms and high touch surfaces. If unknown substances were observed, they would use disinfectant to clean the area. On 1/17/24 at 11:18 AM, the surveyor interviewed Housekeeper (HSK#1) who stated that their general responsibilities included dusting, cleaning the walls, taking out trash, sweeping the floor, and mopping. HSK#1 reported that they were to use disinfectant on high touch surfaces because they did not know what was contagious. HSK#1 further confirmed that they cleaned the resident bathrooms, including the toilet, and all common areas of the unit. When asked the process of reporting broken items in resident rooms, HSK#1 confirmed that they then notify the Director of Housekeeping upon discovery of the item. On 1/18/23 at 11:04 AM, the surveyor interviewed RN/UM#1, who reported that housekeeping would complete their thorough cleaning in the morning and continuously spot check throughout the remainder of the day. RN/UM#1 confirmed that housekeeping was responsible for the resident rooms, bathroom, walls, and railings. The surveyor and RN/UM#1 together observed the brown residue on the handrail at the end of Hallway B by the fire exit; Hallway C linen cart with the brown residue on the sides of the cover; and the exposed underside of the radiator in room [ROOM NUMBER]. In addition, the surveyor showed RN/UM#1 pictures of the brown residue on the handrail in between room [ROOM NUMBER] and 526; dried brown residue of toilet seat in room [ROOM NUMBER]; and the drip/splatter marks beneath the window in room [ROOM NUMBER]. RN/UM#1 confirmed these areas should have been cleaned and acknowledged that the radiator in room [ROOM NUMBER] should have been reported and repaired. On 1/18/24 at 11:29 AM, the surveyors interviewed the Director of Housekeeping (DOH) who stated that the housekeepers have regular assignments and are guided in their tasks by a daily checklist. The DOH acknowledged that housekeepers were responsible for the common areas, resident rooms, including bathrooms, and hand rails. The DOH confirmed that housekeeping was to clean and disinfect any touchable surface daily. When asked about splatters or drippings on the walls, the DOH reported that this was to be wiped and cleaned. The DOH stated that on the [NAME] Glen Unit, housekeeping was expected to go back and forth and monitor the floor for cleaning. Upon reviewing the pictures obtained from the [NAME] Glen Unit, the DOH confirmed that the pictured areas should have been cleaned. The DOH also confirmed that the radiator unit in room [ROOM NUMBER] should have been reported and maintenance work order submitted. The DOH acknowledged that the linen carts covers are able to be cleaned. On 1/18/24 at 12:08 PM, surveyors interviewed the Maintenance Director (MD), who confirmed that they were not made aware of the radiator's condition in room [ROOM NUMBER]. The MD further stated that it was not acceptable and it should have been reported upon its discovery. On 1/23/24 at 12:03 PM, surveyors interviewed the Director of Nursing (DON) who stated that the soiled areas should have been reported and were to be cleaned as soon as it is noticed. The DON stated that nursing can start to clean any area, but housekeeping was to be notified for proper cleaning and disinfecting of the area. The DON advised that all the linen carts were wipeable and expected to be cleaned. Upon review of the pictures, the DON confirmed that all areas should have been cleaned and that the radiator should not have been in that condition. A review of the facility provided undated Homelike Environment policy included . Residents are provided with a safe, clean, comfortable, and homelike environment [ .] 2. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. NJAC 8:39-4.1 (a), 11, 12, 21.3 (a) (b), 27.2 (j), 31.2 (a-e), 31.3, 31.4 (a-f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ#: 165482 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units) and b.) provide nail care to a resident who required extensive assistance from the staff for activities of daily living (ADLs) for 1 of 5 residents, (Resident #114) reviewed for ADLs. a.) ensure that incontinence care was provided to dependent residents in a timely manner for 3 of 6 residents (Residents #65, #84, #89) observed for incontinence care on 1 of 2 units ([NAME] Glen and Laurel Creek units). This deficient practice was evidenced by the following: 1. On 01/12/24 at 12:30 PM, the [NAME] Glen Unit Manager (UM) provided the surveyors with a list of incontinent residents on the unit. On 01/18/23 at 07:38 AM, the surveyor met with the Certified Nursing Assistant (CNA#1) on [NAME] Glen unit to complete an incontinence tour. CNA #1 stated she was awaiting her assignment. On 01/18/24 at 07:41 AM, the surveyor and CNA #1 commenced an incontinence tour, per the list provided on 01/12/24 by the UM, and observed the following: On 1/18/24 at 07:46 AM, CNA #1 and the surveyor greeted Resident #84 in their room, and CNA #1 informed the resident she was going to check his/her diaper. The diaper was observed to be saturated with urine. A folded blanket under the resident had a dried yellow stain and the fitted sheet on the bed had a dried yellow stain. CNA #1 stated, it should not be like that. During an interview at that time, CNA #1 was asked what it meant when the blanket and sheet under an incontinent resident had dried stains and CNA #1 stated, They haven't been touched. We do have heavy wetters, but if there is a yellow or brown ring it means they haven't been changed and it seeped through. The CNA stated that it was important to do incontinence checks every 2 hours, and to check the heavy wetters in between, to prevent skin break down or wounds from forming. She further stated that it was important to know your resident's needs. A review of Resident #84's admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, epilepsy (seizure disorder), pneumonia, and primary osteoarthritis (degenerative joint disease). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 11/24/23, revealed Resident #84's cognitive skills for daily decision-making were severely impaired. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 01/18/24 at 07:49 AM, CNA #1 and the surveyor greeted Resident #65 in their room, and CNA #1 informed the resident she was going to check his/her diaper. The diaper was observed to be saturated with urine. The resident was observed to have an open wound on their right buttocks with a moist and dried white substance on the area. There was a fitted sheet under the resident with a wet ring. CNA #1 stated that the wet ring was urine. A review of Resident #65's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, hypertension (high blood pressure), and hyperlipidemia (elevated level of fat in the blood). The Quarterly MDS dated [DATE], revealed Resident #65's cognitive skills for daily decision-making were severely impaired. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 01/18/24 at 08:00 AM, CNA #1 and surveyor greeted Resident #89 in their room, and CNA #1 informed the resident she was going to check his/her diaper. The diaper was observed to be dry. A folded blanket under the resident was observed to have a dried tan stain and there was a blue fitted sheet with a wet ring. CNA #1 stated that the sheet should not have been wet. A review of Resident #89's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Alzheimer's disease, muscle wasting and atrophy, and major depressive disorder. The Quarterly MDS, dated [DATE], revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated the resident had severe cognitive deficits. The MDS further assessed that the resident required assistance from staff for personal hygiene and was always incontinent of bowel and bladder. On 01/18/24 at 08:04 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that it was the CNA and nurse's responsibility to provide incontinence care to the residents. LPN #1 stated the residents were changed every one to two hours if they were wet, and if they were not that they were asked if they needed to use the bathroom. LPN #1 stated that the staff constantly checked for incontinence and that they knew which residents used the bathroom more often. LPN #1 stated that she expected the CNA to make sure the residents were taken care of, diapers were dry, that the bed was not soiled, and that the residents were toileted. She further stated that a resident should not have been lying on soiled linens and that if the CNA found a resident with soiled linens, that she would have expected them to have changed them. LPN #1 was informed of the surveyor's incontinence rounds observations. LPN #1 acknowledged that the residents should not have had soiled diapers and linens and that it was important to make sure the residents were clean and dry to maintain dignity and to avoid skin breakdown. On 01/18/24 at 08:12 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that she expected the incontinent resident's diapers to have been changed every two hours, on every shift, and for any soiled linens to also have been changed. The RN/UM was informed of the surveyor's incontinence rounds observations. The RN/UM acknowledged that the resident's linens should not have been soiled and stated that it was important to make sure the residents were clean and dry for the prevention of skin breakdown. On 01/23/24 at 12:07 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurses and CNAs were responsible for incontinence care and that if a resident was identified as being incontinent, that the protocol was for the staff to change them every two hours. The DON was informed of the surveyor's incontinence rounds observations. The DON stated that she would not have expected the residents to be wet like that but if they were, that they should have received incontinence care and the dirty linens should have been changed. The DON further stated it was important for residents to have clean linens and to stay clean and dry for overall skin health. A review of the facility policy, Urinary Incontinence-Clinical Protocol, revised April 2018, does not speak to incontinence care. On 01/23/24 at 12:31, the surveyor inquired from the DON any additional policies on incontinence care. The DON stated there were no other incontinence policies. A review of the facility documentation, Certified Nursing Assistant/Geriatric Nursing Assistant job description, provided on 01/18/24 at 08:42 AM by the DON, revealed Duties and Responsibilities, Personal Nursing Care Functions: Keep residents dry (i.e., change gown, clothing, linen, etc., when it becomes wet or soiled). Change bed linens. Complaint NJ #: 168814 b.) provide nail care to a resident who required extensive assistance from the staff for activities of daily living (ADLs) for 1 of 5 residents, (Resident #114) reviewed for ADLs. This deficient practice was evidenced by the following: 2. On 1/10/24 at 11:00 AM, the surveyor observed Resident #114 in bed. The surveyor observed the resident's fingernails to be long, jagged and soiled underneath. Resident #114 stated they would like to have their nails cleaned and trimmed. On 1/18/24 at 11:04 AM, the surveyor observed Resident #114 in bed. The surveyor observed the resident's fingernails to be long, jagged and soiled underneath. The resident stated that they still needed their nails cleaned and trimmed. According to the admission Record, Resident #114 had diagnoses which included, but were not limited to diabetes mellitus, peripheral vascular disease, depression and the need for assistance with ADL care. Review of Resident #114's MDS, dated [DATE], reflected the resident had a BIMS score of 8 out of 15 which indicated the resident had a moderate cognitive impairment. The MDS further assessed that Resident #114 required assistance with ADLs. On 1/18/24 at 11:10 AM, the surveyor interviewed LPN#2 who stated that nail care should have been provided by the CNAs on shower days and acknowledged that it was obvious that it had not been done since Resident #114's nails were observed to be soiled, long and unfiled. On 1/18/24 at 11:17 AM, in the presence of the RN/UM, the surveyor interviewed CNA #2 who stated that the CNAs were responsible for providing nailcare every two weeks. CNA #2 stated that she had not cleaned, clipped, or filed resident #114's fingernails but acknowledged that it should have been done as part of the resident's Activities of Daily Living (ADL) care daily. The RN/UM acknowledged that the resident's nails had not been cleaned or trimmed and stated that fingernails should be assessed daily and nail care should be provided as needed. A review of the facility's policy, Activities of Daily Living (ADLs), Supporting, with a revised date of 3/2018, reflected .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal care. On 1/23/24 at 1:30 PM, the survey team met with the Licensed Nursing Home Administrator, DON, Regional Nurse, and Regional Director of Operations to discuss the above observations and concerns. On 1/24/24 at 9:46 AM, the DON stated that the facility had no set schedule for providing nail care but that it was part of the residents daily ADL care and that nurses and CNAs were responsible for providing residents with nail care. NJAC 8:39-27.1 (a), 27.2 (g, h, j)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to meet the professional standards of practice related to pain management. Specifically not a.) obtaining a physician's order for severe pain and administering pain medication according to the appropriate pain level, b.) administering pain medications as ordered by a physician and c.) appropriately assessing, monitoring, and recognizing verbal and non-verbal signs and symptoms of pain during a wound care treatment. This deficient practice was identified for three (3) of 3 residents (Resident #52, #114 and #200) reviewed for pain management. The deficient practice was evidenced by the following: a.) On 01/10/24 at 11:07 AM, during the initial tour, the surveyor observed Resident #52 lying in bed watching the television. When asked if they had any concerns, Resident #52 stated that he/she did not feel like their pain was managed well. Resident #52 stated they had a standard oxycodone (pain medication) low dose ordered for every 12 hours and a prn (as needed) medication as well but that it took a long time before it was administered. The surveyor reviewed the medical record for Resident #52. A review of the admission Record (AR) face sheet (an admission summary) indicated that the resident had the diagnoses which included chronic pain syndrome, cognitive communication deficit, rheumatoid arthritis (immune system attacks healthy cells in your body by mistake, causing inflammation [painful swelling] in the affected parts of the body), difficulty in walking and pressure ulcer of sacral region (located below the lumbar spine and above the tailbone). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 12/30/23, reflected the resident had a Brief Interview for Mental Status (BIMS) score 15 out of 15, which indicated a fully intact cognition. A further review indicated the resident received routine scheduled pain medications and as needed pain medications in the last five days. It also revealed that frequent pain limited day-to-day activities, and the intensity of the worst pain was severe. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 5/11/23, for I have pain and/or potential for pain r/t [related to] chronic pain syndrome and rheumatoid arthritis. Interventions included to administer analgesia (pain relieving medication) as per orders, observe for effectiveness and signs and symptoms of side effects; anticipate my need for pain relief and respond to reports and signs and symptoms of pain; encourage me to use non-pharmacological interventions for pain relief as applicable; evaluate the effectiveness of pain management interventions; monitor and record the presence of pain daily and as needed. A further review of the ICCP included a focus area dated 1/10/24, for I am on pain medication therapy. Interventions included to administer medication as ordered and monitor for effectiveness and adverse effects; monitor for altered mental status, anxiety, constipation, depression .observe for adverse reactions with every interaction with the resident; monitor safety due to potential increased risk for falls; and opioids, Narcan/naloxone can rapidly reverse opioid overdose, have available in case of emergency. A review of the December 2023 and January 2024 Medication Administration Record (MAR), reflected the following: -Start date 5/11/23: Pain evaluation every day shift for monitoring of patient's pain level. -Start date 5/11/23: Oxycodone ER (extended release) 12 hour abuse deterrent 40 milligrams (MG). Give one (1) tablet by mouth every 12 hours for pain. -Start date 9/28/23: Acetaminophen tablet 325mg. Give two (2) tablets by mouth every 6 hours as needed for mild pain. -Start date 5/11/23: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every four (4) hours as needed for pain. Discontinued 1/11/24. -Start date 1/11/24: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 4 hours as needed for moderate pain. A further review revealed that the resident had a documented pain level of seven (7) to nine (9) and was administered the oxycodone for moderate pain. There were no as needed pain medications ordered for severe pain. On 01/17/24 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that Resident #52 was alert and complained about pain and requested pain medication every 4 hours on the dot and had a standard pain medication oxycodone 40 mg every 12 hours. LPN #1 further stated that the resident's prn pain medication was oxycodone 20mg every 4 hours for moderate pain and that the resident would tell you the time of the medication. At that time, LPN #1 and the surveyor reviewed the electronic medical record (EMR) together. LPN #1 confirmed she did not see anything for severe pain. The surveyor asked what was the numerical pain scale? LPN #1 stated that the pain scale level was moderate is anything over 4 and mild was 1 to 4. The surveyor asked was there a numerical number for severe pain? She then clarified and stated, mild pain is 1 to 2, moderate is 3 to 4 and severe pain is anything over 4. LPN #1 stated she administered the prn medication based on the pain level that the resident would tell her. She further stated the prn Oxycodone 20mg every 4 hours was for pain and was not specific on the pain level but that it now was indicated for moderate pain. On 01/17/24 at 10:44 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) for the Hartford Glen unit who stated that the numerical pain level was mild, 1 to 3; moderate, 4 to 7; and severe, 8 to10. She stated that if the order was for moderate pain, but the resident was complaining of severe pain then the nurse would call the doctor to get a medication for severe pain. The RN/UM stated that it was important to get the appropriate medication for the type of pain because everyone was different, and it should be individualized based on that resident. At that time, the RN/UM and the surveyor reviewed the EMR together which indicated a physician's order for oxycodone 40mg every 12 hours, pain patches, Tylenol 325mg 2 tablets every 6 hours for mild pain, oxycodone 20mg every 4 hours for moderate pain. She then confirmed she did not see anything for severe pain. The RN/UM and the surveyor review the MAR together which revealed the nurses documented 8 and 9 and the oxycodone 20mg for moderate pain was administered. The RN/UM acknowledged that based on those numerical numbers, that the nurses should have notified the physician and there should have been an order for severe pain. The RN/UM then stated that Resident #52 was always on the call light every 4 hours for their pain medication and for someone like that they should have a medication for severe pain. The RN/UM concluded she just texted the physician to get an order for severe pain. On 01/17/24 at 10:59 AM, the RN/UM informed the surveyor that the physician called back and stated they would keep the oxycodone 20mg every 4 hours for moderate pain but would now add oxycodone 20mg every 3 hours for severe pain. A further review of the January 2024 Medication Administration Record (MAR), reflected the medications listed above and the following: -Start date 5/11/23: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every four (4) hours as needed for pain. Discontinued 1/11/24. - Start date 1/11/24: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 4 hours as needed for moderate pain. - Start date 1/17/24: Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 3 hours as needed for severe pain. A further review revealed that the oxycodone order did not specify if it was for severe pain until after surveyor inquiry. On 01/17/24 at 11:16 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the numerical pain scale was mild pain, 1 to 3; moderate pain, 4 to 7; and severe pain, 8 to10. The surveyor inquired if a resident had a pain level of 9 and only had an order for moderate pain, what should be done? The DON stated that the nurses should call the physician and inform them that the resident's pain level was a 9 and that they needed to give them something else for severe pain. When asked what was the importance of following the numerical pain scale? The DON stated it was important to give in the parameters for effectiveness and to see if there were any adverse effects. On 01/17/24 at 11:21 AM, the DON and the surveyor reviewed the MAR together. The DON acknowledged that there should have been an order for severe pain prior to surveyor inquiry. On 01/17/24 at 01:46 PM, the DON stated in the presence of the survey team that the facility did not have any type of numerical pain scale for the nurses to follow and that they utilized the pain assessment tool which was completed quarterly or when there was a significant change. A review of the Order Summary Report (OSR), indicated the following active orders as of 1/22/24: - Acetaminophen tablet 325mg. Give 2 tablets by mouth every 6 hours as needed for mild pain 1-3. - Oxycodone ER oral tablet 12 hours abuse deterrent 40mg. Give 1 tablet by mouth every 12 hours for chronic pain syndrome. - Oxycodone 20mg. Give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6. - Oxycodone oral tablet 20mg. Give 1 tablet by mouth every 3 hours as needed for severe pain 7-10. On 01/24/24 at 09:56 AM, the DON stated in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, that a pain management in-service was started. The DON concluded since the changes of the pain medication that it had been effective for the resident. c.) On 1/10/24 at 11:00 AM, the surveyor observed Resident #114 in bed. The resident told the surveyor that he/she had a wound on their backside that hurt especially when they put the stuff on to heal it. On 1/11/24 at 11:05 AM, during an interview with the surveyor, LPN#5 stated that she had completed a wound treatment to Resident #114's stage 2 sacral wound that morning. The surveyor asked LPN#5 if she had medicated Resident #114 for pain. LPN #5 replied that the resident had not complained of pain so she did not administer pain medication before the treatment. The surveyor asked LPN #5 if she had assessed the resident's pain level and documented it. LPN #5 reviewed Resident #114's Medication Administration Record (MAR) and Treatment Administration Record (TAR) with the surveyor and replied she had not assessed or documented the resident's pain level. On 1/18/24 at 11:04 AM, the surveyor observed Resident #114 in bed. The resident told the surveyor that he/she had pain in their pelvic area and continued to have pain in their backside. The surveyor asked Resident #114 if he/she had informed the staff that they had pain. Resident #114 replied that they could not remember. On 1/22/24 at 10:00 AM, the surveyor observed the RN/UM #1 on the Hartford Glen unit perform a wound treatment to Resident #114's stage 2 sacral wound. LPN #6 was the assigned nurse for the resident and stated that she would be assisting with the Resident's positioning during the treatment. LPN #6 further stated that she had pre-medicated the resident for pain at approximately 8:00 AM, for a pain level of 8 which indicated the resident was in severe pain. LPN #6 stated that she usually did a pain assessment and medicated the residents before they received wound treatments. The surveyor reviewed the resident's MAR which reflected that LPN #6 was assigned to Resident #114 on 01/09/24, 01/11/24, 01/19/24, and 01/22/24 and had not documented that a pain assessment had been completed, and had not administered any pain medication prior to the wound treatments on any of those dates. LPN#6 could not speak to why she had not conducted a pain assessment or administered pain medication on those days. On that same date, at that same time, during the wound treatment, the surveyor observed Resident #114 in a side-lying position with eyes closed; the resident appeared comfortable. When RN/UM #1 began cleaning the wound, the resident moaned and made a jerking motion forward which indicated she may have experienced pain. The RN/UM #1 removed her gloves and went to wash her hands. The surveyor asked RN/UM #1 if she thought Resident #114 had experienced pain when she cleaned the wound. RN/UM #1 stated that the resident had already been medicated with morphine and continued the treatment. The surveyor observed that RN/UM #1 had not assessed the resident for pain throughout the entire wound treatment. On 1/22/24 at 10:20 AM, during an interview with the surveyor, RN/UM #1 stated that she did not hear Resident #114 moan but did notice he/she winced during the treatment. RN/UM #1acknowledged that she should have assessed the resident for pain during the treatment. On 1/23/24 at 10:50 AM, during an interview, the surveyor asked the RN/UM #1 if she believed that Resident #114's pain was being managed appropriately since the January MAR reflected that Resident #114 had only received two doses of pain medication during the entire month of January. RN/UM #1 replied that she believed the resident needed routine pain medication and had discussed it yesterday with Resident #114's primary care physician and obtained an order. According to the admission record, Resident #114 had diagnoses which included, but were not limited to diabetes mellitus, peripheral vascular disease, depression, and the need for assistance with ADL care. Review of Resident #114's Annual Minimum Data Set (MDS), an assessment tool, dated 05/06/23, reflected the resident had a BIMS score of 8 out of 15 which indicated the resident had a moderate cognitive impairment. The MDS further assessed that Resident #114 required assistance with ADLs. Review of the January 2024 Physician Order Summary reflected a physician's order (PO), with a start date of 11/1/23, for Tramadol HCL 50mg tablet, give 1 tablet by mouth every 6 hours as needed for moderate pain (level 4-7) and a PO for Morphine Sulfate Concentrate oral solution 100mg/5ml, with a start date of 12/27/23, give 0.25 ml by mouth every 3 hours as needed for pain. This order did not indicate the pain level at which this medication should have been administered. The surveyor observed that before the surveyor's inquiry, Resident #114 had not been administered any Tramadol HCL from 01/01/24-01/19/24 nor had Resident #114 been administered Morphine from 01/01/24-01/17/24. Review of the resident's current MAR reflected an order for Morphine Sulfate Concentrate Oral Solution 100mg/5 ml Give 0.25ml by mouth every 3 hours as needed for pain, document pain level with a start date of 12/27/23. There were no initials from 01/01/24-01/11/24 which indicated that the resident had not been evaluated for pain and had not received any Morphine for pain. Review of Resident #114's ICCP for pain reflected administering analgesia as per orders, anticipating the need for pain relief responding to any complaint of pain, and monitoring and recording the presence of pain daily and when needed. On 1/23/24 at 1:30 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), Regional Nurse, and Regional Director of Operations to discuss the above observations and concerns. NJAC 8:39-27.1 (a) b.) According to Resident #200's AR, the resident was admitted with the diagnoses which included, but was not limited to, effusion of the right knee, pain in the right knee and osteoarthritis. The admission MDS, an assessment tool dated 01/04/24, indicated that Resident #200 scored a 4 out of 15 on the BIMS which indicated that the resident had severe cognitive deficits. The MDS also indicate that the resident required maximum assistance with activities of daily living (ADL's) and had occasional complaints of pain. On 01/10/24 at 10:17 AM, the surveyor observed Resident #200 in bed. The resident was observed to have tears coming from his/her eyes and facial grimacing. The surveyor interviewed the resident at this time and the resident stated that he/she had pain in the left hip. The Resident stated that he/she did not have any pain medications since yesterday. He/she stated that he/she did not know if any routine pain medication were provided to manage his/her pain. The surveyor reported the residents' complaints of pain to the nurse. On 01/10/24 at 11:00 AM, the surveyor reviewed Resident #200's medical record which revealed the following documentation: The Physician Order Summary (POS) sheet indicated that Resident #200 had the following medications ordered for pain: -Order dated 12/29/23, for Acetaminophen oral Tablet 325 MG (Acetaminophen) Give 2 (two) tablets by mouth every 4 (four) hours as needed for as needed for mild pain (1-3). -Order dated 12/29/23, for Lidocaine Patch 4 % Apply to right low back topically in the morning for pain for 12 hours then remove and remove per schedule. -Order dated 12/29/23, for Tramadol hydrochloride (HCl) oral Tablet 50 MG *Controlled Drug* Give 1 tablet by mouth every 8 (eight) hours as needed for as needed for severe pain (8-10) According to the documentation on the Medication Administration Record (MAR) Resident #200 had a physicians order for: Acetaminophen 325 mg give two tablets by mouth as needed for mild pain (1-3) on the pain scale. The MAR indicated that on 01/03/24 and 01/05/24, Resident #200 complained that his/her pain was at a pain level of 5 (five) on the pain scale. The MAR indicated that the resident was administered Acetaminophen 325 mg two tabs by mouth as needed for mild pain (1-3) on the pain scale. This medication was administered out of the physician ordered parameters and was given when the resident complained of pain at a level of 5. According to the MAR, Resident #200 had a physician's order for Tramadol 50 mg tab to be given every 8 (eight) hours as needed for severe pain (8-10) on the pain scale. The MAR indicated that on 01/08/24, Resident #200 complained that his/her pain was at a level 7 (seven) on the pain scale. The MAR indicated that the resident was administered Tramadol 50 mg. The medication was ordered to be given when the resident complained of pain (8-10) on the pain scale. The surveyor reviewed Resident #200's ICCP, dated 01/09/24, that indicated the resident had potential for pain. The ICCP interventions included the following: Administer analgesia as per ordered. On 01/11/24 at 10:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2) who stated that she had been employed in the facility for approximately 1 (one) year. LPN #1 stated that if a resident had complaints of pain, she would have asked the resident what their pain level was using a pain scale of 0-10 (0 being no pain, and 10 being excruciating pain). She stated that she would question the resident on how much pain they were having, the description of the pain, and where the pain was located. LPN #2 continued to explain that a 1-3 pain level was mild pain, 4-7 was moderate pain level and 8-10 on the pain scale indicated that the resident had severe pain. She explained that when a resident complained of pain that it would have been documented on the MAR and on the pain monitoring section of the MAR. LPN #2 stated that if the resident had complaints of mild pain (1-3) on the pain scale, then the nurse would have administered the pain medication that was ordered for that pain level. If the resident had moderate pain (4-7) on the pain scale, then the nurse would have administered the pain medication that was ordered for that pain scale. If the resident had severe pain (8-10) the nurse would have then administered the pain medication associated with that pain scale and followed the physician's order. LPN #2 reviewed Resident #200's prn pain medications in the presence of the surveyor and the LPN stated that the nurse should have called the primary care physician (PCP) when the resident complained of moderate pain (4-7) and gotten an order for medication for moderate pain. LPN#2 confirmed that the resident was administered pain medication out of the physician ordered parameters on 01/03/24, 01/05/24 and 01/08/24. She continued to add that if a nurse administered the medication out of parameters that would have indicated that the nurse was not following physician orders. On 01/17/24 at 09:31 AM, the surveyor interviewed the RN/UM #2 on the [NAME] Unit (sub-acute rehab) who stated that if a resident's pain levels were higher than the mild level of pain on the pain scale (1-3) and only had a mild level pain medication ordered, then the nurse should reach out to the PCP to find out if the they wanted a different pain medication given to that resident. She stated that this should have also been done with moderate pain and severe pain level ordered medications. She stated that the nurses should have followed physicians' orders and should not give medication out of the physician ordered parameters. She stated that the nurse should have notified the PCP to get a different pain medication ordered if the resident was complaining of pain at a level higher than what the current medication order was to be used for. On 01/17/24 at 09:48 AM, the surveyor interviewed LPN #3, on the [NAME] Glen Unit, regarding administration of pain medications. LPN #3 stated that if a resident companied of pain above the pain level that a medication was ordered for that the nurse should have called the PCP and should have written it in the progress notes. LPN #3 confirmed that the nurse should not have given any medication out of the physician ordered parameter and should have called the PCP if a resident complained of pain out of the physician ordered parameters. On 01/17/24 at 12:39 PM, the Pharmacy Consultant (PC) stated that she came in monthly to review resident medications. The PC stated that if nurses gave pain medication out of the physician ordered parameters that the nurse would not be following physicians' orders. On 01/17/24 01:43 PM, the surveyor interviewed the DON who stated that the facility did not have a standardized pain scale that the staff could have utilized when they assessed the resident's pain. The DON stated that she could not provide any policy regarding the type of pain scale that the nursing staff used to assess a resident's pain. A review of the facility's policy, Pain Assessment and Management, revised October 2022, included, Assessing pain 5. During the pain assessment gather the following information as indicated from the resident .(2) intensity of pain (as measured on a standardized pain scale). Defining goals and appropriate interventions 1. The pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Implementing pain management strategies 1. Establish a treatment regimen that is specific to the resident based on consideration of the following: b. current medication regimen; d. nature, severity, and cause of the pain.

Based on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 01/10/24 at 09:43 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD#1) for the Assisted Living unit and the Regional Director of Dining Services (RDDS). FSD#1 stated that the FSD#2 for the Long-Term Care unit would be on site shortly. The tour commenced and the following was observed: 1. At handwashing sink #1, there was a step-lid trashcan with no plastic trash bag, with trash and debris observed inside the can. During an interview at that time, FSD#1 acknowledged the unlined trashcan and stated that there should have been a plastic bag in the can. FSD#1 stated that a plastic bag would have made it easier for the trash to have been removed, the inside of the can would not have been contaminated and the trash would have been easier to dispose of. 2. In the walk-in refrigerator, on a rolling metal rack, there was an uncovered metal half pan that contained tan and cream colored gelatinous material, with no label or dates. FSD#1 identified it as cream gravy and stated that it should have been covered with clear plastic wrap and dated when it was made. The pan was removed. 3. On the same rolling metal rack, there were two sealed boxes of bacon with no dates observed on the box. FSD#1 stated she did not know when the bacon was pulled from the freezer and that it should have had a pulled date and a use by date. 4. On the cooked and raw meat rack, resting on a sheet pan, was one defrosted 10 pound (lb) pan roasted turkey breast in a manufacturer's sealed package with no sticker or dates. FSD#1 stated that it should have had a sticker when it was received. 5. On the bottom shelf of the same rack, resting in a four-inch half pan, was one unsealed, opened clear plastic bag with the tan meat visible and exposed to air. The meat was soft and resting in red liquid. There was no label nor dates. FSD#1 identified the meat as chicken thighs and acknowledged that the meat was not sealed correctly. FSD#1 stated that the meat should not have been exposed to air and that the bag should have had a label with a use by date, and dated when it was pulled from the freezer so staff would have known when it should have been discarded. The RDDS stated that the meat would get discarded and removed the chicken from the refrigerator. 6. On the vegetable rack, there was one large clear plastic bin containing five red peppers. The peppers were wrinkled and had visible black spots. The sticker on the bin was marked received 12/28/23 and FSD#1 stated that they were good for a month. The surveyor inquired as to whether the peppers were still good to eat and FSD#1 stated, no and discarded the peppers. 7. On the same rack, there was one plastic bin containing asparagus. On the bin there was one sticker marked received 1/10/24 and one sticker marked received 12/19/23. The asparagus was thin, wrinkled and dried out. FSD#1 stated the asparagus should not have looked dried out and that they should have lasted for a month or longer. FSD#1 stated it was important to inspect produce to prevent spoilage. On 01/10/24 at 10:19 AM, FSD#2 joined the tour and observed the asparagus with the surveyor and staff. 8. On a metal rack, there were three sheet pans of defrosted, soft to touch, salmon. Each pan was covered with clear plastic wrap, and each had a sticker marked, seafood raw/frozen, prep/open on 12/14/23, use by 3/12/24. FSD#1 stated that she prepped them on 12/14/23 when they came in fresh, and then she covered them and put them into the freezer. The surveyor inquired as to when the salmon was pulled from the freezer. FSD#1 stated that she was the one who pulled them, acknowledged there was no pulled sticker, and stated that there should have been a sticker when they were pulled because it would have told the length of time that the salmon could have been used. RDDS told FSD#1 to discard the salmon. FSD#1 left the tour. 9. On a rack in the deep freezer, there were six large, frozen, undated manufacturer sealed packages marked pork. FSD#2 acknowledged the packages of meat were not stickered with any dates and stated that they should have been marked the date that they were received. The RDDS stated that it was important to make sure the food items were marked with a received or use by date so staff would have known when the food was received and when it should have been discarded. 10. There was one frozen, manufacturer sealed package, marked beef bologna, with a manufacturer's stamp marked sell by 6/21/23. There were no received or use by dates. FSD#2 stated, it ain't got no label and acknowledged that it should have had a received date. The surveyor inquired as to how old the bologna was and FSD#2 stated that it was a couple months but that we would have known if there was a received date. At that time, the [NAME] President (VP) joined the tour and told FSD#2 to discard the bologna in the trash. 11. There was one opened 10 lb box marked precooked breaded flounder filets, with an opened, clear plastic bag inside the box with the filets visible and exposed to air. FSD#2 acknowledged that the filets should not have been visible and that there should have been a received and use by date marked. She stated it was important to have a use by date so that the staff would have known when to use them, to use the first in and first out method, and that if they were no good that they would have been thrown away. 12. There was one opened box marked cornstarch that contained five individual clear bags of baked dough, that FSD#2 identified as hoagie rolls, with no labels on the bags and no dates. FSD#2 acknowledged that the bags should have had a label and use by date. The VP told FSD#2 to discard the rolls. 13. There was one metal tray that contained four unwrapped, unlabeled cooked pies. FSD#2 identified them as cherry pies and acknowledged that they were not covered correctly and that they should have been labeled with a use by date. The RDDS told FSD#2 to discard the pies. 14. There was one sealed clear plastic bag containing frozen tan pieces of meat, that FSD#2 identified as chicken thigh pieces, with no label and no dates. FSD#2 stated that the bag should have been labeled chicken and had an expiration date because it was important to use the chicken before the expiration date. The VP told FSD#2 to discard the chicken. 15. On a metal table in the kitchen, there was a slicer covered with a black plastic bag. FSD#2 stated that when the equipment was cleaned that it was then covered with the plastic bag. [NAME] debris was observed on the base of the slicer and white debris was observed on the back of the slicer blade. FSD#2 acknowledged the debris and stated that it should not have been there. FSD#2 stated it was important that the equipment was cleaned correctly so the residents were not exposed to bacteria. 16. On a rack under a metal table was one purple handled, white cutting board with black smudges, one blue handled, white cutting board with gouges and brown debris, one green handled, white cutting board with brown stains and black smudges, and one red handled, white cutting board with gouges and brown smudges. FSD#2 stated that the black smudges were, not mold, it's from the stove, like something burned. The VP stated, Sometimes the bottom of pans with the black char can get on there. The VP told FSD#2 to order new ones and the cutting boards were removed and discarded. 17. In the coffee area, there were four stacked metal trays containing upright coffee cups. The top row of cups were uncovered and exposed to air, and the remaining rows of cups were exposed to the metal underside of the tray. The VP acknowledged that the cups were exposed to air, and stated it was important to store them correctly to prevent debris exposure. The VP told a dietary aide to remove and rewash the cups and store them upside down on parchment paper. 18. Handwashing sink #2 was observed with no trash can in the area. FSD#2 acknowledged there was no trash can and stated it was important to have a trashcan because they need to throw the napkin out. A review of the facility policy, Food Receiving and Storage, revised November 2022, revealed, Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. A review of the facility policy, Food Preparation and Service, revised November 2022, revealed, General Guidelines: 2. Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces . Food Preparation Area: 4.d. cleaning and sanitizing work surfaces (including cutting boards) and food contact equipment between uses, following food code guidelines. A review of the facility policy, Sanitization, revised November 2022, revealed, Policy Interpretation and Implementation: 2. All utensils, counters, shelves and equipment are kept clean .3.All equipment, food contact surfaces and utensils are cleaned and sanitized .4. Cutting boards are washed and sanitized between uses. 8. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are: a. washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution .b. the equipment is reassembled and any food contact surfaces that may have been contaminated during the process are re-sanitized .14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained . NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3). On 01/18/24 at 8:05 AM, the surveyor observed the Licensed Practical Nurse (LPN) check Resident #301's blood pressure (BP) using a wrist BP cuff. Afterwards, the LPN placed the BP cuff on the medication cart, dispensed the resident's medications, and administered the medications to the resident. The LPN did not clean the BP cuff after using it on Resident #301. At 8:23 AM, the surveyor observed the LPN take the same BP cuff that was used on Resident #301 to check Resident #38's BP. Afterwards, the LPN placed the BP cuff on the medication cart, dispensed the resident's medications, and administered the medications to the resident. The LPN did not clean the BP after using it on Resident #38. The LPN then stated she was going to another unsampled resident's room to administer medications and pushed her medication cart in front of the unsampled resident's room. At that time, at 8:40 AM, the surveyor stopped the LPN to interview her. When asked about medical equipment used on multiple residents, the LPN stated she was supposed to clean and disinfect the BP cuff with disinfectant wipes between use and acknowledged that she did not do so during the surveyor's medication pass observation. The LPN further stated that it was important to clean the BP cuff between use to prevent the spread of infection. During an interview with the surveyor on 01/22/24 at 10:52 AM, the Registered Nurse/Unit Manager (RN/UM) stated that re-usable medical equipment was disinfected between resident use to prevent the spread of infection between residents. During an interview with the surveyor on 01/22/24 at 1:07 PM, the Director of Nursing (DON) stated that re-usable medical equipment was cleaned before and after use with disinfectant wipes in order to prevent the spread of infection. Review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, undated, included, Re-usable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). NJAC 8:39-19.4 Complaint NJ #: 168814 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a.) follow appropriate hand hygiene practices during a wound treatment observation by One (1) of two (2) nursing staff observed for 1 of 1 resident reviewed for wound treatments (Resident # 114); b.) follow isolation precautions for a resident who was on Enhanced Barrier Precautions by 1 of 3 nursing staff for 1 of 2 Residents (Resident #102) reviewed for transmission-based precautions c.) follow facility policy regarding not wearing gloves in the hallway by 2 of 2 nursing staff observed transporting soiled linens and trash on the Hartford Glen Unit and d.) clean and disinfect multiuse medical equipment prior to resident use for 1 resident (Residents #38) by 1 of 2 nurses on 1 of 2 nursing units observed during medication pass. This deficient practice was evidenced by the following: 1.) On 1/22/24 at 10:00 AM, the surveyor observed the Registered Nurse/ Unit Manager (RN/UM) on the Hartford Glen Unit perform a wound treatment for Resident #114. The RN/UM stated that the resident had been medicated with Morphine for pain sometime between 8:00-8:30 AM. The RN/UM stated that the Licensed Practical Nurse (LPN#1) would be assisting with the resident's positioning. LPN#1 washed her hands for 20 seconds using acceptable technique and then donned (put on) a pair of gloves. The surveyor observed the RN/UM preparing to wash her hands. The RN/UM turned on the faucet, wet her hands with water, applied soap, lathered her hands for 10 seconds outside the running water, then dried her hands with a paper towel and used the same paper towel to turn off the faucet. The surveyor observed the RN/UM applied gloves and cleaned the overbed table with bleach wipes. The RN/UM removed her gloves applied soap to her hands, lathered for eight (8) seconds outside of the running water then dried her hands with a paper towel and used the same paper towel to turn off the faucet. The RN/UM applied a clean barrier to the overbed table, gathered all supplies which included a small bottle of Normal Saline (NSS), Medi honey (reduces bacteria/debridement), Calcium Alginate (absorbes wound exudate), Collagen particles (stimulates healing), zinc oxide (heals and protects skin), a foam border dressing, and placed them onto the overbed table. The RN/UM wet her hands, applied soap and lathered her hands for 8 seconds outside of the running water, dried her hands and used the same paper towel to turn off the faucet. The RN/UM donned a pair of gloves and removed the resident's soiled dressing which she described as having a moderate amount of serosanguineous exudate (combination of serous fluid and blood indicating wound healing). The RN/UM removed her gloves, applied soap, lathered her hands outside of the running water for 12 seconds, dried her hands, and used the same paper towel to turn off the faucet. The RN/UM applied gloves but then stated that she had forgotten the gauze. The RN/UM removed her gloves, washed her hands for seven (7) seconds outside of the running water, dried her hands and used the same paper towel to turn off the faucet. The RN/UM obtained the gauze from the treatment cart, moistened it with NSS and cleansed Resident #114's wound using a circular motion cleansing from the inside to the outside. At that time, the surveyor heard the resident moan softly and observed the resident's body jerked forward indicating she may have experienced pain. The RN/UM removed her gloves and went to the bathroom to wash her hands. The surveyor asked the RN/UM if she thought the resident had experienced pain when she was cleaning the wound. The RN/UM stated that the resident had already had morphine. The surveyor observed the RN/UM applied soap to her hands and lathered outside of the running water for nine (9) seconds; dried her hands and used the same paper towel to turn off the faucet. The RN/UM returned to the resident's bedside but did not assess the resident for pain. The RN/UM applied the Medi honey, Collagen Particles, and Calcium Alginate to the resident's wound, then applied a foam dressing that was not initialed or dated. The RN/UM did not assess the resident for pain at all during the treatment. The RN/UM discarded all the supplies, removed her gloves, and washed her hands for 12 seconds outside of the running water. The RN/UM left the water running for LPN #1 who washed her hands for 22 seconds and used acceptable technique. The RN/UM stated that she had completed Resident #114's wound treatment and brought the trash to the soiled utility room. The RN/UM did not disinfect the overbed table after she completed the treatment. On 1/22/24 at 10:20 AM, after the wound treatment was completed the surveyor discussed the breaks in technique with the RN/UM. The RN/UM stated that she had not heard the resident moan, but had observed that she had winced during the treatment. The RN/UM further stated that she should have assessed the resident for pain during the treatment. The RN/UM acknowledged that she should have washed her hands for 20 seconds outside of running water and used a clean paper towel to turn off the faucet as that was the facility's policy. The RN/UM stated that she should have dated and initialed the dressing but that she had forgotten her sharpie. The RN/UM acknowledged that she should have disinfected the overbed table after she completed the treatment. 2.) On 1/10/24 at 11:30 AM, the surveyor observed room [ROOM NUMBER] had signage on the door indicating that Resident #102 was on Enhanced Barrier Precautions; the signage instructed that everyone who entered the room must clean their hands including before entering and when leaving the room. The signage further instructed that Providers and Staff must also wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use; central line, urinary catheter, feeding tube, tracheostomy; wound care: any skin opening requiring a dressing; do not wear the same gown and gloves for the care of more than one person. On 1/12/24 at 11:28 AM, the surveyor observed the Licensed Practical Nurse (LPN #2) entered room [ROOM NUMBER] without performing hand hygiene. The surveyor observed the LPN organized items on the resident's bedside table. The LPN exited the room and without sanitizing or washing her hands, went and removed items from the linen cart. At that same time, during an interview with the surveyor, the LPN#2 acknowledged that she should have sanitized her hands before she entered the resident's room and when she left. 3.) On 1/12/24 at 11:15 AM, the surveyor observed the Hospice Aide in the hallway on the Hartford Glen unit wearing gloves and carrying two plastic bags which contained soiled linens and trash. The surveyor observed the Hospice Aide touched the key pad lock with the soiled gloves and entered the soiled utility room. At that same time, during an interview with the surveyor, the hospice aide acknowledged that she should have removed her gloves inside the resident's room. On 1/12/24 at 11:48 AM, the surveyor observed the Nursing Assistant (NA) in the hallway on the Hartford Glen unit wearing gloves while carrying two plastic bags which contained soiled linens and trash. The surveyor observed the NA touched the key pad lock with the soiled gloves and entered the soiled utility room. At that time, during an interview with the surveyor, the NA acknowledged that she should have removed her gloves inside the resident's room. On 1/12/24 at 11:54 AM, during an interview with the surveyor, the RN/UM stated that all staff were aware of the facility's policy that no gloves were to be worn in the hallway. On 1/23/24 at 1:30 PM, the surveyor informed the Director of Nursing (DON) of the above observations and concerns. The DON stated handwashing was expected to be performed for at least 20 seconds; the resident should have been assessed for pain throughout the treatment; the wound dressing should have been dated and initialed and the table should have been disinfected after the treatment was completed. The DON further stated that the LPN should have sanitized her hands before she entered and when she exited Resident #102's room as they were on Enhanced Barrier Precautions. A review of the U.S. Centers for Disease Control and Prevention (CDC) guidelines, Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, included, When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. A review of the facility's policy titled Handwashing/Hand Hygiene with a revised date of August 2019, instructs .Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers .rinse hands with water and dry thoroughly with a disposable towel .use a towel to turn off the faucet. A review of the facility's policy titled, Enhanced Barrier Precautions dated August 2022, reflected .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents .signs are posted in the door or wall outside the resident room indicating the type of precautions and Personal Protective Equipment required. NJAC 8:39-27.1 (a) 19.4 (a) (n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00159128 Based on observation, interview, and review of facility documentation on 09/06/23 and 09/07/23 it was determined that the facility failed to obtain a timely reweigh for a resident with an identified significant weight loss. and contact the Registered Dietitian in writing regarding a resident with an identified significant weight loss. The facility also failed to follow their policy for, Weight Assessment and Intervention for 1 of 3 residents (Resident #2) reviewed for weight loss. The deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 well-being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The surveyor reviewed the closed medical record for Resident #2: According to the admission Record, Resident #2 was admitted to the facility on [DATE] with medical diagnoses which included but were not limited to Muscle Wasting and Atrophy (degeneration), Multiple Sites, Heart Failure (when the heart does not pump enough blood for the body's needs), and Encounter for Surgical Aftercare following Surgery on the Digestive System. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 08/04/22 indicated that the resident had a Brief Interview for Mental Status score of 15 out of a possible 15 which indicated that they were cognitively intact. The MDS also indicated that the resident weighed 162 Lbs. (pounds). The Nutrition care plan dated 07/29/22 indicated, I will be weighed monthly/weekly, as ordered. The care plan also indicated, RD [Registered Dietitian] to evaluate and make diet change recommendations PRN [as needed]. Resident #1's Weight Summary indicated the following: 07/28/22 162.0 Lbs. 07/29/22 162.1 Lbs. 08/04/22 162.0 Lbs. 08/12/22 163.6 Lbs. 08/15/22 162.5 Lbs. 08/17/22 162.0 Lbs. 08/18/22 162.0 Lbs. 08/29/22 161.5 Lbs. 08/31/22 152.0 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/4/2022 162 Lbs., -6.2%, -10 Lbs.] 09/02/22 153.0 Lbs. MDS: MDS: -5.0% change over 30 day(s) [Comparison Weight 8/4/2022, 162 Lbs., -5.6%, -9 Lbs.] 09/06/22 152.8 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/12/2022, 164 Lbs., -6.7%, -11 Lbs.] 09/07/22 153.0 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/12/2022, 164 Lbs., -6.7%, -11 Lbs.] 09/08/22 153.9 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/12/2022, 164 Lbs., -6.1%, -10 Lbs.] 09/09/22 157.5 Lbs. 09/13/22 155.0 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/12/2022, 164 Lbs., -5.5%, -9 Lbs.] 09/16/22 148.8 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/17/2022, 162 Lbs., -8.0%, -13 Lbs.] 09/20/22 147.8 Lbs. MDS: -5.0% change over 30 day(s) [ Comparison Weight 8/29/2022, 162 Lbs., -8.6%, -14 Lbs.] 09/21/22 148.0 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/29/2022, 162 Lbs., -8.6%, -14 Lbs.] 09/22/22 151.8 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/29/2022, 162 Lbs., -6.2%, -10 Lbs.] 09/24/22 150.7 Lbs. MDS: -5.0% change over 30 day(s) [Comparison Weight 8/29/2022, 162 Lbs., -6.8%, -11 Lbs.] Review of the nursing progress notes failed to reveal any documentation that nursing notified the RD of the significant weight loss (5% of body weight lost in 30 days) which began on 08/31/22. Review of the nutrition notes indicated a 09/16/22 note, Dietary Consult Spoke with [Resident #1's] [family member] on phone today who was concerned about decline in PO [by mouth] intake and low serum sodium levels. [Family member] requested a bag of chips and sandwich for lunch, and to try a boost pudding in addition to the ensure that is provided to [Resident #1] BID [twice a day] since [his/her] intake of the ensure BID has been variable. Updated preferences [ .] ordered boost pudding QD [every day] [ .] and will bring menus to [Resident #1's] room for [family member] to fill out to encourage positive PO intake. Further review of the nutrition notes failed to indicate that the RD documented the significant weight loss, reassessed the resident, or implemented interventions related to the significant weight loss. During an interview with the surveyor on 09/07/23 at 11:37 AM, the Registered Nurse/ Unit Manager (RN/UM) stated that when staff identified a significant weight loss that they would confirm the significant weight loss with a reweigh the next day. The RN/UM continued that after the significant weight loss was confirmed that they should let the family know, let the doctor know, and let the RD know. During an interview with the surveyor on 09/07/23 at 1:13 PM, the Regional RD stated that nursing staff should have obtained another weight on Resident #1 on 08/31/22 either later in the day or the next day (09/01/23). The Regional RD stated that there was another weight obtained on Resident #1 on 09/02/22. The Regional RD continued that after the weight was confirmed with a reweigh that the RD would address the weight change by continuing to monitor the weight, update food preference, and supplementation. The Regional RD stated that she did not see where in the resident's medical record that it was documented that the RD was made aware of the significant weight loss. During an interview with the surveyor on 09/07/23 at 1:58 PM, the Director of Nursing (DON) stated that if a resident had a significant weight loss that they would reweigh the resident either right away or the next day at the latest. The DON continued that after the resident was reweighed and the significant weight loss was confirmed that the unit manager would bring that information to the clinical meeting and would then follow up with the physician or medical provider to make them aware. The DON stated that she did not have proof in writing that the RD or physician were notified of the weight change. The undated facility policy, Weight Assessment and Intervention indicated under the Policy Interpretation and Implementation section, 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietitian in writing. 4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. NJAC 8:39-27.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00159128 Based on interviews, medical record review, and review of other pertinent facility documentation on 09/06/23 and 09/07/23, it was determined that the facility staff failed to consistently document on the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the residents according to the facility policy, Activities of Daily Living (ADLs), Supporting for 1 of 2 residents (Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: The surveyor reviewed the closed medical record for Resident #2: According to the admission Record (AR), Resident #2 was admitted on [DATE], with diagnoses that included but were not limited to Muscle Wasting and Atrophy (degeneration), Multiple Sites, Heart Failure (when the heart does not pump enough blood for the body's needs), and Encounter for Surgical Aftercare following Surgery on the Digestive System. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 08/04/22 indicated that the resident had a Brief Interview for Mental Status score of 15 out of a possible 15 which indicated that they were cognitively intact. The MDS also indicated that Resident #2 required total dependence with toilet use. The ADL Self Care Performance Deficit care plan dated 07/28/22 indicated that the resident required 2-person assistance with toileting. Review of Resident #2's DSR (ADL Record) and the progress notes (PN) for the months of 08/2022 and 09/2022 lacked any documentation to indicate that the care for toilet use was provided and/or that the resident refused care on the following dates and shifts: 7:00 AM-3:00 PM shift on 08/03/22, 08/06/22, 08/07/22, 08/10/22, 08/12/22-08/14/22, 08/19/22, 08/21/22, 09/01/22, 09/09/22, 09/18/22, and 09/22/22. 3:00 PM-11:00 PM shift on 08/06/22, 08/07/22, 08/09/22, 08/20/22, 08/30/22, 09/03/22, 09/05/22-09/08/22, 09/13/22, 09/16/22, 09/18/22, 09/19/22, 09/22/22. 11:00 PM-7:00 AM shift on 08/14/22, 08/15/22, 08/29/22, 09/07/22. During an interview with the surveyor on 09/06/23 at 2:25 PM, Certified Nursing Assistant #1 stated that ADL care should be documented in the resident's electronic medical record and that the expectation was to document on every resident every shift. During an interview with the surveyor on 09/07/23 at 10:18 AM, the Licensed Practical Nurse (LPN) #1 stated that ADL care was documented by the CNAs into the resident's electronic health record and that it should be documented on every resident before the end of the shift. LPN #1 stated that the purpose of documenting the ADL care was to provide continuity of care and to document the status of the resident. During an interview with the surveyor on 09/07/23 at 11:37 AM, the Registered Nurse/ Unit Manager (RN/UM) stated that the CNAs were expected to complete the ADL documentation every shift for every resident. The RN/UM stated that the purpose of the ADL documentation was to see if care was provided and to track the amount of assistance that residents needed. During an interview with the surveyor on 09/07/23 at 1:58 PM, the Director of Nursing (DON) stated that CNAs should document ADL care every shift on the tasks available. The facility policy Activities of Daily Living (ADLs), Supporting with a revised date of 3/2018 indicated under the Policy Interpretation and Implementation section, The resident's ability to participate in ADLs and the support provided during ADL care and resident-specific tasks will be documented each shift by Certified Nursing Assistants in the medical record. NJAC 8:39-35.2(d)(6).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ156688 Based on observation, interviews, medical record review, and review of other pertinent facility documentation on 11/28/2022 and 11/29/2022 it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH), the Elopement of a resident (Resident #1). The facility also failed to follow its policy titled Accidents and Incidents-Investigating and Reporting. This deficient practice was identified for 1 of 3 residents and was evidenced by the following: According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 10/25/2022, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #1 needed extensive assistance with one-person physical assistance with bed mobility and transfers and limited assistance with most Activities of Daily Living (ADLs). A review of Resident #1's MQS: Elopement/Wandering Risk Evaluation (EWRE) form dated 10/25/2022 revealed a score: NA (not applicable). Under A. Potential Risk Factors/Resident Status indicated .14. Has the family/responsible party/resident representative voiced concerns that would indicate the Resident may have wandering tendencies or try to leave? b. Yes, 15. Is Resident at risk for wander/elopement? a. Yes, 16. Are parties aware of [the] Risk for Wander/Elopement? a.Yes. 17. Initiate Elopement/Wander Care Plan Focus: I am at actual/potential risk for Elopement r/t Goal: I will not leave the facility without notifying staff before [the] next review date. Intervention: Engage me in group activities to decrease wandering, Photograph in Elopement Book, Provide appropriate diversions for residents, and encourage Residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the Resident's health and/or safety, Psych consult and treat as indicated, Redirect during wandering episodes, Wander Bracelet placed. The DON continued to say [the] CP focus comes up with admission evaluation and add interventions to CP to personalize it. A review of the Resident's Care Plan (CP) initiated on 10/25/2022 revealed under Focus: I am at actual/potential risk for elopement r/t (related/to) cognitive impairment, non-acceptance of long-term placement. The CP also included under Goal: I will accept and adjust to Long Term Care placement. Also, under Interventions: included, Engage me in group activities to decrease wandering, evaluate resident's desire to leave the facility, monitor behaviors, Photograph in Elopement book, Psych (Psychiatrist) consult (consultation) and treat as indicated, Wander Bracelet placed to left ankle Exp (Expiration) 02/05/24. A review of Resident #1's Order Summary Report (OSR) Order Date Range from 10/01/2022 through 11/30/2022 revealed the following Physician Orders (POs): Wander Bracelet: Check[the] Function of [the]Wander Bracelet every day, one time a day order dated 10/25/2022 Wander Bracelet: Check [the] Placement of [the] Wander Bracelet on every shift. Left ankle every shift for elopement risk order dated 10/25/2022 A review of Resident #1's Treatment Administration Record (TAR) dated 10/01/2022 through 11/30/2022 revealed the above POs to check the function, and the placement of the wander guard was documented as being completed on 11/10/2022 on the night shift by the RN. During an interview on 11/28/2022 at 1:30 p.m., CNA #1 stated she was informed by another CNA (CNA #2) that Resident #1 was not in his/her room. She joined the staff in the search for Resident #1. The CNA stated she entered the bedroom of Resident #1 and observed that Resident #1's bedroom window was a little opened, the screen on the window was pushed up, and the window was all the way up. CNA #1 further stated, both the screen and window were up, and I was able to go through. Everyone was there, including Administration, or the owner. She further stated it was not difficult to get through Resident #1's bedroom window, it was easy to get through the bedroom window, and that she and Resident #1 was about the same size. During an interview on 11/28/2022 at 1:53 p.m., CNA #2, assigned to Resident #1, stated that at approximately 7:30 a.m., the CNA got her assignment and did her routine rounds. She entered Resident #1's room, saw the privacy curtain pulled halfway in the middle, the blanket was on the bed and assumed the Resident was in bed. At approximately 9:05 a.m., the CNA entered Resident #1's room to deliver the breakfast tray and realized the Resident was not in his/her room. She then alerted CNA #1, and they both proceeded to look for the Resident. CNA #1 stated they looked in Resident #1's room, bathroom, and other rooms and bathrooms on the unit. They did not see Resident #1 and alerted the Licensed Practical Nurse (LPN) assigned to Resident #1. The CNA stated she was unfamiliar with how Resident #1 looked, but the LPN and CNA #1 described Resident #1. On her way to work, she recalled seeing an older adult fitting the description of Resident #1 sitting on the bench at the bus stop on the main road but did not report this to other facility staff. CNA #1 indicated someone paged (called the code), and they all started looking for Resident #1. She continued to explain that some CNAs looked in the building while others went outside in their car and to the bus stop, where she had recalled seeing an adult sitting on her way to work. The adult was no longer at the bus stop. CNA #1 further stated, I think one of the CNAs said the Resident got out through his/her window. In the same interview, CNA #2 stated CNA #1 said if it was easy for her to get through the window, then Resident #1 must have gotten out the window since they were both the same size (petite). During an interview on 11/28/2022 at 3:25 p.m., the Assistant Director of Nursing (ADON), who was the interim DON at the time of the incident, stated on the morning of the incident, while in the morning meeting, the Administration was notified by the Unit Manager (UM) of the missing Resident (Resident #1). The ADON stated Code yellow was activated, and the entire Administration was involved in the search for Resident #1. She further stated the entire building (rooms, bathrooms, and common areas) was searched as other staff went outside the building, driving around the building and surrounding areas in search of Resident #1. The ADON also stated when the search was initiated. The local Police Department was notified of the missing Resident (Resident #1). During the same interview, the ADON also stated once she realized Resident #1 was not found in the area, the spouse (POA) was notified. The ADON stated during the call with Resident #1's spouse, he/she didn't verbalize concern for the missing Resident (Resident #1). She continued the spouse that if Resident #1 returned to their house, to call and inform the facility. According to the ADON, Resident #1 was later recovered by the Palmyra Police while attempting to enter the bar, stating Resident #1 was fine and did not want to return to the facility. The ADON further stated Resident #1's spouse was informed, and he/she was fine with Resident #1's decision not to return to the facility. The ADON continues to reveal that the spouse (POA) signed Resident #1 out of the facility AMA (Against Medical Advice). The ADON stated, no one knows how Resident #1 got out of the building, but his/her window was not locked. The screen was on the window and intact. I believed the AC Unit was removed the day prior to the incident. When asked by the Surveyor if the window should have been secured properly, the ADON replied, Yes, Resident #1's window should have been locked with screws where the window can only be raised not more than 4 inches. During an interview on 12/29/2022 at 3:33 p.m., the Licensed Nursing Home Administrator (LNHA) stated the Elopement was not reported to the NJ Department of Health or the Ombudsman. He further stated, If we had determined it to be an elopement, it would have been reported, it was AMA, and we do not report AMA to the NJ Department of Health. During the same interview, the Director of Nursing (DON) stated, No, it was not reported to the Ombudsman or the NJ Department of health. She further stated all planned and unplanned discharges are usually sent to the Ombudsman at the end of each month. Review of the facility's undated policy titled Accidents and Incidents-Investigation and reporting Under Policy: All incidents and accidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Under Interpretation: 3. This facility is in compliance with current rules and regulations governing accidents and /or incidents involving a medical device. 6. The director of nursing services shall ensure that the Administrator receives a copy of the report of incident/Accident form for each occurrence. N.J.A.C.: 8:39-13.4 (c) 2 (iv) (v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ159688 Based on interviews, medical record review, and review of other pertinent facility documentation on 11/28/2022, 11/29/2022, and 12/5/2022, it was determined that the facility failed to complete the admission Minimum Data Set (MDS) accurately for 1 of 3 residents (Resident #1) and the Quarterly MDS for 1 of 3 residents (Resident #3) as required by the job description titled Registered Nurse Assessment Coordinator, RNAC/MDS, and the facility's policy titled MDS 3.0 Resident Assessment. This deficient practice was evidenced by the following: A review of Resident #1's Electronic Medical Record (EMR) was as follows: 1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 10/25/2022, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #1 needed extensive assistance with one person's physical assistance with bed mobility and transfers and limited assistance with most Activities of Daily Living (ADLs). Further review of the MDS showed under Section P Restraints and Alarms Under Section P0200. Alarms (a section used to document when an alarm is used) An alarm is any physical or electronic device that monitors resident movement and alerts the staff when the movement is detected. Coding: noted as 0. Not Used, 1. Used less than daily, 2. Used Daily. Coding noted as 0 for Resident #1 under E. Wander/elopement alarm. A review of Resident #1's Order Summary Report (OSR) with an Order Date Range 11/01/2022-11/30/2022 revealed the following Physician Orders (POs): Wander Bracelet: Check Function of Wander Bracelet (WB) every day, wander bracelet expires on 02/05/24, one time a day, order date 10/25/2022. Wander Bracelet: Check Placement of Wander Bracelet on every shift. Left ankle every shift for Elopement risk, order date 10/25/2022. A review of the Resident's Care Plan (CP) initiated on 10/25/2022 revealed under Focus: I am at actual/potential risk for elopement r/t (related/to) cognitive impairment, non-acceptance of long-term placement. The CP also included under Goal: I will accept and adjust to Long Term Care placement. Also, under Interventions: included, Engage me in group activities to decrease wandering, evaluate resident's desire to leave the facility, monitor behaviors, Photograph in Elopement book, Psych (Psychiatrist) consult (consultation) and treat as indicated, Wander Bracelet placed to left ankle Exp (Expiration) 02/05/24. A review of Resident #3's EMR was as follows: 2. According to the AR, Resident #3 was admitted on [DATE] with diagnoses which included but were not limited to Sarcopenia, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the MDS, an assessment tool dated 11/5/2022, Resident #3 had no BIMS, which indicated the Resident had a memory problem. Further review of the MDS revealed the Resident was independent with most ADLs, and under Section P, Restraints and Alarms under Section P0200 Alarms showed the Coding: noted as 0. Not used for E. Wander/elopement alarm. A review of Resident #3's OSR dated Active Orders as of 11/28/2022 revealed the following POs: Wander Bracelet: Check Function of Wander Bracelet every day, wander bracelet on L (left) wrist expires on 01/07/24, one time a day, order date 5/24/2021. Wander Bracelet: Check Placement of Wander Bracelet -L wrist on every shift, order date 05/24/2021. A review of Resident #3's CP initiated on 05/17/2021 revealed under Focus I am an elopement risk/wanderer. Resident wanders aimlessly; I bang on the doors and attempt to force open. I often encourage others to assist me banging on doors and use furniture/objects to attempt to open doors. The CP also included under Goal: My safety will be maintained through the next review date. Also, under Interventions: included, I enjoy washing dishes and cleaning tables. I have my own dishes to wash, dated 10/4/2022, wander guard device to left wrist exp (expiration) on 01/07/24. Check placement of wander guard each shift and function daily. Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television. During an interview on 11/29/2022 at 1:18 p.m., when the surveyor asked her about the coding under Section P, Restraints and Alarms for Resident #1, the MDS Coordinator stated, 0 (zero) means the Wander Guard was not used so that should have been coded as a 2 [used daily] .so the coding is inaccurate. She continued to say she was the one who completed this section. During the same interview, the MDS Coordinator stated, the purpose of the MDS is to get an appropriate picture of the resident who stays in long-term care to get reimbursement from Medicare/Medicaid. A review of an undated job description titled Registered Nurse Assessment Coordinator, RNAC/MDS Coordinator revealed under Purpose of Your Job Position included The primary purpose of your job position is to conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this Center. A review of a facility policy updated 07/15/2015 titled MDS 3.0 Resident Assessment revealed under Policy: A comprehensive, accurate, standardized assessment of each Resident's functional capacity will be completed and documented. MDS assessments within the last 15 months, including signatures of the facility staff attesting to the accuracy and completion of the record, must be kept readily accessible for review. Under Procedure: included .7. The following sections may be delegated to team members for completion .Section P, . -MDS/Designee . N.J.A.C. 8:39-11.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C#: NJ159688 Based on interviews, medical records review, and review of other pertinent facility documentation on 11/28/2022, 11/29/2022, and 12/5/2022, it was determined that the facility failed to follow standards of clinical practice and failed to properly check the function and the placement of a wander guard/bracelet (WG/WB) (a device used to prevent a resident from leaving unattended) as ordered by the Physician for 1 of 3 residents (Resident #1). The facility also failed to follow its policy titled Wander Management and Elopement Prevention. This deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 well being and executing a medical regime as prescribed by a licensed or otherwise legally authorized Physician or Dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a Licensed Practical Nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a Registered Nurse or otherwise legally authorized Physician or Dentist. A review of Resident #1's Electronic Medical Record was as follows: According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. According to the Minimum Data Set (MDS), an assessment tool dated 10/25/2022, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #1 needed extensive assistance with one person's physical assist with bed mobility and transfers and limited assistance with most Activities of Daily Living (ADLs). A review of the Resident's Care Plan (CP) initiated on 10/25/2022 revealed under Focus: I am at actual/potential risk for elopement r/t (related/to) cognitive impairment, non-acceptance of long-term placement. The CP also included under Goal: I will accept and adjust to Long Term Care placement. Also, under Interventions: included, Engage me in group activities to decrease wandering, evaluate resident's desire to leave the facility, monitor behaviors, Photograph in Elopement book, Psych (Psychiatrist) consult (consultation) and treat as indicated, Wander Bracelet placed to left ankle Exp (Expiration) 02/05/24. A review of Resident #1's Order Summary Report (OSR) with an Order Date Range 11/01/2022-11/30/2022 revealed the following Physician Orders (POs): Wander Bracelet: Check Function of Wander Bracelet (WB) every day; wander bracelet expires on 02/05/24, one time a day, order date 10/25/2022. A review of Resident #1's Treatment Administration Record (TAR) dated 11/1/2022-11/30/2022 revealed the above-aforementioned PO to check the Function of the WB was documented on the day shift as checked by the Licensed Practice Nurse (LPN#1) on 11/8/2022. Wander Bracelet: Check Placement of Wander Bracelet on every shift. Left ankle every shift for Elopement risk, order date 10/25/2022. A review of Resident #1's TAR dated 11/1/2022-11/30/2022 revealed the above-aforementioned PO to check the Placement was documented on the night shift as checked by LPN #2 on the following dates: 11/1/2022, 11/2/2022, 11/3/2022, 11/5/2022, 11/6/2022, 11/8/2022, 11/9/2022 and 11/10/2022. During an interview on 11/28/2022 at 4:25 p.m., LPN #1 stated, we personally don't check the function of the wander guard; we just check the placement . During an interview on 11/28/2022 at 4:47 p.m., LPN #2, who was assigned to Resident #1 on the night shift on 11/10/2022, the LPN stated, I believe he/she wears a wander guard (WG), I honestly didn't know he/she had a WG. She continued, the alarm would have gone off, and I did not hear the alarm sounding that night. During a telephone interview on 11/29/2022 at 1:51 p.m., when the surveyor asked her if she signed off on the TAR on the night shift with certain initials for checking on Resident #1's placement of his/her WG, LPN #2 replied, Yes, those are my initials in the computer system, I [was] just clicking on it, I probably don't remember. I signed off but did not realize that the Resident had a WG. I just signed off on the order and did not verify that the Resident had a WG in place. In the same telephone interview, when the surveyor asked her if she checked the function of the WG, she replied, No, I did not check the function of the WG. I can't speak for anybody but me. I don't check even though there is a Physician's Order. I, personally, did not check the function or the placement of the WG. A review of the facility policy titled Wander Management and Elopement Prevention, updated March 2022, revealed the following: Under Policy Statement, included: The facility will maintain the safety of residents who wander and/or are at risk for elopement. Under Policy Interpretation and Implementation, 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .2. The staff will implement a wander management system device, if recommended, as a part of the plan of care .5. When implementing a wander management system device, the staff will implement routine checks for placement and functionality. a. Wander management system devices will be checked for placement each shift by nursing staff. b. Wander management system devices will be checked for functionality daily by nursing staff. N.J.A.C.: 8.39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 9/8/2021 from 9:14 AM to 10:12 AM the surveyors, accompanied by the Director of Dining Services (DODS) observed the following in the kitchen: 1. During observation of the high temperature dish machine the surveyor observed unidentified debris on the top of the dish machine, on the temperature gauge panel and below the power and motor switches. Unidentified white, dried, splash type stains were observed on the door of the machine. When interviewed the DODS stated, It gets cleaned weekly but should be wiped down daily. Review of the facility provided Daily/Weekly Cleaning Schedule for the kitchen revealed that cleaning of the dish machine is not listed as a daily procedure and is delimed on a weekly basis. 2. A stack of approximately 15 cleaned and sanitized sheet pans were on the drying rack and were in the inverted position. The surveyor lifted the top sheet pan and determined that the surface of the pan below was wet and greasy to the touch, generally termed wet nesting (occurs when wet dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow). The surveyor requested the DODS to also touch the sheet pans. The DODS responded, They are a little wet and greasy. 3. (3) cleaned and sanitized casserole dishes and (4) bowls used to serve resident meals were observed on the drying rack. The 3 plates and 4 bowls were not covered or stored in the inverted position and had the food contact surfaces exposed. On interview the DODS stated, They need to be covered or inverted when not in use to prevent contamination. 4. On a lower rack of the canned storage rack/cart, (2) cans of Tropical Fruit Cocktail had significant dents on the lower seams. The DODS removed the cans to the designated dented can area and stated. They must have missed those when they were received. 5. In the walk-in refrigerator on a lower shelf, a carton contained shell eggs used for resident meal service. An egg in the carton was broken and the contents of the egg were exposed. The DODS stated, That must have just happened because we used these eggs this morning for breakfast. 6. During the tour of the walk-in freezer the floor of the freezer was observed to be littered with unidentifiable debris under the food storage racks. The DODS stated on interview, It gets cleaned weekly or as needed. The surveyor questioned whether this was currently an as needed situation. The DODS stated, Yes. On 9/13/2021 from 9:19 to 9:29 AM the surveyor, accompanied by the Certified Nursing Assistant (CNA) observed the following in the Hartford-Glen unit pantry: 1. On a middle shelf in the rear of the pantry refrigerator an unidentified food product wrapped in paper (sub-like) had no name, room number or use by date. When interviewed the CNA stated That is going to be thrown away. It has no name and no dates. It was just put in there last night though. On 9/13/2021 from 9:31 to 9:43 AM the surveyor, accompanied by the Assistant Director of Nursing/Infection Control Preventionist (ADON/ICP), observed the following on the [NAME]-Glen unit pantry: 1. In an upper cabinet above the pantry sink the surveyor observed an opened box that contained a sleeve of crackers. The sleeve of crackers was opened, and the crackers were exposed. The top of the box was also opened and exposed the crackers. The crackers had no use by date, name, or room number. In addition, on the same shelf an opened, individual size bag of whole wheat pretzels was opened, and the pretzels were exposed. The bag had no name, dates, or room number. The ADON stated, I'm throwing them in the trash. On 9/14/2021 from 11:20 AM to 12:04 PM the surveyors, accompanied by the DODS observed the following in the kitchen: 1. On an upper shelf of the drying rack 3 cleaned and sanitized beverage carafes and 1 clear plastic beverage pitcher used for residents were not stored in the in the inverted position and were exposed. On interview the Dietary Aide (DA #1) stated, They were cleaned last night. On interview the DODS stated, They should be inverted. 2. The surveyor observed the DODS perform handwashing at the designated handwashing sink. The DODS turned on the faucet and wet his hands under running water. The DODS then applied soap and performed vigorous handwashing for 11 seconds by the surveyor's count. The DODS then rinsed their hands under running water and then proceeded to turn off the faucet with his bare hand. The DODS then grabbed a hand towel from the dispenser and dried his hands and threw the hand towel in the waste receptacle beneath the handwashing sink. The DODS provided the surveyor with a copy of the Employee Education Attendance Record with a topic of in-service identified as: 2021 Handwashing Procedure. The DODS signature indicated that he had been in-serviced for handwashing on 9/13/21. 3. At 11:36 AM during lunch meal preparation DA #2 was observed to open a bag of shredded cheese in preparation for the lunch meal. DA #2 opened the bag of cheese then proceeded to don a single, disposable blue glove. The DA did not perform hand washing prior to donning the disposable glove. DA #2 then proceeded to reach into the bag of shredded cheese with the gloved hand and apply cheese to what appeared to be cheese lasagna. On interview the DODS stated Staff are to perform handwashing before donning gloves, yes. 4. At 11:50 AM during lunch meal preparation the surveyors observed DA #2, who hadn't performed handwashing, carry two 1/3 pans that contained broccoli. The DA had no gloves and was carrying the two 1/3 pans with his fingers on the internal surface of the pan. 5. The surveyors observed the plate warmer cart prior to the start of the lunch meal. The top of the cart adjacent to the clean and sanitized plates to be used for the resident lunch meal was observed to be covered with a white, unidentified powdery substance. When interviewed the DODS stated,That should be cleaned prior to loading clean plates in there. The DODS then instructed the cook to remove all plates and wipe the plate warmer cart top surface. 6. The surveyor observed DA #2 perform hand washing at the designated hand washing sink. DA #2 turned on the faucet and wet his hands under running water. DA #2 then applied soap and vigorously washed his hands for 10 seconds by 2 surveyors counts. DA #2 then rinsed his hands under the running water and proceeded to turn off the faucet with his bare hands. DA #2 then dried his hands with a paper towel and threw the hand towel in the waste basket below the sink. On interview the DODS stated, Hand washing should be performed for a minimum of 20 seconds. The surveyor made DODS aware that staff were turning the faucet off with bare hands after performing hand washing. The DODS stated, Oh, really? The surveyor reviewed the facility policy titled Dishwashing Machine Use, undated. The following was revealed under the heading Policy Interpretation and Implementation: 1. The following guidelines will be followed when dishwashing: j. After running items through entire cycle, allow to air-dry. k. Clean dishwashing machine after each meal. The surveyor reviewed the facility provided policy titled Handwashing/Hand Hygiene, version 2.3 (H5MAPL0362). The Policy Statement revealed: This facility considers hand hygiene the primary means to prevent the spread of infection. Under the heading Policy Interpretation and Implementation, the following was revealed: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Under the Procedure heading the following was revealed: Washing Hands 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to the hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel.' 4. Use towel to turn off faucet. Under the heading Applying and Removing Gloves the following was revealed: 1. Perform hand hygiene before applying non-sterile gloves. 5. Perform hand hygiene. (after removing gloves). The surveyor reviewed the facility titled Dented Cans Policy, undated. The Policy Statement revealed, All cans must be inspected for dents/damages and place into designated dented can area or discarded. Under the heading Policy Interpretation and Implementation, the following was revealed: 1. During delivery, inspect cans for dents, bulges, and dings by visually inspecting and placing hand around the can while rotating all the way around. Discard into waste area or place into dented can area. The surveyor reviewed the facility policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, undated. The Policy Statement revealed Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. The following was revealed under the heading Policy Interpretation and Implementation: 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to the residents. 6. Employees must wash their hands: a. After personal body functions, (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.) b. After using tobacco, eating, or drinking. c. Whenever entering or re-entering the kitchen. d. Before coming in contact with any food surfaces. e. After handling raw meat, poultry, or fish and when switching between working with raw food and working with ready-to-eat food. f. After handling soiled equipment or utensils. g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and or h. After engaging in other activities that contaminate the hands. 8. Contact between food and bare (ungloved) hands is prohibited. 9. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. The surveyor reviewed the facility policy titled Foods Brought by Family/Visitors, version 2.0 (H5MAPL0337). The following was revealed under the heading Policy Interpretation and Implementation: 6. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 7. The nursing staff will discard perishable foods on or before the use by date. 8. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). N.J.A.C. 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10/28/19 at 10:30 AM, the surveyor observed Resident #53 sitting up in bed, with the head of bed elevated. The resident was pleasant and agreed to be interviewed. The surveyor asked the resident if he/she had experienced any instances of abuse. The resident could not recall any such incidents. The surveyor reviewed the medical record for Resident #53. A review of quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE] and had diagnoses which included but were not limited to major depressive disorder, Alzheimer's Disease, history of falling, short and long term memory loss and severely impaired cognitive skills for decision making. A review of Resident #53's Incident/Accident Report document titled, Safety/Security/Conduct Event revealed on 9/13/19 at 9:15 AM, staff overheard Resident #53 and another resident arguing. Staff entered the room and observed Resident #53 holding his/her face and crying. The Incident/Accident Report revealed that the resident had wandered into another resident's room and rubbed that resident on the shoulders, which prompted the verbal altercation and an alleged physical abuse. The Incident/Accident Report further reflected that the residents were separated and relocated to safe areas. Resident #53 was assessed by the nurse and no no facial injuries, red marks or swelling were noted. A review of the the Incident/Accident Report statement by a Physical Therapy (PT) staff dated 9/13/19 documented that the PT staff member heard the residents arguing and went to mediate to ensure the residents' safety. The PT staff member observed Resident #53 was holding his/her face and crying due to an alleged hit. The staff member did not see Resident #53 being struck. The Incident/Accident Report statement by the DON dated 9/13/19 reflected that the resident was startled when Resident #53 entered the room and touched his/her shoulder, but the other resident did not strike Resident #53. A review of Resident #53's undated ICCP included a problem area that the resident wandered in and out of other resident's rooms and was not easily redirected. On 10/28/19 at 10:15 AM, the surveyor interviewed the CNA who stated Resident #53 had behaviors of wandering and the resident wore a wander guard (an alarming device worn to alert staff that a resident is approaching a restricted area). On 10/28/19 at 10:35 AM, the surveyor interviewed an LPN who stated that Resident #53 had become much calmer, but still wandered into other residents' rooms. On 10/28/19 at 3:10 PM, during the exit conference, the DON stated abuse and neglect were usually reported within 24 hours to the NJDOH. The DON further stated that the resident-to-resident altercation between Resident #53 and another resident on 9/13/19 was not reported to NJDOH because the alleged physical altercation was unwitnessed and Resident #53 had no evidence of marks when a body assessment was performed on the resident. On 10/28/19 at 3:12 PM, during the exit conference, the LNHA stated allegations of abuse or neglect should be reported and investigated regardless of the intent, and the facility's investigation would substantiate or unsubstantiated the allegation of abuse or neglect based on the investigation. The LNHA further stated the resident-to-resident altercation on 9/13/19 should have been reported to the NJDOH. 10/30/19 at 11:13 AM, the surveyor conducted a follow up interview with the LNHA who stated allegations of abuse with serious injury should be reported to the NJDOH within 2 hours, and all others should be reported within 24 hrs. 2. On 10/23/19 at 10:26 AM, the surveyor observed Resident #63 seated upright in bed in their room. The resident stated that he/she had spoken to the LNHA about a specific staff member who was, nasty to him/her. The resident further stated that since he/she spoke to the LNHA, the staff member had not taken care of him/her. The resident was unable to recall specific dates when the incident had occurred. The surveyor reviewed the medical records for Resident #63. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had diagnoses which included but were not limited to major depressive disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and psychosis not due to substance or known physiological condition (a mental disconnect from reality). A review of the resident's most recent quarterly, MDS (an assessment tool used to facilitate the management of care) dated 10/2/19 reflected that the resident had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. A review of a Grievance Form provided by the LNHA dated 2/1/19 reflected the resident made an accusation that on either 1/30/19 or 1/31/19 he/she was, thrown in the shower by an aide. The resident further reported on the Grievance Form that the specific staff member he/she mentioned to the surveyor was, rough when providing care. A review of Resident #63's undated ICCP included a problem area that the resident had conflict with staff due to ineffective coping skills, an anger management problem, manipulative behavior, adjustment disorder, and a knowledge deficit. As evidenced by verbalizing dissatisfaction with staff performance, being verbally and physically abusive to staff members, and having unrealistic expectations of staff. On 10/28/19 at 12:51 PM, the surveyor conducted an interview with the SW in the presence of another surveyor who stated that the LNHA and the DON were the facility staff members ultimately responsible for investigating and reporting abuse. On 10/28/19 at 3:19 PM, the surveyor interviewed the LNHA in the presence of the survey team who stated that all allegations of abuse would be investigated as abuse and would be reported to the NJDOH. The LNHA did not specify time frames for reporting to the New Jersey NJDOH. T he LNHA did not speak as to why Resident #63's Janaury allegation of abuse was not reported to the NJDOH. On 10/29/19 at 12:52 PM, the surveyor conducted a follow up interview with the LNHA in the presence of the survey team. The LNHA stated the facility reported the allegation of abuse made by Resident #63 to the NJDOH last night after surveyor inquiry and the resident's perception was their reality so all allegations of abuse and neglect would be investigated and reported. A review of the facility's Resident/Participant Abuse Protection Policy and Procedure revised on 6/30/17 included, Reporting/response- The reporting and filing of accurate documents relative to incidents of abuse; reporting to the State agencies as required, analyze and implement necessary changes to prevent future occurrences of abuse. The facility's Resident/Participant Abuse Protection Policy and Procedure did not specify time frames for the reporting of abuse to the New Jersey Department of Health. A review of the facility's Abuse Policy provided by the LNHA dated 4/1/19 included, A seven-step approach to abuse and neglect detection and prevention will be utilized which includes Screening, training, prevention, identification, investigation, protection and reporting and response. The facility's Abuse Policy further included, 7. REPORTING AND RESPONSE: 1. Initial reporting and allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. Refer to F610 NJAC 8:43-10.6(b); 8:39-9.4(e)(3)(i) Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health an incident pertaining to a.) an incident of resident-to-resident verbal altercation and alleged physical abuse on 9/13/19, and b.) a resident allegation of physical abuse on 2/1/19. This deficient practice was identified for 2 of 4 residents reviewed for abuse (Residents #53 and #63) and was evidenced by the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. On 10/23/19 at 10:26 AM, the surveyor observed Resident #63 seated upright in bed in their room. The resident stated that he/she had spoken to the LNHA about a specific staff member who was, nasty to him/her. The resident further stated that since he/she spoke to the LNHA, the staff member had not taken care of him/her. The resident was unable to tell the surveyor specific dates when the incident had occurred. The surveyor reviewed the medical records for Resident #63. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had diagnoses which included but were not limited to major depressive disorder, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, and psychosis not due to substance or known physiological condition (a mental disconnect from reality). A review of the resident's most recent quarterly Minimum Data Set, MDS (an assessment tool used to facilitate the management of care) dated 10/2/19 reflected that the resident had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. A review of the resident's undated CP included a problem area that the resident had conflict with staff due to ineffective coping skills, an anger management problem, manipulative behavior, adjustment disorder, and a knowledge deficit. As evidenced by verbalizing dissatisfaction with staff performance, being verbally and physically abusive to staff members, and having unrealistic expectations of staff. A review of the Grievance Form provided by the LNHA dated 2/1/19 reflected the resident made an accusation that on either 1/30/19 or 1/31/19 he/she was thrown in the shower by an aide. The resident further reported on the Grievance Form that the specific staff member he/she mentioned to the surveyor was rough when providing care to the resident. A further review of the Grievance Form indicated that Resident #63 had not made an allegation of abuse or neglect. The Grievance Form indicated that if the resident had made an allegation of abuse or neglect to initiate the abuse protocol. A review of the Grievance Form steps taken to investigate the grievance indicated, Spoke with resident. Resident was unhappy about taking a shower. [He/She] said 'OK' when asked about taking a shower. Then stated [he/she] was unhappy afterwards. A review of a typed statement dated 2/4/19 completed by the DON indicated that the CNA who was accused of being rough during care by the resident stated that he was not rough when providing care to the resident and the resident had not complained to him regarding the type of care he/she had received. A review of the Grievance Form Summary of Findings indicated that the resident was verbally abusive to staff and had impaired cognition. The Summary of Findings further indicated that the resident's perception on what occurred was skewed due to his/her declining condition and the staff reported that the resident was very accusatory. A complete review of the Grievance Form did not indicate additional statements obtained from staff or alert and oriented residents on 1/30/19 and 1/31/19. On 10/24/19 at 10:45 AM, the surveyor interviewed the resident's 7:00 AM - 3:00 PM CNA who stated that the resident was alert to person, place, and time, but had behaviors where he/she would accuse people of doing things that were not true. For example, the resident would say that a male staff member was going to kidnap him/her and take the resident to [NAME]. The CNA further stated that the resident would be perfectly normal and then accuse someone of stealing something from him/her. The CNA stated that she would spend time talking with the resident to calm him/her down when the resident had behaviors. On 10/28/19 at 9:25 AM, the surveyor interviewed Resident #63's LPN who stated that the resident was, very paranoid and had, trust issues. The LPN stated that if the resident had a nurse he/she wasn't familiar with the resident would be reluctant to take his/her medications. The LPN told the surveyor that she would take her time during care with the resident and would sit and talk with the resident and offer him/her snacks to calm him/her down. The surveyor asked the LPN what she would do if the resident told her someone did something to him/her. The LPN stated she would go directly to the unit manager working and report it so we could investigate it. On 10/28/19 at 10:50 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that the resident was very paranoid and would ask staff members repetitive questions while providing care for reassurance. The RN/UM stated that she had met with the resident several times and the resident had asked her what her name and position was on multiple occasions. The RN/UM stated that she believed the resident had confabulated stories at times and had altercations with staff. The RN/UM further stated that if a resident made an allegation of abuse directed toward a staff member, that staff member would be removed from providing care and an investigation would ensue. The RN/UM stated, Any allegation of abuse regardless of the mentation of the resident or resident's behaviors needs to be investigated as an abuse investigation and taken seriously. On 10/28/19 at 12:51 PM, the surveyor interviewed the SW in the presence of another surveyor who stated that abuse could be physical, mental, financial, or sexual in nature. The SW further stated that any concerns a resident had would need to be investigated and the nature of the concern would depend if the facility would investigate it as a grievance or an abuse. The surveyor asked the SW what the difference between a grievance and an abuse investigation was. The SW stated that she did not make that determination and that would be determined by the LNHA or the DON. The SW stated that if an allegation of abuse was made by a resident the facility would conduct an abuse investigation and statements would be obtained from all potential witnesses and the statements would be reviewed by her and the LNHA. The SW further stated that the facility would also interview residents on the unit who were alert and oriented in relation to the care the alleged staff member provided. The SW told the surveyors that she was responsible for teaching the staff on orientation to report any and all allegations of abuse to a nurse or supervisor. On 10/29/19 at 9:39 AM, the surveyor interviewed the CNA who was accused of being rough during care. The CNA stated that the resident was alert with confusion and had stated in the past that the resident had told other staff members that he was going to take him/her out of the facility to Route 38. The CNA further stated that he didn't know why the resident thought that because sometimes when he walked by the resident's room the resident would say hello to him. The CNA told the surveyor that he had never provided the resident with one on one intimate care because the resident preferred female staff members. This statement contradicted the statement provided in the Grievance Form completed by the DON. The CNA stated that at times he would bring the resident his/her breakfast tray or answer the resident's call bell, but was told not to go into the resident's room a few months back because of the resident's accusations and behaviors. The CNA further stated that if a resident made an allegation of abuse he would follow the chain of command and tell the nurse and also the unit manager. On 10/29/19 at 12:52 PM, the surveyor conducted an interview with the LNHA in the presence of the survey team. The LNHA stated that a resident's perception was their reality so all allegations of abuse and neglect would be investigated and reported. On 10/30/19 at 10:47 AM, the surveyor conducted a follow up interview with the LNHA in the presence of the survey team. The LNHA stated that if a resident alleged that a staff member was abusive, they would send the staff member home until the allegation of abuse was thoroughly investigated. A review of the facility's Resident/Participant Abuse Protection Policy and Procedure revised on 6/30/17 included, All residents/participants have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property and exploitation. The facility's Resident/Participant Abuse Protection Policy and Procedure further included, Investigating- timely and thorough investigations of all reports and allegations of abuse to include injuries of unknown origin. Reporting/response- The reporting and filing of accurate documents relative to incidents of abuse; reporting to the State agencies as required, analyze and implement necessary changes to prevent future occurrences of abuse. Refer to F609 NJAC 8:39-4.1(a)5 Based on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to thoroughly investigate, a resident allegation of physical abuse on 2/1/19. This deficient practice was identified for 1 of 4 resident's reviewed for abuse, (Resident #63) and was evidenced by the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a.) carry out a physician's order for a psychiatric consultation in a timely manner and b.) take vital signs prior to the administration of cardiac medication with hold parameters in accordance with professional standards of nursing practices. This deficient practice was identified for 2 of 20 residents reviewed for professional standards of practice, (Resident #10 and #57). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The evidence was as follows: 1. On 10/23/19 at 11:01 AM, the surveyor observed Resident #10 laying in bed listening to music. The resident stated that he/she was epileptic (neurological disorder which causes seizures) and preferred to stay in bed. The surveyor reviewed the medical record for Resident #10. A review of the Face Sheet (an admission summary) reflected that the resident was admitted to the facility on [DATE] and had diagnoses which included generalized muscle weakness, hypertension (high blood pressure), Asperger's syndrome (developmental disorder affecting the ability to effectively socialize and communicate), and unspecified convulsions (seizures). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/22/19 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating a fully intact cognition. A review of the resident's individualized, comprehensive care plan (ICCP) dated effective 7/16/19 to present, included that the resident had a potential for social isolation related to the history of shyness, diagnosis of Asperger's syndrome, cognitive impairment, paranoia, socially inappropriate behavior, and altered thought process. Interventions included were to give positive feedback for participation in social activities, give resident as many choices as possible, and encourage to express feelings. A further review of the ICCP included a problem area that the resident had behavioral symptoms not directed towards others with interventions that included to encourage the resident to contact appropriate staff with concerns, provide medication as ordered, and remove resident from the situation. A review of the Statewide Clinical Outreach Program for the Elderly (S-COPE; a statewide program that provides crisis response and clinical outreach to adults [AGE] years old and older residing in nursing facilities who experience mental health and/or behavioral crisis) dated 9/5/19 indicated that the resident was referred for a consult for reason which included calling the police, accusing staff, and yelling at staff. Based on the clinical assessment, the resident's behaviors appear related to autism spectrum disorder. Although past psychiatric history is unclear and underlying psychiatric history is unclear,psychiatric disorder cannot be ruled out. Recommendations made by S-COPE included to consider psychotherapy and/or counseling support to assist and manage coping skills and decrease behaviors. A review of a follow-up S-COPE dated 9/26/19 included resident's behaviors remained the same and recommended to consider on-going psychiatric support for the resident. A review of the physician's progress note dated 10/3/19 included an assessment plan for a psychiatric consultation. A review of the Medication Management Assessment completed by the psychiatric Nurse Practitioner (NP) on 10/22/19 included that the resident was seen for mood and behavioral issues; that the resident was calmer than previous visit but does again discuss his/her frustration with facility issues. On 10/28/19 at 9:26 AM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) who stated that the resident was alert but confused at times. The resident refuses to get out of bed and sometimes could be fussy if he/she did not get things when he/she wanted them. At 11:50 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN), who stated that the resident was alert, able to makes needs known, and had Asperger's syndrome. The resident was encouraged to get out of bed and sit in his/her chair, but he/she refused. The resident had a history of seizures, and felt that if he/she got out of bed, they would have a seizure. The LPN denied the resident having a seizure at the facility since admission. At 2:46 PM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that the Social Worker initiated the S-COPE in response to the resident calling the police. The matter was investigated, and found to be unsubstantiated. On 10/29/19 at 12:52 PM, the LNHA informed the surveyor that the Medication Management assessment dated [DATE] was the only assessment the facility could locate. At 1:28 PM the LNHA in the presence of the administration team and survey team stated that the Social Worker, who was not present that day, reviewed the S-COPE. The LNHA could not speak to why the recommendations made on the S-COPE for psychiatric support on 9/5/19 and 9/26/19 were not followed until 10/22/19. At that time, the Director of Nursing (DON) stated that a psychiatric recommendation could have been made sooner, but it sometimes takes a while for psychiatric consultation. The DON stated that it could take up to three weeks, but would follow-up on that. The DON added that the previous Unit Manager (UM) was no longer here, and the recommendation could have been missed during the transition. On 10/30/19 at 10:41 AM, the LNHA in the presence of the [NAME] President of Clinical Services (VPCS) and the survey team, stated that the original request for Resident #10 to receive a psychiatric consultation was made on 8/4/19. An additional request was made in October for a psychiatric consultation, and the resident was first seen on 10/14/19. The LNHA could not speak to why the resident was not seen in August, and was not seen until an additional request in October was made. At 12:30 PM, the VPCS informed the surveyor that she could not locate a policy concerning carrying out a physician's order for a psychiatric consultations. A review of the facility's Medication & Treatment Orders policy dated 10/2/17 did not include a procedure for following physician's orders written for psychiatric consultations. 2. On 10/24/19 at 9:23 AM, the surveyor, in the presence of another surveyor, observed the LPN3 preparing to administer 11 medications to Resident #57 which included a 0.125 milligrams (MG) tablet of Digoxin (a cardiac medication used to control arrhythmia) and a 25 MG tablet of Metoprolol Tartrate (Lopressor) (a medication used for high blood pressure and chest pain). The LPN3 referred to a paper that she stated she had recorded the resident's apical pulse (AP) of 74 and a blood pressure (BP) of 146/74. The LPN2 stated that she needed the AP for the Digoxin and the BP for the Lopressor because the physician's orders required the vital signs to be obtained before administering the medication because if the vital signs were too low she would have to hold the medications. On 10/24/19 at 9:30 AM, the surveyor in the presence of another surveyor observed the resident lying in bed with eyes closed. At that time, the resident awakened and was agreeable to take his/her medications. On 10/24/19 at 9:31 AM, the surveyor in the presence of another surveyor, observed the nurse administer the Digoxin and Lopressor. On 10/24/19 at 9:48 AM, the surveyor in the presence of another surveyor, interviewed the LPN2 who stated that her routine was to come in for her 7:00 AM to 3:00 PM shift and get report from the 11:00 PM to 7:00 AM shift and then make her rounds. The LPN2 added that she would then review which residents required vital signs for the medication pass and obtain the vital signs. The LPN2 then stated that she thought she had taken the resident's AP and BP approximately 30 minutes or so before administering the medications. The LPN2 stated that her routine helped for an easier medication pass. On 10/24/19 at 10:27 AM, the surveyor reviewed the eMR for Resident #57. A review of the Face Sheet (an admission summary) included that the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, atherosclerotic heart disease and congestive heart failure. A review of the quarterly MDS, an assessment tool used to facilitate the management of care, dated 5/13/19 reflected the resident had a BIMS score of 5 out of 15, indicating that the resident had a moderately impaired cognition. A review of the October 2019 POS revealed a PO dated 3/6/19 for Digoxin 0.125 MG tablet, one tablet once a day five times a week. A review of the October 2019 POS revealed a PO dated 5/8/19 for Lopressor 25 MG, one tablet, by mouth twice a day, hold for systolic blood pressure less than 110 and/or pulse less than 60. On 10/28/19 at 2:48 PM, the survey team met with the LNHA, the DON and the VPCS. The DON acknowledged that vitals signs such as AP and BP were required to be obtained just prior to the administration of the medication as a nursing standard of practice. A review of the facility policy dated 10/2/2017 for Administering Medications included that vitals signs must be checked prior to administering medications. NJAC 8:39-11.2(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record, it was determined that the facility failed to a.) monitor an enteral tube feeding administration pump to assure the total volume administered was in accordance with physician's orders, and b.) maintain a resident's weight which resulted in both a significant weight loss and a significant weight gain. This deficient practice was identified for 1 of 1 residents reviewed for enteral tube feeding, (Resident #266), and was evidenced by the following: On 10/23/19 at 10:32 AM, the surveyor observed Resident #266 asleep in bed with an enteral tube feeding pump (TF; a tube feeding surgically inserted to the stomach) administering Jevity 1.2 (nutritional formula) at a rate of 100 milliliters (mL) an hour with a total volume infused thus far of 266 mL. On 10/24/19 at 8:59 AM, the surveyor observed the resident in bed awake, but non-responsive to surveyor questioning. The surveyor observed Jevity 1.2 being administered at a rate of 100 mL per hour with a total volume infused thus far of 202 mL. The Jevity 1.2 bottle was labeled as hung on 10/24/19 at 12:50 AM. At 10:17 AM, the surveyor observed the resident in bed with the TF administering Jevity 1.2 at a rate of 100 mL per hour with a total volume infused thus far of 331 mL. On 10/25/19 at 8:44 AM, the surveyor observed the resident in bed with the TF administering Jevity 1.2 at a rate of 100 mL per hour with a total volume infused thus far of 237 mL. The Jevity 1.2 bottle was labeled as hung on 10/25/19 at 6:30 AM. The surveyor reviewed the medical record for Resident #266. A review of the Face Sheet (an admission record) reflected that the resident was admitted to the facility on [DATE] and had diagnoses which included dysphagia (difficulty swallowing), memory deficit, pressure ulcer of sacral region (wound to the lower back caused from pressure), pressure ulcer to the left heel, and gastrostomy status (TF surgically inserted to the stomach). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/25/19 reflected that the resident had both a short and long-term memory problems with severely impaired cognition. A review of the MDS section K. Swallowing/Nutritional Status, reflected that the resident received more than 51% of his/her total calories and more than 501 mL of fluids per day through a TF. A review of the resident's individualized, comprehensive care plan (ICCP) dated effective 9/18/19 to present, included that the resident required a TF for nutritional support related to a history of cerebrovascular accident (stroke) with dysphagia, history of aspiration (sucking food into the airway), with a weight decline of 5% over the last two weeks since admission. On 10/7/19 weight increase was noted with a return to usual body weight range. Interventions included to monitor labs when available, monitor tolerance of TF, provide Jevity 1.2 as ordered, and monitor weight monthly. A review of the October 2019 Physician Order Sheet (POS) indicated a physician's order (PO) dated 10/3/19 for Jevity 1.2 administered at a rate of 100 mL an hour for fifteen hours; from 7:00 PM to 10:00 AM for a total volume of 1500 mL. An additional order indicated to record total volume infused for all shifts three times a day at 6:30 AM, 2:30 PM, and 10:30 PM. A review of the corresponding October 2019 electronic Medication Administration Record (eMAR) indicated the following: The total volume for the TF formula documented on the eMAR on 10/5, 10/6, 10/7, 10/8, 10/9, 10/12, 10/13, 10/14/ 10/15, 10/16, 10/19, 10/20, 10/21, 10/22, and 10/23 indicated an excess of 1500 mL. The total volume for the TF formula documented on the eMAR on 10/10, 10/11, 10/17, and 10/18 indicated a deficit of 1500 mL. A review of the October 2019 POS indicated a PO dated 9/21/19 to flush the TF with 30 mL of water before and after medication administration each shift. A review of the corresponding October 2019 eMAR reflected the following for first shift: 10/1 30 mL; 10/3 30 mL; 10/7 150 mL; 10/8 150 mL; 10/9 150 mL; 10/10 30 mL; 10/13 150 mL; 10/17 30 mL; 10/18 30 mL; 10/22 30 mL; and 10/23 150 mL A review of the corresponding October 2019 eMAR reflected the following for second shift: 10/1 150 mL; 10/3 150 mL; 10/4 150 mL; 10/5 150 mL; 10/6 30 mL; 10/7 30 mL; 10/8 350 mL; 10/9 30 mL; 10/10 30 mL; 10/15 30 mL; 10/16 120 mL; 10/17 150 mL; 10/20 120 mL; 10/21 150 mL; 10/22 120 mL; and 10/23 120 mL A review of the corresponding October eMAR reflected the following for third shift: 10/1 30 mL; 10/2 30 mL; 10/3 30 mL; 10/5 30 mL; 10/6 150 mL; 10/7 150 mL; 10/8 30 mL; 10/9 150 mL; 10/10 30 mL; 10/11 30 mL; 10/12 150 mL; 10/13 30 mL; 10/14 30 mL; 10/15 30 mL; 10/16 30 mL; 10/17 30 mL; 10/18 30 mL; 10/19 30 mL; 10/20 150 mL; 10/21 30 mL, 10/22 30 mL; and 10/23 30 mL. A further review of the October POS indicated a PO dated 10/3/19 for weekly weights three times a week during 7:00 AM to 3:00 PM medication pass starting on 10/4/19. A review of the electronic Vital Signs indicated the following weights: 9/18 191.8 pounds (lbs) 9/26 185.2 lbs 10/2 181 lbs; reweigh 181.6 lbs 10/7 189.6 lbs 10/11 190.2 lbs 10/16 192.2 lbs 10/24 191.6 lbs The weight from 9/18/19 through 10/2/19 indicated a significant weight loss of 5.63%. The weights had not corresponded with the PO dated 10/4/19 for weights three times a week. A review of the most recent labs on 10/7/19 indicated a serum albumin (a lab value that determined protein stores in the body) of 3.2 grams per deciliter (g/dL) and a total protein level of 6.2 g/dL which were both below normal levels. On 10/25/19 at 10:26 AM, the surveyor interviewed the resident's Certified Nursing Aide #1 (CNA) who stated that the resident received nothing by mouth, had a TF, and received incontinence care every two hours for a heavy bladder. The CNA stated that she went to the nurse every two hours to have the TF turned off when it was running to perform incontinence care, then the nurse turned the TF back on afterwards. The resident also had a wound on the top of his/her buttocks that was healing. At 10:30 AM, the surveyor interviewed the resident's Licensed Practical Nurse (LPN) who stated that the resident had dysphagia, was complete care, and received Jevity 1.2 via TF at a rate of 100 mL per hour for a total volume of 1500 mL. The resident also received 30 mL of water before and after each medication pass for a total volume of 60 mL. The LPN continued that she turned off the pump when the total volume read 1500 mL. The resident's head of the bed was positioned at a forty-five degrees before, during, and after the TF. The resident wore multipodus boots (a protective boot used to correct foot misalignment) that were only taken off during care and treatments to that area. At 10:41 AM, the LPN accompanied the surveyor to Resident #266's room. The resident was observed in bed with the TF running at a rate of 100 mL per hour with a total volume of 422 mL infused. The surveyor observed the resident was wearing multipodus boots. The LPN stated that the CNA took the weights with another CNA utilizing a hoyer lift (an assistive device used to transfer residents) scale. The LPN stated that the CNA told the nurse the weight, and the nurse entered the weight directly into the the computer system. At 10:52 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that she was new to the facility, and just started on this unit in the middle of September. The RN/UM stated that Resident #266 had a TF, received nothing by mouth, and was admitted to the facility with wounds that were healing. The RN/UM confirmed that all the resident's weights were in the computer. The RN/UM stated that the nurses stopped the TF each day when the pump reflected a total volume of 1500 mL; the pump was not cleared after each shift. At that time, the RN/UM accompanied the surveyor into Resident #266's room. They observed the TF running with a total volume of 466 mL infused. The RN/UM reviewed the October eMAR with the surveyor. The RN/UM stated that the totals for each shift were incorrect. She stated that maybe nurses included water flushes in the total. The surveyor asked the RN/UM how the eMAR would be read if the pump had not reflected a total volume of 1500 mL when turned off. The RN/UM stated that she could not speak to that. The RN/UM reviewed the water flushes during each medication pass, and confirmed that the total volume should have been 60 mL each medication pass. At 11:18 AM, the LPN informed the surveyor that the nurses used a manual irrigation system to flush the TF with the appropriate amount of water administered according to the PO. At 11:24 AM, the surveyor interviewed the Registered Dietitian (RD) who stated that the resident was new to the facility and had a new TF. Prior to admission to the facility, the resident received Jevity 1.2 in the hospital, but the facility only had Jevity 1.5 (nutritional formula with more calories than Jevity 1.2) in stock. The facility had not received many enteral feeding residents, so the formula usually expired before being used. The physician wrote an order for the Jevity 1.5 until the facility received the Jevity 1.2. The original PO when the resident was here, was for Jevity 1.5 administered at 55 mL per hour continuously for twenty-four hours with a total volume of 1320 mL. The resident tolerated that feeding. The RD stated that the feeding provided a total of 1980 calories and 90 grams of protein which met his/her calculated caloric energy needs of 1920 calories a day based on the admission weight of 191.8 lbs. At 12:18 PM, the LPN, CNA #1, and CNA #2 accompanied the surveyor into Resident #266's room for a weight check. CNA #1 confirmed she was the CNA who always weighed the resident, and the last time the resident was weighed was probably last week. CNA #1 stated that the resident always had on his/her multipodus boots when weighed. CNA #2 stated that she usually did not assist CNA #1 with Resident #266's weight, but she took the resident's weight upon entrance. CNA #2 stated that the resident wore boots from the hospital during that weight. As per the LPN, the resident came in from the hospital with boots that were black and cushiony, but she was unable to recall the name of the boots. The LPN stated that she thought the current multipodus boots were heavier than his/her original boots. At 12:38 PM, the surveyor observed CNA #1 and CNA #2 in the presence of the LPN weigh the resident after incontinence care with the multipodus boots on. The weight observed was 202.4 .lbs. The surveyor than observed a weight of 198.4 .lbs. At that time, the LPN stated that she was verbally told that morning by the 11:00 PM to 7:00 AM shift nurse that the resident received 1000 mL of Jevity 1.2 thus far. The LPN stated that the pump must have somehow reset itself, but she usually stopped the pump when it reflected the total volume of 1500 mL infused. The LPN stated that maybe the nurse wrote the total volume on the twenty-four hour nursing report. The surveyor reviewed the twenty-four hour nursing report with the LPN. The report had not reflected the total volume of Jevity 1.2 infused per shift. The surveyor reviewed with the LPN all the twenty-four hour nursing reports for the resident from admission; the reports had not reflected the total volumes infused by shifts. At 12:45 PM, the LPN informed the surveyor that the resident received incontinence care every two hours, which was performed around the clock through all shifts. The LPN stated that the TF was turned off prior to incontinence care, and then the CNA alerted the nurse to turn the pump back on after care was completed. At 1:04 PM, the RN/UM stated that she went through the resident's physician's orders, and there was no PO to explain how the documentation was to be completed each shift. The order only indicated to record the total volume of each shift. The RN/UM continued that the nurses possibly included the flushes in the total volume. The RN/UM stated that the order was confusing so the nurses were probably confused with how to document. The RN/UM stated that the plan was to have the physician discontinue that order. The RN/UM confirmed that the nurse should have clarified with the physician the order prior to surveyor inquiry. The RN/UM stated that they were clarifying with the nurses that the pump would not get cleared or stopped until the total volume infused was 1500 mL. The RN/UM stated that there was no policy that she could locate for enteral TF. The RN/UM stated that there had not been another resident on TF since she started at the facility, and believed it had been a while since the facility had a resident on a TF. The UM/RN was unsure the last time staff was educated on TF, and that the Assistant Director of Nursing (ADON) was in charge of staff education. At 1:21 PM, the surveyor interviewed the ADON who stated she started at the facility four months ago, and had not completed staff education on the administration of the TF. The ADON further stated that she could not locate any prior TF education. The ADON stated that there was no policy regarding enteral TF. The surveyor continued reviewing the medical record for Resident #266. A review of the September 2019 eMAR reflected a PO dated 9/18/19 for Jevity 1.5 administered at 55 mL per hour continuously. An additional PO dated 9/19/19 reflected to record the total volume of feeding infused one time per day. The eMAR reflected this corresponding order as followed: On 9/19 a total volume of 10 mL was infused. On 9/20 a total volume of 1500 mL was infused. On 9/21 a total volume of 1134 mL was infused. On 9/22 a total volume of 417 mL was infused. On 9/23 a total volume of 440 mL was infused. On 9/24 a total volume of 440 mL was infused. On 9/25 a total volume of 440 mL was infused. On 9/26 a total volume of 600 mL was infused. On 9/27 a total volume of 420 mL was infused. On 9/28 a total volume of 600 mL was infused. On 9/29 a total volume of 600 mL was infused. On 9/30 a total volume of 400 mL was infused. The surveyor reviewed the weights for the resident. From the weight on 10/16/19 of 192.2 lbs (which was the weight the resident was upon admission) to the weight observed on 10/25/19 of 202.4 lbs, reflected a significant weight gain of 5.31%. On 10/28/19 at 11:09 AM, the surveyor re-interviewed the RD who stated you would generally expect to see weight loss from a resident admitted from the hospital due to edema or fluid losses. Other factors that could contribute to weight fluctuations was how staff was weighing the resident; if the heel boots were on or off. The RD stated she had not observed the resident being weighed, so could not speak to how staff was weighing the resident. The RD reviewed the resident's weights with the surveyor. The RD acknowledged that the continued weight loss reflected between 9/26 and 10/2 was most likely not from hospital fluid loss. The RD stated weight loss could occur from malabsorption such as vomiting or diarrhea, but she was unaware that had occurred with the resident. The RD stated that when the resident was first admitted , he/she received 1320 mL of Jevity 1.5 in twenty-four hours based on a rate of 55 mL per hour. The RD acknowledged that the pump had not run continuously for twenty-four hours, that the pump was turned off for care throughout each shift. The RD was unsure how many times in twenty-four hours the pump was turned off for care, but stated it was not for a long period of time. The RD stated that the nurses documented the total volume infused on the eMAR. The RD stated that she had reviewed the eMAR, and was aware there was some confusion with nurse documentation after surveyor inquiry. The RD reviewed the September 2019 eMAR with the surveyor. The RD confirmed that a total volume of 1500 mL that was documented on 9/20 would not be feasible if the resident was administered Jevity 1.5 at a rate of 55 mL per hour for twenty-four hours because the maximum total volume at that rate would be 1320 mL. The RD stated that the resident needed at least 1800 to 1900 calories per day for adequate nutrition. The RD acknowledged that all the total volume's recorded on the eMAR besides the total volume on 9/20 of 1500 mL, were all less than the resident's required daily caloric intake. The RD acknowledged that the calories the resident received based on the total volume of Jevity 1.5 documented on the September eMAR as received could, correlate with the weight loss documented in the electronic Health Record (eHR). The RD stated that she had reviewed the September 2019 eMAR, but the documentation was written in several different places. The RD stated that she had not conducted inservices on TF in the past, but had inserviced staff on weights because the facility did not have many residents on TF. The RD informed the surveyor that serum albumin was a marker used for protein stores in the body, which was found to not be the most reliable marker because different stressors could effect the level. The various stressors included inflammation, variations in enzymes, and fluid changes. The RD also stated that protein stores were also affected by similar stressors. The RD and surveyor reviewed the lab results from the hospital dated 9/12/19 which indicated the serum albumin level was 2.9 g/dL and 5.6 g/dL which were both below normal values. The RD and surveyor compared the hospital lab values with the lab values on 10/7 which showed that the albumin and total protein levels were still low but had improved. The RD also confirmed that the resident had two healing wounds, which would have also affected the low serum albumin and protein levels. On 10/29/19, the surveyor interviewed the Consultant Pharmacist (CP) who stated that she did not review the eMAR for the administration of enteral formula; that would be something the RD reviewed. On 10/30/19 at 11:00 AM, the [NAME] President of Clinical Services (VPCS) in the presence of the Licensed Nursing Home Administrator (LNHA) and survey team indicated that the facility did have an enteral feeding policy. The VPCS stated that the nurses needed to work on their documentation; that they misunderstood the PO and included flushes in the total volumes. The order was confusing and it had to be clarified. The VPCS continued that the RD was adjusting the formula based on the weights, and the ICCP was updated to reflect to weigh the resident with the multipodus boots on. The VPCS could not speak to how staff was ensuring that the resident was receiving the total amount of formula per PO if the pump was not shut off at 1500 mL as observed by the surveyor on three consecutive days, and there was no documentation that reflected the actual amount of formula the resident received during each shift to equal the total volume of 1500 mL. A review of the facility's Weight Assessment and Intervention policy dated 3/23/17 included that the threshold for significant unplanned and undesirable weight loss and/or gain in one month of 5% is significant and greater than 5% is severe. A review of the facility's Enteral Nutrition policy dated 6/10/13 included that the total rate for continuous feedings will be calculated over a twenty-two hour time period, allowing for feedings to be turned off for care and activities. The policy also included that feedings are administered using a feeding pump; pump accuracy is assessed by the nurse. The policy further included that the volume infused is assessed at the end of each shift. At the end of each shift, the nurse documents the total volume infused for that shift. The nurse documents the volume of water flushes. The policy also included to assure that volume infused has been cleared when total volume to be infused is reached. Set rate and total volume to be infused based on the feeding schedule. If the feeding is intermittent, set the volume to be infused for that interim. If the feeding is continuous, set the total volume for each twenty-four hours. Start pump. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 10/24/19 and 10/25/19, the surveyor observed three (3) nurses administering medications to six (6) residents. There were 32 opportunities and five (5) errors observed which calculated to a medication administration error rate of 15.6 %. The deficient practice was identified for 2 of 3 nurses for 2 of 6 residents, (Resident #57 and #59) as evidenced by the following: 1. On 10/24/19 at 08:47 AM, the surveyor in the presence of another surveyor, observed the Licensed Practical Nurse (LPN1) preparing to administer medications to Resident #59. The LPN1 stated that according to the electronic medication administration record (eMAR) the resident was to receive two medications which included one multivitamin tablet. The LPN1 then explained that the multivitamin was supplied by the facility house stock and was labeled Multivitamin Daily and removed one red tablet from the bottle. On 10/24/19 at 8:51 AM, the surveyor in the presence of another surveyor, observed the LPN1 administer the two (2) medications which included the Multivitamin Daily red tablet. On 10/24/19 at 10:45 AM, the surveyor reviewed the medical record for Resident #59. A review of the October 2019 physician order (PO) sheet revealed an order dated 3/29/18 for Multivitamin with Minerals, one tablet by mouth daily. On 01/04/19 at 11:37 AM, the surveyor, in the presence of another surveyor, interviewed the LPN1 at the medication cart. The LPN1 acknowledged that she had administered the red tablet from the facility house stock labeled Multivitamin Daily to Resident #59. At that time, the surveyor read the ingredients of the Multivitamin Daily which revealed that the product had not contained minerals. The LPN1 explained that the PO was for the product labeled Multivitamin Daily. The LPN1 further explained that she had another facility house stock multivitamin in the medication cart labeled Daily Vitamin Formula plus Minerals but did not think that was what the physician ordered. The surveyor, in the presence of another surveyor, observed that the Daily Vitamin Formula plus Minerals were orange tablets. The LPN1 stated that she thought she was following the PO. On 10/24/19 at 11:46 AM, the surveyor, in the presence of another surveyor, interviewed the Unit Manager, in the presence of the Assistant Director of Nursing (ADON) and LPN1 with regard to the two (2) house stock multivitamins in the medication cart. The UM stated that the Daily Vitamin Formula plus Minerals contained minerals and the Multivitamin Daily did not contain minerals. At that time, the PO was reviewed and the UM and ADON acknowledged that the PO indicated to administer a multivitamin that contained minerals. The UM and ADON stated that the PO was not specific to the label of the house stock multivitamin product and that the PO indicated to administer a multivitamin that contained minerals. The UM stated that the resident should have received the Daily Vitamin Formula plus Minerals. (ERROR#1) On 10/29/19 at 1:50 PM, the surveyor, in the presence of the survey team, interviewed the Consultant Pharmacist (CP) who stated that she instructs the nurses to administer the correct house stock medications according to what the physician ordered. The CP added that she recalled having done a couple of med passes with LPN1 and stated that after each med pass she would review a medication pass in-service. A review of the facility policy dated 10/2/17 included that medications must be administered in accordance with orders and the nurse administering must check to verify the right medication. 2. On 10/24/19 at 9:23 AM, the surveyor, in the presence of another surveyor, observed the LPN2 preparing to administer 11 medications to Resident #57 which included a 10 milligram (MG) tablet of Glipizide (a medication for high blood sugar), a 100 MG tablet of Acarbose (Precose) (a medication to control blood sugar), an 8 MG tablet of Galantamine (Razadyne) (a medication used for memory impairment) and a 25 MG tablet of Metoprolol Tartrate (Lopressor) (a medication used for high blood pressure). On 10/24/19 at 9:30 AM, the surveyor in the presence of another surveyor observed the resident lying in bed with eyes closed. At that time, the resident awakened and was agreeable to take his/her medications. At 9:31 AM, the surveyor in the presence of another surveyor observed the nurse administer 9 of the 11 medications which included the Glipizide, Precose, Razadyne and Lopressor. On 10/24/19 at 9:48 AM, the surveyor in the presence of another surveyor interviewed the LPN2 who stated that during morning report from the night shift she was told that the resident was up late and added that was the reason that he/she was still in bed and not dressed which was unusual for the resident. The LPN2 also stated that the resident had eaten breakfast between 8 AM and 8:30 AM. Neither surveyor observed food trucks or meal trays on the unit. On 10/24/19 at 10:27 AM, the surveyor reviewed the eMR for Resident #57. A review of the October 2019 Physician Order Sheet (POS) revealed a PO dated 8/22/19 for Glipizide 10 MG, one tablet by mouth twice a day scheduled for 7 AM and 4 PM administration times. Further review of the POS revealed the following PO with dates and scheduled administration times: Precose 100 MG, one tablet by mouth two times a day dated 1/29/19 and scheduled for 9 AM and 5 PM. Razadyne 8 MG, one tablet by mouth two times a day dated 1/29/19 and scheduled for 9 AM and 5 PM. Lopressor 25 MG, one tablet by mouth twice a day dated 5/8/19 and scheduled for 9 AM and 5 PM. In addition, the POS indicated for each PO a physical monitors section with Precautions acknowledged as dispensing label. On 10/24/19 at 11:41 AM, the surveyor, in the presence of another surveyor, interviewed LPN2. The LPN2 stated that she was not sure where to find the cautionary warnings for medications. The LPN2 explained that she had access to drug information for each medication in the eMAR. The LNP2 then stated that she knew Lopressor should be administered with food. The LPN2 then stated that the Glipizide was timed for 7:00 AM and should have been administered by the 11: 00 PM to 7:00 AM shift but the resident was sleepy that morning because he/she was up all night so she administered the medication on her shift. The LPN2 could not speak to why she administered the Glipizide at 9:31 AM after the resident had already eaten breakfast. At that time, the surveyor, in the presence of another surveyor, observed with the LPN2 the labels of the medications for Resident #57 in the medication cart which revealed the following: 1. Glipizide 10 MG tablets with a cautionary warning on the label, Take half-hour before meals. (ERROR #2) 2. Precose 100 MG tablets with a cautionary warning on the label, Take this med with a meal. (ERROR #3) 3. Razadyne 8 MG tablets with a cautionary warning on the label, Take this med with a meal. (ERROR #4) 4. Lopressor 25 MG tablets with a cautionary warning on the label, Take with or immediately after meal. (ERROR #5) The LPN2 then stated that she thought she had an hour after a resident finished eating to administer medications with food and the resident had eaten breakfast around 8:30 AM. The LPN2 added that if a resident had not eaten a meal then she would offer a snack with the medications. On 10/25/19 at 8:13 AM, during a medication pass, the LPN3 stated that she was waiting to administer medications until the breakfast trays were delivered. The LPN3 stated that she had several medications that required the resident to have food or a meal. The LPN3 explained that the cautionary warnings for medications were on the label of the medications and the nurses were responsible for reading and following the cautionary warnings. The LPN3 also stated that the eMAR had a Notes section for each medication and sometimes the cautionary warnings were typed into that section. The LPN3 also added that the nurses would have to manually input the cautionary information into the electronic Notes section and that was not always done. A review of the facility policy dated 10/2/17 for Administering Medications included that medications must be administered in accordance with orders, including any required time. In addition, the policy included that the nurse administering the medications must check the label and verify the right time for the medication prior to administering the medication. On 10/28/19 at 2:48 PM, the survey team met with Licensed Nursing Home Administrator, the Director of Nursing and the [NAME] President of Clinical Services (VPCS). The VPCS stated that the current Administering Medications policy was to be followed but had not been updated to include the electronic process. On 10/29/19 at 1:50 PM, the surveyor, in the presence of the survey team, interviewed the Consultant Pharmacist (CP) who stated that she instructs the nurses to read and follow cautionary warnings before administering a medication and also instructs the nurses to find the cautionary warnings printed on the medication label. The CP added that she was aware that the nurses could enter the cautionary into the electronic system but was unsure if that was always done. The CP stated that she had done a medication pass every month but was unsure if she had ever done a medication pass with LPN2. A review of the manufacturer's specifications for Glipizide reflected that the medication was to be administered 30 minutes before a meal. A review of the manufacturer's specifications for Precose reflected that the medication was to be administered with the first bite of a meal. A review of the manufacturer's specifications for Razadyne reflected that the medication was to be administered with food. A review of the manufacturer's specifications for Lopressor reflected that the medication was to be administered with or immediately following a meal. NJAC 8:39-11.2(b), 29.2(d)