Alaris Health At St Marys

Based on interviews, medical record review, and review of pertinent facility documentation on 10/23/25, it was determined that the facility failed to consistently document Activities of Daily Living (ADL) as being provided to residents for 2 of 4 residents reviewed for ADLs (Resident #1, Resident #2). The findings were as followed: A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; morbid obesity, osteoarthritis, muscle weakness, and difficulty walking. A review Resident #1's comprehensive Minimum Data Set (MDS) an assessment tool dated 6/5/25 that the resident had a Brief Interview Mental Status (BIMS) score of 14 out of 15, indicating that the resident's cognition was intact. A review of Resident #1's June 2025 Documentation Survey Report v2, a form included blank spaces indicating that the task, were not completed as follows: Personal Hygiene on 6/11/25, and 6/23/25 on the day shift. On 6/8/25, 6/10/25, 6/18/25, 6/26/25, and 6/30/35 on the evening shift. On 6/13/25, 6/14/25, 6/15/25 and 6/30/25 on the night shift. Turned and position every 2 hours on 6/2/25, 6/13/25, 6/14/25, 6/15/25, and 6/16/25 on the day shift. On 6/1/25, 6/11/25, and 6/23/25 on the evening shift. On 6/1/25, 6/8/25, 6/10/25, 6/18/25, and 6/26/25 on the night shift. Bladder continence on 6/11/25, and 6/23/25 on the day shift. On 6/8/25, 6/10/25, 6/18/25, 6/26/25, and 6/30/25 on the evening shift. On 6/13/25, 6/14/25, 6/15/25, and 6/30/25 on the night shift. Bowel continence and movements on 6/11/25, and 6/23/25, on the day shift. On 6/8/25, 6/10/25, 6/18/25, 6/26/25, and 6/30/35 on the evening shift. On 6/13/25, 6/14/25, 6/15/25 and 6/30/25 on the night shift. Roll left and right on 6/11/25, and 6/23/25 on the day shift. On 6/8/25, 6/10/25, 6/18/25, 6/26/25 and 6/30/25 on the evening shift. On 6/13/25, 6/14/25, 6/15/25, and 6/30/25 on the night shift. Preventative mattress on 6/11/25, and 6/23/25 on the day shift. On 6/8/25, 6/10/25, 6/26/25 and 6/30/25 on the evening shift. On 6/13/25, 6/14/25, 6/15/25, and 6/30/25 on the night shift. A review of Resident #1's July 2025 Documentation Survey Report v2, a form included blank spaces indicating that the task, were not completed as follows: Personal hygiene on 7/15/25, 7/26/25, 7/30/25, and 7/31/25 on the day shift. 7/15/25, 7/26/25, 7/27/25, and 7/29/25 on the evening shift. On 7/25/25, 7/28/25, 7/29/25, and 7/31/25 on the night shift. Turn and position every 2 hours on 7/24/25, 7/26/25, 7/29/25, 7/30/25 and 7/31/25 on the night shift. On 7/15/25, 7/24/25, 7/26/25, 7/30/25, and 7/31/25 on the evening shift. On 7/26/25, 7/27/25, and 7/29/25 on the night shift. Bladder Continence on 7/15/25, 7/26/25, 7/30/25 and 7/31/25 on the day shift. On 7/15/25, 7/26/25, 7/27/25, and 7/29/25 on the evening shift. On 7/16/25, 7/28/25, 7/29/25, and 7/30/25 on the night shift. Bowel continence and movement on 7/15/25, 7/26/25, 7/30/25, and 7/31/25 on the day shift. On 7/15/25, 7/26/25, 7/27/25, and 7/29/25 on the evening shift. On 7/25/25, 7/28/25, 7/29/25, 7/30/25, 7/31/25 on the night shift. Roll left and right on 7/15/25, 7/26/25, 7/30/25, and 7/31/25 on the day shift. On 7/15/25 7/26/25, 7/27/25 and 7/29/25 on the evening shift. On 7/25/25, 7/28/25, 7/29/25, and 7/30/25 on the night shift. Preventative mattress on 7/26/25, 7/30/25, and 7/31/25 on the day shift. On 7/26/25, 7/27/25, and 7/29/25 in the evening shift. On 7/16/25, 7/23/25, 7/28/25, 7/29/25 and 7/30/25 on the night shift. Review of Resident #1's August 2025 Documentation Survey Report v2, a form included blank spaces indicating that the task, were not completed as follows: Personal hygiene on 8/2/25, 8/8/25, 8/9/25, 8/13/25, and 8/15/25 on the day shift, and 8/10/25 on the evening shift. On 8/1/25, 8/3/25, 8/11/25 and 8/14/25 on the night shift. Turn and reposition every 2 hours on 8/2/25, 8/4/25, 8/12/25, 8/15/25, and 8/19/25 on the day shift. On 8/2/25, 8/8/25, 8/9/25, 8/13/25 and 8/15/25 on the evening shift. On 8/1/25 and 8/10/25 on the night shift. Bladder Continence on 8/2/25, 8/8/25, 8/9/25, 8/13/25 and 8/15/25 on the day shift. On 8/1/25, and 8/10/25 on the evening shift. On 8/1/25, 8/3/25, 8/11/25 and 8/14/25 on the night shift. Bowel continence and movement on 8/2/25, 8/8/25, 8/9/25, 8/13/25, and 8/15/25 on the day shift. On 8/1/25, and 8/9/25 on the evening shift. On 8/1/25, 8/3/25, 8/11/25 and 8/14/25 on the night shift. Roll left and right on 8/2/25, 8/8/25, 8/9/25, 8/13/25, and 8/15/25 on the day shift. On 8/1/25, and 8/10/25 on the evening shift. On 8/1/25, 8/3/25, 8/11/25 and 8/14/25 on the night shift. Preventative mattress on 8/2/25, 8/8/25, 8/9/25, and 8/13/25 on the day shift. On 8/1/25, and 8/10/25 on the evening shift. On 8/1/25, 8/3/25, and 8/11/25 on the night shift. On 10/23/25 at 10:17 AM, an interview was conducted with the CNA who stated that the residents who were in bed and are incontinent of bowels and bladder are turned and positioned every 2 hours. The CNA further stated that the nurse provided a report to the CNAs identifying which residents were to be turned and positioned. On 10/23/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON), who stated, if it is not documented it is not done. The DON further stated that both the nurses and the CNAs were responsible for completing the ADL documentation, and that it was important to document that the care was being provided as required. The DON also reported that the Assistant Director of Nursing (ADON) and the nurse manager were responsible for auditing ADL documentation to ensure completion. 2. A review of the admission Record (AR) revealed that Resident #2 was admitted to facility with diagnoses that included but were not limited to; heart failure, muscle weakness and morbid obesity. Review of Resident #2's June 2025 Documentation Survey Report v2, a form included blank spaces indicating that the task, were not completed as follows: Personal hygiene on 6/4/25 and 6/28/25 on the day shift. On 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/7/25, 6/8/25, 6/13/25, 6/14/25, 6/16/25, 6/20/25, 6/21/25, 6/22/25, 6/24/25, 6/26/25,6/27/25, 6/28/25, 6/29/25 and 6/3025 on the evening shift. On 6/30/25 on the night shift. Turn and reposition every 2 hours on 6/1/25 on the day shift. On 6/4/25, and 6/28/25 on the evening shift. On 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/11/25, 6/13/25, 6/14/25, 6/16/25, 6/20/25, 6/21/25, 6/22/25, 6/24/25, 6/26/25, 6/27/25, 6/28/25, 6/29/25, and 6/30/25 on the night shift. Bladder continence on 6/4/25 and 6/28/25 on the night shift. On 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/7/25, 6/8/25, 6/13/25, 6/14/25, 6/16/25, 6/20/25, 6/21/25, 6/22/25, 6/24/25, 6/26/25,6/27/25, 6/28/25, 6/29/25 and 6/3025 on the evening shift. On 6/30/25 on the night shift. Bowel continence and movements on 6/4/25 and 6/28/25 on the day shift. On 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/7/25, 6/8/25, 6/13/25, 6/14/25, 6/16/25, 6/20/25, 6/21/25, 6/22/25, 6/24/25, 6/26/25,6/27/25, 6/28/25, 6/29/25 and 6/3025 on the evening shift. On 6/30/25 on the night shift. Roll left and right on 6/4/25 and 6/28/25 on the day shift. On 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/7/25, 6/8/25, 6/13/25, 6/14/25, 6/16/25, 6/20/25, 6/21/25, 6/22/25, 6/24/25, 6/26/25,6/27/25, 6/28/25, 6/29/25 and 6/3025 on the evening shift. On 6/30/25 on the night shift. Preventative mattress on 6/4/25 and 6/28/25 on the day shift. On 6/2/25, 6/3/25, 6/4/25, 6/5/25, 6/7/25, 6/8/25, 6/13/25, 6/14/25, 6/16/25, 6/20/25, 6/21/25, 6/22/25, 6/24/25, 6/26/25,6/27/25, 6/28/25, 6/29/25 and 6/3025 on the evening shift. On 6/30/25 on the night shift. Review of Resident #2's July 2025 Documentation Survey Report v2, a form included blank spaces indicating that the task, were not completed as follows: Turn and reposition every 2 hours on 7/3/25 and 7/725 on the day shift. On 7/5/25 on the evening shift. On 7/1/25, 7/4/25, 7/5/25, 7/6/25, and 7/9/25 on the night shift. Bladder continence on 7/29/25 on the day shift. On 7/1/25, 7/4/25, 7/5/25, 7/6/25, 7/9/25, 7/21/25, and 7/25/25 on the evening shift. On 7/2/25 and 7/6/25 on the night shift. Bowel continence and movements on 7/29/25 on the day shift. On 7/1/25, 7/4/25, 7/5/25, 7/6/25, 7/9/25, 7/21/25, and 7/25/25 on the evening shift. On 7/2/25 and 7/6/25 on the night shift. On 10/23/25 at 10:17 AM, an interview was conducted with the CNA who stated that the residents who were in bed and are incontinent of bowels and bladder are turned and positioned every 2 hours. The CNA further stated that the nurse provided a report to the CNAs identifying which residents were to be turned and positioned. On 10/23/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON), who stated, if it is not documented it is not done. The DON further stated that both the nurses and the CNAs were responsible for completing the ADL documentation, and that it was important to document that the care was being provided as required. The DON also reported that the Assistant Director of Nursing (ADON) and the nurse manager were responsible for auditing ADL documentation to ensure completion. A review of the Charting and Documentation Policy and Procedure with a revised date of July 2021, revealed under Policy Interpretation and Implementation 3. Documentation in the medical record will be objective, complete and accurate. NJAC 8:39, 27.2(b), (h).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2641999, 2562115 Based on interview and record review and review of other pertinent facility documents on 10/23/25, it was determined that the facility failed to ensure that the nursing services were provided and documented consistently on the Treatment Administration Record (TAR) in accordance with professional standards of practice. This deficient practice was identified for 2 of 3 residents reviewed for standards of practice (Resident #1, Resident #2).The evidenced was as follows: Reference: 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 otherwise legally authorized Physician or Dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to morbid obesity, osteoarthritis, muscle weakness, and difficulty walking. A review Resident #1's comprehensive Minimum Data Set (MDS) dated [DATE], an assessment tool revealed that the resident had a Brief Interview Mental Status (BIMS) score of 14 out of 15, indicating that the resident's cognition was intact. A Review of the June 2025 TAR revealed blanks for the following treatments: Boudreauxs butt paste ointment 16% (zinc oxide), apply to sacrum topically every shift for wound prevention, skin care status post hygienic cleanse, pat dry and apply butt paste was blank on 6/8/25 on the 7:00 AM shift and was blank on 6/30/25 on the 3:00 PM shift. Lac-Hydrin Five External Lotion 5% (lactic acid ammonium lactate) Apply to bilateral feet topically every shift for dry skin, was blank on 6/8/25 on the 7:00 AM shift and was blank on 6/30/25 on the 3:00 PM shift. Turn and reposition every 2 hours, every shift was blank on 6/8/25 on the 7:00 AM shift, and on 6/30/25 on the 3:00 PM shift. A Review of Resident #1's TAR revealed blanks for the following: Boudreauxs butt paste ointment 16% (zinc oxide), apply to sacrum topically every shift for wound prevention, skin care sp [status post] hygienic cleanse, pat dry and apply butt paste was blank on 7/24/25 on the 7:00 AM shift. Gel cushion every shift check placement was blank on 7/24/25 on the 7:00 AM shift. Heel lifts, apply to bilaterally heels when in bed every shift, check placement was blank on 7/24/25 on the 7:00 AM shift. Lac-hydrin five external lotion 5% apply to bilateral feet topically every shift for dry skin, was blank on 7/24/25 on the 7:00 AM shift. Turn and reposition every 2 hours every shift was blank on 7/24/25 on the 7:00 AM shift. Vitamins A and D ointment apply to sacrum topically every shift for wound prevention was blank on 7/24/25 on the 7:00 AM shift. Zinc oxide cream 10% apply to sacrum topically every shift for wound care was blank on 7/24/25 on the 7:00 AM shift. A Review of the August 2025 TAR revealed blanks for the following treatments: Mupirocin external ointment 2% apply to low back topically every day shift for wound care for 30 days cleanse with Normal Saline (NSS) pat dry cover with dry dressing was blank on 8/26/25 on the 7:00AM shift, and on 8/27/25 on the 7:00 AM shift. Boudreauxs butt paste ointment 16% (zinc oxide), apply to sacrum topically every shift for wound prevention, and skin care was blank on 8/26/25 on the 7:00 AM. Gel cushion every shift check placement was blank on 8/16/25 on the 11:00 PM shift. Heel lifts, apply to bilateral heels when in bed every shift check placement was blank on 8/26/25 on the 7:00 AM shift. Lac-hydrin five external lotion 5% apply to bilateral feet topically every shift for dry skin was blank on 8/26/25 on the 7:00 AM shift. Pressure relieving bed, mattress every shift check function was blank on 8/4/25 on the 3:00 PM shift. Turn and reposition every 2 hours every shift was blank on 8/26/25 on the 7:00 AM shift. Zinc oxide cream 10% apply to sacrum topically every shift for wound care was blank on 8/16/25 on the 11:00 PM shift. 2. A review of the admission Record (AR) revealed that Resident #2 was admitted to facility with diagnoses that included but were not limited to heart failure, muscle weakness and morbid obesity. A Review of the June 2025 TAR revealed blanks for the following treatments: Turn and reposition every 2 hours every shift was blank on 6/29/25 on the 7:00 AM shift. A Review of the July 2025 TAR revealed blanks for the following treatments: Turn and reposition every 2 hours every shift was blank on 7/15/25 on the 7:00 AM shift. On 10/23/25 at 10:54 AM the surveyor interviewed the Unit Manager (UM) who stated that nurses documented on the TAR each shift. The UM further stated that the residents were turned and positioned. On 10/23/25 at 2:33 PM, an interview was conducted with the Director of Nursing (DON) who stated that the nurses documented in the TAR after completing the resident's ordered treatment. The DON further revealed that the nurses also documented in the nursing progress notes. A review of the facility's policy Charting and Documentation Policy and Procedure with a revision date of July 2021 revealed in the Policy Interpretation and Implementation revealed that Documentation in the medical record will be objective, complete, and accurate. NJAC 8:39-3.2(a)(b)

Complaint #: NJ00185165
Based on interviews, medical record reviews, and review of other pertinent facility documents on 04/08/25, it was determined that the facility's Director of Social Services (DSS) failed assist a resident in obtaining needed community services, as required by the Job Description for Social Services Director. The DSS also failed to follow the facility's Discharge Policy policy for 1 of 3 residents (Resident #2). This deficient practice was evidenced by the following:
Review of the Electronic Medical Records (EMRs) is as follows:
The surveyor reviewed the admission Record of Resident #2 which revealed that the resident was admitted to the facility 02/2025 with diagnoses that included but not limited to: Spinal stenosis, Alzheimer's Disease, fall from bed, muscle weakness and difficulty walking.
A review of Resident #2's admission Minimum Data Set (MDS) (an assessment tool) dated 03/28/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. The Functional Status portion of the assessment specified that the resident required supervision or touching assistance to transfer and ambulate with a walker. Additional active diagnoses noted on the assessment included: history of falling and repeated falls.
A review of Resident #2's Care Plan (CP), with a focus that was initiated on 2/20/25, showed [Resident #2] wishes to be discharged to their home. The interventions included but were not limited to: Make arrangements with required community resources to support independence post-discharge i.e. Home care, PT/OT, MD, Wound Nurse; Provide needed assistance with community services upon discharge to community.
A review of the Order Summary Report (OSR), Resident #2 had an order to discharge to home with VNS/PT/OT, (Visiting Nursing Services/Occupational Therapy /Physical Therapy), dated 3/27/25.
The Surveyor reviewed in Progress notes a Interdisciplinary Team (IDT) note written by the Director of Social Service (DSS) on 3/28/25 at 1:08 PM. The note indicated [Resident #2] was discharged to [Boarding Home] located at SW spoke to [Resident #2's family member] via telephone, [Resident #2's family member # .], prior to setting up Uber transport to notify of [Resident #2's] discharge location. [Resident #2's family member] was also informed that [Resident #2] was not appropriate for LTC due to not meeting LTC criteria. [Family member] verbalized understanding.
No further documentation was provided regarding discussions on discharge to boarding home prior to time of discharge.
During an interview with DSS on 4/08/25 at 3:29 PM, he revealed that VNS/PT/OT services were not initiated as ordered. He further stated that even though VNS/PT/OT services are ordered, does not necessarily mean that the resident needs those services. The DSS further revealed VNS/PT/OT do not usually provide services in boarding homes or shelters, and he was not sure which facilities would accommodate the ordered services due to not being familiar with the area.
In a phone interview on 4/9/25 at 3:06 PM with Resident #2's Physician, he stated that he was not aware of Resident #2's discharge to a boarding home, and that the VNS/PT/OT services were not initiated according to his orders. He further stated, he expects staff to follow the Physician orders, and for the staff to find appropriate facilities to accommodate VNS/OT/PT services.
Review of the Job Description for Social Services Director revealed the following: Under the heading Position Summary, The Social Service Director is responsible for planning and administering social service programs. He/she supervises nursing home social workers and assists in developing facility policies regarding participation in community planning for health and welfare services. The Social Services Director plans and assists in research projects and is responsible for discharge planning/community resources. Under the heading titled, Responsibilities/Accountabilities, included but not limited to: .4. Assures medically related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating, ambulating, etc.) and mental and psycho social needs (e.g., sense identify, coping abilities, and sense of meaning and purpose .14. Coordinates discharge planning, including the development of an organized discharge plan for all residents; .16. Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individual's needs and rights .
Review of the facility policy titled Discharge Policy last reviewed on 1/2025 indicated the following: Under the heading titled, Policy statement, revealed When a resident's discharge is anticipated, a discharge plan, summary and instructions will be developed to assist the resident to adjust to his/her new living environment. Under: Policy Interpretation and Implementation .2. The discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family. 3. The Social Services Department will review the discharge plan with the resident and family before the discharge is to take place .
N.J.A.C. 8.39-39.4 (f)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ 185165
Based on observation, interview, record review and review of other facility documentation on 4/08/25 and 4/15/25, it was determined that the facility failed to implement and document an effective discharge plan to ensure a safe and effective transition of care for 1 of 3 residents reviewed for discharge planning, (Resident # 2). This deficient practice was evidenced by the following:
The surveyor reviewed the admission Record of Resident #2 which revealed that the resident was admitted to the facility 02/2025 with diagnoses that included but not limited to: Spinal stenosis, Alzheimer's Disease, Repeated Falls, Muscle Weakness and Difficulty Walking.
A review of Resident #2's admission Minimum Data Set (MDS) (an assessment tool) dated 03/28/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident was cognitively intact. The Functional Status portion of the assessment specified that the resident required supervision or touching assistance to transfer and ambulate with a walker. Additional active diagnoses noted on the assessment included: history of falling and repeated falls.
Resident #2's Care Plan (CP), with a focus that was initiated on 2/20/25, showed [Resident #2] wishes to be discharged to their home. The interventions included but were not limited to: Make arrangements with required community resources to support independence post-discharge i.e. Home care, PT/OT, MD, Wound Nurse; Provide needed assistance with community services upon discharge to community.
A review of the Order Summary Report (OSR), Resident #2 had an order to discharge to home with VNS/OT/POT, (Visiting Nursing Services/Occupational Therapy /Physical Therapy), dated 3/27/25.
The surveyor reviewed a document titled, PT Discharge Summary, with dates of service 2/20/25-3/18/25, revealed under discharge recommendations: 24 Hour care.
The Surveyor reviewed a document titled Discharge Instructions Form with date of discharge on [DATE], however, was signed by Resident #2 on 3/28/25, revealed Resident was to be discharged to home with family.
The surveyor reviewed in Progress notes a Interdisciplinary Team (IDT) note written by the Director of Social Service (DSS) on 3/28/25 at 1:08 PM. The note indicated [Resident #2] was discharged to [Boarding Home] located at SW spoke to [Resident #2's family member] via telephone, [Resident #2's family member # .], prior to setting up Uber transport to notify of [Resident #2's] discharge location. [Resident #2's family member] was also informed that [Resident #2] was not appropriate for LTC due to not meeting LTC criteria. [Family member] verbalized understanding.
Surveyor reviewed an email that was provided by the Director Admissions (DA) dated 3/17/25 at 1:01 PM, that she had sent to the DSS, Director of Nursing (DON), and LPN/Regional Clinical Reimbursement Specialist (RCRS). The email stated Resident #2's Case Manger (CM), requested for Resident #2 to remain in facility for LTC and that the CM would assist with a custodial authorization.
There was no further documentation provided on the discussion of Resident #2's discharge.
In a phone interview on 4/8/25 at 12:06 PM with the CM with Resident #2's insurance company, she stated that due to Resident #2 being a fall risk and having a diagnosis of Alzheimer's Disease that Resident #2's discharge would be unsafe, and that they would provide a custodial authorization so Resident #2 could remain in facility while she would find placement. She further stated that she spoke with the DSS prior to Resident #2's discharge on [DATE]. CM stated that Resident #2 was re-admitted into the hospital on 4/1/25.
On 4/8/25 at 12:32 PM, in an interview with the DSS, he stated that Resident #2 was not able to be discharged back home, and placement was found with a boarding home. The DSS stated that he does not make the decision regarding discharges, the discharges are discussed at the Utilization Review (UR) meeting, and Resident #2's discharge was discussed at the UR meeting. He stated that he does not recall a request for a custodial authorization.
In a phone interview on 4/8/25 at 2:22 PM with LPN/RCRS, she stated that she is familiar with discussions of Resident #2 during the UR meetings. She stated that on 3/25/25, the UR team discussed discharge due to resident meeting prior level of function. She stated that she was not familiar with the discussion to the boarding home, and that the last time the discharge location was discussed was on 3/11/25 and Resident #2 was going to be discharged home with family member. She does not recall an email that was sent from the DA for a request of custodial authorization.
During an interview with DSS on 4/08/25 at 3:29 PM, he revealed he was aware of the order for VNS/PT/OT services, however, the VNS/PT/OT services were not initiated for Resident #2 as ordered. He further stated that even though VNS/PT/OT services are ordered, it does not necessarily mean that the resident needs those services. The DSS further revealed VNS/PT/OT do not usually provide services in boarding homes or shelters, and he was not sure which facilities would accommodate the ordered services due to not being familiar with the area.
In a phone interview on 4/8/25 at 3:45 PM, with the Executive Director of the [Boarding Home], she stated that she was familiar with Resident #2 and was present when they arrived at the boarding home. She stated that a criterion to be admitted into their boarding home is the resident must be independent.
In an interview with the DON on 4/8/25 at 2:40 PM, she stated that all discharges are discussed in the Interdisciplinary Team meetings as well as the Utilization Review meetings. She stated that Resident #2's discharge was discussed in the UR meeting, and due to the resident being independent, the resident no longer fit the criteria to remain in the facility.
In an interview with a Certified Nursing Assistant (CNA) on 4/8/25 at 5:21 PM, she stated Resident #2 was extensive assist with Activities of Daily Living (ADLs). She further stated that Resident #2 was unsteady on his feet, and stated the residet would self-propel with a wheelchair or stand and walk holding onto the wheelchair.
In exit interview on 4/8/25 at 5:37 PM with DON, Administrator, Regional Clinical Quality Assurance Nurse, the DON stated that discharges are discussed in UR meetings, and that Resident #2 was alert and ambulatory at time of discharge. Surveyor requested for UR meeting documentation where the discharge was discussed, but no UR documentation was provided.
In a phone interview on 4/9/25 at 3:06 PM with Resident #2's Physician, he stated that he was not aware of Resident #2's discharge to a boarding home, and that the VNS/PT/OT services were not initiated according to his orders. He further stated, he expects staff to follow the Physician orders, and for the staff to find appropriate facilities to accommodate VNS/OT/PT services.
The surveyor reviewed the facility policy, Discharge Planning (Effective 10/2018), last reviewed on 1/2025 which revealed the following:
Under the heading titled, Policy Interpretation and Implementation: 1. When the facility anticipates a resident's discharge a discharge plan, summary and instructions will be developed which will assist the resident to adjust to his or her new living environment. 2. The discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family. 3. The Social Services Department will review the plan with the resident and family before the discharge is to take place
NJAC 8:39-5.4(b)(c); 39.1

Based on interview and document review it was determined that the facility failed to ensure that a Surety Bond was in place to protect all resident funds held by the facility. This deficient practice affected all residents who maintained a Personal Needs Account with the facility and was evidenced by the following:
On 01/15/25 at 2:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the facility's surety bond and a list of all the resident funds held by the facility.
On 01/15/25 at 2:37 PM, the LNHA provided a copy of a Certificate of Liability Insurance Date: 01/15/2025 (the survey entrance date) with Crime- Including Burglery listed as the type of insurance coverage provided. The surveyor questioned the LNHA regarding the policy that he provided and he stated, this is what they (corporate oversight) gave me.
A review of the Funds Balance Report for 01/15/2025 revealed a list of eighty five active resident names with a balance of $84, 036.27 Due to patients.
On 01/17/25 at 8:38 AM, the surveyor asked the LNHA about the residents funds and if they were kept in interest bearing accounts. The LNHA stated that information was not kept at the facility, and I'm still working on it, I will have it later this morning. The surveyor again, asked about the surety bond and showed the document to the LNHA that was titled Certificate of Liability, and asked if there was another document. The LNHA stated, no, that is what the facility used, and he confirmed he was told by the corporate management staff.
NJAC 8:39-9.5c(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 177957, # NJ 180392
Based on interviews, record review, and pertinent facility documents provided by the facility from 01/15/25 through 1/22/25, it was determined that the facility failed to notify the family/responsible party when a resident (Resident #264) had a change in condition and required transport to the emergency room. This deficient practice occurred for 1 of 1 closed medical records reviewed for resident (Resident #264) who had a change in condition. The deficient practice was evidenced by the following:
According to Resident #264's admission Record, the Resident was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Acute and chronic respiratory failure hypoxia, Epilepsy, tracheostomy status and dependence on respiratory ventilators.
The Discharge assessment dated [DATE], reflected that Resident #264 was severely cognitively impaired and totally dependent on staff for all activities of daily living (ADLs).
Review of Resident #264's Care Plan (CP) initiated 2/27/2024, revealed the following: Under Focus: The resident is at risk for falls related to poor safety awareness, impaired balance, poor trunk control side effects of medication and non verbal. Mechanical lift transfer. Under Goal: The resident will be free of falls. Under Interventions: Mechanical lift transfer x 2 assist, initiated 2/27/2024.
Further review of Resident #264's CP initiated 08/13/2024, revealed the following: under Focus, at risk for bleeding related to anticoagulation therapy related to Atrial Fibrillation, Under Goal, resident will be free from adverse reactions of signs and symptoms of bleeding related to anticoagulation therapy.
Review of an 11/06/24 Progress Notes (PN) timed 11:13 AM, written by the Respiratory Therapist, revealed the following: Resident received in recliner chair, on [NAME] vent setting: AC18/350/40%/P+5. Alarm on and audible functional. Trach [name redacted] in placed, secured midline and airway patent. Suction with scanty secretion. No respiratory distress noted. Will continue to monitor.
Review of Resident #264's PN written by the Respiratory Therapist on 11/6/2024 at 4:53 PM, revealed that the resident was in bed, and had no bruises.
Review of a PN dated 1/06/2024, at 9:30 PM, written by the Registered Nurse (RN), revealed that the resident representative came to visit and reported at 9:15 PM that Resident #264 had a hematoma (collection of blood) to the the right eye and ecchymosis (bruise) to the facial area measuring 16 centimeters (cm) x 10 cm. In addition, the RN revealed that staff provided care to Resident #264 at 5:00 PM, and did not report any discoloration or concerns.
Review of Resident #264's medical records showed no documentation that the resident had a bruise to the right facial area, and a hematoma to the right eye prior to the 11/06/24 at 9:30 PM. The medical records did not reveal how Resident #264 acquired the bruise to the right facial area and the hematoma to the right eye, or that the resident's family and responsible party was notified.
Review of Resident #264's Incident Report (IR) dated 1/06/24 at 9:30 PM, revealed the following:
Resident representative reported hematoma and bruise to the right facial area. The Nurse Practitioner was called and ordered to transfer Resident #264 to the hospital for evaluation.
Further review of Resident #264's IR dated 11/6/24 at 9:59 PM, showed that the Physician was notified of the incident at 9:20 PM when the resident representative reported the incident. Based on the nurse's statement and a phone interview conducted on 1/21/25 at 1:20 PM, with the nurse, the Certified Nursing Assistant (CNA) did not report the incident. The RN stated during the interview that, a resident family is notified whenever a resident has a fall or any incident, it does not have to be a fall with injury. The RN stated that she was very concerned and could not explain why the CNA did not report the incident immediately. The nurse was made aware of the incident at 9:15 PM, 5 hours later. The Director of nursing (DON) classified the incident as a significant event and reported the incident on 11/06/24 at 11:18 PM, to the Department of Health.
Review of the Jersey Universal Transfer Form (NJUTF) dated 11/06/24, revealed the resident was transferred to the hospital. The reasons for transfer was right eye swelling with discoloration.
On 1/22/25 at 10:15 AM, the surveyor conducted a face to face interview with the CNA who was assigned to Resident #264 on 11/6/24. When asked if she had reported the bruise to the nurse immediately, she presented some conflicted stories, she stated that the night was very chaotic, she could not remember the time she reported the incident. The surveyor then asked if she remained in the room until the resident was assessed by the nurse. She replied, No . The CNA Confirmed that she transferred Resident #264 in bed between 3:00 PM-5:00 PM. She observed the bruise after executing the transfer and stated the bruise was identified and reported to the nurse by the resident representative five hours later at 9:15 PM.
Resident #264 was transferred to the hospital and diagnosed with traumatic hematoma of the right orbit.
During an interview with the Director of Nursing (DON) on 1/16/25 at 11:30 AM, the surveyor reviewed the statements written by all the staff involved in the residents care over the last 24 hours from the incident. The DON stated that she noticed the discrepancies but did not want to ask staff to change their statements.
The resident representative (RR) contacted the surveyor on 1/23/24 at 3:10 PM, and the expressed concerns over not being informed of the incident prior to finding the bruise. The RR stated Resident #264 was transferred to another facility.
Review of the facility's policy titled, Notification of Changes with a revised date of 1/2025, included but was not limited to the following: Under Policy Statement: It is the policy of this facility to immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: An accident involving the residents which results in injury and has the potential for requiring physician interventions Significant change in the residents's physical, mental, or psychological status. A decision to transfer or discharge the resident from the facility.
N.J.A.C: 8:39-13.1(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to maintain safe handrails on 1 of 5 Resident Units. This deficient practice was evidenced by the following:
On 1/15/25 at 9:53 AM, the surveyor toured the 3rd floor and observed the following:
Outside of room [ROOM NUMBER], the corner handrail was not securely connected to the next piece of handrail.
Outside of room [ROOM NUMBER], the handrail was cracked.
By the soiled linen room, the handrail was not secure.
Across from room [ROOM NUMBER], the handrail was not secure to the wall.
Outside of room [ROOM NUMBER], the handrail was not connected to the next piece.
In the out cove by the telephone for resident use, the handrail was not secure to the wall.
Outside of room [ROOM NUMBER], the handrail was cracked and not secure.
Outside of room [ROOM NUMBER], the corner piece of handrail was loose from the connecting piece.
On 1/15/25 at 10:00 AM, a maintenance worker was on the 3rd Floor Unit. The maintenance worker stated that maintenance staff was responsible for checking the handrails. He further stated that the handrails should all be connected, and he confirmed that the handrails observed on the 3rd floor were not safe or secure.
On 1/16/25 at 11:06 AM, the surveyor observed that the 3rd Floor Unit handrails were in the same condition as observed on 01/15/25 and were not fixed .
On 1/16/25 at 11:41 AM, the surveyor reviewed the 3rd floor Maintenance Log. There was one page with two entries dated 1/13/25, but there was no entry on 01/15/25 when the handrails were identified as needing to be repaired and secured.
On 1/16/25 at 11:45 AM, the Registered Nurse Unit Manager (RN/UM) on the 3rd floor stated she had entered the handrails into the maintenance log. The RN/UM stated maintenance knew about the handrailsdays ago, but that the other pages in the logbook related to the handrails appeared to have been removed.
On 1/16/25 at 12:06 PM, two maintenance staff entered the conference room in the presence of two surveyors. One maintenance staff stated that the 3rd floor was a Dementia Unit, and the residents tear the handrails out all the time. The surveyor asked if there was a process in place to address his concerns that the residents tear the handrails out, and the maintenance staff stated, no, but that would be good.
On 1/21/25 at 11:16 AM, the surveyor requested a policy and procedure regarding the maintenance of the handrails from the facility. The facility provided a policy, Maintenance Repairs and the surveyor was informed that there was no policy or procedure for the handrails.
A review of the facility provided policy, Maintenance Repairs revised 1/2025, included but was not limited to; Policy: maintain a safe, clean, and functional environment for residents . through timely repairs, routine maintenance, and room inspections. Procedure: 1. The maintenance department is responsible for conducting routine checks, repairs and inspections throughout the facility. 7. Maintenance performs routine checks of . hallways .
On 1/23/25 at 11:32 AM, the above concerns were presented to the facility administration.
NJAC 8:39-31.2(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 180392
Based on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was completed to determine the causal factor of an injury of unknown origin to ensure that resident abuse or neglect had not occurred for a resident (Resident #264) who was in a persistent vegetative state (disorder of consciousness caused by brain damage), dependent on staff for all care, and required a mechanical ventilator for breathing. Resident #264 was found on 11/06/24, with a hematoma (blood filled injury) to the right eye, and ecchymosis (a bruise) to the right facial area measuring 16-centimeter (cm) x 10 cm. Resident #264 was transferred to the emergency room on [DATE], and was diagnosed with traumatic hematoma of the right eye. The deficient practice was identified for 1 of 2 residents reviewed for accidents and evidenced by the following:
On 01/21/25 at 10:00 AM, the surveyor reviewed the closed electronic medical record for Resident #264.
According to the admission Record, Resident #264 was admitted to the facility with diagnoses which included, but were not limited to; acute and chronic respiratory failure, hypoxia, Epilepsy, tracheostomy status and dependence on respiratory ventilators.
A review of Resident #264's Quarterly Minimum Data Set (an assessment tool used to facilitate the management of care) dated 09/04/24, reflected that the resident was coded as being Comatose and yes to being in a persistent vegetative state/ no discernible consciousness. Resident #264 was totally dependent on staff for all care.
A review of Resident #264's Care Plan (CP) included a Focus Initiated: 02/27/24 for being at risk for falls related to poor safety awareness, impaired balance and poor trunk control, side effects of medications, non-verbal, and required mechanical lift transfers. Interventions included to use mechanical lift for transfers with two persons assisting with the transfer.
The Progress Notes revealed an Interdisciplinary Team (IDT) Note dated 11/06/24 at 10:20 PM, which revealed: Made aware by CNA (Certified Nurse Aide) that Resident #264 was noted with discoloration and swelling of the right eye. NP (Nurse Practitioner) notified. Per NP send Resident #264 out to hospital for further evaluation and treatment. Report given to the nurse, Resident Representative (RR)was at bedside.
A review of the IDT Progress Note dated 11/06/22 at 10:22 PM, revealed: Transportation arranged with the Hospital (name redacted) Emergency Services.
Further review of the IDT Progress Note dated 11/07/24 at 8:05 PM revealed: Follow up to emergency room. Resident was admitted with diagnoses traumatic hematoma to right orbit (eye socket).
On 1/16/25 at 10:30 AM, the surveyor reviewed the facility's investigation and the Reportable Event Record received by the Department of Health on 11/08/24. There was no causal factor identified for the injury and the statements attached to the incident report contained the following discrepancies:
CNA #1 who provided care to Resident #264 on 11/06/24, provided two statements which revealed the following:
The first statement dated 11/06/24, CNA #1 documented that on 11/06/24, that she put [Resident #264] in bed and found the resident with a black eye to the right side of the face and reported to the nurse. Signed CNA #1, 3:00 PM-11:00 PM shift [Prior to the mechanical lift transfer].
The second statement dated 11/06/24, CNA #1 documented that on 11/06/24, in the evening I put resident back in bed with mechanical lift. Resident was sitting in recliner chair and we assisted back to bed lying on left side. Once back in bed. I noticed resident had redness to face by eye. I reported discoloration to the nurse [After the mechanical lift transfer].
The surveyor reviewed the statement provided by CNA #2 who documented that on 11/06/24, in the evening I assisted my co-worker to place resident [#264] back into bed with the mechanical lift. Resident was sitting in the recliner chair and we assisted back to bed lying on left side. Once back in bed I noticed resident had redness to face by eye. The assigned CNA reported the discoloration to the nurse.
Review of the Registered Nurse's (RN) statement dated 11/6/24 at 9:15 PM, documented that they worked the 3:00 PM to 11:00 PM shift on the 2nd floor ventilator unit (a unit with residents that are dependent on a mechanical breathing machine) and was assigned to the Resident in room [ROOM NUMBER]. At 3:00 PM, I made rounds and the resident was sitting in recliner chair along the bedside and did not notice any changes to [Resident #264]. At 5:00 PM, resident was provided care and placed back to bed by CNA. At approximately 8:30 PM, Resident's family came to the unit to provide care for her parent. At 9:15 PM, Resident #264's family member informed me that the resident was noted with a hematoma and swelling of the right eye.
On 1/17/25 at 8:52 AM, the surveyor interviewed the Respiratory Therapist (RT) who confirmed that two staff members had to be in the room to transfer a ventilator dependent resident from the bed to the recliner chair. The RT confirmed that on 11/06/24, he had assisted CNA #3 with the transfer from the bed to the recliner chair during the day shift (7:00 AM to 3:00 PM), and confirmed that there was no injury observed. The RT informed the surveyor that on 11/06/24 at 4:53 PM, he observed Resident #264 in bed and did not assist with the transfer back to the bed, and he was not made aware of the injury to the resident's eye.
On 01/17/25 at 11:59 AM, the surveyor reviewed the facility provided incident report, including the statements attached, with the Director of Nursing (DON). The DON stated that she was aware of the discrepancies in CNA #1's statements, and could not provide any rationale for not clarifying the discrepancies prior to submitting the investigation to the Department of Health (DOH). The DON stated, there was a misunderstanding and miscommunication about the investigation. The DON stated she had understood Resident #264 sustained the injury during the transfer, and then stated that Resident #264 possibly hit the right eye on the mechanical lift.
On 01/17/25 at 12:05 PM, the surveyor conducted a second interview with the RT. The RT was on duty that day and stated that one nurse and one CNA were supposed to transfer any resident out of the bed and then back to bed if the resident was using a mechanical ventilator (machine that moves air in and out of the lungs to assist with breathing). The RT stated that some CNAs worked as floaters (worked on various units) to the unit and they had not been trained to transfer residents with the ventilator attached. The RT stated, for safety reasons, a nurse had to be in the room to assist with the transfer, or if the nurse could not assist, she would then delegate the task to the respiratory therapist who would supervise the transfer of the ventilator dependent resident. When asked if there was a policy for transferring a resident who used a ventilator, he stated, this is the norm, not too sure if there is a policy. Based on the documents provided by the facility, which included the Incident Report, Reportable Event Record, Investigative Summary, Skin Assessment and Impairment Form and Statements, there was no documented evidence that the RN or the RT assisted CNA #1 with the transfer of Resident #264 as explained by the RT as being the standard protocol for transferring a ventilator dependant resident when the injury was observed on 11/06/24.
On 1/21/2025 at 1:09 PM, the surveyor interviewed the RN who worked and cared for Resident #264 on 11/06/24. The RN stated that CNA #1 did not report the injury to her and stated the resident representative visited at 9:15 PM and reported the injury. The RN stated once she was made aware, she attended to the injury by measuring the area, initiated neurological checks, applied ice compresses, monitored for bleeding, and notified the nursing supervisor and the NP. She then received an order to transfer Resident #264 to the hospital for further evaluation and treatment.
On 01/21/25 at 11:47 AM, the surveyor interviewed the Medical Director (MD) regarding the injury sustained by Resident #264 during the transfer. The MD stated that he was told by the DON the injury was caused by the hook from the mechanical lift and was not provided with any additional information.
In the summary provided to Department of Health along with the Reportable Event Record, the DON indicated that Resident #264 had periods of involuntary movements related to hypoxia and seizure disorder as well as cough spasms. The Interdisciplinary Team concluded that the resident during transfer may have coughed or had involuntary movement and may have leaned into [Resident #264] mechanical lift cross- bar. Interviews with staff familiar with the resident routine revealed that the resident was immobile.
On 1/22/24 at 10:15 AM, two surveyors conducted an in person interview with CNA#1 who stated that she recalled the incident, and she confirmed that she observed the injury after transferring Resident #264 in bed. When asked if she remained in the room with the resident and waited for the nurse to come and assess the injury, CNA #1 stated she had too much to do that day, and she moved on and attended to other residents. The surveyor then inquired regarding the 2nd statement, CNA #1 read the statement and stated, another co-worker coached her to write the second statement, but she did not observe any injury to the resident face and right eye while the resident was sitting in the chair.
On 1/22/24 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2 (whom CNA #1 claimed assisted with the transfer for Resident #264). CNA #2 stated that when she entered the room, [Resident #264] was in the room and on the mechanical lift alone with CNA#1. She then observed the facial bruise and advised CNA #1 to report the injury to the nurse. When asked if she had assisted CNA #1 with care she stated, No, I left the room and continued with my assignment.
On 1/22/25 at 1:15 PM, the surveyor interviewed CNA #3 assigned to the 7:00 AM- 3:00 PM shift regarding Resident #264's care. CNA #3 stated that she cared for Resident #264 daily, Resident #264 was immobile, had poor trunk control, and required two persons assist with transfer. CNA #3 further stated that on 11/06/2024, she transferred Resident #264 to the recliner chair with the Respiratory Therapist. During the day she periodically checked Resident #264 and no injury was noted to the right eye.
On 1/23/25 at 10:56 AM, the surveyor reviewed the investigation with the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The LNHA stated that in reviewing the RN's statement and the investigation, he could see there was some discrepancies. The LNHA added the investigation was not concise and thorough, and that his expectation was that the facility would thoroughly investigate injuries of unknown origin.
On 1/23/25 at 1:30 PM, during the exit conference no additional information was provided.
On 1/23/25 at 2:30 PM, the RR for Resident #264 contacted the surveyor and stated the that the facility informed them that they could not determine how the injury occurred.
On 02/05/25 at 12:30 PM, the surveyor reviewed the Hospital records for Resident #264's transfer to the Emergency Department on 11/06/24. The records revealed a physician note dated 11/07/24 at 7:58 AM which documented: Patient presented to the Emergency Department for recently noticed orbital trauma. Clinical Impression: Final Diagnosis: Suspected Elder Abuse, Initial Encounter; Traumatic Hematoma of Right Orbit, Initial Encounter.
A review of the facility titled, Abuse Prevention Program last revised 1/2025, under identification indicated the following: All residents sustaining bruises, skin tears, any marks of the skin, and any fractures or injuries, which are of unknown origin, shall be identified as potential abuse incidents and investigated as such.
NJAC 8:39 4.1 (a)(5), 27.1(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.) On 1/22/25 at 11:27 AM, during an interview with Surveyor #2, the MDS coordinator stated the process to perform MDS review would be that she would review the Progress Notes (PN), medications and would interview residents to collect the information needed for MDS'. She further stated she was responsible for the information in the MDS and that it was, important to truly reflect resident status.
On 1/22/25 at 12:24 PM, Surveyor #2 reviewed the closed record for Resident #26 which documented the following:
The AR revealed that Resident #26 was admitted with diagnoses which included but were not limited to; chronic pain syndrome, anxiety, and dependence on renal dialysis (the process of filtering waste from the blood when the kidneys are not functioning).
The PN dated 10/17/24, documented a discharge summary and noted the resident was discharged home today.
The most recent MDS in the electronic medical record was dated 09/02/24 and was an admission assessment.
On 1/23/25 at 11:32 AM, the concern was presented to the facility administration.
On 1/23/25 at 12:31 PM, the facility provided an MDS documenting Resident #26's discharge on [DATE] that was dated as completed after surveyor inquiry on 01/22/25.
A review of the facility provided policy, MDS 3.0 Assessment Process effective 01/09/25, included but was not limited to; . completed on admission, quarterly, annually, when a change in condition occurs and as per [name redacted] schedule. The purpose . is to accurately assess residents . 2. Mandatory transmission of export ready assessments will be done weekly .
NJAC 8:39-11.1, 11.2(d)(e)(g)1
Based on interview and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 36 residents (Resident #143 and Resident #26) reviewed for accuracy of MDS coding.
The deficient practice was evidenced as follows:
On 1/15/25 at 9:39 AM, during initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room, No Smoking (in red), Piped in Oxygen in Use. Upon entrance to Resident #143's room, the surveyor observed the resident watching television (TV) in bed. The surveyor observed a pack of cigars on the table next to the resident and asked the resident what that was. The resident took a cigar out of the case and stated it's a cigar while showing it to Surveyor #1.
On 1/16/25 at 8:50 AM, the surveyor reviewed the medical record for Resident #143.
According to the admission Record (AR), Resident #143 was admitted to the facility with diagnoses which included but were not limited to; Hypertension (high blood pressure), Heart Failure (is a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), hyperlipidemia (abnormally high levels of fats in the blood), and Diabetes mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces).
A review of Resident #143's most recent Comprehensive MDS, dated [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderately impaired cognition. The further review of the MDS revealed the resident was coded no as being a current tobacco user.
A review of Resident #143's Individualized Care Plan (CP) reflected the resident was a smoker. Interventions included Smoking contract reviewed with the resident. Resident signed updated smoking agreement on 07/09/24 and understands smoking safety procedures and hours of operation 10 AM-12:30 PM, 4:00 PM and 7:00 PM.
On 1/17/25 at 11:37 AM, during an interview with Surveyor #1 the MDS Coordinator (MDSC) stated the nurses would complete the smoking assessment on all newly admitted residents. The MDSC further stated if a newly admitted resident was a smoker, that would be coded in the Comprehensive MDS by her. The MDSC reviewed the MDS in the presence of the surveyor and confirmed the MDS was not coded that the resident was a smoker. The MDSC further stated that she should have coded Resident #143 as a smoker in section J and stated it was missed.
On 1/23/25 at 11:33 AM, the survey team met with the facility administration. The surveyor notified the facility management of the above-mentioned concerns for Resident #143.
On 1/23/25 at 2:10 PM, the survey team met with the facility administration for an Exit Conference. The facility had no additional information to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, it was determined that the facility failed to administer medication in accordance with the physician order and professional standards of nursing practice. This deficient practice was observed for one of 1 of 1 residents (Resident #60) reviewed for medications during the initial tour conducted on 01/15/25 and was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
On 1/15/25 at 8:46 AM, the surveyor observed Resident #60 sitting in a wheelchair at the bedside. The resident was awake and alert and on the bedside table, the surveyor observed a medication cup with 5 tablets inside. On the right side of the bedside table, the surveyor observed 5 vials of albuterol sulfate (medication used to treat breathing difficulties caused by asthma and other lung conditions). The surveyor then observed the nurse at the other end of the hallway. The medications in the cup were identified by the nurse as colace 100 mg (milligrams) (a stool softener), Steglator 5 mg (medication used to help lower blood sugar), lasix 40 mg (a diuretic agent), potassium chloride 40 Meq (milliequivalent - a mineral supplement used to treat or prevent low amounts of potassium in the blood), metoprolol 25 mg (medication used to treat high blood pressure).
On 1/15/2025 at 9:00 AM, the surveyor interviewed the resident regarding the medications observed on the bedside table. The resident informed the surveyor that the nurses would leave the medication at the bedside and they would then take the medication with their meals. The breakfast meal had been delivered to the 4th floor around 7:30 AM.
On 1/15/25 at 9:15 AM, the surveyor accompanied the Unit Manager Registered Nurse (UM/RN) to Resident #60's room and we both observed the medications left on the bedside table. The UM/RN stated that the resident will take the medication after breakfast. When inquired if the resident was assessed as being capable to self-administered medication, the UM/RN replied, No. The UM/RN stated, the nurse had to ensure that the resident took the medication prior to exit the room. It is a concern, another resident can go to the room and take the medications.
On 1/15/25 at 9:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who left the medications at the bedside. The LPN confirmed that she left them at the bedside and she stated she forgot to return to ensure that the resident took the medications. When inquired regarding the facility protocol for administering medications, the nurse stated that she should not leave the medication at the bedside as another resident can go to the room and interfere with the medications.
On 1/21/25 at 12:40 PM, the surveyor reviewed the Electronic medical record and noted there was no assessment that the resident could self administered medications.
A review of the admission Record reflected that the resident was admitted to the facility with diagnoses, which included but were not limited to; acute respiratory failure, shortness of breath and pulmonary fibrosis.
The Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #60 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition.
A review of the Physician Order Sheet (POS) for January 2025 reflected a physician order (PO) dated 10/05/23 for Ipratropium-Albuterol Solution 0.5-2.5 (3 ml) (milliliter) inhale orally every 6 hours for shortness of breath. The POS also included the following orders for January 2025: Colace 100 mg twice daily, (dated 01/07/2023), Lasix 40 mg twice daily (01/09/2023) metoprolol tartrate 25 mg (milligram) twice daily (02/04/2023) Steglatro 5 mg (03/15/2023), Potassium chloride 20 Meq (milliequivalent) (04/08/2023).
The surveyor reviewed the electronic medication administration record (EMARs) for January 2025 that revealed the nurses had been documenting that the Albuterol was administered to Resident # 60 as ordered by the physician. On 01/15/25, the LPN initialed the EMAR that the following medications: colace 100 mg, lasix 40 mg, potassium chloride, 20 Milliequivalent, Steglatro 5 mg, and metoprolol 25 mg, had been administered although the medications were still on the bedside table.
The Comprehensive Care Plan initiated on 6/20/2019, did not reflect a focus for Self administering medication. There was no documented evidence that Resident #60 was assessed by the Interdisciplinary Team, nor there was a physician order for self administration of medication.
On 1/21/25 at 12:40 PM, the surveyor again reviewed the Electronic medical record and noted there was no assessment that the resident was able to self administered medications.
The facility was made aware of the above concerns on 1/22/2025. The Director of Nursing (DON) stated that was not the facility protocol to leave medications at the bedside.
A review of the facility policy and procedure titled, Medication Administration Policy last revised 1/2025, revealed the following:
Policy: Medications shall be administered in a safe and timely manner, and as prescribed.
Procedure:
1. Only persons licensed or permitted by the State to prepare, administer and document the administration of medication may do so.
Procedure #19. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Team, has determined that they have the decision-making capacity to do so safely.
NJAC 8:39-11.2(b), 29.2(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ 167555
Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 2 of 2 residents (Resident #33 and Resident #8) reviewed for Activities of Daily Living. The deficient practice was evidenced by the following:
1. On 1/15/25 at 9:45 AM, the surveyor observed Resident #33 in bed and a strong urine odor was observed in the room. The resident was able to answer questions and informed the surveyor that they had not been changed since last night.
On 1/15/25 at 10:15 AM, the surveyor returned to the room and observed the resident in the same position. The resident indicated that they had not had incontinence care.
On 1/15/25 at 10:30 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who had Resident #33 on her assignment. The CNA revealed that she reported to work at 7:00 AM this morning, she delivered the breakfast tray and she had not yet provided care to Resident #33. The CNA added that incontinence care was provided by the 11:00 PM-7:00 AM shift.
On 1/15/25 at 10:40 AM, the surveyor entered Resident #33's room accompanied with the Unit Manager (UM) and the CNA. The surveyor requested the resident's incontinent brief to be checked by the staff. The surveyor observed that Resident #33 was wearing two incontinent briefs which were both saturated with urine. The UM asked the resident why do you have two briefs on and the resident replied, ask the staff.
On 1/17/25 at 10:30 AM, the surveyor reviewed Resident #33's electronic medical record.
Resident #33's admission Record (AR) revealed Resident #33 was admitted to the facility with diagnoses which included but were not limited to; Morbid obesity, chronic kidney disease, hypertension and unspecified glaucoma.
The quarterly Minimum Data Set (MDS) an assessment tool dated 1/14/25, revealed that Resident #33 had some cognitive impairment, Resident #33 received a score of 07 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #33 was dependent on staff for care.
Review of the Care Plan for Resident #33 initiated on 4/15/2020, included a Focus area for Bowel and Bladder incontinence related to Dementia and impaired mobility. The goal was Resident #33 will remain free from skin breakdown due to incontinence and brief use. The interventions were to establish voiding patterns, and check as required for incontinence. The care plan did not indicate when staff were to provide care to the resident and the frequency for staff to turn and reposition the resident.
On 1/21/25 at 8:43 AM, the surveyor went to Resident #33's room, Resident #33 was in bed sleeping. The breakfast tray was left opened on the bedside table. The surveyor checked with the CNA for incontinence care. at that time and the resident's incontinent brief was saturated with urine.
2. On 1/15/25 at 10:03 AM, the surveyor observed Resident #8 after morning care had been provided with the nails long and jagged, and a yellow substances was underneath all of the finger nails. Resident #8 was unable to engage with the surveyor.
On 1/16/25 at 10:04 AM, the surveyor returned to the room and observed that Resident #8 had just completed breakfast. The resident's nails were still long, jagged with a yellow substance underneath.
On 1/16/25 at 10:19 AM, the surveyor interviewed the CNA who cared for Resident #8. The CNA stated that Resident #8 was on hospice and cared for by the hospice aide.
On 1/17/25 at 11:15 AM, the surveyor reviewed Resident #8's medical record which revealed the following:
Resident #8 was admitted to the facility with diagnoses which included but were to limited to; Dysphagia, sepsis and diabetes mellitus.
According to the MDS dated [DATE], Resident #8 had a BIMS score of 01 out of 15 indicating that Resident #8 was cognitively impaired. The MDS also indicated that Resident #8 required extensive assistance for ADLs.
A review of Resident #8's Comprehensive Care plan provided by the facility on 01/22/25, initiated on 06/29/22 and last revised 01/14/25, revealed that Resident #8 did not have a care plan in place for ADLs self care performance deficit. The comprehensive Care Plan last revised 1/14/25, addressed falls, skin integrity, abnormal bleeding, nutrition . The care plan did not address ADL care. Based on the MDS assessment, Resident #8 was totally dependent on staff for care.
On 01/21/25 at 8:52 AM, the surveyor observed staff at the bedside. The staff identified herself as the Hospice Aide. The surveyor then inquired regarding nail care and the staff stated clearly, I am a Home Health Aide. I am not allowed to trim the residents nails. The CNAs were responsible to trim the resident's nails.
The above concerns with incontinence care and nails care were discussed with the facility management during the survey and again on 01/22/25. The Director of Nursing (DON) indicated that the staff were responsible to provide resident nail care.
NJAC 8:39-27.1 (a)(e)(of)

Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure there was no delay in treatment for a resident who required podiatry care that was ordered on 12/04/2024 and the podiatrist consult was completed 01/20/25, and the resident wore pressure relieving boots as per physician order. This deficient practice was identified for 1 of 1 resident (Resident #38) reviewed for foot care and was evidenced by the following:
On 1/15/25 at 10:07 AM, the surveyor observed Resident #38 was in awake and alert in bed, with feet outside of covers and were not off loaded or in boots. Both feet were observed to be encrusted with a thick yellow, cracked and dry skin. The right foot had approximately a dime sized round black area above the right heel on the sole of the foot. The left foot had what appeared to be a black pencil eraser sized area on the ball of the foot. There were various colored flakes of what appeared to be skin scattered on the bed sheet by the resident's feet.
On 01/22/25 at 8:00 AM, the surveyor reviewed the medical record for Resident #38 which revealed:
A twenty-five-page Care Plan (CP) with current and canceled Focus areas that included a list of diagnoses, which included, but was not limited to; Type Diabetes Mellitus, hypertension, pneumonia and dependence on supplemental oxygen. A CP Focus: Resident has diagnosis of Diabetes Mellitus and is at risk for endocrine complications, Date Initiated: 12/04/24 with a Goal: Resident will have no complications related to Diabetes through the review date. Target Date: 03/20/2025 with Interventions, Dated Initiated: 12/04/24 Check all of body for breaks in skin and treat promptly as ordered by Medical Doctor; Check skin when assisting with ADLs (activity of daily living) Date Initiated 12/04/24 and Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness. Report any of the above to the Medical Doctor, Date Initiated 12/04/24.
The Order Summary Report dated, 01/17/25 revealed:
- Heel boots to b/l (bilateral heels every shift, Order Date: 12/11/24.
-Consults: Podiatry consult and treat as needed, Order Date:12/04/24.
-Skin Assessment every day shift every Monday and Friday, document using the following codes: O-No skin impairments, 1-Previous skin impairment present, 2-Newly identified skin impairment if you respond with a *2*, further documentation in progress notes is required.
On 01/21/25 at 1:19 PM, the surveyor reviewed the paper medical record and could not locate a Podiatry consult.
On 01/22/25 at 8:46 AM, two surveyors (#2 and #3) observed Resident #38 in bed without off loaded heels or wearing boots. Both heels remained dry, cracked with flakes present and the blackened areas remained.
On 01/22/25 at 9:22 AM, the Surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) regarding the Podiatry consult ordered 12/04/24. The LPN/UM stated that the Podiatrist was at the facility weekly, confirmed the order was on 12/04/24 and stated the Podiatrist consult for Resident #38 was completed on 1/20/25 and the LPN/UM printed a copy for the surveyor. The LPN/UM stated normally, he normally comes right away [the podiatrist] and not sure why he came so late. The surveyor asked if the resident was supposed to wear the heel protectors and she stated, the resident was supposed to wear them. The LPN/UM also reviewed the entire paper record to ensure there was no other Podiatry consultation. The surveyor reviewed the Podiatry consultation Dated 01/20/2025, Late Entry, which documented Moderate Xerosis Bilateral [dry skin], Assessment: Plan. Debridement nails x 10 topical applied, lotion for dry skin. Encourage Physical Therapy Range of Motion for Lower Extremity. Discussed need for support hose for Lower Extremity Bilateral, Diabetes Mellitus care discussed with staff will follow, suggest foot and heel protectors due to immobility daily for pressure relief.
On 01/22/25 at 9:29 AM, the surveyor explained the observations to the LPN/UM regarding the blackened areas observed on Resident #38's feet. The LPN/UM reviewed the Podiatry Consultation and the areas were not indicated and the LPN/UM went with the surveyor to observe Resident #38's feet. The LPN/UM looked at Resident #38's feet and confirmed the black areas and stated she would call the Podiatrist to make sure the areas were not overlooked.
The Podiatry Services Policy, Effective 2/2017, Revised 1/2025 revealed Policy: Routine and emergency podiatry services are available to meet the resident's health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: 1. Routine and emergency podiatry services are available to meet the resident's needs.
On 01/23/25 at 2:10 PM, during the facility exit conference, the Director of Nursing provided a copy of a Late Entry Note Effective Date: 01/22/25 documented by the LPN/UM which revealed spoke with the Podiatrist who stated the resident had aging spot on bottom of both feet that are not open wounds, and are not DTIs (deep tissue injuries). The facility did not respond to why the resident was not wearing the ordered boots, or why the Podiatry Consultation was completed six weeks after it was ordered.
NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician order, and ensure oxygen equipment was stored properly.
This deficient practice was identified for 1 of 3 residents (Resident #47) reviewed for respiratory care and was evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
During initial tour on 1/15/25 at 11:04 AM, the surveyor observed Resident #47 sitting in a wheelchair in their room. The resident was on Oxygen (O2) via nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 5 Liter per Minutes (LPM). The surveyor observed an O2 tank behind the resident's wheelchair, connected to a NC which was wrapped around the left handle of the wheelchair. The NC was not in any protective covering and was exposed to the environment.
On 1/21/25 at 9:14 AM, the surveyor observed Resident #47 resting in the bed. The resident was on O2 at 4 LPM. The surveyor observed the resident's wheelchair closer to the window with the NC wrapped around the left handle of the wheelchair and in direct contact with resident's socks which were hanging back of the wheelchair. The NC was not in any protective covering and was exposed to the environment.
The surveyor reviewed the medical records of Resident #47 and revealed:
According to the admission Record, Resident #47 was admitted to the facility with Pneumonia (an infection that affects one or both lungs), Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs) with exacerbation (flare up), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) without complications.
A review of the Quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, dated 11/15/24, revealed the resident had a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident had intact cognition. Further review of the MDS did not document that Resident #47 received O2 therapy.
A review of the Order Summary Report for Resident #47 revealed Physician Orders (PO) as follows:
- O2 at 4 LPM via NC every shift with the start date from 4/12/24 to 1/16/25.
- O2 at 3 LPM via NC every shift with the start date 1/20/25.
A review of the resident's Care Plan (CP) included a focus area that indicated, . O2 therapy related to SOB (shortness of breath)/ CHF (Congestive Heart Failure) (heart failure). The Interventions included give medications as ordered by physicians; O2 at 2 L/NC as ordered, initiated on 6/11/22.
On 1/21/25 at 9:48 AM, during an interview with the surveyor, the Registered Nurse (RN) stated when she made rounds, she would check if the residents were on the correct amount of oxygen as per physician orders. The RN stated that she would store the oxygen tubing or other equipment in a special bag when the oxygen was not in use because of safety precautions and to avoid contamination. The RN stated Resident #47 was on 3LPM of oxygen as per physician order. The surveyor informed the RN of above-mentioned findings regarding resident's O2 at 5 LPM during initial tour and 4 LPM prior to the interview. The surveyor accompanied the RN to Resident #47's room. The RN spoke with the resident and the resident stated, I use 4 LPM at night.The resident confirmed that the oxygen was at 4 LPM. The RN stated, they (the residents) need to be educated on the importance of maintaining doctor's orders. In the presence of the surveyor, the RN observed the NC wrapped around the left handle of the wheelchair. RN stated the NC should have been placed in the bag. The RN then discarded the NC from the wheelchair.
On 1/21/25 at 1:20 PM, during an interview with the surveyor, the Assistance Director of Nursing (ADON) stated when residents are on oxygen, the nurses should follow physician orders and make the sure the residents were on the right setting as per the physician orders. The ADON stated that all oxygen equipment would be stored in a special plastic bag when not in use. The surveyor informed the ADON of the above findings. The ADON stated NC wrapped around the wheelchair handle was not acceptable.
On 1/23/25 at 11:33 AM, the survey team met with the facility administration. The surveyor notified the facility management of the above-mentioned concerns for Resident #47.
A review of the facility provided Oxygen Therapy revised 1/2025 included: Under Preparation and Observations: The licensed nurse shall: 1. Review the physician's order for oxygen administration. Oxygen therapy is administered only as ordered by a physician or as The physician's order will specify the rate of flow, route, and rationale. 2. Review the resident's care plan. 3. Assemble the equipment and supplies as needed - 3rd bullet point- Plastic bag for oxygen equipment storage. Under Procedure: 1. Review Physician's order for oxygen therapy. 5. Connect oxygen tubing And turn on oxygen to the prescribed flow rate. 7. Store unused devices in plastic bag.
On 1/23/25 at 2:10 PM, the survey team met with the facility administration for an Exit Conference. The facility had no additional information to provide.
NJAC 8:39-11.2(b); 25.2(c)4; 27.1(a)

Based on interview and document review, it was determined that the facility failed to ensure residents had cognitive ability before signing arbitration agreements. This deficient practice was identified for 1 of 3 residents (Resident #61) reviewed for arbitration agreements. This had the potential to result in resident representatives not being able to resolve disputes with the facility in a court of law. The deficient practice was evidenced by the following:
On 1/15/25 at 10:18 AM, Surveyor #4 observed Resident #61 in bed. The resident did not respond to the surveyor when spoken to. A staff member was entering the room and stated the resident could not see.
On 1/15/25 at 11:12 AM, the Licensed Nursing Home Administrator (LNHA) informed Surveyor #1 that the facility utilized arbitration agreements which were part of the admission agreement. The facility provided a list of residents who had signed arbitration agreements.
On 01/16/25 at 11:06 AM, during a phone conversation with Surveyor #1, Resident #61's representative explained the resident was legally blind. The representative further stated that the staff does not involve them with anything and that they were unaware of an arbitration agreement. The representative included the resident was not able to sign any papers and stated what are you talking about?
A review of the admission Record (an admission summary) revealed Resident #61 had diagnoses which included but were not limited to; legal blindness, brief psychotic disorder, and cerebral infarction (a pathological process resulting in an area of dead tissue in the brain). A review of the Voluntary Binding Arbitration Agreement (VBAA) revealed it was signed by Resident #61 on 7/10/19. Page 3 of the Agreement revealed a section for the resident's legally authorized representative or resident but was signed only by the resident and the facility representative. A review of the Minimum Data Set (MDS) an assessment tool dated 8/10/19, included a Brief Interview for Mental Status (BIMS) of 02 out of 15 indicative of severe cognitive impairment.
On 1/23/25 at 9:11 AM, in the presence of two surveyors the Admissions Director (AD) stated it was her responsibility to provide the VBAA along with other papers. She stated it would be provided to the resident and/or the family to read over and they can sign or decline. The Ad explained she would go through and read the papers with the resident and/or family and go into detail if they wanted. She further explained that the VBAA was, in essence, the arbitration was . if there was anything we [facility] did we would go in front of a small group and a judge? When inquired about a resident's cognitive status, the AD responded that the BIMS would always be checked prior to any papers being signed and that the resident would require a BIMS of 13 or higher. She stated that a BIMS of 12 would be when a resident would be getting impaired. When inquired about Resident #61, the AD revealed she was not working at the facility at that time and that a BIMS of 02 was not sufficient for the resident to understand or sign an agreement.
A review of the facility provided policy, Arbitration Agreement revised 1/2024, included but was not limited to; Procedure: . will be explained to the resident or their representative in a form, manner and language they understand; . ensure the resident or their representative acknowledges they understand the agreement and have the right to rescind the agreement within 30 calendar days.
On 1/23/25 at 11:32 AM, the above concern was addressed with the facility administration. The facility had no additional information to provide.
NJAC 8:39-4.1(a)8(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of pertinent documents it was determined that the facility failed to maintain an effective comprehensive data driven Quality Assurance and Performance Improvement program by failing to review all services provided including to ensure significant events were reviewed to determine root cause to prevent further occurrences. This deficient practice occurred for residents with a history of smoking in their room, holding drug paraphernalia and a lighter in their room (Resident #143 and Resident #34), and for a resident (Resident # 264) who was dependent on staff for all care, and sustained an injury of unknown origin that required hospitalization on 11/06/24. This deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following:
Refer to 689L, 610G
a. During the survey, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR Part 483.25(d)(2) F 689 as the facility failed to follow their smoking policy to ensure effective interventions were implemented and monitored for a resident with a history of smoking in their room. The facility documented Resident #143 was found smoking in their room on 10/19/24. Observations on 1/15/25, 1/16/25 and 1/17/25, confirmed that the Resident #143 held their cigars in their room.
The IJ began on 10/19/24 when Resident #143 was found by a Registered Nurse to be smoking in their room. From 1/15/25 through 1/17/25 the surveyor observed smoking materials inside of the resident's room and within arm's reach of Resident #143. Resident #143 had piped in oxygen into their room. The facility was notified of the IJ on 1/17/25 at 2:26 PM. The facility provided an acceptable Removal Plan (RP) which was verified on-site by the survey team on 1/21/25.
On 1/15/25 at 9:39 AM, during the initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room, No Smoking (in red), Piped-In Oxygen In Use. Upon entrance to Resident #143's room, Surveyor #1 observed the resident was in bed watching television. At that time, Surveyor #1 observed a pack of cigars on the table next to the resident and asked the resident what they were. The resident took a cigar out of the case and stated it's a cigar while holding it and showing it to the surveyor.
On 1/16/25 at 11:44 AM, Surveyor #1 observed resident #143 sitting in a wheelchair in their room, with two loose cigars adjacent to the resident's meal tray and within the resident's reach.
On 01/17/25 at 8:20 AM, Surveyor #1 observed Resident #143 again sitting in a wheelchair in their room, and two loose cigars were on the tray table within reach of the resident, and a cigar box was on top of the nightstand. The resident stated, I buy my own cigars. I walk to the store. Surveyor #1 asked Resident #143 if they had a lighter and the resident then gestured with both hands waving towards the nightstand, and stated, I put it up. Surveyor #1 asked the resident if they could show their lighter to the surveyor, and Resident #143 then began rummaging through their nightstand and stated, I can't find it.
On 1/17/25 at 8:45 AM, during an interview with Surveyor #1, the Registered Nurse (RN) stated the residents smoked in the designated area as per the smoking schedule. The RN stated all residents were assessed for smoking upon admission and staff would then let Security know if the resident was a smoker. The RN stated the residents were not allowed to smoke in their rooms and if they were caught smoking in their rooms, their smoking supplies would be removed from their room and stored either with Security, or inside the medication cart. The RN stated Resident #143 had smoked in their room before, and all the smoking supplies were taken away from the resident. The RN further stated smoking was not allowed in the rooms due to residents using oxygen and due to the risk of fire.
On 01/17/25 at 9:16 AM, Surveyor #1 accompanied the RN to Resident #143's room and the RN observed two packs of sealed cigars inside the resident's nightstand drawer. The RN stated Resident #143 was not allowed to have smoking supplies in their room and immediately removed the cigar packs from the resident's room.
b. On 01/17/25 at 8:46 AM, Surveyor #2 reviewed the closed electronic medical record (EMR) for Resident #34.
Review of the admission Record revealed Resident #34 had diagnoses including, but not limited to; sepsis, chronic viral hepatitis C, and opioid dependence.
Review of a Progress Notes (PN) - Type: IDT Note, Effective Date: 07/14/24 10:50 AM, Created Date: 07/15/24, Department: Nursing: Created by Unit Manager: On July 14, 2024, the primary nurse called the supervisor for the patient in room [ROOM NUMBER]B, and upon the supervisor's arrival, the supervisor found the patient on the bed with erratic behavior and uncontrolled movement. The room was fully searched, and drug related equipment was found on the patients' bed. The supervisor immediately confiscated the equipment. Education was given to the resident about the risks of substance abuse, and that these actions violate the policies of the hospital MD (physician) was made aware, and ordered the resident to be transferred to the hospital for evaluation, and ordered a toxicology screen .
Review of the Lab Results Report, Collection Date 07/16/24, revealed Resident #34 tested positive for Cocaine Metabolite.
Review of a PN - Type: IDT [Interdisciplinary] Note, Late Entry, Effective Date: 08/08/2024, 1:26 PM, Created by Date: 11/24/24 at 1:27 PM, by the Director of Nursing (DON), 08/08/824 at 1:20 PM, resident noted with restless behavior, talking very animated and excited, slurring speech, at time making incoherent statements .Declined transfer to ER for evaluation Resident educated on risk verse benefit of using illicit substances, urine toxicology obtained per physician order .
Review of the Lab Results Report, Collection Date 08/08/2024, revealed Resident #34 tested positive for Cocaine Metabolite, Opiates, Morphine and Methadone.
Review of an IDT Note: Dated 08/15/25 at 10:12 AM, Note Text: Urine drug screen results received. Resident positive for opiates, positive for cocaine, positive for morphine. Resident positive for Methadone which is prescribed. DON and physician notified.
Review of a PN - Type: IDT Note, Late Entry, Effective Date: 12/19/24 at 11:56 AM, At 10:39, resident noted in wheelchair in room lethargic with pupils dilated and not responding to commands. NP (Nurse Practitioner) ordered for resident to be sent to ER (Emergency Room). 911 Called. STAT (immediate) drug screen ordered per physician and resident refused. Resident Noted with vape pen and lighter in possession which were confiscated. NP made aware of resident's refusal to go to ER .
On 01/23/25 at 8:53 AM, Surveyor #2 interviewed the Medical (MD) Director and asked if he was made aware of Resident #34 who was found in the facility in his/her room, not responding, and found with vape and a lighter and drugs were found in the resident's system. The MD he was not aware, stated no, not at all was I aware of this. Surveyor #2 asked what should have been done after that should have been done. The MD stated, that is concerning the resident should get a warning discharge as could cause a huge fire, of course.
c. On 1/16/25 at 10:30 AM, the surveyor reviewed the investigation and the Reportable Event Record completed by the facility. There was no causal factor identified for the injury.
CNA #1 who cared for the resident provided two statements.
-11/06/24 CNA #1 documented that on 11/06/24 that she came this afternoon to put resident 114 in bed, I found right face with a black eye and I reported to the nurse. Signed CNA 3:00 PM-11:00 PM shift. [Before the mechanical lift transfer]
-11/06/24 CNA #1 documented that on 11/06/24 in the evening I put resident back in bed with mechanical lift. Resident was sitting in recliner chair and we assisted back to bed lying on left side. Once back in bed. I noticed resident had redness to face by eye. I reported discoloration to the nurse. [After the mechanical lift transfer]
The surveyor reviewed the statement provided by CNA #2 who also worked on the unit with CNA #1. CNA #2 documented that on 11/06/24 in the evening I assisted my co-worker to place resident back in bed with mechanical lift. Resident was sitting in recliner chair and we assisted back to bed lying on left side. Once back in bed I noticed resident had redness to face by eye. Assigned CNA reported the discoloration to the nurse.
The Registered Nurse's (RN) statement dated 11/6/24 at 9:15 PM, documented that at 3:00 PM, worked the 3:00 PM to 11:00 PM shift on the 2nd floor ventilator unit and assigned to the Resident in room [ROOM NUMBER]. At 3:00 PM I made rounds and the resident was sitting in recliner chair along the bedside and did not notice any changes to Resident #264. At 5:00 PM resident was provided care and placed back to bed by CNA. At approximately 8:30 PM Resident's family came to the unit to provide care for her parent. At 9:15 PM, Resident #264 and informed her that the resident was noted with a hematoma and swelling of the right eye.
On 1/17/25 at 8:15 AM, the surveyor interviewed a random CNA regarding the protocol to transfer residents with the mechanical lift. The CNA stated that two staff members had to be in the room for the transfer.
On 1/17/25 at 8:52 AM, the surveyor interviewed the Respiratory Therapist (RTF) and he confirmed two staff had to be in the room to transfer a ventilator dependent resident from the bed to the recliner chair. When inquired regarding Resident #264, he confirmed that on 11/06/24 he had assisted CNA #3 with the transfer from the bed to the recliner chair in the morning, and there was no injury observed. The RTF informed the surveyor that on 11/06/24 at 4:53 PM, he observed Resident #264 in bed and did not assist with the transfer back to bed, nor was he made aware of the injury.
On 01/17/25 at 11:59 AM, the surveyor reviewed the facility provided incident report and the statements attached with the Director of Nursing (DON). The DON stated that she was aware of the discrepancies in CNA #1's statements and could not provide any rationale for not clarifying the discrepancies prior to submit the investigation to the Department of Health (DOH). The DON stated there was a misunderstanding and miscommunication about the investigation. The DON stated she had understood Resident #264 sustained the injury during the transfer and stated that Resident #264 possibly hit the right eye on the mechanical lift.
On 01/17/25 at 12:05 PM, the surveyor conducted a second interview with the RTF. The RTF on duty that day revealed that one nurse and one CNA were to transfer any resident out of the bed and back to bed if the resident was on a mechanical ventilator (machine that act as bellows to move air in and out of the lungs). The RTF stated that some CNAs worked as floaters to the unit and they were not trained to transfer residents with the ventilator attached. For safety reasons, a nurse had to be in the room to assist or if the nurse could not assist, she would delegate the task to the respiratory therapist who would supervise the transfer. When asked if there was a policy for transferring a resident with a ventilator, he stated, this is the norm, not too sure if there is a policy.
Based on the documents provided, the RN nor the respiratory therapist assisted CNA #1 with the transfer.
On 01/21/25 at 11:47 AM, the surveyor interviewed the Medical Director (MD) regarding the injury sustained by Resident #264 during the transfer. The MD stated that he was told by the DON the injury was caused by the hook from the mechanical lift and was not provided with any additional information.
On 1/21/25 at 1:45 PM, the surveyor interviewed the NP who ordered that Resident #264 be transferred to the hospital for a CT scan (computed Tomography Scan a noninvasive medical procedure that uses X-Rays to create detailed cross-sectional images of the body). The NP stated that since the bruise was significant and since no one knew the source of the injury she ordered the CT scan to ensure there were no fractures.
On 1/22/25 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2. CNA #2 stated that CNA #1 was waiting in the resident's room. When she entered the room, Resident #264 was already in the mechanical lift and being transferred. Once the resident was in bed, she observed the bruise and advised CNA #1 to report the bruise to the nurse. CNA #2 stated that she did not assist CNA#1 with care, and she left the room to attend to her assignment.
In the summary provided to DOH, the DON indicated the following: Resident #264 has periods of involuntary movements related to hypoxia and seizure disorder as well as cough spasms. The Interdisciplinary Team concludes that resident during transfer may have coughed or had involuntary movement and may have leaned into [Resident #264] mechanical lift cross- bar. Interviews with staff familiar with the resident routine revealed that the resident was immobile.
Actions .
4. Transfer to Hospital for Evaluation.
5. Mechanical lift Competencies with CNAs.
6. Maintain 2 person assist with mechanical lift transfer and care.
CNA #1 had Resident #264 on the mechanical lift alone in the room. CNA #2 was not in the room when CNA #1 initiated the transfer and placed Resident #264 on the mechanical lift.
Utilize soft padding on the mechanical lift crossbar during resident transfers.
On 1/22/24 at 10:15 AM, two surveyors conducted an in-person interview with CNA#1. CNA #1 stated that she recalled the incident. She stated that the evening shift was very chaotic. She confirmed that she observed the injury after transferring Resident #264 in bed. She stated that Resident #264 always scratched their face, the injury could be self-inflicted. When asked if she remained in the room with the resident and waited for the nurse to come and assess the injury, CNA #1 stated she had too much to do that day, she moved on and attended to other residents. The surveyor then inquired regarding the 2nd statement, CNA #1 read the statement and stated, another co-worker coached her to write the second statement, but she did not observe any injury to the resident face and right eye while the resident was sitting in the chair.
On 1/22/24 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2 whom CNA #1 claimed assisted with the transfer. CNA #2 stated that when she entered the room, [Resident #264] was in the room and on the mechanical lift alone with CNA#1. She observed the bruise and advised CNA #1 to report the injury to the nurse. When asked if she assisted CNA #1 with care, she stated, No. I left the room and continued with my assignment.
On 1/22/25 at 1:15 PM, the surveyor interviewed CNA #3 assigned to the 7:00 AM- 3:00 PM shift regarding Resident #264's care. CNA #3 stated that she cared for Resident #264 daily, Resident #264 was immobile, had poor trunk control, and required two persons assist with transfer. CNA #3 further stated that on 11/06/2024 she transferred Resident #264 to the recliner chair with the Respiratory Therapist. During the day and she periodically checked Resident #264 and no injury was noted to the right eye.
On 1/23/25 at 10:56 AM, the surveyor reviewed the investigation with the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team. The LNHA stated that in reviewing the RN statement and the investigation, he could see there was some discrepancies. The LNHA added the investigation was not concise and thorough, and that his expectation was that the facility would thoroughly investigate injuries of unknown origin.
On 01/17/25 at 2:51 PM, the facility provided the surveyor with 2 QAPIs:
1.
Dated 10/19/24, Date Completed: . to be continued on a monthly basis until 4 quarters of 100 % is achieved; Contact: Administrator and Director of Nursing (DON); Problem Statement: All current smokers are assessed and care planned accordingly; Goal: to ensure that all residents and staff are aware of the facility smoking policy and all residents who smoke may do so safely; Root Causes: 1. Resident non-compliance, 2. Residents were identified needing frequent, 3. Resident responsible party education on the facility smoking policy; Under Tasks: Eight tasks listed with a Start Date 10/19/24 for 1-4 and for 5-8 the Start Date was left blank. The Comments (status, outcomes, evaluations, etc.) was left blank for all eight tasks.
2.
An undated QAPI with a Problem Statement: Substance abuse creates safety risks, disrupts care, and violates facility policy: Contact: Administrator and DON; Goal: Implement a program to identify and manage substance abuse, and to reduce incidents. Four Tasks, with a Start Date: 07/15/24 and 07/17/24, with an Estimated Completion Date: Ongoing; Comments (status, outcomes, evaluation, etc.) was left blank.
On 01/23/25 at 8:53 AM, the Surveyor #2 interviewed the Medical (MD) Director and asked if he was made aware of Resident #34 who was found in the facility in his/her room, not responding, and found with vape and a lighter and drugs were found in the resident's system. The MD he was not aware, stated no, not at all was I aware of this. Surveyor #2 asked what should have been done after the that occurred. The MD stated, that is concerning the resident should get a warning discharge as could cause a huge fire, of course. The surveyor asked about the MD's role in QAPI. The MD stated he attended the quarterly QAPI meeting. The surveyor asked if there was any specific QAPI he was involved with and he stated, no. The surveyor asked the MD if he had been made aware of the IJ related to the smoking paraphernalia found during multiple observations, and the surveyor asked if that was a concern. The MD stated, yes, of course this is a concern, this is the first I am hearing of the IJ. The surveyor asked if the MD had been aware that the resident was found smoking in the bathroom and the MD replied, no. The MD stated he was surprised that he had not been made aware, especially with the piped in oxygen he should have been made aware.
On 01/23/25 at 10:16 AM, in the presence survey team, the surveyor interviewed the LNHA about the QAPI program. The surveyor asked who oversaw the QAPI program and he confirmed he was the QAPI coordinator. The surveyor asked the LNHA to list of the current active QAPIs. The LNHA stated the facility had the following active QAPIs: falls, substance abuse, and smoking. The surveyor reviewed the previously provided QAPIs with the LNHA and asked if the QAPI for smoking was related to the incident on 10/19/24 when the resident was found smoking in the bathroom. The LNHA stated, no, this is what I have. The surveyor asked about the QAPI titled Substance Abuse. The surveyor asked the LNHA what the specifics were related to the goal To implement a program to identify and manage substance abuse, and to reduce incidents and was there any supporting documentation. The LNHA stated the goal was to identify the origin of the issue, to collectively establish and intervention to prevent it. The LNHA stated, he did not have more than the document that was already provided. The surveyor asked the LNHA if significant events and incidents/ reportable events were reviewed at QAPI. The LNHA stated we review finding but we don't necessarily review all incidents. The surveyor asked if the incident with Resident #264 sustaining the injury was reviewed at QAPI and the LNHA stated that was not brought to QAPI, we reviewed the general concept. The surveyor asked if that incident was considered a significant event, and the LNHA stated, yes.
The Quality Assurance and Performance Improvement Plan policy (undated) revealed: Design and Scope: The purpose of QAPI in the organization is to take a proactive approach to continually improve the way we care for and engage our residents . Feedback, Data Systems and Monitoring: Performance Indictors for all QAPI Designated goals are evaluated. These indicators can be process and/ or outcome measures. All data will utilize internal and external benchmarking . On a quarterly basis, data will be collected and reported to the QAPI Committee from the following areas: Input from caregivers, residents, families and others, Adverse Events, Performance Indicators
The Administrator's Job Description, signed by the Licensed Nursing Home Administrator (LNHA) on 07/22/24 revealed: The Administrator is responsible for planning and is accountable for all activities and departments of Facility subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents. 9. Concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents. Also, ensures that the facility adheres to the legal, safety, health, fire and sanitation codes by being familiar with his/her role in carrying out the facility's fire, safety and disaster plans and by being familiar with current MSDS (material safety data sheets).
NJAC 8:39- 33.1 (c)(e); 33.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to prevent the spread of potential infection by failing to don (put on) Personal Protective Equipment (PPE) prior to entering the room of residents on contact precautions. This deficient practice was identified for 2 of 2 residents (Resident #144 and Resident #147) reviewed for Transmission-based Precautions (TBP).
The deficient practice was evidenced by the following:
1. On 01/15/25 at 8:57 AM, the surveyor observed Resident #144's room with signage outside the door alerting all to stop, Contact Precautions everyone must: . put on gown before room entry, put on gloves before room entry . There was a three-drawer plastic bin outside of the door with PPE gowns and gloves. At that time, the Registered Nurse Unit Manager (RN/UM) walked past the Licensed Practical Nurse (LPN) who was outside the door and into Resident #144's room. The RN/UM did not don a PPE gown or gloves. The RN/UM placed an item in the resident's drawer.
On 01/15/25 at 8:58 AM, the RN/UM exited the room and stated to the surveyor, I was not doing care. The surveyor asked what the expectation would be when entering a contact precaution room. The RN/UM replied, I have nothing to say, you got me. I should have worn a gown.
On 01/15/25 at 12:11 PM, the surveyor reviewed the admission Record R) which revealed Resident #144 had diagnoses which included but were not limited to; dependence of respirator ventilator status, and sepsis (an extreme reaction to an infection in the body). A review of the Order Summary Report (ORS) as of 01/14/25, included an order dated 10/25/24, Contact Precaution every shift for C. Auris Colonized (Candida Auris a fungus that can cause multidrug resistant infections). A review of the most recent admission Minimum Data Set (MDS) an assessment tool dated 10/31/24, included a Brief Interview for Mental Status (BIMS) of 00 out of 15 which indicated a severely impaired cognition. A review of the individual comprehensive care plan (ICCP) documented a focus area date initiated 10/24/24, on Contact Precautions related to C-Auris Colonized and interventions included to wear PPE gown and gloves when entering the room.
2. On 1/16/25 at 8:06 AM, the surveyor observed Resident #147'2 room with signage outside the door alerting all to stop, Contact Precautions everyone must: . put on gown before room entry, put on gloves before room entry . There was a three-drawer plastic bin outside the door with PPE gowns and gloves. The surveyor observed the Registered Dietitian (RD) inside the room and was handling the tube feeding bottle which was hanging up and connected to Resident #147. The RD was not wearing a PPE gown or gloves. Upon exiting the room, the RD was asked about the signage and the resident being on contact precautions. The RD stated she should have followed the contact precaution sign and wore PPE to prevent spreading infection.
On 1/16/25 at 9:42 AM, the surveyor reviewed the AR which revealed Resident #147 had diagnoses which included but were not limited to; sepsis, dependence on respirator ventilator status, and gastrostomy (artificial opening in the stomach for nutritional support). A review of the ORS dated 1/21/25, included the following physician's orders (PO) dated 1/2/25 for Contact Precautions every shift for positive C. Auris and positive CPO (a bacteria resistant to a class of antibiotics). A review of the most recent quarterly MDS dated [DATE], included documentation that a BIMS was not conducted as the resident was not understood. A review of the ICCP documented a focus area date initiated 11/13/24, on enhanced barrier precaution due to colonized C. Auris and positive CPO gene and an intervention for Contact precaution to wear PPE gowns and gloves when entering the resident room.
A review of the facility provided education revealed the following:
The RD was trained in Infection Control PPE and competency. The training was signed by the RD and the instructor and dated 9/25/24.
The RN/UM was trained on the proper use of PPE which was signed and dated 6/4/24; wearing the appropriate PPE in resident rooms which was signed and dated 6/18/24; Proper use of PPE which was signed and dated 7/22/24; and preventing spread of infection with TBP and the use of PPE which was signed and dated 9/26/24.
A review of the facility provided policy, Infection Control-Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions revised 3/22/24, included but was not limited to; the policy to ensure appropriate infection prevention and control measures area taken to prevent the spread of . infections. Contact Precautions shall apply to all residents infected or colonized with an infectious agent . Contact Precautions require the use of gown and gloves every entry into a resident's room .
On 01/21/25 at 9:16 AM, the Director of Nursing (DON) and the Infection Preventionist (IP) were interviewed by the surveyor. The DON and IP both acknowledged that they were made aware of the two above breaches in infection control. The IP confirmed that the facility currently had an influenza outbreak, and had residents with C. Auris, and with CRE/CPO.
On 1/23/25 at 11:32 AM, the facility administration was made aware of the above concerns regarding infection control.
NJAC 8:39-19.4(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part B
Refer to F610
On 01/21/25 at 10:00 AM, the surveyor reviewed the closed electronic medical record for Resident #264.
According to the admission Record face sheet, Resident #264 was admitted to the facility with diagnoses which included but were not limited to; acute and chronic respiratory failure, hypoxia, epilepsy, tracheostomy status and dependence on respiratory ventilators.
A review of Resident #264's quarterly MDS dated [DATE], reflected that the resident was coded as being comatose and yes to being in a persistent vegetative state/no discernible consciousness. Resident #264 was totally dependent on staff for all care.
A review of Resident #264's ICCP included a focus area initiated on 02/27/24, for being at risk for falls related to poor safety awareness, impaired balance and poor trunk control, side effects of medications, non-verbal, and required mechanical lift transfers. Interventions included to use mechanical lift for transfers with two persons assisting with the transfer.
A review of the Progress Notes revealed an Interdisciplinary Team (IDT) Note dated 11/06/24 at 10:20 PM, which included the IDT was made aware by CNA that Resident #264 was noted with discoloration and swelling of the right eye. The Nurse Practitioner (NP) was notified and ordered the resident to be sent to the hospital for further evaluation and treatment. A report was given to the nurse, and Resident's Representative (RP) was at bedside.
A review of the IDT Note dated 11/06/22 at 10:22 PM, revealed that transportation was arranged with the [hospital name redacted] Emergency Services.
A review of the IDT Note dated 11/07/24 at 8:05 PM, revealed a follow-up to the emergency room. The resident was admitted with diagnoses traumatic hematoma to right orbit (eye socket).
On 1/16/25 at 10:30 AM, the surveyor reviewed the investigation and the Reportable Event Record completed by the facility dated 11/06/24. There was no causal factor identified for the injury.
A review of a statement for CNA #1's, who cared for the resident revealed the following:
On 11/06/24, CNA #1 documented that on 11/06/24, that she went in the afternoon to put Resident #264 in bed, and I found right face with a black eye and I reported to the nurse. The statement was signed CNA 3:00 PM-11:00 PM shift. (This note was documented before the mechanical lift transfer)
On 11/06/24, CNA #1 documented that on 11/06/24, in the evening I put resident back in bed with a mechanical lift. The resident was sitting in the recliner chair and we assisted the resident back to bed lying on their left side. Once back in bed, I noticed resident had redness to face by eye. I reported discoloration to the nurse. (This note was documented after the mechanical lift transfer)
The surveyor reviewed the statement provided by CNA #2, who also worked on the unit with CNA #1. CNA #2 documented that on 11/06/24, in the evening I assisted my co-worker to place resident back in bed with mechanical lift. The resident was sitting in the recliner chair and we assisted the resident back to bed lying on their left side. Once back in bed, I noticed the resident had redness to face by eye. The assigned CNA reported the discoloration to the nurse.
A review of RN #2's statement dated 11/6/24 at 9:15 PM, indicated that they worked the 3:00 PM to 11:00 PM shift on the 2nd floor ventilator unit and was assigned to Resident #264. At 3:00 PM, I made rounds and the resident was sitting in a recliner chair along the bedside and I did not notice any changes to Resident #264. At 5:00 PM, the resident was provided care and placed back to bed by the CNA. At approximately 8:30 PM, the Resident Representative (RR) came to the unit to provide care for the resident. At 9:15 PM, the RR informed her that the resident was noted with a hematoma and swelling of the right eye.
On 1/17/25 at 8:15 AM, the surveyor interviewed a staff CNA regarding the protocol to transfer residents with the mechanical lift. The CNA stated that two staff members had to be in the room for the transfer.
On 1/17/25 at 8:52 AM, the surveyor interviewed the Respiratory Therapist (RT), and he confirmed that two staff had to be in the room to transfer a ventilator dependent resident from the bed to the recliner chair. When inquired regarding Resident #264, he confirmed that on 11/06/24, he had assisted CNA #3 with the transfer from the bed to the recliner chair in the morning, and there was no injury observed. The RT informed the surveyor that on 11/06/24 at 4:53 PM, he observed Resident #264 in bed and he did not assist with the transfer back to bed, nor was he made aware of the injury.
On 01/17/25 at 11:59 AM, the surveyor reviewed the facility provided incident report and the statements attached with the DON. The DON stated that she was aware of the discrepancies in CNA #1's statements and could not provide any rationale for not clarifying the discrepancies prior to the submission of the investigation to the Department of Health (DOH). The DON stated there was a misunderstanding and miscommunication about the investigation. The DON stated she had understood Resident #264 sustained the injury during the transfer and stated that Resident #264 possibly hit the right eye on the mechanical lift.
On 01/17/25 at 12:05 PM, the surveyor conducted a second interview with the RT. The RTF on duty that day revealed that one nurse and one CNA were to transfer any resident out of the bed and back to bed if the resident was on a mechanical ventilator (machine that acts as bellows to move air in and out of the lungs). The RT stated that some CNAs worked as floaters to the unit and they were not trained to transfer residents with the ventilator attached. The RT stated for safety reasons, a nurse had to be in the room to assist or if the nurse could not assist, the nurse delegated the task to the RT who supervised the transfer. When asked if there was a policy for transferring a resident with a ventilator, he stated, this is the [normal], not too sure if there is a policy.
A review of the documents provided revealed that the RN nor the Respiratory Therapist assisted CNA #1 with the transfer.
On 01/21/25 at 11:47 AM, the surveyor interviewed the Medical Director (MD) regarding the injury sustained by Resident #264 during the transfer. The MD stated that he was told by the DON the injury was caused by the hook from the mechanical lift and was not provided with any additional information.
On 1/21/25 at 1:45 PM, the surveyor interviewed the NP, who ordered Resident #264 to be transferred to the hospital for a computed tomography scan ( CT Scan; a noninvasive medical procedure that uses X-Rays to create detailed cross-sectional images of the body). The NP stated that since the bruise was significant and since no one knew the source of the injury, she ordered the CT scan to ensure there were no fractures.
A review of the summary provided to DOH on 11/08/2024, the DON indicated the following: Resident #264 has periods of involuntary movements related to hypoxia and seizure disorder as well as cough spasms. The Interdisciplinary Team concludes that resident during transfer may have coughed or had involuntary movement and may have leaned into [Resident #264] mechanical lift cross- bar. Interviews with staff familiar with the resident routine revealed that the resident was immobile.
Actions included to: .4. Transfer to Hospital for Evaluation; 5. Mechanical lift Competencies with CNAs; 6. Maintain 2 person assist with mechanical lift transfer and care; CNA #1 had Resident #264 on the mechanical lift alone in the room. CNA #2 was not in the room when CNA #1 initiated the transfer and placed Resident #264 on the mechanical lift. Utilize soft padding on the mechanical lift crossbar during resident transfers.
On 1/22/24 at 10:15 AM, two surveyors conducted an in person interview with CNA #1, who stated that she recalled the incident. CNA #1 stated that the evening shift was very chaotic, and that she observed the injury after transferring Resident #264 in bed. CNA #1 stated that Resident #264 always scratched their face, and the injury could be self-inflicted. When asked if she remained in the room with the resident and waited for the nurse to come and assess the injury, CNA #1 stated she had too much to do that day; she moved on and attended to other residents. The surveyor then inquired about the 2nd statement, and CNA #1 read the statement and stated, another co-worker coached her to write the second statement, but she did not observe any injury to the resident face and right eye while the resident was sitting in the chair.
On 1/22/24 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2, whom CNA #1 claimed assisted her with the transfer. CNA #2 stated that when she entered the room, [Resident #264] was in the room and on the mechanical lift alone with CNA#1. CNA #2 observed the bruise and advised CNA #1 to report the injury to the nurse. When asked if she assisted CNA #1 with care, CNA #2 stated, No, I left the room and continued with my assignment.
On 1/22/25 at 1:15 PM, the surveyor interviewed CNA #3, who was assigned to the 7:00 AM-3:00 PM shift regarding Resident #264's care. CNA #3 stated that she cared for Resident #264 daily; that Resident #264 was immobile, had poor trunk control, and required a two-persons assist with transfers. CNA #3 further stated that on 11/06/24, she transferred Resident #264 to the recliner chair with the Respiratory Therapist. During the day she periodically checked Resident #264, and no injury was noted to the right eye.
On 1/23/25 at 10:56 AM, the surveyor reviewed the investigation with the LNHA in the presence of the survey team. The LNHA stated that in reviewing RN #2's statement and the investigation, he could see there were some discrepancies. The LNHA added the investigation was not concise and thorough, and that his expectation was that the facility would thoroughly investigate injuries of unknown origin.
On 1/23/25 at 1:30 PM, during the exit conference no additional information was provided.
A review of the facility's Incident/Accidents policy dated 05/01/14, and last revised 1/2024, included Policies and Procedures are guidelines. They are intended to communicate information that generally applies to facility operations. Current rules, regulations and laws take precedence over guidelines. Policy: Each resident receives adequate supervision and assistive devices to prevent accidents; Purpose: A system to prevent and/or minimize further incidents and accidents; All interventions should be placed in treatment record and signed by nurses.
A review of the facility's Abuse Prevention Program dated last revised 1/2025, under identification indicated the following: All residents sustaining bruises, skin tears, any marks of the skin, and any fractures or injuries, which are of unknown origin, shall be identified as potential abuse incidents and investigated as such .
The policy for Hoyer lift transfer was not provided.
Part C
On 01/17/25 at 8:46 AM, Surveyor #2 reviewed the closed electronic medical record (EMR) for Resident #34.
A review of the admission Record face sheet revealed Resident #34 had diagnoses including, but not limited to; sepsis, chronic viral hepatitis C, and opioid dependence.
A review of an IDT Progress Notes (PN) dated effective 07/14/24 10:50 AM, and created on 07/15/24, by the nursing department included that on 7/14/24, the primary nurse called the supervisor for the Resident #34, and upon the supervisor's arrival, the supervisor found the resident on the bed with erratic behavior and uncontrolled movement. The room was fully searched, and drug related equipment was found on the resident's bed. The supervisor immediately confiscated the equipment. Education was given to the resident about the risks of substance abuse, and that these actions violate the policies of the hospital (the facility). The MD was made aware, and ordered the resident to be transferred to the hospital for evaluation, and ordered a toxicology screen.
A review of the Laboratory (Lab) Results Report with a collection date of 07/16/24, revealed Resident #34 tested positive for cocaine metabolite.
A review of the IDT PN dated late entry effective 08/08/24 at 1:26 PM, created on 11/24/24 at 1:27 PM, by the DON, included the resident was noted with restless behavior; talking very animated and excited; slurring speech; at time making incoherent statements. The resident declined to be transferred to the emergency room (ER) for evaluation. The resident was educated on risk versus benefit of using illicit substances, and urine toxicology obtained per physician order.
A review of the Lab Results Report with a collection date of 08/08/24, revealed Resident #34 tested positive for cocaine metabolite, opiates, morphine, and methadone.
A review of a IDT Note dated 08/15/25 at 10:12 AM, included urine drug screen results received. The resident was positive for opiates, positive for cocaine, and positive for morphine. The resident was positive for methadone which was prescribed. The DON and physician were notified.
A review of the IDT PN dated late entry effective 12/19/24 at 11:56 AM, included at 10:39 AM, the resident was noted in the wheelchair in room lethargic with pupils dilated and not responding to commands. The NP ordered the resident be sent to the ER, and 911 was called. A STAT (immediate) drug screen ordered per physician and resident refused. The resident was noted with a vape pen and lighter in possession which were confiscated. The NP was made aware of the resident's refusal to go to ER.
A review of the Order Summary Report for the admission date of 07/15/24, for Resident #39, revealed an physicians order (PO) to maintain one-to-one (1:1) supervision every shift ordered on 11/27/24. A PO that may have visitors under supervision as needed ordered 12/02/24, and an order for methadone HCL oral concentrate 10 (milligram/milliliter) (mg/ml); give 50 mg by mouth once a day for opioid dependence.
A review of Resident #34's ICCP included the following focus areas:
A focus area initiated on 07/15/24, for the resident having a past history of drug abuse and was a risk for relapse. The goal was to keep Resident #34 safe with the interventions including daily room searches initiated on 07/15/24.
A focus area initiated 10/25/24, that the resident was a smoker with a goal to be a safe smoker. An Intervention included the Smoking Contract was reviewed and signed on 10/25/24.
A focus area for the resident being on methadone for substance abuse, and on 07/14/24, the resident was noted with erratic behavior and uncontrolled movements, room check was done and suspected drug related items found on resident bed .
A focus area for Resident #34 noted on 12/20/24, with erratic behaviors and uncontrolled movements and a room check was done and suspected drug related items found on the bed. A lighter and vape was confiscated.
A focus area that Resident #34 will be free of illicit substances was initiated on 12/20/24.
On 01/22/25 at 9:02 AM, Surveyor #2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who was familiar with Resident #34. The LPN/UM stated she used to be on Resident #34's floor, and she stated that Resident #34 was alert and oriented and had an issue with addiction. Surveyor #2 asked about the methadone clinic process and when Resident #34 was found with drug paraphernalia. The LPN/UM stated Resident #34 smoked and went outside and was observed going to the fence and someone came and handed the resident something and quickly ran off. Resident #34 was asked what was given and stated to the LPN/UM it was nothing, and the LPN/UM then found Resident #34 not responding properly and they lifted the bed and found a home-made type twisted-up metal object under the resident's bed that was some sort of item used with drugs. Surveyor #2 asked about what was done to prevent Resident #34 from obtaining illegal drugs again, and the LPN/UM stated Resident #34 had 1:1 monitoring for a few weeks and then, got off of 1:1.
On 01/22/25 at 9:45 AM, Surveyor #2 asked the DON for all incidents, grievances, investigations related to Resident #34 and they were provided them at 11:30 AM the same day.
An Investigative Summary for the Concern on 07/14/24 at 8:55 PM, when Resident #34 was acting erratic and drug related paraphernalia was found on the bed. The undated Investigative Findings included that Resident #34's roommate observed the resident going to the fence in the smoking courtyard, but could not see what was happening. The resident (Resident #34) was found with a glass pipe on the resident's bed shortly after, and the drug panel was positive for cocaine metabolites. The conclusion revealed that the DON told the resident that illicit substances will not be tolerated due to risk of harm to self. Actions included: 1. Resident placed on every thirty-minute checks for 3 days . A statement signed by an unidentified person on 07/14/24, revealed Resident #34 was observed going to the gate continuously during the smoking time. Three Thirty-Minute Monitoring Sheets dated 07/15/24, 07/16/24, and 07/17/24, had a time and space next to the time for the 11:00 PM-7:00 AM (11-7) shift, 7:00 AM-3:00 PM (7-3) and 3:00 PM-11:00 PM (3-11) shift. The handwritten documents did not identify who filled them out each shift, and did not represent all meals, or smoking times.
An Incident Report dated 08/08/24, and completed by the DON, revealed Resident #34 was noted with restless behavior . slurring speech .making incoherent statements. Immediate Action Taken was the resident was educated on the risk versus benefit of using illicit substances. There was no Investigative Summary Attached with additional actions to prevent recurrence.
An Incident Report dated 12/19/24, completed by the LPN/UM, revealed the resident was noted with a vape pen and lighter in their position; pupils were dilated and resident was not responding to commands. 911 was called and the resident refused to go .There was no Investigative Summary with additional actions to prevent recurrence.
On 01/22/25 at 1:46 PM, Surveyor #2 interviewed the DON in the presence of the survey team, and the DON was asked to explain what the drug paraphernalia found in Resident #34's room was. The DON stated there was a spoon with black residue on it, and another incident when a wire was found. The DON stated the resident was placed on 1:1 monitoring and room checks. Surveyor #2 asked if the police were contacted and the DON stated, we wouldn't do that, we did an investigation. Surveyor #2 asked if other residents obtained the drugs from Resident #34, and the DON stated no other residents appeared to be under the influence. The DON was asked who was to monitor the smoking area to see if items were passed through the fence, and she stated it would be seen on the security camera. Surveyor #2 asked what was done to prevent the recurrence, and the DON stated we asked Resident #34 initially about the drugs and Resident #34 denied it, and we did 1:1 observation for three days. The DON stated they could not prove where the drugs came from, and they must do the least restrictive intervention. The surveyor asked the DON why the 08/08/24, incident note was written in November 2024, and the DON stated she could not recall why and stated that the facility did not report any of the instances. Surveyor #2 asked where the resident received the cocaine that was identified on the drug screen. The DON stated the facility did not know, and stated maybe when the resident went to the methadone clinic as the residents were very sneaky at times and we can't always pin down where the drugs come from. Surveyor #2 asked the DON what the facility's responsibility was to protect all the residents in the facility from the drugs and for safety when the resident was found with a vape and lighter in the room. The DON stated Resident #34 was placed on 1:1 supervision for a while, and Surveyor #2 stated that the resident then was found having drugs, a vape, and a lighter while on 1:1 monitoring. The DON stated we confiscated the paraphernalia the first time. Surveyor #2 asked what about when it happened a second time in August. The DON stated it was discussed as a team and the DON stated it was her responsibility to protect the other residents, and she did not think Resident #34 was giving drugs to other residents, and stated, I think we would have known.
On 01/23/25 at 8:53 AM, Surveyor #2 interviewed the Medical Director (MD) in the presence of the survey team, and asked if he was made aware of Resident #34's incidents with drug paraphernalia and was found in the facility in their room not responding, and found with a vape and a lighter and drugs were found in the resident's system. The MD stated he was not aware, and then stated, no, not at all was I aware of this. Surveyor #2 asked what should have been done after that occurred. The MD stated, that is concerning, the resident should get a warning discharge as could cause a huge fire, of course.
On 01/23/25 at 11:32 AM, the survey team reviewed the above concerns with the LNHA, DON, [NAME] President of Clinical Services, and Quality Assurance Nurse.
On 01/23/25 at 2:15 PM, during the exit conference, the facility administration had no further information to provide.
NJAC 8:39 31.6(e); 4.1 (a)(5); 27.1(a)(b)
Complaint NJ # 180392
Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to a.) ensure effective interventions were implemented and monitored for a resident (Resident #143) who resided in a piped-in oxygen room and was identified as a smoker and was observed smoking inside their room on 10/19/24. This deficient practice occurred for 1 of 1 residents reviewed for safe smoking.
Observations on 1/15/25, 1/16/25, and 1/17/25, confirmed Resident #143 who resided in a piped-in oxygen room, kept their smoking materials in their room. The facility's failure to ensure all residents were protected from serious injury, harm or death from explosion or fire, from smoking inside of a room that had oxygen piped in through the walls resulted in an Immediate Jeopardy (IJ) situation.
The IJ began on 10/19/24, when Resident #143 was found by a Registered Nurse (RN #1) to be smoking in their room. From 1/15/25 through 1/17/25, the surveyor observed smoking materials inside of the resident's room and within arm's reach of Resident #143 and inside of an oxygen rich environment due to the facility utilizing oxygen that was piped in through the walls. The facility was notified of the IJ on 1/17/25 at 2:26 PM. The facility provided an acceptable Removal Plan (RP) which was verified on-site by the survey team on 1/21/25.
The facility further failed to b.) ensure that two staff members were present to safely transfer a resident who was dependent on a ventilator for breathing and utilized a mechanical lift, who sustained a 16-centimeter (cm) x 10 cm traumatic hematoma to the right orbit (eye socket) and required hospitalization on 11/06/24. This deficient practice was identified for 1 of 1 residents (Resident #264) reviewed for accidents; the facility also failed to c.) ensure effective interventions and adequate supervision was provided to a resident (Resident #34) with a history of substance abuse who was found on 07/14/24, with erratic behavior and drug paraphernalia observed on the bed and on 08/08/24, with slurred speech making incoherent statements that tested positive for cocaine, opiates, and morphine; and d.) protect all residents from potential fire or gaining access to illicit drugs by ensuring effective interventions for the same resident (Resident #34) who on 12/19/24 was found lethargic, not responding to commands, and had a lighter and a vape (electronic cigarette) pen in their room. This deficient practice was identified for 1 of 2 closed records reviewed for accidents (Resident #34).
The evidence was as follows:
Part A
A review of the facility's Smoking Safety policy revised/reviewed 1/2025, revealed Policy: It is the purpose of this facility to ensure smoking safety at all times while resident in the facility. Procedure: 1. All smoking residents will receive and sign the Smoking Agreement Contract. If the resident refuses to sign the contract, the resident will lose the privilege of smoking. 2. Upon admission, smokers will be assessed for smoking safety. 3. The Social Worker will review the Smoking Assessment Contract with the resident and answer any questions if needed. The Social Worker will have the resident sign the contract at this time. 4. Cigarettes and lighting materials are held in the security office. The resident will not keep lighters, matches and/or lighting materials with them while not actively smoking or in a smoking area.
On 1/15/25 at 9:39 AM, during the initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room which indicated, No Smoking (in red), Piped-In Oxygen In Use. Upon entering Resident #143's room, Surveyor #1 observed the resident in bed watching television. At that same time, Surveyor #1 observed a pack of cigars on the table next to the resident and the surveyor asked the resident what they were. The resident took a cigar out of the case and stated it's a cigar while holding it and showing it to the surveyor.
On 1/16/25 at 8:50 AM, Surveyor #1 reviewed the electronic medical record for Resident #143.
According to the admission Record face sheet (an admission summary) Resident #143 was admitted to the facility with diagnoses which included but were not limited to; hypertension (high blood pressure), heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), hyperlipidemia (abnormally high levels of fats in the blood), and diabetes mellitus (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces).
A review of Resident #143's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/28/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated the resident had a moderately impaired cognition.
A review of a nursing Progress Notes (PN), created on 10/19/24 at 7:18 PM, indicated [resident] was seen in room smoking cigarette; educated [resident] not to smoke in room. The [resident] shown area designated for smoking, states okay .
A review of Resident #143's individualized comprehensive care plan (ICCP) initiated on 7/09/24, reflected that Resident #143 was a smoker. Interventions included: Smoking contract reviewed with [Resident #143]. Resident signed updated smoking agreement on 07/09/24, and understands smoking safety procedures and hours of operation 10:00 AM, 12:30 PM, 4:00 PM, and 7:00 PM.
A further review of the resident's ICCP revealed a smoking focus area created on 10/19/24 at 7:18 PM, which revealed Resident #143 was seen smoking a cigarette in their room. The goal was for the resident to not smoke in their room. Interventions initiated on 10/22/24, included: cigarettes and lighter given to security; cigarettes and lighter were taken from resident's room; educated on risk of smoking in room; encouraged to ask for assistance if needs help; Medical Doctor and family made aware; Resident #143 will be monitored for smoking every shift for smoking; the resident was shown designated smoking area; smoke detector was immediately placed in room.
On 1/16/25 at 11:44 AM, Surveyor #1 observed Resident #143 sitting in a wheelchair in their room with two loose cigars adjacent to the resident's meal tray and within the resident's reach.
On 1/17/25 at 8:19 AM, Surveyor #2 interviewed the Security Guard (SG) who stated he was responsible to distribute the smoking materials and lighters for resident use. The SG Stated there was a Smoking Times list and a list of residents who smoked affixed to the wall and Resident #143's name was not listed. The SG stated for each smoking time, there would be a staff member assigned at 10:00 AM, 1:00 PM, 4:00 PM and 7:00 PM. Surveyor #2 asked if Resident #143 smoked since their name was not on the list of residents who smoked, and the SG removed a plastic bag labeled with Resident #143's name out of the desk drawer and the bag contained two packages of cigars and a lighter. Surveyor #2 asked if the residents could smoke in their rooms and the SG stated, no, we have oxygen on the floor. Surveyor #2 asked why Resident #143 was not on the list of smokers, and the SG stated Social Services needed to update the list. Surveyor #2 asked if a resident smoked in their room would it be a problem, and the SG stated, yes, because I would need to know, the resident's room would have to be checked, and the resident would have to be closely monitored. The SG stated, anything tobacco would have to come through me. Surveyor #2 asked if residents were allowed to keep the cigarettes in their room, and the SG stated, no, they cannot keep cigarettes in their room. Surveyor #2 then asked what should happen if staff found a resident with cigarettes in their room, and the SG stated he should be notified because the residents were not allowed to have them on the floors at all, there is oxygen on the floors. Surveyor #2 then asked if Resident #143 had been found smoking in their room, and the SG stated, he heard nothing about that, and that he should be immediately notified if any cigarettes were found in the room. The SG stated Resident #143 usually smoked once a day or less; usually at 1:00 PM.
On 01/17/25 at 8:20 AM, Surveyor #1 observed Resident #143 sitting in a wheelchair in their room with two loose cigars on the tray table within reach of the resident and a cigar box was on top of the nightstand. The resident stated, I buy my own cigars; I walk to the store. Surveyor #1 asked Resident #143 if they had a lighter and the resident then gestured with both hands waving towards the nightstand, and stated, I put it up. Surveyor #1 asked the resident if they could show their lighter to the surveyor, and Resident #143 then began rummaging through their nightstand and stated, I can't find it.
On 1/17/25 at 8:45 AM, Surveyor #1 interviewed RN #1, who stated that the residents smoked in the designated area as per the smoking schedule. RN #1 stated all residents were assessed for smoking upon admission, and staff let Security know if the resident was a smoker. RN #1 stated the residents were not allowed to smoke in their rooms and if they were caught smoking in their rooms, their smoking supplies were removed from their room and stored either with Security or inside the medication cart. RN #1 stated Resident #143 had smoked in their room before, and all the smoking supplies were taken away from the resident. RN #1 further stated smoking was not allowed in the rooms due to residents using oxygen and the risk of fire.
On 01/17/25 at 9:16 AM, Surveyor #1 accompanied RN #1 to Resident #143's room, and the RN observed two packs of sealed cigars inside the resident's nightstand drawer. RN #1 stated Resident #143 was not allowed to have smoking supplies in their room and immediately removed the cigar packs from the resident's room.
On 1/17/25 at 9:21 AM, Surveyor #1 interviewed the Assistant Director of Nursing (ADON), who stated residents were not allowed to smoke

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. On 1/15/25 at 11:15 AM, while touring the 400 Unit, the surveyor observed Resident #91 sitting in the room, the resident was awake and alert. The resident informed Surveyor #2 that he /she had some concerns that he/she would like to address. Surveyor #2 observed 4 urinals hung on the footboard all almost full with urine. The resident informed the surveyor that the 11:00 PM - 7:00 AM shift did not empty the urinals. According to the resident the staff delivered the breakfast tray and did not empty the urinals.
Surveyor #2 returned to the room around 11:30 AM to meet with the resident. The resident told the surveyor that they had some concerns regarding the call light mostly on the 11 PM - 7 AM shift. When they activated the call light, the staff will not show up and some had attitude. The 11:00 PM - 7:00 AM staff were to empty the urinal, they do not pay attention. The resident told the surveyor that the CNA did not come to the room and they will turn the light off.
On 1/16/25 at 10:46 AM, the surveyor interview the Quality Assurance (QA) /CNA who revealed that in the morning she would check the schedule, make the make the assignment, make rounds either alone or with the Unit Manager, and assist with care. The QA/CNA further stated that the norm was to check the residents, make rounds, and provide incontinence care prior to breakfast.
On 1/16/25 at 11:50 AM, Surveyor #2 reviewed Resident #91's medical record with revealed diagnoses which included; unspecified osteoarthritis, respiratory failure, difficulty in walking and muscle weakness. The Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed Resident #91 was awake, alert, oriented and able to make his/her needs known. Resident #91 received a score of 15 out of 15 on the Brief Interview for Mental Status indicative of intact cognition.
On 1/18/25 at 9:30 AM, Surveyor #2 interviewed the CNA who cared for the resident. The CNA revealed that the resident was awake, alert and oriented and able to make their needs known. The CNA also revealed that the resident used the urinal and would activate the call bell when assistance was needed. When inquired regarding the urinals with urine in the room, the CNA stated that she would empty them.
On 1/21/27 at 12:45 PM, Surveyor #2 visited Resident #91 in the room while the resident was eating lunch. The surveyor observed the urinal was full of urine and was hung on the footboard. The resident stated that the night shift forgot to empty the urinals.
On 1/21/25 at 1:15 PM, Surveyor #2 reviewed Resident #91's Care Plan (CP). The CP Focus dated 08/06/21, indicated that Resident #91 had limited mobility on bilateral lower extremities, and needed assistance with toileting . The plan of care further indicated to provide prompt response to all requests for assistance.
On 1/22/25 at 10:00 AM, the surveyor interviewed the Unit Manager regarding the urinals observed at the bedside while meals were being served. The UM stated that the staff were to make rounds and ensure that the residents were being cared for. When the surveyor showed her the urinals full of urine while the resident was eating their meals, the UM then stated, not on my floor. The UM stated that the QA/CNA was to make rounds in the morning and that the staff should have emptied the urinal prior to the resident being served the breakfast meal.
On 1/23/25 at 11:30 PM, the above concerns were discussed with the administrative staff, no further information was provided.
NJAC 8:39-4.1(a, 11, 12), 27.1(a)
Based on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to provide residents with a dignified environment by not providing bed linens, and not consistently emptying multiple urinals. This deficient practice was identified for 2 of 2 residents (Resident #113 and Resident #91) reviewed for dignity and was evidenced by the following:
a. On 01/15/25 at 10:10 AM, Surveyor #1 observed Resident #113 in their room and in their bed, wearing a hospital type gown. There were no linens, pillows, or blankets on the bed and crumbs were observed in the bed.
On 01/15/25 at 10:49 AM, Surveyor #1 and Surveyor #2 went to Resident #113's room. Both surveyors observed the resident was still sitting on the bed with no linens, pillows, or blankets on the bed as observed by the surveyor approximately 40 minutes prior.
On 01/16/25 at 8:19 AM, Surveyor #1 observed Resident #113 sitting in a wheelchair in the room. There were no linens, pillows, or blankets on the resident's bed.
On 01/16/25 at 8:19 AM, Surveyor #1 and the Registered Nurse Unit Manager (RN/UM) went to Resident #133's Room. Both the RN/UM and Surveyor #1 observed the bed without linens, blankets, or pillows. The RN/UM was made aware of the two prior similar observations by two surveyors on 01/15/25. The RN/UM stated that was not acceptable and it was a dignity issue.
On 01/16/25 at 10:26 AM, Surveyor #1 reviewed the admission Record (an admission summary) which revealed that Resident #113 had diagnoses which included, but were not limited to; unspecified Dementia, Anxiety, and muscle weakness. A review of the annual Minimum Data Set (MDS), an assessment tool, dated 10/18/24, included but was not limited to; a Brief Interview for Mental Status of 01 out of 15 which indicated Resident #113 had a severely impaired cognition; and needed substantial/maximal assistance to transfer to and from the bed to a chair or wheelchair. A review of the individual Care Plan included a Focus area initiated 04/22/24, for self-care/mobility performance deficit with interventions which included required staff participation with transfers.
On 01/16/25 at 10:11 AM, the RN/UM informed Surveyor #1 that the CNA informed the RN/UM that on 01/15/25, Resident #113's bed was soiled so the CNA stripped the bed and the CNA went to assist another resident, however, the RN/UM did not address the address if leaving a resident in that condition for almost 40 minutes was acceptable and the RN/UM had no comment on the 01/16/25 observation.
A review of the facility provided, Position Title: Certified Nurse Aide undated, included but was not limited to; Summary . performs various resident care activities . essential to caring for personal needs and comfort of residents. 25. Obtains clean linens and supplies . 29. Ensures that residents and families receive the highest quality of service.
A review of the facility provided policy, Quality of Life: Dignity revised 1/25, included but was not limited to; Policy: each resident . shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Procedure: 1 residents shall be treated with dignity and respect at all times.
On 01/23/25 at 11:32 AM, the above concerns were presented to the facility administration.

Complaint # NJ 168201, # NJ 179357
Based on observations, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that a resident call light was readily accessible and within reach on 01/15/25, 01/16/25, and 01/21/25. The deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for accommodation of needs and was evidenced by the following:
On 01/15/25 at 10:45 AM, during an initial tour, the surveyor observed Resident #43 watching television (TV) in the bed. The resident stated, I am paralyzed (unable to move) from a stroke and not able to move my right arm. The surveyor observed resident's left hand elevated on a pillow. The surveyor observed the resident's call bell (a round disk-shaped flat device with a red cross in the middle) was placed close to their right shoulder. Resident #43 stated, I am not able to use my call bell and have asked them (staff) to place it on more towards left side.
On 01/16/25 at 11:57 AM, the surveyor observed Resident #43 watching TV in the bed and the call bell was placed by resident's right shoulder in the same location as the previous observation. While the surveyor was in the room, the resident called the attention of the Certified Nursing Assistant (CNA) to help lower their head. The surveyor observed that the resident was not able to reach and/or use the call bell with their left hand.
On 01/21/25 at 10:08 AM, the surveyor observed Resident #43 in bed. The resident's call bell was placed on the right side by their pillow and the resident was not able to reach the call bell.
On 01/16/25 at 1:08 PM, the surveyor reviewed the electronic medical record for Resident #43 which revealed:
According to the admission Record (admission summary), Resident #43 was admitted to the facility with diagnoses which included, but were not limited to; paraplegia (a form of paralysis that mostly affects the movement of lower body), and muscle weakness.
A review of the Quarterly Minimum Data Set Assessment (MDS), an assessment tool, dated 11/02/24, revealed that the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated that the resident had a moderately impaired cognition. Further review of the MDS revealed that resident had impairment on both sides on Upper Extremities (UE) (arms).
A review of the Order Summary Report (OSR) for Resident #43 revealed a Physician Order (PO) for- Call Bell Within Reach Every Shift; Start Date: 12/30/23.
A review of the Care Plan (CP) dated 1/12/24, with a focus that reflected that the resident has an ADL (activities of daily living) Selfcare performance deficit related to activity intolerance, hemiplegia (complete or severe paralysis on one side of the body) limited UE mobility, b/l (bilateral) (both) hand contractures. The interventions reflected encourage to use call bell to call for assistance. Further review of the CP with a focus [Name Redacted] is high risk for falls related to generalized weakness, side effects of medications and seizures. The interventions reflected be sure call light is within reach and encourage to use it for assistance as needed Call bell within reach.
On 1/21/25 at 10:17 AM, during an interview with the surveyor, the Certified Nurse Aide (CNA) stated she was familiar with Resident #43. The CNA stated Resident #43 was not able to take care of themselves and would use the call bell when they needed any help. The CNA further stated the resident could move their right side (right arm) only, so the CNA stated she would place the call bell to resident's right side which was the resident's good side. The surveyor accompanied the CNA to resident's room and observed the resident's left hand out of the blanket. Resident #43 was moving their left arm, and the right arm was covered under the blanket. In the presence of the surveyor and the CNA, Resident #43 stated I can't reach the call bell with my right arm. The CNA moved the call bell closer to the resident's left side where the resident could reach. The CNA stated the call bell should not be on the resident's right side because the resident would not be able to use the call light.
On 1/21/25 at 10:53 AM, during an interview with the surveyor, the Registered Nurse (RN) stated Resident #43 was quadriplegic (paralyzed in their both arms and legs). The RN further stated that Resident #43 was able to use their call bell when it was placed on their special side. The surveyor notified the RN of the above-mentioned observations. The RN confirmed if the call bell was on Resident #43's right side, then the resident would not be able to use the call bell. The RN further stated that the call bell should be placed where the resident can reach it comfortably.
On 1/21/25 at 1:34 PM, during an interview with the surveyor, the Assistant Director of Nursing (ADON) stated if the resident was paralyzed on their right side, the call bell would be placed on their dominant (Left) side where they could reach it in case the resident had an emergency and needed to call for help. The surveyor notified the ADON of the above-mentioned observations.
A review of the facility's policy, Call Bells revised 1/2025, included under Policy section: Resident will utilize a call bell at bedside as a means for communication to respond to resident's request and needs.
On 1/23/25 at 11:33 AM, the survey team met with the facility administration. The surveyor notified the facility management of the above-mentioned concerns for Resident #43. The DON acknowledged that the resident should have the call bell placed on their unaffected side.
On 1/23/25 at 2:10 PM, the survey team met with the facility administration for an Exit Conference. The facility had no additional information to provide.
NJAC 8:39-27.1 (a)

Based on interview and document review it was determined that the facility failed to ensure that all residents that maintained a Personal Needs Account (PNA) that approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplimental Security Income (SSI). This deficient practice was identified for all residents who maintained Personal Needs Accounts at the facility and was evidenced by:
A review of the Funds Balance Report for 01/15/2025 revealed a list of eighty five active resident names with a balance of $84, 036.27 Due to patients. There were twenty -one residents listed with PNA funds that range from $1,852.93 to $3,997.38.
On 01/21/25 at 10:32 AM, the surveyor, in the presence of the survey team interviewed the Certified Social Worker (CSW) regarding the PNA accounts and if the CSW was involved with the PNA. The CSW stated that the business office handled the PNA. The CSW stated the business office will send a list of residents with PNA money, and the Certified Nurse Aide or family would let us know if the resident needed anything and the facility had catalogues to order items from. The CSW stated that if the family ordered items that we could reimburse them if they provide the receipt. The surveyor asked if the resident had money in their PNA that was more than $2,000.00 would that be a concern? The CSW stated, They cannot go over $2,000.00, or they are not eligible for Medicaid. The CSW stated we are working getting the residents to spend the money and if the resident's cannot tell us what they need we try to ask staff. The surveyor asked the CSW about an Unsampled Resident (UR) who had a balance of $2,195.16 and what was the plan for the UR's PNA. The CSW stated that is not what she handled, it was the Per Diem Social Worker's responsibility to handle the PNA over $2,000.00.
On 01/21/25 at 10:52 AM, the surveyor interviewed the Business Office Manager (BOM) who confirmed that there was a list of active residents who had PNA and she received the list monthly. She stated that the list would be reviewed and whoever had money the facility would spend it down on the resident's behalf.
On 01/22/25 at 10:43 AM, the surveyor interviewed the Per Diem (PDSW) Social Worker regarding her role related to the PNA accounts. The PDSW stated she stated, I got the list today, and when asked if that was her usual job she responded, no, ma ' am. The PDSW stated she is the Social Work Director at another facility and at the current facility one day per week. The PDSW stated, the process would be that the business office manager is supposed to send out the statements and there should also be a system in place to confirm that the statements for the resident PNA were sent. The PDSW stated she received the list of the current PNA money that morning and reviewed the list of the resident accounts with PNA funds over/ approaching $2,000.00. The PDSW looked at the list and stated, it hasn't been touched and when the PNA funds approached $1,800.00, the money should be spent down. She stated there is no way around it and confirmed since surveyor inquiry, it is happening now.
On 01/23/24 at 2:30 PM, the facility administration had no further information to provide regarding the PNA balances.
NJAC 8:39-9.5(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined that the facility failed to 1. enter weekly weights in the electronic medical record (EMR) for 3 of 4 residents, Resident #133, #16, and #85, 2. Address the cause(s) between current medical condition and significant (sig) weight losses for 4 of 4 residents, Resident #133, #16, #31 and #85 and 3. address identified actual or possible reasons of significant weight losses in the resident's care plan for 4 of 4 residents, Resident #133, #16, #31 and # 85, all reviewed for weight loss per facility policy.
This deficient practice was evidenced by the following:
1. On 9/5/2023 at 10:35 AM, the surveyor observed Resident #133 in bed with a Tube Feeding (TF) (tube feeding is a flexible tube that goes through the nose or belly area and delivers liquid nutrition directly into the stomach or small intestine) Glucerna 1.5 (a diabetic based tube feeding formula) running at 65 milliliter per hour (ml/hr.) delivering nutritional formula to the resident.
On 9/7/2023 at 9:25 AM, the surveyor reviewed the resident's EMR and found the following information:
Resident #133 was admitted to the facility on [DATE] with diagnoses which included but were not limited to: Acute Respiratory Failure with Hypoxia, Aphasia, Type 2 Diabetes and Gastrostomy Status.
A review of Resident #133 Significant Change Minimum Data Set (MDS) which is a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) showed an MDS dated for 5/9/2023, under Section K Swallowing and Nutrition Status that the resident had a loss of 5% or more in the last month or loss of 10% or more in last 6 months and that the resident is not on a prescribed weight-loss regiment.
Continued review of the 5/9/23 MDS Section C, Cognitive Patterns Brief Interview for Mental Status (BIMS), (BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment.) Per section C0100. Should Brief Interview for Mental Status be Conducted? Resident #131 could not have a BIMS conducted due to not being able to be understood or express themselves.
The surveyor reviewed the weight record in the EMR. Weights were documented as the following:
8/09/2023 23:28 153.2 Pounds (lbs.)
7/10/2023 12:37 154.5 lbs.
6/12/2023 13:48 154.2 lbs.
5/10/2023 23:27 162.4 lbs.
5/08/2023 12:08 159.4 lbs.
5/02/2023 13:29 175.0 lbs.
4/10/2023 20:12 175.0 lbs.
3/10/2023 20:36 175.0 lbs.
2/22/2023 09:51 189.0 1bs
The documented weights reflect a significant weight loss on 5/08/2023 of 29.6 lbs. which supports a 15.7% over 90 days.
A review of the Registered Dietitian (RD) documented nutrition progress note dated 5/10/2023, May weight on 05/10/23 is 162.4 lbs., Prior weights, 1 month on 3/10/2023 175.0 lbs., down 12.6 lbs./-7.2% Significant Loss, 2 months 2/16/2023 189.3 lbs., down 26.9 lbs./-14,2% Significant Loss. Nursing notified of weight change. Recommend change TF to Glucerna 1.5, 60 milliliters per hour to TF Total Volume (TV) 1200 mls./day, with ProStat SF x 1/day, for 1900 calories, 114 grams protein, 910 mls free H2O in TF + 800 in Flushes, for 1710 mls/day. Monitor, intervene (intervene means to become involved in a situation in order to alter or prevent an action such as weight loss) as needed.
Review of the RD's 5/10/2023 progress note, there was no documentation of the relationship between the resident's current medical condition which includes but was not limited to acute respiratory failure with hypoxia, tracheostomy, and type 2 diabetes with recent changes in weight, as the facility weight loss policy dictates. The RD does not explain why a resident on a TF who is receiving a predetermined measure of calories, protein and fluids would have a significant weight loss.
A review of Resident #133's individualized care plan for nutrition with an onset date of 5/9/2023 and completed on 7/25/2023, failed to address any identified causes of weight loss, as the facility weight loss policy dictates.
On 9/7/2023 the Regional Registered Dietitian (RRD) provided the surveyor with a paper copy of weekly weights for all residents who resided on the 5th floor of the facility from February through August 2023. The RRD informed the surveyor that the weekly weight sheet is kept by the RD in a notebook in her office. The information submitted was not stored in the paper medical chart and unavailable to the facility staff for review.
The surveyor observed weekly weights for Resident #133 starting on 5/29/2023 and ending on 8/28/2023. Weights were documented as follows:
5/29/2023: 159 lbs.
6/05/2023: 151 lbs.
6/12/2023: 154 lbs.
6/19/2023: 156 lbs.
6/26/2023: 153 lbs.
7/03/2023: 150 lbs.
7/10/2023: 154 lbs.
7/17/2023: 155 lbs.
7/24/2023 152 lbs.
7/31/2023: 154 lbs.
8/07/2023: 155 lbs.
8/14/2023: 158 lbs.
8/21/2023: 157 lbs.
8/28/2023: 155 lbs.
None of the weekly weights were documented into the EMR as per facility policy.
The Surveyor observed a Physician Order (PO) for weekly weights in the electronic medication administration record (eMAR), one time a day every Mon for weight monitoring obtain weight and document on weight form at nurses' station, starting on 5/29/2023 and discontinued on 9/7/2023. No weekly weights were reflected in the eMAR from 5/2023 to 9/2023
2. On 9/5/2023 at 10:46 AM, the surveyor observed Resident #16 in bed with a TF pump at their bedside, not currently running. Resident #16 was also observed with a tracheostomy tube (a tube placed in the neck to provide an air passage to help breathing) in place.
On 9/7/2023 at 10:13 AM, the surveyor reviewed the resident's EMR. The resident was admitted on [DATE] with diagnosis which included but were not limited to: Sepsis, Acute Respiratory Failure with Hypercapnia, Gastrostomy and Dependence on Respiratory (ventilator) Status.
A review of Resident #16's Significant Change MDS dated [DATE], Under Section K Swallowing and Nutrition Status that the resident had a loss of 5% or more in the last month or loss of 10% or more in last 6 months and that the resident in not on a prescribed weight-loss regiment. Resident #16 was noted under Section C, Cognitive Patterns section C0100, could not have a BIMS conducted due to not being understood.
The surveyor reviewed the weight record in the EMR. Weights were documented as follows:
8/09/2023 23:29 162.5 lbs.
7/10/2023 12:38 166.7 lbs.
6/15/2023 10:18 175.2 lbs.
6/07/2023 15:28 165.6 lbs.
5/10/2023 23:51 164.6 lbs.
5/08/2023 12:08 166.5 lbs.
4/20/2023 02:01 180.4 lbs.
3/7/2023 20:44 202.4 lbs.
2/22/2023 09:55 222.0 lbs.
2/14/2023 18:26 228.0 lbs.
The weights documented reflect significant weight losses on 3/7/2023 of 25.6 lbs. supporting an 11.2% over 30 days, weight loss on 4/20/2023 of 22 lbs. which reflects a 10.9% over 30 days and an additional weight loss on 5/8/2023 of 61.5 lbs. which reflects a 27% over 90 days.
A review of the RD documented nutrition progress note dated 3/11/2023, March Wt., 3/7/2023 202.4 lbs., Prior Weight. 2/14/2023 228 lbs. Weight change, down 26 lbs./-11.4% 1 month. Rec, change to Glucerna 1.5, 65 mls/hr. to TF TV 1000 ml/day, with ProStat SF x2/day, and Flush 70 mls/hr. to TV Flush 1000 mls/day, for 1700 calories, 112.5 gm pro, 759 mls free H2O in TF + 1000 in Flushes, for 1759 mls total free H2O/day, to meet 100% calories/protein/fluid needs. Monitor, intervene as needed.
Review of an additional RD documented nutrition weight review note dated 4/28/2023 documented, April Weight., 4/20/2023 180.4 lbs., Prior Weights, 1 month 3/7/2023 202.4 lbs., down -22.0 lbs./-10.8% Sig Loss, 2 months 2/14/2023 228 lbs., down 47.6 lbs./-20.8% Sig Loss. Rec, increase TF to Glucerna 1.5 65 mls/hr. to TF TV 1100 mls/day, with ProStat SF x2/day and Flush 70 mls/hr. to Flush TV 1100 mls/day, to provide 1850 calories, 120.7 gm pro, 834 mls free H2O in TF + 1100 in Flushes, for 1934 mls free H2O/day, to meet 100% calories/protein/fluid needs, as assessed. Monitor, intervene as needed.
An additional RD documented nutrition weight review note dated 5/10/2023 documented, May Weight., 05/10 164.6 lbs., Prior Weights., 1month 4/20/2023 180.4 lbs., down 15.8 lbs./-8.7% Sig Loss, 3 months 2/14/2023 228.0 lbs., down 63.4 lbs./-27.8% Sig Loss. Nursing notified of Sig. Weight. change. Rec (recommend), increase TF TV to 1200 mls/day, continue ProStat and Flush as before, to provide 2000 calories, 129 grams protein, 910 mls free H2O in TF + 1000 in Flushes, for 1910 mls free H2O/day. Monitor, intervene as needed.
Review of the RD's progress notes dated 3/11/2023, 4/28/2023, and 5/10/2023, there was no documentation of the relationship between the resident's current medical condition which includes but not limited to Sepsis, Acute Respiratory Failure with Hypercapnia, Gastrostomy and Dependence on Respiratory (ventilator) Status and recent changes in weight, as the facility policy dictates. The RD added no documentation in the progress notes to explain why a resident on a TF who is receiving a predetermined measures of calories, protein and fluids would have a significant weight loss.
A review of Resident #16's individualized care plan for nutrition with an onset date of 2/14/2023 and completed on 7/18/2023, failed to address any identified causes of weight loss, as the facility weight loss policy dictates.
On 9/7/2023 the RRD provided the surveyor with a paper copy of weekly weights for all residents who resided on the 5th floor of the facility from February through August 2023. The RRD informed the surveyor that the weekly weight sheet is kept by the RD in a notebook in her office. The surveyor reviewed the documented weekly weights for Resident #16 starting on 5/29/2023 and ending on 6/5/2023. Weights were documented as follows:
5/29/2023: 162 lbs.
6/05/2023: 165 lbs.
None of the weekly weights were entered into the EMR.
The surveyor observed a Physician Order (PO) for weekly weights, one time a day every Mon for weight monitoring, with a start date of 5/29/2023 and a discontinuation date of 6/10/2023. The eMAR had no weekly weights documented for facility staff to access.
3. On 9/5/23 at 10:28 AM, the surveyor observed Resident #31 in bed asleep with tracheostomy tube connected.
On 9/7/23 at 11:23 AM, the surveyor reviewed the resident's EMR. The resident was admitted on [DATE] with diagnoses which included but not limited to: Anoxic Brain Damage, Chronic Atrial Fibrillation, Essential Hypertension, and Dependence on Respirator (ventilator) Status.
A review of Resident #31's Quarterly MDS dated [DATE] noted under Section K Swallowing and Nutrition Status that the resident had a loss of 5% or more in the last month or loss of 10% or more in last 6 months and that the resident in not on a prescribed weight-loss regiment.
Review of the Resident's noted documentation under Section C, Cognitive Patterns. BIMS section C0100. Should Brief Interview for Mental Status be Conducted, Resident #13 could not have a BIMS conducted to due not being understood.
The surveyor reviewed the weight record in the EMR. Weights were documented as follows:
9/07/2023 16:45 154.0 lbs.
8/09/2023 23:34 154.9 lbs.
7/17/2023 13:49 153.8 lbs.
7/10/2023 12:45 154.6 lbs.
6/12/2023 13:49 154.6 lbs.
6/05/2023 13:49 156.4 lbs.
5/10/2023 13:18 179.6 1bs.
These weights reflect a significant weight loss on 6/5/2023 of 23.6 lbs. which supports a 15.7% over 90 days.
A review of the RD nutrition weight review note dated 6/12/2023, June Weight., 6/12/2023 154.6 lbs., Prior Weights., 1 month 5/10/2023 179.6 lbs., down 25.0 lbs./-13.9% Sig Loss. 3 month 3/4/2023 180.9 lbs., down 26.3 lbs./-16.3% Sig Loss. 6 month 12/1/2023 184.8 lbs., down 30.2 lbs./-16.3% Sig Loss.1 yr. 6/1/2023 179.6 lbs., down 25.0 lbs./-13.9% Resident on Hospice Level of Care. Monitor, intervene as needed.
In the RD's progress notes dated 6/12/2023 there was no documentation of the relationship between current medical condition which included Anoxic Brain Damage, Chronic Atrial Fibrillation, Essential Hypertension, and Dependence on Respirator (ventilator) Status with recent changes in weight as the facility policy dictates.
A review of the 6/23/23 resident's individualized care plan for nutrition, failed to address any identified causes of weight loss as the facility weight loss policy dictates.
4. On 9/5/23 at 10:30 AM, the surveyor observed Resident #85 in bed, non-verbal but able to nod to yes/no questions. Resident goes to Hemodialysis (HD) treatment (Hemodialysis is a treatment that removes wastes and extra fluid from your blood) 3 times per week in the late morning, as per PO. Resident made surveyor aware that he/she does not get an early breakfast, but sometimes gets a bagged lunch to bring, but that this is very inconsistent.
On 9/8/2023 at 9:00 AM, the surveyor reviewed the resident's EMR. The resident was admitted on [DATE] with diagnoses which included but were not limited to: End Stage Renal Disease, Dysphagia, Dependence on Renal Dialysis and Type 2 Diabetes.
A review of Resident #85 Quarterly MDS dated [DATE] noted under Section K Swallowing and Nutrition Status that the resident had not any significant weight loss.
Review of the Resident's MDS documentation noted under Section C, Cognitive Patterns, BIMS per section C0100, BIMS could not be conducted to due not being understood.
The surveyor reviewed the weight record in the EMR. Weights were documented as follows:
8/11/2023 01:53 179.3 1bs.
7/24/2023 22:04 191.8 lbs.
7/19/2023 19:51 189.0 1bs.
6/07/2023 15:30 197.3 lbs.
5/16/2023 16:06 194.4 lbs.
5/08/2023 12:53 190.0 lbs.
4/10/2023 17:26 192.4 lbs.
3/06/2023 03:39 200.0 lbs.
3/05/2023 23:22 200.0 lbs.
3/05/2023 11:25 200.0 lbs.
2/01/2023 09:25 208.5 lbs.
These weights reflect significant weight losses on 5/8/23 of 18.5 lbs. reflecting an 8.9% over 90 days, a weight loss on 8/11/2023 of 22 lbs. reflecting a 10.9% over 30 days and an additional weight loss on 5/8/2023 of 12.5 lbs. reflecting 6.5% over 30 days.
A review of the RD nutrition weight review note dated 5/19/2023, May Weight., 5/10/2023 194.4 lbs., Prior Weights, 1 month 4/10/2023 192.4 lbs., up 2.0 lbs./+1.0%. 3 months 2/1/2023 208.5 lbs., down 14.1 lbs./-6.7%. 6 months 11/2/2023 217.8 lbs., down 23.4 lbs./-10.7% Sig Loss. 1 year (yr.), 5/4/2022 224.8 lbs., down 30.4 lbs./-13.5%. Rec, add ProStat SF 30 mls x2/day. Follow new Labs, Weight trends, Monitor, intervene as needed.
An additional RD nutrition weight review note dated 8/16/2023 documented, Aug Weight. 8/14/2023 180.0 lbs., Prior Weights, 1 month 7/19/2023 189.0 lbs., down 9.0 lbs./-4.7%. 3 months 5/8/2023 190.0 lbs., down 10.0 lbs./-5.2%. 6 months 2/1/2023 208.5 lbs., down 28.5 lbs./-13.6% Sig Loss. 1 year. 8/1/2023 225.2 lbs., down 45.2 lbs./-20.0% Sig loss. Supplement appropriate. Recommended, add VitD3 2000 Iu/day. Monitor, intervene as needed.
On 9/7/2023 the RRD provided this surveyor with a paper copy of weekly weights for all residents who resided on the 5th floor of the facility from February through August 2023. The RRD informed the surveyor that the weekly weight sheet is kept by the RD in a notebook in her office. The Surveyor observed weekly weights for Resident #85 starting on 5/24/2023 and ending on 8/28/2023. Weights were documented as follows:
5/24/2023: 200.6 lbs.
5/29/2023: 199 lbs.
6/5/2023: 193.4 lbs.
6/14/2023: 195.1 lbs.
6/19/2023: 195.8 lbs.
6/26/2023: 185.2 lbs.
7/3/2023: 190.3 lbs.
7/10/2023: 184.4 lbs.
7/17/2023: 190.7 lbs.
7/24/2023: 191 lbs.
7/31/2023: 185.2 lbs.
8/7/2023: 177.5 lbs.
8/14/2023: 179.5 lbs.
8/21/2023: 175.6 lbs.
8/28/2023: 179.5 lbs.
None of the weekly weights were entered into the EMR, as the facility policy dictates should be done. The Surveyor observed a PO, weekly weights-obtain from hemodialysis communication sheet
one time a day for weight monitoring, with start date of 5/24/2023 and a discontinue date of 9/7/2023. A review of the hemodialysis communication sheets from 5/24/23 to 9/7/23, revealed that weights were not taken consistently.
A review of Resident #85's individualized nutrition care plan with an onset date of 3/12/2023 and completed on 7/6/2023, failed to address any identified causes of the resident's weight loss.
On 9/7/23 the RRD provided the surveyor with a copy of the facility policy titled, Weight Assessment and Intervention. Under the Policy Interpretation and Implementation section of the policy, subsection weight assessment it states, 3. Verified weights will be recorded in each residents Electronic Medical Record. Under the subsection analysis it states, 1. Assessment information shall be analyzed, and conclusions shall be made regarding the: c. The relationship between current medical condition or clinical situation and recent fluctuations in weight. Under subsection Care Planning it states, 2 Individualized care plans shall address to the extent possible: a. The identified causes of weight loss.
On 9/11/23 at 10:50 AM, the surveyor interviewed the RD and RRD. Both the RD and RRD stated they are familiar with the facility weight policy. The RRD informed the surveyor that weekly weights are not put into the EMR but kept in a notebook in the RD's office. Neither the RRD nor RD could state why the weekly weights were not entered into the EMR per the facility policy. The surveyor reviewed the policy with the RD and RRD in reference to whether the RD's progress or weight notes should include weight change, whether it is desirable or undesirable and what medical conditions could be the cause of the weight change. The RRD responded, That is at the discretion of the RD. Surveyor asked, in the resident's care plan should address and identify the cause of the weight loss? The surveyor asked if in the resident's care plan what is entered regarding weight changes? The RRD responded, We state what interventions are in place. The RRD agreed that weekly weights should be entered in the EMR. The RD and RRD provided no further information regarding the analysis and care plan sections of the policy.
On 9/14/2023 at 01:34 PM, the surveyors met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) and Regional DON. The Regional DON stated they would provide the surveyor with a timeline for the residents who were observed with significant weight loss but could not provide any other additional information.
On 9/16/2023 at 10:38 AM, the Regional DON provided the surveyor with a timeline sheet for Residents #133, #16, #31 and #85 weight loss, which included the resident's name, weights, RD note/additional interventions, Nursing Notes/additional team interventions and RD care plans. No further information was provided to explain weight losses or why the facility failed to follow their policy and procedure.
NJAC 8:39-11.2(e), 17.1(c), 27.1(a)

Based on observation, interview, and review of facility polices it was determined that the facility failed to maintain proper kitchen sanitation practices.
This deficient practice was evidenced by the following:
On 9/5/23 from 9:35 AM through 10:20 AM, the surveyor completed the initial kitchen tour with the Food Service Director (FSD) and Regional Registered Dietitian (RRD). Upon entering the dish room, the surveyor observed a dietary aide (DA) using the dish washing machine, that was filled with soiled breakfast dishes. The surveyor observed the wash and rinse cycle reaching 114 degrees Fahrenheit (F). The FSD stated, the dish machine is a low temperature machine. The wash and rinse cycles should be 120 F. The FSD ran the dish machine two more times, with the wash and rinse cycle temperature maintaining 114 F.
The RRD provided the temperature log showing the dish machine temperature readings of 120 F from 9/1-9/5/23. The FSD informed the surveyor that the temperature of the dishwashing machine is checked with the initial use of the machine. Neither the DA, FSD, or RRD could explain the sudden change in temperature.
Observation of the identification tag of the low temperature dish washing machine revealed, Wash temperature 120 degrees F minimum. Rinse temperature 120 degrees F minimum.
Temperature settings for the low-temperature dishwasher are designed to reach a minimum temperature of 120 °F, to avoid the following risks: inadequate sanitization of dishes, glasses, and utensils, which may lead to the spread of harmful bacteria and viruses. It is important to ensure that dishwashers meet the required temperature standards to maintain proper hygiene and prevent potential health hazards.
On 9/18/23 at 11:47 AM, the RRD provided a copy of the facility policy titled, Dishwashing Machine Use. Under the section, Low Temperature Machine Chemical Sanitizer Temperatures and Concentrations, the policy states, 4. Wash Temp/Rinse Temp 120/120.
NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to address a Full code status (code status that indicates a patient wants all resuscitation procedures to be provided to keep them alive in case of a medical emergency) order signed by the resident's family with no follow up from the Physician. This deficient practice was identified for 1 of 32 residents, Resident #15 reviewed for advanced directives.
This deficient practice was evidenced by the following:
On 9/5/23 at 11:14 AM, the resident was observed in the day room seated in a reclining Geri-chair watching TV.
The surveyor reviewed Resident #15's hybrid medical record. Resident #15 was admitted to the facility with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension.
A review of the Social Services progress notes revealed documentation on 1/11/23, 1/12/23 and 1/13/23 that the resident's family member (listed in the admission Record as one of the emergency contacts) requested that Resident #15's advance directive status would be as a full code status.
On 9/8/23, the surveyor reviewed the POLST (Practitioner Orders for Life Sustaining Treatment) form (medical form signed by a patient's physician, advance practice nurse or physician's assistant, provides instructions for health care personnel to follow for range of life-prolonging interventions) which documented FULL CODE status, signed by Resident #15's family member but was not completed due to the lack of the Physician's signature. This POLST could not be implemented because of this.
Continued review of the resident's chart, revealed another POLST form dated 7/9/18, which indicated a DNR code (Do not Resuscitate) that was signed by the Advanced Practice Nurse.
A review of the POLST form Section F directions stated that the POLST must be signed by a practitioner, a Physician or Advance Practice Nurse, to be valid.
On 9/8/23 at 11:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #15 who stated that in case of any emergency, she would verify the code status of any resident via the electronic medical record and if there's none indicated, she would proceed to check the paper chart for the POLST form whether resuscitation should be started. The LPN could not provide any information for Resident #15's code status in the electronic medical record when reviewed with the surveyor, it was blank.
On 9/8/23 at 12:22 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who showed the POLST form indicating a full code status for Resident #15 signed by the resident's family member. Further review of the POLST form revealed that it was not signed by the physician nor an advance practice nurse. The RN/UM could not explain why there was another POLST form which indicated a DNR status. The RN/UM could not explain how she would proceed in an emergency situation involving Resident #15.
On 9/8/23 at 1:38 PM, the surveyor spoke with the facility's Licensed Nursing Home Administrator and the Director of Nursing (DON). The DON stated to the surveyor that if the POLST was not signed by the physician or advance practice nurse, it was invalid. The DON stated that the 7/9/18 POLST was the only valid document, and this designated Resident #15, DNR. There was no additional information provided to explain why Resident #15's family's end of life wishes was never validated by the physician.
NJAC 8:39-4.1(a)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 9/5/23 at 11:14 AM, Resident #15 was observed in the day room seated in a reclining Geri-chair watching TV. The surveyor also observed that Resident #15's bilateral hands were flexed inward and were contracted.
The surveyor reviewed Resident #15's hybrid medical record. Resident #15 was admitted to the facility with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension.
A review of the September 2023 Order Summary Report showed an order to, Provide R. hand-roll/carrot splint and L. wrist extension splint to be worn as per schedule: 10:00 AM-2:00 PM.
A review of the resident's Annual MDS, dated [DATE] reflected under Section G0400A (used to assess functional limitation in range of motion to upper extremity including shoulder, elbow, wrist, and hand during a seven-day look-back period from 8/29/23), the assessment showed that Resident #15 had an impairment to one side of the upper extremity.
On 9/12/23 at 10:51 AM, the surveyor interviewed the Certified Nursing Assistant assigned to the resident who confirmed that the resident required assistance with personal hygiene/grooming due to the limitation of movement to both hands.
On 9/13/23 at 10:30 AM, the surveyor interviewed the facility's RN(Registered Nurse)/MDS Coordinator who was responsible for completing the MDS assessments and confirmed that she had verified with the facility's Rehab Director that Resident #15 had limitation to both upper extremities. The RN/MDS Coordinator acknowledged the MDS assessment dated [DATE] was inaccurately coded in Section G0400A.
The surveyor reviewed the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual updated October 2019. The manual indicated, Functional Limitation in Range of Motion. Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury .Steps for Assessment: 6 Upper Extremity - includes shoulder, elbow wrist and fingers For each hand, instruct the resident to make a fist and then open the hand. With resident seated in a chair, instruct him or her to reach with both hands and touch palms to back of head. Then ask resident to touch each shoulder with the opposite hand. Alternatively, observe the resident donning or removing a shirt over the head. If assessing upper extremity ROM by observing the resident, making a fist mimics useful actions for grasping and letting go of utensils. When an individual reaches both hands to the back of the head, this mimics the action needed to comb hair.
On 9/14/23 at 1:35 PM, the above concerns were discussed with the facility's Licensed Nursing Home Administrator and Director of Nursing. No further information was provided.
NJAC 8:39-11.1, 11.2(e)(1)
Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 32 residents (Resident # 147, and #15) reviewed for accuracy for MDS coding.
This deficient practice was evidenced by the following:
1. On 9/12/23 at 1:18 PM, the surveyor reviewed the closed medical chart for Resident #147 who was MDS coded for hospitalization. The surveyor reviewed the Discharge Summary (DS) created on 7/31/23 by the Social Worker (SW) for Resident #147. The DS documented that Resident #147 was discharged home per their family's request.
Review of the 7/29/2023 Nursing Progress Note (PN), indicated that Resident #147 was discharged at 1:15 PM with their family member, without any distress or discomfort, all discharge papers ready and signed by the resident.
Review of Resident #147's Face Sheet (FS) (a one-page summary of important information about the patient) reflected that the resident was admitted to the facility on [DATE] with diagnosis that included but were not limited to cervical disc degeneration, xerosis cutis, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, and spinal stenosis.
Review of the A section of the 7/29/23 MDS for Resident #147 revealed that section A2100 Discharge Status documented, 03. Acute hospital. There was another option 01. Community (private home/apt., board/care, assisted living, group home) which identified the correct discharge for Resident #147 which was not specified.
On 9/13/23 at 9:55 AM, the surveyor interviewed the part time MDS coordinator. The MDS coordinator explained, I incorrectly coded where the resident was discharged to. The resident should have been coded discharge to community not to acute hospital when the MDS was completed for Resident #147.

Based on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan (CCP) for 2 of 32 residents reviewed, Resident #127 and Resident #106.
This deficient practice was identified by the following:
1. On 9/5/23 at 11:00 AM, the surveyor observed Resident #127 in the day room seated in their wheelchair. The resident was alert and verbally responsive.
The surveyor reviewed Resident #127's hybrid medical records. The admission Record (AR) reflected that Resident #127 was admitted to the facility with medical diagnoses which included but not limited to Congestive Heart Failure, Type 2 Diabetes Mellitus, Acute Kidney Failure and Hypertension.
A review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/10/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 14 indicating that the resident was cognitively intact.
A review of the form titled; Wound Evaluation & Management Summary dated 8/17/23 revealed that Resident #127 had a Stage 2 pressure wound to their sacrum that was reported as healed on 8/17/23.
The surveyor reviewed the resident's CCP which reflected a care plan for Resident #127 indicating that the resident had a break in skin integrity.
On 9/13/23 at 11:30 AM, the Registered Nurse/Unit stated that the care plan was not updated to reflect the resident's pressure ulcer that had healed.
2. On 9/5/23 at 11:02 AM, the surveyor observed Resident #106 in their room laying on the bed with eyes closed.
The surveyor reviewed Resident #106's hybrid medical records. The AR reflected that Resident #106 was admitted to the facility with medical diagnoses which included but not limited to Sepsis, Cerebral Infarction, and Dysphagia.
A review of the Annual MDS, an assessment tool used to facilitate the management of care, dated 7/3/23 reflected that the resident had a BIMS score of 00 indicating that the resident had severely impaired cognition.
A review of the September 2023 Order Summary Report revealed a physician's order dated 8/23/23 for NPO (nothing by mouth) diet.
The surveyor reviewed the resident's CCP which reflected a care plan for Resident #106 titled, [Resident's Name] .has nutritional problem or potential nutritional problem r/t h/o Cerebral Ischemia, DM, cardiac arrest, ischemic heart disease, AMS, HTN, HL, Pulmonary Embolism, PEG insertion, PEG malfunction, generalized weakness, difficulty walking, aphasia, NPO w TF (tube feed) for nutrition/hydration, Low ALB (Albumin). Under the Interventions portion for this care plan the documentation included, Encourage PO (intake by mouth).
On 9/12/23 at 11:45 AM, the Licensed Practical Nurse assigned to Resident #106 confirmed that the resident was NPO.
On 9/13/23 at 2:05 PM, the surveyor met with the facility's Licensed Nursing Home Administrator and Director of Nursing (DON), to discuss the above concerns. The DON stated to the surveyor that the care plan was not updated to reflect the current resident's status. There was no additional information provided.
NJAC 8:39-11.2(i)

**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 follow acceptable standards of clinical practice with regards to 1. accurately following a physician's order (PO) in administering pain medication to treat varying pain levels (Resident #15, Resident #108); 2. ensure the positioning mobility to prevent contracture was applied prior to signing the administration record (Resident #15); 3. accurately documenting the urinary output for residents with a suprapubic catheter (Resident #39, Resident #78).
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
The deficient practice was evidenced by the following:
1. On 9/5/23 at 11:14 AM, Resident #15 was observed in the day room seated in a reclining Geri-chair watching TV.
The surveyor reviewed Resident #15's hybrid medical record.
Review of the facility Face sheet (an admission summary sheet) revealed that Resident #15 was admitted to the facility with diagnoses that included but was not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension.
A review of the Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 8/29/23 reflected that the resident had a Brief Interview for Mental Status (BIMS) of 12 out of 15 indicating that the resident had moderately impaired cognition.
On 9/8/23 at 11:26 AM, the surveyor reviewed the resident's September 2023 Order Summary Report (OSR) which revealed a PO for Tylenol Tablet 325 milligrams (mg) (Acetaminophen) with an order date of 5/27/20, Give 2 tablets by mouth every 4 hours as needed for mild pain (1-3).
There was another PO dated 5/27/20 for Pain Assessment every shift document pain using one of the codes below 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain.
Review of the May, June, July, and September 2023 electronic Medication Administration Record (eMAR) revealed that Resident #15 received several doses of Tylenol 325 mg 2 tablets (650 mg) for documented pain scale rates between 4 to 8.
On 9/12/23 at 12:30 PM, the surveyor interviewed Resident #15, who stated that the pain medication that was ordered by the Physician was not too effective at times.
On 9/12/23 at 12:56 PM, the surveyor interviewed the Licensed Practical Nurse #1 (LPN #1) who provided care for Resident #15. The LPN #1 stated that before administering the pain medication, she would assess the level of pain of the resident. LPN #1 added that she considered mild pain to be rated from 1-3 and if the resident's pain level was above 3, the LPN #1 explained that she would call the physician.
On 9/13/23 at 1:15 PM, the surveyor presented this concern to the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). No further information was provided.
2. On 9/5/23 at 11:14 AM, Resident #15 was observed in the day room seated in a reclining Geri-chair watching TV. The surveyor also observed that Resident #15's bilateral hands were flexed inward and contracted.
The surveyor reviewed Resident #15's hybrid medical record.
Review of the facility Face sheet revealed that Resident #15 was admitted to the facility with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Hypertension.
A review of the Annual MDS, dated [DATE] reflected that the resident had a BIMS of 12 out of 15 indicating that the resident had moderately impaired cognition.
A review of the September 2023 OSR revealed a PO to Provide Right hand-roll/carrot splint and Left wrist extension splint to be worn as per schedule: 10:00am-2:00pm.
A review of the September 2023 electronic Treatment Administration Record (eTAR) revealed that from September 1st through September 5th, 2023, the assigned nurses to Resident #15 signed for the PO in the electronic medication administration record (eMAR) indicating that the hand roll and carrot splint were provided to the resident.
On 9/5/23 at 11:21 AM, the surveyor interviewed LPN #1 who stated that the Registered Nurse/Unit Manager (RN/UM) applies the splint on the resident in the morning.
The surveyor interviewed the RN/UM who stated that she was the person responsible to place the devices on the resident's hands in the morning. The RN/UM in the presence of the surveyor tried to place the hand roll and carrot splint on Resident #15's hands. The resident refused and stated to the surveyor that they never wear it every day.
The surveyor interviewed the LPN #1 who cared for Resident #15, acknowledged that she signed the PO documenting that the devices were applied to Resident #15, when the devices were not applied.
On 9/13/23 at 1:15 PM, the surveyor presented this concern to the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). No further information was provided.
3. On 9/5/23 at 10:52 AM, during the initial tour, the surveyor observed Resident #39 inside their room, seated on a wheelchair, watching TV. The surveyor also observed that there was a urinary bag hanging on the left side of the wheelchair covered in a black privacy bag.
The surveyor reviewed Resident #39's hybrid medical record.
Review of Resident #39's Face sheet revealed that they were admitted to the facility with diagnoses that included but were not limited to Benign Prostatic Hypertrophy, Malignant Neoplasm of bladder and Partial traumatic amputation of left foot.
A review of the Quarterly MDS, dated [DATE] reflected that the resident had a BIMS of 15 out of 15 indicating that the resident was cognitively intact.
Review of section H0100A of the MDS, dated [DATE] which revealed that Resident #39 had an indwelling catheter (including suprapubic catheter and nephrostomy tube).
A review the resident's September 2023 OSR revealed a PO for Measure and record [Suprapubic] urine output every shift that was ordered on 3/7/23.
A review of the eTAR revealed the following: for the month of July 2023, the nurse's failed to document the urinary output for 14 of 93 shifts.
For the month of August 2023, the nurse's failed to document the urinary output for 8 of 93 shifts.
For the month of September 2023, the nurse's failed to document the urinary output for 1 of 39 shifts.
On 9/12/23 at 1:04 PM, The surveyor interviewed LPN #1 who was assigned to care for Resident #39 and stated that the blank portions found in the eTAR indicated that the output was not documented at the end of the shift as indicated by the PO.
A review of the facility's policy titled, Suprapubic Catheter Care under Procedure #12. Maintain an accurate record of the resident's daily output, if indicated.
On 9/13/23 at 1:15 PM, the surveyor presented this concern to the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). No further information was provided.4. On 9/5/23 at 11:01 AM, Resident #108 was observed lying in bed, alert and able to communicate their needs. The resident informed the surveyor that they had episodes of migraines and received pain medication.
The surveyor reviewed the electronic health record (EHR) of Resident #108 which revealed the following:
According to the facility Face sheet, Resident #108 was admitted with diagnoses that included but were not limited to Acute and Chronic Respiratory Failure with Hypoxia, Neuromuscular Dysfunction of the Bladder, and Unspecified Injury at unspecified level of Cervical Spinal Cord.
The resident's 7/31/23 Annual MDS, revealed that the facility performed a BIMS which indicated that Resident #108 had a score of 15 out of 15. The resident was assessed to be cognitively intact.
A physician's order dated 7/25/22 read Morphine Sulfate Tablet 15 MG Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6).
A physician's order dated 7/25/22 read Tylenol Tablet 325 mg (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for Mild Pain (1-3) .
A review of the August 2023 eMAR revealed as needed (PRN) morphine sulfate 15 mg was administered 9 of 16 times outside of the order's parameters, with documented pain levels of 8, 9, and 10.
Review of the August 2023 eMAR revealed PRN Tylenol 325 mg 2 tablets were administered 2 of 4 times outside of the order's parameters, with a documented pain level of 5.
A review of the September 2023 eMAR revealed PRN Morphine Sulfate 15 mg was administered 5 of 10 times outside of the order's parameters, with documented pain levels of 0, 8 and 10.
Review of the September 2023 eMAR revealed PRN Tylenol 325 mg 2 tablets was administered 1 of 2 times outside of the order's parameters, with a documented pain level of 8.
On 9/13/23 at 11:23 AM, the surveyor interviewed LPN #2 about pain assessment and administering prn [as needed] pain medication. LPN #2 stated if the resident was alert, he would ask the resident to rate their pain using a numeric pain scale [1-10]. LPN #2 stated a PRN pain medication order in the EHR would specify the numeric pain level a medication should be given. LPN #2 further stated if a resident had a pain level outside the medication order parameters, the physician would be notified to obtain instruction or new pain orders.
On 9/13/23 at 11:26 AM, the surveyor interviewed RN #2 who stated she would assess the resident's numeric pain level, review pain medication orders and call the physician if the pain level was outside of the medications' parameters.
On 9/13/23 at 11:51 AM, the surveyor interviewed 2nd floor Registered Nurse/Unit Manager #2 (RN/UM #2) in reference to administering PRN pain medication and pain assessment. RN/UM #2 stated that nurses should follow the physician's medication order parameters specific for the ordered pain level. The RN/UM #2 added that nurses should call the physician if resident's pain levels are outside the parameters ordered in the PO for instruction.
The surveyor reviewed the September 2023 eMAR with the RN/UM #2 for Resident #108. The RN/UM #2 acknowledged that nurses were documenting pain levels outside the PO medication's parameters with the administration of the PRN Tylenol 325 mg and Morphine Sulfate 15 mg.
On 9/13/23 at 1:15 pm, the surveyor informed the LNHA and DON in reference to the above concerns involving the medication administration for PRN Tylenol 325 mg and Morphine Sulfate 15 mg medication with documented pain levels outside of the PO pain level parameters.
On 9/14/23 at 1:36 PM, the surveyor met with the LNHA, DON, and regional nurse. The DON stated that the resident's pain management was effective for the resident. No further information was provided.
Review of the facility's policy titled, Pain Assessment and Management, with a reviewed date of January 2023, under Procedure: .7. The physician must be notified of new onset of pain, need to re-evaluation or medical intervention (e.g. pain medication ineffective).
Review of the facility's policy titled, Medication Administration Policy, with a reviewed date of September 2022, under Procedure read: .3. Medications must be administered in accordance with the orders, including any required time frame .
N.J.A.C. 8:39-11.2 (b); 27.1(a); 29.2 (d)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain a urinary catheter and provide services in a manner consistent with standards of practice for 2 of 3 residents reviewed for urinary catheter care (Resident #108, and #78).
This deficient practice was evidenced by the following:
1. On 9/5/23 at 11:01 AM, Resident #108 was observed lying in bed, alert and able to communicate their needs. The resident was observed with a urinary catheter attached to a drainage bag hanging at their bedside. The surveyor smelled a strong urine odor at the resident's bedside. The resident verbalized no concerns.
The surveyor reviewed the electronic health record (EHR) of Resident #108 which revealed the following:
According to the admission Record, Resident #108 was admitted with diagnoses that included but were not limited to Acute and Chronic Respiratory Failure with Hypoxia, neuromuscular dysfunction of the bladder, and unspecified injury at unspecified level of cervical spinal cord.
Review of the 7/31/23 Annual Minimum Data Set (MDS), an assessment tool, revealed that the facility performed a Brief Interview for Mental Status (BIMS) which indicated that the resident had a score of 15 out of 15. The resident was assessed to be cognitively intact.
A physician's order dated 7/25/22 read, Change suprapubic catheter (size) Fr 24 with 20 ml balloon when clogged or dislodged using sterile technique. Change catheter bag as well. as needed. The resident had a suprapubic catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag that is inserted into the bladder through a surgical cut in area a few inches below the belly button).
Another physician's order dated 7/25/22 read, Irrigate Suprapubic catheter with 60 ml NSS. Check irrigation solution. Good for 24 hours only. Must be signed and dated when opened. Use sterile syringe daily as needed.
A review of the July 2023, August 2023, and September 2023 electronic Treatment Administration Record (eTAR) revealed there were no entries documented that the resident's suprapubic catheter had been changed.
On 9/13/23 at 11:51 AM, the surveyor interviewed 2nd floor Registered Nurse/Unit Manager #2 (RN/UM #2) in reference to Resident #108's catheter status. RN/UM #2 explained that she followed up with the physician who recommended to follow up with urologist and called the urologist's office. She explained that it should be documented in the progress notes as she could not recall when it was.
RN/UM #2 revealed that the resident had a urologist appointment previously, but there were transportation issues and the appt had to be rescheduled. She could not recall the approximate date and stated it should be in the progress notes. No further information was provided nor could be located in the progress notes.
The RN/UM #2 identified that Resident #108's catheter had not been functioning properly or draining urine since July 2022. The RN/UM #2 that the physician recommended to maintain the suprapubic catheter and follow up with the urologist.
The RN/UM #2 added that the resident had refused to go to the hospital to change the catheter, documented in the progress notes on 7/28/22 in the progress notes provided.
The RN/UM #2 further stated that the catheter was changed as needed, per the physician's order and would have to look up for when the last time it was changed. The RN/UM #2 identified that the resident had no urinary tract infections, no discomfort, and there was no urine output recorded as the resident was voiding in their incontinent brief.
On 9/13/23 at 1:15 PM, the surveyor informed the Licensed Nursing Home Administration (LNHA) and Director of Nursing (DON) regarding the above concerns for the suprapubic catheter of Resident #108 not draining urine.
On 9/14/23 at 1:36 PM, the surveyor met with the DON, LNHA and a Regional Nurse. The DON stated Resident #108 was admitted with the suprapubic catheter and the resident had a follow up appointment for the next month on 8/29/22, which was cancelled as the resident was scheduled to be discharged the day of appointment to another facility. The resident remained in the facility and a urology appointment was scheduled for January 2023. There was an issue with the resident's transport on January 2023 and the resident did not go to the appointment. No further information was provided to explain what the issue with transportation involved.
The DON continued to explain that Resident #108's catheter worked for two days after admission. She presented that on 7/28/22 the catheter was not draining urine and was changed at that time. The DON revealed that after the catheter was changed it was not functioning correctly and the resident was incontinent, voiding into an incontinent brief.
The surveyor discussed the concern for Resident #108 potentially being a higher risk of infection as the resident had an extended period of time with a catheter that was not functioning. The DON explained that it was generally recommended not to frequently change a urinary catheter and it had been discussed with primary physician team and Infection Disease team. No further documentation was provided.
At that time the DON provided a timeline of the resident's catheter status and progress notes regarding the resident's suprapubic catheter. The DON stated the documentation included any progress notes about follow-ups with urology, and if the suprapubic catheter was changed.
A review of the timeline and progress notes revealed the following:
A progress note, dated 7/28/22, documented the resident's catheter was not draining urine, the catheter was changed, and drained little to no urine. The progress note documented that the nurse practitioner was instructed to monitor for urination in an incontinent brief and if voiding of urine was not evident, the resident would be sent to the hospital. The documentation included that the resident refused to go to hospital despite education.
A progress note dated 7/29/22, documented that the resident was scheduled for a urology appointment on 8/29/22. The resident at this time was voiding urine in their incontinent brief. The catheter was not draining urine.
A progress note dated 8/30/22, documented the resident was to be discharged to another facility on 8/29/22 and the facility Social Worker was made aware on 8/30/22 that the resident was not accepted to the other facility.
From September 2022 to December 2022 there was no documented follow up with the urologist.
A progress note, dated 1/30/23, documented the resident had a urology appointment that day and the appointment had to be rescheduled due to transportation issues (not disclosed).
There was no documentation that indicated a follow up with urology or documentation of catheter functioning draining urine from February 2023 to August 2023.
There was no other documentation provided to show that the resident's catheter was changed after 7/28/22.
A review of the facility's policy titled, Suprapubic Catheter Care, with a reviewed date of January 2023, under Procedure read: Maintain an accurate record of the resident's daily output, if indicated .Document assessment data in the resident's clinical record. The policy did not address the process of maintain a catheter in the event the resident's catheter was not functioning.
On 9/18/23 at 10:40 AM, the survey team met with the DON and LNHA. The DON provided the policy for urinary catheter. No further information was provided.
2. On 9/5/23 at 11:50 AM, Resident #78 was observed lying in bed, alert, oriented and verbally responsive. Resident #78 had a urinary catheter.
The surveyor reviewed the electronic health record (EHR) of Resident #78 which revealed the following:
According to the admission Record, Resident #78 was admitted with diagnoses that included but were not limited to Urinary Tract Infection, neuromuscular dysfunction of the bladder, and Multiple Sclerosis.
The 8/8/23 Annual MDS, revealed that the facility performed a BIMS which indicated that the resident had a score of 15 out of 15. The resident was assessed to be cognitively intact.
A physician's order dated 4/21/23 read, Measure urinary output from foley catheter . every Shift.
A progress note, dated 9/4/23, indicated the resident's catheter was leaking and the resident's incontinent brief was wet with urine.
On 9/8/23 at 12:41 PM, the surveyor interviewed the Registered Nurse (RN #1) about suprapubic and urinary catheter care. RN #1 explained that her responsibilities included reviewing and following the physician orders, monitoring urine odor, urine color, urine output and any signs and symptoms of infections. She continued to explain that at the end of the shift the resident's urine output should be documented into the electronic Treatment Administration Record (eTAR). RN #1 stated that if the catheter was not working or draining, the physician should be called to be made aware and for instruction.
A review of the August 2023 eTAR for the urine drainage output pertaining to Resident #78 revealed that 0 was coded as the output for 22 of 93 entries for the month. There were also 13 of 93 entries that were blank and had no documented urine output for the month.
Review of the September 2023 eTAR for the urine drainage output pertaining to Resident #78 revealed that 0 was coded as the output for 30 of 40 entries for the month. There were also 3 of 40 entries that were blank and had no documented urine output for the month.
On 9/11/23 at 12:36 PM, the surveyor spoke with the 6th floor RN/UM (RN/UM #3)who stated at this time Resident #78's catheter was not working well, draining little to no urine, and the resident had incontinent episodes, voiding large amounts of urine in their incontinent brief. RN/UM #3 explained that Resident #78 had gone for a Urology consult last month, but the urologist was not able to see Resident #78, which was documented in the progress notes. The appt was rescheduled for November 2023.
On 9/11/23 at 12:56 PM, the surveyor visited with Resident #78 to inquire about their urinary catheter. Resident #78 stated that their urinary catheter was not working right, not draining urine and was not sure about what would be done about the catheter.
On 9/13/23 at 1:15 PM, the surveyor reviewed their findings with the Licensed Nursing Home Administration (LNHA) and Director of Nursing (DON) regarding the above concerns for the suprapubic catheter not functioning for Resident #78 and urine output documented as 0. The DON stated they would review and provide further information.
On 9/14/23 at 1:36 PM, the surveyor met with the DON, LNHA and a regional nurse. The DON revealed that for the August 2023 entry dates where the eTAR for urine output were documented as 0, the resident's catheter had periods of not draining urine and Resident #78's catheter was changed on August 14th. The DON confirmed the resident had a urology appointment on 8/24/23 and was not able to be seen by the urologist.
The DON provided a timeline of the resident's catheter, which included progress notes from 8/11/23 to 9/11/23. There was no further verbal response provided by the facility.
A review of the timeline and progress notes provided included the following:
A urology consult note, dated 1/17/23, was provided and documentation from July 2023 of the resident's suprapubic catheter insertion procedure. There were no further urology consultation notes.
A progress note dated 8/11/23, documented that the resident's incontinent brief was saturated, and no urine was noted in the drainage bag. The progress notes further indicated the primary physician, and the urologist were notified.
A progress note dated 8/24/23, documented that the resident returned from urology appointment without being seen by the urologist.
A review of the facility's policy titled, Suprapubic Catheter Care, with a reviewed date of January 2023, under Procedure read: Maintain an accurate record of the resident's daily output, if indicated .Document assessment data in the resident's clinical record. The policy did not further address the documentation of the resident's urinary output by the nurses. The policy did not address the process in the event of a resident's catheter is not functioning.
No further information was provided by the facility.
NJAC-8:39-27.1 (a); 33.2 (c) 5

Based on observation, interview, and record review, it was determined that the facility failed to follow accepted nursing standards of practice while 1.) administering an oral inhaler medication and 2.) applying splints without a physician's order. The deficient practice was identified for 1of 5 nurses observed during the Medication Administration task and 1 of 1 residents (Resident #86) reviewed for limited Range of Motion.
The deficient practices were evidenced by the following:
Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of 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.
1. The surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #99 on 01/06/22 at 08:02 AM.
The LPN administered the following medication which was ordered by the physician on 8/17/21 - Advair HFA Aerosol 230-21 micrograms, 2 puffs inhale orally two times a day for asthma. The LPN did not instruct Resident #99 to rinse with water and spit after inhaling the second puff of Advair HFA. The surveyor interviewed the LPN at 8:35 AM when Resident #99's medication pass was completed. The LPN stated she does not routinely instruct residents to rinse and spit after administration of oral inhalers.
The surveyor interviewed the Registered Nurse Unit Manager (RNUM) on 1/06/22 at 09:08 AM. The RNUM stated the LPN was nervous and should have instructed the resident to rinse after puffs.
The manufacturer specifications for Advair HFA Oral Inhaler Use Highlights of Prescribing Information, revised August 2021, instructs the user to (Step 7.) Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it.
The facility's policy and procedure entitled Administering Medications through a Metered Dose Inhaler, issued 9/2019, was provided to the surveyor by the Administrator on 1/11/22. Procedure #10 indicated the nurse should instruct the resident to rinse with water and spit after the inhalation.
2. On 1/6/22 at 10:00 AM, the surveyor observed Resident #86 lying in bed with eyes closed attached to a ventilator via a tracheostomy and had tube feeding infusing via a gastrostomy tube (feeding tube through the stomach area). Heel lifts were on both feet to keep pressure off the heels. The surveyor observed hand rolls in both hands and bilateral elbow splints.
The surveyor reviewed Resident #86's hybrid medical records (paper and electronic) that revealed the following.
According to the admission Record, Resident #86 was admitted with diagnoses that included Acute and Chronic Respiratory Failure and Encephalopathy.
The resident was ventilator dependent via tracheostomy tube (a surgical incision in the windpipe too allow direct access to a breathing tube). According to the Quarterly Minimum Data Set an assessment tool, dated 11/23/21, the resident is severely cognitively impaired.
There were three current care plans related to the resident's mobility status that included following interventions:
1. FMP for passive ROM and splinting with the following intervention FMP Perform passive range of motion to BUE [bilateral upper extremities] and BLE [bilateral lower extremities] 10 reps [repetitions] x3 sets all planes daily.
2. Restorative Nursing Program: B. [bilateral] hand rolls and B. [bilateral] elbow extension splints Brace The interventions included: FMP: Provide B. hand-rolls/B. elbow extension splints to B. hands/elbows to be worn 9:00 AM to 3:00 PM dated 11/3/21.
3. [The resident] has alteration in musculoskeletal status r/t contracture on B/L upper extremities with the following intervention: Apply bilateral hand rolls to both hands as ordered. Apply at 9:00 am - 3:00 pm.
The December 2021 Order Summary Report (monthly physician's orders) and the electronic order sheet, indicated that Resident #86 had an order for the following: needed to be turn and repositioned every 2 hours every shift. However, there was no order for the hand rolls and elbow splints that the surveyor had observed were in use.
On 1/10/22 at 12:06 PM, the surveyor interviewed the Registered Nurse Unit Manager who stated that she wasn't aware that the splints weren't included on the FMP care plan and wasn't aware there were no physician's orders for the splints and hand rolls.
On 1/10/22 at 12:30 PM, the surveyor discussed the above concern with the Administrator and Director of Nursing. At 2:15 PM, the Administrator provided information that there was documentation that the splints and hand rolls were being applied by the nursing staff. However, the Administrator stated that when the resident was discharged to the hospital and returned to the facility the order for hand rolls and splints were not carried over.
NJAC 8:39-11.2(b); 27.1(a)

19. Resident #105's hybrid medical records revealed the 11/2021 and 12/2021 monthly Order Summary Reports, filed in the paper record, were not hand signed by physician. The electronic record of physician orders did not contain an electronic signature for 11/2021 or 12/2021.
20. Resident #10's hybrid medical records revealed the 9/2021, 11/2021 and 12/2021 monthly Order Summary Reports, filed in the paper record, were not hand signed by physician. The electronic record of physician orders did not contain an electronic signature for 9/2021, 11/2021 or 12/2021.
21. Resident #74's hybrid medical records revealed the 9/2021, 10/2021, 11/2021 and 12/2021 monthly Order Summary Reports, filed in the paper record, were not hand signed by physician. The electronic record of physician orders did not contain an electronic signature for 9/2021, 10/2021, 11/2021 or 12/2021.
On 01/06/22 at 09:59 AM the surveyor interviewed the Registered Nurse Unit Manager (RNUM) on the fifth floor who stated the orders should be signed by the physician each month. She stated she was not aware the orders were not signed.
On 1/10/22 at 10:30 AM spoke to the RNUM on the third floor who stated that all the nurses were responsible to make sure the physician's were signing their monthly orders. The RNUM stated it was difficult to get the physician's to sign orders. At 12:15 PM, the surveyor interviewed the RNUM on the second floor who stated we got to work on this.
On 1/10/22 at 12:48 PM, the surveyors discussed the above concerns with the Administrator and Director of Nursing. The Administrator acknowledged that having difficult with the physician's signing their physician orders.
The facility's policy titled Physician Visits and Services revised on 2018 indicated under Procedure The attending physician must directly supervise the activities leading to the treatment of the resident. The policy did not include the review, signing and dating of monthly physician's orders.
NJAC 8:39-35.2,7
12. Resident #49's hybrid medical records revealed that the physician did not sign and date the monthly physician's orders (PO) and there was no electronic signature for the months of October, November, and December 2021.
13. Resident #67's hybrid medical records revealed that the physician did not sign and date the monthly PO and there was no electronic signature for the months of October, November, and December 2021.
14. Resident #76's hybrid medical records which revealed that the physician did not sign and date the monthly PO and there was no electronic signature for the months of November, and December 2021.
15. Resident #82's hybrid medical records revealed that the physician did not sign and date the monthly PO and there was no electronic signature for the months of November, and December 2021.
16. Resident #114's hybrid medical records revealed that the physician did not sign and date the monthly PO and there was no electronic signature for the month of November 2021. There was no printed PO sheet in the resident's medical record for the month of December 2021 and no electronic signature.
17. Resident #130's hybrid medical records revealed that the physician did not sign and date the monthly PO and there was no electronic signature for the month of December 2021. According to the admission record the resident was admitted in November 2021.
18. Resident #120's revealed that the physician did not sign and date the monthly PO and there was no electronic signature for the months of October and December 2021. There was no printed PO sheet in the resident's medical record for the month of November 2021 and no electronic signature.
Based on interview and record review, it was determined that the facility failed to ensure that the residents primary physician sign and date monthly physician orders to ensure that the residents current medical regimen was appropriate. This deficient practice was observed for 21 of 30 residents (Resident #17, #58, #39, #2, #37, #61, #86, #75, #38, #96, #131, #130, #120, #49, #67, #114, #76, #82, #105, #10, and #74) reviewed and occurred over several months.
This deficient practice was evidenced by the following:
The surveyors reviewed the hybrid medical records (paper and electronic) for the residents listed above that revealed the residents primary physician had not hand sign the Order Summary Reports (monthly physician's orders) located in the residents chart. In addition there were no electronic signatures under the physician's orders for the following residents:
1. Resident #2's hybrid medical record revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for October 2021, November 2021 and December 2021 monthly physician's orders was not in the chart and there was no electronic signature.
2. Resident #17's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021 and December 2021.
3. Resident #37's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician orders for October 2021 and November 2021. December 2021 monthly physician's orders were not in the chart and there was no electronic signature.
4. Resident #38's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for September 2021 and November 2021. October 2021, December 2021 monthly physician's orders were not in the chart and there was no electronic signature.
5. Resident #39's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for October 2021 and November 2021. December 2021 monthly physician's orders was not in the chart and there was no electronic signature.
6. Resident #58's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021 and December 2021. October 2021 monthly physician's orders was not in the chart and there was no electronic signature.
7. Resident #61's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for December 2021. October 2021, November 2021 monthly physician's orders was not in the chart and there was no electronic signature.
8. Resident #75's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for October 2021, November 2021 and December 2021.
9. Resident #86's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the monthly physician's orders for November 2021 and December 2021. October 2021 monthly physician's orders was not in the chart and there was no electronic signature.
10. Resident #96's hybrid medical records revealed the resident's physician had not signed the monthly physician's orders for September 2021, November 2021 and December 2021. October 2021 monthly physician's orders was not in the chart and there was no electronic signature.
11. Resident #131's hybrid medical records revealed the resident's physician had not hand sign or electronically sign the admission orders from 10/5/21. The resident was discharged soon after admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow the physician's order for the administration of oxygen. This was found with 1 of 5 residents reviewed for respiratory care, Resident # 120.
The deficient practice was evidenced by the following:
On 1/5/22 at 12:02 PM, the surveyor observed Resident #120 in bed. Oxygen was being delivered to the resident through a nasal cannula (a tube with prongs that sit in the nostrils) that was attached to wall oxygen set at 4 lpm (liters per minute).
The surveyor reviewed the resident's record which revealed the following:
An admission Record with diagnoses which included Respiratory Failure, and Shortness of Breath.
A Physician's Order Sheet (POS) with an order that read Oxygen inhalation via nasal cannula @ 3 lpm every shift. Check every shift. The order was dated 11/24/21. The same order was repeated by the physician when the resident was re-admitted from the hospital on [DATE], then on 1/2/22.
A electronic Medication Administration Record (eMAR) that listed the oxygen order and read Oxygen inhalation via nasal cannula @ 3 lpm every shift. Check every shift. The eMAR was initialed by the nurse on 1/5/22, 7 am-3 pm to indicate that the oxygen had been delivered to the resident at the rate that was prescribed by the physician in contrary to the observation by the surveyor on that date.
On 1/6/22 at 8:53 AM, the surveyor observed the resident in their bed receiving oxygen through their nasal cannula. The wall oxygen mechanism was set just below 2 lpm.
On 1/6/22 at 10:57 AM the surveyor observed the resident, who was still in bed. The oxygen remained set just below 2 lpm.
On 1/06/22 at 11:31 AM, the surveyor spoke with the Licensed Practical Nurse (LPN) who was assigned to the resident. The surveyor and the LPN went to the resident's room. The surveyor asked him what the oxygen setting was supposed to be. The LPN said 3 liters. He looked at it and said he couldn't see what the setting was because he didn't have his glasses on. He looked at it several times and then readjusted the dial to 3 lpm. The LPN said he could not wear his reading glasses under the face shield he was wearing because he couldn't see when he walked. He said he checked the resident that morning, took the resident's vital signs and checked the resident's oxygen saturation level (oxygen saturation in the residents body is checked with a pulse oximeter placed on the finger). He said the resident's oxygen saturation level was fine so he wasn't worried. He said he didn't check the setting yet because there was no reason to. He reiterated that he wasn't worried because the resident's oxygen saturation level was fine.
On 1/6/22 at 11:38 AM, the surveyor asked the Unit Manager (UM) who was responsible for monitoring the oxygen setting when a resident was receiving oxygen. She said it was the nurse who checked the oxygen settings during rounds, and they adjust the oxygen depending on the oxygen saturation level. If the resident maintained a good oxygen level they would decrease the oxygen setting and call the doctor. She said she had just called the doctor to see if they could decrease the oxygen setting. The surveyor asked the UM if that process was in the facility's policy. The UM said she didn't know but the pulmonologist who saw the residents in the facility told the staff they could adjust the oxygen settings and call the physician afterwards.
On 1/10/22 at 12:51 PM, the survey team spoke with the Director of Nursing (DON), and the Administrator about the concern with the oxygen not being set at the level ordered by the physician. The surveyor asked the DON if the UM's statement was accurate. The DON said Whatever is the doctor's order is what should be followed.
On 1/11/21 at 10:15 AM, the surveyor reviewed the facility's policy and procedure titled Oxygen Therapy and dated 9/2018. Under Policy the policy read The purpose of oxygen therapy is to administer oxygen in cases where insufficient oxygen is carried to the tissues by the blood. Oxygen therapy is administered only as ordered by a physician or as an emergency measure until an order can be obtained. The physician's order will specify the rate of oxygen flow. Under Procedure number 7 read Make sure oxygen flow rate and concentration remain as ordered by the physician.
NJAC 8:39-27.1 (a)

Based on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan for floor maintenance program (FMP) and failed to revise restorative nursing program (RNP) care plan after the RNP was discontinued. The deficient practice occurred for 1 of 1 resident (Resident #86) reviewed for limited range of motion.
On 1/6/22 at 10:00 AM, the surveyor observed Resident #86 lying in bed with eyes closed attached to a ventilator via a tracheostomy and had tube feeding infusing via a gastrostomy tube (feeding tube through the stomach area). Heel lifts were on both feet to keep pressure off the heels. The surveyor observed hand rolls in both hands and bilateral elbow splints.
The surveyor reviewed Resident #86's hybrid medical records (paper and electronic) that revealed the following.
According to the admission Record, Resident #86 was admitted with diagnoses that included Acute and Chronic Respiratory Failure and Encephalopathy.
The resident was ventilator dependent via tracheostomy tube (a surgical incision in the windpipe too allow direct access to a breathing tube). According to the Order Summary Report (monthly physician's orders), Resident #86 needed to be turn and reepositioned every 2 hours every shift. However, there was no order for the hand rolls and elbow splints that the surveyor had observed.
During a review of the resident's care plans, the surveyor observed three active care plans:
1. [The resident] has alteration in musculoskeletal status r/t contracture on B/L upper extremities initiated on 8/31/21 that included an intervention to Apply bilateral hand rolls to both hands as ordered. Apply 9:00 am - 3:00 pm.
2. FMP: Passive ROM and splinting initiated on 9/1/20 and revised on 9/8/20. Under Intervention the following: FMP Perform passive range of motion to BUE [bilateral upper extremities] and BLE [bilateral lower extremities] 10 reps [repetitions] x3 sets all planes daily. This intervention was the only one listed and dated 11/3/21.
3. Restorative Nursing Program: B. [bilateral] hand rolls and B. [bilateral] elbow extension splints Brace initiated on 9/1/20 and revised on 9/8/20. The interventions included the following: FMP: Provide B. hand-rolls/B. elbow extension splints to B. hands/elbows to be worn 9:00 AM to 3:00 PM dated 11/3/21. Refer to Therapy Department for questions or change of status dated 9/1/20 and Check skin integrity of RUE/LUE (including hand/forearm/elbow) before application and removal. dated 9/1/20.
According to the Quarterly Minimum Data Set an assessment tool, dated 11/23/21, Resident #86 was not receiving RNP.
On 1/10/22 at 12:06 PM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM) who stated that the resident was not on RNP, that RNP care plan should have been discontinued. The RNUM wasn't aware that the splints weren't included on the FMP care plan and wasn't aware there were no physician's orders for the splints and hand rolls. The RNUM was unable to find documentation of the splinting and use of hand rolls.
On 1/10/22 at 12:30 PM, the surveyor discussed the above concern with the Administrator and Director of Nursing (DON). At 2:15 PM, the Administrator provided information that there was documentation that the splints and hand rolls were being applied by the nursing staff. However, the Administrator stated that when the resident was discharged to the hospital and returned to the facility the order for hand rolls and splints were not carried over. The DON could not explain why the FMP care plan was not developed as a comprehensive care plan and why the RNP care plan was not revised to show the RNP was discontinued.
NJAC 8:39-27.1(a)