Actors Fund Home

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the medications were administered in accordance with the physician's order, facility's policy, and accepted professional standards of practice. This deficient practice was identified for 1 of 21 residents reviewed for medications (Resident #8).The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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. 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. On 7/16/25 at 10:50 AM, the surveyor observed Resident #8 seated in a wheelchair with a leg rest and left leg immobilizer in use. The surveyor also observed an IV (intravenous) pole. The resident stated that they had an order for IV ABT (antibiotic) daily, on skilled nursing for their infected left surgery, and rehabilitation (rehab). The surveyor reviewed the medical records of Resident #8, and revealed the following: A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses (dx) that included but were not limited to; aftercare following explantation of knee joint prosthesis (in which surgical revision was performed. Explantation was carried out and a cement spacer was introduced), infection following procedure, other surgical site, unspecified osteoarthritis, essential hypertension (elevated blood pressure), and muscle weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 6/26/25, under Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 15 of 15, which reflected that the resident had intact cognition. Section J: Health Condition revealed that the resident had pain and was coded frequently. Section N: Medications included ABT, diuretic (water pill), opioid (controlled pain medication), and convulsive medications (meds). A review of the June 2025 electronic Medication Administration Record (eMAR) revealed the following: -A physician order (PO) with an order date of 6/20/25, oxycodone 5 mg (milligram) tablet (tab) oral as needed (PRN) every 8 hours (hrs), for moderate pain. The eMAR was electronically signed as administered: On 6/21/25 at 9:06 AM, by Registered Nurse #1 (RN#1).On 6/21/25 at 1:49 PM, by RN#1.On 6/22/25 at 6:00 PM, by RN#1. -A PO with an order date of 6/20/25, oxycodone 5 mg, 2 tablets (tabs) (total 10 mg) oral PRN every 8 hrs, for severe pain. The eMAR was electronically signed as administered: On 6/20/25 at 5:48 PM, by Licensed Practical Nurse #1 (LPN#1).On 6/21/25 at 5:54 AM, by LPN#2.On 6/22/25 at 5:17 AM, by RN#2.On 6/22/25 at 1:51 PM, by RN#1.On 6/22/25 at 3:00 PM, by RN#1.On 6/23/25 at 9:15 AM, by LPN#3. Further review of the above June 2025 eMAR revealed that the PO to administer oxycodone 5 mg tab PRN every 8 hrs for moderate pain was not followed on 6/21/25, when it was administered at 9:06 AM and then at 1:49 PM, which was 4 hrs apart. The PO to administer oxycodone 5 mg, give 2 tabs (total 10 mg) PRN every 8 hrs for severe pain was not followed on 6/22/25, when it was administered on 6/22/25 at 1:51 PM and 3:00 PM, which was an hour apart. A review of the Controlled Drug Administration Record (CDAR), also known as the declining sheet for controlled meds, with date received on 6/12/25, included information for oxycodone tab 10 mg, 30 tabs, and resident's name. The following were documented in the declining sheet from 6/20/25 to 6/23/25: -6/20/25 at 5:48 PM, signed by LPN#1.-6/21/25 at 5:54 AM, signed by LPN#2.-6/21/25 at 2:00 PM, signed by RN#1. The medication (med) was dropped and wasted with presence of another nurse.-6/22/25 at 5:17 AM, signed by RN#2.-6/22/25 at 2:00 PM, signed by RN#1.-6/22/25 at 6:00 PM, signed by RN#1. The med was dropped and was wasted with presence of another nurse. -6/22/25 at 10:30 PM, signed by RN#1.-6/23/25 at 9:15 AM, signed by LPN#3. Further review of the declining sheet for oxycodone 10 mg tab revealed that the CDAR was filled out by RN#1 on 6/22/25 at 10:30 PM, and there was no documented evidence that the eMAR was signed for the same date and time. There were no CDAR for 5 mg tab oxycodone. A review of the CP's EPIC (Electronic Pharmacist Information Consultant) review done by Consultant Pharmacist #1 (CP#1) on 6/24/25, revealed, there was no documented evidence that the above irregularities for oxycodone PRN was identified. On 7/17/25 at 11:09 AM, the surveyor notified the Director of Nursing (DON) of the above concerns and findings. The DON after reviewing the June 2025 eMAR, stated that there were no reports from CP#2 about the above concerns. The DON also stated that there were no reports from nurses and subacute unit that there were discrepancies with PRN oxycodone. She further stated that she was unaware of the med error until surveyor's inquiry. On that same date and time, the DON informed surveyor that RN#1 was a part time nurse, and no previous disciplinary action. The DON stated that it was considered a med error, and it will be investigated. The surveyor asked for the oxycodone reports from June 2025 to current, policies for med error, med administration, and controlled meds. On 7/17/25 at 12:10 PM, the surveyor interviewed Resident #8 inside their room. The resident informed the surveyor that when they returned to the facility in June 2025, after the surgery, they had terrible pain to the left surgical site and infection. The stated that pain was better now. The resident further stated that they were on oxycodone PRN, used to be every 8 hrs. The resident also stated that due to terrible pain, they were getting it even before 8 hrs, and eventually the order was changed to every 4 hrs PRN. At that same time, the resident stated that they went for a follow up ortho (orthopedic) consult last week, 7/10/25, and the stitches were removed. The resident further stated that they were still on NWB (no weight bearing) status to the left foot. On 7/17/25 at 12:20 PM, the surveyor interviewed LPN#3, who informed the surveyor that Resident #8 was cognitively intact, on IV ABT, rehab, and pain management. LPN#3 stated that the resident's pain was getting better. The surveyor asked LPN#3 about the PRN oxycodone, and she stated that the nurse should follow the order. She further stated, if the med will be administered beyond the required time, the physician should have been notified, and the physician will order for stat (immediate) order. LPN#3 also stated that the nurse should document in the progress notes (PN). At that same time, the surveyor and LPN#3 reviewed the CDAR for oxycodone 10 mg. LPN#3 informed the surveyor that there were no CDAR for oxycodone 5 mg since the resident was admitted and up to this time, it had been oxycodone 10 mg. On 7/22/25 at 8:43 AM, the DON informed the surveyor that as soon as the surveyor notified the DON of the above concerns, she investigated (after 27 days) the med error with PRN oxycodone of Resident #8. The DON stated that she spoke to the RN/Unit Manager (RN/UM) and found out that the RN/UM was unaware of the above findings and concerns, and that there was no report about it. The DON further stated that she reviewed the resident's notes and assessments of the resident, found no ill effects from the med error. She also reached out to the physician and notified the med error; the physician documented that resident continued on pain management and no ill effects. On that same date and time, the DON informed the surveyor that after the investigation of the med error, RN#1 was suspended pending investigation, and eventually terminated. The DON stated that RN#1 was unable for interview. On 7/22/25 at 11:34 AM, the surveyor interviewed CP#2, who stated that she was responsible for monthly MRR (medication record review) of residents, review declining sheets for controlled meds, the eMAR, and compared them with the PO. CP#2 stated that the orders should be followed, and the order should be clarified if we had 10 mg order for oxycodone and there was an available 10 mg tab, the order should be clarified to prevent confusion. CP#2 acknowledged the med error for above findings and concerns. She also stated that CP#1 was unable for an interview. She further stated that she was unaware of the med error report. On 7/22/25 at 12:57 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor notified the LNHA and DON of the above findings and concerns regarding Resident#8's PRN oxycodone med error. A review of the facility's Medication Errors Policy with a revised date of 1/23/25, that was provided by the DON, revealed under policy, a medication error must immediately be reported to the resident's physician and Medication Error Form (MEF), must be initiated by the nurse discovering the error. The type of error and cause of error must be indicated on the MEF. A copy of the MEF is to be sent to the pharmacy within 24 hours .Medication Errors are categorized as follows:Medication OmissionWrong doseExtra dose Wrong Dosage form/route Wrong timeIncomplete Documentation. On 7/24/25 at 12:10 PM, there was no additional information provided by the LNHA and DON. NJAC 8:39-11.2(b); 27.1 (a); 29.2(d)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/16/25 at 9:27 AM, the surveyor, in the presence of a Kitchen Supervisor/Cook (KS/C) observed the following during the initial kitchen tour:1. A milk chest which contained beverages including milk, juices and soda, the internal thermometer reading was observed at 49 degrees. The KS/C stated the cook was in refrigerator (ref) stocking items and that was why the temperature (temp) was high. The KS/C acknowledged the ref temp should be below 41 degrees. A temp log on the ref also indicated the ref temp should be 41 degrees or less. 2. A walk-in ref which stored food items, the internal thermometer was observed at 52 degrees. The KS/C stated the temp should below 40 degrees. The KS/C that staff had entered the ref, the door was open, the kitchen was warm, and that's why the temp reading was higher. The KS/C went for a new thermometer placed in ref to be rechecked. 3. The stove top had three of twelve burners in use with large pots. The stove top was observed soiled in multiple areas with dry, crusted debris. The KS/C stated the stove was cleaned after every use and the burners looked like that as the stove was in use. The surveyor discussed areas which had a buildup of crusted, burned debris and the observation that not all of the burners were in use. The KS/C provided no additional verbal response. 4. In a storage room on top of a freezer chest, there was an open cardboard box with two exposed loaves of bread. In the box there were other types of bread that were secured in a plastic bag. The surveyor asked the KS/C about the two exposed loaves in the box. The KS/C stated they just received the delivery from the vendor and that was how some of the bread was received. The KS/C further explained that she believed kitchen staff had already spoken to the vendor about it, and sometimes it was still received uncovered. The KS/C stated staff would secure uncovered items with plastic wrap before storing the deliveries. The KS/C acknowledged the loaves of bread should be covered for proper storage, to protect the food items and help preserve its freshness.5. On a drying rack there were a stack of two-inch half pans. Two of the pans were observed wet inside. The KS/C stated washed items should be stacked when completely dry to prevent wet nesting (stacking of wet dishes before completely dry which can lead to bacteria growth due to trapped moisture, potentially contaminating food and causing illness) and the FSD (Food Service Director) always educated staff about wet nesting. On 7/16/25 at 10:10 AM the surveyor with the KS/C re-checked the ref temp for the milk chest and the walk-in refrigerator. The milk chest's internal thermometer was observed with a temp of 38 degrees. The walk-in ref's internal temp was observed with a temp of 42 degrees, indicating the temp had decreased. On 7/17/25 at 11:07 AM, the surveyor, in the presence of the FSD conducted a follow up tour in the kitchen.6. The walk-in ref's internal thermometer was observed with a temp of 46 degrees. The surveyor discussed with the FSD about the temp concerns observed during the initial tour in the kitchen. The surveyor asked the FSD what the expected ref temp was. The FSD replied that the ref temp should be below 41 degrees and believed the temp reading was due to the staff going in and out of the ref for lunch preparation.On 7/17/2025 at 12:01 PM, the surveyor with the FSD rechecked the internal thermometer of the walk-in ref which read 40 degrees. On 7/17/2025 at 12:14 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) about concerns in the kitchen during the initial and follow up tours. The LNHA stated he would review and discuss with the FSD. On 7/22/25 at 10:47 AM, the surveyor inspected the nutrition ref near the East unit with a Registered Nurse (RN). The RN stated outside food items were to be dated and labeled with the resident's name when placed in the ref by staff. The RN stated dietary staff were responsible for checking the ref temp. The surveyor inspected the ref with the RN and observed the following:6. On the front of the ref was a ref temp log. The entries for 7/21/25 (PM) and 7/22/25 (AM) were blank and unsigned. 7. In the freezer, there was a 1.5-quart container of ice cream secured in a clear plastic bag which was unlabeled and had no date. The RN could not say who the ice cream belonged to. The RN acknowledged the item should have been dated and labeled with a resident's name. 8. In the freezer, was a container of a tomato feta soup which was red-orange colored liquid. The item was not dated or labeled with a resident's name. The RN could not say who the item belonged to. The surveyor and RN checked the container's manufacturers date which had a use by date of 4/15/24. The RN removed and stated she would dispose the food item. 9. In the freezer, there was a small foil disposable container with a clear top. Inside the container was a whip cream with red colored center topping dessert. The item was undated and unlabeled. On the bottom of the container was a sticker which had a printed date of 7/14.The RN could not say who the food item belonged to. The RN removed the food item and stated she would dispose it.On 7/22/25 at 11:25 AM, the surveyor interviewed the FSD about nutrition refrigerators (refs). The FSD stated dietary would remove outdated items and checked the ref's temp. The FSD stated it was a group effort between dietary and nursing staff. He further explained outside food items should be clearly labeled and dated with the resident's room number, their name, date brought in and placed in ref. The FSD stated food items would be disposed after 48 hours, and the nurses were responsible for ensuring items were labeled and not expired. The surveyor discussed the observed concerns with the nutrition ref. On 7/22/2025 at 1:31 PM, the surveyor notified the LNHA and Director of Nursing (DON) of the kitchen tour and nutrition ref concerns. On 7/24/2025 at 8:47 AM, the LNHA provided the surveyor with the following:- In-service education to staff regarding ref temperatures (temps), caution leaving the doors open for prolonged periods, and entering refs too often. The LNHA stated that they have been monitoring ref temps closely after surveyor inquiry with no concerns, believed it was very warm on those specific days and staff going in and out of refs for items and the door being open while storing deliveries contributed to the out-of-range temp findings. -In-service education for stove cleanliness and ensuring the stove top was clean after each mealtime. The LNHA stated that the stove had some oatmeal from breakfast and that the staff were preparing for the next meal, lunch at the time of the surveyor's observation. -In-service education to staff of ensuring delivered bread items were covered, if items were received uncovered staff were to discard them immediately and the FSD would contact vendor. The LNHA provided email communication between the FSD and the vendor requesting that all items be securely packaged for delivery in which they responded and were agreeable. -In-service education to dietary staff about wet nesting and appropriately drying items prior to storing them. The LNHA stated the FSD readily reminds and educates staff about wet nesting and ensuring items were stored when completely dry. -In-service education to staff about completing the ref log for nutrition refs. The LNHA stated that the dietary staff checked the temp but forgot to complete the ref temp log. There was no additional information provided by facility management. A review of the facility's Labeling and Dating System Protocol Policy with a last revised date of May 2023, indicated opened sliced, or shredded cheese were good for 1 week from their open date. A review of the facility's Refrigerator, Reach-in Policy with a last revised date of August 2008, under Procedure revealed,.13. Replace food items when temp inside ref reaches 41[degrees Fahrenheit] .A review of the facility's Refrigerator, Walk-in Policy with a last revised date of August 2008, under Procedure revealed,.9. When temp is down to 41[degrees Fahrenheit], replace all food.A review of the facility's Stove Top-solid Top Policy with a last revised date of August 2008, under Policy revealed,.Solid top stove tops shall be cleaned and sanitized after each use.A review of the facility's STOVE - RANGE Policy with a last revised date of August 2008, under Policy revealed,.All stoves and ranges shall be cleaned and sanitized as needed or at a minimum weekly.A review of the facility's Foods brought in By Family or Visitor Policy with a last revised date of January 2025, under Procedure revealed,.2. The food will be clearly labeled with the patient's name and room number, as well as the date and time the food was brought into the facility. Food items will be stored the pantry ref using proper sanitation, temp, light, moisture, ventilation and security. If not eaten within 24 hours, the refrigerated foods will be discarded.A review of the facility's Warewashing Policy with a last revised date of 2/10/2025, under Procedure revealed,.10. Do not stack wet items. Do not wipe dry with towels or cloths to prevent contamination.NJAC 8:39-17.2(g)

Complaint NJ#186231Based on observation, interview, and review of facility documentation, it was determined that the facility failed to dispose of garbage and refuse properly in a manner to maintain a sanitary environment and prevent potential pests for 1 of 2 days of observation. This deficient practice was evidenced by the following:On 7/16/25 at 10:06 AM, the surveyor in the presence of the Kitchen Supervisor/Cook (KS/C), toured the designated garbage disposal area outside the facility. The surveyor observed an enclosed white privacy fence, which the KS/C indicated the dumpster for recyclable items such as cardboard was disposed and picked up by the garbage company. The KS/C unlatched the fence, and the surveyor observed that there was one dumpster with both of its lids opened. Scattered on the floor around the dumpster were plastic items such as bottles, plastic bags, gloves; a #10 metal can; an empty plastic milk crate; a few paper items; and four mop/broom sticks to the side of the dumpster. The KS/C was unsure who was responsible for cleaning the dumpster area but believed it was maintenance. On 7/17/25 at 11:24 AM, the surveyor in the presence of the Food Service Director (FSD) conducted a follow up tour of the garbage disposal area. The dumpster enclosed by white fence was observed clean with no debris on the floor and the lids were closed. The FSD stated it was cleaned yesterday by staff. The surveyor and the FSD were joined by the Housekeeping Director (HD). The surveyor asked the FSD and HD who was responsible for maintaining the garbage disposal area. The FSD and HD stated that both housekeeping and the dietary staff were responsible for ensuring that the area was clean.On 7/17/25 at 12:14 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) about the observed concerns at the garbage disposal area. The LNHA was made aware by staff after the surveyor's observation and stated that the staff were always on top of the garbage disposal area to ensure that it remained orderly and clean. On 7/22/25 at 1:31 PM the surveyor notified the LNHA and the DON of the concern with the garbage disposal area. On 7/24/25 at 8:47 AM, the LNHA provided in-service education that dietary staff received regarding the maintenance of the recycling dumpster area. The LNHA stated that he was surprised as that have been on top of maintaining the disposal area clean and that there may have been a recent pick up by the garbage company as was left in that condition as observed. There was no additional information provided by facility management. A review of the facility's Cardboard Recycling Policy which was last updated on 2/15/25, under Procedure revealed, .2. Once pick up is complete dietary/housekeeping needs to thoroughly check the fenced in enclosure for any boxes or debris that fell out and on the ground.3. In addition, a daily check of the area should be done to ensure no cardboard or other debris is on surrounding ground.4. Lid to recycled container must be closed when not in used.NJAC 8:39-19.7

Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, accurate and readily accessible medical records. This deficient practice was identified for 1 of 21 residents reviewed, Resident #25.This deficient practice was evidenced by the following: On 7/16/25 at 10:48 AM, the surveyor observed Resident #25, sitting on a wheelchair (w/c) by the nursing station, with a tab alarm (personal safety alarm which alerts caregivers if someone attempts to get up from a bed or chair) attached to the back of their w/c. The resident was alert, pleasant and stated that they fell about 1 to 2 months ago, I slid on the floor, and broke something. The resident further stated that they were on therapy, healing, doing good and I'm just being careful.On 7/17/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) fall investigations in the last four months for Resident #25.On 7/21/25 at 11:28 AM, the surveyor reviewed the electronic Medical Record (eMR) for Resident #25, which revealed:The Face Sheet (a summary of important information about the resident) revealed Resident #25 had diagnoses (dx) which included but were not limited to; left femur fracture, encounter for closed fracture with routine healing, encounter for orthopedic aftercare, dementia, unspecified macular degeneration, history of falling, muscle weakness, and difficulty in walking.A review of the physician's orders (PO) revealed:-A PO dated 2/12/25, for pain assessment, document location in notes 3x/day (three times a day).-A PO dated 3/4/25, for Tylenol 325 mg (milligram) tablet (tab), 2 tablets (tabs) [equals 650 mg] orally every 6 hours PRN (as needed) for pain.-A PO dated 6/17/25 at 11:55 PM, for x-ray 2 views left hip dx r/o (rule/out) fracture.A review of the modified quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 5/15/25, revealed a Brief Interview of Mental Status (BIMS) score of 6 out of 15, which indicated the resident's cognition was severely impaired. A review of the current care plan (CP) of Resident #25 revealed a focus for pain related to (r/t) history of falls and recent fall resulting in a left hip fracture and ORIF on 6/20/25. Interventions included document pain assessment particularly location, nature, intensity and duration of pain. On 7/21/25 at 11:31 AM, the surveyor interviewed License Practical Nurse #1 (LPN#1), who cared for Resident #25 at the time of their fall. LPN#1 stated the resident was trying to ambulate in their room on their own, did not see well, and was found sitting on the floor. LPN#1 further explained the resident at the time of the fall complained of left hip pain and was guarding their left hip. LPN#1 stated the physician was called, gave order for a STAT (means immediately) left hip x-ray and depending on the results would determine the next step for the resident.At that same time, LPN#1 explained that the diagnostic services vendor (DSV) did not come STAT. The resident was given pain medicine, transferred to the hospital the next morning, and admitted to the hospital with a fracture, and had surgery. LPN#1 could not recall any additional details regarding the resident's fall incident. On 7/21/2025 at 2:30 PM, the surveyor reviewed the facility investigation, Adverse Event Documentation of Resident #25's fall on 6/17/25, which was provided by the LNHA, and revealed the following:- On 6/17/25 at approximately 8:43 PM, during routine rounds, LPN#1 found the resident sitting on the floor next to the foot of their roommate's bed with both legs extended and the resident was guarding their left hip. The resident complained of left hip pain. The resident was assessed, vital signs were stable, the resident denied hitting their head and there was no visible injury to the resident. The resident was assisted back to bed.- On 6/17/25 at 8:45 PM, the physician was made aware of the fall incident and the resident's condition with an order to complete a left hip x-ray.-On 6/17/25 at 8:50 PM, the resident's representative (RR) was made aware about the fall incident. -On the following day, 6/18/25 at 12:23 PM, the Advance Practical Nurse (APN) visited the resident in which the left hip x-ray was not completed and ordered for the resident to be sent to the emergency room (ER) for further evaluation due to the resident being non-compliant with bedrest and had been complaining of left hip pain.A review of eMR revealed the following progress notes (PN):-A PN dated 6/17/25 at 9:08 PM, by LPN#1, revealed, at 8:35 PM, Resident #25 was observed very anxious while sitting at their bedside.-At 8:42 PM, LPN#1 administered PRN Atarax and the nurse encouraged the resident to rest. LPN#1 documented the resident stated, Just get out my room. -At 8:43 PM, LPN#1 found the resident sitting on floor at bedside. A head-to-toe assessment was completed. The resident was noted to be guarding their left hip and complained of left hip pain. The resident was also noted with a left knee abrasion which was treated with normal saline, patted dry, xeroform (non-adherent treatment dressing for wounds) dressing applied, and covered with a band aid. -At 8:45 PM, the physician was notified of the fall incident and with a new order for X-ray to left hip 2 views (STAT). A confirmation number from the DSV was obtained for the x-ray. The resident was assisted into bed.A review of the eMR revealed a PN dated 6/18/25 at 9:04 AM, by LPN #2 (the 11:00 PM-7:00 AM nurse), that the resident was received resting in bed s/p [status post] fall day # 1, with pain and discomfort to left hip, Tylenol 650 mg was given, and all meds [medications] rendered and tolerated. Vitals taken and recorded. Resident was waiting for XRAY to be done and Staff continued to monitor resident's progress. (the pain assessment revealed pain level of 3 out of 10) Further review of LPN#2's PN on 6/18/25 at 9:04 AM, did not include documentation that the physician was notified of continued complaint of pain, and was still waiting on stat x-ray to be done.A review of PN dated 6/18/25 at 9:42 AM, written by LPN#1, revealed, the resident was received in bed, still waiting for the left hip x-ray to be completed. The resident was assessed as having pain 5 out of 10 (with 10 being the worst pain) on a numerical pain scale. At 8:51 AM, the resident was administered Tylenol 650 mg. LPN#1 documented the resident was non-compliant with remaining in bed, was having episodes of being very anxious, and was given PRN Atarax with positive effect. A review of the eMAR revealed the Tylenol was given on 6/18/25 at 8:50 AM, and the effective result at 9:50 AM.A review of PN dated 6/18/25 at 11:30 AM, written by LPN#1, revealed, the DSV was called at 11:23 AM to request the estimated time of arrival (ETA) for the x-ray. The DSV stated the request was assigned to a technician, and the facility requested they call back with the ETA. The PN did not include documentation that the physician was notified that the stat x-ray was not done.A review of the PN dated 6/18/25 at 12:55 PM, by LPN#1, revealed:-At 12:23 PM, the APN saw the resident, due to the stat x-ray not completed by the DSV, the APN ordered the resident be sent to the hospital for further evaluation.-At 12:35 PM, transport was arranged for the resident's transfer to the ER.-At 12:41 PM, the RR was made aware of Resident #25 being sent to the ER for further evaluation.A review of the APN's PN dated 6/18/25 at 12:41 PM, revealed, the resident was seen and examined in bed, attempting to get up with injured left extremity from fall yesterday. The left hip x-ray remained pending, followed up by the primary nurse with multiple calls to the DSV since yesterday. The APN further documented the resident continues to c/o [complain of] left hip pain, noted slight abduction [movement of a limb away from the midline of the body] to left lower extremity. The APN wrote the resident had dementia, was forgetful, and unable to comply with fall and hip precautions currently. The APN recommended to send the resident to the ER for evaluation and treatment. A review of the PN dated 6/18/25 at 4:28 PM, by LPN#1, indicated the resident was admitted to the hospital for a closed left hip fracture.A review of pain assessment documentation on 6/17/25 and 6/18/25, under the vitals section were as follows:-On 6/17/25 at 1:25 AM, the resident's pain level was documented as 0 by LPN#1.-On 6/17/25 at 11:12 AM, the resident's pain level was documented as 0 by LPN#3.-On 6/17/25 at 5:15 PM, the resident's pain level was documented as 0 by LPN#1.-On 6/17/25 at 11:02 PM, the resident's pain level was documented as 0 by LPN#1.-On 6/18/25 at 3:56 AM, the resident's pain level was documented as 3 by LPN#2.-On 6/18/25 at 8:51 AM, the resident's pain level was documented as 5 by LPN#1.A review of June 2025 electronic Medication Administration Record (eMAR) revealed:-June 2025, a PRN Tylenol entry, was administered a dose on 6/18/25 at 8:50 AM. There was no additional documentation of the resident being administered Tylenol PRN on 6/17/25 and 6/18/25 according to what were documented in the PN.-Further review of the above eMR revealed that there was no documented evidence that the resident received a pain medication (med) when the resident's pain assessment resulted for pain level of 3 as documented by the LPN#2 on 6/18/25 at 3:56 AM, in the vital sign section of eMR.On 7/22/2025 at 11:15 AM, the surveyor interviewed the Director of Nursing (DON) about Resident #25's fall incident and fall incident procedures. The DON did not recall details of the resident's fall. The DON stated if a resident complained of pain after a fall incident the resident should have been sent out, and it would be expected for the nurse to call the physician again to notify that the resident was in pain and the resident should be sent for further evaluation. The DON acknowledged that the nurse should have documented in the resident medical records. The DON stated that she would further review to provide additional information.On 7/22/25 at 1:27 PM, the surveyor notified the LNHA and the DON about the above concerns with 6/17/25 fall incident that revealed concerns with continued complaint of pain by the resident, pain management of Tylenol for 2 shifts not documented, and no documentation that the physician was notified of the delay in x-ray. There was no documentation by nurses on 6/17/25 on the evening and night shifts of the resident receiving Tylenol as indicated in their PN. The LNHA and DON had no verbal response at this time. On 7/23/25 at 2:37 PM, the surveyor placed a call to LPN#2, who cared for the resident on 6/17/25 on the 11-7 shift. There was no answer, and the surveyor left a message for a return call.On 7/23/25 at 2:50 PM, the surveyor interviewed LPN#1, who stated that the resident was administered PRN Tylenol after their fall and the resident was compliant with bedrest. LPN#1 stated that at the end of her shift, approximately 11:30 PM, she called the physician and spoke with an on-call physician covering and informed them that the x-ray had not been completed. LPN#1 continued that the on-call physician instructed her to follow up with the RR about their preference and the RR wanted the resident to have the x-ray completed at the facility first. LPN#1 stated she called the physician and the RR again in the morning that the DVR did not come. LPN#1 further explained that the APN happened to be rounding on the unit, and LPN#1 asked her to see the resident. LPN#1 stated the APN then ordered for the resident to be transferred to the hospital.On that same date and time, LPN#1 acknowledged that she did not document any of the discussions or notifications in the resident's medical record and that it was expected for the nurses to document everything in their PN. LPN#1 stated she documented on the 24-hour report (shift to shift report of important resident information). At that same time, the surveyor asked LPN#1 what the protocol for documentation was when administering a med (med). LPN #1 stated a med was signed in the eMAR at the time of administration and a follow up assessment for effectiveness of the pain med would be conducted and documented in the eMR. LPN#1acknowledged she did not document and sign the eMAR when she administered PRN Tylenol to the resident on 6/17/25. On 7/23/25 at 4:40 PM, the surveyor interviewed the primary physician over the phone about Resident #25's fall incident. The primary physician could not recall details from that day, would check her records and return a call to the surveyor.On 7/23/25 at 4:50 PM, the primary physician called the surveyor back. The primary physician informed the surveyor that they reviewed their phone records in which she did receive a phone call and a text message from the facility that day. The primary physician further stated she ordered for an x-ray and for the resident to be transferred. The physician recalled that the APN followed up on the resident.On 7/23/25 at 4:55 PM, the surveyor interviewed LPN#2 over the phone. LPN#2 stated she received report from LPN#1 that the RR wanted the x-ray to be done at the facility first prior to sending the resident out to the hospital. LPN#2 recalled that she gave the resident Tylenol for pain and that it was effective. LPN#2 acknowledged she did not document the Tylenol administration in the eMAR and that she wrote it on the 24-hour report. On 7/24/25 at 8:53 AM, the DON informed the surveyor that she followed up with LPN#1 on 7/22/25, after surveyor inquiry. The DON stated she was informed by LPN#1 that the resident was not sent to the hospital as the RR requested to wait for the in-house x-ray results. The DON stated LPN#1 did not document discussions with the RR in the resident's eMR and only documented it on the 24-hour report. The DON stated she followed up with the RR who confirmed that she had the discussion with LPN#1. The DON provided a written statement from the RR. On that same date and time, the DON stated it was expected for nurses to document meds administered to a resident in the eMAR. The DON added that LPN#1 and LPN#2 would receive disciplinary action for not documenting the administration of Tylenol to the resident, as well as, not documenting follow up communication with the RR and the physicians.On 7/24/25 at 8:50 AM, the DON provided an undated statement from the RR, and the 24-hour report which revealed in the RR's written statement that they were called on the 6/17/25 about the fall incident, the complained of pain, and delayed in the xray of the resident. The RR's statement also included that would be beneficial for the resident to stay at the facility until the xray was done for resident's safety and comfort. A review of the provided 24-hour report dated 6/17/25, revealed that LPN#1 documented that the RR was made aware of fall and primary physician's stat x-ray order. It also included that at 11:00 PM, LPN#1 documented STAT x-ray was not done, and covering MD [medical doctor] made aware.[RR] made aware.; LPN #1 documented conversation with RR which indicated [RR] wants to wait for in house x-ray to be done. As [RR] does not want [Resident #25] waiting in ER alone. Further review of the 24-hour report, revealed, did not include documentation of pain assessment or level of pain for 3:00 PM -11:00 PM, 11:00 PM-7:00 AM and 7:00 AM-3:00 PM shifts.On 7/24/25 at 11:31 AM, the survey team met with the DON and the LNHA and there was no additional documentation provided by the LNHA and DON. The surveyor asked the DON if the 24-hour report was part of the resident's medical record. The DON replied that it was a legal facility documentation but not included as part of the resident's medical record. A review of the facility's Incident and Accidents Policy with a revised date of 2/18/25, revealed under Procedure.When a hip fracture is suspected, the resident is not moved.If the injury appears serious or questionable, the individual will be sent to the hospital via 911.ambulance.A review of the facility's Pain Management Policy with a revised date of 1/7/25, revealed, under policy, Control of pain is essential in order to assist each person to achieve his or her highest practicable level of function .Under procedure of the policy, for electronic charting documentation revealed .Date and time of physician notification and change of treatment .NJAC 8:39-35.2(d)5

Based on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the specified timeframe as required. This deficient practice was identified for 1 of 21 residents (Resident #74), whose MDS assessments were reviewed and was evidenced by the following: The Centers for Medicare and Medicaid (CMS) MDS Version 3.0 Resident Assessment Instrument (RAI) Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and the completion date was no later than 14 days after the ARD. On 7/17/25 at 8:40 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) for the transmission reports of Resident #74, and both stated that they would get back to the surveyor. A review of the provided MDS Transmission Activity for Resident #74, with start date of 2/1/24 and ending 7/17/25, revealed: ARD 11/29/24 Entry=was accepted and was uploaded on 12/2/24.ARD 12/6/24 Admission-5 day=was accepted and was uploaded on 12/12/24.ARD 3/6/25 Not OBRA=was accepted and was uploaded on 3/19/25. A review of the resident's MDS revealed there were no further MDS done for Resident#74. There was no quarterly 1 for March 2025 and quarterly 2 for June 2025 as per RAI Manual. On 7/22/25 at 9:24 AM, the DON informed the surveyor that Resident#74 was admitted to the facility on skilled services, the last MDS was on December 2024, a discharge MDS was done from skilled to non-skilled. The DON stated that what had happened was, for Resident#74, last year, the facility transitioned to a new electronic medical records (eMR), new program was set up, when the resident was changed from skilled to nonskilled in order for an OBRA (Omnibus Budget Reconciliation Act, an assessment is due no less frequently than every 92 days) schedule to kick in, it did not switch. She further stated that after surveyor's inquiry, she contacted the outside vendor responsible for the switch, the vendor told the DON that someone from the facility's finance department should have switched the skilled to nonskilled residents, therefore as a result Resident#74 missed the quarterly MDS for March and June 2025. The DON further stated that we did an audit and all residents were okay except for Resident#74. On 7/22/25 at 12:57 PM, the survey team met with the LNHA and DON, and the surveyor notified them of the above findings and concerns that Resident #74 did not have two quarterly MDS's. A review of the facility's MDS Policy that was provided by the DON, with a revised date of 2/6/25, revealed under Policy: to ensure that each resident has a complete medical record, the RAI coordinator will ensure that each MDS (Entry, Initial, Quarterly, Annual, Discharge (d/c), and Significant Change) are completed and submitted within the regulation guidelines. Under Procedure .4. On OBRA assessment the following schedule is done on the 1st quarter, 2nd quarter, 3rd quarter, Annual assessment, significant change as needed and d/c. IDCP (Interdisciplinary) team has 14 days from the ARD to complete and close their assessment. MDS is to be submitted within 14 days of the completion date .12. DON/MDS Coordinator will obtain weekly MDS missing report monthly to ensure all MDS are completed and submitted . On 7/24/25 at 11:28 AM, the survey team met with the LNHA and the DON, and the LNHA did not provide additional information. N.J.A.C. 8:39 - 11.1; 11.2(h)

**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 update and revise the comprehensive care plan of a resident. This deficient practice was identified for 1 of 21 residents reviewed, Resident#34, and as 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.The surveyor reviewed Resident #34's electronic Medical Record (eMR).A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but not limited to; hypertension (high blood pressure), chronic kidney disease (a condition where the kidneys do not function fully), and schizoaffective disorder bipolar (a chronic mental health condition characterized primarily by symptoms of mood changes and hallucinations or delusions).A review of the resident's comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of [DATE], had a Brief Interview of Mental Status (BIMS) score that could not be completed which indicated the resident was rarely/never understood. Section N: Medications, reflected that the resident was taking an antipsychotic medication (med), a med that is primarily used to manage symptoms in schizophrenia or bipolar disorder.A review of the resident's med list reflected an order for olanzapine 2.5 mg (milligram) tablet (tab) 1 tab oral one time daily (Zyprexa), an antipsychotic med, with a diagnosis of schizo-affective bipolar disorder.A review of the resident's Psychiatrist Consult, dated [DATE], reflected a plan to continue Zyprexa as an adjunct for anti-depressant. The consult did not reflect any diagnosis of schizoaffective or bipolar disorder.A review of the resident's Comprehensive Care Plan (CCP), with a date last revised [DATE], did not reflect any mention of the use of anti-psychotic medications (meds) or olanzapine for schizoaffective, bipolar, or other diagnosis. A review of a current Care Plan Report (CPR), a document that highlights changes in the resident's CCP. The CPR did not reflect any use of anti-psychotic meds or olanzapine for any diagnosis. The CPR reflected that the resident was taking antidepressant meds, but did not reflect use of olanzapine. On [DATE] at 12:08 PM, the surveyor interviewed the Nursing Supervisor (NS). The surveyor asked the NS who was primarily responsible for updating the CCP. The NS stated the MDS Coordinator was and that they were currently out on leave. The NS further stated that, in their absence, the Director of Nursing (DON) and the 3 to 11 shift NS, along with the nursing staff would work on the CCP. The NS could not locate Resident #34's CCP. The surveyor asked the NS if olanzapine and schizoaffective disorder should be included in the resident's CCP. The NS stated yes, they should be part of the CCP.On [DATE] at 12:58 PM, the survey team met with the Licensed Nursing Home Administrator and DON and the surveyor discussed the concern with the CCP for Resident #34.On [DATE] at 9:00 AM the surveyor asked the DON if antipsychotic med use should be included in the CCP along with the diagnosis and/or indication for use. The DON stated yes, they should be. The DON also stated that the olanzapine was ordered [DATE], and the resident had a significant change [DATE], so the CCP would be updated on the next Quarterly MDS which was due [DATE]. The DON stated it should be updated as needed if appropriate. The DON also stated that the diagnosis/indication for olanzapine was now updated to match the Psychiatrist Consult (after surveyor inquiry) as an adjunct for antidepressant.A review of the facility's Care Plans Policy, dated as revised [DATE], reflected, under policy, .the care plan (CP) is a living document. Under process: 4. The CP plan will be reviewed by each discipline prior to an Interdisciplinary Care Plan Team meeting and amended as needed. 5. The CP will be reviewed and revised as need as the residents' care needs are updated. Any updates or changes in the CP should be done as needed.The facility did not provide any further pertinent information. NJAC 8:39-11.1

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to; a.) follow the physician order with regard to application of an ointment and b.) ensure the skin assessment was accurate and completed in accordance with professional standards of practice and facility's policy and procedure, for 1 of 21 residents (Resident #8) reviewed.This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/16/25 at 10:50 AM, the surveyor observed Resident #8 seated in a wheelchair with a leg rest and left leg immobilizer in use. The surveyor also observed a zinc oxide ointment tube on top of the nightstand which the resident claimed that it was being applied to their back sacral area due to rashes and redness which they obtained from the hospital, and now getting better. The surveyor reviewed the medical records of Resident #8, and revealed the following: A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses (dx) that included but were not limited to; aftercare following explantation of knee joint prosthesis (in which surgical revision was performed. Explantation was carried out and a cement spacer was introduced), infection following procedure, other surgical site, unspecified osteoarthritis, essential hypertension (elevated blood pressure), and muscle weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 6/26/25, under Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 15 of 15, which reflected that the resident had intact cognition. A review of the active Resident Medication Profile of Resident #8, included but not limited to the following: -A physician order (PO) with a start date of 6/20/25, zinc oxide 20% topical ointment, apply to sacral/buttocks area 3x/day (three times a day). -A PO with a start date of 6/20/25, klayesta 100,000 unit/gram topical powder apply under breasts, abdominal folds, bilateral groin 3x/day starting 6/20/25. The above PO for zinc oxide ointment and klayesta topical powder were transcribed to June and July 2025 electronic Treatment Administration Record (eTAR) signed by nurses as administered every shift at 11:30 PM-7:30 AM (11-7 shift), 7:30 AM-3:30 PM (7-3 shift), and 3:30 PM-11:30 PM (3-11 shift). A review of the Care Plan (CP) Report, with an effective date of 6/20/25 to present, that was provided by the Director of Nursing (DON), included but not limited to the following: -A CP for urinary incontinence, the resident was occasionally incontinent r/t (related to) muscle weakness/need for assistance with personal care, impaired bed mobility/transfers/ambulation, dx: explantation of joint prosthesis s/p (status post) left TKR (total knee replacement) with spacer The interventions included but not limited to; check for incontinence, change if wet/soiled, clean skin with mild soap and water, and apply moisture barrier, with frequency of 3x/day starting 6/23/25. -A CP for at risk for impairment skin integrity r/t bladder incontinence, muscle weakness/need for assistance with personal care, impaired bed mobility/transfers/ambulation, dx: explantation of joint prosthesis s/p left TKR with spacer. The interventions included but not limited to zinc oxide to sacrum/buttocks as ordered. Further review of the above CP for urinary incontinence and at risk for impairment skin integrity revealed that the disciplines tab was blank and did not indicate the responsible staff for the interventions mentioned for CP urinary incontinence as indicated on other CP. A review of the Nursing admission Assessment Comprehensive (NAAC) that was done and electronically signed by Licensed Practical Nurse #1 (LPN#1) on 6/20/25, revealed that the resident's time of arrival at the facility was at 5:12 PM. The NAAC, under skin included that the resident upon assessment had a surgical wound, other skin problems: erythema and rash. Under comments section, there was no documented evidence to further describe the erythema and rash. On 7/17/25 at 12:20 PM, the surveyor interviewed Licensed Practical Nurse #2 (LPN#2), who claimed that she was the assigned nurse of Resident #8. LPN#2 informed the surveyor that the resident was cognitively intact, on IV ABT, rehab, and pain management. The surveyor notified LPN#2 of the above concern that on the 1st day of tour, the surveyor observed the zinc oxide on top of the nightstand table, and the LPN responded that it was probably the Certified Nursing Aide (CNA) who left it. LPN#2 further stated that it was the CNA who applied the zinc ointment to the resident, and it was LPNs responsibility just to make sure it was done, and then LPN#2 sign it off in the eTAR. She acknowledged that it should have been stored properly. On 7/17/25 at 12:35 PM, the surveyor interviewed the CNA regarding resident's zinc oxide. The CNA informed the surveyor that every continence care she applied the zinc oxide as preventative, and the nurse will sign the record that it was applied. The surveyor notified the concern that it was on top of the nightstand table yesterday (7/16/25) during the initial tour, and the CNA had no response. On 7/22/25 at 8:43 AM, the Director of Nursing (DON) informed the surveyor that if the order to apply ointment was in the eTAR the nurse should administer the ointment unless if it was a standard of care it would of the CNA, the ointment could be zinc oxide and any type of lotion OTC (over the counter). The DON also stated that we do encourage the CNA after incontinence care to apply ointments especially when changing them. On that same date and time, the DON stated that there should be an actual skin assessment, what kind of redness, the nurse should identify if it was a pressure wound or not, monitor and refer them. The DON further stated that if it was MASD (Moisture-Associated Skin Damage, is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus) or stage 1 pressure, the wound protocol should be followed. At that same time, the surveyor asked the DON if it was appropriate for the CNA to apply the ointment if it was ordered and transcribed in the eTAR, and the nurse to sign once done by the CNA. The DON stated, yes and no, if the nurse signed the eTAR, the nurse should be the one to apply the ointment. The DON further stated, it was a yes a problem because it should be the nurse to apply the ointment. She added, as facility's practice, it there was no pressure ulcer or skin impairment and it was a preventative being done for every incontinence, the CNA could apply the cream, then it was a no not a problem. Furthermore, the DON stated that she would get back to the surveyor regarding the surveyor's concern with LPN#1's documentation on 6/21/25 for redness in b/l buttocks and other areas and the discrepancy in the assessment on 6/20/25, and what was in the progress notes. On 7/22/25 at 12:57 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor asked the DON if the admission assessment had no skin impairment upon admission and there was a redness in the b/l buttocks, perineal area the following day what would be the process, and the DON stated that the facility monitor them and did not need to measure them. The DON further stated that after surveyor's inquiry, she checked resident's buttocks and there was no redness. The surveyor notified the LNHA and DON of the above concerns regarding Resident#8's order for zinc oxide and discrepancy with documentation and assessment was incomplete. On that same date and time, the DON confirmed there was a discrepancy with resident#8's skin assessment on 6/20/25 versus the progress notes on 6/21/25, which the DON claimed the continuation of LPN#1's assessment. The DON confirmed that it was LPN#1 who did the assessment on 6/20/25 and 6/21/25 notes. The DON also stated that education will be provided to LPN#1 regarding skin assessment. The DON stated that area in the skin assessment should have been documented and specified what location for redness and rash. The DON also reviewed the progress notes and acknowledged that the notes should have been clearer. A review of the facility's Skin Assessment Policy with a revised date of 9/19/24, that was provided by LNHA, revealed under policy statement that the facility is committed to maintaining optimal skin health for all residents by conducting thorough skin assessments upon admission and performing daily skin checks. On 7/22/25 at 1:50 PM, the surveyor asked the DON about the facility's Skin Assessment Policy and notified that there was no mention about measurements of wound and skin impairment as part of the parameters of comprehensive skin assessment, and the DON stated that there should be something about measurements in the policy. On 7/24/25 at 12:10 PM, there was no additional information provided by the LNHA and DON. NJAC 8:39-11.2(b)

Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 21 residents (Resident #8) reviewed. This deficient practice was evidenced by the following: On 7/16/25 at 10:50 AM, the surveyor observed Resident #8 seated in a wheelchair with a leg rest and left leg immobilizer in use. The surveyor also observed an IV (intravenous) pole. The resident stated that they had an order for IV ABT (antibiotic) daily, on skilled nursing for their infected left surgery, and rehabilitation (rehab). The surveyor reviewed the electronic medical records (eMR) of Resident #8, and revealed the following: A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses (dx) that included but were not limited to; aftercare following explantation of knee joint prosthesis (in which surgical revision was performed. Explantation was carried out and a cement spacer was introduced), infection following procedure, other surgical site, unspecified osteoarthritis, essential hypertension (elevated blood pressure), and muscle weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 6/26/25, under Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 15 of 15, which reflected that the resident had intact cognition. Section J: Health Condition revealed that the resident had pain and was coded frequently. Section N: Medications (meds) included ABT, diuretic (water pill), opioid (controlled pain medication), and convulsive meds. A review of the June 2025 electronic Medication Administration Record (eMAR) revealed the following: -A physician order (PO) with an order date of 6/20/25, oxycodone 5 mg (milligram) tablet (tab) oral as needed (PRN) every 8 hours (hrs), for moderate pain. The eMAR was electronically signed as administered: On 6/21/25 at 9:06 AM, by Registered Nurse #1 (RN#1).On 6/21/25 at 1:49 PM, by RN#1.On 6/22/25 at 6:00 PM, by RN#1. -A PO with an order date of 6/20/25, oxycodone 5 mg, 2 tablets (tabs) (total 10 mg) oral PRN every 8 hrs, for severe pain. The eMAR was electronically signed as administered: On 6/20/25 at 5:48 PM, by Licensed Practical Nurse #1 (LPN#1).On 6/21/25 at 5:54 AM, by LPN#2.On 6/22/25 at 5:17 AM, by RN#2.On 6/22/25 at 1:51 PM, by RN#1.On 6/22/25 at 3:00 PM, by RN#1.On 6/23/25 at 9:15 AM, by LPN#3. Further review of the above June 2025 eMAR revealed that the PO to administer oxycodone 5 mg tab PRN every 8 hrs for moderate pain was not followed on 6/21/25, when it was administered at 9:06 AM and then at 1:49 PM, which was 4 hrs apart. The PO to administer oxycodone 5 mg, give 2 tabs (total 10 mg) PRN every 8 hrs for severe pain was not followed on 6/22/25, when it was administered on 6/22/25 at 1:51 PM and 3:00 PM, which was an hour apart. A review of the CP's EPIC (Electronic Pharmacist Information Consultant) review done by Consultant Pharmacist #1 (CP#1) on 6/24/25, revealed, there was no documented evidence that the above irregularities for oxycodone PRN was identified. On 7/17/25 at 11:09 AM, the surveyor notified the Director of Nursing (DON) of the above concerns and findings. The DON after reviewing the June 2025 eMAR, stated that there were no reports from CP#2 about the irregularities from PRN oxycodone. She acknowledged that the above irregularities should have been identified by the CP. On 7/22/25 at 11:34 AM, the surveyor interviewed CP#2, who stated that she was responsible for monthly MRR (medication record review) of residents, review declining sheets for controlled meds, the eMAR, and compare them with the PO. She further stated that if she found discrepancies or irregularities, she would notify the Nurse Manager and submit an inspection reports. CP#2 also stated that for new admission or re-admission, EPIC review will be done with same protocol. She added that PO should be followed and if not, that should be identified as an irregularity, and should be part of the CP's reports. She acknowledged that she was not the CP who reviewed the resident's meds on 6/24/25. On 7/22/25 at 12:57 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The surveyor asked the LNHA and the DON what the facility's process was with regard to EPIC review. The DON stated that the facility send resident's face sheet, order sheets, eMAR via fax to the CP for remote review. The DON further stated that the CP had access to their eMR as part of their remote EPIC review. At that same time, the surveyor notified the LNHA and DON of the above findings and concerns regarding Resident#8's PRN oxycodone irregularities and that it was not identified in 6/24/25 EPIC review. The surveyor asked the LNHA and DON of facility's policies with regard to EPIC and MMR review. On 7/22/25 at 1:50 PM, the Director of Operations (DoO) of the CPs called back and informed the surveyor that CP#1, who was responsible for the 6/24/25 EPIC review was unable for an interview. The surveyor asked the DoO of the EPIC process, and he stated that EPIC review was being done remotely and unsure if the CPs had an access remotely to the facility's eMR and would have someone from the EPIC department to speak with the surveyor. On 7/22/25 at 2:04 PM, the Director of EPIC Division (DoEPICD) called and informed the surveyor that CP#1 was unable for an interview. The DoEPICD stated that the EPIC review was done remotely for new admission and re-admission residents. She further stated that CP review medication (med) list from the hospital, POs, eMAR, electronic Treatment Administration Record (eTAR) that were faxed by the facility. She also added that the CP had access to the facility's eMR. The DoEPICD stated that EPIC review done within 48 business hours unless there was a holiday it will be later. On that same date and time, the surveyor notified the DoEPICD of the above findings and concerns with PRN oxycodone. The surveyor asked DoEPICD if that should that be considered an irregularity and should have been identified, and she responded that she was unsure and would get back to the surveyor. A review of the undated facility's provided EPIC Consultant Pharmacist Responsibilities Policy that was provided by the DON, revealed that the EPIC CP will perform a drug regimen review with the information provided by the POs, MAR, and Medication Discharge List (if available) and will report any drug regimen irregularities. A review of the undated facility's Consultant Pharmacist Responsibilities Medication Regimen Review Policy that was provided by the DON, revealed that the monthly reviews of the drug regimen of each resident, if not done by EPIC department, with reports of any irregularities. On 7/24/25 at 12:10 PM, there was no additional information provided by the LNHA and DON. NJAC 8:39-29.3(a)(1)

Based on record review, interviews and review of pertinent facility documents it was determined that the facility failed to notify a representative from the Office of the State of Long-Term Care Ombudsman about a resident's emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, (Resident #74) reviewed for hospitalization as was evidenced by the following:
Review of Resident #74s Face sheet (an admission summary), indicated that the resident was discharged on 9/16/23 with a return not anticipated.
Review of the progress note dated 9/16/23 at 6:21 PM, reflected that Resident #74 was sent to the emergency room for evaluation.
Review of a progress note dated 9/18/23 at 4:25 PM, reflected that Resident #74 was admitted to the hospital.
Review of the facility's Notice of Emergency Transfer dated 9/19/23, reflected that the resident was sent out to the emergency room on 9/16/23 for evaluation and treatment.
Review of an email to the Office of the New Jersey Long-Term Care Ombudsman dated 11/13/23 reflected that the facility notified the office of resident's emergency transfers for the time period of May 2023 through October 2023.
On 2/2/24 at 9:59 AM, the surveyor interviewed the Director of Social Service (DSW) in the presence of the survey team. He stated that he was not told he was responsible to notify the state Ombudsman's office of resident's emergency transfers. He further stated that he inferred this since the previous director had done so. The DSW stated that at past jobs, it was the Admissions Director's responsibility. He stated that he found a binder from the facility's previous director that had records of notification to the resident or family regarding emergency transfers which she emailed to the state Ombudsman's office quarterly and he continued to do so. He stated that the purpose of notifying the state Ombudsman's office was to ensure that the facility was not sending residents out just to get them out.
On 2/2/24 at 2:48 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss this concern. The LNHA stated that the facility had always sent the resident emergency transfer's information to the state Ombudsman's office on a quarterly basis.
On 2/5/24 at approximately 9:30 AM, the LNHA provided the surveyor with the name and phone number for a representative of the Office of the Long-Term Care Ombudsman who he stated he spoke to regarding this concern.
On 2/5/24 at 1:08 PM, the surveyor interviewed the Chief of Advocacy Services from the Office of Long-Term Care Ombudsman via phone. She stated that she spoke to the LNHA on Friday related to the frequency to which the facility should have notified the office of resident emergency transfers. She stated that she educated the LNHA that moving forward, the facility should notify the office on a monthly basis.
On 2/5/24 at 1:21 PM, the surveyor interviewed the DSW in the presence of the survey team. He confirmed that when he emailed the state Ombudsman's office resident emergency transfers, he sends the residents face sheet and each individual notice of transfer.
Review of the facility policy Emergency Transfer Notification dated May 2017, included the following:
-CMS [Centers for Medicare and Medicaid Services] requires that copies of the NOTICE for temporary emergency transfer MUST also be sent to the Ombudsman.
-CMS states that notification to the Ombudsman MUST be sent by the facility, but allows that this notification can be made when practicable such as quarterly.
NJAC 8:39-5.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of pertinent facility documents, it was determined that the facility failed to transmit the Minimum Data Set (MDS) assessments, a tool to facilitate the management of care, in a timely manner and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 2 of 2 residents, (Resident #13 and #74). The evidence was as follows:
According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Guide Version 1.17.1, October 2019 which included that an Entry (admission) MDS must be transmitted within 14 days of the Event Date (date of admission).
Resident #13:
The surveyor reviewed the Entry MDS dated [DATE].
Review of the MDS Transmission Results Summary dated 8/31/23, provided by the Director of Nursing (DON) revealed that the residents MDS should have been transmitted by 8/25/23 but was not submitted until 8/31/23 at 10:04 AM.
Review of the undated Final Validation Report for Resident #13 provided by the DON, revealed a Warning message Record Submitted Late: The submission date is more than 14 days after . entry tracking record .
Resident #74:
The surveyor reviewed the Entry MDS dated [DATE].
Review of the MDS Transmission Results Summary dated 9/18/23, provided by the DON revealed that the residents MDS should have been transmitted by 9/9/23 but was not submitted until 9/18/23 at 7:09 AM.
Review of the undated Final Validation Report for Resident #74 provided by the DON, revealed a Warning message Record Submitted Late: The submission date is more than 14 days after . entry tracking record .
On 2/02/24 at 1:43 PM, the surveyor interviewed the DON in presence of the survey team. She stated that the MDS Coordinator (MDSC) completed the MDS and that she transmitted the MDS data to CMS. She stated that she transmitted data in a batch every other Friday. The DON acknowledged and stated that maybe I am late since she did not transmit data based on the residents individual MDS schedule.
On 2/05/24 at 12:29 PM, the surveyor interviewed the MDSC, in the presence of the DON and survey team. The MDSC stated that she needed to complete Entry MDS's within seven days of admission but usually completed an Entry MDS on the day of admission. She further stated that two weeks after the MDS completion date, the DON should transmit the MDS. The surveyor reviewed the MDS Transmission Results Summary with the MDSC. She acknowledged that the Transmit by date revealed the date the MDS should have been transmitted and the Status Date was the date the MDS was actually transmitted. The MDSC also stated that she communicated to the DON verbally as to when MDS's were completed.
On 2/05/24 at 12:41 PM, the DON acknowledged that she focused on MDS's that were rejected and not on those that were late. Both the MDSC and the DON acknowledged that the Final Validation Report would indicate a warning message if there was a late transmission.
On 2/05/24 at 12:44 PM, the DON acknowledged that she did not know about these late transmissions prior to surveyor inquiry. The DON reviewed the reports in the presence of the surveyor and acknowledged that the Entry MDS's for both Resident #13 and #74 were transmitted late, . She also acknowledged that each resident had a different MDS schedule, and they should have been transmitted more frequently.
Review of the facility policy MDS dated 10/2023, included that the RAI coordinator will ensure that each MDS is completed and transmitted within the regulation guidelines. It further included that an MDS should be transmitted within 14 days after the completion date.
N.J.A.C. 8:39-11.2(e)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to accurately post staffing information to include the total number and actual hours worked for licensed and unlicensed staff responsible for resident care.
This deficient practice was evidenced by the following:
On 01/29/24 at 01:22 PM, the surveyor observed the nurse staffing information posted at the nursing station on the South unit on a large visible monitor as follows:
-Census Hours
-January 29th, 2024
-Census: 93
-7am-3 pm Shift; RN (Registered Nurse)/LPN (Licensed Practical Nurse) Hous (hours): 48; CNA (Certified Nursing Aide) Hours:128
-3 pm-11 pm Shift; RN/LPN Hours: 40; CNA Hours: 88
-11 pm-7am Shift; RN/LPN Hours: 40 CNA Hours: 64
On 01/30/24 at 10:05 AM, the surveyor observed the following nurse staffing information posted on the monitor on the South unit as follows:
-Census Hours
-January 30th, 2024
-Census: 92
-7 am-3 pm Shift; RN/LPN; Hous: 48; CNA Hours: 136
-3 pm-11 pm Shift; RN/LPN Hours: 40; CNA Hours: 88
-11 pm-7 am Shift RN/LPN Hours:40; CNA Hours: 64
On 01/31/24 at 09:50 AM, the surveyor observed the following nurse staffing information posted on the monitor on the South unit as follows:
-Census Hours
-January 31st, 2024
-Census: 90
-7 am-3 pm Shift; RN/LPN Hous: 48; CNA Hours: 104
-3pm-11pm Shift; RN/LPN Hours: 40; CNA Hours:104
-11pm-7am Shift; RN/LPN Hours:40; CNA Hours: 64
On 02/01/24 at 12:14PM, the surveyor interviewed the Certified Nursing Aide/Quality Coordinator (CNA/QC) in reference to the daily staffing and posting of the nursing staffing information. The CNA/QA explained that the purpose of the nurse staffing posting was to account for the number of staff in the building. She stated that the unit secretary was responsible to post the nurse staffing information daily. She further explained that the required information to be posted was, how many nurses were in the building, CNA's, administration staff and the resident census.
On 02/01/24 at 12:34 PM, the surveyor interviewed the DON regarding the information posted on the nurse staffing report. The DON explained that the purpose of the nurse staffing report was to inform the residents and family of the staffing ratios. She explained that the facility used regulations to determine the staffing levels. The DON stated that the current date, census, CNA hours and RN/LPN hours per shift should be posted on the nurse staffing report. She stated that the RN/LPN hours were combined on the nurse staff report, however, on the daily staffing sheets, the RN/LPNs were identified. The DON stated, that it was the unit secretary's responsibility to update and post the nurse staffing information which was reviewed by her and the nursing supervisor to ensure accuracy of the staffing notification.
On 02/05/24 at 9:47 AM, the surveyor interviewed the unit secretary that completes the nurse staffing report, who stated that he obtains the information to enter on the nurse staffing report by counting who was on the daily staffing book for all shifts. He then obtains the census from each unit, and then tallies the census (from every unit), the nurses and the CNA's and calculates it. He explained that he was shown how to complete the nurse staffing report from the previous unit secretary.
Review of the facility policy titled Facility Census and Staffing Ratio dated 12/1/2021 and revised 5/8/23, revealed Procedure: the facility documents the unit clerk will post the following on the digital signage, located in the NH (nursing home) Nursing station daily in the morning: (a.) date, (b) total current census of the day for the [NAME] (Broadway and [NAME]), East, South and SP Unit, (c) total number of RN and LPN hours for each shift, (d) total number of hours of CNAs on each shift, (e) names of nurses on duty on each shift.
NJAC 8:39-41.2(c)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in 1 of 5 medication carts inspected.
This deficient practice was evidenced by the following:
On 02/1/24 at 11:20 AM, the surveyor inspected the Broadway unit medication cart in the presence of the Licensed Practical Nurse (LPN). The surveyor observed an unopened bottle of Xalatan eye drops (medication for pressure in the eye) stored in the medication cart and an opened Breo inhaler (medication for breathing) with an opened date of 12/15/23 that was expired.
The surveyor interviewed the LPN who stated that an unopened bottle of Xalatan eye drops should have been stored in the refrigerator and once removed from the refrigerator it should have been dated. LPN also acknowledge that the Breo inhaler was expired and should have been removed from the medication cart.
A review of the Manufacturer's Specifications for the following medications revealed the following:
1. Unopened Xalatan eye drops should be stored in the refrigerator.
2. Xalatan stored at room temperature has an expiration date of 42-days.
3. Breo inhaler once opened has an expiration date of 42-days.
On 2/2/24 at 3:00 PM, the surveyor discussed the above observations and findings with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON).
There was no additional information provided.
A review of the facility's policy titled Storage of Medications dated 3/19/23 and provided by the DON included the following:
H.
Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.
Under Temperature:
D. Medications requiring refrigeration are kept in a refrigerator at temperatures between 35 F (2 C) and 46 F (8 C) with a thermometer to allow temperature monitoring. All other medications should be stored in accordance with manufacturer label and instructions.
Under Expiration Dating:
D. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, blood sugar testing solution and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency.
G. The nurse will check the expiration date of each medication before administering it.
H. No expired medication will be administered to a resident.
I. All expired medications will be removed from active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.
NJAC: 8:39-29.4 (a) (h) (d)

**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 complete a Significant Change in Status Assessment (SCSA) Minimum Data Assessment (MDS) for 1 of 21 residents reviewed, (Resident # 18) as evidenced by the following:
On 10/27/21 at 10:13 AM, the surveyor reviewed the medical records of Resident # 18. The resident was admitted to the facility on [DATE] with diagnosis that included but not limited to; unspecified osteoarthritis, edema, diabetes mellitus without complications, pneumonia and sequelae of cerebral infraction.
Review of the October 2021 Physician Orders (PO) indicated a PO dated 3/12/21 for Hospice Eval and Treat.
The surveyor reviewed the MDS assessments for Resident # 18. There was no evidence in the electronic and paper chart that the SCSA MDS was completed.
SCSA MDS is a federally mandated comprehensive assessment that is required when a resident enrolls in a hospice program due to a Significant Change in Status and must be completed within 14 days after the determination date.
On 10/27/21 at 10:48 AM, the surveyor interviewed the Director of Nursing (DON) who stated the facility's previous MDS coordinator resigned on 9/30/21 and a new MDS coordinator was newly hired. The DON acknowledged and stated that a significant Change in Status MDS should have been completed at the time hospice services was started in accordance with the RAI manual.
There was no additional information provided.
NJAC 8:39-11.7

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a.) provide treatment, consistent with professional standards of practice to an existing pressure injury and b.) implement an element of the facility policy and procedure concerning a wound dressing, for 1 of 1 Resident (Resident#4) observed during wound treatment observation.
This deficient practice was evidenced by the following:
On 10/21/21 at 10:51 AM, the Registered Nurse (RN) informed the surveyor that Resident #4 currently received wound care treatment for a facility acquired stage 3 pressure wound to the sacrum. The RN further stated that the resident's wound to the sacrum was improving.
On 10/21/21 at 11:07 AM, the surveyor observed the resident laying on a specialized mattress, positioned on the right side, with eyes closed and a pillow in between the resident's legs. There was a wheelchair at the bedside with a cushion.
A review of the resident's Face sheet (an admission summary), reflected that the resident was admitted to the facility with diagnoses that included Dementia without behavioral disturbance, anemia (low blood count), and hyperlipidemia (abnormally high levels of fats in the blood).
A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool dated 9/30/21, indicated that the Cognitive Skills for Daily Decision Making score of 3 which indicates that the resident's decision making was severely impaired. The CMDS showed that the resident had a stage 3 facility acquired wound.
A review of the October 2021 Physician's Orders dated 10/13/21, revealed an order to cleanse the sacrum with NS (normal saline), don't scrub, pat to dry, apply Medihoney paste (used for wound bed preparation and through all phases of wound healing) to wound and cover with silicone foam adhesive dressing daily.
A review of the wound assessment dated [DATE] by the Nurse Practitioner (NP) revealed that the stage 3 sacral wound was improving.
On 10/22/21 at 11:46 AM, the Certified Nursing Assistant #1 (CNA #1) informed the surveyor that Resident #4 was cognitively impaired and required total assistance with activities of daily living (ADLs). She further stated that the resident was on a specialized bed, incontinent care, turning, and repositioning to promote wound healing. CNA #1 stated that the resident had a very tiny wound to the sacrum with wound treatment provided by the nurse daily, getting better, and almost healed.
On 10/22/21 at 12:19 PM, the RN informed the surveyor that resident's sacral wound was getting better and smaller. She further stated that the resident was being followed up by the wound doctor once a week.
On 10/25/21 at 9:07 AM, the surveyor observed the RN perform a wound treatment to Resident #4's sacral wound with the assistance of CNA #2. The RN informed the surveyor that the resident was pre-medicated with routine Tylenol. The surveyor observed the RN perform handwashing before and after removing gloves, during and after setting up the treatment table, preparing the supplies including the Medihoney paste, and removing the old dressing. The RN did not change gloves after cleansing the sacrum with normal saline solution with a gauze. She immediately took a clean, dry gauze to pat dry the sacral area using the same gloves. Then, the RN with the same gloves applied the Medihoney to the sacrum and applied the foam dressing. The RN disposed the unused supplies, disinfected the table, removed gloves, performed handwashing, and signed the electronic Treatment Administration Record (eTAR).
On that same date and time, during an interview in the presence of CNA #2, the RN stated that it was facility practice and protocol to change gloves after cleaning the wound and before applying the medication and new dressing. The RN further stated, I don't remember, when asked by the surveyor if she changed her gloves after cleansing the sacral wound with NS, administered medication, and applied the new dressing.
Furthermore, CNA #2 acknowledged that the RN did not change her gloves and perform handwashing after cleansing the sacral wounds with NS and immediately applied the Medihoney paste and covered the wound without changing gloves in between.
On 10/25/21 at 12:53 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and discussed the above observations and concerns.
On 10/28/21 at 11:51 AM, the survey team met with the LNHA, DON, and there was no additional information provided by the facility.
A review of CDC Hand Hygiene in Healthcare Settings guidance for Healthcare Providers page last reviewed January 8, 2021, included, When and How to Wear Gloves: Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene immediately after removing gloves. Changes gloves and perform hand hygiene during patient care, if gloves become damaged, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs
A review of the facility Wound Dressing: Clean Policy and Procedure revised 12/16/20, provided by the LNHA included, Procedure: #16. Cleanse area following physician's orders #18. Remove soiled gloves and place in plastic bag. #19. Wash hands. #20. Apply treatment medication as ordered utilizing Q-tip, sterile tongue blade, or gauze pad onto which medication has been applied, taking care not to touch exposed are in any way.
A review of the undated facility protocol for Continued Quality Improvement Treatment Observation, provided by the DON, indicated that Criteria #20. Wear another pair of gloves when cleaning or irrigating lesion. #21. Discard second pair of gloves after cleaning/irrigation process is finished. #22. When applying topical medications and clean/sterile dressing, use no-touch technique or a clean pair of gloves .)
NJAC 8:39-27.1 (b) (e)

Based on observation, interview, and record review, it was determined that the facility failed to assure that a resident received the appropriate diet consistency prescribed by a physician. This deficient practice was identified for 1 of 21 residents, (Resident #4) reviewed.
This deficient practice was evidenced by the following:
On 10/21/21 at 11:07 AM, the surveyor observed Resident #4 laying on a specialized mattress with eyes closed.
A review of the resident's Face sheet (an admission summary), reflected that the resident was admitted to the facility with diagnoses that included Dementia without behavioral disturbance, anemia (low blood count), and hyperlipidemia (abnormally high levels of fats in the blood).
A review of the Comprehensive Minimum Data Set (CMDS), an assessment tool dated 9/30/21, indicated that the Cognitive Skills for Daily Decision Making score of 3 which means decision making was severely impaired. The CMDS showed that the resident was on a mechanically altered diet.
A review of the October 2021 Physician's Orders dated 10/16/21, revealed a diet order of mechanical soft chopped/ground and nectar thick liquids.
On 10/22/21 at 11:46 AM, the Certified Nursing Assistant (CNA) informed the surveyor that Resident #4 was cognitively impaired and required total assistance with activities of daily living (ADLs) and a feeder. She further stated that the resident was on thickened liquids and well-tolerated.
On 10/22/21 at 12:31 PM, the surveyors observed the resident seated in a wheelchair with eyes closed. The lunch tray was on top of the table in front of the resident. The meal ticket on the lunch tray indicated a Regular-Mech Soft (Ground) diet with thin liquids. The surveyor observed unthickened four ounces (oz) of apple juice, four oz of whole milk, and eight oz of hot beverage on the resident's lunch tray. The surveyors did not observe the resident being fed at that time.
On that same date and time, the Director of Nursing (DON), Registered Nurse/Supervisor (RN/S), assigned Registered Nurse (RN), and CNA were present in the resident's room and observed the diet slip and the resident's tray. The DON and the CNA acknowledged that the resident should have received the appropriate diet order for nectar liquids. The CNA further stated that the resident received a nectar liquid for breakfast and that she was aware of the nectar liquid order for the resident.
On 10/22/21 at 1:47 PM, the survey team met with the Licensed Nursing Home Administration (LNHA) and the DON and discussed the above observations and concerns. The DON stated that the resident's diet slip should have reflected the appropriate diet order for nectar liquids. She further stated that the Food Service Director did not receive the diet order change for Resident #4 which was why the diet slip was not updated. The DON stated that there was no negative effect on the resident because the CNA was aware of the correct diet order and the resident was a feeder.
On 10/28/21 at 11:51 AM, the survey team met with the LNHA, DON, and there was no additional information provided by the facility.
A review of the facility Diet Order Policy and Procedure revised 10/22/21, provided by the DON included, In order to assure provision of the appropriate diet for each patient and to maximize patient care, this facility will provide a diet regimen consistent with physician's orders and current diet manual. Procedure: 1. A physician will prescribe diet in the medical chart .The Diet Order and Communication form will be filled out and scanned and emailed to the Director of Food Services .2. Diet should be as specific as possible. It may include one or more of a combination of the following. A comprehensive list of diets and descriptions can be found in the nursing home diet manual: a. Consistency Modification, b. Therapeutic Modification, c. Special Orders .
NJAC 8:39-17.4 (a) (1)