Care One At New Milford

F-F689

On 2/25/25 at 8:43 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #123.

A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility that included diagnoses but were not limited to; unspecified dementia, low back pain, and chronic pain related to neoplasm (abnormal growth of tissue).

A review of comprehensive Minimum Data Set (MDS), an assessment a tool, with an assessment reference date of 7/21/23, reflected a Brief Interview Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. Additionally, the resident was documented as needing supervision (oversight, encouragement or cueing) with activities of daily living (ADLs) which included walking and did not require an assistive device.

A review of hospital medical records, dated 7/10/23, indicated the resident had a history of elopement and had required staff supervision while under their care.

A nursing progress note (NPP) dated 7/29/23 at 9:53 PM written by Registered Nurse (RN) revealed the following:

At 5:00 PM, the RN served the meal tray to the resident.

At approximately 6:00 PM, the RN searched for Resident #123, the resident was not found on the unit and

the Licensed Practical Nurse/Supervisor (LPN/S) was notified.

At approximately 7:00 PM, the police came to the unit and the RN provided information regarding the resident. The Resident Representative (RR) and the Physician were made aware of the resident's elopement.

A NPP dated 7/29/23 at 10:01 PM written by the Assistant Director of Nursing (ADON) indicated the resident was returned to the facility, a body check was completed, there were no visible injuries, and a wanderguard was applied to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 There was no documentation in the facility's investigation that indicated notification of the elopement event to

the NJDOH and the Ombudsman's office. Level of Harm - Minimal harm or potential for actual harm A review of the submitted AAS-45 (Reportable Event Record/Report) submitted to the NJDOH was dated 8/4/23. The date of event was documented 7/29/23 at 5:30 PM. The AAS-45 further revealed the significant Residents Affected - Few event was called in to the NJDOH on 7/31/23 at 11:05 AM and that the Ombudsman's office was notified 7/29/23. There was no exact time indicated for when the Ombudsman's office was notified by the facility.

A review of a police report dated 7/29/23 for the incident, indicated that the police notified the Ombudsman's office regarding the resident's elopement. Ombudsman's office documentation indicated that the police informed them of the resident's elopement and not the facility.

A review of the fax cover sheet sent with the facility's investigation to NJDOH revealed the summary and conclusion for the elopement incident was faxed on 8/8/23, 10 days after the event.

On 2/27/25 at 11:48 AM, the surveyor interviewed the Director of Nursing (DON) and the DON about reporting facility reported events (FRE). The DON stated that any allegations of abuse, whether substantiated or not, were to be reported within two hours to the NJDOH and the ombudsman's office. The surveyor asked about other significant events, such as resident elopement. The DON did not provide a verbal response at this time and stated that she would review the facility's policy to provide an answer.

On 2/27/25 at 12:16 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the DON, and the ADON of the concern with the delayed reporting of Resident #123's elopement. The facility was still looking at policy to provide response for the appropriate notification to the NJDOH and the Ombudsman's office.

On 3/3/25 at 10:20 AM, the LNHA, the DON, and the ADON met with the survey team. The LNHA stated the facility followed state and federal regulations on notifying state agencies regarding reportable event. The surveyor asked for Resident #123's elopement when should it be reported to the NJDOH and the Ombudsman's office. The LNHA stated that the incident should have been reported within two hours. There was no additional information provided by the facility.

A review of the facility's Accidents and Incidents-Investigating and Reporting Policy, with a last revised date 6/4/24, did not address notification of an incident to the NJDOH and the Ombudsman's office.

A review of the facility's Wandering and Elopements Policy, with a last revised date of March 2019, did not address notification of an incident to the NJDOH and the Ombudsman's office.

A review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy, with a last revised date of September 2022 revealed under Policy Statement:

All reports of abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 NJAC 8:39-9.4(f)

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or 46049 potential for actual harm Based on observation, interview, and record review it was determined that the facility failed to accurately Residents Affected - Few code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 35 residents (Resident #72 and #110), reviewed for MDS accuracy.

This deficient practice was evidenced by the following:

Reference: A review of the latest version of the MDS 3.0 Manual (updated October 2024), Chapter 3-page K-4, under steps for assessment revealed:

This item compares the resident's weight in the current observation period with their weight at two snapshots

in time:

-At a point closest to 30-days preceding the current weight.

-At a point closest to 180-days preceding the current weight.

1. On 3/3/25 at 9:17 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #72.

A review of the Admission Record (AR; an admission summary) revealed that Resident #72 had diagnoses that included, but were not limited to; Parkinson's disease, cerebral infarction (stroke), and type 2 diabetes mellitus.

A review of the quarterly MDS, with an Assessment Reference date (ARD) of 1/11/25 revealed under section K (Swallowing/Nutritional Status), the resident was coded as having a significant weight loss of 5% or more

in the last month or loss of 10% or more in the last 6 months. The resident weight was documented as 158 pounds (lbs.).

A review of the resident's documented weights revealed the following:

7/5/24- 171.8 lbs.

8/5/24- 175 lbs

9/5/24- 172 lbs.

9/24/24- 179.4 lbs

9/25/24- 179.4 lbs

9/26/24-180.0 lbs.

10/4/24- 180 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 10/21/24- 178.2 lbs.

Level of Harm - Minimal harm or 11/12/24- 160.4 lbs. potential for actual harm 12/2/24- 162.8 lbs. Residents Affected - Few 1/3/25- 158.4 lbs.

2/18/25- 160.2 lbs.

3/1/25- 159.6 lbs.

On 7/5/24, the resident weighed 171.8 lbs. On 1/3/25, the resident weighed 158.4 pounds which is a -7.80 % Loss.

On 12/2/24, the resident weighed 162.8 lbs. On 1/3/25, the resident weighed 158.4 pounds which is a -2.70 % Loss.

2. On 3/3/25 at 10:15 AM, the surveyor reviewed the EMR of Resident #110.

The AR revealed that Resident #110 had diagnoses that included, but were not limited to; chronic kidney disease, dementia, adult failure to thrive, and anemia.

A review of the Significant Change MDS, with an ARD of 1/21/25 revealed under section K, the resident was coded as having a significant weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Additionally, the resident was coded as having a significant weight gain if 5% or more in the last month or gain iof 10% or more in the last six months on a physician-prescribed regimen. The resident weight was documented as 110 lbs.

A review of the resident's documented weights revealed the following:

7/2/24- 113.6 lbs.

7/4/24- 112 lbs.

8/5/24- 117 lbs.

9/4/24- 117 lbs.

9/5/24- 118 lbs.

10/2/24- 123.8 lbs.

11/4/24- 118 lbs.

11/5/24-118 lbs.

11/6/24-116 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 12/2/24- 108 lbs.

Level of Harm - Minimal harm or 12/4/24- 108 lbs. potential for actual harm 1/14/25- 110.3 lbs. Residents Affected - Few 1/31/25- 113.6 lbs.

2/1/25- 113.6 lbs.

2/6/25- 114.4 lbs.

On 12/424, the resident weighed 108 lbs. On 1/14/25, the resident weighed 110.3 pounds which is a 2.13 % Gain.

On 7/4/24, the resident weighed 112 lbs. On 1/14/25, the resident weighed 110.3 pounds which is a -1.52 % Loss.

On 3/3/25 at 11:03 AM, the surveyor interviewed Registered Dietician #1 (RD#1) at the facility. RD#1 stated there were two RDs in the facility and were responsible for completing section K. RD#1 stated that the closest weight to the ARD would be used to determine if the resident had significant weight gain or loss (5%

in 1 month and 10% in 6 months). RD#1 stated that RD #2 completed Section K for Resident #72's MDS assessment, RD #2 was not working today, and would be back tomorrow. The surveyor reviewed concerns regarding the accuracy of coding in the MDS assessments for Resident #72 and Resident #110, and RD #1 stated she would review and provide a response to the surveyor.

On 3/3/25 at 11:45 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) about the concern for the MDS coding accuracy for Resident #72 and Resident #110.

On 3/3/25 at 12:37 PM, RD #1 informed the surveyor that Resident #72 did not have a weight loss of 5% or more in the last month or loss of 10% or more in the last six months during the look back period from the ARD of the MDS assessments. RD#1 stated Resident #110 did not have a weight loss or weight gain of 5% or more in one month or 10% or more in the last six months during the look back period from the ARD of the MDS assessment. RD #1 acknowledged that the MDS assessments were not accurately coded and stated it could be a data entry error by RD #2.

On 3/4/25 at 9:17 AM, the surveyor interviewed RD #2 about completion of Section K in the MDS assessment. RD#2 stated the weight closest to the ARD date was used to determine significant weight changes in one month and six months. The surveyor notified RD #2 of the concerns found with the MDS assessments. RD #2 stated she believed it was human error when reviewing and coding the data.

On 3/4/25 at 11:33 AM, the LNHA, DON, and ADON met with the survey team. There was no additional information provided by the facility.

NJAC 8:39-33.2 (d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 38327

Residents Affected - Few Based on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 1 of 35 residents reviewed (Resident #63).

This deficient practice was evidenced by the following:

On 2/24/25 at 10:59 AM, the surveyor observed Resident # 63 was seated in a wheelchair (w/c) in front of their room, repeatedly stated, why, I am here, come here. The resident was able to self propel their w/c in short distance.

The surveyor reviewed Resident #63's medical records and revealed:

A review of the Admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a substance or known physiological condition, and repeated falls.

A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 1/10/25, with a brief interview for mental status (BIMS) score of 5 out of 15, reflected that the resident's cognition was severely impaired.

A review of the current Resident #63's Kardex (is a documentation system used in nursing that allows nursing to write, organize, and easily reference key resident information for their CP) Report revealed that

the resident required one to two persons assist with ADLs (activities of daily living), two persons assist with bed mobility and on FMP (functional maintenance program) for ambulation in the room with supervision as tolerated.

A review of the Rehabilitation (rehab) Screen that was signed by the Physical Therapist (PT) on 7/12/24, reflected that the resident's current status was supervision with bed mobility, transfers, ambulation, eating, and toilet use. The PT also documented that there was no change in functional status since last seen in rehab.

A review of the Rehab Screen that was signed by the PT on 1/10/25 reflected that there were no changes with the resident and no indication for skilled therapy at this time.

On 2/27/25 at 1:23 PM, the surveyor notified the MDS Coordinator (MDSC) and the Assistant Director of Nursing (ADON) the above concerns that the current Kardex Report and the Rehab Screen did not match.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 On 3/3/25 at 10:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, and MDSC. The surveyor asked should the CP be updated and revised to reflect Level of Harm - Minimal harm or the current condition of the resident if the MDS and Kardex Report were accurate, and the ADON stated that potential for actual harm the CP should have been revised for Resident#63.

Residents Affected - Few NJAC 8:39-11.2(f)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 38327 potential for actual harm REPEAT DEFICIENCY Residents Affected - Few Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to ensure that the recommendations of the Consultant were followed and reviewed by the Primary Care Physician for 1 of 6 residents, (Resident #32), reviewed for use of psychoactive medications according to the standard of clinical practice.

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 2/24/25 at 11:06 AM, the surveyor observed Resident #32 seated in a wheelchair in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide, who informed the surveyor that the resident will be going down for lunch.

The surveyor reviewed the medical records for Resident #32.

A review of the Admission Record (an admission summary) reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, generalized anxiety disorder, bipolar disorder (a mental health condition characterized by significant mood swings) unspecified, and major depressive disorder, single episode, unspecified.

A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 12/23/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive medications (meds).

A review of the electronic Medication Administration Record (eMAR) revealed that the resident was on the following psychotropic meds:

A physician's order (PO) dated 3/21/24, and was discontinued (d/c) on 2/18/25, Risperidone (antipsychotic medication) 1 mg (milligram) give 3 tablets (tabs) by mouth two times a day for bipolar disorder, 3 tabs=3 mg.

A PO dated 2/18/25, Risperidone 1 mg give 1 tablet (tab) by mouth at HS (bedtime) for bipolar disorder to be given with 4 mg to equal a total of 5 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 A PO dated 3/18/24, Mirtazapine Oral tab 15 mg give 1 tab by mouth at HS for depression.

Level of Harm - Minimal harm or A PO dated 3/19/24, Sertraline HCL (hydrochloride) Oral tab 100 mg give 1 tab by mouth one time a day for potential for actual harm depression.

Residents Affected - Few A PO dated 3/19/24, Benztropine Mesylate Oral Tab 10 mg give one tab by mouth one time a day for tremors.

A PO dated 4/26/24, Divalproex Sodium tab delayed release 500 mg give 3 tabs by mouth at HS for bipolar disorder, 3 tabs=1500 mg.

A review of the Progress Notes dated 2/18/25, Psych (Psychiatric) Follow Up, that was electronically signed by the Advanced Practice Nurse (APN) had an assessment and plan that included but were not limited to; d/c Benztropine, add Venlbenazine 40 mg at HS for tardive dyskinesia if approved by PCP (Primary Care Physician), add psychology consult and psychotherapy.

Further review of the medical records revealed that there was no documented evidence that the Psychology and Psychotherapy was initiated, and if the PCP was made aware of the recommendations to d/c Benzotropine and to add Venlbenazine (or Ingrezza, is used to treat tardive dyskinesia). There was no documented evidence that the recommendations of the APN were relayed to the PCP and if the PCP approved or declined the recommendations.

On 3/3/25 at 12:58 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), and the surveyor notified of the concerns about

the 2/18/25 psyche recommendations that were not followed.

On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. The DON stated that for surveyor's concern about APN's recommendations that were not followed, we do not have further documentation.

A review of the facility's Psychopharmacologic Medication Policy, with revision date of 9/6/18, that was provided by the DON revealed:

Policy: It is the policy of the facility to ensure that psychoactive meds are used only when appropriate indications are present and when the medication regimen helps to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being .

Implementation:

2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others.

3. The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic meds .

Other:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 22. The physician shall respond appropriately by changing or stopping problematic doses or meds, or clearly documenting why the benefits of the med outweigh the risks or suspected or confirmed adverse Level of Harm - Minimal harm or consequences . potential for actual harm

On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for exit conference, and there Residents Affected - Few was no additional information provided by the LNHA.

NJAC 8:39-11.2(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 38327 potential for actual harm Based on observation, interview, record review, and review of pertinent facility documents, it was determined Residents Affected - Few that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, by failing to; a.) ensure that the fall and pain evaluations were done as part of fall investigation, b.) care plan (CP) intervention was followed, and c.) CP intervention was in place for each fall and revised to reflect current condition of the resident. This deficient practice was identified for 1 of 5 residents, (Resident #107), reviewed for accidents 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.

Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for

the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under

the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.

During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, the surveyor observed Resident #107 lying on bed. There was an ankle-foot orthosis (AFO, is a hard brace worn on the lower leg that improves overall walking safety and efficiency for people with certain medical conditions. AFOs provide gait stability, keep joints properly aligned, and help compensate for muscle weakness) in the windowsill.

On that same date and time, the resident informed the surveyor that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. The resident further stated that they had incidents of falls in the facility, and unsure when and where in the facility the fall incidents happened. The resident's bed was not in a low position.

At that same time, Certified Nursing Aide #1 (CNA#1) entered the resident's room and confirmed that she was the aide of Resident #107. CNA#1 left the room afterward.

The surveyor reviewed the medical records of Resident #107 and revealed:

A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to other sequelae of cerebral infarction (stroke) and hemiplegia (is a condition characterized by paralysis on one side of the body) and hemiparesis (is a condition characterized by one-sided muscle weakness, often caused by disruptions in the brain, spinal cord, or nerves connecting to the affected muscles) following cerebral infarction affecting left non-dominant side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/7/25, with a brief interview for mental status (BIMS) score of 9 of 15, which Level of Harm - Minimal harm or reflected that the resident's cognitive status was moderately impaired. Section GG Functional Abilities: potential for actual harm Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair), toilet transfer, and ambulation were coded 3 (partial/moderate assistance). Section J Health Conditions reflected that the Residents Affected - Few resident was coded 1 for number falls since admission or prior assessment with injury except major.

A review of the two fall investigations that was provided by the Director of Nursing (DON) revealed:

-12/30/24 fall investigation reflected that the resident was found lying on the floor with their head against the wall and the resident sustained a left forehead bump.

The 12/30/24 fall investigation had an attached Progress Notes dated 12/31/24 that included Care Conference Note that was electronically signed by the DON, documented that the fall incident happened on 12/30/24 at 11:30 AM and the team believed that the resident's medical condition was the predisposing factor to the fall, and we will continue to monitor and encourage to take resident's medications.

-1/15/25 fall investigation reflected that CNA#2 notified the Licensed Practical Nurse (LPN) that the resident was found sitting on the floor in resident's room with wheelchair behind the resident and cane on the right side lying on the ground. The resident did not have an injury at the time of incident.

The 1/15/25 fall investigation had an attached Progress Notes dated 1/16/25 that included Nursing/Clinical note that was electronically signed by the Registered Nurse (RN), documented that the IDT (Interdisciplinary Team) reviewed the fall incident happened on 1/15/25 at approximately 11:30 AM, that Resident #107 was cognitively intact, ambulates independently with quad cane, resident reported they were walking with their cane and their legs became weak and fell . It was also documented that therapy to continue gait/balance/transfer training and will continue basic fall precautions per CP. Included in the attachment for 1/15/25 fall investigation were the Pain Evaluation and Fall Risk Evaluation both dated 1/15/25.

Further review of the above two fall investigations revealed that on 12/30/24 fall incident, there were no fall and pain evaluations that were completed.

A review of the current Resident #107's Kardex (is a documentation system used in nursing that allows nursing to write, organize, and easily reference key resident information for their CP) Report revealed that

the resident required

supervision with ambulation and transfer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In addition, the CP reflected a focus CP for at risk for falls due to history of falls, impaired balance/poor coordination, left side paralysis, medication side effects, noncompliance with use of assistive devices that Level of Harm - Minimal harm or was initiated on 2/2/24 and revised on 2/6/24 with an interventions/task that included but were not limited to; potential for actual harm raised toilet seat (initiated on 5/13/24), therapy evaluation and treatment as ordered, encourage to transfer and change positions slowly, have commonly used articles within reach, maintain bed in low position, and Residents Affected - Few provide assistant to transfer and ambulate as needed that were initiated on 2/2/24.

Further review of the CP revealed that the CP did not include new interventions for fall incidents that happened on 12/30/24 and 1/15/25. Also, there was a discrepancy on what was resident was coded for in MDS (partial and moderate assistance) and what was reflected on resident's CP (supervision) with regard to ADLs.

On 2/27/25 at 11:10 AM, the surveyor interviewed the MDS Coordinator (MDSC), who informed the surveyor that the facility followed the RAI (Resident Assessment Instrument) manual when doing MDS and there was no separate policy for MDS. The surveyor notified the MDSC of the above concerns, and the MDSC responded that she would get back to the surveyor to review the Kardex Report and MDS Section GG for accuracy.

On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant Director of Nursing (ADON), and the surveyor notified them of the above concerns.

On 2/27/25 at 1:23 PM, the MDSC in the presence of the ADON with the provided documents informed the surveyor that the MDS was coded accurately. The surveyor asked the MDSC if the MDS was coded accurately, why the CP did not reflect the current condition of the resident, and both ADON and the MDSC did not respond.

A review of the facility's Accidents and Incidents-Investigating and Reporting Policy, with a revision date of July 2017, that was provided by the ADON revealed:

Policy Interpretation and Implementation:

2. The following data, as applicable, shall be included on the Report of Incident/Accident form:

k. any corrective action taken;

l. follow up information;

m. other pertinent data as necessary or required; and .

A review of the facility's Fall Risk Assessment, with a revision date of March 2018 revealed:

Policy Interpretation and Implementation:

1. Upon admission, the nursing staff and the physician will review resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 6. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls . Level of Harm - Minimal harm or potential for actual harm A review of the facility's Pain Assessment and Management Policy, with a revision date of October 2022, that was provided by the ADON revealed: Residents Affected - Few General Guidelines:

1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive CP, and the resident's choices related to pain management .

On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. The DON stated that for the surveyor's concerns, no further information to provide.

NJAC 8:39-3.2(a,b); 11.2(b);27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 39885 potential for actual harm Complaint NJ #176146 Residents Affected - Few Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to; a.) determine the cause, implement a new intervention, and start treatment to prevent further pressure injury/pressure ulcer (PI/PU) for a facility acquired PI/PU for 1 of 2 residents reviewed for PU, (Resident #102), b.) follow the recommendations of the wound care consultant physician for 1 of 2 residents reviewed for PU, (Resident #102), c.) follow a physician order for Braden Scale assessment for 2 of 2 residents reviewed for PU, (Resident #102 and #302), and d.) clarify multiple physician orders for 1 of 2 residents reviewed for PU, (Resident #302).

This deficient practice was evidenced by the following:

1. On 2/24/25 at 10:19 AM, Surveyor #1 (S#1) observed Resident #102 seated in a wheelchair and the resident's legs were wrapped with ace bandages. S#1 interviewed Resident #102 who stated that they did not think they had any wounds or PI/PU.

On 2/25/25 at 10:25 AM, S#1 interviewed Resident #102's Certified Nurse Assistant (CNA) who stated that Resident #102 had a PU on the heel.

On 2/25/25 at 10:28 AM, S#1 interviewed Resident #102's Licensed Practical Nurse #1 (LPN#1) regarding

the process for a new PI/PU. LPN#1 stated that when a resident had a new PI/PU that it would be reported to the wound team. She added that an incident report and investigation would be done. She added that a Braden Scale was in the computer.

On 2/25/25 at 11:13 AM, S#1 requested from the Licensed Nursing Home Administrator (LNHA) any incident report and/or investigation for Resident #102 that was related to (r/t) the resident's skin.

On 2/25/25 at 12:42 PM, S#1 reviewed the facility provided incident report and investigation for Resident #102 which was dated 1/16/25, and included the following:

Incident Report: Incident description: The patient (also known as the resident) was seen today by Wound Consultant Physician (WCP), the wound team and the undersigned. The patient noted with a P2 collapsed blister to right lateral heel 6.5 x 6.0 x 0 P2, left lateral heel P2 collapsed blister 4.5 x 3 x 0. There was no conclusion listed on the incident report.

WC Multi Wound Chart Details with 2 PU listed and 1 wound listed as blanchable redness to the right, dorsal second toe.

Facility Acquired PU Investigation Form which under summary indicated patient has CKD4 (chronic kidney disease stage 4), liver transplant status, recently admitted to hospice Dx (diagnosis) pulmonary fibrosis. Although skin care and turning/positioning provided, wound developed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Unavoidable PU Physician Documentation which indicated that despite preventive measures outlined above and in consideration of the underlying clinical conditions identified, this PU is an unavoidable outcome . Level of Harm - Minimal harm or potential for actual harm Care Plan (CP) Report which did not contain the date(s) the actual skin breakdown CP was initiated or the interventions that were placed. Residents Affected - Few

A review of Resident #102's Admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to lung transplant status, congestive heart failure and anemia.

A review of Resident #102's most recent comprehensive Minimum Data Set (cMDS), an assessment tool, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #102 was cognitively intact. Further review under Section M Skin Conditions indicated the resident had 2 Stage 2 PU which were not present upon admission/entry or reentry.

A review of Resident #102's comprehensive CP included the following focus areas:

At risk for alteration in skin integrity r/t impaired mobility with an initiated date of 1/10/2025, with the following interventions: Encourage and assist to reposition; use assistive devices as needed; Observe skin condition with ADL (activities of daily living) care daily; report abnormalities; Obtain labs as ordered and report results to physician.

Actual skin breakdown r/t right lateral heel P2 with an initiated date of 1/13/2025, with the following intervention that was initiated the same date: Administer treatment (tx) per physician orders (PO). The following interventions were initiated on 1/27/25: Encourage and assist as needed to turn and reposition; use assistive devices as needed; Specialty low air loss mattress/wheelchair; Suspend/float heels as able; Use pillows and/or positioning devices as needed; WC as needed.

The CP indicated that Resident #102 had developed a PU on 1/13/25. The incident report for the development of the PU was dated 1/16/25 when the WCP saw the resident. There were no added interventions in addition to wound treatment to prevent further PI/PU until 1/27/25.

A review of Resident #102's progress notes (PN) did not include any description of skin breakdown prior to 1/16/25.

A review of Resident #102's January 2025 electronic Treatment Administration Record (eTAR) included a PO for Braden Scale on admission x three weeks post admission in the evening every Mon (Monday) for three Weeks with a start date of 1/13/2025, which was not administered or signed by the nurse as being done for 1/13/25, 1/20/25 and 1/27/25.

Further review of the eTAR included a PO for Braden Scale on admission x three weeks post admission one time only for one Day with a start date of 1/10/2025, which was signed by a nurse as administered on 1/10/25.

A review of Resident #102's electronic medical record under the Forms tab (assessments and evaluations section) revealed that the only Braden Scale assessment that was done was on admission and it was included in the Resident Evaluation. The PO was not followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 2/26/25 at 10:28 AM, S#1 interviewed the Registered Nurse (RN) regarding the process for assessing skin and new PI/PU. The RN stated that upon admission, the skin was assessed and a Braden Scale Level of Harm - Minimal harm or assessment was done. She added that a second day skin check was also ordered but that one was in the potential for actual harm PN. The RN stated that there was an order for a weekly skin observation and it would note no skin breakdown, a previously identified wound or a new wound. S#1 asked the RN what the process was if a new Residents Affected - Few skin issue was seen between the weekly observation, and the RN stated that for every new opening a risk management/skin incident report would be done. She added that it would be reported to the wound team that came to the facility on Monday and Thursday. The RN further stated that there would be a PN that would document the location and size. She added that the CP would be updated by unit manager (UM). The RN stated that the wound team also saw residents when they first came to the facility.

On 2/26/25 at 10:37 AM, S#1 interviewed the first floor UM regarding the process for a new skin issue. The first floor UM stated that when a staff saw a new opening that the staff would report it to the nurse or herself and that they would notify the wound team. She added that they would put an air mattress and skin prep

before the wound team saw them. The first floor UM stated that the new skin issue would be documented in

a PN and an incident report would be done. She added that the CP would be updated usually by the Infection Preventionist (IP) or that she herself could also do it. S#1 asked the first floor UM about Resident #102's incident report. The first floor UM stated that the wound team would visit all new admits and also if a referral was done. She added that maybe the wound team saw the PI/PU when they assessed the resident and in that case there would not have been a note before. S#1 then asked the first floor UM for more information regarding the CP that was initiated on 1/13/25 for an actual skin breakdown to the right lateral heel. The first floor UM stated she would get back to S#1.

On 2/26/25 at 10:58 AM, S#1 interviewed the Assistant Director of Nursing (ADON) regarding the process of

a new skin issue. The ADON stated that an assessment was done and would be documented in the PN and

an incident report would also be done. She added the regular doctor would be notified and they would refer to wound healing. The ADON stated that usually there would be some documentation about the issue prior to

the wound consultant. The ADON stated that when there was an actual opening a CP would be initiated. The ADON stated that Resident #102 was transferred from a sister facility. The ADON stated that Resident #102's PU was facility acquired. S#1 asked the ADON the reason there was no documentation regarding the PU when there was a CP initiated. The ADON stated she would have to look into it.

On 2/26/25 at 12:37 PM, the ADON stated that CP was initiated by accident. She added that the resident was admitted to the facility and three days later when the CP was being reviewed the staff clicked on wound and then revised it on 1/16/25 when they saw the fluid filled blister. The ADON stated that according to the Nurse Practitioner note the resident was seen and noted no pressure wound on 1/13/25.

A review of Resident #102's wound consultant notes (WCN) dated 1/16/25, included the following orders:

Wound #2 Right, Lateral Heel

Other Orders

Wound Dressing

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Apply: - Skin Prep. Foam Dressing Every Mon and Thursdays (Thur). Offload. Monitor for changes.

Level of Harm - Minimal harm or Wound #3 Left, Lateral Heel potential for actual harm Other Orders Residents Affected - Few Wound Dressing

Apply: - Skin Prep. Foam Dressing Every Mon and Thur. Offload. Monitor for changes.

Wound #4 Right, Dorsal Second Toe

Other Orders

Wound Dressing

Apply: - Skin Prep BID (twice a day) with Hygiene. Offload. Monitor for change

A review of Resident #102's WCN dated 1/23/25, included the following orders:

Wound #2 Right, Lateral Heel

Other Orders

Wound Dressing

Apply: - Skin Prep. Foam Dressing Every Mon and Thur. Offload. Monitor for changes.

Wound #3 Left, Lateral Heel

Other Orders

Wound Dressing

Apply: - Skin Prep. Foam Dressing Every Mon and Thur. Offload. Monitor for changes.

Wound #4 Right, Dorsal Second Toe

Other Orders

Wound Dressing

Apply: - Skin Prep BID with Hygiene. Offload. Monitor for changes.

A review of Resident #102's January 2025 eTAR included the following orders that were not the recommended orders that were written by the WCP:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Skin prep to bilateral heels, and second toe (blanchable redness) every day shift for collapsed blister with an order date of 1/18/25, and a start date of 1/19/25. The order was not started until three days after the Level of Harm - Minimal harm or resident was seen by the WCP. The WCP order was for bilateral heels to have skin prep applied and a foam potential for actual harm dressing on Mon and Thur and not be done daily. The WCP order was for the second toe to have skin prep applied two times a day and not only once a day. Residents Affected - Few

A review of Resident #102's WCN dated 1/27/25, included the following orders:

Wound #2 Right, Lateral Heel

Other Orders

Wound Dressing

Apply: - Skin Prep. BID Leave open to air. Offload. Monitor for changes.

D/C Treatment - Foam Dressing

Wound #3 Left, Lateral Heel

Other Orders

Wound Dressing

Apply: - Skin Prep. BID Leave open to air. Offload. Monitor for changes.

D/C Treatment - Foam Dressing

Wound #4 Right, Dorsal Second Toe was resolved.

A review of Resident #102's eTAR included the following order that was not the recommended order that was written by the WCP:

Skin prep to bilateral heels (blanchable redness) every day shift for collapsed blister with a start date of 1/29/25. The WCP recommended that the skin prep was to be applied to bilateral heels two times a day.

On 2/27/25 at 11:01 AM, S#1 interviewed the LPN regarding WCP. The LPN stated that the WCP after the assessment would pass the note to the UM and she put the notes in. She added that usually the tx was put

in place the same day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 2/27/25 at 12:42 PM, S#1 notified the LNHA, Director of Nursing (DON) and ADON the concerns that Resident #102 did not have any documentation of a PI/PU when a CP for actual skin breakdown was Level of Harm - Minimal harm or initiated on 1/13/25 and the only description and measurement of the PI/PU was not until the incident report potential for actual harm on 1/16/25 that the WCP did; there was no conclusion for the investigation related to the cause of the PI/PU and an added intervention to prevent further PI/PU until 1/27/25; the recommended initial tx and subsequent Residents Affected - Few tx for Resident #102 from the WCP was not followed and an initial tx was not started until three days after the initial wound consult (WC) visit; and the order for Braden Scale was not followed.

On 3/3/25 at 10:20 AM, the survey team met with the LNHA, DON, ADON and MDS Coordinator for their responses to the concerns that they were notified of from the previous day.

At 10:41 AM, the ADON stated that there was no additional information for Resident #102.

A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol Policy, with a revised date of March 2014, included the following:

Assessment and Recognition

1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history or pressure ulcer(s).

2. In addition, the nurse shall describe and document/report the following:

a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue;

d. Current tx, including support surfaces: .

Cause Identification

1. The physician will help identify factors contributing or predisposing resident to skin breakdown; .

2. The physician will help clarify relevant medical issues; .

Tx/Management

1. The physician will authorize pertinent orders related to wound tx, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration

2. The physician will help identify medical interventions r/t wound management; .

Monitoring

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. Level of Harm - Minimal harm or potential for actual harm 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions Residents Affected - Few

A review of the facility's Accidents and Incidents-Investigating and Reporting Policy, with a revised date of July 2017, included the following:

Policy Statement

All accidents or incidents involving residents, employees, visitors, vendor, etc. occurring on our premises shall be investigated and reported to the administrator.

Policy Interpretation and Implementation

1. The nurse supervisor/charge nurse and/or the department director of supervisor shall promptly initiate and document investigation of the accident or incident.

2. The following data, as applicable, shall be included on the Report of Incident/Accident form:

a. The date and time the accident or incident took place;

b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); .

k. Any corrective action taken;

l. Follow-up information;

m. Other pertinent data as necessary or required; and .

46049

2. On 2/26/25 at 9:48 AM, Surveyor #2 (S#2) reviewed the electronic medical record (EMR) of Resident #302.

A review of the AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; left and right knee contracture (a fixed tightening of muscle, tendons, ligaments, or skin preventing normal movement of the associated body part), left and right hip contracture, left and right ankle contracture, muscle wasting atrophy (loss of muscle mass and strength), osteoporosis (condition in which bones become weak and brittle), dysphagia (difficulty swallowing foods or liquids), malnutrition, failure to thrive, and Alzheimer's disease.

A review of the cMDS, with an assessment reference date of 6/14/24, reflected a BIMS score of 99, which indicated the resident was unable to complete the interview. Under Section M (Skin Conditions), the resident was coded as a risk for pressure ulcer/injury and the resident had an unhealed unstageable PU.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 A review of PO included the following:

Level of Harm - Minimal harm or A PO dated 6/7/24, indicated Braden scale on admission times three weeks post admission every evening potential for actual harm shift, every Friday for three weeks.

Residents Affected - Few Wound tx #1: A PO dated 6/7/24, indicated apply silver sulfadiazine cream (an antibiotic cream used to treat or prevent serious skin infections) 1% to sacral area topically every day and evening shift for wound care

after cleansing with normal saline (NS) then cover with dry dressing. The order had a start date of 6/8/24, and was discontinued (d/c) on 6/17/24.

Wound tx #2: A PO dated 6/17/24, indicated apply santyl ointment 250 Unit/gm (grams) (an ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas) to sacrum topically every day shift for PU post cleanse with NS cover with dry dressing. The order had a start date of 6/18/24, and a d/c date of 7/1/24.

Wound tx #3: A PO dated 6/24/24, indicated to apply compound ointment- (flagyl) metronidazole (an antibiotic) ointment 0.5% with (Bactroban) muciporin (cream used to treat skin infections) 1% (1:1) (100 gm) every day shift for PU post cleanse with Dakin's solution, cover with dry dressing. The order had a start date of 6/25/24, and was d/c on 7/23/24.

Wound tx #4: A PO dated 7/1/24, indicated to apply Mupirocin Ointment (Bactroban) 2% to sacral area topically every day and evening shift for PU post hygiene, cleanse with Dakin's (mix with santyl). The order had a start date of 7/2/24, and was d/c on 7/8/24.

Wound tx #5: A PO dated 7/1/24, indicated to apply santyl ointment 250 unit/gm to sacrum topically every day shift for PU post cleanse with Dakin's cover with dry dressing (Santyl mix with Bactroban [mupirocin]).

The order had a start date of 7/2/24, and was d/c on 7/8/24.

Wound tx #6: A PO dated 7/8/24, indicated to apply Mupirocin Ointment 2% to sacrum topically every day and evening shift for P4 [PU stage 4] post cleanse with Dakin's, pack lightly with calcium alginate cover with dry dressing. The order had a start date of 7/9/24, and was d/c on 7/12/24.

Wound tx #7: A PO dated 7/8/24, indicated to apply to sacrum compound ointment -metronidazole ointment 0.5% with muciporin 1% (200 gm) every day shift for P4 post cleanse with Dakin's, pack lightly with calcium alginate cover with dry dressing. The order had a start date of 7/10/24, and a d/c date of 7/31/24.

Wound tx #8: A PO dated 7/23/24, indicated to apply to sacrum compound ointment-metronidazole ointment 0.1% with gentamycin 1% (100 gm) every day shift for P4[PU stage 4] post cleanse with Dakin's. pack lightly with calcium alginate cover with dry dressing. The order had a start date of 7/29/24, and was d/c on 7/31/24.

A review of WCN revealed the following:

On 6/3/24, the WCP recommended wound orders for the resident's sacral PU to apply Silvadene two times a day and as needed (PRN) with hygiene. Miconazole (antifungal) cream to peri (around) wound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 6/13/24, the WCP recommended wound orders for the resident's sacral PU to cleanse with NS, apply santyl and 3 in 1 cream to peri-wound daily. Level of Harm - Minimal harm or potential for actual harm On 6/18/24, the WCP recommended wound orders for the resident's sacral PU to cleanse with NS, apply santyl and 3 in 1 cream to peri-wound daily. Residents Affected - Few

On 6/24/24, the WCP recommended wound orders for the resident's sacral PU to d/c santyl and 3 in 1 cream; to cleanse with dakin's solution, apply flagyl, and Bactroban daily.

On 6/27/24, the WCP recommended wound orders for the resident's sacral PU as, cleansing with Dakin's solution, apply flagyl, Bactroban, and cover with dry dressing daily and PRN.

On 7/1/24, the WCP recommended wound orders for the resident's sacral PU to d/c flagyl; cleanse with dakin's, apply santyl, Bactroban, and apply dry dressing daily and PRN.

On 7/4/24, the WCP recommended wound orders for the resident's sacral PU to cleanse with dakin's solution, apply santyl, Bactroban, and apply dry dressing daily and PRN.

On 7/11/24, the WCP listed the resident's recommended wound orders as cleanse with Dakin's solution, pack with flagyl ointment, calcium alginate, Bactroban and cover with dry dressing daily and PRN.

On 7/15/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with flagyl ointment, calcium alginate, Bactroban and cover with dry dressing daily and PRN.

On 7/18/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with flagyl ointment, calcium alginate, Bactroban and cover with dry dressing daily and PRN.

On 7/22/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with calcium alginate, flagyl ointment, gentamycin cream and foam dressing daily. Additionally, 3 in 1 cream to peri (around) wound.

On 7/22/24, the WCP listed the resident's wound orders to d/c calcium alginate; cleanse with Dakin's solution, pack with gauze, flagyl ointment, gentamycin cream and foam dressing daily. Additionally, 3 in 1 cream to peri (around) wound.

On 7/25/24, the WCP listed the resident's wound orders as cleanse with Dakin's solution, pack with calcium alginate, flagyl ointment, gentamycin cream and foam dressing daily. Additionally, 3 in 1 cream to peri (around) wound.

A review of the June 2024 eTAR revealed:

The order entries for wound tx #2 and #3 were both signed as administered for the resident's sacral wound from 6/26/24 to 6/30/24.

A review of the July 2024 eTAR and the electronic Medication Administration Record (eMAR) revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 The order entries for wound tx #3, #4, and #5 were signed as administered for the resident's sacral wound from 7/2/24 to 7/8/24. Level of Harm - Minimal harm or potential for actual harm The order entries for wound tx #3, and #6 were signed as administered for the resident's sacral wound from 7/9/24 to 7/12/24. Residents Affected - Few

The order entries for wound tx #3, and #7 were signed as administered for the resident's sacral wound from 7/10/24 to 7/23/24.

The order entries for wound tx #7 and #8 were signed as administered for the resident's sacral wound from 7/29/24 to 7/31/24.

On 2/26/25 at 12:24 PM, S#2 interviewed the IP. The IP stated that the resident had one sacral wound which was present upon admission to the facility. The resident was seen by the wound consultants who recommended wound tx for the resident. The IP stated that there was wound tracking documentation for each resident that kept weekly track of their wound status and tx recommendations. The IP stated she would provide the wound tracking for the resident.

On 2/27/25 at 11:40 AM, S#2 interviewed the DON and the ADON about Resident #302's wound. The ADON and DON stated the resident had one sacral pressure ulcer and had also received tx for moisture associated skin damage. The DON provided the wound tracking form, a facility tool used to keep track of the resident's wound progress and wound tx. The wound tx corresponded to the WCP notes. S#2 reviewed with the DON and ADON the eMAR and eTAR of Resident #302 about the multiple wound tx that were signed as administered to the resident's sacral wound. S#2 asked if the multiple wound tx signed were ordered to be administered together. The DON and ADON stated that an ordered topical tx may have been unavailable at

the time, and another order was placed until the topical tx was available. The DON stated that if there was a temporary order until an original tx was available, the nurses should clarify the orders with the physician, d/c

the original tx order while the alternative tx was ordered. The DON and ADON acknowledged it would be expected if there were multiple tx orders which did not specify to use in combination, the nurses should have called the physician to clarify the orders. The DON and ADON stated they would review further to provide any additional response.

On 2/27/25 at 12:16 PM, S#2 notified the LNHA, the DON, and the ADON of the above concerns.

On 3/3/25 at 9:46 AM, S#2 interviewed LPN #2 who stated Braden scale assessments were completely weekly x 3 after the resident's admission per admission protocol. LPN#2 stated it would be found documented under the forms section of the EMR when completed.

A review of the June 2024 eTAR indicated a Braden scale assessment was to be completed on 6/14/24, 6/21/24, and 6/28/24. The eTAR entries for 6/14/24 and 6/21/24 were signed as completed by the nurses.

The 6/28/24 entry was left blank by the nurse.

A review of the EMR for Braden scale assessments revealed there were no Braden scale assessments found completed for 6/14/24, 6/21/24 and 6/28/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 On 3/3/25 at 10:00 AM, S#2 interviewed the DON about Braden scale assessments upon admission. The DON stated it was done as part of the facility's admission protocol and when completed could be found Level of Harm - Minimal harm or documented with the skin assessment of the resident. S#2 notified the DON of the concern that no Braden potential for actual harm scale evaluation was found for Resident #302 for the 3 weeks after admission as per the PO and the facility's protocol. The DON stated she would review to provide documentation of the Braden scale evaluations Residents Affected - Few completion.

On 3/3/25 at 10:20 AM, the DON, ADON, and LNHA met with the survey team. The DON and ADON stated

they had no additional information to provide for the concerns r/t Resident #302.

A review of the facility's Medication and Treatment Orders Policy, revealed under Policy Statement, Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Policy Section:

A review of the facility's Pressure Injury Risk Assessment Policy, revealed under General Guidelines revealed: .

4. Use only a facility-approved risk assessment tool to obtain risk assessment data .

7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Orders for medications and treatments will be consistent with principles of safe and effective order writing .

NJAC 8:39-27.1 (a)(e)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46049 safety Complaint # NJ: #166361; #173486 Residents Affected - Few Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to adequately assess a cognitively impaired resident, with a history of elopement as an elopement risk, and implement interventions to prevent the resident from exiting a secured unit, subsequently the facility, which resulted in the resident eloping on 7/29/23. This deficient practice was identified for 1 of 1 resident reviewed for elopement (Resident #123).

On 7/29/23, Resident #123 who was cognitively impaired and ambulated independently with a history of elopement, eloped from the facility and was last seen by staff at 5:30 PM, in the television (TV) room. At 6:00 PM, the Registered Nurse (RN #1) could not locate the resident, and a code gray was called, and the facility began to search for the resident. The local police department and the police department from the adjacent town were called. The police from the adjacent town went to the resident's last known home address to conduct a wellness check and located the resident approximately four miles away from the facility. The resident was returned to the facility on [DATE REDACTED] at approximately 9:40 PM, and was assessed with back pain.

The facility's failure to provide adequate supervision to a cognitively impaired resident with a history of elopement who was able to exit the facility unsupervised posed a likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation which ran from 7/29/23 at 5:30 PM, when Resident #123 was last seen by staff, until 7/29/23 at 9:40 PM, when the police located Resident #123 and returned the resident to the facility. The IJ was Past Non-Compliance (PNC).

The IJ was identified from 7/29/23 at 5:30 PM, to 7/29/23 at 9:40 PM, when the resident was found by the police and returned to the facility. The facility's administration was notified of the IJ on 2/26/25 at 3:30 PM.

The facility submitted an acceptable Removal Plan (RP) on 2/27/25 at 9:42 AM.

The facility was back in compliance when the facility addressed the situation by immediately searching and locating the resident; completed a full body assessment of the resident; a wanderguard alarm (personal alarm that triggers at exits to alert staff) was applied to the resident; the resident was re-assessed for an elopement risk; the facility reviewed the event with clinical leadership to identify areas for improvement and initiated immediate corrective actions and performance improvement; the resident's individualized comprehensive care plan (ICCP) was updated; and all staff were in-serviced on the facility's elopement protocol. The survey team verified the completion of the RP was 7/31/23, during an on-site survey on 3/6/25, and determined the IJ was PNC.

This deficient practice was evidenced by the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of a facility's Wandering and Elopements policy with a last revised date of March 2019, included Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent Level of Harm - Immediate harm while maintaining the least restrictive environment for residents. Policy Interpretation and jeopardy to resident health or Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's safety [care plan] will include strategies and interventions to maintain the resident's safety .

Residents Affected - Few A review of the facility's Admission Assessment and Follow Up: Role of the Nurse policy with a last revised date of September 2012, included Purpose: .to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating

the [care plan], and completing required assessment instruments .Steps in the Procedure: 10. Conduct an admission assessment (history and physical), including .a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission. b. Relevant medical, social, and family history. c. A list of active medical diagnoses and patient problems .

On 2/25/25 at 8:43 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #123.

A review of the Admission Record face sheet (an admission summary) reflected that the resident had diagnoses that included but were not limited to; unspecified dementia, low back pain, and chronic pain related to neoplasm (abnormal growth of tissue).

A review of the comprehensive Minimum Data Set (MDS), an assessment tool dated 7/21/23, reflected a Brief Interview Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. Additionally, the resident was documented as needing supervision (oversight, encouragement or cueing) with activities of daily living (ADLs) which included walking and did not require an assistive device.

A review of hospital medical records dated 7/10/23, indicated the resident had a history of elopement and had required staff supervision while under their care.

A review of the resident's admission elopement risk assessment (ERA), a questionnaire completed by the nurse to determine if the resident needed additional safety measures dated 7/14/23, determined that based

on the potential risk factors, Resident #123 was not at risk for elopement. The Licensed Practical Nurse (LPN #1), who completed the assessment, answered Yes to the resident being able to ambulate independently and had a history of elopement while at home or in another setting. LPN #1 answered No on the assessment for the resident being cognitively impaired or having a diagnosis such as dementia. (The resident was both cognitively impaired with a diagnosis of dementia on admission) A further review of the ERA revealed that

the initial assessment was edited by a user to change the resident's risk for elopement from at risk to not at risk for elopement. The surveyor was unable to see the audit history of the assessment at that time.

A review of the resident's ICCP included a focus area for cognitive loss due to dementia. The ICCP did not include a focus area initiated for the resident being at risk for elopement prior to the resident's actual elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the Nursing Progress Note (NPN) dated 7/29/23 at 9:53 PM, written by RN #1 revealed the following: Level of Harm - Immediate jeopardy to resident health or At 5:00 PM, RN #1 served the meal tray to the resident. safety At approximately 6:00 PM, RN #1 searched for Resident #123. The resident was not found on the unit and Residents Affected - Few the LPN/Nurse Supervisor (LPN/NS #1) was notified.

At approximately 7:00 PM, the police came to the unit and RN #1 provided information regarding the resident. The Resident's Representative (RR) and the Physician were made aware of the resident's elopement.

A review of the NPN dated 7/29/23 at 10:01 PM, written by the Assistant Director of Nursing (ADON), indicated that the resident was returned to the facility; a body check was completed; there were no visible injuries; and a wanderguard was applied to the resident. The ADON documented that the resident verbalized walking out the front door and the resident just started walking and had planned to come back after their walk.

A review of the NPN dated 7/29/23 at 10:16 PM, written by RN #1, revealed that the RN was notified by LPN/NS #1 that the resident was found by police at their last known home address. At approximately 9:30 PM, the resident returned to the facility. A body assessment was completed with no bruises or injuries noted, and the resident requested pain medication. The RN provided medication and a wanderguard was placed on

the resident and functioning.

A review of the facility's undated investigation revealed the following:

Under the background section:

The resident had a diagnosis of unspecified dementia, ambulated independently, and did not verbalize wanting to leave facility. The resident's BIMS was documented as 10 (moderately impaired cognition), which did not match with the comprehensive assessment completed by the facility prior to the elopement incident.

Under the timeline for the event on 7/29/23, was the following:

At 3:00 PM, the resident was seen by RN #1 during shift change in their room.

At 5:00 PM, RN #1 delivered the resident's dinner tray and Resident #123 was sitting on their bed.

At 5:30 PM, the resident was seen in the TV room by two nurses at the time.

At 6:00 PM, LPN #2 went to check on Resident #123 in their room and noticed the resident was not there and had not touched their tray.

At 6:30 PM, LPN/NS #1 was made aware and staff continued to search for the resident.

At 6:45 PM, a code gray was initiated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 At 7:15 PM, the RR and the primary Physician were notified of the resident's elopement.

Level of Harm - Immediate At 7:38 PM, the local police department were called. jeopardy to resident health or safety At 7:45 PM, the local police came and interviewed staff.

Residents Affected - Few At 7:50 PM, LPN/NS #1 called the police department in the adjacent town where the resident last resided to request a wellness check at the home.

At 8:45 PM, LPN/NS #1 was made aware by the local police department to prepare for a canine (K-9; police dog) search to be conducted at the facility.

At 8:55 PM, the police department in the town where the resident last resided called LPN/NS #1 and informed her that Resident #123 was found at that location.

At 9:00 PM, the facility informed the local police department that the resident was found during a wellness check by the adjacent town's police department.

At 9:05 PM, the ADON requested from the local police department for the resident to be transported back to

the facility.

At 9:40 PM, Resident #123 was back in the facility. A body check was performed with no visible injuries. A wanderguard was applied to the resident. The staff interviewed the resident, who verbalized walking out the front door, and continued to walk until they reached their apartment. The resident stated to staff that they planned to come back to the facility after their walk.

Under Intervention, the following were included:

A wanderguard was applied to the resident's right ankle; an elopement assessment was done; a full body assessment was done upon the resident's return; and the resident complained of back pain and medication was administered.

Under Conclusion of the Investigation, it documented a summary of the event. The conclusion did not include how the resident exited the facility.

On 2/25/25 at 10:57 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM #1) about the resident's elopement. LPN/UM #1 stated that she did not work the day the resident eloped and she could not speak to

the actual event. LPN/UM #1 recalled that at the time, the resident was not considered an elopement risk and that staff received in-service education after the elopement event. LPN/UM #1 stated at the time of the incident, the third floor only had a wanderguard alarm system for the elevator which locked the elevator if a resident with a wanderguard alarm went to it. LPN/UM #1 further explained the electromagnetic lock on the double doors of the unit were not there at the time of the elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 2/25/25 at 11:40 AM, the surveyor interviewed RN #1, who recalled not being able to find the resident; searched for the resident; and notified LPN/NS #1. RN #1 stated LPN/NS #1 informed the Director of Nursing Level of Harm - Immediate (DON) and the ADON; the police were called; and the resident was later found at their last known address. jeopardy to resident health or RN #1 further explained a body assessment was performed when the resident returned to the facility and the safety Physician was called. RN #1 could not recall if it was determined how the resident exited the facility. RN #1 recalled after the resident's elopement, education was provided by the Nurse Educator to staff. Residents Affected - Few

On 2/25/25 at 11:52 AM, the surveyor interviewed LPN/NS #1, who recalled RN #1 informed her that the resident could not be found; a code gray was initiated; the resident was not found in the facility; and the local police, DON, and Licensed Nursing Home Administrator (LNHA) were called. LPN/NS #1 further explained that the local police department searched for the resident. LPN/NS #1 stated she also called the police department in the town of the resident's last known address, and the resident was found during the wellness check at that address. The resident was returned to the facility; a head-to-toe assessment was completed; and a wanderguard was applied to the resident. LPN/NS #1 stated the RR and the Physician were made aware of the resident being located. LPN/NS #1 could not speak to Resident #123's risk for elopement as

she was unfamiliar with the resident at the time of the incident. LPN/NS #1 stated that camera footage was reviewed at the time of the incident by the facility, but she could not recall if it was determined how the resident exited the facility.

The surveyor asked LPN/NS #1 about completion of the ERA for residents, and LPN/NS #1 stated the ERA were completed upon admission and at least quarterly. LPN/NS #1 stated based on the entries answered on

the assessment, a result of whether the resident was at risk for elopement or not was automatically triggered. LPN/NS #1 stated that if the resident was triggered to be at risk for elopement, then an ICCP was initiated.

On 2/25/25 at 12:20 PM, the surveyor interviewed the Director of Maintenance (DM), who confirmed that if camera footage needed to be reviewed, he was asked to help pull the footage for review. The DM recalled when the resident had an elopement incident, but he could not recall how the resident exited the facility. The DM stated at the time of the incident, there were not as many cameras in the facility as they had now. The DM could not say how long camera footage was stored for at the facility.

On 2/25/25 at 12:28 PM, the surveyor interviewed the ADON about Resident #123's elopement and ERA.

The ADON stated at the time of the incident, she was notified by staff that the resident could not be located.

The ADON stated she arrived at the facility around the same time the resident had been returned to the facility. The ADON stated at the time of the incident, there were only cameras in the stairs at the first floor and the front lobby. The ADON recalled reviewing camera footage with other staff, and that it could not be determined how the resident exited the facility since the resident was not seen on the cameras. The ADON stated that after the incident, an ERA was completed; a wanderguard was applied to the resident; and the electromagnetic lock and keypad door was added to the unit. The ADON stated prior to incident, there was only a wanderguard alarm system for the elevator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 At that same time, the surveyor asked the ADON about how elopement risk was determined for a resident.

The ADON replied that upon admission, the resident's medical records from the sending facility and medical Level of Harm - Immediate history were reviewed to identify the resident's risk factors and the facility's ERA was completed by the jeopardy to resident health or nurse. The ADON stated the nurse answered the questions on the ERA and it automatically triggered safety whether the resident was at risk for elopement. The ADON confirmed it was expected that the nurses followed up if a resident triggered as a risk for elopement and an ICCP was initiated with appropriate Residents Affected - Few interventions and updated as needed.

On 2/25/25 at 1:26 PM, the surveyor interviewed LPN #1 over the phone about the ERA completion. LPN #1 stated the ERA was completed as part of a resident's admission assessment and at least quarterly. LPN #1 stated that the nurse answered the questions on the ERA based on the resident's history which included a

review of their medical records from the sending facility. LPN #1 further explained that the results of whether

the resident was at risk for elopement was automatically triggered on the assessment. LPN #1 stated that an assessment could be edited by the person completing it and she was not sure if another person could edit

the assessment. The surveyor asked LPN #1 about the elopement risk assessment for Resident #123 which was completed on 7/14/23, and LPN #1 replied that she could not recall the details about completing or editing the assessment.

On 2/25/25 at 1:46 PM, the surveyor interviewed the DON and the ADON about the facility's protocol and Resident #123's elopement incident. The DON stated that residents were assessed for elopement risk factors such as verbalizing desire to leave, demonstrating exit seeking behavior, having a history of elopement, and if they were cognitively impaired. An ERA was completed by the nurse. If the resident was triggered as a risk for elopement, appropriate interventions such as, a photo of the resident was placed at the receptionist's desk; a wanderguard was applied to the resident; and initiation and update of an ICCP was implemented. The DON further stated that the hospital medical records and the resident's overall history were reviewed upon admission to the facility to identify if the resident was a risk for elopement.

On that same date and time, the DON and ADON confirmed that the third-floor nursing unit at the time of elopement was considered a secure unit even though it was not a locked unit. The surveyor asked what a secured unit meant, and the DON and the ADON replied that the residents were supervised and could not leave the unit unattended.

Furthermore, the ADON and the DON stated an investigation of an incident was conducted in coordination between nursing management and the LNHA. Individual statements were collected for the incident, and an interdisciplinary team (IDT) met to complete a root cause analysis as part of the conclusion and investigation findings. The DON and ADON stated that the facility could not determine the resident's exit point from the facility after reviewing cameras and interviewing staff. The DON and the ADON stated that they reviewed the camera footage for the front lobby, back exit door, and 1st floor stairway, which were the only cameras in the facility at that time, and the resident was not seen on any of the cameras at the time of the incident. The DON and the ADON could not speak to how long camera footage was stored at the facility and would find out if the camera footage was still available to review.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 At that same time, the surveyor asked the ADON and the DON if an ERA could be edited. The DON stated that only the nurse completing the assessment could edit the assessment. The surveyor with the DON and Level of Harm - Immediate the ADON reviewed the ERA for Resident #123 completed on 7/14/23. The DON and the ADON jeopardy to resident health or acknowledged that the assessment did not document that the resident had a diagnosis of dementia, and it safety should have been based on the resident's medical history. The DON and ADON also acknowledged that the resident was documented as having a history of elopement and ambulated independently which were risk Residents Affected - Few factors for elopement. The DON and the ADON could not speak to why it was noted that the assessment results had an edited response and would provide an audit history for the assessment. The DON and the ADON acknowledged that it was expected that the nurses completed the assessments accurately and if an elopement risk was triggered for the nurse to initiate an ICCP and the appropriate interventions for the resident.

The surveyor reviewed with the DON and the ADON the hospital medical records for Resident #123. The ADON and the DON confirmed that the resident was considered an elopement risk at the time of admission since the resident had a history of elopement and a diagnosis of dementia.

On 2/25/25 at 2:50 PM, the DON informed the surveyor that the camera footage was no longer available as it could not go back that far. The DON provided an audit history report for the ERA completed on 7/14/23.

A review of the audit history report revealed that on 7/14/23 at 11:52 PM, the assessment results for the resident were at risk for elopement (implement plan of care for unsafe wandering/exit seeking behavior). On 7/14/23 at 11:58 PM, LPN #1 edited the entry to reflect that the resident was not at risk for elopement at this time.

On 2/25/25 at 3:02 PM, the surveyor met with the LNHA, DON, ADON, and LPN/UM #1. The LNHA was not

the administrator at the time of the incident and could not speak to the specifics of the event. The DON and ADON reiterated that prior to the incident, there was only a wanderguard alarm on the elevator and that residents were required to be accompanied by staff if they left the third floor. The facility expressed interventions were put into place after the event to ensure that it would not recur.

The acceptable Removal Plan on 2/27/25 at 9:42 AM, indicated the action the facility took to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: the staff initiated the elopement protocol and contacted the police to search for the resident; Resident #123 was located, returned to the facility, and a full body assessment was completed; a wanderguard was applied to the resident; Resident #123's ICCP was updated to include a risk for elopement with interventions that included wanderguard placement and 30 minute monitoring; an ERA was completed;

the facility reviewed the event with clinical leadership to identify areas for improvement and initiated immediate corrective actions and performance improvement; an electromagnetic lock was applied to the double doors on the third-floor unit; and staff were educated on the facility's elopement protocol including awareness of elopement risk factors, evaluation of elopement risk, interventions to prevent elopement, and elopement response. The facility self-corrected the deficient practice and it was determined that the IJ was Past Non-Compliance (PNC); that the facility corrected their non-compliance on 7/31/23.

The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 3/6/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 NJAC 8:39-27.1(a)

Level of Harm - Immediate jeopardy to resident health or safety

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or 48781 potential for actual harm Based on interview and record review, it was determined that the facility failed to provide care and services Residents Affected - Few in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times. This deficient practice was identified for 1 of 2 residents, (Resident #22), reviewed for dialysis services and was evidenced by the following:

On 2/24/25 at 11:00 AM, the surveyor observed the Resident #22 lying in bed, who stated, I have dialysis on Tuesday, Thursday, and Saturday. I get picked up around 11:00 AM and I get back around 5:00 PM.

A review of the Admission Record (an admission summary) revealed diagnoses which included but not limited to end stage renal disease (ESRD-kidneys have permanently lost their ability to function adequately) and dependence on renal dialysis (procedure which removes wastes and excess fluid from the blood).

A review of the resident's medications (meds) order summary revealed:

-Hemodialysis Tuesday - Thursday - Saturday, chair time: 11:55 AM.

-Humalog Injection Solution 100 unit/ML (milliliters) inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units call MD (medical doctor) if greater than 400 mg/dl (milligrams/deciliter), subcutaneously before meals and at bedtime for diabetes mellitus-Start Date 1/30/2025-discontinue (d/c) date 2/11/25.

-Humalog Injection Solution 100 unit/ml inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units call MD if greater than 400 mg/dl, subcutaneously before meals for diabetes mellitus-Start Date 2/11/2025-d/c date 2/17/25.

-Velphoro oral tablet (tab) chewable 500 mg give 1 tab by mouth three times a day for supplement (phosphorus binder), give with meals. Start date 2/3/25 and d/c 2/20/25.

- Velphoro oral tab chewable 500 mg give 1 tab by mouth three times a day for supplement, give with meals. Chew or crushed, do not swallow whole. Start date 2/20/25.

-Midodrine HCl tab 2.5 MG, give 1 tab by mouth every 8 hours for hypotension. Do not administer after the evening meal or 4 hours from bedtime to avoid supine hypertension (HTN). Please hold if systolic blood pressure (SBP) greater than 130 mm/hg (milliliters per mercury)-Start Date 1/30/25 and d/c date 2/11/25.

-Midodrine HCl Tab 2.5 mg, give 1 tab by mouth three times a day for hypotension. Do not administer after

the evening meal or 4 hours from bedtime to avoid supine HTN. Please hold if SBP greater than 130-Start Date 2/11/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference dated of 2/6/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12 Level of Harm - Minimal harm or out of 15, indicating that the resident had a moderately impaired cognition. potential for actual harm

A review of the electronic Medication Administration Record (eMAR) revealed, Midodrine was scheduled on Residents Affected - Few dialysis days to be given at 12 Noon, Velphoro was scheduled on dialysis days to be given at 11:30 AM. The blood sugar check and Humalog Insulin as per sliding scale was scheduled at 12 Noon on dialysis days for

the months of January and February 2025.

The nursing progress notes on some dialysis days revealed, nurses documented for meds to be on hold, patient is out for hemodialysis.

Humalog Injection 100 Unit/ML as per sliding scale was timed for 12:00 PM, revealed on 2/13/25, out for dialysis.

Midodrine was not given on 2/6/25, 2/8/25, 2/13/25, and 2/27/25.

Velphoro was not given on 2/27/25 and 3/4/25.

A review of the License Practical Nurse's #1 (LPN#1), Orders Administration Note in the Electronic Health

Record (EHR) dated 2/13/25, revealed, Humalog Injection Solution as per sliding scale and Midodrine HCl Tablet 2.5 mg as Hold med Patient is out for dialysis.

A review of the Registered Nurse's (RN) Orders Administration Note in the EHR dated 2/27/25 revealed, Velphoro Oral Tab Chewable 500 mg, patient out to hemodialysis (HD).

On 3/4/25 at 9:16 AM, the surveyor observed the Resident #22 lying in bed, and stated, I get pick up for dialysis around 11 AM. I do not get the Midodrine at noon time because I'm in dialysis and Velsporo sometimes I take it but at times I miss some. I do not get blood sugar done anymore.

On 3/4/25 at 9:22 AM, the surveyor interviewed LPN #2 and the Unit Manger (UM) on the 2nd floor. The surveyor reviewed the eMAR with the LPN #2 and UM for February 2025. LPN #2 stated, I do the blood sugar and blood pressure, give meds before the resident leaves for dialysis. The UM stated, The Midodrine and Velphoro should have been adjusted during dialysis days that's our process. Nursing can adjust the times; anyone can do it. LPN#2 and UM both confirmed that the meds should have been adjusted on dialysis days.

On 3/4/25 at 11:40 AM, the surveyor notified the License Nursing Home Administrator (LNHA), Director of Nursing (DON) and Assistant (DON), regarding the meds time of Midodrine, Velphoro, and Humalog Insulin/Blood Sugar not adjusted on dialysis days.

A review of the facility's Administering Medications Policy, revealed, Meds are administered in accordance with prescriber orders, including any required time frame.

NJAC 8:39-11.2(b), 27.1(a), 29.2(d)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Level of Harm - Minimal harm or potential for actual harm 38327

Residents Affected - Few Based on interviews and review of other facility documentation, the facility failed to ensure that the physician must review the resident's total program of care and date progress notes at each visit. This deficient practice was identified for 1 of 35 residents, (Resident #63), reviewed for physician services.

This deficient practice was evidenced by the following:

On 2/24/25 at 10:59 AM, the surveyor observed Resident #63 was seated in a wheelchair in front of their room, repeatedly stated, why, I am here, come here.

The surveyor reviewed Resident #63's medical records and revealed:

A review of the Admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a substance or known physiological condition, and repeated falls.

A review of the most recent comprehensive Minimum Data Set (MDS, with an assessment reference date of 1/10/25, reflected a brief interview for mental status (BIMS) score of 5 out of 15, that the resident's cognition was severely impaired.

A review of the electronic medical records revealed that there was no documented evidence that the physician review the resident's care, medications, and date progress notes (PN) at each visit.

On 2/26/25 at 10:59 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) regarding the physician's visits and notes. The RN/UM stated that the surveyor should ask the Director of Nursing (DON) about physician visits and about how often the physician should document and visit the resident.

At that same time, the RN/UM confirmed after reviewing with the surveyor the resident's paper and electronic medical records, that she did not find the physician's visit notes. She further stated that the last time the physician documented in the PN was in paper medical record dated 2/6/24.

On 2/26/25 at 11:30 AM, the surveyor notified the DON of the above concerns with physician services.

On 3/4/25 at 10:15 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant DON (ADON), and the LNHA confirmed that the surveyor's concern about physician's timely monthly visits was not discussed in the most recent QAPI (Quality Assurance Performance Improvement) meeting, and the team decided to include it in the next planned meeting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for exit conference, and there was no additional information provided by the LNHA. Level of Harm - Minimal harm or potential for actual harm NJAC 8:39-11.2(1); 23.2(b)

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38327

Residents Affected - Few COMPLAINT #NJ175735

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to provide or obtain routine medications in order to meet the needs of each resident for 3 of 35 residents reviewed (Residents #5, #32, and #352).

This deficient practice was evidenced by the following:

1. On 2/26/25 at 7:57 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) prepared and administered medications (meds) of Resident #5 (from the 2nd floor unit). LPN#1 informed the surveyor that there was no available Florastor (used as a probiotic, or friendly bacteria, to prevent the growth of harmful bacteria in the stomach and intestines) 250 mg (milligrams) in the medicine (med) cart. LPN#1 stated that

she would check later in the back up machine for Florastor.

LPN#1 did two residents for med pass observation. The surveyor did not observed LPN#1 went to get the Florastor or notified the physician of unavailable med.

The surveyor reviewed the medical records for Resident #5.

A review of the Admission Record (AR, an admission summary) reflected that Resident #5 was admitted to

the facility with the diagnoses which included but not limited to other sequelae of cerebral infarction (ischemic stroke) and ulcerative colitis (is a chronic condition characterized by an abnormal immune response where

the immune system attacks the cells in the digestive tract. This leads to inflammation and ulcers in the lining of the large intestine and rectum), unspecified, without complications.

A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 1/8/25, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated severely impaired cognition.

A review of the electronic Medication Administration Record (eMAR) revealed that the resident had a physician's order (PO) with a start date of 4/21/22 for Florastor capsule (cap) 250 mg give one cap by mouth two times a day for GI (gastrointestinal) stabilizer.

The above order for Florastor was transcribed to the February 2025 eMAR, to be administered at 9:00 AM and 5:00 PM.

A review of the Order Audit Report revealed that the Florastor 250 mg cap was reordered by LPN#2 on 1/21/25 and the med was exhausted on 1/22/25.

On 2/26/25 at 10:51 AM, the surveyor observed LPN#1 on the 1st floor. The surveyor asked if she was able to administer the Florastor to Resident#5, and she responded that she was about to go and get it from the backup machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 In the back up room, a contracted Staff from the backup company informed LPN#1 that it would be 15-20 minutes more before the LPN could use the machine. The surveyor asked LPN#1 if she notified the Level of Harm - Minimal harm or physician about the med, and she responded that she would call the physician later if she was unable to potential for actual harm administer or get the med. LPN#1 further stated that she would call and follow up with pharmacy.

Residents Affected - Few A review of the medical records revealed that there was no documented evidence that Resident #5's physician was notified that the Florastor was unavailable.

On 3/3/25 at 10:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant DON (ADON), and the surveyor notified them of the concern with med pass

observation and unavailable med of Resident #5.

A review of the provided packing list of the ADON on 3/4/25 at 10:12 AM, for shipping dates of 12/13/24 and 12/18/24, revealed that the facility did not have a backup med for Florastor.

2. On 2/24/25 at 11:06 AM, the surveyor observed Resident #32 seated in a wheelchair in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide, who informed the surveyor that the resident will be going down for lunch.

The surveyor reviewed the medical records for Resident #32.

A review of the AR reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, generalized anxiety disorder, bipolar disorder (a mental health condition characterized by significant mood swings) unspecified, and major depressive disorder, single episode, unspecified.

A review of the most recent comprehensive MDS, with an ARD of 12/23/24, indicated that the resident had a BIMS score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive meds.

A review of the eMAR revealed that the resident was on the following psychotropic meds:

A PO dated 3/21/24, and was discontinued (d/c) on 2/18/25, for Risperidone 1 mg give 3 tablets (tabs) by mouth two times a day for bipolar disorder, 3 tabs=3 mg.

A PO dated 2/18/25, Risperidone 1 mg give 1 tablet (tab) by mouth at HS (bedtime) for bipolar disorder to be given with 4 mg to equal a total of 5 mg.

Further review of the above orders for Risperidone revealed that it was transcribed to the February 2025 eMAR, and from 2/18/25 through 2/22/25, the eMAR was not signed by nurses as administered, and was left blank. The Risperidone order was signed not until 2/23/25. The Risperidone was not administered for total of five days.

A review of the medical records revealed that there was no documented evidence as to why the Risperidone was not administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Further review of the Order Audit Report revealed:

Level of Harm - Minimal harm or Risperidone 1 mg tab was on hand (available) and dispensed on 2/23/25. potential for actual harm Risperidone 4 mg tab was on hand and dispensed on 2/23/25. Residents Affected - Few

On 2/27/25 at 12:16 PM, the survey team met with the LNHA, DON, and ADON. The surveyor notified of the concern regarding Risperidone not signed from 2/18-2/22/25.

On 3/3/25 at 10:19 AM, the survey team met with the LNHA, DON, ADON, and the ADON stated we did staff education about missing meds and the physician of Resident #32 was notified about the Risperdal.

On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for exit conference, and there was no additional information provided by the LNHA.

48781

3. A review of Resident #352's electronic health records (EHR) revealed:

A review of the AR reflected that the resident was admitted to the facility with a diagnosis that included but not limited to Alzheimer's disease unspecified (a brain disorder that gradually destroys memory and thinking skills) and glaucoma (a condition where the eye ' s optic nerve, which provides information to the brain, is damaged with or without raised intraocular pressure).

A review of the MDS, with an ARD of 7/10/24, reflected a BIMS score of 2 out of 15 indicating severely impaired cognition.

A review of the eMAR revealed that the resident was on the following eyedrop meds:

A PO for Alphagan P Solution 0.1 % (Brimonidine Tartrate) Instill 1 drop in both eyes every 12 hours for glaucoma, ordered 7/7/24, d/c on 7/8/24.

A PO for Alphagan P Solution 0.1 % (Brimonidine Tartrate) Instill 1 drop in both eyes three times a day for glaucoma, start date 7/ 8/2024, d/c on 7/11/24.

Further review of the eMAR revealed that Resident #352 did not receive Alphagan P Solution eye drops from 7/7/24 to 7/10/24 (total of 4 days). The eMAR was coded as 9 indicating other/see nurses notes. The nursing progress note (PN) revealed that the Medical Doctor (MD) was notified that med was unavailable on 7/7/24, and no MD notification from 7/8/24 to 7/10/24.

A review of Registered Nurse #1's (RN#1) PN on 7/7/24, revealed a note text stating, Awaiting delivery from pharmacy MD aware.

A review of the RN#2's PN on 7/9/24, revealed a note text stating, Pending pharmacy delivery. RN#2's PN

on 7/10/24, revealed, Awaiting med from pharmacy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 2/25/25 at 10:25 AM, the 3rd floor Licensed Practical Nurse/Unit Manager (LPN/UM) stated, If a med is not available, we call the doctor and get an alternate, or we hold it, we also have a for back up [name of Level of Harm - Minimal harm or machine] meds. potential for actual harm

On 2/26/25 at 10:45 AM, the LPN/UM stated, If the Alphagan med was not given, that means the med was Residents Affected - Few not here. That is something that is not going to be in the backup machine. I do not recall about the eye drops why it was not given. There was no indication that the doctor or pharmacy was called.

On 2/26/25 at 11:08 AM, the surveyor interviewed RN #2, who confirmed that she indicated on the e[DATE REDACTED]

on 7/9/24 and 7/10/24, pending pharmacy delivery for the Alphagan P Solution eye drop. The surveyor asked what the process was when a med was not available and RN #2 stated, We notify the doctor and call the pharmacy if the med is not there. I do not know why I did not do that or document it. The LPN/UM and RN#2 confirmed that the process was not followed.

On 2/27/25 at 12:26 PM, the surveyor notified the concern regarding Alphagan eye drops not being administered with the LNHA, DON, and ADON.

A review of the facility's Administering Medication-Medication Unavailable Flow Chart Policy and Procedure revealed, Check med stock box; call pharmacy for Stat (immediate) delivery; notify supervisor and Medical Director; implement orders from physician; add a detailed entry to the medical record.

On 3/3/25 at 10:40 AM, the survey team met with the LNHA, DON, ADON, and the ADON stated, We were able to narrow down on who the staff were that were involved, and we educated them regarding what to do when med is not available.

NJAC 8:39-29.2(d); 29.6

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38327 potential for actual harm Based on observation, interview, review of the medical records and other facility documentation, it was Residents Affected - Few determined that the facility failed to provide adequate monitoring for the use of psychoactive medications (meds). This deficient practice was identified for 2 of 6 residents reviewed for psychoactive meds used (Residents #32 and #63), and was evidenced by the following:

1. On 2/24/25 at 11:06 AM, the surveyor observed Resident # 32 seated in a wheelchair (w/c) in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide #1 (RA#1), who informed the surveyor that the resident will be going down for lunch.

The surveyor reviewed the medical records for Resident #32.

A review of the Admission Record (AR, an admission summary) reflected that Resident #32 was admitted to

the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) without dyskinesia, without mention of fluctuations, other specified persistent mood disorders, generalized anxiety disorder, bipolar disorder (a mental health condition characterized by significant mood swings) unspecified, and major depressive disorder, single episode, unspecified.

A review of the most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 12/23/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive meds.

A review of the electronic Medication Administration Record (eMAR) revealed that the resident was on the following psychotropic meds:

A physician's order (PO) dated 3/21/24, and was discontinued (d/c) on 2/18/25, for Risperidone (antipsychotic medication) 1 mg (milligram) give 3 tablets (tabs) by mouth two times a day for Dx (diagnosis) bipolar disorder, 3 tabs=3 mg.

A PO dated 2/18/25, Risperidone 1 mg give 1 tablet (tab) by mouth at HS (bedtime) for Dx bipolar disorder to be given with 4 mg to equal a total of 5 mg.

A PO dated 3/19/24, Sertraline HCL (hydrochloride) Oral tab 100 mg give 1 tab by mouth one time a day for depression.

A PO dated 3/18/24, Mirtazapine Oral tab 155 mg give 1 tab by mouth at HS for depression.

A PO dated 4/26/24, Divalproex Sodium tab delayed release 500 mg give 3 tabs by mouth at HS for bipolar disorder, 3 tabs=1500 mg.

A PO dated 6/12/24 and d/c on 2/7/25, Behavior Tracking: very demanding at times, can be resistant to care, every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 A PO dated 2/20/25, Behavior Tracking: Sad affect every shift.

Level of Harm - Minimal harm or A Review of Resident #32's eMAR and the electronic Treatment Administration Record (eTAR) did not potential for actual harm include documentation that the facility was monitoring the resident's behavior for the use of psychotropic meds and target behavior was not identified for each identified psychotropic meds. Residents Affected - Few

A review of the individual comprehensive Care Plan (CP) which included the following focus area:

A focus area date initiated 10/18/24, that Resident #32 at risk for behavior symptoms (resist care/treatments) related to (r/t) mental illness. Interventions included: administer meds per PO, observe for mental status/behavioral changes when new medication (med) started or with changes in dosage, Psych (Psychiatrist) referral as needed (PRN), and consistent approaches when giving care.

A review of the medical records revealed that the Monthly Nursing Summary which included the evaluation for psychotropic meds were completed for dates 10/18/24, 12/16/24, and 1/28/25.

Further review of the Nursing Summary revealed that there were no monthly summaries done from April 2024 through September 2024, and November 2024. The 1/28/25 Monthly Nursing Summary did not include

the med Sertraline as part of psychoactive meds being reviewed and there was no documented mood and behavior identified to be reviewed.

A review of the medical records also revealed that the AIMS (Abnormal Involuntary Movement, a 12-item clinician-rated scale to assess severity of dyskinesias (specifically, orofacial movements and extremity and truncal movements) in residents taking antipsychotic meds) assessment were completed for dates 4/26/24 and 10/18/24.

A review of the 2/18/25 Psychiatric follow up consult revealed that the resident when asked when their last psychotic episode was, the resident stated that they did not recall ever hallucinating.

On 2/26/25 at 10:59 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding

the resident's psychoactive meds and behavior monitoring. The RN/UM stated that she was unsure if there should be a target behavior for each psychoactive meds. The RN/UM confirmed, after reviewing the medical records that the Monthly Nursing Summary were not done routinely as well as the AIMS. She further stated that the AIMS should be done quarterly according to MDS schedule that was being provided by the MDS Staff and the Monthly Nursing Summary with psychoactive summary should be done monthly, and it was the assigned nurse should be responsible for documenting them in the electronic medical records.

On 2/26/25 at 11:42 AM, the surveyor observed the resident seated in a w/c in the ground floor dining area, assisted by RA#2 in cutting their food.

Afterward, the surveyor interviewed RA#2, who informed the surveyor that the resident was cognitively intact, no unusual behavior, very sociable, loves bingo with friends, and very calm.

2. On 2/24/25 at 10:59 AM, the surveyor observed Resident # 63 was seated in a w/c in front of their room, repeatedly stated, why, I am here, come here.

The surveyor reviewed Resident #63's medical records and revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 A review of the AR reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, Level of Harm - Minimal harm or psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition potential for actual harm characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a substance or known physiological condition, and repeated falls. Residents Affected - Few

A review of the most recent cMDS, with an ARD of 1/10/25, revealed a BIMS score of 5 out of 15, reflected that the resident's cognition was severely impaired.

A review of the eMAR revealed that the resident was on the following psychotropic meds:

A PO dated 1/22/24, Depakote sprinkles oral capsule (cap) delayed release sprinkle 125 mg give one cap by mouth one time a day for mood disorder.

A PO dated 4/2/24, Alprazolam tab 0.25 mg give one tab by mouth at HS for anxiety.

A PO dated 10/03/24 and d/c on 2/21/25, Seroquel (Quetiapine Fumarate) Oral tab 25 mg give 0.5 tab (12.5 mg) by mouth one time a day for psychosis.

A PO dated 2/23/25 and d/c on 2/25/25, Seroquel Oral tab 25 mg give 0.5 tab (12.5 mg) by mouth one time a day for psychosis.

A PO dated 2/26/25, Quetiapine Fumarate tab 25 mg give one tab by mouth at HS for agitation.

A PO dated 2/21/25, Lorazepam oral tab 0.5 mg give one tab by mouth every 24 hours PRN for anxiety x 14 days.

A PO dated 3/21/24, Intrusive Wandering: going into other residents' room every shift.

A PO dated 3/19/24, Verbally abusive: yelling and cursing staff and other resident every shift.

A Review of Resident #63's eMAR and the eTAR did not include documentation that the facility was monitoring the resident's behavior for the use of psychotropic meds and target behavior was not identified for each identified psychotropic meds.

A review of the individual comprehensive CP which included the following focus areas:

A focus area date initiated 9/16/24, that Resident #63 was at risk for behavior symptoms r/t dementia: kneeling on bathroom floor I'm cleaning floor, pushing w/c while walking, continually saying where is [name], . in my nice house, and calling staff [derogatory word]. Interventions included: observe for mental status/behavioral changes when new med started or with changes in dosage, Psych referral as needed, redirected on how to push w/c, and use of consistent approaches when giving care.

A focus area date initiated 7/18/22, that Resident #63 was at risk for changes in mood r/t cognitive loss, self-reported feelings of depression. Interventions included: assess for physical/environmental changes that may precipitate changes in mood, observe for mental status/mood state changes when new med was started or with dose changes, and offer choices to enhance sense of control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 A review of the medical records revealed that the Monthly Nursing Summary which included the evaluation for use of psychotropic meds were completed for dates 2/12/24, 6/3/24, 7/11/24, 10/14/24, 11/6/24, and Level of Harm - Minimal harm or 12/5/24. potential for actual harm Further review of the Nursing Summary revealed that there were no monthly summaries done from March Residents Affected - Few 2024 to May 2024, from August 2024 to September 2024, and January to February 2025. The 12/6/24 Monthly Nursing Summary did not include the med Depakote as part of meds being reviewed, the documented mood and behavior were period of agitation, cursing and yelling, and did not indicate if the target behavior was increased or decreased.

A review of the medical records also revealed that the AIMS assessment was completed for dates 5/10/24 and 9/26/24. There was no documented evidence that the AIMS were done prior to 5/10/24, and every quarter (none was done for December 2024) AIMS were not done.

A review of the 2/21/25 Psychiatric follow up consult revealed that Staff report resident's mood was stable, but resident had some anxiety especially at night. The GDR (gradual drug reduction) was recommended and agreed by the Resident Representative (RR) for Seroquel to be d/c and to add Lorazepam 0.5 mg by mouth every 24 hours PRN for anxiety.

Further review of the medical records revealed there was no documented evidence that the resident had presented behavior after the Seroquel was d/c on 2/21/25 and the PRN Lorazepam was not administered.

On 2/26/25 at 10:59 AM, the surveyor interviewed RN/UM regarding the above concern with Resident #63 and why the Seroquel was increased on 2/25/25 without documented evidence that the resident had increased or presented behavior after the GDR was done on 2/21/25 (d/c Seroquel). The RN/UM responded that she was not the nurse who was giving meds and the surveyor should ask the Psychiatric doctor for that.

On that same date and time, the RN/UM confirmed after reviewing the medical records that the AIMS assessment and Monthly Nursing Summary were not done according to their practice. The surveyor then asked the RN/UM what the facility's standard of practice for use of psychoactive meds will be, should there be a documentation of behavior and reason for increasing the meds, and she responded yes.

On 2/26/25 at 11:30 AM, the surveyor notified the DON of the above concerns with the psychoactive meds and behavior monitoring. The DON stated that she was aware of the concern with the psychoactive meds that was why she had a meeting with the Psychiatrist, and educated the Psychiatrist that she should follow

the regulation.

A review of the Consultant Pharmacist (CP) Monthly Medication Review (MMR) for dates 10/8/24, 11/8/24, and 12/6/24, revealed that the resident's psychoactive summaries were not up to date.

A review of the provided Employee Education Attendance Record dated 2/14/25 for an in-service r/t to content: antipsychotic meds, putting orders in electronic records, and GDR, reflected that the Advance Practice Nurse (APN) who did the follow up Psychiatric consult and Assistant Director of Nursing (ADON) signed the in-service that was presented by the Director of Nursing (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and ADON, and the surveyor notified them of the above concerns. The surveyor also asked the facility Level of Harm - Minimal harm or management about the provided in service dated 2/14/25, and the surveyor asked why after the in service potential for actual harm provided to the APN, the problem still persisted when the resident's Seroquel was d/c on 2/21/25 and increased on 2/25/25 when there was no documented evidence of behavior was observed or increased, and Residents Affected - Few the LNHA, DON, and ADON did not respond.

On 2/27/25 at 1:00 PM, the surveyor interviewed the APN who provided a follow up psychiatrist consult for Resident #63. The APN informed the surveyor that she was unsure if the guidelines she followed for GDR was according to the regulations that the facility was following. The surveyor asked the APN if the target behavior was to be identified for each psychoactive meds in order to evaluate the effectiveness of meds and to be able to GDR the psychoactive meds, and the APN responded, it depends, because at times nurses had different views on what to monitor for behavior. The surveyor then asked the APN should the nurse and the APN communicated and discussed the appropriate behavior to effectively evaluate the resident's psychoactive meds, and the APN responded, that was a good idea.

On that same date and time, the surveyor asked the APN, for Resident #63, what behavior should monitored by the staff, and she responded hitting. The surveyor then notified the APN of the above concerns that the medical records reflected that the yelling, screaming, and intrusive behaviors were documented behavior as being monitored for the resident.

On 3/3/25 at 10:19 AM, the survey team met with the LNHA, DON, ADON, and the surveyor notified them of

the above findings. The DON confirmed that the AIMS Assessment should be done quarterly and the Monthly Nursing Summary that included the monthly psychiatric summary should be done monthly. The DON stated no additional response with AIMS, monthly summary, moving forward were doing an audit. The surveyor asked if there was an additional information that the LNHA, DON, and ADON wanted to add, and

they said no additional information as per LNHA.

A review of the facility's Behavioral Assessment, Intervention and Monitoring Policy, with revision date of March 2019 revealed:

Policy Statement:

2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment .

Management:

8. Interventions and approaches will be based on a detailed assessment of physical, psychological land behavioral symptoms and their underlying causes, as well as the h potential situational and environmental reasons for the behavior. The care plan will include, as a minimum:

b. targeted and individualized interventions for the behavioral and/or psychosocial symptoms;

d. specific and measurable goals for targeted behaviors; and

e. how the staff will monitor for effectiveness of the interventions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 10. When meds are prescribed for behavioral symptoms, documentation will include:

Level of Harm - Minimal harm or e. specific target behaviors and expected outcomes; . potential for actual harm h. monitoring for efficacy and adverse consequences; and Residents Affected - Few i. plans (if applicable) for GDR .

Monitoring:

1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function .

On 3/4/25 at 10:15 AM, during the Quality Assurance Performance Improvement (QAPI) meeting by the surveyor with the LNHA, DON, and the ADON, the DON confirmed that it was the surveyor who identified the concern with regard to quarterly AIMS assessment and Monthly Nursing Summary, and these will be added to their QAPI meeting.

NJAC 8:39-27.1(a); 33.2(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 49078 Residents Affected - Few Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to properly store medications securely and appropriately according to facility's policy and standard of clinical practice. The deficient practice was identified in 1 of 4 medication carts inspected on 3 of 3 units.

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.

On 3/3/25 at 12:04 PM, the surveyor entered the 1st floor nursing unit. The surveyor observed a medication storage cart (medcart) that was unlocked as evidenced by the locking button not pressed in and activated.

The medcart was unattended by a licensed staff member. The surveyor approached the nurses' station and asked who was assigned to the medcart. A Licensed Practical Nurse (LPN) identified themselves as the assigned staff for the medcart assigned to 1st floor, wing 1. The surveyor asked the LPN if was common to leave a medcart open and unattended. The LPN stated, no, the medcart should always be locked when not

in use and she had just walked away from it. The surveyor asked the LPN why it would need to be locked when unattended. The LPN stated that a resident or other person could get access to medications (meds).

The surveyor continued the inspection of the medcart in the presence of the LPN.

On 3/3/25 at 1:09 PM the survey team met with Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) to notify them the concern with the medcart and requested a medication storage policy.

On 3/4/25 at 12:05 PM, the survey team met with the LNHA, DON and ADON. The facility had no further pertinent documentation to provide.

A review of the facility's Medication Labeling and Storage Policy, dated February 2023 reflected under Policy Statement, the facility stores all meds and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. It also reflected under Medication Storage, 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing meds and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

N.J.A.C. 8:39-29.4(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 38327

Residents Affected - Few Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 1 of the 35 residents reviewed (Residents #107).

This deficient practice was evidenced by the following:

During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, the surveyor observed Resident #107 lying on bed.

On that same date and time, the resident informed the surveyor that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. The resident further stated that they had incidents of falls in the facility, and unsure when and where in the facility the fall incidents happened. The resident's bed was not in a low position.

The surveyor reviewed the medical records of Resident #107 and revealed:

A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to other sequelae of cerebral infarction (stroke) and hemiplegia (is a condition characterized by paralysis on one side of the body) and hemiparesis (is a condition characterized by one-sided muscle weakness, often caused by disruptions in the brain, spinal cord, or nerves connecting to the affected muscles) following cerebral infarction affecting left non-dominant side.

A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/7/25, with a brief interview for mental status (BIMS) score of 9 of 15, which reflected that the resident's cognitive status was moderately impaired.

A review of the provided fall investigations revealed that the resident had two fall incidents/accidents. The 12/30/24 fall investigation resulted to a bump to left forehead and the resident's blood pressure was 205/125.

The 1/15/25 fall investigation had no injury.

A review of the Progress Notes (PN) that was electronically signed by the Physician revealed:

-For effective date of 1/3/25 was created on 2/24/25.

-For effective date of 12/3/24 was created on 2/6/25.

-other late entry notes: 11/1/24, 10/01/24, 9/6/24, and 8/3/24.

Further review of the above Physician PN revealed that Assessment and Plan dated 8/3/24, 9/6/24, 10/1/24, 11/1/24, 12/3/24, and 1/3/25, included requesting to change Seroquel (antipsychotic medication) to Trazodone (antidepressant) psych (Psychiatrist) to be contacted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 The above 1/3/25 Physician PN did not reflect documented evidence that the physician assessed the resident post fall incidents on 12/30/24 and 1/15/25. Level of Harm - Minimal harm or potential for actual harm A review of the physician orders (PO) revealed that the resident's order for Seroquel was discontinued on 12/29/23. Residents Affected - Few

A review of the February 2025 electronic Medication Administration Record (eMAR) revealed that the resident had no order for Trazodone. The February 2025 eMAR reflected a PO for Sertraline HCL (hydrocholoride) oral tablet (tab) 50 mg (milligram) one tab by mouth one time a day for MDD (Major Depressive Disorder) with a start date of 1/29/25.

On 2/26/25 at 11:19 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), and the surveyor notified the RN/UM of the above findings and concerns. The RN/UM after reviewing the resident's paper and electronic medical records, she confirmed that the physician's PN were late entries and had duplicate notes about Seroquel, Trazodone, and Psych. The RN/UM stated that the surveyor should ask the Director of Nursing (DON) about what facility should follow with regard to physician's PN and could not speak

on why the repeated documentation of the physician.

On 2/26/25 at 11:30 AM, the surveyor notified the DON of the above concerns, and the DON stated that the physician should have done monthly and as needed notes for LTC (Long Term Care) residents. The DON acknowledged that the medical records should have been accurate according to the current condition of the resident.

On 2/27/25 at 12:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant Director of Nursing (ADON), and the surveyor notified them of the above concerns.

On 3/4/25 at 11:30 AM, the survey team met with the LNHA, DON, and ADON. The DON stated that for the surveyor's concerns, no further information to provide.

NJAC 8:39-23.2 (a)(b); 35.2 (d)(6)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 38327 potential for actual harm REPEAT DEFICIENCY Residents Affected - Few Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 of 3 staff (Licensed Practical Nurse) and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy.

This deficient practice was evidenced by the following:

According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed:

Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications:

Immediately before touching a patient .

Before moving from work on a soiled body site to a clean body site on the same patient .

After touching a patient or the patient's immediate environment

After contact with blood, body fluids, or contaminated surfaces

Immediately after glove removal.

On 2/26/25 at 7:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) during medication (med) administration, performed handwashing after removal of gloves inside the toilet room of Resident #5. The surveyor observed the LPN scrubbed her hands with soap under the stream of running water for 18 seconds.

On 2/26/25 at 8:12 AM, the surveyor observed the LPN donned (put) gloves, disinfected the blood pressure (bp) apparatus, entered Resident #119's room, and checked the resident's bp with use of same gloves. The LPN did not doff (remove) used gloves after disinfecting the bp apparatus. After the LPN obtained the bp of

the resident, the LPN doffed off gloves, and exited the room without performing hand hygiene. In addition,

the LPN prepared and administered medications of the resident without performing hand hygiene.

During an interview after med pass observation, the surveyor notified the LPN of the above hand hygiene concerns, and LPN stated that it was okay to perform hand scrubbing under the stream of water. The LPN further stated that she should have doffed off gloves and performed hand hygiene after disinfecting the bp app.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 3/3/25 at 10:19 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Assistant DON (ADON), and the surveyor notified them of the above concerns with Level of Harm - Minimal harm or med pass observation with regard to hand hygiene and gloves use. potential for actual harm

A review of the facility's Handwashing/Hand Hygiene Policy, with an edited date of 3/18/24, that was Residents Affected - Few provided by the ADON revealed:

Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.

Indications for Hand Hygiene:

1. Hand hygiene is indicated:

a. immediately before touching a resident; .

d. after touching a resident; .

f. before moving from work on a soiled body site to a clean body site on the same resident; and

g. immediately after glove removal .

Washing Hands:

1. Wet hands first with warm water, then apply an amount of product recommended by the manufacturer to hands.

2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.

3. Rinse hands with water and dry thoroughly with a disposable towel.

4. Use towel to turn off the faucet .

On 3/4/25 at 12:17 PM, the survey team met with the LNHA, DON, and ADON for an exit conference, and there was no additional information provided by the LNHA.

NJAC 8:39-19.4(a)(1),(n)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 58 315306 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315306 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at New Milford 800 River Road New Milford, NJ 07646

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 39885

Residents Affected - Few Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 1 of five 5 Certified Nurse Assistants (CNAs) reviewed for mandatory education.

This deficient practice was evidenced by the following:

On 3/3/25 at 9:13 AM, the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs showed the following:

CNA #1 had a date of hire (doh) of 1/25/18. According to the Transcript, CNA #1 did not have QAPI training.

CNA #2 had a doh of 11/20/07. According to the Transcript, CNA #2 did not have QAPI training.

On 3/3/25 at 12:16 PM, the surveyor interviewed the Facility Educator (FE) regarding CNA education and mandatory topics. The FE stated that she tracked their education based on their anniversary date. She added that if a mandatory topic was done offline that it would still be logged on the staff's transcript. The surveyor asked the FE about the QAPI training. The FE stated that it was done offline but that it was tracked

on the computer training transcript as offline. The surveyor notified the FE that CNA #1 and CNA #2 did not have QAPI training listed on their transcript. The FE stated that it could have been a transcription error on her part and that she did not put it in the system. The FE stated that she would look at the sign in sheet.

On 3/3/25 at 12:25 PM, the FE provided the surveyor a sign in sheet for QAPI training that CNA #2 had signed as completed. The FE stated that CNA #1 had not completed the training.

On 3/3/25 at 1:00 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Assistant DON (ADON) the concern that CNA #1 did not have the QAPI inservice.

On 3/4/25 at 11:33 AM, in the presence of the LNHA and ADON, the DON stated that CNA #1 was inserviced after surveyor inquiry on the topic of QAPI.

A review of the facility's In-service Training, Nurse Aide Policy, with a revised date of August 2022, included

the following:

9. Required training topics for all staff (including nurse aides) include: .

d. quality assurance and performance improvement (QAPI) .

N.J.A.C. 8:39-33.1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 58 315306