Alaris Health At St Mary's

F-F610

On 01/21/25 at 10:00 AM, the surveyor reviewed the closed electronic medical record for Resident #264.

According to the Admission Record face sheet, Resident #264 was admitted to the facility with diagnoses which included but were not limited to; acute and chronic respiratory failure, hypoxia, epilepsy, tracheostomy status and dependence on respiratory ventilators.

A review of Resident #264's quarterly MDS dated [DATE REDACTED], reflected that the resident was coded as being comatose and yes to being in a persistent vegetative state/no discernible consciousness. Resident #264 was totally dependent on staff for all care.

A review of Resident #264's ICCP included a focus area initiated on 02/27/24, for being at risk for falls related to poor safety awareness, impaired balance and poor trunk control, side effects of medications, non-verbal, and required mechanical lift transfers. Interventions included to use mechanical lift for transfers with two persons assisting with the transfer.

A review of the Progress Notes revealed an Interdisciplinary Team (IDT) Note dated 11/06/24 at 10:20 PM, which included the IDT was made aware by CNA that Resident #264 was noted with discoloration and swelling of the right eye. The Nurse Practitioner (NP) was notified and ordered the resident to be sent to the hospital for further evaluation and treatment. A report was given to the nurse, and Resident's Representative (RP) was at bedside.

A review of the IDT Note dated 11/06/22 at 10:22 PM, revealed that transportation was arranged with the [hospital name redacted] Emergency Services.

A review of the IDT Note dated 11/07/24 at 8:05 PM, revealed a follow-up to the emergency room . The resident was admitted with diagnoses traumatic hematoma to right orbit (eye socket).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 315352 Department of Health & Human Services Printed: 09/10/2025 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 315352 B. Wing 01/23/2025

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

Alaris Health at St Mary's 135 South Center Street Orange, NJ 07050

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 1/16/25 at 10:30 AM, the surveyor reviewed the investigation and the Reportable Event Record completed by the facility dated 11/06/24. There was no causal factor identified for the injury. Level of Harm - Immediate jeopardy to resident health or A review of a statement for CNA #1's, who cared for the resident revealed the following: safety

On 11/06/24, CNA #1 documented that on 11/06/24, that she went in the afternoon to put Resident #264 in Residents Affected - Many bed, and I found right face with a black eye and I reported to the nurse. The statement was signed CNA 3:00 PM-11:00 PM shift. (This note was documented before the mechanical lift transfer)

On 11/06/24, CNA #1 documented that on 11/06/24, in the evening I put resident back in bed with a mechanical lift. The resident was sitting in the recliner chair and we assisted the resident back to bed lying

on their left side. Once back in bed, I noticed resident had redness to face by eye. I reported discoloration to

the nurse. (This note was documented after the mechanical lift transfer)

The surveyor reviewed the statement provided by CNA #2, who also worked on the unit with CNA #1. CNA #2 documented that on 11/06/24, in the evening I assisted my co-worker to place resident back in bed with mechanical lift. The resident was sitting in the recliner chair and we assisted the resident back to bed lying

on their left side. Once back in bed, I noticed the resident had redness to face by eye. The assigned CNA reported the discoloration to the nurse.

A review of RN #2's statement dated 11/6/24 at 9:15 PM, indicated that they worked the 3:00 PM to 11:00 PM shift on the 2nd floor ventilator unit and was assigned to Resident #264. At 3:00 PM, I made rounds and

the resident was sitting in a recliner chair along the bedside and I did not notice any changes to Resident #264. At 5:00 PM, the resident was provided care and placed back to bed by the CNA. At approximately 8:30 PM, the Resident Representative (RR) came to the unit to provide care for the resident. At 9:15 PM, the RR informed her that the resident was noted with a hematoma and swelling of the right eye.

On 1/17/25 at 8:15 AM, the surveyor interviewed a staff CNA regarding the protocol to transfer residents with

the mechanical lift. The CNA stated that two staff members had to be in the room for the transfer.

On 1/17/25 at 8:52 AM, the surveyor interviewed the Respiratory Therapist (RT), and he confirmed that two staff had to be in the room to transfer a ventilator dependent resident from the bed to the recliner chair. When inquired regarding Resident #264, he confirmed that on 11/06/24, he had assisted CNA #3 with the transfer from the bed to the recliner chair in the morning, and there was no injury observed. The RT informed

the surveyor that on 11/06/24 at 4:53 PM, he observed Resident #264 in bed and he did not assist with the transfer back to bed, nor was he made aware of the injury.

On 01/17/25 at 11:59 AM, the surveyor reviewed the facility provided incident report and the statements attached with the DON. The DON stated that she was aware of the discrepancies in CNA #1's statements and could not provide any rationale for not clarifying the discrepancies prior to the submission of the investigation to the Department of Health (DOH). The DON stated there was a misunderstanding and miscommunication about the investigation. The DON stated she had understood Resident #264 sustained

the injury during the transfer and stated that Resident #264 possibly hit the right eye on the mechanical lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 315352 Department of Health & Human Services Printed: 09/10/2025 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 315352 B. Wing 01/23/2025

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

Alaris Health at St Mary's 135 South Center Street Orange, NJ 07050

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 01/17/25 at 12:05 PM, the surveyor conducted a second interview with the RT. The RTF on duty that day revealed that one nurse and one CNA were to transfer any resident out of the bed and back to bed if the Level of Harm - Immediate resident was on a mechanical ventilator (machine that acts as bellows to move air in and out of the lungs). jeopardy to resident health or The RT stated that some CNAs worked as floaters to the unit and they were not trained to transfer residents safety with the ventilator attached. The RT stated for safety reasons, a nurse had to be in the room to assist or if the nurse could not assist, the nurse delegated the task to the RT who supervised the transfer. When asked if Residents Affected - Many there was a policy for transferring a resident with a ventilator, he stated, this is the [normal], not too sure if there is a policy.

A review of the documents provided revealed that the RN nor the Respiratory Therapist assisted CNA #1 with the transfer.

On 01/21/25 at 11:47 AM, the surveyor interviewed the Medical Director (MD) regarding the injury sustained by Resident #264 during the transfer. The MD stated that he was told by the DON the injury was caused by

the hook from the mechanical lift and was not provided with any additional information.

On 1/21/25 at 1:45 PM, the surveyor interviewed the NP, who ordered Resident #264 to be transferred to the hospital for a computed tomography scan ( CT Scan; a noninvasive medical procedure that uses X-Rays to create detailed cross-sectional images of the body). The NP stated that since the bruise was significant and since no one knew the source of the injury, she ordered the CT scan to ensure there were no fractures.

A review of the summary provided to DOH on 11/08/2024, the DON indicated the following: Resident #264 has periods of involuntary movements related to hypoxia and seizure disorder as well as cough spasms. The Interdisciplinary Team concludes that resident during transfer may have coughed or had involuntary movement and may have leaned into [Resident #264] mechanical lift cross- bar. Interviews with staff familiar with the resident routine revealed that the resident was immobile.

Actions included to: .4. Transfer to Hospital for Evaluation; 5. Mechanical lift Competencies with CNAs; 6. Maintain 2 person assist with mechanical lift transfer and care; CNA #1 had Resident #264 on the mechanical lift alone in the room. CNA #2 was not in the room when CNA #1 initiated the transfer and placed Resident #264 on the mechanical lift. Utilize soft padding on the mechanical lift crossbar during resident transfers.

On 1/22/24 at 10:15 AM, two surveyors conducted an in person interview with CNA #1, who stated that she recalled the incident. CNA #1 stated that the evening shift was very chaotic, and that she observed the injury

after transferring Resident #264 in bed. CNA #1 stated that Resident #264 always scratched their face, and

the injury could be self-inflicted. When asked if she remained in the room with the resident and waited for the nurse to come and assess the injury, CNA #1 stated she had too much to do that day; she moved on and attended to other residents. The surveyor then inquired about the 2nd statement, and CNA #1 read the statement and stated, another co-worker coached her to write the second statement, but she did not observe any injury to the resident face and right eye while the resident was sitting in the chair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 315352 Department of Health & Human Services Printed: 09/10/2025 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 315352 B. Wing 01/23/2025

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

Alaris Health at St Mary's 135 South Center Street Orange, NJ 07050

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 1/22/24 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2, whom CNA #1 claimed assisted her with the transfer. CNA #2 stated that when she entered the room, [Resident #264] was in the Level of Harm - Immediate room and on the mechanical lift alone with CNA#1. CNA #2 observed the bruise and advised CNA #1 to jeopardy to resident health or report the injury to the nurse. When asked if she assisted CNA #1 with care, CNA #2 stated, No, I left the safety room and continued with my assignment.

Residents Affected - Many On 1/22/25 at 1:15 PM, the surveyor interviewed CNA #3, who was assigned to the 7:00 AM-3:00 PM shift regarding Resident #264's care. CNA #3 stated that she cared for Resident #264 daily; that Resident #264 was immobile, had poor trunk control, and required a two-persons assist with transfers. CNA #3 further stated that on 11/06/24, she transferred Resident #264 to the recliner chair with the Respiratory Therapist.

During the day she periodically checked Resident #264, and no injury was noted to the right eye.

On 1/23/25 at 10:56 AM, the surveyor reviewed the investigation with the LNHA in the presence of the survey team. The LNHA stated that in reviewing RN #2's statement and the investigation, he could see there were some discrepancies. The LNHA added the investigation was not concise and thorough, and that his expectation was that the facility would thoroughly investigate injuries of unknown origin.

On 1/23/25 at 1:30 PM, during the exit conference no additional information was provided.

A review of the facility's Incident/Accidents policy dated 05/01/14, and last revised 1/2024, included Policies and Procedures are guidelines. They are intended to communicate information that generally applies to facility operations. Current rules, regulations and laws take precedence over guidelines. Policy: Each resident receives adequate supervision and assistive devices to prevent accidents; Purpose: A system to prevent and/or minimize further incidents and accidents; All interventions should be placed in treatment

record and signed by nurses.

A review of the facility's Abuse Prevention Program dated last revised 1/2025, under identification indicated

the following: All residents sustaining bruises, skin tears, any marks of the skin, and any fractures or injuries, which are of unknown origin, shall be identified as potential abuse incidents and investigated as such .

The policy for Hoyer lift transfer was not provided.

31654

Part C

On 01/17/25 at 8:46 AM, Surveyor #2 reviewed the closed electronic medical record (EMR) for Resident #34.

A review of the Admission Record face sheet revealed Resident #34 had diagnoses including, but not limited to; sepsis, chronic viral hepatitis C, and opioid dependence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 315352 Department of Health & Human Services Printed: 09/10/2025 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 315352 B. Wing 01/23/2025

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

Alaris Health at St Mary's 135 South Center Street Orange, NJ 07050

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 an IDT Progress Notes (PN) dated effective 07/14/24 10:50 AM, and created on 07/15/24, by the nursing department included that on 7/14/24, the primary nurse called the supervisor for the Resident #34, Level of Harm - Immediate and upon the supervisor's arrival, the supervisor found the resident on the bed with erratic behavior and jeopardy to resident health or uncontrolled movement. The room was fully searched, and drug related equipment was found on the safety resident's bed. The supervisor immediately confiscated the equipment. Education was given to the resident about the risks of substance abuse, and that these actions violate the policies of the hospital (the facility). Residents Affected - Many The MD was made aware, and ordered the resident to be transferred to the hospital for evaluation, and ordered a toxicology screen.

A review of the Laboratory (Lab) Results Report with a collection date of 07/16/24, revealed Resident #34 tested positive for cocaine metabolite.

A review of the IDT PN dated late entry effective 08/08/24 at 1:26 PM, created on 11/24/24 at 1:27 PM, by

the DON, included the resident was noted with restless behavior; talking very animated and excited; slurring speech; at time making incoherent statements. The resident declined to be transferred to the emergency room (ER) for evaluation. The resident was educated on risk versus benefit of using illicit substances, and urine toxicology obtained per physician order.

A review of the Lab Results Report with a collection date of 08/08/24, revealed Resident #34 tested positive for cocaine metabolite, opiates, morphine, and methadone.

A review of a IDT Note dated 08/15/25 at 10:12 AM, included urine drug screen results received. The resident was positive for opiates, positive for cocaine, and positive for morphine. The resident was positive for methadone which was prescribed. The DON and physician were notified.

A review of the IDT PN dated late entry effective 12/19/24 at 11:56 AM, included at 10:39 AM, the resident was noted in the wheelchair in room lethargic with pupils dilated and not responding to commands. The NP ordered the resident be sent to the ER, and 911 was called. A STAT (immediate) drug screen ordered per physician and resident refused. The resident was noted with a vape pen and lighter in possession which were confiscated. The NP was made aware of the resident's refusal to go to ER.

A review of the Order Summary Report for the admitted [DATE REDACTED], for Resident #39, revealed an physicians order (PO) to maintain one-to-one (1:1) supervision every shift ordered on 11/27/24. A PO that may have visitors under supervision as needed ordered 12/02/24, and an order for methadone HCL oral concentrate 10 (milligram/milliliter) (mg/ml); give 50 mg by mouth once a day for opioid dependence.

A review of Resident #34's ICCP included the following focus areas:

A focus area initiated on 07/15/24, for the resident having a past history of drug abuse and was a risk for relapse. The goal was to keep Resident #34 safe with the interventions including daily room searches initiated on 07/15/24.

A focus area initiated 10/25/24, that the resident was a smoker with a goal to be a safe smoker. An Intervention included the Smoking Contract was reviewed and signed on 10/25/24.

A focus area for the resident being on methadone for substance abuse, and on 07/14/24, the resident was noted with erratic behavior and uncontrolled movements, room check was done and suspected drug related items found on resident bed .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 315352 Department of Health & Human Services Printed: 09/10/2025 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 315352 B. Wing 01/23/2025

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

Alaris Health at St Mary's 135 South Center Street Orange, NJ 07050

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 focus area for Resident #34 noted on 12/20/24, with erratic behaviors and uncontrolled movements and a room check was done and suspected drug related items found on the bed. A lighter and vape was Level of Harm - Immediate confiscated. jeopardy to resident health or safety A focus area that Resident #34 will be free of illicit substances was initiated on 12/20/24.

Residents Affected - Many On 01/22/25 at 9:02 AM, Surveyor #2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who was familiar with Resident #34. The LPN/UM stated she used to be on Resident #34's floor, and she stated that Resident #34 was alert and oriented and had an issue with addiction. Surveyor #2 asked about

the methadone clinic process and when Resident #34 was found with drug paraphernalia. The LPN/UM stated Resident #34 smoked and went outside and was observed going to the fence and someone came and handed the resident something and quickly ran off. Resident #34 was asked what was given and stated to

the LPN/UM it was nothing, and the LPN/UM then found Resident #34 not responding properly and they lifted the bed and found a home-made type twisted-up metal object under the resident's bed that was some sort of item used with drugs. Surveyor #2 asked about what was done to prevent Resident #34 from obtaining illegal drugs again, and the LPN/UM stated Resident #34 had 1:1 monitoring for a few weeks and then, got off of 1:1.

On 01/22/25 at 9:45 AM, Surveyor #2 asked the DON for all incidents, grievances, investigations related to Resident #34 and they were provided them at 11:30 AM the same day.

An Investigative Summary for the Concern on 07/14/24 at 8:55 PM, when Resident #34 was acting erratic and drug related paraphernalia was found on the bed. The undated Investigative Findings included that Resident #34's roommate observed the resident going to the fence in the smoking courtyard, but could not see what was happening. The resident (Resident #34) was found with a glass pipe on the resident's bed shortly after, and the drug panel was positive for cocaine metabolites. The conclusion revealed that the DON told the resident that illicit substances will not be tolerated due to risk of harm to self. Actions included: 1. Resident placed on every thirty-minute checks for 3 days . A statement signed by an unidentified person on 07/14/24, revealed Resident #34 was observed going to the gate continuously during the smoking time. Three Thirty-Minute Monitoring Sheets dated 07/15/24, 07/16/24, and 07/17/24, had a time and space next to the time for the 11:00 PM-7:00 AM (11-7) shift, 7:00 AM-3:00 PM (7-3) and 3:00 PM-11:00 PM (3-11) shift.

The handwritten documents did not identify who filled them out each shift, and did not represent all meals, or s [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 315352