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 30 of 49 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 31 of 49 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 32 of 49 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 33 of 49 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 34 of 49 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 35 of 49 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 48423 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 administer oxygen therapy according to the physician order, and ensure oxygen equipment was stored properly.

This deficient practice was identified for 1 of 3 residents (Resident #47) reviewed for respiratory care and was evidenced by the following:

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

the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.

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

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

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

During initial tour on 1/15/25 at 11:04 AM, the surveyor observed Resident #47 sitting in a wheelchair in their room. The resident was on Oxygen (O2) via nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower O2 levels) at 5 Liter per Minutes (LPM). The surveyor observed an O2 tank behind the resident's wheelchair, connected to a NC which was wrapped around the left handle of

the wheelchair. The NC was not in any protective covering and was exposed to the environment.

On 1/21/25 at 9:14 AM, the surveyor observed Resident #47 resting in the bed. The resident was on O2 at 4 LPM. The surveyor observed the resident's wheelchair closer to the window with the NC wrapped around the left handle of the wheelchair and in direct contact with resident's socks which were hanging back of the wheelchair. The NC was not in any protective covering and was exposed to the environment.

The surveyor reviewed the medical records of Resident #47 and revealed:

According to the Admission Record, Resident #47 was admitted to the facility with Pneumonia (an infection that affects one or both lungs), Anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), chronic obstructive pulmonary disease [COPD] (an ongoing lung condition caused by damage to the lungs) with exacerbation (flare up), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) without complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 49 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 0695 A review of the Quarterly Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, dated 11/15/24, revealed the resident had a score of 15 out of 15 on the Brief Interview Level of Harm - Minimal harm or for Mental Status (BIMS), which indicated that the resident had intact cognition. Further review of the MDS potential for actual harm did not document that Resident #47 received O2 therapy.

Residents Affected - Few A review of the Order Summary Report for Resident #47 revealed Physician Orders (PO) as follows:

- O2 at 4 LPM via NC every shift with the start date from 4/12/24 to 1/16/25.

- O2 at 3 LPM via NC every shift with the start date 1/20/25.

A review of the resident's Care Plan (CP) included a focus area that indicated, . O2 therapy related to SOB (shortness of breath)/ CHF (Congestive Heart Failure) (heart failure). The Interventions included give medications as ordered by physicians; O2 at 2 L/NC as ordered, initiated on 6/11/22.

On 1/21/25 at 9:48 AM, during an interview with the surveyor, the Registered Nurse (RN) stated when she made rounds, she would check if the residents were on the correct amount of oxygen as per physician orders. The RN stated that she would store the oxygen tubing or other equipment in a special bag when the oxygen was not in use because of safety precautions and to avoid contamination. The RN stated Resident #47 was on 3LPM of oxygen as per physician order. The surveyor informed the RN of above-mentioned findings regarding resident's O2 at 5 LPM during initial tour and 4 LPM prior to the interview. The surveyor accompanied the RN to Resident #47's room. The RN spoke with the resident and the resident stated, I use 4 LPM at night.The resident confirmed that the oxygen was at 4 LPM. The RN stated, they (the residents) need to be educated on the importance of maintaining doctor's orders. In the presence of the surveyor, the RN observed the NC wrapped around the left handle of the wheelchair. RN stated the NC should have been placed in the bag. The RN then discarded the NC from the wheelchair.

On 1/21/25 at 1:20 PM, during an interview with the surveyor, the Assistance Director of Nursing (ADON) stated when residents are on oxygen, the nurses should follow physician orders and make the sure the residents were on the right setting as per the physician orders. The ADON stated that all oxygen equipment would be stored in a special plastic bag when not in use. The surveyor informed the ADON of the above findings. The ADON stated NC wrapped around the wheelchair handle was not acceptable.

On 1/23/25 at 11:33 AM, the survey team met with the facility administration. The surveyor notified the facility management of the above-mentioned concerns for Resident #47.

A review of the facility provided Oxygen Therapy revised 1/2025 included: Under Preparation and Observations: The licensed nurse shall: 1. Review the physician's order for oxygen administration. Oxygen therapy is administered only as ordered by a physician or as The physician's order will specify the rate of flow, route, and rationale. 2. Review the resident's care plan. 3. Assemble the equipment and supplies as needed - 3rd bullet point- Plastic bag for oxygen equipment storage. Under Procedure: 1. Review Physician's order for oxygen therapy. 5. Connect oxygen tubing And turn on oxygen to the prescribed flow rate. 7. Store unused devices in plastic bag.

On 1/23/25 at 2:10 PM, the survey team met with the facility administration for an Exit Conference. The facility had no additional information to provide.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 49 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 0695 NJAC 8:39-11.2(b); 25.2(c)4; 27.1(a)

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 38 of 49 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or 38079 potential for actual harm Based on interview and document review, it was determined that the facility failed to ensure residents had Residents Affected - Few cognitive ability before signing arbitration agreements. This deficient practice was identified for 1 of 3 residents (Resident #61) reviewed for arbitration agreements. This had the potential to result in resident representatives not being able to resolve disputes with the facility in a court of law. The deficient practice was evidenced by the following:

On 1/15/25 at 10:18 AM, Surveyor #4 observed Resident #61 in bed. The resident did not respond to the surveyor when spoken to. A staff member was entering the room and stated the resident could not see.

On 1/15/25 at 11:12 AM, the Licensed Nursing Home Administrator (LNHA) informed Surveyor #1 that the facility utilized arbitration agreements which were part of the admission agreement. The facility provided a list of residents who had signed arbitration agreements.

On 01/16/25 at 11:06 AM, during a phone conversation with Surveyor #1, Resident #61's representative explained the resident was legally blind. The representative further stated that the staff does not involve them with anything and that they were unaware of an arbitration agreement. The representative included the resident was not able to sign any papers and stated what are you talking about?

A review of the Admission Record (an admission summary) revealed Resident #61 had diagnoses which included but were not limited to; legal blindness, brief psychotic disorder, and cerebral infarction (a pathological process resulting in an area of dead tissue in the brain). A review of the Voluntary Binding Arbitration Agreement (VBAA) revealed it was signed by Resident #61 on 7/10/19. Page 3 of the Agreement revealed a section for the resident's legally authorized representative or resident but was signed only by the resident and the facility representative. A review of the Minimum Data Set (MDS) an assessment tool dated 8/10/19, included a Brief Interview for Mental Status (BIMS) of 02 out of 15 indicative of severe cognitive impairment.

On 1/23/25 at 9:11 AM, in the presence of two surveyors the Admissions Director (AD) stated it was her responsibility to provide the VBAA along with other papers. She stated it would be provided to the resident and/or the family to read over and they can sign or decline. The Ad explained she would go through and read

the papers with the resident and/or family and go into detail if they wanted. She further explained that the VBAA was, in essence, the arbitration was . if there was anything we [facility] did we would go in front of a small group and a judge? When inquired about a resident's cognitive status, the AD responded that the BIMS would always be checked prior to any papers being signed and that the resident would require a BIMS of 13 or higher. She stated that a BIMS of 12 would be when a resident would be getting impaired. When inquired about Resident #61, the AD revealed she was not working at the facility at that time and that a BIMS of 02 was not sufficient for the resident to understand or sign an agreement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 49 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 0847 A review of the facility provided policy, Arbitration Agreement revised 1/2024, included but was not limited to; Procedure: . will be explained to the resident or their representative in a form, manner and language they Level of Harm - Minimal harm or understand; . ensure the resident or their representative acknowledges they understand the agreement and potential for actual harm have the right to rescind the agreement within 30 calendar days.

Residents Affected - Few On 1/23/25 at 11:32 AM, the above concern was addressed with the facility administration. The facility had no additional information to provide.

NJAC 8:39-4.1(a)8(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 49 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31654 potential for actual harm Based on interview and review of pertinent documents it was determined that the facility failed to maintain an Residents Affected - Many effective comprehensive data driven Quality Assurance and Performance Improvement program by failing to

review all services provided including to ensure significant events were reviewed to determine root cause to prevent further occurrences. This deficient practice occurred for residents with a history of smoking in their room, holding drug paraphernalia and a lighter in their room (Resident #143 and Resident #34), and for a resident (Resident # 264) who was dependent on staff for all care, and sustained an injury of unknown origin that required hospitalization on [DATE REDACTED]. This deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following:

Refer to 689L, 610G

a. During the survey, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR Part 483.25(d)(2) F 689 as the facility failed to follow their smoking policy to ensure effective interventions were implemented and monitored for a resident with a history of smoking in their room. The facility documented Resident #143 was found smoking in their room on 10/19/24. Observations on 1/15/25, 1/16/25 and 1/17/25, confirmed that the Resident #143 held their cigars in their room.

The IJ began on 10/19/24 when Resident #143 was found by a Registered Nurse to be smoking in their room. From 1/15/25 through 1/17/25 the surveyor observed smoking materials inside of the resident's room and within arm's reach of Resident #143. Resident #143 had piped in oxygen into their room. The facility was notified of the IJ on 1/17/25 at 2:26 PM. The facility provided an acceptable Removal Plan (RP) which was verified on-site by the survey team on 1/21/25.

On 1/15/25 at 9:39 AM, during the initial tour, Surveyor #1 observed a sign posted on the wall outside of Resident #143's room, No Smoking (in red), Piped-In Oxygen In Use. Upon entrance to Resident #143's room, Surveyor #1 observed the resident was in bed watching television. At that time, Surveyor #1 observed

a pack of cigars on the table next to the resident and asked the resident what they were. The resident took a cigar out of the case and stated it's a cigar while holding it and showing it to the surveyor.

On 1/16/25 at 11:44 AM, Surveyor #1 observed resident #143 sitting in a wheelchair in their room, with two loose cigars adjacent to the resident's meal tray and within the resident's reach.

On 01/17/25 at 8:20 AM, Surveyor #1 observed Resident #143 again sitting in a wheelchair in their room, and two loose cigars were on the tray table within reach of the resident, and a cigar box was on top of the nightstand. The resident stated, I buy my own cigars. I walk to the store. Surveyor #1 asked Resident #143 if

they had a lighter and the resident then gestured with both hands waving towards the nightstand, and stated, I put it up. Surveyor #1 asked the resident if they could show their lighter to the surveyor, and Resident #143 then began rummaging through their nightstand and stated, I can't find it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 49 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 0865 On 1/17/25 at 8:45 AM, during an interview with Surveyor #1, the Registered Nurse (RN) stated the residents smoked in the designated area as per the smoking schedule. The RN stated all residents were assessed for Level of Harm - Minimal harm or smoking upon admission and staff would then let Security know if the resident was a smoker. The RN stated potential for actual harm the residents were not allowed to smoke in their rooms and if they were caught smoking in their rooms, their smoking supplies would be removed from their room and stored either with Security, or inside the medication Residents Affected - Many cart. The RN stated Resident #143 had smoked in their room before, and all the smoking supplies were taken away from the resident. The RN further stated smoking was not allowed in the rooms due to residents using oxygen and due to the risk of fire.

On 01/17/25 at 9:16 AM, Surveyor #1 accompanied the RN to Resident #143's room and the RN observed two packs of sealed cigars inside the resident's nightstand drawer. The RN stated Resident #143 was not allowed to have smoking supplies in their room and immediately removed the cigar packs from the resident's room.

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

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

Review of a Progress Notes (PN) - Type: IDT Note, Effective Date: 07/14/24 10:50 AM, Created Date: 07/15/24, Department: Nursing: Created by Unit Manager: On July 14, 2024, the primary nurse called the supervisor for the patient in room [ROOM NUMBER]B, and upon the supervisor's arrival, the supervisor found the patient on the bed with erratic behavior and uncontrolled movement. The room was fully searched, and drug related equipment was found on the patients' bed. The supervisor immediately confiscated the equipment. Education was given to the resident about the risks of substance abuse, and that these actions violate the policies of the hospital MD (physician) was made aware, and ordered the resident to be transferred to the hospital for evaluation, and ordered a toxicology screen .

Review of the Lab Results Report, Collection Date 07/16/24, revealed Resident #34 tested positive for Cocaine Metabolite.

Review of a PN - Type: IDT [Interdisciplinary] Note, Late Entry, Effective Date: 08/08/2024, 1:26 PM, Created by Date: 11/24/24 at 1:27 PM, by the Director of Nursing (DON), 08/08/824 at 1:20 PM, resident noted with restless behavior, talking very animated and excited, slurring speech, at time making incoherent statements . Declined transfer to ER for evaluation Resident educated on risk verse benefit of using illicit substances, urine toxicology obtained per physician order .

Review of the Lab Results Report, Collection Date 08/08/2024, revealed Resident #34 tested positive for Cocaine Metabolite, Opiates, Morphine and Methadone.

Review of an IDT Note: Dated 08/15/25 at 10:12 AM, Note Text: Urine drug screen results received. Resident positive for opiates, positive for cocaine, positive for morphine. Resident positive for Methadone which is prescribed. DON and physician notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 49 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 0865 Review of a PN - Type: IDT Note, Late Entry, Effective Date: 12/19/24 at 11:56 AM, At 10:39, resident noted

in wheelchair in room lethargic with pupils dilated and not responding to commands. NP (Nurse Practitioner) Level of Harm - Minimal harm or ordered for resident to be sent to ER (emergency room ). 911 Called. STAT (immediate) drug screen ordered potential for actual harm per physician and resident refused. Resident Noted with vape pen and lighter in possession which were confiscated. NP made aware of resident's refusal to go to ER . Residents Affected - Many

On 01/23/25 at 8:53 AM, Surveyor #2 interviewed the Medical (MD) Director and asked if he was made aware of Resident #34 who was found in the facility in his/her room, not responding, and found with vape and a lighter and drugs were found in the resident's system. The MD he was not aware, stated no, not at all was I aware of this. Surveyor #2 asked what should have been done after that should have been done. The MD stated, that is concerning the resident should get a warning discharge as could cause a huge fire, of course.

c. On 1/16/25 at 10:30 AM, the surveyor reviewed the investigation and the Reportable Event Record completed by the facility. There was no causal factor identified for the injury.

CNA #1 who cared for the resident provided two statements.

-11/06/24 CNA #1 documented that on 11/06/24 that she came this afternoon to put resident 114 in bed, I found right face with a black eye and I reported to the nurse. Signed CNA 3:00 PM-11:00 PM shift. [Before

the mechanical lift transfer]

-11/06/24 CNA #1 documented that on 11/06/24 in the evening I put resident back in bed with mechanical lift. Resident was sitting in recliner chair and we assisted back to bed lying on left side. Once back in bed. I noticed resident had redness to face by eye. I reported discoloration to the nurse. [After the mechanical lift transfer]

The surveyor reviewed the statement provided by CNA #2 who also worked on the unit with CNA #1. CNA #2 documented that on 11/06/24 in the evening I assisted my co-worker to place resident back in bed with mechanical lift. Resident was sitting in recliner chair and we assisted back to bed lying on left side. Once back in bed I noticed resident had redness to face by eye. Assigned CNA reported the discoloration to the nurse.

The Registered Nurse's (RN) statement dated 11/6/24 at 9:15 PM, documented that at 3:00 PM, worked the 3:00 PM to 11:00 PM shift on the 2nd floor ventilator unit and assigned to the Resident in room [ROOM NUMBER]. At 3:00 PM I made rounds and the resident was sitting in recliner chair along the bedside and did not notice any changes to Resident #264. At 5:00 PM resident was provided care and placed back to bed by CNA. At approximately 8:30 PM Resident's family came to the unit to provide care for her parent. At 9:15 PM, Resident #264 and informed her that the resident was noted with a hematoma and swelling of the right eye.

On 1/17/25 at 8:15 AM, the surveyor interviewed a random CNA regarding the protocol to transfer residents with the mechanical lift. The CNA stated that two staff members had to be in the room for the transfer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 49 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 0865 On 1/17/25 at 8:52 AM, the surveyor interviewed the Respiratory Therapist (RTF) and he confirmed two staff had to be in the room to transfer a ventilator dependent resident from the bed to the recliner chair. When Level of Harm - Minimal harm or inquired regarding Resident #264, he confirmed that on 11/06/24 he had assisted CNA #3 with the transfer potential for actual harm from the bed to the recliner chair in the morning, and there was no injury observed. The RTF informed the surveyor that on 11/06/24 at 4:53 PM, he observed Resident #264 in bed and did not assist with the transfer Residents Affected - Many back to bed, nor was he made aware of the injury.

On 01/17/25 at 11:59 AM, the surveyor reviewed the facility provided incident report and the statements attached with the Director of Nursing (DON). The DON stated that she was aware of the discrepancies in CNA #1's statements and could not provide any rationale for not clarifying the discrepancies prior to submit

the investigation to the Department of Health (DOH). The DON stated there was a misunderstanding and miscommunication about the investigation. The DON stated she had understood Resident #264 sustained

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

On 01/17/25 at 12:05 PM, the surveyor conducted a second interview with the RTF. The RTF on duty that day revealed that one nurse and one CNA were to transfer any resident out of the bed and back to bed if the resident was on a mechanical ventilator (machine that act as bellows to move air in and out of the lungs).

The RTF stated that some CNAs worked as floaters to the unit and they were not trained to transfer residents with the ventilator attached. For safety reasons, a nurse had to be in the room to assist or if the nurse could not assist, she would delegate the task to the respiratory therapist who would supervise the transfer. When asked if there was a policy for transferring a resident with a ventilator, he stated, this is the norm, not too sure if there is a policy.

Based on the documents provided, the RN nor the respiratory therapist assisted CNA #1 with the transfer.

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

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

On 1/21/25 at 1:45 PM, the surveyor interviewed the NP who ordered that Resident #264 be transferred to

the hospital for a CT scan (computed Tomography Scan a noninvasive medical procedure that uses X-Rays to create detailed cross-sectional images of the body). The NP stated that since the bruise was significant and since no one knew the source of the injury she ordered the CT scan to ensure there were no fractures.

On 1/22/25 at 12:00 PM, the surveyor conducted a telephone interview with CNA #2. CNA #2 stated that CNA #1 was waiting in the resident's room. When she entered the room, Resident #264 was already in the mechanical lift and being transferred. Once the resident was in bed, she observed the bruise and advised CNA #1 to report the bruise to the nurse. CNA #2 stated that she did not assist CNA#1 with care, and she left the room to attend to her assignment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 49 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 0865 In the summary provided to DOH, the DON indicated the following: Resident #264 has periods of involuntary movements related to hypoxia and seizure disorder as well as cough spasms. The Interdisciplinary Team Level of Harm - Minimal harm or concludes that resident during transfer may have coughed or had involuntary movement and may have potential for actual harm leaned into [Resident #264] mechanical lift cross- bar. Interviews with staff familiar with the resident routine revealed that the resident was immobile. Residents Affected - Many Actions .

4. Transfer to Hospital for Evaluation.

5. Mechanical lift Competencies with CNAs.

6. Maintain 2 person assist with mechanical lift transfer and care.

CNA #1 had Resident #264 on the mechanical lift alone in the room. CNA #2 was not in the room when CNA #1 initiated the transfer and placed Resident #264 on the mechanical lift.

Utilize soft padding on the mechanical lift crossbar during resident transfers.

On 1/22/24 at 10:15 AM, two surveyors conducted an in-person interview with CNA#1. CNA #1 stated that

she recalled the incident. She stated that the evening shift was very chaotic. She confirmed that she observed the injury after transferring Resident #264 in bed. She stated that Resident #264 always scratched their face, the injury could be self-inflicted. When asked if she remained in the room with the resident and waited for the nurse to come and assess the injury, CNA #1 stated she had too much to do that day, she moved on and attended to other residents. The surveyor then inquired regarding the 2nd statement, CNA #1 read the statement and stated, another co-worker coached her to write the second statement, but she did not observe any injury to the resident face and right eye while the resident was sitting in the chair.

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

On 1/22/25 at 1:15 PM, the surveyor interviewed CNA #3 assigned to the 7:00 AM- 3:00 PM shift regarding Resident #264's care. CNA #3 stated that she cared for Resident #264 daily, Resident #264 was immobile, had poor trunk control, and required two persons assist with transfer. CNA #3 further stated that on 11/06/2024 she transferred Resident #264 to the recliner chair with the Respiratory Therapist. During the day and she periodically checked Resident #264 and no injury was noted to the right eye.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 49 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 0865 On 01/17/25 at 2:51 PM, the facility provided the surveyor with 2 QAPIs:

Level of Harm - Minimal harm or 1. Dated 10/19/24, Date Completed: . to be continued on a monthly basis until 4 quarters of 100 % is potential for actual harm achieved; Contact: Administrator and Director of Nursing (DON); Problem Statement: All current smokers are assessed and care planned accordingly; Goal: to ensure that all residents and staff are aware of the facility Residents Affected - Many smoking policy and all residents who smoke may do so safely; Root Causes: 1. Resident non-compliance, 2. Residents were identified needing frequent, 3. Resident responsible party education on the facility smoking policy; Under Tasks: Eight tasks listed with a Start Date 10/19/24 for 1-4 and for 5-8 the Start Date was left blank. The Comments (status, outcomes, evaluations, etc.) was left blank for all eight tasks.

2. An undated QAPI with a Problem Statement: Substance abuse creates safety risks, disrupts care, and violates facility policy: Contact: Administrator and DON; Goal: Implement a program to identify and manage substance abuse, and to reduce incidents. Four Tasks, with a Start Date: 07/15/24 and 07/17/24, with an Estimated Completion Date: Ongoing; Comments (status, outcomes, evaluation, etc.) was left blank.

On 01/23/25 at 8:53 AM, the Surveyor #2 interviewed the Medical (MD) Director and asked if he was made aware of Resident #34 who was found in the facility in his/her room, not responding, and found with vape and a lighter and drugs were found in the resident's system. The MD he was not aware, stated no, not at all was I aware of this. Surveyor #2 asked what should have been done after the that occurred. The MD stated, that is concerning the resident should get a warning discharge as could cause a huge fire, of course. The surveyor asked about the MD's role in QAPI. The MD stated he attended the quarterly QAPI meeting. The surveyor asked if there was any specific QAPI he was involved with and he stated, no. The surveyor asked

the MD if he had been made aware of the IJ related to the smoking paraphernalia found during multiple

observations, and the surveyor asked if that was a concern. The MD stated, yes, of course this is a concern,

this is the first I am hearing of the IJ. The surveyor asked if the MD had been aware that the resident was found smoking in the bathroom and the MD replied, no. The MD stated he was surprised that he had not been made aware, especially with the piped in oxygen he should have been made aware.

On 01/23/25 at 10:16 AM, in the presence survey team, the surveyor interviewed the LNHA about the QAPI program. The surveyor asked who oversaw the QAPI program and he confirmed he was the QAPI coordinator. The surveyor asked the LNHA to list of the current active QAPIs. The LNHA stated the facility had the following active QAPIs: falls, substance abuse, and smoking. The surveyor reviewed the previously provided QAPIs with the LNHA and asked if the QAPI for smoking was related to the incident on 10/19/24 when the resident was found smoking in the bathroom. The LNHA stated, no, this is what I have. The surveyor asked about the QAPI titled Substance Abuse. The surveyor asked the LNHA what the specifics were related to the goal To implement a program to identify and manage substance abuse, and to reduce incidents and was there any supporting documentation. The LNHA stated the goal was to identify the origin of the issue, to collectively establish and intervention to prevent it. The LNHA stated, he did not have more than the document that was already provided. The surveyor asked the LNHA if significant events and incidents/ reportable events were reviewed at QAPI. The LNHA stated we review finding but we don't necessarily review all incidents. The surveyor asked if the incident with Resident #264 sustaining the injury was reviewed at QAPI and the LNHA stated that was not brought to QAPI, we reviewed the general concept.

The surveyor asked if that incident was considered a significant event, and the LNHA stated, yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 49 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 0865 The Quality Assurance and Performance Improvement Plan policy (undated) revealed: Design and Scope:

The purpose of QAPI in the organization is to take a proactive approach to continually improve the way we Level of Harm - Minimal harm or care for and engage our residents . Feedback, Data Systems and Monitoring: Performance Indictors for all potential for actual harm QAPI Designated goals are evaluated. These indicators can be process and/ or outcome measures. All data will utilize internal and external benchmarking . On a quarterly basis, data will be collected and reported to Residents Affected - Many the QAPI Committee from the following areas: Input from caregivers, residents, families and others, Adverse Events, Performance Indicators

The Administrator's Job Description, signed by the Licensed Nursing Home Administrator (LNHA) on 07/22/24 revealed: The Administrator is responsible for planning and is accountable for all activities and departments of Facility subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs, and coordinates all activities of the facility to assure that the highest degree of quality of care is consistently provided to the residents. 9. Concerns his/herself with the safety of all nursing facility residents in order to minimize the potential for fire and accidents. Also, ensures that the facility adheres to the legal, safety, health, fire and sanitation codes by being familiar with his/her role in carrying out the facility's fire, safety and disaster plans and by being familiar with current MSDS (material safety data sheets).

NJAC 8:39- 33.1 (c)(e); 33.2(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 49 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38079 potential for actual harm Based on observations, interviews, record reviews, and review of pertinent documentation, it was determined Residents Affected - Few that the facility failed to prevent the spread of potential infection by failing to don (put on) Personal Protective Equipment (PPE) prior to entering the room of residents on contact precautions. This deficient practice was identified for 2 of 2 residents (Resident #144 and Resident #147) reviewed for Transmission-based Precautions (TBP).

The deficient practice was evidenced by the following:

1. On 01/15/25 at 8:57 AM, the surveyor observed Resident #144's room with signage outside the door alerting all to stop, Contact Precautions everyone must: . put on gown before room entry, put on gloves

before room entry . There was a three-drawer plastic bin outside of the door with PPE gowns and gloves. At that time, the Registered Nurse Unit Manager (RN/UM) walked past the Licensed Practical Nurse (LPN) who was outside the door and into Resident #144's room. The RN/UM did not don a PPE gown or gloves. The RN/UM placed an item in the resident's drawer.

On 01/15/25 at 8:58 AM, the RN/UM exited the room and stated to the surveyor, I was not doing care. The surveyor asked what the expectation would be when entering a contact precaution room. The RN/UM replied, I have nothing to say, you got me. I should have worn a gown.

On 01/15/25 at 12:11 PM, the surveyor reviewed the Admission Record R) which revealed Resident #144 had diagnoses which included but were not limited to; dependence of respirator ventilator status, and sepsis (an extreme reaction to an infection in the body). A review of the Order Summary Report (ORS) as of 01/14/25, included an order dated 10/25/24, Contact Precaution every shift for C. Auris Colonized (Candida Auris a fungus that can cause multidrug resistant infections). A review of the most recent admission Minimum Data Set (MDS) an assessment tool dated 10/31/24, included a Brief Interview for Mental Status (BIMS) of 00 out of 15 which indicated a severely impaired cognition. A review of the individual comprehensive care plan (ICCP) documented a focus area date initiated 10/24/24, on Contact Precautions related to C-Auris Colonized and interventions included to wear PPE gown and gloves when entering the room.

2. On 1/16/25 at 8:06 AM, the surveyor observed Resident #147'2 room with signage outside the door alerting all to stop, Contact Precautions everyone must: . put on gown before room entry, put on gloves

before room entry . There was a three-drawer plastic bin outside the door with PPE gowns and gloves. The surveyor observed the Registered Dietitian (RD) inside the room and was handling the tube feeding bottle which was hanging up and connected to Resident #147. The RD was not wearing a PPE gown or gloves. Upon exiting the room, the RD was asked about the signage and the resident being on contact precautions.

The RD stated she should have followed the contact precaution sign and wore PPE to prevent spreading infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 49 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 0880 On 1/16/25 at 9:42 AM, the surveyor reviewed the AR which revealed Resident #147 had diagnoses which included but were not limited to; sepsis, dependence on respirator ventilator status, and gastrostomy Level of Harm - Minimal harm or (artificial opening in the stomach for nutritional support). A review of the ORS dated 1/21/25, included the potential for actual harm following physician's orders (PO) dated 1/2/25 for Contact Precautions every shift for positive C. Auris and positive CPO (a bacteria resistant to a class of antibiotics). A review of the most recent quarterly MDS dated Residents Affected - Few [DATE REDACTED], included documentation that a BIMS was not conducted as the resident was not understood. A

review of the ICCP documented a focus area date initiated 11/13/24, on enhanced barrier precaution due to colonized C. Auris and positive CPO gene and an intervention for Contact precaution to wear PPE gowns and gloves when entering the resident room.

A review of the facility provided education revealed the following:

The RD was trained in Infection Control PPE and competency. The training was signed by the RD and the instructor and dated 9/25/24.

The RN/UM was trained on the proper use of PPE which was signed and dated 6/4/24; wearing the appropriate PPE in resident rooms which was signed and dated 6/18/24; Proper use of PPE which was signed and dated 7/22/24; and preventing spread of infection with TBP and the use of PPE which was signed and dated 9/26/24.

A review of the facility provided policy, Infection Control-Standard Precautions, Enhanced Barrier Precautions and Transmission Based Precautions revised 3/22/24, included but was not limited to; the policy to ensure appropriate infection prevention and control measures area taken to prevent the spread of . infections. Contact Precautions shall apply to all residents infected or colonized with an infectious agent . Contact Precautions require the use of gown and gloves every entry into a resident's room .

On 01/21/25 at 9:16 AM, the Director of Nursing (DON) and the Infection Preventionist (IP) were interviewed by the surveyor. The DON and IP both acknowledged that they were made aware of the two above breaches

in infection control. The IP confirmed that the facility currently had an influenza outbreak, and had residents with C. Auris, and with CRE/CPO.

On 1/23/25 at 11:32 AM, the facility administration was made aware of the above concerns regarding infection control.

NJAC 8:39-19.4(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 49 315352