Every finding on record at Accelerate Skilled Nursing and Rehab Piscataway

Repeat Deficiency Based on interviews and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure that the newly hired staff underwent the following a.) 47 of 210 staff for criminal background checks, b.) verification of licenses of 10 of 210 nurses, and c.) verification of certification of 15 of 210 Certified Nursing Assistants (CNAs), check before they began employment at the facility, in accordance with facility's Abuse, Neglect, Exploitation. This deficient practice was evidenced by the following: On 6/1/26, 6/2/26, and 6/3/26, Surveyor #1 reviewed the Human Resources Record (HRR), including the Criminal Background Investigations (CBI) for 47 employees hired since the last recertification survey on 12/3/24. The following concerns were revealed: Employee #1 (E #1), a Certified Nursing Assistant (CNA), began employment on 3/20/25. There was no CBI reported in the file. E#4, a CNA, began employment on 4/3/25. There was no CBI reported in the file. E#6, a CNA, began employment on 4/3/25. There was no CBI reported in the file. E#12, an Activity Aide (AA), began employment on 6/20/25. There was no CBI reported in the file. E#13, a CNA, began employment on 10/2/25. The CBI was reported on 10/6/25. E#15, a CNA, began employment on 2/20/25. There was no CBI reported in the file. E#16, an Assistant Director of Nursing (ADON), began employment on 6/30/25. There was no CBI reported in the file. E#17, a Registered Nurse (RN), began employment on 4/10/25. There was no CBI report. E#18, a CNA, began employment on 8/11/25. There was no CBI reported in the file. E#19, a CNA, began employment on 4/24/25. There was no CBI reported in the file. E#21, a CNA, began employment on 3/27/25. There was no CBI reported in the file. E#22, a CNA, began employment on 3/27/25. There was no CBI reported in the file. E#34, a CNA, began employment on 4/24/25. There was no CBI reported in the file. E #36, a Licensed Practical Nurse (LPN), began employment on 3/27/25. There was no CBI reported on file. E#37, a CNA, began employment on 2/13/25. The CBI was reported on 2/16/26 in the file. E#43, a CNA, began employment on 4/3/25. There was no CBI reported in the file. E#49, a CNA, began employment on 11/13/25. There was no CBI reported in the file. E#50, an LPN, began employment on 2/3/25. There was no CBI reported on file. E#51, a CNA, began employment on 4/3/25. There was no CBI reported in the file. E#53, an RN, began employment on 4/3/25. There was no CBI reported in the file. E#68, a CNA, began employment on 3/28/25. There was no CBI reported in the file. E#77, a CNA, began employment on 4/10/25. There was no CBI reported in the file. E#79, an LPN, began employment on 3/13/25. There was no CBI reported on file. E#80, an LPN, began employment on 4/3/25. There was no CBI reported on file. E#82, an LPN, began employment on 4/10/25. There was no CBI reported on file. E#84, an admission Director (AD), began employment on 2/10/25. There was no CBI reported on file. E#85, a CNA, began employment on 2/27/25. There was no CBI reported in the file E#86, an LPN, began employment on 4/17/25. There was no CBI reported on file. E#89, an LPN, began employment on 3/27/25. There was no CBI reported on file. E#92, a CNA, began employment on 4/3/25. There was no CBI reported in the file. E#119, a CNA, began employment on 1/7/26. The CBI was reported on 11/6/25 in the file. E#121, a CNA, began employment on 10/9/25. The CBI was reported on 10/20/25 in the file. E#124, an Administrative Staff (AS), began employment on 1/2/25. The CBI was reported on 8/6/25 in the file. E#137, an LPN, began employment on 5/1/25. The CBI was reported on 5/5/25 in the file. E#141, a CNA, began employment on 9/18/25. The CBI was reported on 9/19/25 in the file. E#156, a CNA, began employment on 4/17/25. There was no CBI reported in the file. E#157, a CNA, began employment on 9/25/25. The CBI was reported on 9/29/25 in the file. E#161, a Licensed Nursing Home Administrator (LNHA), began employment on 12/8/25. The CBI was reported on 12/16/25 in the file. E#163, an AD, began employment on 1/27/25. The CBI was reported on 8/6/25 in the file. E#173, a Social Service (SS) intern, began employment on 10/22/25. There was no CBI reported on file. E#174, an LPN, began employment on 5/8/25. The CBI was reported on 4/14/26 in the file. E#176, a CNA, began employment on 1/22/26. The CBI was reported on 1/29/26 in the file. E#179, an AS, began employment on 3/24/25. The CBI was reported on 8/11/25 in the file. E#185, a CNA, began employment on 5/9/25. The CBI was reported on 5/27/25 in the file. E#189, an LPN, began employment on 5/1/25. There was no CBI reported on file. E#191, an RN, began employment on 7/8/25. The CBI was reported on 7/14/25 in the file. E#199, a CNA, began employment on 3/26/26. There was no CBI reported on file. On 6/1/26, 6/2/26, and 6/3/26, S#1 reviewed the HRR for 10 Nurses hired since the previous Department of Health Recertification Inspection on 12/3/24. The following concerns were revealed: E#17, an RN, began employment on 4/10/25. No documentation for nursing license verification was present in the employee's file. E#24, an LPN, began employment on 6/19/25. No documentation for nursing license verification was present in the employee's file. E#46, an LPN, began employment on 3/20/25. No documentation for nursing license verification was present in the employee's file. E#53, an RN, began employment on 4/3/25. No documentation for nursing license verification was present in the employee's file. E#79, an LPN, began employment on 3/13/25. No documentation for nursing license verification was present in the employee's file. E#82, an LPN, began employment on 4/10/25. No documentation for nursing license verification was present in the employee's file. E#88, an LPN, began employment on 3/6/25. No documentation for nursing license verification was present in the employee's file. E#189, an LPN, began employment on 3/6/25. No documentation for nursing license verification was present in the employee's file. E#209, an LPN, began employment on 5/6/26. No documentation for nursing license verification was present in the employee's file. E#221, an RN, began employment on 6/12/25. No documentation for nursing license verification was present in the employee's file. On 6/1/26, 6/2/26, and 6/3/26, S#1 reviewed the HRR for 14 CNAs hired since the previous Department of Health Recertification Inspection on 12/3/24. The following concerns were revealed: E#4, a CNA, began employment on 4/3/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #8, a CNA, began employment on 3/20/25. No documentation for Nursing Assistant Certification verification was present in the employee's file. E #10, a CNA, began employment on 5/15/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #15, a CNA, began employment on 20/20/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #19, a CNA, began employment on 4/24/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #34, a CNA, began employment on 4/24/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #44, a CNA, began employment on 2/20/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #47, a CNA, began employment on 3/20/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #81, a CNA, began employment on 3/6/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #85, a CNA, began employment on 2/27/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #92, a CNA, began employment on 4/3/25. No documentation of Nursing assistant certification verification was present in the employee's file. On 6/1/26 at 12:29 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), who both acknowledged that a number of background checks in the employee files were reported and documented after the employee's date of hire. They both acknowledged they had presented all documentation for the 149 employee files under review. On 6/3/26 at 1:18 PM, the survey team met with the LNHA and the DON regarding concerns with employee files. No further information was provided by the LNHA. A review of the facility's policy titled Abuse, Neglect, and Exploitation, with the revised date on 3/26, stated, The components of the facility abuse prohibition plan are discussed herein: 1. A. Potential employees will be screened for a history of abuse, neglect, and exploitation, or misappropriation of residential property. 1. Background reference and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screening may be conducted by the facility itself, a third-party agency, or academic institutions. NJAC 8:39-4.1(a)5; 43.15 On 6/3/26, Surveyor #2 reviewed the Human Resources records, including CBI for employees who were hired since the previous Department of Health Recertification Inspection. The following concerns were revealed. E #119, CNA, began employment on 1/7/26. The CBI was requested by the facility on 11/6/25. E #121, CNA, began employment on 10/9/25. The CBI was requested on 10/20/25. E #124, admission assistant, began employment on 1/2/25. The CBI was requested on 8/6/25. E #137, nurse, began employment on 5/1/25. The CBI was requested on 5/5/25. E #141, CNA, began employment on 9/18/25. The CBI was requested on 9/19/25. E #169, nurse, began employment on 1/19/26. The CBI was not provided. E #179, administrative assistant, began employment on 3/24/25. The CBI was requested on 8/11/25. E #189, nurse, began employment on 5/1/25. The CBI was not provided. NJAC 8:39-4.1(a)5

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) Residents' nebulizer mask and tubing were stored in a clean and sanitary manner, b.) was dated, and c.) Physician's Order (PO) for Oxygen was obtained. This deficient practice was identified for 3 of 3 residents, (Resident #4, #5 and #45), reviewed for respiratory care and was evidenced by the following: 1. On 5/28/26 at 10:57 AM, the surveyor observed Resident #5 was not in their room. The surveyor observed a nebulizer mask, attached to the tubing was draped on top of the bedside table and the same tubing was undated. The surveyor reviewed the medical record for Resident #5. According to the admission Record, face sheet, an admission summary, reflected that Resident #5 was admitted to the facility with diagnoses that included the following: acute bronchitis, asthma dementia, chronic kidney disease, nephrostomy catheter (4/3/26). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD; end point of the clinical look-back observation period) of 3/18/26. The Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15, which indicated the resident was cognitively intact. Section O0400 Therapies reflected that the resident was administered Respiratory Therapy at least 15 minutes a day within the A review of the Care Plan included a focus for Resident #5's respiratory complications related to asthma, presence of pulmonary embolism, acute bronchiolitis due to respiratory syncytial virus dated/revised on 3/14/26. The interventions included administration of aerosols as ordered and as indicated, dated 3/11/26. A review of the physician orders included an order for the following: - Ipratropium Albuterol inhalation, inhale two (2) times a day for acute bronchitis, maximize bronchodilation, scheduled for 9:00 AM and 4:00 PM. The order was initiated on 3/12/26. -Replace (if used) and date nebulizer tubing and mouthpiece every Monday for infection control. The order was initiated on 3/16/26. A review of the electronic Treatment Administration Record (eTAR) reflected a PO dated 3/16/26, Replace nebulizer tubing and mouthpiece/mask, every Monday. The eTAR revealed missing nursing documentation for the replacement of them nebulizer mask and tubing on 5/11/26 and 5/25/26. On 5/28/26 at 11:04 AM, during an interview with the surveyor, in Resident #5's room, the Licensed Practical Nurse (LPN) confirmed the observation of the nebulizer mask, and tubing on top of the bedside table. The LPN also could not state the date of when the nebulizer tubing was last changed since the same tubing was not dated. At that time, LPN stated that the nebulizer mask and tubing should have been placed in a sterile packaging for infection control. At that time, the LPN stated that the tubing should have been dated. The LPN also stated that she would remove, replace and date the new mask attached to the nebulizer tubing. On 6/1/26 at 12:40 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA)and the Director of Nursing (DON), the surveyor discussed the concern with the mask and nebulizer tubing that was stored on top of the side dresser and the same tubing that was undated. At that time, the DON stated that the mask and tubing should have been placed in a bag, and the same tubing should have been dated. No further information was provided. A review of the facility provided policy, dated 2026 reflected for nebulizer treatment, once ordered, to be administered by nursing staff as directed using proper technique and standard precaution. Change nebulizer tubing every seventy-two hours or per facility policy. 2. On 5/28/26 at 11:10 AM, the surveyor observed Resident #45 sitting in a chair at the bedside, alert and verbally responsive. Resident #45 was receiving oxygen via a nasal cannula (NC; plastic prongs attached to a tube inserted into the nostrils that oxygen flow through) which was attached to a wall oxygen flow meter (an oxygen delivery system) at 3 liters per minute (LPM). Resident #45 stated they used oxygen daily throughout the day. On 5/29/26 at 9:14 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #45. The admission Record (a summary of important resident information) revealed Resident #45 had diagnoses that included but were not limited to, myocardial infarction (heart attack), respiratory disorders (in diseases classified elsewhere) and obstructive sleep apnea. A Comprehensive Minimum Data Set assessment, a tool used to facilitate management of care, dated 5/10/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #45 scored 14 out of 15, which indicated the resident was cognitively intact. A review of the physician's orders for Resident #45 revealed there were no orders for oxygen. A review of the resident's care plans revealed no documentation regarding the use of oxygen therapy. On 5/29/26 at 11:01 AM, the surveyor observed Resident #45 sitting in their room, eating oatmeal. The resident had a NC resting on their lap while they ate. The NC was connected to the wall oxygen flowmeter on 3 LPM. On 5/29/26 at 11:18 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to care for Resident #45. The LPN stated there should be a physician's orders for oxygen therapy if in use. The surveyor informed the LPN of the concern Resident #45 had oxygen in use and there was no physician's order. The LPN stated she would review and follow up with the physician. On 5/29/26 at 11:56 AM, the surveyor informed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) of the concern that there was no physician's order for Resident #45's oxygen therapy. There was no verbal response at this time. On 6/1/26 at 9:22 AM, the LNHA, and the DON met with the survey team. The DON stated the concern of there being no physician's order for Resident #45's oxygen was addressed. There was no additional information provided by the facility. 3. On 5/29/26 at 9:44 AM, the surveyor reviewed the EMR of Resident #4. The admission Record documented that the resident had diagnoses that included but were not limited to end stage renal [kidney] disease, dependence on renal dialysis, obstructive sleep apnea, congestive heart failure, and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, dated 5/12/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 15 out of 15, which indicated the resident was cognitively intact. A physician's order dated 5/5/26 indicated for Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml), give 3 ml inhale orally via nebulizer every 6 hours for COPD [Chronic Obstructive Pulmonary Disease]. A review of the May 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no documentation for nebulizer tubing change. On 5/29/26 at 11:03 AM, the surveyor observed Resident #4 was not in their room. The resident's assigned Registered Nurse (RN) stated the resident had left for dialysis outside of the facility. On 5/29/26 at 11:30 AM, the Registered Nurse (RN) accompanied the surveyor to observe Resident #4's room. While in the room, the surveyor observed a nebulizer machine. The RN observed the date on the nebulizer tubing with the surveyor and confirmed the written date as 5/09/26. The RN stated nebulizer tubings were changed weekly and acknowledged it should have been changed. On 5/29/26 at 11:56 AM, the surveyor informed the DON of the above concern. The DON confirmed that nebulizer tubing was to be changed weekly and as needed. The surveyor requested policies relating to nebulizer tubing. On 6/1/26 at 9:22 AM, the LNHA and the DON met with survey team. The DON stated the nebulizer tubing concerns were addressed. There was no additional information provided by the facility. A review of the facility's provided policy titled Oxygen Administration. with a last reviewed date of 2/4/26 revealed: Under Policy, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Under Policy Explanation and Compliance Guidelines of the policy revealed: 1. Oxygen is administered under orders of a physician, except in case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable. 5b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. 5d. If applicable, change nebulizer tubing and delivery devices as needed if they become soiled or contaminated. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to: a) ensure timing of a resident's medication was adjusted to accommodate their dialysis (a treatment that filters waste and fluid from your blood when your kidneys are failing) schedule, for 3 of 3 residents (Resident #4, #9, and #45); and b) consistently complete post dialysis assessments for 2 of 3 residents (Resident #4 and #45), reviewed for dialysis services. 1. On 5/29/26 at 9:44 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #4. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to end stage renal [kidney] disease, dependence on renal dialysis, obstructive sleep apnea, congestive heart failure, diabetes mellitus type II (DMII), and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS) assessment, an assessment tool used to facilitate the management of care, dated 5/12/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 15 out of 15, which indicated the resident was cognitively intact. A physician's order dated 5/5/26 indicated for Admelog Solostar Subcutaneous Solution Pen-Injector 100 unit/milliliter, give 15 units subcutaneously with meals three times a day for DMII. The medication was scheduled to be given at 8 AM, 12 PM, and 5 PM. A physician's order dated 5/5/26 indicated for Ipratropium-Albuterol Solution (Duoneb) 0.5-2.5 (3) milligram (mg)/3 milliliter (ml), give 3 ml inhale orally via nebulizer every 6 hours for COPD [Chronic Obstructive Pulmonary Disease]. The medication was scheduled to be given at 12 AM, 6AM, 12 PM, and 6 PM. A physician's order dated 5/5/26 indicated for Sodium Zirconium Cyclosilicate (Lokelma) oral packet 10 grams, give one packet by mouth in the afternoon for hyperkalemia (elevated level of potassium in the blood) inhibitor. The medication was scheduled to be given at 2 PM. A physician's order dated 5/13/26 indicated the resident had dialysis on Monday, Wednesday and Friday at 11 AM. A review of the May 2026 Medication Administration Record (MAR) revealed the above medications had entries signed AW [away from center] and were timed when the resident would be out of the facility at dialysis as follows: For the Admelog insulin order entry, the 12 PM dose was signed AW on 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26, 5/20/26, 5/22/26, 5/25/26, and 5/27/26. A review of progress notes revealed one note for Admelog administration dated 5/15/26 which documented the resident was at dialysis. For the Duoneb order entry, the 12 PM dose was signed as AW on 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/20/26, 5/22/26, 5/25/26, and 5/27/26. A review of progress notes, revealed no additional information regarding the medication not being administered. For the Lokelma order entry at 2PM, was signed as AW on 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26, 5/18/26, 5/20/26, 5/22/26, 5/25/26, and 5/27/26. A review of progress notes revealed two notes for Lokelma dated 5/15/26 and 5/18/26 which indicated the resident was at dialysis. On 5/29/26 at 11:03 AM, the surveyor observed Resident #4 was not in their room. The Registered Nurse (RN) who was the resident's assigned nurse stated the resident had left for dialysis outside of the facility. On 5/29/26 at 11:07 AM, the surveyor interviewed the RN who stated a dialysis resident's medications were timed around their dialysis session. The RN confirmed there was dialysis communication book that was sent with the resident. The RN explained that the binder had a hemodialysis communication record (HCR) form which was completed for each dialysis session. The top portion of the form was completed by the sending nurse at the facility, middle portion of the form was completed by the dialysis center, and the bottom portion was completed by the facility nurse receiving the resident from dialysis. On 5/29/26 at 11:30 AM, the surveyor informed the RN about the concern with above medication entries signed as AW and timed when the resident was scheduled to be at dialysis. The RN stated it would be reviewed and discussed with the Director of Nursing (DON). On 5/29/26 at 11:56 AM, the surveyor informed the DON of the above concerns with Resident #4's medications. On 6/1/26 at 9:22 AM, the Licensed Nursing Home Administrator (LNHA) and the DON met with the survey team. The DON stated the medication timing was reviewed and adjusted to accommodate the residents' dialysis times. On 6/2/26 at 11:25 AM, the surveyor reviewed the dialysis communication book for Resident #4 at the nurses' station which revealed the post dialysis section on the HCR was signed by the nurse but not fully completed on: 5/8/26, 5/13/26, 5/15/26, 5/18/26, 5/20/26, 5/22/26, 5/25/26, 5/27/26, and 5/29/26. A review of the progress notes for documentation of post dialysis assessment for the above identified dates revealed there was no post dialysis assessment note found for 5/8/26, 5/15/26, 5/18/26, 5/22/26, and 5/27/26. On 6/2/26 at 1:31 PM, the surveyor informed the LNHA and the DON of the concern that Resident #4's post dialysis assessments were not being consistently documented in the HCR or progress notes. On 6/3/26 at 9:38 AM, the LNHA and the DON met with the survey team. The DON acknowledged it was expected for the nurses to complete the post dialysis assessment on the HCR; if they could not fill out the HCR the nurses were expected to document a progress note about the resident's status upon return from dialysis. 2. On 5/28/26 at 11:10 AM, the surveyor observed Resident #45 sitting in a chair at the bedside, alert and verbally responsive. Resident #45 stated they received dialysis and had a right chest permacath (a tunneled, long-term central venous catheter for receiving dialysis). On 5/29/26 at 9:14 AM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #45. The admission Record (a summary of important resident information) revealed Resident #45 had diagnoses that included but were not limited to, end stage renal [kidney] disease, dependence on renal dialysis, myocardial infarction (heart attack), respiratory disorders (in diseases classified elsewhere) and obstructive sleep apnea. A Comprehensive MDS assessment dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #45 scored 14 out of 15, which indicated the resident was cognitively intact. A physician's order dated 5/6/26 indicated to give Bumetanide 2 milligram (mg) one tablet by mouth one time a day for fluid retention. The medication was scheduled to be given at 9 AM. A physician's order dated 5/5/26 indicated for Humalog KwikPen Subcutaneous Solution 100 unit/ml to inject units of insulin as per the indicated sliding scale, subcutaneously four times a day for DMII. The medication was scheduled to be given at 7AM, 11 AM, 5 PM, and 9 PM. A physician's order dated 5/3/26 indicated for Insulin Glargine (Lantus) Subcutaneous Solution Pen injector 100 unit/ml, to inject 10 units subcutaneously in the morning for diabetes. The medication was scheduled to be given at 6 AM. A physician's order dated 5/3/26 indicated for midodrine 5 mg oral tablet, to give one tablet by mouth every 8 hours for hypotension; hold for systolic blood pressure greater than 130. The medication was scheduled to be given at 6 AM, 2 PM, and 10 PM. A physician's order dated 5/3/26 indicated for ocuvite oral capsule, give one capsule by mouth one time a day for supplement. The medication was scheduled to be given at 9 AM. A physician's order dated 5/3/26 indicated for oxycodone 10 mg extended-release tablet, give one tablet by mouth every 12 hours for moderate to severe pain. The medication was scheduled to be given at 9 AM and 9 PM. A physician's order dated 5/3/26 indicated for Protonix delayed release 40 mg tablet, give one tablet by mouth two times a day for esophageal reflux. The medication was scheduled to be given at 6 AM and 6 PM. A physician's order dated 5/4/26 indicated for Vitamin D3 250 microgram tablet, give one tablet by mouth one time a day every Monday for supplement. The medication was scheduled to be given at 9 AM. A physician's order dated 5/3/26 indicated the resident was scheduled for dialysis on Monday, Wednesday, and Friday at 5:30 AM with a pick up time of 5 AM. A review of the May 2026 MAR revealed the above medications had entries signed AW[away from center] and/or were timed when the resident would be out of the facility at dialysis as follows: For the Bumetanide order entry, the 9 AM dose was signed as AW and not administered on 5/18/26. For the Humalog insulin order entry, the 7 AM dose was signed AW and not administered on 5/6/26, 5/8/26, 5/11/26, 5/13/26, 5/15/26, 5/18/26, 5/20/26, 5/22/26, 5/25/26, 5/27/26, and 5/29/26. For the Lantus insulin order entry, the 6 AM dose was signed AW and not administered on 5/6/26, 5/13/26, 5/18/26, 5/20/26, 5/22/26, and 5/27/26. For the Midodrine order entry, the 6 AM dose was signed as AW and not administered on 5/6/26, 5/13/26, 5/18/26, and 5/22/26. For the Ocuvite order entry, the 9 AM dose was signed as AW and not administered on 5/4/26 and 5/18/26. For the Oxycodone order entry, the 9 AM dose was signed as AW and not administered on 5/4/26 and 5/18/26. For the Protonix order entry, the 6 AM dose was signed as AW and not administered on 5/6/26, 5/13/26, and 5/18/26. For the Vitamin D3 order entry, the weekly 9 AM dose was signed as AW and not administered on 5/18/26. On 5/29/26 at 11:01 AM, the surveyor observed Resident #45 sitting in their room eating oatmeal. Resident #45 reported they had just returned from their dialysis session. On 5/29/26 at 11:07 AM, the surveyor interviewed the RN who stated a dialysis resident's medications were timed around their dialysis session. The RN confirmed there was dialysis communication book that was sent with the resident. The RN explained that the binder had a hemodialysis communication record (HCR) form which was completed for each dialysis session. The top portion of the form was completed by the sending nurse at the facility, middle portion of the form was completed by the dialysis center, and the bottom portion was completed by the facility nurse receiving the resident from dialysis. On 5/29/26 at 11:18 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to care for Resident #45. The LPN confirmed the resident had returned from dialysis almost 11 [11 AM]. The LPN acknowledged medications should be timed around dialysis. The surveyor informed the LPN of the concern that resident medications were signed AW and timed when the resident was at dialysis. The surveyor asked what would a nurse do if there was routine medication timed for when the resident was at dialysis. The LPN replied they would wait until the resident came back to see if the medication could be administered. The surveyor asked if there was anything else that would be done by the nurse. The LPN replied they were not sure if any other actions that should be taken by the nurse. On 5/29/26 at 11:56 AM, the surveyor informed the DON of the above concerns with Resident #45's medications. On 6/1/26 at 9:22 AM, the Licensed Nursing Home Administrator and the DON met with the survey team. The DON stated medication timing was reviewed and adjusted accommodate the resident's dialysis times. On 6/2/26 at 11:25 AM, the surveyor reviewed the dialysis communication book for Resident #45 at the nurses' station which revealed: The post dialysis section of the HCR was signed by the nurse but not fully completed on: 5/4/26, 5/8/26, and 5/27/26. A review of the progress notes for documentation of post dialysis assessment for the above identified dates revealed there was no post dialysis assessment note found for 5/8/26. The post dialysis section of the HCR documented an assessment of an arteriovenous (AV) shunt (a type of dialysis access site) on the following dates: 5/6/26, 5/11/26, 5/15/26, 5/20/26, 5/22/26, and 5/25/26. Resident #45 had a right chest permacath and did not have an AV shunt. On 6/2/26 at 1:31 PM, the surveyor informed the LNHA and the DON of the concern that Resident #4's post dialysis assessments were not being consistently documented as completed in the HCR or progress notes. On 6/3/26 at 9:38 AM, the LNHA and the DON met with the survey team. The DON acknowledged it was expected for the nurses to complete the post dialysis assessment on the HCR; if they could not complete the HCR the nurses were expected to document a progress note about the resident's status post dialysis. 3.) On 5/28/26 at 11:21 AM, the surveyor observed that Resident #9 was not in their room. On 5/28/26 at 11:26 AM, during an interview with the surveyor, LPN #3 stated that Resident #9 was out of the facility and was at the dialysis center. On 6/2/26 at 9:46 AM, the surveyor reviewed the medical record for Resident #9. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: end stage renal (kidney) disease and dependence on renal dialysis. A review of the significant change Minimum Data Set (MDS), an assessment tool, dated 4/28/25, reflected a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. Section N- Medication, under High-Risk Drug Classes: Use and Indication included that Resident #9 was taking an anticoagulant, and the indication was noted. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 3/18/26, that the resident was at risk for complications related to failed kidney transplant, presence of lower left quadrant peritoneal dialysis catheter and dependence on renal dialysis. Interventions included: Monitor external hemodialysis catheter and site for catheter integrity, excessive redness, swelling, pain at site, sign and symptoms of infection and excessive bleeding from sure and report to physician as indicated, dated 3/18/26. Special instructions reflected the resident went to dialysis on Tuesday, Thursday, and Saturday with a chair time (appointment time) of 11:30 AM. The ICCP did not include any interventions to schedule medications around the resident's scheduled dialysis times. A review of the May 2026 electronic Medication Administration Record (eMAR) included the following Physician's Orders (PO): A PO, dated 4/23/26, for Heparin 5000 units/milliliters (ml), inject 5000 units subcutaneously every 8 hours for clotting prevention, was scheduled to be administered at 5:00 AM, 1:00 PM, 4:00 PM and 9:00 PM. Further review of the eMAR reflected Heparin 5000 scheduled for 1:00 PM was documented by the nurse, as away from the center and not administered on the following dates: 5/7/26, 5/9/26, 5/12/26, 5/14/26, 5/19/26. 5/21/26, 5/23/26, 5/26/26 and 5/28/26. A PO, dated 5/22/26 for Nepro (nutritional supplement) 8 ounces, two times a day, was scheduled to be administered at 2:00 PM, and 8:00 PM. Further review of the eMAR revealed that the Nepro scheduled at 2:00 PM was documented by the nurse, as away from the center and not administered on 5/27/26. On 6/2/26 at 1:32 PM, during a meeting with the survey team, the LNHA and the DON, the surveyor discussed the concern with Resident #9's PO for Heparin and Nepro that were not scheduled to accommodate the Resident's dialysis times. On 6/3/26 at 9:37 AM, during a meeting with the survey team, the DON stated that scheduled administration for the Heparin and Nepro were adjusted to accommodate Resident #9's dialysis schedule. On 6/3/26 at 10:12 AM, during an interview with the surveyors, Resident #9 confirmed that while they were at the dialysis center the Heparin 5000 dose and the Nepro were not administered. On 6/3/26 at 10:29 AM, during an interview with the surveyors, LPN #4 confirmed and acknowledged that medications should have been scheduled and administered to accommodate the resident's dialysis schedule. A review of the facility provided policy, titled Hemodialysis, dated/revised on 2025 included that the facility will provide the necessary care and treatment consistent with professional standard of practice, physician orders, the comprehensive person-centered care plan and resident's goals and preference to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis NJAC 8:39 - 27.1 (a)

Based on observation, interview, and record review, it was determined the facility failed to ensure that a resident with a known history of trauma who experienced flashbacks, received care and services in accordance with standards of practice, which accounted for their past experiences to minimize or prevent the risk of re-traumatization. This deficient practice was identified for 1 of 1 sampled resident reviewed for behavioral and emotional health needs (Resident #1). On 5/28/26 at 11:11AM, during the initial tour of the facility, the surveyor observed the Resident #1 in their room, in bed, which was in a low position, the room was dark, and the lights were off. At that time, Resident #1 stated they did want to be bothered.On 5/28/26 at 11:47 AM, during an interview with the surveyor, Licensed Practical Nurse (LPN) stated she worked on both sides of the floor where Resident #1 resided. The LPN also stated that the facility had a psychologist and psychiatrist that saw the residents when needed. The LPN stated she was not aware of a resident with a diagnosis PTSD.The surveyor reviewed the medical record for Resident #1According to the admission record, an admission summary, reflected that Resident #1 was admitted to the facility with diagnoses that included, major depressive disorder, adjustment disorder, insomnia, and post-traumatic stress disorder (PTSD).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/17/26 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Section D for Mood reflected that an interview was conducted and was assessed; In the last two weeks of the assessment, Resident #1 had not reported feelings of having little pleasure in doing things, feelings of being down, depressed and/or hopelessness.Further review of the MDS dated [DATE], 1/17/26, 10/16/25 and 7/17/25, Section I- Active Diagnoses, under psychiatric/mood disorder included PTSD. A review of the 7/10/25, Social Services Assessment under Trauma History, reflected that the resident did not report or the medical record did not indicate history of PTSD.According to 7/16/25, initial psychiatric consultation (psych consult), Resident #1 was shot three (3) times in their life by a gang related violence and was diagnosed with PTSD. Further review of the psych consult revealed Resident #1 reported having flashbacks of being shot in 2001, 2007 and 2013.A review of the following psychiatric consultation for the following dates: 8/12/25, 10/16/25, 12/1/25, 2/6/26, and 4/22/26, did not address Resident #1's diagnosis of PTSD.A review of Resident #1's individualized comprehensive care plan (ICCP) did not identify strategies to manage their symptoms of PTSD, and the delivery of trauma informed care to eliminate or mitigate triggers and preferences, which may cause re-traumatization under focus, interventions, and goals.A review of the 7/10/26, Social Services Assessment and Documentation under Trauma History reflected that the medical record did not reflect any history of trauma and/or PTSD.On 6/1/26 at 11:11 AM, during an interview with the surveyors, the Licensed Social Worker/Director of Social Services (LSW/DSS) stated that within 48 to 72 hours she conducted psychosocial assessments that included collection of historical data. The interdisciplinary team met with and created an individualized baseline care plan for the Resident within 14 days of admission.On 6/2/26 at 11:02 AM, during an interview with the surveyor, the Registered Nurse/MDS-Coordinator stated that they were responsible for Section I of the MDS that indicated the active diagnosis of PTSD. The MDS-C also stated that Section I -Active Diagnoses of the MDS gave insight into the resident's clinical needs and after the clinical needs were determined, that information was transferred into the Residents ICCP.On 6/2/26 at 1:32 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing, the surveyor discussed the concern with the care and services for Resident #1 that did not include trauma informed care, identification, minimizing/elimination of triggers, creation of an ICCP and the resident's preferences. The surveyor also discussed the concern with the gaps in care that continued even though the psychiatrist diagnosed the resident with PTSD during their initial encounter in 7/16/25 and four (4) assessments made by the MDS team, against the professional standards of practice.On 6/3/26 at 9:37 AM, in the presence of the survey team and the LNHA, during a meeting, the DON stated that in response to the surveyor's inquiry, Resident #1 was scheduled for an appointment with the psychiatric provider later that day, to address the PTSD diagnosis.A review of the facility provided policy, titled Trauma Informed Care, dated/revised 3/2026 reflected: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. NJAC 8:39-27.1 (a), 28.1 (c)

Based on interviews with facility staff and a review of facility-provided documentation, it was determined that the facility failed to ensure the nursing staff possessed and maintained the appropriate competencies and skills to provide nursing care to the facility's residents for 5 of 5 nursing employees reviewed. This deficient practice was evidenced by the following: On 6/1/26 at 10:20 AM, the surveyor requested documentation of nursing competencies and annual performance evaluations for five nurses selected from the facility's provided active employee roster. On 6/2/26 at 10:07 AM, the team of surveyors met with the Director of Nursing (DON) and provided 5 forms titled Nurse Annual Competency Checklist with the handwritten names of 5 nurses on top of the form and the date below, signed by the nurse as final review. The DON did not provide an in-service sign-in sheet that reflected for each subject or skill for each nursing competency performed, and the time of the in-service, or hours credited to the attendees of the in-service. The DON confirmed with the surveyor the following: Employee #1 (E#1), a Licensed Practical Nurse (LPN), hired on 2/27/25, had no competencies or evaluations on file. E#2, a Registered Nurse (RN), hired on 9/23/24, had no competencies or evaluations on file. E#3, an LPN hired on 1/30/18, had no competencies or evaluations on file. E#4, an LPN hired on 5/15/25, had no competencies or evaluations on file. E#5, an LPN hired on 3/5/24, had no competencies or evaluations on file. On 6/3/26 at 9:39 AM, the team of surveyors met with the Licensed Nursing Home Administrator and the DON regarding the above concern. There is no additional information provided, including the policy for nursing competencies. NJAC 8:39-25.1; 25.2(a), (b); 26.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) quality control testing (QCT; a process to verify the functionality and accuracy of results) of the blood glucose meter (BGM; a medical device that measured the approximate concentration of sugar in the blood, often used for insulin dosing) were consistently conducted and the BGM tested had an identifier for 3 of the 4 carts reviewed, b.) label and store medication in accordance with acceptable professional standards for 2 of the 4 carts reviewed and 1 of 3 residents reviewed for respiratory care, and c.) expired and discontinued medications and were removed from active inventory for 1 of 1 medication room inspected. This deficient practice was evidenced by the following: 1.) On 6/3/26 at 10:59 AM, during the inspection of the third-floor cart 3C, the surveyor, in the presence of Licensed Practical Nurse (LPN #1), observed two (2) BGM. The surveyor and LPN #1 reviewed the QCT log which reflected one (1) meter was tested on [DATE].At that time, the surveyor asked LPN #1 which of the BGM was tested and the LPN could not find an identifier on both BGM to correspond with the QCT log. LPN #1 stated she did not perform the QCT that morning and was unsure who was responsible to ensure the BGM functioned properly and provided accurate results.On 6/3/26 at 11:55 AM, during an interview with the surveyor LPN #1 stated she would inform the Unit Manager that the QCT was not performed on 6/2/26 and 6/3/26 and the missing identifier to show which meter was tested, prior to use with the residents.2.) On 6/3/26 at 11:45 AM, during the inspection of the third-floor cart D, the surveyor, in the presence of LPN #2 observed two (2) BGM. The surveyor and LPN #2 reviewed the QCT log which reflected one (1) meter was last tested on [DATE]. At that time, the surveyor asked LPN #2 which of the BGM was tested and the LPN could not find an identifier on either BGM to correspond with the QCT log. 3.) On 6/3/26 at 12:33 PM, during the inspection of the second-floor cart A, the surveyor, in the presence of the Registered Nurse (RN) observed two (2) BGM. The surveyor and the RN reviewed the QCT log which reflected one (1) meter was last tested on [DATE]. At that time, the surveyor asked LPN #2 which of the BGM was tested and the RN could not find an identifier on either BGM to correspond with the QCT log. The RN could not state why the machines were not tested since 10/27/25.On 6/3/26 at 1:17 PM, during a meeting with the survey team the surveyor discussed the concern with the three (3) of the four (4) medications carts inspected revealed QCT were not consistently performed, the two BG monitors found on each medication carts had no identifier to determine which of the BGM was checked for functionality and accuracy.No further information was provided. 4.) On 5/28/26 at 10:57 AM, the surveyor observed an opened and undated sodium chloride (NaCl) in Resident #5's room, on the center console.On 5/28/26 at 10:59 AM, during an interview with the surveyor, theLicensed Practical Nurse (LPN #3) confirmed and acknowledged the observation of the opened and undated NaCl that was left in the resident's room on the center console. At that time, LPN #1 stated she did not provide treatment to the resident that day although she was assigned to the resident that day. At that time, LPN #1 stated that the NaCl was a one-time use, for treatment, and should have been discarded after use. LPN #1 could not state when the NaCl was opened. LPN #3 also stated she would discard the opened and undated NaCl.On 6/1/26 at 12:40 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, and the DON, the surveyor discussed the concern with the opened and undated NaCl found in Resident #5's room. At that time, the DON stated that the opened and undated NaCl should have been discarded after use.5.) On 6/3/26 at 12:03 PM, during the inspection of the third-floor cart D, the surveyor, in the presence of LPN #2 observed the following:- opened and undated Insulin Lispro (fast acting manmade insulin used to lower high blood sugar) without a pharmacy label and had Resident #5's name handwritten on the bottle.- opened and undated protein supplement [brand redacted]At that time, the LPN could not identify when both medications were opened and without a documented opened date, she could not identify when they both expired. The LPN stated that the insulin expired 30 days from the date it was opened and that protein supplement expired 90 days from the date it was opened. The LPN stated she did not open either medication, both medications should have been dated when opened, would remove both medications from her cart and inform her supervisors of the findings.6.) On 6/3/26 at 11:08 AM, the surveyor, in the presence of LPN # 1, during the inspection of the third-floor cart C, observed Unsampled Resident #125's Medrol Dose Pak (steroid). LPN #2 stated Resident #125 had been discharged but could not recall when. LPN #1 further stated that the nurse who discharged the resident should have removed the medication from the medication cart. At that time, LPN #2 stated that she would remove the medication stored with active inventory to avoid medication error administration.A review of the admission Record, face sheet, an admission summary reflected Resident #125 was discharged from the facility on 4/26/26.7.) On 6/3/26 at 11:19 AM, the surveyor, in the presence of LPN #1 entered the medication room on the third floor and began the inspection of the refrigerator. A review of the refrigerator log reflected that temperature was checked daily and was within range.The freezer portion of the refrigerator had frost, and the refrigerator contained the following:- Resident #61's Vancomycin eye drops (antibiotic), labeled with a use by date of 3/8/26.-Resident #123's Potassium Chloride 40 milliequivalent (KCl 40 meq) in Dextrose 5% in water (D5W) intravenous (IV) to run at a rate of 75 milliliters /1 hour (ml/hr), labeled with a use by date of 5/20/26. The IV was frozen.-Resident #123's KCl 40meq in D5W IV to run at the rate of 75ml/hr, labeled with a use by date of 5/30/26.- Resident #123's KCl 40meq in D5W IV to run at the rate of 75ml/hr, labeled with a use by date of 6/1/26.On 6/3/26 at 11:25 AM, LPN #1 confirmed and acknowledged that Resident #61's Vancomycin eye drops were expired, Resident #123 KCl in D5W were all expired and the one (1) of three (3) was frozen. At that time, the LPN stated she would let the Assistant Director of Nursing and the DON of the expired medication and the refrigerator with the frost.On 6/3/26 at 1:17 PM, during a meeting with the survey team the surveyor discussed the concern with the opened and undated insulin, and protein liquid supplements that were opened and undated medications found in the medication cart, discharged resident's medication that was stored in the medication cart wherein one (1) of four (4) was found frozen, intermingled with the active inventory and expired medications found in the refrigerator. At that time, the LNHA confirmed that the refrigerator had been temporarily replaced with a newly functioning refrigerator.A review of March 2026, Consultant Pharmacist report reflected that there were no expired medications in the refrigerators.A review of April 2026, CP reflected that there were expired medications in the refrigerator, noted the Vancomycin and cart C did not have expired or discontinued prescription in the medication cart.A review of May 2026, CP reflected that there were no expired or discontinued medications in the refrigerator, noted the Vancomycin, and cart C did not have expired or discontinued prescription in the medication cart.On 6/4/26 at 9:57 AM, during a meeting with the survey team the surveyor discussed the concern with the expired and discontinued medications observed that was also reflected in the CP reports for April 2026 and May 2026.No further information was provided.A review of the facility provided policy titled, Blood Glucose Monitoring, dated/revised 3/26 included that calibration checks on glucometers must be performed as per manufacturer's instructions [the frequency per shift was left blank].A review of the facility provided policy titled, Medication Storage, dated/revised 2/11/26 included: The facility ensured all medications in the facility would be stored in the pharmacy and medication rooms in accordance with the manufacturer's recommendations and sufficient to ensure proper sanitation temperature, light, ventilation, moisture control, segregation, and security. The pharmacy and all medication rooms were routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with the facility's destruction policy. N.J.A.C. 8:39-29.4 (d)3(f)(g)(h)

Based on interviews of facility staff and review of facility-provided documentation, it was determined that the facility failed to ensure and document that all Certified Nursing Assistants (CNAs) completed 12 hours of in-service training, including the topics of preventing resident abuse, dementia management, and areas of weakness identified in the individual CNA's annual review for 5 of 5 CNA employees reviewed.This deficient practice was evidenced by the following: On 6/1/26 at 10:20 AM, the surveyor requested documentation of annual training records for five selected CNAs from the facility's provided active employee roster. The DON provided the surveyor with 3 out of 5 CNAs selected for annual training. On 6/2/26 at 10:07 AM, the team of surveyors met with the Director of Nursing (DON) and provided 3 forms titled Certificate of Completion with the names of 3 CNAs and the date signed below. The DON confirmed with the surveyor the following: Employee#1 (E#1), a CNA, hired on 5/15/25, had 5.3 hours in Part 1, dated 9/6/25, and in Part 2, 5.65 hours dated 9/22/25, with a total of 10.98 hours of annual training. E#2, a CNA hired on 9/12/24, had 5.3 hours in Part 1, dated 7/25/25, and in Part 2, 5.65 hours dated 7/25/25, with a total of 10.98 hours of annual training. E#3, a CNA hired on 5/18/21, had 5.3 hours in Part 1, dated 7/25/25, and in Part 2, 5.65 hours dated 7/25/25, with a total of 10.98 hours of annual training. E#4, a CNA hired on 6/11/24, had no documentation of annual training provided. E#5, a CNA hired on 7/9/24, had no documentation of annual training provided. On 6/3/26 at 9:39 AM, the team of surveyors met with the Licensed Nursing Home Administrator and the DON regarding the above concern. The DON stated that they cannot pull out the file of the dates of the CNAs' training from their system. She added that the CNAs can do their training anytime during their spare time, but did not provide further documentation of the in-service signing sheet, including the policy for CNAs' annual training. NJAC 8:39-43.17

Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to treat the residents with a respectful manner and dignity by allowing them to wear their own clothes and to be served with meals together with other residents during mealtimes for 1 (one) of 22 residents (Resident #47) who had a review for dining observation. This deficient practice was evidenced by the following: On 5/29/26 at 12:02 PM, the surveyor observed that the staff were serving food trays for all the residents getting lunch from the 2nd-floor main dining room. The residents are observed eating their meals at this time. On the same day at 12:03 PM, the surveyor observed that the Certified Nurse Assistant (CNA#2) was feeding Resident #2 while the unsampled Resident#47 was on the other side of the same table and had no meal tray. Resident#47 was out of bed to the geriatric chair, wearing a gown, and was grabbing the tray of Resident#2, who was at the same table, in the presence of CNA #2. The surveyor interviewed CNA#2, who stated that the tray of Resident #47 is not in the truck of food, and it will come soon because there are batches of trucks coming to the 2nd floor. Not at the same time. On 5/29/26 at 12:22 PM, the surveyor observed that Resident #47's lunch tray came, and CNA#1, who is assigned to the resident, stated that the resident is a feeder and added that there are no clothes in the resident's room after the surveyor asked why the resident is not wearing their own clothes. On the same day, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and the CNA#1regarding the lunch tray, which was not available to Resident #47 at this time, but did not provide further information. On 5/29/26 at 12:31 PM, the surveyor interviewed the LPN/UM, who interpreted for Resident #47, who spoke Spanish, and asked the resident if the resident wanted to wear their own clothes. Resident #47 agreed. On the same day at 12:35 PM, the surveyor and the UM/LPN went to Resident #47's room. The LPN/UM stated that the resident's laundry just came today. The laundry was picked up early on Wednesday, and they usually get it either Thursday or Friday, but the resident's laundry was delivered today. The UM/LPN stated that they have a vendor who is doing the laundry for the residents. The surveyor and the UM/LPN observed that there are 10 shirts, 2 pairs of pants, socks, and 2 sweatshirts inside the bag that was delivered today. The UM/LPN opens up the residents' cabinet, and there is one sweatshirt hanging in the closet, and no other clothes were seen. A review of the Care Plan (CP) report initiated on 2/13/26 under focus Resident #47 is dependent on eating/require assistance/need cueing at meals. Interventions included, but are not limited to, assisting the resident with mealtimes as needed, and the resident is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, impaired balance/dizziness, limited mobility, and change in cognitive status. On 5/29/26 at 1:13 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the above concerns; no additional information was provided. A review of the facility policy with the title Promoting/Maintaining Resident Dignity During Mealtimes, with the review date on 2/26 stated under Policy: it is a practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality life, recognizing each resident's individuality and protecting the rights or each resident. NJAC 8:39-4.1(a)14,28

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach and access for all of the residents. This deficient practice was identified for 2 of 22 of sampled residents and 1 unsampled resident reviewed for accommodation of needs (Residents #7, #14 and #52 )and was evidenced by the following:On 05/28/26 at 10:25 AM, the surveyor conducted initial rounds of the second-floor nursing care unit and made three observations of call bell buttons out of reach of the residents. In room [ROOM NUMBER] Resident #7 was observed in bed and the resident's call bell was observed on the floor to the left the resident's bed. In room [ROOM NUMBER] Resident #14 was observed in bed and the resident's call bell was observed on the resident's left side lying on the floor, out of the resident's reach. In room # 259 Resident #52 was observed seated in a bedside chair and the call bell button was observed on the floor wrapped around the wheel of the bed, outside of the resident's reach.On 5/29/26 at 9:52 AM, the surveyor made a second observation of in room # 249 of Resident #7's call bell on floor to the resident's left side and out of reach of the resident.On 5/29/26 at 10:45 AM, the surveyor interviewed the housekeeper assigned to the second floor in room [ROOM NUMBER]. The housekeeper acknowledged it was a housekeeping responsibility to clean the walls and fixtures in the resident rooms and acknowledged the surveyor's finding's on the condition of the Resident #7's room were a detraction from the facility's homelike environmentOn 5/29/26 at 10:49 AM, the surveyor Interviewed the Licensed Practical Nurse (LPN) assigned to Resident #7's care. The LPN accompanied the surveyor to bedside of Resident #7. The LPN acknowledged call bell was positioned on the floor and that call bell buttons should always be positioned with the resident's reach. The LPN cleaned the call bell and wire and positioned it securely within the residents reach.On 5/29/26 at 11:10 AM, the surveyor interviewed the Unit Manager (UM), The UM acknowledged that residents in their rooms should always have had the call buttons within their reach and that staff should have checked frequently to assure they remained within reach at all times.On 5/29/26 at 1:40 PM, the surveyor and survey team met with the Director of Nursing and Licensed Nursing Home Administrator to discuss concerns. Both acknowledged that call bell buttons or devices should remain with reach of Residents in their rooms at all times.A review of the facility' provided policy titled Call Lights: Accessibility and Timely Response dated 2/2026 reflected .Staff will ensure the call light is within reach of each resident and secured as needed . The call system will be accessible to residents while in the bed or other sleeping accommodations.NJAC 8:39- 27.1(a); 31.8 (c)(9)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment for 1 of 22 residents (Resident #7) reviewed for homelike environment.The deficient practice was evidenced by the following:On 5/28/26 at 10:25 AM, the surveyor made the following observations in the single occupancy room [ROOM NUMBER]. Resident # 7 was positioned in bed, to the resident's right was an enteral feeding (EF) set up and pump attached to a portable utility pole. The surveyor observed the pump and utility pole splattered with dried light brown substance, the wall next to the utility pole was streaked with dried brown substance, the bedside cabinet to the left of the resident's bed had splattered light brown substance on the top and front and the handle on the top drawer on the bedside table was observed hanging off attached by only one screw, The small refrigerator to the resident's surveyor observed the small refrigerator to Resdient#7s left had splatters of dried light brown substance on the front and top of the unit.On 05/29/26 at 9:52 AM, the surveyor observed the same soiled conditions on Resident # 7s utility pole, EF pump, the wall and the rooms fixtures on both sides of the bed.On 5/29/26 at 10:45 AM the surveyor interviewed the housekeeper assigned to the second floor in room [ROOM NUMBER]. The housekeeper acknowledged it was a housekeeping responsibility to clean the walls and fixtures in the resident rooms and acknowledged the surveyor's finding's on the condition of the Resident #7's room were a detraction from the facility's homelike environment.On 05/29/26 at 11:10 AM, the surveyor interviewed the Unit Manager (UM) for the second floor nursing care unit. The UM acknowledged the bedside cabinet next to resident was in disrepair and that maintenance would be notified to repair the handle. The UM acknowledged the soiled condition of the walls and room fixtures and verbalized that housekeeping was responsible for cleaning the environment of the residents including their walls and fixtures and that nurses should have cleaned enteral feeding equipment and spills that occur during care of the resident's. The UM acknowledged the surveyor's findings on the condition of the Resident #7's room and agreed they were a detraction from the facility's homelike environment.On 5/29/26 at 1:40 PM, The surveyor and survey team met with the Director of Nursing and Licensed Nursing Home Administrator to discuss concerns. Both acknowledged the surveyor's findings in room [ROOM NUMBER] were a detraction from the facility's homelike environment and would be corrected immediately.A review of the facility provided policy titled Safe and Homelike Environment reflected .The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.NJAC 8:39-31.2(e)

Based on observation, interview, and record review it was determined that the facility 1) failed to perform a vascular wound treatment in a manner to reduce the spread of infection for 1 of 1 treatments observed (Resident #122). 2) failed to document assessments of a resident's condition and report changes in the resident's condition as well as an inability to administer ordered medications to a resident's physician or provider in 1 of 1 resident reviewed for change of condition (Resident # 121).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. 1. On 5/28/26 at 10:43 am, the surveyor observed and interviewed the resident, who was seated in a wheelchair at the bedside. The resident explained they were here for rehabilitation and would be returning home. The resident was noted to have gauze bandages to right and left lower legs which were swollen with dry, cracked skin. A review of the electronic medical record revealed the following information. The 3/4/26 admission Minimum Data Set (MDS) assessment tool indicated the resident had no long or short term memory deficits and no decision making deficits. The MDS indicated that the resident was admitted with 1 vascular or arterial wound. The June 2026 Physician Order Summary included 2 wound treatment orders as follows. 6/2/26 Cleanse left lower extremity (side) with normal saline solution, pat dry, apply telfa pads, secure with tape once daily on the day shift. 6/2/26 Cleanse right lower extremity with normal saline solution, pat dry, apply telfa pads, then apply abdominal pads and wrap with white ace bandage once daily on the day shift. On 6/2/26 at 10:45 am, the surveyor observed the Assistant Director of Nursing, Registered Nurse (RN) perform wound treatments to the left and right lower legs. The RN began by removing a pair of scissors and pen from her pants pocket and placing them on top of the treatment cart without first sanitizing the items. The RN donned (put on) gloves without performing hand hygiene and donned a disposable gown. The over-bed table, which was to be used as a clean field for treatment supplies, was sanitized using a bleach wipe. The RN doffed (removed) gloves and donned clean gloves without performing hand hygiene. The RN placed a disposable cloth barrier on the table without waiting for the sanitizing bleach to dry completely. A towel covered by a disposable cloth barrier was placed on the resident's bed. The resident, who was seated at the bedside in a wheelchair, put their left leg up on the barrier cloth, as was their preference. The RN applied sanitizing gel to her hands and donned new gloves. The RN cleansed the left lower leg using gauze pads and normal saline solution, patted dry with gauze, doffed gloves, and performed hand hygiene with sanitizing gel. New gloves were donned. Without first applying telfa pads to the open area on the left leg, the RN placed an abdominal pad to the front of the leg and used medical tape to secure the pad. The tape extended around to the back of the resident's calf and covered open areas on the skin directly with tape. The cover of the wound dressing remained undated and uninitialed. The RN washed her hands with soap and water and turned the faucet off with bare hands. The RN donned new gloves and cleansed the right lower leg with gauze pads and normal saline solution and patted dry with gauze. The RN doffed gloves, used sanitizing gel on her hands, and donned new gloves. The RN performed the right leg treatment according to the physician's order. When she was done, she wrote the date and her initials on the dressing which was already on the resident. The RN doffed her gloves, and without performing hand hygiene applied new gloves, and removed the unused supplies from the clean field to the resident's countertop next to the television. She removed the disposable barrier from the over-bed table and placed it in the trash bag along with used treatment supplies. She tied up the trash bag and placed it near the door to the hallway. The RN removed the disposable cloth barrier which was under the resident's legs during the treatment and placed it under her right arm. She closed the lid of the sanitizing wipes container with the same gloves. The RN removed her gown and gloves near the doorway to the room. She did not perform hand hygiene. She moved the unused treatment supplies from the resident's countertop to the top of the treatment cart. The RN placed a box of gloves, a roll of tape, and a box of gauze into the treatment cart. The items were not sanitized. A plastic bag containing disposable cloth barriers were returned to the plastic bin outside of the room which contained clean personal protective equipment (PPE). The bag was not sanitized. An unsanitized pair of scissors and a pen were placed in the RN's pants pocket. At that time, the surveyor discussed the infection control breaches with the RN. On 6/2/26 at 1:47 pm, the surveyor spoke with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) regarding the infection control concerns observed during Resident 122's wound treatment on 6/2/26. On 6/3/26 at 9:45 am, the DON provided the surveyor with the facility's policy titled Wound Treatment Management, revised 1/9/26. The policy indicated treatments would be provided in accordance with physician's orders and current standards of nursing practice. Complaint # 2999283 2.) A review of Resident #121's electronic health record (EHR) reflects the resident was admitted to the facility with diagnoses that included but were not limited to aftercare following surgery on the circulatory system, myocardial infarction (heart attack) and chronic obstructive pulmonary disease. A review of a Skilled Care Summary documented on 4/25/26 at 10:58 PM reflected at that time the resident was assessed as oriented to person place and time and situation and that resident could understand verbal content and express himself clearly. Review of progress notes reflected a progress note documented on 4/26/26 at 6:19 AM by LPN #1 reflected the resident was restless throughout the night, attempting to get out of bed multiple times and removing his oxygen on several occasions. the note reflects when the resident was without the oxygen his oxygen level measured by pulse oximetry fell below 90 percent. The note reflects the resident appeared anxious, exhibiting signs of agitation such as fidgeting and removed his diaper and linens. The note concluded with safety precautions initiated by placing the resident in a recliner near the nurses station with one on one assistance. The note did not reflect any communication of the change in behaviors to resident's provider or physician. No other documentation recorded by LPN #1 indicates the findings were reported to the resident's provider A review Resident #121's medication administration record (MAR) for 4/26/26 indicated the resident was ordered the following medications for 9:00 AM including: 1 metoprolol succinate 50 milligram ER tablet 1 Aspirin 81 milligram tablet 1 Benazepril 20 milligram tablet 1 Clopidogrel Bisulfate 75 milligram tablet 8 ounces of ensure plus nutritional supplement 1 Flomax 0.4 milligram capsule 1 Isosorbide Mononitrate 30 milligram ER tablet 1 rosuvastatin calcium 10 milligram tablet 1 sertraline hydrochloride 25 milligram tablet 1 Theragram-m multivitamin tablet All the 9:00 AM medications were marked in the MAR with an S. The key on the facility MAR indicated they were not administered that the resident was sleeping. A review of Resident #121's progress notes form 4/26/26 does not reflect any documentation of communication with resident's physician that medications at 9:00 AM were not administered as ordered or alternative orders to the administration were obtained A review of progress notes for 4/26/26 reflects there was no documentation by nurses asssessing resident condition or documenting any interaction with resident or his spouse from 7:00 AM to 7:00PM, the day shift for the facility A progress note on 4/26/26 at 8:09 PM documented by the Director of Nursing (DON) reflected the resident's wife had visited, the wife expressed concern that resident was sleeping all day. the note reflects the resident was assessed including vital signs and was found to be easily aroused and the findings were within the normal limits for the resident. The note reflects the spouse still requested transfer to the hospital A second progress note documented by the DON at 8:12 PM reflects the resident was transported to the hospital an the wife and Physician were aware. On 6/3/26 at 10:30 AM, The surveyor interviewed the DON. The DON acknowledged that no communication with resident's physician or provider was documented for change of behavior demonstrated 4/25/26 into 4/26/26 and that new behavior and documented difficulties with oxygen tubing and maintaining oxygen saturations should have been reported to the resident's physician or provider. The DON acknowledged that the medications not administered at 9:00 AM on 4/26/26 marked as S should have been documented in a written note with details of effort made, interventions taken and the notification to the resident's physician or provider. The DON verbalized the residents spouse made request to call 911 several times, without specifying specific times and that the nurses assessed residents and didn't consider the condition in need of emergency medical intervention or hospital evaluation but acknowledged no documentation of communication with a physician or provider by any nurse between 4/25/26 and the resident being sent to the hospital at 8:12 PM detailing the residents condition or interaction with or requests from the resident's spouse The DON acknowledged nursing supervisor RN#1 wrote statement that several assessments of resident were made throughout day of 4/26/26 but no documentation made in residents but no documentation of assessments were located in the EHR. On 6/3/26 at 11:37 AM, the surveyor interviewed RN#1. RN#1 acknowledged she was the nursing supervisor on 4/26/26 from 7:00 AM to 7:00 PM. RN#1 stated she assessed Resident#121 in morning when the resident's wife arrived to visit, at the wife's request. RN#1 states she assessed the resident including a sternal rub with a reaction and acknowledged she did not chart the assessment or interaction with resident or spouse and stated she did not notify the provider or physician of findings, The surveyor Reviewed RN#1's previous written statement for 4/26/26 that reflected several assessments made during day, RN#1 stated that LPN #2 was the nurse assigned to the resident's care and conducted the other assessments. RN#1 acknowledged no documentation of these assessments were in the EHR. On 6/3/26 at 1:17 PM, The surveyor and the survey team met with DON and the Licensed Nursing Home Administrator. Both acknowledged that communication with the physician or provider was required for changes in resident's condition and held or omitted medications. Both acknowledged accurate documentation of the resident condition, changes in status, interactions with residents and families was a requirement for all nurses providing care to the resident. A review of the facility provided policy Documentation in Medical Record reflects . Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the residents' medical record in accordance with state law and facility policy .documentation shall be accurate, relevant and complete, containing sufficient detail about the resident's care and or response to care . documentation shall be timely and in chronological order. NJAC 8:39-19.4; 27.1

Based on observation, interview, and record review it was determined facility staff failed to consistently ensure that residents at risk for weight loss were offered feeding assistance for 1 of 4 residents (Resident #123) reviewed for nutrition. The deficient practice was evidenced by the following. On 5/28/2026 at 10:19am, the surveyor observed Resident #123 in bed with eyes closed. The resident did not respond to the surveyor's greeting. Next to the bedside, out of reach, was their breakfast tray containing a puree meal with thin liquids. The food and liquids on the tray were untouched.On 5/28/2026 at 11:45am, the surveyor returned to the resident's room. The breakfast tray was no longer in the room. The resident was observed to be awake and lethargic. When asked, the resident stated she did not eat breakfast. On 5/29/2026 at 9:13am, the surveyor observed the resident in bed with eyes closed. There was no meal tray in the room.On 5/29/26 at 10:20am, the surveyor telephoned the resident's responsible party who stated the resident was dependent on staff for meals and had to be encouraged to eat.On 5/29/2026 at 11:00am the surveyor interviewed the resident's regularly assigned Certified Nursing Assistant (CNA #1) who stated she makes an attempt to feed the resident and if the resident doesn't want to eat she offers a nutritional drink which the resident likes. CNA #1 stated she was not scheduled to work on 5/28/26.On 5/29/2026 at 1:18pm, the surveyor telephoned the CNA (CNA #2) who was assigned to Resident #123 on the 5/28/26 day shift. CNA #2 stated she attempted to feed the resident breakfast, but she wouldn't take it. The surveyor questioned why the tray was untouched if she attempted to feed the resident. She offered no explanation.The surveyor reviewed the resident's electronic medical record. The following information was obtained.The 3/26/26 admission Minimum Data Set (MDS) assessment tool indicated at the time of admission to the facility the resident was sometimes able to understand others and sometimes able to make themself understood. The resident was assessed with severe cognitive impairment, dementia, diabetes, and a possible swallowing disorder.The June 2026 Order Summary Report contained nutritional physician's orders as follows:Regular diet with dysphagia puree texture and thin liquids; Magic Cup sugar free 4 ounces twice a day for malnutrition to be provided on all meal trays; Super Cereal 6 ounces once daily for risk of malnutrition to be provided on breakfast trays.The current Care Plan Report identified the resident as being at risk of malnutrition and indicated the resident was dependent for eating and was to be fed by staff at all mealtimes.On 6/1/26 at 10:30am, the surveyor spoke with the Director of Nursing (DON) regarding the untouched meal tray on 5/28/26 and requested the facility policy for feeding assistance of dependent residents.On 6/2/26 at 9:48am, the DON stated to the surveyor that she spoke with CNA #2 and asked the resident if they wanted to eat breakfast and the resident replied no. The statement conflicted with CNA #2's statement to the surveyor on 5/29/26.The facility policy for feeding dependent residents was not provided to the surveyor.NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain precautions to prevent complications with the enteral feedings of the residents. This deficient practice was identified for 1 of 1 resident (Resident#7) reviewed for enteral feeding.and was evidenced by the following:On 05/29/26 at 9:52 AM, the surveyor observed Resident #7 in bed with the head of the bed raised approximately 10 degrees. The Enteral feeding pump was observed , powered on and the screen reflected the pump was infusing at 65ml/hr.On 5/29/2026 at 10:44 AM, the surveyor made a second observation of Resident #7's enteral feeding pump infusing at 65ml/hr and resident in bed positioned with her head raised at approximately 10 degrees.On 5/29/26 at 10:49 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to care for Resident #7 at the resident's bedside. The LPN confirmed Enteral feeding pump was infusing at 65milliliters per hour as ordered. The LPN acknowledged head of bead for a resident receiving enteral feeding should have been elevated between 30 and 45 degree and that Resident #7 was lying at head elevation of approximately 10 degrees. The LPN elevated the head of the residents bed to approximately 30 degrees.On /29/2026 11:10 AM, the surveyor interviewed the Unit Manager (UM). The UM acknowledged that Resident #7 should have positioned at head elevation of 30-45 degrees during and active enteral feeding. The UM acknowledged that all residents receiving enteral feedings should have the heads of their beds elevated to 30-45 degrees during and for 40 minutes after the conclusion of the feeding to prevent aspiration.On 5/29/26 at 1:40 PM, the surveyor and survey team met with the Director of Nursing (DON) and Licensed Nursing Home Administrator to discuss concerns. The DON acknowledged that all residents receiving Enteral feedings should have the heads of their beds elevated to 30-45 during the feedings and for 40 minutes after the conclusion of the feeding. The DON agreed a resident receiving eternal feedings positioned with their head elevated at approximately 10 degrees presented an increased risk for aspiration.A review of the residents Electronic health record reflects the resident was admitted to the facility with diagnoses including but not limited to malnutrition, difficulty swallowing and need for attention for a gastrostomy (G-tube, an artificial tube in the abdominal wall to receive enteral feedings and or medicines directly to the stomach).A review of the physician's orders for Resident#7 reflects an order dated 2/23/26 to elevate the head of the bed from30-45 degrees during feeding and for at least 30-45 minutes after feedings, elevate the head of the bed for 60 minutes after medication administration via the G-tube.NJAC 8:39 25.2(c)2, 5

Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure appropriate dispensing and administration of a medication for: a.) 1 of 3 residents (Resident #49) observed during medication administration, and b.) 1 of 3 residents (Resident #4) reviewed for dialysis care services, The evidence was as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.1.) On 6/1/26 at 9:03 AM, the surveyor observed the Licensed Practical Nurse (LPN) knocked on Unsampled Resident #49's door, explained that she would be taking their vitals and would administer their medications afterward. Unsampled Resident #49 (UR #49) was observed seated in their wheelchair, their breakfast tray was at bedside, and the meal was eaten. At that time, UR #49 could not recall the time when the meal arrived or when they finished their breakfast. At 9:24 AM, the LPN began to prepare medications for UR #49. The medications prepared included the following: -Calcium Acetate 667 mg oral tablet (a phosphate binder), two (2) tablets by mouth 2 times a day every Monday, Wednesday, and Friday for End Stage Renal Disease (ESRD). The physician order (PO) was started on 5/27/26 and scheduled for administration at 7:00 AM. -Lokelma 10 grams (gm) oral packet, one packet by mouth one time a day for high potassium in the blood, mix with four (4) to 8 ounces of liquid. The PO was started on 5/10/26 and scheduled for administration at 9:00 AM. At that time, the surveyor asked the LPN, at what time, she should have administered the Calcium Acetate that was scheduled at 7:00 AM. The LPN stated that she could have administered the Calcium Acetate at the latest time of 8:00 AM, admitted and confirmed that administration was late. The LPN continued to prepare medications for UR #49. At 9:39 AM, the surveyor observed the LPN opened the packet of Lokelma, spilled powder on her hand, on the cart, on the floor and poured the remainder of the powder in a plastic cup, mixed with water. At 9:43 AM, the LPN informed the surveyor that she was ready to administer the prepared medications to UR #49. At 9:49 AM, the surveyor observed the LPN completed the administration of the medications that included the Calcium Acetate and Lokelma. At 9:52 AM, the surveyor observed the LPN signed the electronic Medication Administration Record (eMAR). At 9:53 AM, when the surveyor asked if the UR #49 received the prescribed dose of Lokelma, the LPN stated, I don't know what to say, I can't say the resident received the full dose. On 6/1/26 at 12:40 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator(LNHA) and the Director of Nursing (DON), the surveyor discussed the concern with the LPN who administered the Calcium Carbonate that was scheduled at 7:00 AM, did not call the physician, and the administration of Lokelma that spilled on her hand, the cart, and the floor. At that time, the DON acknowledged the concerns and stated the LPN should have disposed of the spilled Lokelma and started all over again with a new packet. On 6/2/26 at 9:42 AM, during a follow-up meeting with the survey team, and the LNHA, the DON stated that they acknowledged the concerns and had no further information to provide. A review of the provided facility policy, titled, Medication Administration, dated/revised 1/13/26 included: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 2. On 5/29/26 at 9:44 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #4. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to end stage renal [kidney] disease, dependence on renal dialysis, hypertension (high blood pressure) and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, dated 5/12/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 15 out of 15, which indicated the resident was cognitively intact. A physician's order dated 5/5/26 indicated for lactulose (10 grams/15 milliliters) to give 15 milliliters (ml) by mouth at bedtime as needed (PRN) for constipation. A review of the May 2026 Medication Administration Record (MAR) revealed lactulose PRN was administered on 5/19/26 at 1:49 PM and 8:46 PM. The physician's order indicated lactulose should be administered at bedtime. On 5/29/26 at 11:07 AM, the surveyor interviewed the Registered Nurse who stated medications at bedtime should be administered 8 PM to 9 PM. The surveyor reviewed with the RN that Resident #4's lactulose on 5/19/26 was administered at 1:49 PM. The RN acknowledged it should not have been given at that time as the order was for bedtime. The RN explained the nurse should have called the physician to obtain a one-time order to administer the medication to the resident. The RN added the lactulose PRN order would be better if clarified to be given daily PRN for the nurse to be able to administer at other times during the day. The RN stated she would follow up with the physician to clarify the order. On 5/29/26 at 11:56 AM, the surveyor informed the Director of Nursing (DON) of the above concerns. The DON stated she would follow up with the RN and review Resident #4's order. On 6/1/26 at 9:22 AM, the Licensed Nursing Home Administrator (LNHA) and the DON met with the survey team. The DON stated the concern was addressed, the resident's order was clarified. There was no additional information provided by the facility. A review of the facility provided policy titled, Medication Administration with a last reviewed date of 1/13/26 under Policy revealed: Medications are administered as ordered by the physician and in accordance with professional standards of practice. Under Policy Interpretation and Implementation of the policy revealed: 10. Ensure the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation NJAC 8:39-27.1(a); 29.2

Based on observation, interview, and record review it was determined the facility failed to administer medications with parameters in accordance with a physician's order and standards of practice for 1 of 3 residents (Resident #4) reviewed for dialysis services.Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 5/29/26 at 9:44 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #4.The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to end stage renal [kidney] disease, dependence on renal dialysis, hypertension (high blood pressure) and atrial fibrillation (an irregular, often rapid heart rate).A comprehensive Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, dated 5/12/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored 15 out of 15, which indicated the resident was cognitively intact.A physician's order dated 5/13/26 indicated to give losartan 100 milligram (mg) one tablet by mouth in the afternoon every Monday, Wednesday, and Friday for hypertension (high blood pressure); and to hold if Systolic Blood Pressure (SBP; the top number in a blood pressure reading which measures the maximum pressure in your arteries when the heart beats) was less than 100. The medication was scheduled to be given at 4 PM.A review of the May 2026 Medication Administration Record (MAR) revealed there was no documentation of the blood pressure (BP) results at the time of the losartan medication's administration to Resident #4.A review of the Weights and Vitals section of the EMR revealed no consistent documentation of Resident #4's BP for each losartan administration to reflect that the medications were administered as per the physician's orders.A review of the progress notes revealed no additional documentation of Resident #4's BP result at each losartan medication's administration.On 5/29/26 at 11:07 AM, the surveyor interviewed the Registered Nurse (RN) who stated medications with BP parameters were administered according to the physician's order. The RN stated the BP was checked prior to the medication's administration and the results were documented in the MAR order entry.On 5/29/26 at 11:30 AM, the surveyor reviewed with the RN that Resident #4's losartan medication with parameters had no documented BP at the time of its administration. The RN stated it would be reviewed and followed up.On 5/29/26 at 11:56 AM, the surveyor informed the Director of Nursing (DON) of the above concern. The DON stated she would review and provide any additional information.On 6/1/26 at 9:22 AM, the LNHA and the DON met with survey team. The DON stated that the medication order was clarified. There was no additional information provided by the facility.A review of the facility provided policy titled, Medication Administration with a last reviewed date of 1/13/26 under Policy revealed: Medications are administered as ordered by the physician and in accordance with professional standards of practice.Under Policy Interpretation and Implementation of the policy revealed:8. Obtain and record vital signs, when applicable or per the physician orders.21. Sign MAR after administration. For those medications requiring vital signs, record vital signs onto the MAR.NJAC 8:39-11.2 (b); 29.2(d)

Based on interviews and review of pertinent facility documents on 11/05/25, 11/06/25, and 11/10/25, it was determined that the facility failed to ensure a cognitively impaired resident (Resident #1) was protected from neglect when the resident was found unresponsive outside on the patio during a heat wave and was sent to the emergency room for heat stroke (life-threatening from environmental heat exposure). This deficient practice was identified for 1 of 4 residents reviewed for abuse and neglect (Resident #1).On 07/29/25 at 11:15 AM, Resident #1's Representative (RR #1), a companion, discovered Resident #1 outside on the second-floor patio unresponsive. RR #1 immediately informed the Registered Nurse (RN #1), who went outside and found the resident unconscious. Resident #1 was brought inside to their room, and RN #1 performed a sternal rub (rubbing the chest area) which the resident became alert, but drowsy with a temperature of 103.8 degrees Fahrenheit (F) (normal range 97.7 to 99.0 degrees F) and a heart rate (HR) of 124 beats per minute (bpm) (normal range 60-100 bpm). Resident #1 received treatment of an ice pack and Tylenol and was sent to the emergency room (ER). The resident remained in the ER for twenty-four hours being treated for heat stroke.The facility's failure to protect a cognitively impaired resident by ensuring staff provided residents supervision and oversight, placed Resident #1 as well as all residents at risk for neglect. This posed the likelihood of serious physical harm, injury, or death which resulted in an immediate jeopardy (IJ) situation.The IJ began on 07/29/25, at approximately 11:15 AM, when Resident #1 was found unresponsive outside on the patio in extremely hot weather. The facility's Administration was notified of the IJ on 11/10/25 at 2:43 PM. The facility submitted an acceptable Removal Plan (RP) on 11/13/25 at 4:52 PM. The surveyor verified the implementation of the Removal Plan on-site during the continuation of the survey 11/17/25. The deficient practice was evidenced as follows:A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy dated 06/18/25, included Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; 2. Develop and implement policies and protocols to prevent and identify:.b. neglect of residents;.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.A review of the facility's Extreme Heat Policy dated implemented 07/29/25, included it is the policy of the facility to maintain a safe, comfortable, and temperature-controlled environment. In periods of extreme heat, staff must take all necessary actions to prevent heat-related illness, dehydration, or other complications among resident and staff. Definitions: 1. Extreme heat: ambient indoor or outdoor temperatures that exceed 80 degrees F and/or the heat index or local heat advisory indicates hazardous conditions. 2. Heat related illness: includes heat exhaustion, heat cramps, or heat stroke caused by prolong exposure to high temperatures.The surveyor reviewed the medical record for Resident #1.A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple sclerosis (an autoimmune disorder between the brain and the body leading to symptoms such weakness, numbness, coordination problems, and vision issues), encephalopathy (a condition that affects the brain's function resulting in altered mental state), muscle weakness, atherosclerotic heart disease (heart disorder), dementia, repeated falls, and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke).A review of the Minimum Data Set (MDS), an assessment tool dated 09/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs).A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 06/30/22, that the resident required assistance/potential to restore function for mobility as evidenced by limited mobility related to inability to move independently. Interventions included but were not limited to; one person assistance with ambulation.A review of the Resident #1's Progress Notes included a nurse's note documented by RN #1 on 07/29/25 at 11:20AM, that the resident was seen sitting on the patio and this writer was going to do vital sign checks when they were called by RR #1 to check on the resident. The resident was initially drowsy, responded to verbal stimuli, and become unconscious with breathing present. Vital signs were taken; blood pressure 123 millimeters of mercury (mmHg) over 78 mmHg (123/78), HR 124 bpm, unlabored breathing 18 breaths per minute, temperature 103.8 degrees F, oxygen saturation 97% on room air, and blood sugar 94. The resident was assisted back to room in cool environment, ice pack was applied, the resident responded to sternum rub and regained consciousness. The resident denied pain or distress. Supplemental oxygen and cool sponge were provided, and Tylenol was administered. The physician was notified and ordered the resident transferred out to ER for further evaluation.A review of the facility's investigation report dated 07/31/25, included the following:Incident: On 7/29/25 at approximately 11:15 AM, [RN #1] noted [RR #1] was trying to get [the resident] up in the patio. [The resident] was observed drowsy but responded to verbal stimuli. Vital signs were checked, and the resident's temperature was 103.8 degrees F and heart rate was 124 bpm. The resident was immediately assisted back to their bed via wheelchair, and the resident became more alert and verbally responsive. Cooling measures were applied, and the resident was given Tylenol at 11:50 AM. The physician was notified and ordered to transfer the resident to the hospital. Resident #1's Representative (RR #2) was notified, and they agreed to the hospital transfer.Investigation: that per interview with staff, RN #1 on 07/29/25, at approximately 10:00 AM, noticed that the Certified Nursing Assistant (CNA #1) was still providing care on Resident #1, and she proceeded to give morning medications to another resident. Per CNA #1, after he provided care to Resident #1, he walked them out of their room, and another CNA (CNA #2) took the resident to the dayroom. CNA #1 stated he noted that the resident was in the dayroom at around 11:00 AM, during his dayroom assignment to watch the residents, but he did not realize if the resident's private companion (RR #1) brought the resident out of the dayroom to the patio when RR #1 arrived. RR #1 arrived at the facility at 11:03 AM. At approximately 11:15 AM, RN #1 noted the resident was at the patio with RR #1 trying to get the resident up. Resident #1 was observed sitting on the couch with some shade, drowsy but responded to verbal stimuli. Resident #1 was assisted back to their room via a wheelchair. Vital signs were checked and noted with elevated temperature and heart rate. Cooling measures were provided, and Tylenol was given. Vital signs were rechecked: blood pressure-119/70, HR-104 bpm, breathing 18 breaths per minute, oxygen saturation on room air-96%, temperature- 97.1 degrees F, and resident was back to their baseline. The physician was informed and ordered the resident to be sent to the hospital to rule/out seizure. Other CNAs that worked that day were interviewed, but no one noticed Resident #1 going out to the patio by themself. They also stated, Resident #1's family did not want the resident out to patio unless with the companion (RR #1). Transport [ name redacted] was called and the resident was picked up at 1:15 PM. They left for the hospital with no signs of distress. Resident #1 was sent to hospital [name redacted].The investigation did not include a statement from RR #1 who was with the resident at the time.A review of ER paperwork dated 07/29/25 at 1:50 PM, included history of present illness that Resident #1 arrived at the ER by emergency medical services (EMS) for an episode of unresponsiveness. Per [Resident #1's sending facility name redacted], [Resident #1] was outside 30-40 minutes sitting on a bench on the patio when [the resident] became unresponsive, tachycardic (fast heart rate), and was found to be febrile 103.8 degrees F. The facility gave [the resident] Tylenol and wiped the resident with cold sponge and [the resident's] temperature went down to 97.1 degrees F before [they] were sent to the [ER]. The report also indicated the resident was diagnosed with transient alteration awareness (loss of normal awareness or behavior) and heat stroke. On 11/05/25 at 12:40 PM, the surveyor interviewed the Unit Manager (UM), who stated that on 07/29/25, she was in a care meeting when the nurse (RN #1) called her. The UM further stated that when she came to the floor, the resident was seen sitting outside on the patio with the companion (RR #1). The UM stated RR #1 called the nurse (RN #1) to check on the resident. The UM stated she did not know if the resident was taken outside by RR #1, and normally there was staff or a CNA in the dayroom that oversaw the residents outside on the patio as well. The UM stated that the companion (RR #1) did not provide care to Resident #1.The surveyor requested for a copy of dayroom assignment on that day of 07/29/25. The facility document titled as Dayroom Schedule dated 07/29/25, and shift: the 7:00 AM to 3:00 PM shift revealed that CNA #1 was assigned in dayroom that day from 11:00 AM to 11:30 AM.On 11/05/25 at 1:08 PM, the surveyor interviewed RN #2, who was Resident #1's regular nurse. RN #2 stated that the companion, RR #1, did not provide care for the resident.On 11/5/25 at 3:46 PM, the surveyor interviewed CNA #1, who was assigned to the dayroom at the time of the incident as well as Resident #1's assigned aide. CNA #1 stated he was regularly assigned to the resident, and the resident could not transfer by themself but would try. CNA #1 stated the resident required one person assistance from staff and supervision during eating. CNA #1 stated that after he washed the resident, he walked the resident to the dayroom for activities. CNA #1 further stated he would sometimes catch the resident trying to go to the patio. CNA #1 stated that we had an every 30-minute rotating assignment to watch the residents in the dayroom. CNA #1 stated on 07/29/25, after washing the resident at around 10:00 AM, I took [Resident #1] to the dayroom. My scheduled dayroom assignment was from 11:00 AM to 11:30 AM. When I went back to the dayroom at 11:00 AM, I saw the resident [at] the long table. The [television] was on, I did not see the activity person. I did not see the companion (RR #1). I did not see [RR #1] taking the resident out to the patio. CNA #1 further stated that at 12:00 PM, while he was [providing] care to another resident, the nurse called [him] because they needed help outside [on] the patio to pick [up] and put [the resident] in wheelchair and back to [Resident #1's] room. [The resident] was sweating and was not talking. [The resident] looked different. [The resident] was sent out to the hospital. CNA #1 stated that the companion, RR #1, did not provide care to the resident.On 11/05/25 at 4:30 PM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON stated that Resident #1's companion, RR #1, did not provide care to the resident.On 11/06/25 at 12:29 PM, the surveyor interviewed CNA #2, who was assigned to the dayroom on 07/29/25 from 11:30 AM to 12:00 PM. CNA #2 stated she could not recall the incident on 07/29/25, and she did not recognize the resident's companion (RR #1). CNA #2 also stated she could not remember her schedule that day. The surveyor informed CNA #2 that she was assigned to the dayroom from 11:30 AM to 12:00 PM, and CNA #2 stated, it was so long ago, and the resident went out to the patio always with the family.On 11/06/25 at 12:55 PM, the surveyor interviewed CNA #3, who was assigned in the dayroom on 07/29/25 from 10:00 AM to 10:30 AM. CNA #3 stated that the resident did not go out by themself but usually with the companion. CNA #3 further said, I did not see the resident from 10:00 AM to 10:30 AM outside while I was there in the dayroom. CNA #3 stated she did not see the companion (RR #1) taking the resident out to the patio.The surveyor was not able to interview RN #1 who was reportedly out of the country.On 11/07/25 at 12:17 PM, the surveyor conducted a telephone interview with RR #2, who stated on 07/29/25, the UM called them to inform RR #2 that the facility was sending Resident #1 to the hospital for evaluation. RR #2 stated that the UM informed them of the incident, that the resident was outside for approximately 40 minutes, and the facility notified the physician who ordered to send the resident to the ER.On 11/07/25 at 2:13 PM, the surveyor conducted a telephone interview with the resident's companion, RR #1, who stated they arrived at the facility around 11 o'clock that day. RR #1 stated, I got out from the elevator and [the resident] was not there in the dayroom, so I went to check [the resident's] room, and [the resident] was not there, too. I went to look for [the resident] and going back to the dayroom, I saw [the resident] through the glass door. [The resident] was outside on the patio sitting on the right area of patio and was on [the resident's] right side. [The resident] was out open under the sun; [they were] seated in one of the chair with [their] rolling walker beside [them]. I thought [the resident] was asleep. I called [the resident's] name and [the resident] was not responding. I saw saliva from [the resident's] mouth and drainage coming out from [the resident's] nose. I rushed inside to ask for help. I met the nurse halfway in and told her the resident needed help. [The] nurse rushed to [the resident] and checked [the resident], and they assisted [the resident] back to bed. At around 1:20 PM, they took [the resident] to the hospital. RR #1 further stated sometimes they took the resident outside, and RR #1 did not leave the resident unattended, and the resident did not go outside by themself. RR #1 stated when RR #1 came out from the elevator after they arrived, there were some residents in the dayroom and there was no CNA. RR #1 said they knew because RR #1 started looking for the resident.On 11/10/25 at 10:45 AM, the surveyor interviewed the DON, who stated that the facility had CNAs assigned every thirty-minutes in the dayroom to watch the residents, providing supervision and ensuring safety. The DON further stated the CNA assigned did not leave the dayroom until the relieving CNA arrived.On 11/10/25 at 2:08 PM, the surveyor interviewed the LNHA and DON, who stated that it was RR #1 who took the resident out to the patio. The DON stated that after the incident, she gathered statements from the nurse and the CNA. The LNHA confirmed there was a heat wave on that day as he said he made an announcement regarding safety and precautions against extreme heat. (This interview contradicted the ER report that the facility reported that the resident was outside for 30 to 40 minutes since RR #1 entered the facility that day at 11:03 AM, and RR #1 ask RN #1 for help at 11:15 AM. RR #1 was only in the facility for twelve minutes before RN #1 was called.)A Removal Plan was submitted on 11/13/25 at 4:52 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including on 07/29/25, Resident #1 was assessed and transferred to emergency room for evaluation, and the resident returned to the facility on [DATE], and was placed hourly monitoring. The nurse and CNA who were assigned to Resident #1 were in-serviced on resident safety and protection from neglect. On 11/12/25, Resident #1 was placed on one-to-one (1:1) supervision, and all cognitively impaired residents were placed on every thirty-minute monitoring. The LNHA, DON, and ADON reviewed the abuse and neglect policy, taking residents outside the facility, hot weather, enhanced supervision, and nursing round policies with no revisions made. The DON, ADON, LNHA provided the nurses and CNAs with training on the abuse and neglect policy, resident supervision, protection of resident from neglect, and resident safety. On 11/12/25, the DON, ADON, and LNHA provided non-clinical staff training on abuse and neglect and residents' rights to be free from neglect.The surveyor verified the implementation of the RP on-site during the continuation of the survey on 11/17/25.NJAC 8:39-4.1(a)5

Based on interviews and review of pertinent facility documents on 11/05/25, 11/06/25, and 11/10/25, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of neglect that occurred on 07/29/25. This deficient practice was identified for 1 of 4 residents reviewed for abuse and neglect (Resident #1), and was evidenced by the following:The surveyor reviewed the medical record for Resident #1. A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple sclerosis (an autoimmune disorder between the brain and the body leading to symptoms such weakness, numbness, coordination problems, and vision issues), encephalopathy (a condition that affects the brain's function resulting in altered mental state), muscle weakness, atherosclerotic heart disease (heart disorder), dementia, repeated falls, and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke). A review of the Minimum Data Set (MDS), an assessment tool dated 09/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the Resident #1's Progress Notes included a nurse's note documented by RN #1 on 07/29/25 at 11:20AM, that the resident was seen sitting on the patio and this writer was going to do vital sign checks when they were called by RR #1 to check on the resident. The resident was initially drowsy, responded to verbal stimuli, and become unconscious with breathing present. Vital signs were taken; blood pressure 123 millimeters of mercury (mmHg) over 78 mmHg (123/78), HR 124 bpm, unlabored breathing 18 breaths per minute, temperature 103.8 degrees F, oxygen saturation 97% on room air, and blood sugar 94. The resident was assisted back to room in cool environment, ice pack was applied, the resident responded to sternum rub and regained consciousness. The resident denied pain or distress. Supplemental oxygen and cool sponge were provided, and Tylenol was administered. The physician was notified and ordered the resident transferred out to ER for further evaluation. A review of the facility's investigation report dated 07/31/25, included the following: Incident: On 7/29/25 at approximately 11:15 AM, [RN #1] noted [RR #1] was trying to get [the resident] up in the patio. [The resident] was observed drowsy but responded to verbal stimuli. Vital signs were checked, and the resident's temperature was 103.8 degrees F and heart rate was 124 bpm. The resident was immediately assisted back to their bed via wheelchair, and the resident became more alert and verbally responsive. Cooling measures were applied, and the resident was given Tylenol at 11:50 AM. The physician was notified and ordered to transfer the resident to the hospital. Resident #1's Representative (RR #2) was notified, and they agreed to the hospital transfer. Investigation: that per interview with staff, RN #1 on 07/29/25, at approximately 10:00 AM, noticed that the Certified Nursing Assistant (CNA #1) was still providing care on Resident #1, and she proceeded to give morning medications to another resident. Per CNA #1, after he provided care to Resident #1, he walked them out of their room, and another CNA (CNA #2) took the resident to the dayroom. CNA #1 stated he noted that the resident was in the dayroom at around 11:00 AM, during his dayroom assignment to watch the residents, but he did not realize if the resident's private companion (RR #1) brought the resident out of the dayroom to the patio when RR #1 arrived. RR #1 arrived at the facility at 11:03 AM. At approximately 11:15 AM, RN #1 noted the resident was at the patio with RR #1 trying to get the resident up. Resident #1 was observed sitting on the couch with some shade, drowsy but responded to verbal stimuli. Resident #1 was assisted back to their room via a wheelchair. Vital signs were checked and noted with elevated temperature and heart rate. Cooling measures were provided, and Tylenol was given. Vital signs were rechecked: blood pressure-119/70, HR-104 bpm, breathing 18 breaths per minute, oxygen saturation on room air-96%, temperature- 97.1 degrees F, and resident was back to their baseline. The physician was informed and ordered the resident to be sent to the hospital to rule/out seizure. Other CNAs that worked that day were interviewed, but no one noticed Resident #1 going out to the patio by themself. They also stated, Resident #1's family did not want the resident out to patio unless with the companion (RR #1). Transport [ name redacted] was called and the resident was picked up at 1:15 PM. They left for the hospital with no signs of distress. Resident #1 was sent to hospital [name redacted]. A review of emergency room (ER) paperwork dated 07/29/25 at 1:50 PM, included history of present illness that Resident #1 arrived at the ER by emergency medical services (EMS) for an episode of unresponsiveness. Per [Resident #1's sending facility name redacted], [Resident #1] was outside 30-40 minutes sitting on a bench on the patio when [the resident] became unresponsive, tachycardic (fast heart rate), and was found to be febrile 103.8 degrees F. The facility gave [the resident] Tylenol and wiped the resident with cold sponge and [the resident's] temperature went down to 97.1 degrees F before [they] were sent to the [ER]. The report also indicated the resident was diagnosed with transient alteration awareness (loss of normal awareness or behavior) and heat stroke. On 11/05/25 at 12:40 PM, the surveyor interviewed the Unit Manager (UM), who stated that on 07/29/25, she was in a care meeting when the nurse (RN #1) called her. The UM further stated that when she came to the floor, the resident was seen sitting outside on the patio with the companion (RR #1). The UM stated RR #1 called the nurse (RN #1) to check on the resident. The UM stated she did not know if the resident was taken outside by RR #1, and normally there was staff or a CNA in the dayroom that oversaw the residents outside on the patio as well. On 11/10/25 at 2:08 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) with the Director of Nursing (DON). The LNHA and the DON stated that it was RR #1 who took the resident out to the patio. The DON stated that after the incident, she gathered statements from the nurse and the CNA. The LNHA confirmed there was a heat wave on that day as he said he made an announcement regarding safety and precautions against extreme heat. The LNHA and DON further stated they did not report the incident to the NJDOH because they believed the incident was not an allegation of neglect. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy dated 06/18/25, included Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; 2. Develop and implement policies and protocols to prevent and identify:.b. neglect of residents;.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.NJAC 8:39-9.4(f)

Based on interviews and review of pertinent facility documents on 11/05/25, 11/06/25, and 11/10/25, it was determined that the facility failed to thoroughly investigate an incident of resident heat stroke (life-threatening from environmental heat exposure) to rule out neglect. This deficient practice was identified for 1 of 4 residents reviewed for abuse and neglect (Resident #1), and was evidenced by the following:The surveyor reviewed the medical record for Resident #1. A review of the admission Record (AR) face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to; multiple sclerosis (an autoimmune disorder between the brain and the body leading to symptoms such weakness, numbness, coordination problems, and vision issues), encephalopathy (a condition that affects the brain's function resulting in altered mental state), muscle weakness, atherosclerotic heart disease (heart disorder), dementia, repeated falls, and personal history of transient ischemic attack (TIA) and cerebral infarction (stroke). A review of the Minimum Data Set (MDS), an assessment tool dated 09/30/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which reflected a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 06/30/22, that the resident required assistance/potential to restore function for mobility as evidenced by limited mobility related to inability to move independently. Interventions included but were not limited to; one person assistance with ambulation. A review of the Resident #1's Progress Notes included a nurse's note documented by RN #1 on 07/29/25 at 11:20AM, that the resident was seen sitting on the patio and this writer was going to do vital sign checks when they were called by RR #1 to check on the resident. The resident was initially drowsy, responded to verbal stimuli, and become unconscious with breathing present. Vital signs were taken; blood pressure 123 millimeters of mercury (mmHg) over 78 mmHg (123/78), HR 124 bpm, unlabored breathing 18 breaths per minute, temperature 103.8 degrees F, oxygen saturation 97% on room air, and blood sugar 94. The resident was assisted back to room in cool environment, ice pack was applied, the resident responded to sternum rub and regained consciousness. The resident denied pain or distress. Supplemental oxygen and cool sponge were provided, and Tylenol was administered. The physician was notified and ordered the resident transferred out to ER for further evaluation. A review of the facility's investigation report dated 07/31/25, included the following: Incident: On 7/29/25 at approximately 11:15 AM, [RN #1] noted [RR #1] was trying to get [the resident] up in the patio. [The resident] was observed drowsy but responded to verbal stimuli. Vital signs were checked, and the resident's temperature was 103.8 degrees F and heart rate was 124 bpm. The resident was immediately assisted back to their bed via wheelchair, and the resident became more alert and verbally responsive. Cooling measures were applied, and the resident was given Tylenol at 11:50 AM. The physician was notified and ordered to transfer the resident to the hospital. Resident #1's Representative (RR #2) was notified, and they agreed to the hospital transfer. Investigation: that per interview with staff, RN #1 on 07/29/25, at approximately 10:00 AM, noticed that the Certified Nursing Assistant (CNA #1) was still providing care on Resident #1, and she proceeded to give morning medications to another resident. Per CNA #1, after he provided care to Resident #1, he walked them out of their room, and another CNA (CNA #2) took the resident to the dayroom. CNA #1 stated he noted that the resident was in the dayroom at around 11:00 AM, during his dayroom assignment to watch the residents, but he did not realize if the resident's private companion (RR #1) brought the resident out of the dayroom to the patio when RR #1 arrived. RR #1 arrived at the facility at 11:03 AM. At approximately 11:15 AM, RN #1 noted the resident was at the patio with RR #1 trying to get the resident up. Resident #1 was observed sitting on the couch with some shade, drowsy but responded to verbal stimuli. Resident #1 was assisted back to their room via a wheelchair. Vital signs were checked and noted with elevated temperature and heart rate. Cooling measures were provided, and Tylenol was given. Vital signs were rechecked: blood pressure-119/70, HR-104 bpm, breathing 18 breaths per minute, oxygen saturation on room air-96%, temperature- 97.1 degrees F, and resident was back to their baseline. The physician was informed and ordered the resident to be sent to the hospital to rule/out seizure. Other CNAs that worked that day were interviewed, but no one noticed Resident #1 going out to the patio by themself. They also stated, Resident #1's family did not want the resident out to patio unless with the companion (RR #1). Transport [ name redacted] was called and the resident was picked up at 1:15 PM. They left for the hospital with no signs of distress. Resident #1 was sent to hospital [name redacted]. The investigation did not include a statement from RR #1 who was with the resident at the time. A review of emergency room (ER) paperwork dated 07/29/25 at 1:50 PM, included history of present illness that Resident #1 arrived at the ER by emergency medical services (EMS) for an episode of unresponsiveness. Per [Resident #1's sending facility name redacted], [Resident #1] was outside 30-40 minutes sitting on a bench on the patio when [the resident] became unresponsive, tachycardic (fast heart rate), and was found to be febrile 103.8 degrees F. The facility gave [the resident] Tylenol and wiped the resident with cold sponge and [the resident's] temperature went down to 97.1 degrees F before [they] were sent to the [ER]. The report also indicated the resident was diagnosed with transient alteration awareness (loss of normal awareness or behavior) and heat stroke. On 11/05/25 at 12:40 PM, the surveyor interviewed the Unit Manager (UM), who stated that on 07/29/25, she was in a care meeting when the nurse (RN #1) called her. The UM further stated that when she came to the floor, the resident was seen sitting outside on the patio with the companion (RR #1). The UM stated RR #1 called the nurse (RN #1) to check on the resident. The UM stated she did not know if the resident was taken outside by RR #1, and normally there was staff or a CNA in the dayroom that oversaw the residents outside on the patio as well. The UM stated that the companion (RR #1) did not provide care to Resident #1. The surveyor requested for a copy of dayroom assignment on that day of 07/29/25. The facility document titled as Dayroom Schedule dated 07/29/25, and shift: the 7:00 AM to 3:00 PM shift revealed that CNA #1 was assigned in dayroom that day from 11:00 AM to 11:30 AM. On 11/05/25 at 1:08 PM, the surveyor interviewed RN #2, who was Resident #1's regular nurse. RN #2 stated that the companion, RR #1, did not provide care for the resident. On 11/5/25 at 3:46 PM, the surveyor interviewed CNA #1, who was assigned to the dayroom at the time of the incident as well as Resident #1's assigned aide. CNA #1 stated he was regularly assigned to the resident, and the resident could not transfer by themself but would try. CNA #1 stated the resident required one person assistance from staff and supervision during eating. CNA #1 stated that after he washed the resident, he walked the resident to the dayroom for activities. CNA #1 further stated he would sometimes catch the resident trying to go to the patio. CNA #1 stated that we had an every 30-minute rotating assignment to watch the residents in the dayroom. CNA #1 stated on 07/29/25, after washing the resident at around 10:00 AM, I took [Resident #1] to the dayroom. My scheduled dayroom assignment was from 11:00 AM to 11:30 AM. When I went back to the dayroom at 11:00 AM, I saw the resident [at] the long table. The [television] was on, I did not see the activity person. I did not see the companion (RR #1). I did not see [RR #1] taking the resident out to the patio. CNA #1 further stated that at 12:00 PM, while he was [providing] care to another resident, the nurse called [him] because they needed help outside [on] the patio to pick [up] and put [the resident] in wheelchair and back to [Resident #1's] room. [The resident] was sweating and was not talking. [The resident] looked different. [The resident] was sent out to the hospital. CNA #1 stated that the companion, RR #1, did not provide care to the resident. On 11/05/25 at 4:30 PM, the surveyor interviewed the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The DON stated that Resident #1's companion, RR #1, did not provide care to the resident. On 11/06/25 at 12:29 PM, the surveyor interviewed CNA #2, who was assigned to the dayroom on 07/29/25 from 11:30 AM to 12:00 PM. CNA #2 stated she could not recall the incident on 07/29/25, and she did not recognize the resident's companion (RR #1). CNA #2 also stated that she could not remember her schedule that day. The surveyor informed her she was assigned to the dayroom from 11:30 AM to 12:00 PM, and CNA #2 stated, it was so long ago, and the resident went out to the patio always with the family. On 11/06/25 at 12:55 PM, the surveyor interviewed CNA #3, who was assigned in the dayroom on 07/29/25 from 10:00 AM to 10:30 AM. CNA #3 stated that the resident did not go out by themself but usually with the companion. CNA #3 further said, I did not see the resident from 10:00 AM to 10:30 AM outside while I was there in the dayroom. CNA #3 stated she did not see the companion (RR #1) taking the resident out to the patio. The surveyor was not able to interview RN #1 who was reportedly out of the country. On 11/07/25 at 12:17 PM, the surveyor conducted a telephone interview with RR #2, who stated on 07/29/25, the UM called them to inform RR #2 that the facility was sending Resident #1 to the hospital for evaluation. RR #2 stated that the UM informed them of the incident, that the resident was outside for approximately 40 minutes, and the facility notified the physician who ordered to send the resident to the ER. On 11/07/25 at 2:13 PM, the surveyor conducted a telephone interview with the resident's companion, RR #1, who stated they arrived at the facility around 11 o'clock that day. RR #1 stated, I got out from the elevator and [the resident] was not there in the dayroom, so I went to check [the resident's] room, and [the resident] was not there, too. I went to look for [the resident] and going back to the dayroom, I saw [the resident] through the glass door. [The resident] was outside on the patio sitting on the right area of patio and was on [the resident's] right side. [The resident] was out open under the sun; [they were] seated in one of the chair with [their] rolling walker beside [them]. I thought [the resident] was asleep. I called [the resident's] name and [the resident] was not responding. I saw saliva from [the resident's] mouth and drainage coming out from [the resident's] nose. I rushed inside to ask for help. I met the nurse halfway in and told her the resident needed help. [The] nurse rushed to [the resident] and checked [the resident], and they assisted [the resident] back to bed. At around 1:20 PM, they took [the resident] to the hospital. RR #1 further stated sometimes they took the resident outside, and RR #1 did not leave the resident unattended, and the resident did not go outside by themself. RR #1 stated when RR #1 came out from the elevator after they arrived, there were some residents in the dayroom and there was no CNA. RR #1 said they knew because RR #1 started looking for the resident. On 11/10/25 at 10:45 AM, the surveyor interviewed the DON, who stated that the facility had CNAs assigned every thirty-minutes in the dayroom to watch the residents, providing supervision and ensuring safety. The DON further stated the CNA assigned did not leave the dayroom until the relieving CNA arrived. On 11/10/25 at 2:08 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) with the DON. The LNHA and the DON stated that it was RR #1 who took the resident out to the patio. The DON stated that after the incident, she gathered statements from the nurse and the CNA. The DON further stated she investigated but was not able to interview and obtained the statement of RR #1. The DON provided an investigation report with statements from the CNA and the RN involved only. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy reviewed and signed by the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and dated June 18, 2025, included Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Interpretation and Implementation: The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone; 2. Develop and implement policies and protocols to prevent and identify:.b. neglect of residents;.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. NJAC 8:39-4.1(a)5

Based on record review, interview, and review of facility policy, the facility failed to ensure that medical records were provided to residents or their legal representatives in a timely manner. This deficient practice was identified for three of six sampled residents (R)13, (R)15, and (R)16 which delayed access to essential health information. Review of the facility's policy titled Authorization for Release of Information dated 05/01/22 revealed that access to view documents must be provided within 24 hours of receipt of a request, and copies of records must be provided within two working days. 1.Review of R13's diagnosis sheet provided by the facility revealed an admission date of 05/20 and discharge date in 06/20. Review of correspondence from the New Jersey Department of Health (NJDHS) dated 04/23/25 revealed R13's legal representative made multiple medical record requests on 09/20/24, 11/08/24, and 08/13/24. During an interview on 08/04/25 at 11:30 AM with the Administrator revealed as of 02/25, all medical record requests for residents cared for under the previous facility are to be made or forwarded to Paralegal (PL)2 and this may be the cause of why requests are delayed. During an interview with (PL)1 on 08/08/25 confirmed receipt of R13's medical records from April 2024, but records for the following dates 09/20/24, 11/08/24, and 08/13/24 had not been received. 2.Review of R15's Face Sheet located in the electronic medical record (EMR) revealed an admission date of 07/24 and discharge date of 01/24. Review of a detailed timeline provided by R15's family member revealed she submitted a medical records request in person on 04/08/25 and sent a certified request on 05/27/25 addressed to the Administrator. During an interview with R15's family member on 08/08/25, she confirmed she had not received the requested records. 3.Review of R16's diagnosis sheet provided by the facility revealed an admission date of 04/24 and discharge in 05/24. Review of NJDHS correspondence dated 03/14/25 revealed multiple record requests on 09/06/24, 10/13/24, and 11/15/24. Review of email correspondence provided by the facility showed the requests remained unfulfilled until 07/25/25. During an interview with PL3 on 08/08/25 at 11:32AM the PL3 revealed they followed up with the facility on 07/23/35 expressing that R16's request was not fulfilled. She confirmed she did receive the records finally on 07/25/25.

Based on interview, record review, and review of facility policy, the facility failed to provide care and treatment in a timely manner for an unavoidable pressure ulcer for one of three residents (Resident (R) 5) reviewed for pressure ulcers out of a total sample of 20. The wound was not properly assessed for seven days. This resulted in harm when the wound was determined to be an unstageable pressure ulcer that resulted in hospitalization for the resident with a diagnosis of sepsis, with the pressure ulcer being the possible source of the sepsis.Review of the facility's policy titled, Pressure Injury Prevention Guidelines, dated 03/04/25, revealed, . to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present . The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound . Review of R5's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on 01/25 with diagnoses that included pressure ulcer of sacral region stage II, malignant neoplasm of unspecified part of the right bronchus or lung, secondary malignant neoplasm of mediastinum, chronic obstructive pulmonary disease, chronic viral hepatitis C, hepatomegaly, and polyneuropathy. Review of R5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/25 and located in the resident's EMR under the MDS tab, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R5's cognition was intact for decision-making. It was recorded R5 required partial to moderate assistance with bed mobility, was occasionally incontinent of bladder and bowel, and had one stage 2 pressure ulcer. It was recorded pressure reducing devices were in use for the resident's chair and bed, a turning program was in place, and nutritional interventions were implemented. Review of R5's Initial Wound Assessment, located in the EMR under the Assessment tab and dated 01/17/25, revealed R5 was seen by the Wound Care Nurse (WCN) for an initial evaluation of a stage II sacral pressure sore. It was recorded, . Initial wound encounter measurements are 0.5cm length x 0.4cm width x 0.1 cm depth, with an area of 0.2 sq cm and a volume of 0.02 cubic cm. There is a Moderate [sic] amount of sero-sanguineous drainage noted which has no odor . Review of R5's Physician Order, dated 01/17/25 and located under the Orders tab of the EMR, revealed an order to cleanse R5's pressure ulcer with wound cleanser and to apply Calazime Skin Protectant to the sacrum once daily. It was also ordered for the resident to have weekly skin assessments on Mondays. Review of R5's Care Plan, dated 01/17/25 and located under the Care Plan tab of the EMR, revealed R5 had a documented pressure ulcer. Interventions included to evaluate ulcer characteristics and monitor ulcer for signs of progression or declination. Review of R5's Physician Orders, dated 01/30/25 and located under the Orders tab of the EMR, revealed an order for Phytoplex Z-Guard Paste to R5's sacrum twice daily for IAD (incontinence associated dermatitis). Review of R5's Progress Note, dated 01/31/25, located under the Progress Notes tab of the EMR, and written by the WCN, indicated the stage II sacral pressure ulcer was healed/resolved. It was recorded there was no slough or eschar present, there were no signs or symptoms of infection, and there was 100% epithelialization. Review of R5's eMAR PN (electronic Progress Note), dated 02/10/25 at 9:05 PM and located under the Progress Notes tab of the EMR, revealed, . Weekly skin assessment: Monday one time a day every Mon No new skin issues noted . Review of R5's eMAR PN, dated 02/14/25 at 2:41 PM and located under the Progress Notes tab of the EMR, revealed, . Phytoplex A-Guard . wound care completed as per current order and wound nurse on rounds today and patient has wound care consult and asked wound nurse to see . Review of R5's Progress Notes tab revealed no documented evidence of why the WCN was asked to see R5. There was no other documented evidence related to R5's skin integrity at this time, including if R5's sacral pressure ulcer had reopened or that R5 had developed a new pressure ulcer. There was no documented evidence R5 still had IAD. Review of R5's Orders and Progress Notes tabs of the EMR and review of the WCN's consolidated Progress Note Details revealed no documented evidence R5 was seen by the WCN on 02/14/25. Review of R5's Progress Note, dated 02/17/25 at 11:55 AM and located under the Progress Notes tab of the EMR, revealed, . Pt [patient] picked up by family for his appointment . Wound care completed prior to leaving . Review of the TAR, dated 02/17/25 at 9:00 AM, revealed R5 received Phytoplex Paste to the sacrum. Review of R5's entire EMR revealed no further information related to R5's skin integrity. There was no documentation to show if R5's pressure ulcer had reopened or if a new pressure ulcer had developed. There was no documented evidence R5 still had IAD. Review of R5's Progress Notes tab of the EMR for 02/18/25 revealed no documented evidence related to R5's skin integrity. Review of R5's Progress Note, dated 02/19/25 at 2:34 PM and located under the Progress Notes tab of the EMR, revealed, . Sacral wound was cleaned as per order. Unit manager informed to f/u [follow up] with wound care nurse as the current order isn't effective and wound is worsening and requested for air mattress which will be followed up with maintenance by UM [Unit Manager]. Patient is repositioned regularly . Review of R5's Progress Notes tab revealed no further documented evidence related to R5's skin integrity. Review of R5's Progress Note, dated 02/21/25 at 1:06 PM, revealed, . 1000 [10:00 AM] Wound care nurse came to see patient. Wound seen by wound nurse and new order placed. NP [Nurse Practitioner] was notified 2/20 [02/20/25] for worsening wound and to evaluate. Instructed to see wound care as pt has wound care consult in place . Review of R5's Progress Note, dated 02/21/25, written by the Nurse Practitioner Wound Care Nurse (NP WCN)1 and located under the Misc (Miscellaneous) tab of the EMR, revealed, . Wound #2 is an unstageable Pressure Injury, obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of 'Not healed' . Initial wound encounter measurements are 10.5cm length x9.5cm width x 0.2cm depth with an area of 99.75sq cm and a volume of 19.95 cubic cm. There is a moderate amount of sero-sanguineous drainage noted which has a strong odor . Wound bed has no granulation,100% slough, no eschar, and no epithelialization present . Review of the Emergency Department (ED) provider notes, dated 02/21/25 and provided by the facility, revealed, . deep sacral wound with surrounding erythema concerning for cellulitis as possible source or at least contributing source of sepsis . During a telephone interview on 08/08/24 at 1:00 PM, Registered Nurse (RN)1 stated on or about 02/17/25, she noticed R5 had a 2x2 cm reddened area to the sacral area. RN1 stated R5's previous pressure ulcer had opened, and she notified the doctor. She stated the pressure ulcer was red, had clear drainage, and no order. She stated the information should have been in the progress notes. She stated she had asked for a wound consult at that time and placed the order for the consult. RN1 stated she worked with R5 on 02/17/25, 02/19/25, and 02/20/25. RN1 stated she notified the NP on 02/19/25 because the wound was worsening, and the NP stated to continue with the standing order treatment. RN1 stated the NP did not ask for any wound measurements. RN1 stated on 02/20/25, she asked the UM to follow up for a wound consult. RN1 stated she took measurements on 02/20/25, wrote them on her gloves, and then accidentally threw the gloves in the trash. RN1 stated that when a pressure ulcer is found, the nurse should document an assessment of the wound. She stated she did not remember documenting an assessment on R5's pressure ulcer on 02/20/25 but should have. During an interview on 08/08/25 at 2:42 PM, the WCN stated R5's wound was completed epithelized on 01/31/25. She stated she was notified to see the resident on 02/21/25 and when she did, he had a pressure ulcer that measured 10.5 cm x 9.5cm x 0.02 cm depth with 100% slough on the wound bed. The WCN stated the ulcer was unstageable because of the slough. She stated the wound had a strong odor, and she ordered a new treatment. The WCN stated she did not know what happened to the patient. During an interview on 0 8/08/25 at 3:45 PM, the Medical Doctor (MD) stated it was his expectation that nurses would notify him of changes in skin condition. He stated he did give an order for R5 to be seen by the WCN. The MD stated that in a perfect world, the nurses would measure and assess pressure ulcers, but the WCN would be the best one to get measurements.During an interview on 08/08/25 at 6:50 PM, the Director of Nursing (DON) stated nurses conduct weekly skin assessments on the residents' shower days. The DON stated that the Certified Nurse Aides (CNAs) were instructed to report any skin irregularities/change to the nurses, and the nurses will conduct a skin assessment. The DON stated the facility's expectation was that nursing staff conduct and document weekly skin assessments and measure and describe any identified skin injury or pressure ulcer. Further interview with the DON confirmed that measurements and description of R5's unstageable pressure ulcer were not documented and should have been.

Based on observation, interviews, medical record review and other pertinent facility documentation, it was determined that the facility's Administrator failed to ensure that the facility was in compliance with the following regulatory requirements, which affected the safety of all the residents in the facility. The Administrator failed to ensure: 1.) immediate action was taken to initiate contact tracing upon the identification of a COVID positive staff member, Registered Nurse #1 (RN #1), who was symptomatic and provided care to 9 residents on 1 of 2 units and tested positive for COVID-19 while at work on 12/24/22, 2) conduct contact tracing to identify residents and staff who had close contact with symptomatic COVID-19 positive residents (Resident #33 and #235), 3.) a process was in place to conduct immediate resident and staff testing upon identification of a COVID-19 positive staff and residents, 4.) COVID-19 surveillance and monitoring were completed for the residents, 5.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 6.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. The Administrator's failure to ensure facility wide infection control prevention standards, policies and procedures were implemented and immediately conduct contact tracing and testing upon the identification of COVID-19-positive staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/11/23. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/12/23. The IJ began on 11/15/22 when the former Director of Nursing (DON) who was primarily responsible for infection control left the facility without notice. On 12/24/22 at 7:00 PM, RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated that the contact tracing policy was never initiated for the 9 residents on the RN's assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone (a glucocorticoid medication used to suppress the immune system and decrease inflammation) use, Sickle Cell Anemia (an inherited disease in which the red blood cells have an abnormal crescent shape, and block small blood vessels), Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways), 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19. Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no contact tracing or subsequent resident testing performed. There were no consistent COVID-19 surveillance/assessments completed for the residents. The IP stated that she did not have a line list or notify the local health department of the positive cases. There was no screening or education provided to visitors entering the facility. The IP stated she was following the direction and guidance of the Administrator. The Administrator stated that she assumed that the IP was aware of her responsibilities and fulfilling her role as the IP. Refer to F880L and F886L as it pertains to the facility's failure to ensure the implementation of infection control practices and precautions during an identified COVID-19 outbreak. This deficient practice was evidenced by the following: A review of the Administrator's job description provided by the facility revealed the following: Manages all business related activity to achieve the organization's vision and supporting strategies and assures that the company image as an ethical and high quality provider of health services is maintained. Communicates new Policy and Procedures and regulations to staff to ensure compliance. Ensures that facility operations comply with local, state, and federal standards, laws, and licensing and certifying bodies. Understands and uses company policies, procedures and compliance program to promote quality of care. Develops all facility policies consistent with corporate guidelines. During the entrance conference on 1/3/23 at 11:00 AM, the Infection Preventionist (IP), along with the DON, informed the surveyors there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation. On 1/4/23 at 9:18 AM, Surveyor #2 asked the DON for the facility line list (a table that contains key information about each case in an outbreak). The DON stated that there was no line list and that it had not been done since the prior DON had left. She stated she had started at the facility in December and was not aware there wasn't a line list until yesterday (1/3/23). On 1/4/22 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day RN #1 worked was 12/24/22. Surveyor #1 reviewed the COVID Tracker that included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents tested . The surveyor asked the IP about the line list for COVID-19 cases in the facility. The IP stated she was new, did not have access to everything, and was not sure of the line list. The IP confirmed the line list was not completed and was following up with the LHD about it. The IP stated the previous DON was completing the line list and was not sure of the date the previous DON had left. During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half. RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 said she received report from the outgoing nurse, checked on her residents, and did her first medication administration pass before testing herself at 10:00 PM and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one . only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting. RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work. On 1/4/23 at 11:54 AM, the IP provided the surveyor RN#1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM. On 1/4/23 at 12:38 pm, the IP provided the surveyor with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and there was no documentation that the residents were tested . The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested . Additionally, the IP stated that the contact tracing policy was not initiated. A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents: Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone (a corticosteroid medication that suppresses the immune system and decreases inflammation) treatment; Resident #240 who had a diagnosis that included Sickle Cell Anemia; and Resident #238, who had a diagnosis that included COPD. Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix. The COVID-19 Surveillance Assessment and progress notes relating to COVID-19 surveillance and monitoring for the 9 residents' electronic medical records were not consistent and were not completed every shift as per the facility's COVID-19 Clinical Monitoring and Measures Plan policy. The policy indicated a Screening UDA [User Defined Assessment] which included vital signs was to be completed every shift for residents in the affected unit (where a resident tested positive or positive employee worked). On 1/4/23 at 12:53 PM, the IP provided to the surveyor a copy of the facility's Contact Tracing Worksheet, dated 10/05/2022, and COVID-19 Outbreak and Contact Tracing Tool, dated 10/19/22. The IP confirmed this was not initiated after positive staff and resident cases in the facility. The Contact Tracing Worksheet indicated the process for contract tracing when a positive COVID-19 case was identified, which included recording COVID-19 positive demographic and exposure data on the COVID-19 Outbreak and Contact Tracing Tool, identifying the first day of symptoms, determining where the symptomatic individual visited and others who were in close contact with the COVID-19 positive individual. The COVID-19 Outbreak and Contact Tracing tool was to be completed for staff and residents, included the COVID-19-positive individual's date of symptom onset, assignment for staff, room number for resident, potentially exposed individuals, if they were in close contact, for how long, and PPE (personal protective equipment, clothing or equipment worn to protect the person from infection) used during contacts. On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. The surveyor requested from the DON and IP documentation of any resident testing conducted. On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing. A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23. During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for COVID-19-positive residents and testing of residents in contact but was not done. The surveyor asked for the contact information of the LHD, and the IP handed an email address to the surveyor and stated that she did not have a phone number for the LHD and had not notified the LHD of any of the positive cases. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator. On 1/11/23 at 9:35 AM, the surveyor interviewed the DON who provided the infection control policy. The policies for isolation precautions, PPE, Infection Surveillance, outbreak investigations, and antibiotic stewardship had a review date of 7/2021. The DON stated she could not find the policy reviewed for the year 2022 and that the infection control policy was reviewed and approved in January 2023. The DON provided policies with an Annual Review page signed by the DON, Administrator, IP, and Medical Director, dated 1/9/2023. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case. The Administrator stated she could not recall a positive staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator further stated the LHD should have been notified after the first positive COVID-19 case and that the IP had a contact in the LHD but was not sure who. The Administrator acknowledged the facility's infection control policies and procedures should be reviewed annually and could not recall if the policy was reviewed in 2022. The Administrator stated the DON and herself were responsible for ensuring policies were reviewed. The Administrator stated she was not aware that there was no line list and that there was no contact with the LHD. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON would be responsible for ensuring the IP was carrying out her responsibilities. During an interview with Surveyor #1 on 1/13/23 at 8:45 AM, the Human Resource Director confirmed that the last day of the prior DON was on 11/15/22. The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed. A review of the Job Description provided for the IP with a date of hire of 10/22/22 did not indicate her role and responsibilities as an IP. A review of an undated facility's policy titled Outbreak Plan included the following: Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance. A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA (User Defined Assessment) consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual. Testing during an outbreak revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. A review of CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22, indicated if healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. The guidance further indicated the following: A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed; The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission; Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status; Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 NJAC 8:39- 19.1(a); 19.2(a)(c),8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure: 1.) immediate action was taken to initiate contact tracing upon the identification of a COVID positive staff member, Registered Nurse #1 (RN #1), who was symptomatic and provided care to 9 residents on 1 of 2 units and tested positive for COVID-19 while at work on 12/24/22 2. 2) conduct contact tracing to identify residents and staff who had close contact with symptomatic COVID-19 positive residents (Resident #33 and #235) 3.) COVID-19 surveillance and monitoring were completed for the residents, 4.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 5.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly highly transmissible infectious disease. The facility's system-wide failure to immediately conduct contact tracing upon the identification of COVID-19-positive staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/5/23 at 3:35 PM. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/6/23. The IJ situation began on 12/24/22 at 7:00 PM, when RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated that the contact tracing policy was never initiated for the 9 residents on the RN's assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone (a glucocorticoid medication used to suppress the immune system and decrease inflammation) use, Sickle Cell Anemia (an inherited disease in which the red blood cells have an abnormal crescent shape, and block small blood vessels), Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways). 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19. Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no contact tracing or subsequent resident testing performed. There were no consistent COVID-19 surveillance/assessments completed for the residents. The IP stated that she did not have a line list or notify the local health department of the positive cases. There was no screening or education provided to visitors entering the facility. The IP stated she was following the direction and guidance of the Administrator. This deficient practice was evidenced by the following: Refer to F 886L Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 9/23/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements. Reference: Centers for Disease Control and Prevention (CDC) guidance, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22. During the entrance conference on 1/3/23 at 11:00 AM, the Infection Preventionist (IP), along with the Director of Nursing (DON), informed the surveyors there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started working in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation. On 1/4/23 at 9:18 AM, Surveyor #2 asked the DON for the facility line list. The DON stated that there was no line list and that it had not been done since the prior DON had left. She stated she had started at the facility in December and was not aware there was not a line list until yesterday (1/3/23). On 1/4/23 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff) titled COVID-19 Employee Detail, which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day RN #1 worked was 12/24/22. During an interview with Surveyor #1 and Surveyor #2 on 1/4/23 at 11:05 AM, the IP, in the presence of the DON, stated the facility's infection control practice was based on the infection control manual and facility policies based on corporate, CDC guidelines and guidance from the Local Health Department (LHD). The IP stated COVID-19 testing was conducted twice a week and in between that time if someone was symptomatic. The IP stated the residents and staff were tested twice a week on Mondays and Thursdays. Surveyor #1 reviewed the COVID Tracker that included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents tested . The surveyor asked the IP about the line list (a table that contains key information about each case in an outbreak) for COVID-19 cases in the facility. The IP stated she was new, and did not have access to everything, and was not sure of the line list. The IP confirmed the line list was not completed and was following up with the LHD about it. The IP stated the previous DON was completing the line list and was not sure of the date the previous DON had left. Surveyor #2 requested the contact information for RN #1, timecards, and residents assigned to RN #1 on 12/24/22. During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half. RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 said she received report from the outgoing nurse, checked on her residents, and did her first medication administration pass before testing herself at 10:00 PM and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one .only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting. RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work. On 1/4/23 at 11:54 AM, the IP provided the surveyor RN#1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM. On 1/4/23 at 12:38 PM, the IP provided Surveyor #2 with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and there was no documentation that the residents were tested . The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested . Additionally, the IP stated that the contact tracing policy was not initiated. A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents: Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone treatment; Resident #240 who had a diagnosis that included Sickle Cell Anemia; and Resident #238, who had a diagnosis that included COPD. Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix. The COVID-19 Surveillance Assessment and progress notes relating to COVID-19 surveillance and monitoring for the 9 residents' electronic medical records were not consistent and were not completed every shift as per the facility's COVID-19 Clinical Monitoring and Measures Plan policy. The policy indicated a Screening UDA [User Defined Assessment] which included vital signs was to be completed every shift for residents in the affected unit (where a resident tested positive or positive employee worked). On 1/4/23 at 12:53 PM, the IP provided Surveyor #2 a copy of the facility's Contact Tracing Worksheet, dated 10/05/2022, and COVID-19 Outbreak and Contact Tracing Tool, dated 10/19/22. The IP confirmed this was not initiated after positive staff and resident cases in the facility. The Contact Tracing Worksheet indicated the process for contract tracing when a positive COVID-19 case was identified, which included recording COVID-19 positive demographic and exposure data on the COVID-19 Outbreak and Contact Tracing Tool, identifying the first day of symptoms, determining where the symptomatic individual visited and others who were in close contact with the COVID-19 positive individual. The COVID-19 Outbreak and Contact Tracing tool was to be completed for staff and residents, included the COVID-19-positive individual's date of symptom onset, assignment for staff, room number for resident, potentially exposed individuals, if they were in close contact, for how long, and PPE used during contacts. On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. Surveyor #1 requested from the DON and IP documentation of any resident testing conducted. On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing. A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23. During an interview with Surveyor #1 on 1/5/23 at 10:42 AM, the RNS stated if someone said they were calling out sick or not feeling well, she would ask about their symptoms, how long, and when they last worked. The RNS could not recall if she received any callouts when working on 12/22/22 and 12/23/22. The surveyor asked the RNS if she was aware of a positive COVID-19 staff case on 12/24/22. The RNS stated she knew they had a case but does not know who it was. The RNS stated there was a schedule logbook where callouts are written. During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for COVID-19-positive residents and testing of residents in close contact but was not done. The surveyor asked for the contact information of the LHD, and the IP handed an email address to the surveyor and stated that she did not have a phone number for the LHD and had not notified the LHD of any of the positive cases. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator. On 1/5/23 at 1:30 PM, the DON provided Surveyor #1 with the call-out log for December 2022. The call-out log was in calendar format, which included the employee's name written on the day the employee called out. RN #1's name was documented on the December 2022 call-out log for 12/22/22 and 12/23/22. There was no further information documented on the call-out log. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case. The Administrator stated she could not recall a positive staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator further stated the LHD should have been notified after the first positive COVID-19 case and that the IP had a contact in the LHD but was not sure who. The Administrator stated she was not aware that there was no line list and that there was no contact with the LHD. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON were responsible for ensuring the IP was carrying out her responsibilities. During an interview with Surveyor #1 and Surveyor #2 on 1/13/23 at 9:13 am, the Medical Director, stated he was made aware of the COVID-19 tracking and testing concerns. The Medical Director stated that the facility followed CDC and CMS guidelines for policies and was unaware they were not being followed. The Medical Director stated he was always made aware of positive COVID-19 cases in the facility and testing of residents should be based on contact tracing. The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed. A review of the Job Description provided for the IP with a date of hire of 10/22/22, did not indicate her role and responsibilities as an IP. A review of an undated facility's policy titled Outbreak Plan included the following: Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance. A review of the facility's policy Infection Control Manual, 07/10/2021 included the following: Under Surveillance, Section 4: Outbreak Investigations read, An epidemic or outbreak is an excess over the expected or usual level of a disease within a geographic area. One case may constitute an epidemic and warrant an outbreak investigation .The Infection Preventionist or DON, under the direction of the Medical Director, manages an outbreak investigation. Under Outbreak Strategies, it read Upon identification of a potential outbreak, conduct an outbreak investigation. The objectives of any outbreak investigation are to describe the situation (what is happening), determine the etiology (where did the infection start), what is the agent, where is the source and what is the method of spread. It is important to identify the incubation period (interval between exposure and onset of symptoms). A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA [User Defined Assessment] consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual. Testing during an outbreak revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. A review of CDC guidance Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, revised 9/23/22, indicated if healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. The guidance further indicated the following: A single new case of SARS-CoV-2 infection in any healthcare personnel (HCP) or resident should be evaluated to determine if others in the facility could have been exposed; The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission; Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status; Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Part B F880 remains a deficiency at a scope and severity of an F based on the following: Based on observations, interviews, and review of other facility documentation, it was determined that the facility failed to: 1) conduct screening or education for visitors entering the facility, 2) review annually the facility's infection control and infection prevention plan and policies, and 3) maintain proper infection control practices identified during the: a) tour of the kitchen b) dining observation, and c) medication administration observation identified on 1 of 2 Nursing Units (Second Floor), and for 1 of 2 nurses (Licensed Practical Nurse #2) observed during the medication pass. This deficient practice was evidenced by the following: 1) On 1/3/23 at 9:05 AM, six surveyors entered the facility and were greeted by the front desk receptionist, who was not wearing a mask. The receptionist after greeting the surveyor applied a surgical mask. The receptionist instructed the surveyors to sign in with their names and date. There was no COVID-19 screening or education. Surveyor #2 interviewed the receptionist about the process of visitor check-in. The receptionist stated visitors sign in who they are visiting, they do not check temperatures anymore, and was not sure if there were COVID-19-positive residents in the facility. The receptionist stated there was no COVID-19 screening of visitors since November 2022. The receptionist further stated previously they would check temperatures and had a form for visitors to fill out. There was a sign on the reception desk for all visitors to always wear a mask in the facility. There was no signage about COVID-19 observed by the main entrance or reception area. On 1/3/23 at 10:29 AM, Surveyor #2 used the elevator, where there was signage observed for visitors about COVID-19, signs and symptoms, and signage that indicated a mask and face shield was required for the 2nd and 3rd-floor units. Signs were also observed in front of the elevators for visitors about COVID, its signs and symptoms, and a small sign was noted behind the reception area that was not visible. On 1/4/23 at 8:59 AM, the surveyors entered the facility, there were no visible signs posted about COVID-19 by the main entrance. On 1/4/23 at 11:05 AM, Surveyors #1 and #2 interviewed the infection preventionist (IP) and the Director of Nursing (DON) about visitor education and screening. The IP stated they did not conduct visitor screening since before she started working there and that the facility cannot close to visitors. The surveyor asked about any COVID-19 education for visitors. The IP stated signs were posted, though she was not sure if any were posted by the main entrance. On 1/4/23 at 11:50 AM, Surveyor #3 interviewed Guest Services/Recreation Director about visitor screening, who stated there used to be a Visitors/Staff Attestation. The Visitor/Staff had their temperature taken, they answered questions about COVID-19 signs and symptoms and then the second form had contact information and verified that the person was aware that the building had Covid positive residents. The Guest Services/Recreation Director stated the Administrator informed the staff in November they would not be using COVID-19 attestation forms and that she sent out an email to staff on November 4, 2022. A copy of the email was provided to the surveyor. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated in November 2022, the policy of screening visitors changed based on a zoom meeting with the corporate level nurse who provided an update on CDC guidance. The Administrator further stated visitors were given masks and were informed of proper PPE (personal protective equipment, protective clothing or equipment used to protect the body from injury or infection) to use when coming into the facility. A review of an undated facility's policy titled Outbreak Plan included the following: Under Screening & Protective Measures, it read Healthcare personnel and permitted visitors entering ProMedica Piscataway will be screened for COVID-19 illness; Under Notification Plan, it read Signage is posted at entrance doors to alert visitors to Covid-19. A review of the facility's Infection Control Manual policy with a revised date of 07/2021 included the following: Section 2: Precaution Systems, under Visitor Management, it read, Visitor management is the control of access and actions of people visiting for the safety and prevention of disease transmission. The policies provided did not further address COVID-19 visitor screening and education. 2) On 1/11/23 at 9:35 AM, the surveyor interviewed the DON who provided the infection control policy. The policies for isolation precautions, PPE, Infection Surveillance, outbreak investigations, and antibiotic stewardship had a review date of 7/2021. The DON stated she could not find the policy reviewed for the year 2022 and that the infection control policy was reviewed and approved in January 2023. The DON provided policies with an Annual Review page signed by the DON, Administrator, IP, and Medical Director, dated 1/9/2023. During an interview with the surveyor on 1/11/23 at 10:05 AM the Administrator acknowledged the facility's policies and procedures should be reviewed annually and could not recall if the policy was reviewed in 2022. The Administrator stated the DON and herself were responsible for ensuring policies were reviewed. During an interview with the surveyor on 1/13/23 at 9:13 AM, the Medical Director stated he was not sure exactly, but believed the policies were reviewed at the last QAPI meeting in December. The surveyor informed the Medical Director that the DON and the Administrator could not find an annual infection control policy review for 2022. The Medical Director provided no direct response and further stated the interdisciplinary team discussed protocols in morning meetings. 37547 3) On 01/03/23 at 9:52 AM, during the initial tour of the kitchen, the surveyor observed the Dining Services Director (DSD) who touched the lid of a trash can with her bare hands as she attempted to open the lid after the foot pedal feature malfunctioned. The DSD then proceeded to wash her hands for 14 seconds before she began the tour of the kitchen. During an interview with the surveyor on 01/04/23 at 8:40 AM, the DSD stated that when she washed her hands yesterday in the presence of the surveyor, she sang the happy birthday song once to ensure that she washed her hands for what she thought was the appropriate length of time of 20 seconds. The DSD further stated that if she did not wash her hands for at least 20 seconds prior to the tour of the kitchen there was a concern of contamination. During an interview with the surveyor on 01/11/23 at 10:46 AM, the Administrator stated that if the DSD had not washed her hands for at least 20 seconds prior to the tour of the kitchen, She could have passed germs onto the food and all around the kitchen. During an interview with the surveyor on 01/12/23 at 11:35 AM, the Infection Preventionist (IP) stated that the DSD should have washed her hands for 20 seconds prior to the tour of the kitchen to prevent the spread of infectious agents or bacteria. On 01/12/23 at 12:25 PM, during a follow-up visit to the kitchen, the surveyor observed Dietary Aide (DA #1) who washed her hands for 32 seconds at the handwashing sink, left the water running in the sink, dried her hands on a paper towel, removed her hair net, and replaced it with a larger one that provided full coverage, as the one she wore only covered her ponytail, and not the front or top of her head. DA #1 then proceeded to turn off the faucet with her bare hands. When interviewed at that time, DA #1 stated that she knew that she should have used a paper towel to turn off the faucet, but she had forgotten to. The DSD who was present stated that there was a potential for contamination since DA #1 touched her hair, then touched the faucet with her bare hands. The DSD stated that DA #1's responsibilities included plating food on the food service line, which was in process during the time of the observation. During an interview with the surveyor on 01/13/23 at 9:46 AM, the IP stated that DA #1 should have used a paper towel to turn off the faucet after she washed her hands because she re-contaminated her hands and that could have transferred to the faucet which had a potential for the spread of infection. 4) On 01/03/23 at 12:10 PM, the surveyor observed that a Dietary Aid (DA) delivered the food truck to Hall A of the Second Floor Nursing Station and proceeded to leave the unit. At 12:11 PM, the surveyor observed Certified Nursing Assistant (CNA #4) as she approached the food truck and removed the first meal tray without first performing hand hygiene before she delivered the tray to Unsampled Resident #1. The resident requested a plastic cup. CNA #4 returned to the food truck, obtained a plastic cup, and provided it to the resident as requested. CNA #4 then exited the resident's room without first performing hand hygiene. At 12:12 PM, the surveyor observed CNA #4 as she approached the food truck and reviewed Unsampled Resident #2's meal ticket before she poured coffee from a carafe into a coffee cup and placed it on the resident's tray. CNA #4 then proceeded to deliver the meal tray to the resident without first performing hand hygiene. The surveyor observed that CNA #4 did not offer to assist the resident with hand hygiene prior to the meal service. CNA #4 then exited the resident's room without first performing hand hygiene. At 12:13 PM, the surveyor observed CNA #4 who removed Unsampled Resident #3's tray from the food truck without first performing hand hygiene. The resident was asleep when she entered the room and she attempted to wake the resident by calling the resident's name without success. CNA #4 left the tray at the bedside and exited the resident's room without first performing hand hygiene. At 12:15 PM, the surveyor observed CNA #4 who removed Unsampled Resident #4's tray from the food truck without first performing hand hygiene and delivered it to the resident. CNA #4 offered the resident assistance and opened[TRUNCATED]

Based on interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure: 1.) a symptomatic Registered Nurse #1 (RN #1) notified the supervisor, prior to the start of her shift on 12/24/22 that she was ill, 2.) a process was in place to conduct immediate resident and staff testing upon identification of a COVID-19 positive staff member (RN #1) who provided care to 9 residents on 1 of 2 units while working on 12/24/22, and for two residents who tested positive for COVID-19 (Residents #33 and #235) 3.) the facility followed the relevant Centers for Disease Control and Prevention (CDC), Federal, and State guidance for infection control, and 4.) the facility's Outbreak Plan and COVID-19 policies were followed to prevent exposure and mitigate the spread of COVID-19, a deadly, highly transmissible infectious disease. The facility's system-wide failure to immediately conduct COVID-19 testing upon the identification of COVID-19-positive staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/5/23 at 3:35 PM. The removal plan was accepted and verified as implemented by the survey team during an onsite visit conducted on 1/6/23. The IJ situation began on 12/24/22 at 7:00 PM, when RN #1 reported to work while sick with fever and cough, proceeded to provide care for 9 residents in 1 of 2 resident units, and tested positive for COVID-19 on 12/24/22 at 10:00 PM. The Infection Preventionist (IP) stated there was no process in place to test the residents and staff. There was no evidence that the facility tested the 9 residents the RN had on her assignment. Three residents on the RN's assignment were immunocompromised and had a diagnosis of Human Immunodeficiency Virus (HIV) with prednisone use, Sickle Cell Anemia, and Chronic Obstructive Pulmonary Disease (COPD). 1 of the 3 immunocompromised residents was not vaccinated for COVID-19. Three additional residents were not vaccinated for COVID-19. Additionally, two symptomatic residents tested positive in the facility on 1/1/23 and 1/2/23. There was no subsequent resident testing performed. This deficient practice was evidenced by the following: Refer to 880L Reference: Centers for Medicare & Medicaid Services (CMS), QSO-20-38-NH, revised 9/23/22, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements During the entrance conference on 1/3/23 at 11:00 AM, the IP, along with the Director of Nursing (DON), informed the surveyors that there were two COVID-19-positive residents (Resident #33 and Resident #235) in the facility on the 2nd-floor unit. The IP stated she started in the facility in November and was responsible for staff development and infection control. The IP stated that the Administrator was currently on vacation. On 1/4/22 at 10:00 AM, Surveyor #1 reviewed the facility's COVID tracker (an internal tool that documents COVID-19 positive staff), titled COVID-19 Employee Detail which revealed RN #1 was positive for COVID-19 on 12/24/22. An additional review revealed that the onset of symptoms was on 12/22/22 and the last day the RN #1 worked was 12/24/22. During an interview with Surveyor #1 and Surveyor #2 on 1/4/23 at 11:05 AM, the IP, in the presence of the DON, stated the facility's infection control practice was based on the infection control manual and facility policies based on corporate, CDC guidelines and guidance from the Local Health Department (LHD). The IP stated COVID-19 testing was conducted twice a week and in between that time if someone was symptomatic. The IP stated the residents and staff were tested twice a week on Mondays and Thursdays. Surveyor #1 reviewed the COVID Tracker which included RN #1 with the DON and IP. The DON stated RN #1 tested positive for COVID-19 at work on 12/24/22 and had allergy symptoms that included sinus symptoms and headache, for a couple of days before. The DON stated RN #1 did not work on 12/22/22 and 12/23/22 and worked on 12/24/22 for the 7 pm to 7 am shift on the 2nd-floor unit. The DON further stated RN #1 should not have come in sick to work and should have tested before her shift. The DON stated she did not do contact tracing and would have to check the documentation for residents who were tested . During a telephone interview with Surveyor #1 On 1/4/23 at 11:57 AM, RN #1 stated she started feeling sick on 12/22/22 and called out sick to the Registered Nurse Supervisor (RNS) on 12/22/22 and 12/23/22. RN #1 stated she was running temperatures, had a cough, and reported to the RNS that she was not feeling well. She stated the RNS stated, ok and did not ask any further questions. RN #1 stated it was holiday time and if you call out before the holiday, you don't get time and a half. RN #1 stated she went back to work on 12/24/22 and thought she was ok since she called her primary doctor who gave her antibiotics, and she also took Tylenol. RN #1 stated she still had a fever and cough symptoms when she went to work. RN #1 stated she received report from the outgoing nurse, checked on her residents, did her first medication administration pass before testing herself at 10:00 PM, and tested positive for COVID-19. The surveyor asked if she had told anyone that she was not feeling well or about her symptoms on 12/24/22. RN #1 stated, Who was I gonna tell .there was no one .only nurses and she had called the DON at 10:00 PM after testing positive. RN#1 stated the DON told her that she had to go home and could not work as she tested positive for COVID-19. RN #1 said she gave report to the other nurse and went home. The surveyor asked RN #1 why she tested herself at 10:00 PM and not before that time. RN #1 replied that the outgoing nurses wanted to give report to go home, and she did not want to keep them waiting. RN #1 stated that no one from the facility had called her to ask about contact tracing including residents she had contact with. RN #1 stated she had education about COVID-19 in 2020 and 2021 and acknowledged that the facility had stated if a staff member had symptoms or was COVID-19 positive that the staff member should not come to work. On 1/4/23 at 11:54 AM, the IP provided the surveyor RN #1's timecard which revealed RN #1 worked on Saturday 12/24/22, clocked in at 7:00 PM, and clocked out at 10:45 PM. On 1/4/23 at 12:38 PM, the IP provided the surveyor with the assignment of RN #1 on 12/24/22, which included 9 residents (Resident #236, #69, #239, #47, # 80, #63, #240, #238 and #52). The IP stated that the residents who were exposed were not tested and that there was no documentation that the residents were tested . The IP stated she was new in training, but that she was responsible to ensure they were doing the correct thing and the residents should have been tested . A review of the medical records for the 9 residents that were assigned to RN #1 on 12/24/22, included three immunocompromised residents: Resident #236 who had a diagnosis that included HIV, was receiving dialysis, and prednisone (a corticosteroid medication that suppresses the immune system and decreases inflammation) treatment; Resident #240 who had a diagnosis that included Sickle Cell Anemia; and Resident #238, who had a diagnosis that included COPD. Four of the residents (Resident #236, #69, #239, and #47) were unvaccinated and 5 residents (Resident # 80, #63, #240, #238, and #52) were fully vaccinated according to the facility's resident COVID-19 vaccination matrix. On 1/4/23 at 1:05 PM, Surveyor #1 and Surveyor #2 interviewed the IP and the DON about the process of testing residents and staff, after a positive case. The IP stated testing should be twice a week, positive staff COVID results are logged in the computer's COVID tracker and there was a surveillance log in which results were written for staff testing. The IP stated there was no log for residents, positive results were found on the resident's medical record, and she was not sure where negative results would be documented. The DON stated resident testing, whether positive or negative results, should be documented in the electronic medical record's progress notes. The surveyor requested from the DON and IP documentation of any resident testing conducted. On 1/4/23 at 1:55 PM, Surveyor #1 interviewed the IP about the two COVID-19-positive residents in the facility. The IP stated the two residents were tested because they had symptoms. The IP stated she would check and provide information on contact tracing and resident testing. A review of the progress notes provided by the IP revealed that Resident #235 had chills, muscle aches, and cough, and tested positive for COVID-19 on 1/1/23, and Resident #33 had a sore throat with post-nasal drip and tested positive for COVID-19 on 1/2/23. During an interview with Surveyor #1 on 1/5/23 at 10:42 AM, the RNS stated if someone said they were calling out sick or not feeling well, she would ask about their symptoms, how long, and when they last worked. The RNS could not recall if she received any callouts when working on 12/22/22 and 12/23/22. During a follow-up interview with Surveyor #2 on 1/5/23 at 10:58 AM and 12:03 PM, the IP stated there was no process in place to ensure resident testing was done. The IP stated contact tracing should have been done for the COVID-19-positive residents and testing of residents in contact but was not completed. She stated after the former DON left the facility, she was pulled into so many directions and was following the direction and guidance of the Administrator. During an interview with the surveyors on 1/11/23 at 10:05 AM, the Administrator stated that the former DON had left without notice in November and the IP had a solid week of training and spent a day with the Quality Assurance Consultant. She stated when the DON left, she had assigned the IP to be a Unit Manager on one of the units for oversight and she (the IP) should have been juggling everything. The Administrator stated she would let the IP know if something needed to be addressed and the IP was responsible for in-services, following up with tracking of covid positive residents, ensuring testing was being done, completing surveillance after a positive case, and checking the residents on the assignment after a positive staff case. The Administrator stated she could not recall a positive COVID-19 staff case on 12/24/22. The surveyor informed the Administrator of RN #1, COVID-19 surveillance, and contact tracing concerns. The Administrator stated after a positive COVID-19 case, it was expected for the residents to be tested for COVID-19 and that staff was instructed not to come in to work when sick and to test before starting their shift. The Administrator stated she assumed the IP was doing what she was supposed to do and was not following up with her. She stated there was no team meeting held to discuss RN #1 testing positive on 12/24/22. The Administrator stated that she and the DON would have been responsible for ensuring the IP was carrying out her responsibilities. During an interview with Surveyor #1 and Surveyor #2 on 1/13/23 at 9:13 AM, the Medical Director stated he was made aware of the COVID-19 tracking and testing concerns. The Medical Director stated that the facility followed CDC and CMS guidelines for policies and was unaware they were not being followed. The Medical Director stated he was always made aware of positive COVID-19 cases in the facility and testing of residents should be based on contact tracing. The surveyor reviewed the IP's competency checklist, a twelve page document, titled Infection Preventionist Orientation Plan and Skills Competency Checklist which was dated 11/4/22. Review of the checklist revealed 84 out of 92 tasks were not completed. A review of the Job Description provided for the IP with the date of hire of 10/22/22, did not indicate her role and responsibilities as an IP. A review of the Centers for Medicare and Medicaid Services (CMS) directive QSO-20-38-NH, dated revised 09/23/22, included but was not limited to the definition of Close contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period. Guidance - To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary. The testing summary included that for newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual. Testing during an outbreak revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g. facility-wide) testing. Documentation of testing revealed that upon identification of a new COVID-19 case in the facility, document the date the case was identified, the date that other residents and staff are tested , the dates that staff and residents who tested negative are retested , and the results of all tests. A review of an undated facility's policy titled Outbreak Plan included the following: Under Evidence-Based Outbreak Response Measures, it revealed, if a new/reemergence of an infectious disease is detected, ProMedica Piscataway will follow its Infection Control policies and the measures and procedures set forth by the CDC, CMS, and LHD for guidelines and directives. Under Testing, Refusal of Testing & Isolation/Cohorting, it read ProMedica Piscataway will continue to test healthcare personnel and residents for Covid-19 in accordance with CDC, CMS, and LHD guidelines.; Under Reporting Requirements, it read Any resident or staff suspected or diagnosed according to State-specific criteria shall be promptly reported to appropriate local and/or state health department officials, included but not limited to NHSN. The policies provided did not further address COVID-19 surveillance. A review of the facility's policy titled COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, indicated that when any employee tests positive or a resident (who was not previously being cared for in transmission based precautions [TBP]) tests positive for COVID-19, enhanced measures should be implemented. Enhanced measures included but were not limited to, a Screening UDA [User Defined Assessment] consisting of vital signs every shift for residents in the affected unit (where a resident tested positive or positive employee worked), identifying potential staff, visitor, and other resident prolonged exposure, notification to local department of health of any positive COVID-19 test results, and to refer to CDC Work Restrictions for HCP with SARS-CoV-2 Infection and Exposures to determine status of employee. A review of the facility's policy titled Testing Criteria Summary, dated 10/05/22, for newly identified COVID-19 positive staff or resident (not in TBP) in a facility/community that can identify close contacts included: For newly identified COVID-19 positive staff or resident in a facility that can identify close contacts, the facility should, regardless of vaccination status, test all staff that had a higher-risk exposure with a COVID-19 positive individual and test all residents who had a close contact with a COVID-19 positive individual and testing frequency should be performed Day 1, 3, and 5 unless a positive result is obtained. NJAC 8:39- 19.1(a); 19.2(a)(c)

Based on observation, interviews, and record review, it was determined that the facility failed to ensure that a resident, who had a diagnosis of dysphagia (difficulty swallowing) and was at risk for aspiration (when material such as food or drink enters the respiratory tract), was given cola (soda) with the appropriate consistency of nectar like thickness and when the Regisitered Nurse (RN) attempted to administer thin liquid oral medication. This deficient practice was identified for 1 of 12 residents (Resident #377) reviewed that required liquids to be altered for thickness consistency before consuming. The facility's failure to ensure the appropriate liquid consistency for a resident at risk for aspiration resulted in an immediate jeopardy situation to the resident's health and safety who had difficulty swallowing. According to the Speech Therapist's hospital discharge instructions, dated 04/04/19 at 08:00 AM, Resident #377 was to consume liquids with a nectar consistency. A review of the admission physician orders, dated 04/05/19 at 15:18 (3:18 PM), revealed an order for thick liquids-nectar like consistency. This Immediate Jeopardy (IJ) was identified on 04/08/19 at 08:51 AM when Resident #377 was provided with regular (thin consistency) soda that was not altered to nectar thicken consistency and the resident consumed the soda. The IJ was identified by the surveyor and relayed to the Administrator and DON on 04/08/19 at 3:08 PM. The immediacy was corrected on 04/08/19 at 4:35 PM based on an acceptable removal plan that included; physician assessment of the resident, facility reviewed all residents with an order for altered liquid consistency to ensure no thin liquids were present in their rooms; facility immediately in-serviced the staff that was involved in Resident #377's care: Certified Nurse Aide (CNA), Registered Nurse (RN), and RN Clinical Director on aspiration precautions and thickened liquids. On 04/11/19, the facility completed in-service education on aspiration precautions and thickened liquids to all staff and the survey team verified implementation of the removal plan throughout the remainder of the survey. This deficient practice was evidenced by the following: On 04/08/19 at 08:51 AM, during a medication pass observation, the surveyor and third floor medication Registered Nurse (RN #1) arrived at Resident #377's and observed the resident holding an 8-ounce can of soda with a straw in his/her right hand that the resident then placed onto the breakfast tray. The surveyor noted that there was another 8-ounce can of soda on the resident's breakfast tray. At that time, the surveyor brought the soda to the attention of the DON and the RN #1. The DON entered the resident's room picked up the two cans of soda. The DON reported that one of the cans of soda was empty and the other was mostly full and not thickened. The DON asked Resident #377 if he/she had drank the soda and the resident stated yes. The DON and RN #1 both stated that Resident #377 was ordered thickened liquids and should not have been provided the soda without being thickened to nectar like consistency. At that time, the surveyor attempted to interview the resident but was unable due to the resident's [CONDITION(S)] (difficulty speaking). On 04/08/19 at 09:03 AM, the surveyor observed the RN #1 prepare the liquid medication, [MEDICATION(S)] Sodium (medication for constipation) 50 milligram (mg)/5 milliliter (ml), 20 ml. RN #1 poured the 20 ml of medication into a plastic medication cup. RN #1 had not thickened the liquid medication to a nectar like consistency. RN #1 brought the liquid medication to Resident #377's room and had begun to lift the cup to the resident's mouth, when the surveyor intervened because the liquid had not been thickened. RN #1 stated she had been aware the resident was on nectar thick liquids and was not sure why she had not thickened the liquids medication when she had prepared it. According to the Admission Record, Resident #377 was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)] (weakness of one side of the body), and dysphagia. Resident #377's Care Plan, dated on admission 04/05/19 and was on-going, revealed the resident had expressive language impairments and dysphagia with a goal of NLL (nectar-like liquids) as ordered and interventions that included to maintain strict aspirations precautions at mealtime. Resident #377 had a physician order dated 04/05/19 for [MEDICATION(S)] Sodium 20 ml by mouth two times a day. A review of a Skilled Nursing PN, dated 04/05/19, revealed the resident was to receive a puree diet and nectar thickened liquids. A review of Resident #377's Skilled Nursing Note, dated 04/05/19, revealed a history of right thalamic hemorrhage (bleeding around the brain) with left [CONDITION(S)] and dysphagia. The Skilled Note also revealed, strict aspiration precaution. A review of the food service resident diet list, dated 04/08/19, revealed Resident #377 was to receive nectar like liquids. A review of Resident #377's dietary slips for breakfast, lunch and dinner for 04/08/19 revealed nectar like liquids. During an interview conducted by the surveyor on 04/08/19 at 08:52 AM, the medication Registered Nurse (RN) stated Resident #377 was to receive thickened liquids and should not have been given the cans of soda without being thickened to a nectar-like consistency because of the risk of choking. During an interview conducted by the surveyor on 04/08/19 at 10:55 AM, the third floor CD stated that he had brought the soda cans into the resident's room and left the unopened cans out of the reach of the resident. The RN/CD stated he was aware that the resident had to have thickened liquids and that he had not thickened the soda because he thought the nurse would do it. During an interview conducted by the surveyor on 04/08/19 at 11:15 AM, the Certified Nurses Aide (CNA), who had cared for Resident #377, stated that food trays were handed out by staff other than CNAs most of the time. The CNA stated that if he were to hand out a tray, the nurse would check the diet to ensure the food and liquid were correct first. During an interview conducted by the surveyor on 04/08/19 at 12:38 PM, the Speech Therapist (ST) stated Resident #377 had been admitted with an order for NLL (nectar-like liquids). The ST stated if the resident were to get the thin liquids, there could be a risk of aspiration or pneumonia. The ST stated that everyone in the facility should have provided Resident #377 with nectar thick liquids because it was a doctors order and the resident was at risk for choking or aspiration. The ST stated she evaluated the resident on 04/08/19 for dysphagia and recommended the resident remain on nectar thick liquids. A review of the facility RMS Event Summary Report (incident report), dated 04/08/19, included, Resident admitted to center 4/5 on nectar like liquids. On 04/08/19 at approximately 8:10 am the Resident requested soda from the clinical director. The clinical director went to to the kitchen and brought back two cans of cola which he left on the bedside table a few feet away from the resident. during that time period someone opened the sodas and placed a straw and gave to the resident. The resident drank (1) 8 oz can of cola. During a follow up interview conducted by the surveyor on 04/08/19 at 1:14 PM, the third floor Registered Nurse Clinical Director (CD) stated Resident #377 had been on thick liquids because of effects of stroke. The CD stated he had been aware the resident is ordered nectar thick liquids and that the staff would have also known from verbal reports. The CD further stated that if someone on thickened liquids received thin liquids, they could choke. The CD stated the resident had asked him for soda, and he went to the kitchen and obtained two cans of soda. He then had left the two unopened sodas in the resident's room, on a bedside table a few feet away from the resident, but didn't tell anyone he had done so. He acknowledged that he should not have left the soda without notifying anyone. The CD stated the resident was unable to open the can of soda and that someone would had to have opened the can for the resident. During a follow up interview conducted by the surveyor on 04/08/19 at 1:46 PM, the DON stated that kitchen staff would thicken orange juice or milk before being sent up on the food tray and that all other liquids, such as soda, would be thickened by the nurses. The DON stated the CD should have checked the resident's liquid status and should not have left the soda in the resident's room, even if left unopened, because the resident could have asked anyone to open it. The DON stated that Resident #377 could have aspirated on the thin liquid. Furthermore, the DON stated that staff are aware of resident's diets because the diets are listed in the computer system, on the tray ticket from the kitchen, on the physician order sheet, and given in the daily report. The DON also stated that if a resident requested liquids, the staff inform the resident's nurse and ask what diet the resident was on before providing it to the resident. If a resident is ordered nectar thick liquids and requested thin liquids, the nurse would have to be notified in order to obtain and thicken the liquid to the appropriate consistency. A review of the facility policy, Dysphagia Diet-Liquids provided by the Administrator and dated 06/15/16, revealed residents were to receive liquids in compliance with the physician order, to provide consistent delivery of appropriately thickened liquids. Special request cold beverages are thickened by trained staff members at point of service, and that all spoon thick items are thickened at point of service by trained staff members. A review of the facility policy, Aspiration Precautions provided by the DON and dated 01/02/14, revealed the resident identified as being at risk for aspiration or with a physician order for aspiration precautions will receive appropriate nursing interventions. A review of the facility policy, Meal Service in Patient's Room provided by the Administrator dated 01/02/14, revealed check items on tray against diet card to ensure correct meal is served and provide beverages as indicated on diet card. A review of the facility policy, Consistency Alterations and Therapeutic Menus provided by the Administrator dated 06/15/18, revealed thickened liquid modifications include Nectar-like. NJAC 8:39-17.4(a)(2)