Every finding on record at Alaris Health at Belgrove

Based on observation, interviews, record review, and review of other pertinent facility documentations on 8/20/26, it was determined that the facility failed to ensure that a resident (Resident #1) was free from physical abuse. This deficient practice was identified for 1 of 4 residents (Resident #1) reviewed for abuse.A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 8/10/26, revealed that on 8/9/26 at 6:35 PM, CNA #2 witnessed CNA #1 physically abuse Resident #1 while they were providing care in the resident's room. A review of facility document titled, Summary of Investigation (SI) dated 8/11/26, revealed that CNA #2 did not immediately report the abuse incident to the Nursing Supervisor (NS) on duty, but waited until 8/9/26 at approximately 11:00 PM before she informed the NS. The NS allowed CNA #1 to continue working and providing direct care to residents on the same floor where the alleged abuse occurred with Resident #1.According to the SI, the facility investigation confirmed that CNA #1 slapped Resident #1's hand and then spit into her own hand and wiped the saliva on Resident #1's face. The facility administration became aware of the abuse allegation on 8/10/26. Staff conducted post- incident skin assessment of Resident #1 and found no injuries or discolorations on Resident #1. The facility investigation confirmed the abuse allegation was substantiated. The facility terminated CNA #1 and the Nursing Supervisor's employment with the facility, and they re-educated CNA #2 for not reporting an abuse promptly. The facility's failure to ensure that Resident #1 was protected from physical abuse by CNA #1 posed a likelihood that serious injury, harm, impairment, or death could occur to Resident #1 and the other residents. This resulted in an immediate jeopardy (IJ) situation. The IJ began on 8/9/26 at 6:35 PM when CNA #1 physically abused Resident #1 in the presence of another staff member (CNA #2). The facility administration was notified of the IJ on 8/20/26 at 5:35 PM. The facility submitted an acceptable Removal Plan (RP) on 8/21/26 at 8:56 AM. The surveyor verified the implementation of the RP on-site during the continuation of the survey on 8/25/26. This was evidenced as follows: A review of the facility's policy on Abuse Prevention Program, with a revised date of 01/2026, included under . Part VII-Investigation: Procedure: All facility staff are to immediately report all abuse allegations to the Administrator, who is the Abuse Prevention Program Coordinator, and the DON [Director of Nursing] or Supervisor/Designee who will immediately initiate investigations of any allegations of abuse, obtain statements, and report to the office of the Ombudsman, the Department of Health and Senior Services, and to all other required agencies such as, law enforcement within the specified timeframes Person(s) being investigated for possible involvement in abuse will provide a statement and will be immediately suspended pending the results of the investigation .Part VIII-Reporting Response: Procedure: .When an incident is reported to the Supervisor, the Supervisor is responsible for ensuring that the resident is safe and will notify the Administrator as well as the DON, or their designees . A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 8/10/26, included the date and time of event as 8/9/26 at 6:35 PM. The FRE revealed that on 8/9/26 at 6:35 PM, CNA #2 witnessed CNA #1 physically abuse Resident #1 while both CNA #2 and CNA #1 were providing care to the resident. CNA #2 did not immediately report this abuse incident to the nursing supervisor or to the resident's assigned nurse. Both CNA #1 and CNA #2 continued to work with residents. The FRE further revealed that the Licensed Nursing Home Administrator (LNHA) was made aware of the alleged abuse during morning report on 8/10/26 at approximately 8:30 AM, and that the facility suspended CNA# and the Nursing Supervisor (NS) pending investigation. The surveyor reviewed the medical record of Resident #1. A review of Resident #1's admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses which included but were not limited to: encounter for other orthopedic aftercare (surgery of the bone), displaced intertrochanteric fracture of left femur (fracture of left thigh bone), atrial fibrillation (irregular heart rate), anemia, obesity, major depressive disorder, epilepsy (seizures), hypertension, type 2 Diabetes Mellitus, dementia, chronic kidney disease and anxiety disorder. A review of the resident's Minimum Data Set (MDS), a comprehensive assessment tool, dated 5/2/26, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident's cognition was intact. The MDS further revealed that the resident required total assistance from staff in the completion of their Activities of Daily Living (ADLs). A review of the resident's Care Plan (CP) included a focus (problem area/need) which indicated that Resident #1 was resistive to care, was physically abusive to staff by hitting and spitting at staff due to their mental disorder and mild dementia. Interventions included but were not limited to allow resident time to vent fears and feelings, give clear explanation of all care activities prior to and during each contact with the resident. The care plan also indicated that if the resident resists ADL care, staff were to reassure the resident, leave the resident and return later. A review of Progress Note (PN) dated 8/9/26 at 8:10 PM and written by Registered Nurse (RN) #1, revealed that CNA #1 reported to RN #, that Resident #1 was physically and verbally abusive towards her during care while she was assisting the resident's assigned CNA (CNA #2). On 8/20/26 at 12:50 PM, the surveyor observed Resident #1 in their room. When interviewed, the resident told the surveyor that a CNA hit me and pointed to their left side. The resident further stated that there were 2 CNAs in the room at the time but does not know their names. When asked if they were hurt, the resident shook their head to indicate no. The surveyor asked for facility investigation into the incident.According to CNA #1's statement dated 8/10/26, CNA #2 asked for assistance with Resident #1's care. CNA #1 stated that CNA #2 had mentioned to her that Resident #1 was spitting and fighting during care. CNA #1 revealed that when they were changing the resident's bed linens, the resident became aggressive with CNA #2. CNA #1 further stated that she tried to instruct CNA #2 on how to move Resident #1's hand off the side rail so they could turn Resident #1. After the resident was turned, the resident started to spit on both of them. At that time, CNA #2 pointed her finger in Resident #1's face and stated to the resident stop it, stop it, I am not playing. The surveyor reviewed CNA #2's statement dated 8/10/26. CNA #2 stated that on 8/9/26 during Resident #1's care at approximately 6:35 PM, she went into Resident #1's room to help with the resident's care because the resident would not turn to allow their bed linens to be changed and for their care to be done. CNA #2 further stated that Resident #1 became increasingly aggressive towards CNA #1, striking at CNA #1, calling her names and spitting in her direction; and that CNA #1 then slapped the resident's hand. CNA #2 further started that after the resident's care was completed, CNA #1 spit into her own hand and rubbed the saliva on Resident #1's face. CNA #2 stated that she was shocked to see what CNA #1 did to Resident #1, and that when she questioned CNA #1 about her actions towards Resident #1, CNA #1 replied that she was not going to take a beating from the resident. CNA #2 stated that afterwards, CNA #1 approached her in the hallway and instructed her not to report the incident with Resident #1 to anyone. CNA #2 further stated that CNA #1 followed her and shadowed her throughout the shift, which prevented her from reporting the incident to the nurses or to the Nursing supervisor. And that CNA #1 continued to shadow her even while she was speaking with the nursing supervisor at the end of her shift which made her to feel intimidated; and caused her to request that she go home to write her witness statement. A review of the statement from Registered Nurse (RN) #1 revealed that CNA #2 first approached her at approximately 7:00 PM on 8/9/26 to talk about the incident with Resident #1 but CNA #1 came and interrupted the conversation. RN #1 stated that the interruption by CNA #1 occurred 2-3 times during shift and that was why she could not talk with CNA #2 during the shift and was not aware of the abuse allegation till the next day from administration. The surveyor reviewed the NS statement which indicated that at approximately 11:05 PM, CNA #2 approached her and informed her of an abuse incident that occurred during the care of Resident #1. The NS stated that she asked CNA #2 to write a statement, but CNA #2 insisted that she wanted to go home to write her statement. The NS stated that she immediately sent a message to the Director of Nursing (DON) and to the Assistant Director Nursing (ADON) about the abuse incident but did not get a response from them. A review of statement from the ADON indicated that on 8/10/26 at 6:18 AM, she saw a text message on her phone timed for 1:00 AM which was sent by the NS regarding a witnessed allegation of abuse. The ADON stated that she reported the incident to the LNHA and the facility initiated an investigation at that time. On 8/20/26 at 1:32 PM, the surveyor interviewed CNA #3 who was Resident #1's regular CNA. CNA #3 stated that she was familiar with Resident #1's behaviors and preferences and the resident does not like being touched, had increased confusion and aggression since their surgery and that she was not on duty the day of the abuse incident. CNA #3 stated that she would have left Resident #1 alone and informed the nurse if the resident resisted care. On 8/20/26 at 12:40 PM, the surveyor interviewed RN #2 who was Resident #1's regular nurse stated that Resident #1 no longer wants to get out of bed since the abuse incident. The surveyor reviewed a facility document titled: Summary of Investigation (SI) dated 8/11/26. The SI revealed that an incident involving allegation of physical abuse that occurred on 8/9/26 at approximately 6:35 PM between CNA #1 and Resident #1 during the resident's care. The facility investigation summary confirmed that CNA #1 slapped Resident #1's hand, and that CNA #1 also spit into her own hand and wiped the saliva on Resident #1's face. The SI indicated that the account of the abuse incident was provided by CNA #2 who was the staff member that witnessed the abuse. The SI revealed that CNA #2 did not immediately report the abuse incident to the Nursing Supervisor (NS) on duty but waited from 6:35 PM till approximately 11:00 PM on 8/9/26 before she notified the NS of abuse incident. The SI further indicated that after NS became aware of the abuse allegation, she allowed CNA #1 to continue working and providing direct care to residents from 6:40 PM on 8/9/26 until 7:00 AM on 8/10/26. The SI further indicated that staff conducted post- incident skin assessment of Resident #1 and found no injuries. The facility documented that the abuse allegation was substantiated based on facility investigation; and that they terminated both CNA #1 and the Nursing Supervisor's employment with the facility. On 8/20/26 at 2:15 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the interim Director of Nursing (DON). The LNHA stated that the NS and CNA #1 were suspended during investigation; and were terminated on 8/12/26. The LNHA stated that facility protocol was for the supervisor to call for allegations of abuse and not to text. The interim DON stated the NS sent her a text message at 1:00 AM and DON saw the message at 6:18 AM and messaged back but NS did not respond. The DON further stated that she became aware of the abuse incident at 8:00 AM during the morning meeting report. The LNHA stated that the NS should have investigated the incident. LNHA stated that NS told them during interview that she knew she was supposed to investigate the incident and to inform the administration. The LNHA and DON both stated that the NS should have investigated the incident and removed CNA #1 from the schedule and sent her home pending investigation. An acceptable Removal Plan (RP) was submitted by the facility on 8/21/26 at 8:56 AM, indicating the actions the facility will take to prevent serious harm from occurring or reoccurring. The facility addressed the situation by:1. Immediate Removal of the Perpetrator (CNA#1 was suspended pending investigation and permanently removed from all resident care and facility premises effective 8/10/26 at 9:30 AM; CNA#1 received education on 8/10/26, was suspended pending investigation and eventually terminated on 8/12/26; supervisor received education on 8/10/26, was suspended pending investigation and eventually terminated on 8/12/26);2. Immediate Protection of Resident #1 and All Residents (Resident#1 was assessed by nurse on 8/11/26 and physician as indicated for physical/psychological injury immediately upon report; all residents previously assigned to or cared for by CNA#1 on 8/9/26-8/10/26 were assessed for signs/symptoms of abuse or injury; continuous observation, monitoring of Resident #1 was implemented as clinically indicated while the investigation was on going and completed and the resident was determined safe);3. Immediate Reporting (the incident was reported to the DOH, ombudsman, and the police within required timeframes; the resident's responsible party/physician were notified);4. Immediate Staff Accountability and Education (CNA#1 received education on 8/10/26, was suspended pending investigation and eventually terminated on 8/12/26; CNA#2 received counselling/education for delayed reporting on 8/10/26; all current staff on duty and coming on duty received immediate re-education on 8/10/26 that included: zero tolerance abuse policy, recognition of physical/psychological abuse, mandatory immediate reporting to the charge nurse/supervisor and Administrator/DON, protection of residents pending investigation);5. System Safeguards Implemented Immediately (abuse prohibition policy was reviewed and reinforced with all staff; any needed clarifications on immediate reporting and supervisor response were added, a temporary heightened monitoring process is in place: any allegation or witnessed incident of abuse results in immediate removal of the alleged perpetrator from resident contact, simultaneous notification of Administrator/DON (or designee 24/7), and initiation of the investigation protocol, and the DON/Administrator (or designee) verifies daily (including weekends) that no staff member under investigation has resident access. The surveyor verified the implementation of the RP on-site on 8/25/26 and determined the immediacy was removed as of 8/20/26. N.J.A.C. 8:39- 4.1(a)5

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 4/27/26 at 11:33 AM, in the presence of the Regional Food Service Director (RFSD), the surveyor observed the cook take the temperature of Veal [NAME] without sanitizing the food thermometer prior to use. The cook stated, I forgot to sanitize the thermometer before using. The Veal [NAME] was thrown away in the garbage by the RFSD.On 4/28/26 at 11:08 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor a facility policy titled, Temperature Monitoring During Meal Service with a reviewed date of 1/2026. The procedure section of the policy revealed, 3. How to take temperature; Sanitize the probe before and after each use.On 4/29/26 at 12:15 PM, the surveyor met with the LNHA and Director of Nursing (DON) to review concerns found during the survey. The LNHA stated the concerns in the kitchen would be addressed immediately.On 4/30/26 at 11:30 AM, the surveyor met with the LNHA and DON for the exit conference. No further pertinent information was provided. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a specialty low air loss mattress (a medical-grade mattress that uses continuous airflow to keep the skin dry, cool, and pressure-free, helping prevent and treat pressure injuries) was accurately set and monitored according to the resident's weight for 6 of 8 residents (Resident #3, #4, #11, #12, #123, and #127). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 4/23/26 at 10:54 AM, the surveyor observed Resident #3 awake in bed laying on an air mattress. Resident #3's air mattress was set at 180 pounds (lb.). Resident #3 revealed their usual body weight is between 105-115 lb but was not sure of their current body weight (CBW). On 4/23/26 at 11:55 AM, the surveyor reviewed Resident #3's electronic medical record (e-MAR) which revealed the following: A review of the Resident #3's admission Record ((AR) an admission summary) revealed that the resident was admitted to the facility with diagnoses that included: dysphagia (difficulty swallowing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and cerebral infarction (ischemic stroke, is the death of brain tissue caused by an interruption of blood flow to the brain). A review of the 5 Day Medicare [NAME] Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/14/26, revealed that the resident had a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive function. The MDS further revealed under Section M, that Resident #3 was receiving a pressure reducing device for bed. A review of the April 2026 Physician Orders (PO) for Resident #3 revealed multiple POs: Pressuring Relieving Bed/Mattress, every shift check function, dated 4/13/26 and Pressure Relieving Mattress – LOW AIR LOSS, every shift check function, dated 4/13/26. A review of Resident #3's most recent weight revealed the resident weighed 102 lb on 3/11/26. A review of the Care Plan Report (CPR) revealed a Care Plan (CP) with a focus of, resident has a deep tissue injury pressure ulcer left heel and interventions including, requires pressure relieving/reducing device on bed and Administer treatments as ordered and monitor for effectiveness. On 4/27/26 at 7:26 AM, the surveyor observed Resident #3 in bed with their eyes closed and the air mattress was set to 180 lb. 2. On 4/23/26 at 10:56 AM, the surveyor observed Resident #4 in bed with eyes closed and their air mattress observed set at 100 lb. A review of the Resident #4's AR documented that the resident was admitted to the facility with diagnoses that included: osteomyelitis (serious infection or inflammation of the bone), pressure ulcer of sacral region (localized injury to the skin and underlying tissue over the sacrum), and protein-calorie malnutrition (insufficient intake of protein and calories, leading to impaired growth, weakened immunity, and overall poor health). A review of the Quarterly MDS, with an ARD of 4/14/26, revealed that the resident had a score of 13 out of 15 on the BIMS, which indicated intact cognitive function. The MDS further revealed under Section M, that Resident #4 was receiving a pressure reducing device for bed. A review of the April 2026 Physician Orders (PO) for Resident #4 revealed a PO dated 4/13/26, Pressure Relieving Mattress – LOW AIR LOSS, every shift check function. A review of Resident #3's most recent weight revealed the resident weighed 228.8 lb on 4/9/26. A review of the CPR revealed a CP with a focus of, Resident has a break in skin integrity due to presence of sacral wound (stage 4 pressure ulcer) and an intervention of low air loss mattress. On 4/27/26 at 7:29 AM, the surveyor observed Resident #4 in bed with their eyes closed and the air mattress was set to 100 lb. 3. On 4/23/2026 at 11:08 AM, the surveyor observed Resident #123 in bed with their eyes open and surveyor further observed Resident #123's air mattress set at 180 lb. A review of the Resident #123's AR documented that the resident was admitted to the facility with diagnoses that included: acute respiratory failure with hypoxia (condition where the lungs fail to provide sufficient oxygen to the blood, leading to tissue hypoxia), pressure ulcer of sacral region, and protein-calorie malnutrition. A review of the Quarterly MDS, with an ARD of 3/6/26, revealed that the resident had a score of 0 on the BIMS, which indicated severe cognitive impairment. The MDS further revealed under Section M, that Resident #4 was receiving a pressure reducing device for bed. A review of the April 2026 Physician Orders (PO) for Resident #123 revealed a PO dated 4/13/26, Pressure Relieving Mattress – LOW AIR LOSS, every shift check function. A review of Resident #123's most recent weight revealed the resident weighed 78 lb on 4/27/26. A review of the CPR revealed a CP with a focus of, Resident has stage 2 pressure ulcer to right hip and an intervention of requires pressure relieving/reducing device on bed. On 4/27/26 at 7:22 AM, the surveyor had a secondary observation of Resident #123's air mattress. The air mattress setting remained at 180 lb. On 4/27/2026 at 10:25 AM, the surveyor and the Licensed Practical Nurse/Unit Manager (UM) observed Resident #3, #4, and #123's air mattresses, the UM confirmed all the residents' air mattresses were set incorrectly. The UM stated all air mattresses should be set to the resident's current body weight. On 4/27/26 at 12:00 PM, the Director of Nursing (DON) provided the surveyor with a facility policy titled, Air Mattress) with a reviewed dated 1/2026. The care and monitoring portion of the policy revealed, checking mattress function every shift. 4. On 4/23/26 at 11:45 AM, and on 4/27/26 at 7:30 AM, the surveyor observed Resident #11 in bed and a specialty mattress in place. The resident's air mattress pump was set at 120 pounds (lbs.) on both observations. The surveyor reviewed the electronic medical record (E-mar) for Resident #11. A review of the admission Record (AR) reflected that Resident #11 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dementia (decline in cognitive function) and stage 4 (full-thickness skin loss exposing muscle, tendon, or bone) pressure ulcer of the left lower back. A review of the Quarterly MDS dated [DATE] reflected that Resident #11 had a BIMS score of 3 out of 15, indicating severe cognitive impairment. The MDS further indicated that the resident's weight was 88 lbs., was receiving hospice services, had a stage 4 ulcer, and had a low air loss pressure-reducing device for the bed. A review of the CP included a focus that the resident had the potential for skin breakdown. The CP did not include an intervention for a low-air-loss mattress. A review of the current Physician Order Summary Report (OSR) reflected a Physician's order (PO) for a low-air-loss mattress for pressure relief, check every shift for function with a start date of 9/20/25. A review of the current TAR included a low-air-loss mattress in place and to monitor every shift for pressure relief; check for function with a start date of 9/20/25 and signed by nurses, which indicated it was being monitored. A review of the resident's vital signs revealed the resident's last known weight was 88 lbs. on 12/19/25. On 4/27/26 at 10:35 AM, the surveyor showed the Registered Nurse (RN) assigned to Resident #11 the gauge setting on the specialty mattress. The RN acknowledged that the setting was at 120 lbs. and stated that the air pump was set to a specific firmness level and the pump setting had nothing to do with the resident's weight. 5. On 4/27/26 at 9:00 AM, the surveyor observed Resident #12 in bed and a specialty mattress in place. The resident's air mattress pump was set at 260 lbs. The surveyor reviewed the E-mar for Resident #12. A review of the AR reflected that Resident #12 was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke). A review of the most recent MDS dated [DATE] reflected that Resident #12 had a BIMS score of 3 out of 15, indicating a severe cognitive impairment. The MDS further indicated that the resident's weight was 184 lbs. and that a pressure-reducing device was in place on the bed. A review of the CP included a focus that the resident had a potential for skin breakdown with interventions that included but were not limited to: pressure-relieving devices for bed and wheelchair, initiated 1/15/26. A review of the current OSR reflected a PO for a low-air-loss mattress every shift for pressure relief; Check for function with a start date of 3/3/26. A review of the current TAR included a low-air-loss mattress in place and to monitor every shift for function, with a start date of 3/3/26, and signed by nurses indicating it was being monitored. A review of the resident's vital signs revealed the last known weight was 179.2 lbs. on 4/9/26. On 4/27/26 at 9:40 AM, the surveyor showed the Licensed Practical Nurse/Unit Manager (LPN/UM) the gauge setting on the specialty mattress. The LPN/UM acknowledged that the setting was at 260 lbs. and further stated it should have been set to the resident's weight, which was 179.2 lbs. On 4/27/26 at 9:45 AM, the surveyor showed the LPN assigned to Resident #12's care the pump setting. The LPN confirmed that the resident's weight was 179.2 and that she should have ensured the pump was set to the correct weight, since the air mattress was ordered to prevent or heal pressure ulcers. 6. On 4/27/26 at 9:10 AM, the surveyor observed Resident #127 in bed and a specialty mattress in place. The resident's air mattress pump was set at 220 lbs. A review of the CP identified a focus area that included the potential for skin breakdown but did not include a low-air-loss mattress as an intervention. A review of the current OSR reflected that there was no PO for a low-air-loss mattress. A review of the current TAR did not indicate that the low-air-loss mattress was being monitored. A review of the resident's hospital records revealed the resident's last known weight was 124.3 lbs. on 4/21/26. On 4/27/26 at 9:40 AM, the surveyor showed the LPN/UM gauge setting on the specialty mattress. The LPN/UM acknowledged that the setting was at 220 lbs. and stated that the resident was admitted on [DATE] and that staff had not obtained the resident's weight yet. The LPN/UM further stated that the Resident's hospital weight was 124 lbs., on 4/21/26. The LPN/UM stated that the physician had not written an order for an air mattress and that she did not think the resident should have had one in place, but would check with the resident's physician. On 4/29/26 at 12:25 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), to discuss the above observations and concerns. The DON confirmed that the nurses were responsible for monitoring the specialty mattresses and ensuring that the gauges were set according to the resident's weight. On 4/30/26 at 10:58 AM, no further information was provided. A review of the facility's Air Mattress policy and procedure, dated 1/26, reflected.The facility will provide pressure-redistribution support surfaces (including air mattresses) based on individual resident assessment, risk level, and clinical need to prevent skin breakdown and promote healing of existing pressure injuries.Air mattresses are considered a treatment and preventive medical intervention and should be ordered, monitored, and documented. NJAC 8:39-19.4(a); 27.1 (a)

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored appropriately, according to manufacturer's guidelines and standards of practice. This deficient practice was identified in 2 of 2 medication refrigerators inspected.This deficient practice was evidenced by the following: On 4/28/26 at 12:56 PM, the surveyor began inspecting the medication (med) storage room located on the facility 1st floor in the presence of the 1st floor Unit Manager (UM1). The surveyor accessed the med refrigerator located in the med room. The surveyor observed the thermometer inside the med refrigerator that reflected twenty-five (25) degrees Fahrenheit (F). The surveyor asked the UM1 to verify the temperature, and what range the temperature should be. UM1 stated that it was 25 degrees F, was too cold and should be between 36 degrees F and 46 degrees F. UM1 stated they would adjust the refrigerator control. On the same date, at 1:17 PM, the surveyor began inspecting the 2nd floor med storage room in the presence of the 2nd floor Unit Manager (UM2). of the facility. The surveyor accessed the med refrigerator located in the med room. The surveyor observed the thermometer inside the med refrigerator that reflected 32 degrees F. The surveyor asked the UM2 to verify the temperature, and what range the temperature should be. UM2 stated that it was 32 degrees F and should be between 36 degrees and 46 degrees. UM2 stated that they would put in a work order for the refrigerator. The surveyor concluded the observation. On 4/29/26 at 9:54 AM, the surveyor interviewed the regional supervisor for the facility Consultant Pharmacist (CP). The surveyor asked the CP if they check the med refrigerator temperatures. The CP stated yes, they do and they were checked on 4/27/26 and found to be in range. The surveyor informed the CP of the observed med refrigerator temperatures. On 4/29/26 at 12:49 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss concerns with medication storage. The surveyor informed the DON of the temperature findings for the 1st and 2nd floor med refrigerators. On 4/30/26 at 9:19 AM, the survey team met with the LNHA and DON for responses to concerns. The DON stated that the 1st floor med refrigerator was adjusted, and the 2nd floor med refrigerator was replaced. The facility did not provide any further pertinent information. The surveyor reviewed the facility policy provided by the LNHA titled, Storage of Medications dated 1/26 reviewed. The policy did not reflect medication refrigerator temperatures. NJAC 8:39-29.4(h)

Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 5 residents (Resident #85 and #126) observed for incontinence care on 1 of 3 Nursing units (3rd floor).This deficient practice was evidenced by the following:On [DATE] at 7:55 AM, the surveyor conducted an incontinence tour on the 3rd floor Nursing Unit and observed the following: 1. On [DATE] at 8:00 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #126 in bed. CNA #1 exposed Resident #126's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated. The surveyor reviewed the medical record for Resident #126. A review of the admission Record (AR) reflected that Resident #126 was admitted to the facility with diagnoses that included but were not limited to; hemiplegia (paralysis causing loss of muscle) and hemiparesis (mild to moderate weakness on one side of the body). A review of the admission Minimum Data Set (MDS), an assessment tool, dated [DATE], reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The MDS further assessed that Resident #126 was always incontinent with bowel and bladder and was dependent on staff for toileting hygiene. A review of Resident #126's Care Plan Report (CPR) included a Focus area that the resident was incontinent of bowel and bladder, with interventions that included but were not limited to; offer/assist with toileting during care, before/after meals, at bedtime, and when needed. 2. On [DATE] at 8:10 AM, the surveyor, accompanied by CNA #1, observed Resident #85 in bed. CNA #1 exposed Resident #85's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated. The surveyor reviewed the medical record for Resident #85. A review of the AR reflected that Resident #85 was admitted to the facility with diagnoses that included but were not limited to; traumatic subdural hemorrhage (serious brain injury where blood collects between the dura mater and the brain surface caused by high impact). A review of the Quarterly MDS dated [DATE] reflected Resident #85 had a BIMS score of 9 out of 15, indicating a moderate cognitive impairment. A further review of the MDS indicated the resident required staff assistance for toileting hygiene and was frequently incontinent of bladder. A review of Resident #85's CP had a focus that indicated the resident was incontinent of bladder and bowel with interventions that included but were not limited to; offer/assist with toileting during care, before/after meals, and activities. On [DATE] at 8:15 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) on the 3rd floor nursing unit stated that she was aware that the staffing regulation was 1:14 on the night shift and that the 11-7 CNAs each had 20 and 21 residents on their assignments. The LPN/UM stated that the facility policy was for CNAs to provide incontinence care every 2 hours.A review of the CNA assignment sheet for the 3rd floor indicated that CNA #2 had 21 residents on their assignment, and CNA #3 had 20.On [DATE] at 8:20 AM, the surveyor conducted a telephone interview with CNA #2 assigned to Resident #85 for the 11:00 PM-7:00 AM shift. CNA #2 stated that she was responsible for 21 residents during that shift and was unable to provide incontinence care every two hours as required. CNA #2 further stated that she was doing her very best. On [DATE] at 8:35 AM, the surveyor conducted a telephone interview with CNA #3 assigned to Resident #126 for the 11:00 PM-7:00 AM. CNA #3 stated that she was responsible for 20 residents during that shift and was unable to provide incontinence care every two hours as required. CNA #3 further stated that she was doing her very best. On [DATE] at 12:25 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that incontinence care should be provided every 2 hours. On [DATE] at 10:58 AM, no further information was provided. A review of the facility's Incontinence Care policy and procedure dated as reviewed 1/2026 reflected.The facility shall provide care for all incontinent residents.Check residents at least every two to four hours. NJAC 8:39-27.1 (a), (e), 27.2 (h)

Based on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that a resident received proper assistance in using hearing assistive devices for one (1) of twenty-two (22) residents reviewed, (Resident #6).The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/23/26 at 11:05 AM, the surveyor observed Resident #23 in their room seated in a wheelchair (WC). The surveyor interviewed the resident and observed that the resident had some difficulty hearing. The surveyor did not observe any hearing aids or other hearing assistance devices applied to the resident.On 4/27/26 at 11:44 AM, the surveyor observed Resident #23 seated in a chair in the hallway outside their room. The surveyor did not observe any hearing aids applied to the resident.On 4/28/26 at 10:37 AM, the surveyor observed Resident #23 seated in a WC in their room. The surveyor asked the resident if they have hearing aids and who put them in. The resident gestured toward a bedside table and stated, the nurse helps. The surveyor asked the resident why they didn't have them in now. The resident responded by shrugging their shoulders and stated broken.On 4/28/2026 at 1:26 PM, the surveyor interviewed the 2nd Floor Unit Manager (UM2). The surveyor asked UM2 about Resident #23's hearing aid use. UM2 stated that they believe the resident puts them in themselves and charting was just accountability, but they need to check the Care Plan. On 4/28/26 at 1:33 PM, UM2 informed the surveyor that the staff probably does help Resident #23 with hearing aids and that they should be in. The surveyor informed UM2 that the surveyor had not observed the resident with them in at all.The surveyor reviewed the electronic medical record (EMR) for Resident #23 which revealed the following: An admission Record (AR) reflected that Resident #6 was admitted to the facility with medical diagnoses that included but were not limited to essential hypertension, overactive bladder and dysphagia (difficulty swallowing). A Quarterly Minimum Data Set (qMDS) an assessment tool, with an assessment reference date (ARD) of 2/11/26, reflected, in Section C, that the resident had a brief interview for mental status (BIMS) score of 13 out of 15 indicating the resident was cognitively intact. A Comprehensive Care Plan (CCP), a summary of a person's health conditions, specific care goals, and current interventions, which revealed an Intervention dated revised 6/26/23, CNA to check that resident has their hearing aids. An electronic treatment administration record (eTAR), which reflected a physician's order to check hearing aid to both ears every shift. The eTAR also reflected that the hearing aids were documented as applied on the day and evening shifts from 4/2/26 through 4/26/26. On 4/29/26 at 12:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for concerns regarding Resident #23 and the documentation for hearing aid use. The surveyor notified the DON that the surveyor did not observe Resident #23 with hearing aids, there was documentation by the staff that they were being used, and the hearing aids were observed in a case on a table. On 4/30/26 at 9:19 AM, the surveyor met with the LNHA and DON for responses to concerns for Resident #23. The LNHA stated that the facility obtained new hearing aids for the resident and staff was educated. The surveyor reviewed the policy titled Hearing Impaired Resident, dated 1/30/26, provided by the LNHA. The policy reflected: Staff will assist residents with care and maintenance of hearing devices. The facility did not provide any further pertinent information. N.J.A.C. 8:39-27.5(a)(b)

Based on observation, interview, record review and review of facility policy it was determined that the facility failed to ensure the Registered Dietitian (RD#1) completed a nutritional reassessment for a resident who was readmitted to the facility in a timely fashion. This deficient practice was identified for 1 of 4 residents reviewed for Nutrition (Resident #123), and was evidenced by the following: On 4/23/26 at 11:08 AM, the surveyor observed Resident #123 in bed with their eyes open, resident noted with confusion.On 4/23/26 at 11:13 AM, the surveyor interviewed Resident #123's Licensed Practical Nurse (LPN#1), who stated the resident had recently been readmitted to the facility.A review of the Resident #123's admission Record ((AR) an admission summary) indicated that the resident was admitted to the facility with diagnoses that included: acute respiratory failure with hypoxia (condition where the lungs fail to provide sufficient oxygen to the blood, leading to tissue hypoxia), pressure ulcer of sacral region (localized injury to the skin and underlying tissue over the sacrum), and protein-calorie malnutrition (insufficient intake of protein and calories, leading to impaired growth, weakened immunity, and overall poor health).A review of the Entry Medicare Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/18/26, revealed that the resident had been readmitted from a short-term general hospital. A review of the nursing progress notes revealed, Resident #123 was readmitted to the facility on [DATE] from the hospital with a diagnosis of respiratory failure. Further review of the progress note revealed a nutrition reassessment note dated 4/27/26 at 2:30 PM, 9 days after the resident was readmitted to the facility.On 4/29/26 at 11:39 AM, the surveyor interviewed RD#1, who stated she would try to conduct initial and readmission assessments within 24 hours of a resident entering the facility but has 72 hours to complete the assessments. Surveyor reviewed Resident #123's readmission and nutrition reassessment dates with RD#1, who confirmed the nutrition reassessment note was not completed until ninth day after readmission. RD#1 acknowledged the nutrition note was late. On 4/29/26 at 11:55 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LHNA) and the Director of Nursing (DON) who stated initial and readmission nutrition assessment should be completed within five days of admission and/or readmission into the facility. Both the LNHA and DON acknowledged Resident #123's readmission assessment was late.On 4/29/26 at 12:10 PM, the DON provided the surveyor with a facility policy titled, Medical Nutrition Therapy (MNT) Documentation, reviewed on 1/2026. The procedure section of the policy revealed, the initial comprehensive MNT assessment for a new or readmitted individual is generally initiated and/or completed with 5 days of admission.On 4/29/26 at 12:15 PM, the surveyor met with the LNHA and DON to review concerns found during the survey. The DON stated nutrition notes would be reviewed for any irregularities.On 4/30/26 at 11:30 AM, the surveyor met with the LNHA and DON for the exit conference. No further pertinent information was provided. NJAC 8:39 - 11.2(e)(1)(f), 17.1(c), 17.2(c)(d), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents completed monthly progress notes. This deficient practice continued over several months for 1 of 22 residents, Resident #6, reviewed for physician progress notes and current physician orders.This deficient practice was evidenced by the following: On 4/28/26 at 12:20 PM, the surveyor observed Resident #6 in bed in their room. The resident was alert, oriented and conversed with the surveyor. The surveyor reviewed the electronic medical record (EMR) of Resident #6 which revealed the following: An admission Record (AR) reflected that Resident #6 was admitted to the facility with medical diagnoses that included but were not limited to; bullous pemphigoid (a chronic autoimmune skin disorder), anemia, and essential hypertension. A Quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 3/29/26, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. A review of Resident # 6's EMR revealed that from 8/3/25 to 4/1/26 the Primary Physician (Physician #1) had not written any monthly Medical Progress Notes (PN) in the electrotonic or paper chart. On 4/29/26 at 12:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for concerns regarding physician documentation. The surveyor notified the LNHA that Resident #6's primary physician, who was also the facility's medical director, did not have any completed progress notes in the medical record for the period of 8/3/25 through 4/1/26 inclusive. On 4/30/26 at 10:35 AM, the survey team met with the LNHA and DON for responses to concerns. For the concern regarding physician documentation, the LNHA stated that the physician is not satisfying the regulation requirements for documentation. The facility did not provide any further pertinent information. The surveyor reviewed the policy provided by the LNHA titled, Physician Visits and Services with a reviewed date of 1/26. Under Procedure: 4. The attending physician shall visit the resident in accordance with the resident's needs. 5. Progress notes and orders must be written, signed and dated at each physician visit. NJAC 8:39-23.2(b)(d)

Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 2 of 5 residents (Resident #85 and #126) on 1 of 3 units (3rd floor) Nursing unit.This deficient practice was evidenced by the following:Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. Direct care staff member means any registered professional nurse, licensed practical nurse, or certified nurse aide who is acting in accordance with that individual's authorized scope of practice and pursuant to documented employee time schedules. The following ratio(s) were effective on 02/01/2021: 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) One certified nurse aide to every eight residents for the day shift. (2) One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties, and (3) One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties. 1.A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks of staffing from 4/5/26 through 4/18/26 prior to the Standard survey of 5/7/26, revealed the facility was deficient in staffing hours as evidenced by the following: a. For the 2 weeks of staffing prior to survey from 04/05/2026 to 04/18/2026, the facility was deficient in CNA staffing for residents on 12 of 14 day shifts as follows: -04/05/26 had 9 CNAs for 103 residents on the day shift, required at least 13 CNAs.-04/06/26 had 10 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/07/26 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/08/26 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/09/26 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/10/26 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/11/26 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs. -04/12/26 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/13/26 had 10 CNAs for 100 residents on the day shift, required at least 12 CNAs.-04/14/26 had 10 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/17/26 had 10 CNAs for 99 residents on the day shift, required at least 12 CNAs.-04/18/26 had 11 CNAs for 102 residents on the day shift, required at least 13 CNAs. b For the 2 weeks of Complaint staffing from 10/19/2025 to 11/01/2025, the facility was deficient in CNA staffing for residents on 12 of 14 day shifts as follows: -10/19/25 had 8 CNAs for 99 residents on the day shift, required at least 12 CNAs.-10/20/25 had 11 CNAs for 99 residents on the day shift, required at least 12 CNAs.-10/21/25 had 11 CNAs for 97 residents on the day shift, required at least 12 CNAs.-10/23/25 had 11 CNAs for 97 residents on the day shift, required at least 12 CNAs.-10/25/25 had 10 CNAs for 97 residents on the day shift, required at least 12 CNAs. -10/26/25 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs.-10/27/25 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs.-10/28/25 had 12 CNAs for 101 residents on the day shift, required at least 13 CNAs.-10/29/25 had 12 CNAs for 101 residents on the day shift, required at least 13 CNAs.-10/30/25 had 12 CNAs for 101 residents on the day shift, required at least 13 CNAs.-10/31/25 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs.-11/01/25 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs. c. For the 2 weeks of Complaint staffing from 12/28/2025 to 01/10/2026, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: -12/28/25 had 8 CNAs for 110 residents on the day shift, required at least 14 CNAs.-12/29/25 had 12 CNAs for 109 residents on the day shift, required at least 14 CNAs.-12/30/25 had 11 CNAs for 109 residents on the day shift, required at least 14 CNAs.-12/31/25 had 12 CNAs for 109 residents on the day shift, required at least 14 CNAs.-01/01/26 had 8 CNAs for 109 residents on the day shift, required at least 14 CNAs.-01/02/26 had 11 CNAs for 105 residents on the day shift, required at least 13 CNAs.-01/03/26 had 12 CNAs for 103 residents on the day shift, required at least 13 CNAs. -01/04/26 had 8 CNAs for 103 residents on the day shift, required at least 13 CNAs.-01/05/26 had 9 CNAs for 103 residents on the day shift, required at least 13 CNAs.-01/06/26 had 11 CNAs for 103 residents on the day shift, required at least 13 CNAs.-01/07/26 had 11 CNAs for 103 residents on the day shift, required at least 13 CNAs.-01/08/26 had 12 CNAs for 103 residents on the day shift, required at least 13 CNAs.-01/09/26 had 12 CNAs for 103 residents on the day shift, required at least 13 CNAs.-01/10/26 had 12 CNAs for 103 residents on the day shift, required at least 13 CNAs. 2. On 4/27/26 at 7:20 AM, the surveyor conducted an incontinence tour on the 3rd floor Nursing Unit and observed the following: a.On 4/27/26 at 8:00 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #126 in bed. CNA #1 exposed Resident #126's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated. b. On 4/27/26 at 8:10 AM, the surveyor, accompanied by CNA #1, observed Resident #85 in bed. CNA #1 exposed Resident #85's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated. Review of the 11:00 PM-7:00 AM CNA assignment sheet revealed that the 3rd floor nursing unit had a census of 41 residents with 2 assigned aides. CNA #2 and CNA #3 had assignments of 20 and 21 residents, respectively, on that 11 PM -7 AM shift. On 04/27/2026 at 12:05 PM, the surveyor interviewed the staffing coordinator (SC), who stated that they were aware of the staffing ratios for CNAs. The SC also stated that staffing for the night shift was more difficult than the other shifts and that the facility did not use agency staff. The SC further stated that she was unaware that the 3rd-floor Nursing Unit had a Census of 41 and that there were only 2 CNAs scheduled for the 11-7 shift. On 4/27/26 at 8:15 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that she was aware that the staffing regulation was 1:14 on the night shift and that her expectation was that the CNAs provide incontinence care every 2 hours. On 4/27/26 at 8:20 AM, the surveyor conducted a telephone interview with the 11:00 PM-7:00 AM CNA (CNA #2) assigned to Resident #85. CNA #2 stated that she was responsible for 21 Residents during that shift and was unable to provide incontinence care every two hours as required. CNA #2 stated that she was doing her very best. 4/27/26 at 8:35 AM, the surveyor conducted a telephone interview with the 11:00 PM-7:00 AM CNA (CNA #3) assigned to Resident #126. CNA #3 stated that she was responsible for 20 Residents during that shift and was unable to provide incontinence care every two hours as required. CNA #3 further stated that she was doing her very best. On 4/29/26 at 12:25 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that the minimum CNA-to-staff ratio on the 11:00 PM-7:00 AM shift was 1:14 and the facility had not met that requirement. On 4/30/26 at 10:58 AM, no further information was provided. A review of the facility's policy, Staffing, dated 01/2026, revealed. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met.Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. A review of the facility's Incontinence Care policy and procedure, dated as reviewed 1/2026, reflected.The facility shall provide care for all incontinent residents.Check residents at least every two to four hours. NJAC 8:39-27.1 (a), (e), 27.2 (h)

Based on observation, interview, record review, and review of facility policies it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication reviews for 1 of 6 Residents, (Resident #3). On 4/23/26 at 10:54 AM, the surveyor observed Resident #3 awake in bed, the resident stated they were currently on a tube feeding ((TF), also known as enteral feeding, delivers liquid nutrition through a flexible tube directly into your stomach or small intestine) and does not consume anything by mouth.On 4/23/26 at 11:55 AM the surveyor reviewed Resident #3's electronic medical record (e-MAR) which revealed the following: A review of the Resident #3's admission Record (an admission summary) documented that the resident was admitted to the facility with diagnoses that included: dysphagia (difficulty swallowing), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and cerebral infarction (ischemic stroke, is the death of brain tissue caused by an interruption of blood flow to the brain). A review of the 5 Day Medicare [NAME] Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/14/26, revealed that the resident had a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive function. The MDS further revealed under Section K, that Resident #3 was receiving a TF.A review of the April 2026 Physician Orders (PO) for Resident #3 revealed multiple POs: NPO (nothing by mouth), every shift. Dated 4/13/2026, Mylanta Suspension 200-200-20 milligram/milliliter (MG/5ML) (Alum & Mag Hydroxide-Simeth) Give 30 ml orally every 4 hours as needed for heartburn & indigestion AND Give 30 ml orally every 4 hours as needed for dyspepsia SHAKE WELL. TAKE AFTER MEALS.' Dated 4/14/2026, and Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide) - Give 30 ml by mouth as needed for no BM after 2 days Give at bedtime. If ineffective after 24 hours, call MD. Dated 4/14/2026.A review of Resident #3's progress notes revealed a note from the Pharmacy consultant dated 4/16/2026, Medication Regimen Reviewed. No recommendations made.On 4/28/26 at 9:17 AM, the surveyor interviewed the 2nd Floor Unit Manager (UM) and Director of Nursing (DON) who both confirmed that Resident #3 is NPO and had two POs for milk of magnesia by mouth. The DON further stated that this discrepancy should have been caught by the CP as well as facility staff.On 4/28/26 at 9:18 AM, the DON provided the surveyor with a copy of the CP's report for 4/302026-4/30/2026. The report does not mention Resident #3's medication discrepancy.On 4/29/26 at 9:29 AM, the surveyor conducted a phone interview with the Regional Pharmacy Consultant (RPC) who stated the CP conducts medication reviews a for all residents monthly and two times per week for new and re-admitted residents. The RPC revealed Resident #3's medication discrepancy should have been caught and noted by the CP.On 4/29/26 at 12:00 PM, the DON provided the surveyor with a facility policy titled, Consultant Pharmacy Reports revised on 1/2026. The procedure section of the policy revealed, 2. The Consultant Pharmacy will perform a drug regiment review (DRR) of all new admission/readmission orders.4. Any medication irregularities identified will be documented on a separate, written report and notification to attending physician, and director of nursing, listing the resident name, relevant drug and irregularity that was identified with resolution noted by the physician.On 4/29/26 at 12:15 PM, the surveyor met with the LNHA and Director of Nursing (DON) to review concerns found during the survey. The DON stated the medication irregularity for Resident #3 has been fixed, and the facility willing be conducting an addition medication audit.On 4/30/26 at 11:30 AM, the surveyor met with the LNHA and DON for the exit conference. No further pertinent information was provided. NJAC 8:39- 29.3 (a)

Based on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication, by diagnosis, indication and effectiveness, for one (1) of twenty-two (22) residents reviewed, (Resident #6).The deficient practice was evidenced by the following: The surveyor reviewed Resident #6's electronic medical record (EMR) which revealed the following: An admission Record (AR) reflected that Resident #6 was admitted to the facility with medical diagnoses that included but were not limited to bullous pemphigoid (a chronic autoimmune skin disorder), anemia, and essential hypertension. A Quarterly Minimum Data Set (qMDS) an assessment tool, with an assessment reference date (ARD) of 3/29/26, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact.Section H of the MDS reflected that the resident was always incontinent of urine. A review of Resident #6's Order Summary Report (OSR), a listing of the resident's physician orders, revealed that the resident was being administered Tamsulosin .4mg, (Flomax), a medication used to relax muscles in the bladder and prostate in men to facilitate the flow of urine.The order reflected the instructions: Give 1 capsule by mouth one time a day for BPH (an enlargement of the prostate gland). A review of the resident's electronic medication administration record (eMAR) revealed the order dated 10/24/25, Tamsulosin HCL oral capsule .4mg Give 1 capsule one time a day for BPH. A review of Resident # 6's EMR revealed that from 8/3/25 to 4/1/26 the Primary Physician (Physician #1) had not written any monthly Medical Progress Notes (PN) in the electrotonic or paper chart that reflected a diagnosis, indication, or other comment relating to the unapproved or off-label use, or benefit vs risk for the use of tamsulosin. Further review of the EMR revealed PN from the Nurse Practitioner (NP). A note dated as a Late Entry 3/13/26, reflected a diagnosis of urinary retention. There were no NP notes that reflected the use of Tamsulosin that included the benefit vs risk for use, the effectiveness or that the resident was incontinent. Further review of the EMR revealed Consultant Pharmacist (CP) notes. The CP notes did not reflect any mention of off-label use of tamsulosin, or requests for physician supportive documentation. On 4/29/26 at 9:54 AM, the surveyor interviewed the Regional CP. The surveyor asked the CP if it is an expectation of the CP to request documentation for tamsulosin use in females from the MD. The CP stated yes, it is an expectation to request supportive documentation. The surveyor reviewed the Manufacturer Package Insert for Flomax (PI) which reveal the approved use of Flomax under INDICATIONS AND USAGE FLOMAX (tamsulosin hydrochloride, USP) capsules are indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH).The (PI) also reflected the statement FLOMAX is not indicated for use in women. On 4/29/26 at 12:49 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) for concerns regarding the Resident #6 and the documentation for tamsulosin use. The surveyor notified the LNHA that Resident #6's primary physician did not have any documentation regarding the use of tamsulosin for Resident #6. Additionally, the NP had not documented anything about the use of tamsulosin in the resident at all. The surveyor also notified the DON of the indication reflected on the order and asked if BPH would be appropriate for Resident #6. The DON stated, no, it is not. On 4/30/26 at 9:19 AM, the surveyor met with the LNHA and DON for responses to concerns for Resident #6. The DON stated that the resident saw urology in the hospital and got a diagnosis of urinary retention. The DON also stated that the indication of BPH was missed at several levels, admission nurses, 24 chart checks, pharmacists. The facility did not provide any further pertinent information. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication administration, four (4) nurses administered meds to six (6) residents. There were twenty-eight (28) opportunities for error, two (2) errors were observed which calculated to a medication administration error rate of 7.1%. This deficient practice was identified for 2 of 6 residents, (Resident #125, Resident #129), that were administered meds by 2 of 4 nurses observed.The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/27/26 at 9:00 AM, the surveyor observed the Registered Nurse (RN) assigned to Resident #125 (RN#1) prepare meds for the resident. The meds included an active physician's order (PO) for the following:Multivitamin-Minerals Tablet Give 1 tablet by mouth one time a day for supplement. (MVI).The surveyor observed the RN prepare and administer Resident #125's medications which included one (1) MULTIVITAMIN TABLET (MV).The surveyor then observed RN#1 administer the multivitamin, along with other due medications to the resident. Upon return to the medication cart (med-cart), the surveyor asked RN#1 to identify the bottle she took the MVI from. RN#1 showed the surveyor the bottle labeled Multivitamin tablets. The surveyor asked RN#1 to compare the bottle label to the order on the resident's electronic medication administration record (eMAR). RN#1 stated that it should have been with minerals. On 4/27/26 at 10:08 AM the surveyor interviewed RN#1. The surveyor asked RN#1 if they should follow physician orders as written. RN#1 stated yes, they should. On 4/28/26 at 8:50 AM, the surveyor observed the RN assigned to Resident #129 (RN#2) prepare meds for administration to the resident. The meds included an active PO for the following: Midodrine HCl 5 MG Tablet (Midodrine) 1 TABLET BY MOUTH TWICE DAILY FOR HYPOTENSION HOLD FOR SBP GREATER THAN 120 (a medication given for low blood pressure), scheduled for administration at 7:30 AM. The surveyor observed RN#2 document the resident's blood pressure (BP) in the electronic medication administration record (eMAR). The surveyor did not observe RN#2 obtain a BP from the resident, the surveyor asked RN#2 when the BP reading was taken. RN#2 stated that they took the BP around 7:30 AM. RN#2 stated that they were holding (not administering) the med per the instructions if the BP was over 120 and the BP was 148. The surveyor asked RN#2 if they normally use the BP reading from the morning to give meds later. RN#2 stated that if the BP was not taken earlier, they would have taken it right before giving the med.The surveyor concluded the medication pass observation with RN#2. On 4/28/26 at 9:16 AM, the surveyor interviewed the Director of Nursing (DON). The surveyor asked what the expectations are for the staff taking BP for meds that require it. The DON stated that the BP should be taken just before administration. The surveyor reviewed the electronic medical record (EMR) for Resident #129 which revealed the following:An eMAR entry for Midodrine on 4/28/26 with a code of 5 that indicated hold/see nurse notes.An eMAR - Medication Administration Note dated 4/28/26 at 8:53 AM that reflected, Midodrine HCl Oral Tablet 5 MG Give 1 tablet by mouth two times a day for Hypotension Hold for SBP greater than 120 med held B/P 148/75. On 04/29/26 at 12:49 PM, the survey team met with the DON and Licensed Nursing Home Administrator (LNHA) to discuss concerns with the medication pass. The surveyor informed the DON and LNHA of the errors observed during the observation.On 4/30/26 at 9:19 AM, the survey team met with the LNHA and DON for responses to concerns. The DON stated that the staff was educated about following physician orders and proper recording of BP.The facility did not provide any further pertinent information. The surveyor reviewed the policy provided by the LNHA titled Medication Administration Policy dated 1/26 Reviewed. The policy reflected, under Procedure: 3. Medications must be administered in accordance with the orders, including any required time frame. Line 10. Medications. must be administered within one (1) hour of their prescribed time, unless otherwise specified. N.J.A.C 8:39-29.2 (d)

Complaint # NJ184029 Based on interview, review of the medical record, and pertinent facility documents, it was determined that the facility failed to ensure staff documented on the Treatment Administration Record (TAR) according to the physician's orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing Statutes for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). This deficient practice was evidenced by the following: According to the Admission Record received on 3/27/25, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to Acute Pyelonephritis, Depression, Hypertension, and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/4/25, indicated that the resident was cognitively intact and required assistance with activities of daily living (ADLs). A review of the Order Summary Report (OSR) received on 3/27/25 given by the Administrator for Resident #1, with a physician order date of 4/02/25 revealed the call bell within reach every shift. A review of the January 2025 Treatment Administration Record (TAR) for Resident #1 revealed that the 3:00 p.m. (1500) call bell within reach every shift on 1/4/25 was blank. A review of the March 2025 Treatment Administration Record (TAR) for Resident #1 revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. According to the Admission Record received on 3/27/25, Resident #2 was admitted to the facility on [DATE], with diagnoses that included but not limited to Restless Legs Syndrome, Type 2 Diabetes, Major Depressive Disorder, Hypertension, and Hyperglycemia. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/17/25, indicated that the resident was cognitively intact and independent with activities of daily living (ADLs). A review of the Order Summary Report (OSR) received on 3/27/25, given by the Administrator for Resident #2, with a physician order date of 4/27/21 revealed the call bell within reach every shift. A review of the March 2025 Treatment Administration Record (TAR) for Resident #2 revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/26/25 was blank. According to the Admission Record received on 3/27/25, Resident #3 was admitted to the facility on [DATE], with diagnoses that included but not limited to Encephalopathy, Transient Ischemic Attack (TIA), Cerebral Infarction, Acute Kidney Failure, Hyperlipidemia, (COPD), and Hypertension. The Quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, indicated that the resident was severely impaired and required assistance with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 6/19/24 revealed call bell within reach every shift. A review of the Order Summary Report (OSR) received on 3/27/25, given by the Administrator for Resident #3, with a physician order date of 6/19/24 revealed the call bell within reach every shift. A review of the March 2025 Treatment Administration Record (TAR) given by the Administrator for Resident #3, revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. During interview with the surveyor on 3/27/25 at 2:05 p.m., the Administrator confirmed the blanks for call bell within reach on the Medication Administration Record/Treatment Administration Record (MAR/TAR). The Administrator stated that staff failed to acknowledge and document on the MAR/TAR. The Administrator stated that the expectation was for all orders to be signed as per doctor's order. She further stated that it was important for staff to sign off and acknowledge to ensure that the doctor's orders were being followed. During interview with the surveyor on 3/27/25 at 3:09 p.m., the Director of Nursing (DON) stated that there should have been no blanks and agreed that there were blanks on the MAR/TAR. The DON stated that the nurses should have signed because it was a part of the doctor's order. During interview with the surveyor on 3/28/25 post survey at 12:31 p.m. via telephone, Registered Nurse (RN #1) who was assigned to Resident #1 on 1/4/24, stated that she worked one day and one shift at the facility as an agency nurse. RN #1 stated that she always checked to make sure resident's call bell was within reach. She further stated that she does not remember if there was a documentation that she needed to sign off on. Surveyor attempted to reach RN #2 on 3/28/25 post survey at 12:37 p.m. via telephone, who was assigned to Resident #1 on 3/21/25 and Resident #3 on 3/21/24, and was unsuccessful. During interview with the surveyor on 3/28/25 post survey at 12:40 p.m. via telephone, RN #3 who was assigned to Resident #2 on 3/26/24, stated that she checked call bells and made sure the call bell was within reach when doing rounds. RN #2 stated that she should have documented, I forgot to document. RN #2 further stated that it was important to document to show the work was done. Review of the Clinical Charting and Documentation Policy and Procedure with an effective date of 11/2010, revealed that under the Policy statement that all services provided to the resident, or any changes in the resident's electronic medical record (EMR). Under Policy Interpretation and Implementation #5 revealed, Documentation of procedures and treatments shall include care-specific details and shall include at a minimum b. The name and title of the individual who provided the care The signature and title of the individual documenting. NJAC 8:39-27.1 (a) Complaint # NJ184029 Based on interview, review of the medical record, and pertinent facility documents, it was determined that the facility failed to ensure staff documented, and that prescribed treatments were completed according to the physician's orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing Statutes for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). This deficient practice was evidenced by the following: According to the Admission Record received on 3/27/25, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to Acute Pyelonephritis, Depression, Hypertension, and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/4/25, indicated that the resident was cognitively intact and required assistance with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 4/02/25 revealed call bell within reach every shift. The January 2025 Treatment Administration Record (TAR) revealed that the 3:00 p.m. (1500) call bell within reach every shift on 1/4/25 was blank. The March 2025 Treatment Administration Record (TAR) revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. According to the Admission Record received on 3/27/25, Resident #2 was admitted to the facility on [DATE], with diagnoses that included but not limited to Restless Legs Syndrome, Type 2 Diabetes, Major Depressive Disorder, Hypertension, and Hyperglycemia. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/17/25, indicated that the resident was cognitively intact and independent with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 4/27/21 revealed call bell within reach every shift. The March 2025 Treatment Administration Record (TAR) revealed that the 11:00 p.m. (2300) call bell within reach every shift was blank on 3/26/25 was blank. 3. According to the Admission Record received on 3/27/25, Resident #3 was admitted to the facility on [DATE], with diagnoses that included but not limited to Encephalopathy, Transient Ischemic Attack (TIA), Cerebral Infarction, Acute Kidney Failure, Hyperlipidemia, (COPD), and Hypertension. The Quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, indicated that the resident was severely impaired and required assistance with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 6/19/24 revealed call bell within reach every shift. The March 2025 Treatment Administration Record (TAR) revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. During interview with the surveyor on 3/27/25 at 2:05 p.m., the Administrator confirmed the blanks for call bell within reach on the Medication Administration Record/Treatment Administration Record (MAR/TAR). The Administrator stated that staff failed to acknowledge and document on the MAR/TAR. The Administrator stated that the expectation was for all orders to be signed as per doctor's order. She further stated that it was important for staff to sign off and acknowledge to ensure that the doctor's orders were being followed. During interview with the surveyor on 3/27/25 at 3:09 p.m., the Director of Nursing (DON) stated that there should have been no blanks and agreed that there were blanks on the MAR/TAR. The DON stated that the nurses should have signed because it was a part of the doctor's order. During interview with the surveyor on 3/28/25 post survey at 12:31 p.m. via telephone, Registered Nurse (RN #1) stated that she worked one day and one shift at the facility as an agency nurse. RN #1 stated that she always checked to make sure resident's call bell was within reach. She further stated that she does not remember if there was a documentation that she needed to sign off on. During interview with the surveyor on 3/28/25 post survey at 12:40 p.m. via telephone, RN #2 stated that she checked call bells and made sure the call bell was within reach when doing rounds. RN #2 stated that she should have documented, I forgot to document. RN #2 further stated that it was important to document to show the work was done. Review of the Clinical Charting and Documentation Policy and Procedure with an effective date of 11/2010, revealed that under the Policy statement that all services provided to the resident, or any changes in the resident's electronic medical record (EMR). Under Policy Interpretation and Implementation #5 revealed, Documentation of procedures and treatments shall include care-specific details and shall include at a minimum b. The name and title of the individual who provided the care The signature and title of the individual documenting. NJAC 8:39-27.1 (a) Surveyor: [NAME], Janese Complaint # NJ184029 Based on interview, review of the medical record, and pertinent facility documents, it was determined that the facility failed to ensure staff documented on the Treatment Administration Record (TAR) according to the physician's orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing Statutes for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). This deficient practice was evidenced by the following: According to the Admission Record received on 3/27/25, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to Acute Pyelonephritis, Depression, Hypertension, and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/4/25, indicated that the resident was cognitively intact and required assistance with activities of daily living (ADLs). A review of the Order Summary Report (OSR) received on 3/27/25 given by the Administrator for Resident #1, with a physician order date of 4/02/25 revealed the call bell within reach every shift. A review of the January 2025 Treatment Administration Record (TAR) for Resident #1 revealed that the 3:00 p.m. (1500) call bell within reach every shift on 1/4/25 was blank. A review of the March 2025 Treatment Administration Record (TAR) for Resident #1 revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. According to the Admission Record received on 3/27/25, Resident #2 was admitted to the facility on [DATE], with diagnoses that included but not limited to Restless Legs Syndrome, Type 2 Diabetes, Major Depressive Disorder, Hypertension, and Hyperglycemia. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/17/25, indicated that the resident was cognitively intact and independent with activities of daily living (ADLs). A review of the Order Summary Report (OSR) received on 3/27/25, given by the Administrator for Resident #2, with a physician order date of 4/27/21 revealed the call bell within reach every shift. A review of the March 2025 Treatment Administration Record (TAR) for Resident #2 revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/26/25 was blank. According to the Admission Record received on 3/27/25, Resident #3 was admitted to the facility on [DATE], with diagnoses that included but not limited to Encephalopathy, Transient Ischemic Attack (TIA), Cerebral Infarction, Acute Kidney Failure, Hyperlipidemia, (COPD), and Hypertension. The Quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, indicated that the resident was severely impaired and required assistance with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 6/19/24 revealed call bell within reach every shift. A review of the Order Summary Report (OSR) received on 3/27/25, given by the Administrator for Resident #3, with a physician order date of 6/19/24 revealed the call bell within reach every shift. A review of the March 2025 Treatment Administration Record (TAR) given by the Administrator for Resident #3, revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. During interview with the surveyor on 3/27/25 at 2:05 p.m., the Administrator confirmed the blanks for call bell within reach on the Medication Administration Record/Treatment Administration Record (MAR/TAR). The Administrator stated that staff failed to acknowledge and document on the MAR/TAR. The Administrator stated that the expectation was for all orders to be signed as per doctor's order. She further stated that it was important for staff to sign off and acknowledge to ensure that the doctor's orders were being followed. During interview with the surveyor on 3/27/25 at 3:09 p.m., the Director of Nursing (DON) stated that there should have been no blanks and agreed that there were blanks on the MAR/TAR. The DON stated that the nurses should have signed because it was a part of the doctor's order. During interview with the surveyor on 3/28/25 post survey at 12:31 p.m. via telephone, Registered Nurse (RN #1) who was assigned to Resident #1 on 1/4/24, stated that she worked one day and one shift at the facility as an agency nurse. RN #1 stated that she always checked to make sure resident's call bell was within reach. She further stated that she does not remember if there was a documentation that she needed to sign off on. Surveyor attempted to reach RN #2 on 3/28/25 post survey at 12:37 p.m. via telephone, who was assigned to Resident #1 on 3/21/25 and Resident #3 on 3/21/24, and was unsuccessful. During interview with the surveyor on 3/28/25 post survey at 12:40 p.m. via telephone, RN #3 who was assigned to Resident #2 on 3/26/24, stated that she checked call bells and made sure the call bell was within reach when doing rounds. RN #2 stated that she should have documented, I forgot to document. RN #2 further stated that it was important to document to show the work was done. Review of the Clinical Charting and Documentation Policy and Procedure with an effective date of 11/2010, revealed that under the Policy statement that all services provided to the resident, or any changes in the resident's electronic medical record (EMR). Under Policy Interpretation and Implementation #5 revealed, Documentation of procedures and treatments shall include care-specific details and shall include at a minimum b. The name and title of the individual who provided the care The signature and title of the individual documenting. NJAC 8:39-27.1 (a) Complaint # NJ184029 Based on interview, review of the medical record, and pertinent facility documents, it was determined that the facility failed to ensure staff documented, and that prescribed treatments were completed according to the physician's orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing Statutes for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). This deficient practice was evidenced by the following: According to the Admission Record received on 3/27/25, Resident #1 was admitted to the facility on [DATE], with diagnoses that included but not limited to Acute Pyelonephritis, Depression, Hypertension, and Chronic Kidney Disease. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/4/25, indicated that the resident was cognitively intact and required assistance with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 4/02/25 revealed call bell within reach every shift. The January 2025 Treatment Administration Record (TAR) revealed that the 3:00 p.m. (1500) call bell within reach every shift on 1/4/25 was blank. The March 2025 Treatment Administration Record (TAR) revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. According to the Admission Record received on 3/27/25, Resident #2 was admitted to the facility on [DATE], with diagnoses that included but not limited to Restless Legs Syndrome, Type 2 Diabetes, Major Depressive Disorder, Hypertension, and Hyperglycemia. The Quarterly Minimum Data Set (MDS), an assessment tool dated 1/17/25, indicated that the resident was cognitively intact and independent with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 4/27/21 revealed call bell within reach every shift. The March 2025 Treatment Administration Record (TAR) revealed that the 11:00 p.m. (2300) call bell within reach every shift was blank on 3/26/25 was blank. 3. According to the Admission Record received on 3/27/25, Resident #3 was admitted to the facility on [DATE], with diagnoses that included but not limited to Encephalopathy, Transient Ischemic Attack (TIA), Cerebral Infarction, Acute Kidney Failure, Hyperlipidemia, (COPD), and Hypertension. The Quarterly Minimum Data Set (MDS), an assessment tool dated 12/27/24, indicated that the resident was severely impaired and required assistance with activities of daily living (ADLs). The Order Summary Report (OSR) received on 3/27/25 with an order date of 6/19/24 revealed call bell within reach every shift. The March 2025 Treatment Administration Record (TAR) revealed that the 11:00 p.m. (2300) call bell within reach every shift on 3/21/25 was blank. During interview with the surveyor on 3/27/25 at 2:05 p.m., the Administrator confirmed the blanks for call bell within reach on the Medication Administration Record/Treatment Administration Record (MAR/TAR). The Administrator stated that staff failed to acknowledge and document on the MAR/TAR. The Administrator stated that the expectation was for all orders to be signed as per doctor's order. She further stated that it was important for staff to sign off and acknowledge to ensure that the doctor's orders were being followed. During interview with the surveyor on 3/27/25 at 3:09 p.m., the Director of Nursing (DON) stated that there should have been no blanks and agreed that there were blanks on the MAR/TAR. The DON stated that the nurses should have signed because it was a part of the doctor's order. During interview with the surveyor on 3/28/25 post survey at 12:31 p.m. via telephone, Registered Nurse (RN #1) stated that she worked one day and one shift at the facility as an agency nurse. RN #1 stated that she always checked to make sure resident's call bell was within reach. She further stated that she does not remember if there was a documentation that she needed to sign off on. During interview with the surveyor on 3/28/25 post survey at 12:40 p.m. via telephone, RN #2 stated that she checked call bells and made sure the call bell was within reach when doing rounds. RN #2 stated that she should have documented, I forgot to document. RN #2 further stated that it was important to document to show the work was done. Review of the Clinical Charting and Documentation Policy and Procedure with an effective date of 11/2010, revealed that under the Policy statement that all services provided to the resident, or any changes in the resident's electronic medical record (EMR). Under Policy Interpretation and Implementation #5 revealed, Documentation of procedures and treatments shall include care-specific details and shall include at a minimum b. The name and title of the individual who provided the care The signature and title of the individual documenting. NJAC 8:39-27.1 (a)

PART A Based on observation, record review, interview, and facility policy review, the facility failed to ensure there was emergency tracheostomy equipment for a resident with a tracheostomy (a surgical opening in the neck to provide an airway and remove secretions from the lungs) at the bedside and readily available for use and ensure staff were trained to use the emergency tracheostomy equipment for one (1) of 1 resident (Resident #86) reviewed with a tracheostomy. Resident #86 was admitted to the facility on [DATE] and had a tracheostomy. Observation and interviews during the survey revealed that emergency tracheostomy supplies were not being kept at the bedside and readily available for use. There was only one obturator (A device that fits inside a tracheostomy tube to guide it during insertion) in Resident #86's room with no extra ones in the storage room. The primary nurses responsible for the care of Resident #86 did not know what an obturator looked like or what it was to be used for. The facility's failure to ensure there was emergency equipment at the resident's bedside and readily available and failure to ensure staff were trained to use emergency tracheostomy equipment placed the resident at risk for serious harm, serious impairment, or death. This resulted in an Immediate Jeopardy (IJ) Situation which was identified on 12/03/24. The facility's Administrator, Director of Nursing (DON), Regional Quality Assurance (QA) Nurse, and [NAME] President (VP) of Operations were notified of the IJ on 12/03/24 at 8:00 PM. The facility submitted an acceptable Removal Plan (RP) on 12/04/24 at 3:40 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/05/24 at 9:45 AM. The evidence was as follows: Review of Lippincott Manual of Nursing Practice, dated 2018, page 544, revealed .Have available at the patient's bedside .a resuscitation bag, oxygen source, and a mask to ventilate the patient in the event of accidental tube removal. Anticipate your course of action in such an event .Tracheostomy-have extra tracheostomy tube, obturator .at the bedside. Be aware of reinsertion technique, if facility policy permits, or know how to contact someone immediately for reinserting the tube . 1. A review of Resident #86's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed Resident #86 was admitted to the facility on [DATE], with the admitting diagnosis of throat cancer. A review of Resident #86's significant change Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 08/25/24, coded the resident as having a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated Resident #86 was moderately cognitively impaired. Resident #86 was also coded as requiring oxygen therapy, suctioning, and tracheostomy care while a resident in the facility. A review of the Physician Orders located under the Orders tab in the EMR revealed an order dated 08/18/24, to include suction trach [tracheostomy] every shift and as needed and to Change trach inner cannula every day. Trach size: 6. During an observation on 12/03/24 at 10:30 AM, the Licensed Practical Nurse (LPN #1) pulled the drawers to the bedside table out where the emergency and extra supplies were stored. LPN #1 could not locate an inner cannula with the size the resident was currently ordered to have, an extra inner cannula that was a size smaller, and an obturator. LPN #1 and the surveyor went into the supply room and could not locate any inner cannulas except for a size six and there were no extra obturators. LPN #1 was Resident #86's primary care nurse for the day shift on 12/03/24. During another observation and interview on 12/03/24 at 10:55 AM, LPN #2 went into the resident's room and could not find a size smaller inner cannula or an obturator. There was one inner cannula size six in the bedside table that the surveyor observed LPN #1 placing in the drawer at 10:44 AM. LPN #2 was asked what supplies were needed to be at the bedside and LPN #2 stated, A size smaller of the inner cannula, an Ambu bag, suction machine with suction tubing, and an obturator. At 11:13 AM, LPN #2 went into the storage room, and she could not find any obturators or extra cannulas that would be a size smaller. During an observation and interview on 12/03/24 at 3:06 PM, the Director of Nursing (DON) went into Resident #86's room with the surveyor and was able to find one inner cannula size #6, and an obturator, but was unable to find a smaller inner cannula. When asked where the extra obturators were kept, the DON stated, In the supply closet. In the supply room, the DON could not locate any more obturators, and the only size of inner cannulas was size six. The DON stated the maintenance director was the one responsible for ordering the specialty supplies that the nurses would use on Resident #86 for trach care. The DON was asked her expectations of the nursing staff that were taking care of Resident #86, and she stated, I expect the nurses to have the emergency equipment at the bedside of this resident such as extra cannulas size six, extra obturators, an Ambu bag, and suction machine with tubing. During an interview on 12/03/24 at 3:25 PM, the Maintenance Director (MD) stated, I do not order any medical supplies that the nurses use on the floors. During an interview on 12/03/24 at 3:49 PM, Registered Nurse (RN #1) was asked if extra obturators were kept in the crash cart. RN #1 went to the crash cart and could not locate an extra obturator. RN #1 opened a box that had a disposable inner cannula and an obturator in it. RN #1 confirmed there were no extra obturators in the crash cart at that moment. When asked if she knew what an obturator looked like and what it was used for, RN #1 stated, I really don't know what it looks like, and I have never had to use one. RN #1 confirmed that she was the primary nurse to provide care to Resident #86 tonight and it was her first night in the facility as a travel nurse. A review of the education that was provided by the facility reflected LPN #1 received Tracheostomy Suctioning and Care education on 08/02/24, LPN #2 received Tracheostomy Care and Suctioning on 10/24/24, and RN #1 received Tracheostomy Care and Suctioning and Trach Care in an Emergency Situation on 12/03/24. During an interview on 12/03/24 at 6:26 PM, the Administrator confirmed RN #1 was in-serviced today on the Tracheostomy Care and Suctioning and Trach Care in an Emergency Situation prior to reporting to work on the floor this evening by the Infection Preventionist Nurse. During an interview on 12/03/24 at 6:26 PM, the Administrator stated the facility did not employ a respiratory therapist. An acceptable Removal Plan (RP) was received on 12/04/24 at 3:40 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice which included: all nurses, including new hires, will be educated on tracheostomy care, emergency tracheostomy care, and identifying supplies needed with competency and return demonstration prior to the start of their next shift; a nursing supervisor will check the supplies in Resident #86's room every shift to assure all required supplies are present in the room; central supply will maintain weekly inventory of tracheostomy supplies; and the DON will assure tracheostomy supplies are available prior to admission. The survey team verified the implementation of the RP during the continuation of the on-site survey on 12/05/24 at 9:45 AM. NJAC 8:39-27.1(a) PART B Based on observation, record review, interview, and facility policy review, the facility failed to ensure oxygen filters were cleaned for 3 of 3 residents, Resident #33, Resident #44, and Resident #60 reviewed for oxygen. 1. A review of Resident #33's undated Admission Record located in the EMR under the Resident tab included an original admitted [DATE], and most recent re-admission on 11/18/24, with a primary diagnosis of osteomyelitis and comorbidities including a history of Covid-19, acute pulmonary edema, hypertension, and heart failure. A review of Resident #33's Order Summary located in the EMR under the Orders tab included oxygen at two liters per minute (LPM) every shift and tubing change every seven days starting 11/19/24. A review of Resident #33's Care Plan located in the EMR under the Care Plan tab, revised 12/04/24, included oxygen therapy related to chronic respiratory failure. A review of Resident #33's entry Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/18/24 was In Progress and incomplete. During an observation on 12/05/24 at 1:45 PM, Resident #33's concentrator inlet filter had a gray/white substance covering the filter. 2. A review of Resident #44's undated Admission Record located in the EMR under the Resident tab included an original admitted [DATE], with a primary diagnosis of metabolic encephalopathy and comorbidities including dependence on supplemental oxygen, congestive heart failure (CHF), shortness of breath, history of pneumonia, chronic obstructive pulmonary disease (COPD), and acute respiratory failure with hypoxia. A review of Resident #44's Order Summary located in the EMR under the Orders tab included oxygen at three LPM every shift for COPD every shift starting 10/03/24, and tubing change every seven days starting 06/05/24. A review of Resident #44's Care Plan located in the EMR under the Care Plan tab, revised 12/04/24, included the administration of oxygen as ordered. A review of Resident #44's annual MDS located in the EMR under the MDS tab with an ARD of 10/17/24, included the use of oxygen. During an observation on 12/04/24 at 7:14 PM, Resident #44's concentrator inlet filter had a gray/white substance covering the filter. 3. A review of Resident #60's undated Admission Record located in the EMR under the Resident tab included an original admitted [DATE], and most recent re-admission on 10/23/24, with a primary diagnosis of type two diabetes mellitus and comorbidities including congestive heart failure, COPD, and shortness of breath. A review of Resident #60's Order Summary located in the EMR under the Orders tab included oxygen at two LPM every shift for CHF and COPD dated 10/24/24. A review of Resdient #60's Care Plan located in the EMR under the Care Plan tab included oxygen usage related to CHF. A review of Resident #60's five-Day MDS located in the EMR under the MDS tab with an ARD of 10/27/24, included the use of oxygen. During an observation on 12/04/24 at 7:14 PM, Resident #60's concentrator inlet filter had a gray/white substance covering the filter. During an interview on 12/04/24 at 7:21 PM, Licensed Practical Nurse (LPN #5) confirmed that the filters had a gray/white substance that she called lint. LPN #5 stated that the Maintenance Department was responsible for cleaning the oxygen concentrator filters and was not sure how often that was done. LPN #5 contacted the Administrator via telephone who informed her that it was the Maintenance Director's responsibility to clean the filters and sent her a copy of the policy. During an interview on 12/05/24 at 5:32 PM, with the Maintenance Director (MD) who stated that it was his responsibility to clean the filters on a monthly basis and as needed. The MD stated that he had not cleaned the filters until this day, 12/05/24, and that he was not sure why Resident #60's concentrator filter was documented as having been cleaned on 12/04/24, but that all filters had been cleaned as of 12/05/24. The MD also stated that the nurses sometimes entered a request on the maintenance log if the filters needed to be cleaned prior to the monthly cleaning, to his knowledge, no additional requests for dirty filters had been made by staff recently. A review of the facility's policy titled, Care of Oxygen Concentrators, dated 03/24, and provided by the facility, indicated .It is the policy of the facility to ensure oxygen concentrators and filters are cleaned regularly. Protocol 1. Cleaning occurs monthly and as needed. Procedure for filters is as follows .2. Check air inlet filters for dust buildup .4. Remove air inlet filters and wash in warm, soapy water and rinse. 5. Absorb excess water from filter with a dry towel .7. Reapply a new pair of disposable gloves and place the air inlet filters back on the oxygen concentrator . A review of the facility document titled Concentrator Cleaning Log, dated 12/04/24, and provided by the facility, indicated that room [ROOM NUMBER]'s (Resident #60) concentrator filter was cleaned on 11/02/24 and 12/04/24. Rooms 114-A (Resident #33) and 312-A (Resident #44) concentrators were most recently cleaned on 11/02/24. NJAC 8:39- 27.1(a)

40824 Based on record review, interview, and facility policy review, the facility failed to ensure residents were provided with written transfer/discharge notice that contained the option to appeal the transfer/discharge for nine of nine residents and their representatives (Resident (R) 21, R27, R75, R9, R60, R69, R71, R91, and R86) reviewed for facility initiated emergent hospital transfer of 31 sample residents This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the Notice of Emergency Transfer form provided by the Administrator supplied to the residents/representatives during a transfer to the hospital did not indicate the appeal information such as the appeal contact name, telephone number, or address. 1. Review of R21's Admission Record located in the electronic medical record (EMR) under the Resident tab indicated R21 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of R21's Discharge Assessment with an Assessment Reference Date (ARD) of 02/07/24 located under the MDS (Minimum Data Set) tab indicated that R21 had an unplanned discharge from the facility on 02/07/24 to a short-term general hospital. Review of R21's Notice of Emergency Transfer, dated 02/07/24 and provided by the facility, indicated that the resident was transferred from the facility to a hospital for dehydration. And .If the resident or his/her representative disagree with this transfer, the resident and/or representative may contact the following entity: NJ (New Jersey) Long-Term Care Ombudsman .Note to facility staff: A copy of this notice must be provided to the resident/resident representative, as well as to the Office of the Ombudsman (via the fax number listed above), with confirmation of fax transmission placed in the resident's chart. 2. Review of R27's undated Admission Record located in the EMR under the Resident tab indicated R27 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of R27's Discharge Assessment with an ARD of 11/06/24 located under the MDS tab indicated that R27 had an unplanned discharged from the facility on 02/07/24 to a short-term general hospital. Review of R27's Notice of Emergency Transfer, dated 11/06/24 and provided by the facility, indicated that the resident was transferred from the facility to a hospital for urinary tract infection .If the resident or his/her representative disagree with this transfer, the resident and/or representative may contact the following entity: NJ Long-Term Care Ombudsman .Note to facility staff: A copy of this notice must be provided to the resident/resident representative, as well as to the Office of the Ombudsman (via the fax number listed above), with confirmation of fax transmission placed in the resident's chart. 3. Review of R75's undated Admission Record located in the EMR under the Resident tab indicated R75 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of R75's MDS tab did not include a Discharge assessment dated [DATE]. Review of R75's Notice of Emergency Transfer, dated 09/21/24 and provided by the facility, indicated that the resident was transferred from the facility to a hospital for evaluation post fall .If the resident or his/her representative disagree with this transfer, the resident and/or representative may contact the following entity: NJ Long-Term Care Ombudsman .Note to facility staff: A copy of this notice must be provided to the resident/resident representative, as well as to the Office of the Ombudsman (via the fax number listed above), with confirmation of fax transmission placed in the resident's chart. 4. Review of R9's Census tab located in the EMR revealed R9 was originally admitted to the facility on [DATE]. Review of the discharge MDS with an ARD of 11/17/24 located in the MDS tab in the EMR revealed R9 was discharged with an anticipated return. Review of the Progress Note, dated 11/17/24 and located under the Prog Note tab in the EMR, revealed R9 was transferred to the hospital due to severe lethargy and no responsiveness to stimuli. The transfer form provided to the resident/representative did not indicate the appeal contact name, telephone number, or address. 5. Review of R60's Census tab located in the EMR revealed R60 was originally admitted to the facility on [DATE]. Review of the discharge MDS with an ARD of 10/16/24 located in the MDS tab in the EMR revealed R60 was discharged with an anticipated return. Review of the Progress Note, dated 10/16/24 and located under the Prog Note tab in the EMR, revealed R60 was transferred to the hospital for low blood sugar and for being unarousable upon verbal and tactile stimuli. The transfer form provided to the resident/representative did not indicate the appeal contact name, telephone number, or address. 6. Review of R69's Census tab located in the EMR revealed R69 was originally admitted to the facility on [DATE]. Review of the discharge MDS with an ARD of 09/12/24 located in the MDS tab in the EMR revealed R69 was discharged with an anticipated return. Review of the Progress Note, dated 09/12/24 and located under the Prog Note tab in the EMR revealed R69 was transferred to the hospital for increased altered mental status and involuntary jerking movements. The transfer form provided to the resident/representative did not indicate the appeal contact name, telephone number, or address. 7. Review of R71's interdisciplinary (IDT) progress notes located in the progress notes tab of the EMR revealed a note, dated 06/12/24 and timed 11:49 AM, which revealed the resident was transferred to the hospital because of altered mental status and tachycardia. Review of a nurse's note located in the progress notes tab of the EMR, dated 6/13/24 and timed 4:09 AM, revealed the hospital was called and she was admitted to the hospital with a diagnosis of urinary tract infection. Review of an IDT note located in the Progress Notes tab of the EMR, dated 06/19/24 and timed 10:27 PM, revealed the resident was readmitted to the facility. Review of the discharge notice revealed she was issued a Notice of Emergency Transfer on 06/12/24. Review of the issued document titled, Notice of Emergency Transfer, dated 06/12/24 and provided by the facility, revealed the document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 8. Review of R91's nurses note located in the progress notes tab of the EMR, dated 11/06/24 and timed 10:28 PM, revealed the resident was admitted to the hospital with a diagnosis of right sided cerebral infarction. Review of an IDT note located in the Progress Notes tab of the EMR, dated 11/13/24 and timed 4:33 PM, revealed he was readmitted to the facility from the hospital at 4:30 PM. Review of the document titled Notice of Emergency Transfer, dated 11/06/24 and provided by the facility, revealed the document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 9. Review of R86's nurse's note located in the Progress Notes tab of the EMR, dated 08/13/24 and timed 9:45 AM, revealed the resident was sent to the hospital because of having trouble breathing. Review of a nurse's note located in the Progress Notes tab of the EMR, dated 08/13/24 and timed 3:15 PM, revealed R86 was admitted to the hospital with respiratory distress. Review of an IDT note located in the Progress Notes tab of the EMR, dated 08/19/24 and timed 3:04 AM, revealed R86 was readmitted to the facility. Review of an IDT note located in the Progress Notes tab of the EMR, dated 07/28/24 and timed 9:28 PM, revealed the resident was sent to the hospital due to having bright red blood when R86's tracheostomy was suctioned. Review of an IDT note located in the Progress Notes tab of the EMR, dated 08/08/24 and timed 5:50 PM, revealed R86 returned to the facility from the hospital. Review of the document titled Notice of Emergency Transfer, dated 07/29/24 and 08/13/24 and provided by the facility, revealed the document did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. During an interview on 12/04/24 at 2:30 PM, the Social Services Director (SSD) stated she was the person who issued the discharge notices. She verified it did not include a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which received such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. She stated she was told to use these forms for the discharge notices and was not aware of the appeal's right information. During an interview on 12/5/24 at 5:06 PM, the Administrator and [NAME] President of Operations stated they felt the facility was meeting the requirement because the residents were given the bed hold policy upon admission and since they were emergency hospital transfers, and because the residents are always allowed to return to the facility, they did not need to include the statement. They stated the transfer/discharge notice they were using was printed from the New Jersey (NJ) web site and was what NJ Department of Health required the facility to send to the resident or the responsible party. They provided the information from the website and provided the documents on the State web site. The paper printed off the web site and titled LTCO [Long Term Care Ombudsman] Guidance on Emergency Transfer Notification Requirements number four of the document stated the notice must contain Contact information for the NJ LTCO and other entities referred to in the Content Notice as stated in the CMS [Centers for Medicare and Medicaid Services] regulations. Review of the facility's policy titled, Discharge/Transfers, dated 01/23, indicated .It is the policy of this facility to provide guidelines for the discharge/transfer process .The facility will safely discharge/transfer a resident/patient based on what is appropriate to the resident/patient's welfare and needs . The policy did not include information related to the contents of the transfer/discharge documents. NJAC 8:39-4.1(a)31 46592

40824 Based on record review, interview, and facility policy review, the facility failed to ensure residents were provided with a written bed hold notice which included the cost per day information for the resident/representative to have informed consent for nine of nine residents and their representatives (Resident (R) 21, R27, R75, R9, R60, R69, R71, R91, and R86) reviewed for facility initiated emergent hospital transfer of 31 sample residents. This failure had the potential for the residents to be denied return to their original room or denial of the resident returning to the facility. Findings include: 1. Review of R21's undated Admission Record located in the electronic medical record (EMR) under the Resident tab indicated R21 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of R21's Discharge Assessment with Assessment Reference Date (ARD) of 02/07/24 located in the EMR under the MDS (Minimum Data Set) tab indicated that R21 had an unplanned discharge from the facility on 02/07/24 to a short-term general hospital. Review of R21's untitled document dated 02/08/24 and provided by the facility stated, This letter is to inform you that [Facility Name] will hold your bed for 10 days. In accordance with Medicaid guidelines, the bed will be held starting on the day of discharge. If you or your family member have any concerns, please contact me at [PHONE NUMBER] . 2. Review of R27's undated Admission Record located in the EMR under the Resident tab indicated R27 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of R27's Discharge Assessment with an ARD of 11/06/24 located in the EMR under the MDS tab indicated that R27 had an unplanned discharged from the facility on 02/07/24 to a short-term general hospital. Review of R27's untitled document dated 11/07/24 and provided by the facility stated, This letter is to inform you that [Facility Name] will hold your bed for 10 days. In accordance with Medicaid guidelines, the bed will be held starting on the day of discharge. If you or your family member have any concerns, please contact me at [PHONE NUMBER] . 3. Review of R75's undated Admission Record located in the EMR under the Resident tab indicated R75 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of R75's EMR under the MDS tab did not include a Discharge assessment dated [DATE]. Review of R75's untitled document dated 09/23/24 and provided by the facility stated, This letter is to inform you that [Facility Name] will hold your bed for 10 days. In accordance with Medicaid guidelines, the bed will be held starting on the day of discharge. If you or your family member have any concerns, please contact me at [PHONE NUMBER] . 4. Review of R9's Census tab located in the electronic medical record (EMR) revealed R9 was originally admitted to the facility on [DATE]. Review of the discharge MDS with an ARD of 11/17/24 located in the MDS tab in the EMR revealed R9 was discharged with an anticipated return. Review of the Progress Note, dated 11/17/24 and located under the Prog Note tab in the EMR revealed R9 was transferred to the hospital due to severe lethargy and no responsiveness to stimuli. The bed hold form provided to the resident/representative indicated the length of the bed hold, but did not indicate the price for each day of the bed hold. 5. Review of R60's Census tab located in the EMR revealed R60 was originally admitted to the facility on [DATE]. Review of the discharge MDS with an ARD of 10/16/24 located in the MDS tab in the EMR revealed R60 was discharged with an anticipated return. Review of the Progress Note, dated 10/16/24 and located under the Prog Note tab in the EMR revealed R60 was transferred to the hospital for low blood sugar and for being unarousable upon verbal and tactile stimuli. The bed hold form provided to the resident/representative indicated the length of the bed hold, but did not indicate the price for each day of the bed hold. 6. Review of R69's Census tab located in the EMR revealed R69 was originally admitted to the facility on [DATE]. Review of the discharge MDS with an ARD of 09/12/24 located in the MDS tab in the EMR revealed R69 was discharged with an anticipated return. Review of the Progress Note, dated 09/12/24 and located under the Prog Note tab in the EMR revealed R69 was transferred to the hospital for increased altered mental status and involuntary jerking movements. The bed hold form provided to the resident/representative indicated the length of the bed hold, but did not indicate the price for each day of the bed hold. 7. Review of R71's interdisciplinary (IDT) progress notes located in the progress notes tab of the EMR revealed a note, dated 06/12/24 and timed 11:49 AM, which revealed the resident was transferred to the hospital because of altered mental status and tachycardia. Review of a nurse's note located in the progress notes tab of the EMR, dated 6/13/24 and timed 4:09 AM, revealed the hospital was called and R71 was admitted to the hospital with a diagnosis of urinary tract infection. Review of an IDT note located in the Progress Notes tab of the EMR, dated 06/19/24 and timed 10:27 PM, revealed the resident was readmitted to the facility. Review of the discharge notice revealed she was issued a Notice of Emergency Transfer on 06/12/24. Review of the issued undated document titled, [Facility Name], provided by the facility, revealed the resident's bed would be held for 10 days. The notice was absent for the reserve bed payment policy in the state plan as required. 8. Review of R91's nurses note located in the progress notes tab of the EMR, dated 11/06/24 and timed 10:28 PM, revealed the resident was admitted to the hospital with a diagnosis of right sided cerebral infarction. Review of an IDT note located in the Progress Notes tab of the EMR, dated 11/13/24 and timed 4:33 PM, revealed R91 was readmitted to the facility from the hospital at 4:30 PM. Review of the paper discharge notices, provided by the facility, revealed she was issued a bed hold notice on 11/07/24. Review of the issued document titled, [Facility Name] dated 11/07/24 and provided by the facility, revealed the resident's bed would be held for 10 days. The notice was absent for the reserve bed payment policy in the state plan as required. 9. Review of R86's nurse's note located in the Progress Notes tab of the EMR, dated 08/13/24 and timed 9:45 AM, revealed the resident was sent to the hospital because of having trouble breathing. Review of a nurse's note located in the Progress Notes tab of the EMR, dated 08/13/24 and timed 3:15 PM, revealed R86 was admitted to the hospital with respiratory distress. Review of an IDT note located in the Progress Notes tab of the EMR, dated 08/19/24 and timed 3:04 AM, revealed R86 was readmitted to the facility. Review of an IDT note located in the Progress Notes tab of the EMR, dated 07/28/24 and timed 9:28 PM, revealed the resident was sent to the hospital due to having bright red blood when his tracheostomy was suctioned. Review of an IDT note located in the Progress Notes tab of the EMR, dated 08/08/24 and timed 5:50 PM, revealed R86 returned to the facility from the hospital. Review of the paper discharge notices, provided by the facility, for the days R86 was discharged revealed R86 was issued a bed hold notice on 07/29/24 and 08/14/24. Review of the issued undated document titled, [Facility Name] provided by the facility, revealed the resident's bed would be held for 10 days. The notice was absent for the reserve bed payment policy in the state plan as required. During an interview on 12/05/24 at 5:06 PM, the Administrator and [NAME] President of Operations stated they felt the facility was meeting the requirement because the residents were given the bed hold policy upon admission and since they were emergency hospital transfers, and because the residents are always allowed to return to the facility, they did not need to include the statement. They verified the bed hold notices did not include a reserve bed payment policy. They stated the payment would have been different for each resident. Review of the facility's policy titled, Temporary Discharge (Bed-Hold) and dated 01/24, indicate .The facility agrees to a temporary bed hold for resident's that are discharged for a temporary leave to a hospital or any other facility .Upon Resident/Sponsor written request to reserve the resident's accommodations for seven (7) days, starting on the day of discharge. After the initial seven (7) day period, the resident/Sponsor may request, in writing, for continued bed-hold at the regular Daily Rate . The policy did not include the Daily Rate or cost per day of the bed hold. Review of the facility's undated policy titled, Admission Agreement indicated .During Resident's temporary leave from the Facility to a hospital or any other facility, the Facility agrees as follows: .Upon Resident/Sponsor written request to reserve a Resident's accommodations for seven (7) days, starting on the day of discharge, with payment of charges continuing at the at [sic] regular Daily Rate. After the initial seven (7) day period, the Resident/Sponsor may request, in writing, for continued bed-hold at the regular Daily Rate . The Admission Agreement did not include the daily rate charge. NJAC 8:39-5.3 46592

Based on record review and interviews, the facility failed to ensure residents had cognitive ability before signing arbitration agreements for four of five residents (Resident (R) 71, R84, R75, and R44) reviewed for arbitration of 31 sample residents. This had the potential to result in resident representatives not being able to resolve disputes with the facility in a court of law. Findings include: 1. Review of R71's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/24 and located under the MDS tab of the electronic medical record (EMR) revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident had severely impaired cognition. Review of R71's Voluntary Binding Arbitration Agreement located under the Misc tab of the EMR revealed the resident signed the agreement on 06/27/23. On the last page of the agreement above the signature line the document revealed I _____, being a Resident or Resident's legally authorized Representative, hereby acknowledge that I read this entire agreement and understand the terms of this agreement. With space for initials after this statement. R71's name was type written into the blank and the resident signed by putting R71's initials into the line stating, Signature of Resident/Resident's Legally Authorized Representative. Under the section labeled Facility's representative The Admissions Coordinator (AC) printed and signed her name and dated it 06/27/23. During an interview on 12/05/24 at 11:50 AM, the AC stated the resident's niece was present at the time R71 signed the agreement. According to the AC, the niece was working on getting power of attorney papers approved. The niece stated she understood the agreement, however she did not want to sign it but said it was ok for R71 to sign it. During an interview on 12/05/24 at 11:50 AM, the Admissions Director (AD) verified R71 did not have the cognitive capacity to understand the agreement. 2. Review of R84's admission MDS with an ARD of 12/15/24 and located under the MDS tab of the EMR revealed the resident was assessed to have a BIMS score of one out of 15 indicating the resident had severely impaired cognition. Review of R84's Voluntary Binding Arbitration Agreement located under the Misc tab of the EMR, revealed the resident signed the agreement on 12/08/23. On the last page of the agreement above the signature line the document revealed I _____, being a Resident or Resident's legally authorized Representative, hereby acknowledge that I read this entire agreement and understand the terms of this agreement. With space for initials after this statement. R84's name was type written into the blank and the resident signed by putting their initials into the line stating, Signature of Resident/Resident's Legally Authorized Representative. Under the section labeled Facility's representative The AC printed and signed her name and dated it 12/08/24. During an interview on 12/05/24 at 11:53 AM, the AD and the AC verified R84 did not have the ability to understand the agreement. AC stated R84 only spoke Spanish, and she did not speak Spanish, so she spoke to R84's grandson over the phone and had him explain it to her in Spanish and the grandson stated it was ok for his grandmother to sign the agreement. She stated she was not able to determine if the resident understood it because she did not speak Spanish, but she felt the grandson understood it. 3. Review of R75's resident's admission MDS with an ARD of 08/02/23 and located under the MDS tab of the EMR revealed the resident was assessed to have a BIMS score of one out of 15 which indicated that the resident had severely impaired cognition. Review of R75's Voluntary Binding Arbitration Agreement located under the Misc section of the EMR revealed the resident signed the agreement on 08/04/23. On the last page of the agreement above the signature line the document revealed I _____, being a Resident or Resident's representative legally authorized Representative, hereby acknowledge that I read this entire agreement and understand the terms of this agreement. With space for initials after this statement. R75's name was typewritten into the blank and the resident signed by putting their initials into the line stating, Signature if Resident/Resident's Legally Authorized Representative. Under the section labeled Facility's representative The AC printed and signed her name and dated it 08/04/23. During an interview on 12/05/24 at 12:00 PM, the AD and the AC verified R75 did not have the ability to understand the agreement. AC stated R75's daughter was present when the agreement was signed and because the resident only spoke Spanish, she had the daughter explain it to her mother and stated it was ok to have her mother sign the agreement. According to the AC and AD the daughter did not have power of attorney over the resident. 4. Review of R44's resident's admission MDS with an ARD date of 10/23/24 and located under the MDS tab of the EMR revealed the resident was assessed to have a BIMS score of one out of 15 which indicated the resident had severely impaired cognition. Review of R44's Voluntary Binding Arbitration Agreement located under the Misc section of the EMR revealed the resident signed the agreement on 10/20/24. On the last page of the agreement above the signature line the document revealed I _____, being a Resident or Resident's representative legally authorized Representative, hereby acknowledge that I read this entire agreement and understand the terms of this agreement. With space for initials after this statement. R44's name was typewritten into the blank and the resident signed by putting their initials into the line stating, Signature if Resident/Resident's Legally Authorized Representative. Under the section labeled Facility's representative, the AC printed and signed her name and dated it 10/20/24. During an interview on 12/05/24 at 11:38 AM, the AD and the AC verified R44 did not have the ability to understand the agreement. AC stated the R44 did not have any power of attorney, family, or responsible party. She stated she called the resident's friend (she could only remember the first name of the friend) and the friend said it was ok to have the resident sign the agreement. During an interview on 12/05/24 at 11:50 AM, the AD was asked what BIMS score he felt would be high enough for the residents to understand the binding arbitration agreement and he stated they should have at least an 11. During an interview on 12/05/24 at 12:20 PM, the Administrator was informed of each of the instances in which the cognitively impaired residents were assisted with signing the binding arbitration agreement. She stated it was not acceptable for the residents to sign the arbitration agreement if they did not have the capability to understand it. She stated if the resident was not capable of understanding it and did not have a legal representative or the resident representative did not want to sign it, she would consider it a refusal. NJAC 8:39-13.1(a)

Based on record review, interview, and facility policy review, the facility failed to maintain a functional Antibiotic Stewardship Program that followed the McGeer criteria for antibiotic usage for four out of 12 months reviewed for tracking and trending of antibiotics of 88 census residents. This failure had the potential to affect residents being prescribed antibiotics that were potentially unnecessary. Findings include: Review of the Antibiotic Orders Daily Log, provided by the facility and dated for the months of November 2023 through November 2024, revealed information contained on these logs were date, room number, resident's name, antibiotic ordered, diagnosis, facility acquired, or community acquired, stop date of the antibiotic, dose schedule of the antibiotic, number of treatment days, and the route of administration of the antibiotics. Review of the Revised McGeer Criteria for Infection Surveillance Checklist, which was provided by the facility revealed the following: -For the month of January 2024, there was one McGeer surveillance form filled out but there were 36 facility acquired infections documented on the line listing. There was no documentation of 35 of those infections to see if the infection met the McGeer criteria for being treated appropriately with an antibiotic. -For the month of February 2024, there was no documentation of the McGeer surveillance forms filled out for the month. However, the line listing for February revealed 24 facility acquired infections documented. These infections had no documentation if the infection met the McGeer criteria for being treated appropriately with antibiotics. -For the month of March 2024. There was no documentation of the McGeer surveillance forms filled out for the month however, the line listing for March revealed 18 facility acquired infections documented. These infections had no documentation if the infections met the McGeer criteria for being treated appropriately with antibiotics. -For the month of April 2024, there were two McGeer surveillance forms filled out but there were 23 facility acquired infections documented on the line listing. There was no documentation for 21 of those infections to see if the infection met the McGeer criteria for being treated appropriately with an antibiotic. During an interview on 12/05/24 at 7:27 PM, the Infection Preventionist (IP) nurse stated, The unit managers fill out the McGeer's criteria for each of the facility acquired infections. In the beginning they were not submitting these to me on a regular basis; during these months [January 2024 through April 2024], we did education telling them they [Revised McGeer Criteria for Infection Surveillance Checklist] had to be filled out and started tracking, so now all the unit managers are responsible for doing these on their units . For the months that the McGeer's wasn't filled out for, I don't know if the infections met criteria to be treated with an antibiotic or not. During an interview on 12/05/24 at 8:07 PM, the Director of Nursing (DON) stated, I expect my unit managers to fill out a McGeer's surveillance form with the appropriate information each time there is an antibiotic given to our residents then forward this to the IP nurse for her review. Review of the facility's policy titled, Antibiotic Stewardship, dated 01/24 and was provided by the facility, revealed .Antibiotic stewardship is important to our nursing facilities because antibiotics are one of the most commonly prescribed medications. Overuse of antibiotics allows for drug-resistant strains of bacteria to emerge. When this happens, the result if increased hospitalization s, higher mortality, and escalating costs . NJAC 8:39-19.4(d)

Based on record review, interview, and facility policy review, the facility failed to update a resident's advanced directive in the medical record after the resident decided to change it from full code to a do not resuscitate (DNR) for one of nine residents (Resident (R) 66) reviewed for advanced directives of 31 sample residents. Failure to accurately record a resident's advanced directive in the medical record had the potential to result in the resident receiving cardiopulmonary resuscitation against their wishes. Findings include: Review of R66's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident's cognition was moderately impaired. Diagnoses as listed under the Diagnosis tab of the EMR revealed a personal history of transient ischemic attack, cerebral infarction without residual deficits, acute kidney failure, and hypertensive heart disease without heart failure. During an interview on [DATE] at 3:01 PM, the resident was asked if they were to be found by staff without any vital signs would the resident want to be resuscitated. R66 stated that someone had just asked them that the other day and told the person who asked the resident that they would not want to be resuscitated. R66 could not remember who asked them the question. Review of R66's electronic medical record (EMR) Physician's Order dated [DATE] and located under the Orders: tab revealed a full code and located on the dashboard. Review of the miscellaneous section located under the Misc section of the EMR revealed there was no advanced directive or documentation of R66 being informed of the resident's right to formulate an advanced directive. Review of a social service progress note dated [DATE] and timed 10:16 PM and located in the Progress note tab of the EMR revealed the resident wanted to be full code. Review of a document titled, New Jersey Practitioner orders for Life-Sustaining Treatment (POLST) revealed it was signed by R66 and R66's physician with the date of [DATE]. Under the section of the form labeled Cardiopulmonary Resuscitation (CPR) .Do not attempt resuscitation/DNAR .Allow Natural Death was checked. During an interview on [DATE] at 2:15 PM, Licensed Practical Nurse (LPN) 2 was asked about R66's code status. After checking the cover/spine of the hard chart and the dashboard located at the top of the EMR screen and physician's order located under the orders tab in the EMR she stated the resident was a full code therefore she would start cardiopulmonary resuscitation (CPR) and continue it until the emergency medical services arrived. During an interview on [DATE] at 2:35 PM, the document and the information posted in the EMR, and paper chart was reviewed with the Social Service Director (SSD), and she verified the POLST dated [DATE] and stated R66 was a DNAR, and the chart was documented to indicate the resident was a full code. During an interview on [DATE] at 3:37 PM, the SSD and the Administrator stated that after they investigated it, they discovered the date of [DATE] was written in error and should have been [DATE]. The SSD stated the part-time social worker spoke to the resident around 5:00 PM on [DATE]. R66 stated they did not want CPR if they were to be found without vital signs and signed the POLST stating they wanted to be a DNAR. The SSD stated the physician was at the facility that evening and signed the form. The SSD stated the Social Worker called the resident's son prior to the resident signing the form and stated he was good with it if it was what his father wanted. Both the SSD and the Administrator verified that a new order should have been written and the paper chart and the EMR should have been changed to reflect the residents' wishes to be DNAR. Review of the facility's policy titled, Advanced Directive with a revised date of ,d+[DATE], revealed it was the facility's policy to establish and maintain a system for residents to formulate an advanced directive, and to accept or refuse medical or surgical treatment. According to the policy the health care decision documents would be filed in the medical record under the advanced directive tab and charts would be flagged on the front cover to signify the existence of such documents. NJAC 8:,d+[DATE].6(b)(e)(g)

Based on record review, interview, and facility policy review, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 203) reviewed for baseline care plan out of 31 sample residents. This failure had the potential for residents and/or RP not to be informed of the plan of care. Findings include: Review of R203's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included diabetes mellitus, metabolic encephalopathy, obstructive and reflux uropathy, and dementia. Review of R203's Physician's Admission Note, dated 11/17/24 and located under the Progress Note tab in the EMR, revealed R203 was .AO x 3 [alert and oriented x 3] . Review of R203's Care Plan located under the Care Plan tab in the EMR revealed the areas of the care plan that was completed on 11/16/24 and 11/17/24 included nutritional risk related to therapeutic diet, mechanically altered diet, falls risk, self-care deficits, at risk for COVID-19 infection, transmission based precautions (Enhanced Barrier Precautions) related to the presence of the Foley catheter, and resident presents with decline in functional and gait status following recent hospitalization . During an interview on 12/02/24 at 12:10 PM, Family Member (FM) 2 stated, I haven't been given anything about my father's care since [R203] has been admitted here. During an interview on 12/04/24 at 6:02 PM, the Social Services Director (SSD) stated, When we do our baseline care plan, we do them within 48 hours, then I go over the care plan with the resident or the representative and explain all of it to them. I haven't been documenting where I have been giving these to them. When asked where in the EMR can the base line care plan be found, the SSD stated, There isn't a separate one. It's all one care plan that is started on admission and all the areas are completed within 48 hours. During an interview on 12/05/24 at 5:00 PM, the Director of Nursing (DON) stated, I expect the baseline care plan to be completed within 48 hours from admission and a written summary be given to the resident and/or RP. Review of the facility's policy titled, Plan of Care and IDCP [Interdisciplinary Care Planning] Team Meeting Policy dated 01/24 and provided by the facility, revealed .The baseline care plan shall be developed within 48 hours of a resident's admission .The facility must provide the resident and his/her representative with a written summary of the baseline care plan . NJAC 8:39-11.2(d)

COMPLAINT # NJ00161781 and NJ00161918 Based on interviews, and review of medical records (MR) and other facility documentation on 3/2/23, 3/6/23 and 3/7/23, it was determined that the facility failed to a.) provide a 3 day written notice prior to the resident's voluntary discharge and b.) document in the residents MR that the responsible parties (RP) were given a thirty-day notice in advance of an impending discharge for an involuntary transfer or discharge. In addition, the facility failed to follow their policy on discharge and admission agreement. This deficient practice had caused psychosocial harm to the residents who was discharged on [DATE] for 6 of 8 residents (Residents #1, #2, #3, #5, #6, and #8) reviewed for discharge. This deficient practice is evidenced by the following: The surveyor reviewed facility 2023 Discharges on 3/2/23. The 2023 Discharges revealed that Residents #1, #2, #3, #5, #6, and #8 were discharged from the facility (F1) to another facility (F2) on 2/9/23. Review of the facility ADMISSION AGREEMENT (AG), under SECTION 3. DISCHARGE AND TRANSFER .D. Voluntary Discharge. Thee (3) days-advance written notice is required prior to the Resident's voluntary discharge to complete appropriate discharge planning .G. Involuntary Transfer or Discharge. Resident/Sponsor will be given thirty (30) days advance notice of an impending transfer or discharge, unless: 1. Transfer or discharge is necessary for the resident's welfare and Resident's needs cannot be met in the facility. 2. Transfer or discharge is appropriate because the Resident's health has improved sufficiently the Resident no longer needs the service provided by the facility. 3. The safety of individuals in the facility is endangered. 4. The health of individuals in the facility would otherwise be endangered. 5. Resident/Sponsor has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare of Medicaid benefits) the stay at the facility. 6. An immediate transfer or discharge is required by the Resident's urgent medical needs. 7. The Facility ceases to operate. Review of the facility policy titled Discharge/Transfers, dated 1/2023, revealed Policy Statement It is the policy of this facility to provide guidelines for the discharge/transfer process. Procedures 1. Discharge planning begins on admission. 2. the facility IDT [interdisciplinary team] will discuss discharge plans with the resident/patient and/or representative (i.e., return home/community, assisted-living, long-term care, etc.) throughout the resident/patient's stay at this facility. 3. If the resident/patient and/or representative requires long-term care and the facility does not have a bed available, the facility shall offer options including [F2], if those options meet the resident/patient needs. 4. Any changes to the discharge plan during the resident/patient stay shall be communicated to the IDT. 5. The facility will safely discharge/transfer a resident/patient based on what is appropriate to the resident/patient's welfare and needs . 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included but were not limited to: Glaucoma, Rhabdomyolysis, and Lack of Coordination. The Minimum Data Set (MDS), an assessment tool dated 11/3/22 and 1/27/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated intact cognition and the resident required extensive and total assistance with Activities of Daily Living (ADL). The admission assessment MDS, dated [DATE], further revealed in Section Q, Resident #1 participated, expected to be discharged to the community, and active discharge planning was already occurring for the resident to return to the community. The quarterly assessment MDS, dated [DATE], included that the resident participated and that an active discharge plan was already occurring for the resident to return to the community. A care plan (CP), initiated on 10/28/22, indicated that Resident #1 wished to return home with his/her RP. Interventions included but were not limited to; make arrangements with required community resources to support independence. There was no indication on the CP that the resident was to be discharged to F2. Review of Resident #1's AG, dated 1/10/23 indicated the RP signed the AG acknowledging the involuntary discharge and voluntary discharge requirements. The Order Summary Report (OSR), dated 2/9/23, revealed a Physician order for Transfer to [F2]. A review of Resident #1's progress notes (PN), dated 11/3/22 at 10:54 am, documented by the social worker (SW), revealed that Resident #1 expressed interest in long term care and the RP was made aware. There was no documentation in the MR regarding plans for discharge to F2 until 2/8/23, one day prior to discharge. A PN by the SW on 2/8/23 at 9:33 pm, revealed SW spoke with LTC [long term care] resident along with their family to discuss that [F1] is transitioning to sub acute facility and offered transition to [F2]. Both provided consent for the transfer by Friday [2/10/23]. A PN dated 2/9/23 at 11:24 am, documented by the Assistant Director of Nursing (ADON), further revealed 1100 [11:00 am] discharged ; [transport company] arrived to transport via W/C [wheelchair] to [F2]. All personal belongings and medication transported w/ [with] resident. A PN at 12:23 pm, documented by the Quality Assurance Registered Nurse (QARN), revealed Resident discharged to [F2]. Transported by [transport company] via wheelchair. All paperwork, personal belongings and medications were taken. Resident left in no distress .Family and MD [physician] aware. The PNs and MR revealed no documented evidence that voluntary discharge and/or involuntary discharge requirements was given to the resident and/or RP. The surveyor conducted a post survey interview with Resident #1 on 3/8/23 at 11:00 am at F2. Resident #1 stated that she/he was not aware that there was a plan of moving to F2 until the night before the transfer, 2/8/23. The resident further stated that the facility advised her/him that they were to be transferred on Friday, 2/10/23. However, on 2/9/23 during lunch time, the resident stated when they delivered the tray, I was about to grab the spoon, one of the staff told me 'no time to eat, lets go.' I said what about my lunch? She [staff] said no time to eat .I didn't have time to say no. I was never notified about the discharge, I was surprised, it was never discuss to me or my husband. If they [F1] told me ahead of time, I would want to check [F2] first before moving, but they never said anything about it. Resident #1 further stated When they moved me [to F2] I heard them say 'at least put a coat on, the girl said 'no time.' My [husband/wife] did not know that I was moved here, [he/she] found out when [he/she] called [F1]. The resident further stated I don't know how I felt, they had to do what they had to do, it was sudden. If they told me ahead of time, I would want to check [F2] it out or my [husband/wife] first before moving, but they never said anything about it .the move was a surprise because they said Friday [2/10/23], then they moved us on Thursday [2/9/23]. 2. According to AR, Resident #2 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included but were not limited to: Dementia, Glaucoma, and Schizoaffective Disorder. The MDS admission assessment, dated 8/24/22, revealed a BIMS score of 6/15, which indicated severely impaired cognition. Section Q of the MDS revealed the resident and RP participated and indicated the resident expected to remain in the facility. The MDS significant change assessment, dated 11/24/22, revealed the BIMS score was not conducted as Resident #2 was rarely/never understood. The significant change MDS further revealed under Section Q the resident and RP participated, and active discharge planning was not occurring for the resident to return to the community. A CP, initiated on 9/1/22, indicated that the RP requested for Resident #1 to stay in the facility for LTC. There was no indication on the CP that the resident was to be discharged to F2. Review of Resident #2's AG, dated 8/17/22 and signed on 8/18/22 indicated that the RP was acknowledging the involuntary discharge and voluntary discharge requirements. The OSR, dated 2/9/23, revealed a Physician order for Transfer to [F2]. A review of Resident #2's PN, dated 8/2/22 at 11:41 am, documented by SW #2, indicated PT [patient] will remain in facility for LTC. A PN on 9/1/22 at 8:48 am and 11/28/22 at 12:00 pm, by SW #2, indicated that the resident will remain in the facility for LTC [long term care]. A PN on 2/8/23 at 9:26 pm, by the SW, indicated SW spoke with LTC resident along with their family to discuss that [F1] is transitioning to sub acute facility and offered transition to [F2]. Both provided consent for the transfer by Friday [2/10/23]. A PN on 2/9/23 at 12:30 pm, documented by the QARN, indicated Resident discharged to [F2]. Transported by [transport company] via wheelchair. All paperwork, personal belongings and medications were taken. Resident left in no distress .Family and MD [ (physician] aware. A PN on 2/9/23 at 1:00 pm, by RN #1, indicated that the resident was transferred to F2 and the resident's belongings were to follow. The PNs and MR revealed no documented evidence that voluntary discharge and/or involuntary discharge requirements were given to the resident and/or RP. 3. According to AR, Resident #3 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included but were not limited to: Schizophrenia, Major Depression, and Mental Disorder. The MDS, dated [DATE] and 1/13/23, revealed a BIMS score of 14/15, which indicated intact cognition and the resident required limited assistance with ADLs. The MDS admission assessment, dated 4/29/22, reflected under section Q that Resident #3 participated, expected to be discharged to the community, active discharge planning was already occurring for the resident to return to the community, and referral was not needed. The MDS quarterly assessment, dated 1/13/23, under section Q included that Resident #3 participated, active discharge planning was already occurring for the resident to return to the community, and a referral was not needed. A CP, initiated on 4/29/22, indicated Resident #3 may need assistance to coordinate community resources for discharge to home. There was no indication on the CP that the resident was to be discharged to F2. Review of Resident #3's AG, dated 4/22/22 and signed on 6/17/22 indicated the resident was acknowledging the involuntary discharge and voluntary discharge requirements. The OSR, dated 2/9/23, revealed a Physician order for Transfer to [F2] A review of Resident #3's PN, dated 4/29/22 at 10:58 am, documented by SW #2, indicated that Resident #3 verbalized he/she lived with his/her brother/sister and wishes to return home after rehabilitation. A PN on 5/9/22 at 11:28 am, by SW #3, revealed SW spoke with patient and [Responsible Party] to inform them about patient's room change. Patient will move to LTC floor as [he/she] will stay in the facility for LTC .Both patient and [Responsible Party] expressed understanding . A PN on 7/20/22 at 2:47 by SW #2, revealed; Followed up with [Responsible Party] regarding PT [patient] coverage and discharge by insurance. PT [patient] been discharged to an Assisted living discussed with [Responsible Party]. [Responsible Party] declined. [Responsible Party] states [he/she] wants PT [patient] to remain in the facility for LTC. [Responsible Party] requested a 30 days discharge notice . A PN On 9/1/22 at 3:48 pm, by SW #2, indicated that the resident was not qualified for LTC and needed to be discharged back to the community. A PN on 9/15/22 at 2:32 pm, documented by SW #2, indicated IDCP [Interdisciplinary Care Plan] Team met with [Responsible Parties] .Purpose of meeting was to complete PT [patient] screening for LTC .Case manager requested documents be sent to her to review and a determination will be made regarding PT [patient] qualification to remain in a LTC facility or discharge home. A PN on 2/8/23 at 9:23 pm, documented by SW, indicated SW spoke with LTC [long term care] resident along with their family to discuss that [F1] is transitioning to sub acute facility and offered transition to [F2]. Both provided consent for the transfer by Friday [2/10/23]. A PN on 2/9/23 at 12:30 pm by the QARN further revealed Resident discharged to [F2]. Transported by [transport company] via wheelchair. All paperwork, personal belongings and medications were taken. [Responsible Party] present during transfer and assisted with belongings. Resident left in no distress .MD aware. A PN on 2/9/23 at 1:16 pm, by RN #1 revealed .transferred to [F2] via wheelchair with all [his/her] medication .belongings. The surveyor conducted a post survey interview with Resident #3 on 3/8/23 at 11:55 am at F2. Resident #3 stated Everything was a surprised. I was never told about the transfer to [F2], I get in to the van, they said you are being transferred to [F2], they never ask me if I wanted to be moved to [F2]. If I was asked, I would refuse because my [brother/sister] was just around the corner .I picked [F1] because my [brother/sister] was nearby and can visit me anytime. My [brother/sister] and I was not aware that there was a plan of moving to [F2]. We were surprised that they were moving me that day [2/9/23], I was rushed and did not have time to say no, [F1] should have given us more time to prepare and to pack, the [F1] said they were moving us on Friday [2/10/23] but I was surprised that they were moving us earlier than that [2/9/23]. My rights were violated, they didn't give us enough time to decide. 4. According to AR, Resident #5 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease and Muscle Weakness. The MDS admission assessment, dated 10/25/22, revealed a BIMS score of 12/15, which indicated moderately impaired cognition. The MDS further revealed that the resident participated in Section Q, the resident was expected to be discharged to the community and active discharge plan was already occurring for the resident to return to the community. The MDS significant assessment, dated 11/14/22, revealed a BIMS score of 12/15, which indicated cognition was moderately impaired and the resident required extensive assistance with ADL. The MDS further revealed that the resident participated in Section Q and an active discharge plan was already occurring for the resident to return to the community. A CP, initiated on 10/22/22, indicated that Resident #5 wished to return home. There was no indication on the CP that the resident was to be discharged to F2. Review of Resident #5's AG, dated 12/30/22 indicated that Resident #5 was acknowledging the involuntary discharge and voluntary discharge requirements. The OSR revealed there was no Physician order for Resident #5 to be transferred to F2. Review of a PN on 10/31/22 at 3:20 pm, by SW #2, revealed .admitted to the facility on ,d+[DATE] from [hospital]. [Resident #5] is alert able to make [his/her] needs known. [Resident #5] states [she/he] resides alone and wishes to return home after rehab [rehabilitation] . A PN On 11/7/22 at 2:03 pm, by SW #2, revealed IDCP [Interdisciplinary [NAME] Plan] Team met with PT [patient] and children to discuss .discharge plan. PT [patient] is alert with periods of confusion .Family states prior to admission, PT [patient] lived alone and discharge plan is to return home after rehab [rehabilitation]. Family made aware team recommends LTC or 24hrs care if PT [patient] is discharged home. Aware no discharge date at this time .At this time, PT [patient] discharge plan is to return home . A PN on 11/21/22 at 10:41 am, by SW #2, indicated that the RP was undecided regarding the plan for discharge. A PN on 2/8/23 at 9:26 pm, by the SW, indicated SW spoke with LTC resident along with their family to discuss that [F1] is transitioning to sub acute facility and offered transition to [F2]. Both provided consent for the transfer by Friday [2/10/23]. The surveyor attempted to conduct a post survey interview with Resident #5 on 3/8/23 at 12:25 pm at F2, however, the resident did not answer any surveyor questions. Review of the residents BIMS, dated 2/15/23 assessed by F2, indicated that resident #5 had severely impaired cognition. 5. According to AR, Resident #6 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included but were not limited to: Hemiplegia and Hemiparesis, Ataxia, Muscle Weakness, and Lack of Coordination. The MDS admission assessment, dated 5/30/22, revealed a BIMS score of 15/15, which indicated cognition was intact. The MDS further revealed that the resident participated in section Q, which indicated the resident expected to be discharged to the community and active discharge planning was already occurring to return to the community. The MDS quarterly assessment, dated 11/30/22, revealed a BIMS score of 15/15. Section Q indicated that the resident participated, and an active discharge plan was already occurring for the resident to return to the community. A CP, initiated on 5/23/22, indicated that the RP requested for Resident #6 to stay in the facility for LTC. There was no indication on the CP that the resident was to be discharged to F2. Review of Resident #6's AG, dated 5/23/22 and signed on 6/2/22 indicated that the resident was acknowledging the involuntary discharge and voluntary discharge requirements. The OSR, dated 2/9/23, revealed a Physician order for Transfer to [F2]. Review of Resident #6's PN, dated 5/25/23 at 1:36 pm, documented by SW #3, indicated .admitted from private home on 5/23/22 for LTC placement. Patient is AAOx3 .able to make [his/her] needs known to staff .Patient's DC [discharge] plan is to stay in the facility for LTC . A PN on 2/8/23 at 10:31 pm, by the SW, indicated SW spoke with LTC resident along with their family to discuss that [F1] is transitioning to sub acute facility and offered transition to [F2]. Both provided consent for the transfer by Friday [2/10/23]. A PN on 2/9/23 at 1:11 pm, by RN #1 revealed .transferred to [F2] via wheelchair with [his/her] medication, belongings to follow, picked up [transport company] . The surveyor conducted a post survey interview with Resident #6 on 3/8/23 at 11:29 am at F2. Resident #6 confirmed that on 2/8/23, the RP was made aware he/she was moving to F2 on 2/10/23. Resident #6 stated that he/she was scared because there was no explanation was given. Resident #6 explained that on 2/9/22, he/she was surprised and rushed because [F1] decided to move the residents to [F2] and did not have the time to decide. Resident #6 stated I would refuse to be moved if I was given the time, I didn't have time to pack, a lot of my personal belongings got lost. I picked [F1] because it is close to my family. I was upset, I was crying, never got a solid reason. 6. According to AR, Resident #8 was admitted to the facility on [DATE] and was discharged on [DATE]. Diagnoses included but were not limited to: Congested Heart Failure, Chronic Pain Syndrome, Bipolar, Schizoaffective Disorder, Tremor, and Seizure. The MDS admission assessment, dated 10/13/21, revealed a BIMS score of 15/15, which indicated intact cognition. The MDS further revealed that Resident #8 participated in section Q which indicated the resident expected to be discharged to the community, and active discharge plan was already occurring for the resident to return to the community. The MDS quarterly assessment, dated 12/22/22, revealed a BIMS score of 15/15. Resident #8 participated in section Q and active discharge plan was already occurring for the resident to return to the community. A CP, initiated on 10/7/21, indicated that the resident will be staying in the facility for LTC. There was no indication on the CP that the resident was to be discharged to F2. Review of Resident #6's AG dated 10/7/21 and signed on 10/8/21, revealed that the resident was acknowledging the involuntary discharge and voluntary discharge requirements. The OSR, dated 2/9/23, revealed a Physician order for Transfer to [F2]. A PN on 2/8/23 at 10:32 pm, by the SW, indicated SW spoke with LTC resident along with their family to discuss that [F1] is transitioning to sub acute facility and offered transition to [F2]. Both provided consent for the transfer by Friday [2/10/23]. A PN on 2/9/23 at 1:08 pm, by RN #1, indicated 12noon [12:00 pm] transferred to [F2] via wheelchair . The surveyor conducted a post survey interview with Resident #8 on 3/8/23 at 10:42 am at F2. According to Resident #8, I was not aware that they are moving me to [F2[, they told me about few days before the move. I told them I didn't want to move but they said I have to. One week before the move, they said I'm going to [F2] but didn't say the reason and when. So, on Thursday (2/9/23), the nurse said go to your wheelchair, time to go. I said, what do you mean? I don't want to go, she [nurse] said, go, don't cry. I felt hurt, they didn't let me make the decision, they just moved me here [F2], they violated my rights. At 10:50 am, the surveyor interviewed the RP. The RP stated that he/she was not aware that Resident #8 was going to be moved to F2. The surveyor conducted an interview with the LNHA and QARN on 3/2/23 and 3/7/23. The LNHA and QARN confirmed Residents #1, #2, #3, #4, #5, #6, #7, and #8 were transferred to F2 on 2/9/22. The LNHA stated they transferred residents to F2 because they needed sub acute beds for upcoming short-term admissions. The LNHA further stated that the first floor was closed due to staffing issue. The LNHA explained residents had options to stay in the facility when offered to move them to F2 and their choices were honored. The LNHA and QARN stated that the transfer was a voluntary discharge because the facility and the RPs had an agreement prior to the resident's admission to F1. The RPs were made aware that F1 had only short-term care bed available and did not have LTC beds available prior to the resident's admission. The LNHA and QARN stated that the admission process starts when the residents arrived in the building, and discharge planning and CP will be initiated. The LNHA confirmed that the transfer to F2 on 2/9/23 was not communicated to the office of Long-Term Care Ombudsman because the discharges were not acute, and it was the plan prior to admission to the facility. During an interview with the surveyor on 3/7/23 at 10:16 am the QARN confirmed that Residents #1, #2, #3, #5, #6, and #8 did not met the criteria for the Involuntary Transfer or Discharge as indicated on AG. The surveyor conducted an interview with the Admission Director (AD) on 3/7/23 at 11:30 am, the AD stated that the resident/RPs and the facility agreement prior to admission had nothing to do with the admission agreement. The AD further stated that the content of the AG was discussed/explained to the residents/RPs prior of them signing, when the residents/RPs sign the AG meant that they were agreeing what was discussed and explained related to the content of the AG. The AD also stated the residents/RPs were entitled to change their mind and will be honored and will be documented in the MR. The surveyor conducted an interview with the Regional Admission Director (RAD) on 3/7/23 at 2:56 pm. The RAD stated that residents who were moved to F2 on 2/9/23 were all voluntary discharges because of the verbal agreement prior to admission. The RAD further stated that the RPs were notified in November 2022 that the moving will happen once the LTC bed is available at F2. The RAD was unable to provide documentation in the residents MR that the residents/RPs were notified of the upcoming transfer prior to 2/8/23. The facility was unable to provide documentation that residents and/or RPs were notified in writing, prior to discharge to F2, for the residents who were a voluntary discharge to the F2. In addition, the facility was unable to provide documentation in the residents MR indicating that a 30 day notice was provided to the residents who were involuntary transferred to F2. The SWs were not available for interview on 3/2/23, 3/6/23, and 3/7/23. Further review of Residents #1, #2, #3, #5, #6, and #8's MR, revealed that there was no documented evidence that residents were provided with the voluntary discharge and/or involuntary discharge requirements which was not according to the AG's. NJAC 8:39- 4.1(a)31(iii)(32) NJAC 8:39- 5.1(b)(e)

Based on observation, interview, and record review it was determined that the facility failed to provide effective pain management for 1 of 9 residents, Resident #7, reviewed for pain. The deficient practice was evidenced by the following: On 6/16/15 at 9:25 a.m., the surveyor observed Resident #7 seated at the bedside receiving intravenous antibiotics. The Registered Nurse Unit Manager (RNUM) told the surveyor the resident was interviewable with no memory impairment, blind, had fallen in the facility, had an infection in the spine, and used an indwelling urinary catheter. On 6/16/15 at 12:15 p.m. the surveyor observed the resident in the dayroom for the lunchtime meal. The resident was seated in a wheelchair, moaning loudly, and calling out. A staff person removed the resident to the bedroom area for lunch. The surveyor reviewed the electronic and paper medical records on 6/16/15 at 12:30 p.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A pain care plan was initiated on 5/23/15, the day of admission, for acute pain related to Discitis and Nephrolithiasis. The June, 2015, physician's orders [REDACTED]., 1 tab by mouth every 12 hours routinely for pain management (initiated 5/26/15); and [MEDICATION NAME] 2 tabs (10-650 mg.) by mouth every 4 hours as needed for severe pain (initiated 5/23/15). The resident also had an order for [REDACTED]. The 5/30/15 Initial Minimum Data Assessment indicated the resident had experienced occasional severe pain during the past 5 days. However, following a second fall during a 6/6/15 transfer, the resident told the Physical Therapist the pain had worsened (6/6/15 Physical Therapy Treatment Encounter). The 6/10/15 Pain Assessment by nursing indicated the resident had frequently complained of pain at a severity of 8 on the 1 to 10 pain scale, where 1 is the least pain and 10 is the worst pain. The 5/30/15 Assessment documented that the facility assessed Resident #7 as having a a cognitive score of 15 indicating the resident was alert and oriented. According to the May and June, 2015, Medication Administration Records, the resident received 22 doses of [MEDICATION NAME] between 5/23/15 and 5/31/15 and 34 doses of [MEDICATION NAME] between 6/1/15 and 6/21/15 for complaints of severe pain in addition to the routine administration of [MEDICATION NAME] every 12 hours. [MEDICATION NAME] for muscle spasms was administered 4 times in June and not administered in May. Nurses documented in daily electronic progress notes that the resident routinely rated pain at a 9 or 10 on the pain scale, representing the most severe pain. The location of pain was described as back and leg pain by the resident as noted by nurses in daily electronic progress notes. The nurse documented on 6/4/2015 and 6/21/15 in electronic progress notes that the resident verbalized the pain medication was not effective in relieving the pain. The night nurse documented in a 6/22/15 (6:56 a.m.) Progress Note-Pain Note that she gave the resident [MEDICATION NAME] at the end of the night shift on 6/22/15 for pain at the level of 8 on the 1 to 10 scale and instructed the day shift nurse to continue to monitor the resident for pain. On 6/22/15 at 10:10 a.m. the surveyor observed the resident seated in a wheelchair in the dayroom. The resident moaned loudly and stated Oh God, Oh God. The Recreation staff person asked the resident if he/she was having pain. The resident said, yes. The staff person immediately left to tell the nurse. The staff person returned to tell the resident he/she had already received pain medicine that morning. The resident replied I did? At 10:15 a.m. the nurse approached the resident and told the resident he/she had already received medicine for pain and needed to give it time to work. The resident repeated I did? The nurse did not assess the resident for the location, intensity, or duration of the pain. The nurse did not offer to provide non-pharmaceutical comfort measures to alleviate the resident's pain. The nurse did not assess for muscle spasms for which [MEDICATION NAME] could have been offered to the resident. At 10:20 a.m. the Rehabilitation transport person came for Resident #7. As they waited for the elevator, the resident moaned loudly several times and verbalized, My legs, Oh God! The staff person did not address the resident, the elevator arrived, and they got onto the elevator. At 10:25 p.m. the surveyor interviewed the nurse who gave the resident morning medications. The nurse stated the resident was given [MEDICATION NAME] at 9:00 a.m. The nurse did not state she had offered the resident [MEDICATION NAME]. She said she would call the Rehabilitation Department to let them know of the resident's pain. She returned to the surveyor and said Rehabilitation staff said the resident was all right. At 10:30 a.m. the surveyor entered the Rehabilitation gym and observed the Rehabilitation staff person telling the resident they were going to practice ambulation. As the surveyor approached the resident, the staff person handed the resident one hand weight and instructed the resident to do bicep curls. The surveyor returned to the gym at 11:15 a.m. and observed the resident continuing with upper body exercises. The resident appeared confused and unable to follow cueing, but did not appear in pain. In the 6/22/15 Physical Therapy Treatment Encounter Note, the Physical Therapist documented the resident continued to complain of significant back pain of 8 on the 1 to 10 pain scale. Ambulation training was not noted to have occurred during the 6/22/15 visit. On 6/22/15 at 1:15 p.m. the surveyor discussed with the Administrator the resident's frequent high scores on the pain scale, frequent use of [MEDICATION NAME] for breakthrough pain in addition to twice daily use of [MEDICATION NAME], and the observations of the resident demonstrating significant pain on 6/22/15 without a nursing pain assessment. The Administrator stated he would respond with further information the following day. On 6/23/15 at 8:50 a.m. the surveyor interviewed the RNUM after having observed that Resident #7 's name was taken off the bedroom door. The RNUM explained the resident was sent out of the facility on 6/22/15 at 2:30 p.m. to go to the spine surgeon's office because of worsening pain. The physician admitted the resident to the hospital directly from his office for diagnostic testing related to the resident's complaints of increased pain. The surveyor further reviewed the electronic medical record on 6/23/15 at 9:00 a.m. On 6/22/15 at 2:00 p.m. the Interdisciplinary Team (IDT) documented in an IDT Note that Nursing staff, Physician, Social Worker, and Rehabilitation met to discuss the resident's current pain management and resident's refusal of prn pain meds at times. On 6/22/15 at 2:50 p.m. the day shift medication nurse documented pain scale in am noted 8/10, relief noted, despite the 6/22/15 note by the Physical Therapist that the resident continued to complain of significant back pain of 8/10. On 6/22/15 at 3:00 p.m. the day shift medication nurse documented that on 6/22/15 at 10:15 a.m. resident observed with s/sx of pain whilst in common area. Offered pain interventions, resident refused [MEDICATION NAME] 5/325 mg. PRN. This statement conflicted with the observation made by the surveyor. On 6/23/15 at 1:35 p.m. the Administrator spoke with the survey team and stated the Physiatrist had offered the resident alternate pain medications in the past and the resident had refused. Surveyor review of 13 Physical Medicine & Rehabilitation evaluations written by the Physiatrist and filed on the medical record, showed that the physician documented the presence of pain in all 13 of the reports and in 2 of the 13 reports discussed alternative medications. The Administrator stated an Interdisciplinary Team meeting was held on 6/22/15 at 2:00 p.m. to review the resident's pain management program. The resident was sent out to the spinal surgeon's office on 6/22/15 at 3:00 p.m. The surgeon admitted the resident to the hospital for further diagnostic testing for worsening pain. The Administrator provided a clarification to previous note written by the medication nurse on 6/23/15 at 3:22 p.m. regarding the progress note of 6/22/15 at 3:00 p.m. The clarification noted that the nurse did not offer pain interventions to the resident and the resident did not refuse administration of [MEDICATION NAME] as previously documented in the 6/22/15 (3:00 p.m.) note. The surveyor reviewed the facility policy/procedure for Pain Management, revised 3/2014. Step 5 under the heading, Criteria for Assessment, instructed staff that when the resident experiences breakthrough pain, such as complaining of pain 4 hours after receiving a pain medication ordered for every 6 hours, resident may need adjunct therapy or adjustment in non-pharmacological intervention. NJAC 8:39-27.1(a)