Every finding on record at Alaris Health at The Chateau

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the kitchen exhaust hood assembly in a safe operating condition by ensuring hood panels were properly fitted without gaps. This deficient practice had the potential to affect all residents residing in the facility due to the increased risk of grease accumulation and fire associated with gaps in the kitchen exhaust hood system and was evidenced by the following: On 5/28/26 at 9:40 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). During the kitchen tour, the surveyor observed the kitchen exhaust hood system located above the stove and oven, approximately two one-inch gaps, one on each side of the hood panels. The gaps were visible between adjoining hood panel sections.At that time, the surveyor interviewed the FSD regarding the observation. The FSD acknowledged the presence of the gaps and acknowledged the surveyor's concern that the openings could present a fire hazard.On 5/29/26 at 8:45 AM, the surveyor conducted a follow-up observation of the kitchen with the FSD and Regional Food Service Director (RFSD). The surveyor observed that the two approximately one-inch gaps in the hood panels remained present. During interview, both the FSD and RFSD acknowledged the gaps remained in the hood assembly, and stated they would contact maintenance personnel or the hood cleaning contractor to evaluate and correct the condition.A review of the facility's Kitchen Hood Cleaning Policy, dated 6/2/26, included that professional cleaning of the kitchen hood, internal ducts, fans, and racks shall be performed by a licensed, certified third-party contractor. The policy further included that management shall maintain inspection reports, service invoices, and supporting documentation related to the exhaust hood system.A review of the facility's Kitchen Equipment Cleaning and Sanitation Policy, reviewed 1/2026, included that kitchen equipment shall be properly cleaned and maintained to ensure safe operation and to prevent hazards within the food service department.On 6/2/26 at 10:38 AM, the Licensed Nursing Home Administrator, in the presence of the survey team, FSD, and RFSD, acknowledged the presence of the two approximately one-inch gaps in the kitchen hood panels, and stated the condition would require repair or evaluation to ensure the hood system was maintained in a safe operating condition.NJAC 8:39-17.2(e)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat residents with respect and dignity during mealtime. This deficient practice was identified for 9 of 18 Unsampled Residents (UR #1, #2, #3, #4, #5, #6, #7, #8, and UR #9) and 2 of 3 dining areas (North 3rd and 4th floors) observed during dining observations.This deficient practice was evidenced by the following:1. On 5/29/26 at 8:11 AM, the surveyor observed North 3rd (third) floor dining area for breakfast, there were 11 residents seated at five tables, with four staff assisting residents. The surveyor observed Unsampled Resident #1 (UR #1) grabbed one used tray on the side and wanted to eat from the left over, was seen by the staff, and the staff removed the used tray away. The surveyor also observed UR #1 had asked food to eat and was told to wait while other residents were eating.On 5/29/26 at 8:21 AM, the surveyor asked Registered Nurse/Unit Manager #1 (RN/UM #1) who was at the dining area about UR #1's breakfast tray, and RN/UM #1 responded that they were still waiting for UR #1's tray. The surveyor observed all residents were eating except for UR #1.On 5/29/26 at 8:28 AM, the surveyor went back to North 3rd floor dining area and observed UR #1 wandering, and was looking for their food. The surveyor interviewed the Certified Nursing Aide (CNA) regarding UR #1's breakfast tray, and she responded that the tray of the resident was not here, and waiting for the next food truck.On that same date and time, RN/UM #1 confirmed who was in the dining area at that time that they were still waiting for UR #1's tray. The surveyor observed all residents were eating except for UR #1. On 5/29/26 at 8:30 AM, the surveyor observed the 2nd (second) and 3rd food truck came and UR #1 received their breakfast tray after 19 minutes. On 5/29/26 at 8:42 AM, the surveyor interviewed RN/UM #1 regarding Resident #40's breakfast tray was late, and the RN/UM stated that the resident should not have waited that long. RN/UM #1 also acknowledged that all residents should receive their meals at the same time. She further stated but the concern was that the resident should be getting their tray in the 2nd truck, and that they only have one elevator that caused the delay.On 6/2/26 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Administrator (AA), and Regional Nurse, and the surveyor notified them of the above concerns with North 3rd floor dining area that UR #1 did not have breakfast tray while other 10 residents were eating, some done eating, and UR #1 receive their tray after 19 minutes.On 6/3/26 at 11:03 AM, the survey team met with the LNHA, AA, and DON stated that for UR #1's tray, the Unit Manager sent communication to the dietary to ensure the tray be on the 1st truck.2. On 6/3/26 at 8:06 AM, the surveyor observed North 4th (fourth) floor food truck was in front of the nursing station and between the dining area that was not being distributed. There were employees in the nursing station including the Assistant Director of Nursing (ADON) and RN/UM #2. In the dining area, there were six residents who were seated in front of the tables and the 7th (seventh) resident, UR #2 was eating their breakfast, and the other six residents did not have breakfast in front of them. UR #3, UR #4, UR #5, UR #6, UR #7, and UR #8 were the residents who did not received their breakfast trays. The (LNHA) observed the surveyor checked UR #2's diet slip for resident's name.On 6/3/26 at 8:09 AM, the surveyor observed the food truck was picked up by the staff and distributed the trays to the residents in their room, while the dining area with residents still waiting for their tray.On 6/3/26 at 8:11 AM, the surveyor observed the 2nd food truck came in and staff distributed it to the residents in their room, and not with the residents in the dining area. UR #2 was the resident with breakfast tray, and the rest of the residents in North 4th floor dining area had no trays.On 6/3/26 at 8:14 AM, RN/UM #2 confirmed the names of seven residents who had not received their breakfast while UR #2 was eating in the dining area in North 4th floor.On 6/3/26 at 8:17 AM, the surveyor observed four employees came to North 4th floor dining area and served breakfast trays to the rest of the residents. The last tray was distributed to the resident at 8:25 AM in North 4th floor dining area, that was a total of 19 minutes when all were able to serve breakfast. A review of the facility's Resident Rights Policy that was provided by the LNHA, with a reviewed date of 1/2026, revealed under policy, the facility is committed to assuring the rights and protection of its residents as stipulated under federal and state laws.Resident's rights include but are not limited to the following.treated with respect, dignity, and self-determination with care.A review of the facility's Dining Policy that was provided by the LNHA, with a reviewed date of 1/2026, revealed under policy that the facility to provide the resident a pleasant dining experience with the level of assistance needed. Procedure.3. Meals will be served three times per day according to scheduled meal times.The above policies did not include information about residents who will be served at the same time.On 6/4/26 at 11:01 AM, the survey team met with the AA, the DON, and the LNHA did not provide additional information. N.J.A.C. 8:39-4.1(a)(12), 27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 4 of 4 dining areas (North 1st floor, North 3rd floor, North 4th floor, and South 1st floor), 2 of 2 shower rooms (North 3rd and 4th floors), 3 of 35 residents' rooms (Rooms #123, #257, and #360), and was evidenced by the following: 1. During the dining observation on 5/29/26 at 8:15 AM, of Surveyor #1 (S #1) in North 3rd (third) floor, in the presence of the Assistant Administrator (AA), both S #1 and the AA observed six ceiling tiles with gaps, the ceiling tiles near the ceiling fan was being used at that time with accumulation of grayish substances. Both S #1 and the AA also observed floor molding was blackish, red substances on the floor under the table, and there was a positioning device on the floor near the air conditioned (AC) system by the window. On 5/29/26 at 8:55 AM, S #1 observed the 1st (first) floor of the North main dining area in the presence of the Food Service Director (FSD) the wall paper peeled off, the area near the entrance with chipped wood, and the ceiling vent with heavy accumulation of blackish substances. S #1 asked the FSD about the concerns, and he replied that it was better to talk to the maintenance people. At that time, the Regional FSD (RFSD) joined the FSD, and both the FSD and the RFSD stated to get Director of Maintenance #1 (DM #1) about S #1's concerns in the dining area. At that same time, S #1 asked the FSD about the water dispenser in North main dining area with a date of 5/28, the surrounding bottom part with brownish accumulation, and the FSD replied that he was about to replace the water and did not respond as to what those brown substances were. On 5/29/26 at 9:00 AM, S #1 interviewed DM #1 in North 1st floor main dining area about S #1's concerns with environment, and he stated that he had ordered self-adhesive, and it was a challenge to put them on for those wall papers that peeled off. He also stated that the chipped wood should not be like that, the ceiling vent should have been cleaned, and he confirmed they were accumulation of dust. S #1 also showed the floor, and he also confirmed it should have been dust off. On 6/1/26 at 9:33 AM, S #1 observed South 1st floor main dining area wall near the kitchen entrance for employee with chipped wood, there were two trucks with piled plate covers, just above was a ceiling vent with accumulation of grayish substances. The trucks with plate covers were uncovered, there was another ceiling vent with light accumulation of grayish substances, and on another end which was near the patio exit two ceiling vents with heavy accumulation of grayish substances. S #1 asked the Registered Nurse (RN) about the above concerns with uncovered plate covers and with ceiling vent above with grayish substances, and she acknowledged they were accumulation of dust. The RN further stated that it was better for S #1 to talk to the DM about environmental concerns. She also stated that the room was being used for dining and activities of residents. On 6/1/26 at 9:37 AM, the Dietary Aide (DA) came out from the kitchen door and the surveyor asked the DA about the plate covers, and he stated that they were considered clean. The DA acknowledged that they were uncovered. S #1 asked about the ceiling vent just above the plate covers and he did not respond. On 6/1/26 at 9:39 AM, S #1 notified and showed DM #2 of the above concerns with South main dining room. On 6/3/26 at 8:06 AM, both S #1 and the Licensed Nursing Home Administrator (LNHA) observed North 4th floor dining area with flooring gaps, six ceiling tiles with gaps, two AC systems near the windows with accumulation of dust and dirt inside the metal grills. The LNHA confirmed the observation and stated that it should have been cleaned. 2. On 5/29/26 at 8:22 AM, S #1 and the AA observed North 3rd floor shower rooms ceiling vent with accumulation of blackish substances, the ceiling tiles with gaps, the 2nd shower cubicle with two shower chairs, and at the back of the shower chair was floor mats in a plastic bag. The surveyor asked the AA for the shower cubicle that was being used as a storage for floor mats, the AA replied he was unsure and would ask the nurse. On 6/3/26 at 8:27 AM, S #1 with RN/Unit Manager #1 (RN/UM #1) observed the North wing 4th (fourth) floor central bath (also known as the shower room), the middle section (Training Restroom) upon entry to the door with broken and missing tiles and the toilet area floor with uneven flooring. 3. On 5/29/26 at 8:33 AM, S #1 with Certified Nursing Aide #1 (CNA #1) entered room [ROOM NUMBER] (R#360), observed the ripped privacy curtain, sink below with peeled molding, the light above sink with peeled wall paper, and the resident who was inside the room stated that it had been like that for two months. Both S #1 and CNA #1 also observed the closet doors were uneven. Both also observed inside the toilet room of R#360, the vent with accumulation of blackish substances. On 5/29/26 at 8:42 AM, S #1 asked Registered Nurse/Unit Manager #2 (RN/UM #2) to accompany the surveyor inside R#360. Inside the room, RN/UM #1 confirmed S #1's observation of ripped privacy curtain which she said should not be like that. She also stated that she would ask for maintenance to fix the closet doors, and that the vent should have been cleaned. On 6/1/26 at 6:30 AM, both S #1 and the RN Supervisor (RNS) went to room [ROOM NUMBER] (R#257), observed the bed by the window with no mattress, with clothes that were unfolded on top of the empty bed. The unsampled resident inside R#257 informed S #1 and the RNS those clothes were their clothes. On 6/2/26 at 12:41 PM, the survey team met with the LNHA, Director of Nursing (DON), AA, and Regional Nurse, and S #1 notified them of the above findings and concerns. On 6/3/26 at 1:10 PM, S #1 asked the DON for Resident Rights policy. On 6/3/26 at 11:03 AM, the survey team met with the AA, DON, and the LNHA stated with regard to environmental concerns that S #1 pointed out with dust and gaps, I went with maintenance and took care of the concerns that included the chipped wood, wall papers both dining rooms, privacy curtain fixed right away, vent pulled down and cleaned thoroughly. A review of the facility's Facility Environment Policy that was provided by the LNHA, with a revised/reviewed date of 1/2026, revealed under policy, it is the policy of this facility to provide a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Procedure 2. Housekeeping and maintenance shall maintain a sanitary, orderly and comfortable environment. 3. This facility shall ensure clean bed and bath linens are in good condition, private closet space in each resident room, adequate and comfortable lighting in all areas, comfortable and safe temperature levels and maintenance of comfortable sound levels. On 6/4/26 at 11:01 AM, the survey team met with the AA, the DON, and the LNHA did not provide additional information. 4. On 5/28/26 at 11:33 AM, Surveyor #2 (S#2) observed Resident #123 lying in bed without a call device within reach of the resident. The call device cord had been removed from the wall jack. On 5/29/26 at 11:04 AM, S#2 conducted a second observation of Resident #123 and observed again that Resident #123 was lying in bed without a call device within reach of the resident. The call device was not present still. On 5/29/26 at 11:07 AM, S#2 interviewed Certified Nursing Assistant #2 (CNA #2) who stated that the call bell was broken. CNA #2 further stated that the expectation was to make sure the call bell was within reach of the resident. CNA #2 acknowledged that they did not check the resident's call bell today and should have checked the resident's call bell was within reach of the resident. On 5/29/26 at 11:19 AM, S#2 interviewed the Licensed Practical Nurse (LPN), who acknowledged the call device was not present and searched for it underneath Resident #123's bed. The LPN further stated that the resident should have had a call device that was within reach of the resident. At that time, RN/UM #3 obtained a call device, attached it to the wall jack, and clipped it to the bed within reach of the resident. A review of the admission Record or face sheet (an admission summary) revealed that Resident #123 was admitted to the facility with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (a condition in which the lungs cannot deliver enough oxygen (02) to the blood, leading to low O2 levels in the body) and history of falling. A review of the care plan report, initiated 4/28/26, revealed that Resident #123 is at risk for falls. Interventions included, but were not limited to, Be sure call light is within reach and encourage to use it for assistance as needed. Provide prompt response to all requests for assistance. On 6/3/26 at 11:04 AM, S #2, in the presence of the survey team, discussed the concern with the LNHA, DON, and AA. On 6/4/26 at 10:28 AM, the survey team met with the DON, AA, and the LNHA stated they knew what needs to be corrected, in-serviced, and audited. A review of the facility's Call Bell Response Policy, reviewed 1/2026, revealed, it is the policy of the facility to ensure that all residents have timely access to staff assistance through a functioning call bell system in order to promote resident safety, dignity, comfort, and quality of care .Call bells shall be placed within residents' reach. NJAC 8:39-31.2(e); 31.4(a)(c)(f); 31.8(c)9

Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to include in the written notification of emergency transfer and bed hold that was provided to the Resident or Resident Representative, the facility's bed hold reserve payment for 3 of 3 residents, (Residents #7, #16 and #18), reviewed for hospitalizations. This deficient practice was evidenced by the following: 1. On 5/29/26 at 9:31 AM, Surveyor #1 (S#1) observed Resident #7 asleep in bed. A review of Resident #7's admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to heart failure (heart's muscle cannot pump blood efficiently enough to meet the body's needs) and tracheostomy with dependence on respirator (surgically created opening in the windpipe (trachea) connected to a mechanical ventilator). A review of Resident #7's most recent Discharge Return Anticipated Minimum Data Set (DRAMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 3/11/26, reflected that the resident's cognitive skills for daily decision making was severely impaired. Further review reflected that the resident was transferred to a short term general hospital. A review of Resident #7's hybrid (electronic and paper) medical record included a letter to the resident's representative (RR) dated 3/11/26 which included that the resident was discharged (d/c'd) to the hospital and the bed hold policy which had one of the options listed as the Resident's accommodations could be reserved for seven days, starting on the day of discharge (d/c), with payment of charges continuing at the regular daily rate. The letter did not include the bed hold reserve payment amount. 2. On 5/29/26 at 11:30 AM, S #1 reviewed Resident #16's closed hybrid medical record. A review of Resident #16's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to cerebrovascular disease (encompasses conditions that affect the blood vessels and blood supply to the brain) and hydronephrosis (the swelling of one or both kidneys that occurs when urine cannot drain properly and builds up, causing the kidney to stretch and enlarge). A review of Resident #16's most recent DRAMDS with an ARD of 5/18/26, reflected that the resident's cognitive skills for daily decision making was independent. Further review reflected that the resident was transferred to a short term general hospital. A review of Resident #16's hybrid medical record included a letter to the RR dated 5/19/26, which included that the resident was d/c'd to the hospital and the bed hold policy which had one of the options listed as the Resident's accommodations could be reserved for seven days, starting on the day of d/c, with payment of charges continuing at the regular daily rate. The letter did not include the bed hold reserve payment amount. On 6/3/26 at 11:46 AM, S #1 notified the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA) and Director of Nursing (DON) the concerns that Resident #7's and #16's bed hold notification did not have the reserve payment amount. 3. On 5/28/26 at 11:03 AM, Surveyor #2 (S#2) observed Resident #18 lying in bed with oxygen on. Resident #18 stated they came back from the hospital about two weeks ago due to pneumonia (an infection in one or both lungs). The resident further stated that they went back to the hospital at different times due to the BiPap (a non-invasive machine to help you breathe at night) not working and another time for left sided heart failure. S #2 asked the resident if they signed anything about a bed hold and if the facility informed them of any dollar amount for reserve payment, whenever they were transferred to the hospital. Resident #18 stated that they did not sign anything, and was not informed about any payment but stated they had a bed when they came back. A review of the AR of Resident #18, revealed diagnoses that included but not limited to; acute on chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow) with (acute) exacerbation, and moderate persistent asthma with status asthmaticus, pneumonia, unspecified organism. A review of the DRAMDS and Progress Notes revealed that Resident #18 had five acute transfers to the hospital. On 6/1/26 at 10:01 AM, S#2 interviewed the 4th floor Unit Manager (UM), regarding the process for bed hold during an emergency transfer. The UM stated she would call the hospital to follow up, if the resident was admitted she would do a bed hold, and the admission department would handle that. On 6/1/26 at 10:51 AM, S#2 interviewed the Director of Social Services (DSS) in the presence of the Regional of Social Services (RSS) regarding her role for emergency transfers. The DSS stated that Resident #18 had a difficult time accepting being in the facility. She further stated that she was responsible for filling out the emergency transfer forms, bed hold notifications, and added that they were in the process of transferring the responsibility to the admission department for the bed hold notifications. She further stated there was a form for bed holds to give to the RR or next of kin. She also stated that most of their residents were Medicaid, and always take them back. She added that if it was a private pay resident, the admission department handled the financial piece. On that same date and time, the DSS stated the bed hold notification for 5/4/26 d/c was done by the admission department. S #2 was provided with the bed hold notifications for the five emergency transfers which revealed the forms did not indicate the reserve payment. S #2 asked if they were familiar with the regulations for bed hold and reserve payment, and the DSS replied she did not know the specifics, and would need to review it. On 6/1/26 at 11:21 AM, S#2 interviewed the Director of Admissions (DA) regarding bed hold reserve payments. The DA stated that he was familiar with the bed hold regulation and stated it was the facility's responsibility to tell the resident of the reserve payment and rate would be. The DA further stated, I do not know how private pay works, and I am not familiar. On 6/3/26 at 11:25 AM, the survey team met with the LNHA, AA, and the DON, and S #2 notified them of the above findings and concerns with Resident #18. A review of the facility's Transfer/Discharge and Bed Hold Policy, with a review date of 4/19/26 revealed under policy, it is the policy of the facility to ensure that all transfer/discharges and Bed Holds are conducted in accordance with New Jersey Department of Health (NJDOH) regulations, resident rights, and federal requirements .Under procedure .Bed Hold Notification: In New Jersey, long term care (LTC) facilities follow specific guidelines regarding bed hold policies. These policies ensure that residents who temporarily leave the facility, for instance due to hospitalization, have their bed reserved for a certain period #1 Hospitalization or Therapeutic Leave: If a resident is transferred to a hospital the LTC must offer the resident (or their family) the option to reserve the bed. The facility policy did not include a written, dollar amount for the reserve payment for bed hold, regardless of payor source, on their bed hold transfer forms. On 6/4/26 at 10:27 AM, the survey team met with the LNHA, AA, and the DON for their responses to the notified concerns. They did not provide any response to the concern regarding bed hold reserve payment amount. The LNHA did not provide any additional information. NJAC 8:39-5.4(c)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to store medications and biologicals in accordance with facility policy by failing to ensure opened treatment items were labeled with the date opened for 5 of 5 treatment carts. The deficient practice was evidenced by:On 6/2/26 at 9:15 AM, the surveyor conducted a medication (med) storage inspection in the presence of the Assistant Director of Nursing (ADON). During inspection of treatment carts located in the North Building and South Building, the surveyor identified multiple opened treatment items that were not labeled with the date opened.On 6/2/26 at 9:20 AM, the surveyor observed the North Building 4th Floor Side A treatment cart contained three opened treatment items without an opening date, including:Hydrocortisone Cream 2.5% (an over the counter or prescription corticosteroid med)Iodine SolutionRetrogel Skin CreamOn 6/2/26 at 9:22 AM, the surveyor observed the North Building 4th Floor Side B treatment cart contained three opened tubes of Santyl (med used for debridement of dead tissue in wounds) that were not labeled with an opening date.On 6/2/26 at 9:35 AM, the surveyor observed the North Building 3rd Floor Side B treatment cart contained two opened treatment items without an opening date, including:PetrogelGoodSense GelOn 6/2/26 at 9:37 AM, the surveyor observed the North Building 3rd Floor Side A treatment cart contained two opened treatment items without an opening date, including:SantylL-Mesitran Honey (med used for wounds)On 6/2/26 at 9:50 AM, the surveyor observed the South Building 1st Floor treatment cart contained two opened treatment items without an opening date, including:Hy[DATE].25%Vashe Wound Solution (used for cleansing wounds)These observations were made in the presence of the ADON.On 6/2/26 at 10:05 AM, the surveyor interviewed the ADON who acknowledged the opened treatment items did not contain dates indicating when they were opened. The ADON stated that opened treatment items should be dated when opened so staff can determine the period of use and ensure proper med storage practices.On 6/2/26 at 10:28 AM, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that the treatment items identified by the surveyor did not contain opening dates and stated that opened treatment products should be dated when opened.A review of the facility's Storage of Medications Policy, reviewed 1/2026, included that drugs and biologicals shall be stored in a safe, secure, and orderly manner. The policy further included that drug containers with improper or incorrect labels shall be returned to the pharmacy for proper labeling before storage and that nursing staff shall be responsible for maintaining med storage and preparation areas in a clean, safe, and sanitary manner.NJAC 8:39-29.4(a)

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to: a.) follow appropriate hand hygiene practices for 1 of 3 staff (Registered Nurse Supervisor) during incontinence round and b.) replaced sharp containers for 4 of 4 residents (Residents #6, #7, #9, and #67), and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, it revealed . Key Times to Perform Hand Hygiene: Before having direct contact with residents. Before putting on gloves and immediately after removing gloves. Before performing invasive procedures or handling resident medication. After contact with blood, body fluids, or contaminated equipment. After moving from a contaminated body site to a clean body site on the same resident. After touching objects or environmental surfaces in the immediate resident vicinity. 1. On 6/1/26 at 6:26 AM, Surveyor #1 (S #1) and Registered Nurse Supervisor #1 (RNS #1) went inside room [ROOM NUMBER] (R222) for incontinence tour. S #1 observed RNS #1 donned (put) gloves without performing hand hygiene, checked the resident's adult incontinence brief. On 6/1/26 at 6:30 AM, both S #1 and RNS #1 went to the next room, room [ROOM NUMBER] (R257), the RNS did not perform hand hygiene prior to entering the resident's room, and prior to donning a new pair of gloves when she entered the resident's room. S #1 observed there was a PPE (personal protective equipment) sequencing and EBP (enhanced barrier precautions) posted signs, a PPE box outside the room, and an ABHR (alcohol base hand rub) on the wall. The RNS informed S #1 that the resident in R257 was incontinent. RNS #1 did not follow the posted sign for EBP to perform hand hygiene prior to entering the room and to put gown when providing direct care. S #1 observed RNS #1 checked the resident inside R257 for incontinence and performed hand washing after discarding used gloves. Outside R257, S #1 asked RNS #1 as to why she did not perform hand hygiene after doffing off used gloves in R222 and prior to entering R257 with posted sign for EBP with instructions to perform hand hygiene before entering the room and to put on gown when performing direct care. RNS #1 stated that because S #1 asked her to check resident's incontinence brief. S #1 asked RNS #1 if she should follow the posted instructions, and she did not reply. 2. On 5/28/26 at 10:53 AM, S #1 observed Resident #9 lying on their air mattress bed with indwelling catheter hung on the lower left side of the bed. Outside the door was posted sign for EBP and PPE sequencing, and a PPE box. Upon entry to the door there was a red covered bin and on top of the wall was a sharp container which was above full line. A review of Resident #9's May and June 2026 electronic Medication Administration Record (eMAR) revealed a physician order (PO) that included but were not limited to: Insulin Aspart Injection Solution, inject as per sliding scale: if 0 - 200 = 0; 201 - 250 = 2; 251 - 300 = 4; 301 - 350 = 6; 351 - 400 = 8; 401+ = 10 BS (blood sugar) > 400, administer 10 units and call MD (medical doctor), subcutaneously (SQ) one time a day for DM (diabetes mellitus)-Start Date 4/9/26. Lovenox Injection Solution Prefilled Syringe 40 mg (milligrams)/0.4 ml (milliliters), inject 0.4 ml SQ one time a day for prevention of blood clots-Start Date 3/12/26. 3. On 5/28/26 at 11:02 AM, S #1 observed Resident #67 was lying on air mattress bed, outside the door with posted signs for EBP, PPE sequencing, and a PPE box. Upon entering the door there was a red covered bin on top of the wall was a sharp container above full line. A review of Resident #67's May and June 2026 eMAR revealed a PO that included but was not limited to: Insulin Glargine Solution 100 unit/ml, inject 10 unit SQ at bedtime for diabetes-Start Date 3/11/26. HumaLOG Injection Solution 100 unit/ml, inject as per sliding scale: if 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12 then call MD, SQ two times a day for DM please hold TF (tube feeding) before checking BS for at least-Start Date 3/4/26. On 6/1/26 at 9:16 AM, S #1 interviewed the Registered Nurse (RN) regarding the resident's sharp container that was observed on 5/28/26, that was above full line. The RN stated that she was aware that it was above full line and she notified the assigned person to replace it, the Central Supply Staff since Monday (5/25/26) that the sharp containers in the unit in all rooms except for rooms [ROOM NUMBERS] needed to be replaced because they were full. She further stated that when the Central Supply Staff came back, he only had the body of the sharp container but no cover that was why it was not replaced not until the Surveyor #2 (S #2) came back on 5/29/26. On 6/2/26 at 10:45 AM, S #1 interviewed the Infection Preventionist Nurse (IPN) regarding infection control, and she stated that she was responsible for staff education and competency for hand hygiene, PPE use, and EBP. She further stated that it was expected for the staff to perform hand hygiene prior to entering the resident's room with posted sign of EBP, the minimum requirement were to wear a gown and gloves when doing high contact care that included incontinence care or checking the adult brief of the resident, and prior to exiting to doff (remove) PPE, and perform again hand hygiene. At that same time, the IPN informed S #1 that the Central Supply Staff was responsible for South Pavilion sharp containers for ordering and replacing them. She further stated that it was important to replace the sharp containers when they reach the full line level to prevent needlestick infection. S #1 notified the IPN of the above findings and concerns. On 6/2/26 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Administrator (AA), and Regional Nurse, and S #1 notified them of the above findings and concerns about the RNS's hand hygiene and use of PPE, and the concerns with Resident #9 and Resident #67's sharp containers. On 6/3/26 at 11:03 AM, the survey team met with the LNHA, AA, and the DON stated we have sharp containers available and we in service the staff that they have to replace the sharp container if they reached the dotted line. She further stated that staff was educated that if there was a question about sharp containers availability, they could reach out with the LNHA and DON to ensure it would be replaced as soon as possible. 4. On 5/28/26 10:55 AM, S #1 observed in Resident #6's room a sharps container that was filled above the full line. On 5/29/26 at 9:26 AM, S #2 observed in Resident #6's room a sharps container that was full. A review of Resident #6's admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to tracheostomy (surgically created opening in the windpipe (trachea)) and scleroderma (rare, chronic autoimmune and connective tissue disease characterized by the overproduction and buildup of collagen, which leads to hardened, tight skin and potential damage to internal organs). A review of Resident #6's most recent comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/26, reflected that the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #6's May 2026 eMAR reflected that the resident had two separate insulin injection orders that would require the needle to be disposed of in the sharps container. 5. On 5/28/26 at 10:59 AM, S #1 observed Resident #7's room with a sharps container that was filled above the full line. On 5/29/26 at 9:31 AM, S #2 observed in Resident #7's room a sharps container that was full. A review of Resident #7's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to heart failure (heart's muscle cannot pump blood efficiently enough to meet the body's needs) and tracheostomy with dependence on respirator (surgically created opening in the windpipe (trachea) connected to a mechanical ventilator). A review of Resident #7's most recent discharge return anticipated MDS with an ARD of 3/11/26, reflected that the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #7's May 2026 eMAR reflected that the resident had one insulin injection order that would require the needle to be disposed of in the sharps container. On 5/29/26 at 9:33 AM, S #2 interviewed the Licensed Practical Nurse (LPN) who stated that it was usually the nurse that changed the sharps containers, and that they should be changed before it was half full. S #2 asked about Resident #6's and #7's room sharps containers. The LPN stated that they definitely needed to be changed. She added that she had contacted someone to get the containers but that they did not have any in stock. On 5/29/26 at 9:51 AM, S #2 interviewed RNS #2 who stated that when the sharps in the container reached the preprinted full line that they had to be changed. She added that they were waiting for a shipment. On 6/3/26 at 11:46 AM, S #2 notified the LNHA, AA, and DON the concerns that Resident #6's and #7's room sharps containers were observed full on 5/28/26 and 5/29/26. On 6/4/26 at 10:27 AM, the survey team met with the LNHA, AA, and the DON for their responses to the notified concerns. They did not provide any response to the concern. The LNHA did not provide any additional information. A review of the facility's Biohazard Waste Storage Policy with a reviewed date of 4/19/26, included the following: Policy: The facility shall maintain all biohazardous waste, including sharps containers, in a safe, secure, sanitary, and compliant manner. Procedure:3. Sharps shall be disposed of immediately after use in approved sharps containers. Sharps containers shall be replaced when designated fill line. NJAC 8:39-19.4(a)(1)(6)

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services by ensuring the accurate administration of a medication, Midodrine, (medication used to increase the blood pressure), with a parameter according to the physician's order and professional standards of practice to meet the needs of the resident for 3 of 6 residents reviewed (Resident #4, #7 and #8). The deficient practice was evidenced by the following:1. On 6/2/26 at 9:39 AM, the surveyor observed Resident #4 sleeping in bed.A review of Resident #4's admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant) and tracheostomy with dependence on respirator (surgically created opening in the windpipe (trachea) connected to a mechanical ventilator).A review of Resident #4's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 3/27/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that Resident #4's cognition was mildly impaired. A review of Resident #4's May 2026 electronic Medication Administration Record (eMAR) included the following physician order (PO):Midodrine HCl (hydrochloride) Oral Tablet (tab) 10 mg (milligram) give 1 tab via PEG-Tube (Percutaneous Endoscopic Gastrostomy) is a medical feeding tube surgically placed through the abdomen directly into the stomach) every 8 hours as needed (prn) for hypotension - for systolic (the top (or first) number in a blood pressure reading) BP (blood pressure) less than 100 mmHg (millimeters of mercury) with a start date of 3/23/26. Further review revealed the following:The medication (med) was administered once in the month of May 2026 on 5/30/26, for a BP of 100/77. The resident's systolic BP was not less than 100 and should not have been administered.Further review of Resident #4's May 2026 eMAR included the following:An order to check vital signs every shift reflected that Resident #4's BP on the night shift on 5/5/26 was 96/68, and on 5/7/26 was 99/60. The systolic BP was less than 100, and there was no documented evidence that the PRN Midodrine order was administered. 2. On 5/29/26 at 9:31 AM, the surveyor observed Resident #7 asleep in bed.A review of Resident #7's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to heart failure (heart's muscle cannot pump blood efficiently enough to meet the body's needs) and tracheostomy with dependence on respirator (surgically created opening in the windpipe (trachea) connected to a mechanical ventilator).A review of Resident #7's most recent discharge return anticipated MDS with an ARD of 3/11/26, reflected that the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #7's May 2026 eMAR included the following PO:Midodrine HCl Oral Tab 5 mg give 3 tablets (tabs) via PEG-Tube three times a day for hypotension Total dose= 15 mg. Hold for systolic BP greater than 110 with a start date of 4/15/26.Further review of the eMAR reflected that the nurses either administered the med indicated by a check mark or did not administer the med indicated by a number code that described why it was not given. There were no BP's listed on the eMAR for the order. 3. On 5/29/26 at 9:44 AM, the surveyor observed Resident #8 awake in bed. The resident was not interviewable.A review of Resident #8's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death within minutes) and gastrostomy (a surgical procedure that creates a small opening directly into the stomach through the abdominal wall used to insert a specialized feeding tube).A review of Resident #8's most recent quarterly MDS with an ARD of 4/10/26, reflected that the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #8's May 2026 eMAR included the following PO:Midodrine HCl Oral Tab 10 mg give 1 tab via PEG-Tube every 6 hours for HYPOTENSION HOLD for systolic BP above 130 mmHg with a start date of 3/17/26.Further review reflected that the 12:00 AM dose had five days that the BP was not listed and marked with an X; the 6:00 AM dose had three days that the BP was not listed and marked with an X and one day the midodrine was administered for a BP of 138/66 (5/29/26) which was outside the parameter; and the 6:00 PM dose had one day that the BP was not listed and marked with an X.On 6/1/26 at 12:28 PM, the surveyor interviewed the Registered Nurse Supervisor (RNS) who stated that if a med order had a parameter for a BP then it should be checked. She added that if the BP was above the hold parameter then the nurse would have to hold the med (not administer it). The surveyor asked the RNS to view Resident #8's May 2026 eMAR midodrine order. The RNS stated that there should be a BP listed and not an X. She added that she was not sure what X meant. The RNS stated that the midodrine should not have been given on 5/29/26 when the BP was outside the parameter. On 6/2/26 at 11:29 AM, in the presence of the RNS, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that for midodrine order with parameters that the BP would be taken first and that the med could not be given if it was above the parameter. She added that if the med was not administered, then the nurse would put in a code to indicate that. The LPN stated that the nurse has to put in the BP. The surveyor asked how a Midodrine prn order was administered. The LPN stated that it depended on the order parameter and that it may be if systolic BP was less than 100 give midodrine. She added that there was an order for vital signs every shift and that may determine if the prn med was to be given.At that same time, the surveyor asked if a resident had a listed BP that was less than 100 would the expectation be to see a midodrine prn order for less than 100 administered. The LPN stated that she would expect to see it administered. The surveyor then asked the LPN and RNS to view Resident #4's May 2026 eMAR midodrine prn order. The RNS stated that the midodrine should not have been given on 5/30/26 for the [systolic] BP that was 100, The RNS stated that they check BP every shift and then confirmed that the Midodrine prn order should have been given for the BP that was below 100 on 5/5/26 and 5/7/26. The surveyor then asked the LPN and RNS to view Resident #7's May 2026 eMAR midodrine order. The RNS confirmed that the eMAR did not have a section to document the BP for the midodrine order and she was going to add it in the computer. She added that the person who put in the order did not set up the order in the computer correctly.On 6/3/26 at 11:47 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and Director of Nursing (DON) the concerns that Resident #4 received Midodrine outside of the ordered parameter on 5/30/26, and that the resident did not receive Midodrine for a BP within the ordered parameter on 5/5/26 and 5/7/26; Resident #7 had an order for Midodrine with a hold parameter but that there were no BP's listed on the eMAR when the med was given; and Resident #8 Midodrine order with a hold parament did not have BP (had an X) listed on the eMAR when held and received Midodrine outside the ordered parameter on 5/29/26. On 6/4/26 at 10:31 AM, in the presence of the LNHA and AA, the DON stated that the staff were educated regarding midodrine orders. The LNHA did not provide any additional information.A review of the facility's Medication Administration with Specific Instructions Policy with a reviewed date of 1/2026, included the following:Policy: It is the policy of this facility to ensure that meds are administered according to all specific instructions provided in the PO, med administration record, pharmacy recommendations and manufacturer guidelines. Procedure:Prior to administration, the nurse shall review the med order for any special instructions.Meds shall be administered according to ordered requirements, including:.BP, pulse, or blood glucose.Required assessments shall be completed and documented prior to administration when indicated.Administration and any required monitoring shall be documented on the MAR and in the medical record as appropriate.Questions regarding med administration instructions shall be clarified with the practitioner or consultant pharmacist prior to administration.N.J.A.C. 8:39 11.2 (b); 29.2(a,d)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for 1 of 38 residents, (Resident #17), reviewed for Minimum Data Set (MDS).This deficient practice was evidenced by the following:According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2025, reflected, a SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. Criteria for SCSA include two areas of decline or improvement, or IDT (Interdisciplinary team) recommendation. Documentation of criteria met is essential in the resident's medical record.On 5/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #17 in activity room with other residents. The Licensed Practical Nurse (LPN) stated that for the past six months, the resident had fall incident in their room, the roommate stated that Resident #17 wanted to use the bathroom, fell, and complained of pain. The LPN further stated that the x-ray showed hip displacement, and no other falls after that. Surveyor #2 (S #2) reviewed the medical records of Resident #17, and revealed:A review of the admission Record or face sheet (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified fracture of left pubis, subsequent encounter for fracture with routine healing, fracture of superior rim of left pubis, initial encounter for closed fracture, difficulty walking, not elsewhere classified, other specified anxiety disorders, and unspecified dementia mild with anxiety.A review of the comprehensive MDS (cMDS) with an assessment reference date (ARD) of 7/16/25, and quarterly MDS (qMDS) with an ARD of 10/15/25, revealed in Section C-Cognitive Patterns, a brief interview for mental status (BIMS) score of 4 of 15, which reflected severely impaired cognition. Section GG-Functional Abilities and Goals (it measures a resident's independence and functional status in performing basic daily tasks, specifically tracking their baseline (usual performance) upon admission, their progress during a stay, and their discharge goals) was coded for their four late loss (are four critical self-care and mobility functions used to evaluate a nursing home resident's functional independence over time and they are considered late-loss because residents typically lose the ability to perform these tasks last as physical dependence increases) adls (activities of daily living) as follows:Eating=was coded for set upToileting=was coded for partial assistanceChair to bed transfer=was coded independentWalking=was coded independentThe above cMDS and qMDS were also coded for no wheelchair (w/c), no impairment both upper and lower extremities, and no adaptive device in use.A review of the qMDS with an ARD of 1/14/26, revealed that the resident had BIMS score of 3 of 15, which reflected severe cognitive impairment. Section GG revealed that the resident had no impairment, no w/c and adaptive devices in use, was coded set up for eating, partial assistance with toileting, and independent for both chair to bed transfer and walking.A review of the qMDS with an ARD of 4/13/26, revealed that the resident had BIMS score of 3 of 15. Section GG revealed that the resident had impairment to one side of lower extremity, w/c in use, coded partial assistance for eating, dependent with toileting and chair to bed transfer, and walking not attempted.Further review of the MDS revealed that Resident #17 had declined in four late loss adls.A review of the medical records revealed there was no documentation that the team met and discussed the above decline in four late loss adls and as to why a SCSA should or should not be made.On 5/29/26 at 10:36 AM, S #2 interviewed the Registered Nurse/MDS Coordinator (RN/MDSC), and the RN/MDSC stated that if the decline was identified and will not return to baseline, a SCSA would be done. The RN/MDSC further stated that would be considered a decline or temporary decline depends on type of fracture, most of the time with fracture, the resident who came back from the hospital and rehab examined, did their eval (evaluation), and team decided that the resident was ambulatory before, would not return to previous adls, we usually give it 14 days somewhat to wait and see if there was an improvement. She also stated that the interdisciplinary team (IDT) meet to discuss the decline or improvement and then documented the decision to proceed or not with SCSA and document it in the progress notes.On that same date and time, S #2 asked the RN/MDSC if the qMDS with an ARD 4/13/26, be a SCSA since the resident had a fracture and the four late loss adls were all coded that showed a decline. The RN/MDSC responded, I say it should have been a SCSA for Quarterly 4/13/26. S #2 asked the RN/MDSC for any documentation that the IDT decided not to do a SCSA, and she stated that she would get back to S #2.On 5/29/26 at 11:40 AM, the RN/MDSC informed S #2 that the 4/13/26 qMDS should have been a SCSA but we cannot back date, and that they would open an MDS for SCSA. She also stated that she notified the IDT about the SCSA. She further stated that there was no documentation that the IDT decided not to initiate a SCSA for ARD 4/13/26. S #2 asked for facility's policy about MDS with regard to SCSA, and she stated that she would get back to S #2. On 5/29/26 at 11:47 AM, the RN/MDSC informed S #2 that the facility had no policy about MDS with regard to SCSA, and they followed the RAI manual.On 6/2/26 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Administrator (AA), and Regional Nurse, and S #2 notified them of the above findings and concerns about Resident #17's MDS. On 6/3/26 at 11:03 AM, the survey team met with the AA, DON, and the LNHA stated that the SCSA was not done for Resident #17, and in service was provided to the RN/MDSC by Regional MDS.NJAC 8:39-11.2(i)

Based on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure a.) the resident's current active care plan contained the interventions that were implemented after each resident's fall, in order to prevent any additional falls, b.) fall investigations interventions were appropriate, and c.) fall investigations were thoroughly completed in accordance with standards of practice and facility's policies and procedures for 1 of 2 residents (Resident #17) reviewed for falls.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.On 5/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #17 in activity room with other residents. Licensed Practical Nurse #1 (LPN #1) stated that for the past six months, the resident had fall incident in their room, the roommate stated that Resident #17 wanted to use the bathroom, fell, and complained of pain. LPN #1 further stated that the x-ray showed hip displacement, and no other falls after that. On 5/29/26 at 8:33 AM, Surveyor #2 (S #2) with Certified Nursing Aide #1 (CNA #1) entered Resident #17's room and both observed the resident was lying on the bed. There were no floor mats.On 5/29/26 at 8:42 AM, S #2 was accompanied by the Registered Nurse/Unit Manager (RN/UM) inside Resident #17's room, and there were no floor mats. Surveyor #2 (S #2) reviewed the medical records of Resident #17 and revealed:A review of the admission Record or face sheet (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified fracture of left pubis, subsequent encounter for fracture with routine healing, fracture of superior rim of left pubis, initial encounter for closed fracture, difficulty walking, not elsewhere classified, other specified anxiety disorders, and unspecified dementia mild with anxiety.A review of the fall investigations provided by the Director of Nursing (DON) for Resident #17 for the last eight months revealed:On 9/8/25, a fall incident was reported by LPN #1, reflected that the unwitnessed fall happened in resident's room, at approximately 11:55 AM, assessment was done and revealed no injuries.Statements: no statements found.On 9/9/25, the IDT (interdisciplinary team) met and discussed the fall with interventions that included but were not limited to floor mats. On 11/10/25, a fall incident was reported by LPN #1, reflected that the unwitnessed fall happened in resident's room, at approximately 1:00 PM, assessment was done and revealed no injuries.Statements: no statements found.On 11/11/25, the IDT met and discussed the fall with interventions that included but were not limited Social Worker stated she would be getting new shoes, Rehab will screen, and medications will be reviewed.On 1/23/26, a fall incident was reported by Registered Nurse #1 (RN #1), reflected that the unwitnessed fall happened in resident's bathroom area, at 5:35 AM, assessment was done and noted with 3 cm (centimeter) x (by) 3 cm elevation with no bleeding, and the resident claimed they hit their head.Statements: RN #1.On 1/24/26, the IDT met and discussed the fall with interventions that included but were not limited to educated and encouraged Resident #17 to use the call bell for assistance, and rehab screen.On 1/24/26, a fall incident was reported by RN #2, reflected that the unwitnessed fall happened in resident's room, at 5:30 PM, assessment was done and revealed no injuries.Statements: CNA #2 and RN #2.On 1/25/26, the IDT met and discussed the fall with interventions that included but were not limited to reminded to use the call bell for assistance and rehab screen.On 3/22/26, a fall incident was reported by LPN #2, reflected that the fall happened in resident's room, at 7:30 PM, assessment was done and noted with laceration to the right forearm, right side localized swelling, and complained of pain.Immediate Action taken: assessment, pain medication (med) Tylenol was administered, neuro (neurological) checks were initiated, and physician and resident's representative (RR) were notified.Statements: LPN #2.There was no IDT meeting.On 4/1/26, a fall incident was reported by LPN #1, reflected that the fall happened in resident's room, at approximately 8:00 AM, assessment was done and the resident complained of right hip pain and right hip bruising.Immediate Action taken: assessment, pain med Tylenol was administered, Nurse Practitioner was notified and ordered stat (means immediately or without delay) xray of bilateral hips, and RR was notified.Statements: No statements found.There was no IDT meeting.A review of the comprehensive MDS (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/16/25, and quarterly MDS (qMDS) with an ARD of 10/15/25, revealed in Section C-Cognitive Patterns a brief interview for mental status (BIMS) score of 4 of 15, which reflected severely impaired cognition. Section J-Health Conditions were coded with no falls.A review of the discharge return anticipated (DRA) MDS with an ARD of 4/1/26, revealed in Section J that the resident had one fall with no injury and a fall with injury except major.A review of the qMDS with an ARD of 4/13/26, revealed that the resident had BIMS score of 3 of 15. Section J was coded with one fall with major injury.A review of the personalized care plan (CP) revealed there was no documentation about fall intervention on IDT meeting 9/9/25 for floor mats.A review of the physician orders revealed there was no order for floor mats.Further review of the medical records of Resident #17, revealed no documentation as to why the intervention for floor mats were not followed.On 6/1/26 at 10:14 AM, S #2 interviewed the RN/UM in 3rd (third) floor nursing station regarding the resident's floor mats. The RN/UM confirmed there were no floor mats for two days of observations, and the order for floor mats were probably dropped when the resident went to the hospital, because it was previously ordered in September 2025, when the resident had a fall incident. She further stated that there should be an order for the floor mats.At that same time, S #2 notified the RN/UM of the concern that the floor mats were not in the CP until surveyor's inquiry. The RN/UM acknowledged that it should have been in the CP.On 6/2/26 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Assistant Administrator (AA), and Regional Nurse, and S #2 notified them of the above findings and concerns about Resident #17's fall incidents that not all fall investigations had statements for unwitnessed falls, fall interventions were not in the CP, fall interventions for education and encouraged to use call bell for a resident with BIMS score of 3 and 4 (severely impaired), and not all fall investigations had an IDT meeting.A review of the facility's Accident/Incident Report Policy that was provided by the LNHA, with a reviewed date of 1/2026, revealed under policy, the facility has a system whereby all resident incidents/accidents are reported to the department supervisor and implementation of timely interventions to establish a reduction of repeated incidents/accidents. Procedure .2. Obtain witness statements using the designated facility statement form. For injuries of unknown origin-obtain statements from employees 72 hours prior to the incident. 3. Attach witness statements to the incident report to be kept on file in the DON office. 4. Review entire file for completion and discuss with IDCP team members for appropriate interventions. 5. Carry out physician orders and ensure appropriate interventions are in place. Update CP with new interventions as appropriate. 6. All incident/accident reports are tracked and reviewed by the IDCP team for trends and appropriateness of current interventions .A review of the facility's Interdisciplinary Plan of Care Policy that was provided by the LNHA, with a reviewed date 1/2026, revealed under policy, this facility shall provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the residents' needs, strengths, and goals. Procedures .Care Planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable .On 6/3/26 at 11:03 AM, the survey team met with the LNHA, AA, and the DON stated we started to re-educate the staff about fall investigations, appropriateness of interventions because Resident #17 was unable to understand, with BIMS score of 4, to ensure the resident able to understand when putting intervention.N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to, a.) ensure that a resident with indwelling catheter was monitored routinely for urine output and documented and b.) ensure the collection container used to empty drainage bag were maintained clean and stored properly, in accordance with physician's order and facility's policy and procedure for 1 of 2 residents (Resident #48) reviewed for urinary catheter.This deficient practice was evidenced by the following:On 5/28/26 at 11:40 AM, Surveyor #1 (S #1) observed Resident #48's outside door with posted signs for EBP (enhanced barrier precautions), PPE (Personal Protective Equipment, refers to specialized gear and clothing worn by healthcare workers, patients, and visitors to create a physical barrier against germs, bodily fluids, and infectious diseases), ABHR (alcohol base hand rub). The resident was lying in an air mattress urinary catheter hung on left side of bed with privacy bag.Surveyor #2 (S #2) reviewed the medical records of Resident #48, and revealed:A review of the admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease unspecified, malignant neoplasm of bladder (commonly known as bladder cancer) unspecified, and difficulty in walking, not elsewhere classified.A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 4/9/26, revealed in Section C-Cognitive Patterns, a brief interview for mental status (BIMS) score of 15 out of 15, which reflected that the resident's cognition was intact. Section H-Bladder and Bowel revealed that the resident was coded for an indwelling catheter.A review of the personalized care plan (CP) revealed a focus that the resident with neoplasm of bladder that was initiated on 6/11/24, and revised on 1/16/26, that included interventions that was not limited to, monitor/record/report to MD (Medical Doctor) for s/sx (signs/symptoms): pain, burning, blood tinged urine, cloudiness, no output.that was initiated on 11/18/22.A review of the Order Summary Report with a physician order that included and not limited to: Measure and record suprapubic urine output every shift. Start date 9/1/25.The above order was transcribed to the May 2026 electronic Treatment Administration Record (eTAR) plotted for 6:30 AM, 2:30 PM, and 10:30 PM, and revealed:At 6:30 AM, for dates 5/7, 5/8, 5/16, and 5/19/26, the eTAR had missing nurses' initials and amount of urine, and did not follow the PO to measure and record suprapubic urine output.At 2:30 PM, for dates 5/2 and 5/3/26, the eTAR had missing nurses' initials and amount of urine, and did not follow the PO to measure and record suprapubic urine outputAt 10:30 PM, for dates 5/8 and 5/13/26, the eTAR had missing nurses' initials and amount of urine and did not follow the PO to measure and record suprapubic urine output.Further review of the resident's medical records revealed no documented evidence that the urine output were obtained for the above dates.On 5/29/26 at 8:33 AM, S #2 with the Certified Nursing Aide (CNA) observed Resident #48 lying on their bed with indwelling catheter hung on the left lower side of the bed inside a privacy bag.At that same time, both S #2 and the CNA went inside the resident's toilet room and observed two urinals hung on the metal handrail. Both S #2 and the CNA observed one urinal with yellowish output and the other urinal with blackish substances on the bottom of the urinal, and both urinals were not properly stored in a bag and with no label. On 5/29/26 at 8:42 AM, S #2 asked the Registered Nurse/Unit Manager (RN/UM) to accompany S #2 inside the resident's room. Inside Resident #48's toilet room, S #2 asked the RN/UM about the two urinals, and the RN/UM stated that should not be like that. The RN/UM also stated that the emptying of the urinary bag was the responsibility of the CNA, and the CNA would report the amount to the nurse, the nurse would document the amount in the eTAR, and there should be no blanks in the eTAR. On 5/29/26 at 10:06 AM, S #2 notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Assistant Administrator (AA) of the above concerns with regard to the blanks in the urine output documentation and the two urinals.A review of the facility's Catheter Care, Urinary Policy that was provided by the LNHA, with a reviewed date of 1/2026, revealed under policy, the facility to prevent catheter-associated urinary tract infections and to maintain the dignity and privacy of residents utilizing urinary catheters.Catheter Care:Maintain an accurate record of the resident's daily output.Empty the drainage bag regularly using a separate, clean collection container for each resident.Empty the collection bag at least every shift.On 6/3/26 at 11:03 AM, the survey team met with the LNHA, AA, and the DON stated that Resident #48's urinals were replaced, and education was provided. The DON further stated that when they empty it they have to clean it but if it looks dirty they have to replace it and not to recycle, because we have urinals.NJAC 8:39-19.4(a)5; 33.2(c)5

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a) ensure oxygen tubing was labeled and dated in accordance with physician orders and facility protocol for 1 of 8 residents (Resident #118) and b) provide ordered respiratory care consistent with professional standards of practice for 1 of 8 residents (Resident #206), reviewed for respiratory care. This deficient practice was evidenced by the following: Reference: National Institutes of Health defines oxygen (O2) as a colorless, odorless and tasteless gas. It will support life. It is noncombustible, but will actively support the burning of combustible materials. Some materials that will not burn in air will burn in O2. Materials that burn in air will burn more vigorously in O2. 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 5/28/26 at 8:40 AM, Surveyor #1 (S #1) observed Resident #118 lying in bed inside their room. S #1 observed an oxygen (O2) concentrator was observed at the bedside and set at 2 liters per minute (lpm). The O2 tubing connected to the concentrator was observed without a date label. The disposable humidifier water bottle was also observed without a visible date label. A non-rebreather mask was observed positioned over the resident's tracheostomy. On 5/29/26 at 9:05 AM, S #1 observed Resident #118 with an O2 tubing remained without a date label. The resident stated that they believed staff changed the tubing regularly. On 5/29/26 at 9:55 AM, S #1 reviewed the medical record for Resident #118. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; cerebral infarction (stroke), acute respiratory failure with hypoxia, tracheostomy status, dysphagia, chronic obstructive pulmonary disease, and atrial fibrillation. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/8/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. Further review of the MDS revealed the resident received tracheostomy care. A review of the resident's comprehensive care plan (CP) revealed a focus area that the resident had a tracheostomy to maintain an adequate airway and O2 delivery related to impaired breathing. Interventions included administering O2 via tracheostomy collar as ordered, providing humidified O2 as prescribed, and monitoring respiratory status. A review of physician orders (PO) included an order dated 6/1/24, for O2 Equipment - Change tubing every 7 days during the night shift every Saturday. On 5/29/26 at 10:05 AM, S #1 interviewed the Unit Manager (UM), who observed the O2 tubing with no date. The UM stated the tube should have the date on it. The UM further stated that O2 tubing and humidifier water were changed weekly and as needed (PRN) and that nursing staff document completion on the electronic Medication Administration Record (eMAR) or electronic Treatment Administration Record (eTAR). The UM also stated that O2 tubing changes were performed according to physician orders (PO) and facility protocol. A review of the facility's Respiratory Tubing Policy, reviewed 1/2026, included that staff should mark the bottle with the date and initials, change O2 cannula and tubing according to facility protocol, and ensure respiratory equipment is properly maintained and stored. On 6/4/26 10:00 AM, S #1 interviewed the Director of Nursing (DON) who acknowledged that O2 tubing was expected to be dated and labeled. The DON further stated that O2 tubing should be labeled and changed in accordance with the PO and facility protocol. 2. On 5/28/26 at 11:05 AM, Surveyor #2 (S #2) observed Resident #206 in bed, receiving O2 via a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which O2 flows). S #2 observed that the O2 flow meter was set at 4 lpm. On 5/29/26 at 10:55 AM, S #2 conducted a second observation of Resident #206 in bed, receiving O2 via NC. S #2 observed that the O2 flow meter was set at 4 lpm. At this time, S #2 interviewed the licensed practical nurse (LPN) who stated that the order for Resident #206 was O2 Inhalation via NC at 2 lpm every shift check every shift. The LPN, in the presence of S #2, observed the resident's O2 flow meter. The LPN stated that the O2 was currently set at 4 lpm and that it was supposed to be set at 2 lpm. The LPN then adjusted the setting to 2 lpm per the PO. The LPN stated that O2 should be administered as ordered by the physician, and the nurses were expected to check the setting every shift. A review of the AR revealed that Resident #206 was admitted to the facility with diagnoses that included, but were not limited to; cystic fibrosis, unspecified (a genetic disorder that causes thick, sticky mucus to build up in the body, leading to problems with breathing and digestion), bronchiectasis, uncomplicated (a chronic lung disease that causes the lung's airways to become damaged and widened), and acute respiratory failure with hypoxia (a condition in which the lungs cannot deliver enough O2 to the blood, leading to low O2 levels in the body). A review of the comprehensive MDS, with an ARD of 5/28/26, revealed that Resident #206 had a BIMS score of 15 out of 15, which indicated intact cognition. A review of the Order Summary Report for Resident #206 revealed a PO with a start date of 5/21/26, for O2 Inhalation (via nasal cannula at 2 lpm) every shift check every shift. A review of the May 2026 eMAR for Resident #206, revealed that the nurses recorded O2 use every shift on 5/28/26 as well as day shift on 5/29/26. A review of the CP report, initiated 5/28/26, revealed that Resident #206 has altered respiratory status/Difficulty Breathing related to Cystic fibrosis and bronchiectasis. Interventions included, but were not limited to, Provide O2 as ordered. On 6/3/26 at 11:04 AM, S #2, in the presence of the survey team, discussed the concern with the LNHA, DON, and AA. On 6/4/26 at 10:28 AM, the survey team met with the DON, AA, and the LNHA stated they knew what needs to be corrected, in-serviced, and audited. A review of the facility's Oxygen Administration policy, last reviewed 1/2026, revealed, verify that there is a PO for this procedure. Review the PO or facility protocol for O2 administration. NJ 8:39-25.2(c)3; 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) residents received timely and appropriate incontinence care for 1 of 4 residents (Resident #59) and b.) controlled medications accountability log was accurately endorsed and accounted for 1 of 3 nurses (Licensed Practical Nurse) observed during medication administration, to achieve highest practical wellbeing of residents. This deficient practice was evidenced by the following: 1. On 6/1/26 at 6:23 AM, Surveyor #1 (S #1) went to North 2nd (second) floor nursing unit and met with the Registered Nurse Supervisor (RNS) who was currently on her medication (med) cart, and informed S #1 that she was helping the nurse in the 2nd floor unit. She stated that there was one nurse in the unit and four CNAs, and she would get back to S #1 for the census (total number of residents) in the unit. On 6/1/26 at 6:26 AM, S #1 and the RNS went inside Resident #59's room for incontinence tour, and both observed the resident with double incontinence briefs and was wet. The resident informed both S #1 and the RNS that they did not request double incontinence briefs. Resident #59 further stated that the 11-7 shift Certified Nursing Aide (CNA) was the one who did it, and the resident asked the CNA as to why they had two, and the CNA responded that it was because the resident pee a lot. On that same date and time, outside the resident's room, the RNS stated that Resident #59 was cognitively intact and incontinent. She further stated that it was not their practice to use double incontinence briefs, and the RNS confirmed that the resident was wet. S #1 asked who the CNA was last night, and she responded that she would get back to S #1. A review of the care plan (CP) of Resident #59, revealed that the resident had bowel and bladder incontinence, and there was no documented intervention to provide double incontinence briefs. A review of the North 2nd floor 11-7 shift CNA assignment, that was provided by the Licensed Nursing Home Administrator (LNHA), dated 5/31/26, revealed a census of 45 with three CNAs. CNA #1 with 15 residents, CNA #2 with 16 residents that included Resident #59, and CNA #3 with 14 residents. A review of the 5/31/26 Daily Schedule Report Sunday Night shift that was provided by the LNHA revealed that there was one Registered Nurse (RN), RN #1, for 11:00 PM-7:00 AM, and three CNAs, CNA #1, CNA #2, and CNA #3 in 2 North. On 6/1/26 at 6:36 AM, S #1 went to the North 3rd floor unit and interviewed CNA #4, who stated that she was the aide from 11-7, and she had 15 residents in her assignment. On 6/2/26 at 12:41 PM, the survey team met with the LNHA, Director of Nursing (DON), Assistant Administrator (AA), and Regional Nurse, and S #1 notified them of the above findings and concerns about Resident #59's double incontinence briefs. On 6/3/26 at 11:03 AM, the survey team met with the AA, the DON, and the LNHA stated that the assigned CNA of Resident #59 who put double incontinence briefs to the resident was an agency CNA, CNA #4, who will not be working in the facility anymore. A review of the 5/31/26 Daily Schedule Report Sunday Night shift that was provided by the LNHA, revealed that there was one RN, RN #2, for 11:00 PM-7:00 AM, and there were four CNAs in 3 North that included CNA #4. A review of the 3rd floor (also known as the 3 North) 11-7 shift CNA assignment, that was provided by the LNHA, dated 5/31/26, with four CNAs, revealed a census of 55. CNA #4 with 15 residents, CNA #5 with 12 residents, CNA #6 with 15 residents, and CNA #7 with 17 residents. Further review of the above 5/31/26 daily schedule report Sunday night and 11-7 shift CNA assignment sheet did not match with census provided, and CNA #4 was assigned to 3rd floor assignment sheet and not in the North 2nd floor CNA assignment sheet where Resident #59 was observed during incontinence round. On 6/4/26 at 9:35 AM, Surveyor #2 (S #2) met with the AA, DON, and the LNHA during QAPI (quality assurance performance improvement) meeting. The LNHA stated the ratio for CNAs in the South Pavillion was the same in the North Pavillion (included 2 North and 3 North), we follow the State regulations which were day shift 1 CNA per 8 residents 1:8; evening 1:10, and night shift 1:14. He further stated that We go above the requirement for South because of the vent (ventilator) unit. On that same date and time, the LNHA informed S #2 that he was aware of the short staffing especially during weekends, and the short staff was because of call outs. 2. On 6/2/26 at 8:34 AM, the survey team met with the LNHA, DON, and AA. The DON stated that the Licensed Practical Nurse (LPN) had to work a double shift on 5/31/26 from 11:00 PM to 7:00 AM, and 6/1/26 from 7:00 AM to 3:00 PM, because the facility was short-staffed on 6/1/26 for the 7:00 AM to 3:00 PM shift that was why the LPN forgot to notify the incoming nurse from 7-3 shift of concern with controlled med bingo card discrepancy. A review of the facility's assignment sheets revealed that the LPN worked on 5/31/26 from 11:00 PM to 7:00 AM on the third floor, and 6/1/26 from 7:00 AM to 3:00 PM on the second floor. On 6/3/26 at 11:04 AM, Surveyor #3 (S #3), in the presence of the survey team, discussed the concern with the LNHA, DON, and AA about controlled med accountability log discrepancy and short staff during med administration observation. A review of the facility's Staffing Policy that was provided by the LNHA, with a reviewed date of 1/2026, revealed under policy statement, the facility provides adequate staffing to meet needed care and services for our resident population. Policy Interpretation and Implementation: 1. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. CNAs are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive CP. On 6/4/26 at 10:28 AM, the survey team met with the DON, AA, and the LNHA stated they knew what needed to be corrected, in-serviced, and audited. NJAC 8:39-25.2(b); 27.2(h)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 2 of 6 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 5/28/26 at 8:53 AM, the survey team entered the facility-North building reception area and Surveyor #1 (S #1) observed the Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the main lobby. The posted NHRCSR was dated 5/27/26 for the [7:00 AM to 3:00 PM] day shift with a census of 189, with 21 Certified Nursing Assistants (CNA), and a ratio of 1 CNA to 7.9 residents. There was no NHRCSR posted for 5/28/26.On 6/1/26 at 6:48 AM, Surveyor #2 (S#2) observed in the lobby area on the reception desk a posted sign for NHRCSR dated 5/31/26 for 7-3, 3-11, and 11-7 shifts with census of 191. On 6/1/26 at 9:00 AM, S#1 observed the posted NHRCSR was dated 6/1/26, with a census of 189. S#1 asked the License Nursing Home Administration (LNHA) what the census was for 6/1/26, and he confirmed the census was 189 that morning.On 6/1/26 at 10:47 AM, S#1 reviewed the staffing sheets provided by Staffing Coordinator #1 (SC #1) which revealed for Sunday 5/31/26, the Active Residents in house for the North building were 120 residents and the South building 69 residents (120 +69 In House=189 residents). Further review of the above posted NHRCSR for 5/31/26 with a census of 191 did not match the provided copy of SC #1 census of 189 for 5/31/26.On 6/2/26 at 11:23 AM, S#1 interviewed the SC#1 in the North building regarding the process for posting. SC #1 stated that the SC #2 from the South Building was responsible for posting the NHRCSR including on Saturdays. S #1 and the SC #1 from the North building conferenced called SC #2 from the South building. SC #2 stated she was responsible for posting and that every morning she obtained the numbers from SC #1 (North) and adds them with her numbers (South), then she e-mails it to the front desk receptionist, and it was posted on the front desk. SC #2 further stated, if no one was at the front desk, she will post it herself. SC #2 stated that on the weekends, she would post on Saturdays, but unfortunately no one was there on Sundays to change or update the NHRCSR. She stated they must wait until Monday morning to update the posting. At that same time, S #1 asked about the posting on Thursday, 5/28/26, day #1 of recertification survey that it was dated 5/27/26 upon entry, and she confirmed the date was incorrect because, It was not updated yet until I came in. S#1 asked about the NHRCSR posting on Monday 6/1/26, which revealed the census for Sunday, 5/31/26, was inaccurate, and she confirmed there was no one on Sunday to correct the posting. S #1 asked SC #2 if she was familiar with the State regulation for posting and she responded, I do not know how to answer to you right now. On 6/3/26 at 11:25 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and the Director of Nursing (DON) regarding inaccurate posted NHRCSR for two days, and that no one in the facility updated the NHRCSR during weekends. On 6/4/26 at 10:29 AM, survey team met with DON, AA, and the LNHA stated, We know what needs to be done. The DON replied, We will be doing additional in-services to address all the concerns mentioned. A review of the facility's Staffing Policy, with a revision date of 6/2/26, revealed, daily staffing (as reported to state agencies) is posted at reception, while reflecting accurate staffing numbers, and current census for the day. NJAC 8:39-41.2

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation for the inventory of Resident #127's Methadone, a controlled substance (narcotic) for 1 of 3 medication carts (side A, third floor), identified during the medication pass. This deficient practice was evidenced by the following:On 6/1/26 at 8:15 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) preparing medications (meds) for Resident #127. The surveyor observed that LPN #1 popped out five tablets (tabs) of methadone hydrochloride (HCl) 10 milligram (mg) tabs (an opioid medication used to manage severe pain) from Resident #127's bingo card (a multi-dose card containing individually packaged meds). Then, LPN #1 signed the Individual Patient's Controlled Substance Administration Record (IPCSAR; declining inventory sheet used to track removal of a controlled drug from inventory). At that time, the surveyor observed that Resident #127's bingo cards containing methadone HCl 10 mg tabs contained a total of 36 tabs. The resident's IPCSAR did not match the number of tabs in the bingo cards, as the IPCSAR reflected a balance of 37 tabs. On 6/1/26 at 8:35 AM, the surveyor interviewed LPN #1 who stated the expectation was that when a nurse pops out a controlled medication (med) from a resident's bingo card, the nurse must sign the IPCSAR, which was supposed to reflect the correct count.On 6/1/26 at 8:46 AM, LPN #1 spoke to the Registered Nurse/Unit Manager (RN/UM) about the above concern. LPN #1 and the RN/UM, in the presence of the surveyor, searched for a loose tablet (tab) in the side A third floor med cart, including the narcotic box, but they did not find one. The RN/UM stated to the surveyor that they were going to inform the Director of Nursing (DON) of the issue.On 6/1/26 at 12:53 PM, two surveyors met with the Licensed Nursing Home Administrator (LNHA), DON, and Assistant Administrator (AA) to discuss the concern. The DON stated the process was that two nurses were expected to do a count of the controlled meds at the change of each shift, and the IPCSAR should match the number of tabs in the bingo cards.On 6/2/26 at 8:43 AM, two surveyors met with the LNHA, AA, and the DON stated they conducted an investigation, which revealed the following concerns:-On 6/1/26, toward the end of LPN #2's shift of 11:00 PM to 7:00 AM, LPN #2 found one loose methadone pill in the narcotic box and wasted it in the drug buster without a second nurse.-LPN #2 did not sign that they wasted the methadone pill.-LPN #2 did not do an outgoing count of the controlled meds with the incoming nurse, LPN #1.-LPN #2 and LPN #1 did not perform an endorsement with each other (nurse-to-nurse communication during shift transitions to convey patient information).The DON further stated to the surveyors that the expectation was the outgoing shift nurse had to have an endorsement and do a count of the controlled meds with the incoming shift nurse. Moreover, the DON stated that the protocol was to waste a controlled med with another nurse, and LPN #2 did not waste it the right way. The DON stated that LPN #2 failed to follow the facility's protocol. The LNHA stated the nurses were wrong. The LNHA and DON stated they gave LPN #1 and LPN #2 counseling, did an audit, and started in-servicing the staff.A review of the admission Record (AR) or face sheet (an admission summary) revealed that Resident #127 was admitted to the facility with diagnoses that included, but were not limited to, other chronic pain.A review of the Order Summary Report for Resident #127, revealed physician's orders (PO) which included, but were not limited to, the following:-Methadone HCl Oral Tablet (tab) 10 mg give 5 tabs by mouth one time a day for chronic pain. The PO started on 3/29/25.-Methadone HCl Oral Tab 10 mg give 1 tab by mouth at bedtime for chronic pain. The PO started on 3/29/25.A review of the Facility Assessment, updated 4/28/26, revealed .the facility is able to care for residents that are on Methadone for opioid dependence or pain management only at levels that can be provided by the facility pharmacy. The level of treatment is determined by the physician and dosed accordingly .The facility will secure the med in the med cart, double locked. Resident will be assigned to a physician who is experienced with managing methadone .On 6/3/26 at 11:04 AM, the surveyor, in the presence of the survey team, discussed the concerns with the LNHA, DON, and AA.On 6/4/26 at 10:28 AM, the survey team met with the DON, AA, and the LNHA stated they knew what needs to be corrected, in-serviced, and audited.A review of the facility's Controlled Substance Handling Policy, reviewed 1/2026, revealed .if one or more doses of controlled substance are removed from the container for administration but refused by the resident or not given for any reason, the doses cannot under any circumstances be returned to the container or taped back into the blister pack. They must be destroyed in the presence of two licensed nurses, and the disposal documented by both nurses on the accountability record .A physical inventory of all controlled drugs is made at the change of each shift by two licensed nurses and is documented on an audit record .NJAC 8:39-29.2; 29.7

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 6/1/26, the surveyor observed 3 nurses administering medications to 6 residents. There were 38 opportunities, and 4 errors were observed which resulted in a medication error rate of 10.53%. This deficient practice was identified for 1 of 6 residents (Resident #82), that was administered by 1 nurse. This deficient practice was evidenced by the following:On 6/1/26 at 10:49 AM, the surveyor observed the Registered Nurse (RN) preparing medications (meds) for Resident #82. The meds included, but were not limited to, the following physician's orders (POs):-Carvedilol Oral Tablet (tab) 3.125 milligrams (mg) give 1 tab by mouth two times a day for hypertension (high blood pressure) give with breakfast and dinner. The PO started on 5/9/26.-Gabapentin Capsule (cap) 100 mg give 1 cap by mouth two times a day for neuropathic pain (nerve pain). The PO started on 5/9/26.-Levetiracetam Oral Tab 750 mg give 2 tablets (tabs) by mouth two times a day for seizure disorder 750 mg x 2 tabs = 1500 mg total per dose. The PO started on 5/8/26.-Valsartan Oral Tab 80 mg give 1 tab by mouth two times a day for hypertension (high blood pressure) Hold for systolic blood pressure (BP) less than 110 millimeters of mercury (mmHg). The PO started on 5/9/26.On 6/1/26 at 10:49 AM, the surveyor observed the POs above were highlighted in red on the electronic medication administration record (eMAR), indicating the meds were overdue.On 6/1/26 at 11:10 AM, the surveyor observed the RN administering the meds to Resident #82.A review of the Medication Administration Audit Report of 6/1/26, for Resident #82 revealed the following:-Carvedilol Oral Tab 3.125 mg was scheduled for 6/1/26 at 8:00 AM, was administered on 6/1/26 at 11:11 AM, and documented on 6/1/26 at 11:11 AM.-Gabapentin Cap 100 mg was scheduled for 6/1/26 at 9:00 AM, was administered on 6/1/26 at 11:11 AM, and documented on 6/1/26 at 11:11 AM.-Levetiracetam Oral Tab 750 mg was scheduled for 6/1/26 at 9:00 AM, was administered on 6/1/26 at 11:11 AM, and documented on 6/1/26 at 11:11 AM.-Valsartan Oral Tab 80 mg was scheduled for 6/1/26 at 9:00 AM, was administered on 6/1/26 at 11:10 AM, and documented on 6/1/26 at 11:11 AM.On 6/1/26 at 11:15 AM, the surveyor interviewed the RN who stated the expectation was to give the meds within an hour before or an hour after their scheduled times. The RN acknowledged that they administered the POs listed above late to Resident #82, and did not follow the instructions to give carvedilol with breakfast. The RN stated they should have followed the POs.On 6/1/26 at 12:05 PM, the surveyor interviewed the RN/Unit Manager (RN/UM) who confirmed the expectation was to give the meds within an hour before or an hour after their scheduled times.On 6/2/26 at 11:50 AM, the surveyor interviewed the RN/UM who stated that if respiratory emergencies had actually occurred, then other nurses, the RN/UM, and a respiratory therapist would have been there as well, and they were not there. The surveyor requested the 24 Hours Report of 6/1/26 (a report that includes residents that have had any condition changes within the past 24 hours and remarks from the nurses) from the RN/UM for the district on the unit that would include the RN's residents. However, the RN/UM could not find that report and did not provide it to the surveyor.At that same time, the RN/UM stated that the RN should have been able to administer Resident #82's meds on time with proper time management. Moreover, the RN/UM further stated that the nurses could always ask for help from another floor nurse, the RN/UM, or a respiratory therapist.A review of the RN/UM's Nursing Progress Note (PN), effective 6/1/26, revealed that the doctor was notified and aware of delay in medication (med) administration of Carvedilol 3.125 mg BID (two times a day). However, the PN did not include that the doctor was notified about the other meds that were administered late, including gabapentin, levetiracetam, and valsartan.On 6/2/26 at 11:55 AM, the surveyor interviewed the RN/UM who stated that the expectation was to document in their PN that they notified the doctor of the delay of all of the resident's meds that were administered late. The RN/UM acknowledged that they should have included all of the resident's meds that were late in the PN.On 6/3/26 at 11:04 AM, in the presence of the survey team, the surveyor discussed the concerns with the LNHA, DON, and AA.On 6/4/26 at 10:28 AM, the survey team met with the LNHA, AA, and the DON stated the RN/UM entered a clarification PN to now include that the doctor was notified of the delay of all the resident's meds that were administered late after surveyor's inquiry. The LNHA stated they knew what needs to be corrected, in-serviced, and audited.A review of the facility's Medications Administration Policy, reviewed 1/2026, revealed .Meds must be administered in accordance with the orders, including any required time frame .Meds may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified .A review of the facility's Medication Administration with Specific Instructions Policy, reviewed 1/2026, revealed .Meds shall be administered according to the ordered requirements, including: Before, with, or after meals .NJAC 8:39-29.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide documented evidence that written notification to the beneficiary of the potential liability charges for services not covered, when the resident was discharged from Medicare Part A services with benefit days remaining were provided for them to choose which option they wanted on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Forms for 2 of 3 residents reviewed for beneficiary notice (Resident #42 and Resident #178). This deficient practice was evidenced by the following: On 6/3/26 at 1:20PM, the surveyor reviewed the facility provided SNFABN Forms for Resident #42 and Resident #178 which revealed the following:ABN form had the following information: Note: If Medicare does not pay for D. below, you may have to pay.What you need to do now: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.Resident #42's SNFABN form, which had under additional information ending 4/30/26, had handwritten left message with resident representative (RR) on the signature line and date of 4/27/26. The form under section G. Options: Check only one. We cannot choose a box for you had Option 1 (I want the D. [service listed above] listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare does not pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles) checked. There was no signature of the resident or RR.Resident #178's SNFABN form, which had under additional information ending 5/11/26, had handwritten emailed to [name redacted] above the signature line. The form had handwritten Resident unable to sign with date of 5/8/26 on the signature line. The form under Section G. Options had Option 1 checked. There was no signature of the resident or RR.On 6/3/26 at 1:30PM, the surveyor interviewed the Director of Social Services (DoSS) regarding the process. The DoSS stated that admissions department let her know what resident needed the notification and that she would send them. The DoSS stated that if the resident was alert and oriented that she would go and talk to them and have them sign the papers. The DoSS stated that if the resident was not alert and oriented then she would call the RR or email the forms. The DoSS stated that the RR would give her verbal confirmation and that she would document it on the forms. The DoSS stated that she would let them know what the options were and that sometimes they wanted to appeal. The surveyor asked the DoSS to view Resident #42's and #178's ABN form and why the option 1 was marked and there was no signature on the forms. The DoSS confirmed that each form had a mark on option 1 and then stated that she was not sure about the mark on the sheet and why it was there.On 6/3/26 at 1:49PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) regarding the SNFABN. The LNHA stated that the social worker provided them. The DON stated that there were options given. The surveyor asked the LNHA and DON to view Resident #42 and #178's ABN form which had a mark on Option 1 but there was no signature of the resident or RR. The DON stated that it must have been checked off by accident. The LNHA stated that he would have to get a blank form and look to see about the mark. The surveyor notified the LNHA and DON the concern regarding the ABN form for Resident #42 and #178.On 6/4/26 at 10:27 AM, in the presence of the Assistant Administrator (AA) and DON, the LNHA stated that the ABN form that was being used must have been from the previous company and should not have been filled out with the option. He added that maybe they had one form and made copies. The LNHA stated that they should not have been using that form and that they had a new form now.The LNHA did not provide any additional information. A review of the facility's NOMNC/ABN Policy with an effective date of 10/24/25, included the following:Policy: Medicare will only pay for services that are determined to be reasonable and necessary. Notice of Medicare Non-Coverage letter must be provided if services are determined to no longer meet skilled nursing or rehab needs. Advance Beneficiary Notice (ABN) must be provided if applicable.Procedure: The guidelines listed below outline the situations in which a Notice of Medicare Non-Coverage(NOMNC)/ABN (if applicable) is provided in accordance with Medicare requirements.1. In the event that the Medicare beneficiary no longer qualifies for the skilled level of care, the social worker (SW)/designee will prepare the NOMNC/ABN (if applicable) informing the resident and/or responsible party that they no longer qualify for Medicare payment.2. The SW/designee will prepare the NOMNC/ABN notice at least two calendar days before Medicare-covered services end.3. The SW will assess the resident's cognitive status. In the event that the resident is cognitively impaired, the resident's NOK (next of kin) or designated rep will be notified.4. The NOMNC/ABN must be provided regardless of the beneficiary's agreement on service.5. The SW will discuss the NOMNC/ABN with the resident or their designated RR and will proceed with the option chosen by the resident or designated RR as outlined in the notices.6. The SW will ensure that the beneficiary or the responsible party signs and dates the NOMNC/ABN, confirming that they have received the notice and understand their rights to appeal.7. In the case that a resident is cognitively impaired and unable to sign the required notices, the SW will reach out to the designated RR of the resident via telephone or email to inform them of the NOMNC/ABN notice. The SW will also discuss the preferred options and the appeal process with the RR. A verbal acknowledgement will be obtained.8. The SW department will keep a binder containing copies of all NONMC/ABN notices given to residents for record-keeping purposes. NJAC 8:39-4.1(a)(8), 5.1

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure that; a.) the physician orders (PO) were clarified with regard to duplicate orders for 2 of 38 residents (Residents #9 and #17), b.) the PO was followed for 1 of 5 residents (Resident #4) reviewed for unnecessary medications, c.) the PO was obtained for pressure relieving air mattress and set according to the resident's assessed needs for Resident # 3, and d.) the PO was clarified with regard to tube feeding orders for Resident #8, in accordance with standards of clinical practice and facility's policies and procedures. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and 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 stated, 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 5/28/26 at 9:35 AM, Surveyor #1 (S #1) observed Resident #3 lying in bed on an air mattress, with oxygen (O2) was in use via nasal cannula, with a concentrator set at 2 liters per minute. The air mattress control unit was observed set at 300 pounds (lbs), the maximum setting available. On 5/29/26 at 10:26 AM, S #1 observed Resident #3's air mattress remained set at 300 lbs. The resident stated that the mattress was not working properly and believed there was a hole in it because they had repeatedly reported concerns to staff. On 5/29/26 at 10:35 AM, S #1 reviewed the medical record for Resident #3. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; chronic obstructive pulmonary disease (COPD), emphysema, fibromyalgia, atrial fibrillation, and osteoporosis. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/13/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident's cognition was intact. A review of the PO, dated as of 5/29/26, revealed orders for O2 therapy and respiratory equipment changes. There was no PO was identified for use of an air mattress. A review of the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) revealed a PO to check the function of the pressure-relieving bed/mattress every shift, initiated 2/10/26. A review of the monthly nursing assessment dated [DATE], revealed the resident's weight was documented as 149 lbs. On 5/29/26 at 11:46 AM, both S #1 and the Registered Nurse/Unit Manager (RN/UM) went inside the resident's room and observed the mattress setting, and the RN/UM acknowledged that the mattress was set at 300 lbs despite the resident weighing approximately 149 lbs. The RN/UM stated that the setting was incorrect and that nursing staff were expected to check the mattress settings at least once per shift. The RN/UM further stated that maintenance would be contacted to evaluate the mattress because of the resident's concerns regarding its function. A review of the facility's Air Mattress Policy, with a reviewed date of 1/2026, included that air mattresses are treatment and preventive medical interventions that should be ordered, monitored, and documented. The policy further included that nursing staff would check mattress function every shift, ensure the mattress was functioning properly, and report malfunction immediately. On 6/4/26 at 10:00 AM, the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) both acknowledged that Resident #3's air mattress was set at 300 lbs despite the resident's documented weight of 149 lbs, and stated the setting should have reflected the resident's current weight. 2. On 6/2/26 at 9:39 AM, Surveyor #2 (S #2) observed Resident #4 sleeping in bed. A review of Resident #4's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to end stage renal disease (permanent kidney failure that requires a regular course of dialysis or a kidney transplant) and tracheostomy with dependence on respirator (surgically created opening in the windpipe (trachea) connected to a mechanical ventilator). A review of Resident #4's most recent comprehensive MDS (cMDS), an assessment tool used to facilitate the management of care, with an ARD of 3/27/26, reflected that the resident had a BIMS score of 12 out of 15, which indicated that Resident #4's cognition was mildly impaired. A review of Resident #4's May 2026 eMAR included the following PO: Antianxiety medication (med)-monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document: 'N' if none of the above observed. 'Y' if any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note (PN) findings every shift with a start date of 3/24/26. Further review reflected that the nurses had a checkmark to indicate that the order was administered. The nurses were not using the Y or N as indicated in the order. On 6/3/26 at 11:49 AM, S #2 notified the LNHA, Assistant Administrator (AA), and DON the concern that Resident #4's side effect monitoring was not followed. On 6/4/26 at 10:31 AM, in the presence of the LNHA and AA, the DON stated that Resident #4's side effect monitoring order was corrected. 3. On 5/29/26 at 9:44 AM, S #2 observed Resident #8 awake in bed. The resident was not interviewable. A review of Resident #8's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death within minutes) and gastrostomy (a surgical procedure that creates a small opening directly into the stomach through the abdominal wall used to insert a specialized feeding tube). A review of Resident #8's most recent quarterly MDS (qMDS) with an ARD of 4/10/26, reflected that the resident's cognitive skills for daily decision making was severely impaired. A review of Resident #8's May 2026 eMAR included the following PO: a. Enteral feed order five times a day Peptamen 1.5 liquid using [PEG TUBE] via bolus by gravity 250 ml (milliliters) total volume (TV) to be administered: 1,250 ml/24 hrs (hours). 250 ml 5 x a day with a start date of 3/23/26. The nurses wrote that 250 ml was given five times each day which totaled 1250 ml. b. Enteral feed order every evening shift total volume given in 24 hrs as TV 1,185 ml with a start date of 3/23/26. The nurses wrote 1185 ml each day. The two orders contained different amounts. The nurses were writing that the resident received different amounts. The orders were not clarified. On 6/1/26 at 12:23 PM, S #2 interviewed the Registered Nurse Supervisor (RNS) who stated that if there were different amounts on the orders then the orders should have been clarified. On 6/3/26 at 11:47 AM, S #2 notified the LNHA, AA, and DON the concern that Resident #8's enteral feed orders had different amounts and that the orders were not clarified. On 6/4/26 at 10:23 AM, Registered Dietician #1 (RD #1), in the presence of RD #2, stated that there was a discrepancy in Resident #8's 2 orders. She stated that when the resident entered the nurse must have put in 237 ml which was the standard for a carton of Jevity but that the resident's order was for Peptamen which came in a carton of 250 ml. On 6/4/26 at 10:27 AM, the survey team met with the LNHA, AA, and the DON for their responses to the notified concerns. They did not provide any response to the concern. The LNHA did not provide any additional information. A review of the facility's Physician Orders Policy with a revised date of 1/2026, included the following: Policy: It is the policy of this facility to follow all PO. Procedure:1. The licensed nurse receives the order from the physician.2. Orders are transcribed to the electronic medical record, and reviewed to identify any duplicate, conflicting, discontinued, or contraindicated orders and all are acknowledged on the POS (physician order summary), MAR (med administration record) and TAR (treatment administration record). 3. Any questionable, duplicate, incomplete, or conflicting orders shall be clarified with the prescribing practitioner before implementation.5. The licensed nurse shall document all PO were administered and followed to each resident on their medical record. A review of the facility provided policy titled Medication Administration with Specific Instructions with a reviewed date of 1/2026, included the following: Policy: It is the policy of this facility to ensure that medications are administered according to all specific instructions provided in the physician's order, medication administration record, pharmacy recommendations and manufacturer guidelines. Procedure: Prior to administration, the nurse shall review the medication order for any special instructions. Administration and any required monitoring shall be documented on the MAR and in the medical record as appropriate. Questions regarding medication administration instructions shall be clarified with the practitioner or consultant pharmacist prior to administration. 3. On 5/28/26 at 10:53 AM, Surveyor #3 (S #3) observed Resident #9 lying on their air mattress bed with indwelling catheter hung on the left side of the bed railing and inside a privacy bag. S #3 reviewed Resident #9's medical records and revealed: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; amyotrophic lateral sclerosis (ALS is a progressive disease in which a person's brain loses connection with the muscles, slowly taking away their ability to walk, talk, eat and eventually breathe), heart failure unspecified, type 2 diabetes mellitus with other specified complication, and neuromuscular dysfunction of bladder (occurs when neurological conditions interrupt nerve signals between the brain, spinal cord, and bladder muscles), not elsewhere classified. A review of the cMDS, with an ARD of 3/21/26, revealed that the resident had severely impaired cognitive skills for daily decision making, and never/rarely made decisions. A review of the Order Summary Report (OSR) revealed the following PO: Ondansetron HCl (hydrochloride) oral tablet (tab) 4 mg (milligram), give 1 tab via peg tube (Percutaneous Endoscopic Gastrostomy) is a soft, flexible feeding tube surgically placed through the abdominal wall directly into the stomach) every 6 hrs as needed (PRN) for nausea/vomiting. Start Date 4/12/26. Reglan oral tab 5 mg (Metoclopramide HCl), give 5 mg via peg tube every 8 hrs PRN for nausea and vomiting. Start Date 5/21/26. The above orders for PRN Ondansetron and Reglan were transcribed to the May and June 2026 eMAR and were administered on the following dates: Ondansetron was signed by nurses as administered on 5/21/26 at 5:33 PM and on 5/29/26 at 11:51 AM. Reglan was signed by nurses as administered on 5/21/26 at 8:43 PM. On 5/28/26 at 11:46 AM, Surveyor #4 (S #4) observed Resident #17 in activity room with other residents. S #3 reviewed the medical records of Resident #17 and revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified fracture of left pubis, subsequent encounter for fracture with routine healing, fracture of superior rim of left pubis, initial encounter for closed fracture, difficulty walking, not elsewhere classified, other specified anxiety disorders, and unspecified dementia mild with anxiety. A review of the qMDS with an ARD of 4/13/26, revealed that the resident had BIMS score of 3 of 15. A review of the OSR revealed the following PO: Milk of Magnesia Suspension 400 mg/5 ml, give 30 ml by mouth PRN for constipation in evening of 3rd day of no BM (bowel movement). Start Date 4/8/26. Milk of Magnesia Suspension 400 mg/5 ml, give 30 ml by PRN for constipation. Start Date 4/8/26. Enema Rectal Enema 7-19 gm (gram)/118 ml, insert 1 suppository rectally PRN for evacuation of bowel. Start Date 4/8/26. Bisacodyl laxative rectal suppository 10 mg, insert 1 suppository rectally PRN for constipation. Start date 4/8/26. On 5/29/26 at 10:06 AM, S #3 in the presence of the LNHA and AA, notified the DON of the above concerns with Residents #9 and #17's duplicate orders for bowel regimen. A review of the facility's Medication Sequencing Policy that was provided by the LNHA, with a review date of 1/2026, revealed under policy, it is the policy of the facility to ensure medications are administered safely, accurately, and in the proper sequence according to PO and manufacturer recommendations . On 6/3/26 at 11:03 AM, the survey team met with the AA, DON, and the LNHA stated that for Resident #9's duplicate orders, the PO for Reglan was discontinued, and spoke to the doctor about it. The DON further stated that the bowel regimen for Resident #17 duplicate PO was clarified also. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 2 of 38 residents, (Residents #17 and #23), reviewed for MDS accuracy. This deficient practice was evidenced by the following: 1. On 5/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #17 in activity room with other residents. Licensed Practical Nurse #1 (LPN #1) stated that for the past six months, the resident had fall incident in their room, the roommate stated that Resident #17 wanted to use the bathroom, fell, and complained of pain. LPN #1 further stated that the x-ray showed hip displacement, and no other falls after that. Surveyor #2 (S #2) reviewed the medical records of Resident #17, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified fracture of left pubis, subsequent encounter for fracture with routine healing, fracture of superior rim of left pubis, initial encounter for closed fracture, difficulty walking, not elsewhere classified, other specified anxiety disorders, and unspecified dementia mild with anxiety. A review of the fall investigations provided by the Director of Nursing (DON) for Resident #17 for the last eight months revealed: On 9/8/25, a fall incident was reported by LPN #1, reflected that the fall happened in resident's room, at approximately 11:55 AM, assessment was done and revealed no injuries. On 11/10/25, a fall incident was reported by LPN #1, reflected that the fall happened in resident's room, at approximately 1:00 PM, assessment was done and revealed no injuries. On 1/23/26, a fall incident was reported by Registered Nurse #1 (RN #1), reflected that the fall happened in resident's bathroom area, at 5:35 AM, assessment was done and noted with 3 cm (centimeter) x (by) 3 cm elevation with no bleeding, and the resident claimed they hit their head. On 1/24/26, a fall incident was reported by RN #2, reflected that the fall happened in resident's room, at 5:30 PM, assessment was done and no injuries noted. On 3/22/26, a fall incident was reported by LPN #2, reflected that the fall happened in resident's room, at 7:30 PM, assessment was done and noted with laceration to the right forearm, right side localized swelling, and complained of pain. On 4/1/26, a fall incident was reported by LPN #1, reflected that the fall happened in resident's room, at approximately 8:00 AM, assessment was done and the resident complained of right hip pain and right hip bruising. A review of the comprehensive MDS (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/16/25, and quarterly MDS (qMDS) with an ARD of 10/15/25, revealed in Section C-Cognitive Patterns, a brief interview for mental status (BIMS) score of 4 of 15, which reflected severely impaired cognition. Section J-Health Conditions were coded with no falls. A review of the qMDS with an ARD of 1/14/26, revealed that the resident had BIMS score of 3 of 15, which reflected severe cognitive impairment. Section J was coded with no falls. A review of the discharge return anticipated (DRA) MDS with an ARD of 4/1/26, revealed in Section J that the resident had one fall with no injury and a fall with injury except major. A review of the qMDS with an ARD of 4/13/26, revealed that the resident had BIMS score of 3 of 15. Section J was coded with one fall with major injury. Further review of the above fall investigations and MDSs revealed: The cMDS with an ARD 10/15/25, the fall was not captured for fall incident that happened on 9/8/25 with no injury. The qMDS with an of ARD 1/14/26, the fall was not captured for fall incident that happened on 11/10/25 with no injury. The DRA MDS with an ARD of 4/1/26, the falls were not captured for fall incidents that happened on 1/23/26 (fall with injury not major), 1/24/26 (fall with no injury), 3/22/26 (fall with injury not major), and 4/1/26 (fall with major injury). On 5/29/26 at 10:36 AM, S #2 interviewed the Registered Nurse/MDS Coordinator (RN/MDSC), and the RN/MDSC stated that if a resident fell and there was a fracture, it should be coded in MDS as major injury. She also stated that if a resident had complained of pain from a fall incident and had a laceration, and elevation at the back of the head, it should be coded in MDS as injury not major. She agreed that for those six fall incidents there were three with no injuries, two with injury not major, and one with major injuries. The RN/MDSC stated that she would get back to S #2 as to why there were discrepancies in the MDS for captured falls. On 5/29/26 at 11:40 AM, the RN/MDSC informed S #2 that she corrected the MDS with an ARD of 4/13/26, to reflect that fall. She also stated that the MDS with an ARD of 4/1/26 was also corrected to capture two falls with no injuries, 1 fall with injury not major, and 1 fall with major injury. S #2 asked for facility's policy about MDS with regard to MDS accuracy, and she stated that she would get back to S #2. On 5/29/26 at 11:47 AM, the RN/MDSC informed S #2 that the facility had no policy about MDS with regard MDS accuracy, and they followed the RAI (Resident Assessment Instrument) manual. On 6/2/26 at 12:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Assistant Administrator (AA), and Regional Nurse, and S #2 notified them of the above findings and concerns about Resident #17's inaccurate MDS. On 6/3/26 at 11:03 AM, the survey team met with the AA, DON, and the LNHA stated that the in-service was provided to the RN/MDSC by Regional MDS. 2. On 5/28/26 at 10:35 AM, Surveyor #3 (S #3) observed Resident #23 lying in bed with partial side rails in the upright position. An air mattress was in place and observed to be set at 300 pounds. On 5/29/26 at 10:55 AM, S #3 observed Resident #23 lying on bed inside their room and stated that all of their needs were being met. A review of the AR revealed the resident had diagnoses which included, but were not limited to; acute and chronic respiratory failure, type 2 diabetes mellitus with complications, peripheral vascular disease, and morbid obesity. A review of the resident's qMDS, with an ARD of 3/11/26, included a BIMS score of 9 out of 15, which indicated the resident's cognition was moderately impaired. The qMDS was coded No for the presence of pressure injury. A review of the Order Summary Report, dated as of 6/2/26, included physician orders dated 5/26/26, for treatment of a left ischial wound, left buttock wound, and scrotal wound. A review of a wound care consultation note dated 3/10/26, revealed the resident was evaluated at bedside and was identified as having a stage 2 pressure injury requiring ongoing assessment and treatment. On 6/2/26 at 10:50 AM, S #3 interviewed the RN/MDSC. The RN/MDSC reviewed the resident's wound care consultation note dated 3/10/26, and the qMDS with an ARD of 3/11/26. The RN/MDSC stated, Looks like the pressure ulcer wound stage 2 should have been captured on the MDS. I will have to correct that. On 6/2/26 at 1:15 PM, S #3 interviewed the DON who stated that the MDS assessment should accurately reflect the resident's clinical condition and documented wounds during the assessment reference period. On 6/2/26 at 3:00 PM, the LNHA, in the presence of the DON and the survey team, acknowledged that Resident #23's stage 2 pressure injury documented on 3/10/26 was not accurately coded on the qMDS assessment dated [DATE]. NJAC 8:39-11.2(g); 33.2 (d)

Based on review of facility policy, record review, and interviews, the facility failed to ensure four Residents (R) (R6, R8, R9 and R10) out of fifteen residents reviewed for assistance with Activities of Daily Living (ADLs) were not bathed according to their plans of care. The facility's failure to ensure residents were bathed routinely created the potential for the residents to experience negative effects related to poor hygiene. A total of 15 residents were reviewed in the sample. Findings include:1. Review of R6's admission Record, dated 04/16/26 and located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia and history of stroke. Review of R6's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/26 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3 out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated the resident required assistance from staff for bathing and grooming. Review of R6's ADL Care Plan, most recently dated 03/06/26 and located in the EMR under the Care Plan tab, revealed R6 required staff participation for bathing. The care plan did not indicate R6 routinely refused bathing.Review of R6's ADL Documentation, dated 03/19/26 through 04/17/26 and located in the EMR under the Point of Care (POC) tab, revealed R6 refused bathing on 04/03/26. The was no additional documentation in the resident's record to indicate he had been bathed or had refused to be bathed within the most recent 30 days. R6 was not able to be interviewed due to his poor cognition.2. Review of R8's admission Record, dated 04/16/26 and located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included schizophrenia and depression. Review of R8's quarterly MDS, with an RD of 03/26/26 and located in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated the resident required assistance from staff for bathing. Review of R8's ADL Care Plan, most recently dated 04/06/21 and located in the EMR under the Care Plan tab, revealed R8 required staff participation with bathing. The record did not indicate R8 had a tendency to refuse bathing.Review of R8's ADL Documentation, dated 03/19/26 through 04/17/26 and located in the EMR under the Point of Care (POC) tab, revealed nothing to show R8 had been bathed within the last 30 days. The record indicated not bathing refusals.3. Review of R9's admission Record, dated 04/16/26 and located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and heart failure. Review of R9's quarterly MDS, with an ARD of 03/04/26 and located in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. Review of R9's ADL Care Plan, most recently dated 08/22/25 and located in the EMR under the Care Plan tab, revealed R9 required staff participation with bathing.Review of R9's ADL Documentation, dated 03/19/26 through 04/17/26 and located in the EMR under the Point of Care (POC) tab, revealed R9 had been bathed one time in the most recent 30 days (on 04/13/26). The record indicated no bathing refusals. 4. Review of R10's admission Record, dated 04/16/26 and located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included spastic hemiplegic cerebral palsy. Review of R10's quarterly MDS, with an ARD of 03/04/26 and located in the EMR under the MDS tab, revealed a BIMS assessment score of 15 out of 15, which indicated the resident was cognitively intact. Review of R10's ADL Care Plan, most recently dated 12/12/25 and located in the EMR under the Care Plan tab, revealed no bathing care plan for R10.Review of R10's ADL Documentation, dated 03/19/26 through 04/17/26 and located in the EMR under the Point of Care (POC) tab, revealed nothing to show the resident had been bathed in the most recent 30 days. The document indicated no bathing refusals.On 4/15/26 at 3:00PM, a group interview was conducted with R8, R9 and R10. All three residents stated they never received more than one bath per week and had not been bathed per their plans of care.R9 stated he/she had just been bathed on 04/13/26 but had not been bathed for three weeks prior. R9 stated a preference to be bathed twice weekly and stated he/she thought he/she stank due to not receiving regular bathing.R10 stated a preference to be bathed twice weekly and reported it had been two weeks since the last bath. R10 stated a family member had taken he/she home to bathe a few days prior to the interview. R8 stated a preference to be bathed twice weekly and reported he/she had not received a bath in a while. On 4/15/26 at 4:45PM an interview was conducted with the Administrator, Assistant Administrator, and the Director of Nursing (DON2). DON2 confirmed documentation could not be located to demonstrate R6, R8, R9 and R10 had been consistently bathed according to their preferences. DON2 stated the expectation was that residents were to be bathed consistently according to their preferences and this was to be documented in each resident's record. DON2 further stated staff were expected to re-approach residents who refused bathing and document refusals and all attempts. Review of the facility's ADL Care Policy and Procedure dated last reviewed in 01/2026 indicated, Residents shall receive assistance with activities of daily living (ADLs) every shift, as appropriate; and ADLs include: bathing, grooming, dressing, eating, oral hygiene, ambulation and toilet activities.NJAC 8:39-27.2 (i)

Based on review of facility policy, record review, observations, and interviews, the facility failed to ensure significant medication errors were not made during the administration of medication for one of one resident (Resident (R) 2) observed for medication administration. The facility's failure to ensure R2 received his/her medication as ordered created the potential for this and other residents to experience significant negative physical effects related to the incorrect administration of medication. A total of 15 residents were reviewed in the sample.Findings include:Review of R2's admission Record, dated 04/16/26 and located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke, type 2 diabetes, prostate cancer, acute respiratory failure with hypoxia, gastrostomy (g-tube) status, and hemiplegia and hemiparesis affecting his right dominant side. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/25 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) assessment score of 1 out of 15, which indicated the resident was severely cognitively impaired.Review of R2's Physician's Order Report, with active orders dated 04/16/26 and located in the EMR under the Orders tab, revealed the following:-Thiamine (a vitamin/mineral supplement) 100 Milligrams (MG) once daily via gastrostomy (g)-tube-Lactulose (a stool softener) 30 milliliters (ML) daily via g-tube-Chewable aspirin(non-steroid anti-inflammatory drug) 81 MG once daily via g-tube-Miralax ( a stool softener) 17 grams daily via g-tube-Duoneb (an inhaled medication used open airways to treat COPD) one vial via nebulizer four times daily-Budesonide (an inhaled steroid medication used to treat COPD) one vial via nebulizer every twelve hours -Scopolamine (a medication to control oral secretions) one patch to be applied to the resident topically once every 72 hours-Glucerna 1.5 360 ML (milliliters) four times daily via his g-tube. Review of R2's Medication and Treatment Administration Records (MARs/TARS), dated 04/01/26 through 04/17/26 and located in the EMR under the Orders tab, indicated the resident received his/her medications as ordered.On 4/15/26 at 9:45am, Licensed Practical Nurse (LPN1) was observed administering R2's medications. LPN1 administered aspirin despite the expiration date being smeared and not visible. LPN1 did not administer lactulose or thiamine after determining the medications were not available in the medication cart. LPN1 stated an intention to assess R2's bowel status prior to administering Miralax; however, no assessment was performed, and Miralax was not administered. LPN1 administered Budesonide (steroid) inhaled medication before administering the resident's Duoneb. LPN1was observed administering 330 ML of Glucerna 1.5 (rather than the ordered 360 ML). LPN1 was unable to locate documentation on the MAR to indicate the application of a Scopolamine patch. Without verifying the physician's order, LPN1 removed the patch from behind the resident's left ear and did not replace it. The patch had been applied the previous day and was ordered to remain in place for 72 hours.On 04/15/26 at 10:50 AM, the surveyor interviewed LPN1. LPN1 confirmed lactulose and thiamine were not administered due to unavailability in the medication cart. LPN1 stated he/she would order the medications from the pharmacy so that they are available for the next medication pass. LPN1 also confirmed administering aspirin despite the expiration date being unreadable, stating the pharmacist had reviewed the medications the previous week and indicated they were acceptable. LPN1 confirmed that he/she gave R2 his/her aspirin in spite of the expiration date not being visible.LPN1 confirmed R2's scopolamine patch was removed because he/she did not see an order for it on the daily MAR and stated he/she did know when the patch was supposed to be applied. LPN1 stated he/she was not aware of a specific order in which to administer nebulized/inhaled medications. LPN1 stated he/she forgot to administer R2's Miralax. LPN1 confirmed he/she administered Glucerna 1.5 330ml instead of 360ml as ordered by the Physician and stated that the physician order was for 330ml. On 4/15/26 at 1:52pm, the surveyor interviewed with Director of Nursing (DON1) and DON2. Both confirmed that medications are expected to be available and administered as ordered. They stated medications should not be administered if the expiration date cannot be verified. They further confirmed that bronchodilator nebulized medications should be administered prior to inhaled steroids. DON1 and DON2 confirmed the scopolamine patch should not have been removed, as it was applied the previous day and ordered for a 72-hour duration.DON2 confirmed R2 was expected to receive 360 ML of Glucerna 1.5 four times daily via his/her g-tube according to physician's orders. Review of the facility's Medication Administration Policy, dated last reviewed in 01/2026, indicated, Medications shall be administered in a safe and timely manner; and Medications must be administered in accordance with the orders, including any required times frame; and The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication; and The expiration date on the medication label must be checked prior to administering. Review of the facility's Enteral Feeding Policy and Procedure, dated last reviewed in 01/2026, indicated, Enteral feeding orders will be recommended by the dietician and physician's orders will be obtained. Orders will be obtained and written by the dietician or nurse as follows: B. Bolus Feeding Order: Will include the product name, cc's for each bolus, and number of bolus feedings to be given per day.NJAC 8:39-29(d)