Every finding on record at Arnold Walter Nursing & Rehabilitation Center

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to follow professional standards of practice and physician orders to ensure resident's receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This deficient practice was identified for 3 of 3 residents (Residents #2, #8 and #75), reviewed for tube feeding.This deficient practice was evidenced by the following: 1. On 6/9/26 at 10:17AM, the surveyor observed Resident #2 lying in bed with a tube feeding (a medical device that delivers nutrition, fluids, and medications directly into the digestive system when a person cannot eat or swallow safely) in place and the pump turned off. The tube feed bottle was labeled Glucerna 1.5 and was dated for 6/7/26 at 9 AM. There was a breakfast tray on the bedside table against the wall that appeared untouched. On 6/9/26 at 11:57 AM, the surveyor observed a new bottle of Glucerna 1.5 dated 6/9/26 at 10:30 AM running at 50mL/hr (milliliters per hour). Resident #2 was in bed with their eyes closed. On 6/10/26 at 1:14 PM, the surveyor observed Glucerna 1.5 tube feed running at 50mL/hr with 220mL intake recorded on the pump. The tube feed bottle was dated 6/10/26 at 6 AM. The surveyor reviewed the electronic medical record (EMR) for Resident #2. A review of the admission Record (AR-an admission summary) reflected diagnoses that included but were not limited to; Type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels) without complications, dysphagia (difficulty swallowing), oropharyngeal phase, and adult failure to thrive (a multifactorial syndrome in older adults characterized by unintentional weight loss, decreased appetite, functional decline, and social withdrawal). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 5/28/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. The MDS also revealed section I malnutrition, and section K swallowing disorder, feeding tube, and mechanically altered diet (designed to be easy to chew and swallow, often used for individuals with dysphagia). A review of the individualized comprehensive care plan (ICCP) included a focus area dated 2/25/26 of the resident requires tube feeding/PEG tube (a feeding tube inserted directly into the stomach to provide nutrition when oral intake is insufficient or unsafe) in place. A focus area of at risk for malnutrition related to mechanically altered diet, history of poor oral intake .with intervention Monitor tube feed tolerance. A review of the Order Summary Report (OSR) revealed physician's orders (PO) for: A PO dated 5/19/26, Enteral Feed Order one time a day for nutrition Glucerna 1.5 @ 50ml/hour x24 hours (total volume 1200ml) via Gtube at 6 PM. A PO dated 6/4/26, 72-hour calorie count-document % consumed on tray ticket in yellow envelope (including snacks) three times a day for 3 days. A PO dated 6/8/26, Document food % consumed on the tray ticket in yellow envelope with meals for poor intake. A review of the Medication Admin Audit Report for June 1-10, 2026, revealed the enteral feed order Glucerna 1.5 @ 5oml/hr x 24 hours was signed by a nurse on 6/7/26 at 5:05 PM, indicating the tube feed was hung at this time. On 6/8/26 the order was signed by a nurse at 5:05 PM. On 6/9/26 at 12:12 PM, the surveyor interviewed Licensed Practical Nurse #1 (LPN#1), Resident #2's assigned nurse, who stated, I stopped the tube feed this morning, it was giving me issues. I started a new one. LPN#1 also stated Resident #2 will refuse at least one meal tray per day and staff would hold the tray for later. He stated the resident does have pleasure feeds (a type of feeding that focuses on comfort and quality of life rather than on providing full nutritional support) and snacks. On 6/11/26 at 9:44 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager #1 (LPN/UM#1), who stated the Glucerna 1.5 tube feed was hung every day at 6 PM. The amount of tube feed intake was reviewed in the presence of the surveyor with 50ml/hr x 24 hours being a total volume of 1200ml in 24 hours and the Glucerna 1.5 bottle being a 1000mL bottle. LPN/UM#1 stated, It should be continuous. I definitely think it is hung at 6 PM. LPN/UM#1 confirmed with the surveyor there was an order to document the amount of food consumed on each meal tray, but no order to document the amount of tube feed consumed in a shift. On 6/12/26 at 10:28 AM, the surveyor interviewed the Director of Nursing (DON) who confirmed the amount of tube feed in a Glucerna 1.5 bottle was 1000mL. The DON further stated the nurse would hang a new bottle to run the other 200mL when the 1000mL bottle was empty, and this should be signed and documented when it was hung. A review of the facility provided Tube Feedings policy, last reviewed 1/20/26, revealed Policy: Tube feeding will be given as per physician's order via gastrostomy tube utilizing the enteral pump. Unless otherwise specified by the physician, it is the policy of this facility to begin all feedings at approximately 4pm on the evening shift and run as ordered until dose completed. Equipment: .Bags are changed every 24 hours on the evening shift. 2. On 6/10/26 at 8:22 AM, the surveyor observed Resident #8 eating breakfast in their bed. The resident verbalized the food was good. Resident #8 was cooperative and did not present any care concerns. The surveyor reviewed the EMR for Resident #8: A review of the AR reflected that the resident was admitted to the facility with diagnoses which included but was not limited to: gastrostomy (a surgical procedure to make a hole into the stomach through the abdomen to insert a TF into the stomach) status, and dysphagia oral phase (is a specific subtype located only in the mouth, referring to problems with chewing, forming a bolus, or moving food to the back of the throat). A review of the Quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, indicating that the resident was cognitively intact. Further review of the MDS indicated the resident was receiving nutrition both by mouth and through TF while a resident. A review of the ICCP revealed a Focus which indicated that the resident was at risk for malnutrition related to (r/t) diagnoses (dx) of FTT (Failure to thrive), dehydration, . dependence on enteral feeding to meet nutrition and hydration needs, mechanically altered diet needs, date initiated 2/4/26. Interventions included but were not limited to: Monitor enteral feed tolerance and provide enteral feed and flushes as ordered. A review of the OSR revealed a PO, dated 1/30/26, for Enteral Feed - one time a day check tube for residual (the amount of liquid—a mix of previous formula, water, and stomach juices—left in the stomach right before the next scheduled feeding) prior to continuous feeding – If residual > (greater than) 100mls (milliliters), hold feeding x (for) 1 hour and recheck. If residual > 50 mls on recheck, notify MD (physician). A review of February 2026 through June 2026 electronic Medication Administration Record (eMAR) reflected the above PO was entered with an area to document the temperature (instead of the residual) and an area scheduled for 8:00 am daily for the nurse to sign it was completed. Further review of the eMAR reflected the temperature was entered daily and a checkmark with the nurse's initials, that indicated the order was completed, was entered daily at 8:00 AM. A further review of the eMARs did not reflect a documented amount of the TF residuals. On 6/11/26 at 12:59 PM, during an interview with the surveyor, LPN #2 stated Resident #8 received two bolus tube feeds during her shift. LPN #2 stated she would check residual with the piston syringe (a medical device that uses a plunger moving within a calibrated cylinder to draw in, measure, or push out fluids primarily used for body and wound irrigation, administering liquid diets, flushing catheters, and delivering precise medication doses) prior to administering the boluses and she would document the amount of the residual in the eMAR. In the presence of the surveyor, LPN #2 reviewed the June 2026 eMAR and confirmed it was her initials for seven (7) out of the ten (10) days where she documented temperatures (temps) instead of the amount of the residual. LPN #2 stated she should have read the order correctly before she signed the eMAR. LPN #2 stated she should have noticed the PO earlier and had it changed. LPN #2 confirmed for the above-mentioned PO, there was no documentation for the residual amount since the PO was put in on 1/30/26. LPN #2 acknowledged that was an issue. On 6/11/26 at 2:09 PM, the surveyor made LPN/UM #2 aware of the above findings. LPN/UM #2 reviewed the PO in the presence of the surveyor and confirmed it was supposed to be the residual amount, and everyone was documenting the temps. LPN/UM #2 stated the documentation was wrong and the nurses should have notified the physician and had the PO changed. LPN/UM #2 stated improper documentation was technically a med error. She stated checking the residual prior to TFs was important because the resident could have 200 mls of residual which could actually cause complications like vomiting. The LPN/UM stated the nurses should pay better attention before signing the POs on the eMAR. On 6/12/26 at 12:12 PM, the surveyor made the DON aware of the above-mentioned findings. The DON stated the expectation from the nurses was to document the amount of the residual. The DON stated if they (the nurses) saw that order (PO), they should have called the doctor and corrected it. On 6/12/26 at 1:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, the Administrator in Training (AIT) and the regional nurse. The surveyor made the facility administration aware of the above-mentioned concerns. A review of the facility provided policy Tube feedings with date reviewed 1/20/26 revealed a Policy statement: Tube feedings will be given as per physician's orders. Persons with new feeding tubes or concerns about absorption (e.g. vomiting or increases in the rate of feeding) will be checked for residual before each feeding.The amount of residual will be recorded if over 100 cc .If ordered, check amount of gastric residual by withdrawing stomach contents with flat top syringe. If > 100 cc. of gastric contents in aspirated, return aspirate to stomach, hold tube feedings and notify MD. Document in the progress notes. 3. On 6/9/26 at 10:47 AM, the surveyor entered Resident #75's room during initial tour of the facility. Resident #75 was in bed wearing a patient gown, foam elbow protectors and was observed lying on a specialized air mattress. Resident #75 was alert, oriented and able to answer the surveyor's questions. A tube feeding pump was noted hanging on a pole next to the resident's bed, which was heavily soiled with a tan substance; as was the bedside table, air mattress pump, and the ground underneath the feeding pump were noted to be soiled with the same tan substance. The tan substance was hard to the touch and could not be wiped away. A piston syringe was noted on the bedside table and was labeled with the resident's room and bed number and dated 6/7 [June 7] with black marker. The resident told the surveyor that they received liquid tube feeding overnight and that the feeding would usually finish in the mornings. The resident stated their medications were crushed and given through their feeding tube, and that they had already received their morning medications through the feeding tube on that day. The surveyor then asked the resident what was used to give medications through the feeding tube; the resident explained that staff used the syringe on their bedside table for medications and hydration. On 6/9/26 11:48 AM, the surveyor entered Resident #75's room and noticed the same labeled piston syringe on the resident's bedside table. At that time, the surveyor went to the Nurse's station, LPN/UM #3 told the surveyor that Resident #75 took their medications through their feeding tube and the resident had already been administered their morning medications for the day. She stated the tube feeding formula was administered during the evening and that the resident was allowed pleasure foods during the day. LPN/UM #3 informed the surveyor that tubing and syringes were changed daily during the overnight shift for residents with tube feedings. On 6/9/26 12:09 PM, the surveyor entered Resident #75's room with LPN/UM #3. LPN/UM#3 was shown the substance on the air mattress pump, bedside table, feeding pump, and the ground underneath it. LPN/UM #3 stated that the areas should have been clean and not soiled with the tan substance. LPN/UM #3 acknowledged the piston syringe, she grimaced and stated, June 7th is written on the syringe. LPN/UM #3 immediately discarded the piston syringe into a waste basket, LPN/UM #3 stated the piston syringe should not have been on the resident's bedside table because they should be changed every 24 hours.The surveyor reviewed the EMR for Resident #75.A review of the admission Record reflected diagnoses that included but were not limited to; cerebral infarction (stroke), Type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels) without complications, dysphagia (difficulty swallowing), and aphagia (inability to swallow). A review of the most recent comprehensive MDS, dated [DATE], revealed the resident had a BIMS score of 14 out of 15, indicating that the resident's cognition was intact. Further review of the MDS revealed in section K; swallowing disorder, feeding tube, and mechanically altered diet (designed to be easy to chew and swallow, often used for individuals with dysphagia).A review of the ICCP included a focus area dated 1/2/26, that the resident required tube feeding related to respiratory failure and stroke. Goals included the resident's insertion site would be free of signs and symptoms of infection and the resident would remain free of side effects or complications related to tube feeding. Interventions included site care, monitoring for infections, tube care and maintenance per a physician's order.A review of the (OSR) revealed PO's for: A PO dated 4/6/26 for: Enteral Feed Order one time a day for nutrition Glucerna 1.5 @ 60ml/hour x24 hours (total volume 1080ml) via PUMP at 4 PM and down when total volume is infused.A PO dated 12/16/25 for: Enteral Feed Order every night shift CHANGE PISTON SYRINGE and perform GT site care – every 24 hours.On 6/12/26 at 11:57 AM, the surveyor interviewed the DON regarding Resident #75's tube feed orders. The DON stated that tube feeding orders were placed by a physician with input from staff and various healthcare consultants. The DON stated the tube feeding and the piston syringe were replaced every 24 hours, and tubing was replaced with each new bottle of tube feeding formula that was hung. She stated the importance of changing them frequently and as ordered was to maintain infection control practices. The surveyor made the DON aware of the above observation for the resident's piston syringe. The DON stated that the syringes were supposed to be changed every 24 hours for infection control.On 6/12/26 at 1:44 PM, in the presence of the survey team and the DON, the surveyor presented the concerns to the LNHA regarding Resident #75's tube feeding.A review of the facility provided Tube Feedings policy, last reviewed 1/20/26, revealed Policy: Tube feeding will be given as per physician's order via gastrostomy tube utilizing the enteral pump. Unless otherwise specified by the physician, it is the policy of this facility to begin all feedings at approximately 4pm on the evening shift and run as ordered until dose completed.Equipment: .New tubing is provided with each new bag/bottle. Bags are changed every 24 hours on the evening shift. Piston syringes are changed every 24 hours on the night shift. NJAC 8:39-25.2(c); 27.1 (a)

Based on observations, interviews, and review of pertinent facility documentation, it was determined that the facility failed to maintain infection control practices implemented to prevent the spread of infection in accordance with accepted national standards, Centers for Disease Control (CDC) guidelines by ensuring a.) proper sanitizing of point of care equipment, (blood pressure machine) between residents during the medication administration observation for one (1) of two (2) nurses observed while administering medications, b.) performing appropriate hand washing technique during the medication administration observation for one (1) of two (2) nurses observed while administering medications, c.) appropriate handling of medications during the medication administration observation for one (1) of two (2) nurses observed while administering medications to one (1) resident, d.) posting appropriate signage for contact isolation precautions (used to help stop the spread of germs from one person to another by alerting staff to utilize PPE when entering the resident's room) observed for 1 of 1 resident (Resident #170) and e.) appropriate donning (putting on) and doffing (taking off) of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP) observed for 1 of 1 resident (unsampled Resident #140).The deficient practices were evidenced by the following:According to the CDC Guideline for Hand Hygiene in Health-Care Settings, dated October 25, 2002, indicates when washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. 1. On 6/10/26 at 8:18 AM, during the medication administration observation, the surveyor observed the Licensed Practical Nurse (LPN #1) obtain a blood pressure (BP) using the blood pressure machine and cuff provided by the facility for unsampled Resident #64. On 6/10/26 at 8:38 AM, continuing the medication administration observation, the surveyor observed LPN #1 obtain a BP using the same blood pressure machine and cuff for unsampled Resident #132. The surveyor had not observed LPN #1 clean or disinfect the cuff before obtaining a BP or after obtaining a BP in between the two (2) residents. On 6/10/26 at 9:43 AM, the surveyor interviewed LPN #1 who acknowledged she had not disinfected the BP cuff in between the two residents during the medication administration observation. LPN #1 stated the correct method to clean the BP machine was to use the purple wipes before putting the BP cuff on a resident. On 6/10/26 at 1:18 PM, interviewed the Consultant Pharmacist (CP) via telephone who stated she does individual medication observations with the nurses and educates the nurse at the time for correct procedures which included infection control practices. CP added the nurses should disinfect the BP cuff before and after each resident. On 6/11/26 at 9:12 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN #1) who stated the nurses should wipe the BP cuff with the purple top wipes before and after each use. A review of the facility policy dated with a last review date of 12/10/26 for Sanitizing and Disinfecting of Reusable Equipment revealed the purpose was to prevent transmission of infectious agents through proper cleaning and disinfection of resident care equipment and devices used in resident care. The policy indicated all reusable resident care equipment such as blood pressure cuffs shall be cleaned and disinfected according to manufacturer instructions and infection prevention standards before use on another resident. In addition, the nursing staff was responsible for cleaning and disinfecting resident care equipment after each use. 2. On 6/10/26 at 8:49 AM, during the medication administration observation, the surveyor observed LPN #1 empty a urinal in the bathroom of unsampled Resident #132. Then, LPN #1 proceeded to wash her hands. LPN #1 turned on the faucet and lathered her hands with soap for three (3) seconds and placed her hands under the stream of water and scrubbed for 20 seconds. Upon returning to the medication cart, LPN #1 stated the Infection Preventionist (IP) had instructed her on the hand washing technique and timed them. LPN #1 added hand washing had to be 20 seconds and the hands should be scrubbed in the stream of water for 20 seconds. On 6/10/26 at 1:18 PM, interviewed the CP via telephone who stated she does individual medication observations with the nurses and educates the nurse at the time for correct procedures which included infection control practices. CP added she makes sure the nurses wash their hands when appropriate and felt the nurses took longer than 20 seconds to wash their hands but does not time them or watch whether the hands are being scrubbed in or out of the water. On 6/11/26 at 9:12 AM, the surveyor interviewed the UM/LPN #1 who stated the proper procedure for hand washing was lathering with soap and scrubbing the hands for 20 seconds outside the stream of water, then rinse with water. On 6/12/26 at 10:34 AM, the surveyor interviewed the IP/LPN in the presence of another surveyor. The IP/LPN explained the proper procedure for hand washing was to wet hands first then lather for at least 20 seconds outside of the stream of water and then rinse as per CDC recommendations. The IP/LPN added she performed Hand Hygiene Competency Validation reports for the nurses and inservices with handouts. A review of a Hand Hygiene Competency Validation for LPN #1 provided and completed by the IP/LPN dated 11/24/25 and 4/30/26 indicated the nurse was competent for hand hygiene with soap and water. A review of an inservice dated 4/14/26 to 4/16/26 given by the IP/LPN on Handwashing; Donning (putting on) & Doffing (taking off) of PPE (personal protective equipment): Cough Etiquette included lecture, handouts and demonstration was attended by LPN #1. A review of the CDC handout titled Your hands carry germs you can't see. Provided during the inservice included instructions on how to wash hands with steps to wet hands with clean water, soap them up, scrub them front and back, between fingers and under nails for 20 seconds then rinse with clean water. The surveyor observed the same handout posted throughout the facility. A review of the facility policy dated as last reviewed 4/8/26 for Hand Washing/Waterless Hand washing provided by the Licensed Nursing Home Administrator revealed handwashing, performed effectively by all personnel is essential for the prevention and control of infection. In addition, the procedure for the standard technique was to wet hands with water and apply enough soap to cover the hands and apply friction to all wetted surfaces, including between the fingers, for a period of 20 seconds and then rinse hands under running water from wrist to fingers. 3. On 6/10/26 at 9:31 AM, during the medication administration observation, the Registered Nurse #1 (RN #1) had prepared seven (7) medications in a medicine cup to be administered to unsampled Resident #128. RN #1 stated one of the medications was incorrect and was going to verify all the medications, remove the incorrect medication and replace it with the correct medication. The surveyor observed RN #1 take out two (2) tablets that she verified from the medicine cup containing the seven (7) tablets using her finger to push them into an empty medicine cup. RN #1 then stopped and put gloves on. RN #1 stated she put on gloves so she would not touch the medication with her hands. RN #1 proceeded to verify the medications and added the tablets to the medicine cup that contained the two (2) tablets she had pushed in using her ungloved finger. RN #1 discarded the incorrect medication and replaced it with the correct medication in the same medication cup. On 6/10/26 at 9:37 AM, the surveyor observed RN #1 administer the seven (7) tablets in the same medication cup to Resident #128. On 6/10/26 at 9:38 AM, the surveyor interviewed RN #1 who acknowledged she had touched two (2) of the medications with her finger before putting on the gloves. RN #1 acknowledged the tablets she had touched were all in the same medicine cup with the tablets she used the gloves on. On 6/10/26 at 1:18 PM, interviewed the Consultant Pharmacist (CP) via telephone who stated she does individual medication observations with the nurses and educates the nurse at the time for correct procedures which included infection control practices. The CP added the nurses were not to touch the medications with their hands. A review of the facility policy dated as reviewed 1/26 for Medication Administration provided by the Director of Nursing (DON) revealed infection control protocols must be maintained at all times. 4.On 6/10/26 at 8:19 AM, the surveyor observed signage posted at Resident #170's door for EBP (Enhanced Barrier Precautions is an approach of targeted gown and glove use during high contact resident care activities) and an orange-colored dot next to the resident's name on the name plate. The surveyor observed a bin containing PPE at the doorway. The surveyor observed Resident #170 resting in bed with their eyes closed. On 6/11/26 at 12:40 PM, the surveyor observed an orange-colored dot next to the resident's name on the name plate. The surveyor observed the EBP signage posted on the door and the PPE bin was available at the door. The surveyor observed the resident resting with their eyes closed. The surveyor reviewed the electric medical record (EMR) for Resident #170. A review of the admission Record (AR; an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; presence of left artificial hip joint, and Hepatic encephalopathy (a serious condition that occurs when the liver is unable to filter toxins from the blood, including ammonia from the intestines). A review of individualized comprehensive care plan (ICCP) initiated on 5/21/26 included a focus area for Enhanced Barrier Precautions, was at risk for transfer of MDRO (multi drug resistant organisms) due to:.history [hx] ESBL (Extended Spectrum Beta Lactamase; superbug / antibiotic resistant bacteria) left hip. Interventions included you will be under EBP for the duration of your stay with us. A review of Order Summary Report (OSR) included the following physician orders (PO): A PO #1 dated 5/5/26 for - Single Room Isolation / Contact Precautions (As per CDC guidelines, Everyone must put on gloves and gown before room entry) for ESBL left hip sx wound- resident in the room alone and remains in room with all services taken to the patient such as meals, therapy and activities, every shift ESBL in left sx wound A PO #2 dated 5/28/26 for - Enhanced Barrier Precautions (PICC (Peripherally inserted central catheter; a long, thin, flexible tube inserted into a vein in the upper arm), hx ESBL left hip), every shift A review of June 2026 Medication Administration Record (MAR) reflected PO #1 transcribed in the MARs. The MARs indicated a check mark with nurse's initials for each shift (Day, Evening and Night), which meant the nurses were signing off as completed / confirming the resident was on Single Room Isolation/Contact precautions. A review of June 2026 Treatment Administration Record (TAR) reflected PO #2 transcribed in the TARs. The TARs indicated a check mark with nurse's initials for each shift (Day, Evening and Night), which meant the nurses were signing off as completed / confirming the resident was on EBP. On 6/11/26 at 1:17 PM, during an interview with the surveyor, LPN #2 stated the resident had ESBL at their left hip surgical site. LPN #2 stated if a resident has ESBL, we usually keep them in a single room and further stated Resident #170 was on contact isolation precautions. She stated the resident had Contact Precaution signage at their room. The surveyor accompanied the LPN #2 to Resident #170's room and observed EBP signage posted on the door. In the presence of the surveyor, LPN #2 reviewed the POs and stated the resident had a PO for Single room isolation/ Contact Precaution and then confirmed the resident did not have the correct signage at their door. LPN #2 stated, for EBP, when the aides go into residents' room to provide care to the resident then they had to use gloves and gown up. LPN #2 further stated for Contact isolation precautions, no matter what we are doing with the resident such as if I am administering meds, feeding the resident, and even if we are not doing anything with the resident, we all have to use gloves and gown up before entering the resident's room. She stated it was important to have the correct signage at the resident's door due to the kind of infection the resident had and alerting other staff to put gloves and gown up before entering the resident's room. LPN #2 stated if she did not gown up before entering in the contact isolation room then she would be putting herself and other residents in danger. On 6/11/26 at 2:17 PM, the surveyor interviewed UM/LPN #2, who stated the resident was on IV antibiotics for ESBL at the Left hip surgical site. The surveyor made UM/LPN #2 aware of the above-mentioned findings. She stated, I believe [Gender Redacted] is now on EBP and was taken off of the isolation. In the presence of the surveyor, UM/LPN #2 reviewed the POs and confirmed the resident had POs for contact isolation. UM/LPN #2 was made aware that the nurses were signing off for Contact precautions on the MARs and EBP on the TARs. UM/LPN #2 stated if the resident was supposed to be on contact precautions and had EBP signage on the door, we are putting staff and the roommate at risk for spread of infection. On 6/12/26 at 10:34 AM, during an interview with the surveyor, the Infection Preventionist (IP) nurse stated she was responsible for facilitating the discontinuation of Transmission Based Precautions (TBP; which includes contact isolation) and once the TBP was discontinued, she would go out and take the signage off from the resident's door. The IP nurse stated she would speak with the residents and the staff to make them aware that the residents were off the isolation. The IP nurse stated she placed the EBP signage on Resident #170's door and further stated I forgot to discontinue the isolation order. The surveyor made the IP nurse aware of the above-mentioned findings. The IP nurse stated, I cannot answer why the nurses were signing off both orders for EBP and contact isolation. On 6/12/26 at 12:12 PM, during an interview with the surveyor, the Director of Nursing (DON) stated once the isolation precautions were discontinued, the PO should be discontinued from the EMR. The surveyor made the DON aware of the above findings for Resident #170. The DON stated the nurses should be checking what the correct order was and not signing off for something that was not active. 5. On 6/12/26 at 9:16 AM, during incontinence rounds with UM/LPN #2 and the Certified Nurse Aide (CNA) on the C Wing, the surveyor observed an Enhanced Barrier Precautions sign outside of unsampled Resident #140's door. The EBP sign included but were not limited to; Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Care Activities.Providing HygieneChanging briefs or assisting with toileting At that time, the surveyor observed a PPE bin containing gowns, gloves and surgical mask in the hallway at the door entrance. UM/LPN #2 and the CNA entered the room and then UM/LPN #2 asked the resident for permission to conduct an incontinence check. The resident granted permission, and the surveyor went into the room. UM/LPN #2 and the CNA performed hand hygiene and put gloves on. UM/LPN #2 then pulled the curtain and turned the resident to their left side. The surveyor observed the resident with a thin flexible tube connected to a drainage bag, which was placed on the right side of the bed. The surveyor observed UM/LPN #2 and the CNA did not wear the disposable gown. Upon exiting the resident's room, the surveyor inquired about the tube. UM/LPN #2 stated that it was a tube which was placed in the gallbladder and the drainage bag gets emptied every shift. The surveyor interviewed UM/LPN #2, who stated EBP was for residents with wounds, catheters, tracheostomies, IV antibiotics and for hemodialysis. UM/LPN #2 stated the resident had EBP signage on their door and PPE was not required if the staff were passing out meds (medications) or meals. UM/LPN #2 then stated PPE was required only if you were providing hands on patient care and confirmed that she should have put the gown on. UM/LPN #2 stated, donning PPE was important to protect me from getting what they (the resident) have and protecting them (the resident) as well. On 6/12/26 at 10:34 AM, the surveyor made the IP nurse aware of the above-mentioned findings for unsampled Resident #140. The IP nurse stated that when residents were on EBP, they were at risk for acquiring or transmitting MDRO, during high contact patient care. The IP nurse explained that the staff should follow precautions such as hand hygiene (HH), donning gown and gloves during care to prevent cross-contamination. The IP nurse stated they should have put on PPE this morning during incontinence rounds. The surveyor reviewed the EMR for unsampled Resident #140. A review of the AR revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; Ogilvie syndrome (a sudden, temporary paralysis of the large intestine), disease of digestive system (any health condition that prevents your body from properly breaking down food, absorbing nutrients, or removing waste) and gastrostomy (a surgical procedure to make a hole into the stomach through the abdomen to insert a feeding tube into the stomach) status. A review of the OSR revealed the PO for unsampled Resident #140 with a start date 1/2/26, for Enhanced Barrier Precautions every shift. On 6/12/26 at 1:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, the Regional Nurse and the Administrator in Training (AIT). The surveyor made the administration aware of the above-mentioned concerns for Resident #170 and unsampled Resident #140. A review of the facility's policy Enhanced Barrier Precautions last reviewed 4/14/26 included Policy: It is the policy of this facility to follow CDC guidelines by utilizing Enhanced Barrier precautions in the care of patients with multiple drug resistant organisms (MDRO) to reduce the spread of infection with MDRO even if the resident is asymptomatic. Enhanced Barrier Precautions – The use of gown and gloves for high-contact resident care activities is indicated,.with wounds and/or indwelling medical devices .Enhanced Barrier Precautions require: Use of gown and gloves during high-contact resident care activities – Changing briefs, incontinence pads, toileting assistance. A review of the facility's policy Infection Control / Transmission Based Precautions last reviewed 1/2026 included under section Transmission based tracer: Signs indicating a resident is on transmission-based precautions are clear and visible. NJAC 8:39-19.4 (a) (1) (2); (b)(n)

Complaint #s: NJ2676162, NJ2786980Based on observation and interview, it was determined that the facility failed to maintain the facility in a clean and sanitary environment. This deficient practice was identified for 1 of 4 units, (D Wing) and was evidenced by the following: On 6/09/2026 at 10:19 AM, during initial tour of D wing, the surveyor observed dark brown areas on the floors throughout the hallways. On 6/10/2026 at 8:58 AM, the surveyor observed the D wing hallways to have multiple dark brown areas on the floors. On 6/11/2026 at 10:01 AM, the surveyor observed the D wing hallways with wet floor signs in front of the nurse's station. The floor around the wet floor sign was observed with multiple dark brown areas. On 6/11/2026 at 10:15 AM, the surveyor interviewed a porter who stated that the floors were mopped daily as were the hallways. He further indicated that he had worked the prior two days and that the hallways on D wing were mopped daily. He further explained that D wing needed to be stripped and waxed, that this stuff (indicating to the floor) wouldn't come up with mopping. He was unsure how often the floors were stripped and waxed. When specifically asked about the area in front of D wing nurse's station, he stated the dirt was ground in and wouldn't come up. He indicated to the surveyor the area by the television and stated that area was stripped and waxed recently but the main hallway was not. The surveyor observed the area by the television observed to be without stains and was shinier. On 6/11/2026 at 10:27 AM, the surveyor interviewed the Administrator in Training (AIT) who indicated that the housekeeping director had resigned about two to three months ago. He explained that stripping and waxing the floors were a big job and they started with C wing, which was worse than D wing. He further stated that the floors were probably stripped and waxed once a year. He also stated that D wing was next and that it definitely needed it. When asked about the area in front of D wing nurse's station he agreed that it needed to be done but repeated that they started on C wing. On 6/11/2026 at 10:40 AM, the Licensed Nursing Home Administrator (LNHA) provided the resignation date for the housekeeping director, which was 1/8/26. On 6/12/2026 at 9:17 AM, the surveyor observed the porter buffing the hallways on the D wing. The surveyor observed the hallways to appear as they had on the prior days of the survey, with dark brownish areas evident. On 6/12/2026 at 9:42 AM, the surveyor interviewed the porter who was observed buffing the floor on D wing. He stated he was bringing the shine up. He also stated the floor had been previously mopped. When the surveyor asked about the marks and brown areas that were still present on the floor, he stated those were deep and would have to be stripped and scrubbed to take them up, then more wax applied.On 6/12/26 at 1:15 PM, the survey team met with the facility leadership and notified them of above concerns. The LNHA stated the schedule for stripping and waxing was twice yearly and that it was due in May; however, it was too humid due to the rain to do the floors at that time. On 6/15/26 at 8:55 AM, the surveyor reviewed the facility provided schedule for strip and wax of hallways which indicated:1st week November C wing hallways signed and dated for 11/12/25.4th week November A wing hallways signed and dated 11/15/25. 2nd week November C & D wing dayrooms with no date or signature.3rd week of November D wing hallways with no date or signature. On 6/15/2026 at 9:24 AM, the surveyor observed the hallway in front of D wing nurse's station had been stripped and waxed over the weekend. The floor in front of the nurse's station was noted to be shiny without any dark brown areas. No further information was provided by the facility. The surveyor reviewed the facility provided policy, Housekeeping Services, reviewed January 2026, which included: Purpose:To ensure a clean, sanitary, safe, and comfortable environment for residents, staff, visitors, and volunteers through the provision of comprehensive housekeeping services that comply with federal, state, and local regulations. Policy:The facility shall maintain an effective housekeeping program that promotes infection prevention and control, resident comfort, safety, and a homelike environment. Housekeeping services shall be provided on a routine and as-needed basis throughout the facility.Procedure: 1. General ResponsibilitiesHousekeeping staff shall maintain all resident care areas, common areas, administrative offices, and ancillary departments in a clean and sanitary condition.Cleaning schedules shall be maintained and documented.3. Common AreasCommon areas shall be cleaned according to established schedules and include:Lobbies and reception areas.Dining rooms.Activity rooms.Corridors and elevators.Nursing stations.Public restrooms.6. Floor CareFloors shall be maintained in a clean and safe condition.Wet floor signs shall be utilized during cleaning services.Stripping, waxing, buffing, and carpet cleaning shall be performed according to established schedules.9. Quality AssuranceRoutine environmental rounds shall be conducted by housekeeping supervisors.Deficiencies identified during inspections shall be corrected promptly.Housekeeping services shall be monitored through the facility's Quality Assurance and Performance Improvement (QAPI) program. N.J.A.C. 8:39-31.4 (a) (b) (f)

Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete reference checks for 10 out of 102 employees (Employee #7, #21, #22, #26, #33, #35, #50, #72, #91, #97) and b.) complete background checks for 14 out 102 employees (Employee #2, #19, #23, #29, #30, #35, #41, #50, #62, #70, #72, #76, #84, #97). This deficient practice was identified for newly hired employees reviewed since the last Department of Health recertification survey of 1/24/25. This deficient practice was evidenced by the following:On 6/9/26 at approximately 10:31 AM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), all newly hired employee files for active and inactive employees from 1/24/25 to the current date. 1.) A review of the employee personnel files revealed the following:For Employee #7, a Licensed Practical Nurse (LPN) with a date of hire (DOH) of 1/16/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 1/21/25.For Employee #21, a Recreation Aide with a DOH of 8/20/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 8/22/25.For Employee #22, an LPN with a DOH of 10/21/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 10/28/25. For Employee #26, an LPN with a DOH of 9/16/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 9/22/25.For Employee #33, a Registered Nurse (RN) Supervisor with a DOH of 3/13/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 3/24/25. For Employee #35, an LPN with a DOH of 1/10/26, there was no evidence of a reference check prior to the start of employment; a reference check was dated 1/27/26.For Employee #50, an LPN with a DOH of 4/29/25, there was no evidence of a reference check prior to the start of employment.For Employee #72, a Certified Nurse Aide (CNA) with a DOH of 3/13 /25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 3/24/25.For Employee #91, a Dietary Aide with a DOH of 11/3/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 11/10/25.For Employee #97, a Concierge with a DOH of 8/25/25, there was no evidence of a reference check prior to the start of employment; a reference check was dated 8/29/25. 2.) A review of the employee personnel files revealed the following:For Employee #2, a CNA with a DOH of 3/6/25, a background check was completed 10/30/23.For Employee #19, a CNA with a DOH of 3/13/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 3/14/25.For Employee #23, a Social Worker with a DOH of 1/21/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 2/10/25.For Employee #29, a Registered Nurse (RN) Supervisor with a DOH of 11/26/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 12/2/25.For Employee #30, a CNA with a DOH 11/17/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 11/18/25.For Employee #35, an LPN with a DOH 1/10/26, there was no evidence of a background check prior to the start of employment; a background check was completed on 1/27/26.For Employee #41, an LPN with a DOH 11/26/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 12/1/25.For Employee #50, an LPN with a DOH 4/29/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 10/30/25.For Employee #62, a CNA with a DOH 2/23/26, there was no evidence of a background check prior to the start of employment;a background check was completed on 2/26/26. For Employee #70, a Director of Admissions with a DOH 2/17/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 2/18/25.For Employee #72, a CNA with a DOH 3/13/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 3/14/25.For Employee #76, an LPN/Unit Manager (LPN/UM) with a DOH 5/19/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 5/20/25.For Employee #84, a Physical Therapist with a DOH 8/4/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 8/14/25.For Employee #97, a Concierge with a DOH 8/25/25, there was no evidence of a background check prior to the start of employment; a background check was completed on 8/26/25. On 6/11/26 at 1:43 PM the surveyor interviewed the Director of Human Resources who stated she was responsible for background checks, onboarding process, and setting up a new hire orientation. She further stated that a new employee cannot start until a background check and reference checks were completed. She then stated that the importance of reference checks and background checks prior to hire was to be in compliance with the state regulations. On 6/12/26 at 1:16 PM, in the presence of the survey team, the LNHA, Director of Nursing (DON), and Regional Nurse were made aware of the above concerns regarding reference checks and background checks for newly hired employees. The Regional Nurse stated that Human Resources (HR) was responsible for completing background checks and reference checks prior to hire. She further stated that the background checks should be fully completed prior to starting. On 6/15/26 at 10:00 AM, the survey team met with the LNHA, DON, Regional Nurse, and Administrator in Training (AIT). The LNHA acknowledged the reference checks and background checks should be completed prior to hire. A review of the facility's Abuse, Mistreatment, Neglect, Misappropriation of Resident's Property policy, last review 2/20/26 revealed .the facility shall ensure the screening and training of employees, protection of residents, and for the prevention, identification, investigation, and reporting of abuse, mistreatment, neglect, and misappropriation of property.Section I: Screening.All potential employees and applicants shall be screened for past arrests including a history of abuse and other crimes before being afforded a position within the facility.will obtain a waiver of written consent on the employment application indicating that hire for employment is contingent upon the completion of a satisfactory reference screening.shall obtain information from previous employers and or current employers to validate applicant references. A review of the facility's New Hire Process policy, reviewed 1/2026 revealed .Policy.Employment is contingent upon successful completion or required background checks, license verification, and health screenings.all offers of employment are conditional upon successful completion of the following.background checks.health screen.start date is contingent upon pre-employment requirements. NJAC 8:39-9.3(b)

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 2 of 10 residents (Resident #22 and Resident #153) reviewed for timing of assessments and was evidenced by the following: On 6/10/26, the surveyor reviewed the electronic medical records (EMR) of the residents in the Resident Assessment task which revealed:Resident #22 had an annual MDS with a date of 3/19/26 which was completed on 4/6/26 (due 4/2/26). Resident #153 had an annual MDS with a date of 5/14/26 which was completed on 5/29/26 (due 5/28/26).On 6/11/26 at 10:54 AM, the surveyor interviewed the Regional MDS Coordinator (RMDSC), who stated Resident #22's MDS should have been completed on 4/2/26 and Resident #153's MDS should have been completed on 5/28/26. He also stated that the facility MDS Coordinator resigned on 6/2/26. On 6/12/26 at 1:15 PM, the survey team met with facility leadership and notified them of the above concerns.On 6/15/26, no further information was provided by the facility.According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2025, page 2-17, the Annual assessment must be completed no later than the Assessment Reference Date + 14 calendar days.The surveyor reviewed the facility provided policy, MDS RAI Process reviewed 1/4/26, which included: Policy:It is the policy of [facility] to comply with the existing federal and state regulations governing the implementation of Resident Assessment Instrument (RAI) Process as basis for provision of quality of care to its residents. Purpose:To outline the procedure of identifying and addressing the resident's strengths and needs through the RAI process. NJAC 8:39-11.2 (e)

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 9 residents (Resident #121) reviewed for timing of assessments and was evidenced by the following: On 6/10/26, the surveyor reviewed the electronic medical records (EMR) of the residents in the Resident Assessment task which revealed: Resident #121 had a Quarterly MDS with a date of 2/5/26 was completed on 2/21/26 (due 2/19/26).On 6/11/26 at 10:54 AM, the surveyor interviewed the Regional MDS Coordinator (RMDSC), who stated Resident #121's MDS should have been completed by 2/19/26. He also stated that the facility MDS Coordinator resigned on 6/2/26.On 6/12/26 at 1:15 PM, the survey team met with facility leadership and notified them of the above concerns.On 6/15/26, no further information was provided by the facility.According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated October 2025, page 2-17, the Annual assessment must be completed no later than the Assessment Reference Date + 14 calendar days.The surveyor reviewed the facility provided policy, MDS RAI Process reviewed 1/4/26, which included: Policy:It is the policy of [facility] to comply with the existing federal and state regulations governing the implementation of Resident Assessment Instrument (RAI) Process as basis for provision of quality of care to its residents. Purpose:To outline the procedure of identifying and addressing the resident's strengths and needs through the RAI process. NJAC 8:39-11.2 (e)

Based on interviews, review of medical records, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to electronically transmit the Minimum Data Set (MDS, an assessment tool), within 14 days of completing the resident's assessment. This deficient practice was identified for 6 of 9 residents, (Sampled Resident # 8 and #22, Unsampled Resident #40, #60, #100, and #121) reviewed in the Resident Assessment Task for MDS record over 120 days old. This deficient practice was evidenced by the following:On [DATE] and [DATE], the surveyor reviewed the MDS history in the electronic medical records for the residents in the Resident Assessment task which revealed the following:Resident #8's Quarterly MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #21died in the facility on [DATE] and the Discharge Tracking was completed and transmitted [DATE] (completion due on [DATE] and transmission due [DATE]).Resident #22's Quarterly MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #40's Quarterly MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #43's Discharge MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #60's Quarterly MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #100's Quarterly MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #121's Quarterly MDS dated [DATE] was completed on [DATE] and transmitted on [DATE] (due [DATE]).Unsampled Resident #126 was discharged on [DATE], no discharge assessment was found in the electronic medical record (completion due [DATE] and transmission due [DATE]).On [DATE] at 10:54 AM, the surveyor interviewed the Regional MDS Coordinator (RMDSC) via telephone. He stated that all MDS assessments completed on [DATE] should have been submitted by [DATE] at the latest. He stated he wasn't sure what happened with Resident #43. He stated that the death tracking for Resident #21 should be completed within 7 days of the death. He confirmed there was no discharge MDS for Resident #126. He further stated that [DATE] was the week the MDS Coordinator in the facility had resigned. On [DATE] at 1:15 PM, the survey team met with facility leadership and notified them of the above concerns. On [DATE], no further information was provided by the facility. According to Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual dated [DATE], page 2-18, the Quarterly assessment must be transmitted no later than MDS Completion Date + 14 calendar days, page 2-19, the discharge assessment must be completed no later than discharge date + 14 calendar days with the transmission date no later than MDS completion date +14 days, and page 2-20, the Death in Facility tracking record must be completed no later than the death date + 7 calendar days with the transmission date no later than MDS completion date +14 days. The surveyor reviewed the facility provided policy, MDS RAI Process reviewed [DATE], which included: Policy:It is the policy of [facility] to comply with the existing federal and state regulations governing the implementation of Resident Assessment Instrument (RAI) Process as basis for provision of quality of care to its residents. Purpose:To outline the procedure of identifying and addressing the resident's strengths and needs through the RAI process. NJAC 8:39-11.2 (e) 3

Based on observations, interviews, record review and facility documents it was determined the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level 1 a.) was completed and b.) was accurate for a newly admitted resident. This deficient practice was identified for one of three residents reviewed for PASRR (Resident #68) and was evidenced by the following: On 6/9/2026 at 11:40 AM, during the initial tour, the surveyor observed Resident #68 lying in bed, with their eyes closed. On 6/10/2026 at 10:54 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #68.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility in April of 2026 with diagnoses which included but were not limited to; depression, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities), anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and Manic Episode, unspecified (involves extreme mood elevation, increased energy, and hyperactivity, often accompanied by disorganized behavior and impulsivity). A review of the admission Minimum Data Set (MDS), an assessment tool dated 4/17/2026, revealed the resident had a Brief Interview for Mental Status of 14 out of 15, indicating the resident was cognitively intact. Further review of the MDS, active diagnoses of anxiety disorder, depression, bipolar disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and activity levels). A review of the individual comprehensive care plan (ICCP) revealed a focus area of uses antidepressant and anti -anxiety medication r/t [related to] depression and anxiety, date Initiated: 04/11/2026.A review of the EMR revealed a PASRR dated 9/24/2025. Further review of the PASRR revealed under section two titled Mental Illness Screen was marked No for the resident having a diagnosis or evidence of a major mental illness or evidence of a major mental illness. Further review of the EMR did not reveal an updated PASRR for the most recent admission. On 6/12/2026 at 8:30 AM, the surveyor interviewed the Director of Social Services (DSS), who stated a PASRR was done on admission and was required for every resident. She stated the admissions department tried to request the PASRR from the hospital before admission but if the PASRR wasn't done, the social worker (SW) at the facility would do it. The DSS reviewed the EMR in the presence of the surveyor and stated the PASRR for Resident #68 was dated 9/24/2025. She stated the PASRR should have been reviewed for accuracy and updated if it was not accurate. The DSS reviewed the admission note from the SW dated 4/14/2026 and acknowledged the note did not include the PASRR was reviewed and accurate. On 6/12/2026 at 9:23 AM, the surveyor interviewed the Director of Nursing (DON), who stated a PASRR should be done with all new admissions that come from the hospital and if there were any changes, a new one should be done. She stated the purpose of the PASRR was for evaluation for a psych diagnosis and mental health. The DON stated the SW should make sure the PASRR was accurate and up to date. The DON stated, Absolutely psych diagnosis and mental health should be included, I believe it is on the 1st page. The DON stated if a resident had bipolar it should have been checked on the PASRR. On 6/12/2026 at 12:20 PM, the DSS provided the surveyor with an updated PASSR for Resident #68 dated 4/9/2026. She stated it was found in the admission's paperwork. Further review of the updated PASRR revealed under section two titled Mental Illness Screen was marked No for the resident having a diagnosis or evidence of a major mental illness or evidence of a major mental illness, which did not include the resident's diagnosis of bipolar. The provided updated PASRR had the same telephone number written on the top right corner on page 1, not in a space requested on the form, as the previous PASRR dated 9/24/2025.On 6/12/2026 at 12:30 PM, during a follow-up interview with the DON, the surveyor presented the PASRR dated 9/24/25 and the one dated 4/9/26 to the DON for review. The DON compared the 2 PASRRs and acknowledged the similarities in the forms. She stated, I will have to speak to the DSS. On 6/12/2026 at 1:16 PM, in the presence of the survey team, the Licensed Nursing Home Administrator, the DON, the Regional Nurse, and Administrator in Training were made aware of all the above-mentioned concerns. No additional information was provided. A review of the facility's policy Pre-admission Screening and Resident Review (PASRR) Policy last reviewed 8/1/2025 revealed it is the policy of this facility to comply with all federal and New Jersey Pre-admission Screening and Resident Review (PASRR) requirements to ensure that individuals with Serious Mental Illness (SMI).are appropriately identified, evaluated, admitted , and provided necessary services. No resident shall be admitted or retained in the facility without compliance with applicable PASRR requirements.A. Pre-admission Screening: 1, The facility shall ensure that a PASRR Level 1 Screening is completed before admission to the facility.3. Admissions personnel shall: review referral documentation. Obtain and verify PASRR documentation from hospitals. Ensure the completed Level 1 screening accompanies the resident at admission. Place PASRR documentation in the active medical record. NJAC 8:39-5-1 (a); 27.1(a)

Complaint #: NJ00187199 (406115), 2676162Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to timely provide incontinence care to residents who required assistance with the activities of daily living (ADL). This deficient practice was identified for 2 of 9 residents (Resident #7 and 141) reviewed for Incontinence care.This deficient practice was evidenced as follows:This deficient practice was evidenced as follows:1.) On 6/12/26 at 9:13 AM, during incontinence rounds with the Licensed Practical Nurse Unit Manager (LPN UM), Resident #7 was agreeable to be checked, and it was noted that the resident's incontinence brief was saturated with urine, the draw sheet was soaked with urine, and the bed pad was soaked with urine. The LPN UM confirmed Resident #7's incontinence brief was saturated with urine through to the draw sheet, and bed pad. The LPN UM stated the process for a resident who was incontinent was the resident should be changed at least every two hours, and the resident should not have been this soaked to maintain skin integrity. The LPN UM further stated the expectation was for the CNA to check the residents at the start of the shift. On 06/12/26 9:36 AM, during a follow up observation of Resident #7, the assigned CNA (CNA #1) confirmed that he did not check the resident at the start of the shift and confirmed the resident's night gown, draw sheet, and bed pad was soaked with urine. CNA #1 stated the resident should not have been this soaked, because it could cause bed sore, and that he should have changed the resident after feeding the other residents. The surveyor reviewed the electronic medical record (EMR) for Resident #7.A review of the admission Record (an admission summary) reflected diagnoses that included but were not limited to; Other Alzheimer's Disease, hyperlipidemia (high fats in the blood), and dementia (loss of memory).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/16/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. Further review of the MDS revealed the resident was dependent on staff for toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.A review of the individualized comprehensive care plan (ICCP) included a focus area for ADL self-care performance deficit related to (r/t) Alzheimer's, fatigue, impaired balance, musculoskeletal impairment, weakness initiated on 2/1/26, with interventions that included bathing/showering, personal hygiene/oral care requires maximum assistance of one person. 2.) On 6/12/26 at 9:46 AM, during incontinence rounds with the LPN/UM, Resident #141 was agreeable to be checked. The resident stated they were changed an hour ago. The resident's incontinence brief was very saturated with urine, the bed pad was wet, and the surveyor noted a very strong urine odor. The LPN/UM confirmed the resident's incontinence brief was saturated, confirmed the urine odor, and stated the resident should not have been left in this condition for wound prevention and skin integrity. On 06/12/26 10:15 AM, during a follow up observation of Resident #141 with the assigned Registered Nurse (RN), the resident was agreeable to be checked. The RN confirmed the resident's incontinence pad was soaked with urine and there was a very strong urine odor. The RN stated the resident should not have been left in this condition; the resident should have been changed earlier to protect the resident's skin and for dignity. The nurse also stated the resident often refused care. On 06/12/26 10:21 AM, during a follow up observation of Resident #141, the assigned CNA (CNA #1) stated when he did rounds, the resident stated they were changed an hour ago. CNA #1 stated he did not confirm if the resident was wet at the time, but stated the resident refused care. In the presence of the surveyor, the resident again stated that they were changed an hour ago. The resident was agreeable to be checked and was not resistive or refused care. The CNA then checked and confirmed that the resident's incontinence brief was soaked with urine through to the bed pad. CNA #1 told the resident that he was going to wash and do morning (AM) care. Again, Resident #141 was agreeable for the CNA to do AM care. The surveyor observed no refusal or resistance to care at this time.The surveyor reviewed the EMR for Resident #141.A review of the admission Record reflected diagnoses that included but were not limited to; cerebral vascular disease (conditions that affect blood flow and the blood vessels in the brain) and Dementia.A review of the most recent quarterly MDS, dated [DATE], indicated the resident had a BIMS score of 5 out of 12, indicating severely impaired cognition. Further review of MDS revealed the resident was dependent on staff for toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.A review of the ICCP revealed the resident had an ADL self-care performance deficit r/t Dementia initiated on 2/4/26, with intervention that included toilet use with one assist. Further review of the ICCP revealed no focus area for refusals or resistive to care.On 06/12/26 at 12:34 PM, during an interview with the surveyor, the Director of Nursing (DON) stated the residents should not have been left wet through to the bed pad for skin protection, hygiene, and infection control. The DON stated the CNAs should have changed the residents when the residents were wet. The DON also confirmed there was no refusal of care in Resident #141's care plan in the current EMR system.On 6/12/26 at 1:15 PM, the surveyor presented the above-mentioned concerns to the Licensed Nursing Home Administrator, the DON, the Administrator in Training, and the Regional Nurse.On 6/15/26 at 9:00AM, the DON submitted an updated care plan reflecting Resident #141's non-compliance and resistance to care at times, after surveyor inquiry.A review of the facility provided Care Plans, Comprehensive Person-Centered policy dated 10/1/21, last reviewed 1/28/26, revealed Policy Interpretation and Implementation 8.b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. A review of the facility provided Documentation policy dated 11/10, last reviewed 1/26, revealed Policy Statement, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation revealed 2. The following information is to be documented in the resident ('s) medical record: c. Treatments or services performed.A review of the facility provided Incontinence Care policy, dated 11/10, last reviewed 1/26, revealed Purpose, to ensure residents received individualized care that promotes comfort, dignity, skin integrity, and the highest possible level of incontinence. 4. Incontinence Products - change when soiled; 5. Skin Care and Infection Prevention - Provide perineal care after episodes of incontinence.A review of the facility provided undated CNA Job Description revealed, Duties and Responsibilities, under Personal Nursing Care Functions - keep residents dry (i.e. [that is] change gown, clothing, linen, etc. [and so on], when it becomes wet or soiled).A review of the facility provided undated RN Job Description revealed, Duties and Responsibilities - Supervises and coordinates nursing personnel in providing direct resident care in adherence to State and Federal regulations.A review of the facility provided undated UM Job Description revealed, Supervises that all nursing services personnel are following their respective job description; Make daily rounds of the Nursing Services Department to ensure that all nursing service personnel are performing their work assignments in accordance with the acceptable nursing standards. N.J.A.C.:8:39-27.1(a)

Based on observations, interviews, record review and 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 morning medication administration observation on 6/10/26, the surveyor observed two (2) nurses administered medications to four (4) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.41%. The deficient practice was identified for two (2) of four (4) unsampled Residents, (unsampled Resident #147 and #128), that were administered medications by one (1) of two (2) nurses that were observed. The deficient practices were evidenced by the following: 1. On 6/10/26 at 8:59 AM, during the morning medication administration observation, the surveyor observed the Registered Nurse (RN#1) obtaining blood pressure results from unsampled Resident #147. RN #1 asked the resident if they wanted their medications crushed. The resident stated they wanted their medications smashed in applesauce because it was easier to swallow. On 6/10/26 at 9:06 AM, the surveyor observed RN #1 preparing to administer five (5) medications to unsampled Resident #147. RN #1 stated Ferrous Sulfate (an iron supplement) was in a bottle because it was an over-the-counter house stock (OTC-HS) medication, meaning the facility provided the medication. RN #1 stated she was allowed to crush the medications and crushed the five (5) medications which included one (1) tablet of Iron (Ferrous Sulfate) 325 milligrams (MG). On 6/10/26 at 9:07 AM, the surveyor observed RN#1 administer the five (5) crushed medications which included the Ferrous Sulfate tablet in applesauce to unsampled Resident who stated, That was a little bitter. On 6/10/26 at 9:08 AM, upon returning to the medication cart, the surveyor with RN#1 reviewed the electronic medication administration record (EMAR) for the Ferrous Sulfate. There was no physician's order to crush the Ferrous Sulfate and there was no cautionary warning indicating the Ferrous Sulfate should not be crushed on the EMAR. (ERROR #1) On 6/10/26 at 12:24 PM, the surveyor interviewed RN #1 who stated there was no handout regarding medications that cannot be crushed on the medication cart. RN #1 also stated the cautionary warnings such as Do not crush were indicated on the medication package labelling from the provider pharmacy. RN #1 acknowledged the Ferrous Sulfate was an OTC-HS and there was no label with cautionary warnings from the provider pharmacy. RN #1 stated she knew the Ferrous Sulfate tablets could be crushed and the unsampled Resident #147 wanted their medications crushed. RN #1 added she could look up if any medication could be crushed on her phone. At that time, RN #1 reviewed her phone and stated Ferrous Sulfate could irritate the stomach but was not a hard stop on crushing the medication. RN #1 then closed her phone and had not shown the surveyor what she had read. RN #1 added the resident had breakfast and had no stomach issues. The surveyor reviewed the medical record for unsampled Resident #147. A review of the admission Record revealed diagnoses that included, but not limited to, anemia (a lack of enough healthy red blood cells). A review of a quarterly comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 4/2/2026, reflected the resident had a brief interview for mental status (BIMS) score of 12 out of 15, indicating that the resident had a moderately impaired cognition. A review of the Order Summary Report revealed an active physician's order (PO) with a start date of 12/17/25 for Ferrous Sulfate 325 MG tabs Give 1 tablet orally one time a day related to Anemia, unspecified Avoid dairy products. On 6/10/26 at 1:18 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated she does individual medication observations with the nurses and educates the nurse at the time for correct procedures. The CP added there was a list of medications that cannot be crushed that was provided to the facility. The CP also stated Ferrous Sulfate tablets cannot be crushed and should be changed to liquid form. The CP added she would instruct a nurse if she saw them crushing Ferrous Sulfate during a medication observation. A review of a Medication Pass Audit Tool provided by the Director of Nursing (DON) dated 1/12/26 completed by the CP for RN #1 indicated only products suitable for crushing were observed. On 6/11/26 at 8:51 AM, the DON provided the surveyor an inservice dated 4/14/26 for the topic Med Administration completed by the DON and the Assistant Director of Nursing and signed by RN #1 as attending. The inservice included a handout titled Drugs that SHOULD NOT be crushed developed by the CP. The handout revealed Ferrous Sulfate was not to be crushed. The inservice also included a handout titled Medications & Documentation which revealed instructions for crushing medications was to verify the medication may be crushed before preparation and to refer to the list of pharmacy medication. On 6/11/26 at 12:08 PM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated the OTC-HS medications usually had no cautionary warnings on the bottles, but the nurses could check. The UM/LPN added the CP lets the nurses know which medications cannot be crushed. The UM/LPN also stated if Ferrous Sulfate tablets needed to be crushed she would call the physician to change the physician's order to a liquid form. A review of a facility policy Medication Administration dated as reviewed 1/26, provided by the DON, reflected to obtain an order for crushing medications as appropriate or necessary as per manufacturer's directions. A review of the manufacturer specifications for Ferrous Sulfate revealed the tablets should be swallowed whole and do not crush, chew or break it. 2. On 6/10/26 at 9:37 AM, during the morning medication administration pass, the surveyor observed RN#1 administer seven (7) medications to unsampled Resident #128 which included a 25 MG tablet of Metoprolol Succinate (a medication used to lower blood pressure). There was no observation of a breakfast tray in the resident's room or collected trays in the hallway. On 6/10/26 at 9:38 AM, upon returning to the medication cart, the surveyor reviewed the medication label printed by the provider pharmacy for the Metoprolol Succinate 25 MG tablets which revealed a cautionary warning Take this drug preferably with or right after a meal. The surveyor, with the RN #1, reviewed the EMAR which indicated the Metoprolol Succinate had an administration time of 8 AM. RN #1 explained the EMAR indicated the medication was noted in a red color because it was late. RN #1 also explained she administered the most sensitive medications first such as insulin and that it was difficult to administer the 8 AM medications all at the same time. (ERROR #2) On 6/10/2026 at 9:53 AM, the surveyor interviewed a Certified Nursing Assistant (CNA #1) who stated Resident #128 had breakfast earlier and was unsure of the exact time. CNA #1 added that usually the trays are delivered by 7 AM and thought the resident would be finished by 8 AM. On 6/10/26 at 12:24 PM, the surveyor interviewed the RN #1 who stated Resident #128 was a very good eater for meals and always had a full stomach because they went to activities where there were many snacks. RN #1 could not speak to any difference between a medication ordered with a meal or with food. RN #1 also stated breakfast was delivered quite early between 7 to 7:30 AM. The surveyor reviewed the medical record for Resident #128. A review of the admission Record revealed diagnoses that included, but not limited to; heart failure and hypertension (high blood pressure). A review of a quarterly comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 4/23/2026, reflected the resident had a brief interview for mental status (BIMS) score of nine (9) out of 15, indicating that the resident had a moderately impaired cognition. A review of the Order Summary Report revealed an active PO with a start date of 2/17/26 for Metoprolol Suc (succinate) tab 25 MG ER (extended release), Give 1 tablet orally one time a day related to heart failure, unspecified, Hold for SBP (systolic blood pressure) less than 110. On 6/10/2026 at 1:18 PM, the surveyor interviewed the CP via telephone who stated she does individual medication observations with the nurses and educates the nurse at the time for correct procedures. The CP added the cautionary warnings were on the labels of the medication cards by the provider pharmacy and observed the nurses when she did a medication observation to see if the nurses were following them. The CP explained Metoprolol Succinate should be administered with food and felt if the medication was administered 30 minutes after a meal that was allowed. The CP further stated if breakfast was at 8 AM then a 9AM administration time was totally fine. The CP was unable to speak to whether with food or with a meal had different times of administration. On 6/11/26 at 8:51 AM, the DON provided the surveyor an inservice dated 4/14/26 for the topic Med Administration completed by herself and the Assistant Director of Nursing and signed by RN #1 as attending. The inservice included Medications Administration which revealed instructions before administration were to verify a physician's order and apply the Rights of Medication Administration which included the right time. A review of a Medication Pass Audit Tool provided by the DON dated 1/12/26 completed by the CP for RN #1indicated the medication label was compared to the EMAR to ensure the correct time and medications were given before, with, or after meals when ordered by the physician. On 6/11/2026 at 12:08 PM, the surveyor interviewed the UM/LPN who stated the nurses were able to filter the administration times of medications to know which medications were to be administered first and keep within the hour before and hour after an administration time. The UM/LPN stated RN #1 had not filtered the medications by time because she was not a regular nurse on the unit. The UM/LPN added the nurses were to follow cautionary warnings indicated on the labels and a medication indicating with a meal would have an administration time of 8 AM for the breakfast meal on the unit and should be administered as close to breakfast as possible. The UM/LN acknowledged 9:37 AM was not with a meal. A review of a facility policy Medication Administration dated as reviewed 1/26, provided by the DON, reflected medications were to be administered within a two-hour time frame (i.e. one hour before or after the medication order time. A review of the manufacturer specifications for Metoprolol Succinate revealed the medication should be taken with a meal or just after a meal. NJAC 8:39-11.2(b), 29.2(a)(d), 29.4(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure insulin was administered in accordance with physician ordered parameters to prevent significant medication (med) errors. This deficient practice was identified for 1 of 1 resident (Resident #19) reviewed for insulin administration. 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 6/10/26 at 8:23 AM, the surveyor observed Resident #19 eating breakfast in their bed. The resident stated that they get insulin. The surveyor reviewed the electric medical record (EMR) for Resident #19. A review of admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; alcoholic cirrhosis (a condition where the liver is severely damaged) of liver without ascites (abnormal buildup of fluid within the abdomen usually causing swelling, abdominal pain and sometimes breathing difficulties), type 2 diabetes mellitus (DM; a common, long-term condition where the body cannot effectively use or produce enough insulin, causing sugar (glucose) to build up in the blood) without complications, and hepatic encephalopathy (loss of brain function occurs when the liver is unable to remove toxins from the blood).A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 5/14/26, reflected that the resident had a Brief Interview for Mental Status score of 10 out of 15, which indicated that Resident #19 had moderately impaired cognition. Further review of the MDS indicated the resident had received insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) injections.A review of the resident's individualized comprehensive care plan (ICCP) revealed a focus area dated 6/9/25 for Diabetes Mellitus Type 2. Interventions included but were not limited to; diabetes medication as ordered by doctor. Monitor/document .Monitor blood sugar per MD (doctor of medicine) orders dated 6/9/25. A review of the Order Summary Sheet ([NAME]) included the following physician orders (POs): A PO, dated 4/8/26, for Humalog KwikPen (a prefilled, disposable insulin injection pen) Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) - Inject 5 unit subcutaneously before meals related to HYPERGLYCEMIA (high blood sugar). Hold for Blood Sugar (BS) less than 200. A review of the May 2026 electronic Medication Administration Record (eMAR) revealed that the above PO for Humalog insulin was marked with a check which indicated the medication was administered for 5 doses when the resident's BS was recorded less than 200 for the following dates:5/2/26 at 11:30 AM= BS 1895/6/26 at 7:30 AM= BS 1895/13/26 at 11:30 AM = BS 1815/19/26 at 11:30 AM = BS 1985/27/26 at (1630) 4:30 PM = BS 189A review of the June 2026 eMAR revealed that the above PO for Humalog insulin was marked with a check as administered for 3 doses when the resident's BS was recorded less than 200 for the following dates:6/4/26 at 7:30 AM= BS 1826/10/26 at 7:30 AM= BS 1236/10/26 at 11:30 AM = BS 138On 6/11/26 at 12:42 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated the check mark on the MARs meant the medication was administered. In the presence of the surveyor, the LPN reviewed Resident #19's POs and stated the resident received 5 units of Humalog before every meal and the insulin had hold parameters for if the BS was below 200 then the insulin would be held. The LPN stated Humalog insulin 5 units should not be given for a BS less than 200 as the resident was already getting insulin coverage as per the sliding scale and if the resident received 5 units for BS less than 200 then it could drop the BS. The surveyor reviewed the May 2026 eMAR and the LPN confirmed her initials and stated that it was her who administered insulin on 5/6/26 when the resident's BS was 189. The LPN acknowledged, It was a mistake and further stated she should have held the insulin. The LPN further stated that we should read the PO before med administration. On 6/11/26 at 1:58 PM, the surveyor interviewed the LPN/Unit Manager (UM), who stated Resident #19 was receiving 5 units of Humalog insulin before meals and the PO had parameters to Hold insulin if the BS was less than 200. In the presence of the surveyor, the LPN/UM reviewed the May 2026 eMAR and stated on 5/2/26 at 11:30 AM, it might have been her who administered the insulin when the resident's BS was 189. The LPN/UM stated the resident should not have received 5 unit of insulin because the BS was below the parameters and the insulin could drop the BS. The LPN/UM stated she should have paid more attention to the PO and should have called the physician when the resident's BS was less than 200. The surveyor made the LPN/UM aware of the above findings for May and June 2026. The LPN/UM acknowledged, I see the BS are low especially on 6/10/26, the BS were 123 and 138 and further stated the nurses need to follow the PO during med administration. On 6/12/26 at 12:12 PM, the surveyor made the Director of Nursing (DON) aware of the above concerns. The DON stated the insulin should not have been given for BS less than 200 as per the PO and the resident could have hypoglycemic (low BS) episodes which meant when the BS drops, the resident could feel weak, diaphoretic (excessive sweating due to a secondary condition), pass out and/or bottom out on us. On 6/12/26 at 1:15 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Nurse and the Administrator in Training (AIT). The surveyor made the administration aware of the above-mentioned concerns for Resident #19. A review of the facility's policy Insulin Administration date reviewed 1/26 did not address that the medications should be accurately administered as per physician orders. A review of the facility's Medication Administration policy date reviewed 1/26 did not address that the medications should be accurately administered as per physician orders. NJAC 8:39-11.2 (b); 29.2(d)

Based on observations, interviews, record review, and pertinent facility documentation, it was determined that the facility failed to ensure a.) a medication (Lactulose solution) was properly labelled for one (1) of four (4) medication carts inspected and b.) an expired refrigerated medication (Omeprazole solution) was removed from active inventory for one (1) of two (2) medication refrigerators inspected. The deficient practices were evidenced by the following: 1. On 6/10/26 at 8:16 AM, during the medication administration observation, the Licensed Practical Nurse (LPN #1) was preparing medications for unsampled Resident #64. LPN #1 stated there was a physician's order for Lactulose solution (a medication used to relieve constipation) and removed the bottle from the medication cart. The surveyor with LPN #1 reviewed the bottle for a label. LPN #1 stated the label came off but she knew the bottle of Lactulose was for unsampled Resident #64 and showed the surveyor a corner of a label remaining that was unreadable. LPN #1 asked the surveyor if that was allowed. A review of the Order Summary Report for unsampled Resident #64 revealed a physician's Order for Lactulose Oral Solution 10 GM (grams)/15 ML (milliters) Give 30 ML by mouth every 12 hours for constipation. On 6/10/26 at 1:18 PM, the surveyor interviewed the Consultant Pharmacist (CP) via telephone who stated she performed unit inspections every month at the facility. The CP also stated all medications should be labelled and any medication from the provider pharmacy should have a label which included the resident's name. The CP added she points out to the nurses any time a label was missing. On 6/15/26 at 9:59 AM, the survey team met with the facility administrative team. The Director of Nursing (DON) stated the Lactulose solution was ordered from the provider pharmacy with a label for unsampled Resident #64. 2. On 6/12/26 at 8:33 AM, the surveyor in the presence of the Unit Manager/LPN (UM/LPN) reviewed the unit medication refrigerator for active inventory of medications. The surveyor observed a 140 ML Omeprazole solution bottle with approximately 38 ML remaining with a Use By date of 5/29/26 for unsampled Resident #67. The UM/LPN stated the Omeprazole solution for unsampled Resident #67 should have been removed because it was past the use by date. A review of the Order Summary Report for unsampled Resident #64 revealed a physician's order with a start date of 12/16/25 for Omeprazole 2 MG/ML soln (solution) (20) Give 10 ML via g-tube (gastrostomy tube) (a tube inserted into the stomach) one time a day related to Gastro-esophageal Reflux Disease without Esophagitis (a chronic digestive condition where stomach acids flows back to the esophagus without inflammation of the esophagus) 10 ML = 20 MG. On 6/10/26 at 1:18 PM, the surveyor interviewed the CP via telephone who stated she performed unit inspections every month at the facility. The CP added that any expired medications should be removed from active inventory. On 6/15/26 at 9:59 AM, the survey team met with the administrative team. The Regional Nurse stated she called the provider pharmacy and was told the Omeprazole solution had a do not use beyond date that was further than the use by date. The Regional Nurse acknowledged the use by date, indicated on the medication, was the date the nurses would have to rely on whether to remove any medication from active inventory. A review of the facility policy dated as last reviewed 12/15/26 for Medication Storage which revealed the purpose was to ensure the safe, secure, and compliant storage of medications in order to maintain drug integrity, prevent diversion, reduce medication errors, and comply with all applicable federal, state, and regulatory requirements for long-term facilities. In addition, the policy indicated medications shall be kept in their original labeled containers and expired medications shall be removed immediately per facility procedure. NJAC 8:39-29.4(a)(g)

Based on interviews, record review, and review of other pertinent facility documents, it was determined that the facility failed to: ensure a physician's order to administer medication was followed for one of two residents reviewed, Resident # 2. Resident #2 did not received their Liothyronine medication (medication used to treat hypothyroidism) insufficient thyroid hormone. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.According to the intake forwarding to the New Jersey Department of Health (NJDOH) on 2/13/25, the complainant reported that they left the faciity on 2/5/25 AMA (Against Medical Advice), because they did not receive their Liothyronine as ordered by the physician. 1. On 10/30/25 at 10:30 AM, the surveyor reviewed the closed medical record for Resident #2. The admission Face Sheet) admission summary) reflected that Resident #2 was admitted to the facility with diagnoses which included but were not limited to, Acute and chronic respiratory failure with hypoxia, unspecified congestive heart failure and hypothyroidism.The Physician Order Activity Detail Report (POADR) dated 1/27/25 timed 8:22 PM, reflected an order to administer Liothyronine 25 micrograms (mcg) 1 tablet orally four times a day for hypothyroidism. Schedule: Every Day at 10:00 AM, 3:00 PM, 5:00 AM, and 8:00 PM. A review of a Progress Note (PN) dated 1/28/25 timed 3:04 PM, written by the nurse, reflected that Resident #2 was awake, alert and oriented to time, place and person and was able to make their needs known. Another (PN) dated 1/29/25 timed 3:09 PM, written by the Social Worker revealed that Resident #2 was able to make their requests known Further review of the electronic PNs revealed a note written on 1/29/25 timed 6:34 PM, by the nurse which revealed the following: Spoke with wife regarding Liothyronine medication. Explained to wife there was no communication that family will be providing this medication. Medication issue cleared up; family will be providing medication for now on. Resident received medication. On 10/30/25 at 10:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN /UM) regarding the process to obtain medications for new admission. The UM stated: The Unit Manager (UM) will review and enter the order into the computer. The Pharmacy will verify the order and sent the medication to the facility. If the medication was not available, the physician would be contacted, and the physician would usually write an order for a substitute. The UM stated she started in July and could not comment on the above concerns regarding Resident #2.On 10/30/25 at 11:32 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process of administering medications to residents. The DON stated that there would be a physician's order for medication administration and the order will be transcribed on the Medication Administration Record (MAR). The nurse would administer the medication and if the medication was not administered, the computer would prompt the nurse to add a comment. The surveyor then reviewed the medication administration record with the DON which showed that Resident #2 did not receive Liothyronine on 1/28/25 at 4:00 PM, 1/28/25 at 8:00 PM, 1/29/25 at 5:00 AM. Comment: Awaiting pharmacy delivery. There was no documentation that the physician was informed of the omission. On 2/1/25 and 2/2/25 Resident #2 did not receive Liothyronine as ordered at 8:00 PM, and there was no comment regarding the omission. The surveyor then asked the DON if Resident #2 should have received the Liothyronine as ordered, the DON stated that there should be a rationale added if the medication was not administered. The surveyor then asked the DON what her expectations regarding medications administration/ omission of medication was. The DON stated the physician, and the Unit manager were to be notified, the staff should have followed up with the pharmacy for a stat delivery or an alternative.A review of the facility provided policy titled, Policies, Procedures and Information last revised 12/27/24 included the following: POLICYIt is the policy of this facility to ensure that Medication Administration and Documentation occurs in a timely and accurate manner.The Electronic Medication Administration Record (EMAR) is the form onto which all medication orders are transcribed from physician electronic orders, from which medications are poured and administered and on which medication doses are documented. Under procedure the following were documented:Immediately notifies nursing supervisor if medication is unavailable for administration and notifies Physician/NP of the same. Contacts pharmacy to obtain medications.Documents administration of medication in the EMAR immediately following administration. Notes in the EMAR medications not administered (i.e. refused, etc.) and identifies reason. NJAC 8:39-29.2 (d)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] at 9:23 AM, during the initial tour of the facility kitchen in the presence of the Food Service Director (FSD) and the Regional FSD (RFSD), the surveyor observed the following: The FSD performed hand hygiene at the hand washing station and was timed by the surveyor using a digital stopwatch to lather her hands with soap for 16 seconds prior to rinsing. The trash receptacle by the hand wash station was positioned under a stainless-steel shelf which had a tray of clean plastic cups stacked. When the FSD used the foot pedal to open the receptacle lid, it hit against the tray of clean cups. Paper towels at the hand washing station were not stored in the paper towel dispenser, they were stored on the stainless-steel shelf above the trash receptacle, with the first few paper towels of the stack appeared to be wet. The exhaust hood spanning above the stove and cooking area had areas where the surface was showing paint chipping. The FSD acknowledged the hood needed to be resurfaced/painted. The food preparation area by the bread toaster, there were one brown and one white cutting boards, both had extensive discoloration, stained, and pitted. The drying rack had two yellow and one red discolored, stained, and pitted cutting boards. The FSD acknowledged the cutting boards were in use and should have been discarded. The walk-in freezer contained two opened boxes of corn on the cob dated opened [DATE], and one opened box of croissants with an opened date [DATE]. The plastic bags inside the boxes were opened exposing the contents to air. The corn showed signs of what the RFSD stated was freezer burn and acknowledged it should not be that way. On [DATE] at 10:32 AM, the surveyor interviewed the FSD, who stated that hand washing should be 30 seconds of lathering outside the flow of water; the trash bin should not be able to come in contact with clean kitchen supplies; and the paper towels should be stored in the dispenser and not on the shelf. On [DATE] at 11:59 AM, the surveyor interviewed the Infection Preventionist (IP) in the presence of the Director of Nursing (DON) and the survey team, who stated that the current Centers for Disease Control and Prevention (CDC) guidelines for hand washing was a minimum of 20 seconds of soap lathering prior to rinsing. The IP further stated that having a trash receptacle in the kitchen in a position where it can come in contact with clean kitchen supplies was not appropriate for infection control. A review of the facility's Hand Washing/Waterless Hand Washing policy with a last reviewed date of [DATE], included under the section labeled procedure, .b. wet your hands with water. c. apply enough soap to cover your hands. d. apply friction to all wetted surfaces, including between the fingers, for a period of 20 seconds. e. if a nail stick is used, clean the nails under running water. f. rinse hands under running water from wrist to fingers . A review of the facility's Dietary Sanitation Policy with an effective date of [DATE], included employees must wash hands for at least 20 seconds when they come in before they start their assignment, when they walk out of the kitchen and/or as needed . A review of the facility's food service Equipment in Use policy included all kitchen equipment are either fixed or replaced as they get damaged, small ware, pots, pans, dishes, cutting boards, can opener, and so on. It is up to the dietary department head to keep replacing them and maintained cleaned, sanitized before it is in use . A review of the facility's food service Environmental policy with an effective date of [DATE], included environmental rounds are done daily, this include dumpsters, patios, loading dock, kitchen, building in general .housekeeping is responsible for providing soap and hand sanitizer plus drying towels for the building . A review of the facility's food service Cold Food policy with an effective date [DATE], included all boxes must be checked, date manufactured, date which will be expired, they must be closed, unopened, once they are in the refrigerators or freezers, they must have a received date and always closed to avoid freezer burn, they must be rotated . NJAC 8:,d+[DATE].2(g)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 2 of 4 nursing units (A Wing and D Wing) reviewed for environmental concerns, and was evidenced by the following: 1. On 1/16/24 at 9:24 AM, the surveyor observed the A-wing nursing unit and identified the following concerns: The Shower Room was a large room with two shower stalls, three windows, and three metal wall heaters. The left shower stall had copious amount of standing water with a white milky coloring that filled half of the shower floor. Two of the three metal wall heaters had a red/orange discoloration on the heaters and on the tile under the heaters. The three window units' coverings were made of a thin paper-like material that contained holes throughout which did allow for privacy making the shower room visible from the outside. Resident Room #A-30 had a damaged window screen that did not fit into the window frame. On 1/16/25 at 11:18 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2), who stated that facility management was aware of the standing water in A-wing's Shower Room; that the water pooled every time the water was used. LPN/UM #2 acknowledged that the water had been stagnant for two hours since the surveyor's last observation. On 1/16/25 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON), who stated that LPN/UM #2 made her aware of the surveyor's concern. At that time, the surveyor and the DON toured the Shower Room together, and the DON acknowledged the shower water, the decolonization on the two heaters, and the window coverings in disrepair. The DON agreed and verbalized it was not a homelike environment for the residents. On 1/21/25 at 10:05 AM, the surveyor interviewed the Maintenance Staff (MS), who stated that there was an electronic maintenance system that all staff entered a problem or concern. The MS stated that the turn around time for maintenance work was same day or within twenty-four hours if no parts needed to be ordered. On 1/21/25 at 10:13 AM, the surveyor interviewed the Regional Maintenance Director (RMD), who acknowledged the surveyor's concerns with the Shower Room and the window screen. 44833 2. On 1/16/25 at 11:23 AM, during initial tour of the facility, the surveyor observed on the D Wing nursing unit the following: The wallpaper behind the resident's bed in Resident Room #D-4, bed two, had an approximated two and a half (2.5) inch wide by approximately four and a half (4.5) feet long section ripped off exposing the wall behind. The wall/wallpaper and vinyl baseboard along the base of the wall in the hallway next to the Shower Room by Resident Room #D-5 appeared to be wrinkled and coming off the wall. A portion of the vinyl baseboard next to the bathroom door in Resident Room #D-28 was missing and the drywall appeared to be damaged with a rust-like discoloration. On 1/23/25 at 1:31 PM, the surveyor interviewed the RMD, who stated that the facility utilized an electronic work order request system that all staff members had access to in order to notify maintenance of repairs needing to be completed. The RMD further stated that the facility was responsible to ensure that the building was in good repair to maintain a comfortable, homelike environment for all residents. On 1/23/25 at 10:45 AM, the Regional Nurse, in the presence of the Director of Nursing (DON), Assistant Administrator, and survey team acknowledged the surveyor's environmental concerns. A review of the facility's Quality of Life - Homelike Environment policy dated reviewed 12/20/24, included .residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment . NJAC 8:39-31.4(a)

Based on observation, interview, and reviewed of pertinent facility documents, it was determined that the facility failed to a) label, date, and store respiratory equipment in a manner to prevent contamination for infection control; b) obtain a physician's order for the administration of oxygen; c.) document the assessment of vital signs as ordered for a nebulizer treatment; and d) perform tracheotomy care with aseptic (sterile) technique to prevent infection. This deficient practice was identified for 3 of 4 residents reviewed for respiratory care (Resident #71, #73, and #85) and 1 of 1 resident reviewed for tracheostomy care (Resident #115), and was evidenced by the following: 1. On 1/16/25 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #85 sleeping in their bed. Resident #85 was receiving oxygen via nasal cannula (device that delivers additional oxygen through the nose) at 2 liters per minute (lpm). On 1/16/25 at 11:18 AM, the surveyor observed the nasal cannula tubing placed on the oxygen concentrator (device that delivers oxygen) unbagged and exposed to the air. On 1/17/25 at 11:20 AM, the surveyor reviewed the medical record for Resident #85. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; obstructive sleep apnea (sleep disorder that affects your breathing while you sleep), shortness of breath, Alzheimer's disease (brain disorder that causes memory loss), difficulty in walking, unspecified abnormalities of gait and mobility (abnormal walking pattern). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/3/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating a severely impaired cognition. A review of the Order Summary Report included a physician's order (PO) dated 1/8/25, for oxygen at 2 lpm via nasal cannula as needed if oxygen saturation (SPO2; percent of oxygen in a persons blood) was less than 92%. On 1/21/25 at 10:07 AM, the surveyor observed the nasal cannula tubing draped over the resident's nightstand, not bagged and exposed to the air. On 1/21/25 at 10:31 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #3), who stated that oxygen tubing should be stored in a bag when not in use. LPN/UM #3 further stated that the tubing should be stored in a bag for infection control purposes. At that time, LPN/UM #3 accompanied the surveyor to the resident's room and confirmed that the resident's tubing was draped over the resident's nightstand, not bagged and exposed to the air. LPN/UM #3 then replaced Resident #85's oxygen tubing, dated it, and placed it in a bag. On 1/21/25 at 10:47 AM, the surveyor interviewed the Director of Nursing (DON), who stated that oxygen tubing was changed once a week on the night shift. The DON further stated that oxygen tubing should be stored in a bag when not in use for infection control purposes. On 1/21/25 at 12:11 PM, the surveyor interviewed the LPN Infection Preventionist (IP), who stated that all oxygen tubing was required to be changed on the night shift once a week. The IP also explained that all respiratory tubing had to be labeled with a date and stored in a designated respiratory bag with the resident's name. She confirmed that if the tubing was not stored correctly in a bag and exposed to air, it could become contaminated. On 1/23/25 at 10:43 AM, the Regional Nurse, in the presence of the DON, Regional Administrator, and the survey team, confirmed that oxygen tubing should be stored in a bag when not in use to ensure it did not touch any surfaces and become contaminated. 2. On 1/17/25 at 12:04 PM, the surveyor observed Resident #71 in their bedroom sitting on the side of the bed. The surveyor observed an oxygen concentrator near the resident's bed. Resident #71 stated that they put on their own oxygen at night and removed it in the morning. The resident stated that the facility did not provide a bag to store the oxygen tubing in when not in use. The oxygen tubing was observed lying on the resident's bed, not bagged, and exposed to air. The surveyor did not observe any bag to store the oxygen tubing. On 1/17/25 at 11:44 AM, the surveyor reviewed the medical record for Resident #71. A review of the Resident Face Sheet reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic obstructive pulmonary disorder (lung disease that makes it difficult to breathe), shortness of breath, wheezing (high pitched sound that occurs when the airways in the lungs become narrow), and seasonal allergic rhinitis (allergic reaction that causes sneezing). A review of the most recent comprehensive MDS dated [DATE], indicated the resident had a BIMS score of 15 out of 15, indicating a cognitively intact cognition. A review of the Order Summary Report did not include a physician's order for oxygen. On 1/21/25 at 10:31 AM, the surveyor interviewed LPN/UM #3, who stated that oxygen tubing should be stored in a bag when not in use. LPN/UM #3 further stated that the tubing should be stored in a bag for infection control purposes. On 1/21/25 at 10:47 AM, the surveyor interviewed the DON, who stated that oxygen tubing was changed once a week on the night shift. The DON further stated that oxygen tubing should be stored in a bag when not in use for infection control purposes. On 1/21/25 at 12:03 PM, the surveyor interviewed LPN #2, who stated Resident #71 used oxygen at night as needed. The surveyor asked LPN #2 to confirm the physician's order for the oxygen, and LPN #2 stated that there was no physicians order for the oxygen and acknowledged that there should have been. LPN #2 further stated that she would submit a physician's order for the oxygen at that time. On 1/21/25 at 12:11 PM, the surveyor interviewed the IP, who stated that all oxygen tubing was required to be changed on the night shift once a week. The IP also explained that all respiratory tubing had to be labeled with a date and stored in a designated respiratory bag with the resident's name. She confirmed that if the tubing was not stored correctly in a bag and exposed to air, it could become contaminated. The IP further stated that any resident that required oxygen should have a physician's order. On 1/23/25 at 10:43 AM, the Regional Nurse, in the presence of the DON, Regional Administrator, and the survey team, stated that oxygen tubing should be stored in a bag when not in use to ensure it did not touch any surfaces and become contaminated. The Regional Nurse further stated that there should be a physician's order for any resident that required oxygen, and she acknowledged that there was no physician's order for Resident #71's oxygen until surveyor inquiry. A review of the facility's Respiratory Tubing policy dated reviewed 12/17/24, included . Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: .7. Store the circuit in plastic bag, marked with date and residents name, between uses . A review of the facility's Oxygen Administration policy dated reviewed 12/17/24, included .Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration (for new admission check hospital discharge summary for oxygen orders and verify with admitting MD.) 2. Review the residents care plan to assess for any special needs of the resident . A review of the facility's Physicians Orders policy dated reviewed 12/17/24, included .Policy: It is the policy of our center to write physicians orders to establish a plan of care to follow for the care of the patient. Physician's orders are grouped into types of orders. Treatment Medications and Treatment orders: All treatments should include the treatment to be used and location of where the treatment should be placed, frequency and if appropriate, how the area should be cleaned and how it should be covered. Reason for the treatment required (diagnosis). This will be reflected on the Treatment Administration Record (TAR) . 33106 3. On 1/16/25 at 10:15 AM, the surveyor observed Resident #73 lying in bed with a nebulizer machine (a small breathing machine that turns liquid medication into a mist that can be inhaled, a nebulizer allows medication to enter the lungs directly) on the bedside table with the tubing and mask undated and uncovered lying on the resident's personal belonging. The resident stated that they used the nebulizer machine at times to help them breathe better. On 1/17/25 at 11:25 AM, the surveyor observed a nebulizer machine on the bedside table with the nebulizer tubing undated and uncovered lying in the resident's drawer on the resident's personal belonging. 1/17/25 at 11:45 AM, the surveyor reviewed the medical record for Resident #73. A review of the Resident Face Sheet indicated that Resident #73 was admitted to the facility with the diagnoses which included but was not limited to; Parkinson's Disease and chronic obstructive pulmonary disease. A review of the most recent comprehensive MDS dated [DATE], indicated that the resident was cognitively intact and required moderate assistance with activities of daily living. A review of the physician's order (PO) dated 12/30/24, for a bronchodilator ipratropium 0.5 milligram (mg) and albuterol 3 mg (2.5 mg base) per 3 milliliters (ml) nebulization solution to be administered by inhalation route every six hours as needed for fifteen minutes. The PO instructed the nurse to obtain pre and post lungs sounds, pre and post vital signs (VS), oxygen saturation (measures oxygen levels in the blood), and enter the number of minutes that it took the nurse to administer the medication and document in the comment section of the Medication Administration Record (MAR). On 1/17/25 at 11:45 AM, the surveyor reviewed the MAR which revealed that on 1/5/25 at 9:36 AM, the resident received the nebulizer treatment ipratropium nebulization solution which required the nurse to document in the comment section of the MAR the resident's pre and post lung sounds, blood pressure, oxygen saturation, pre and post VS, and the number of minutes it to to administer the medication. In the comment section, the nurse documented that these vital signs were not collected and there were no documented pre or post lung sounds, or minutes that it took to administer the medication. On 1/17/25 at 11:55 AM, the surveyor reviewed the Progress Notes (PR) and there were no Progress Notes documented on 1/5/25, regarding why the resident received the nebulizer treatment, pre and post lung sounds, pre or post VS, or how many minutes it took to administer the medication. On 1/21/25 11:13 AM, the surveyor interviewed the LPN #5, who stated that nebulizer tubing should be labeled and dated and put into a designated respiratory storage bag to protect the tubing from contamination. LPN #5 explained that a PO was required to change and date the nebulizer tubing and the facility's process was that all respiratory tubing was changed on Thursday by the nurses on the 11:00 PM to 7:00 AM shift. LPN #5 added that if the resident's tubing had been left unbagged and lying on the resident's table or anywhere else that it should not be, it was because the resident and the resident's responsible party (RP) were constantly moving stuff in the resident's room and they were probably removing the tubing from the bag and placing it on the resident's bedside table or in the resident's bedside drawer. LPN #5 stated that Resident #73 and their RP required education on the importance of keeping the tubing free from contaminates by not placing the tubing on top or under the resident's personal belongings. At that time, LPN #5 accompanied the surveyor to the resident's room and confirmed that the resident's tubing was not labeled or dated and was laying on the bedside table with personal belongings piled on top the tubing and nebulizer machine. On 1/21/25 at 11:30 AM, LPN #5 reviewed with the surveyor Resident #73's medical record. A review of the physician's orders and Treatment Administration Record (TAR) confirmed there was not a physician's order to change the resident's nebulizer tubing. LPN #5 confirmed that it was not included on the individualized comprehensive care plan (ICCP) that the resident removed the nebulizer tubing from the respiratory bag and placed it on top of and under personal belongings and it should have been documented the resident was educated on the importance of keeping their nebulizer tubing bagged. LPN #5 reviewed Resident #73's MAR and confirmed that the resident received a nebulizer treatment on 1/5/25 at 9:36 AM, and there was no documentation in the comment section of the MAR that Resident #73's blood pressure (B/P), oxygen saturation, pulse, or respiration were obtained pre and post nebulizer treatment. There was also no documentation of pre or post lung sounds or documentation regarding how many minutes it took to administer the medication. On 1/21/25 at 12:07 PM, the surveyor interviewed the LPN Infection Preventionist (IP), who stated that all oxygen tubing and nebulizer tubing were required to be changed on the night shift once a week and documented on the TAR. The IP also explained that all respiratory tubing had to be labeled with a date and stored in a designated respiratory bag with the resident's name. The IP confirmed that if the tubing was not stored correctly and the tubing was not covered and protected, it could become contaminated. On 1/21/25 at 12:54 PM, the surveyor interviewed LPN/UM #3, who stated that if a resident was on a nebulizer treatment, the nurse was required to document pre and post VS to include oxygen saturation, pre and post lung sounds, and how many minutes the treatment was administered which was usually approximately 15 minutes. At that time, LPN/UM #3 reviewed Resident #73's MAR and confirmed that the nurse did not follow the PO for documentation of pre and post VS, oxygen saturations, pre and post lung sounds, or how many minutes it took to administer the medication. LPN/UM #3 stated that the nurse also did not document in the Progress Notes and confirmed that there was no order to change the nebulizer tubing weekly. LPN/UM #3 stated that the nebulizer tubing should be stored in designated respiratory bag dated with the resident's name, and if the resident had a history of removing the respiratory tubing from the bag or moving the tubing around the room, it should be included in their ICCP. On 1/23/25 at 10:54 AM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated that the nurses should be documenting pre and post VS to include oxygen saturation, pre and post lung sounds, and how many minutes the treatment was administered in the supplemental (comment) section of the MAR. The RDON also added that all respiratory tubing should be dated and stored in a bag to prevent contamination of the tubing. A review of the facility's Administering medications through a small volume Nebulizer policy dated 12/20/24, included the purpose of this procedure was to safely and aseptically (free from microorganisms) administer aerosolized particles of medication into the resident's airway .staff were to obtain and document the resident's pulse, respiratory rate and lung sounds, date and time the length of the treatment and to obtain VS pre and post treatment . A review of the facility's Care Plans, Comprehensive Person-Centered policy dated 12/17/24, included a comprehensive person-centered care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs . A review of the facility's Respiratory Tubing policy dated 12/17/24, included respiratory equipment (oxygen cannula, tubing reservoir and distilled water) would be marked with date and initials and that oxygen cannula and tubing would be stored in a plastic bag when not in use . 45208 4. On 1/16/25 at 11:30 AM, the surveyor observed Resident #115 lying in bed with a tracheostomy (trach; a surgically created opening in the neck that allows air to reach the lungs) and tracheostomy collar (are used to hold tracheostomy tubes in place; they wrap around the neck and secure with either Velcro or ties) connected to an oxygen (O2) concentrator at four liter per minute (4 lpm) providing O2 therapy. On 1/21/25 at 10:40 AM, the surveyor reviewed the medical record for Resident #115. A review of the Resident Face Sheet reflected the resident was admitted to the facility with diagnoses including acute respiratory failure with hypoxia and tracheostomy care. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/17/24, reflected that the resident had a BIMS score of a 15 out 15, which indicated a fully intact cognition. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated 8/9/24, for enhanced barrier precautions (a set of infection control practices that use personal protective equipment (PPE) to reduce the spread of multidrug resistant organisms (MDRO's). Interventions included to provide trach care per physician's order. An additional focus area dated 8/9/24, for tracheostomy with interventions to provide trach care and maintenance per physician's order. A review of the Physician's Orders (PO) included the following: A PO dated 8/26/24, to administer oxygen at 4 lpm via trach collar continuous for 35% trach collar. A PO dated 8/8/24, to perform trach care every shift. On 1/21/25 at 11:27 AM, the surveyor observed LPN #4 perform trach care on Resident #115 and observed the following: LPN #4 performed hand hygiene using alcohol-based hand rub (ABHR) and donned PPE of a gown and gloves. LPN #4 removed the gauze dressing from the resident's trach and discarded it into the trash receptacle. Then without performing hand hygiene or changing his gloves, LPN #4 proceeded to walk across the room and [NAME] through supplies to obtain clean gauze and normal saline solution (NSS). With the same contaminated gloves, LPN #4 opened the sterile trach care kit, which he held in his left hand, and then proceeded to clean the surface of the bedside table with a germicidal wipe in his right hand. LPN #4, with the same gloves since removing the resident's trach gauze, placed a protective sheet on the bedside table and placed the trach kit on top. With no observed hand hygiene or glove change, LPN #4 proceeded to touch the sterile gauze from the trach care kit to begin cleaning the resident's trach stoma. At that time, the surveyor asked LPN #4 to stop the treatment. LPN #4 then removed his gloves, performed hand hygiene using soap and water, donned new gloves, and placed clean gauze on the resident's trach stoma. On 1/21/25 at 11:44 AM, the surveyor interviewed LPN #4, who acknowledged he did not perform hand hygiene and aseptic technique according to facility policy and regulatory standards while attempting to perform tracheostomy care. On 1/21/25 at 11:44 AM, the surveyor met with the LPN/UM #2 in the presence of LPN #4, who acknowledged the concerns the surveyor observed during trach care. On 1/21/25 at 12:00 PM, the surveyor interviewed the Infection Preventionist (IP), who stated she conducted education and performed competencies with all staff. The IP stated if they were an Agency Nurse, the unit manager went over special competencies that directly related to the resident's care. The IP acknowledged the surveyors concerns for infection control and hand hygiene during trach care. On 1/22/25 at 1:04 PM, the surveyor interviewed the DON, who stated that facility staff or agency should be able to perform trach care under their scope of practice and competencies were reviewed with upon entering the facility. On 1/23/25 at 10:44 AM, the survey team met with the Assistant Administrator, Regional Nurse, and DON, who all acknowledged the surveyor's concerns for trach care and infection prevention. No other documents were provided. A review of the facility's Tracheostomy Care/Tracheal Suctioning policy dated revised 12/17/24, included policy: to ensure the timely removal of secretions on the inner cannula to maintain a patent airway and help prevent infection, coupled with close monitoring of the stoma site. Procedure .tracheostomy care will be ordered & performed with aseptic technique .both tracheostomy care and tracheal suctioning will be performed with aseptic technique . A review of the facility's Infection Control Policy, Procedure, and Information policy dated revised 12/10/24, included Policy: handwashing, performed effectively by all personnel is essential for the prevention and control of infection. Procedure: Hands should be washed .before and after donning and doffing PPE when handling residents on transmission-based precautions .and after handling soiled dressing . NJAC 8:39-11.2(b); 19.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) that a physician's ordered pain medication specified a pain level and b.) appropriate monitoring of pain with adequate assessment and re-assessment was consistently completed for a resident who exhibited pain. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #133), and was evidenced by the following: On 1/16/25 at 9:39 AM, the surveyor interviewed Resident #133 who was sitting at the side of the bed. The resident was cognitively intact and stated that they were admitted to the facility with a right below knee amputee (BKA). The surveyor observed that the resident had a dressing intact to the right stump area and that was wrapped in a bandage. The resident reported that they had frequent pain in the surgical area of the right stump. On 1/17/25 at 10:20 AM, the surveyor reviewed the medical record for Resident #133. A review of the Resident Face Sheet reflected the resident was admitted to the facility with the diagnoses which included but was not limited to; heart failure and right BKA. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/30/24, indicated that Resident #133 was cognitively intact and required partial to moderate assistance with activities of daily living (ADLs). The MDS also reflected that the resident occasionally had pain at a level of five on the numeric pain scale 0-10. A review of the Physician Order Activity Report (POAR) included a physician's order (PO) dated 12/23/24, for the pain medication acetaminophen (Tylenol) 325 milligram (mg) tablets; give two tablets (650 mg) by oral route every six hours as needed for pain and to monitor pain and follow up in 60 minutes. There was no documentation in the PO as to what the resident's pain level should be before the administration of the pain medication. A review of the corresponding Medication Administration Record (MAR) reflected that the resident received Tylenol on 12/24/24 at 5:52 AM. There was no documentation that there was follow-up regarding the effectiveness of the medication in 60 minutes as ordered. An additional review of the POAR included a PO dated 12/24/24, for the narcotic pain medication oxycodone acetaminophen (Percocet) 5 mg-325 mg; give one tablet by oral route every four hours as needed for moderate to severe pain (4-10). A review of the corresponding January 2025 MAR from 1/1/25 to 1/16/25, Resident #133 received pain medication on 15 out of 16 days. The MAR revealed that the facility had no documentation that the resident was assessed for a pain level, location of pain, description of pain, or if the pain medication was effective at controlling the resident's pain on the following dates: 1/1/25, 1/2/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25 and 1/16/25. A review of the Nursing Progress Notes reflected that there was no consistent documentation that indicated where the resident had complaints of pain, what the level the pain was, or if the pain medication that the resident received was effective at controlling the resident's pain from 1/1/25 until 1/16/25. The surveyor reviewed the POAR which reflected a PO dated 12/23/24, to monitor the resident's pain every shift according to the following pain scale: 0 = no pain, 1-4 = mild pain, 5-6 = moderate pain, 7-8 = severe pain, 9-10 = very severe horrible pain. A review of the corresponding January 2025 MAR from the dates of 1/1/25 to 1/16/25, the resident only had documented complaints of pain on 1/3/25, 1/10/25, 1/12/25, 1/15/25 and 1/16/25, however the resident was administered pain medication on the following dates: 1/1/25, 1/2/25, 1/3/25, 1/5/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/10/25, 1/11/25, 1/12/25, 1/13/25, 1/14/25, 1/15/25, and 1/16/25. A review of the individualized comprehensive care plan (ICCP) included a focus area for the resident's pain. Interventions included that the resident would be assessed for pain and a baseline through pain assessment. On 1/17/25 at 9:45 AM, the surveyor interviewed the Certified Nursing Aide (CNA #1), who stated that Resident #133 only required supervision for all aspects of ADLs, and that the resident complained of severe pain in their surgical amputation site and would request to see the nurse for pain medications. On 1/17/25 at 10:11 AM, the surveyor interviewed the resident's Physical Therapist (PT), who stated that the resident had a new right knee BKA and was working on strengthening so that the resident would eventually receive a prosthetic. The PT stated that the resident complained of phantom pain in the right lower extremity and the nurse usually provided pain medication prior to attending PT. The PT stated that the resident also complained of right shoulder pain, and they complained to the PT that they had not received their pain medication prior to participating in PT. The PT stated that he was not sure if the pain medication was administered as needed (PRN) or routine. On 1/17/25 10:36 AM, the surveyor interviewed LPN #5, who explained that if a resident had complaints of pain, she tried non-pharmalogical approach to pain management, and if that was ineffective, she asked the resident what their pain level was to administer the proper as needed (PRN) medication. LPN #5 stated that pain medications were administered according to what the resident's pain level was, and the nurse was responsible to document location of pain, level of pain and type of pain. LPN #5 stated this documentation was located in the Progress Notes as well as the MAR in the comment section. LPN #5 stated the nurse was also responsible to monitor and document the effectiveness of pain medication. At that time, LPN #5 reviewed Resident #133's MAR and Progress Notes with the surveyor and confirmed there was no consistent documentation regarding the pain level the resident had, location of the pain, or if the pain medication was effective at managing the resident's pain. LPN #5 stated that the nurses were sometimes busy and forgot to document. On 1/17/25 at 11:56 AM, the surveyor interviewed LPN/Unit Manager (LPN/UM #3), who stated that the resident's Tylenol order should have a numeric number level for when the pain medication should be administered to the resident. LPN/UM #3 stated that when a nurse administered a pain medication, the nurse was responsible to document where the pain location was, pain level, when the pain started, and a description of the pain. LPN/UM #3 stated the nurse documented in the Progress Note and the comment section of the MAR because it was important to follow-up with the resident to assure continuity of care and to monitor the effectiveness of the pain medication given. LPN/UM #3 stated that the nurses were not documenting, it could mean lack of education. On 1/23/25 at 10:48 AM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated a physician's order should contain a pain level for pain medications; all assessments of resident's complaints of pain should be documented in the supplemental documentation (comment section) located in the MAR which included the resident's pain level, description of the pain, location of the pain, and follow- up to assure the effectiveness of the pain medication administered. A review of the facility's Pain Management and Documentation policy dated 12/23/24, indicated that the facility utilized the electronic medical record (EMR) to monitor pain and pain response using the pain rating score, assess resident's pain level and monitors the resident's response to pain interventions including side effects and documents response. A review of the facility's Physician's Orders policy dated 12/17/24, included that the policy of the center was to write physician's orders to establish a plan of care to follow for the patient. The orders were to include monitoring should include height, weight, vital signs, blood sugar, pulse [oximetry]. This included entering a value for the monitoring . NJAC: 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain a resident's dignity while providing feeding assistance. This deficient practice was identified for 1 of 29 residents observed for dignity (Resident #7), and was evidenced by the following: On 1/16/25 at 12:09 PM, during initial tour of the facility, the surveyor observed Resident #7 in bed in their room with a Certified Nurses Aid (CNA #3) providing feeding assistance to the resident. CNA #3 had the tray table with the lunch tray back and slightly to the side behind her while she stood over Resident #7 feeding them. CNA #1 was observed turning away from the resident to obtain a spoonful of food which was positioned away from the resident and she was not seated alongside the resident during this care. On 1/17/25 at 11:02 AM, the surveyor observed Resident #7 in their room, who informed the surveyor that the CNAs in the facility usually stood while assisting them with their meal. Resident #7 stated that one CNA sometimes sat on the side of the bed to assist them with feeding, which caused the resident to have to move their leg slightly so that the CNA could sit. On 1/22/25 at 10:56 AM, the surveyor reviewed Resident #7's medical record. A review of the Resident Face Sheet (an admission summary) indicated that the resident was admitted to the facility with diagnosis which included but was not limited to; legal blindness, weakness, cerebral infarction (stroke). A review of the resident's Physicians Orders Summary included a physician's order (PO) dated 10/29/2024, for a low fat, soft consistency diet. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/19/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. A review of Section GG - Functional Abilities, indicated that the resident required substantial/maximal assistance with eating, meaning the helper did more than half of the effort with feeding. On 1/22/25 at 11:59 AM, the surveyor observed CNA #2 assisting Resident #7 with their meal while standing over the resident in bed. On 1/22/25 at 12:00 PM, after CNA #2 finished with the resident's feeding assistance and left the resident's room, the surveyor interviewed CNA #2, who stated that it was proper procedure while assisting a resident with eating to sit in a chair next to the resident. CNA #2 stated it was important to ensure and maintain a comfortable and dignified meal experience for the resident. On 1/22/25 at 12:45 PM, the surveyor interviewed the Director of Nursing (DON), who stated that in order to maintain a dignified meal feeding experience, staff were expected to sit alongside the resident while assisting them with eating. The DON stated staff was also to present the meal to the resident so the resident could visually see what was offered rather than be told what was served. The surveyor informed the DON of the observations made of CNA #3 and CNA #2's feeding assistance, to which the DON confirmed was not appropriate. A review of the facility's Assistance with Meal policy with a last reviewed date of 12/23/24, included .residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity for example: a. not standing over residents while assisting them with meals . NJAC 8:39-4.1(a)(12)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to a) revise an individual comprehensive care plan (ICCP) for a resident with floor mats and b) revise an ICCP for residents who received oxygen. This deficient practice was identified for 2 of 29 residents reviewed for care plans (Resident #71 and Resident #85), and was evidenced by the following: 1. On 1/16/25 at 10:15 AM, during the initial tour of the facility, the surveyor observed Resident #85 sleeping in their bed. Resident #85 was receiving oxygen via nasal cannula (device that gives additional oxygen through the nose) at 2 liters per minute (lpm). The surveyor observed floor mats folded up in the resident's room. On 1/17/25 at 11:12 AM, the surveyor observed Resident #85 lying in bed awake looking around the room. Resident #85 was receiving oxygen via nasal cannula at 2 lpm. The surveyor observed floor mats located on both sides of the resident's bed. The resident's bed was in a low position with the call device within reach. On 1/17/25 at 11:20 AM, the surveyor reviewed the medical record for Resident #85. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; obstructive sleep apnea (sleep disorder that affects your breathing while you sleep), shortness of breath, Alzheimer's disease (brain disorder that causes memory loss), difficulty in walking, unspecified abnormalities of gait and mobility (abnormal walking pattern). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/3/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating a severely impaired cognition. A further review in Section GG, Functional Abilities, reflected the resident used a walker and wheelchair. It further reflected that the resident was completely dependent for transfers. A review of the Order Summary Report included a physician's order (PO) dated 1/8/25, for oxygen at 2 lpm via nasal cannula as needed if oxygen saturation (SPO2; percent of oxygen in someone's blood) was less than 92%. A further did not include a PO for bedside floor mats. A review of the ICCP included a focus area dated 8/14/24, that the resident was at risk for falls based on score risk (an assessment for fall risk). Interventions included but not limited to; maintain a clutter free environment, ensure proper footwear or socks with non-skid bottoms, schedule daily rest periods and routines. The ICCP did not include an intervention for floor mats to both sides of the bed. A further review revealed a focus area dated 8/21/24, that the resident had a respiratory disorder caused by chronic rhinitis (nose inflammation) and shortness of breath. Interventions included but not limited to; monitor respiratory symptoms per physician order, assess for signs and symptoms of respiratory distress, and keep head of bed elevated per physician's order. The ICCP did not include an intervention to administer oxygen. During an interview with the surveyor on 1/21/25 at 10:31 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM #3) identified that a ICCP should be updated with interventions as changes occurred and during the quarterly care plan meetings. LPN/UM #3 stated that focus areas on the care plan included items specific to the resident such as oxygen, falls, and wounds. The surveyor then asked LPN/UM #3 if floor mats should be on a resident's care plan as an intervention if a resident was at risk for falls, and LPN/UM #3 confirmed yes. LPN/UM #3 further stated an intervention to keep the bed in low position would also be in place. LPN/UM #3 acknowledged that Resident #85's ICCP did not include floor mats as an intervention and they were at risk for falls. LPN/UM #3 acknowledged that Resident #85's ICCP did not include oxygen administration as an intervention under the respiratory focus area. LPN/UM #3 stated that she was going to update the ICCP now to include the oxygen and floor mats for Resident #85. On 1/21/25 at 10:47 AM, the surveyor interviewed the Director of Nursing (DON) who stated the ICCPs included focus areas such as skin, falls, and pain. The DON further stated that if a resident used floor mats or oxygen it would be included on the ICCP as an intervention. On 1/23/25 at 10:43 AM, the Regional Nurse (RN), in the presence of the Director of Nursing (DON), Regional Administrator, and the survey team, confirmed that floor mats and oxygen should be on the ICCP listed as interventions. 2. On 1/17/25 at 12:04 PM, the surveyor observed Resident #71 in their bedroom sitting on the side of the bed. The surveyor observed an oxygen concentrator (device that delivers oxygen) near the resident's bed. Resident #71 stated that they put on their own oxygen at night and removed it in the morning. The resident stated that the facility did not provide a bag to store the oxygen tubing in when not in use. The oxygen tubing was observed lying on the resident's bed. The surveyor did not observe any bag to store the oxygen tubing. On 1/17/25 at 11:44 AM, the surveyor reviewed the medical record for Resident #71. A review of the Resident Face Sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic obstructive pulmonary disorder (lung disease that makes it difficult to breathe), shortness of breath, wheezing (high pitched sound that occurs when the airways in the lungs become narrow), seasonal allergic rhinitis (allergic reaction that causes sneezing). A review of the most recent comprehensive MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, indicating a cognitively intact cognition. A review of the ICCP included a focus area dated 8/10/24, that the resident had a respiratory disorder caused by wheezing. Interventions included but not limited to; give nebulizer treatments as ordered, monitor for response, and assess for signs and symptoms of respiratory distress. The ICCP did not include an intervention to administer oxygen. On 1/21/25 at 10:47 AM, the surveyor interviewed the DON, who stated the ICCP's included focus areas such as skin, falls, and pain. The DON further stated that if a resident used floor mats or oxygen it would be included on the ICCP as an intervention. On 1/21/25 at 12:05 PM, the surveyor interviewed LPN #2, who stated that Resident #71 used oxygen as needed during the night. LPN #2 further stated that she thought oxygen should be on the care plan as an intervention. On 1/23/25 at 10:43 AM, the Regional Nurse, in the presence of the DON, Regional Administrator, and the survey team, stated that floor mats and oxygen should be on the ICCP listed as interventions. A review of the facility's Care Plans, Comprehensive Person-Centered policy last reviewed 12/17/24, included . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being .g. Incorporate identified problem areas .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change . A review of the facility's Policy and Procedure for the Prevention of Fall policy reviewed 12/17/24, included . It is the policy of the facility to identify specific risk factors that may indicate the resident is at risk for falls upon admission, readmission, quarterly annually, and with any significant change. Based upon the assessment the residents will have a preventative plan of care initiated as well as be revised, monitored, and evaluated throughout their stay at the facility. The interdisciplinary team will collaborate in developing, evaluating, and revising fall prevention plan of care to prevent falls/injury, or to minimize injury and/or complications if a fall prevention plan of care to prevent falls/injury, or to minimize injury and/or complications if a fall should occur .5. The preventative measures will be identified on risk assessment and will assist with the development of an individualized care plan by the assigned nurse upon admission/readmission. Preventative measures: Beds: Utilize a floor mattress as indicated and needed. Communication of risk: Residents at risk for falls will be communicated to the interdisciplinary team via the care plan . NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to: a) properly secure medication being administered during medication pass and b) ensure that a resident received care and services for the provision of dressing changes to a peripherally inserted central catheter (PICC) site consistent with professional standards of practice. The deficient practice was identified for 2 of 29 residents reviewed for medication administration (Resident #77 and Resident #127) . 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. The evidence was as follows: 1. On 1/17/25 at 10:10 AM, Surveyor #1 and Surveyor #2 observed the Licensed Practical Nurse (LPN #3) prepare medications for Resident #127. The nurse removed a lidocaine patch (pain medication patch) from a locked drawer on the medication cart and placed it on top of the cart. LPN #3 then removed Miralax (a powdered laxative) and poured a measured amount into a plastic cup, then poured an additional measured amount into a second cup and placed both cups on the medication cart. LPN #3, with the cup containing the medication pills and one cup of Miralax powder, accompanied by Surveyor #1 proceeded into Resident #127's room to administer the medication to the resident who was in bed two by the window. Surveyor #2 stayed in the hallway next to LPN #3's unsecured cart that had the lidocaine patch and Miralax unsecured on top. There were no residents present by the cart at that time. The surveyors observed Resident #127 take their oral medications, and LPN #3 returned to the cart to retrieve the lidocaine patch and administered it on the resident. LPN #3 then returned to the cart and discarded the second Miralax cup that was left on the cart in the drug buster. On 1/17/25 at 10:35 AM, Surveyor #1 interviewed LPN #3 in the presence of the LPN/Unit Manager (LPN/UM #2), who stated that she poured two doses of Miralax because the first dose, the cap touched the powder so she felt it was an infection control concern. Surveyor #1 asked LPN #3 if it was okay to leave the lidocaine patch and Miralax on the medication cart unattended, and UM/LPN #2 responded no because there were residents that wandered and could potentially grab it off the cart. On 1/17/25 at 11:35 AM, Surveyor #1 interviewed the Director of Nursing (DON), who confirmed that the nurse should not have left the lidocaine patch and Miralax unattended because it was a safety hazard for other residents that may be in the hallway. On 1/17/25 at 1:03 PM, the surveyor reviewed the medical record for Resident #127. A review of the Resident Face Sheet (an admission summary) reflected Resident #127 was admitted to the facility with medical diagnoses which included but was not limited to; spinal stenosis lumbar region (narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs), spondylosis without myelopathy or radiculopathy lumbar sacral region (a radiographic diagnosis referring to degenerative changes in the disc), difficulty walking, and muscle weakness. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/5/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a cognitively intact cognition. A review of the Order Summary Report included physician's orders (PO) dated 12/10/24, for lidocaine 4% topical patch; apply once daily to lower back and a PO dated 12/23/24, for Miralax 17 grams per dose oral powder; mix in 4-8 ounces of juice or water. On 1/23/25 at 10:34 AM, the survey team met with the DON, the Assistant Administrator, and the Regional Nurse, who all acknowledged the surveyor's concerns. A review of the facility's undated Medications policy included policy statement; medications are administered in a safe and timely manner and as prescribed . 33106 2. On 1/17/25 at 11:55 AM, the surveyor observed the resident in the room sitting in a wheelchair waiting for lunch. The surveyor interviewed Resident #77 and asked the resident if they were receiving intravenous antibiotics and the resident stated, not for a couple days. At that time, the resident showed the surveyor an intravenous (IV) access site in the left upper extremity. The IV access site had a clear plastic dressing in place and under the dressing was a small gauze dressing over the insertion site of the catheter (where the catheter goes into the resident's skin) so that site could not be assessed. There was an illegible date on the dressing. The surveyor asked the resident if the facility had changed the IV access dressing and the resident stated that it was the dressing that the company put on, when they put it in. The surveyor asked the resident when they the IV was placed and they told the surveyor that they could not remember what day it was. On 1/17/25 at 12:00 PM, the surveyor reviewed the medical record for Resident #77. A review of the Resident Face Sheet reflected the resident was admitted to the facility with the diagnoses which included but was not limited to; chronic respiratory failure, opened wound on the buttocks and methicillin staphylococcus aureus (MRSA) infection. A review of the most recent comprehensive MDS dated [DATE], indicated that Resident #77 had a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the physician's orders included a PO dated 1/4/25, to insert midline catheter for antibiotic infusion. A review of the Progress Notes included a Nurse's Noted dated 1/4/25 at 1:27 PM, which indicated that a new midline (PICC) was placed on left arm with measurements of 15 centimeters (cm); vitals were stable; and the resident was resting in bed with no distress or discomfort noted. On 1/17/25 at 12:17 PM, the surveyor reviewed the Medication Administration Record (MAR) which included a PO dated 12/19/24, to change dressing weekly for right upper arm midline with one lumen and as needed (PRN). On the day of observation, the resident had a PICC line in the left arm, not the right. There were no physician's orders to change the dressing for the left upper extremity PICC line site. On 1/21/25 at 11:03 AM, the surveyor interviewed the Registered Nurse (RN) who was providing care for Resident #77. The surveyor asked the RN if the resident had a peripherally inserted catheter (PICC) and where it was located. The RN told the surveyor the resident had one in the left arm. The surveyor asked about dressing changes and what the policy was at the facility. The RN explained that the dressings were changed weekly and as needed. The surveyor asked if the staff used a gauze dressing under the transparent dressing and the RN said no just the transparent dressing. The surveyor asked the RN to show the surveyor where the staff signed for dressing changes and the RN showed the surveyor the MAR that had an order for right arm PICC dressing changes weekly and as needed. The RN told the surveyor that the dressing should have been changed on the 12th of January and the 19th of January, but there were no nursing signatures on the MAR to indicate that it was done. At that time, the surveyor asked the RN to enter the resident's room and expose the PICC line site. The RN showed the surveyor the PICC dressing which had a date of 1/4/25, the date the left arm PICC line was inserted. The nurse stated, this has to be changed. The surveyor asked about the gauze under the dressing, and the RN said they put it there when they inserted the PICC line, and the facility did not use gauze. On 1/21/25 at 12:18 PM, the surveyor interviewed the Infection Preventionist (IP) regarding PICC line dressing changes. The IP stated that a new PICC line dressing was changed within 24 hours and then weekly. The IP stated the nurse was responsible to date and initial the dressing and sign the treatment record that it was completed. The IP also stated that physician's orders were required for PICC line dressing changes. On 1/23/25, the Regional Nurse, in the presence of the Assistant Administrator, DON, and the survey team acknowledged that Resident #77's PICC line should have been changed within twenty-four hours of admission. A review of the facility's undated Catheter Dressing Changes policy included that the facility was to change transparent semi-permeable membrane dressings as per regulation and as needed (when wet, soiled or not intact). The transparent dressing must be labeled with initials, date and time . NJAC 8:39-25.2 (c)5; 29.4(h)