Every finding on record at Atlas Rehabilitation and Healthcare at Daughters O

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following:On 7/8/26 at 9:30 AM, the surveyor entered the kitchen for the initial tour, in the presence of the Food Service Director (FSD), and FSD/Registered Dietician (RD)(FSD/RD), and observed the following:In the produce walk in refrigerator (ref), an opened box with bags of carrots inside, the received date was 5/19/26, and use by date was 6/8/26, which expired, past the used by date. The FSD/RD confirmed it did not belong in the ref because it was past the use by date.In the enteral supplements' storage room, an opened box with 12 thickened orange juice (OJ) had a use by date of 7/2/26, which was expired. A closed box of 48 thickened OJ had a use by date of 6/6/26 (expired). The FSD/RD confirmed the dates and stated they should be disposed of immediately, and all items to be checked in the storage room. The Dietary Aide (DA) joined the kitchen tour, who stated he was responsible for checking deliveries, and he last checked the dates last week on Wednesday. In the dry storage and emergency supply room, one can of butterscotch pudding with a 1-inch dent on the side, one can of diced potatoes 1 inch dent, four cans of sauerkraut leaking with brownish/blackish residue on the sides, two cans of [NAME] sauce, one with a 1-inch dent and the other with 1 1/2-inch dent. The DA stated he received deliveries every Tuesday, cans were checked twice a week, and was checked last week.In the presence of the Food Service Manager (FSM), FSD, and the FSD/RD, the surveyor observed the stand-up convection ovens in the dairy section, the two stand up convection ovens, upper parts with blackish, brownish residue, and dried grease build up. The FSM stated the ovens were cleaned every two weeks and confirmed the convection ovens should not be like that. The stove in the dairy section, the area under the stove burners with blackish/brownish residue. The stove drip tray catch with thick, dried grease drippings, brownish/black residue, burnt pasta and carrots. The FSM stated the cooks were responsible for cleaning the stoves, and it was cleaned more than two weeks ago.In the meat section area the stove's drip tray catch with thick, brownish/yellowish grease build up, beans and pasta, and brownish residue. The FSD/RD stated the area should have been cleaned daily and after each use. The vegetable can opener with oil buildup, yellow/brownish residue. The FSD/RD lifted the can opener from the base and stated, Very sticky. The FSM further stated the DAs were responsible for cleaning the can openers, and should be cleaned after each use.The beverage ref with no thermometer, the FSD/RD stated that they would order all new thermometers.The small ice cream freezer with ice frost build up all around the upper portion of the freezer, two boxes of ice cream cups inside the freezer, and inside was an oven thermometer, confirmed by the FSD/RD. The FSM stated everything would be disposed of and freezer would be cleaned.On 7/9/26 at 11:44 AM, the surveyor, in the presence of the FSD, FSD/RD and the FSM, conducted a second tour of the kitchen, all observed in the dry storage room one can of sweet corn dented approximately 1 inch. The FSD stated he checked all the cans the previous day.On 7/10/26 at 9:55 AM, the surveyor conducted an inspection in the 1st (first) floor, 1 [NAME] Unit of the nourishment ref/pantry, in the presence of License Practical Nurse #1 (LPN #1), and observed the ref/freezer located in the office room with a freezer temperature (temp) of 18 F (Fahrenheit) degrees. Inside the freezer was an open container of strawberry Italian ice, undated and unlabeled, yellowish/reddish spilled substances on the bottom of the freezer. The surveyor and LPN #1 observed the ref and inside were juices, water and puddings, with no thermometer found inside the ref. LPN #1 confirmed and stated there should have a thermometer. LPN #1 further stated it was the Kitchen Staff (KS) who were responsible for ensuring there was a thermometer and maintained cleaned once a week. At that same time, the surveyor observed temp logs on top of the ref for May and June 2026, and none for July 2026. LPN #1 stated that the 11:00 PM-7:00 AM shift would be responsible to log temp, LPN #1 did not know as to why the July 2026 temp log was missing. LPN #1 also confirmed the missing ref temp logs for 5/19/26 through 5/18/26, and 6/7/26 through 6/30/26. On 7/10/26 at 10:13 AM, the surveyor in the presence of the Assistant Director of Nursing (ADON), FSD, and the Registered Dietician (RD) observed the 3rd (third) floor [NAME] Unit supply room. The nourishment freezer (ice cream cups inside) registered at 8 F degrees, the ref (supplements, thickened milk, regular milk, and puddings were inside) registered 50 F degrees. The FSD stated that it was nursing staff who were responsible for maintaining the cleanliness and temp of the nourishment ref. The ADON further stated everyone in nursing was responsible and not the KS.On 7/10/26 at 11:16 AM, the surveyor with the ADON observed the 4th (fourth) floor nourishment/pantry, located in the activity room, the freezer had the wrong thermometer inside, it was an oven thermometer, and the ref thermometer registered 70 F degrees (there were juices in the ref). On 7/10/26 at 12:12 PM, the surveyor interviewed LPN #2, in the 2nd floor nursing unit, who stated the KS were responsible for cleaning and maintaining the nourishment ref/freezers. On 7/14/26 at 12:07 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Regional Director of Clinical Services (RDCS), Regional Director of Operations (RDO), and the ADON, and surveyor notified them of the concerns found in the kitchen and the nourishment rooms in the nursing units. On 7/15/26 at 11:29 AM, the survey team met with the DON, ADON, RDO, the Assistant LNHA, and the LNHA stated all items identified in the kitchen were corrected immediately, opened boxes were discarded, thermometers were replaced in all refrigerators and freezers in the kitchen and nourishment stations in the units, and temp logs were put in place. He further stated, stoves and ovens and catch trays de-greased, ice cream freezer defrosted, and dietary staff were educated. The LNHA also stated they initiated a Quality Assurance Performance Improvement (QAPI) Program after surveyor's inquiry.On 7/15/26 at 2:20 PM, during the exit conference, the LNHA did not provide additional information. A review of the facility's Sanitization Policy, dated 11/2022, revealed under Policy Interpretation and Implementation .#2. All.equipment are kept clean, maintained in good repair.Seals.are kept in good repair. #3. All equipment.are cleaned and sanitized using heat or chemical sanitizing solutions. #8, When cleaning fixed equipment, the removable parts are: a. washed and sanitized.with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution.A review of the facility's Food Receiving and Storage Policy, dated 11/2022, revealed under Dry Food Storage .#3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. #4. Dry foods that are stored. labeled and dated ( use by date). Under Refrigerated/Frozen Storage #7. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded. Under Foods and Snacks Kept on Nursing Units .#3. Refrigerators must have working thermometers and are monitored for temperature according to state specific guidelines.A review of the facility's Refrigerators and Freezers Policy, dated 11/2022, revealed under Policy Statement, the facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines.NJAC 8:39-17.2(g)

REPEAT DEFICIENCYBased on interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments, and timely write, sign, and date progress notes at each visit. This deficient practice was identified for 6 of 35 residents, (Residents #1, #7, #9, #21, #63, and 101), reviewed for physician services. This deficient practice was evidenced by the following: 1. On 7/8/26 at 11:12 AM, the surveyor in the presence of the Activity Aide observed Resident #1 seated in a specialized wheelchair (w/c) inside the dining room of 3 [NAME] with other residents. On 7/8/26 at 12:07 PM, the surveyor reviewed the medical records of Resident #1, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, pressure ulcer of sacral region unstageable, moderate protein-calorie malnutrition, and depression. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/27/26, revealed a Brief Interview for Mental Status (BIMS) score of 00, which reflected the resident's cognition was severely impaired. A review of the Progress Notes (PN) in the electronic medical records (eMR), signed by Physician #1 (P #1), with effective dates of 4/15/25, 5/15/25, 6/15/25, 7/15/25, 8/15/25, 9/15/25, 10/15/25, 11/15/25, 12/15/25, 1/5/26, 2/15/26, 3/15/26, 3/29/26, were all created on 3/29/26. The PN with effective dates of 4/7/26, 5/14/26 (H&P [History & Physical]), and 6/14/26 (H&P), were all created on 7/8/26. A review of the signed monthly orders by P #1, revealed, from April 2025 through July 2026, P #1 had signed the monthly for the following dates, 6/4/25, 12/2/25, 5/6/26, and 7/9/26. There were no signed monthly orders for April, May, July, August, September, October, and November 2025. There were no signed monthly orders for January, February, March, April, and June 2026. On 7/13/26 at 12:03 PM, Registered Nurse #1 (RN #1) stated that there were no signed monthly orders printed in the chart because P #1 signed monthly orders should be in the eMR. 2. On 7/10/26 at 8:29 AM, the surveyor reviewed the eMR of Resident #7, and revealed: A review of the AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke) due to unspecified occlusion or stenosis of left middle cerebral artery, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral, and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting right dominant side. A review of the comprehensive MDS (cMDS), with an ARD of 4/18/26, reflected that the resident had severely impaired cognition. A review of the PN that was electronically signed by P #1, revealed PN with effective dates of 4/12/26 (H & P), 4/15/26, 4/18/26, 4/21/26, 4/24/26, 4/27/26, 4/30/26, 5/3/26, 5/6/26, 5/9/26, 5/12/26, 5/15/26, 5/18/26, and 5/21/26, was created on 5/24/26. There were no PN for June and July 2026. A review of the signed monthly orders by P #1 of Resident #7, revealed, from April 2026 through July 2026, P #1 had signed the monthly for the following dates, 5/14/26 and 7/9/26. There were no signed monthly orders for April 2026 and June 2026. 3. On 7/8/26 at 10:49 AM, the surveyor observed Resident #9's room was closed. Inside the resident's room, the surveyor observed there were two staff providing care to the resident and notified the surveyor to return at later time. On 7/13/26 at 8:49 AM, the surveyor reviewed the eMR of Resident #9, and revealed: A review of the AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke) unspecified, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and anemia. A review of the modified cMDS, with an ARD of 4/28/26, revealed a BIMS score of 12 out of 15, which reflected moderately impaired cognition. A review of the follow up physiatry consult notes, with an effective date of 5/14/26, revealed UE (upper extremity) edema secondary to superficial venous thrombosis in setting of PICC (Peripherally Inserted Central Catheter. It is a long, thin, flexible tube inserted into a vein in the upper arm to deliver medications, fluids, or blood over a long period) line. A review of the nutrition PN, that was electronically signed by Registered Dietician (RD), with an effective date of 5/27/26, revealed edema to RUE (right upper extremity) secondary to superficial venous thrombosis in the setting of the PICC line. A review of the 6/30/26 nutrition PN that was electronically signed by the RD, revealed + 1 (positive one; the mildest classification of pitting edema, it occurs when excess fluid in body's tissues causes slight swelling, leaving a barely perceptible indentation when you press your finger into the swollen area), LE (lower extremity) edema present per 6/29/26 provider note. A review of the PN of P #1, with an effective date of 5/14/26, created on 7/9/26, revealed that P #1 documented that Resident #9 had no edema. Further review of P #1, RD, and the Physiatrist PN, there were discrepancy about edema that were documented. A review of the PN that was electronically signed by P # 1 revealed PN with effective dates of 5/14/26 and 6/16/26, were all created on 7/9/26. A review of the signed monthly orders by P #1 of Resident #9, revealed, from April 2026 through July 2026, P #1 had signed the monthly for the following dates, 5/26/26 and 7/9/26. There were no signed monthly orders for April 2026 and June 2026. On 7/13/26 at 10:19 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that there were no other place where the physicians documented their visit notes except the eMR. The LPN/UM stated that monthly orders were being signed by the physicians in the eMR that included P #1. She further stated that there were no printed monthly orders that were being signed by the physician. On 7/13/26 at 11:47 AM, the surveyor interviewed RN #2, who confirmed that Resident #9's monthly signed orders should be in the eMR, and there were no printed monthly orders. She further stated that the physician visit notes should be in eMR. On 7/13/26 at 11:50 AM, the LPN/UM confirmed that the monthly signed orders should be done by the physician in the eMR. The surveyor notified the LPN/UM of the above concerns with monthly orders not signed routinely, the visit notes were done as late entries, and that there was documentation from P #1 about the edema noted and documented by the RD and the Physiatrist. At that same time, the LPN/UM confirmed that the resident upon admission, for few weeks, and months the resident had edema in the right upper arm due to swelling, I think from IV (intravenous) infiltration. She acknowledged the late entries for PN and signing of monthly orders that were not done. The LPN/UM further stated that the PN should be done timely, and monthly orders should have been signed. 4. On 7/10/26 at 1:26 PM, the surveyor reviewed the eMR of Resident #21, and revealed: A review of the AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; syncope and collapse, difficulty in walking, not elsewhere classified, and muscle weakness. A review of Resident #21's cMDS, with an ARD of 3/3/26, revealed a BIMS score of 15 out of 15, which reflected Resident #21's cognition was intact. On 7/13/26 at 1:13 PM, the surveyor reviewed the OSR and PN of Resident #21, and revealed: A review of the PN in the eMR, electronically signed by P #1, with effective dates of 2/28/26, 3/3/26, 3/9/26, 3/12/26 (documented twice for 7:30 AM), 3/15/26, 3/18/26, 3/21/21, 3/24/26, 3/27/26, 3/30/26, 4/2/26, 4/5/26, 4/8/26, 4/11/26, 4/14/26 (documented twice for 7:36 AM and 7:42 with the same information), 4/17/26 (documented twice for 7:42 AM and 8:00 AM with the same information), 4/20/26 (documented twice for 7:43 AM and 8:05 AM with the same information), 4/23/26, 4/26/26, 4/27/26, 4/29, 26, 4/30/26, 5/2/26, 5/3/26, 5/5/26, 5/6/26, 5/8/26, 5/9/26, 5/11/26, 5/12/26, 5/15/26, and 5/18/26, were all created on 5/27/26. A review of the signed monthly orders by P #1, revealed, from February 2026 through July 2026, P #1 had signed the monthly on 5/14/26. There were no signed monthly orders for February, March, April, June, and July 2026. On 7/14/26 at 9:43 AM, the surveyor called and spoke to Receptionist of P #1, who informed the surveyor that the doctor was not in the office. The Receptionist stated that she would notify P #1 to call the surveyor for an interview. On 7/14/26 at 12:08 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO), Director of Nursing (DON), Assistant DON (ADON), Regional Director of Clinical Services (RDCS), and the surveyor notified them of the above findings and concerns with regard to Residents #1, #7, #9, and #21's PN and signed monthly orders. The surveyor also notified them of the concern that P #1 did not return the call of the surveyor for an interview with regard to the above findings and concerns. At that same time, the RDCS stated that as part of their last year's plan of correction (POC) was to print the monthly orders, signed by the physician, and should be in the eMR, in the miscellaneous (misc) tab. The surveyor notified the facility management including the RDCS that the surveyor had checked Residents #1, #7, #9, and #21's misc tab and did not find any signed monthly orders for the above months identified. On 7/15/26 at 11:28 AM, the survey team met with DON, ADON, RDO, LNHA, and the RDCS stated the Medical Director (also known as P #1) and other Attending Physicians were reminded on timely documentation, we made a weekly audit tool, and did in service that included accuracy of documentation in PN of P #1. The RDCS confirmed that all monthly orders were signed after surveyor's inquiry. On that same date and time, the surveyor asked why the physicians had to review orders and monthly orders, and the RDCS stated to ensure the plan of care, assessments, and recommendations were correct. Furthermore, the RDCS stated that for Resident #9, P #1 was asked to review his PN and to reconcile the documentation to reflect the actual status, the edema noted with other IDT (interdisciplinary team). 5. On 7/13/26 at 9:45 AM, the surveyor observed Resident #63 seated in a w/c in the resident's room. On 7/13/26 at 11:13 AM, the surveyor reviewed the medical record for Resident #63. A review of the AR revealed diagnoses which included, but were not limited to; displaced fracture of the right ulna with routine healing, Parkinson's disease, hyperlipidemia, hypertension, hypothyroidism, and protein-calorie malnutrition. On 7/13/26 at 1:06 PM, the surveyor reviewed the PN, electronically signed by P #1, with visit notes for February, March, April, May, and June 2026, were all late entries PN that was created on 7/8/26. Further review of the resident's medical record revealed the monthly PO were not routinely signed by P #1. On 7/15/26 at 11:30 AM, the DON acknowledged that the PN for February through June 2026, were entered as late entries on 7/8/26, and that PO had not been authenticated monthly. The RDCS stated that the Medical Director had been notified of the concern and that an order-signature tracking process had been implemented to ensure monthly physician orders were reviewed and signed within the required timeframe. 6. On 7/8/26 at 9:49 AM, during an initial tour, the surveyor observed Resident #101 lying in their bed in their room. The resident stated they required staff assistance to get out of bed. On 7/8/26 at 12:24 PM, the surveyor reviewed the EMR for Resident #101. A review of the AR reflected the resident was admitted with diagnoses that included but were not limited to; polyneuropathy (a widespread nerve condition that may cause numbness, pain, or trouble walking), muscle weakness, and repeated falls. A review of the quarterly MDS, with an ARD of 7/6/26, reflected the resident's BIMS score was 7 out of 15, which indicated moderate impairment in cognition. A review of the Order Review History, a list indicating when orders were reviewed by the primary physician, reflected the following order review dates by the primary physician: Reviewed date 7/9/26, electronically signed by web application. Reviewed date 5/26/26, electronically signed by web application. Reviewed date 2/3/26, signed (printed copy provided). Reviewed date 12/2/25, electronically signed by [cellphone brand name redacted]. On 7/15/26 at 11:00 AM, the surveyor reviewed P #1's PN in the eMR, for Resident #101, which reflected the following: A late entry with an effective date of 3/16/26 at 7:39 AM, was created on 7/8/26 at 3:40 PM. A late entry with an effective date of 4/16/26 at 7:40 AM, was created on 7/8/26 at 3:40 PM. A late entry with an effective date of 5/16/26 at 7:40 AM, was created on 7/8/26 at 3:40 PM. A late entry with an effective date of 6/16/26 at 7:40 AM, was created on 7/8/26 at 3:41 PM. On 7/15/26 at 11:29 AM, the survey team met with the DON, ADON, RDO, LNHA, and the RDCS acknowledged that P #1 PN were created in the resident's eMR late with regard to their effective date for Resident #101. The RDCS acknowledged an ongoing problem of PO not being reviewed and signed off by the physician monthly. She stated the physician PN and order reviews by the physician were important for therapy, nursing, other departments to be able to follow the plan of care for the resident. She further stated those disciplines did review the physician PN on a regular basis, but acknowledged the notes that were not created until months later, were not identified by staff until after surveyors' inquiry. A review of the facility's Physician Services Policy, with revision date of February 2021, that was provided by the LNHA, revealed, once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialists. Physician orders and progress notes are maintained in accordance with current regulations and facility policy. A review of the facility's Attending Physician Responsibilities Policy, revised August 2014, revealed, that each attending physician is responsible for providing appropriate, timely, and pertinent documentation. The policy further included: The physician will maintain progress notes that cover pertinent aspects of a resident's medical condition and his/her current status and goals. At each visit, the attending physician will provide a progress note (written, typed, or electronic) in a timely manner for placement in the medical record. The attending physician will provide timely and appropriate medical orders. The physician will verify the accuracy of verbal orders when they are given and will authenticate, co-sign, and date them in a timely manner no later than the next visit to the resident. On 7/15/26 at 2:22 PM, the survey team met with DON, RDCS, ADON, RDO, Assistant in Training for exit conference, and the LNHA did not provide additional information. NJAC 8:39-11.2(1); 23.2(b)(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the urinary catheter bag was covered. This deficient practice was identified for 1 of 2 residents who had urinary catheters (Resident #3), and was evidenced by the following:On 7/8/26 at 11:46 AM, the surveyor observed that Resident #3 was lying in bed and had a urinary catheter bag that was uncovered and was visible from the door.On 7/9/26 at 11:54 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident had to have a privacy bag. The LPN confirmed they saw on 7/8/26, that there was no privacy bag. The LPN further stated that the urinary catheter bag must be covered for privacy. The LPN acknowledged that the urinary catheter bag was uncovered.On 7/9/26 at 12:30 PM, the surveyor reviewed the electronic medical record of Resident #3.A review of the admission Record or face sheet (an admission summary) revealed that the resident had diagnoses that included, but were not limited to neuromuscular dysfunction of bladder, unspecified (dysfunction of the urinary bladder caused by damage to the nerves that control bladder function).A review of the quarterly minimum data set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/13/26, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which reflected that the resident's cognition was severely impaired.The Order Summary Report revealed a physician order with a start date of 2/12/26, foley bag privacy cover in place at all times every shift for Care.On 7/14/26 at 12:08 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO).On 7/15/26 at 11:30 AM, the survey team met with the LNHA, DON, ADON, RDCS, RDO, and Administrators in Training for responses. The RDCS stated that a privacy bag was placed upon identification that there was no privacy bag. She further stated, a facility wide check was completed to confirm privacy covers were in place on all foley catheters, and staff were re-educated on resident dignity and privacy. A review of the facility's Catheter Care, Urinary Policy, revised August 2022, did not address the covering of urinary catheter bags.NJAC 8:39-4.1(a)12

Based on observation, interview, and review of other facility documentation, it was determined the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 8 units, (1 East and 3 West), 1 of 2 tub room (1 East), 1 of 2 dining areas (3 West), and 3 of 35 Residents (Residents #1, #9, and #94). This deficient practice was evidenced by the following:1. On 7/8/26 at 11:12 AM, the surveyor in the presence of the Activity Aide (AA) observed Resident #1 seated in a specialized wheelchair (w/c) with right arm rest uncovered that showed the wooden part of the chair with two protruding metal parts, and the headboard with peeling of cover.On 7/9/26 at 8:52 AM, the surveyor with the Registered Nurse (RN) both observed Resident #1 inside the dining area with a new specialized w/c. The RN confirmed to the surveyor that the resident was seated with two other residents at the time the surveyor observed the resident seated with w/c with uncovered right arm rest. She further stated that it was only this morning that the w/c was replaced, which was after surveyor's inquiry.2. On 7/9/26 at 8:41 AM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM) toured 1 East tub room (also known as the shower room), and both observed the privacy curtain were not properly hooked, below the sink there was a cracked floor, the floor tiles with accumulation of blackish substances, the ceiling vent with accumulation of grayish to blackish substances just above the sink, and there were three ceiling tiles near the window with brownish stains. Both the surveyor and the LPN/UM observed also at the back of the shower area, white pail with water accumulation, with a floating white urine hat collection container inside the white pail, and with dead fly.On that same date and time, LPN/UM acknowledged the privacy curtain and stated would have someone to fix it. She further stated that floor tiles need to be cleaned, the ceiling vent was dusty, and she did not know as to why the pail of water was there with urine collection [NAME] with a dead fly. The LPN/UM confirmed that the residents uses the tub room for showers. 3. On 7/9/26 at 8:36 AM, the surveyor with the LPN/UM went inside Resident #9's room and observed accumulation of grayish substances on the floor near the window and around the resident's room toward the toilet room, which the LPN/UM confirmed accumulation of dust and should have been cleaned. The LPN/UM acknowledged the peeling off wall paint near the resident's headboard, and missing tiles inside the toilet room.4. On 7/9/26 at 8:48 AM, the surveyor with the Registered Nurse (RN) both toured 3 [NAME] dining area and observed peeling off of wall paint and wall paper near the window area around the other corner of the room. Both the surveyor and the RN also observed the ceiling vent near the window with heavy accumulation of blackish substances, which the RN confirmed accumulation of dust and there were three ceiling tiles near the entrance of the dining area with at least one and half inches gaps, which the RN stated should have been fixed due to safety and fire hazards. 5. On 7/13/26 at 12:12 PM, the surveyor and the RN went to Resident #94's room and both observed the peeling of wall paper above the headboard part of the bed, to the ceiling.On 7/13/26 at 12:19 PM, the surveyor with the Assistant Director of Nursing (ADON) both observed 3 [NAME] dining room with total of 19 residents that included Resident #94 during lunch time. The surveyor notified the ADON and showed the peeling off wall papers in the dining room, and the ADON stated that she would take pictures and show it to the facility management.Afterward, both the surveyor and the ADON went to Resident #94's room and both observed the peeling of wall paper, and the ADON stated she would notify the Licensed Nursing Home Administrator (LNHA) about it. On 7/14/26 at 8:22 AM, the surveyor interviewed the Maintenance Technician (MT), who informed the surveyor that he was responsible for day to day routine log of temperature, turning on air conditioned units, roof top chillers, ensure water running, and do general toilet sink maintenance. He further stated that there was no accountability log for environmental rounds, it was all based on as needed basis only.On 7/14/26 at 8:40 AM, the surveyor interviewed the Director of Housekeeping (DH), who informed the surveyor that the Housekeeper in each nursing unit were responsible for daily room cleaning, followed the seven step process from top to bottom that included sweeping and dusting, and maintaining the toilet room in resident's room. The DH stated that he had a binder for deep cleaning log of residents' rooms and there was no daily housekeeping cleaning check of residents' rooms, instead, he would eyeball when he check the room.At that same time, the surveyor asked if he was made aware of the environment concerns that the surveyor observed with LPN/UM in 1 East and the RN in 3 West, and he responded he was aware. He further stated that he adjusted the hooks in room [ROOM NUMBER] East tub and that it was important that those hooks were properly hooked for privacy and safety of the residents. He also stated that they cleaned the ceiling vent and dust them off. The DH stated that it was the responsibility of the maintenance department to replace the stained ceiling tiles, and that was from water stain from pipe with rust. He added that the cracked tiles would be the responsibility of maintenance department to be replaced for safety and maintaining a homelike environment.On 7/14/26 at 10:24 AM, the DH informed the surveyor that he checked the room of Resident #9, the resident was bed ridden, and it was a challenge for housekeeper to move the bed around to clean thoroughly. The DH stated that he would talk to nursing about their concern with cleaning the resident's room, when asked by the surveyor if housekeeper notified the concern with nursing.On 7/14/26 at 12:08 PM, the survey team met with the LNHA, Regional Director of Operations (RDO), Director of Nursing (DON), ADON, Regional Director of Clinical Services (RDCS), and the surveyor notified them of the above findings and concerns with the environment of Residents #1, #9, and #94, 1 East tub room, and 3 [NAME] dining room.A review of the facility's Homelike Environment Policy, with a revision date of February 2021, that was provided by the LNHA, revealed under policy statement, residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Policy Interpretation and Implementation.2. The facility staff and management maximizes.the characteristics of the facility that reflect personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment.c. inviting colors and decor.3. d. chair and bed alarms.On 7/15/26 at 11:28 AM, the survey team met with DON, ADON, and RDCS for responses, and later on the RDO and the LNHA joined the meeting. The LNHA informed the surveyor that the facility established coordinate cleaning of the room, nursing will assist with positioning or schedule cleaning appropriate time so room would be cleaned thoroughly.At that same time, the LNHA stated for the 3rd floor dining room wall paper and homelike environment cleanliness, we discussed about the facility's plans and hiring additional personnel. The LNHA further stated that all identified concerns were repaired, ceiling tiles were replaced, water bucket inside 1 East tub room was removed, shower room cleaned, and broken tiles replaced.NJAC 8:39-31.4(a)(b)(f)

REPEAT DEFICIENCYBased on interview and record review, it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool, to accurately reflect the residents' status as of the Assessment Reference Date (ARD) for 3 of 38 residents (Residents #5, #6, and #191) reviewed for MDS accuracy. The deficient practice was evidenced by the following: 1. On 7/8/26 at 12:06 PM, the surveyor observed Resident #5 sitting on a wheelchair (w/c) in the 4th (fourth) floor activity room with other residents. On 7/9/26 at 9:29 AM, the surveyor reviewed the medical records of Resident #5. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included but not limited to; Alzheimer's disease, unspecified, and dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. A review of the quarterly MDS (qMDS) with an ARD of 5/27/26, reflected Resident #5 was rarely understood and the staff interview indicated short-term and long-term memory problem. Section N (medications) reflected antipsychotic medication (med) received on a routine basis with a diagnosis of schizophrenia (severe brain and mental health disorder), which was coded in Section I (diagnosis) of the MDS. A review of another qMDS with an ARD of 6/28/26, revealed section N, an antipsychotic med received on a routine basis with no diagnosis in Section I indicated. A review of the resident's care plans (CP) revealed psychotropic medications (meds) to help manage. target symptoms related to (r/t) psychosis, schizophrenia, date initiated 10/30/25, and mood problem r/t schizophrenia. date initiated 10/30/25. A review of the physician orders (PO) revealed the following orders: On 6/26/26, Olanzapine (Zyprexa-antipsychotic) tablet (tab) 5 mg (milligram), give 1 tab by mouth at bedtime (HS) for schizophrenia. Another order, give 1 tab by mouth and 0.5 tab for total of 7.5 mg at HS for schizoaffective disorder. An order on 5/20/26, Depakote sprinkles oral capsule delayed release sprinkle 125 mg, give 2 capsules (caps) by mouth three times a day 2- 125 mg = 250 mg r/t schizophrenia. A review of the Psychology/Psychiatry consult on 6/24/26, revealed, on Olanzapine 10 mg at HS, resident was a poor historian, reported long history of mental illness/schizophrenia. now on Depakote sprinkle's 250 mg three times per day. On 7/13/26 at 11:36 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC), who stated, according to the Resident Assessment Instrument (RAI) manual, the diagnosis would be coded for the indication of an antipsychotic med. The RN/MDSC confirmed the diagnosis should have been coded in the qMDS 6/28/26, and she further stated, due to MDS inaccuracy, she would modify the MDS assessment to reflect the diagnosis. On 7/14/26 at 12:07 PM, the survey team met with the License Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Clinical Services (RDCS), Regional Director of Operation (RDO), and Assistant DON (ADON), and the surveyor notified them of the above concerns with MDS inaccuracy. On 7/15/26 at 11:29 AM, the survey team met with the DON, ADON, RDO, LNHA, Assistant Administrator, and the RDCS stated the diagnosis of schizophrenia was amended to reflect that in the MDS. 2. On 7/8/26 at 11:14 AM, the surveyor observed Resident #191 in their room lying in bed, with a right arm splint. The surveyor was unable to observe the right leg, it was covered with the bed sheet. The resident stated they had therapy a month and a half ago and was paralyzed on the right side. On 7/9/26 at 10:50 AM, the surveyor interviewed License Practical Nurse (LPN), who stated the splint was to apply during the day, taken off every two hours but not at night. The LPN confirmed she applied the splint in the morning. On 7/9/26 at 3:33 PM, the surveyor reviewed the electronic medical records (eMR) of Resident #191. A review of the AR revealed diagnosis of cerebral infarction (stroke). A review of the qMDSs with an ARD of 4/4/25, 6/30/25, and 9/23/25, and a review of the comprehensive MDS with an ARD of 12/17/25, revealed in section GG (Functional Abilities), no ROM (range of motion) impairments for upper extremities and lower extremities were coded to reflect the actual status of the resident. A review of the qMDS with an ARD of 3/12/26 and 6/12/26, revealed a ROM impairment on the upper extremity (UE) on one side. A review of the resident's CP reflected the resident had limited physical mobility and limited motion in right hand r/t cerebral infarction, date initiated 12/26/24; and right lower extremity (RLE) ROM/positioning in bed, date initiated 4/7/25. A review of the PO revealed: An order dated 11/19/25, for splinting, don right elbow extension splint to right elbow and right modified resting hand splint to right hand/wrist after AM (morning) care, doff splints before PM (afternoon) care, or as tolerated, remove for skin checks and hygiene care, discontinued on 7/8/26. An order dated 7/9/26, for skilled Occupational (OT) evaluation and treatment 3-5x/week x 83 days (3 to 5 times/week times 83 days) for therapeutic exercises, therapeutic activities, manual treatment, caregiver education and training, contracture management, orthotic fitting/training. An order dated 7/9/26, for trial splints to RUE during OT treatment session. An order dated 7/10/26, for skilled PT evaluation + treatment 3-5x/week x 83 days for therapeutic exercise, therapeutic activities, neuromuscular re-education, splinting assessment and safe wear plan for contracture management, patient/caregiver education + discharge plan. An order dated 7/10/26, to trial with (R) [right] extension splint to establish tolerance and wearing schedule. On 7/10/26 at 12:43 PM, the surveyor interviewed the Rehabilitation (Rehab) Director, who stated, the resident was admitted with nontraumatic cerebral infarct, right arm was spastic with impaired ROM and was picked up yesterday for OT again because the resident did not want that elbow splint anymore, and was ordered a different splint. The Rehab Director further stated the right arm usually gets worst for spasticity because of the stroke, and it was expected. On 7/13/26 at 10:00 AM, the Rehab Director provided PT (physical therapy)/OT evaluations completed on admission, 9/17/25 and 7/10/26, which indicated the resident had impaired RUE ROM. On 9/17/25, PT evaluation indicated RLE ROM impairment which were not coded in the MDS assessments. On 7/13/26 at 11:43 AM, the surveyor interviewed the RN/MDSC in the presence of the DON, who stated, her process for coding ROM was to looked at the resident, collaborate with nursing and rehab. The RN/MDSC confirmed the MDS assessments were inaccurate since admission, and further stated, Resident #191 had RUE impairment according to the therapy notes and she would modify all MDS. On 7/14/26 at 12:07 PM, the survey team met with the LNHA, DON, RDCS, RDO, ADON, and the surveyor notified them of the concern regarding MDS inaccuracies for Resident #191's RUE and RLE ROM impairments. On 7/14/26 at 1:47 PM, the RN/MDSC in the presence of the ADON stated over the phone that she would modify all the MDS assessments from admission for RLE ROM impairment because the Physiatry (Rehab physician) consultations, nursing notes, and hospital records indicated the resident had RLE impairment since admission due to the stroke. A review of the Physiatry notes dated 2/25/25, revealed chief complaint of deficits in gait and ADL (activities of daily living) secondary to recent hospitalization for CVA (stroke) with right sided hemiparesis. On 7/15/26 at 11:29 AM, the survey team met with the DON, ADON, RDO, LNHA, Assistant LNHA, and the RDCS stated the MDS assessments were modified to indicate the RUE and RLE ROM impairments since admission. She further stated that education was provided to the RN/MDSC. 3. On 7/8/26 at 10:32 AM, the surveyor observed Resident #6 in bed with the call bell within reach of the resident. On 7/9/26 at 10:05 AM, the surveyor reviewed Resident #6's eMR. A review of the immunization tab revealed the resident received a COVID-19 vaccine on 2/29/24, 12/30/21, and 3/25/21. There was no COVID-19 vaccine from 2025-2026, influenza vaccine, or pneumonia vaccine documented in the resident's eMR. On 7/13/26 at 1:33 PM, the surveyor reviewed Resident #6's eMR, under the immunization tab, which revealed the resident's immunizations were updated. The vaccines that were added included a COVID-19 2025-2026 vaccine, influenza vaccine, and pneumococcal vaccine. Each of the vaccines that were added had Status: Pending Consent. A review of the AR revealed that the resident had diagnoses that included but were not limited to; chronic kidney disease, stage 4 (severe loss of kidney function), type 2 diabetes mellitus (a disease characterized by high levels of blood sugar) with diabetic neuropathy (nerve damage), unspecified, hyperlipidemia (high cholesterol or fats in the blood), unspecified, and essential (primary) hypertension (high blood pressure). A review of the qMDS, with an ARD of 6/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident's cognition was intact. The MDS revealed that the resident did not receive the influenza vaccine in the facility for this year's influenza vaccination season. The reason stated for why the influenza vaccine was not received was resident was not in this facility. However, the resident was in the facility in February and March 2026. The MDS also revealed that the resident's pneumococcal vaccination was not up to date. The reason stated for why the pneumococcal vaccine was not received was that it was not offered. In addition, the MDS revealed the resident's COVID-19 vaccination was not up to date. On 7/13/26 at 1:37 PM, the surveyor interviewed the RN/MDSC, who stated that the influenza season ended 3/31/26, and if the resident was in the facility in February 2026, the MDS was coded inaccurately. In addition, the RN/MDSC further stated that the pneumococcal vaccine was coded not offered in the MDS because at the time of the assessment in the MDS, there was no documented evidence of consent for the pneumococcal vaccine. On 7/14/26 at 10:35 AM, the surveyor reviewed Resident #6's eMR, under the immunization tab, which revealed the resident's vaccines were updated again. The status for each of the vaccines that were added was changed to Historical. In addition, the COVID-19 2025-2026 vaccine had an administration date of 12/3/25, the influenza vaccine had an administration date of 11/23/25, and the pneumococcal vaccine had an administration date of 11/23/25. On 7/14/26 at 12:08 PM, the survey team met with the LNHA, DON, ADON, RDCS, and RDO, and the surveyor discussed the concern that the MDS was coded inaccurately for the influenza vaccine, pneumococcal vaccine, and COVID-19 vaccine. The MDS did not reflect that the resident received the influenza vaccine as well as the pneumococcal vaccine, and the MDS did not reflect that the resident was up to date with the COVID-19 vaccine. On 7/15/26 at 11:30 AM, the survey team met with the LNHA, ADON, RDCS, RDO, Administrators in Training (AIT), and the DON provided the surveyor with the resident's personal immunization record from the New Jersey Department of Health, which confirmed the resident received the COVID-19 vaccine on 12/3/25, influenza vaccine on 11/23/25, and pneumococcal vaccine on 11/23/25. The RDCS stated the resident's MDS was updated. The RDCS also stated that they did an audit of the facility to ensure the immunization tab reflected the status of the offering, refusal, and history of immunizations. On 7/15/26 at 1:32 PM, the survey team met with the RDO, DON, ADON, RDCS, and the LNHA provided no additional information. A review of the most recent facility's Resident Assessments Policy, dated 10/2023, revealed under Policy Interpretation and Implementation #11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. #12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. A review of the facility's Psychotropic Medication Use Policy, with a revision date of 2/2025, revealed under Policy Statement, residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Under Policy Interpretation and Implementation #3. Psychotropic med management is an interdisciplinary process that involves.and includes: a. determining adequate indications for use. NJAC 8:39-33.2(d)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to; a.) ensure physician-ordered treatments were documented as administered in accordance with physician orders for 1 of 35 residents (Resident #154) reviewed for treatment administration, b.) clarify the physician order with regard to medication with parameters for 1 of 4 residents (Resident #17) reviewed, and c.) ensure resident's concerns and assessment were documented and notified the physician for 1 of 35 residents (Resident #17), in accordance with standards of clinical practice and facility's policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 7/8/26 at 10:45 AM, the surveyor observed Resident #17 lying in bed, and the call bell was within reach of the resident. Resident #17 stated that they had diarrhea on 7/6/26 from afternoon until evening with no relief and told a staff while this was happening. On 7/9/26 at 11:42 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who confirmed that Resident #17 was experiencing diarrhea on 7/6/26. The CNA stated they changed the resident three times during the 7:00 AM to 3:00 PM shift on 7/6/26. On 7/9/26 at 11:49 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated the nurse should have contacted the physician, and documented everything, including what the resident had said, and what the nurse told the doctor. In addition, the LPN stated the nurse should have told the Unit Manager (UM). At that time, the surveyor and the LPN reviewed the electronic medical records (eMR) of Resident #17. The LPN confirmed there were no progress notes (PN) written on 7/6/26 about resident's diarrhea. On 7/9/26 at 11:57 AM, the surveyor interviewed the LPN/UM, who stated nothing was reported about the diarrhea, and there were no PN about it. On 7/9/26 at 12:15 PM, the surveyor reviewed the eMR of Resident #17. A review of the admission Record (AR) or face sheet (an admission summary) revealed that the resident had diagnoses that included but were not limited to; end stage renal disease (ESRD, also known as kidney failure), type 2 diabetes mellitus without complications (a disease characterized by high levels of blood sugar), and essential (primary) hypertension (high blood pressure). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 4/19/26, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which reflected that the resident's cognition was moderately impaired. A review of the Order Summary Report (OSR) revealed a physician order (PO) with a start date of 7/9/26, midodrine HCl (hydrocholoride) (a medication (med) that treats low blood pressure) oral tablet (tab) 2.5 milligrams (mg). The directions stated, give 1 tab by mouth one time a day every Tuesday, Thursday, and Saturday for hypotension (low blood pressure), hold if systolic blood pressure (the top number in a blood pressure (BP) reading) was less than 130 do not give after the evening meal or within four hours of bedtime. On 7/9/26 at 1:16 PM, the surveyor interviewed LPN/UM, who stated the PO to hold midodrine if systolic BP (SBP) was less than 130, was incorrect, instead, the PO should be to hold the med if SBP was more than 130. The LPN/UM further stated, she would contact the physician and change the order. The above PO for midodrine was transcribed to the electronic Medication Administration Record (eMAR) and signed by the nurse as administered on 7/9/26 at 5:30 AM with BP of 122/89. The eMAR revealed that a nurse held the midodrine at that time because they followed the hold parameter that was incorrect. On 7/10/26 at 9:23 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Operations (RDO), and the Regional Director of Clinical Services (RDCS) confirmed that the midodrine PO was wrong, and was considered as a med error. The RDCS further stated that the investigation for med error copy would be provided to the surveyor. On 7/14/26 at 12:08 PM, the surveyor discussed the concerns with Resident #17's condition and midodrine order with the LNHA, DON, ADON, RDCS, and RDO. On 7/15/26 at 11:30 AM, the survey team met with the LNHA, ADON, RDCS, RDO, and Administrators in Training (AIT), and the DON confirmed that the hold parameter, which was wrong, was followed by the nurse. The DON further stated there was no adverse effect to the resident. In addition, the DON stated that the nurses were re-educated on following parameters and documented accordingly. The DON also stated that the PO was updated to have the correct parameters. The RDCS stated that it was an expectation of the nurse to document in resident's medical records the concern with diarrhea. The RDCS further stated that the nurse was educated on reporting changes in conditions in a timely manner as well as documenting. A review of the facility's Charting and Documentation Policy, revised July 2017, revealed, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical 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. The review of the facility's Medication Orders Policy, revised November 2014, revealed, the purpose of this procedure is to establish uniform guidelines in the receiving and recording of med orders. 2. On 7/13/26 at 9:20 AM, the surveyor observed Resident #154 lying in bed with the head of the bed elevated. On 7/13/26 at 9:34 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated the resident had a sacral pressure injury, was followed weekly by wound care, and received hospice services. On 7/13/26 at 9:58 AM, the surveyor reviewed the medical record for Resident #154. A review of the AR revealed diagnoses which included, but were not limited to; metabolic encephalopathy, osteomyelitis of the sacral region, urinary tract infection, obstructive uropathy, and advanced dementia. A review of the OSR, dated as of 7/13/26, revealed PO including, but not limited to: Ammonium Lactate 12% cream to the skin every day and evening shift for dry skin. Foley catheter care every shift. Foley catheter output monitoring every shift. Foley catheter privacy cover in place at all times. Foley catheter irrigation as ordered. Low air loss mattress placement and function checked every shift. A review of the July 2026 electronic Treatment Administration Record (eTAR) revealed there was no documentation that the above PO treatments had been completed during the evening shifts of 7/4/26 and 7/6/26. There were no corresponding PN accounted for the treatments being administered during these dates. A review of the resident's comprehensive care plan (CP), included interventions to provide catheter care per protocol, provide a catheter privacy bag, monitor catheter function, maintain a low air loss mattress, monitor skin care, provide pressure-relieving devices, and administer treatments as ordered. On 7/13/26 at 10:15 AM, the surveyor interviewed the RN/UM regarding the missing eTAR documentation, and the RN/UM stated she would check the records and would get back to the surveyor as to why there were missing signatures of nurses on 7/4/26 and 7/6/26 of evening shifts. The RN/UM further stated there should be no missing signatures in the eTAR to reflect that care was provided to the resident according to PO. On 7/13/26 at 10:53 AM, the surveyor interviewed the DON in the presence of the RDCS, who stated that she would check the record first, and would get back to the surveyor. A review of the facility's Administering Medications Policy, revised April 2019, revealed, included, medications (meds) are administered in a safe and timely manner, and as prescribed. Meds are administered in accordance with prescriber orders. As required or indicated for a med, the individual administering the med records in the resident's medical record the date and time the med was administered, the dosage, the route of administration, the indication, any complaints or symptoms, any results achieved when observed, and the signature and title of the person administering the drug. On 7/15/26 at 11:30 AM, the DON, RDCS, and the LNHA acknowledged the findings and reported that the missing eTAR documentation for the evening shifts of 7/4/26 and 7/6/26, had been identified and corrected. The RDCS further reported that nursing staff had been re-educated regarding real-time eTAR documentation, and that ongoing audits of eTAR had been implemented to monitor compliance and prevent recurrence. NJAC 8:39-11.2(b)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure a.) recommendation to continue weekly weight monitoring was followed for a resident identified as at risk for nutritional problem and b.) monitored weight according to the physician's order and care plan for 1 of 2 residents, (Resident #1), reviewed for nutrition.This deficient practice was evidenced by the following:On 7/8/26 at 11:12 AM, the surveyor in the presence of the Activity Aide observed Resident #1 seated in a specialized wheelchair (w/c) inside the dining room of 3 [NAME] with other residents.On 7/8/26 at 12:07 PM, the surveyor reviewed the medical records of Resident #1, and revealed:A review of the admission Record or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, pressure ulcer of sacral region unstageable, moderate protein-calorie malnutrition, and depression.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/27/26, revealed a Brief Interview for Mental Status (BIMS) score of 00, which reflected the resident's cognition was severely impaired. The MDS also revealed that the resident's weight was 120 pounds (lbs).A review of the Care Plan (CP), with a focus that the resident was at risk for malnutrition/dehydration related to medical history, significant weight (wt) change, and increased needs for wound healing, that was initiated on 12/21/23, and was revised on 7/7/26, by the Registered Dietician (RD), with interventions that included but not limited to; assess for signs/symptoms (s/s) of malnutrition included weights (wts) per facility protocol, intake, hydration, GI (gastrointestinal) status, skin integrity, and laboratory that was initiated on 6/6/26.A review of the Nutrition Progress Notes (PN) revealed the following plan:On 4/8/26, the RD documented that the resident was followed by RD for readmission, significant wt change, and wound assessment. The resident was triggered for unplanned and undesired significant wt loss x 1 (times 1), x 3, x 6 months prior to hospitalization, and new admission wt currently pending. On weekly wts x 4 to monitor.On 5/12/26 and 6/16/26, the RD documented insignificant wt loss x 1 month noted, resident triggered for significant wt loss x 3 and x 6 months and continued on weekly weights for now.On 6/23/26, the RD documented wt 6/13/26 was 126.5 lbs with 3.5 % significant wt loss for one week and would continue weekly weights x 4 to monitor.A review of the Weight Summary revealed:July (7) 2026=120.2 lbs on 7/8.June (6) 2026=120.1 lbs on 6/10, 126.5 lbs on 6/13, 122 lbs on 6/19, and 120.1 lbs on 6/25.May (5) 2026=127.9 lbs on 5/10.April (4) 2026=129 lbs on 4/1, 130 lbs on 4/8, 131 lbs on 4/15, 130.7 lbs on 4/22, and 131.8 lbs on 4/29.March (3) 2026=139.7 lbs on 3/19 and 124 lbs on 3/25.A review of the March 2026 Order Summary Report (OSR) revealed a physician order (PO) for weekly wts with a start date of 3/25/26, and was discontinued (d/c'd) on 4/4/26.The above PO was transcribed to the electronic Medication Administration Record (eMAR), was signed by Registered Nurse #1 (RN #1) and documented with a check mark. There was no wt recorded and did not follow the PO.A review of the April 2026 OSR revealed a PO for weekly wts every Wednesday (Wed) for monitoring for 4 weeks, with start date of 4/8/26.The above PO was transcribed to April 2026 eMAR and weekly wts were recorded, 130 lbs on 4/8, 131 lbs on 4/15, 130.7 lbs on 4/22, and 131.8 lbs on 4/29.A review of the May 2026 OSR revealed a PO for wt on admission and weekly x 4 weeks, every Wed for wt protocol for 28 days, with a start date of 4/8/26.The above PO was transcribed to May 2026 eMAR, there were no documented wts, and the PO was not followed. There was no documentation that weekly wts were obtained and documented.A review of the June 2026 OSR revealed a PO for weekly wts, every Wed for monitoring for 4 weeks, with a start date of 6/17/26, and was d/c'd on 6/23/26. There was another PO for weekly wts every Wed for monitoring for 4 weeks, with a start date of 6/24/26.The above orders for weekly weights were transcribed to June 2026 eMAR and revealed, on 6/17 and 6/24, there were no wts documented, and the PO was not followed.A review of the July 2026 eMAR revealed that weekly weight for date 7/1 was blank, and the PO was not followed.On 7/9/26 at 8:52 AM, the surveyor and RN #2 both observed the resident inside 3 [NAME] dining area with new w/c. RN #2 informed the surveyor that Resident #1 was cognitively impaired, with good appetite, extensive assistance with care, with history of wt loss, and being monitored because resident eats well, and still losing wt. On 7/13/26 at 10:21 AM, the surveyor interviewed the RD in the presence of the LPN/UM, who informed the surveyor that the wt records of the residents should be in the eMR and that they had a wt book which was in her office.On 7/13/26 at 10:30 AM, the surveyor and the RD went to her office to look at the wt book. The Regional Dietician, who was at the office of the RD informed the surveyor that she was unsure if the surveyor could have a copy of the resident's wt. The Regional Dietician further stated that she had to check with other Regional Directors first if the surveyor was allowed to have a copy.On 7/13/26 at 10:43 AM, Regional Director of Clinical Services #1 (RDCS #1), in the presence of the Regional Dietician, RDCS #2, and the RD, informed the surveyor that the wt book was an internal documents of the facility, and the surveyor was not allowed to have a copy. The surveyor was also not provided with an opportunity to review the wt book. RDCS #1 further stated that all residents' weight should be in the eMR. On 7/13/26 at 12:03 PM, the RN informed the surveyor that the resident's order for weekly wts should be in eMR and documented in the eMAR. The surveyor notified the concern that the PO for weekly wts were not followed and there were blanks in the eMR, and the RN did not respond. The RN was the assigned nurse on 5/13, 5/20, 5/27, 6/17, 6/24, and 7/1/26, for wts that were not documented according to PO.On 7/14/26 at 12:08 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO), Director of Nursing (DON), Assistant DON (ADON), RDCS #2, and the surveyor notified them of the above findings and concerns with regard to Resident #1's PO and wt records.A review of the facility's Physician Services Policy, with revision date of February 2021, that was provided by the LNHA, revealed, once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialists. Physician orders and progress notes are maintained in accordance with current regulations and facility policy.On 7/15/26 at 2:22 PM, the survey team met with DON, RDCS #2, ADON, RDO, Assistant in Training for exit conference, and the LNHA did not provide additional information. NJAC 8:39-17.1(c); 27.1(a); 27.2(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a.) consistent accountability and b.) accurate documentation for the inventory of controlled dangerous substances (medications with high potential for drug diversion) for 2 of 4 medication carts inspected.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.1. On 7/14/26 at 10:13 AM, in the presence of the Registered Nurse (RN), the surveyor began the narcotic medication (med) inspection, which was stored in a separately locked, permanently affixed compartment of the med cart (narcotic box), located in med cart A on the third floor.A review of the shift-to-shift accountability log reflected that the RN did not sign at the beginning of the shift on 7/14/26. In addition, the RN did not write the total number of narcotic cards, packs, and bottles received at the beginning of the shift on 7/14/26. The shift-to-shift accountability log revealed that Signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each med counted is in agreement with the quantity stated on the Controlled Drug Record. Write total number of narcotic cards, boxes/patches, & liquid bottles received at the beginning of the shift; add in whatever additional controlled meds and subtract empty containers in the presence of the accepting nurse.At that time, the surveyor and the RN reviewed the Controlled Drug Administration Record (a declining inventory log (DIL) for Resident #78's clonazepam (a controlled substance med to treat seizure disorders and panic disorder), which reflected that two tablets (tabs) remained, and it was compared against the corresponding bingo card (a multidose card containing individually packaged medications (meds)) that contained one tab. The RN stated that they had administered clonazepam to Resident #78 that morning and did not sign the DIL when they removed the med from the bingo card to administer to the resident.A review of the electronic Medical Records (eMR) reflected an order for clonazepam oral tablet (tab) disintegrating 0.5 milligrams (mg), to be given one tab by mouth two times a day for anxiety, and revealed that it was administered on 7/14/26 at 8:01 AM.On 7/14/26 at 10:22 AM, the surveyor and the RN reviewed the DIL for Resident #49's tramadol (an opioid med to treat pain), which reflected that two tabs remained, and it was compared against the corresponding bingo card that contained one tab. The RN stated that they had administered tramadol to Resident #49 that morning and did not sign the DIL when they removed the med from the bingo card to administer to the resident.A review of the eMR reflected an order for tramadol oral tab 50 mg, to be given one tab by mouth one time a day for sacral pain, please also give 30-45 minutes before wound care, started on 9/17/25, and revealed that it was administered on 7/14/26 at 8:51 AM.2. On 7/14/26 at 10:34 AM, in the presence of the RN, the surveyor began the narcotic med inspection, which was stored in a separately locked, permanently affixed narcotic box, located in med cart B on the third floor.At that time, the surveyor and the RN reviewed the DIL for Resident #210's methylphenidate (a controlled substance med to treat Attention-Deficit/Hyperactivity Disorder, ADHD, a disorder that affects the brain's ability to focus). The DIL reflected that 11 tabs remained, and it was compared against the corresponding bingo card that contained 10 tabs. The RN stated that they had administered methylphenidate to Resident #210 that morning and did not sign the DIL when they removed the med from the bingo card to administer to the resident.The surveyor and RN reviewed the eMAR together that reflected an order for methylphenidate oral tab 5 mg, to be given one tab by mouth in the morning for ADHD, started on 7/8/26, and revealed that it was administered on 7/14/26 at 9:11 AM.On 7/14/26 at 10:39 AM, the surveyor interviewed the RN, who acknowledged they did not sign the shift-to-shift accountability log at the beginning of their shift on 7/14/26. In addition, the RN stated they should sign the DIL as they give the med to keep track of what was given and what remains. Then, the RN signed the accountability log and DIL for Resident #49, #78, and #210 after surveyor inquiry.On 7/15/26 at 11:50 AM, the surveyor discussed the concerns with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services (RDCS), Regional Director of Operations (RDO), and Administrators in Training (AIT).On 7/15/26 at 12:34 PM, the survey team met with the LNHA, DON, ADON, RDO, AIT, and the RDCS stated the nurse was re-educated on signing the narcotic record upon removing a tab from the bingo card and reinforced the shift-to-shift accountability log. The RDCS also stated that remaining nurses at the time of the in-service were also educated.A review of the facility's Controlled Substances Policy, revised November 2022, revealed, the controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up .The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.NJAC 8:39-29.2; 29.7

Based on observation, interview, record review, and a review of pertinent facility documents, it was determined that the facility failed to act on the Consultant Pharmacist's (CP) recommendations for 1 of 5 residents (Resident #1) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 7/8/26 at 11:12 AM, the surveyor in the presence of the Activity Aide observed Resident #1 seated in a specialized wheelchair inside the dining room of 3 [NAME] with other residents.On 7/8/26 at 12:07 PM, the surveyor reviewed the medical records of Resident #1, and revealed:A review of the admission Record or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, pressure ulcer of sacral region unstageable, moderate protein-calorie malnutrition, and depression.A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/27/26, revealed a Brief Interview for Mental Status (BIMS) score of 00, which reflected the resident's cognition was severely impaired. The MDS also revealed that the resident was on antidepressant during the lookback period.A review of the comprehensive MDS, with an ARD of 3/27/26, revealed a BIMS score of 11 out of 15, which reflected moderately impaired cognition. The MDS also reflected that the resident received antianxiety and antidepressant medications (meds).A review of the March, April, June, and July 2026 Order Summary Reports (OSR) revealed the following Physician Orders (PO):Duloxetine HCl (hydrochloride) capsule (cap) delayed release (DR) 30 mg (milligram), give 2 capsules (caps) by mouth in the morning for anxiety/depression, 2 caps=60 mg. Start date 8/21/25 and was discontinued (d/c'd) on 3/26/26.Duloxetine HCl oral cap DR sprinkle 40 mg, give 1 cap by mouth one time a day for depression. Start date 3/27/26 and was d/c'd on 4/4/26.Duloxetine HCl cap DR 20 mg, give 2 caps by mouth one time a day for depression, 2 caps= 40 mg. Start date 4/7/26 and was d/c'd on 4/10/26.Duloxetine HCl cap DR 20 mg, give 1 cap by mouth one time a day for depression. Start date 4/11/26 and was d/c'd on 4/23/26.Mirtazapine tablet (tab) 7.5 mg, give 1 tab by mouth at bedtime (HS) for depression for 7 Days. Start date 3/26/26.Mirtazapine tab 15 mg, give 1 tab by mouth at HS for depression for 7 Days. Start date 4/2/26 and was d/c'd on 4/4/26.Mirtazapine tab 15 mg, give 1 tab by mouth at HS for depression. Start date 4/18/26 and was d/c'd on 4/23/26.Mirtazapine tab 15 mg, give 2 tabs by mouth at HS for depression, 2 tabs=30 mg. Start date 4/23/26.Trazodone HCl oral tab 100 mg, give 2 tablets (tabs) by mouth at HS for depression, 2 tabs = 200 mg total dose. Start date 2/13/26 and was d/c'd on 3/24/26.Ativan oral tab 0.5 mg, give 1 tab by mouth two times a day for anxiety. Start date 8/20/25 and was d/c'd on 3/24/26.Divalproex sodium oral tab DR 250 mg, give 1 tab by mouth two times a day for depression. Start date 5/8/26. The above PO were transcribed to March through July 2026 electronic Medication Administration Record (eMAR) and signed by nurses as administered.A review of the assessment tab in eMR revealed highlighted in red Psychoactive Review (PR) that was 163 days overdue, with last documented PR review was on 1/4/26. A review of the CP Monthly Report dated 4/16/26 and 6/15/26, revealed a recommendations note that the resident's psychoactive summaries were not up to date. There were no action taken in the printed forms of the CP Monthly Report.On 7/13/26 at 12:03 PM, the surveyor interviewed the Registered Nurse (RN), who informed the surveyor that she was unsure who reviewed and responded to the CP monthly recommendations.On 7/14/26 at 10:33 AM, the surveyor interviewed the Director of Nursing (DON), who informed the surveyor that it was the responsibility of the nurses to do monthly psychoactive summary notes for all residents with psychoactive meds, and it should be documented it in eMR. The surveyor then asked for copy of the facility's policy with regard to Psychoactive meds.On 7/14/26 at 12:08 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO), DON, Assistant DON (ADON), Regional Director of Clinical Services (RDCS), and the surveyor notified them of the above findings and concerns with regard to CP monthly visits on 4/16/26 and 6/15/26, revealed the resident's psychoactive summaries were not up to date and it was not acted upon.A review of the facility's Psychotropic Medication Use Policy, with a revision date of 2/2025, revealed under Policy Statement, residents do not receive psychotropic meds that are not clinically indicated and necessary to treat a specific condition documented in the medical record. Under Policy Interpretation and Implementation #3. Psychotropic med management is an interdisciplinary process that involves.and includes: a. determining adequate indications for use .should be in the medical record.On 7/15/26 at 2:22 PM, the survey team met with DON, RDCS, ADON, RDO, Assistant in Training for exit conference, and the LNHA did not provide additional information. NJAC 8:39-29.3(a)(1)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to properly store, and label with a date, medications in 1 of 3 medication rooms and 1 of 6 medication carts inspected. The deficient practice was evidenced by the following:1. On [DATE], the surveyor inspected the medication (med) room on the 1st (first) floor East wing in the presence of the Licensed Practical Nurse /Unit Manager (LPN/UM). During the inspection, the surveyor found nine expired shielded IV (intravenous) catheters (devices designed to retract the needle after use). Three of them expired on [DATE], two expired on [DATE], one expired on [DATE], and three expired on [DATE]. The LP/UM acknowledged they were expired and disposed of them in the red sharps disposal container in the med room on the 1st floor East wing.On [DATE] at 12:08 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO).On [DATE] at 11:30 AM, the survey team met with the LNHA, DON, ADON, RDO, Administrators in Training (AIT), and the RDCS stated that the expired needles found in the med room were discarded. The RDCS further stated they did a full audit of the med rooms to check for expired supplies and also educating staff on checking expirations dates and rotating stocks.2. On [DATE] at 9:24 AM, the surveyor inspected the 1st floor East wing side A med cart in the presence of the Registered Nurse (RN). Upon opening a drawer of the cart, the surveyor observed the following:Resident #113's budesonide inhalation suspension 0.5 milligrams (mg)/2 milliliters (ml) (a med to treat breathing disorders) foil pouch was opened with no date on it. The foil pouch originally contained five single-dose ampules as was written on the pouch, and there were two ampules remaining inside the pouch. It was written on the foil pouch, Once the foil pouch is opened, use the ampules within 2 weeks.Resident #113's albuterol inhalation solution 2.5 mg/3 ml (a med to treat and prevent difficulty breathing) foil pouch was opened with no date on it. The foil pouch originally contained five sterile unit-dose vials as was written on the pouch, and there were four vials remaining inside the pouch.On [DATE] at 9:40 AM, the surveyor interviewed the RN, who stated that once they open the pouch, the expectation was to label each pouch with the date. The RN further stated that the budesonide pouch and the albuterol pouch should have been labeled with the date of opening, and someone failed to date them.A review of the admission Record (AR) or face sheet (an admission summary) revealed that the resident had diagnoses that included but were not limited to; acute respiratory failure with hypoxia (a condition in which the lungs cannot release enough oxygen into the blood) and chronic obstructive pulmonary disease (COPD; a chronic lung disease that prevents airflow to the lungs, causing breathing problems) with (acute) exacerbation (a sudden worsening of symptoms).A review of the comprehensive minimum data set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which reflected that the resident's cognition was intact.On [DATE] at 11:50 AM, the surveyor discussed the concern with the LNHA), DON, ADON, RDCS, RDO, and AIT.On [DATE] at 12:34 PM, the survey team met with the LNHA, DON, ADON, RDO, AIT, and the RDCS stated they were continuing to educate the staff.A review of the facility's Medication Labeling and Storage Policy, revised February 2023, revealed, labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.NJAC 8:39-29.4

Based on interview and review of pertinent facility-provided documentation, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) obtained specialized Infection prevention and control (IPC) training beyond initial professional training or education prior to assuming the role, for 2 of 2 Infection Preventionists (IP #1 and IP #2) reviewed.This deficient practice was evidenced by the following:On 7/14/26 at 9:49 AM, the surveyor attempted to interview IP #1, and the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) both stated that IP #1 was unavailable for interview.At that same time, the surveyor reviewed the facility provided job description, professional license, resume, and CDC (Centers for Disease Control and Prevention) Nursing Home Infection Preventionist Training Course (NHIPTC)documentation for IP #1, and revealed that IP #1 was awarded the 19 contact hours completion for NHIPTC on 12/15/25.A review of the Quality Assurance Performance Improvement (QAPI) quarterly sign in sheets revealed that IP #1 was the IP who attended and signed on 10/31/25, 1/15/26, and 4/16/26. Further review of the above documentation revealed that IP #1 assumed the role of an IP on 10/31/25 in the QAPI meeting prior to completing the NHIPTC certification, which was completed on 12/15/25.In addition, IP #2 attended and signed the quarterly QAPI sign in sheets on 4/24/25 and 7/31/25.On 7/15/26 at 10:41 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that IP #1 had left the facility and would not be returning. The surveyor notified the LNHA of the above concern that IP #1 assumed the role of an IP on 10/31/25, prior to completing the NHIPTC certification.On 7/15/26 at 11:28 AM, the survey team met with the DON, Assistant DON (ADON), Regional Director of Operations (RDO), LNHA, and the RDCS acknowledged that she was aware of the requirement that the IP should complete the IP certificate prior to assuming the role. The RDCS confirmed that IP #2 was the other IP of the facility prior to IP #1. The RDCS reviewed the employee file of IP #2 and confirmed that IP #2 had no signed job description and certificate on the files and would get back to the surveyor.On 7/15/26 at 1:41 PM, the DON provided a copy of IP #2's NHIPTC that was completed with 19.7 contact hours on 4/27/25. Further review of IP #2's provided documents revealed that IP #2 assumed the role of an IP as evident in the QAPI sign in sheet on 4/24/25, which was prior to completing the NHIPTC on 4/27/25.A review of the facility's Infection Preventionist Policy, with a revision date of January 2026, that was provided by the DON, revealed that the IP is responsible for coordinating, implementing, and updating the IPC. The IP is scheduled with enough time to properly assess, develop, implement, monitor, and manage the IPC program, address training requirements, and participate in required committees such as the QAPI and IPC committees.Specialized Training:1.The IP has obtained specialized IPC training beyond initial professional training or education prior to assuming the role.2.Evidence of training is provided through a certificate(s) of completion or equivalent documentation.N.J.A.C. 8:39-19.1(b)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to; a.) obtain written consent, b.) ensure documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunizations, and c.) Resident or Resident Representative were given an opportunity to accept or decline pneumococcal and influenza immunizations. This deficient practice was identified for 2 of 6 residents (Residents #1 and #63), reviewed for immunizations. This deficient practice was evidenced by the following: 1. On 7/8/26 at 11:12 AM, the surveyor in the presence of the Activity Aide observed Resident #1 seated in a specialized wheelchair (w/c) inside the dining room of 3 [NAME] with other residents. On 7/8/26 at 12:07 PM, the surveyor reviewed the medical records of Resident #1, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, pressure ulcer of sacral region unstageable, moderate protein-calorie malnutrition, and depression. A review of the most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/27/26, revealed a Brief Interview for Mental Status (BIMS) score of 00, which reflected the resident's cognition was severely impaired. The MDS also revealed that the resident was offered influenza vaccine, and it was declined, and the pneumococcal vaccine was not offered. A review of the electronic medical record (eMR) revealed that the influenza and pneumococcal vaccines had a pending consents and the information were incomplete. The eMR reflected that the influenza vaccine was refused by the resident on 10/23/24, and there were no documented evidence that the influenza and pneumococcal vaccines were offered and declined by the resident for 2025. On 7/13/26 at 12:03 PM, the surveyor in the presence of the Registered Nurse (RN) reviewed Resident #1's paper chart and both observed the pneumonia and flu informed consent forms were blank. The RN also reviewed the resident's eMR and found that the flu and pneumonia were documented as pending consents. At that same time, the RN notified the Assistant Director of Nursing (ADON) of the concern with immunization records, and the ADON stated that she would notify the Infection Preventionist Nurse (IPN) about the concern and would ask the IPN to talk to the surveyor. On 7/13/26 at 12:30 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) regarding the above concern that the IPN was called in 3 [NAME] nursing station by ADON for a surveyor's interview and did not show up. The LNHA stated that the IPN had to leave the facility due to an emergency. The LNHA further stated that he was unsure if the surveyor was allowed to review the immunization record binder of the residents' immunization and had to get back to the surveyor. On 7/13/26 at 1:13 PM, the Director of Nursing (DON) informed the surveyor that the IPN was unavailable for an interview, and she would get back to the surveyor about the residents' immunization binder. On 7/13/26 at 1:37 PM, the RN/MDS Coordinator (RN/MDSC) informed the surveyor that Resident #1's Section O (covers Special Treatments, Procedures, and Programs for residents in long-term care facilities) for pneumococcal vaccine was coded not offered because at the time of assessment in MDS there were no documented evidence that the consent was signed for pneumococcal vaccine. The RN/MDSC further stated that the MDS notified the nurses that consent should be obtained. On 7/14/26 at 8:47 AM, the DON informed the surveyor that the IPN was unavailable for an interview, and she would get back to the surveyor about the residents' immunization binder. On 7/14/26 at 12:08 PM, the survey team met with the LNHA, Regional Director of Operations (RDO), DON, ADON, Regional Director of Clinical Services (RDCS), and the surveyor notified them of the above findings and concerns with regard to Resident #1's immunizations. On 7/15/26 at 9:56 AM, the surveyor interviewed the RDCS in the presence of the DON, who informed the surveyor that immunizations should be offered upon admission by the admitting nurse, nursing supervisor who also obtain consents, and then the IPN would follow up. The RDCS stated that at the end, the immunization consents should be in the resident's chart or IPN. She further stated that the IPN had left and did not return. On 7/15/26 at 11:28 AM, the survey team met with DON, ADON, RDO, LNHA, and the RDCS stated the vaccines not offered and was confirmed by the RN/MDSC, we do offer flu and pneumococcal vaccines. The RDCS further stated the vaccines consent refusal not documented, incomplete, and did not match the record. She further stated that the immunization tab should reflect the status of immunization of the resident. 2. On 7/13/26 at 9:45 AM, the surveyor observed Resident #63 seated in a w/c in the resident's room. On 7/13/26 at 11:13 AM, the surveyor reviewed the medical record for Resident #63. A review of the AR revealed diagnoses which included, but were not limited to; displaced fracture of the right ulna with routine healing, Parkinson's disease, hyperlipidemia, hypertension, hypothyroidism, and protein-calorie malnutrition. A review of the Physician Order (PO) Report, dated as of 7/13/26, included PO for flu vaccine yearly if not contraindicated and may have pneumococcal vaccine unless contraindicated per CDC (Centers for Disease Control and Prevention) recommendations. On 7/13/26 at 11:29 AM, the surveyor reviewed Resident #63's immunization record, revealed, did not contain documentation that the resident had been offered, received, declined, or had a medical contraindication for the influenza or pneumococcal vaccines. On 7/13/26 at 11:33 AM, the surveyor interviewed the RDCS while reviewing the resident's eMR. The RDCS confirmed there was no documentation of influenza or pneumococcal vaccinations, vaccines refusal, medical contraindication, or vaccine offer contained within the resident's eMR. A review of the facility's Pneumococcal Vaccine Policy, with a revision date of August 2025, that was provided by the DON, revealed, all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Policy Interpretation and Implementation: 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. 4. Provision of information, education, and the VIS (vaccine information statement) are documented in the resident's medical record. 5. The resident (or representative) has the right to refuse vaccines. If refused, the date of and stated reason for the refusal of the vaccine are documented in the resident's medical record. 8. Inquiries concerning facility's policies governing vaccinations should be referred to the Infection Preventionist (IP) or DON. A review of the facility's Influenza Vaccine Policy, with a revision date of March 2022, that was provided by the DON, revealed, all residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Policy Interpretation and Implementation: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. 4. Prior to the vaccination, the resident (or representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's/employee's medical record. 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. 8. The IP will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among residents and staff. Surveillance data will be made available to staff as part of educational efforts to improve vaccination rates among employees. 10. Residents and staff may obtain their influenza vaccines from their personal physicians. Documentation of previous vaccination should be provided to the facility. On 7/15/26 at 2:22 PM, the survey team met with DON, RDCS, ADON, RDO, Assistant in Training for exit conference, and the LNHA did not provide additional information. NJAC-8:39-19.4(a)(1)(h)(i)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to maintain documentation that a resident was assessed for, offered, received, or declined the COVID-19 vaccine. This deficient practice was identified for 2 of 6 residents (Residents #63 and Resident #146) reviewed for COVID-19 immunization, and was evidenced by the following: 1. On 7/13/26 at 9:45 AM, the surveyor observed Resident #63 seated in a wheelchair in the resident's room. On 7/13/26 at 11:13 AM, the surveyor reviewed the medical record for Resident #63. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; displaced fracture of the right ulna with routine healing, Parkinson's disease, hyperlipidemia, hypertension, hypothyroidism, and protein-calorie malnutrition. On 7/13/26 at 11:29 AM, the surveyor reviewed the resident's immunization record, which did not contain documentation that the resident had been offered, received, declined, or had a medical contraindication for the COVID-19 vaccine. The only immunization documentation available in the resident's electronic medical record (eMR) was a Tuberculosis (TB) two-step Mantoux skin test completed on 12/20/25. On 7/13/26 at 11:33 AM, the surveyor interviewed the Regional Director of Clinical Services (RDCS) while reviewing the resident's eMR. The RDCS confirmed there was no documentation of COVID-19 vaccination, vaccine refusal, medical contraindication, or vaccine offer contained within the resident's medical record. 2. On 7/9/26 at 10:23 AM, the surveyor reviewed Resident #146's eMR. A review of the immunization tab revealed the resident's COVID-19 vaccine 24-25, had status: pending consent. The other COVID-19 vaccines listed under the immunization tab were dated 2/4/24, 6/14/22, 4/21/21, and 3/23/21. On 7/14/26 at 9:40 AM, the surveyor reviewed Resident #146's eMR, under the immunization tab, which revealed the resident's, COVID-19 vaccine 24-25 information was updated to COVID-19 2025-2026. Status: Refused. Confirmation Date: 3/2/26. There was no consent form for 3/2/26 for the COVID-19 vaccine in the eMR. A review of the AR revealed that the resident had diagnoses that included but were not limited to; other lack of coordination, depression, unspecified, anxiety disorder, unspecified, and muscle weakness (generalized). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which reflected that the resident's cognition was intact. The MDS revealed that the resident's COVID-19 vaccination was not up to date. On 7/14/26 at 9:51 AM, the surveyor reviewed Resident #146's paper medical records on the unit which had blank informed consent forms for the influenza and pneumococcal vaccines. There was no informed consent form for the COVID-19 vaccine in the resident's paper medical records. On 7/14/26 at 9:58 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who confirmed they could not find an informed consent form for the COVID-19 vaccine for the resident. On 7/14/26 at 12:08 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, RDCS, and Regional Director of Operations (RDO). On 7/15/26 at 11:30 AM, the survey team met with the LNHA, ADON, RDCS, RDO, and Administrators in Training, and the DON provided the surveyor with the resident's completed COVID-19 vaccine consent form dated 2024. The surveyor showed the DON that the resident's completed COVID-19 vaccine consent form was dated 2024, not 2026. The RDCS confirmed that the consent forms the DON provided to the surveyor were the only consent forms they found for Resident #146. The RDCS stated that they did an audit of the facility to ensure the immunization tab reflected the status of the offering, refusal, and history of immunizations. A review of the facility's COVID-19 Vaccination Policy, reviewed/revised 11/10/25, revealed, Residents or their representatives and staff will sign the consent form . this information will be retained in the resident's medical record or the staff's medical file. The policy included, it was the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering our residents and staff the COVID-19 vaccine. COVID-19 vaccinations will be offered to residents when supplies are available, unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. The facility will educate and offer the COVID-19 vaccine to residents, resident representatives (RR) and staff and maintain documentation of such. The resident's medical record will include documentation of: education to the resident or RR regarding the risks, benefits and potential side effects of the COVID-19 vaccine; each dose of vaccine administered to the resident; and if the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. NJAC 8:39-5.1(a)

REPEAT DEFICIENCYBased on interviews and record review, it was determined that the facility failed to a.) encode within 7 days and completes residents' assessments, the residents' transfer and discharge and b.) complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool, within 14 days as required, for 2 of 38 residents, (Residents #7 and #21), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Minimum Data Set 3.0 Resident Assessment Instrument (RAI) User's Manual, Required Assessment Summary, revealed:The comprehensive MDS completion date no later than 14th calendar day of resident's admission (admission date + 13 calendar days). The CAA (Care Area Assessment) completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The care plan (CP) completion date no later than CAA(s) completion date + 7 calendar days. The transmission completion date no later than CP completion date + 14 calendar days.The discharge (d/c) assessment return not anticipated, and d/c return anticipated MDS completion date no later than d/c date + 14 calendar days. The transmission date no later than MDS completion date + 14 calendar days.1. On 7/9/26 at 11:12 AM, the Director of Nursing (DON) informed the surveyor that the closed records files of the residents were all uploaded in the electronic medical records (eMR) and there were no paper charts. She confirmed that all medical records should be in the eMR.On 7/10/26 at 8:29 AM, the surveyor reviewed the eMR of Resident #7, and revealed:A review of the admission Record (AR) or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke) due to unspecified occlusion or stenosis of left middle cerebral artery, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral, and hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting right dominant side.A review of the late entry Progress Notes (PN), with an effective date of 7/3/26 at 10:17 PM, with a created date of 7/7/26 at 12:18 PM, that was electronically signed by the Licensed Practical Nurse/Unit Manager (LPN/UM), revealed that Resident #7 was admitted to the hospital with diagnosis of seizure like activity. A review of Resident #7's eMR revealed there was no d/c MDS that was encoded and transmitted when the resident was transferred and admitted to the hospital.2. On 7/10/26 at 1:26 PM, the surveyor reviewed the eMR of Resident #21, and revealed:A review of the AR revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; syncope and collapse, difficulty in walking, not elsewhere classified, and muscle weakness.A review of the PN that was electronically signed by the Licensed Practical Nurse (LPN) on 5/18/26 at 5:10 PM, revealed that Resident #21 was discharged (d/c'd) home.A review of the MDS revealed a highlighted in red information that the next tracking was for d/c MDS, Assessment Reference Date (ARD) 5/18/26, and it was 40 days overdue. There was no d/c MDS that was done when the resident was d/c'd home.A review of Resident #21's comprehensive MDS, with an ARD of 3/3/26, was completed on 4/16/26 (was in red), care areas and CP decision were completed on 4/16/26 (was in red) and accepted (or transmitted) on 4/17/26.On 7/10/26 at 1:38 PM, the DON and the Regional Director of Clinical Services (RDCS) informed the surveyor that the Registered Nurse/MDS Coordinator (RN/MDSC) was not at the facility. The surveyor notified the DON and the RDCS of the above findings and concerns with regard to Resident #7 and Resident #21's MDSs. The surveyor asked for copy of transmission reports.On 7/13/26 at 8:33 AM, the surveyor reviewed the transmission reports provided of Resident #21, revealed the MDS with an ARD of 3/3/26, assessment was completed late which was more than 14 days after the ARD; and CP completed late, was more than 13 days after entry date.On 7/13/26 at 10:45 AM, the surveyor interviewed the RN/MDSC, who informed the surveyor, we follow RAI manual for MDS. The RN/MDSC stated she was not sure when to complete the d/c MDS. She further stated, to initiate the d/c MDS, after the ARD pass, the d/c MDS could be started, and she uses the d/c date as the ARD. The surveyor notified the RN/MDSC of the above concern with d/c MDS for Resident #7 that was not done. The RN/MDSC confirmed that the red MDS in the eMR was considered late MDS. The RN/MDSC further stated that she would get back to the surveyor.On 7/14/26 at 12:08 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO), DON, Assistant DON (ADON), RDCS, and the surveyor notified them of the above findings and concerns with Resident #7 and Resident #21's MDSs.On 7/15/26 at 11:28 AM, the survey team met with DON, ADON, and RDCS for responses, and later on the RDO and the LNHA joined the meeting. The RDCS stated that the RN/MDSC confirmed the late assessments and the d/c assessment that were not done. The RDCS further stated that education was provided to the RN/MDSC, and that the RAI manual should be followed that included completing and transmitting MDSs.A review of the facility's Resident Assessment Policy, with a revision date of October 2023, that was provided by the LNHA, revealed, a comprehensive assessment of each resident is completed at intervals designated requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (iQIES) as required. The comprehensive MDS assessments include both the completion of the MDS as well as completion of the CAA process and care planning.A review of the facility's MDS Completion and Submission Timeframes Policy, with a revision date of October 2023, that was provided by the LNHA, revealed, the facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes.On 7/15/26 at 2:22 PM, the survey team met with the DON, ADON, RDCS, Assistant Administrator, RDO, Assistant in Training (AIT) for exit conference, and the LNHA did not provide additional information. NJAC 8:39 - 11.1

REPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accuracy of daily reports of certified nursing assistant staffing and the resident census (total number of residents in the facility) posted at the beginning of the current shift for 3 of 6 days during the annual re-certification survey. This deficient practice was evidenced by the following:On 7/8/26 at 9:07 AM, the survey team entered the facility, and the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the receptionist desk in the front lobby was dated 7/8/26, with a census (total number of residents in the facility) of 199 for the day shift (7:00 AM to 3:00 PM). Under the heading Staff Category for Certified Nurses Aide (CNA) the # (number) of staff was 25.On 7/8/26 at 9:34 AM, the Director of Nursing (DON) informed the survey team the census this morning was 197. On 7/9/26 at 9:58 AM, the surveyor observed a NHRCSR posted at the receptionist desk, was dated 7/9/26, with a census of 196 for the day shift and the number of CNA staff was 28. On 7/9/26 at 9:58 AM, the surveyor interviewed the Receptionist, who stated she received the staffing numbers from the Staffing Coordinator (SC), then looked up the census in [EMR name redacted] then filled in the template of the NHRCSR form on her computer, printed and posted it daily. On 7/9/26 at 10:00 AM, the surveyor interviewed the SC, who stated she was familiar with New Jersey state staffing requirements and was able to meet those requirements consistently. The SC further stated, for today's staffing we have 28 CNAs for a census of 197. The information provided by the SC did not match the posted NHRCSR on 7/9/26 day shift.On 7/10/26 at 12:33 PM, the surveyor requested and received the Nursing Daily Staffing Sheet for 7/8/26, which reflected 27 CNA names listed for the day shift, which did not match the posted NHRCSR on 7/8/26 of 25 CNAs. In addition, the DON provided what she referred to as a working copy of the Nursing Daily Staffing Sheet for 7/8/26, which reflected 28 CNA names listed for the day shift. On 7/14/26 at 12:08 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO), the Regional Director of Clinical Services (RDCS), DON, and the ADON, and the surveyor notified them of the above findings and concerns. On 7/15/26 at 9:05 AM, the surveyor observed a NHRCSR posted at the receptionist desk, was dated 7/15/26, with a census of 194 for the day shift and the number of CNA staff was 26. The surveyor reviewed the list of active residents in the eMR which reflected 195 residents. The information did not match on what was posted in the reception desk for 194 residents versus the provided list of active residents in the eMR. On 7/15/26 at 11:29 AM, the survey team met with the LNHA, RDO, DON, the ADON, and the RDCS acknowledged the daily posted census was incorrect when observed by the surveyor as above. The RDCS further acknowledged the posted census must be accurate at the start of each shift.NJAC 8:39-41.2(b,c,d)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to; a.) maintain documentation demonstrating annual review of Infection Prevention and Control policies, b.) maintain complete and readily accessible hospice skilled nursing communication records for a resident receiving hospice services, and c.) maintain a vaccine consent form that was readily accessible. This deficient practice was identified for 1 of 3 residents (Resident #154) reviewed for hospice services, and 1 of 5 residents (Resident #146) reviewed for unnecessary medications, and was evidenced by the following: 1. On 7/9/26 at 10:23 AM, the surveyor reviewed Resident #146's electronic medical records (eMR), under the immunization tab, which revealed the resident's pneumococcal vaccine had Status: Pending Consent. There were no other pneumococcal vaccines listed under the immunization tab. On 7/14/26 at 9:40 AM, the surveyor reviewed Resident #146's eMR, under the immunization tab, which revealed the resident's pneumococcal vaccine information was updated to Status: Refused. Confirmation Date: 3/2/26. There was no consent form for 3/2/26 for the pneumococcal vaccine in the eMR. A review of the admission Record (AR) or face sheet (an admission summary) revealed that the resident had diagnoses that included but were not limited to; other lack of coordination, depression, unspecified, anxiety disorder, unspecified, and muscle weakness (generalized). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which reflected that the resident's cognition was intact. The MDS revealed that the resident's pneumococcal vaccination was not up to date. In addition, the MDS reflected the reason the pneumococcal vaccine was not received was that it was not offered. On 7/13/26 at 1:37 PM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC), who stated the pneumococcal vaccine was coded not offered in the MDS because at the time of the assessment in the MDS, there was no documented evidence of consent for the pneumococcal vaccine. On 7/14/26 at 9:51 AM, the surveyor reviewed Resident #146's paper medical records on the unit which had blank informed consent forms for the pneumococcal vaccine and the influenza vaccine. On 7/14/26 at 9:58 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who confirmed that the blank vaccine consent forms for the pneumococcal and influenza vaccines were the only vaccine consent forms they found for the resident. The ADON could not find a completed informed consent form for the pneumococcal vaccine in the resident's medical records. On 7/14/26 at 12:08 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), ADON, Regional Director of Clinical Services (RDCS), and Regional Director of Operations (RDO). On 7/15/26 at 11:30 AM, the survey team met with the LNHA, ADON, RDCS, RDO, and Administrators in Training (AIT), and the DON provided the surveyor with the resident's completed pneumococcal vaccine consent form dated 3/2/26, which was not in the resident's eMR or paper chart. The RDCS stated that they did an audit of the facility to ensure the immunization tab reflected the status of the offering, refusal, and history of immunizations. 2. On 7/14/26 at 9:49 AM, the surveyor conducted a review of the facility's Infection Prevention and Control Program. A review of the facility's Infection Prevention and Control policies revealed that multiple policies did not contain documentation that the facility had reviewed annually the policies according to the regulation, that included the Isolation Policy (last revised September 2022), Infection Prevention and Control Program Policy (last revised December 2023), Antibiotic Stewardship Policy (last revised December 2016), Infection Preventionist Policy (last revised September 2022), Influenza Vaccine Policy (last revised March 2022), and the Legionella Water Management Program (last revised September 2022). The Infection Preventionist Nurse (IPN) was unavailable for an interview. On 7/14/26 at 10:55 AM, the surveyor interviewed the DON and the RDCS regarding the annual review of Infection Prevention policies. The DON stated the policies were reviewed annually and when there was a change in recommendations, and it was corporate who made the changes. The DON further acknowledged that review dates were not documented on the individual policies and stated the there was a binder that showed that all facility policies were reviewed annually that was with the LNHA. On 7/15/26 at 10:10 AM, the surveyor reviewed documentation provided by the LNHA consisting of a binder for Administrative Policies and Procedures Manual annual sign-off sheet. The documentation that indicated the manual had been approved, which did not have a date on the form with the signatures, and simply noted the sign off was good through March 16, 2027. There was no date when the policies were reviewed. In addition, documentation demonstrating annual review of the individual Infection Prevention policies were not included, and when requested during the survey was not readily available for review. A review of the facility's Facility Policies and Procedures – Annual Reviews Policy, revised October 2018, included, policies and procedures are reviewed as needed and at least annually, and the quality assurance and performance improvement committee reviews policies and procedures . at least annually. 3. On 7/13/26 at 9:20 AM, the surveyor observed Resident #154 lying in bed with the head of the bed elevated. On 7/13/26 at 9:34 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated the hospice nurse visited the resident weekly. The RN/UM was unable to provide the communication records or hospice weekly visit notes. The RN/UM stated, I think the hospice company kept the visit notes and the facility had no records. The RN/UM further stated that communication between the hospice nurse and facility staff was verbal. On 7/13/26 at 9:52 AM, the surveyor conducted a follow-up interview with the RN/UM, who stated she contacted the hospice provider, and was informed that the hospice nurse should have left a copy of the skilled nursing communication form in the resident's record. The RN/UM stated the hospice provider was faxing the missing documentation to the facility. On 7/13/26 at 9:58 AM, the surveyor reviewed the medical record for Resident #154. A review of the AR revealed diagnoses which included, but were not limited to; metabolic encephalopathy, osteomyelitis of the sacral region, urinary tract infection, obstructive uropathy, and advanced dementia. A review of the resident's comprehensive MDS, with an ARD of 6/8/26, revealed the resident had a BIMS score of 00, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was receiving hospice services. A review of the resident's individual comprehensive care plan included a focus area indicating the resident was receiving hospice services for advanced dementia. On 7/13/26 at 10:53 AM, the surveyor interviewed the DON, who stated there should be a hospice communication binder maintained at the nursing station. The DON stated she would have to check and get back to the surveyor as to why there were no communication visit notes in the resident's medical records. The RDCS further stated, We cleaned out the nursing stations, and she had to checked as to why the binder was not at the nursing station. On 7/13/26 at 12:23 PM, the surveyor conducted a follow-up interview with the RDCS, who provided documentation received from the hospice provider for the skilled nursing visit completed on 7/10/26. The RDCS further stated the remaining hospice skilled nursing communication records were also being obtained from the hospice provider to be added to the resident's hospice binder. A review of the facility's Hospice Program Policy, revised March 2027, included that the facility is responsible for communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The policy further included that the facility is responsible for obtaining the most recent hospice plan of care specific to each resident and coordinating care with hospice representatives. A review of the facility's Medical Records Policy, revised March 2014, revealed, physical charts are maintained on the unit the resident resides. Chart contents are filed timely. When chart contents are removed for quality assurance purposes, they are re-filed timely. NJAC 8:39-35.2(d)

Complaint #185733 (397779)Based on interview, review of medical record, and other pertinent documentation, it was determined that the facility failed to ensure, a.) appropriate incontinence care was provided for 2 of 3 residents, (Residents #1 and #2) reviewed for quality of care and b.) meal trays delivered timely to residents in 1 of 1 nursing unit observed (2 [NAME] unit) in accordance with standard of clinical practice facility's practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 10/30/25 at 8:22 AM, Surveyor #1 (S #1) asked the Director of Nursing (DON) for list of incontinent residents, schedule, staffing, and mealtime schedules, and she stated that she would get back to S #1. On 10/30/25 at 9:00 AM, S#1 interviewed the Licensed Practical Nurse Supervisor (LPNS) from 11:00 PM – 7:00 AM (11-7) shift, who informed S #1 that she usually work at 2 [NAME] unit and that today the census in 2 [NAME] was 35, with one nurse, and two Certified Nursing Aides (CNAs). On that same date at 9:10 AM, S #1 observed 2 [NAME] unit, there were two food trucks that were left opened, two food carts with breakfast trays, and Certified Nursing Aide #1 (CNA #1) distributing trays inside the dining area in front of the nursing station. There were no other staff assisting CNA #1. On that same date and time, S #1 observed the Registered Nurse (RN) in front of the nursing station in their medication (med) cart preparing medications (meds). S #1 also observed Resident #5 came out from the dining area and poured coffee that was on top of the food truck and went back to the dining area. The RN confirmed to S #1 that Resident #5 was a resident in the unit and that staff should be the one to serve residents with their meal. At that same time, S #1 observed CNA #1 was called by the LPNS into Resident #4's room and left the dining area and distribution of meal trays unattended. On 10/30/25 at 9:30 AM, CNA #2 came to the nursing station and distributed the breakfast trays that were in the two food carts to resident rooms. On 10/30/25 at 9:42 AM, CNA #3 informed S #1 in the presence of the RN that the breakfast trucks were delivered to the unit after 8:30 AM, before 9:00 AM. On 10/30/25 at 9:50 AM, CNA #4 informed S #1 that she was floater and when breakfast truck was delivered in, it should be distributed to the residents right away like in 10 minutes. On 10/30/25 at 9:53 AM, CNA #3 stated that she had nine residents in her assignment today and in regular days, she had the same number of residents. She further stated that if they were short of staff in 7-3 shift, she had at least 12 residents in her assignment. She also stated that the breakfast tray usually comes between 8:30 AM-9:00 AM (9 AM), and aides should deliver them to residents immediately. At that same time, S #1 notified the above concern that the breakfast trays were not delivered timely, left unattended, and there was only one aide that was there at that time. CNA #3 informed S #1 that she was at the resident's room and was unaware that the food trucks were delivered. She further stated that she was the only one regular at the unit today and the other aides were floater, and that CNA #3 had to explain to the on what to do. On 10/30/25 at 11:31 AM, S #1 interviewed the DON in the presence of Surveyor #2 (S #2) with regard to meal deliveries and facility practice. The DON informed the surveyors that once the food trucks were delivered in the unit, any CNA could separate the food trays into the food carts, and deliver them to residents as soon as possible, between 5 to 10 minutes to keep the food warm. She further stated that there was no policy with regard to meal distribution in the unit, the staff were aware via verbal communication that they had to pass the trays. She also added that there was no documented evidence in the CNAs assignment sheets about meal delivery to residents. At that same time, S #1 notified the DON of the above findings and concerns that according to CNA #3, the breakfast food trucks were delivered between 8:30 AM and before 9 AM, and it was not until 9:30 AM when the last tray was delivered to the resident. The DON stated that the meal trays should have been delivered between 9:10 AM and 9:20 AM and not 9:30 AM. A review of the provided Meal Truck Delivery Schedule by the DON revealed that for 2 [NAME] 1 breakfast delivery to the floor scheduled at 8:15 AM and for 2 [NAME] 2 at 8:25 AM. 2. On 10/30/25 at 9:40 AM, both S #1 and the RN observed Resident #1 in the dining room seated in a wheelchair with other eight residents. The RN informed S #1 that Resident #1 was cognitively impaired, required extensive assistance with adls (activities of daily living), and incontinent of both bladder and bowel elimination. On 10/30/25 at 10:00 AM, after Resident #1 had breakfast, CNA #2 accompanied the resident inside the tub room, and S #1 observed the resident with two (double) incontinence briefs in used. CNA #2 confirmed that she was the one who put the double incontinence briefs as per resident's request. She further stated that the nurse should be aware of the double incontinence briefs. On 10/30/25 at 10:05 AM, The RN stated that she was unaware that Resident #1 had double incontinence briefs. She further stated that it was inappropriate for staff to put double unless the resident requested for it. On 10/30/25 at 10:10 AM, S #1 asked the LPNS about double incontinence brief, and she stated that it was not a practice of the facility to use double incontinence brief. She also stated that unless the resident requested for it, it should be documented in their care plan (CP). At that same time, S #1 notified the LPNS of the above findings and concerns. LPNS reviewed the electronic medical records of Resident #1 and confirmed that there was no CP information and intervention that was documented for use of double incontinence briefs. On 10/30/25 at 11:31 AM, the DON stated that there were residents in the facility that requested for double incontinence briefs, and those were residents who were cognitively intact and able to decide for their care. She also stated that it was expected that the CP included information about the resident's preference for double incontinence briefs use. She further stated that cognitively impaired residents unable to request for double due to cognitive impairment. The DON stated that it was important not to use double incontinence briefs because the risk of resident of having UTI (urinary tract infection) and skin impairments. S #1 notified of the above concerns with Resident #1. S #1 reviewed the medical records of Resident #1 and revealed: A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 9/9/25, revealed a brief interview for mental status (BIMS) score of 12 out of 15, which reflected that the resident's cognition was moderately impaired. Section H Bladder and Bowel reflected that resident always incontinent of urine and frequently incontinent of bowel. On 10/30/25 at 12:15 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and DON, and S #1 notified them of the above findings and concerns with regard to meal delivery and incontinence care. The DON confirmed that if a resident requested for double incontinence briefs, it should be documented in the resident's CP and honor resident's preferences. The DON further stated that Residents #1 and #2's CP were being updated after surveyors' inquiry to include their preferences for double incontinence briefs. On 10/30/25 at 1:31 PM, the surveyors met with the LNHA and DON, and the DON stated that it was okay for Resident #5 to pour their own coffee. On 10/30/25 at 2:06 PM, the surveyors met with the LNHA, DON, and two Administrators in Training during an exit conference, and the LNHA confirmed that CNA #1 was called by the LPNS during meal tray delivery and left the dining area to attend to Resident #4. 3. On 10/30/25 at 9:25 AM, S #2 entered Resident #2's room and observed the resident lying in bed. Resident #2 stated that they had not seen their assigned CNA yet. On 10/30/25 at 9:32 AM, S #2 requested CNA #2 to check the resident's incontinent brief. S #2 observed that Resident #2 had two incontinent briefs on, one full brief which was white and green and an additional partial brief which was white and purple. CNA #2 confirmed that the resident had two incontinent briefs on. CNA #2 stated that she was not the CNA assigned to care for Resident #2. On 10/30/25 at 9:35 AM, the LPN/S confirmed that Resident #2 had two incontinent briefs on. The LPN/S stated that it looked as if a liner was put inside the incontinent brief. S #2 asked the LPN/S if the resident should have two (double) incontinent briefs on. The LPN/S stated no. On 10/30/25 at 9:42 AM, S #2 interviewed Resident #2's assigned CNA, CNA #1. CNA #1 stated that when she had done her rounds earlier that Resident #2 was sleeping and that she did not change Resident #2 yet. CNA #1 stated that Resident #2 was alert and oriented and that the resident put on the call light when they needed to be changed. S #2 asked CNA #1 about the two incontinent briefs. CNA #1 stated that maybe the night shift put on the double brief. A review of Resident #2's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but were not limited to; hemiplegia and hemiparesis following cerebral infarction, hypertension, and urinary incontinence. A review of Resident #2's most recent quarterly MDS (qMDS), with an ARD of 10/4/25, revealed in Section C Cognitive Patterns, the resident had a BIMS score of 11 of 15, which reflected that the resident's cognitive status was moderately impaired. The qMDS also included that the resident was coded #3 for bladder continence, which reflected that the resident was always incontinent. A review of the personalized care plan (CP) revealed that Resident #2, had an ADL deficit related CVA (stroke) with an initiated date of 1/1/25. The CP interventions included but were not limited to; I am continent of urine (initiated 2/17/25); I use a urinal (initiated 2/17/25); and personal hygiene routine provide me with individualized hygienic routine care as per preference and as per need of assistance I prefer to have extra protection such as a second brief, towel, padding etc to manage my urinary incontinence (initiated 10/30/25). Resident #2's CP was not revised to reflect the resident's incontinence and the preference for extra protection was updated after surveyor inquiry. A review of Resident #2's facility provided Documentation Survey Report of CNA (CNA interventions and tasks accountability) for October 2025, revealed for bladder continence that the resident was coded as incontinent on most of the days of the month. On 10/30/25 at 11:43 AM, S #2 interviewed the DON regarding incontinent care. The DON stated that they allow double diaper. The DON stated that some residents request it and proceeded to name two unsampled residents that resided on a different floor than Resident #2. The DON did not name Resident #2 as a resident that requested two (double) incontinent briefs. The DON stated that any new resident that requested two incontinent briefs that the staff were notified and the request was placed in the CP. The DON then stated that for cognitively impaired residents, two incontinent briefs were not used. S #2 asked the DON the reason that two incontinent briefs should not be used. The DON stated that it would increase the risk for skin impairment and cause a urinary tract infection. S #2 then notified the DON of the concern that Resident #2 was observed to have double incontinent briefs on. On 10/30/25 at 12:14 PM, S #2 notified the LNHA and DON the concern that Resident #2 had double incontinent briefs on. The DON stated that the staff had added to the resident's CP the preference of double briefs today. On 10/30/25 at 1:30 PM, in the presence of the LNHA, the DON stated that CNAs and nurses were in-serviced about not using double incontinent briefs unless it was the resident's preference and in the CP. The DON added that Resident #2 was just interviewed and the resident requested the double brief because they did not want the one brief to leak. S #2 then asked the DON about Resident #2's CP that indicated the resident was continent and used an urinal. The DON stated that Resident #2 was continent in the past and that the CP needed to be updated. The DON also confirmed that the preference for double brief was updated today. The LNHA and DON did not provide any additional information. A review of the facility's Urinary Continence and Incontinence-Assessment and Management Policy with a revised date of August 2022, included the following:Policy Statement1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence.2. Management of incontinence will follow relevant guidelines.The policy did not contain information regarding process of changing incontinent briefs. A review of the facility's Activities of Daily Living (ADL), Supporting Policy with a revised date of April 2025, included the following:Policy StatementResidents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs.Residents who are unable to carry out ADL independently receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene.Policy Interpretation and Implementation5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with:c. elimination (toileting);d. dining (eating, including meals and snacks);.9. The resident's responses to interventions are monitored, evaluated and revised as appropriate. A review of the facility's Resident Rights Policy with a revised date of February 2021, included the following:Policy StatementEmployees shall treat all residents with kindness, respect and dignity.Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect kindness, and dignity;c. be free from .neglect.p. be informed of, and participate in, his or her care planning and treatment; ff. equal access to quality of care, regardless of source of payment. A review of the facility's Frequency of Meals Policy with a revised date of July 2017, included the following:Policy StatementEach resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care. Policy Interpretation and Implementation1. The facility will serve at least three (3) meals or their equivalent daily at scheduled times. There will not be more than fourteen (14) hour span between the evening meal and breakfast. 2. Meals will be served four (4) to six (6) hours apart to help assure that residents receive nutritional requirements.3. A schedule of meal times and snacks shall be posted in resident areas.The policy did not contain any information on meal tray passing. A review of the facility's Care Planning-Interdisciplinary Team Policy with a revised date of March 2022, included the following:Policy StatementThe interdisciplinary team is responsible for the development of resident CPs.Policy Interpretation and Implementation1. Resident CPs are developed according to the timeframes and criteria established by 483.21.2. Comprehensive, person-centered CPs are based on resident assessments and developed by an interdisciplinary team (IDT).4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's CP. NJAC 8:39-11.2(b); 27.1(a)

Complaint NJ#185733 (397779) Based on interview and record review, it was determined that the facility failed to maintain a complete record for 2 of 4 residents records reviewed (Residents #1 and #2). The deficient practice was evidenced by the following: 1. On 10/30/25 at 9:40 AM, both Surveyor #1 (S #1) and the Registered Nurse (RN) observed Resident #1 in the dining room seated in a wheelchair with other eight residents. The RN informed S #1 that Resident #1 was cognitively impaired, required extensive assistance with adls (activities of daily living), and incontinent of both bladder and bowel elimination. S #1 reviewed the medical records of Resident #1 and revealed: A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 9/9/25, revealed a brief interview for mental status (BIMS) score of 12 out of 15, which reflected that the resident's cognition was moderately impaired. Section H Bladder and Bowel reflected that resident always incontinent of urine and frequently incontinent of bowel. A review of the provided documentation log for adls by the CNAs (Certified Nursing Aides) for October 2025 revealed that there were multiple blanks for dates 10/7/25 and 10/11/25. On 10/30/25 at 1:31 PM, the surveyors met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S #1 notified them of the above findings and concerns with CNAs accountability log missing documentations. The DON confirmed that the adl log was the CNAs care log for the resident and it was expected for the CNA every shift. On 10/30/25 at 2:06 PM, the surveyors met with the LNHA, DON, and two Administrators in Training during an exit conference, there was no additional information provided by the LNHA. 2. On 10/30/25 at 9:25 AM, Surveyor #2 (S #2) entered Resident #2's room and observed the resident lying in bed. Resident #2 stated that they had not seen their assigned CNA yet. A review of Resident #2's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with a diagnosis that included but were not limited to; hemiplegia and hemiparesis following cerebral infarction, hypertension, and urinary incontinence. A review of Resident #2's most recent qMDS, with an ARD of 10/4/25, revealed in Section C Cognitive Patterns, the resident had a BIMS score of 11 of 15, which reflected that the resident's cognitive status was moderately impaired. The qMDS also included that the resident was coded #3 for bladder continence, which reflected that the resident was always incontinent. A review of the personalized care plan (CP) revealed that Resident #2, had an adl deficit related CVA (stroke) with an initiated date of 1/1/25. The CP interventions included but were not limited to; I am continent of urine (initiated 2/17/25); I use a bedpan/urinal (initiated 2/17/25); and personal hygiene routine provide me with individualized hygienic routine care as per preference and as per need of assistance I prefer to have extra protection such as a second brief, towel, padding etc to manage my urinary incontinence (initiated 10/30/25). Resident #2's CP was not revised to reflect the resident's incontinence and the preference for extra protection was updated after surveyor inquiry. A review of Resident #2's facility provided Documentation Survey Report of CNA (CNA interventions and tasks accountability) for October 2025, revealed for bladder continence that the resident was coded as incontinent on most of the days of the month. The day shift for 10/7/25 and 10/27/25 were left blank and the night shift on 10/11/25 was left blank. On 10/30/25 at 11:43 AM, S #2 interviewed the DON regarding incontinent care. The DON stated that they allow double diaper. The DON stated that some residents request it and proceeded to name two unsampled residents that resided on a different floor than Resident #2. The DON did not name Resident #2 as a resident that requested two (double) incontinent briefs. The DON stated that any new resident that requested two incontinent briefs that the staff were notified and the request was placed in the CP. The DON then stated that for cognitively impaired residents, two incontinent briefs were not used. S #2 asked the DON the reason that two incontinent briefs should not be used. The DON stated that it would increase the risk for skin impairment and cause a urinary tract infection. S #2 then notified the DON of the concern that Resident #2 was observed to have double incontinent briefs on. On 10/30/25 at 12:14 PM, S #2 notified the LNHA and DON the concern that Resident #2 had double incontinent briefs on. The DON stated that the staff had added to the resident's CP the preference of double briefs today. On 10/30/25 at 1:30 PM, S #2 notified the LNHA and DON the concern that Resident #2's documentation record was left blank for three shifts during October 2025, and that the CP was not accurate. The DON stated that Resident #2 was just interviewed and the resident requested the double brief because they did not want the one brief to leak. S #2 then asked the DON about Resident #2's CP that indicated the resident was continent and used a bedpan/urinal. The DON stated that Resident #2 was continent in the past and that the CP needed to be updated. The DON also confirmed that the preference for double brief was updated today. The LNHA and DON did not provide any additional information. NJAC 8:39-35.2 (d)(6)

REPEAT DEFICIENCY Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 14 of 38 residents, (Residents #13, #18, #48, #60, #68, #77, #102, #103, #121, #162, #172, #175, #180, and #187), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following: 1. Surveyor#1 (S#1) reviewed the medical records of the following residents and their MDS and revealed: A review of Resident #18's comprehensive MDS (cMDS) with an assessment reference date (ARD) of 7/11/24, was completed on 7/18/24. A review of Resident #77's cMDS with an ARD of 10/31/24, was completed on 11/12/24. A review of Resident #162's cMDS with an ARD of 9/27/24, was completed on 10/9/24. A review of Resident #175's cMDS with an ARD of 11/20/24, was completed on 12/3/24. A review of Resident #180's cMDS with an ARD of 12/9/24, was completed on 12/23/24. The above MDS of Residents #18, #77, #162, #175, and #180 completion dates were presented in the electronic medical records (EMR) in red. On 2/12/25 at 1:08 PM, S#1 interviewed the MDS Coordinator/Registered Nurse (MDSC/RN) regarding the MDS of the above residents on which completion dates were presented in red. S#1 asked the MDSC/RN what the facility's protocol was for completing MDS and how many days the MDS should be completed, and the MDSC/RN responded that she had to get back to the surveyor. At that same time, the MDSC/RN informed the surveyor that the facility utilized the Resident Assessment Instrument (RAI) manual as the facility's guidelines for MDS and that the facility had no separate policy for MDS. On that same date and time, S#1 asked the MDSC/RN to review the above Residents # 18, #77, #162, #175, and #180's cMDS, determine if the facility completed the assessments according to the RAI manual, and provide the transmittal reports. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S#1 notified them of the above findings and concerns regarding MDS of Residents #18, #77, #162, #175, and #180. On 2/13/25 at 1:51 PM, the MDSC/RN met with S#1 and provided a CMS's RAI 3.0 Manual (October 2024 version) that included the required assessment summary and specified days when to complete and submit the MDS. The MDSC/RN confirmed that the above MDS for Residents #18, #77, #162, #175, and #180 were completed beyond the required 14 days. A review of the provided documents by the MDSC/RN revealed: The 7/11/24 cMDS of Resident #18 was completed on 7/18/24. The Resident was admitted on [DATE], MDS should have been completed by 7/17/24. The 10/31/24 cMDS of Resident #77 was completed on 11/12/24. The resident was admitted on [DATE], MDS should have been completed by 11/9/24. The 9/27/24 cMDS of Resident #162 was completed on 10/9/24. The Resident was admitted [DATE], MDS should have been completed by 10/3/24. The 11/20/24 cMDS of Resident #175 was completed on 12/3/24. The Resident was admitted on [DATE], MDS should have been completed by 11/26/24. The 12/9/24 cMDS of Resident #180 was completed on 12/23/24. The Resident was admitted on [DATE], MDS should have been completed by 12/15/24. A review of the provided RAI Manual with an October 2024 version, that was provided by the MDSC/RN revealed that the admission (comprehensive) assessment completion date will be no later than the 14th calendar day of the resident's admission (admitted +13 calendar days). 48781 2. Surveyor#2 (S#2) reviewed the medical records of the following residents and their MDS and revealed: A review of Resident #13's quarterly MDS (qMDS) with an ARD of 12/14/24, was completed late on 12/30/24. A review of Resident #60's cMDS with an ARD of 12/21/24, was completed late on 12/26/24, and the care plan decisions were completed late on 12/31/24. A review of Resident #68's qMDS with an ARD of 9/11/24, was completed late on 9/26/24. A review of Resident #102's qMDS with an ARD of 12/30/24, was completed late on 1/17/25. A review of Resident #103's cMDS with an ARD of 11/6/24, was completed late on 11/14/24. A review of Resident #187's cMDS with an ARD of 1/14/25, was completed late on 1/30/25. On 2/14/25 at 9:43 AM, S#2 interviewed MDSC/RN, who stated, We go by the RAI manual, we complete them by 14 days from admission and the others 14 days from the ARD. She further stated that the MDSs were late because it was a big building and I am the only one doing the subacute. Sometimes they are late, I will make sure these are a priority going forward. On 2/14/25 at 1:39 PM, S#2 notified the DON and the LNHA regarding concerns with late MDSs completion. On 2/14/25 at 11:25 AM, the MDSC/RN provided the Final Validation Reports (CMS Submission Report) for the late MDSs which confirmed assessments were completed late. 46049 3. A review of Resident #48's cMDS with an ARD of 12/18/24, was completed late on 1/3/25. A review of Resident #121's cMDS with an ARD of 10/1/24, was completed late on 10/11/24. A review of Resident #121's qMDS, with an ARD 12/24/24, was completed late on 1/16/25. A review of Resident #172's cMDS with an ARD of 10/9/24, was completed late on 10/16/24. On 2/14/25 at 1:07 PM, Surveyor #3 (S#3) notified the LNHA and the DON of the identified late completion of the MDS assessments. A review of the facility's MDS Completion and Submission Timeframes Policy, revealed, Timeframes for completion .is based on the current requirements published in the Resident Assessment Instrument Manual. On 2/18/25 at 1:26 PM, the survey team met with the LNHA, DON, and Regional Director of Clinical Services. The LNHA did not provide additional information. NJAC 8:39 - 11.1

Based on interviews and review of other facility documentation, it was determined that the facility failed to ensure that the physicians must review the residents' total program of care including medications and treatments, and write, sign, and date progress notes at each visit. This deficient practice was identified for 14 of 35 residents, (Residents#10, #13, #16, #18, #50, #60, #68, #102, #103, #121, #131, #149, #175, and #180), reviewed for physician services. This deficient practice was evidenced by the following: 1. On 2/7/25 at 11:49 AM, Surveyor #1 (S#1) observed Resident #18 in the activity room behind the 1 East nursing station seated in a wheelchair with other residents. The surveyor reviewed the medical record of Resident #18 and revealed: A review of the Admission Record (AR, an admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; effusion of left knee (swollen joint), essential hypertension (elevated blood pressure), and lymphedema (most common manifestation of lymphedema is soft tissue swelling). A review of the Progress Notes (PN) and Assessment tabs in the electronic medical records (EMR) revealed that there was no evidence that Physician #1 (P#1) wrote, signed, and dated PN and documented in the assessment tab from July 2024 through February 11, 2025 his visit notes. Further review of the EMR revealed that Nurse Practitioner #1 (NP#1) documented on 1/23/25, that the reason for a visit was due to an acute cough and that the SNF (Skilled Nursing Facility) H & P (history and physical) not yet on file. A review of the monthly physician orders (MPO) revealed that on 7/9/2024, the orders were 225 days overdue for P#1 to sign. 2. On 2/7/25 at 11:28 AM, S#1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who informed the surveyor that Resident # 175 was on contact precaution for ESBL (Extended-spectrum beta-lactamases are a type of enzyme or chemical produced by some bacteria. ESBL enzymes make some antibiotics ineffective in treating bacterial infections) in urine with a foley catheter and required to use PPE (personal protective equipment) gown, gloves when providing direct care. S#1 reviewed the medical records of Resident #175 and revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; urinary tract infection site not specified, ESBL resistance, other retention of urine, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other specified anxiety disorders, unspecified protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD, is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). A review of the PN and Assessment tabs in the EMR revealed that there was no evidence that Physician #2 (P#2) wrote, signed, and dated PN and documented it in the assessment tab from November 2024 through February 11, 2025 his visit notes. Further review of the EMR revealed that Nurse Practitioner #2 (NP#2) documented on 2/10/25, that the reason for a visit was due to a UTI (urinary tract infection)/ESBL. A review of the MPO revealed that on 12/14/2024, the orders were 60 days overdue for P#2 to sign. 3. On 2/7/25 at 11:35 AM, S#1 observed Resident #180 lying on the bed, awake, and stated that they were at the facility for rehabilitation and had to go back to the doctor to remove the metal in their left arm. The surveyor observed the resident with a splint in use on their left arm. S#1 reviewed the medical records of Resident #180 and revealed: A review of the AR reflected that the resident was admitted with diagnoses that included but were not limited to; unspecified intracranial injury with loss of consciousness status unknown, subsequent encounter, undifferentiated schizophrenia (is a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect), unspecified protein-calorie malnutrition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and bipolar disorder (is a mental health condition characterized by significant mood swings) unspecified. A review of the PN and Assessment tabs in the EMR revealed that there was no evidence that P#2 wrote, signed, and dated PN in a timely manner from December 2024 through January 11, 2025. The PN dated 12/6, 12/9, 12/12, 12/15, 12/18, 12/21, 12/24, 12/27, 12/30, and 1/11/25 were all created on 1/13/25. There was no documented evidence that P#2 wrote his visit notes in the assessment tab of EMR December 2024 through from February 11, 2025. Further review of the EMR revealed that there was NP wrote and signed the PN and the Assessment tab. A review of the MPO revealed that on 12/5/2024, the orders were 69 days overdue for P#2 to sign. On 2/12/25 at 1:29 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S#1 notified them of the above findings and concerns regarding physician services for Residents #18, #175, and #180. On 2/13/25 at 2:14 PM, the survey team met with the LNHA, Regional Director for Clinical Services (RDCS), and DON. The RDCS stated that as far as physician services with no physician notes, we did reach out to the physicians and had been periodically reaching out. The RDCS acknowledged it was an ongoing problem with regard to physician services signing orders and writing their visit notes. On 2/18/25 at 11:25 AM, the survey team met with the RDCS, DON, and LNHA. The surveyor asked what the facility's standard of practice was for signing orders and visits, and the RDCS stated that the physician's visits would be done monthly for the 1st 90 days and then convert to every 60 days thereafter. She further stated that the signing of orders should be signed off monthly by the physician in the EMR and the physician had 10 days from the due date. 48781 4. A review of the medical record for Resident #10, revealed the resident's physician had not hand signed or electronically signed the MPO for October 2024, November 2024, and January 2025. 5. A review of the medical record for Resident #13, revealed the resident's physician had not hand signed or electronically signed the MPO for July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, and January 2025. A review of the Physician PN (PPN) for Resident #13, revealed that the physician did not conduct face to face visits and did not write PN for the month of July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, and January 2025. 6. A review of the medical record for Resident #50, revealed the resident's physician had not hand signed or electronically signed the MPO for July 2024, August 2024, September 2024, October 2024, November 2024, December 2024 and January 2025. A review of the PPN for Resident #50, revealed that the physician did not conduct face to face visits and did not write PN for the month of June 2024, July 2024, August 2024, October 2024, and January 2025. 7. A review of the medical record for Resident #60, revealed the resident's physician had not hand signed or electronically signed the MPO for January 2025. 8. A review of the medical record for Resident #68, revealed the resident's physician had not hand signed or electronically signed the MPO for January 2025. A review of the PPN for Resident #68, revealed that the physician did not conduct face to face visits and did not write PN for the month of January 2025, a late entry was created on 2/12/25, and back dated for January 15, 2025. 9. A review of the medical record for Resident #102, revealed the resident's physician had not hand signed or electronically signed the MPO for July 2024, September 2024, November 2024, and January 2025. A review of the PPN for Resident #102, revealed that the physician did not conduct face to face visits and did not write PN for the month of July 2024, August 2024, September 2024, January 2025, a late entry was created on 2/13/25, and back dated for December 28, 2024. 10. A review of the medical record for Resident #103, revealed the resident's physician had not hand signed or electronically signed the MPO for December 2024 and January 2025. A review of the PPN for Resident #103, revealed that the physician did not conduct face to face visits and did not write PN for the month of November 2024, December 2024, and January 2025, a late entry was created on 2/12/25, and back dated for November 2024, December 2024 and January 2025. On 2/14/25 at 10:00 AM, Surveyor #2 (S#2) interviewed the 3rd Floor LPN/UM who stated, I know they're supposed to come in once a month, I have to review the policy. After they see the patient, they usually write a PN in Electronic Health Record (EHR). I'm not sure about signing orders, I have to review it, but I believe it's once a month. They document under the PPN. 46049 11. On 2/13/25 at 9:04 AM, Surveyor #3 (S#3) reviewed Resident #121's medical records. The AR documented that Resident #121 had diagnoses that included but were not limited, type 2 diabetes mellitus, end stage renal disease, kidney transplant, dependence on renal [kidney] dialysis, and anemia. A review of the PN revealed a PN written by P#2, the resident's primary physician, with effective dates of 10/18/24, 11/13/24, 12/17/24, and 1/15/25, were written on 2/12/25, after the surveyor's inquiry. A review of the order review history revealed P#2 last signed orders for the resident on 11/2/24. 12. On 2/13/25 at 9:28 AM, S#3 reviewed Resident #16's medical records. The AR documented that Resident #16 had diagnoses that included but were not limited, left bundle branch block (condition where electrical impulse that causes your heart to beat is disrupted or blocked), heart disease, osteoarthritis, major depressive disorder, and hypertension (high blood pressure). A review of the PN revealed the following: NP #2 wrote a PN on 9/18/24. NP #1 wrote PN on 11/5/24, 11/7/24, 11/14/24, and 2/6/25. There were no PN written by P#3, the resident's primary physician, from June 2024 to February 2025. A review of the order review history revealed the last signed orders for the resident was on 6/27/24 by P#3. 13. On 2/13/25 at 9:36 AM, S#3 reviewed Resident #149's medical records. The AR documented that Resident #149 had diagnoses that included but were not limited, Alzheimer's disease, type 2 diabetes mellitus, anxiety disorder, and anemia. A review of the PN revealed P#3, the resident's primary physician, wrote PN with effective dates of 6/27/24, 7/29/24, and 11/17/24. There were no PN written by P#3 in August 2024, September 2024, October 2024, December 2024, January 2025, and February 2025. A review of the order review history revealed the last signed orders for the resident was on 6/27/24 by P#3. 14. On 2/13/25 at 9:36 AM, S#3 reviewed Resident #131's medical records. The AR documented that Resident #131 had diagnoses that included but were not limited, anemia and thrombocytopenia (blood has lower than normal number of platelets. A review of the PN revealed there were no PN written by P#3, the resident's primary physician, from June 2024 to February 2025. A review of the order review history revealed the last signed orders for the resident was on 6/27/24 by P#3. On 2/13/25 at 2:18 PM, S#3 notified the LNHA, the DON, and the RDCS of the concerns with PPN, review, and signing of orders for residents. A review of the facility's Physician Visits Policy, with a revision date of April 2013, that was provided by the Regional Nurse revealed that the attending physician must make visits in accordance with applicable state and federal regulations. Policy Interpretation and Implementation: 1. The attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The attending physician must visit his/her patients at least once every 30 days for the 1st 90 days following the resident's admission, and then at least every 60 days thereafter. 3. Non-physician practitioners (physician assistant, NP) may perform required visits (initial and follow-up), sign orders, and sign certifications/re-certifications as permitted by state and federal regulations . NJAC 8:39-11.2(1); 23.2(b)(d)

Based on observation, interview, record review, and policy review, the facility failed to sanitize glucometers between uses for one (Resident (R) 111) of two residents (R152 and R111) observed receiving blood glucose testing out of a total sample of 43 residents. The failure to sanitize glucometers between residents resulted in an Immediate Jeopardy (IJ) at F880-J: Infection Control due to the increased likelihood to cause serious harm due to the potential of cross-contamination of blood-borne pathogens. On 05/04/23 at 7:15 PM, the Administrator and Director of Nursing (DON) were notified of the IJ at F880-K: Infection Control. The Immediate Jeopardy began on 05/03/23 when the survey team identified glucometers were not being sanitized between uses for R111. The facility provided an acceptable Removal Plan which included retraining and ensuring competency of all Licensed Practical Nurses (LPN) and Registered Nurses (RN) on the use and sanitization of glucometers. Through interviews with facility staff, observations of glucose testing, and review of staff in-services, the survey team verified implementation and removed the Immediate Jeopardy on 05/05/23 at 12:22 PM. The deficient practice remained at a scope and severity of D (isolated for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of R111's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with a medical diagnosis of type II diabetes. Review of R111's Order Summary from the EMR Orders tab showed an order for Humalog Solution 100 units/milliliter [ML] (Insulin Lispro) Inject as per sliding scale [glucometer reading] If 151-200=1unit; 201-250=2 units; 251-300=3 units; 301-350=4 units; 351-400=5 units; 401-450=6 units; 451-500=7 units; greater than 501 or less than 70 notify MD [physician] Review of R152's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with a medical diagnosis of type II diabetes. Review of R152's May 2023 Medication Administration Record (MAR) from the facility Orders tab showed an order for Humalog Solution 100 u/ML (Insulin Lispro) Inject as per sliding scale: If 151 -200=2units: 201 -250=4units; 251 -300=6 units; 301-350=8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for DM [diabetes] Less than 70 or greater than 400, call MD. During the observation of blood glucose monitoring on 05/03/23 at 10:50 AM, LPN1 took the glucometer from the zippered case (LPN1 stated she had sanitized the glucometer before she put it away; and stated there was only one and all residents share it) and entered R152's room and performed a blood glucose check. LPN1 placed the glucometer back into the zippered case and returned it to the cart. At 10:59 AM, LPN1 retrieved the zipper case, entered R111's room, performed hand hygiene, took an alcohol wipe from the zipper case, and cleaned the glucometer, (LPN1 verified it was an alcohol wipe) let it dry and performed a blood glucose test on R111. The glucometer was placed back into the zipper case and returned to the medication cart. During an interview on 05/03/23 at 4:41 PM, in response to a query regarding the facility policy for sanitizing the glucometer, LPN1 stated, When you want to use the glucometer you clean after each resident with an alcohol wipe before the using it on the next resident. In an interview on 05/04/23 at 1:28 PM, the Director of Nursing (DON) stated, [Nurses] are supposed to use the guidelines according to the manufacture - that's my expectation, not supposed to use alcohol. If they don't have the right product, they can request it from central supply. Review of the facility policy titled Blood Glucose Monitoring, revealed: . 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 4. If possible, glucometers should not be shared between residents, but if this is not possible, the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. Review of the manufacturer's user guide for the Even care G3 Blood Glucose Monitoring System User's Guide, page 46-47, showed: Cleaning and Disinfecting Procedures for the Meter The EVENCARE G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: o Dispatch(R) Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) o Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) o Clorox Healthcare(R) Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) o Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1) . Materials needed: o EVENCARE G3 Meter o Gloves o A validated disinfecting wipe . Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the EVENCARE G3 system, however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry . NJAC 8:39-19.4(a)1

Based on observation, interview, and record review, it was determined that the facility failed to provide supervision in the dining room for a cognitively impaired resident who fell and sustained a fractured hip, failed to properly transport a cognitively impaired resident who then fell and sustained a fractured wrist, and failed to appropriately utilize assistive devices and provide supervision for a cognitively impaired resident which resulted in a fall and fractured hip. This deficient practice was observed for 3 of 13 residents, Residents #12, 16, and 28, reviewed for falls as evidenced by the following: 1. On 02/17/15 at 12 p.m. during the initial tour of the facility with the Unit Manager (UM), the surveyor observed Resident #12 out of bed in the activity room seated in a Broda Chair (a tilt and recline positioning wheelchair) with a TABS monitor (magnetic pull tab personal alarm) and chair sensor in use. The resident's eyes were closed. The UM stated that the resident yelled out at times, was impulsive and had poor safety awareness. According to the UM the resident sustained [REDACTED]. On 02/19/15 at 9:00 a.m. the surveyor observed Resident #12 ambulating with a rolling walker and close supervision of a Certified Nursing Assistant (CNA) from the bathroom in his/her room to the Broda chair near the bed. The resident walked with a stooped posture and required cueing from the CNA. On 02/23/15 at 9:15 a.m. the surveyor observed Resident #12 in the activity room seated in a Broda Chair. A TABS monitor and chair sensor were in use. He/she was seated at a table in the rear corner of the room farthest away from the door. He/she fidgeted while in the chair. The surveyor spoke to the resident about the fall which resulted in a hip fracture. The resident did not remember falling. On 02/18/15 at 7:35 a.m. the surveyor reviewed the medical record for Resident #12 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/29/14 the Interdisciplinary (IDC) team assessed Resident #12 as moderately cognitively impaired utilizing the Minimum Data Set (MDS), an assessment tool. The IDC team further assessed that the resident required the assistance of 1 person for transfers and ambulation and extensive assistance of 1 person for toilet use. The IDC team assessed that the resident used a walker and wheelchair. A review of the Fall Assessment form completed on 06/03/14 at the time of admission revealed that the resident was identified to be at extreme risk for falls. A fall care plan was put into place. The care plan indicated that the resident was at risk for injury from falls/accidents related to impaired mobility, impaired balance, impaired gait, impaired cognition, poor judgment and/or safety awareness. Additionally, the use of certain medications including psychotropic, cardiac, antihypertensive and diuretics could also increase Resident #12's risk for falls/accidents. Interventions in the care plan to prevent falls and injury included the use of a tab alarm monitor and increased monitoring/supervision to maintain safety for Resident #12. A review of the Progress Notes dated 07/20/14 at 8:00 a.m. written by the nurse on duty revealed that the resident was ambulated to the Dining Room with the use of a rolling walker and assistance of a staff member. The resident was seated in a chair and a TABS monitor was connected to his/her clothing. At 9:30 a.m. the resident was found on the floor in the bathroom near the nurse's station. The resident's left leg was turned outward and he/she complained of pain in that leg. Resident #12 was sent to the hospital, diagnosed with [REDACTED]. A review of the facility Incident Report dated 07/20/14 revealed that 3 employees wrote statements regarding the fall. Employee #1 documented that she was coming down the hallway with another resident and found Resident #12 on the floor in the shower room/bathroom. Employee #2 and #3 were each in other residents' rooms providing care. None of these employees witnessed the resident get up from his/her chair in the Dining Room and walk out into the hallway and into the shower room/bathroom. There is no indication that the tabs monitor or sensor alarm sounded. There were no other employee statements. The surveyor reviewed the Timeline of Fall provided by the facility dated 07/21/14 which indicated that the resident was alert, confused and forgetful at times. A TABS monitor was used on the chair but Resident #12 was able to remove the monitor. On the day of the accident, the resident got up from the chair without asking for help and went to the bathroom. The report concluded that Resident #12 was seated in the Dining Room, got up and went to the shower room to use the toilet. The resident lost their balance and fell to the floor. The resident usually used a walker but did not use the walker that time. The conclusion did not specifically address why the resident, who was assessed at extreme high risk for falling, was left in the common area without supervision. The conclusion did not address the alarms used to alert staff when the resident attempted to rise from the chair. The conclusion lacked crucial data of whether the alarms were turned on or off; if turned on why the staff did not hear them in time to intervene and prevent the fall; and if the resident's walker was available or not in the area to assist the resident to ambulate. The facility failed to complete a thorough fall risk analysis to determine the causal factors for the fall. The Falls Committee Meeting Incident Review dated 07/23/14 identified that the nursing staff should consistently stay in the Dining Room. On 02/23/15 at 12:15 p.m. the surveyor spoke with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding lack of staff supervision in the Dining Room at the time of this incident and requested any documentation that the facility could provide related to Resident #12's fall. On 02/24/15 at 10:00 a.m. the ADON stated that staff members were not present in the Dining Room at the time of the incident. The ADON did not know the reason for the lack of staff supervision in the Dining Room but agreed that lack of supervision may have contributed to Resident #12's fall. The surveyor reviewed the Facility Policy and Procedure (P&P) for Fall Prevention which indicated that appropriate interventions that may prevent falls or serious injury to a resident included dining room monitoring. Although the Facility P&P dining room monitoring would be effective in preventing falls or serious injury the facility failed to provide monitoring in the dining room for Resident #12 on the day of the resident's fall and fracture. 2. On 2/24/15 at 11 a.m. the surveyor reviewed the closed record for Resident #28. The resident had [DIAGNOSES REDACTED]. The facility completed a Fall Risk assessment dated [DATE] and documented that the resident had a score of 34. This meant the resident was at "extreme risk" for falling due to the following factors: the resident had a history of [REDACTED]. On 2/24/15 at 11:30 a.m. the surveyor reviewed the resident's care plans. A fall care plan initiated on 2/2014 indicated that the resident had a fall on 11/3/14. At 11:45 a.m. the surveyor reviewed the investigation report for the fall and noted that on 11/3/14 at 8:40 p.m. a Certified Nursing Assistant (CNA) placed the resident on a commode in his/her room next to the bed. The CNA gave the resident a call bell, clipped the tabs alarm monitor to the resident's clothing, and instructed the resident, who was assessed as cognitively impaired, to call for help when finished. The CNA left the room to assist another CNA with a Hoyer lift transfer. When the CNA returned the CNA found Resident #28 on the floor face down complaining of left hip pain. The facility sent the resident to the hospital for an evaluation. Resident #28 was admitted with a [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE] after hip surgery on 11/5/14. According to the investigation report the resident was forgetful at times and needed assistance with all activities of daily living and ambulated with a walker and close supervision of one staff member. The resident's Care Plan included that the resident use non-skid socks to prevent falls. The report did not include if the resident's walker was in close proximity to the resident or if the resident was wearing non- skid socks. The facility form entitled "Summary of Critical Information Obtained during the Investigation" included the facts that the resident required one person to assist with ambulation in the room and the resident did not walk in the corridor. The report noted the resident was impulsive and restless and the CNA acknowledge that the resident may get up without asking for help. On 11/4/14 the Director of Nursing (DON) concluded that "The resident should not have been left alone since it was known that s/he would not be compliant with safety measures. A tab alarm is not to be used when toileting a resident." On 2/24/15 at 11:15 a.m. the DON told the surveyor that the CNA should not have left the resident alone on the commode. 3. Resident #16 was observed on 2/17/15 at 12:10 p.m. during the initial tour of the nurses unit with the Unit Manager (UM). The resident was seated in a regular chair in the dining room. The UM stated the resident was alert, confused, had a history of [REDACTED]. The surveyor reviewed the medical record for Resident #16 which indicated the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16's Quarterly MDS dated [DATE] and the corresponding IDC Care Plan Summary indicated the resident had a fall with a major injury on 1/31/15. The surveyor reviewed the facility's Fall Assessment form dated 1/31/15 completed for Resident #16. The form noted that residents were considered at risk for falls if they scored less than or equal to 10 points; at moderate risk to fall between 10 to 18; at high risk to fall between 19 to 26; and at extreme risk to fall at greater than or equal to 27 points. Resident #16 scored 46 points and therefore was assessed as an extreme risk for falling. The surveyor reviewed the facility's Falls Investigation Form dated 1/31/15. The information documented on the Investigation Form noted that at 10:00 a.m. an activity aide (AA) was in the process of transporting 2 residents at the same time, while they were seated in wheelchairs, down the hall. Resident #16 slid out of the wheelchair and fell on his/her left side. The section of the Falls Investigation Form titled " Immediate Assessment of Resident " was not completed and failed to indicate if Resident #16 sustained an injury as a result of the fall. The Investigation Form noted that the resident was sent to emergency room for evaluation. The facility nursing staff could not determine where the resident had pain due to a language barrier. The resident spoke Russian. The surveyor reviewed the Radiology Report dated 1/31/15 which did not immediately identify the wrist fracture. A repeat x-ray and Radiology Report dated 2/9/15 documented "a transverse fracture of the distal radius." The surveyor reviewed the Investigation Report dated 2/3/2015. The RN documented in the Conclusion section that Resident #16 complained of pain in the left wrist region, was sent to the emergency room , was treated and discharged with a splint and ace bandage to the left wrist. The conclusion reached was that the Activities person should not have been wheeling two residents at the same time and if she hadn't been the resident would not have sustained a fall. On 2/23/15 at 1:00 p.m., in the presence of the DON and the ADON the surveyor reviewed the facility's signed and dated Witness Statement Form dated 2/3/15. The form identified that the Activity Aide was "wheeling 2 people at the same time" at the time of the incident. The DON and the ADON confirmed that the AA attempted to transport 2 residents in wheelchairs at the same time down the hall at the time of the incident. The conclusion made by the Registered Nurse (RN) in the Incident Report was that the AA needed to focus on transporting one resident at a time. On 2/23/15 at 1:15 p.m. during an interview with the Activity Director and the ADON, the AD stated that the AA who transported Resident #16 at the time of the resident's incident had been previously provided with and signed the facility's Transportation to/from Activities Policy and Procedure (P&P). The AD further stated that the P&P instructed that one staff member can transport only one wheelchair resident at a time. The surveyor reviewed the facility's Transportation to/from Activities dated April 2011 and signed by the Activity Aide on 6/25/13 and found that the P&P failed to include directions for one to one transport of residents seated in wheelchairs. The resident was observed on 2/17/15 in the dining room seated at a table with his/her cane at the table. The resident had a small splint to the left wrist and hand. The resident was unable to hold a meaningful conversation with the surveyor. NJAC 8:39-27.1(a)

Based on observation, interview and review of the medical records, it was determined that the facility failed to transfer residents safely as per the physician's orders [REDACTED]. Resident #18 sustained a fracture of the Left femur that required hospitalization and surgical repair. The fracture occurred when Resident #18 was inappropriately transferred. This deficient practice was noted for 2 of 10 residents sampled for falls, Residents #18 and #10, as evidenced by the following: 1. On 4/2/14 at 11:15 a.m. the surveyor toured the 3rd floor unit with the Registered Nurse Unit Manager who revealed that Resident #18 had behavior issues and paranoia, was on Klonopin, and staff were attempting to reduce restraints and tried to provide 1:1 attention to the resident. The surveyor observed the resident in the dayroom in a lounge chair. The surveyor also noted that the resident's bed had padded siderails. The surveyor reviewed the medical record of Resident #18 on 4/8/14 at 10:30 a.m. The [AGE] year old resident was admitted to the facility on [DATE] and had a re-admission on 2/9/14 after being hospitalized with a fracture of the Left femur. This fracture required surgery that is an Open Reduction and Internal Fixation. The resident also has a [DIAGNOSES REDACTED]. Review of the 11/30/13 annual MDS (Minimum Data Set) assessment tool and the 2/16/14 quarterly review indicated that the resident was coded as 4-3 for transfer indicating the resident required the total assistance of 2 staff members for transferring. The MDS also reflected that this resident required total care in all Activities of Daily Living and was severely cognitively impaired. During review of the medical record, the surveyor noted the "Timeline of Injury of Left Leg" dated 2/4/14 and completed by the Assistant Director of Nursing (ADON). The date and time of the incident are identified in this report as 2/4/14 at approximately 4 p.m. There was no date indicating when this report was written. This was part of the facility's investigation as to how the resident was injured. A General Incident Report was made at the time the injury was first identified. The "Timeline" document indicated, "the CNA (Certified Nursing Assistant) said she used the Hoyer lift to get (the resident) up, without any help. The CNA said she got (the resident) out of the geri-chair with the Hoyer lift, and put (the resident) on the tub seat. The mode of transfer for this resident is Hoyer lift, not Vera lift. The resident needs a 2 person transfer." The facility investigation showed that at the time Resident #18 sustained the injury the Unit Nurse and the Nurse Manager went to assess the resident in the tub room. They observed that a Vera Lift and not a Hoyer lift was next to the tub seat. A Vera Lift brings a person from a sitting position to a standing position thus putting weight on a resident's legs. A Hoyer lift transfers a person in a sitting position. When the resident was returned to bed and the nurse manager noticed bruising had begun on the Left leg the ADON was called to the unit. The unit manager and the 3 to 11 nurse explained to the ADON that they believed the CNA used an incorrect means of transfer, the Vera Lift, which caused an injury to Resident #18. Review of the General Incident Report dated 2/4/14 at 3:30 p.m. revealed that the nurse, after being called to the tub room by the CNA who reported a problem with Resident #18's left leg "observed swelling of upper thigh, no bruises or ecchymotic at this time, but lower leg is flaccid and knee cap is flat and external rotation." The report also indicated that X-rays were ordered which revealed an "acute distal femoral shaft fracture." The surveyor reviewed a typed statement of investigation by the RN - Unit Manager which noted that "she asked the CNA how she transferred the resident from the recliner chair to tub chair and she said 'I used the Vera lift I use this all the time'." The CNA had first said that the Hoyer lift was used to transfer the resident. "I ask who was with you and she said by myself I do this all the time but today (the resident) looks terrible." The investigation also included that the Advanced Practice Nurse (APN) was present on the unit at the time and ordered an immediate X-ray of the left hip and left knee which revealed a fracture of the left distal femur. The resident was sent to the hospital on [DATE], had a surgical repair of the fracture and was re-admitted to the facility on [DATE]. The conclusion of the facility as to how the fracture occurred was that the failure of the CNA to use the Hoyer lift with the assist of another person, but rather using a lifting device that put pressure/weight on the resident's legs and this along with the [DIAGNOSES REDACTED]. 2. On 4/2/14 at 11:15 a.m. during the initial tour the Unit Manager told the surveyor that Resident #10 had a [DIAGNOSES REDACTED]. The resident was a fall risk and had fallen 8 months ago during a transfer from the bed to the wheelchair (WC). The resident was observed by the surveyor in the bed sleeping. On 4/4/14 at 9:30 a.m. the surveyor reviewed Resident #10's medical record. The resident's fall assessment completed on the resident's last re-admission and dated 8/4/12 documented that the resident was a very high risk for falls. The resident's most recent fall assessment dated [DATE] documented that the resident remained a very high risk for falls. Resident #10 had a Comprehensive Care Plan (CCP) in place for falls/Accident/Injury initiated on admission on 2/4/08. According to the CCP for Activities of Daily Living (ADLs), also initiated on admitted d 2/4/08, Resident #10 was at that time identified as a 2 person assist for transfer with a mechanical lift. According to the "Method of Transfer" form signed each shift by the CNA caring for Resident #10, the resident was a 2-person assist with the Vera lift, a sit to stand lift device. A nurse's note dated 8/29/14 (late entry) indicated that on 8/24/13 at 7:30 a.m. the nurse was called to the room by the CNA. The resident was lying on the floor next to the wheelchair (WC). According to the CNA statement the resident was eased to the floor as the resident slid from the WC. The Resident was assessed with [REDACTED]. On 4/7/14 at 9:00 a.m. the surveyor reviewed the "Incident Reports for Falls" dated 8/24/13 timed 7:30 a.m. The CNA's written statement indicated that she transferred the resident using the Vera lift without the assistance of another staff member as set forth in the CCP. After the resident was transferred into a WC, the CNA turned to get the leg rests for the WC. When she turned back the CNA noticed the resident was starting to slide out of the WC. The CNA called for help and then placed her leg under the resident and eased the resident to the floor. The resident was not injured. The cause of the fall documented on the incident report by the Assistant Director of Nursing stated that the resident slid to the floor because of "poor judgement by the CNA who did not follow the 'method of transfer sheet' for Resident #10 which required a 2 person assist for all transfers with the veralift." NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to consistently implement falls interventions and provide appropriate supervision to prevent falls. This deficient practice was identified in 3 of 7 residents reviewed for falls, Residents #4, #13, and #16. The lack of supervision resulted in harm to 2 residents. Resident #13 who fell , dislocated the right shoulder. Resident #16 fell and subsequently required sutures to a laceration. This deficient practice was evidenced by the following: 1. During the initial tour of the 3rd floor unit on 5/2/11 at 10:30 a.m., the Unit Manager (UM) told the surveyor that Resident #13 was totally dependent on the staff to provide all aspects of care, activities of daily living (ADLs). The surveyor observed the resident who was in a Geri-recliner wheelchair and in a semi-reclined position. The resident, whose eyes were closed, did not respond to the surveyor when spoken to. On 5/2/11, the surveyor reviewed the medical record of Resident #13 . The medical record indicated Resident #13 was [AGE] years old and was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The surveyor reviewed the Annual Minimum Data Set (MDS), an assessment tool dated 12/12/10 and the Quarterly MDS dated [DATE] which indicated the resident was assessed as having a cognitive deficit with short and long term memory problems, severe impairment with decision making, and was totally dependent on the staff for ADLs. The resident required a 2 person physical assist for bed mobility, transfer, toilet use and bathing. The surveyor reviewed the resident's Care Plan dated 11/8/10 which indicated the resident required physical assist of 2 persons for ADLs as assessed in the resident's Annual Minimum Data Set (MDS). The Fall Risk Assessment completed on 11/8/10 and 1/11/11 indicated that Resident #13 was considered at High Risk for falls/injury. The surveyor further reviewed the medical record on 5/2/11 and noted a Physician's Progress note dated 2/4/11, which indicated the resident fell from the bed to the floor when the Certified Nursing Assistant (CNA) left the bedside to go to the resident's bathroom. The resident was sent to the Emergency Dept. for evaluation and treatment. The surveyor reviewed the physician progress notes [REDACTED]. A Physician's Progress note date 2/10/11 indicated that the resident required the shoulder to be "reset" and ordered pain medication in response to staff assessment that the resident may be having pain secondary to the dislocated shoulder. A review of the 2/4/11 Fall/Incident report on 5/9/11 at 10: 30 a.m. revealed that on 2/4/11 at 9:35 a.m. morning care was being provided by 1 CNA. During care the resident started to have a bowel movement. The CNA turned the resident onto the resident's left side, left the bedside and went into the resident's bathroom to get clean water, resulting in a fall from the bed with an injury. The report indicated that a half, left side rail was in use. Refer F279 2. Resident #16 was [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This assessment tool also indicated that the resident did not ambulate and was totally dependent, needing the physical assistance of 1 person for movement on and off the unit. Upon the surveyor's review of the resident's medical record on 5/3/11, it was noted that the resident had sustained 3 falls since admission to the facility. This resident was observed at various times during the survey in the wheel chair in the Dining Room. The resident was able to greet the surveyor and was noted to be able to feed herself. At each observation the TABS alarm was attached. The surveyor reviewed the medical record on 5/3/11. The record documented that Resident #16, while in the Dining Room, fell from her wheelchair on 3/17/11 at 12:40 p.m.. The resident was found on her left side with a cut on her forehead, a small cut on her lower lip, and a skin tear on her left forearm. The progress note indicated that the resident was aware of what happened and stated that the "wheelchair moved." The resident also asked the staff to call her daughter. On 3/17/11 at 1:10 p.m., Resident #16 was sent to the hospital where she received sutures to the forehead. On 5/10/11 at 2:00 p.m. the surveyor questioned the Administrator concerning the fall of 3/17/11. The Administrator said that Certified Nursing Assistants (CNAs) are assigned to the dining room for 30 minutes at a time all day long. These CNA's only job is to monitor the residents in order to protect against falls. The day Resident #16 fell in the dining room, the CNA assigned to monitor was passing lunch trays and not monitoring the residents. On 5/11/11 at 10:00 a.m. the ADON told the surveyor that he came to a conclusion about what happened when Resident #16 fell in the dining room. The ADON said that he was called to the dining room when the resident fell . After he examined the resident, he checked the wheel chair and noticed that one of the brakes was not locked. The ADON also said that he believed that Resident #16 was not placed close to the table and as a result the resident fell to the side of the unlocked wheel chair area and injured her head. 3. Resident #4 was [AGE] years old and admitted to the facility on [DATE]. A Minimum Data Set (MDS) facility assessment tool of 10/20/10 reflected that the resident ambulated with supervision and a walker, and that the resident was understood and usually understood the staff. During the initial tour of 5/2/10, the surveyor observed the resident in the activity room seated in a wheelchair with a TABS alert alarm attached. The nurse assisting the surveyor on tour told the surveyor that Resident #4 had a history of [REDACTED]. On 5/5/10 at 9:10 a.m., the surveyor observed the resident seated in a wheelchair in the activity room with the TABS alarm attached. The surveyor attempted to speak with Resident #4, but the resident did not respond, just repeatedly asked the surveyor to "get my walker." The surveyor reviewed the medical record of Resident #4 on 5/4/11 and found that Resident #4 had fallen on 9/19/10, 10/15/10, 12/18/10, and 3/6/11. Each of these falls occurred when the resident was ambulating independently with the rolling walker on the unit. After each fall, the resident was able to continue ambulating with the walker. The Care Plan, dated November 2008, concerning falls for Resident #4 had the statement monitor for steadiness and balance listed as an intervention. After the 10/15/10 fall the intervention of "monitor closely" was added, and on 1/13/11 there was a notation on the Care plan to "closely observe during ambulation." According to a progress note of 4/3/11 timed 2:00 p.m., Resident #4 was taken off the unit to attend an activity in the facility ' s auditorium. The nursing unit was notified at 2:30 p.m. that the resident had fallen. The Fall Incident Report of 4/3/11 timed 2:30 p.m., included a description of the fall as " Resident fell face down while going down the ramp with rolling walker. " The progress note of 4/2/11 timed 2:45 p.m. indicated that the resident was seen by the facility physician and sent to the emergency room for evaluation. A progress note of 4/3/11 timed 7:10 p.m. indicated that Resident #4 was admitted to the hospital. On 5/9/11 at 2:00 p.m. the Administrator told the Survey Team that the protocol for residents going to the auditorium is that a Certified Nursing Assistant (CNA) brings the residents to the auditorium and there is always a recreation staff member at the door who then accompanies the residents down the ramp. On 4/3/11 when Resident #4 fell , the recreation staff member was not at her post and the CNA did not look to see if someone was there before she left the resident. Resident #4 went down the ramp by herself with her rolling walker and fell . On 5/11/11 at 11:30 a.m. the ADON gave the surveyor the facility's policy and procedure on Transportation to/from Activities. The policy included that one staff member shall be assigned to the ramp leading into the auditorium area and all residents shall be accompanied down the ramp. There was no documented evidence this policy was consistently followed. Refer F279 Although Fall Incident Reports were initiated for each of the falls for Residents #4 and #16, the investigations were incomplete. A "Reporting and Investigation Protocol" form attached to the Fall Report of 9/19/10 for Resident #4 indicated that the supervisor would do the follow-up. There was no documentation provided to the surveyor of any followup for this fall; the investigation section of this report was blank. The fall report for the other falls sustained by Resident #4 and #16 did not have a Reporting and Investigation protocol form attached. On 5/5/11 at 9:30 a.m. the surveyor asked the ADON why the reports were incomplete. The ADON did not know why and agreed that the incident reports were incomplete. On 5/9/11 at 11:00 a.m. the surveyor spoke with the Administrator, the DON and the ADON in reference to the incomplete investigations. The DON and ADON agreed that they were incomplete. NJAC 8:39-27.1 (b)