Every finding on record at Autumn Lake Healthcare at Old Bridge

Based on observations, interviews and review of facility documents, it was determined that the facility failed to properly store, label, and date foods to prevent the development of food-borne illness. This deficient practice was identified in the main kitchen and one of two pantries (A-wing), and was evidenced by the following: 1. On 1/29/26 at 9:13 AM, the surveyor toured the kitchen with the Regional Food Service Director (RFSD) and observed the following:Near the dry storage room, two cardboard boxes of bananas were stacked one on top of the other. The top box was partially open with several dark discolored bananas in a clear plastic bag inside. In the presence of the surveyor, the RFSD lifted a plastic bag out of the box. The bag contained several dark brown/black bananas and dark brown liquid. The RFSD stated the bananas were rotten. She could not speak to when the bananas in the top box were last used or inspected by the kitchen staff. She further stated her expectation was that staff would not serve bananas that were wet, or brown or black in color. She removed the box containing the brown/black bananas from the kitchen area. In the front refrigerator on the top shelf, there were twenty-five clear plastic cups with clear lids. The RFSD stated the cups each contained chocolate pudding. Five of the lids were labeled with a use-by date. Twenty of the lids did not have labels. The RFSD stated, they [the staff] may just label one, and that label pertains to the whole group of them. The RFSD acknowledged if/when the five labeled pudding cups were moved, or removed, there would be no indication for the use-by date for the remaining twenty pudding cups. She further acknowledged her expectation was that every item in the group should have been labeled individually. In the front refrigerator on the second shelf down, a silver pan contained eight sandwiches in two stacks of four each. The two top sandwiches were each labeled with use-by dates of 1/26/26. The other six sandwiches in the pan were not labeled. The RFSD acknowledged each sandwich in the pan should have been labeled individually, and that the eight sandwiches were past their use-by date. The RFSD removed the pan with eight sandwiches and disposed of them in the garbage can. In the front refrigerator on the bottom shelf, twenty clear plastic cups with lids were on a sheet pan in a single layer. The cups had contents which were a light-yellow color. One cup had a label on the lid; the others did not. The RFSD stated the contents of each cup was ground pears. She stated the date on the label reflected the date the pears were prepared, not the use-by date. She further stated the label on the one cup meant that each of the other cups on the tray were also prepared on that date. The RFSD acknowledged that if the one labeled cup was removed, there would be no indication for the date(s) the other cups were prepared. She further acknowledged that her expectation was that every item in the group should have been labeled individually. 2. On 1/29/26 at 10:13 AM, in the pantry by the A-wing nurse's station, the surveyor observed the refrigerator which contained five sandwiches individually wrapped in clear plastic bags on the top shelf. The sandwiches did not appear to have labels. The surveyor interviewed the Licensed Practical Nurse (LPN) at the A-wing nurse's station who stated the kitchen provided the sandwiches as snacks for the residents. She could not speak to when the five sandwiches were put in the pantry refrigerator. On further inspection by the LPN in the presence of the surveyor, five of the five sandwiches were not labeled. The LPN acknowledged she could not identify when the sandwiches were prepared or should have been used by. She removed the sandwiches and disposed of them. On 1/30/26 at 10:13 AM, the surveyor interviewed the facility's Food Service Director (FSD) who acknowledged the observations made by the surveyor in the presence of the RFSD during the kitchen tour. The FSD acknowledged bananas that were brown/black in color should not be served and should have been disposed of. The FSD stated their process for storing refrigerated food was to label all items not just the one on top. The FSD stated their process was to go through the refrigerators in the kitchen and pantries each night and dispose of anything not used that day. She acknowledged the eight sandwiches in the front refrigerator should have been disposed of prior to their expiration date. The surveyor reviewed the facility provided policy titled Receiving Food and Storage, undated, which reflected the following: -Foods should be received and stored in a manner that complies with safe food handling practices. -All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).-Food items and snacks kept on the nursing units must be maintained as indicated below:All food items to be kept below 41 degrees F (Fahrenheit) must be placed in the refrigerator located at the nurse's station and labeled with a use by date. NJAC 8:39-17.2(g)

Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain the necessary care and services for residents who were receiving oxygen (O2) treatment according to professional standards of practice and b.) ensure a physician's order was obtained for a resident receiving O2. The deficient practice was identified for three of three residents (Resident #9, #14 and #51) reviewed for Respiratory Care. This deficient practice was evidenced by the following: Reference: New Jersey Statues, 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 or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing a 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 1/29/2026 at 9:45 AM, Resident #9 was observed lying in bed with the head of the bed minimally elevated. Resident #9 had a tracheostomy (a surgical opening in the neck to access the airway) tube with a collar and blue tubing connected to an oxygen concentrator. The concentrator was connected to an undated bottle of water used for humidification. The collar and the tubing were also not dated. On 1/30/2026 at 12:32 PM, the surveyor observed Resident #9 in bed, with the head of the bed elevated at approximately 45 degrees. Resident #9 had blue tubing from the oxygen concentrator to the tracheostomy (trach) collar dated 1/26. The water bottle connected to the concentrator was also dated 1/26. The surveyor reviewed the Electronic medical Record (EMR) for Resident #9. The admission Record (AR), an admission summary, revealed diagnoses which included but not limited to; chronic respiratory failure with hypoxia, adult failure to thrive, and pneumonia. A review of the Minimum Data Set (MDS), a resident assessment tool, revealed a Brief Interview of Mental Status (BIMS) that was not performed, and cognitive skills severely impaired related to daily decision making. A review of the Order Summary Report (OSR) for January 2026 revealed the following Physician Orders (POs) dated 1/21/2026: Tracheostomy (trach) check pulse oximetry every shift; Change nebulizer tubing every Monday; Change trach collar every Monday; Change Oxygen tubing, continuous aerosol tubing, aerosol bottle, drain bag, multi-access adapter if utilized and every Monday; Head of Bed maintained at 30 degrees if not contraindicated; Oxygen via trach collar @6L/35%; Clean oxygen concentrator filters every day shift Monday. A review of the Individualized Comprehensive Care Plan (ICCP) revealed a focus area for Tracheostomy dated 6/12/2025. The interventions did not reflect how often the oxygen supplies should be changed or dated. On 2/5/2026 at 9:33 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who explained the procedure for dating tubing related to oxygen supplies, including the oxygen tubing, nebulizer tubing, tracheostomy tubing, and water for the concentrator was to replace and date them on the Saturday 11pm-7am shift. The trach supplies were changed on Monday 7am-3pm shift. The LPN/UM reviewed the physician's orders for Resident #9, in the presence of the surveyor, and stated Resident #9 had orders for trach nebulizer tubing to be changed on Monday, disposable equipment every Monday, change water and Oxygen inhalation collar every Monday, and replace tubing for suction every Monday. Every shift, tubing is stored in a bag and dated. The nurse who is performing treatments for that day is responsible for dating these items and then signs it off on the Treatment Administration Record (TAR). At that time, the surveyor described the findings of the above-mentioned observations in Resident #9's room to the LPN/UM who stated That is not ok. The supplies should have the date that it was actually changed, or staff should put new ones (supplies) up and put the date for that day. The LPN/UM further stated it was important to date the tubing and water canisters for infection control, and to make sure they were changed routinely so we can monitor if the water and humidification were working properly. On 2/5/2026 at 12:46 PM, the surveyor made the Director of Nursing (DON), the Regional Director of Nursing (RDON), and the Licensed Nursing Home Administrator (LNHA) aware of the above-mentioned findings. 2.On 1/29/26 at 10:14 AM the surveyor observed Resident #14 in bed. The resident was unable to respond to surveyor inquiries. The resident was observed with a tracheostomy collar (an oxygen delivery method for individuals with a tracheotomy) providing oxygen. The tubing for the concentrator, humidification, and oxygen delivery to the resident's tracheostomy collar were not labeled or dated. On 1/30/26 at 9:49 AM, the surveyor observed Resident #14 in bed with a tracheostomy collar. The oxygen tubing was observed to be labeled and dated with 1/25/26. The surveyor reviewed the EMR for Resident #14. A review of the admission Record revealed that the resident had diagnoses which included but were not limited to; Hydrocephalus (pressure on the brain), encephalopathy (altered brain function), acute kidney failure, protein-calorie malnutrition, down syndrome, traumatic subdural hemorrhage (bleeding between the brain and the skull), and altered mental status. A review of the resident's most recent comprehensive MDS, dated [DATE], included in the Brief Interview for Mental Status (BIMS) that the resident was unable to complete the interview for BIMS, indicating the resident's cognition was severely impaired. Further review of the MDS, indicated that the resident received oxygen therapy, suctioning and tracheostomy care as a resident in the facility. A review of the resident's ICCP included a focus area dated 2/12/25, that the resident had a tracheostomy with a goal of no infection through the next review date. Interventions included: Give humidified oxygen as prescribed, maintain enhanced barrier precautions. A review of the Order Summary Report included the following physician orders (PO): A PO, dated 7/31/25, for: Trach: Ensure nebulizer tubing is dated and properly stored in the respiratory bag when not in use every shift for Protocol. A PO, dated 7/31/25, for: Trach: Oxygen Inhalation (via collar) 6L/min @ 35% humidification every shift. A PO, dated 7/31/25, for: Trach: Oxygen Equipment - Change tubing every day shift every Thursday for Protocol. A PO, dated 7/31/25, for: Trach: Change nebulizer tubing every day shift every Thursday for Protocol. A PO, dated 7/31/25, for: Trach: Trach care every shift for Protocol AND as needed. On 2/5/26 at 9:24 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding Resident #14's respiratory care and needs. When asked about the labels present on the tubing and their importance, the LPN responded that the tubing was changed weekly and that along with tracheostomy care changing the tubing helped to prevent infections. On 2/5/26 at 10:39 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #14's respiratory care and needs. When asked about the labels on the tubing and their importance, the DON replied that the tubes were labeled so staff knew when they needed to be changed. She stated that all respiratory tubing was changed weekly per protocol to prevent infections. On 2/5/26 at 12:43 PM, in the presence of the survey team, the surveyor made the Licensed Nursing Home Administrator (LNHA) and the DON aware of the concerns regarding Resident #14's tubing being unlabeled on 1/29/26. The Administrator and DON acknowledged that their expectation was that respiratory tubing would be labeled during weekly changes with the date of change. 3. On 1/29/26 at 10:20 AM, during an initial tour, the surveyor observed an O2 concentrator (medical device that helps people with breathing problems get more O2) with humidifier (a medical setup that adds moisture to the O2 you breathe from a machine or tank) dated 1/24 and a nasal cannula (NC; a light, flexible tube used to deliver extra O2 to a person who has trouble breathing) dated 1/25 was connected to the concentrator. The NC was looped around right side siderails and was hanging in the air. The NC was not in any protective covering and was exposed to the environment. The surveyor did not observe O2 in use signage at the resident's door. On 1/29/26 at 12:07 PM, the surveyor observed Resident #51 sitting in their w/c in the dining room. Resident #51 was observed to be on supplemental O2 via (by way of) NC which was connected to O2 tank behind the wheelchair. On 1/30/26 at 10:39 AM, the surveyor observed that the resident was not in their room. The surveyor observed the NC connected to the O2 concentrator, looped through the right side siderail and was hanging on the O2 concentrator. The NC was not in any protective covering. The surveyor did not observe O2 in use signage at the resident's door. The surveyor reviewed the EMR for Resident #51. A review of the admission Record face sheet reflected that Resident #51 was admitted to the facility with diagnoses which included but were not limited to; Acute respiratory failure with hypoxia (low levels of O2 in your body tissues) and Chronic obstructive pulmonary disease (COPD; a common lung disease causing restricted (blockage) airflow and breathing problems). A review of the most recent comprehensive MDS, dated [DATE], reflected that the resident had a BIMS score of 8 out of 15, indicating that the resident had moderate cognitive impairment. Further review of the MDS, indicated that Resident #51 was coded for O2 while a resident at the facility. A review of ICCP revealed a Focus for Resident #51 [Resident] had diagnosis (dx) of COPD related to smoking, date initiated 12/21/25. Interventions included but were not limited to: give oxygen therapy as ordered by the physician, date initiated 12/21/25. A review of the OSR for January 2026 revealed a POs as follows: Clean oxygen concentrator filters every Saturday night shift for Protocol, dated 11/19/25; Oxygen Equipment - Change tubing every week every night shift every Saturday for Protocol, dated 11/19/25; Oxygen Equipment - Change water canister every week every night shift every Saturday for Protocol, dated 11/19/25; Pulse Oximetry - check every shift for protocol, dated 11/19/25; Oxygen: Change nebulizer tubing/mouthpiece and Date every night shift every Saturday, dated 11/22/25. The OSR did not reflect any active orders to administer O2 continuously or as needed. A review of the OSR for November 2025 revealed a PO for OXY *Oxygen inhalation (via nasal cannula at 2 LPM (liters per minute) as needed for SPO2 (measurement of how much oxygen your blood is carrying as a percentage) below 92% for 14 days, dated 11/19/25. On 1/30/25 at 1:12 PM, the surveyor interviewed Resident #51's Registered Nurse (RN) who stated before O2 administration, he would check the orders first because it's (O2) a medication and an order is an order, if there were no orders then he would call the provider to get orders for O2. The RN stated he would not administer O2 without physician's orders because if resident was hyper oxygenated (giving too much O2) then they (resident) can end up with a pneumothorax (a medical condition where air leaks into the space between the lung and the chest wall). The RN stated if the resident was not using O2, he would store the equipment in the plastic bag and label the tubing and the bag with resident's name, date and time. The RN stated it was important to properly store the NC tubing to prevent contamination, and residents can get infections and pneumonia. At that time, the surveyor inquired about Resident #51's O2 status. The RN stated the resident was on continuous O2 at 2 LPM. The RN stated if the resident was on O2, there should be a O2 in use signage at the door to make visitors aware that the resident was using O2. In the presence of the surveyor, the RN checked Resident #51's O2 tank which was secured in the back of their w/c, he then pointed towards the O2 tank regulator (regulates the flow of oxygen from the tank to deliver the right amount of oxygen to the patient) and stated the resident was on 2L. The RN observed the O2 tank regulator needle pointed towards refill which indicated the O2 tank was empty and needed to be replaced. The RN stated usually if the O2 tank was empty and needed to be replaced then it would beep but there was no beeping sound heard at the time of the interview. On 1/30/26 at 1:25 PM, during an interview with the surveyor, the LPN/UM stated the NC should be placed in the bag when not in use for infection control. The LPN/UM stated residents who were on O2 should have No smoking, O2 in use signage at the door and confirmed Resident #51 did not have signage at their door when. In the presence of the RN, the LPN/UM noted the empty O2 tank that was connected to Resident #51's NC while resident had the NC applied to their nose. The LPN/UM stated all nurses were responsible for monitoring O2 supply to make sure the tank was not empty. The RN stated, I am taking accountability for not checking the O2 tank. The surveyor along with the LPN/UM went to Resident #51's room to check the concentrator filter. She stated the nurses did not change the filter because it was screwed in. The LPN/UM stated the maintenance staff were responsible for changing the filter on O2 concentrators. In the presence of the surveyor, the LPN/UM reviewed the MARs/PO order Clean O2 concentrator filters every Saturday night shift for protocol and confirmed it was not done by the nurses. The LPN/UM further stated, the nurses should not be signing it off if something that they were not doing. On 1/30/26 at 1:40 PM, in the presence of the surveyor and the LPN/UM, the Maintenance Staff (MS) unscrewed the concentrator and removed the filter and noted dark colored debris / build up. The MS stated the filters were usually changed as needed or when the staff would tell them to change them. The MS stated the process was that there was a timer in the concentrator that would either beep or a light would turn red, and then the staff would ask them to change the filter. The MS stated they would write a date on the filter when it was changed last time. In the presence of the surveyor and the LPN/UM, the MS removed the filter, and the surveyor observed the filter was not dated. While looking at the filter, the MS stated, I cannot tell when this was changed and confirmed there were no documentation or logbook for filter change. At that time, the LPN/UM reviewed Resident #51's PO and confirmed that the resident did not have O2 administration orders and should not have been on O2. On 2/5/26 at 12:46 PM, the surveyor made the DON, the Regional DON and the LNHA aware of the above-mentioned concerns. On 2/6/26 at 10:52 AM, the DON, Regional DON and the LNHA met with the survey team. The LNHA confirmed that Resident #51 did not have an order for O2 administration, and the equipment should not have been there in the room. The LNHA further stated the MS were responsible for changing or cleaning the filter and further stated the nurses should not be signing off orders if they have not done it. A review of the facility provided Oxygen Administration policy dated 10/25 under Policy Statement reveals: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. In Section Policy Explanation and Compliance Guidelines: Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control .Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use .Other infection control measures include: Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.change nebulizer tubing and delivery devices every week or per facility policy and as needed. The policy did not reveal how to store oxygen tubing when not in use and how often the concentrator filter should be changed and/or cleaned. A review of the facility provided Oxygen Safety policy dated 10/25 under Interpretation and guidance reveals: 5.k. Replace the oxygen tank before the needle on the gauge drops below 200 psi (Pounds per Square Inch; is a common unit used to measure pressure). 6.f. No Smoking signs will be utilized to clearly identify oxygen is in use before connecting the oxygen supply, and will remain in place until oxygen administration has been discontinued. The policy did not reveal how to store oxygen tubing when not in use and how often the concentrator filter should be changed and/or cleaned. NJAC 8:39-11.2(b); 25.2(c)3; 27.1(a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by a.) ensuring routine medications were acquired in a timely manner and administered as per prescribed physician's orders for one (1) of seven (7) residents, (Resident #110), reviewed for medication management and b.) ensuring proper procedures to acquire routine medications be available for administration for one (1) of four (4) residents, (Resident #13 ), observed during medication administration. The deficient practices were 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 2/4/26 at approximately 8:48 AM, during the medication administration observation, the surveyor was approached by Resident #110 who stated they would like to speak to the surveyor. Resident #110 was agreeable to a private discussion after the surveyor completed the medication administration observation.On 2/4/26 at 9:19 AM, the surveyor interviewed Resident #110 in their room. The resident stated that the observation the surveyor had seen earlier that morning was not usual because the nurse had all their medications. The resident requested the surveyor to review their medication administration because the nurses frequently do not have them. The resident stated they understood there was an insurance issue with one of their medications used for their liver, a while back in November, but thought that was resolved and recently was told it wasn't available. The resident added the nurses just tell them the medication was not in the medication cart and then they don't receive the medication that day. The resident added approximately two (2) weeks ago they were told they didn't have their Zoloft (a medication used for depression), and another day in January it was their blood pressure medication and some other days it was medications that they weren't as upset about.The surveyor reviewed the medical record for Resident #110A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to; essential (primary) hypertension (high blood pressure), alcoholic liver disease and major depressive disorder. A review of the most recent quarterly comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/16/25, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the resident's electronic medication administration record (EMAR) for January 2026 revealed the following dates, times and medications with physician's orders (PO) that were not administered and coded with the number 9 which corresponded to Hold/see progress notes ; On 1/2/26 at 9 AM and on 1/5/26 at 5 PM, a PO dated 4/28/25 for Rifaximin (an antibiotic used to prevent liver damage) oral tablet 550 MG (milligrams), Give 1 tablet by mouth two times a day for Liver Cirrhosis. On 1/2/26 at 9 AM and 5 PM, PO dated 12/10/25 for Fluticasone Propionate (Flonase) Nasal suspension 50 MCG(micrograms)/ACT(actuation), 1 spray in both nostrils two times a day for congestion Shake and prime prior to first use. Instruct resident to bow nose prior to administration.On 1/12/26 at 9 AM, PO dated 12/29/25 for Artificial Tears (an eye lubricant)Ophthalmic Solution 0.2-0.2-1% (Glycerin-Hypromeliose-Propylene Glycol 400) Instill 1 drop in both eyes two times a day for Dry eyes. On 1/29/26 at 9 AM, PO dated 11/11/25 for Sertraline HCL (Zoloft)(a medication used for depression) oral tablet 50 MG Give one tablet by mouth one time a day for anxiety.On 1/31/26 at 8:30 AM, PO dated 3/28/26 for Carvedilol (Coreg) (a medication used to lower blood pressure) Oral Tablet 3.125 MG, Give 1 tablet by mouth two times a day for hypertension. Give with meals. Hold for SBP (systolic/lower number blood pressure) less than 100 or HR (heart rate) less than 60. On 1/31/26 at 12: 30 PM, PO dated 7/29/25 for Polyethylene Glycol 3350 Powder (Miralax) (a medication used to relieve constipation), Give 17 gram (GM) by mouth one time a day for constipation, Mix with 4 oz(ounces) of fluid prior to administration 17 GM = 1 cap.A review of the resident's electronic nursing progress notes (EPN) revealed the following corresponding documentation for the reason the above medications were not administered; On 1/2/26 at 10:51 AM, for the Rifaximin dose, Registered Nurse (RN #1) documented on order. In addition, for the Rifaximin on 1/5/26 at 7:36 PM, RN #2 documented awaiting delivery. On 1/2/26 at 10:55 AM, for the Flonase nasal spray RN #1 documented reorder. In addition, for the Flonase nasal spray, on 1/2/26 at 6:12 PM, Licensed Practical Nurse (LPN #1) documented not at hand.On 1/12/26 at 10:12 AM, for the Artificial Tears, RN #1 documented on order.On 1/29/26 at 9:49 AM, there was no documentation by LPN #2 explaining why Zoloft dose was not administered.On 1/31/26 at 8:54 AM, for the Coreg dose, LPN #3 documented Record showed that medication was reordered. Waiting for pharmacy to delivery medication. Blood pressure was taken, it normal range. On 1/31/26 at 1:53 PM, for the Miralax dose, LPN #3 documented Resident out of facility. There was no other documentation indicating on 1/31/26 the resident had left the facility and was not available for medication administration. There was no documentation on the above dates indicating the physician was notified regarding the above medications that were not administered and follow up orders. On 2/4/26 at 12:31 PM, the surveyor interviewed Unit Manager/LPN (UM/LPN) who explained if a nurse did not have a medication that was ordered by a physician for a resident they should check the back up supply and if the medication could not be obtained then the physician would have to be called for follow up on what should be done and then the nurse should document in the EPN. The UM/LPN stated she was familiar with Resident #110, and the resident was cognitively intact and ambulated on their own. The UM/LPN added the resident walked a lot and usually returned when they had medication due so the nurses should be able to administer the resident's medications. The UM/LPN stated that she was aware at one time there was an issue with the resident's Rifaximin but thought that was taken care of and she was unaware of any other medications that were not administered to the resident. On 2/4/26 at 1:00 PM, the surveyor interviewed the Director of Nursing (DON) who stated she would review Resident #110's January EMAR for medications not being administered. On 2/5/26 at 9:49 AM, the surveyor interviewed the DON, who explained that the nurses were to call the physician if a medication was not available and see if there was another medication in the back up supply or follow instructions from the physician and document in the EPN. The DON had provided documentation that the resident was on a leave of absence from the facility from 1/6/26 until 1/11/26. The DON explained that the nurses were able to reorder medications from the pharmacy electronically. The DON was unable to speak about why there was documentation that medications were not administered and documented as being not available or on order. The DON added that she thought the documentation meant the physician was notified. On 2/5/26 at 10:04 AM, the surveyor interviewed Resident #110 who stated that they do walk a lot but would return for medication administration. The resident stated they had not left the faciity on 1/31/26. The resident then stated that they remembered back in March 2025 there was a problem with their pain medication, Morphine, and was told by the nurses that they didn't have the Morphine on 3/24/25 and 3/25/25. The resident then stated that they knew how the nurses ordered medications from the pharmacy but could not understand why medications continued to not be available. The surveyor further reviewed the resident's medical record. A review of the March 2025 EMAR revealed a PO dated 9/30/24 for Morphine Sulfate ER (a long-acting pain medication) Oral Tablet Extended Release 15 MG, Give one tablet by mouth every 12 hours for pain related to presence of wounds. Do not crush, swallow whole may cause respiratory depression, sedation, constipation, continue to monitor and assess pain management as frequently as necessary. Further review of the March EMAR revealed on 3/24/26 at 9 AM and 9 PM and 3/25/26 at 9 AM the Morphine ER was not administered and coded with the number 9 which corresponded to Hold/see progress notes. The corresponding EPN for the above dates and times revealed the following; On 3/24/25 at 12:01 PM, RN #3 documented the Morphine ER was Pending delivery.On 3/24/25 at 9:46 PM, RN #3 documented the Morphine ER was Pending delivery.On 3/25/26 at 9:47 AM, a nurse documented the Morphine ER was awaiting pharmacy, pharmacy called. There was no documentation on the above dates indicating the physician was notified regarding the above medication that was not administered and follow up orders. On 2/5/26 at 11:30 AM, the surveyor interviewed the DON who stated if a controlled drug was not available the nurses should check the back up supply of controlled drugs to see if the medication was there and if not available the nurses were to call the physician and ask the physician for a substitute or follow up and document in the EPN. The surveyor was provided a list of controlled drugs that were in the back up supply and Morphine ER 15 MG was handwritten on the list. The DON explained that Morphine ER was added to the list due to a need. The DON further stated that agency nurses were utilized and tried to make sure medications were ordered and the nurses must follow up when a medication was not available and were not allowed to just say they don't have it. The DON added she thought the nurse, whose name corresponded to the EPN on 3/25/26, was an agency nurse and was unsure if she worked at the facility. On 2/5/26 at 11:44 AM, the surveyor interviewed RN #3 who acknowledged her initials on the EMAR for Resident #110 on 3/24/25 at 9 AM and 9 PM indicated the Morphine was not administered. RN #3 stated that it was a while back and was unable to speak about what occurred. RN #3 added that she thought she called the physician and documented it in EPN. RN #3 explained when a medication was not available there was a backup supply to check and call the physician who would tell her what to do. RN #3 was unable to speak to why there was no documentation in the EPN that the physician was notified and if there was follow up. On 2/5/2026 at 12:47 PM, during a meeting with the survey team, the surveyor made the LNHA, the DON, and the Regional DON aware of the above findings. On 2/5/26 at 1:34 PM, the surveyor interviewed the DON who stated Morphine ER 15 MG was added to the controlled drug back up list in September 2025. A review of the facility policy Medication Administration provided by the DON with a revision and updated date of October 2025 revealed medications were to be administered .as ordered by the physician and in accordance with professional standards of practice.A review of the facility policy Medication Reordering provided by the DON with a reviewed date of 10/25 revealed It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. In addition, the policy revealed Compliance Guidelines which included, but not limited to, Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. And In the event if medication is not available, the physician will be notified. 2. On 2/4/26 at 8:58 AM, during the medication administration observation, the surveyor observed RN #4 administering the 9 AM medications to Resident #13. RN #4 stated there was a PO for Lactulose solution and Flonase nasal spray but was unable to find the medications in the cart.At that time, RN #4 stated she would have to check and see if she could obtain the medications and administer as the PO indicated.The surveyor reviewed the medical record for Resident #13.A review of the resident's admission Record reflected that the resident had diagnoses, which included but not limited to; essential (primary) hypertension (high blood pressure), dementia, and schizoaffective disorder. A review of the most recent quarterly comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/20/25, reflected the resident had a brief interview for mental status (BIMS) score of 11 out of 15, indicating that the resident had a moderately impaired cognition. A review of the residents' EMAR revealed the following:- PO dated 10/21/25 for Lactulose Oral Solution, Give 30 ML (milliliters) by mouth one time a day for constipation.-PO dated 10/28/25 for Flonase Allergy Relief Naal Suspension (Fluticasone Propionate (Nasal) 1 spray in both nostrils two times a day for allergies. On 2/4/26 at 10:10 AM, the surveyor interviewed RN #4 who stated that both Lactulose and Flonase were not over the counter house stock medications (medications that were stored at the facility as a backup supply). RN #4 added since the Lactulose and Flonase would not be able to be administered within the timeframe for the PO she had called the physician and received a PO to administer the Lactulose and Flonase when the medications were obtained. RN #4 explained when medications were not available the nurses had to notify the physician and receive a follow up PO and document in the EPN what was to be done. RN #4 stated that she thought she had ordered the Flonase nasal spray yesterday but was unsure about Lactulose and would check when the medications were ordered from the pharmacy. On 2/4/26 at 11:01 AM, the surveyor interviewed the DON who stated RN #4 was the usual nurse on the medication cart and had not ordered either Lactulose or Flonase. The DON confirmed that neither was stored as over-the-counter house stock. The DON added that she had called the pharmacy provider, and Lactulose was last dispensed on 12/26/25 and delivered 12/27/25 and Flonase was last dispensed 11/3/25 and delivered 11/4/25. The DON acknowledged the nurses were to reorder routine medications to ensure they were available for administration.On 2/5/26 at 11:21 AM, the surveyor interviewed Resident #13 who stated the nurses bring their medications when they were supposed to take them. The resident was unable to identify any medications or times. The resident stated they need their medications every day for pain and constipation.On 2/5/2026 at 12:47 PM, during a meeting with the survey team, the surveyor made the LNHA, the DON, and the Regional DON aware of the above findings.A review of the facility policy Medication Reordering provided by the DON with a reviewed date of 10/25 revealed Acquiring medication is the process by which the facility requests and obtains a medication. In addition, the policy revealed Compliance Guidelines which included, but not limited to, The facility will utilize a systemic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. And Each time a nurse is administering medications and observes less doses left of one kind, that nurse will reorder the medication, time permitting. NJAC 8:39-11.2(b); 29.2(a)(d)

Based on observation, interview, and review of medical records, it was determined that the facility failed to follow a physician's orders (PO) for medications with a parameter and acceptable professional standards of practice for one (1) of seven (7) residents (Resident #1), reviewed for medication management. The deficient practice is 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 casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 1/29/26 at 10:30 AM, during the initial tour of the unit, the surveyor observed Resident #1's room with a No smoking, O2 (Oxygen) in use signage on the door. The surveyor did not see the resident in the room.The surveyor reviewed the electronic medical records (EMR) for Resident #1.A review of the admission Record (admission summary) revealed that Resident #1 had diagnoses that included but were not limited to; end stage renal disease (the final, permanent stage of kidney failure where kidneys no longer function well enough to support life, usually operating at less than 15% capacity), Essential hypertension (high blood pressure that occurs in the absence of any contributing medical condition), and type 2 diabetes mellitus (a common, long-term condition where the body cannot effectively use or produce enough insulin, causing sugar (glucose) to build up in the blood).A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/9/25, revealed the resident had a Brief Interview Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had intact cognition. Further review of the MDS indicated that Resident #1 had received insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) injections.A review of the resident's individualized comprehensive care plan (ICCP) included a focus area Diabetes Mellitus dated 5/17/23. Interventions included but were not limited to: diabetes medication as ordered by doctor initiated on 5/17/23. Another focus area with date initiated 8/7/25 included that the resident had diagnosis (Dx) Hypertension. Interventions included: Give anti-hypertensive medications (class of drugs that are used to treat high blood pressure(bp)) as ordered. Monitor for side effects .A review of the February 2026 Order Summary Report (OSR) reflected the following POs:1. NovoLOG FlexPen (pre-filled, disposable insulin injection device) Subcutaneous (located underneath the skin) Solution Pen-injector 100 UNIT/ML (Insulin Aspart (a fast acting insulin to treat diabetes)) - Inject 4 unit subcutaneously two times a day every Mon, Wed, Fri for DM Hold for Blood Sugar less than 120 AND Inject 4 unit subcutaneously three times a day every Tue, Thu, Sat, Sun for dm Hold for Blood Sugar less than 120 dated 9/10/25.2.Midodrine HCl Oral Tablet 5 MG (Milligrams) - Give 1 tablet by mouth one time a day every Mon, Wed, Fri for hypotension (low blood pressure) hold for spb (Systolic blood pressure / the top number in a blood pressure reading) greater then 140 dated 9/17/25.A review of the December 2025 electronic Medication Administration Record (eMAR) revealed that the Novolog insulin was marked with a check which indicated the medication was administered for 3 doses when the resident's blood sugar was recorded less than 120 for the following dates:12/5/25 at 12:15 PM= BS 11412/12/25 at 1715 (5:15 PM) = BS 10712/17/25 at 1715 (5:16 PM) = BS 110A review of the January 2025 eMAR revealed that the Novolog insulin was marked with a check as administered for 2 doses when the resident's blood sugar was recorded less than 120 for the following dates:1/20/26 at 8:15 AM= BS 1091/22/26 at 12:15 PM= BS 118A review of the December 2025 eMAR revealed on 12/22/25 resident's BP was recorded to be 137/77 and the midodrine was marked with code #4 which meant medication was not administered due to vital signs out of perm (parameters). The medication should have been given for a BP less than 140.A review of the January 2026 eMAR revealed on 1/21/26 resident's BP was recorded to be 146/72 and the midodrine was marked with a check as administered. The medication should have been held for a BP greater than 140.On 2/5/26 at 10:05 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated the check mark on the MARs meant that the medication was administered. She stated if the medication was held due to hold parameters, there would be a code number entered. The surveyor reviewed Resident #1's Novolog insulin PO with the LPN/UM who stated if the BS was less than (<) 120 then they would not administer and would write a progress note (PN) in the eMAR or they would generate a separate PN in the [Name Redacted] EMR. The LPN/UM stated insulin should not be given if the BS was < 120 as it was a PO and further stated it could cause a drop in the resident's BS and the resident could get confused, diaphoretic (sweating heavily due to BS too low) and loose conscious if the BS dropped too low. The surveyor made the LPN/UM of the above-mentioned Novolog administration concerns. The LPN/UM stated the nurses should have held the insulin if the BS was < 120 as per the PO. In the presence of the surveyor, the LPN/UM reviewed December 2025 and January 2026 MARs and stated they were medication errors and further stated she would notify the physician, fill out a pharmacy incident report, notify the Director of Nursing (DON) and the medical director (MD).At that time, the surveyor interviewed the LPN/UM about the Midodrine, and the LPN/UM stated Resident #1 was on dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys cannot) and medication should be administered so the resident's blood pressure does not drop too low. The LPN/UM further stated if the resident's BP dropped too low then they could lose consciousness, get confused and it could cause multiple other complications. In the presence of the surveyor, the LPN/UM reviewed the December and January 2026 MARs and confirmed the medication was not administered on 12/22/25 for BP 137/77 and it should have been given. The LPN/UM confirmed that the dose was administered on 1/21/26 when the BP was 146/72 and it should have been held. The LPN/UM further stated midodrine elevates BP and can cause a heart attack, stroke with high blood pressure and many other complications. The LPN/UM stated the expectation from the nurses was to follow the PO correctly and they should not be administering mediations if they were out of parameters as they (parameters) are there for a reason.On 2/5/26 at 12:46 PM, the surveyor made the DON, the Regional DON and the Licensed Nursing Home Administrator (LNHA) aware of the above concerns.A review of the facility's Insulin Administration policy dated 10/25 reflected, 1. All insulins will be administered in accordance with physician's orders. 4. Administer insulin per physician order .7. Review the insulin order.A review of the facility's Medication Administration policy dated 10/25 reflected, Under Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, . Under Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to post the daily Nursing Home Resident Care Staffing Report (NHRCSR) that was up to date. This deficient practice was identified on 1/29/2026 and was evidenced by the following:On 1/29/2026 at 8:55 AM, upon entrance to the facility, the surveyor observed the NHRCSR posted in the main lobby dated 1/22/2026 for all three shifts: 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. On 1/30/2026 at 11:41 AM, the surveyor interviewed the Staffing Coordinator (SC), who stated she was responsible for completing the staffing report. She stated she posted the staffing report daily during the week and the weekend supervisor posted it on the weekends. The surveyor made her aware of the above observations. She acknowledged the report should have been changed every day.On 1/30/2026 at 11:55 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the SC was responsible for posting staffing the staffing report during the week and the weekend supervisor posted it on the weekend. On 2/5/2026 at 12:47 PM, during a meeting with the survey team, the surveyor made the LNHA, the Director of Nursing, and the Regional Director of Nursing aware of the above findings. A review of the undated facility policy Nurse Staffing Posting Information revealed Policy: It is the policy of this facility to make sure staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing sheet will be posted on a daily basis.4. A copy of the schedule will be available to all supervisors to ensure the information posted is up to date and current.NJAC 8:39-41.2 (a)(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to consistently write a Progress Note (PN) as per physician orders for residents on hemodialysis (HD-a treatment that replicates the kidney's function and cleans the waste from the blood for individuals with kidney disease or failure) pre and post HD treatment. This deficient practice was identified for 2 of 2 residents (Resident #1 and #6) reviewed for dialysis.This deficient practice was evidenced by the following:1.On 1/29/26 at 10:04 AM, during the initial tour, the surveyor observed Resident #6 resting in their bed. The resident informed the surveyor that they received HD.The surveyor reviewed the electronic medical records (EMR) for Resident #6.A review of Resident #6's admission Record (AR; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dependence on renal dialysis (a state of chronic dependence on a machine and medical professionals to maintain life when the kidneys are no longer able to function properly), and anemia in chronic kidney disease (damaged kidneys cannot produce enough of the hormone erythropoietin (EPO- a hormone produced mainly by the kidneys), which tells the body to make red blood cells).A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/25/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #6 had intact cognition. Further review of the MDS indicated the resident received HD.A review of the individualized comprehensive care plan (ICCP) created on 7/25/25 included a focus care area of the resident was on Hemodialysis related to renal failure, Dialysis days: Monday and Friday. Time for pick up from dialysis: 2:00 pm and approximate return time was 2:30 pm.A review of Resident #6's Order Summary Sheet (OSR) revealed the following physician orders (POs): Dialysis return documentation: under progress note (PN). Select Dialysis every evening shift every Monday, Wednesday, and Friday for dialysis protocol, dated 8/19/25; Dialysis outgoing documentation: under PN every day shift every Monday, Wednesday and Friday for dialysis protocol.A review of Resident #6's December 2025 and January 2026 Medication Administration Record (MAR) reflected both POs were transcribed in the MARs for Monday, Wednesday and Friday. The MARs reflected a check mark with nurse's initial which meant the nurses were signing off as the PN were completed for each HD day.A review of Resident #6's PNs in the EMR indicated the following:There were missing Pre-HD (prior to leaving for HD) notes for the following dates: 12/1/25, 12/3/25, 12/8/25, 12/10/25, 12/12/25, 12/15/25, 12/17/25, 12/19/25, 12/22/25, 12/24/25, 12/26/25, 12/31/25, 1/2/26, 1/7/26, 1/14/26, 1/16/26, 1/19/26, 1/28/26 and 1/30/26.There were missing Post-HD (upon return from HD) notes for the following dates: 12/1/25, 12/3/25, 12/5/25, 12/10/25, 12/12/25, 12/17/25, 12/22/25, 12/24/25, 12/26/25, 12/31/25, 1/7/26, 1/9/26, 1/14/26, 1/16/26, 1/19/26, and 1/28/26. On 2/4/26 at 1:26 PM, the surveyor interviewed the resident's assigned Registered Nurse (RN) who stated the process for a HD resident was to check vital signs (VS; measurements of BP, Heart rate, Respirations .) prior to them leaving the facility and documenting those VS in the HD communication form (a simple, standardized document used to share critical patient information between a dialysis center and another facility). The RN further stated VS would be documented in the EMR also. The RN stated Resident #6 had HD twice a week on Monday and Friday and the resident's old scheduled days were Monday, Wednesday and Friday. The RN further stated they would document PNs in the EMR for post HD including resident's VS and list of medication that they received during HD.On 2/4/26 at 2:06 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated the process for the HD residents was to check resident's VS pre and post HD, check the site for bleeding post HD and assess the site for Bruit (an important sound and indicator of how well your dialysis access is functioning) and Thrill (buzzing sensation can be felt) and all the findings would be documented in the HD book. The LPN/UM further stated VS, and any concerns should be documented in General notes (PN) in the EMR. In the presence of the surveyor, the LPN/UM reviewed Resident #6's HD POs and stated when the nurses sign on the MARs, then they should be documenting in the PNs for Pre and Post HD. The surveyor made the LPN/UM aware of the above-mentioned concerns regarding Resident #6's missing PN for the above listed dates. 2.On 1/29/26 at 10:30 AM, during the initial tour, the surveyor did not observe Resident #1 in their room. The surveyor reviewed the EMR for Resident #1.A review of Resident #1's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dependence on renal dialysis and anemia in chronic kidney disease.A review of Resident #1's most recent quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 13 out of 15, which indicated that Resident #1's had intact cognition. Further review of the MDS indicated the resident received HD.A review of Resident #1's individualized comprehensive care plan (ICCP) created on 7/25/25 included a focus care area that the resident was on Hemodialysis related to renal failure. Dialysis days: Monday, Wednesday and Friday. Chair time at 5:15 AM, pick up at 4:30 AM.A review of Resident #1's OSR revealed the following POs: Dialysis outgoing documentation: under PN every night shift every Tuesday, Thursday, and Sunday for Protocol, dated 9/12/25; Dialysis return documentation: under PN. Select Dialysis every day shift every Monday, Wednesday, and Friday, date 9/10/25.A review of Resident #1's December 2025 and January 2026 MAR reflected that both POs were transcribed on the MARs. The MARs reflected a check mark with nurse's initial which meant the nurses were signing off as the PN were completed for each HD day.A review of Resident #1's December 2025 through January 2026 night shift PNs in the EMR indicated no pre-HD PNs for the following dates: 12/7/25, 12/21/25, 1/1/26, 1/4/26, 1/6/26, 1/20/26, 1/26/26.A review of Resident #1's December 2025 through January 2026 day shift PNs in the EMR indicated no post HD PNs for the following dates: 12/3/25, 12/8/25, 12/23/25, 12/26/25, 12/29/25, 1/7/26, 1/9/26, 1/14/26, 1/16/26, 1/19/26, 1/23/26, and 1/30/26. On 2/5/26 at 10:30 AM, in the presence of the surveyor, the LPN/UM reviewed Resident #1's EMR for HD POs and stated the nurses should be documenting/writing PN because they were signing off POs in the MAR as completed. The LPN/UM stated they (nurses) should be writing a PN each time when the resident went out and returned from HD. The surveyor made the LPN/UM aware of the above-mentioned concern of the missing HD PN.On 2/5/26 at 12:46 PM, the surveyor made the Director of Nursing (DON), the Regional DON and the Licensed Nursing Home Administrator (LNHA) aware of the concerns for Resident #6 and Resident #1. A review of the facility's Hemodialysis policy dated 10/23 revealed under policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders,. of residents receiving hemodialysis.A review of the facility's Documentation in Medical Record policy dated 10/25 revealed under policy Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Under Policy explanation and compliance guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, no later than the shift in which the assessment/evaluation, observation, or care service occurred. 3.a. Documentation shall be factual, objective, and resident centered. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care c. Documentation shall be timely and in chronological order.NJAC 8:39- 27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss (specialized) mattress was functioning properly and accurately setup according to manufacturer instructions and a physician's order for residents who were previously identified to have had an alteration in skin integrity.This deficient practice was identified for 2 of 4 residents (Resident #14 and Resident #48) reviewed for pressure ulcers and was evidenced by the following:A.) On 1/29/26 at 10:14 AM, the surveyor observed Resident #14 lying in bed, resting on an air mattress. The resident's air mattress pump was observed to be set to a weight of 200 pounds.On 1/30/26 at 9:49 AM, the surveyor observed Resident #14 lying in bed, the air mattress pump was noted to be set to a resident weight of 200 pounds.On 02/04/26 at 8:59 AM and 11:58 AM, the surveyor observed the air mattress pump set to a resident weight of 200 pounds.A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included but were not limited to; Hydrocephalus (pressure on the brain), encephalopathy (altered brain function), acute kidney failure, protein-calorie malnutrition, down syndrome, traumatic subdural hemorrhage (bleeding between the brain and the skull), and altered mental status.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 2/10/25, included in the Brief Interview for Mental Status (BIMS) that the resident was unable to complete the interview for BIMS, indicating the resident's cognition was severely impaired. Further review of the MDS indicated that the resident was at risk to develop a pressure ulcer/injury. Additional review of the MDS revealed that the Skin and Ulcer/Injury Treatments section included a pressure reducing device for the bed.A review of the resident's electronic medical record revealed the last recorded weight for the resident was 117.6 pounds.A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 2/6/25, that the resident was at risk for skin impairment related to their history of ulcers, immobility and incontinence. Interventions included: an alternating pressure mattress to prevent further skin breakdown, monitor for functioning and to follow facility policies/protocols for the prevention/treatment of skin breakdown.A review of the Order Summary Report included the following physician orders (PO):A PO, dated 12/8/25, for: Alternating air pressure mattress to prevent further skin breakdown; every shift, monitor for functioning. A PO, dated 7/30/25, for: Consults: Wound consult and treat as needed. A review of the Wound Care Progress Notes included the following:A progress note, dated 1/8/26, included: Assessment states wound is improving.alternating air mattress remains in place; continues on supplements to promote wound healing.A progress note, dated 1/15/26 included: Assessment states wound is resolved on 1/15/26, preventative measures include alternating mattress, [seat] cushion. B.) On 1/29/26 at 10:32 AM, the surveyor observed Resident #48 lying in bed, sleeping, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 280 pounds.On 1/30/26 at 9:31 AM, the surveyor observed Resident #48 lying in bed, awake, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 280 pounds. The resident stated that they were unsure when the mattress or pump was last checked for function or adjusted.On 2/4/26 at 8:52 AM, the surveyor observed Resident #48 lying in bed, awake, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 280 pounds. On 2/5/26 at 9:03 AM, the surveyor observed Resident #48 lying in bed, awake, on an air mattress. The resident's air mattress pump was observed to be set to a weight of 280 pounds.A review of the admission Record revealed the resident had diagnoses which included but were not limited to; Fracture of the right femur (thigh bone), protein-calorie malnutrition, hydrocephalus, cerebellar stroke syndrome (impaired circulation in the brain), acute and chronic respiratory failure with hypoxia.A review of the resident's most recent comprehensive MDS, dated [DATE], included a BIMS score of 11 out of 15, indicating that the resident had moderately impaired cognition. Further review of the MDS, indicated that the resident was at risk to develop a pressure ulcer/injury, and on that date had one stage 4 pressure ulcer (a full-thickness wound that can have exposed muscle, tendon, or bone) present. Additional review of the MDS, revealed that the Skin and Ulcer/Injury Treatments section included a pressure reducing device for the bed and pressure ulcer/injury care. Under nutrition the resident's weight was noted to be 99 pounds.A review of the resident's ICCP included a focus area dated 4/25/19, that the resident had a potential for alteration in skin integrity related to limited mobility, incontinence, and non-compliance with repositioning. Interventions included: Alternating air mattress for skin breakdown prevention; monitor for functioning. A review of the Order Summary Report included the following PO's:A PO, dated 1/16/25, for: Alternating air pressure mattress for skin breakdown prevention; monitor for functioning; every shift.A PO, dated 4/29/25, for: Consults: Wound consult and treat as needed.A review of the Wound Care Progress Notes with a noted dated 12/23/25, noted Wound Dr. saw resident today upon evaluation: no excoriation or wounds found and noted to use Alternating mattress, bilateral heel booties, [seat] cushion for preventative measures. No new wounds have been noted for the resident.On 2/5/26 at 9:24 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding Resident #14's and Resident #48's air mattress settings. The LPN stated air mattresses function was to offload pressure from actual wounds and to alleviate pressure points for at-risk residents. The LPN stated that residents were care planned for them, a wound care consultant wound recommend the air mattress and a doctor would sign an order for it. She then stated that they were initially set up by a vendor for the rented units, or by facility housekeeping for facility owned beds; she continued that they were checked every shift multiple times, and that everyone was responsible for checking proper function. When asked about the different settings on the air mattress pump, the LPN replied that the numbers went by increments, and the number should be set to the one closest to the resident's weight.On 2/5/26 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #14 and #48's air mattress settings. The DON stated that a wound specialist or primary physician would typically place the order for a specialized mattress. She then stated that facility owned beds were set up by staff, and that her expectation was that nursing would check the mattresses after setting up for proper function. She stated that air mattresses were to be set according to the resident weight; that her expectation was that nursing would check for proper function every shift and stated that if the mattress was deflated it could cause injury or affect healing of wounds. At 10:37 AM, the surveyor asked the DON to check Resident #14 and Resident #48's last recorded weights. The DON stated that Resident #14's last recorded weight was 117.6 pounds and Resident #48's last recorded weight was 99 pounds.On 2/5/26 at 10:39 AM, the surveyor and the DON entered Resident #14's room and checked the air mattress setting. The DON confirmed that it was set to 200 pounds and adjusted the mattress to 120 pounds.On 2/5/26 at 10:41 AM, the surveyor and the DON entered Resident #48's room and checked the air mattress setting. The DON confirmed that it was set to 280 pounds and adjusted the mattress to 100 pounds.On 2/5/26 at 12:43 PM, in the presence of the survey team, the surveyor made the Administrator and the DON aware of the concerns regarding Resident #14's and Resident #48's air mattress. The Administrator and DON acknowledged that air mattresses should be set according to a resident's weight to prevent skin breakdown.A review of the facility's Support Surface Policy, reviewed 10/25 by the facility, included: Support surfaces will be utilized in accordance with manufacturer recommendations and physician orders.a schedule for inspection and replacement will be established accordingly.for powered devices, or those requiring air, the licensed nurse will check each shift and PRN (as needed) for proper functioning and/or inflation.A review of the manufacturers Operation Manual for the air mattress and pump provided to the surveyor by the facility states: Step 4.0 system package: Weight, simply press weight button to adjust patient, weight 100 pounds to 325 pounds according to patient weight.Step 7.0 Program Settings, .adjust the mattress' internal pressure according to the patient weight by using the weight button on the control panel.A review of another manufacturers Operation Manual for the air mattress and pump provided to the surveyor by the facility states: Step 6, Determine the patient's weight and set the control knob to that weight setting on the control unit.NJAC 8:39-27.1(a)

Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered Care Plan (CP) to address the needs for a.) a resident who was on an anticoagulant (blood thinners) for Paroxysmal Atrial Fibrillation (A-fib; a type of irregular, rapid heart rhythm that comes and goes on its own) (Resident #51) and b.) a resident with a suprapubic catheter (a medical device used to drain urine from the bladder) (Resident #3). This deficient practice was observed for Two (2) of 23 residents reviewed for CP.This deficient practice was evidenced by the following: 1.On 1/29/26 at 12:07 PM, the surveyor observed Resident #51 sitting in their wheelchair, in the dining room. The surveyor reviewed the electronic medical records (EMR) for Resident #51. A review of the admission Record face sheet (an admission summary) reflected that Resident #51 was admitted to the facility with diagnoses which included but were not limited to; Paroxysmal A-fib and essential hypertension (HTN; high blood pressure that develops over time without a direct, identifiable medical cause). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/25/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating that the resident had moderate cognitive impairment. Further review of the MDS indicated that Resident #51 received Anticoagulants (medicines that prevent harmful blood clots from forming or growing). A review of the physician order summary report for January 2026 revealed a Physician Order (PO) for Apixaban oral tablet 5 MG (milligrams) – give 1 tablet by mouth every 12 hours for A-fib, monitor for bleeding, bruising and black tarry stools, dated 11/19/25. A review of the January 2026 Medication Administration Record (MAR) revealed that Resident #51 was receiving Apixaban 5 mg by mouth twice a day. A review of individualized comprehensive care plan (ICCP) revealed a Focus for Resident #51 at risk for malnutrition related to (r/t) .HTN, A-fib,. Date initiated: 11/20/25, Resident at risk for falls related to h/o (history of; hx) falls prior to admission.Date initiated 11/21/25; [Name Redacted] has dx (diagnosis): Hypertension r/t hx smoking, Date initiated 12/21/25. Further review of the ICCP did not include a CP including interventions for Paroxysmal A-fib and/or for Anticoagulant use. On 2/4/26 at 1:10 PM, during an interview with the surveyor, the Registered Nurse (RN) stated the purpose of the CP was to be able to get an understanding of resident's needs and care and it was a means of communication between different departments. The RN stated the CP would be initiated on admission by the admitting nurse and then would be updated/changed as needed by the Unit Manager (UM). The RN further stated if the resident had a hx of A-fib and was receiving blood thinners, there should be a CP with intervention to monitor the resident for bleeding risks. The surveyor inquired if the RN reviewed the CP for Resident #51 and the RN stated if there was a significant change then she would review the CP but not daily. In the presence of the surveyor, the RN reviewed Resident #51's CP and confirmed there was no FOCUS area CP for A-fib or the blood thinners and further stated there should have been one. On 2/4/26 at 1:53 PM, during an interview with the surveyor, the Licensed Practical Nurse/UM (LPN/UM) stated the purpose of the CP was to follow the care needs of the residents, depending on their diagnoses and treatments. The LPN/UM stated if the resident was on blood thinners like Lovenox, coumadin, Eliquis . behavioral issues, depression, any psychiatry medications all would be included in the CP. The LPN/UM further stated, the interventions for blood thinners would include monitoring the resident for bruising, bleeding and black tarry stools. The LPN/UM stated the CP would be updated with any changes in resident's condition by the Director of Nursing (DON), Assistant DON and myself. In the presence of the surveyor, the LPN/UM reviewed Resident #51's CP and acknowledged there was no CP related to the resident's A-fib diagnosis or Anticoagulant medication use. The LPN/UM acknowledged that there should be one included in the resident's CP. The LPN/UM stated she would update the CP. On 2/5/26 at 12:46 PM, the surveyor made the DON, the Regional DON and the Licensed Nursing Home Administrator (LNHA) aware of the above concerns. 2. On 1/30/2026 at 12:41 PM, the surveyor observed an Enhanced Barrier Precautions (EBP) sign on the wall outside of Resident #3's room, and Personal Protective Equipment (PPE) hanging on the door. Resident #3 was sitting in a wheelchair, dressed, and eating lunch. A blanket was across Resident #3's lap that reached to the bottom of the wheelchair. The surveyor reviewed the electronic medical records (EMR) for Resident #3. A review of the admission Record Face sheet revealed the resident was admitted to the facility with diagnoses that include but are not limited to: Displaced fracture of the patella (a break in the kneecap that required surgical intervention), Hypo osmolality and hyponatremia (an imbalance of water and electrolytes), disorientation, dementia, benign neoplasm of the prostate (enlarged prostate), neuromuscular dysfunction of the bladder (nerve damage that affects bladder control), and Urinary Tract Infection (UTI). A review of physician's orders dated 11/25/25 included Suprapubic catheter (SPC) care, Measure and record output every shift. A review of the most recent MDS dated [DATE], revealed a BIMS of 7 out of 15, which indicated severe cognitive impairment. A further review revealed the resident had an indwelling catheter (including suprapubic catheter), urinary continence not rated. A review of the ICCP initiated 1/8/2026 revealed a focus area to include: Nutrition risk, Alert and able to make his own decisions concerning recreational programming, Left patella fracture related to fall, Pain, At risk for falls, Activities of Daily Living self-care performance deficit, and Chronic/progressive decline in intellectual functioning. No focus areas were identified for the SPC. On 2/5/2026 at 9:37 AM, the surveyor interviewed the LPN/UM regarding Resident #3. The LPN/UM stated care plans were created and updated by the team, including the LPN/UM, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the dietician, the social worker, the activities director, and a representative from the corporate office. Care plans were updated by the team if anything had changed with the patient. Care plan meetings were quarterly, and the LPN/UM or corporate representative would help update the care plan. The LPN/UM acknowledged when a resident had a SPC, we should care plan for that. In the presence of the surveyor, the LPN/UM reviewed the care plan for Resident #3. The LPN/UM confirmed Resident #3 currently had a SPC and there were no focused care plan items for SPC. The LPN/UM further confirmed there should be a focused care plan item for the SPC and stated, I'll create one now. The LPN/UM also stated, the importance of having a care plan is to monitor infection control, placement of the SPC, for the team to know the resident has a SPC, monitoring drainage, privacy bags, follow up with the urologist, and changes. On 2/5/26 at 12:46 PM, the surveyor made the DON, the Regional DON and the Licensed Nursing Home Administrator (LNHA) aware of the above concerns. A review of the facility provided Comprehensive Care Plans Policy, with a copyright of 2022 revealed Policy Explanation and Compliance Guidelines .All Care Assessment Ares (CAAs) triggered by the MDS will be considered in developing the plan of care ., and .The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. N.J.A.C. 8:39-11.2 (d)(e)(1)(2)

Complaint #2684176 Based on interviews, record review and review of facility provided documents, it was determined that the facility failed to ensure that a resident was free from exploitation and misappropriation of resident income. This deficient practice was identified for one of one resident (Resident #115) reviewed for misappropriation of personal property and was evidenced by the following: On 1/29/26 at 10:19 AM, during an initial tour of the facility, the surveyor observed Resident #115 in their room. Resident #115 was not interviewable. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #115. A review of the admission Record, an admission summary, reflected diagnoses which included but were not limited to; major depressive disorder, and altered mental status. Further review reflected: [Resident Representative name #1 redacted] POA (Power of Attorney)-Financial, Emergency Contact #1, Durable POA [address, phone number and email redacted][Resident Representative name #2 redacted] POA-Care, Emergency Contact #2 [phone number and email redacted]A review of the Quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 12/6/25, reflected a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had moderate cognitive impairment. On 2/4/26 at 10:36 AM, the surveyor interviewed the Director of Admissions (DA) who stated she was familiar with Resident #115 and Resident Representative #1, whom she described as being very involved. The DA stated the Business Office, which was offsite, handled all financial information for the residents. On 2/4/26 at 12:14 PM, the surveyor interviewed the Administrator who stated he had limited interactions with Resident representative #1 for Resident #115. The Administrator acknowledged he was aware that Resident representative #1 had concerns that were mainly financial, related to Resident #115's income that went directly to the facility. He further stated Resident representative #1 was the financial POA for Resident #115. On 2/5/26 at 10:29 AM, in the presence of the survey team, the surveyor interviewed the BO Medicaid biller via phone. The BO Medicaid biller stated in the case of Resident #115, the BO filed to be a representative payee (person or organization who receives Social Security benefits for anyone who can't manage or direct the management of his or her benefits. These individuals or organizations receive the Social Security check on behalf of the beneficiary .) with Social Security in November 2025 so we can help manage their income. The BO Medicaid biller further stated, when we file to be representative payee we don't need consent. She further stated Resident Representative #1 would not be able to contact Social Security regarding Resident #115's benefits because the facility has payee status now. The BO Medicaid biller was unable to provide the date the BO became representative payee for Resident #115. The surveyor reviewed the facility-provided admission Agreement dated 9/10/25 for Resident #115. Section 1. C.) Resident Finances reflected .The Resident has the right to manage his or her own financial affairs under the Resident's [NAME] of Rights.The surveyor reviewed the facility-provided Representative Payee Application (Form SSA-11-BK) for Resident #115, signed and dated 11/15/25 by the BO manager. The application reflected the following:Section 2 had instructions Explain why you think the claimant is not able to handle his/her own benefits. (In your answer, describe how he/she manages any money he/she receives now). The typed response reflected patient is unable to handle their finances.Section 3 had instructions Explain why you would be the best representative payee. The typed response reflected patient resides in our nursing facility.Section 8 had instructions List the names and relationship of any (other) relatives or close friends who have provided support and/or show active interest with the claimant. Describe the type and amount of support and/or how interest is displayed. The corresponding response area was blank.On 2/5/26 at 12:47 PM, during a meeting with the survey team, the surveyor made the Administrator, the Director of Nursing, and the Regional Director of Nursing aware of the above findings.On 2/6/26 at 9:53 AM, the surveyor interviewed the AD, in the presence of the Administrator. The AD stated all demographic information was sent to the BO when a resident was admitted to the facility, including contact information and information about POA's. Neither the AD nor the Administrator could speak to why the BO would not have listed Resident Representative #1 and/or Resident Representative #2 on the representative payee application filed on behalf of Resident #115 on 11/15/25. The surveyor requested the following information:1. The date the BO was approved to be representative payee for Resident #115. 2. Documentation that indicated Resident representative #1 was notified the BO was representative payee for Resident #115.3. The facility policy or agreement that stated the facility would apply to be a representative payee on behalf of a resident. On 2/6/26 at 11:24 AM the survey team met for an Exit Conference with the Administrator, Director of Nursing, and Regional Director of Clinical Services. The Administrator acknowledged they were unable to provide any additional information. NJAC 8:39-4.1(a)7, 9.5(a)

Based on observation, interview and review of facility documents, it was determined that the facility failed to maintain a clean/homelike and sanitary environment for 1 of 2 nursing units (B Wing).This deficient practice was evidenced by the following:On 1/30/2026 at 9:47 AM, during an environmental tour on B wing, the surveyor interviewed unsampled Resident #30. During the interview, the surveyor observed a large white patched area with a hole in the wall below the patch on the left wall of the room, just beyond the bathroom door. Further review of the room revealed a white patched area around the soap dispenser near the sink, and a large white patch area on the right side wall, near the resident's bed. The surveyor asked Resident # 30 what happened to the walls. Resident #30 stated they did not know because it was like that since they were admitted in October. The surveyor asked Resident #30 what they thought of the walls, the resident stated, it is not pretty. On 1/30/2026 at 11:14 AM, the surveyor interviewed the Director of Maintenance (DM) in Resident #30's room. The resident was not in the room at the time. The DM acknowledged the white patches on the walls. He identified the white patches as spackle from when the walls had been repaired. He could not speak to why the walls had not been repainted. The DM stated it had been like that for about 2 months. He stated he was not aware of the hole in the wall, but he would fix it right away to keep dust and dirt out of the room. The DM stated it was his priority to make the facility pleasing to the residents. On 1/30/2026 at 11:18 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the walls should have been painted as soon as the spackle was dry. He stated the purpose was for resident rights to a home-like environment. On 2/5/2026 at 12:47 PM, during a meeting with the survey team, the surveyor made the LNHA, the Director of Nursing, and the Regional Director of Nursing aware of the above findings. A review of the facility policy Maintenance Policy updated 1/2025 revealed Policy statement: All facility staff are responsible for identifying and promptly reporting maintenance or environmental issues that may impact infection control.The Maintenance Department will ensure all issues are addressed in a timely and documented manner. Policy purpose: To ensure a safe, clean, and well-maintained environment for residents, staff, and visitors by establishing clear procedures for promptly reporting and addressing maintenance concerns in accordance with state and federal regulation. NJAC 8:39-31.2 (e), 31.4(a)

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication administration times to accommodate for a resident's dialysis scheduled times. The deficient practice was identified for one (1) of one (1) resident, (Resident #151) reviewed for dialysis services and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/2/24 at 1:00 PM, the surveyor interviewed Resident #151 in their room. The resident stated that they go to dialysis on Monday, Wednesday and Friday (MWF) and was usually picked up after 3 PM and would return to the facility around 9 PM. The resident stated that the nurses brought them their medication. The resident was unable to speak to which medications and what times they received their medications. The surveyor reviewed the medical record for Resident #151. A review of the resident's Admission Record revealed diagnoses which included but not limited to, end stage renal disease (a condition which the kidneys cannot filter waste from the blood) and dependence on renal dialysis (a mechanical process used to filter waste from the blood). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 9/9/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the resident's interdisciplinary care plan (IDCP) revealed as a focus that the resident received hemodialysis (same as dialysis and renal dialysis) due to renal failure. An intervention/task included but was not limited to, that the resident received dialysis MWF with a chair time of 4:15 PM and pick up time of 3:15 PM and to offer the resident a dinner tray upon returning from dialysis. The goal reflected that the resident would not have signs and symptoms of complications from dialysis. The IDCP had not indicated any interventions regarding medication times. A review of the resident's dialysis book, that was kept on the unit, reflected that dialysis was scheduled for MWF 3:15 PM pick up time and chair time was 4:15 PM and treatment 4 hours. In addition, the dialysis book contained a Dialysis Communication Form for the dates of 9/27/24 and 10/2/24 that were completed indicating that the resident had received dialysis on those days. A review of the resident's Order Summary Report for active orders as of 9/27/24 revealed a physician's order (PO) dated 9/27/24 for the following: -Ascorbic Acid (Vitamin C, a supplement) Oral Tablet 500 milligrams (MG) (Ascorbic Acid) Give 1 tablet by mouth two times a day (BID) for supplement until 10/27/24 23:59 (11:59 PM) Give Ascorbic Acid 500 MG BID by mouth. -Insulin Lispro Injection solution (a rapid acting insulin medication used to lower blood sugar),100 units per milliliter, Inject 5 units (U) subcutaneously three times a day for Type 2 DM. -Calcium Acetate (Phos Binder) (a medication used to bind phosphates in food consumption) Oral Capsule 667 MG (Calcium Acetate (Phosphate Binder) Give 1 capsule by mouth three times a day for Hypophosphatemia. Administer with meals. -Prostat (sugar free)(SF) (a wound healing supplement) two times a day for supplement until 10/27/24 23:59 Give Prostat SF 30 ML BID by mouth. There were no PO indicating medications to be administered on dialysis days and non-dialysis days or changes in administration times on dialysis and non-dialysis days. A review of the September and October 2024 electronic medication administration record (eMAR) for the POs listed above indicated medication administration times that occurred during the time that the resident was out of the facility at dialysis on 9/27/24 and 10/2/24. The eMAR revealed the following: -on 9/27/24 the doses for Vitamin C 500 MG at 5 PM, Lispro 5 U at 5 PM, Prostat 30 ML at 5pm and Calcium Acetate at 5:30 PM, all indicated for administration the number 5 which corresponded to the code chart hold/see nurses notes. -on 10/2/24 the doses for Vitamin C 500 MG at 5 PM, Lispro 5 U at 5 PM, Prostat 30 ML at 5pm and Calcium Acetate at 5:30 PM, all indicated for administration the number 9 which corresponded to the code chart other/see nurses notes. A review of the resident's corresponding electronic progress notes (EPN) revealed the following: -on 9/27/24 an eMAR Administration Note for 21:25 (9:25 PM) indicated for Vitamin C, Insulin Lispro, Calcium Acetate and Prostat out to hemodialysis. -on 10/2/24 an eMAR Administration Note for 16:39 (4:39 PM) indicated for Vitamin C, Insulin Lispro, Calcium Acetate and Prostat out to dialysis. On 10/4/24 at 11:19 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who verified that Resident #151 on MWF was picked up from the facility at approximately 3:15 PM for dialysis. The LPN stated that she was able to administer all the resident's medications during her shift which was 7 AM to 3 PM. The LPN added that when the resident was out to dialysis then medications should not appear on the eMAR for administration. The LPN added that if a medication was on the eMAR when the resident was out to dialysis then the time of the medication should be changed. On 10/4/24 at 1:00 PM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated that medication times should be reviewed with the physician and adjusted to accommodate the resident being out of the facility at dialysis. The surveyor, with the UM/LPN reviewed the eMAR for Resident #151. The UM/LPN acknowledged that Vitamin C, Insulin Lispro, Calcium Acetate and Prostat had times of administration when the resident was out to dialysis. The UM/LPN stated that those medications should not have an administration time when the resident was at dialysis. The UM/LPN stated, I have to fix that. The UM/LPN added that Resident #151 was recently readmitted to the facility and the prior admission had the medication times adjusted. The UM/LPN explained that upon readmission the nurses should have compared the medication times and obtained a PO for those medications to accommodate when the resident was out to dialysis. On 10/7/24 at 11:50 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that upon the resident's readmission the medications were not timed to accommodate when the resident went out to dialysis. The DON added that a chart review should have been completed to make sure the medications were timed correctly. On 10/8/24 at 12:25 PM, the surveyor interviewed the Consultant Pharmacist (CP), who stated that medication times need to be adjusted to accommodate dialysis times. The CP added that she would make that recommendation during her chart review. The CP also stated that her last chart review was 9/12/24 and the resident was readmitted just last week. A review of the facility policy updated July 2024 for Administering Medications provided by the DON, reflected that medications are to be administered in a timely manner as prescribed. Further review of the policy reflected, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A review of the facility policy dated as revised February 2023 for Hemodialysis provided by the DON, reflected that This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. In addition, the policy reflected that The facility will ensure that the physician's orders for dialysis include: .f. Any medication administration or withholding of specific medications prior to dialysis treatments. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

COMPLAINT # NJ00169735, NJ00170064 and NJ00170351 Based on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards of practice by not ensuring that a.) medications were administered to a resident in a timely manner as ordered by a physician, (Resident #72). This was identified for one (1) of eight (8) residents, reviewed for medication management. and b.) a controlled drug (Oxycodone) was available for administration and accurately documented as per a physician's order in the electronic medication administration record (Resident #87). This was identified for one (1) of eight (8) residents, reviewed for medication management. The deficient practices were 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 10/1/24 at 10:32 AM, the surveyor interviewed Resident #72 in their room. The resident stated that they were blind but had all their faculties. The resident stated that they knew all their medications and what time they were due. The resident added that they had to make sure that they received their fast-acting insulin before they ate and that sometimes was late getting their medications. The resident added that they knew specifically in January 2024 they had received their medications late. On 10/2/24 at 8:27 AM, during the morning medication administration observation with the Licensed Practical Nurse (LPN), the surveyor observed Resident #72 at their room door in a wheelchair calling out to the LPN. The LPN stated that she would be giving medications to the resident next. The surveyor reviewed the medical record for Resident #72. A review of the resident's Admission Record revealed diagnoses which included but not limited to; blindness right eye category 3 (blindness), blindness left eye category 3, and type 2 Diabetes Mellitus (DM) (high blood sugars), glaucoma (a disease that damages the optic nerve), anemia (a condition of deficient red blood cells), peripheral vascular disease (a circulatory condition) and congestive heart failure (a condition where the heart does not pump blood as well as it should). A review of the most recent annual comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 8/21/24, reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating that the resident had an intact cognition. A review of the resident's interdisciplinary care plan (IDCP) revealed as a focus that the resident has DM and an intervention/task included but was not limited to, Diabetes medication as ordered by doctor. Additionally, another focus was that the resident has hypertension (high blood pressure) with an intervention/task to Give antihypertensive medications as ordered. A review of the resident's Medication Administration Audit Report (MAAR) revealed that on 1/10/24 and 1/11/24 Resident #72 had received their medications out of the allowed time range of one hour before or 1 hour after the time of administration as ordered by the physician. The report reflected the following for 1/10/24: -Zinc Gluconate (a supplement) had a scheduled time of 9 AM and had an administration time of 11:36 AM and a documented time of 11:41 AM. -Clonidine (a medication used to lower blood pressure (BP)) had a scheduled time of 2 PM and had an administration time of 3:52 PM and a documented time of 4:53 PM. -Brimonidine Tartrate Ophthalmic Solution 0.2 % (eyedrop used for glaucoma) had a scheduled time of 5:05 PM and had an administration time of 6:51 PM and a documented time of 6:51 PM. -Admelog SoloStar (Insulin Lispro)(a fast-acting insulin used to lower blood sugar) had a scheduled time of 5:15 PM and had an administration time of 6:51 PM and a documented time of 6:51 PM. -Metoprolol Tartrate (a beta-blocker medication used to lower BP) had a scheduled time of 5:30 PM and had an administration time of 6:51 PM and a documented time of 6:51 PM. Further review of the MAAR reflected the following for 1/11/24: -Admelog SoloStar (Insulin Lispro) had a scheduled time of 8:15 AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Accu check with freestyle Libre sensor (a sensor that shows the measurement of the blood sugar level) had a scheduled time of 8:15 AM and had an administration time of 11:14 AM and a documented time of 11:14 AM. -Metoprolol Tartrate had a scheduled time of 8:30 AM and had an administration time of 11:13 AM and a documented time of 11:13 AM. -Magnesium Oxide (a supplement) had a scheduled administration time of 9 AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Dorzolamide HCl Ophthalmic Solution 2 % (eye drop used to treat glaucoma) had a scheduled time of 9AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Aspirin 81 MG had a scheduled time of 9 AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Zinc Gluconate had a scheduled time of 9 AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Fluticasone Propionate Nasal Suspension (a steroid nose spray) had a scheduled time of 9 AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Ferrous Sulfate (an iron supplement) had a scheduled time of 9am and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Claritin (an antihistamine) had a scheduled time of administration for 9 AM and had an administration time of 11:12 and a documented time of 11:13 AM. -Paxlovid (a medication used to treat mild to moderate coronavirus) had a scheduled time of 9 AM and had an administration time of 11:12 AM and a documented time of 11:13 AM. -Polyethylene Glycol 3350 Powder (a medication used to treat constipation) had a scheduled time of 9 AM and had an administration time of 11:14 AM and a documented time of 11:14 AM. -Dorzolamide HCl Ophthalmic Solution 2 % had a scheduled time of 5 PM and had an administration time of 10:46 PM and a documented time of 10:47 PM. -Fish Oil (a supplement) had a scheduled time of 7 PM and had an administration time of 9:16 PM and a documented time of 9:48 PM. -Latanoprost Ophthalmic Solution 0.005 % (an eyedrop used to treat glaucoma) had a scheduled time of 9:05 PM and had an administration time of 10:47 PM and a documented time of 10:47 PM. A review of the January 2024 electronic medication administration record (eMAR) revealed nurse's initials that signified that the above medications were administered at their scheduled times. This contradicted the above administration times. A review of the electronic progress notes (ePN) had not revealed that there was any indication of a need for the above medications to be administered outside of the time of administration that was ordered by the physician. On 10/4/24 at 3:12 PM, the survey team met with the Director of Nursing (DON) and the Regional Director of Nursing (RDON) and reviewed the above concern regarding late medication administration for Resident #72 on 1/10/24 and 1/11/24. The DON stated that she would have to review. The DON was unable to speak to whether audits were reviewed to ensure and identify accurate medication administration times documented on the eMAR. On 10/7/24 at 11:50 AM, the surveyor interviewed the DON who stated that Resident #72 had been on contact precautions for COVID (Coronavirus disease) in January. The DON added that the nurses should be signing the eMAR after the medication was administered and should not be administering or documenting late. The DON acknowledged that according to the MAAR the above medications were administered late. A review of the facility policy updated July 2024 for Administering Medications provided by the DON, reflected that medications are to be administered in a timely manner as prescribed. Further review of the policy reflected, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). In addition, the policy reflected, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 2. On 10/3/24 at 11:56 AM, the surveyor interviewed Resident #87 in their room. The resident stated they felt that the nurses frequently ran out of their medication, Oxycodone. The resident also stated that they were supposed to receive the Oxycodone every four (4) hours. The resident added that the nurses would tell them that they were waiting for the pharmacy to deliver the medication. The resident then stated this past weekend there was a problem on Sunday and Monday with getting the Oxycodone. The resident stated, On Monday morning at 9 AM and 1 PM the nurse did not have any Oxycodone, so I did not receive any until 5 PM. The resident further stated that I was okay because I have a 20 milligram (MG) dose I can take in between, and I took that at 11 AM. The resident also stated that they thought it was odd that the nurse could not get the Oxycodone because usually the nurses would tell them that they had to go to the backup when they did not have the Oxycodone in the medication cart. The surveyor reviewed the medical record for Resident #87. A review of the resident's Admission Record revealed diagnoses which included but not limited to; pain in unspecified hip, stress fracture, left foot, personal history (healed) traumatic fracture and opioid abuse. A review of the most recent quarterly comprehensive MDS, dated [DATE], reflected the resident had a BIMS score of 15 out of 15, indicating that the resident had an intact cognition. A review of the electronic Order Summary Report revealed a physician's order (PO) dated 6/4/24 for Oxycodone HCl(hydrochloride) oral tablet 15 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours for pain management. A review of the September 2024 eMAR revealed the above PO with administration times of 1 AM, 5 AM, 9 AM, 1 PM, 5 PM and 9 PM. In addition, the eMAR revealed that on 9/29/24 at 9 AM and 1 PM, the nurse entered the number 9 for administration which corresponded with the chart code Other/see nurses notes. A review of the ePN dated 9/29/24 at 9:00, titled eMAR Medication Administration Note for Oxycodone indicated medication not given notified MD medication pending delivery from pharmacy. In addition, another eMAR Medication Administration Note dated 9/29/24 at 23:02 (11:02 PM) for Oxycodone indicated pharmacy notified, pending delivery. MD notified. A review of the Control/Narc Backup Box Medications Contents list provided by the DON revealed that Oxycodone 5 MG tablets and 10 MG tablets were available. A review of the removals from the controlled drug backup box revealed the House Stock Control Countdown Sheet (HSCCS) for Oxycodone IR (immediate release) 5 MG tablets reflected that there was removal of one (1) tablet from inventory on 8/19/24 at 12:30 AM, 5 AM, 9 AM, 1:48 PM, 5 PM and 9 PM. In addition, one (1) tablet was removed on 8/20/24 at 1 AM and on 9/29/24 at 1 AM and 6 AM. A review of the HSCCS for Oxycodone IR 10 MG tablets reflected that there was removal of one (1) tablet from inventory on 8/19/24 at 12:30 AM, 5 AM, 9 AM, 1:48 PM, 5 PM and 9 PM. In addition, one (1 ) tablet was removed on 8/20/24 at 1 AM and on 9/29/24 at 1 AM and 6 AM. A review of the September and October 2024 eMAR revealed the above PO and indicated that Oxycodone was administered as a 15 MG tablet for the same dates and times listed above on the HSCCS. A review of the ePN for the same dates and times as the HSCCS had not indicated that one (1) 5 MG tablet and one (1) 10 MG tablet was administered or that a PO was obtained. There was no documentation that there was a PO obtained allowing the administration of one (1) 5 MG and one (1) 10 MG tablet for a total dose of 15 MG for the dates and times indicated on the HSCCS. On 10/4/24 at 11:52 AM, the surveyor interviewed the Registered Nurse (RN), who stated that she was responsible for the medications for Resident #87 and worked at the facility on a regular basis. The RN verified that the resident had a PO for Oxycodone to be administered every four (4) hours. The RN explained that the procedure was to order the Oxycodone or any medication for refill before running out. The RN stated that the Nurse Practitioner (NP) was available every Tuesday and Thursday and if a new prescription was needed then the NP would write one. The RN added that Oxycodone was also in the facility backup supply but she tried not to use that because the Oxycodone was a routine PO and should be available. On 10/4/24 at 3:12 PM, the survey team met with the DON and RDON and reviewed the above concern of Oxycodone not being available on 9/29/24 and the use of the backup supply of Oxycodone. The DON stated that she would have to review. On 10/7/24 at 11:50 AM, the surveyor interviewed the DON, who acknowledged that the Oxycodone was not administered on 9/29/24 at 9 AM and 1 PM. The DON further acknowledged that Oxycodone 5 Mg and 10 MG tablets were available in the backup supply and was unable to speak to why the nurse had not used the backup supply. In addition, the DON stated that according to the HSCCS, the removal of one (1) 5 MG tablet and one (1) 10 MG tablet accounted for all the doses documented as administered on the eMAR for the same dates and times. The DON added that the correct dose was administered. The DON acknowledged that the PO was for Oxycodone 15 MG tablets and that according to the eMAR a 15 MG tablet was documented as administered for the same dates and times as the HSCCS indicated removals from the backup inventory for Oxycodone 5 MG and 10 MG tablets. The DON was unable to speak to the documentation on the eMAR not matching what the physician ordered. On 10/8/24 at 12:25 PM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that the dose of any medication as ordered by the physician had to match the dose being administered. The CP also stated that if the PO was for a 15 MG tablet, then a new PO was needed to administer one (1) five (5) MG tablet plus one (1) ten (10) MG tablet to make the total dose of 15 MG. The CP added that the eMAR must be signed for the actual doses being administered as ordered. A review of the facility policy titled Medication and Treatment Orders provided by the DON dated July 2024 reflected that Drugs and biologicals that are required to be refilled should be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. In addition, the policy reflected that Orders for medications must include: a. name and strength of the drug; A review of the facility policy titled Backup Medications and Controlled Medications in Long-Term Care Setting provided by the DON and updated 10-24 which reflected that The facility will maintain a system for the secure management of backup and controlled medications to ensure availability while minimizing risks of misuse or diversion. In addition, for Administration: Ensure that all staff are trained on the protocols for accessing and administering backup medications. Document administration in the resident's medical record. And 4. Documentation: Ensure administration of controlled medications are documented accurately in the resident's medical record and in a controlled substance log. The policy also revealed for Administration: Ensure that all staff are trained on the protocols for accessing and administering backup medications. Document administration in the resident's medical record. And 4. Documentation: Ensure administration of controlled medications are documented accurately in the resident's medical record and in a controlled substance log. NJAC 8:39-11.2(b), 29.2 (a)(d), 29.4(k), 29.7(c)

Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to: a.) consistently follow a physician's order for the application of a bolster (cushion used for support) to the left arm rest of a wheelchair for a resident with decreased range of motion and mobility, b.) follow the residents individualized comprehensive care plan (ICCP), and c:) consistently document accountability for the placement of the device. The deficient practice was identified for 1 of 1 resident (Resident #10) reviewed for positioning and mobility. This deficient practice was evidenced by the following: On 10/01/24 at 11:40 AM, the surveyor observed Resident #10 in his/her wheelchair in the dayroom without a bolster applied to the left arm of the wheelchair. On 10/02/24 at 11:35 AM, the surveyor observed the Resident in his/her wheelchair in the dayroom without a bolster applied to the left arm of the wheelchair. The surveyor reviewed Resident #10's electronic Medical Record (eMR). A review of the resident's Admission Record revealed diagnoses that included but were not limited to: transient cerebral ischemic attack (a short period of symptoms similar to a stroke) and unspecified dementia. A review of the resident's Quarterly Minimum Data Set (MDS), a tool used to facilitate the management of care, dated 7/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severely impaired cognition. A review of the October 2024 Order Summary Report, revealed a physician's order (PO), dated 6/3/24, for Therapy: apply bolster to L (left) arm rest of w/c (wheelchair)individual daily morning. A review of the October 2024 Treatment Administration Record (TAR), did not reflect the above PO. A review of the ICCP, dated 8/8/24, revealed a care plan for .right and left upper extremities weakness. The goals revealed [name redacted] will maintain or improve ADL [activities of daily living] function over next quarter. Further review revealed the intervention Apply bolster to L arm rest of wheelchair . for positioning. A review of the Certified Nursing Assistant (CNA) Tasks revealed a Task: Apply bolster to left arm rest of wheelchair . for positioning when resident in wheelchair. Further review of the Tasks from the dates of 9/3/24 through 10/2/24, revealed no documented accountability for placement of this device for 13 out of 30 days reviewed. There was no documented accountability for device placement on 10/2/24. On 10/02/24 at 12:23 PM, the surveyor observed Resident #10 in the day room, awaiting lunch, in his/her wheelchair at a table without a bolster applied to the left arm of the wheelchair. The surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) and together observed the resident in his/her wheelchair. She acknowledged that there was no bolster applied to the left arm of the wheelchair. The LPN/UM stated that the purpose of the device was for positioning, and it was the responsibility of the CNA to apply the device when they transfer the resident to his/her wheelchair. She stated that she was not sure if it should be on the TAR for accountability. She further acknowledged that if the device was evidenced in the CNA Tasks, that it would have been the CNA's responsibility to document accountability that the device was in place. The surveyor and the LPN/UM reviewed the TASKs in the eMR, and she acknowledged that there were multiple omissions to account for CNA placement of the bolster device from dates 9/3/24 through 10/2/24, including 10/2/24. She also stated that it should have been both the nurse and therapists' responsibility to oversee this process. The surveyor and LPN/UM went to Resident #10's room which revealed the bolster (black in color) in the top of the resident's closet. In addition, she stated that the CNA assigned to the resident today was new and did not have access to the eMR and TASKs, and therefore he probably did not know the resident required the bolster. She further stated, we should have told him to apply the device. The LPN/UM stated that the staffing coordinator should have provided the CNA with access to the eMR and TASKs. On 10/02/24 at 1:45 PM, the surveyor interviewed the CNA who stated that he had worked at the facility one day in March 2024 and this was his first day back since then. He stated that he requested access to the eMR from the LPN/UM, who then requested the same from the staffing coordinator. He stated that up until this point he still had no access to the eMR. The CNA further acknowledged that he had no knowledge that the resident required a bolster to the left arm of the wheelchair and that no one told him. On 10/02/24 at 2:03 PM, the surveyor interviewed the staffing coordinator. She verified that it was the CNAs first day and that he should have received eMR access. She stated that she was mostly responsible to set up access for the CNA prior to the start date. The staffing coordinator stated that in the event it could not have been done timely, the Licensed Nursing Home Administrator (LNHA) had the ability to gain access as well. She further stated she was busy but that is no excuse. The staffing coordinator acknowledged the LPN/UM requested access for the CNA and that she had not done so yet. On 10/03/24 at 9:00 AM, the surveyor interviewed the Director of Rehabilitation. She stated that the bolster for the left arm of the wheelchair was for positioning and that the resident tends to lean due to a stroke. She stated that the device was trialed, and it was successful. She also stated that it was the responsibility of the CNA to apply the bolster and account for that in the TASKs section of the eMR. She further stated that nursing should oversee this process to ensure placement and accountability, and she was not sure if the PO should have also been on the TAR. She stated that the resident was discharged from therapy on 8/21/24. On 10/08/24 at 9:40 AM, the surveyor interviewed the Director of Nursing (DON) in presence of survey team as well as the LNHA and the Regional DON. She acknowledged that the bolster had not been in place as the surveyor observed and was not accounted for on the TAR. The LNHA acknowledged that the staffing coordinator should have gotten the CNA access to the eMR and provided it to nursing prior to the CNAs arrival. In addition, he stated that he also had the ability to acquire access. The DON stated that in the event eMR access was not available that nursing should have given the CNA a verbal report of the resident's needs. A review of the facility policy Activities of Daily Living (ADLs) dated February 2024, included The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A review of the facility policy Assistive Devices and Equipment dated July 2024, included the following: Our facility maintains and supervises the use of assistive devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the residents care plan. Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. A review of the facility policy Care Plans, Comprehensive Person-Centered dated July 2024, included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation on 10/2/24, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 31 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 6.45 %. This deficient practice was identified for one (1) of five (5) residents, (Resident #72), that were administered medications by one (1) of two (2) nurses. The deficient practice was evidenced as follows: On 10/2/24 at 8:27 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing to administer 12 medications to Resident #72, which included two (2) different insulin pen injectors, Basaglar (a long-acting insulin (a medication used to lower blood sugar)) and Fiasp (a rapid-acting insulin), according to the electronic medication administration record (eMAR). The LPN removed the Basaglar and Fiasp pen-injectors from the medication cart, removed the pen caps and attached a needle to each pen-injector. At that time, the LPN explained that Resident #72 had poor eyesight, was alert and oriented x 3 (meaning that the resident had an intact cognition), was able to administer the pen injectors themself and was very involved and aware of their medications. On 10/2/24 at 8:52 AM, the surveyor observed the LPN give the Basaglar pen-injector to the resident who self-administered a dose of four (4) units (U) and then the surveyor observed the LPN give the resident the Fiasp pen-injector who then self-administered a dose of 16 U. The surveyor had not observed the LPN prime either the Basaglar or the Fiasp pen-injectors before administration. (ERROR #1 and #2) The surveyor reviewed the medical records for Resident #72. A review of the resident's Admission Record reflected that the resident had diagnoses which included but not limited to, type 2 Diabetes Mellitus (DM) with unspecified complications (high blood sugar). A review of the resident's Order Summary Report reflected the following: - a physician's order (PO) with an order date of 8/1/24 for Basaglar KwikPen Subcutaneous (SC) Solution Pen-Injector 100 U/milliliter (ML) (Insulin Glargine), inject 4 units subcutaneously in the morning for DM supervised self-administration Rotate Sites. - a PO with an order date of 8/19/24 for Fiasp Flextouch SC Solution Pen-Injector 100 U/ML (Insulin Aspart(with Niacinamide)), Inject 4 unit subcutaneously in the morning related to Type 2 DM with unspecified complications supervised self-administration refrigerate until opening, store at room temp after opening, rotate sites. -a PO with an order date of 8/19/24 for Fiasp Flextouch SC Solution Pen-Injector 100 U/ML (Insulin Aspart(with Niacinamide)), Inject as per sliding scale: if 0-100 = 0 units; 101-150 =1 units; 151-200 = 2 u; 201-250=3 units; 251-300=4 units; Call MD if greater than 300 , subcutaneously four times a day related to Type 2 DM with unspecified complications supervised self-administration Give 15 minutes prior to a meal or snack, refrigerate until opened. A review of the eMAR reflected the above POs. On 10/3/24 at 8:30 AM, the surveyor interviewed the LPN who stated that she only performed a test on the insulin pen- injectors when they were fresh out of the refrigerator. The LPN explained that the insulin pens were stored in the refrigerator until it was time to use the pen-injector and then it remained stored in the medication cart until it was finished. The LPN further explained that the test was done on the pen-injector by dialing two (2) U and then seeing that the insulin liquid comes out of the needle. The LPN stated that she had not tested the insulin pens before each injection because she thought that would be wasting the insulin. The LPN acknowledged that the test she had described was the same as priming the insulin pen injector but was unaware that the pen injector needed to be primed before each dose. The LPN stated that she had been working at the facility for six (6) months and was unsure if there had been an inservice regarding insulin pen injector technique. The LPN also stated that she would have to do the priming of the insulin pen-injector for Resident #72 because the resident had poor vision. On 10/3/24 at 9:10 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone. The CP stated that the insulin pens were required to be primed before each injection. The CP added that she had done training in the past but not recently. The CP also stated that there had been a handout regarding Insulin pen-injector technique that was posted in the medication room at one time. A review of an information sheet for Insulin Pens & Administration provided by the CP revealed for Administration Techniques 2. Priming the Pen (airshot) a. Dial the specified amount of units. B. Orient the pen properly (point up-vertically-unless otherwise specified) and tap cartridge holder to collect air at the top c. Push the dose knob in until it stops. D. Priming is complete when a drop of insulin appears at the needle tip. E. If a drop of insulin does not appear, repeat priming steps; if no results, change the needle. On 10/3/24 at 1:27 PM, the survey team met with the Director of Nursing (DON) and the Regional Director of Nursing (RDON). The DON acknowledged that the insulin pens were to be primed prior to each injection and by not following the manufacturer's specifications for priming an insulin pen-injector could affect the dosage of the insulin. (ERROR #1 and #2) On 10/4/24 at 3:12 PM, the surveyor team met with the DON and RDON. The DON stated that instructions for priming the insulin pen-injector prior to each injection was added to the eMAR. A review of the facility policy for Insulin Pen, dated as accessed April 2024, provided by the DON reflected for 11. Procedure: h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. A review of the manufacturer specifications for Instructions for Use for Basaglar KwikPen revealed People who are blind or have vision problems should not use the Pen without help from a person trained to use the Basaglar prefilled pen. In addition, the instructions reflected Prime before each injection. Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. A review of the manufacturer specifications for Instructions for Use for Fiasp PenFill revealed Check the insulin flow Step 5: Small amounts of air may collect in the cartridge during normal use. You must do an airshot before each injection to avoid injecting air and to make sure you receive the prescribed dose of your medicine. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to accurately assess and properly code a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for three (3) of 27 residents (Residents #26, #53 and #66). This deficient practice was evidenced by the following: Reference: According to the CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual dated October 2019 indicates the completion of the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. 1. On 5/4/23 at 11:41 AM, the surveyor observed Resident #26 ambulating on his/her own down the hallway using a rolling walker. The resident then stopped at the nursing station and spoke with the Unit Secretary (US) in a different language other than English. The resident then independently went and sat in a chair across from the nursing station. At that time, the US stated that she was getting another employee to interpret because she could not understand everything the resident was saying. The surveyor attempted to interview the resident, but the resident had not responded to the surveyor. On 5/8/23 at 11:05 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that she was familiar with Resident #26 and had been assigned to care for the resident. The CNA stated that the resident needed help with dressing but was able to get in and out of bed and eat independently. The CNA added that the resident spoke another language but was able to understand some English and understand gestures. The CNA was unable to speak to any restraints or alarms that the resident had. On 5/8/23 at 11:16 AM, the surveyor observed Resident #26 sitting on his/her bed folding clothes. The surveyor attempted to interview the resident who was able to shake his/her head yes and no. The surveyor pointed to the half length bed rails on the resident's bed that were in the down position. The surveyor asked the resident if the resident wanted the bed rails, and the resident shook his/her head yes and through gesturing showed the surveyor how he/she used the rails to help themselves when they were in bed. The surveyor observed the resident using the rolling walker and was able to move around the room. The surveyor reviewed the medical records of Resident #26. The Admission Record (admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to hypertension (high blood pressure), hyperlipidemia (high lipid levels), unspecified intellectual disabilities and obstruction of the duodenum (small intestine). The quarterly Minimum Data Set (QMDS) with an Assessment Review Date (ARD) of 3/21/23, reflected a brief interview for mental status (BIMS) score of three (3) out of 15, indicating that the resident had a severely impaired cognition. In addition, in Section P: Restraints and Alarms indicated that Bed Rail was coded used daily as a restraint. On 5/11/23 at 12:36 PM, the surveyor interviewed the Charge Nurse/Registered Nurse (CN/RN) who stated that Resident #26 had no restraints. The surveyor, with the CN/RN, reviewed the resident's interdisciplinary care plan which revealed that the resident had no focus area for a restraint. The CN/RN was unable to speak to the QMDS coding of a restraint and stated that the MDS Coordinator completed the MDS. On 5/12/23 at 10:59 AM, the surveyor, in the presence of another surveyor, interviewed the MDS Coordinator via speaker phone who stated that she had worked for the facility a little over a year. The MDS Coordinator stated that she had completed the QMDS with the ARD of 3/21/23 for Resident #26. The MDS Coordinator verified that she had entered the coding in the MDS that indicated that the resident had a restraint of bed rails in Section P. The MDS Coordinator stated that she had mistakenly coded the QMDS incorrectly for Section P because the resident had never had a restraint. The MDS Coordinator added that she was unaware of any restraint that the resident had and would have to modify the QMDS. On 5/16/23 at 12:18 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Regional Director of Nursing (RDON). The RDON acknowledged that Resident #26 had no restraints. On 5/17/22 at 11:13 AM, the survey team met with the LNHA, the Director of Nursing (DON) and RDON. The LNHA stated that the QMDS with the ARD of 3/21/23 for Resident #26 was modified. The LNHA also stated that the facility policy for Resident Assessment was the current policy. A review of the undated facility policy Resident Assessment provided by the LNHA revealed that All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. NJAC 8:39-11.1, 11.2(e)(1) 46889 2. During the initial facility tour on 5/4/23 at 12:39 PM, the surveyor observed Resident #55 out of bed to a wheelchair inside the main dining room. The surveyor reviewed the medical records of Resident #55 which revealed the following: The QMDS with an ARD of 4/10/23 reflected that the resident had a BIMS score of 15 out of 15 which indicated that the resident's cognition was intact. The QMDS Section J Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) of Resident #55 Fall on 2/5/23 was coded 0 (zero) or No, which did not reflect the resident's fall incident. The Care Plan initiated on 11/24/21 reflected Focus: [NAME] is at risk for falls r/t Dx. Tear of a meniscus of the left knee, Dx.Chronic pain, Dx.Morbid Obesity, Use of Pain medication, Use of Psych medication, Dx. Trigeminal Neuralgia (type of pain that involves facial), Independent transfers from wheelchair level, and Noncompliance with calling for help 2/05/23 Actual Fall, unwitnessed with no injury. The Progress Notes dated 2/05/23 under General Nurses Notes stated that At about 7:49 pm writer was called into the resident room to observed her sitting on her bathroom floor her entire body was assess, no apparent visual injury noted. On 05/12/23 at 11:05 AM, the surveyor, in the presence of another surveyor, interviewed the MDS Coordinator via speaker phone who stated she is not aware that the resident had a fall incident and that it should be coded in the quarterly assessment. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 reflected under Section J: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent under Steps for Assessment 2. If this is not the first assessment/entry or reentry, the review period is from the day after the ARD of the last MDS assessment to the ARD of the current assessment the Coding instructions, Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls, Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) item, whichever is more recent. 3. On 05/04/23 at 11:30 AM, during the initial facility tour, the surveyor observed Resident #53 lying in bed with an indwelling catheter in a privacy bag draining yellowish urine. The surveyor reviewed the medical records of Resident #53 which revealed the following: The Admission Record showed that Resident #53 was admitted to the facility with a diagnosis that included but was not limited to other acute kidney failure and urinary tract infections. The Admission MDS (AMDS) dated [DATE] showed that the resident had a BIMS score of 0 out of 15 which reflected that the resident's had severe impairment in cognition. The AMDS Section H Appliances did not reflect that Resident #53 had an indwelling catheter. The Treatment Administration Record (TAR) for March 2023 reflected an order of 16 french Catheter Care Q shift every shift. The Order Summary Report (OSR) which reflected the active physician order date of 3/24/23 revealed, Maintain 16 french Foley catheter for diagnosis of Chronic Urinary Retention. On 05/09/23 at 10:01 AM, the surveyor interviewed CN/RN regarding resident used of indwelling catheter. CN/RN stated that the resident was using indwelling catheter since admission in March 2023. On 05/12/23 at 11:09 AM, the surveyor interviewed MDS Coordinator who stated that she is not aware that the resident has an indwelling catheter and that it should be coded. NJAC 8:39 - 11.2 (e)

Based on observation, interview, and record review it was determined that the facility failed to provide written notification of the bed hold policy to the resident representative upon emergency transfer for 1 Resident, #14, of 2 residents reviewed for hospitalization . The deficient practice is evidenced by the following. Resident #14 was observed on 5/4/23 seated in a wheelchair in the unit day room. The resident pleasantly engaged in conversation with the surveyor. A review of the electronic medical record revealed the following information. The Census tab indicated the resident was transferred to the hospital on 2/27/23 and 3/4/23. On 5/12/23 at 9:15 AM, the surveyor interviewed the Regional Director of Nursing (RDON) regarding written notification of the bed hold party to Resident #14's resident representative for the emergency transfers on 2/27/23 and 3/4/23. The RDON was unable to provide the documentation of the notifications. On 5/17/23 at 9:00 AM, the RDON provided the facility policy titled Bed Hold Notice Upon Transfer, undated. The policy specified that prior to discharge, the facility will provide to the resident and/or the resident representative written information regarding the bed hold policy. NJAC 8:39-4.1(a)31

Based on observation, interview, and record review it was determined that the facility failed to provide the resident representative with written notification of the reason for emergency transfer for 1 Resident #106, of 2 residents reviewed for hospitalization . The deficient practice is evidenced by the following: A review of the electronic medical record revealed the following information. The Census tab indicated the resident was transferred to the hospital on 11/15/22. On 5/12/23 at 9:15 AM, the surveyor interviewed the Regional Director of Nursing (RDON) who stated the facility is responsible for providing written documentation to the resident representative and the Long-Term Care Ombudsman (LTCO) with the reason for a resident's emergency transfer. She further stated the notification was sent to the LTCO, however, it was not sent to the resident representative. She stated, It was missed. On 5/16/23 and 5/17/23 the surveyor requested the facility policy for notifications to resident representatives regarding the reason for emergency transfers. None was provided. The undated Policy for Transfer and Discharge (including AMA) is revealed under Policy Explanation and Compliance Guidelines 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. NJAC 8:39-4.1(a)31

Based on observation, interview, and record review, it was determined that the facility failed to store four of four linen carts in a sanitary manner. This deficient practice was as evidenced by the following: On 5/8/23 at 11:20 AM, the surveyor observed four blue linen carts outside of the facility on the sidewalk located underneath a tree, which were not covered. The surveyor observed that the items inside the first blue linen bin, nearest the building outside, which were washable incontinence under pads, bed sheets and blankets, was soiled with a small tree branch on top of the items and brown and tan colored debris from the tree above the bin. The surveyor observed that the items inside the second blue linen bin, which were resident gowns, was soiled with brown and tan colored debris from the tree above the bin. The surveyor observed that the items inside the third blue linen bin, which were more bedsheets, was soiled with brown and tan colored debris from the tree above the bin. The surveyor observed that the items inside the fourth blue linen bin, which were towels and washcloths, was soiled with brown and tan colored debris from the tree above the bin. At 11:33 AM, the surveyor showed the House Keeping Director (HKD), Director of Nursing (DON) and Regional DON the carts outside. The HKD stated that these carts contained newly laundered items and were delivered on Saturday 5/6/2023 and they should have been covered. The HKD stated that these items should have been brought inside and kept in a clean environment. At 12:17 PM, the HKD provided the surveyor a delivery receipt from the laundering service that the facility uses which revealed that these carts were delivered on 5/6/23 and included 300 large sheets, 50 knit contours, 40 draw sheets, 50 thermal blankets, 90 pillowcases, 200 washcloths, 600 bath towels, 150 patient gowns and 90 under pads. The HKD stated that the two porters who worked on 5/6/23 should have brought these carts inside once the laundered items were delivered. At 5/8/23 at 1:00 PM, the surveyor discussed the above concerns with the Administrator, DON and, Regional DON. On 5/9/23 at 930 AM, the surveyor received the Receiving and Storing Clean Linen policy, dated December 2022, which revealed that all linens shall be stored in a clean and dry area, free from any potential sources of contamination. N.J.A.C. 8:39-19.4(a)

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) failed to sanitize and air-dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 5/8/23 at 11:06 AM, in the presence of Director of Dietary (DD) the surveyor observed the following: In the dishwashing area, the surveyor observed a dishware drying rack with four shallow one quarter steam table pans stacked with water between them, three deep quarter steam table pans stacked with water between them, and two sheet pans stacked with water between them as well. The DD stated that the dishware should not be stacked on top of each other when wet. On 5/8/23 at 1:13 PM, the surveyor discussed the above concerns with the Administrator, Director of Nursing (DON), and Regional DON. The surveyor reviewed the facility's policy titled, Sanitization dated December 2022 which revealed that food preparation equipment and utensils that area manually washed will be allowed to air dry. NJAC 8:39-17.2(g)

Based on observation, interview, and record review it was determined that the facility failed to ensure that the resident was provided with the consistency of liquid in accordance with the physician's order. This was found with Resident # 57, 1 of 1 residents reviewed for thickened liquids. The deficient practice was evidenced by the following: On 5/9/23 at 1:15 PM, the surveyor observed Resident # 57 being fed by a Certified Nursing Assistant (CNA). The CNA poured a packet of thickening powder that read Honey Consistency into 4 ounces of apple juice that the CNA had poured into a cup. The CNA held the cup and the resident drank the thickened apple juice after feeding the resident half of a portion of chocolate pudding. The surveyor checked the meal ticket. The meal ticket read Nectar Thick. On 5/9/23 at 1:38 PM, the surveyor asked the CNA if she noticed the thickening packet was honey thick but the meal ticket said nectar thick. She said she usually checked the packet to make sure it was the right consistency but today she forgot to check the meal ticket before she mixed it with the apple juice. On 5/9/23 at 1:59 PM ,the surveyor spoke with the Director of Nursing (DON) the Regional Nurse, and the Administrator, and made them aware of the concern with the CNA providing apple juice in a consistency that was contrary to what the physician ordered. On 5/10/23 at 9:30 AM, the surveyor reviewed the resident's record which revealed the following: An admission record with diagnoses which included, Metabolic Encephalopathy, Dysphagia, Oropharangeal Phase, Dementia, Dysphagia Following Cerebral Infarction, and Aphasia. A Physician's Order Sheet with an order that read Regular Diet Pureed texture, Nectar Thickened Liquids consistency. Small portions pleasure feeds. 4 oz. moist puree and 4 oz. nectar liquid via straw or teaspoon sips. Aspiration precautions. Feed only when alert and willing to accept po. Provide pleasure feedings for lunch and supper only. No breakfast tray. A Minimum Data Set Quarterly assessment dated [DATE]. The assessment included a Brief Interview for Mental Status Assessment (BIMS). The BIMS was not able to be completed. The assessment indicated that the resident was rarely/never understood and that their cognitive skills for daily decision making was severely impaired. A quarterly screening by the Speech Language Pathologist dated 4/6/23. The quarterly screen indicated that the resident had Dysphagia. The screen also indicated that the resident was receiving nectar thick liquid and that there was no difficulty with the current diet. On 5/11/23 at 12:15 PM, the surveyor reviewed the facility's policy and procedure titled Thickened Liquids and updated October 2022. Number 6. read; Considerations for safety and to ensure appropriate consistencies: a. Do not add ice to thickened liquids. b. Refrain from heating the liquid, which may inadvertantly thin the liquid, unless product specifications indicate it is safe to do so. Follow any product recommendations. c. C.N.A. may thicken 4 oz of fluid. Number 8. read Per this facility policy, other than the speech therapist, nurses will thicken resident fluids. NJAC 8:39-27.1 (a)

NJ# 156 Based on observation, interview, and record review, it was determined that the facility failed to provide pain management for a resident who exhibited signs of severe pain after sustaining a fall which resulted in fractures of both the hip and arm. The resident continued to experience avoidable pain for 5 1/2 hours duration before being transferred to the hospital. This deficient practice was identified for 1 resident, Resident #4, of the 6 residents reviewed for pain management, and was evidenced by the following: Resident #4 was originally admitted to the facility on [DATE]. The most recent readmission was dated 3/16/12 with [DIAGNOSES REDACTED]. During the initial facility tour on 3/20/12 at 9:40 a.m., the Unit Manager (UM) told the surveyor that Resident #4 "fell last week" after going into another resident's room. The UM stated she thought that the resident "tried to transfer without assist and tripped." At 12 p.m., the surveyor observed Resident #4 being wheeled by a Certified Nursing Assistant (CNA). The resident's left arm and left leg were immobilized with the use of a sling and a brace. On 3/20/12 at 12:25 p.m., the surveyor reviewed the Nurse's Notes (NN) dated 3/10/12 at 8:30 p.m. which indicated that Resident #4 was "taken to room by CNA for PM care transferred into bed and screamed 'my arm, my arm'." According to the NN, the CNA then called the nurse into the room who assessed the resident's arm for "swelling" and "bruising" of the top of the left wrist. At that time, the NN indicated that the doctor was notified and ordered an x-ray of the left wrist and clavicle. There was no documented evidence that the nurse notified the doctor that the resident had fallen, and Resident #4 was neither assessed nor treated for [REDACTED]. An entry in the same note, timed "9 p", indicated that Resident #4 complained of (c/o) pain again "when transferred to bed"; and then "c/o pain at L (left) hip on rounds." At that time, the doctor was notified again and an x-ray of the resident's left hip/femur was ordered. Again, there was no documented evidence that the doctor was notified of the resident's fall, and Resident #4 had not been assessed or treated for [REDACTED]. The surveyor reviewed the NN dated 3/11/12 at 12 a.m. (midnight), which indicated that Resident #4 was yelling for help saying "I'm in terrible pain, my leg I can't move. I don't know what happened." The resident's left wrist was assessed as being "bruised and swollen", and the left leg was assessed as "swollen." There was no documented evidence that the doctor was notified of the resident's severe pain. The NN indicated that the nurse administered 2 routinely ordered regular strength Tylenol; however, the medication was not signed as given on 3/11/12 as per the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The NN of 3/11/12 further indicated that at 2 a.m., an x-ray result was received indicating a [MEDICAL CONDITION]'s left leg femur bone. Resident #4 was then transferred to the hospital. On 3/21/12 at 12:30 p.m., the surveyor reviewed the Reportable Event Record/Report dated 3/12/12, as well as investigation documentation provided by the facility, which indicated that the NN of 3/10/12 was inaccurate. The report indicated that Resident #4 had been found "sitting on the floor" and "was sent to the hospital and admitted with a Left Wrist and Left Femur Fracture." The surveyor reviewed the accompanying statements which indicated that the Licensed Practical Nurse (LPN1) found Resident #4 "sitting on the floor saying please help me." LPN1 documented that the resident's left foot was "turned to the lateral side" and the resident was holding the left hand with the right. LPN1 then unsuccessfully attempted to lift the resident without assistance. After calling for help, 2 LPNs transferred Resident #4 from the floor to a wheelchair (w/c), and then from the w/c into bed before realizing that the resident was in the wrong room. According to the statement, Resident #4 "complained of left leg hurting when touched." The statement provided by the CNA indicated that LPN2 called for help and the CNA saw that Resident #4 was in the wrong bed. The resident was then transferred back into the w/c and then back to the appropriate bed, making a total of 4 separate transfers with an acute injury since being found on the floor. The CNA documented that Resident #4 "was screaming and wrist swollen at time of transfer." In addition, the CNA indicated the need to call another CNA to help turn Resident #4 who was normally able to turn without assistance. The surveyor reviewed the statement provided by LPN3 that indicated that the nurse entered Resident #4's room at 10 p.m., after hearing about the resident's swollen wrist, and documented that Resident #4 "was screaming in pain." During review of the facility "Pain Management Policy Interpretation and Implementation", the surveyor observed the following protocals: "Any resident with changes in condition or a new onset of pain will be assessed using the pain assessment tool." "Once pain is identified, the attending physician will be informed of the pain assessment findings and orders will be obtained as appropriate." NJAC 8:39-27.1(a)