Every finding on record at Avalon Rehabilitation and Healthcare Center

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness.On 11/20/25 at 9:15 AM, the surveyor in the presence of the Food Service Director (FSD#1) observed the following during the kitchen tour:1. In preparation area #1, the surveyor observed a can opener with a reddish caked-on debris on the handle and can opener blade. Also observed on the spice rack; 16-ounce (oz) garlic powder, 16oz taco seasoning, 16oz poultry seasoning, 16oz old bay seasoning, 16oz plastic bottle with a yellowish oil-like substance, and 26oz container of salt all opened and without a use by or discard labels. Under the preparation table the surveyor observed a 1-gallon container of distilled vinegar opened without a use by or discard label, per Dietary Aide #1 (DA#1) the can opner should be cleaned after each use and everything should be labeled with open/use by dates. 2. In the cooking area, the surveyor observed on the top of the standing dish warmer a dust-like debris, on the top of the standing steamer a dust-like debris, on top of the standing dual stack oven a sticky substance, and on inside of the bottom oven the surveyor observed a blackish burnt on debris. Per the FSD, the cooking equipment was due to be cleaned today following the dinner meal. 3. On the three-spout coffee and hot water dispenser, the surveyor observed on the hot water dispenser spout a whitish colored build up. Per the FSD, the whiteish substance was hard water build up, that would be cleaned immediately.4. Surveyor observed Dietary Aide #2 (DA#2) wearing 4 hooped earrings and hair was not fully restrained under their hairnet. DA#2 stated, my hair should be fully restrained, but I was told if the hooped earrings are dime sized or smaller it is ok, but I will remove them.5. In the 3-door standing freezer, the surveyor observed 3 plastic cups with a frozen liquid and a 20 oz lemonade all not labeled. Per the FSD those frozen items were for personal use of the dietary staff and should not be left in the freezer. 6. In the walk-in refrigerator, the surveyor observed two boxes above the 18 inches from the ceiling, a 2-gallon container of whole milk opened without a opened or use by label. The FSD stated nothing should be stored 18 inches from the ceiling and the milk should be labeled.7. Prior to the lunch meal being served the surveyor observed DA#1 check the temperature of ground chicken without sanitizing the thermometer prior to testing. The FSD pulled the food from the tray line and disposed of it in the garbage. DA#1 stated thermometer should have been sanitized before the food was tested and that the ground chicken had now been contaminated and needed to be disposed of.On 11/20/25 at 12:15 PM, the Regional Food Service Director (RFSD) provide the surveyor with three facility policies. The Receiving policy with a revised date of 2/2023 revealed under the procedures section, 5. All food items will be appropriately labeled and dated through manufacturer packaging or staff notation. The Equipment policy with a revised date of 9/2017 revealed under the procedures section, 1. All equipment will be routinely cleaned and maintained in accordance with manufacturers directions and training materials.3. All food contact equipment will be cleaned and sanitized after every use. The Staff Attire policy with a revised date of 10/2023 revealed under the procedures section, 1. All staff members will have their hair off the shoulders, confined in hair net or cap, and facial hair properly restrained.5. Hand jewelry will be limited to a plain band. Arm jewelry and dangling jewelry is not permitted.On 11/20/25 at 12:30 PM the surveyor met with the FSD and RFSD to review concerns found during kitchen inspection. The FSD stated all concerns with be addressed immediately.On 11/26/2025 at12:45 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), the Director of Nursing (DON), and the Assistant DON aware of the above mentioned concerns. NJAC 8:39-17.2(g)

Refer to 756Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that a physician's order for an as needed (PRN) anti-anxiety medication was limited to 14 days for 1 of 6 residents (Resident #89) and b.) follow up on a physicians recommendation for a gradual dose reduction (GDR) of an antipsychotic medication for 1 of 6 residents (Resident #27) reviewed for unnecessary medications.This deficient practice was evidenced by the following:1. On 11/20/2025 at 11:45 AM, the surveyor observed Resident #89 sitting in front of the nurse's station. The surveyor reviewed the electronic medical record (EMR) for Resident #89.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; anxiety disorder, unspecified (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and Alzheimer's Disease, unspecified (a brain disorder that slowly destroys memory and thinking skills). A review of the Minimum Data Set (MDS), an assessment tool dated 9/9/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) of 2 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident was receiving an antianxiety medication. A review of the individual comprehensive care plan (ICCP) revealed a focus for use of an anti-anxiety medication related to anxiety, date initiated 9/12/2025, with an intervention of consult with physician to consider dosage reduction when clinically appropriate. A review of the Order Summary Report (OSR) revealed a physician's order for ALPRAZolam Oral Tablet (Xanax-an antianxiety medication) 0.25 MG (milligrams) Give 1 tablet orally every 6 hours as needed for anxiety -Start Date 09/16/2025. A review of the September 2025 Medication Administration Record (MAR) revealed the above mentioned medication was administered one time on 9/17/2025 at 1528 (3:28 PM). A review of the October 2025 MAR revealed the above mentioned medication was not administered. A review of the November 2025 MAR revealed the above mentioned medication was not administered. On 11/25/2025 at 1:01 PM, the surveyor interviewed Registered Nurse (RN) #1, who stated she was aware Resident #89 had an active physician's order for Xanax. RN #1 stated the resident hadn't needed the medication. On 11/25/2025 at 1:17 PM, the surveyor interviewed License Practical Nurse/Unit Manger (LPN/UM) #1, who stated a prn antianxiety medication should be ordered for 14 days and then it should be reevaluated. She further stated if a resident was not using a prn medication, it should be discontinued. LPN/UM #1 reviewed the EMR for Resident #89 in the presence of the surveyor and confirmed there was an active physician's order for prn Xanax ordered on 9/16/2025. On 11/25/2025 at 1:36 PM, the surveyor interviewed the Director of Nursing (DON), who stated a prn antianxiety should be ordered for 14 days, then it should be reevaluated and if resident was not using it, it should be discontinued. The DON accessed the EMR in the presence of the surveyor and confirmed there was an active physician's order for prn Xanax ordered on 9/16/2025 for Resident #89. On 11/26/2025 at12:45 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), the DON, and the Assistant DON aware of the above mentioned concern. 2. On 11/20/2025 at 11:53 AM, the surveyor observed Resident # 27 in the day room with their head resting on the wall. The resident's eyes were closed. The surveyor reviewed the EMR for Resident #27.A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, unspecified severity, with other behavior disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), and major depressive disorder, recurrent, severe psychotic symptoms (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities). A review of the MDS, dated [DATE], revealed the resident had a BIMS of 00 out of 15, indicating the resident's cognition was unable to be assessed. Further review revealed the resident was receiving an antipsychotic medication. A review of the ICCP revealed a focus of use of anti-psychotic medication, date initiated 5/13/2024, with an intervention of consult physician to consider dosage reduction when clinically appropriate. A review of the psychiatric progress note for Resident #27 dated 9/16/2025 revealed an assessment/plan:.2. GDR: Discontinue current Seroquel order. Recommend Seroquel (antipsychotic medication) 50 mg PO (by mouth) in the morning, 25 mg PO in the afternoon and 50 mg PO in the evening. B>R (benefits outweigh risk) Please hold this recommendation until [identifier redacted] POA (Power of Attorney) consents. Continue the rest as prescribed, B>R. I attempted to speak with the resident's [identified redacted-resident representative] by phone this afternoon but unfortunately I was unable to reach [identifier redacted] and left a detailed voice message to [identifier redacted] cellphone. A review of the OSR revealed a physician's order for QUEtiapine Fumarate (Seroquel)Tablet 50 MG Give 1 tablet by mouth three times a day (TID) related to MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS, dated 5/14/2024. A review of the progress notes did not reveal the GDR was addressed.A review of September, October, and November 2025 MARS revealed the above medication was signed daily as given as ordered at 0800 (8:00 AM), 1300 (1:00 PM) and 1700 (5:00 PM). On 11/25/2025 at 1:01 PM, the surveyor interviewed RN #1, who stated if a psychotropic medication was changed, the family would have to consent to it (the medication change) and it (the consent or refusal) would be documented. On 11/25/2025 at 1:17 PM, LPN/UM #1 reviewed the EMR for Resident #89 in the presence of the surveyor and reviewed the psychiatric progress note for Resident #27 dated 9/16/2025. She acknowledged the recommendation to reduce the Seroquel to 50 mg PO in the morning, 25 mg PO in the afternoon and 50 mg PO in the evening. She confirmed that there was an active physician's order for Seroquel 50 mg PO TID dated 10/4/2023. The LPN/UM stated the purpose of a GDR was to get the resident off psychotic medication if it was not necessary, and to decrease side effects, behaviors. She could not speak to why it was not done. On 11/25/2025 at 1:43 PM, the DON accessed Resident's 27's EMR in the presence of the surveyor and reviewed the psychiatric progress note dated 9/16/25 and acknowledged the above mentioned recommendation. She acknowledged the active physician's order for Seroquel 50 mg TID ordered 5/14/25. The DON stated psychiatric GDR recommendations should be done as soon as possible, usually the same day or next day. She added that there should be documentation of the change or the refusal of the change in the EMR. She confirmed that there wasn't any documentation regarding the GDR. On 11/26/2025 at12:45 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), the DON, and the Assistant DON aware of the above mentioned concern. A review of the facility's policy Psychotropic Medication Use revision date 2/2025, revealed Policy: Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.2. Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics. c. Anti-anxiety medications. 3. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes:.d. determining appropriateness of a gradual dose reduction.PRN medication.3. PRN orders for psychotropic medications are limited to 14 days. a. For psychotropic medications that are NOT antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order.Gradual Dose Reduction 1. Residents on psychotropic medication receive gradual dose reductions.unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in effort to discontinue the medication. N.J.A.C. 8:39-27.1(a)

Based on observations, record reviews, interviews and review of pertinent facility documents, it was determined that the facility failed to ensure that blood and urine lab testing ordered by the physician was completed to monitor and potentially identify changes in a resident's health. This deficient practice was identified for one (1) of one (1) resident, Resident #4, reviewed for completion of ordered lab tests. The deficient practice was evidenced by the following: On 11/20/25 at 12:31 PM, during the initial tour, the surveyor observed Resident #4 lying in bed with their eyes closed and a sheet pulled up to their chest. The surveyor reviewed the electronic medical records (EMR) for Resident #4. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; muscle wasting and atrophy (the wasting or thinning of muscle mass), adult failure to thrive (a state of progressive decline), moderate protein-calorie malnutrition, and type 2 diabetes mellitus with unspecified complications. A review of the Quarterly Minimum Data Set (MDS), a resident assessment and care screening tool dated 9/20/25, reflected a Brief Interview for Mental Status (BIMS) of 6 out of 15, which indicated the resident had a severe cognitive impairment. A review of the Individual Comprehensive Care Plan (ICCP) reflected a focus area, dated 6/23/25, for a nutritional problem or potential. Interventions included: obtain and monitor lab/diagnostic work as ordered. Report abnormal findings to practitioner. Document findings and interventions. Further review reflected a focus area, dated 9/12/25, for at risk for infection. Interventions included: obtain lab and diagnostics as ordered. Report abnormal findings to practitioner. Document findings and interventions and a focus area, dated 6/20/25, for the resident had impaired skin integrity. Interventions included: obtain lab and diagnostics as ordered. Report abnormal findings to practitioner. Document findings and interventions.A review of the Progress Notes reflected the following:1. A health status note dated 11/10/25 at 12:32 am, indicated the resident's [identifier redacted-representative] was at the bed side, stating the resident looked in pain when urinating. MD made aware. New order for a urinalysis. 2. A Medical Doctor (MD) progress note dated 11/12/25 at 12:11 am, indicated that per nurse, the resident's [identifier redacted-representative] mentioned over the weekend the resident felt pain on urinating. 3. A health status note dated 11/12/25 at 3:15 pm, indicated the resident's [identifier redacted-representative] voiced that the resident reported dysuria, the MD was in to see the resident, no new orders. 4. A MD progress note dated 11/13/25 at 12:24 pm, contained the following: **Dysuria (painful) Check UA (urinalysis)] and Urine C/S (culture and sensitivities to common antibiotics).5. A nursing daily skilled pathway note dated 11/13/25 at 6:38pm, reflected the resident is incontinent of urine, yellow. In addition, the note indicated the resident was experiencing vomiting. Furthermore, the note indicated the doctor was aware of the vomiting. A review of the resident's Order Summary Report included, but was not limited to, the following orders:1. An active order for cbc (a hematology lab panel, complete blood count), and cmp (a chemistry lab panel, comprehensive metabolic panel) weekly on Mondays, with an order date of 8/16/25.2. A completed order for urinalysis with microscopic (examination under a microscope to identify specific cells and elements], one time only for UTI (urinary tract infection) for 1 day, with an order date 11/10/25 and end date 11/11/25.3. A completed order for UA, C&S (urine culture and sensitivities to common antibiotics) one time only for monitoring for 2 days, with an order date 11/12/25 and end date 11/14/25. A review of the Medication Administration Record (MAR) for November 2025 reflected the following:1. An order for cbc, cmp weekly on Mondays, had an X for all dates.2. An order for UA C&S had a checkmark on 11/12/25, with LPN #1's initials, timed 6:14pm.Further review of the MAR did not reflect an order dated 11/10/25 for urinalysis with microscopic. A review of the Lab Results Reports from 8/16/25 up to and including the date of surveyor review on 11/24/25 did not reveal chemistry and hematology lab reports for the following Mondays: 8/25/25, 9/1/25, 9/8/25, 9/15/25, 9/22/25, 9/29/25, 10/6/25, 10/13/25, 10/27/25, 11/3/25, 11/10/25, and 11/17/25. Further review did not reveal urine specimen reports. A review of the EMR did not reveal documentation regarding the reason the labs or urine specimens were not obtained. On 11/24/25 at 11:07 AM, the surveyor interviewed the North unit, unit clerk (UC), who stated all labs were done by [laboratory name redacted] and the results would automatically go into the resident's electronic medical records. The UC stated there were no paper copies of lab results maintained on the unit. On 11/25/25 at 12:24 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated she was aware a request was made for a urine specimen for Resident #4 but could not provide additional information. On 11/25/25 at 1:31 PM, the surveyor re-interviewed LPN #1 who stated, the urine culture ordered 11/12/25 was not obtained. LPN #1 stated she recalled Resident #4's representative saying the resident had dysuria. LPN #1 stated Resident #4 had not exhibited any urinary symptoms, and the resident representative had not reported any, since that one time. LPN #1 stated she transcribed the order for the C&S but was not aware of what happened after that. LPN #1 stated the checkmark on the MAR on 11/12/25 indicated the order had been transcribed. When asked by the surveyor how a nurse would determine if a urine specimen was collected or not, LPN #1 stated she would have to get back to the surveyor. On 11/26/25 at 10:59 AM, the surveyor interviewed LPN #2 at the North unit nurses' station. LPN #2 presented the surveyor with a binder. The cover of the binder indicated it was a Daily Lab request log. LPN #2 stated that was where the nurses kept the lab request forms. She stated the lab took the original copy when they came to obtain the specimen, and a copy was left in the binder. In the front inside pocket, the surveyor observed a lab request form for Resident #4. The test requested was a urinalysis with an order date 11/9/25. There was no completion date on the form. The other contents of the binder were tabbed dividers numbered one (1) through 31. LPN #2 stated those tabs were for requests for each day of the month, and more than one month of request forms may be kept in the binder. The surveyor observed behind tab number 10 there was a lab requisition for Resident #4. The test was a urinalysis, with an order date of 11/9/25. The surveyor compared the lab order number of this request form with the request form in the front pocket of the binder, and confirmed they were both copies of the same request. There were no other lab request forms for Resident #4 in the binder. On 11/26/25 at 11:25 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) in the presence of the Director of Nursing (DON). The ADON stated when there was any change in condition of a resident, they notify the MD. The MD may order labs or diagnostic tests. The DON added the MD may also order routine [regularly scheduled] testing depending on the resident. The ADON stated the doctor or nurse would enter orders into the EMR, and added that the nurse would have had to confirm the order if the doctor entered it. That meant the order would not be processed until the nurse reviewed it and marked it as confirmed. The ADON stated there was a tab in the resident's EMR to view all new orders for the day. The nurses should look at that during their shift. The ADON stated that after writing, or confirming, a lab order, the nurse went into the lab portal and put the order in there. Then the nurse printed a request form and put it into the lab book. The laboratory was automatically notified of the order through the portal. The ADON stated the lab sent a technician to obtain specimens on Mondays, Wednesdays, and Fridays every week, or if called for a STAT (Latin abbreviation for immediately) order. The ADON stated the process for collecting specimens was as follows: The lab technician went to the binder and took the request forms for that day and would proceed to obtain the ordered specimens. The lab technician always checked the refrigerator for any urine specimens. The ADON stated the lab results were posted in the resident's EMR under the tab for lab results. There would be a notation from the lab technician if the resident refused, or if the lab technician was unable to draw blood or obtain the specimen for any reason. The ADON stated there was no place in the EMR where the nurse would document a note when labs were ordered or completed. She stated there would be a checkmark on the MAR that meant the order was entered into the lab portal and the request form was printed. The ADON stated the nurses did not document if specimen was or was not obtained. The ADON stated there was no log kept by the facility to track which lab tests were obtained by the lab technician. She stated the results were in the EMR and each nurse looked to see if their resident had labs that day. She added the nurses relayed to the oncoming shift in report, if labs were done and if they were awaiting results. The DON and ADON confirmed that the residents' lab results were no place else except the EMR. The DON stated, if I were the nurse I would follow up on labs if I put the order in, but the nurses should check the results tab in the EMR on their shift. The DON added that the nurse could check the EMR any time during their shift to review results from that day. She added that the review of lab orders should be done by all nurses on any shift, any day, even weekends. The DON stated the unit manager should check to ensure the labs were all completed as ordered. On 11/26/25 at 12:45 PM, during a meeting with the survey team, the DON acknowledged that Resident #4's urine specimen ordered on 11/12/25 was not completed, but that the MD was notified after surveyor inquiry. When asked by the surveyor about the urine specimen ordered on 11/10/25 and the weekly Mondays chemistry and hematology labs, the DON stated there was nothing else available other than what was provided. A review of the facility provided policy titled Lab and Diagnostic Test Results - Clinical Protocol with copyright date 2001 [company name redacted], Incorporated, indicated a subtitle for Assessment and Recognition with the following steps:1. The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.2. The staff will process test requisitions and arrange for tests. NJAC 8:39-11.2(b)

Complaint # NJ2666691 Based on observations, interviews, record review, and pertinent facility documents it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents a.) conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission and b.) were seen by the attending physician or Nurse Practitioner (NP) every thirty days with a physician visit at least every sixty days. This deficient practice was observed for 4 of 4 residents (Resident #2, #6, #10, and #125) reviewed for physician visits.This deficient practice was evidenced by the following:1.On 11/20/25 at 10:57 AM, the surveyor observed Resident #10 sitting in their chair with their eyes closed. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #10.A review of the admission Record (AR) revealed the resident was admitted to the facility with diagnoses which included but not limited to: Type 2 Diabetes Mellitus (a condition that causes blood sugar to rise), difficulty with walking and Asthma (a lung disease that makes it harder to move air in and out of the lungs)A review of the Quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care dated 10/09/25, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 5 out 10, which indicated the resident was severely cognitively impaired. A review of the EMR did not reveal a Progress Notes (PN) from the attending physician from January 2025 through October 2025. On 11/25/25 at 12:22 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM#1) stated for Long Term Care (LTC) residents, the attending physicians and the Nurse Practitioner (NP) would make rounds at least once a month. For newly admitted residents, the LPN/UM #1 stated she was not sure how soon the attending physician would come see the resident. The surveyor inquired about Resident #10's attending physician visit notes. LPN/UM #1 stated Resident #10 should have a PN from the NP and the attending physician. LPN/UM #1 stated the expectation from the attending physician was to document when they made their rounds at the facility. LPN/UM #1 reviewed Resident #10's EMR in the presence of the surveyor and confirmed there were no PN by the attending from January -October.2.On 11/20/25 at 11:18 AM, the surveyor observed Resident #6 lying in bed with their eyes closed. The resident had their call bell within reach.The surveyor reviewed the EMR for Resident #6. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but not limited to: Hyperlipidemia (high lipids), pain in right and left foot.A review of the MDS, dated [DATE], revealed the resident had a BIMS score of 5 out of 15, which indicated the resident was severely cognitively impaired. A review of the EMR did not reveal a History and Physical note (H&P- a comprehensive assessment note completed by physician on admission) from the initial admission and re-admission in September 2025, or a PN from the attending physician from August 2025-October 2025.On 11/25/25 at 12:27 PM, the surveyor inquired about Resident #6's H&P and physician visit notes. LPN/UM #1 reviewed Resident #6's EMR in the presence of the surveyor and confirmed there were no physician notes and/or H&P for the resident. LPN/UM #1 stated Resident #6 was hospitalized for five (5) days in September 2025 and further stated the expectation was when the resident was re-admitted at the facility, the physician should have completed H&P.3.On 11/21/25 at 10:09 AM, the surveyor observed Resident #2 eating breakfast in their bed. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #2. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but not limited to: Low back pain and Anemia. A review of the MDS, dated [DATE], revealed Resident #2 had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact.A review of the EMR revealed an attending physician H&P note dated 12/21/24 and another PN dated 2/18/2025. Further review of the PN reflected PN from the NP dated 1/6/25, 1/7/25, 1/9/25, 1/14/25, 1/16/25, 1/17/25, 1/20/25, 1/23/25, 1/24/25, 1/28/25, 1/31/25, 2/2/25, 2/3/25, 2/12/25, 2/17/25, 2/121/25, 2/27/25, 3/5/25, 3/6/25, 3/10/25, 3/14/25, 3/17/25, 3/24/25, 9/5/25, 9/30/25, 10/28/25, 10/30/25, 11/6/25, 11/18/25, 11/20/25, 11/21/25, 11/26/25. A review of the EMR did not reveal a PN from the attending physician or the NP in April 2025, May 2025, June 2025, July 2025, August 2025 or that the physician and the NP were consistently alternating monthly visits.On 11/26/25 at 11:24 AM, during an interview with the surveyor, LPN/UM #1 stated when the resident was admitted or re-admitted , the physician should come to see them within 48 hours to review hospital records, orders, any labs, follow up appointments and document a H&P. LPN/UM #1 further stated when the physician made their rounds, they should be putting a note in the EMR[name redacted] with a change in the plan of care. LPN/UM #1 further stated documentation was important for communication so that all the staff were on the same page.The surveyor inquired about Resident #2's physician notes. In the presence of the surveyor, LPN/UM #1 reviewed the EMR for Resident #2 and confirmed that the attending physician PN were not there from March through November 2025. LPN/UM #1 stated that the resident was hospitalized for six (6) days in June 2025 and 11 days in October 2025 and the expectation from the attending physician was to write H&P note upon re-admission. 4.The surveyor reviewed the closed record/EMR for Resident #125. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #125. A review of the AR revealed the resident was admitted to the facility with diagnoses which included but not limited to: Anxiety disorder and Anemia. A review of the quarterly MDS, dated [DATE], revealed Resident #125 had a BIMS score of 11 out of 15, which indicated the resident had moderately impaired cognition. A review of the EMR revealed an attending physician H&P note dated 4/9/25 and another PN written by the physician dated 4/10/25. Further review of the PN reflected PN from the NP dated 4/10/25, 4/21/25, 7/8/25, 8/11/25.A review of the EMR did not reveal a PN from the attending physician or the NP in May 2025, June 2025, September 2025, October 2025 and November 2025 or that the physician and the NP were consistently alternating monthly visits.On 11/26/25 at 11:56 AM, during an interview with the surveyor, LPN/UM #2 stated the residents on 200 unit were for Short-term and Long-term care. LPN/UM #2 stated the residents should be seen by either their attending physician or the NP within 24-48 hours after admission and then weekly. LPN/UM #2 stated they (physician/NP) should write PN when they made their rounds. The surveyor inquired about Resident #125's attending physician PNs. In the presence of the surveyor, LPN/UM #2 reviewed the EMR for Resident #125 and stated the resident would be seen weekly if they were admitted for skilled nursing. LPN/UM #2 stated Resident #125's attending physician was the facility's Medical Director (MD), who had completed the resident's H&P note dated 4/9/25 and a PN dated 4/10/25. LPN/UM #2 further stated Our Medical Director does not see all our residents. LPN/UM #2 confirmed there were no PN from the attending physician from May through November 2025. On 11/26/25 at 12:45, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant DON, and the Regional Director of Operations (RDO). The surveyor informed them of the above mentioned concerns for Resident #2, #6, #10 and #125. On 12/2/25 at 9:59 AM, the survey team met with the facility administration for responses. The LNHA stated she did not have additional information for the surveyor.On 12/2/25 at 11:35 AM, in the presence of the survey team, the team leader conducted a telephone interview with the MD, who stated residents would be seen two times in subacute units and once a month in LTC units. The MD further stated new admissions would be seen within 48 hours and a PN would be written directly in EMR [Name Redacted].A review of the facility policy Physician Visits revised 4/13 revealed: Policy Statement: The Attending Physician must make visits in accordance with applicable state and federal regulations. Policy Interpretation and Implementation:1.The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone.2.The Attending Physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and the at least every sixty (60) days thereafter.4.After the first ninety (90) days, if the attending Physician determines that a resident need not be seen by him/her every thirty (30) days, and alternate schedule may be established, but not to exceed every sixty (60) days. A Physician Assistant or Nurse Practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted law or regulation.5. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation.NJAC 8:39-23.2 (b)(d)

Refer to F 605Based on observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 2 of 6 residents reviewed for unnecessary medications (Resident #89 and #27).The deficient practice was evidenced by the following: 1. On 11/20/2025 at 11:45 AM, the surveyor observed Resident #89 sitting in front of the nurse's station. The surveyor reviewed the electronic medical record (EMR) for Resident #89.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and Alzheimer's Disease, unspecified (a brain disorder that slowly destroys memory and thinking skills). A review of the Minimum Data Set (MDS), an assessment tool dated 9/9/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 2 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident was receiving an antianxiety and antidepressant medication. A review of the individual comprehensive care plan (ICCP) revealed a focus of use of an anti-anxiety medication related to anxiety, date initiated 9/12/2025, with an intervention of consult with physician to consider dosage reduction when clinically appropriate. Further review revealed a focus of use anti-depressant medication r/t (related to) depression, dated 9/12/2025. A review of the psychiatric progress note dated 9/16/25 revealed:Psychotropic medications being monitored. Remeron (Mirtazapine) 7.5 mg (milligrams) PO (by mouth) q (every) HS (hour of sleep) Depression. A review of the Order Summary Report (OSR) revealed a physician's order for ALPRAZolam Oral Tablet (Xanax-an antianxiety medication) 0.25 MG Give 1 tablet orally every 6 hours as needed for anxiety -Start Date 09/16/2025 and for Mirtazapine Oral Tablet 7.5 MG (Remeron) Give 1 tablet orally at bedtime for dementia -Start Date 09/12/2025. A review of the September 2025 Medication Administration Record (MAR) revealed the above mentioned Alprazolam was signed as administered one time on 9/17/2025 at 1528 (3:28 PM) and the Mirtazapine was administered daily as ordered at 9:00 PM. A review of the October 2025 and the November 2025 MAR revealed the above mentioned Alprazolam was not administered, and the Mirtazapine was administered daily as ordered at 9:00 PM. A review the progress notes in the EMR from the PC revealed the following notes: -9/13/2025 08:04 Pharmacy Consultant Note Text: ADMIT (admission) MEDS (medications) REVIEWED. MAKE DX (diagnosis) FOR REMERON -10/1/2025 16:33(4:44 PM) Pharmacy Consultant Note Text: psych 9/16-no med changes. Rec(recommend) d/c (discontinue) Xanax if not being used MAKE DX REMERON DEPRESSION no other med issues-11/1/2025 14:37 Pharmacy Consultant Note Text: NO NEW MED ISSUES. PSYCH NOT ADDRESSEDA review of the Certified Pharmacy Consultant recommendations dated 10/1/2025 and 11/1/2025 revealed the same recommendations for both months.7. [name redacted, Resident #89] Make diagnosis Remeron depression per psych consult. Rec d/c PRN Xanax if not being used. 2. On 11/20/2025 at 11:53 AM, the surveyor observed Resident # 27 in the day room with their head resting on the wall. The resident's eyes were closed. The surveyor reviewed the EMR for Resident #27.A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, unspecified severity, with other behavior disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), and major depressive disorder, recurrent, severe psychotic symptoms (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities). A review of the MDS, dated [DATE], revealed the resident had a BIMS of 00 out of 15, indicating the resident's cognition was unable to be assessed. Further review revealed the resident was receiving an antipsychotic medication. A review of the ICCP revealed a focus of use of anti-psychotic medication, dated initiated 5/13/2024, with an intervention of consult physician to consider dosage reduction when clinically appropriate. A review of the psychiatric progress note for Resident #27 dated 9/16/2025 revealed an assessment/plan:.2. GDR: Discontinue current Seroquel order. Recommend Seroquel (antipsychotic medication) 50 mg PO (by mouth) in the morning, 25 mg PO in the afternoon and 50 mg PO in the evening. B>R (benefits outweigh the risk). Please hold this recommendation until [identifier redacted] POA (Power of Attorney) consents. Continue the rest as prescribed, B>R. I attempted to speak with the resident's [identified redacted-resident representative] by phone this afternoon but unfortunately I was unable to reach [identifier redacted] and left a detailed voice message to [identifier redacted] cellphone. A review of the OSR revealed a physician's order for QUEtiapine Fumarate (Seroquel)Tablet 50 MG Give 1 tablet by mouth three times a day (TID) related to MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS, dated 5/14/2024. A review the progress notes in the EMR from the pharmacy PC revealed the following notes: -10/1/2025 16:04 Pharmacy Consultant Note Text: PSYCH 9/16 REC GDR FOR SEROQUEL-PLEASE F/U. NO OTHER MED ISSUES- 11/1/2025 14:27Pharmacy Consultant Note Text: NO NEW MED ISSUES. PSYCH NOT ADDRESSED A review of the Certified Pharmacy Consultant recommendations dated 10/1/2025 and 11/1/2025 revealed the same recommendation for both months.3. [name redacted, Resident #27] Psych 9/16 recommends GDR for Seroquel-please F/U (follow up). On 11/25/2025 at 1:01 PM, the surveyor interviewed Registered Nurse (RN) #1, who stated the PC would call if there were issues with medications and the nurse would then call the doctor to address the concerns. On 11/25/2025 at 1:17 PM, the surveyor interviewed License Practical Nurse/Unit Manger (LPN/UM) #1, who stated the PC recommendations were entered in the EMR, the unit manager should review it and call the physician to make any changes if necessary. She stated the recommendations usually would be addressed immediately. LPN/UM #1 stated the PC also sent a monthly report of any concerns or recommendations and she reviewed it to make sure the recommendations were addressed. LPN/UM #1 reviewed the PC recommendations from 10/1/2025 and 11/1/2025 for Resident # 89 and #27. She could not speak to why the PC's recommendations were not addressed but stated they would be addressed immediately. On 11/25/2025 at 1:36 PM, the surveyor interviewed the Director of Nursing (DON), who stated the PC reviews the charts and then sends an email with his recommendations. She added he also puts a note in the EMR. The DON stated the unit mangers were responsible to follow up on the PC's recommendations and documenting them (the recommendations). The DON reviewed the EMR in the presence of the surveyor for Resident #89 and #27 and acknowledged the PC's recommendations for 10/1/2025 and 11/1/2025, were not addressed. She could not speak to why the PC's recommendations were not addressed. She stated the PC had not come to her about medications not being addressed. On 1/26/2025 at 11:06 AM, the surveyors interviewed the CP via telephone, who stated he reviewed all resident medications monthly. He stated he documented directly in the EMR and he sent his recommendation reports to the Licensed Nursing Home Administrator (LNHA), the DON, the Assistant DON and the unit managers monthly. The CP state the facility had changes in the unit managers so the monthly recommendations had not been addressed. He added, I think they have been addressed now. On 11/26/2025 at12:45 PM, the surveyor made the LNHA, the Regional Director of Operations (RDO), the DON, and the Assistant DON aware of the above mentioned concerns for Resident #89 and #27. A review of the facility's undated policy Medication Regimen Reviews revealed Policy: A licensed pharmacist reviews the medication regimen of each resident at least monthly.2. The purpose of the MMR (medication regimen review) is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 3. The MRR includes a review of the medical record to prevent, identify, report, and resolve medication related problems, medications errors or other irregularities. NJAC 8:39-29.3(a)(1)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) insulin pen devices were dated when opened and had expiration dating on the label in two (2) of four (4) medication carts inspected, b.) a medication for inhalation (Budesonide) was labeled when opened and had expiration dating in one (1) of four (4) medication carts inspected, and c.) an insulin pen device was labeled appropriately with a resident's name (Resident #178) in one (1) of four (4) medication carts inspected. The deficient practices were evidenced by the following: On 11/25/25 at 10:32 AM, the surveyor, in the presence of another surveyor, inspected the 200 Hall medication cart in the presence of the Registered Nurse (RN #1). The surveyor observed an insulin pen device for Lispro (a fast-acting insulin) labelled for Resident #179 that had no date when the insulin pen device was removed from the refrigerator. RN #1 stated she was on that cart for the day and had not administered the resident any insulin. RN #1 acknowledged there should be a date when opened and an expiration date on the label. RN #1 removed the undated insulin pen device and stated she would replace it. On 11/25/25 at 10:46 AM, the surveyor, in the presence of another surveyor, inspected the 700 Back Hall medication cart in the presence of the Licensed Practical Nurse (LPN #1). The surveyor observed an Insulin Aspart (a short-acting insulin) pen device labelled for Resident #59 with a date of 10/21 on the baggie and no date when opened or expiration date on the pen device. LPN #1 stated that she was unsure if 10/20 was the date when opened. LPN #1 added that she thought insulin pens expired after approximately a month. The surveyor also observed a Lantus Solos injection (a long-acting insulin) pen device labelled for Resident # 176 with no date when the device was removed from the refrigerator or an expiration date and a Basaglar (a long-acting insulin) 100 units/ml pen labeled for Resident 177 with no date when the device was removed from the refrigerator or an expiration date. In addition, the surveyor observed an Insulin Lispro (a fast-acting insulin) pen device with no date when the device was removed from the refrigerator or an expiration date. LPN #1 stated the date removed from the refrigerator should be on the pen device. Also, there was no resident's name on the Insulin Lispro pen device and there was a first initial and last name on the baggie. LPN #1 was able to identify the Insulin Lispro was for Resident #176 and stated there should be a label from the provider pharmacy with the resident's name. At that time, the surveyor observed a box of Budesonide Inhalation Suspension 0.5 MG/2 ML ampules labelled for Resident #175 with a handwritten written date of 11/1/25 on the box. The surveyor observed inside the box was one opened foil pouch with no date on the pouch when it was opened. LPN#1 could not speak to if the 11/1/25 was the date the pouch was opened and stated the date the pouch was opened should be on the foil pouch. The surveyor, with the LPN #1, reviewed the storage instructions on the box which indicated When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected. LPN #1 stated that she would remove the remaining Budesonide Inhalation Suspension ampules. On 11/25/25 at 11:06, the Director of Nursing (DON), joined the surveyors and LPN #1 at the 700 Back Hall medication cart. The DON observed and acknowledged the insulin pen devices had no date when removed from the refrigerator and the Budesonide Inhalation Suspension foil pouch had no date. The DON stated that the nurses should date when the insulin pen devices were removed from the refrigerator and when the Budesonide foil pouch was opened and follow the manufacturer expiration dates. In addition, the DON stated the name of the resident should be on the pen device. The DON instructed LPN #1 to remove and replace the insulin pens that were not dated and the Budesonide Inhalation Suspension ampules. On 11/26/25 at 11:08 AM, the surveyor, in the presence of another surveyor, interviewed the Consultant Pharmacist (CP) via telephone. The CP stated he conducted unit inspections monthly which included checking the medication carts and refrigerators and making sure there were no expired medications. The CP also stated that the insulin pen devices had to be dated when removed from the refrigerator because once opened they had a 28-day expiration dating. In addition, the CP stated that he had not done any inservices regarding medication storage but had given handouts for the nurses to use to the DON which identified medications that had to be dated once opened because the expiration dating changed. The CP added that the unit inspections he does were included in his reports. A review of the CP Unit Inspections completed from September 2025 to November 2025 had not identified there was an issue with dating when a pen device was removed from the refrigerator or dating when medications were opened at the time of the inspections. On 11/26/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator, DON and Regional Director of Operations. The DON stated she did not have medication storage handouts from the CP because that was a while ago and was not current. On 12/2/25 at 10:00 AM, the survey team met with the administrative team. The DON stated the nurses were educated on dating when insulin pens were removed from the refrigerator and when medications were opened and following manufacturer expiration dating. A review of the facility policy Medication Labeling and Storage with a revision date of February 2023 provided by the Licensed Nursing Home Administrator reflected Medication label included, at a minimum:.d. expiration date, when applicable; e. resident's name;. In addition, If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. A review of the manufacturer specifications for Lispro, Insulin Aspart, Basaglar indicated to date when the insulin pen device was removed from refrigeration and the expiration date was 28 days at room temperature once removed. A review of the manufacturer specifications for Budesonide Inhalation Suspension indicated to date when the foil pouch was opened, keep the ampules in the foil pouch and discard after 2 weeks any unused ampules. NJAC 8:39-29.4(g)(h)

Based on observations, interviews, review of the medical record and other facility documentation, it was determined that the facility failed to follow fall prevention interventions as written on the resident's plan of care. This deficient practice was identified for 1 of 4 residents (Resident #120) reviewed for accidents. This deficient practice was evidenced by the following: On 11/20/2025 at11:50 AM, the surveyor observed Resident #120 in bed. There was a fall mat on the floor to the right side of the bed. The surveyor reviewed the electronic medical record (EMR) for Resident #120.A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions) and Type 2 Diabetes Mellitus with Diabetic Chronic kidney disease (a condition in which the body has trouble controlling blood sugar that can affect the kidneys). A review of the Minimum Data Set (MDS), an assessment tool dated 10/3/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, indicating the resident's cognition was unable to be assessed. A review of the individual comprehensive care plan (ICCP) revealed a focus of at risk for falls; Fall mat to exit side of the bed at all times when the resident is in bed. Date Initiated: 05/28/2024. A review of the Order Summary Report revealed a physician's order for Floor Mats to exit side of the bed when resident in bedevery shift, dated 2/29/2024. On 11/24/2025 at 8:58 AM, the surveyor observed Resident #120 in bed eating breakfast. The surveyor observed the fall mat leaning against the wall. On 11/25/2025 at 11:43 AM, the surveyor observed Resident #120 in bed, with their eyes closed. The surveyor observed the fall mat against the wall. On 11/25/2025 at 2:20 PM, the surveyor interviewed Registered Nurse (RN) #1, who stated the resident's aide was on break. RN #1 stated Resident #120 was at risk for falls and should have a fall mat on the floor. RN #1 and the surveyor walked to Resident #120's room and observed the fall mat resting on the wall between the resident's bed and the wall. RN # 1 stated the residents bed is broken that is why the mat is not on the floor. She added she needed to follow up with maintenance because they haven't come to fix the bed yet. RN #1 stated fall mats were used for resident safety. She stated fall mats should be down at all times while the resident was in bed. RN #1 was unable to explain why the bed being broken meant the fall mat did not need to be down next to the bed.On 11/25/2025 at 2:30PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated if the resident had a physician order for fall mats while a resident was in bed, that meant the fall mats should be down. On 11/26/2025 at 8:18 AM, the surveyor interviewed the DON, who stated if the resident had a physician order for fall mats while the resident was in bed, that meant the fall mats should be down when the resident was in bed. She stated fall mats were to prevent injuries and should be used unless the staff was doing care. On 11/26/2025 at12:45 PM, the surveyor made the Licensed Nursing Home Administrator (LNHA), the Regional Director of Operations (RDO), the DON, and the Assistant DON aware of the above mentioned concern. NJAC 8:39-27.1 (a)

Complaint # NJ 2601539 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, nourishment supplementation and monitoring administration times to accommodate for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times and was not administered on nine (9) dialysis days from an admission in August 2025 until discharged in September 2025. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was identified for one (1) of two (2) residents, (Resident #166), reviewed for dialysis services and was evidenced by the following: The surveyor reviewed the closed electronic medical record for Resident #166. A review of the admission Record revealed diagnoses that included, but not limited to; acute kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood), anemia (low levels of healthy red blood cells) in chronic kidney disease (CKD), heart failure, hypertension (high blood pressure), Type 2 Diabetes Mellitus (DM) (chronic condition the body does not use insulin properly leading to high blood sugar levels) with diabetic chronic kidney disease and Type 1 Diabetes Mellitus (chronic condition the body does not produce insulin leading to high blood sugar levels requiring the use of insulin) with diabetic neuropathy (nerve damage caused by high blood sugar levels over a long period usually affecting legs and feet). A review of a comprehensive admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 8/19/2025, 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 individualized interdisciplinary care plan revealed a focus area, with an initiated date of 8/12/25, I am on pain medication therapy. The intervention indicated Administer medication as ordered. Another focus area initiated 8/12/25 revealed I need hemodialysis r/t (related to) ESRD. In addition, a focus area initiated 8/13/25 I have a nutritional problem or potential nutritional problem r/t CHF (congestive heart failure), CKD, Diabetes Mellitus, ESRD/Dialysis, morbid obesity, at risk of malnutrition due to comorbidities. The interventions included, but not limited to, initiated 8/14/25 Prosource No CHO (no carbohydrate) BID (twice a day) and initiated 8/20/25 Nepro supplement BID. Additionally, a focus area initiated 8/13/25 I have Diabetes Mellitus-Type and Type 2 DM with complications. The interventions included, but not limited to, Diabetes medication as ordered. And Monitor glucose as ordered. A review of the resident's Order Summary Report (OSR) had no physician's order (PO) indicating the hemodialysis days or times. A review of the electronic nursing progress notes (EPN) revealed the resident's dialysis days were Tuesday, Thursday and Saturday with a pickup time of 1:00 PM and chair time of 2:00 PM. Further review of the OSR revealed the following POs that indicated times of administration that would coincide with the resident being out to dialysis: Hydralazine HCl (hydrochloride) Oral Tablet 100 MG (Hydralazine HCl) Give 1 tablet by mouth every 8 hours for hypertension. Check patient's B/P and HR before giving Hydralazine. With Start Date of 8/13/25. Novolog PenFill Subcutaneous Solution Cartridge 100 Unit/ML (milliliter) (Insulin Aspart) Inject 3 unit subcutaneously before meals for DM. with a Start Date of 8/14/25. Blood Glucose Monitoring before meals and at HS (bedtime) before meals and at bedtime for signs /symptoms of hyper/hypoglycemia Call MD/NP for Blood Sugars less than 60 or greater than 400. With an Start Date of 8/14/25. Prosource No Carb two times a day for low albumin/dialysis. With a Start Date of 8/14/25.Nepro two times a day for dialysis. with a Start Date of 8/20/25. Carvedilol (Coreg) Oral Tablet 25 MG (milligrams) (Carvedilol) Give 1 tablet by mouth two times a day for hypertension. Hold for systolic BP (blood pressure) less than 100 or HR (heart rate) less than 60. With a Start Date of 8/13/25. Gabapentin Capsule 300 MG Give 1 tablet by mouth one time a day for neuropathic pain. With a Start Date of 8/13/25. A review of the August 2025 electronic medication administration record (EMAR) revealed for three (3) dialysis days the following dates and times of medications and supplements were not administered: -On 8/14/25 a code number 3 entered for documentation of medication administration at the times of 1400 (2:00 PM) for Hydralazine (a medication used for high blood pressure), 1630 (4:30 PM) for Novolog (insulin) and blood glucose monitoring, and 1700 (5:00 PM) for Prosource (a medical high protein liquid supplement). The corresponding chart codes revealed 3 indicated Absent from facility. -On 8/16/25 a code number 3 was entered for 1700 Coreg, 1630 Novolog, 1700 Prosource and 1630 blood glucose monitoring. In addition, 1400 Hydralazine and Gabapentin had a code number of 22 which corresponded to the chart code of Drug/Treatment not administered.-On 8/30/25 a code number 3 was entered for 1700 Coreg, 1630 Novolog, 1700 Prosource, 1700 Nepro and 1630 blood glucose monitoring. A review of the corresponding EPN for the three (3) dialysis days revealed the following:-on 8/14/25 indicated the above Hydralazine, Novolog, blood glucose monitoring and Prosource were not administered because dialysis. -on 8/16/25 indicated the above Coreg, Novolog, Prosource, blood glucose monitoring, Hydralazine and Gabapentin were not administered because OOF (out of facility) to dialysis. -on 8/30/25 indicated the above Coreg, Nepro, Novolog, Prosource and Blood Glucose monitoring were not administered because OOF for dialysis. A review of the September 2025 EMAR revealed six (6) dialysis days with the following dates and times of medications and supplements were not administered: -On 9/2/25 there was no entry (blank) for documentation of medication administration at the times of 1630 Novolog and blood glucose monitoring and 1700 Coreg, Nepro and Prosource.-On 9/4/25 a code number 5 was entered for 1400 Hydralazine, 1630 Novolog and blood glucose monitoring, 1700 Nepro, Coreg, and Prosource. In addition, a code number of 1 was entered for 1400 Gabapentin. The corresponding code chart indicated 5 was Hold and 1 was Away from facility with meds.-On 9/6/25 a code number 3 was entered for 1630 Novolog and Blood Glucose monitoring, and 1700 Prosource, Nepro and Coreg.-On 9/9/25 a code number 1 was entered for 1630 Novolog and blood glucose monitoring. There was no entry (blank) for 1400 Hydralazine and Gabapentin.-On 9/11/25 there was no entry (blank) for documentation of medication administration at the times of 1400 Hydralazine and Gabapentin. There was a code number 22 entered for 1700 Coreg, Nepro, Prosource and blood glucose monitoring. -On 9/13/25 a code number 3 was entered for 1400 Hydralazine and 1700 Novolog, blood glucose monitoring, Prosource, Nepro and Coreg. A review of the corresponding EPN for the six (6) dialysis days revealed the following:-on 9/2/25 there was no corresponding EPN.-on 9/4/25 indicated the above Coreg and blood glucose monitoring were not administered because at dialysis. And Nepro, Prosource, Hydralazine, Novolog and Gabapentin indicated dialysis.-on 9/6/25 indicated the above Novolog, Prosource and Blood Glucose monitoring were not administered because OOF for dialysis. And Nepro and Coreg indicated OOF.-on 9/9/25 indicated the above Novolog and Blood Glucose monitoring were not administered because at dialysis. There was no corresponding EPN for the blank entries for Hydralazine and Gabapentin.-on 9/11/25 indicated the above Coreg, Nepro, Prosource and Blood Glucose monitoring were not administered because went to dialysis. There was no corresponding EPN for the blank entries for Hydralazine and Gabapentin.-on 9/13/25 indicated the above Hydralazine, Prosource, Nepro and Coreg were not administered because OOF. There were no EPN indicating the physician was aware when the resident had not received medications, nourishment supplementation or monitoring as ordered on the above dialysis days. On 11/25/25 at 8:59 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated that she administered medications on her unit. LPN #1 stated when residents were scheduled to go to dialysis they should have physician orders that were different on dialysis days if their medications were timed when the resident was out of the facility at dialysis. On 11/25/25 at 9:02 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated when residents had to go to dialysis the nurses were required to review medication orders with the physician to change the times of administration if they had to be administered when a resident was out to dialysis. The UM/LPN explained the nurses should not be documenting on the EMAR or EPN that the resident was out to dialysis for a medication administration time. On 11/25/25 at 12:47 PM, the surveyor, with the Director of Nursing (DON) reviewed Resident #166's EMAR documentation. The DON acknowledged Resident #166 went to dialysis Tuesday, Thursday and Saturday and was picked up at 1 PM and there was documentation on the EMAR indicating medications and supplements were not administered because the resident was out of the facility at dialysis. The DON explained that the nurses would be able to administer the 2 PM medications 1 hour before. The DON was unable to speak to whether the physician was aware that medications were being administered before going to dialysis. The DON also stated the nurses should not be documenting that medications were not administered because a resident was out of the facility at dialysis and the physician should have been notified to obtain POs to accommodate scheduled dialysis times. The DON stated that she would have to review the EMAR further and what the nurses had documented in the EPN. On 11/25/25 at 3:09 PM, the surveyor, in the presence of another surveyor, met with the Regional Director of Operations (RDO) who stated that there was a Quality Assurance Performance Improvement (QAPI) in place regarding medications not being administered when a resident was out of the facility for dialysis. The RDO added he would provide the information. On 11/26/25 at 9:05 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and DON. The LNHA stated that the QAPI had to do with documentation of residents missing medications and Had nothing to do with dialysis. The DON acknowledged that the EMAR should not indicate a resident had not received medications because the resident was out of the facility at dialysis since dialysis had scheduled times which the physician should be aware of. On 11/26/25 at 9:10 AM, the surveyor interviewed the LNHA and DON. The DON stated that she had checked with the nurses who had signed as not administering medications to Resident #166 and they thought that they had administered them. The DON acknowledged the documentation contradicted the nurses verbal statements. The DON and LNHA acknowledged if a nurse were unable to administer a medication then an EPN would indicate what had occurred and the physician would be notified for follow up. The DON further stated the times of administration were to be reviewed with the physician to accommodate the scheduled dialysis times. A review of the facility policy End-Stage Renal Disease, Care of a resident with with a revision date as of September 2010 provided by the LNHA revealed Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. In addition, Education and training of staff includes, specifically: . f. timing and administration of medications, particularly those before and after dialysis;. A review of a facility policy Administering Medications with a revision date of April 2019 provided by the LNHA reflected Medications are administered in a safe and timely manner, and as prescribed. In addition, Medications are administered in accordance with prescriber orders, including any required time frame. And Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication;. NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to have a process in place to post the daily per shift nurse staffing report. This deficient practice was identified on 11/24/2025. This deficient practice was evidenced by the following: On 11/24/2025 at 8:30 AM, the surveyor observed nurse staffing posted at the front receptionist desk for Friday 11/21/25, day shift. On 11/25/2025 at 9:50 AM, the surveyor interviewed the Staffing/Human Resource (SHR) staff member, who stated she posted the staffing at the desk for day and evening shifts and the night supervisor posted the night shifts. The surveyor asked who posted the staffing on the weekend, the SHR stated I do when I come in on Monday. She added the weekend supervisors do not have access to the reports so she did it on Monday, so it was the real count. On 11/25/2025 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated the nurse staffing was posted at the receptionist desk every day, every shift. She stated on the weekend, the supervisor was supposed to posts it. The surveyor made her aware of the observation on Monday morning of the nurse staffing for day shift 11/21/2025. The LNHA acknowledged the staffing should have been changed. A review of the facility's policy Posting Direct Care Daily Staffing Numbers revised 8/2022 revealed Policy: Our facility will post on a daily basis for each shift nursing data, including number of nursing personnel responsible for providing direct care to residents. 1. Within 2 hours of the beginning of each shift, the number of licensed nurses, and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location and in a clear and readable format. NJAC 8:39-41.2 (a)(b)(c)(d)

Based on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a significant medication error did not occur by failing to administer 14 doses of a physician ordered antihypertensive (medicine used to control high blood pressure) medication to a resident who was subsequently transferred to the hospital for uncontrolled hypertension on 8/12/25 and was diagnosed with a Hypertensive Emergency. This deficient practice was identified for 1 of 2 residents reviewed for change in condition (Resident #3) and was evidenced by the following: On 10/24/25 at 10:00 AM, the surveyor reviewed the electronic medical record for Resident #3 which revealed the following: An Emergency Department hospital record with a Physician (MD) History and Physical dated 8/12/2025 at 21:09 (9:09 PM) revealed: Chief Complaint: Patient presents via emergency medical service from [facility name redacted] for uncontrolled HTN (hypertension), blood pressure at facility was 200 [mmHg] (millimeters of mercury)/96 (normal range 120/80), Patient unsure if received blood pressure medications today. Patient also with edema (swelling) to both lower extremities. History of Present Illness: Past medical history of HTN, HFpEF (Heart failure with reduced ejection fraction- heart doesn't pump blood effectively and causes fluid to back up), who presented to the emergency room for evaluation of dizziness, generalized weakness, and markedly elevated blood pressure. The Assessment/Plan: 1. Hypertensive emergency (A clinical condition where severely high blood pressure causes organ damage and requires immediate treatment and hospitalization) . A Cardiology Progress Note, dated 8/14/25 at 12:11 PM and signed by the Advanced Practice Nurse revealed the patient presented from the nursing facility for uncontrolled HTN Blood Pressure 206-190/100, patient was unable to recall if had received HTN meds prior to arrival . HTN urgency resolved after IV (intravenous diuretic) and resumption of full GDMT (Guideline Directed Medical Therapy for patients with heart failure) . ? (question) compliance with prescribed medications- unclear why/how patient suddenly hypertensive if does take all medications as prescribed . A review of the facility Order Summary Sheet dated 7/25/25, revealed an order for Entresto Oral Tablet 24-26 MG (Sacubitril-Valsartan), Give 1 tablet by mouth two times a day for HTN, Start Date: 6/28/25. A review of the Medication Administration Record (MAR) dated August 2025 revealed the following: Entresto Oral Tablet, 24-26 MG (milligrams) (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day; Start Date: 7/26/25 at 09:00 AM. The following Chart Codes/Follow- Up Codes (Legend) were listed on the MAR: (check mark) =Administered 22=Drug / Treatment Not Administered 5=Hold 2=Drug/Treatment Refused 6=hospitalized II=ineffective. The scheduled administration hours were documented on the MAR as 9:00 AM and 17:00 (5:00 PM), and a review of the MAR and Progress Notes (PN) revealed the following: The 8/5/25 MAR entry for the 9:00 AM Entresto dose had a check mark for administered, and the 5:00 PM Entresto dose was coded 22 (not administered). A Progress Note, Effective Date: 08/05/2025 at 15:25 (3:25 PM) Type: Nursing Daily Skilled Pathway note documented by the Licensed Practical Nurse (LPN #1) revealed: Received resident awake and alert X3 (to person, place and time). Resident received medication as ordered without difficulty. While doing resident wound treatment, I noticed swelling in both of resident's legs and feet, pitting edema +3 (fluid in tissues that cause an indent when pressure applied). MD made aware. Resident is elevating legs and feet in bed. Resident is stable. There was no documentation that the MD was made aware of the Entresto that was not administered although LPN #1 documented a Type: eMar - Medication Administration Note Dated: 08/05/2025 at 16:40 (4:40 PM), Text: Entresto Oral Tablet 24-26 MG Give 1 tablet by mouth two times a day for prevention, and was documented, on order. The 8/6/25 and 8/7/25 MAR entry for both days at 9:00 AM and 5:00 PM were coded as 22 (not administered) for the Entresto. A Progress Note: Effective Date: 08/06/2025 at 08:29 (8:29 AM) Type: eMar - Medication Administration Note Text: Entresto Oral Tablet 24-26 MG, give 1 tablet by mouth two times a day for prevention and was documented by LPN #1 as on order. The 8/8/25 MAR entry for the 9:00 AM and 5:00 PM Entresto doses were both coded 5 (Hold), however, there was no corresponding physician order to hold the medication. A Progress Note: Type: eMar (Electronic - Medication Administration Note) Effective Date: 08/08/2025 at 14:19 (2:19 PM), revealed: Note Text: Entresto Oral Tablet 24-26 MG, give 1 tablet by mouth two times a day for prevention, and was documented as unavailable, and signed by a Registered Nurse (RN). Another eMar - Medication Administration PN, also Dated: 08/08/2025 at 17:28 (5:28 PM), Type: Note Text: Entresto Oral Tablet 24-26 MG, give 1 tablet by mouth two times a day was documented as unavailable. The 8/9/25 MAR entry for the 9:00 AM and 5:00 PM doses were both coded with a on the MAR to indicate the Entresto was Administered however, an RN Progress Note, Effective Date: 08/09/25 at 21:32 (7:32 PM), Note Text: Entresto Oral Tablet 24-26 MG Give 1 tablet by mouth two times a day was documented as on order. The 8/10/25 MAR entry for the 9:00 AM and 5:00 PM doses for the Entresto were both coded 22 on the MAR which indicated the medication was not administered. Effective Date: 08/10/2025 16:11 Type: eMar - Medication Administration Note Text: Entresto Oral Tablet 24-26 MG, give 1 tablet by mouth two times a day for prevention was documented by the RN as unavailable. The 8/11/25 MAR entry for the 9:00 AM and 5:00 PM doses for the Entresto were both coded II (Ineffective) on the MAR, and a PN, Effective Date: 08/11/2025 at 9:17 AM, Type: Health Status Note documented: LATE ENTRY, Note Text: Spoke [Pharmacy Name Redacted] medication Entresto was approved and will be shipped out this evening. Awaiting on delivery, signed by LPN #2. An 8/12/25 PN, Effective Date: 08/12/25 at 8:06 AM, Type: eMar - Medication Administration Note: Note Text: Entresto Oral Tablet 24-26 MG Give 1 tablet by mouth two times a day as on order. A Progress Note, Effective Date: 08/12/2025 at 10:30 AM, Type: Note Text: BP (Blood Pressure) elevated today 196 /93, rechecked in left arm 200/95, Resident complained of headache and dizziness. MD made aware and new order for Clonidine (medicine to treat HTN) 0.2 mg one time dose. Nurse notified, resident updated. Will monitor. A subsequent PN, Effective Date: 08/12/25 at 14:34 (2:34 PM), Type: Health Status Note Text: Received resident alert and awake. Resident complained of feeling lightheaded and dizzy . Vital signs checked BP: 196/93. Resident received medication as ordered without difficulty. Resident BP rechecked, resident complained of still feeling lightheaded and dizzy. Vitals rechecked BP: 200/95 (left arm) BP: 214/100 (right arm) . MD made aware, ordered for resident to receive Clonidine 0.2MG. Vital signs rechecked BP:217/104 (left arm) BP:216/107 (right arm) . MD made aware, MD ordered to send resident out for uncontrolled hypertension. Resident was sent to hospital at 2:24PM. The MAR dated 8/12/25, for the Entresto was coded for the 9:00 AM dose as 22 which indicated the medication was not administered and the 5:00 PM dose was coded as 6 indicating the resident was now hospitalized . On 10/24/25 at 11:27 AM, two surveyors interviewed LPN #1, who cared for Resident #3 on 8/5/25, 8/6/25, 8/7/25, and 8/12/25. LPN #1 stated that she recalled that the Entresto was not available for Resident #3, and she confirmed that the facility was waiting to be notified when the pharmacy was going to provide the medication. The surveyors showed LPN #1 the MAR for Resident #3 and asked LPN #1 to explain the codes on the MAR and to confirm the days the Entresto was not administered to Resident #3. LPN #1 looked at the MAR and confirmed Resident #3 did not receive the Entresto on 8/5/25 at 5:00 PM, and neither the 9:00 AM, or 5:00 PM dose on 8/6/25, 8/7/25, 8/8/25, or 8/10/25. LPN #1 stated that on 8/9/25 it was unclear how it could have been documented with a as the Entresto was not available and was not in the back up box (emergency medication storage), and on 8/11/25 the II coding in the MAR meant the Entresto was not administered since the medication was still not available. When asked if LPN #1 notified the MD that the Entresto had not been available, she stated she notified the MD, but when asked to locate the documentation, she confirmed there was no documentation that the MD was notified. On 10/24/25 at 12:35 PM, the surveyors interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) regarding how medications were received at the facility. The DON stated the facility received multiple deliveries per day and by the next day a medication should have been received. The DON stated if the medication had not been received for 3 to 4 days the MD needed to be contacted. The DON stated that due to insurance approvals, sometimes medication was delayed, and it should not be checked off in the MAR if the medication was not administered if it was not available. The DON also stated there should be a corresponding note in the PN regarding medications not being available. On 10/24/25 at 12:44 PM, the surveyor asked if the facility reviewed residents who were transferred to the hospital unexpectedly and the DON stated that it would be quality assurance. The surveyor asked if there were any incidents or investigations related to Resident #3? On 10/24/25 at 1:11 PM, the DON, LNHA and Assistant Director of Nursing (ADON) provided the surveyors with a Quality Improvement (QI) Tool for Review of Acute Care Transfers for Resident #3's hospitalization that occurred on 8/24/25 (after the resident was transferred to the emergency room on 8/12/25 and transferred back to the facility and out again) and documented by the LPN Unit Manager on 8/28/25. The QI tool document revealed that it was designed to help your (facility) team analyze hospital transfers and identify opportunities to reduce transfers that might be preventable. Complete this tool for each or a representative sample of hospital transfers to conduct a root cause analysis. The DON then stated the QI form was for Resident #3 for the emergent transfer to the to the hospital on 8/24/25, due to increased blood pressure and decreased oxygen level. When asked if anything differently could have been done to prevent the emergent hospital transfer? The DON stated, no. The surveyor asked if there were any other incidents/ issues or hospital transfers reviewed for Resident #3, and the DON stated there were no other concerns for Resident #3. The surveyor informed the facility regarding the concerns related to the Resident #3 being transferred to the hospital emergently on 8/12/25. On 10/24/25 at 1:26 PM, the surveyors conducted a telephone interview with the Medical Director (MD) who was also Resident #3's medical doctor. The surveyor asked what Entresto was used for and if there was a substitute for the medication? The MD stated the medication was used to control blood pressure and was for congestive heart failure (CHF- the heart fails to pump blood and fluid buildup occurs). The MD stated the medication was a combination medication and there was no exact substitute for it. The surveyor asked if it would be a problem if the medication was not administered to a resident who required it, and the MD stated, Entresto was a very specific medication and the facility should have it because there was no exact substitute. The MD continued and stated if he had been made aware that Entresto was not available, he could order other multiple medications, or a resident may be sent to the hospital if it was not available. When asked specifically if he had recalled Resident #3 not being administered the Entresto, he was not able to comment if he had been made aware of the Entresto not being available for Resident #3. On 10/24/25 at 1:45 PM, the survey team met with the DON, ADON and LNHA. The surveyor asked the facility if they had been made aware that the Entresto for Resident #3 was not available and not administered prior to the resident being sent out to the emergency room for high blood pressure? The ADON stated they were not made aware of missing medications. When asked if the facility waits to see if insurance will pay for a medication prior to providing it, the LNHA stated the facility will purchase and provide the required medicine. The surveyor informed the facility of the hospital documentation that questioned why Resident #3 became suddenly hypertensive if they received their medications. The LNHA stated they interviewed LPN #1 who confirmed there was no documentation regarding the unavailability of the Entresto, and no further information was provided. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents on 8/7/25, it was determined that the facility failed to follow a resident's care plan interventions to provide safe transfer of a resident utilizing a mechanical lift. Resident #2 was assessed by the facility to weight bear as tolerated and required the use of a mechanical lift for transfers. On 3/11/2025, Resident #2 requested staff transfer the resident from a chair to their bed. The resident became anxious and did not want to wait for the mechanical lift to be transferred. Resident #2 began to slide themself forward from the chair. Two staff members transferred the resident to bed without the use of the mechanical lift. After this transfer occurred, the resident began to complain of pain and a diagnosis of fracture of right distal tibia/fibula was made. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #2). The deficient practice was evidenced by the following:According to an admission Record, Resident #2 was admitted to the facility with diagnoses that included but were not limited to: Muscle Wasting and Atrophy, Unspecified Mood (Affective) Disorder, Muscle Weakness (Generalized), History of Falling. According to the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/16/24, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident had no cognitive impairment. According to a facility Reportable Event Record/Report (FRE) dated 3/17/2025, on 3/11/25, at approximately 4:45 PM while sitting in a wheelchair next to their bed, Resident #2 requested LPN #1 transfer him/her to bed. Resident #2 expressed anxiety and attempted to slide forward in the wheelchair, indicating [he/she] did not want to wait for the lift. LPN #1 and CNA #1 proceeded with transferring the resident back to bed without the Hoyer lift device. Resident #2 stated when I was being put to bed by nurse and other staff, my feet touched the floor and buckled under me, they lifted me so I wouldn't fall. The staff did not observe any distress by the resident. An X-ray of the resident's right ankle revealed Osteopenia with a non-displaced distal tibia and fibula fracture of unknown acuity. The resident was sent to the hospital. The FRE included that the right ankle fracture and cellulitis were likely a result of the incident where [his/her] feet touched the floor during the transfer .A Care Plan initiated on 3/29/2024 for Resident #2 included a Focus of I am at risk for falls r/t [related to] history of falling, medication use resistive to care, use of mechanical lift. Interventions for this focus included but was not limited to: Resident to be transferred via Hoyer Lift with two staff members assisting.A progress note (PN) dated 3/12/25 at 4:45 pm documented via Late Entry by LPN #1 revealed Resident #2 was sitting in a wheelchair next to his/her bed and asked to be put to bed at 4:15 pm. The resident was anxious and sliding themself forward in the wheelchair. LPN #1 called for another staff member for assistance in putting Resident #2 back to bed. The note further indicated Resident #2 did not verbalize complaints at the time.A PN dated 3/12/2025 timed at 6:36 pm included that the nurse and physician assessed Resident #2 related to complaints of pain to both feet. The resident had swelling to both ankles and feet. The right was more swollen than the left. The resident was unable to perform range of motion to extremities due to the resident's pain tolerance of being assessed. Resident voiced that when I was being put to bed by [the] nurse and [the] other staff man, my feet touched the floor [and] buckled under me, they lifted, [sic] so I wouldn't fall. Ice compresses and X rays were ordered. A PN dated 3/13/2025 timed at 6:52 am revealed Resident #2 returned from the hospital at 2:30 am with a soft cast to his/her lower right extremity. The resident was administered medication for pain. The Emergency Documentation discharge summary from the hospital diagnosed the resident as having cellulitis and a fracture of the right ankle.During an interview with the surveyor on 8/7/25 at 10:15 am, LPN #1, stated to keep resident from falling from the wheelchair, LPN #1 and CNA #1 assisted resident back to bed. The LPN #1 stated they were unsure if the resident's foot was injured during the transfer, but the Hoyer lift should have been used for the transfer, per policy. During an interview on 8/7/25 at 11:35 am the Director of Rehabilitation (DR) stated before the fracture, Resident #2 status was weight bearing as tolerated, was not ambulatory and required a Hoyer Lift to transfer. The DR further stated it is the facility policy for two staff to assist during transfer using a Hoyer Lift and if the resident was sliding, the staff would stabilize the resident first, then use the Hoyer lift for transfer. During an interview on 8/7/25 at 12:15 pm the Director of Nursing stated that per the Care Plan, Resident #2 required transfer by Hoyer lift with two persons to assist from bed to chair if resident unable to ambulate. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered Revision Date March, 2022 under Policy Interpretation and Implementation 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care; and e. reflects currently recognized standards of practice for problem areas and conditions.NJAC 8:39-11.2(e) thru (i); 27.1(a), (d)

Complaint: NJ176793 Based on interviews, medical record review, and review of pertinent facility documentation on 5/27/25 and 5/29/25, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted an initial comprehensive visit with in the initial 30 day time period. The facility also failed to follow its policy titled, Physician Visits. This deficient practice was identified for 1 of 9 residents (Resident #2). This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) on 5/27/25 and 5/29/25 was as follows: According to Resident #2's admission Record (AR), the resident was admitted to the facility in October 23, 2023, with diagnoses that included but were not limited to: Schizophrenia, Asthma, and Diabetes. According to the Minimum Data Set (MDS), an assessment tool dated 05/02/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of Residents #2's Progress Notes (PNs) from October 2023 to May 2025 revealed the initial physician visit was completed on 1/07/2024. This was not within 30 days of admission. On 5/29/2025 the surveyor requested Physician notes for Resident #2 since arrival to the facility. DON provided documents titled HISTORY AND PHYSICAL dated 10/24/2023, the documents were signed by Advanced Practice Nurse (APN) APN #1. During an interview on 5/29/2025 at 12:50P.M., the DON explained she did not have any further documents from the physician from arrival. During an interview on 5/29/2025 at 1:53P.M., the Director of Nursing (DON) stated physician should see the resident within 30 days. It's once a month for 3 months then at least every 60 days. The DON stated no, the policy was not followed. If the physician seen the resident, it should be documented and it should be readily available. Review of the facility's Policy titled Physician Visits dated April 2013, under Policy Interpretation and Implementation revealed The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. NJAC 8:39-23.2(d); 27.1(a)

Complaint: NJ176793 Based on interviews, record review, and review of other pertinent facility documentation on 05/29/2025, it was determined that the facility staff failed to a.) consistently document the care provided in the Documentation Survey Report v2 (DSR) b.) follow the facility's policy titled, Point of Care (POC) Documentation. for a resident (Resident #2). This deficient practice was identified for 1 of 9 residents (Resident #2) reviewed. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to Resident #2's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: Schizophrenia, Asthma, and Diabetes. According to the Minimum Data Set (MDS), an assessment tool dated 05/02/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of the facility's DSR commonly called the POC, for August and September 2024, revealed no documentation indicating that bladder or bowel incontinence care, or toileting hygiene was provided on the following dates and shifts: On August 7, 24, 28, 29 of 2024, during the 7:00 A.M. to 3:00 P.M. shift, August 9, 11, 15, 20, 24, 25 of 2024, during the 3:00 P.M. to 11:00 P.M. shift, and August 3, 5, 7, 11, 18, 26, 31 for the 11:00 P.M. to 7:00 A.M. shift. On September 1, 5, 7, 8, 10, 11, 19 of 2024, during the 7:00 A.M. to 3:00 P.M. shift, September 9, 13, 20 of 2024 during the 3:00 P.M. to 11:00 P.M. shift, and September 1, 2, 3, 8, 11, 15, 30 of 2024 for the 11:00 P.M. to 7:00 A.M. shift. A review of Resident #2's Progress Notes (PNs) from August and September 2024 did not reveal refusals of incontinence care. A review of Resident #2's Care Plan (CP) initiated on 10/24/2023 with a Focus of I have ADL (Activities of Daily Living) Self Care Performance Deficit related to schizophrenia with Intervention I am dependent on staff for grooming/personal hygiene. During an interview on 5/27/2025 at 10:22 A.M., the Licensed Practical Nurse/Unit Manager (LPN/UM #1) stated If a resident refuses care, it will be documented as refused on the CP and POC. During an interview on 5/27/2025 at 1:27 P.M., the LPN/UM #2 stated that the CNA's (Certified Nursing Assistants) have to complete the POC for ADL's (Activities of daily living) every day. The CNA reports refusals to the nurse. If resident refuses care, we educate them and try to get the family involved, we would document it in the PNs and put a CP for resident resistant to care. During an interview on 5/29/2025 at 1:20 P.M., the CNA explained incontinence care is documented in the POC daily for every shift. The CNA stated if it is not documented then the care wasn't provided. The blank spaces mean care was not provided. If the resident refuses, I'll tell the nurse and the manager. There should be no blanks. During an interview on 05/29/2025 at 01:53 P.M., with the Director of Nursing (DON), the DON stated, the CNAs are supposed to document for ADL's and the expectation is that they document on the POC. Blanks mean the CNA failed to document. The DON confirmed the blank spaces on Resident #2's POC from August 2024 and September 2024. When asked by the surveyor if the facility's policy was followed, the DON stated, the policy states it should be documented. No, the policy was not followed for the blanks. Review of the facility's undated policy titled Point of Care (POC) Document, under Policy Implementation revealed 1. CNA will provide resident care in accordance with each resident's individualized, plan of care/Kardex which can be accessed from within POC. 2. CNAs will document the resident's self-performance, and the support provided for the activities of daily living, including: c. Toileting and Personal hygiene and 3. Additional CNA documentation includes: b. Bowel and bladder continence. NJAC 8:39-35.2 (g)

NJ00181366, NJ00175401. Based on observation, record review of the medical records, and other pertinent facility documents on 3/11/25 and 3/12/25, it was determined that the facility failed to ensure that a resident received care in accordance with professional standards of practice, 1.) failing to follow Physician's order; 2.) failing to monitor a resident that required continuous oxygen; and 3.) failing to ensure that a resident's oxygen concentrator was on . This deficient practice was identified for 1 of 6 residents, (Resident #1), reviewed for oxygen usages and was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (the body can't adequately remove carbon dioxide, leading to a buildup in the blood), Pneumonia (lung infection) and Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties). The Minimum Data Set (MDS), an assessment on 01/04/2024 Resident #1 was re-admitted to facility, on 2/05/2024 Resident #1 was discharge, return to facility on 2/16/2024 and discharge on [DATE]. Tool dated 12/17/23, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the Resident's cognition was intact. On 2/5/2024, the facility did an investigation. Findings were as followed: Statements from nurse and CNA, Inservices for CNA and Nurses. Conclusion : Staff will closely monitor resident upon return and ensure that concentrator is positioned out of reach. On 3/11/2025 at 12:30 p.m., the Surveyor reviewed Resident #1 Medical record which revealed the following: Physician Order, dated 01/05/2024 and located under the Orders tab of the EMR, indicated . Oxygen at 5 Liter/Minute via Nasal Cannula every shift On 3/11/2025 at 12:30 p.m., the Surveyor reviewed Resident #1 Progress Notes (PN), dated 01/05/2024 and located under the admission Summary indicated, Resident #1 arrived at the facility (on 3pm-11pm shift on 01/04 2024), receiving oxygen at 5 liters/minute via nasal cannula. On 3/11/2025 at 12:30 p.m., the Surveyor reviewed Resident #1's Care Plan, show no mention of Oxygen supplement on care plan. During an interviewed with the Surveyor on 3/11/2025 at 10:52 a.m., the Surveyor interviewed the Licensed Practical Nurse #1 (LPN), and she stated Resident # 1 was on continuous oxygen during the day and BIPAP at night and sometimes would take nasal cannula and BIPAP off. She further stated she was Resident #1 assigned nurse on 2/5/2025 on the 7-3 shift. The LPN stated on 2/05/2025, she clocks in at 7 a.m., got verbal report from 11pm-7 am shift nurse who stated, no changes with resident's during the night. At approximately 8 a.m., the LPN stated she walked in Resident #1's room to try to get his/her attention. She found the resident was unarousable, diaphoretic and nailbeds slightly blue, pulse oximeter (a devise clipped to a fingertip, estimate blood oxygen saturation) was at 50%. The LPN observed the oxygen concentrator was off, but was plugged in the socket in the wall. She immediately turned the concentrator on and placed BIPAP (a non-invasive ventilation therapy that provides pressurized air to help people with breathing difficulties) and placed it on Resident #1 face and called for assistance. During an interviewed with the Surveyor on 3/11/2025 at 11:41 a.m., the Director of Nursing (DON), stated she was aware of the incident and further stated resident could have turn off the machine. DON further stated the 11pm-7am nurse saw the resident at 6 a.m., during medication pass and stated machine was on. On 3/11/2025 at 11:50 a.m., the Surveyor was unable to reach the 11pm-7am. nurse. During an interviewed with the Surveyor on 3/12/2025 at 10:12 a.m., the LPN stated the oxygen concentrator was at the bed side (2 arm's length from the bed) towards the wall and the resident was unable to reach the concentrator and required 2-person assistance to turn from side to side. During an interviewed with the Surveyor on 3/12/2025 at 10:34 a.m., the CNA (Certified Nurse's Assistant) stated she was Resident #1 assigned CNA on 2/5/2025 on the 7-3 shift. Approximately at 7:30 a.m., during rounds she observed Resident #1 in bed covered up, oxygen tubing in nostrils, concentrator close to resident's bed side (1 arm Length). During an interviewed with the Surveyor on 3/12/2025 at 2:40 p.m., The Administrator stated rounds should be made when staff arrive on the floor, during medication pass and throughout the entire shift. Review of the facility's Oxygen Administration. Under: Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Review the resident's care plan to assess for any special needs of the resident. Under:1. Steps in the Procedure: Check the tubing connected to the oxygen cylinder to assure it is free of kinks. 2. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administrator. 3. Policy did not mention guideline on concentrator. Review of the facility's Physician Orders. Under: Policy Statement revealed: Licensed nurses will obtain, document and provide care and service in accordance with orders received from the physician. Under Policy, Interpretation and implementation revealed: 1. Nursing staff will carry out the physician orders as directed by the physician. 2. The provision of care and services in accordance with the physician orders will be documented in accordance with professional standards of practice. NJAC 8:39-3.2a)

C#: NJ 00181366, NJ00175401 Based on interviews, record review, and review of other pertinent facility documents on 03/11/2025, 03/12/2025, it was determined that the facility failed to address a family concern of resident #4 with bathing and changing of clothes. This deficient practice was identified for 1 of 6 residents, Resident #4, and was evidenced by the following: According to the admission Record (AR), Resident #4 was admitted on [DATE] with diagnoses that included but were not limited to Psychoactive Substance Dependence with Psychoactive Substance-Induce Mood Disorder, (depressive, anxiety, psychotic, or manic symptoms that occur as a physiological consequence of the use of substances of abuse or medications), Muscle Wasting and Atrophy (is a loss of muscle and strength). According to the Minimum Data Set (MDS), an assessment tool, dated 12/16/2024, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 1/15, which indicated that the resident's cognition was severely impaired. The MDS also revealed Resident #4 needed supervision with showering/bathing self, set up with upper body dressing and lower body dressing. During an interviewed on 03/12/2025 at 11:30 a.m., the SW stated Resident # 4's family was concerned that resident is not bathed and that the clothes are changed. The SW informed family member that they are working on resolving the issue with the CNA (Certified Nurse's Assistant) to assist Resident #4 with showers and changing clothes. During an interviewed on 03/12/2025 at 11:11 a.m., the Unit Manager (UM) stated Resident #4 was ambulatory and did not like to be engaged and refused to be shower and change clothes. The UM stated residents are showers twice a week and if the residents refuses showers they would be educated on the importance of being cleaned and document in the Progress notes. The UM stated she was not approached by any family member regarding Resident #4 and that the resident had no skin break down. The skin checks are done weekly by the nurses. During an interviewed on 03/12/2025 at 11:46 a.m., the License Practical Nurse (LPN) stated there is a shower list the CNA followed, if the resident's refuses, the CNA will notify the nurses and document in chart. During an interviewed on 03/12/2025 at 11:48 a.m., the CNA stated if resident refuses to shower she would notify the charge nurse and document in chart. During an interviewed on 03/12/2025 at 12:00 p.m., the Staffing Coordinator/ CNA, stated Resident #4 refused showers and changing of clothing. The CNA further stated she was the only staff Resident #4 allowed to give a shower and changed clothes but would refuse care from other staff. During an interviewed on 03/12/2025 at 1:42 p.m., the Director of Nursing (DON) stated she was aware of Resident #4 refusing shower and changing clothes. The DON stated if she received a complaint she would investigate, document as a grievance or incident report, come up with a resolution and notify family of resolution. The DON added that all grievance and complaint are reviewed by Administrator. During a follow up interviewed on 03/12/2025 at 2:16 p.m., the SW stated that during a conversation with Resident #4 family, the family was made aware the staff had given Resident #4 two showers (unable to provide date). The SW further stated the family was informed Resident #4 is refusing shower and the staff would continue to try to provide daily showers for resident. SW stated did not document conversation with the family. During an interviewed on 03/12/2025 at 4:10 p.m., the Administrator who was the Facility grievance officer, stated he was not aware of Resident #4 not getting showered and clothing changed. During record review, the surveyor noted CNA Activity of Daily Living documentation for Resident # 4 revealed that the resident refuses shower/bath selfcare on 12/5/2024, 12/6/2024,12/7/2024, 12/8/2024, 12/11/2024, 12/12/2024. (shower day 7-3 shift). Review of the facility's policy titled Grievance/ Complaint, filing included the following: Under Policy: residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman. Under: Policy Interpretation and Implementation revealed the following: 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning the care, treatment, behavior of other residents, staff members, thief of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances, complaints or recommendations stemming from resident or family groups concerning issues will be responded to in writing, including a rationale for the response. 4. Grievances and / or complaint may be submitted orally or in writing and may be filed anonymously. 5. The administrator is the facility grievance officer. 6. Upon receipt of a grievance and /or complaint, the grievance officer or designee will review and investigate the allegations and submit a written report of such findings within (5) working days of receiving the grievance and / or complaint. Review of the facility's Director of Social Service Job Description. Under: Duties and Responsibilities revealed: Review departmental complaints and grievances from personnel and make written reports to the Administrator of actions(s) taken. 1. Follow Center's established procedures. 2. Involve the resident/family in planning objectives and goals for the residents. 3. Review complaints and grievances made by the resident and make a written/oral report to the Administrator indicating what actions(S) were taken to resolve the complaint or grievance. Follow Center's established procedures. NJAC 8:39-13.2(c)

NJ00181366, NJ00175401. Based on observation, record review of the medical records, and other pertinent facility documents on 3/11/25 and 3/12/25, it was determined that the facility failed to update and revised a resident's Comprehensive Care Plan for 1 of 6 residents (Resident #1), reviewed for oxygen. The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. According to the admission Record, Resident #1 was admitted to the facility with diagnoses which included but not limited to: Acute and Chronic Respiratory Failure with Hypercapnia (the body can't adequately remove carbon dioxide, leading to a buildup in the blood), Pneumonia (lung infection) and Chronic Obstructive Pulmonary Disease The Minimum Data Set (MDS), an assessment on, 01/04/2024 re-admitted to facility on 2/05/2024 and was discharged . Resident #1 returned to the facility on 2/16/2024 and was discharged on 2/26/2024. The MDS dated [DATE], indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the Resident's cognition was intact. A review of Resident #1 Physician Order, dated 01/05/2024 and located under the Orders tab of the EMR, indicated . Oxygen at 5 Liter/Minute via Nasal Cannula every shift A review of Resident #1 Progress Notes (PN), dated 01/05/2024 and located under the admission Summary indicated Resident #1 arrived to the facility (on 3pm-11pm shift on 01/04 2024), receiving oxygen at 5 liters/minute via nasal cannula. A review of Resident #1's Care Plan, admission Date 02/16/2024, noted no indication under Focus, that Resident #1 was care plan for the use of oxygen. During an interviewed with the surveyor on 3/11/2025 at 10:40 a.m., the Licensed Practical Nurse (LPN)#1/Unit Manager (UM) stated Resident #1 care plan should have been initiated upon admission or updated with any new diagnosis especially oxygen. This should have been initiated on care plan. The Surveyor reviewed the Care Plan with UM who further stated Oxygen, should have been mentioned on Care Plan. The UM stated she should have check and updated Resident #1's Care Plan upon return to facility on 01/05/2024. During an interviewed with the surveyor on 3/11/2025 at 11:41 A.M., the Director of Nursing (DON) stated it is the responsibility of the UM to update and reviewed care plan. The Surveyor reviewed Care plan for Resident #1 with DON, who stated Oxygen should have been documented on care plan. During an interviewed with the surveyor on 3/12/2025 at 2:40 P.M., the Licensed Nursing Home Administrator (LNHA) stated that Resident #1's care plan should have been updated by the UM to reflect resident's oxygen on 01/05/2024. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised 03/2023, indicated under Policy Interpretation and Implementation that Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. NJAC 8:39-11.2(e) (h).

NJ00181366, NJ00175401. Based on observation, interview, and record review it was determined that the facility failed to administer the correct oxygen dose as order according to the Physician's order for 1( Resident#2) of 6 resident reviewed for respiratory care and services. The deficient practice was evidenced by the following information: On 3/11/2025 at 10:10 a.m.,the Surveyor and Unit Manager (UM) entered Resident #2 room and observed resident in bed with nasal cannula out of both nostrils and concentrator towards the wall in resident room. According to the gauge on the concentrator (indicate how much oxygen was being delivered to the resident). The Surveyor observed the gauge at 3 liters of oxygen per minute. The Surveyor interviewed UM at this time, she confirmed the oxygen rate was set at 3 liter per minute. The UM left the room to check physician order, return with a new nasal cannula and placed it in resident's nostril's and connect it to the concentrator and confirmed Resident #2 physician ordered stated Oxygen at 2 Liter/Minute via Nasal Cannula every shift . The UM lower the gauge to 2 liters and monitor pulse oximeter (measure the oxygen level (oxygen saturation) of the blood) which read at 99 percent (%). (A 99% oxygen saturation reading, measured by a pulse oximeter, indicates that 99% of your red blood cells are carrying oxygen, which is considered a healthy and normal level). According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but not limited to: Acute Respiratory Failure with Hypoxia, (occur when the lungs fail to adequately oxygenate the blood), Acute and Chronic Respiratory Failure with Hypercapnia (buildup of carbon dioxide in the blood) and Chronic Obstructive Pulmonary Disease (lung condition caused by damage to the lungs). The Minimum Data Set (MDS), an assessment on, 02/25/2025, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the Resident's cognition severe cognitive impairment. A review of Resident #2 Physician Order, dated 03/08/2024 and located under the Orders tab of the EMR, indicated . Oxygen at 2 Liter/Minute via Nasal Cannula every shift . A review of the Resident's Care Plan (CP) initiated on 02/052025, revealed under Focus: that Resident #2 require supplemental oxygen r/t. Under Goal, indicated [resident] will remain free of symptoms and complications of low oxygen levels, such as shortness of breath, dizziness, tachycardia, headache through review date.; Under Interventions, included: Add humidity to oxygen as needed. Change tubing as per facility protocol. Monitor and document breath sounds, breathing patterns, and dyspnea with exertion or while lying flat. Report abnormal findings to physician or designee. Monitor skin on ears and nose for breakdown from oxygen tubing. Pad tubing as needed. Monitor vital signs, including pulse oximeter, as ordered and clinically indicated. Respiratory therapy consults as needed. On 3/11/2025 at 10:23 a.m., the Surveyor interviewed LPN #1 (License Practical Nurse), stated she saw Resident #2 approximately 8 a.m., and nasal cannula was in both nostrils but she did not check the gauge on the concentrator. The Surveyor and LPN #1 reviewed Resident #2 Medical Administration Record (MAR), and it indicated Oxygen at 2 Liter/Minute via Nasal Cannula every shift. On 3/11/2025 at 10:35 a.m., the Surveyor interviewed CNA (Certified Nurses Assistant) stated during rounds she observed oxygen tubing in Resident #2 nostrils and oxygen concentrator at bed side was working. On 3/12/2025 at 10:45 a.m., the Surveyor interviewed LPN #1, who stated she does not know what happen on 3/11/2025, but observed the concentrator by the wall (one arm length), and gauge on 2 liters. The LPN also stated that Resident #2 needed assistance with positioning from side to side. On 3/12/2025 at 1:30 p.m., the surveyor was approached by the Director of Nurses (DON) who further stated, the UM should have notified the Physician because the orders did not match. Review of the facility's policy for Physician Orders. Under: Policy Statement revealed: Licensed nurses will obtain, document and provide care and service in accordance with orders received from the physician. Under Policy, Interpretation and implementation revealed the following: 1. Nursing staff will carry out the physician orders as directed by the physician. 2. The provision of care and services in accordance with the Physician orders will be documented in accordance with professional standards of practice Review of the facility's Oxygen Administration. Under: Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Review the resident's care plan to assess for any special needs of the resident. Under:1. Steps in the Procedure: Check the tubing connected to the oxygen cylinder to assure it is free of kinks. 2. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administrator. NJAC 8:39-25.2

Based on interviews, record review, and review of facility policy, the facility failed to ensure residents were free from abuse for one (1) of five (5) residents (Resident #13) reviewed for abuse. In addition, this failure has the potential to affect 143 other residents residing in the facility who were not protected from the alleged perpetrator. The facility's failure to ensure all residents were free from abuse, by not investigating an allegation of abuse reported by Resident #13 posed a likelihood of serious harm to Resident #13 and all residents. This resulted in an Immediate Jeopardy (IJ) situation. On 06/11/24 at 9:50 PM, the Administrator and Director of Nursing (DON) were notified that the failure to identify and protect one resident from alleged abuse which constituted an Immediate Jeopardy to the health and safety of all residents in the facility at F 600: Free from Abuse and Neglect. The Immediate Jeopardy began on 01/05/24, when Resident #13 reported that Certified Nursing Assistant (CNA #1) pushed him/her. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 06/12/24 at 8:24 PM. The survey team verified the implementation of the removal plan through staff interviews, and review of facility training. The Immediate Jeopardy was removed on 06/13/24 at 6:30 PM. Findings include: Review of Resident #13's undated Admission Record, provided by the facility, indicated that Resident #13 was readmitted to the facility on [DATE], with diagnoses of diabetes mellitus, chronic pain syndrome, and personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of the Progress Notes, provided by the facility and dated 01/05/24, revealed, ''At around 9:00 PM, heard [Resident #13] yelling at a CNA .When approached, [Resident #13] stated .[CNA #1] pushed [Resident #13] out of the way making the hot coffee spill .pantry floor was wet with coffee and [Resident #13's] lap was a little wet .Both hands were checked, but are dry and skin normal temperature. [Resident #13] claims that hands and lap feel tingling .Further skin assessment made. No apparent injury.'' Review of the Full Quality Assurance (QA) Report'' provided by the facility and dated 01/05/24, revealed '' .first degree burn .pelvic area .according to [Resident #13], tingling sensation on lap (close to groin area), [Resident #13's] skin was normal temperature, normal to touch, no redness, no flaking or scales .preventative/protective skin care, cold compress for five minutes .Conclusion: . [Resident #13] stated 'the hot coffee fell on me.' Upon .interviewing [Resident #13] and the [Certified Nursing Assistant (CNA #1)], coffee indeed was noted to spill on [Resident #13's] lap . [CNA #1] was attempting to get fresh ice water for her residents, while [Resident #13] was warming up their coffee. [Resident #13] became angry with [CNA #1] for being in the nourishment room at the same time [Resident #13] was in there. As [CNA #1] attempted to leave the nourishment room, [Resident #13] positioned themselves blocking the entranceway and threatening [CNA #1]. [Resident #13] would pour coffee on her as [Resident #13] stood up from the wheelchair. In the process of [CNA #1] trying to get pass [Resident #13] so [Resident #13] would not pour coffee on her, [Resident #13] spilled a small amount of coffee on themselves. [Resident #13] reported that [CNA #1] physically pushed [Resident #13]. Review of the QA Investigative Statements: (Typed written statement by [Licensed Practical Nurse (LPN #3)] revealed, .[Resident #13] was heard in the hall yelling at a [CNA #1], very upset .[Resident #13] stated that the [CNA #1] pushed [him/her] out of the way making the coffee spill on [Resident #13] and walked away .immediately inspected the surroundings and noted coffee spill on the floor. Checked [Resident #13] and noted smell of coffee lingers on [Resident #13] and lap was a little wet with coffee .Coffee spills was wiped off the floor .[Resident #13] stated tingling sensation on both lap closer to groin. Further review of the QA report revealed a typed written statement documented by [Resident #13]) .that aide [CNA #1] pushed me and made me spill my coffee on me.'' Review of facility provided, undated and untitled handwritten document by CNA #1, revealed ''On 01/05/24 at about 4:00 PM, I was entering the nutrition room to get ice for my residents. [Resident #13] was already in there heating up their meal. [Resident #13] was sitting near the sink. I asked [him/her] to let me get to sink to pour out water. [Resident #13]replied why every time I am in here, you come to disturb me . [Resident #13] continued to curse at me as [he/she] sat back down in the wheelchair. So I left the room to pass ice water. As I returned to get more ice water, [Resident #13] was still using the microwave. I asked [Resident #13] to excuse me again, [Resident #13] replied, I have killed 100 persons-I will kill you . As I was attempting to leave out of the nutrition room [Resident #13] positioned themselves blocking the doorway with the coffee container in [Resident #13's] hand. [Resident #13] was carrying a basin was in their lap. [Resident #13] said to me, I will burn you . I became afraid, and I squeezed past [Resident #13] to get out of [Resident #13's] way.'' On 06/11/24 at 3:15 PM, the surveyor interviewed CNA #1 who confirmed during the incident on 01/05/24, Resident #13 was in the ice room using the microwave, which was on the counter next to the medication room, when she went in there for a cup of ice for one of her 600-hall residents. She stated Resident #13 started yelling at her, asking her why she was in here and said that she was not to be in here when [Resident #13] was in here. She stated she took the cup of ice and left the room without speaking with Resident #13. She then stated that Resident #13 stood up, and threatened to slap her if she did not get out of the room. CNA #1 stated [Resident #13] threatened to beat her up after cursing her out. She stated Resident #13 sat back down in the wheelchair, and this was when she took her ice and left the room. She stated she was only in the nutritional room one time, denied going back for a second time, as her written statement indicated. CNA #1 further stated that she went back to her hall and started doing rounds after exiting the nutrition room. CNA #1 indicated that the nurse [LPN #4] told her that the supervisor [LPN #1], who was not at the facility during this incident, wanted her to write a statement because Resident #13 accused her of burning Resident #13. Then CNA #1 stated because she burned him, pushed [Resident #13] or something like that. CNA #1 stated after she wrote her written statement, she gave it to LPN #1 and confirmed that she was not asked to leave the facility. She stated she wrote Resident #13 was heating coffee in the microwave and had nothing in their hands while speaking with her. CNA #1 indicated that the next day, she was asked to come to the facility in the morning and spoke with the Director of Nursing (DON) and LPN #1. She indicated they asked her what happened, and she said that Resident #13 was warming their coffee, while she got ice, and she left the nutritional room, while Resident #13 remained in the room. CNA #1 confirmed that Resident #13 was sitting near the opened door when she passed Resident #13 and went onto the floor. On 06/11/24 at 7:10 PM, the surveyor interviewed the DON who stated even if the incident happened today, the facility would have suspended CNA #1, but allow CNA #1 to return to work because CNA #1 was not in the room with Resident #13 and Resident #13 made things up. The DON confirmed that when the QA report was completed, it was reviewed the next business day during the morning meeting. The DON stated after completing the QA report, it triggered an email to management and corporate, which generated follow up emails as to what happened. She stated she was told by LPN #3, LPN #4, and CNA #1, that CNA #1 was not in the nutrition room when Resident #13 spilled coffee on themselves. After the DON reviewed the statements, where Resident #13 reported physical abuse by CNA #1, the DON confirmed that this should have been reported within two hours of the staff's knowledge, and that CNA #1 should have been suspended. On that same date at 7:37 PM, after re-reading the abuse policy, the DON stated she would re-open this investigation and report. She stated CNA #1 would have been suspended immediately and confirmed that she dropped the ball. During a follow up interview at 8:32 PM, she confirmed that CNA #1 had been suspended and that the staff currently in the building had been in-serviced on abuse. She stated the state agency (SA) and police had been notified. On 06/12/24 at 11:00 AM, the surveyor interviewed Resident #13 who stated the 01/05/24 incident occurred while [Resident #13] was heating up food in the microwave. Resident #13 confirmed CNA #1 came into the nutritional room, where [Resident #13] was sitting by the ice machine, and CNA #1 pushed past [Resident #13]. Resident #13 stated that [he/she] told CNA #1, At least you can say excuse me. Resident #13 confirmed that CNA #1 said something, but [he/she] could not understand her, and CNA #1 left the nutritional room. Resident #13 indicated that [he/she] finished warming up their food, and coffee. Resident #13 further stated [he/she] had taken the coffee out of the microwave, had it in [his/her] right hand, and was getting ready to go out of the nutritional room, and was near the ice machine. Resident #13 stated CNA #1 entered the nutritional room, pushed past [him/her] on the right side to go to the sink, causing the hot coffee to spill on [Resident #13]. Resident #13 stated [he/she] started yelling and verbally threatening CNA #1 and CNA #1 did not stop and walked out of the nutritional room. Resident #13 stated when CNA #1 went out of the nutritional room, she went straight to the LPN #4 on the 600-hall, where Resident #13 heard CNA #1 telling the LPN #4 what happened and laughing about it. Resident #13 further stated LPN #3 came to find out what was wrong. Resident #13 stated [he/she] told LPN #3 that CNA #1 pushed [Resident #13] causing the hot coffee to spill on [Resident #13] legs. Resident #13 stated a day later, LPN #1 came and spoke with [him/her] about the incident. Resident #13 confirmed that [he/she] told LPN #1 that CNA #1 pushed [Resident #13] causing the coffee to spill on [Resident #13]. Resident #13 stated LPN #1 told [him/her] that CNA #1 was not to be around [Resident #13] anymore. Resident #13 stated that the same day [he/she] spoke with LPN #1 and CNA #1. On 06/12/24 at 2:40 PM, the surveyor interviewed LPN #1 who stated she spoke with Resident #13 following the 01/05/24 incident. She confirmed Resident #13 told her that CNA #1 pushed [Resident #13] and that Resident #13 was able to identify CNA #1 by name. She indicated she would not classify Resident #13's statement to be abuse and indicated that Resident #13 was both verbally and physically threatening towards CNA #1, making CNA #1 afraid. The LPN #1 stated CNA #1 may have accidentally hit Resident #13's wheelchair when exiting the nutritional room. Review of Resident #13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated Resident #13 was cognitively intact and able to make themselves understood and understand others. Review of facility provided CNA #1's ''Regular Monthly Schedule,'' provided by the facility for January 2024, revealed evidence that CNA #1 worked the following dates: 01/05/24, 01/06/24, 01/07/24, 01/09/24, 01/10/24, 01/11/24, 01/12/24, 01/15/24, 01/16/24, 01/17/24, 01/19/24, 01/20/24, 01/21/24, 01/23/24, 01/25/24, 01/26/24, 01/29/24, 01/30/24, and 01/31/24. This schedule showed that CNA #1 worked for 19 days after the allegation of physical abuse occurred. Review of facility policy titled, ''Abuse, Neglect, Exploitation and Misappropriation Prevention Program,'' dated 10/22, revealed ''Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to .physical abuse. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation program consist of a facility-wide commitment and resource to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff .9. Identify .all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.'' An acceptable Removal Plan on 06/12/24 at 8:24 PM indicated the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including suspending CNA #1 pending investigation, notifying the New Jersey Department of Health of the allegation of abuse, and educating all staff on the facility abuse policy. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 06/13/24. NJAC 8:39-4.1(a)5 NJAC 8:39-9.4(f) NJAC 8:39-13.4(c)2

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that two (2) of two (2) residents (Resident #13 and Resident #40) reviewed for accident hazards were given adequate supervision while transporting hot liquids. This failure caused Resident #13 to have a first degree burn on the pelvic area on 01/05/24 and a first degree burn to the abdomen with second degree burns on the left thigh and penis on 05/10/24. Both burns resulted from Resident #13 heating up coffee in the unit microwave which was located in the unlocked nutritional room on the unit. On 11/01/23, Resident #40 suffered a second degree burn to the right hip from self-transferring coffee from the dining room. On 06/10/24, a Past-Non-Compliance (PNC) Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were safe from accident hazards. The IJ was determined to exist on 05/10/24, when a second-degree burn occurred to Resident #13. The IJ was removed on 05/13/24, when the microwaves were removed from the unit nutritional rooms. The Administrator was informed on 06/10/24 at 10:33 PM, that the PNC Immediate Jeopardy situation existed which also constituted Substandard Quality of Care (SQC) for 42 CFR 483.25-Free of Accident Hazards/Supervision/Devices (F 689). The facility provided an Immediate Jeopardy Removal Plan that was accepted on 06/11/24 at 6:51 PM. The survey team verified the implementation of the Removal Plan through interviews and review of training records on 06/13/24 at 2:15 PM. Based on the facility's implementation of corrective actions, the IJ and SQC were determined to be PNC and the IJ was removed, with substantial compliance achieved on 05/13/24. The deficient practice was determined to be PNC related to the facility identifying the IJ and implementing interventions to prevent reoccurrence of the situation, completed on 05/13/24. The facility's actions included the following: -Resident education and care plans updated as indicated. -On 05/13/24, the interdisciplinary care (IDC) team met to discuss hot beverages policy, microwave use, and reviewed trends surrounding hot beverage spills. -On 05/13/24, microwaves were removed from the common area by Maintenance staff/designee. -On 05/13/24, the resident council president and residents were made aware by unit managers/interdisciplinary team (IDT) that microwaves were removed from common areas by maintenance staff/designee and that requests should be made to staff for reheating of food and beverages. -On 05/13/24, the resident council/food committee was held. Residents were educated on hot beverage safety and the removal of microwaves from common areas. The residents were educated that dietary staff would reheat meals and beverages upon request to minimize the risk of injury and validate appropriate beverage temps before resident consumption and/or transporting of hot beverages. -On 05/13/24, staff education was initiated and remained ongoing. -Education on monitoring during meals and during resident transport of hot beverages to assist in minimizing the risk of potential injury and following plan of care. -On 05/13/24, staff were educated to request reheating of meals and beverages from dietary staff. Education to dietary staff regarding reheating food and beverages per policy and facility-initiated process. -On 05/13/24, a review was completed of resident incidents with identified residents reviewed. Care plans were in place, and no further variances were noted. -Kitchen audits related to test trays remain ongoing. Variances addressed as indicated. Findings include: 1. Review of Resident #13's Admission Record, provided by the facility, indicated Resident #13 was readmitted to the facility on [DATE], with diagnoses of diabetes mellitus, chronic pain syndrome, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. During an observation and interview on 06/10/24 at 10:20 AM, Resident #13 stated they had a third degree burn to the abdomen, left thigh, and penis. Resident #13 stated that approximately one and half weeks ago during the evening shift around 6:00 PM, they were warming up coffee in the microwave that was located in the nutritional room. Resident #13 stated the hot coffee spilled on them and that they were hollering. Resident #13 stated no staff were around to warm up the coffee and that was the reason Resident #13 warmed it up themselves. Resident #13 stated that he/she warmed up the coffee for two minutes. Resident #13 denied any further incidents. During the interview, Resident #13 was observed to have a healed area to the abdomen. In addition, Resident #13 showed the surveyor their left thigh area, which had a dressing. During another interview on 06/10/24 at 4:28 PM, Resident #13 stated for the 05/10/24 incident, they were heating up coffee in two plastic 16-ounce (oz) cups, which were doubled. Resident #13 stated I was wheeling out of the open door of the nutritional room that had cardboard holding the door open and the cardboard came loose causing the door to bump into my wheelchair. Resident # 13 stated when the door hit my wheelchair; it caused me to spill the coffee. Resident #13 stated the coffee spilled on their left thigh first and then on the abdomen area. Regarding the incident on 01/05/24, Resident #13 stated, I was in the nutritional room, the door was held opened by a piece of cardboard and I got into an altercation with another resident. Resident #13 stated they went into the nutritional room first and was warming up coffee. Resident #13 stated that the other resident pushed him out of the way, while Resident #13 was by the ice machine and attempting to exit the door. Resident #13 stated this was when the coffee spilled on my legs. Review of ''Full Quality Assurance (QA) Report,'' provided by the facility and dated 01/05/24, revealed '' .first degree burn .pelvis area .according to [R #13], tingling sensation on lap (close to groin area), [Resident #13's] skin was normal temperature, normal to touch, no redness, no flaking or scales .preventative/protective skin care, cold compress for five minutes .Conclusion: . [Resident #13] stated the hot coffee fell on me. Upon investigation and interviewing of [Resident #13] and staff [Certified Nursing Assistant (CNA #1) ], coffee indeed was noted to spill on [Resident #13's] lap. [CNA #1] was attempting to get fresh ice water for her residents, while [Resident #13] was warming up coffee. [Resident #13] became angry with [CNA #1] for being in the nourishment room at the same time [Resident #13] was in there .In the process of [CNA #1] trying to get past [Resident #13] so the resident would not pour coffee on her, [Resident #13] spilled small amount of coffee on [him/herself] .[Resident #13] was assessed by floor nurse and no changes to skin textures were noted .Nurse Practitioner (NP) notified of first degree burn to groin area; however, no changes were visible at the time and new orders to apply cold compress were initiated . Root Cause: No, [R #13] is self-willed and refuses assistance when offered by staff.'' Review of the ''Occupational Therapy Treatment Encounter Note(s),'' provided by the facility and dated 01/12/24, revealed '' .During evaluation process patient demonstrated fair safety awareness with use of microwave, associated transfers and management of hot food items. [Resident #13] did endorse having [his/her] own way to do it. Reviewed safety techniques with patient and patient reporting understanding.'' During another interview on 06/12/24 at 11:00 AM, Resident #13 indicated that the 01/05/24, incident occurred when the Certified Nursing Assistant (CNA #1) came into the nutritional room at the same time Resident #13 was in there. Resident #13 stated I had coffee in my right hand, that I just finished warming up. Resident #13 stated I was getting ready to go out of the nutritional room, when [CNA #1] pushed past me on the right side, causing the hot coffee to spill on me. Resident #13 stated the nurse, [Licensed Practical Nurse (LPN #3)], assessed me and the physician came and saw me. Resident #13 stated that the physician said it was a minor burn. During an interview on 06/12/24 at 11:25 AM, the Director of Rehab (DOR) confirmed that he completed a therapy screen on Resident #13 back in January 2024, that indicated Resident #13 was fairly okay with microwave use. He stated Resident #13 was aware to ask staff for any help. He stated upon Resident #13's hospital return in May 2024, he did not complete a formal evaluation, but did speak with Resident #13. He stated Resident #13 said he/she was not going to drink coffee anymore. Review of the ''Full QA Report,'' provided by the facility and dated 05/10/24, revealed '' .burn to mid left abdomen, reddened area initially then started forming blister within half an hour and burn to left thigh, reddened initially then started forming blister in half an hour .cold compressed wrapped in towel .transferred to [name of hospital] .Conclusion: . On 05/10/24 at 5:45 PM, [Resident #13] was utilizing a different cup to warm up their coffee in the microwave, as [Resident #13] removed the cup, [he/she] spilled the hot coffee on themselves. A full nursing assessment was completed by the nurse, and first aid was immediately rendered. [Resident #13] was noted with a reddened area to mid left abdomen and left thigh, cold compress was refused by [Resident #13], and the resident was transferred to the emergency report (ER) .[Resident #13] returned to the facility on [DATE], the resident was informed that the facility policy was changed and that no residents would be allowed to use microwave independently .Root Cause: most likely [Resident #13] has episodes of forgetfulness and refuses to accept care/assistance.'' Review of the undated ''Summary of the Incident,'' provided by the facility and signed by the DON, revealed ''[Resident #13] is a [AGE] year-old .resident that has been residing at [name of facility] since 03/06/23, with medical diagnoses of diabetes, coronary artery disease (CAD), anemia, gastroesophageal reflux disease (GERD), syncope, benign prostatic hyperplasia (BPH). Resident #13's BIMS score was 13 .On 05/10/24 at 5:45 PM, [Resident #13] was utilizing a different cup to warm up the coffee in the microwave, as the resident removed the cup, the hot coffee spilled onto the resident. A full nursing assessment was completed by the nurse, and first aid was immediately rendered. Resident #13 was noted with a reddened area to the mid left abdomen and left thigh, cold compress was refused by [Resident #13], and was transferred to the emergency department (ED) .[Resident #13] was informed that the facility policy was changed and that no residents would be allowed to use microwave independently. The staff will take any item of food or liquids to the kitchen, where the kitchen staff will warm it up. All microwaves have been removed from the units and staff in-serviced on the new policy.'' During an interview on 06/10/24 at 2:13 PM, the Regional Director of Operations stated Resident #13's incident on 05/10/24, was not reported to the state agency (SA). She stated the Ombudsman came out and investigated at which the case was closed. Review of LPN #3's ''Employee's Statement of Incident,'' dated 05/10/24, revealed, ''At around 5:45 PM, while I was feeding a resident. I heard someone screaming in the distance. When I walked out of the room to investigate, I saw [CNA #2] pulling [Resident #13] out of the pantry. [Resident #13] stating that the hot coffee spilled on him/her and the resident was burned. I told [CNA #2] to get ice and called out for [CNA #3] to help. I immediately took [Resident #13] to their room and [CNA #3] followed me there to take Resident #13's clothes and assess. Noted reddened area on left side stomach and left thigh. Non-blanching, sensitive to touch. Ice compression wrapped in towel placed but [Resident #13] cannot tolerate it. Resident #13 then applied petroleum gel cocoa butter to themselves. [Resident #13] requested to be sent to emergency room (ER). Transport unavailable until 11:30 PM. 911 ambulance called instead .Right before 911 ambulance on last check with [Resident #13], skin noted on left thigh forming blisters.'' Review of CNA #2's ''Employee's Statement of Incident,'' dated 05/10/24, revealed ''I was in [room number] .I heard someone yelling .So I went to see who it was and looked in the pantry, it was [Resident #13]. Resident #13 said they had burnt themselves with hot coffee, so I got the nurse.'' Review of CNA #3's undated ''Employee's Statement of Incident,'' revealed ''I was with another resident when I was called by the nurse. The resident [Resident #13] had burned themselves with hot coffee at that time. The nurse and I went in and took care of the resident, and [Resident #13] was sent to the hospital.'' During an interview on 06/10/24 at 12:40 PM, the LPN #1 confirmed Resident #13 had an incident during the evening shift on 05/10/24. She stated Resident #13 warmed up the coffee in the microwave for two to three minutes which was in a plastic cup and caused burns to the Resident #13's left upper thigh, lower abdomen, and groin/penis area. The LPN #1 confirmed that the facility wound physician called the burns third degree. The LPN #1 stated that Monday after the incident, all microwaves were removed from the nutritional units in the facility. The LPN #1 stated if residents needed their food and/or liquids heated up, the staff took them to the dietary department, who re-heated them for the resident. The LPN #1 stated staff and residents were given education, through word of mouth, about these new guidelines. Also, the LPN #1 stated that the incident was reported to the Ombudsman. During an observation and interview on 06/10/24 at 4:35 PM, LPN #1 stated Resident #13 could transfer themselves into their wheelchair, and that was their mode of transportation. The LPN #1 stated Resident #13 did not walk. LPN #1 confirmed that Resident #13 was independent in their activity of daily living (ADL) and had a history of refusal at times. LPN #1 stated Resident #13 tended to roll themselves backwards in their wheelchair. In addition, during the interview, the nutritional door was observed propped open by a piece of cardboard which was wedged between bottom of door and floor. The LPN #1 stated the nutritional room was usually propped open at the change of shift due to the aides passing ice water. LPN #1 stated that it was made for easy access. LPN #1 could not answer when asked if the door was allowed to be propped open. LPN #1 confirmed the nutritional door was always unlocked. LPN #1 indicated that residents, visitors, and/or staff were allowed to heat up things in the microwave, and staff would always ask residents if they needed any help when staff observed residents using the microwave. When asked if residents had a screen for self-use of the microwave, she stated that after the first incident for Resident #13, he/she was screened by therapy and found safe to use the microwave. She indicated that for the incident on 01/05/24, Resident #13 spilled coffee on themselves during a verbal communication with a staff member. The LPN #1 stated Resident #13 became upset when the staff member came into the nutritional room, and as the resident was backing out, they spilled coffee on themselves. Review of ''Hospital History and Physical,'' provided by the facility and dated 05/11/24, revealed '' .[Resident #13] was having dinner .when he/she spilled coffee to their thigh and penis. [Resident #13] has what appears to be superficial burns on the abdomen with partial thickness burns to his/her thigh and penis. Total body surface area (TBSA) burn: 1% .partial thickness burns .left thigh and penis.'' Review of the ''Quality Assurance Performance Improvement-Action Plan,'' provided by the facility and dated 05/13/24, revealed ''Goal: To ensure resident safety with hot liquids .Resident Communication: Residents have been informed via resident council of the removal of microwave ovens from facility nourishment rooms; to prevent accidentally burns when independently reheating/heating food and hot beverages .target date: 05/31/24. Resident Assessment: Newly admitted /readmitted residents, and those with changes in condition affecting activity of daily living (ADL) functionality/decline will be evaluated by therapy (Occupational Therapy) to determine meal assistance needs .target date: Ongoing. Staff education: Education to facility staff on safety of hot liquids. Reheating of foods by dietary staff; microwave unit removal .target date: 05/18/24. Monitoring: Resident requiring meal assistance including those who receive hot liquids of choice will continue to be monitored by facility staff during dining room, and when eating in rooms to ensure assistance is provided to ensure safety. Residents who request beverages/foods to be re-heated will have this facilitated by facility staff. Dietary staff will continue to monitor food temperatures including hot liquids prior to service to residents. Hot liquids will not be served greater than (>) 180 degrees.'' Review of Resident #13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated the resident was cognitively intact and able to make themselves understood and understood others. 16752 2. Review of the facility's accident/incident log for 2023-2024 and provided by the facility, revealed Resident #40 sustained coffee burns while attempting to transport coffee from the dining room to their room. Resident #40 sustained a second degree burn to the right thigh/hip areas. Review of the facility's investigation of the incident, dated 11/01/23, and provided by the facility, revealed Resident #40 had gone to the dining room for coffee. A dietary staff member placed the coffee cup on the dining room table. The report documented the resident deciding to take the coffee to their room. Resident #40 placed the coffee cup inside the right side of their wheelchair next to their right thigh. Review of an undated witness statement provided by the Maintenance Director revealed the employee was coming out of his office when he observed the resident trying get out of the wheelchair after the resident spilled the coffee on themselves. The Maintenance Director assisted the resident to another chair and notified the nurse of the accident. Interventions put in place after included complete pain assessment, frequent skin checks, and treatments as ordered. Educated the resident to ask for assistance for carrying hot items to his/her room, not to attempt wheeling themselves, and trying to carry items at the same time. Staff education to make sure coffee was cooled before offering it to the residents. Review of Resident #40's Nursing notes, dated 11/01/23 at 7:43 PM, located in the resident's EMR under the Progress Notes tab, revealed the nurse was called to resident's room after the resident spilled hot coffee on themselves. The nurse documented the resident was found grimacing in pain. The resident stated that they had placed a cup of hot coffee by their side in the wheelchair as he/she was trying to propel themselves to their room when the coffee spilled and burned them. The physician was notified and ordered Silvadene cream to the burn area every shift. The resident's responsible party was notified. At the time of the incident, the resident was noted to have redness on their right thigh and upper gluteal area. It was determined that this was a first-degree burn. Additional review of Resident #40's nurses notes, dated 11/03/23 at 7:36 PM, it was noted the resident had developed a blister on the right hip area. The MD [Medical Doctor] was notified and ordered the blister to be cleaned and covered with four-by-four dressings. The burn was now classified as a second-degree burn. During an interview on 06/10/24 at 5:15 PM, the Unit Manager, LPN #5 revealed Resident #40 had gone to the dining room and requested a cup of coffee. LPN #5 stated the dietary staff placed the cup on the table and instructed the resident to stay in the dining room with the coffee. LPN #5 stated the resident was a loner and liked to stay in their room. LPN #5 stated the resident decided to take the cup of coffee to their room. She stated the resident placed the cup of coffee in the wheelchair next to their right leg and left the dining room without asking for assistance. LPN #5 stated the Maintenance staff member was passing by and observed the resident had spilled coffee on themselves. She stated the Maintenance staff member notified the nurse and assisted the resident to transfer to another chair. LPN #5 stated the resident was given a complete physical assessment; at that time, and it was noted the resident had redness on the right hip and upper gluteal area. She stated the facility physician was notified, and orders were obtained to apply Silvadene cream to the affected area three times a day. LPN #5 stated on 11/03/23, the resident's burn changed to a second-degree burn. LPN #5 stated both the resident and staff were educated. She stated the resident was educated on asking for help to carry hot items to their room and not attempt wheeling themselves and trying to carry items themselves. She stated staff were educated in making sure that hot tea and coffee were cooled prior to being given to residents upon request. During an observation on 06/12/24 at 5:15 PM, Resident #40 received their dinner tray in their room. The resident was served coffee with a lid covering the cup to prevent spillage. Review of Resident #40's Admission Record located in the electronic medical records (EMR) under the Profile tab, revealed the resident was initially admitted on [DATE], with diagnoses that included diabetes mellitus type II, depression, acute kidney failure, transient ischemic attacks, and cerebral infarction. Review of Resident #40's five day MDS with an ARD of 07/10/23, located in the resident's EMR under the MDS tab, revealed the resident had a BIMS score 15 out of 15 which indicated the resident had intact cognition. The resident required limited supervision with their activities of daily living (ADLs). Resident #40 utilized a walker and wheelchair for mobility. Review of Resident #40's quarterly MDS with an ARD of 08/28/23, located in the resident's EMR under the MDS tab, revealed the resident had a BIMS score 13 out of 15 which indicated the resident had intact cognition and the resident required supervision with their ADLs. Review of the facility policy titled, ''Safe Use of Microwave Ovens,'' revised 01/08/24, revealed '' .Patient Safety: .2. Hot beverages like coffee, tea or hot chocolate should be served with a lid to help prevent spills if needed.'' Review of facility policy titled, ''Safety of Hot Liquids,'' revised 10/14, revealed '' .Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury.'' NJAC 8:39-27.1(a)

Based on observation, interview, and facility policy review, the facility failed to ensure one of seven medication carts was secured and failed to remove expired supplements and blood equipment from one of two medication storage rooms. This failure has the potential to expose residents to hazards of unsecure medications and expired equipment. Findings include: 1. One of three medication carts located at the nurses' station between 800 hall and 700 hall was observed to be unlocked on 06/12/24 at 11:33 AM. Two staff members were in the office at the nurse station with their backs to the window and the unlocked medication was not in their line of sight. Registered Nurse (RN) 4 was engaged in conversation with another staff member. During this time, several staff members passed by the unlocked cart. One Certified Nursing Assistant (CNA) went to the cart for a straw and left. Two unidentified residents were observed walking by the cart. At 11:59 AM, RN4 returned to the unlocked cart. During an interview on 06/12/24 at 11:59 AM RN 4 revealed that she was not aware the cart unlocked. RN4 stated that she never forgot to lock the cart. RN4 immediately reported the incident of the unlocked med cart to Unit Manager Licensed Practical Nurse (LPN) 6. During an interview on 06/12/24 at 12:05 PM Unit Manager, LPN6 revealed the nurses were trained to ensure the medication carts were always secured. LPN6 stated when the nurse was in the office, the medication carts should have been turned towards the office window so that carts were in the nurses' line of sight. 2. Inspection of the medication storage room located between the 700 hall and 800 Halls on 06/12/24 at 3:18 PM revealed the following expired items: -Four of nine BD Instye Auto guard (intravenous catheter), dated as expired on 07/31/22, 11/30/23, 01/31/23 and 12/31/22 -Nine 14 24 gauge by .75-inch intravenous catheters, dated as expired on 01/31/23 and 01/31/24 -Eight-ounce bottle of Jevity 1.2 Cal (therapeutic nutritional supplement), dated as expired February 2024. -Two of two Sampling Collector (instrument used for collecting specimens), dated as expired on 08/19/23 and 11/19/23 -One non-vented viral access spike (used for withdrawing fluids from vials), dated as expired on 03/31/24. During an interview on 06/12/24 at 3:30 PM with Unit Manager LPN6 revealed after observing the expired items, that she usually checked the medication storage room every Monday and Friday. LPN6 stated that she just checked the medication room yesterday and thought that she had removed all the expired items. LPN6 stated the nurses, and the pharmacy consultant were responsible for checking the medication carts and the medication room for expired drugs. LPN6 also stated she did not realize the blood collection items had expiration dates. Review of the facility's policy titled, Medication Storage and Labeling with a revision date of February 2023, read in part If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items Compartments (including but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes) containing medications and biologicals are locked when not in use, and [NAME] or carts used to transport such items are not left unattended if open or otherwise potentially available to others . NJAC 8:39-29.4