Every finding on record at Bergen New Bridge Medical Center

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation in a manner intended to prevent the spread of food borne illness and in accordance with professional standards for food service safety. This deficient practice could affect all residents. This deficient practice was evidenced by the following:On 8/3/26 at 5:46 PM, the surveyor conducted a kitchen tour with the Food Service Director (FSD) and observed the following concerns:1. The surveyor observed the facility had three air curtain refrigerators (commonly known as an open-air merchandiser or air screen refrigerator (ref) which uses a steady, invisible stream of forced air circulating across the open front or interior opening) on one side of the tray line (a fast assembly method used where workers stand in a straight line along a conveyor belt and each person adds specific food items, drinks, or utensils to a tray based on a printed ticket until it reaches the end for final checking and delivery). The second (middle) air curtain ref had a night curtain (a pull-down blind or shade used during off-hours to boost energy efficiency) pulled down and the items in the refrigerator were not visible. The first and third air curtain refrigerators did not contain a night curtain that could be pulled down. The lower half of these refrigerators had metal pans leaning against the items in the bottom of the ref. The top shelf had refrigerated items that were visible and not covered. The FSD stated that they should have a curtain but that they can work without the curtain. The FSD stated that the air flows over the product and the curtain added a layer of protection. The FSD stated that they are designed to work without the curtain and that the items went into the main ref. 2. The surveyor observed the ice cream reach in freezer had an accumulation of frost on some of the ice cream containers. The FSD confirmed the accumulation of frost and stated that there should not be frost. The FSD stated that every couple of weeks it was emptied and that the frost was because of the humidity.3. The surveyor observed in the walk in ref labeled R010 four yellow heavy duty round garbage containers on wheels, which were lined with white plastic bag and had individual containers of ice tea. Two of the four yellow containers were filled with the ice tea containers. One of the four had a few ice tea containers and the surveyor observed that there was a box on the bottom on the container under the white plastic bag and there was an area of the plastic bag that dropped down below the box and that area contained brownish liquid in it. The fourth container did not have any individual ice tea containers. The surveyor observed that there was brownish liquid in the bottom of the container around the box that was under the white plastic bag.4. The surveyor observed in the walk in ref labeled R010 on the raised back portion of one of the shelves a piece of pie and on the shelf an opened plastic piece of pie shaped container. The FSD stated that it should not be there and that it was last night's dessert.5. The surveyor observed that on each side of the tray line there were three steam tray tables. All of the openings on the six steam tray tables contained a tannish substance on the bottom of opening. 6. The surveyor observed three food service staff members in the pot wash area at three separate compartment sinks. Staff member (SM) #1 and SM #2 did not have a beard guard on. SM #3 did not have a beard guard or hair net. The FSD confirmed the observation and stated that they should have them.7. The surveyor observed in the walk in ref labeled R002 that there was a rolling slatted cart that was used to hold and/or transport trays that was covered by a plastic bag. The surveyor observed that on the cart were trays that contained parchment paper and on the paper were uncooked strips of bacon. The surveyor observed that there were multiple pieces of the uncooked bacon that were hanging off the trays lined with parchment paper and laying over the sides of the tray and touching the side slats of the rolling slatted cart. The FSD stated that the bacon should not be like that and was discarding them.8. The surveyor observed in the walk in freezer which was reachable by walking through the walk in ref labeled R004 there was an accumulation of frost on the containers of food in the front room of the freezer. The surveyor then observed in the back room of the freezer a large accumulation of frost on the ceiling and the pipe that was toward the ceiling. The FSD stated that it should not be like that but that it was due to the humidity and that the staff leave the door open. On 8/5/26 at 9:49 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the above findings and concerns. The surveyor asked the LNHA if the different kitchen area concerns should be that way and to provide the surveyor the facility policy for the kitchen. The LNHA stated that she would see what she could find. On 8/6/26 at 12:50 PM, the surveyor notified the LNHA and Director of Nursing (DON) the concerns observed on the initial kitchen tour.On 8/7/26 at 10:58 AM, in the presence of the DON, the LNHA stated the areas were cleaned and staff were educated on sanitation. The LNHA provided an undated paper that contained type written information about an air curtain without any reference to where the information was obtained with air curtain hand written on it and warranty information.The LNHA did not provide any additional information.A review of the facility's Hair Restraints Policy, dated 8/22/25, included, Policy: All personnel working in Food and Nutrition Services shall wear appropriate hair restraints that effectively prevent hair from contacting exposed food, clean equipment, utensils and single-use articles. Hair restraint Requirements: Hair shall be clean, neat, and securely restrained before entering food production or service areas. Facial Hair: Employees with beards, mustaches, goatees, or other facial hair that may contact exposed food or food-contact surfaces shall wear an approved beard restraint when working with exposed food.A review of the facility's Cleaning of Food and Nonfood Contact Surfaces Policy, with a reviewed/revised date of 8/24/22, included, food contact surfaces are in good condition, made of non-toxic materials and are easily cleanable.Nonfood contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant and nonabsorbent, smooth and easily cleanable.The policy did not have any information regarding the other concerns observed.A review of the facility's Sanitizing Food Contact Surfaces Policy, with a reviewed date of 8/25/25, included, sanitize food contact surfaces after they have thoroughly washed and rinsed.The policy did not have any information regarding the other concerns observed.N.J.A.C. 8:39-17.2 (g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice, by failing to ensure, a.) hospice visit notes were in residents' medical records for 4 of 5 residents (Residents #10, #59, #182, and #273) and b.) hospice recommendations were followed through for 2 of 5 residents (Residents #10 and #273), reviewed for hospice care to promote communication and collaboration between the facility and hospice agency staff. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 8/3/26 at 6:00 PM, the surveyor observed Resident #10 was being fed by a staff inside their room. On 8/3/26 at 6:07 PM, the surveyor reviewed the medical records of Resident #10, and revealed that the resident was currently on hospice care. On 8/4/26 at 10:04 AM, the surveyor further reviewed the medical records of Resident #10, and revealed: A review of the face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; sepsis (infection) unspecified organism, pressure ulcer of left hip stage 3 (a deep, open sore, involves full-thickness skin loss that goes through the outer and middle skin layers down into the fatty layer below), and hyperosmolality and hypernatremia (hyperosmolality means high concentration in the blood, and hypernatremia means blood sodium was elevated). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 3/17/26, revealed the cognitive skills for daily decision making was coded 3 (severely impaired cognition). The MDS also reflected that the resident was in hospice care. A review of most recent quarterly MDS (qMDS) with ARD of 6/16/26, revealed that the resident with severely impaired cognition and on hospice care. A review of the personalized care plan (CP) revealed that the resident was on hospice, end-of-life care related to (r/t) Alzheimer's dementia, with an original date of 3/11/26, with an interventions that included but not limited to hospice nurse follow-up. On 8/4/26 at 10:42 AM, both the surveyor and Registered Nurse #1 (RN #1) observed Resident #10 lying on a specialized air mattress with a call bell within reach, while watching television, and with indwelling catheter inside a privacy bag hung on the right lower side of bed metal frame. Afterward, both the surveyor and RN #1 went to the nursing station, and RN #1 informed the surveyor that when the resident came in to the facility, the resident was not talking and not eating, and with huge wound in the sacral area. RN #1 stated that Resident 10 was currently in hospice care, cognitively impaired, required total care with activities of daily living, and with indwelling catheter. RN #1 further stated that as time went by, the resident now talks, eats well and gained weight, and would probably be off hospice soon because the resident was getting better. On that same date and time, RN #1 showed the chart of the resident, and both observed the admission paper for hospice, and RN #1 stated that the resident was admitted to hospice care on 3/11/26, for end stage dementia. The surveyor observed there were visit sign in sheets that included four visits in March 2026 and April 2026, five visits in May 2026 and July 2026, and two visits in June 2026. The RN stated that the hospice visit signatures from the sign in sheets were from different Hospice Nurses. There were also Hospice Care and Treatment Recommendations for Facility (HCTRF) papers inside the resident's chart, which the RN claimed they were those Hospice Nurse (HN) recommendations when the HN visited. The HN recommendations were dated 3/11/26, 3/25/26, 5/12/26, and 5/20/26. A review of the 3/11/26 HN recommendations included continue with wound care, protein drinks for wound healing such as ensure or boost. There were no other hospice visit notes except for the four HCTRF that were found in the resident's chart, and it did not tally with the number of visit sign in sheets, which were total of 20 visits signatures from March 2026 through July 2026. At that same time, RN #1 confirmed there were no other visit notes except the four notes with recommendations from HN. RN #1 further stated that hospice and facility both different entity with different protocols on writing their notes, and unsure as to why there were no other visit notes. On 8/4/26 at 11:10 AM, the surveyor notified RN Manager #1 (RNM #1), in the presence of RN #1, the concern with hospice visit notes not readily accessible in Resident #10's chart. RNM #1 stated the visit notes should be in the resident's chart, and she was unsure as to why they were not there. On 8/4/26 at 11:19 AM, the surveyor, in the presence of RN #1 and RNM #1, interviewed the HN, who informed the surveyor that he visited Resident #10 at least once a week, and there were times that he visited the resident more than once a week. The HN stated that he documented his visit notes on his computer as required by their company, and the time he had to leave a note was when there would be a recommendation. He further stated that he was not required to leave his visit notes in the resident's chart. He acknowledged that his weekly visit notes included resident's assessment and current status. At that same time, RNM #1 stated that there was an opportunity at this this situation with regard to hospice visit notes to be in Resident #10's medical records, and moving forward, the HN should print his visit notes and file in resident's medical records. On 8/4/26 at 11:32 AM, the Director of Nursing (DON), in the presence of the Assistant DON (ADON) stated that every visit of the HN there should be corresponding visit notes that would be filed in the resident's chart as part of communication between the facility and the hospice. The ADON also confirmed that was the facility's process and expectation. The surveyor then notified both the DON and ADON of the concern that Resident #10's hospice visit notes were not complete in the resident's chart as confirmed by RN #1, RNM #1, and the HN. The surveyor asked for hospice policy. On 8/4/26 at 2:18 PM, the surveyor reviewed the facility's provided copy of hospice agreement that was provided by the DON, and revealed, the agreement were signed by the Hospice Representative/Vice President of Operations and the facility's representative President CEO (Chief Executive Officer) on 5/21/18, which reflected under page 8, agreements #6. Records. A. Preparation. The hospice and the facility shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving services under this agreement in accordance with prudent record keeping procedures and as required by applicable federal and state laws, and regulations and applicable Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided and events concerning each hospice patient. B. Storage. The Hospice and the facility shall each retain such records for 7 years from the date of discharge, or such other time period as required by applicable state law, of each Residential Hospice Patient. Each such record shall be readily available and systematically organized to facilitate retrieval by either party . E. Inspection. The Facility and the Hospice agree to respect and abide by all federal, state and local laws, rules and regulation pertaining to the confidentiality of patient's records. The Facility and the Hospice shall promptly document in the patient's records the services rendered. The Facility and the Hospice shall use confidential data only as necessary for the performance of this agreement, and both parties agree to inform each of its employees of laws and regulations relating to confidentiality. On 8/5/26 at 10:46 AM, RN #1 informed the surveyor that the resident currently on pureed and thickened liquid and had a 100% appetite. RN #1 also stated that the resident currently on Push-20 protein supplement for wound healing. The surveyor asked RN #1 about the 3/11/26 recommendations of the HN for boost or ensure for, which RN #1 said for wound healing. RN #1 further stated that she was unsure if the 3/11/26 recommendations for boost or ensure drink supplement was followed. On that same date and time, RN #1 reviewed the paper chart of the resident and found an order dated 5/13/26, for Push-20, and RN #1 stated that was ordered with regard to 3/11/26 recommendation for wound healing. The surveyor asked as to why the order was dated 5/13/26, over two months on the recommendation of the HN. RN #1 stated that it was probably ordered in March 2026, and she had to look for the thinned chart for March 2026. RN #1 also stated that the resident was on thickened liquid and the reason that the resident was unable to have ensure, and instead had Push-20, was due to thickened consistency. RN #1 had no response when asked by the surveyor as to why the recommendation was not followed on 3/11/26. On 8/5/26 at 10:49 AM, the surveyor notified NM #1 of the above findings and concerns with 3/11/26 recommendation of the HN that was not followed. NM #1 stated that the resident was doing better and eating well now, and the resident was on thickened liquid that was probably why the boost or ensure was not ordered. She did not respond when asked as to why ensure or boost was not ordered when the facility could use a thickener. A review of the 4/10/26 Nutrition notes, in the electronic medical records (eMR) did not include information about boost or ensure recommendations on 3/11/26. On 8/5/26 at 11:54 AM, the surveyor interviewed the Registered Dietitian (RD) in the presence of the Clinical Dietitian Manager (CDM). The RD informed the surveyor that the facility's process was, when the HN had a recommendation, the recommendation would be reviewed, and usually the recommendation would be followed. The RD further stated that if the recommendation would not be appropriate, or appropriate for the resident, there would be documentation in the resident's the eMR. The surveyor notified the RD and the CDM of the above findings that the 3/11/26 recommendation of the HN was not followed, and the RD stated the recommendation for ensure or boost was for wound healing. On that same date and time, the RD informed the surveyor that at that time the resident was not eating well and probably would not take the ensure. The CDM stated that aggressive interventions would not be necessary for hospice resident. The surveyor asked the CDM if the boost or ensure were considered an aggressive interventions, and the CDM replied it depends. Afterward, the CMD acknowledged that the resident with significant weight loss and wounds, the facility should have tried or attempted the recommendations of the HN and that should be shown in the resident's care plan and medical records of the resident. On 8/6/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON, and the surveyor notified them of the above findings and concerns with Resident #10's hospice visit notes, the signed hospice agreements, and 3/11/26 recommendation of the HN that was not followed through. On 8/7/26 at 10:27 AM, the survey team met with the LNHA, and the DON stated that the facility was unaware that the hospice visit notes were not in the resident's medical records until surveyor's inquiry. The DON also stated that Resident #10's hospice recommendation was not followed because the recommendation was put inside the resident's chart, without notifying the nurse of the recommendation, and no one signed the recommendation, which was the standard of practice in the facility as part of communication between the facility and the hospice. The DON further stated that what should have happened was for the HN talked to the nurse in the unit, notified the recommendations that was in the paper, and that did not happen. 2. On 8/3/26 at 6:50 PM, the surveyor observed Resident #59, awake in bed on a low air loss mattress. RNM #2 stated the resident was on hospice care for adult failure to thrive and dementia, and was non-English speaking. On 8/4/26 at 10:51 AM, the surveyor observed the resident awake in bed. A review of the hybrid medical record (paper and electronic documentation) revealed the following information. A review of the qMDS with an ARD of 7/8/26, revealed a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which reflected that the resident's cognition was severely impaired. The qMDS revealed that the resident was receiving hospice care. A review of the CP, with an effective date of 8/4/26, included hospice care. The hospice care intervention, instructed staff to collaborate with the hospice care team, dated 2/11/26. A review of the hospice visit sign in sheet, located on the paper medical record, included 16 hospice nurse sign-ins from May 2026 to August 2026, however, only two visit notes were included in the medical record (5/21/26 and 8/4/26). A review of the hospice services agreement, signed 5/17/26, by the hospice agency representative, stipulated in Section E that the hospice agency shall promptly document in the patient's records the services rendered. On 8/5/26 at 10:53 AM, the surveyor interviewed RN/Charge Nurse #1 (RN/CN #1) and inquired as to the location of the HN visit notes on the medical record. RN/CN #1 was unable to locate the records. She stated the HN gave an oral report to the facility nurse and verbalizes any recommendations. RN/CN #1 further stated she then documented the information in the eMR, and contacted the primary medical doctor. On 8/5/26 at 10:59 AM, the surveyor interviewed RNM #2, who stated HN notes were not consistently provided by the HN. On 8/6/26 at 12:30 PM, the surveyor discussed with the LNHA and the DON concerns regarding HN visit notes. On 8/7/26 at 10:34 AM, the DON stated that the HN failed to place hospice documentation in the medical record. The DON confirmed the policy of the facility and the hospice contract required the HN to include visit notes in the medical record at the time of the visit. 3. On 8/3/26 at 6:30 PM, the surveyor observed Resident #182 lying in bed in the resident's room. A review of the resident's medical record revealed the resident was admitted to the facility and began receiving hospice services on 12/5/25. A review of the resident's qMDS with an ARD of 6/3/26, revealed a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the qMDS revealed the resident was receiving hospice services. On 8/4/26 at 10:00 AM, the surveyor reviewed Resident #182's paper medical record maintained behind the nursing station. A review of the medical record contained only four HCTRF from the time hospice services began on 12/5/25, through the date of the record review. The available hospice nursing documentation was dated 12/5/25, 12/19/25, 7/28/26, and 8/1/26. Further review of the medical record revealed a hospice sign in sheets, which included the date of the visit, name/title, time in and out, and reason for the visit; however, the corresponding hospice nursing visit notes containing the nursing assessments, services provided, and clinical information from those visits were not included in the resident's medical record. On 8/5/26 at 10:40 AM, the surveyor again reviewed Resident #182's medical record. The corresponding hospice nursing visit documentation remained unavailable in the medical record. On 8/5/26 at 11:06 AM, the surveyor, in the presence of RN #2, interviewed RNM #2, who stated that hospice staff verbally communicated with facility nursing staff. Both RN #2 and RNM #2 were unable to provide the missing hospice nursing visit documentation, and both stated that they would have to contact the hospice provider to locate the records. On 8/7/26 at 10:28 AM, the LNHA and DON both acknowledged that the hospice documentation had not been placed in Resident #182's medical record. 4. On 8/3/26 at 6:45 PM, the surveyor observed Resident #273 seated in the day room, calm, not in distress, seated with other residents, and was identified by RNM #3, as a resident who received hospice services. The surveyor reviewed the medical record for Resident #273. A review of the face sheet revealed that Resident #273 was admitted to the facility with diagnoses had diagnoses which included but were not limited to; type 2 diabetes mellitus (high blood sugar) and unspecified dementia. A review of the qMDS with an ARD of 6/17/26, reflected that the resident had a BIMS of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS included that a pain assessment interview was conducted, and the resident was not in pain. A review of the individualized comprehensive CP included a focus initiated on 7/14/26, that Resident #273 was on hospice care who needed emotional, physical, and spiritual support during the terminal phase of their illness. The intervention dated 7/14/26, included, to administer pain medications (meds) as ordered, monitor for effectiveness, call MD (Medical Doctor) if ineffective, or if status changed or worsened suddenly. A review of the hospice documentation sign-in sheet reflected the HN admitted the resident on 6/30/26, and subsequently visited the resident on 7/1/26, 7/8/26, 7/9/26, 7/21/26, and 8/4/26. A review of the hospice communication record reflected that a communication record was not available for review for the 7/1/26, 7/8/26, and 7/9/26. A review of the 6/30/26, hospice communication record included that Resident #273 was easily agitated and was spitting food and meds out of their mouth. The HN also documented that if the resident continued to refuse nutrition, with consistent weight loss, and Alzheimer's disease the prognosis was consistent with the life expectancy of six months or less. The medication (med) recommendation included meds (comfort kit meds) without a start date, and a clarification note from the nurses were not found in the medical record for the following orders: -Morphine 20 milligrams/1 milliliter (mg/ml) 0.25 mg sublingually (sl) every 2 hours as needed (PRN) for shortness of breath (SOB). -Morphine 20 mg/ml, 0.25 ml sl every 2 hours for pain. -Acetaminophen 650 mg suppository, 1 suppository every 4 hours PRN for fever. -Dulcolax suppository 1 rectally every 3 days PRN [for constipation]. -Oxygen 2 to 4 liters (L) per nasal canula for SOB. -Hyoscyamine 0.125 mg 1 sl every 4 to 6 hours PRN, the indication was undefined. A review of June 2026, July 2026, and August 2026, Medication Administration Record (MAR) did not include the meds. Further review of the hospice communication record also reflected a visit occurred on 7/30/26, r/t the resident's restlessness and agitation which was not reflected in the sign-in sheet. The recommendation included Ativan injection 2 mg/ml every 12 hours, a standing order. At that time, the resident had an active order for Ativan liquid 2 mg/ml, 0.25 ml [equal to 0.5 mg] every 4 hours for agitation and was administered on 7/30/26 at 6:00 PM. A review of July 2026 and August 2026, MAR reflected the order was carried out on 8/1/26. On 8/5/26 at 12:10 PM, during an interview with the surveyor, the RNM #3 confirmed the resident was admitted to hospice on 6/30/26, with a life expectancy of six months or less. At that time, RNM #3 could not provide the communication record for the hospice visits on 7/1/26, 7/8/26, and 7/9/26. A clarification note for the admission orders to hospice was also not located. RNM #3 also stated she would inform the DON of the concerns regarding the missing communication record from hospice that was not available to the nurses, and the clarification note that was not found at the time of the interview. On 8/6/26 at 12:21 PM, during a meeting with the survey team, the LNHA and the DON, the surveyor discussed the three visits made by the HN on 7/1/26, 7/8/26, and 7/9/26, did not have a corresponding communication record, and the visit on 7/30/26, that had communication record but was not reflected on the sign-in sheet. On 8/7/26 at 9:15 AM, during a follow-up interview with the DON, the surveyor discussed an additional concern regarding the comfort kit meds that were not clarified and were not reflected on June 2026, July 2026, and August 2026, MAR. On 8/7/26 at 10:27 AM, during a meeting with the survey team, and the LNHA, the DON stated that upon discovery that the hospice visit notes were not consistently left for the nurses, the hospice was called. At that time, the facility confirmed that the hospice policy was that the communication record was supposed be left with the facility. The DON also acknowledged that the recommendations from when the resident was admitted were not clarified, carried out. The DON further stated that when a recommendation was made by the HN, the HN needed to communicate and inform the nurse of the recommendations. No further information was provided by the LNHA. A review of the facility's Hospice Care Policy, dated/revised 2/2024, included that when a resident has elected to receive hospice care services, there must be coordinated plan of care with the resident, hospice care provider and the facility that reflects the hospice philosophy and was based on the resident's individual needs. NJAC 8:39-3.2(a)(b); 11.2(b); 27.1(a)(e)

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services consistent with professional standards of practice for residents with a pressure ulcer (PU). This deficient practice was identified in 4 of 4 residents with PU (Residents #3, #7, #269, and #350) and 4 of 8 residents with risk of developing pressure ulcer (Residents ##170, #174, #182, and #262), reviewed for PU care and prevention. This deficient practice was evidenced by the following: 1. On 8/3/26 at 5:58 PM, the surveyor observed Certified Nursing Aide #1 (CNA #1) exited Resident #3's room who had doffed off their gown in the resident's room. At that time, CNA #1 informed the surveyor that the resident had a pressure ulcer (PU) and was incontinent of bowel and bladder. CNA #1 also stated each time incontinence care was rendered she informed the nurse so that they could change the resident's bandage on the bottom part of their spine which was often soiled and that turning and repositioning (T&P) Resident #3 required two people. At that time the surveyor observed Resident #3 on their back with the head of the bed elevated. On 8/3/26 at 6:26 PM, the surveyor observed Resident #3 in bed, on their back, head of the bed was elevated, the bed was at a low position, fall mats at both sides of the bed, the meal tray was in the room and 25 % was consumed. Resident #3 stated they were not in pain and did not want to eat more. The surveyor reviewed the medical record of Resident #3. According of the face sheet (an admission summary), Resident #3 had diagnoses which included, but were not limited to; diabetes mellitus (DM; high blood sugar) and hypertension. A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/17/26, included the resident's cognition was severely impaired. Further review of the MDS included the resident had two stage 2 (a partial-thickness skin loss where the outer layer (epidermis) and part of the second layer (dermis) are damaged) pressure ulcers that were not present on admission. Additionally, the MDS revealed that the resident was not in a T&P program. A review of the Care Plan (CP) included a focus, initiated on 2 /24/26, that, Resident #3 was at risk for skin breakdown, pressure injury related to (r/t) their need for total assistance with mobility, urinary and bowel incontinence, diagnosis of DM, fragile skin, impaired cognition, and safety awareness. Resident had skin injury to both heels. The right heel measured 3x4 centimeters (cm) and the left heel measured 3x2.5 cm. Further review of the CP included a revised focus on 4/16/26, that included that the resident had an excoriation (scratched, scraped, raw irritated skin) lesion to the sacrum (triangle shaped bone at the base of the spine) that measured 2 x1.5 cm. The intervention initiated on 2/24/26, was to T&P every 2 hours while in bed, and was revised and updated on 4/15/26, to maintain the T&P schedule of at least every 2 hours and as needed. A review of the Occurrence Report, dated 4/20/26, included, sacral excoriation deteriorated to stage 3 (full-thickness skin loss that punches through the outer and inner skin layers into the fatty subcutaneous tissue layer, creating a deep crater-like wound) and required new treatment and measured at 5x3 cm.Physician and resident representative (RR) were made aware. Further review of the investigation reflected that the status was unavoidable since the following routine preventative care was provided: -use of pressure reduction surface -good skin care (clean, protect from moisture) -clean and dry bed linens -maintenance of adequate nutrition and hydration -consistent turning and positioning. A review of the facility provided, plan of care system record (POC; CNA documentation of care activities provided for their assigned resident) for April 2026, revealed that the CNAs signed/affirmed Resident #3 was T&P 19 times out of 90 shifts. On 8/5/26 at 10:13 AM, the surveyor observed Resident #3 in bed on their back with their heels off loaded with two pillows underneath their calves. At that time, during an interview with the surveyor, CNA #2 stated that she checked on the resident every 2 hours, and repositioned the resident every 2 hours, and signed the POC once during her shift. On 8/5/26 at 11:29 AM, during an interview with the surveyor, Registered Nurse Manager #1 (RNM #1) stated that every CNA had a POC and that was where they signed the care given to the residents during their shift. At that time, the surveyor, and RNM #1 reviewed the POCs for Resident #3 associated with the PU investigation dated 4/20/26. At that time, RNM #1 acknowledged and confirmed that the POCs for April 2026 were not consistently signed as provided. RNM #1 stated that she would inform the Director of Nursing (DON) of the concerns. On 8/6/26 at 12:21 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), and the DON, the surveyor discussed the concern regarding the accountability for Resident #3's plan of care against pressure injury that included T&P every 2 hours were not consistently signed as completed on all shifts for April 2026 r/t the wound investigation conducted on 4/20/26. On 8/6/26 at 1:00 PM, during an interview with the surveyor, the DON stated that the facility had identified previously that the POCS were not consistently completed on all shifts. 2. On 8/4/26 at 10:33 AM, the surveyor observed Resident #7 resting in bed alert, non-verbal, and had an alternating pressure system with low air loss (APS/LAL) mattress in use. The surveyor observed the setting of the mattress' indicator, which was based on the resident's weight (wt), was above 250 pounds (lbs). On 8/4/26 10:35 AM, the surveyor reviewed Resident #7's paper chart on the unit which revealed the resident's most recent wt was 128.5 lbs on 7/13/26. On 8/4/26 at 10:55 AM, the surveyor interviewed Registered Nurse #1 (RN #1) assigned to Resident #7, who confirmed the mattress setting was dependent on the resident's wt. RN #1 acknowledged the nursing staff should check the mattress settings. At that same time, RN #1 accompanied the surveyor to check Resident #7's mattress settings, and RN #1 confirmed the settings were set above 250 lbs, which was not the resident's most recent wt. RN #1 could not explain why the setting was at that level and would follow up with RNM #1. On 8/4/26 at 11:38 AM, the surveyor interviewed RNM #1, who stated the nursing staff were responsible for ensuring the mattress settings were appropriate when in use and the setting was based on the resident's wt. The surveyor notified RNM #1 about the above concerns with Resident #7's air mattress settings. RNM #1 stated that she would follow up and provide any information if there was a reason why the mattress was at a higher setting than the resident's wt. On 8/5/26 at 11:01 AM, the surveyor with RN #2 went to Resident #7's room to check their air mattress setting. RN #2 with the surveyor observed the dial setting which reflected the resident's most recent wt. RN #2 confirmed it should be set to the resident's wt, and the RN explained that if the mattress was set at a wt setting that was too high it could be too firm and a risk for a resident to develop a PU. On 8/5/26 at 11:20 AM, the surveyor reviewed the paper chart and electronic medical record (eMR) of Resident #7. A review of the quarterly MDS (qMDS), with an ARD of 7/7/26, indicated Resident #7 was rarely/never understood. Section M (Skin Conditions), Resident #7 was coded as being at risk of developing PU/injuries, and had one stage 4 (worse PU that showed bone) PU. A review of physician's orders (PO) revealed no order related to an air mattress. A review of the resident's care plans (CP) revealed no documentation regarding an air mattress in use for Resident #7. A review of the August 2026 Treatment Administration Record (TAR) revealed no documentation related to an air mattress in use. 3. On 8/5/26 at 9:14 AM, the surveyor reviewed the eMR of Resident #350. A review of the face sheet documented that the resident had diagnoses that included but were not limited to; Parkinson's disease and a seizure disorder. A review of the comprehensive MDS (cMDS) with an ARD of 7/14/26, indicated Resident #350 was documented as being rarely/never understood. Section M, Resident #350 was coded as being at risk of developing PU/injuries, and had one stage 4 PU. A review of PO revealed no order related to an air mattress. A review of the resident's CP revealed no documentation regarding an air mattress in use for Resident #350. A review of the August 2026 TAR revealed no documentation related to an air mattress. On 8/5/26 at 1:26 PM, the surveyor reviewed the resident's paper chart on the unit which revealed the resident's most recent wt on 7/13/26, was 186 lbs. On 8/5/26 at 1:27 PM, the surveyor observed Resident #350 lying on their bed with an air mattress in use. The surveyor observed the air mattress setting at 325 lbs, which was the highest setting. On 8/5/26 at 1:31 PM, the surveyor interviewed RN #2, who confirmed the air mattress setting should be adjusted according to a resident's wt. The surveyor discussed the above concerns of Resident #350's most recent wt and the current settings. At that same time, RN #2 accompanied the surveyor to check Resident #350's air mattress setting, and RN #2 confirmed the setting was at 325 lbs. RN #2 stated the setting should be adjusted to the resident's current wt. RN #2 checked the unit's wt book for Resident #350's wt for this month (August) which was documented as 184.6 lbs. RN #2 changed the setting to reflect the resident's most recent wt. On 8/6/26 at 8:58 AM, the surveyor interviewed the DON, who stated that residents were assessed using a Braden scale assessment to determine their risk for developing PUs. The DON further explained residents assessed to be at high risk would be provided with an air mattress. The DON stated it would be documented in a resident's CP regarding their use of an air mattress. The surveyor asked the DON if it would be documented elsewhere. The DON replied only in the CP. The surveyor requested from the DON the manufacturer's instructions for the air mattress and the facility's policy regarding air mattress use. The DON stated the facility did not have a specific air mattress policy and that it was included in their PU prevention policy. On 8/6/26 at 9:05 AM, the DON provided the surveyor with the air mattress manufacturer's instructions, and the policy titled Pressure Injury Prevention and Management. On 8/6/26 at 12:20 PM, the surveyor notified the LNHA, and the DON of the above concerns regarding Resident #7 and Resident #350's air mattress setting concerns. On 8/7/26 at 10:27 AM, the survey team met with the DON, and the LNHA stated staff were re-educated about the air mattress settings and testing of the mattress to ensure appropriate pressure. A review of the undated [brand name redacted] air mattress manufacturer's operation manual. Under Control Panel Features revealed, patient wt knob is used to adjust the pressure of the mattress according to patient wt. A review of the facility's Pressure Injury Prevention and Management Policy, with a last reviewed date of July 2026, under Process/Procedure revealed .4. Place pressure re-distribution mattress on bed as indicated for at risk patients. The policy did not further address air mattress settings or the checking by staff of the settings. 4. On 8/3/26 at 6:15 PM, the surveyor observed Resident #170 in bed and the resident's pressure-reducing air mattress was set at 325 lbs. On 8/4/26 at 11:15 AM, the surveyor again observed Resident #170's pressure-reducing air mattress set at 325 lbs. The surveyor reviewed Resident #170's medical records. A review of the qMDS, with an ARD of 6/24/26, revealed a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. The qMDS documented the resident's wt as 131 lbs. Section M, identified the resident as being at risk for developing PU/injuries, and identified the use of a pressure-reducing device for the bed. A review of the resident's Braden Pressure Ulcer Risk Assessment (BPURA), dated 6/23/26, revealed a Braden score of 14, at moderate risk. A review of the resident's PO revealed no order for an air mattress. The PO included weekly skin assessments on shower days. On 8/4/26 at 11:20 AM, the surveyor interviewed RN #3 regarding the air mattress setting, who stated they were not sure whether the air mattress setting was related to the resident's wt, and would have to determine how the air mattresses were set and monitored. On 8/4/26 at 11:25 AM, the surveyor interviewed RNM #2 regarding the air mattress, who stated they would have to determine how the air mattresses were set and monitored. 5. On 8/3/26 at 6:45 PM, the surveyor observed Resident #174 in bed with a pressure-reducing air mattress was set at 325 lbs. On 8/4/26 at 11:00 AM, the surveyor observed Resident #174 was seated in a geriatric chair next to the bed, and the pressure-reducing air mattress was again observed set at 325 lbs. The surveyor reviewed Resident #174's medical records. A review of qMDS with an ARD of 5/27/26, revealed the resident's wt as 108 lbs. Section M, identified the use of pressure-reducing devices for the resident's chair and mattress. A review of the resident's BPURA, dated 7/31/26, revealed a Braden score of 14, at moderate risk. On 8/4/26 at 11:20 AM, the surveyor interviewed RNN #3 regarding the air mattress setting, who stated they would have to check on the appropriate setting and did not think the air mattress setting was based on the resident's wt. The surveyor interviewed RNM #2 regarding the air mattress, who stated they would have to look into the appropriate setting. On 8/5/26 at 10:30 AM, the surveyor conducted a follow-up observation of Resident #174's air mattress. The air mattress was set between 105 and 150 lbs. RNM #2 stated they had conducted an in-service with staff regarding checking and monitoring air mattresses to ensure they were set appropriately according to the residents' weights. On 8/7/26 at 10:28 AM, the LNHA and DON both acknowledged the concern and stated that all nurses had been educated on setting and monitoring air mattresses, knowing the resident's wt when setting the mattress, and following the manufacturer's recommendations. 6. On 8/3/26 at 6:30 PM, the surveyor observed Resident #182 lying in bed and the resident's pressure-reducing air mattress was set at 325 lbs. A review of Resident #182's qMDS, with an ARD of 6/3/26, included a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. The resident's wt was documented as 118 lbs. Section M identified the resident as being at risk for developing PU and identified the use of a pressure-reducing mattress. A review of the resident's BPURA, dated 6/2/26, revealed a Braden score of 13, at moderate risk. A review of the resident's PO revealed no order for an air mattress. On 8/4/26 at 11:26 AM, the surveyor interviewed RN #3, who stated the air mattress had been provided by the hospice company and the setting was established when the mattress was initially set up. RN #3 further stated that ongoing checks were not performed to ensure the air mattress remained at a specific setting and was unsure whether the setting was correct for the resident's wt. At that same time, the surveyor interviewed RNM #2, who similarly stated they were unsure whether the air mattress setting was correct for the resident's wt and would have to check. 7. On 8/4/26 at 12:41 AM, the surveyor reviewed the paper chart and eMR of Resident #262. A review of the face sheet reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; acute respiratory distress (a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood) and dependence on respirator [ventilator] (a machine that helps someone breathe). A review of the comprehensive MDS (cMDS), with an ARD of 6/15/26, revealed that the resident was rarely understood. Further review of the MDS reflected that the resident was at risk of developing PU and skin treatments included but were not limited to a pressure reducing device for the bed. A review of the CP, with an effective date of 6/22/26, revealed, the resident had impaired skin integrity r/t existing wounds and is at risk for further developing skin breakdown/PU. On 8/6/26 at 12:20 PM, the surveyor, in the presence of the survey team, discussed the concern with the LNHA and DON. On 8/7/26 at 10:27 AM, the survey team met with the DON, and the LNHA stated that they reeducated the nurses on air mattress requirements and how to determine what the settings should be. The DON stated the expectation was that the nurses should know the resident's wt, set the dial, and do the pressure test to see if the mattress was firm or not firm. The LNHA further stated that the manufacturer's recommendations should have been followed. 8. On 8/3/26 at 7:35 PM, during an initial tour, the DON identified Resident #269 with a facility-acquired sacral wound. The surveyor observed the door to the resident's room was closed. On 8/4/26 at 11:14 AM, the surveyor observed the resident lying in bed, asleep. At the foot of the bed, the surveyor observed the pump for an air mattress. The dial was turned to point at the number 285. Afterward, the surveyor stepped out of the room and asked RN #4, who confirmed the dial was set to 285, and stated that was the pressure of the bed. She added that the resident had an air mattress because they had a sacral wound. RN #r stated she would have to ask Assistant Director of Nursing #1 (ADON #1) as to why the bed was set up at 285. On 8/4/26 at 12:09 PM, ADON #1 stated the air mattress number was set approximate to the resident's wt. She stated the nurse placed hands on the mattress to make sure it was inflated enough, that it should not have been too soft or too firm. ADON #1 stated she was familiar with Resident #269, and believed the resident's wt was in the 150's. ADON #1 further stated the air mattress dial set at 285 corresponded to the resident's wt, the facility did not h ave a policy with regard to air mattress, and they had an instructions for the air mattress setting. On 8/4/26 at 1:06 PM, the surveyor reviewed the reviewed Resident #269's medical record. A review of the face sheet, reflected diagnoses which included, but were not limited to; diabetes, multiple sclerosis, and anemia. A review of the weekly skin assessment dated [DATE], reflected a sacral wound with treatment in progress. A review of the monthly wt record reflected the wt recorded for the month of July 2026, was 157.2 lbs. A review of the progress notes (PN) reflected a Social Services quarterly note dated 8/4/26, which reflected the resident with a BIMS score of 3 out of 15, which indicated the resident was cognitively impaired. The PN did not reflect an air mattress in use. A review of the PO reviewed from 5/4/26 to date, did not reflect the use of an air mattress. A review of the comprehensive CP did not reflect the use of an air mattress. A review of an Incident Summary dated 6/2/26, reflected a sacral wound. The summary, conclusion, and plan did not reflect the use of an air mattress. The summary contained the phrase submitted by: and the name of ADON #2. On 8/6/26 at 9:41 AM, the surveyor interviewed ADON #1, and ADON #2 stated the nurse documented when an air mattress was initially put onto a resident's bed, but after that there was no further documentation done. ADON #1 and ADON #2 both acknowledged air mattress settings were not documented in the medical record. ADON #2 further stated the nurses did not document regarding the air mattress, we just know they (residents) have it (air mattress). A review of the operation manual for [name redacted] alternating pressure system with low air loss (air mattress) reflected the device was designed to treat and prevent wounds by facilitating blood circulation and decreasing pressure of each tissue's contact area. The indications also reflected always consult a physician or health professional before using this mattress system. The section titled Lockable Patient Wt Knob reflected the knob was used to adjust the pressure of the mattress according to patient wt. A review of the facility's Pressure Injury Prevention and Management Policy, reviewed 7/26, reflected.all patients/residents will be assessed and reassessed for pressure injury risk, that a plan of care will be developed and implemented to address risk needs and will receive preventative care to maintain skin integrity and to promote wound healing. The process/procedure section reflected 12. Observation of skin condition, interventions rendered and patients/residents response or outcome will be documented in the medical record. 15. The nurse will ensure that appropriate preventative measures and CP interventions are in place on all patients/residents. Documentation and CP must reflect the use of anti-pressure devices. On 8/6/26 at 12:20 PM, the survey team met with the DON and LNHA, and the surveyor notified them of the above concern. On 8/7/26 at 10:28 AM, the survey team met with the DON, and LNHA stated the nurses were re-educated on how to determine what the air mattress settings should be. The LNHA acknowledged the nurses should know the resident's wt and adjust the mattress accordingly and they needed to add documentation of the resident's wt to their mattress tracking tool. The LNHA further stated that the manufacturer's operation manual instructions should have been followed. On 8/3/26 at 6:49 PM, the surveyor observed Resident #262 lying in bed, non-verbal, and had an APS/LAL mattress in use. The surveyor observed the setting of the mattress' indicator, which was based on the resident's wt, and the setting was 325 lbs. On 8/4/2026 at 11:07 AM, the surveyor observed the setting of the mattress' indicator was 325 lbs. On 8/4/26 11:38 AM, the surveyor reviewed Resident #262's paper chart on the unit which revealed the resident's most recent wt was 205 lbs. on 7/13/26. On 8/4/26 at 11:55 AM, the surveyor interviewed RN #4 assigned to Resident #262, who confirmed the mattress setting was dependent on the resident's wt. RN #4 acknowledged the nursing staff should check the mattress settings. RN #4 confirmed the resident's most recent wt was 205 lbs. At that time, RN #4 accompanied the surveyor to check Resident #262's mattress settings. RN #4 thought the setting was 325 lbs but wanted to check to confirm. Then, RNM #3 and RN #4 checked the resident's mattress settings in the presence of the surveyor. RNM #3 acknowledged the setting was 325 lbs, which was not the resident's most recent wt. RNM #3 stated it should have been set to the resident's wt. RNM #3 stated the setting was too high for the resident and needed to be fixed. RNM #3 stated that the nurses, CNAs, and wound care were responsible for checking the setting, and she further stated there were opportunities to ensure it should be based on resident's wt. On 8/4/26 at 12:09 PM, the surveyor interviewed the Biomedical Engineer in the presence of RNM #3, who confirmed the setting was too high for the resident's wt. NJAC 8:39-27.1 (a)(e)

Based on observation, interview, and review of other pertinent documents, it was determined that the facility failed to ensure 8 of 35 sampled residents (Residents #1, #5, #6, #7, #8, #262, #282, and #350) and 13 of 13 unsampled residents (Unsampled Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) medical information were maintained in a manner that residents' privacy were not visible to all other residents, visitors, and staff, for 2 of 4 nursing units (Building 11-6 and Building 6-3) observed in their survey results binders. This failure placed residents at risk of loss of the right to personal privacy and confidentiality of medical information.This deficient practice was evidenced by the following:On 8/4/26 at 8:05 AM, the surveyor observed on the 1st (first) floor, Building 8 elevator a bulletin board that included posted sign information that the latest LTC (Long Term Care) facility survey report by the NJDOH (New Jersey Department of Health) was available for review in the main lobby and the LTC dayrooms.On 8/6/26 at 8:54 AM, the surveyor toured Building 11-6, and met with the Unit Clerk (UC) and the Nurse Manager (NM). Both the UC and NM stated that the survey binder results should be inside the dining area where everyone could access and see the results of the survey.On that same date and time, both the surveyor and the UC walked toward the dining room and observed Unsampled Resident #1 (UR #1) seated by themselves, and the UC identified UR #1. The UC then showed where inside the dining room the white survey result binder was located on the wall, visible to everyone, and both the surveyor and the UC went back to the nursing station.In the nursing station, the surveyor, with the UC and the NM reviewed the survey results binder, and found on the 1st page Unit 11-6 Residents on Enhanced Barrier Precautions (EBP), that included total of five residents names, with room numbers, and reason for EBP, revealed, Unsampled Resident #2 (UR #2), reason for EBP was due to ESBL (extended-spectrum beta-lactamase; when found in a urine test, it means a urinary tract infection caused by bacteria that resist many common antibiotics) in urine and with GT (gastrostomy tube, a tube surgically placed to abdomen due to difficulty eating). Also, UR #3, UR #5, and UR #6, reasons for EBP was due to ESBL in urine, and UR #4, reason for EBP was due to a wound.At that same time, the NM stated that she was unsure who placed the list inside the binder, and that was HIPAA (stands for the Health Insurance Portability and Accountability Act of 1996, a federal law designed to protect sensitive patient health data from being shared without a patient's consent or knowledge) and should not be there. The UC also stated that she knew there was a reason as to why it was there, but she was unsure who put it there.On 8/6/26 at 9:10 AM, the surveyor toured Building 6-3, and met with the Registered Nurse (RN), who stated that he was unsure where the survey results binder was located. Both the surveyor and the RN toured the unit pantry/dining area (also known as the kitchen) and the nursing station and did not find the survey results binder.On 8/6/26 at 9:20 AM, the DON (Director of Nursing) showed a black binder, and the DON stated to the surveyor that was the survey results binder that the surveyor was looking for Building 6-3, that was located in the dining room. The surveyor opened the binder and observed the 1st page with EBP List Unit 6-3, and revealed:-UR #7, UR #8, and Resident #282, were on EBP due to GT.-UR #9, UR #10, UR #13, and Resident #7, were on EBP due to GT and trach (tracheostomy, a surgically created hole (stoma) in the front of the neck and into the windpipe (trachea). A short tube is placed inside the hole to help a person breathe directly into their lungs when their normal airway is blocked, narrowed, or unable to support breathing).-UR #8, UR #11, UR #12, UR #14, Resident #1, Resident #5, Resident #6, Resident #8, Resident #262, and Resident #350, were on EBP due to vent (ventilator, a medical machine that moves air in and out of lungs when a person cannot breathe well on their own), GT, and trach.On 8/6/26 at 9:33 AM, the surveyor interviewed the DON regarding the survey results binders, and the DON informed the surveyor that it was placed in easily accessible areas for visitors, residents, and staff to see. The surveyor notified the concerns with survey results binders in building 11-6 and building 6-3, where the survey result binders with residents' names, room numbers, and reasons for EBP. The DON stated that she was unaware who put those EBP list in the survey result binders and that should not be there for privacy and HIPAA. On 8/7/26 at 10:27 AM, the survey team met with the DON, and the Licensed Nursing Home Administrator (LNHA) stated she was unaware and unsure who placed the EBP lists inside the survey results binders, and it should not be there. The LNHA further stated there were no additional information to provide, and the survey team could proceed with decision making. A review of the facility's HIPAA-Protected Health Information (PHI) and Privacy Policy, with a reviewed date of 1/2026, that was provided by the DON, revealed under policy, during the course of employment, workforce members.may have access to PHI. Any PHI whether oral, written, photographic or electronic should be maintained in a manner that ensures its privacy and security. Workforce members also have the responsibility to safeguard such information. All workforce also have a responsibility to limit access, use, and disclosure to those that are allowed by permission, authorization and/or law. The access, use, and disclosure must be appropriate to the individual's job responsibilities and duties.Level 1-One-time or Isolated Errors: this level occurs when a workforce member unintentionally discloses or, on an isolated basis, fails to exercise care or makes a mistake in handling PHI. This applies to verbal, written, and electronic methods of communication. Examples include, but are not limited to, leaving a copy of a patient information in a public area.NJAC 8:39-4.1(a)18

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by failing to follow a physician's order for 1 of 35 residents reviewed (Resident #2).This deficient practice was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case-finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 8/4/26 at 10:37 AM, the surveyor observed Resident #2 lying in bed with their head of the bed elevated.A review of Resident #2's face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain, damaging brain tissue) and type 2 diabetes mellitus (DM, a long-term health condition where your body does not make enough insulin or cannot use it the right way that causes sugar to build up in the blood).A review of Resident #2's most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 5/19/26, reflected that the resident's cognitive skills for daily decision making were moderately impaired.A review of Resident #2's Physician Orders (PO) included the following telephone orders:On 7/30/26 at 8:00 PM, discontinue BGM (blood glucose monitoring) every 6 hours with sliding scale coverage novolog [insulin] SQ (subcutaneous) for DM.Greater than 400=10 units.On 7/30/26 at 8:00 PM, start BGM 2 times a day at 6:00 AM and 6:00 PM with novolog insulin coverage SQ for DM 151-200=2 units.351-400=8 units greater than 400 less than 70 call MD (Medical Doctor).A review of Resident #2's August 2026 Medication Administration Record (MAR) included the following:On 8/3/26 at 6:00 PM, nurse administered 10 units of novolog insulin for BG (blood glucose) result of 436. The order indicated to call MD for BG greater than 400.Further review of the PO did not include a PO for 8/3/26, to administer 10 units of insulin for the resident's BG result of 436.A review of Resident #2's Progress Notes (PN) did not include a note on 8/3/26, to indicate that the nurse called the MD to notify them of the BG result of 436 or that the MD ordered 10 units of insulin.On 8/5/26 at 11:58 AM, the surveyor interviewed Building 8-7 Nurse Manager (NM), who confirmed that there was no written PO in Resident #2's medical record for the 10 units of insulin given on 8/3/26. The surveyor asked the NM if there should be a written PO for the BG result higher than 400. The NM stated that she would have to check if there was a PN that the nurse called the MD. On 8/6/26 at 10:31 AM, the NM stated that she spoke with the nurse that administered the insulin on 8/3/26, and she said that she had spoke with the physician and that the physician ordered the 10 units to be given. She added that the nurse told her that she did not write the order or document in the PN. The NM stated that she did call the physician and she verified that the physician gave the order. The surveyor asked the NM if the nurse should have written the order, and the NM did not respond. The surveyor asked if the expectation was that an order was written, and the NM stated that she would have to check. On 8/6/26 at 12:50 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that Resident #2's PO was not followed, that there was no PO to administer 10 units of insulin, and no documented evidence that the nurse called the physician.On 8/7/26 at 10:33 AM, in the presence of the LNHA, the DON stated that the nurse called the physician and forgot to write the order. The DON stated that she verified with the physician that the physician ordered the 10 units of insulin. The DON further stated that they put in a late entry order and that they updated and clarified the order. The surveyor asked the DON if the expectation was to have written the order when received. The DON stated yes of course.A review of the facility's Physician Order and Documentation Policy, with a reviewed date of 1/2026, included the following:4. Telephone, Verbal and Protocol orders must be cosigned within 48 hours.a. It is the responsibility of the individual to correctly identify the ordering physician when entering or writing the order.5. Written orders (Downtime or LTC (Long Term Care) only) must be written legibly, dated, timed, be complete with medication name, route, dose, frequency and indication as appropriate and signed (with printed name) by the ordering physician.N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularities for 1 of 5 residents (Resident #9) for unnecessary medications.This deficient practice was evidenced by the following:On 8/3/26 at 6:18 PM, the surveyor observed Resident #9 asleep in bed. On 8/5/26 at 9:55 AM, the surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical record of Resident #9, which revealed the following:A review of the face sheet (an admission summary) reflected that Resident #9 was admitted to the facility with diagnoses which included but were not limited to' CVA (cerebrovascular accident also known as stroke) and neurocognitive disorder (also known as dementia, a decline in cognitive function) with behavioral disturbance. A review of the recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 7/21/26, reflected a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had a severe impairment in cognition. Further review of the MDS revealed that the resident was taking an antipsychotic medication (med).A review of the Physician Orders (PO) form revealed the following med orders:-Quetiapine (Seroquel) 12.5 mg (milligrams) daily for agitation. Start date 12/9/25 and was discontinued on 1/14/26.-Quetiapine 12.5 mg twice daily for agitation. Start date 1/14/26.-Quetiapine 12.5 mg daily at 5:00 PM for agitation. Start date 2/4/26.A review of the medical records revealed there was no documented evidence that a target behavior was identified with the use of Quetiapine.A review of the CP Monthly Drug Regimen Review form revealed that the CP documented that the resident's chart was reviewed for the period of December 2025 through July 24, 2026, and there was no documented evidence that the CP identified any irregularities with the use of quetiapine med.On 8/6/26 at 1:14 PM, the surveyor interviewed the CP regarding the quetiapine used. The CP stated that she documented the resident's increased behavior and psych consult recommendations when Resident #9 started to receive the psychotropic med. The CP stated that she would get back to the surveyor as to why the CP did not identify the irregularity with use of quetiapine as antipsychotic med with no adequate monitoring and appropriate indication of use. On 8/7/26 at 10:27 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON) stated that there was no consultant pharmacy documentation that the irregularities were identified for appropriate diagnosis and inadequate monitoring from December 2025 to the current time, until the surveyor's inquiry. Both the LNHA and DON acknowledged that there should be an adequate monitoring for use of quetiapine and appropriate indication of use.A review of the facility's Consultant Pharmacist Interim Medication Regimen Review (MRR) Request Policy, with the reviewed date of 6/2026, revealed under Procedure II. C. The Consultant Pharmacist's MRR shall include but not be limited to the following areas: 1. Identification of Irregularities, including unnecessary drugs and adverse consequences.NJAC 8:39- 29.1(b), 29.3 (a)1

Based on observation, interview, and record review, it was determined that the facility failed to; a.) ensure expired medication and supplies were removed from active inventory, b.) ensure accountability and reconciliation of the controlled dangerous substance (CDS; narcotic medications; with high potential for abuse and drug diversion) were tracked with detail. This deficient practice was identified in 1 of 5 medication rooms and 4 of 11 medication carts inspected during the medication and storage observation and was evidenced by the following:1. On 8/4/26 at 10 :59 AM, during the inspection of the medication (med) room on the second floor of Building 5, in the presence of Registered Nurse #1 (RN #1), the surveyor observed a bottle of Acetic Acid 0.25% irrigation solution that expired on 6/2025. At that time, RN #1 stated she would remove the expired med and inform her supervisor of the concern.2. On 8/6/26 at 9:24 AM, during the inspection of the med cart/respiratory treatment cart, on the third floor of Building 6, in the presence of the Respiratory Therapist (RT), the surveyor observed the following:-an opened arterial blood sampling kit-four packets of lubricating jelly that expired on 5/31/26.At that time, the RT stated the lubricating jelly was used during tracheostomy tubing changes and stated she had not used a packet that morning. RT also stated that the expired lubricating jelly should not have been with the active inventory. The RT stated that she had not opened the arterial blood sampling kit that morning and should not have been opened.At that same time, the RT stated that all the RTs and pharmacy staff were responsible for ensuring single use supplies were not opened and left in the cart and that expired medications (meds) were removed.3. On 8/6/26 at 9:40 AM, during the inspection of the med cart/wound treatment cart on the third floor of Building 6, in the presence of RN #2, the surveyor observed a locked box within the cart. At that time, RN #2 stated he did not have the keys to the lock box and could not state how its contents if any were accounted for. At that time, RN #2 called the in-house lock [NAME] to unlock the locked box with the med cart. At 8/6/26 at 10:09 AM, the box was opened by the in-house locksmith and found the following:-[brand redacted] precision cleanroom swabs (low-lint swabs for contamination-free maintenance of sensitive optical, electronic, and medical components) that expired on 1/2023.-one packet of collagen particles that expired on 1/2023.- 1 bottle of Nystop powder (antifungal med) that expired on 8/31/24.At that time, the surveyor discussed the concern with the accountability to ensure expired meds were not in the med cart and when was the locked box last checked to ensure resident care meds were available. RN #2 stated that he would dispose of the expired supply and meds and inform his supervisor of the concern.4. On 8/6/26 at 10:24 AM, in the presence of RN #3, the surveyor began the narcotic med inspection, stored in a mounted, double locked portion of the med cart (narcotic box) located on the second floor of Building 11, district #3. At that time, the surveyor and RN #3 reviewed Resident #136's Controlled Drug Receipt, Record and Disposition Form (declining sheet; an accountability and reconciliation form used to document each narcotic removed for administration, from each resident's designated and prescribed narcotic inventory) for Oxycodone 5 milligram (mg)/ Acetaminophen 325 mg (Percocet; narcotic med used for pain) reflected a quantity of six remained, and was last signed on 8/5/26 at 5:00 PM.At that time, the surveyor and RN #3 compared the Percocet declining sheet against the resident's bingo card (a multidose card containing individually packaged meds) of Percocet that contained five tablets (tabs).At that time, the surveyor and RN #3 reviewed Resident #136's Medication Administration Record (MAR) for Percocet 5/325 mg together which revealed an administration was not signed on 8/6/26 at 9:00 AM.At that time, RN #3 stated that it was hectic that morning and that she should have signed the declining sheet when she removed the med and again should have signed the MAR when she administered the med to Resident #136 that morning.On 8/6/26 at 10:29 AM, the surveyor, in the presence of RN #3, reviewed Resident #323's declining sheet for Lorazepam 0.5 mg (narcotic med; indicated for anxiety) that reflected a quantity of 23 remained, and was last signed on 8/5/26 at 5:00 PM.At that time the surveyor compared the Lorazepam declining sheet against the resident's bingo card of Lorazepam 0.5 mg that contained 22 tabs.At that time, the surveyor and RN #3 reviewed Resident #323 MAR for Lorazepam which revealed an administration signed that morning on 8/6/26 at 9:00 AM.At that time, RN #3 acknowledged she should have signed the declining sheet when the Lorazepam was removed from Resident #136's inventory as it was the facility's policy and part of the five rights of med administration protocol.5. On 8/6/26 at 10:48 AM, the surveyor, in the presence of Licensed Practical Nurse (LPN), reviewed Resident #352's declining sheet for Pregabalin 50 mg (narcotic med, used for pain) that reflected a quantity of 15 remained, and was last signed on 8/5/26 at 9:00 PM.At that time the surveyor compared the Pregabalin declining sheet against the resident's bingo card of Pregabalin 50 mg that contained 14 capsules (caps).At that time, the surveyor and the LPN reviewed Resident #352's MAR for Pregabalin which revealed an administration was not signed administered that morning on 8/6/26 at 9:00 AM.On 8/6/26 at 11:01 AM, the surveyor, in the presence of the LPN, reviewed Resident #14's declining sheet for Lorazepam 0.5 mg that reflected a quantity of 15 remained, and was last signed on 8/5/26 at 9:00 PM.At that time the surveyor compared the Lorazepam declining sheet against the resident's bingo card of Lorazepam 0.5 mg that contained 14 tabs.At that time, the surveyor and the LPN reviewed Resident #14's MAR for Lorazepam which revealed an administration was signed, that morning, on 8/6/26 at 9:00 AM.At that time, the LPN acknowledged and confirmed that the declining sheet should have been signed as soon as the med was removed from the narcotic box and the MAR should have been signed after administration as part of the five rights of med administration protocol.6. On 8/6/26 at 11:38 AM, the surveyor, in the presence of RN # 4, reviewed Resident 246's declining sheet for Tramadol 50 mg (narcotic med, used for pain) that reflected a quantity of 19 remained, and was last signed on 8/5/26 at 5:00 PM.At that time the surveyor compared the Tramadol declining sheet against the resident's bingo card of Tramadol 50 mg that contained 18 tabs.At that time, the surveyor and RN #4 reviewed Resident #246's MAR for Tramadol which revealed an administration was signed administered that morning on 8/6/26 at 9:00 AM.At that time, RN #4 stated that it was her mistake not to have signed the declining log when she removed the med from the narcotic box.On 8/6/26 at 1:27 PM, during a meeting with the survey team, with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns with the expired meds and supplies found in the med room and cart. At that time the surveyor also discussed the concern with the accountability and reconciliation discrepancies found during the med cart inspection.No further information was provided by the LNHA.A review of the facility's Medication Storage Policy, dated/revised 2/2026, included that expired, discontinued and/or contaminated meds will be removed from the med storage area and sent back to the pharmacy for proper disposal.A review of the facility's Controlled Substances Policy, dated/revised on 1/2026, included that when a CDS are administered, in addition to following proper procedures for charting of meds, the nurse/designee must document in the declining inventory sheet the date of administration, the quantity administered, the amount remaining and his/her initials.NJAC: 8:39-19.1(a)29.4 (c)(g) (h)

Based on interview and record review, it was determined that the facility failed to ensure Resident #282 was offered pneumococcal (PNA) vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. This deficient practice was identified for 1 of 5 residents reviewed for immunization status. The deficient practice was evidenced by the following:Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 3/2025, included the following: The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV20 or PCV21) for all adults 19 to [AGE] years old with chronic health conditions who had prior administration of pneumococcal polysaccharide vaccine (PPSV23) only at any age and the alternative option was PCV15.The surveyor reviewed the hybrid (electronic and paper) medical record for Resident # 282.A review of the face sheet (an admission summary), Resident #282 was admitted to the facility with diagnoses that included but were not limited to; acute respiratory failure, pneumonitis (inflammation of the lung tissue) due to inhalation of food, and sepsis (a life-threatening medical emergency that happens when your body overreacts to an infection).A review of Resident #282's most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 5/28/26, reflected a Brief Interview for Mental Status (BIMS) score of 00, which reflected severe cognitive impairment.A review of the electronic Medical Record (eMR) under immunization, the eMR did not reflect if Resident #282 had their PNA vaccine.On 8/5/26 at 11:04 AM, the surveyor interviewed the Infection Preventionist Registered Nurse (IPRN), who stated that she was unware of the updated guidelines from CDC for PNA vaccination, and was not aware that Resident #282 was not up to date with their PNA vaccination.On 8/6/26 at 12:36 PM, the surveyor interviewed the Registered Nurse (RN), who stated that the resident had gotten a PNA vaccine a while ago and that it may have been thinned from the file.At 1:45 PM, the Director of Nursing (DON) provided the surveyor with a consent form for Resident # 282, which revealed that on 12/15/15, the resident received Pneumovax 23, and there was no other PNA vaccine provided to update the resident's status for PNA vaccines per CDC recommendations. The DON stated that the resident was not up to date with their PNA vaccine and she stated that the facility should have given the resident the updated PNA vaccine.On 8/6/26 at 12:45 PM, the surveyor discussed the above concerns with Licensed Nursing Home Administrator (LNHA), and DON.The surveyor reviewed the Resident and Patient PNA and influenza vaccine policy, dated June 2025, which revealed that if established criteria are met, they will receive the current recommended vaccine for pneumonia. On 8/7/26 at 10:40 AM, the LNHA stated that after looking the resident's status, the resident did not receive the updated PNA vaccine as recommended by CDC. N.J.A.C. 8:39-19.4 (i)

Based on observations, interviews and review of facility provided documents, it was determined that the facility failed to treat a resident with dignity while providing care during a meal. This deficient practice was identified for 1 of 15 residents (Resident #236) reviewed for their dining experience, and was evidenced by the following:On 8/5/26 at 12:03 PM, the surveyor observed 15 residents being served lunch in the day room in Building 11 on the 5th floor. The surveyor observed Resident #236 in a recliner chair, with the left side of the recliner chair next to a table, near the center of the room while a Registered Nurse (RN) standing at the table with a tray of food items and beverages in front of the RN, and Resident #236 to the left side of the table. The surveyor observed the RN with a spoon in her right hand, scooped pureed food from the plate, reached over the tray and table to her left side, and fed the resident. Afterward, the surveyor approached the RN, observed the meal ticket and items on the tray, and confirmed the resident was on a pureed diet and required someone to feed them. The surveyor continued to observe the RN who stood to feed lunch to Resident #236 until the resident acknowledged to the RN they did not want to eat any more. The surveyor reviewed the hybrid (electronic and paper) medical record for Resident #236. A review of the face sheet (an admission record) reflected diagnoses which included but were not limited to; dementia and bipolar disorder. A review of the quarterly Minimum Data Set (MDS), an assessment tool, reflected a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating the resident was cognitively impaired. A review of the individualized comprehensive Care Plan (CP) with an effective date of 6/15/26, reflected a problem with mood, with an associated intervention was to approach resident in a calm, direct and friendly manner to set a positive tone for activities, and to provide positive encouragement.to boost self-esteem. A problem with function reflected an associated intervention to provide total assistance with.feeding.On 8/6/26 at 10:35 AM, the surveyor interviewed the RN, who stated Resident #236 could not feed themselves and needed to be fed by a staff. The RN further stated yesterday was not the first time she fed Resident #236. The surveyor notified the RN of the above findings and concerns, and the RN stated it was convenient and easier for the RN to feed the resident while standing because of her height and I usually stand when she feed other residents. On 8/6/26 at 10:47 AM, the surveyor interviewed the RN Nurse Manager (RNNM), who stated when staff feed a resident, the staff should be positioned where they could reach the residents comfortably. The RNNM added that some staff members sit and some stand while feeding. She further stated, It all depends on what was easiest for the staff member. On 8/6/26 at 12:22 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), and the surveyor notified them of the above findings and concerns. The DON acknowledged the staff should be seated and at eye level with the resident while feeding them. On 8/7/26 at 10:28 AM, the survey team met with the DON and the LNHA stated that the RN stood in front of Resident #236 while feeding them, because the RN was not comfortable sitting. The LNHA acknowledged the RN was standing over the resident while feeding them, which was not in line with promoting the residents' dignity. The LNHA further stated the RN should have looked for a different location to place the tray or the resident. The LNHA stated the expectation was that staff were able to sit with, and able to engage with, the residents while feeding them. A review of the facility's Resident Privacy/Dignity Policy, last reviewed August 2024, reflected the purpose of the policy was to protect and promote the rights of each resident. The procedure reflected.D. Protecting the resident's privacy/dignity is a very important aspect of resident care and a right guaranteed by the Resident Rights and Responsibilities. NJAC 8:39-4.1(a)12

REPEAT DEFICIENCYComplaint NJ #2680081Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure residents had access to their call bells to request staff assistance. This deficient practice was identified for 2 of 35 residents (Resident #170 and Resident #182) reviewed for call bell accessibility and was evidenced by the following: 1. On 8/5/26 at 10:22 AM, both the surveyor and the Nurse Manager (NM) observed Resident #170 seated in a geriatric chair next to the resident's bed. The resident's call bell was attached with a clip to the opposite side of the bed and was not within the resident's reach. The NM acknowledged that the resident could not reach the call bell, and would not be able to use the call bell to request assistance if needed. The NM immediately relocated the call bell within the resident's reach.A review of the quarterly Minimum Data Set (qMDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/24/26, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired.A review of the face sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), anemia, and gastrointestinal hemorrhage (bleeding).2. On 8/3/26 at 9:50 AM, the surveyor observed Resident #182 lying in bed in the resident's room. The resident's call bell was located behind the resident, hung from the back of the bed, and was not within the resident's reach.On 8/4/26 at 11:26 AM, the surveyor observed Resident #182's call bell located behind the resident, hung from the back of the bed, and not within the resident's reach. At that time, the surveyor notified the Registered Nurse (RN), who moved the call bell to be within reach of the resident. The RN acknowledged that the call bell was located behind the resident and out of the resident's reach. The RN stated that the call bell should be located next to the resident and relocated the call bell to the resident's side.A review of Resident #182's qMDS, with an ARD of 6/3/26, reflected a BIMS score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS further reflected the resident received hospice services.A review of the face sheet revealed the resident had diagnoses which included, but were not limited to; traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space that covers the surface of the brain, caused by a physical head injury), history of falling, and personal history of transient ischemic attack (a temporary blockage of blood flow to part of the brain).On 8/6/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with Residents #170 and #182's call bell. A review of the facility's Call Bell/Light Policy, revised on 11/2025, included that the facility was to ensure the home was adequately equipped to allow a resident to call for assistance through a call bell communication system. Further review of the policy, under Procedure with Responsibility, included: Ensure the call bell is in easy reach of the resident.On 8/7/26 at 10:27 AM, the survey team met with the LNHA, and the DON acknowledged that the call bell should be within reach of the residents.N.J.A.C. 8:39-27.1(a)

Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the psychotropic medication was used with adequate monitoring and indication for use for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 8/3/26 at 6:18 PM, the surveyor observed Resident #9 asleep in bed. On 8/5/26 at 9:55 AM, the surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical record of Resident #9, which revealed the following:A review of the face sheet (an admission summary) reflected that Resident #9 was admitted to the facility with diagnoses which included but were not limited to' CVA (cerebrovascular accident also known as stroke) and neurocognitive disorder (also known as dementia, a decline in cognitive function) with behavioral disturbance. A review of the recent quarterly Minimum Data Set (qMDS), an assessment tool, with an Assessment Reference Date (ARD) of 7/21/26, reflected a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had a severe impairment in cognition. Further review of the qMDS reflected in Section N (medications) revealed that the resident was taking antipsychotic medication (med).A review of the Physician Orders (PO) form revealed the med orders:-Quetiapine (Seroquel) 12.5 mg (milligrams) daily for agitation, with a start date of 12/9/25, and was discontinued on 1/14/26.-Quetiapine 12.5 mg twice daily for agitation, started on 1/14/26.- Quetiapine 12.5 mg daily at 5:00 PM for agitation, with the start date of 2/4/26.A review of the Physician's Progress Notes (PN) form from December 2025 to July 2026, the physician handwritten notes that Resident #9 had a diagnosis of neurocognitive disorder with behavioral disturbances. The PN included that the staff reported continued agitation with confusion, not easily redirected, staff unable to provide care due to cursing, and fighting staff during care, getting out of chair, pulling peg tube. The physician started quetiapine for agitation on 12/9/25, and increased the dosage on 1/14/26 and 2/4/26, respectively.A review of the psych (psychiatric) consult from December 2025 to July 2026, documented that the quetiapine med was ordered for the diagnosis of agitation. A review of the Consultant Pharmacist (CP) Monthly Drug Regimen Review (MDRR) form on 12/14/25 and 2/27/26, documented as psych consult and behavior monitoring, increase agitation, increase Seroquel.The above CP MDRR had no other documentation.A review of the Behavior/Intervention Monthly Record form from February 2026 to August 2026, indicated that there was no targeted behavior or adequate monitoring for the use of quetiapine med.A review of the Psychotropic Med Monthly Evaluation from the electronic medical record (eMR) on 7/13/26, indicated that quetiapine orders targeted behavior was for agitation and fidgeting. A review of the plan of care from the eMR with an original date on 4/27/26, under problems/strengths Resident #9 episodes of behavioral symptoms such as attempting to pull peg-tube, restlessness, agitation related to dementia, CVA, and mood disorder.On 8/5/26 at 10:01 AM, the surveyor interviewed the Registered Nurse (RN), who stated that she missed monitoring the use of quetiapine, and she was aware that the resident was taking the psychotropic med, and it should be included in the behavior monitoring sheet.On 8/6/26 at 10:30 AM, the surveyor interviewed the RN Manager (RNM), who stated that Resident #9 had a behavior of screaming, agitation, pulling the peg- tube, and getting out of bed to the wheelchair and that was why the psychiatrist was made aware, and increased the dosage of quetiapine. The RNM did not provide further documentation for behavior monitoring.On 8/6/26 at 1:14 PM, the surveyor interviewed the CP regarding the quetiapine used, who stated that she documented the resident's increased behavior and psych consult recommendations when Resident #9 started to receive the psychotropic med. The CP did not provide further information when asked by the surveyor if there was target behavior and appropriate diagnosis should have been identified with use of psychoactive med.On 8/6/26 at 10:59 AM, the surveyor interviewed the Psychiatrist, who stated that she knew the medical history of the resident. Resident #9 had a diagnosis of CVA, major depression, and mixed vascular dementia with behavioral disturbances. The Psychiatrist further stated that fidgeting behavior was not an acceptable target behavior for the resident who was taking quetiapine, and she added that pulling out the peg tube (percutaneous endoscopic gastrostomy tube, is a flexible feeding tube placed through the abdominal wall directly into the stomach) was the appropriate target behavior because it jeopardizes medical conditions or the well-being of the resident.On 8/7/26 at 10:27 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON acknowledged that the Psychiatrist documented a diagnosis of agitation with the target behavior, and there was no consultant pharmacy documentation were identified for appropriate diagnosis and inadequate monitoring from December 2025 to the current time, until the surveyor's inquiry.A review of the facility's Psychotropic Drug Use Policy, with the revised date of 4/2025, revealed under Procedure: 5. The PO will contain an appropriate diagnosis for use based on the current established diagnostic criteria and 6. Behavior monitoring will be initiated for all residents on psychotropic medications to monitor targeted behaviors and side effects.N.J.A.C. 8:39-27.1(a); 33.2(c)2; 4.1(a)6

Based on interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the Resident or Resident Representative with a written notification of the facility's bed hold policy that included the reserve payment information for 1 of 1 resident (Resident #5) reviewed for hospitalizations.This deficient practice was evidenced by the following:On 8/3/26 at 6:40 PM, the surveyor interviewed the Registered Nurse (RN), who stated that Resident #5 was sent to the emergency room last week and was admitted to the hospital, as the resident had bloody urine, atrial fibrillation (an irregular heart rhythm), tachypnea (rapid, shallow breathing), and respiratory distress (difficulty breathing).The surveyor reviewed the medical records of Resident #5, which revealed the following:A review of the face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; respiratory failure, unspecified (a condition in which the lungs cannot release enough oxygen into the blood) and chronic obstructive pulmonary disease (COPD; a chronic lung disease that prevents airflow to the lungs, causing breathing problems).A review of the resident's Discharge Return Anticipated Minimum Data Set (DRAMDS) revealed in Section A-Identification Information, the resident had an unplanned transfer to the hospital in July 2026.A review of the quarterly minimum data set (MDS; an assessment tool), with an Assessment Reference Date (ARD) of 5/28/26, revealed that the resident was rarely understood.A review of the medical records revealed that the Director of Social Services sent a letter to the resident or Resident Representative (RR) on 7/30/26, informing them that the resident who was transferred to the hospital had a 10 days bed hold in place. The letter did not include information about reserve payment.On 8/6/26 at 10:30 AM, the surveyor interviewed the Admissions Director (AD), who stated that the 10 days bed hold was discussed with the resident when they were doing the admission paperwork. The AD stated that they only document the reserve payment if a resident was private pay (also known as paying out of pocket). The AD stated the two different prices per day for a semi-private room and a private room. The AD confirmed that there was no documentation of the reserve payment for Resident #5.On 8/6/26 at 12:20 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). On 8/7/26 at 10:27 AM, the survey team met with the DON, and the LNHA stated that upon admission, everyone [the resident or RR] signed a private pay bed hold policy letter. The LNHA provided the surveyor with a copy of the bed hold policy that they provide upon admission. The LNHA acknowledged that the facility may not only give it upon admission. The LNHA stated that in the future, they would add the reserve payment to the letter that was sent to the resident when they were transferred to the hospital.A review of the facility's Social Work Services in Long Term Care (LTC): Insurances, Bed Holds, Passes Policy, with a reviewed date of 8/2024, and revised date of 1/2023, revealed, the Bed Hold Policy allows for up to 10 days under Medicaid coverage when the resident is hospitalized .N.J.A.C. 8:39-4.1(a)(31);5.1(a)(b)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the compactor/garbage area free of pooled liquid and debris. This deficient practice was evidenced by the following:On 8/3/26 at 5:46 PM, the surveyor conducted a kitchen tour with the Food Service Director (FSD). After the kitchen tour, the surveyor and FSD went outside to observe the garbage and compactor area.The surveyor observed the first garbage container which had liquid with rice and carrots spilled on the ground next to the container. The surveyor observed that under the garbage opening area and on top of the metal area had carrots. The FSD stated that it looked like soup on the ground. The FSD stated that Environmental Services maintained the area and that the kitchen staff helped. He added that it looked like it just happened. The surveyor observed the second garbage container which had debris under and around the side of the container on the ground. The surveyor observed the third garbage container which also had debris around the sides of the container on the ground. The surveyor asked the FSD if the area was supposed to be that way. The FSD stated that he would say no.On 8/5/26 at 9:49 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the surveyor's observations of the garbage/compactor area. The surveyor asked the LNHA if the area should be that way and to provide the surveyor the facility policy for the area. The LNHA stated that she would see what she could find. On 8/6/26 at 12:50 PM, the surveyor notified the LNHA and Director of Nursing (DON) the concerns regarding liquid and debris in the garbage/refuse area.On 8/7/26 at 10:58 AM, in the presence of the DON, the LNHA stated the areas were cleaned and that it was not an active nest. She added that staff were educated on sanitation.A review of the facility's Waste Compactor Usage and Maintenance Policy, with a reviewed date of 9/2025, included, Policy: All waste compactors shall be operated, inspected, cleaned, and maintained according to manufacturer specifications, hospital safety requirements, and applicable local, state, and federal regulations.E. Infection Prevention and Sanitation: 1. Compactor loading areas shall be kept clean and free of waste accumulation. 2. Spills shall be cleaned immediately according to hospital spill response procedures. 3. Compactor surfaces shall be cleaned and disinfected routinely.N.J.A.C. 8:39-17.2(g)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure residents who received an oxygen treatment received care and services according to the standards of clinical practice. This deficient practice was identified for 2 of 3 residents (Resident #103, and #282) reviewed for respiratory care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 8/3/26 at 6:52 PM, during an initial tour, the surveyor observed resident #103 in their room, with eyes closed, lying in bed, on an oxygen (O2) via nasal cannula (NC, delivers O2 via tubing inserted into the nares, from an external source of O2), and the NC tubing was connected to an O2 source mounted on the wall behind the resident's bed. On 8/4/26 at 10:01 AM, the surveyor interviewed Certified Nursing Assistant #1 (CNA) #1, who stated she was assigned to care for Resident #103, and was ready to get the resident out of bed (OOB) but was waiting for the nurse. CNA #1 stated Resident #103 needed to wear their O2 continuously (meaning all the time), and she had to notify the nurse before she transferred the resident OOB to go to the day room. She stated the process was that the nurse disconnected the resident from the O2 on the wall and connected them to a portable tank (a portable pressurized container that provides supplemental O2 at a regulated rate via inhalation through connected tubing). CNA #1 would then transport the resident to the day room using the portable tank, then the nurse disconnected them from the portable tank and connected them to a concentrator (mechanical device that delivers O2 at a regulated rate via inhalation through connected tubing) which was set up in the day room. CNA #1 further stated she was not permitted to disconnect and reconnect a resident's O2, only the nurse was allowed. On 8/4/26 at 11:04 AM, the surveyor observed Resident #103 in a wheelchair (w/c) in their room, facing the open door. CNA #1 was standing behind the resident and the surveyor observed Resident #103 did not have NC tubing in place. At this moment Registered Nurse #1 (RN #1) came to the door of Resident #103's room, and stated she would take the resident to the day room. RN #1 propelled Resident #103 in their w/c out of their room and down the hall. The surveyor observed RN #1 carrying a plastic bag containing NC tubing. The surveyor asked RN #1 if Resident #103 needed to wear O2 during transport, and RN #1 stated there was an O2 concentrator at the nurses station desk, and she would put the resident on O2 there. Afterward, in the presence of the surveyor, RN #1 proceeded to propel Resident #103 to the nurses station desk, RN #1 stopped, looked around, and RN #1 asked where was the concentrator twice. RN #1 was unable to locate the O2 concentrator. The surveyor observed RN #1 propelled the resident inside the dayroom without an O2. At 11:08 AM, the surveyor observed Resident #103 received an O2 via NC, after observation of being without O2 for four minutes. The surveyor did not observe Resident #103 in any distress. RN #1 then exited the dayroom to attend to another resident. On 8/5/26 at 11:27 AM, the surveyor interviewed RN #1, who stated Resident #103 required O2 continuously. She stated the resident wore O2 via NC during the day and via BIPAP (Bilevel Positive Airway Pressure, a type of noninvasive ventilation that helps people breathe more easily when they cannot get enough O2) at night. RN #1 stated Resident #103 was never without O2. RN #1 acknowledged she transported the resident without providing O2 the day prior, during surveyor observation. RN #1 further stated the resident was ok without it for a little while. On 8/5/27 at 11:40 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who acknowledged, after review of the resident's chart that Resident #103 had a PO for continuous O2. The surveyor reviewed the hybrid (electronic and paper) medical record for Resident #103. A review of personalized care plan (CP) reflected diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD, an ongoing condition of damage to the lungs resulting in swelling and irritation of the airways), dementia, and edema (swelling caused by excess fluid in body tissues). The CP further reflected a problem with effective date 7/22/26, of COPD/Resp (respiratory), resident had potential for shortness of breath (SOB) due to dx (diagnosis) COPD.on continuous O2 via NC and BIPAP. The associated interventions included but were not limited to, O2 per MD (Medical Doctor) order. A review of the Physician's Orders (PO) reflected a treatment order dated 4/25/25, for O2.via NC continuously for SOB/COPD. On 8/6/26 at 12:22 PM, the survey team met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), and the surveyor notified the of the above concern. 2. On 8/4/26 at 9:38 AM, the surveyor observed Resident # 282, in bed, with the television on, and observed that O2 via NC at 2 liters per minute (LPM). The resident was unable to answer the surveyors questions. The surveyor observed that there was no date on the O2 tubing. At 10:35 AM, the surveyor interviewed the RN #2, who stated that the resident had O2 and that the tubing was changed weekly. RN #2 stated that there should be a bag in the resident's room which was dated for the O2 tubing to be stored in. At that same time, RN #2 accompanied the surveyor to Resident #282's room, both observed that there was no date on the O2 tubing, and there was no dated bag for the O2 tubing, in the resident's room. A review of Resident # 282's PO's revealed an order dated 5/12/25, for O2 at 2 LPM via NC continuously, may titrate LPM to keep SPO2 (O2 saturation (SpO2) is a measurement of how much O2 your blood is carrying as a percentage of the maximum it could carry) above 91%. There was no order to change the O2 tubing in the PO. At 10:43 AM, the surveyor interviewed the Respiratory Therapist (RT), who stated that the O2 tubing did not need to be dated since there should be an order to change the tubing weekly and that there should be a bag in the room which indicated the date that the tubing was changed. The RT accompanied the surveyor to Resident #282's room and observed that there was no date on the O2 tubing and there was no dated bag for the O2 tubing. The RT stated that any RT could make a determination of what LPM the O2 should be at, if the O2 saturation was below 91%. The RT then stated that there should be an order for a specific LPM from the Physician and that the RT could make a recommendation for the LPM as well. The surveyor reviewed the hybrid medical record for Resident #282. According to the face sheet, Resident #282 was admitted to the facility with diagnoses that included but were not limited to; acute respiratory failure, pneumonitis (inflammation of the lung tissue) due to inhalation of food, and sepsis (a life-threatening medical emergency that happens when your body overreacts to an infection). A review of Resident #282's most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 5/28/26, reflected a Brief Interview for Mental Status (BIMS) score of 00, which reflected severe cognitive impairment. A review of the resident's CP revealed resident was on Respiratory/O2 and intervention included O2 at 2 LPM via NC, monitor vital signs per order, report abnormalities to MD with follow up as needed, and change tubing as needed. On 8/6/26 at 12:45 PM, the surveyor discussed the above concerns with the LNHA and the DON. On 8/7/26 at 10:40 AM, the LNHA stated that the resident's O2 tubing was not dated as it was supposed to be and also the O2 order was not appropriate, and should have been clarified. NJAC 8:39-25.2(c)3

Complaint # 2665060 Based on interviews, medical record review, and review of pertinent facility documentation, it was determined on 11/18/25, that the facility failed to ensure the Certified Nursing Assistant (CNA) flow sheets were complete and accurate. this deficient practice was identified for 2 of 3 residents reviewed for resident accuracy (Resident #1, and Resident #2).The findings were as followed: 1.A review of the admission Record (AR) revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; pneumonia and urinary tract infection. A review of Resident #1's comprehensive Minimum Data Set (MDS), an assessment tool dated 10/28/25, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 of 15, indicating that the resident's cognition was severely impaired. A review of Resident #1's care plan with an original date of 5/5/25 revealed that the resident needed assistance with self care and mobility due to non-ambulatory status and impaired functional mobility related to hx (history) of [stroke] with right hemiparesis and aphasia. A review of Resident #1's CNA Flow Sheet a form utilized for Activities of Daily Living (ADL) care by the CNAs for November 2025, revealed multiple blank sections where care tasks were not recorded. These blank areas further revealed that the CNAs did not document care was provided, as follows: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing, drying face and hands (excludes baths, showers and oral hygiene) were blank on 11/1/25, 11/2/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, and 11/17/25 on the day shifts. The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment were blank on 11/1/25, 11/2/25, 11/4/25, 11/6/25, 11/8/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, 11/16/25, and 11/17/25 on the day shift. The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment were blank on 11/5/25, 11/7/25, 11/8/25, and 11/9/25 on the night shift. The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in and out of tub and shower was blank on 11/9/25 during the night shift The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing and drying face and hands (excludes baths, showers, and oral hygiene) were blank on 11/2/25, 11/5/25, 11/7/25, 11/8/25,11/9/25, 11/11/25, 11/12/25, and 11/17/25 on the night shift. On 11/12/25 at 10:50 AM, an interview was conducted with the CNA, who revealed that the CNAs were responsible for providing the residents with activities of daily living care. The CNA further revealed that all tasks were required to be documented in the Point of Care (POC) system. On 11/12/25 at 11:00AM, an interview was conducted with the Nurse Manager, who stated that it was the expectation that the CNAs documented in the POC and that the assigned nurses reviewed and confirmed the documentation. On 11/12/25 at 2:04 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that all nursing staff was responsible for the resident's care. The ADON further revealed that CNAs document all care in the POC and the ADON also confirmed that there should not be any blanks in the POC. 2.A review of Resident #2's admission Record (AR) revealed on 11/12/25, that the section designated for the resident's medical diagnoses was left blank. A review of Resident #2's Medication Administration Record for November 2025, revealed in the section designated for diagnoses that the resident had diagnoses, that included but were not limited to; disease of spinal cord and quadriplegia. A review of Resident #2's comprehensive MDS dated [DATE], revealed that the resident had a BIMS score of 15 of 15, indicating that the resident's cognition was intact. A review of Resident #2's care plan with an original date of 9/2/25, revealed that the resident had self care deficit secondary to quadriplegic status, dx. (diagnosis) disease of spinal cord, diabetes, hypertension, gastroesophageal reflux disease, polyneuropathy [nerve damage]. The resident was dependent for assistance in all ADL areas. A review of Resident #2's CNA Flow Sheet for November 2025, revealed multiple blank sections where care tasks were not recorded. These blank areas further revealed that the CNAs did not document care provided as follows: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing, drying face and hands (excludes baths, showers and oral hygiene) were blank on 11/1/25, 11/2/25, 11/4/25, 11/5/25, 11/7/25, 11/8/25, 11/10/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, and 11/16/25 on the night shift. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing, drying face and hands (excludes baths, showers and oral hygiene) were blank on 11/1/25, 11/2/25,11/5/25, 11/6/25, 11/8/25, 11/9/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/16/25, and 11/17/25 on the day shift. The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing, drying face and hands (excludes baths, showers and oral hygiene) were blank on 11/2/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25, 11/15/25, and 11/17/25 on the afternoon shift. The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in and out of tub and shower were blank on 11/1/25, 11/2/25, 11/3/25, 11/4/25, 11/5/25, 11/7/25, 11/8/25, 11/9/25, 11/10/25, 11/12/25, 11/13/25, 11/14/25, and 11/16/25 on the night shift. The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in and out of tub and shower were blank on 11/3/25, 11/4/25, 11/7/25, and 11/15/25 on the day shift. The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in and out of tub and shower were on 11/1/25 11/8/25, 11/9/25, and 11/16/25 on the afternoon shift. On 11/12/25 at 10:50 AM, an interview was conducted with the CNA, who revealed that the CNAs were responsible for providing the residents with activities of daily living care. The CNA further revealed that all tasks were required to be documented in the Point of Care (POC) system. On 11/12/25 at 11:00AM, an interview was conducted with the Nurse Manager, who stated that it was the expectation that the CNAs documented in the POC and that the assigned nurses reviewed and confirmed the documentation. On 11/12/25 at 2:04 PM, an interview was conducted with the ADON, who stated that all nursing staff was responsible for the resident's care. The ADON further revealed that CNAs documented all care in the POC and also confirmed that there should not be any blanks in the POC. A review of the facility's policy titled ADL [Activity of Daily Living], Functional Abilities and Self Care with a revision date of 1/2025, under Monitoring and Documentation item1 indicated Record ADL/Functional Abilities assistance in the Point of Care in the EMR [electronic medical record].

Based on observation, interview, record review, and policy review, it was determined that the facility failed to; a) sanitize and air-dry steam table pans correctly to prevent microbial growth, b) follow labeling requirements on food products and use-by dates, and c) maintain food and supply storage. This deficient practice was evidenced by the following: On 5/8/25 at 9:45 AM, in the presence of the Operations Managers (OM #1 and # 2) and Executive Administrator (EA), the surveyor observed the following: 1. In the dishwashing area, the surveyor observed 42 steam table pans wet nested as they were stacked with pooling water between them. The surveyor interviewed the Food Service Worker (FSW), who stated, In the morning we stack the pans. The FSW could not explain why there was water between the pans. At this time, the surveyor also interviewed the OM # 1 and # 2, who stated The pans need to be air dried. 2. At 9:55 AM, in the dish washing area, the surveyor observed the three-compartment sink and the Food Service Director (FSD) used a test strip to check the chemical in the sanitizing third sink. The FSD showed the surveyor the test strip which revealed an improper sanitation level according to manufacturer specifications. The FSD stated that he acknowledged the issue. 3. At 10:10 AM, in the dishwashing area, the surveyor observed four fans in use the had significant dust buildup and they were blowing directly onto cleaned items. OM #1 and #2 stated, The fans should be cleaned before use. OM #1, #2, and EA acknowledged the concern regarding unclean fans in operation. 4. At 10:15 AM, in the walk-in milk refrigerator the surveyor observed five items inspected had past use by dates as well as three items that had no opened date or use-by date. The items with past use by dates included: Greek salad dressing, pickle relish, thousand island dressing, and balsamic dressing (expired 4/26/25). The opened containers with no date labels included mustard, sweet and sour sauce, and BBQ (barbecue) sauce. OM #1 and #2 acknowledged the concerns and stated the items needed to be removed for disposal. 5. At 10:20 AM, the surveyor observed in the prep refrigerator two containers of chicken soup and one full container of mac, and that were wrapped in plastic wrap with no dated labels indicated when they were made or when the needed to be used by. OM #1 and #2 could not confirm preparation date or expiration dates and stated the items would need to be discarded. 6. At 10:35 AM, The surveyor observed the following in the dry storage area. Two dented #10 cans were observed in the presence of the OM #1 and #2. One of the items was a #10 can of mushrooms with a 2-inch dent and the other was a #10 can of pork and beans with a 1-inch dent. OM #1 and #2 pulled the cans aside. A review of the facility's policy titled, Food Safety Product Labeling and Dating Guidelines, dated 12/6/22, revealed the product should be used by the use by date. A review of the facility's policy titled, Cleaning of Food and Nonfood Contact Surfaces, dated 8/24/22, revealed that the third (sink compartment) must contain sanitizer solution at the proper concentration. A review of the facility's policy titled, Storage or Pots, Dishes, Flatware, Utensils, dated 8/24/22, revealed that the facility is to air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet. A review of the facility's policy titled, Food Supply and Storage, dated 8/30/22, revealed that dented cans must be removed and placed on a designated shelf for return to the vendor. During an interview on 5/14/25 at 12:00 PM, the surveyor brought the above concerns to the attention of the Licensed Nursing Home Administrator and Director of Nursing. NJAC 8:39-17.2(g).

Complaint NJ # 169798 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that the devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents residing in Unit 8-7. This deficient practice was evidenced by the following: On 5/12/25 at 1:33 PM, the surveyor upon exit from the elevator, the surveyor observed unit 8-7's call light system machine in the nursing station had a red button on with no audible sounds. There were five staff in the nursing station including the Registered Nurse/Unit Manager (RN/UM). Afterward, the surveyor went to left wing side of Unit 8-7. While the surveyor in the hallway, the surveyor heard one resident yelling for a nurse in Resident room [ROOM NUMBER] (RR#709). The light on top of the door for RR#709 was on with no audible sounds. There was no staff responded to RR#709's call light. On 5/12/25 at 1:40 PM, the surveyor observed no one responded to the call light of RR#709, and the resident by the window was yelling for a nurse. At that time, the surveyor went to the nursing station to ask for the nurse of RR#709. The surveyor also asked the staff how the staff know that the resident was calling or need assistance. The RN/UM informed the surveyor that the resident use call bell then the staff responds to the call bell. The surveyor then asked the RN/UM why the call light of RR#709 was on from 1:33 PM to 1:40 PM, there were no audible sounds, and no staff had responded to the call light. The RN/UM then went to the call light system in the nursing station, the RN/UM press the button with light on and the audible sound was immediately heard. Furthermore, the RN/UM stated that she would have someone go RR#709. The surveyor also asked the RN/UM what happened why there was no audible sounds when the call light was on, the RN/UM stated she was unsure, and she would get back to the surveyor. On 5/12/25 at 1:59 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON) the concerns regarding the call bell light system in Unit 8-7, and the LNHA stated that she would get back to the surveyor. On 5/13/25 at 8:49 AM, the surveyor followed up about the call light system concerns. The LNHA stated that I guess it was on listen mode, and that should have been on a standby mode for them (staff) to be able to hear who were calling. The surveyor then asked the LNHA if that appropriate to be on a listen mode and unable to hear audible sound when residents call, and the LNHA responded that it should not be. She further stated that it was an expectation that the call light system should be in a standby mode for them to be able to hear the call bell. At that same time, the DON stated that education was provided to all staff that call bell should be answered in timely manner and not to put on a listen mode. On 5/16/25 at 10:30 AM, the survey team met the LNHA and DON. The LNHA and DON did not provide additional information except that the LNHA stated that they provided a written response yesterday. A review of the provided Response/Follow Up, typewritten information that was provided by the DON and LNHA, reflected that after surveyor's inquiry, it was identified that there was a delay in responding to the resident call light, after review of the call bell system, it was noted that the audible part of the call bell system was in listen mode. Further investigation indicated that this was inadvertently done by a staff member after answering another call light. The typewritten information also included that the staff were in-serviced and re-educated same day to ensure the button was toggled to standby for the audible sound and to ensure response to visual lights even if audible is not heard. A review of the provided Call Bell/Light Policy with a reviewed date of 7/20/24, that was provided by the LNHA, revealed: Policy: It is the policy of the facility to ensure that the home is adequately equipped to allow a resident to call for assistance through a call bell communication system which contacts a staff member in the nurses' station. The call bell system will have an auditory alert at the station ensure high quality resident care and outcomes. Procedure with Responsibility: 1. Residents will be shown and demonstrate the use of the call bell light located at bedside and in the bathroom/shower room to new resident. 2. Ensure the call bell is in easy reach of the resident. 3. If a resident is unable to use a call bell button, ensure there are regular checks on theses residents. 4. Answer and acknowledge the call bell light in a timely manner as soon as possible . On 5/16/25 at 11:26 AM, the survey team met with the LNHA and DON for an exit conference, there was no additional information provided by the LNHA and DON, and the did not refute the findings. NJAC 8:39-31.8(c), 31.2(e)

Based on observation, interview, and record review, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic medications. This deficient practice was identified for 1 of 5 residents (Resident #213), reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 5/8/25 at 10:35 AM, the surveyor observed Resident #213 walking in the hallway towards the activity room. On 5/12/25 at 10:00 AM, the surveyor observed the resident in the day/activity room sitting on a chair with other residents, non-verbal, and no behaviors observed. The surveyor reviewed the medical records of Resident #213, and revealed: A review of the face sheet (admission summary) reflected that the resident was admitted to the facility with diagnosis which included but was not limited to; Alzheimer's (progressive disease that affects memory, thinking and behavior), dementia (declining memory and thinking skills), major depressive disorder (MDD) recurrent, unspecified mood affective disorder, and psychosis (a mental state where the individual loses touch with reality). A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/26/25, revealed the resident as rarely understood. A review of the order summary, revealed the following orders for antipsychotic medication (med) as followed: -Seroquel 50 milligram (mg), 1 tablet (tab) orally at bedtime for psychosis, ordered on 7/31/24. -Seroquel 25 mg, one-half tab (12.5 mg) orally every morning for psychosis, ordered on 7/31/24, and was discontinued (d/c) on 3/10/25. -Seroquel 25 mg, 1 tab orally every morning for psychosis, ordered on 3/10/25. A review of the resident's care plan, reflected, alteration in mood and behavior due to impaired cognition and impaired safety awareness related to; advanced neurocognitive disorder with behavior disturbance, MDD with psychosis, mood disorder, has episodes of exploring/entering to other residents' room and pulling pants down, episodes of pacing/walking around in the unit without purpose, sad face, and dementia. A review of the psychiatry notes, dated 3/10/25, which revealed, the resident continued to ambulate in and out of other resident's rooms uninvited. Resident had a habit of standing over residents' bed and staring at them while they were asleep. Plan at was to start seroquel in the morning and monitoring. Further review of the medical records, revealed, there was no documented evidence that consents was obtained or the resident representative (RR) was notified and agreed in writing when antipsychotic med was changed. On 5/12/25 at 11:36 AM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) regarding consents for antipsychotic med-seroquel. The RN/UM stated that the facility just started getting consents, we were educated in April 2025 about it, and that we did not know before. She further stated that I understand whenever antipsychotic med was increase of new med was started, consent should have been obtained. The RN/UM also confirmed that she did not have the written consent, and that she will look for the documentation that the RR was notified. The surveyor asked the RN/UM if the expectation was to have a written consent for psychotropic med, and she stated, Yes, I will get consent as soon as possible. On 5/12/25 at 2:01 PM, the RN/UM confirmed that there was no written consent at the time on 7/31/24 and 3/10/25, when the seroquel order was changed. The RN/UM provided a written consent for seroquel dated 5/12/25, signed by the RR, after surveyor's inquiry. A review of the facility's Psychotropic Drug Use Policy, revised 4/2025, reflected that in the event a psychotropic drug/agent must be used, this facility shall implement a system to assure proper consent .The written or witnessed verbal consent form (Informed Consent for use of Psychotropic Med) will serve as evidence of a resident's consent to receive the new or increased dose of a psychotropic med . On 5/14/25 at 12:30 PM, the survey team met with the License Nursing Home Administrator (LNHA) and Director of Nursing (DON), and the surveyor notified them of the above concern with antipsychotic med-seroquel. On 5/16/25 at 10:31 AM, the surveyor asked the LNHA and the DON what was the facility's process with regard to change in the psychotropic med order was, and the DON responded, We really did not have anything regarding consent, we have it now starting April 23, 2025, for the new regulations. The LNHA stated, It was a loose process. At that same time, the surveyor asked the DON, regarding the change of order to increase seroquel on 3/10/2025, what was the expectation when there were changes. The DON and the LNHA confirmed, consents should have been issued and the RR should have been informed. NJAC 8:39-4.1(a)2

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 3 of 32 residents (Residents #20, #83, and #228) call bells were within reach and able to use to accommodate residents' needs. This deficient practice was evidenced by the following: 1. On 5/8/25 at 1:09 PM, Surveyor #1 (S#1) observed Resident #20 in their room and observed that the call bell was not visible. The resident stated that they did not know where the call bell was located. On 5/12/25 at 10:20 AM, Surveyor #2 (S#2) interviewed Certified Nursing Assistant #1 (CNA#1), who cared for Resident #20, who stated that the resident should have the call bell in reach for use. 2. On 5/8/25 at 12:20 PM, S#1 observed Resident #228 awake and alert in their bed. The surveyor observed that the call bell was not visible. The resident stated that they did not know anything about a call bell and that they would call out to the staff for help. On 5/12/25 at 10:48 AM, S#2 observed Resident #228 in bed, and observed the call bell hanging off the wall, behind the residents' bed, and not in reach of Resident #228. At 10:55 AM, S#2 interviewed CNA#2, who cared for Resident # 228, who stated that Resident # 228 would shout out for help, and then stated that the resident should have the call bell in reach for use. CNA#2 went to the resident's room and gave them the call bell for use. On 5/15/25 at 12:25 PM, S#2 discussed above concerns with Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and DON both stated that the residents should have their call bells within reach. 3. On 5/8/25 at 11:51 AM, Surveyor #3 (S#3) observed Resident #83 lying on bed and did not observe a call bell within reach. The resident stated that there was no call bell and had to yell for help for anything and even to change television (TV) channel. Surveyor #4 (S#4) reviewed the medical record for Resident #83. A review of the face sheet (admission summary) reflected that the resident was admitted with diagnoses that included but were not limited to; osteoarthrosis (the joints affected most commonly are the knee, hip, hands and the first metatarsophalangeal joint, the three main symptoms are pain, morning stiffness and a tendency for the affected joint to gel with immobility) and allied disorders, interverbal disc disorders, and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/18/25, revealed in Section C Cognitive Patterns, revealed that resident had moderately impaired cognitive skills for daily decision making. Section GG Functional Abilities revealed that the resident had functional limitation in range of motion (ROM) and was coded 2, impairment on both sides for upper and lower extremities. On 5/13/25 at 9:08 AM, S#4 observed Resident #83 lying on an air mattress with a push button call bell within reach on top of resident's bed. The surveyor observed the resident unable to use the call bell due to limitations to both upper extremities. CNA#3 was inside the resident's room and stated that morning care was done. On 5/13/25 at 9:15 AM, S#4 interviewed the Registered Nurse/Unit Manager (RN/UM) in the presence of the Assistant Director of Nursing (ADON) in unit 8-7 nursing station. The RN/UM informed S#4 that Resident # 83 was alert with some forgetfulness, able to make needs known to staff and can follow directions. The RN/UM further stated that the resident had bilateral upper extremities (BUE) limitations. The ADON stated the contracture was not something new to the resident. At that same time, S#4 asked if the resident had contracture BUE, would the resident be able to use the push button call bell and how the resident would be able to call for assistance. The ADON and RN/UM both stated that staff anticipate needs and do rounds. Both ADON and RN/UM also stated that they would re-evaluate the need of the resident. Furthermore, the ADON stated that there were residents on the same problem with inability to use push button call bell due to limitations and the facility was able to provide a flat call bell to accommodate the need of the residents. S#4 then asked the ADON and RN/UM, why it was not provided to the resident if they were aware of the limitations of the resident, and the ADON stated they would reevaluate the resident. On 5/13/25 at 9:30 AM, S#4 interviewed CNA#3, who informed the surveyor that Resident #83 was cognitively intact, able to follow the commands, and make needs known to staff verbally. CNA#3 further stated that the resident was unable to use call bell due to limitations to BUE, total care, and incontinent of both bladder and bowel. S#4 asked how the resident call for help can if the resident unable to use the call bell, and CNA#3 responded that staff anticipate needs and do rounds. On 5/14/25 at 12:15 PM, the survey team met with the LNHA and DON, and S#4 notified the LNHA and DON of the above concerns regarding Resident #83's call bell. The LNHA stated that Resident #83's call bell was changed yesterday to a flat call bell after surveyor's inquiry. S#4 followed up with the DON about the policy that S#4 asked regarding accommodation of needs, and the DON stated that there was no specific policy about accommodation of needs. The DON further stated that the policy for call bell was the policy they follow for accommodation of needs for call bell. On 5/16/25 at 10:30 AM, the survey team met the LNHA and DON, and there was no additional information provided by the LNHA and DON except for the typewritten Response/Follow Up paper that reflected that after the surveyor's inquiry on 5/12/25, the facility reviewed the resident's needs, identified that the resident was unable to push the call light system due to contracture and physical limitations, and the resident was provided with pad call bell alarm that the resident was able to utilize. A review of the provided Call Bell/Light Policy with a reviewed date of 7/20/24, that was provided by the LNHA, revealed: Policy: It is the policy of the facility to ensure that the home is adequately equipped to allow a resident to call for assistance through a call bell communication system which contacts a staff member in the nurses' station. The call bell system will have an auditory alert at the station ensure high quality resident care and outcomes. Procedure with Responsibility: 1. Residents will be shown and demonstrate the use of the call bell light located at bedside and in the bathroom/shower room to new resident. 2. Ensure the call bell is in easy reach of the resident. 3. If a resident is unable to use a call bell button, ensure there are regular checks on theses residents. 4. Answer and acknowledge the call bell light in a timely manner as soon as possible . On 5/16/25 at 11:26 AM, the survey team met with the LNHA and DON for an exit conference. The LNHA and the DON did not provide additional information and did not refute the findings. NJAC 8:39-4.1(a)11, 31.8 (c)(9)

Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 1 of 32 residents (Resident #132), and 1 unsampled resident (Resident room [ROOM NUMBER]). The deficient practice is evidenced by the following. 1. On 5/8/25 at 11:10 AM, the upon initial tour of the 6th floor, the surveyor observed that inside of Resident room [ROOM NUMBER] (RR#606), there was damage to residents' wall with paint chipped off in five areas, across from the residents' bed. The surveyor also observed damage to the cove base near the residents' closet. The surveyor also observed a 1 inch sized break in the floor tile, also near the resident's closet. 2. On 5/8/25 at 11:16 AM, the surveyor observed that inside Resident #132's room, there were 11 areas of chipped off paint on wall near bathroom. The surveyor also observed damage to the cove base near the resident's closet and damage to wall, exposing sheetrock near closet as well. Lastly, the surveyor observed a 1 inch sized broken piece of wood on residents door, under the residents' door handle. On 5/15/25 at 12:25 PM, the surveyor discussed above concerns with Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA and the DON both stated that the resident's rooms should be in good repair. NJAC 8:39-4.1(a), 11, 31.4 (a), (b), (c), (f)

C #NJ159085 C #NJ158716 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to follow the facility post fall procedure to ensure appropriate care was provided and there was no delay in treatment and ensure: a.) a supervisor was notified, b.) a physical assessment was completed and documented, c.) the physician was notified, and d.) the fall incident was documented in the medical record. This deficient practice occurred for 1 of 34 residents reviewed for quality of care (Resident #168) who had a history of falls, including a fall with a shoulder fracture on 11/30/21, and who sustained an unwitnessed fall when a noise was heard in Resident #168's room on 01/22/23 at 10:35 PM, and the Licensed Practical Nurse (LPN) found Resident #168 lying on the floor and transferred the resident back into bed. On 01/23/23 at 2:10 AM, Resident #168 complained of pain (approximately 4 hours later) and stated he/she had fallen out of bed and had been placed back into bed which resulted in a right distal tibia fracture that required surgical intervention on 01/24/23; and failed to d.) ensure a bed-bound resident was turned and repositioned every two hours per the resident centered Care Plan (CP). This deficient practice occurred for 1 of 34 residents reviewed for quality of care, and for 1 of 2 residents reviewed (Resident #38) for hospice care and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 03/27/23 at 11:35 AM, Surveyor #1 observed Resident #168, sitting in the dayroom, appeared well groomed, and responded to the surveyor's greetings. Surveyor #1 reviewed Resident #168's electronic medical record which revealed in the Care Area Assessment Documentation that Resident #168 was triggered for Activities of Daily Living, (ADL), secondary to decline in overall ADL functions due to a recent post right ankle Open Reduction Internal Fixation (ORIF) on 02/03/23, status post fall with fracture of the right tibia. According to the Admission face sheet, Resident #168 was admitted to the facility with diagnoses which included but were not limited to, other fracture of lower end of right tibia, major depressive disorder, and unspecified schizophrenia. The Significant Change Minimum Data Set (MDS), an assessment tool used by the facility to prioritize care, dated 02/05/23, reflected that Resident #168 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicative of moderate cognitive impairment. On 01/22/23, Resident #168 had an unwitnessed fall in their room. According to the facility provided incident report, Resident #168 was found on the floor next to the bedside. Resident #168 did not have any visible injuries. However, several hours later, Resident #168 complained of pain on the right leg. Upon assessment, Resident #168 was noted to have soft tissue swelling and pain. An X-ray was ordered and performed on 01/23/23 at 8:32 AM. The results were forwarded to the facility on [DATE] at 10:29 AM and revealed oblique comminuted fracture of the distal tibia diaphysis. Resident #168 was transferred to the hospital and underwent surgical intervention to repair the fracture. Review of Resident #168 electronic progress notes dated 01/22/23, did not contain any documentation regarding the fall that occurred on 01/22/23. A nursing progress note dated 01/23/23 at 2:00 AM, revealed the following documentation, Resident #168, c/o [complained of] pain to right leg to the CNA (Certified Nurse Aide). The CNA informed the nurse. The nurse went and assessed the resident and noted that the resident right shin was swollen. Resident #168 informed the nurse that he/she sustained a fall during the 3:00 PM-11:00 PM shift. The nurse alerted the Assistant Director of Nursing (ADON) on duty who came and assessed the resident. Resident #168 stated that he/she sustained a fall after dinner and the LPN assisted him/her into bed. Further review of Resident #168's medical record progress notes dated 01/23/23 timed at 11:58 AM, documented severe pain to the leg, Motrin (a non-steroid analgesic) 600 milligram (mg) administered for pain. The physician ordered to transfer Resident #168 to the hospital. A late entry dated 01/23/22 timed at 10:50 PM, revealed that Resident #168 was found on the floor the evening of 01/22/23 and was assisted to bed by a staff member. There was no evidence of a documented assessment. There were no progress notes to indicate that the physician was called and informed of the fall. The facility's post fall procedure was not available for review. On 03/28/23 at 9:07 AM, Surveyor #1 observed Resident #168, in the room sitting in a wheelchair next to the bed. An interview with the resident revealed that he/she fell while attempting to go to the bathroom. The resident stated the floor was slippery. The surveyor asked the resident how he/she managed to go back to bed, Resident #168 stated, he picked me up, but was unable to recall the name of the staff. On 03/28/23 at 11:30 AM, Surveyor #1 requested the fall investigation for review. According to the Occurrence Report dated 01/23/23, the resident reported the fall at 2:15 AM. Resident #168 informed the ADON that he/she fell after dinner and before 11:00 PM. The fall was not entered on the 24-hour report or in the clinical record to alert the incoming shift to monitor the resident during the night. On 03/28/23 at 12:21 PM, Surveyor #1 interviewed the LPN on duty regarding staffing on the floor. The LPN stated that staffing was very bad on the weekend. The LPN stated that sometimes there were only three CNAs for 56 residents and stated, we try to do our best. On 03/28/26 at 12:26 PM, Surveyor #1 then inquired about the facility post fall protocol. The LPN stated that the process was to ensure no fall recurrence. The LPN stated after a fall a resident assessment must be completed, the physician and the nursing supervisor must be notified. An incident report must be generated. The LPN further added it should be done immediately. You do not want any delay in treatment. The family or the resident's representative were to be made aware also. On 03/29/23 at 10:38 AM, during a second interview with the LPN, she stated that at the end of the shift, a unit report was written regarding day-to-day activities of the unit and a detailed report was entered on the computer. Surveyor #1 requested the detailed report for 01/22/23 for the 3:00 PM-11:00 PM shift, however, there was no detailed report available for review. On 03/29/23 at 11:39 AM, Surveyor #1 conducted a telephone interview with the LPN who worked the 3:00 PM - 11:00 PM shift on 01/22/23, the actual day of the fall. The LPN stated that he heard some movements emerging from Resident #168's room. He then entered the room and observed Resident #168 on the floor, and there was also water on the floor. Resident #168 stated that he/she wanted to go the bathroom and he/she fell . The LPN confirmed that he assisted Resident #168 back to bed. When asked if he assisted Resident #168 to the bathroom, he stated, No. The surveyor asked the LPN if he could recall the time of the incident, the nurse stated it was between 9:00 PM-10:00 PM. The nurse did not inform the physician nor the resident's representative of the fall. The LPN did not inform the ADON on duty that Resident #168 had a fall and needed to be assessed. During the telephone interview, the LPN did not indicate that he forgot to log the fall on the 24 hours report, or in the resident clinical record. The LPN stated clearly to the surveyor, I did not do it. The surveyor then asked the LPN if he was familiar with the facility's policy and protocol post fall, and he stated, Yes. The LPN went on to state the resident must be assessed, an incident report must be initiated, and the physician and the family are to be notified. The LPN further stated that it was negligence on his part not to report or discuss the fall with the ADON on duty that evening. On 03/29/23 at 12:11 PM, Surveyor #1 interviewed the Director of Nursing (DON) regarding the above incident. The DON revealed that she was aware of the incident. The DON stated that the LPN did not follow their protocol. The DON stated that the incident was not reported to DOH (Department of Health). The DON stated, My expectation is to ensure that our residents were safe. For staff, my expectation was that they follow the policy. All policies were reviewed during orientation and as necessary if there is a change in the policy. All policies could be accessed on the computer. The LPN did not follow the facility's policy. The DON stated that she had an open-door policy and staff were free to discuss any concerns. On 03/29/23 at 12:30 PM, Surveyor #1 interviewed the ADON who conducted the 01/22/23 fall investigation. The ADON revealed that the Fall Team committee investigated all falls for Long Term Care. The ADON stated normally all falls must be reported and entered on the 24-hour report. The Unit Managers must report all falls. Disciplines which participated in the Fall Committee included nursing, activities, and Physical Therapy (PT). All must interview the resident. The resident's clinical record was reviewed prior to interview. The ADON stated that the facility had daily meetings which discuss residents that were at risk or needed additional monitoring. The ADON stated that Resident #168 had a fall on 01/22/23, during the evening shift after dinner. The resident stated that he/she was trying to get out of bed to the bathroom, and he/she hit his/her leg. The ADON stated staff were looking for the incident report and could not locate the occurrence report that should have been initiated on 01/22/23. An investigation was started on 01/23/23. All CNAs who worked that shift were interviewed and were not aware of the fall. The ADON and the UM interviewed the LPN who worked that evening. The LPN stated that he was monitoring another resident next door when he heard noises in Resident #168's room. He entered the room and observed Resident #168 on the floor. The LPN did not observe a visible injury and then assisted the resident back to bed. The LPN was asked to elaborate on the protocol to follow a fall. He stated that he was aware of the need to write an incident report, notify the physician, notify the family and report to the next shift. The LPN stated he was sorry and received one day suspension and was reeducated verbally. On 03/30/23 at 8:54 AM, Surveyor #1 obtained and reviewed the LPN's employee file. On 01/31/23, the LPN received one day suspension for the 01/22/23 incident. On 03/30/23 at 9:01 AM, during an interview with the UM regarding the fall, she stated that she interviewed the LPN regarding the fall. The LPN stated that he was focused on another patient. The UM stated that the LPN did not mention that he forgot to report the fall. The UM stated that the LPN was reeducated. On 03/31/23 at 9:11 AM, Surveyor #1 interviewed the Administrator (LNHA) regarding the fall incident. The LNHA revealed that she was made aware that Resident #168 reported that he/she fell and was injured. The evening shift nurse did not report the incident. The incident should have been reported to the next shift for follow up. Any fall must be reported. The LNHA stated that they identified the event as an issue before the survey. The administrator added, As an Administrator, I expected all staff to follow the facility's policies. Interventions should have been put to place immediately. A review of the facility's policy titled,Policy/Procedure: Occurrences-Assessment, Reporting and Intervention, last revised 12/21, included the following: Policy: The facility will maintain systems for reporting, patient/resident, staff, visitor, and property occurrences or potential occurrences (near misses). This date will be used to monitor, evaluate, and trend occurrences to identify opportunities for improvement in patient/resident care and overall safety in the medical center. Occurrence: An occurrence is defined as any incident that is not consistent with routine hospital operation or patient/resident care or any circumstance that threatens physical safety and well-being regardless of whether an actual injury is involved. Responsibility The employee discovering the incident is responsible for completing the occurrence report and informing his/her immediate supervisor of the event. The supervisor will begin an initial investigation of the occurrence and forwarded to the Department/Division VP (Vice President). The VP/designee of the area is responsible to determine if additional action is required and for overseeing a complete and thorough investigation with corrective action plan when applicable. Under Guidelines for completing an Occurrence Report, the following were entered: An Occurrence Report should be completed ASAP [as soon as possible], while the facts are still fresh in everyone's mind. Include essential information, including complete names of all witnesses. Describe only what you saw and heard, and the actions taken on the scene, for example, unless you saw the patient fall, document Patient found on the floor . The Falls Prevention and Management Policy, Revised 12/2021 revealed a Post-Fall Algorithm: Fall; Perform Physical Assessment; Notify Physician, Supervisor; Patient/Resident's Next of Kin; Document Occurrence in Medical Record, Complete Occurrence Report; Perform Post Fall Huddle or Fall Team Meeting as per Divisional Protocol; Review and Update Care Plan Conduct a Fall Re-Assessment as per Policy & Procedure; Continue to re-evaluate patient for fall risk and follow division protocols. 38079 2.) On 03/22/23 at 11:02 AM, Surveyor #2 observed Resident #38 lying flat on his/her back with the head of the bed slightly elevated. The resident was lying on a pressure relieving mattress. On 03/23/23 at 10:08 AM, Surveyor #2 observed Resident #38 lying in bed, flat on his/her back and was sleeping. There was cushioning observed under the resident's legs. On 03/23/23 at 12:18 PM, Surveyor #2 observed Resident #38 lying in bed flat on his/her back with cushioning under the resident's legs and in the same position as observed at 10:08 AM. Surveyor #2 observed there had been no repositioning or turning for the resident. On 03/27/23 at 8:51 AM, Surveyor #2 observed Resident #38 lying in bed flat on his/her back with cushioning under the resident's legs. On 03/27/23 at 9:55 AM, Surveyor #2 observed Resident #38 lying flat on his/her back in bed. The television was on. The surveyor observed cushioning under the resident's legs. On 03/27/23 at 10:30 AM, Surveyor #2 observed Resident #38 lying flat on his/her back in bed with cushioning under the resident's legs. On 03/27/23 at 10:54 AM, Surveyor #2 observed Resident #38 in the same position on his/her back as initially observed at 8:51 AM. At that time, the resident's CNA was in the hallway. During an interview with Surveyor #2, the CNA stated the resident was on hospice and required total care. The CNA stated she would do everything for the resident because the resident was unable to do anything for him/herself. The CNA stated the staff would have to change, wash, and clean up the resident. The resident remained in the same position for approximately two hours, and had not been turned or repositioned. Surveyor #2 reviewed Resident #38's hybrid medical records which revealed the resident had been admitted with diagnoses which included but were not limited to; unspecified dementia with behaviors, hypertensive (elevated blood pressure) heart disease with heart failure, and Type 2 diabetes mellitus. A review of the most recent Quarterly MDS dated [DATE], included but was not limited to: Section B, rarely/never understood and rarely/never understands. Section C, a BIMS was not conducted related to the resident rarely/never understood. Section G, functional status revealed the resident had total dependence on staff for Activities of Daily Living (ADL). Section H revealed the resident was always incontinent of urine and bowels. Section O revealed Resident #38 had been on hospice care while a resident. The facility provided, Plan of Care-Current, dated 3/30/23, included but was not limited to: a focus area of ADL self-care deficit and at risk for development of contractures due to impaired mobility; Intervention dated 5/18/22, turn and reposition q (every) 2 hours and prn (as needed), keep off body prominences, if able, use pillows to reposition; provide total assistance with ADL including bed mobility, toileting needs. A review of the Kardex Summary (a care guide) revealed the resident was dependent on staff for care; to turn and reposition q (every) 2 hours, pillows to offload pressure areas; On hospice care. On 03/29/23 at 10:03 AM, Surveyor #2 observed Resident #38 lying in bed on his/her back with cushioning under the resident's legs. On 03/29/23 at 12:05 PM, Surveyor #2 observed Resident #38 in bed lying on his/her back with cushioning under the resident's legs. Surveyor #2 observed that no repositioning or turning had been done for over two hours. On 03/30/23 at 8:44 AM, Surveyor #2 observed Resident #38 lying flat on his/her back with cushioning under the resident's legs. On 03/30/23 at 10:45 AM, Surveyor #2 observed Resident #38 lying in bed flat on his/her back with cushioning under the resident's legs. Surveyor #2 observed that no turning or repositioning had been done for two hours. On 03/30/23 at 11:07 AM, Surveyor #2 observed Resident #2 lying flat on his/her back with cushioning under his/her legs. The CNA was observed in a resident room across from Resident #38's room, hanging up clothes. On 03/30/23 at 11:09 AM, during an interview with the surveyor, the CNA stated she would use the computer Kardex to see what she would need to do for residents. The CNA showed Surveyor #2 the Kardex for Resident #38 on the computer. The Kardex indicated the resident was to be turned and repositioned every 2 hours. Surveyor #2 asked the CNA what repositioning and turning the resident involved. The CNA stated, we go one side, back, and other side. When asked how the CNA knew what the last position was, the CNA responded, I've been here all morning. Surveyor #2 and the CNA went to Resident #38's room. The CNA acknowledged the resident was positioned on his/her back. The CNA showed the surveyor what she would do to reposition a resident. The CNA lifted the two pads that were under the resident and stated she would put a pillow under there to keep the resident on their side. Surveyor #2 observed no other pillows in the room except the one under the resident's head and legs. The CNA stated a resident would be repositioned and turned to avoid pressure ulcers. When asked why Resident #38 had not been turned or repositioned, the CNA stated the hospice aide had been there about 9:00 AM and it was not time to reposition the resident. On 03/30/23 at 11:21 AM, during an interview with Surveyor #2, the Registered Nurse (RN) showed Surveyor #2 the book that the hospice aides use to sign in which revealed the hospice aide had been there at 7:45 AM. The RN stated a resident in bed should be repositioned and turned every 2 hours. She stated the CNA should be documenting the turning and repositioning in the computer. The RN stated, we want to prevent skin breakdown as the reason for turning and repositioning resident who were dependent on staff. On 03/30/23 at 11:32 AM, during an interview with Surveyor #2, the DON stated that bed bound residents should be repositioned every two hours to avoid skin breakdown. A review of the facility provided, CNA Flow Sheet, dated 2/1/23 to 2/28/23, revealed an area for turning/repositioning. Did you turn the resident Q2H [every two hours]? N (night), D (day), P (PRN-as needed). The dates of 2/1 through 2/15 revealed no documentation to indicate the resident had been turned or repositioned every 2 hours or at all on the night shift, day shift, or as needed. On the night shift it was documented 1 on 2/16, to indicate the resident was repositioned and turned only one time and not every 2 hours of the day. On 27 of 28 days there was no documentation to indicate that the resident was turned or repositioned on the night shift. On the day shift it was documented 1 on 2/16, 2/18, 2/20, 2/22, and 2/24, which indicated the resident was not turned and repositioned every 2 hours of the day. There was no documentation that the resident was turned and repositioned every 2 hours on the day shift on 8 of 28 days: 2/17, 2/19, 2/21, 2/23, 2/25, 2/26, 2/27, or 2/28. On the as needed area, it was documented that the resident was turned and repositioned only 1 time on 4 of the 28 days. This indicated the resident was not repositioned or turned every 2 hours of the day. A review of the facility provided, CNA Flow Sheet, dated run date 3/31/23 at 8:07 AM, revealed an area for turning/repositioning. Did you turn the resident Q2H? The night shift documented 1 on 28 of 30 dates (not including 3/31/23), and 2 on 1 of 31 dates. This indicated that the resident was not repositioned and turned every 2 hours of the day. Two of the dates, 3/4 and 3/5 had no indication that the resident had been turned or repositioned every two hours or at all. The day shift documented 1 time on 15 of 30 dates; 2 times on 5 of the 30 dates; and 3 times on 1 of the 30 dates. This indicated that the resident had not been turned or repositioned every 2 hours of the day. Nine of the dates, 3/2, 3/4, 3/5, 3/7, 3/14, 3/18, 3/19, 3/23, and 3/28 had no indication that the resident had been turned or repositioned every two hours or at all. On the as needed area, it was documented that the resident was turned and repositioned 1 time on 21 days and 2 times on one day. This indicated that the resident had not been turned and repositioned every 2 hours of the day. A review of the facility provided, Nursing Orientation for Assistive Personnel Clinical Staff C.N.A. & MHA [Mental Health Assistant], revised 1/23, included but was not limited to Pressure Injuries, preventative measures, and avoid pressure on bony prominences, turn and position q (every) 2 hours. Included in the book was a card the facility used which had turning and repositioning schedule times and positions as follows: 12 a.m. back, 2 a.m. door, 4 a.m. window, 6 a.m. door, 8 a.m. back, 10 a.m. window, noon back, 2 p.m. door, 4 p.m. window, 6 p.m. back, 8 p.m. door, and 10 p.m. window. Notes: follow above schedule when patient is in bed; otherwise directed by nurse. The turning and repositioning schedule had not been followed. The surveyor requested the facility policy regarding turning and repositioning for residents. The facility provided, Pressure Injury Prevention and Management, dated revised 8/22, included but was not limited to the responsibility of the RN, Licensed Practical Nurse (LPN), and CNA to ensure all residents in bed will be turned and repositioned every 2 hours per repositioning schedule or more often as indicated. A review of the facility provided, Certified Nursing Assistant, undated, included but was not limited to performs basic, routine duties related directly and indirectly to nursing care of patients; and assists patient with activities of daily living. A review of the facility provided, Registered Nurse, undated, included but was not limited to utilized patient care standards in clinical practice; and provides clinical supervision of LPN's, CNA's, and ancillary staff. NJAC 8:39-27.1 (a)

C#: NJ 0 Based on interviews, review of medical records and review of other pertinent facility documentation, it was determined that the facility failed to maintain the accepted professional standards for medication administration by administering the wrong medication to the wrong resident (Resident #2). In addition, failed to follow their policies and procedure titled General Guidelines for the Administration of Medication and Medication Incidents when on 4/12/2020, during the 9 p.m. medication pass, the Licensed Practical Nurse( LPN) poured Resident #3's medication in a cup and gave it to the Assistant Director of Nursing ( ADN) to administer it to Resident #3. Instead the ADN administered Resident 3#'s medication which were poured by the LPN to Resident #2. At approximately 11:15 p.m., Resident #2 was found unconscious by the oncoming nurse on the 11 p.m. - 7 a.m. shift. This deficient practice was identified for 1 of 3 sampled residents reviewed for receiving the wrong medication, as evidenced by the following: A review of Electronic Medical Record (EMR) for Resident #2 revealed the following: The Admission sheet revealed Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Physician's Renewal Order (PRO) in the EMR indicated the following medications were prescribed for Resident #2, by the physician were [MEDICATION NAME] ([MEDICATION NAME]) Tab (tablet) 500 milligram (MG) orally. Give 2 tablets (1000 MG) at bedtime at 9:00 p.m for MOOD, dated 5/17/2017. [MEDICATION NAME] ([MEDICATION NAME]) Tab 10 MG tab. Give 1 Tablet orally at 9:00 p.m., for [MEDICAL CONDITION]. (May cause drowsiness), dated 5/26/2017. [MEDICATION NAME] ([MEDICATION NAME]) Tab 3 MG tab. Give 2 tablets (6 MG) orally daily at bedtime for [MEDICAL CONDITION], dated 4/23/2018. Review of the Interdisciplinary Progress Notes (IPN) dated 4/13/2020 at 1:27 a.m., written by the Registered Nurse (RN #1) who found Resident #2 unconscious while making her rounds revealed the Resident was found unresponsive at 11:15 p.m. The IPN also showed that Resident #2 was assessed and oxygen (O2) was initiated via (by) a nonrebreather mask. The Rapid Response Team (RRT) was called and arrived at 11:35 p.m. The IPN also revealed that an intravenous line was placed into Resident #2's left hand for intravenous fluids (IVF), which was started on the unit. Resident #2 was then transferred to the ER (emergency room ) at 12:00 a.m. for an evaluation. The surveyor requested the investigation, which was provided by the Director of Nursing (DON) on 6/12/2020, review of the incident report titled Incidents: Modify Incident report with an incident date of 4/12/2020, completed by the ADN, revealed that Resident #2 had a Loss of Consciousness, and that the ADN give the wrong meds, [MEDICATION NAME] 30 MG tab and [MEDICATION NAME] 2 MG tab to (Resident #2) . Review of a facility document titled Individual Statement Form (ISF) dated 4/15/2020, written by the LPN revealed that on 4/12/2020 on the 3:00 P.M. to 11:00 p.m. shift, the LPN poured Resident #3's medication in a paper cup, and wrote the Resident's name and room number on a second cup for the ADN to administer the medications to Resident #3.The statement further explained that at 10:00 p.m., Resident #3 asked the LPN for his/her medications. The LPN then called the ADN and asked her who she gave Resident #2's medication to, and the ADN told the LPN that she gave Resident #3's medication to Resident #2, and it was a mistake. Review of a second ISF dated 4/25/2020, written by the ADN revealed that on 4/12/2020 at 9:30 p.m., I was helping (the LPN) to administer medications. I administered the [MEDICATION NAME] 30 MG and [MEDICATION NAME] 2 MG to (Resident #2, when it should have been for (Resident #3). A review of the EMR for Resident #3's revealed the following: The Admission Sheet revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed that Resident #3 had a BIMS score of 15/15, which indicated the Resident was cognitively intact. The PRO in the EMR indicated the following medications were prescribed, by the physician for Resident #3: [MEDICATION NAME] ([MEDICATION NAME]) tablet 2 MG. 1 tab orally daily at 9:00 p.m. for Anxiety, dated 3/27/2018. [MEDICATION NAME] tab 10MG, 3 tablets (30MG) orally at 6:00 A.M., 2:00 p.m., and 10:00 p.m. for pain management, dated 6/12/2018. During a telephone interview on 6/11/2020 at 10:53 a.m., RN #1 stated she found Resident #2 unresponsive lying in bed, during her rounds. RN #1 also indicated she told LPN #1 that Resident #2 was unresponsive. LPN #1 explained to RN #1 that Resident #2 was given Resident #3's medication, and she told the LPN to call the RRT. RN #1 also indicated that she took the crash cart to Resident #2's room and placed the O2 nonrebreather on the Resident, however; the Resident was not responding. RN #1 further explained at this time the RRT arrived in Resident 2's room and took over caring for the resident. During an interview on 6/11/2020 at 11:15 a.m., LPN #1 stated that around 9:00 p.m., the ADN was assisting her with administering the medication, she wrote Resident #3's name and room number on the cup and gave the cup to the ADN to administer the medication to the resident and then signed off on the Medication Administration Record. LPN #1 indicated that Resident #3 came to her around 9:30 p.m. and asked for her medication. The LPN explained she then called the ADN and asked her who she gave Resident #3 medication to, and the ADN indicated she gave the medication to Resident #2. In addition, LPN #1 stated when giving medication the policy is to check the (resident's) hand band which has the Resident's name. During a telephone interview on 6/11/2020 at 1:17 p.m., the RRT Physician stated that she was told that Resident #2 was given [MEDICATION NAME] and [MEDICATION NAME]. The RRT Physician also indicated, when she arrived at the scene the Resident #2 was lethargic, and the Resident's blood pressure and O2 were fluctuating. The RRT Physician also indicated Resident #2 was placed on a 100 % non-rebreather O2 and [MEDICATION NAME] was administered. In addition, the Physician stated that Resident #2 responded to the [MEDICATION NAME] and was stable. During an interview on 6/11/2020 at 11:52 a.m., with the with the DON, in the presence of the ADN, the DON indicated the ADN should have checked Resident #2's hand band prior to administering the medication. During an interview on 6/12/20 at 9:39 a.m., the ADN stated she was helping the LPN to administer the 9 p.m., medication. The LPN prepared Resident #3's medication and indicated the medication was for Resident #3 and gave her the medication to administer to Resident #3. However, the ADN indicated she did not look to see if it was a male or female resident and she administered Resident #3's medication to the wrong resident, Resident #2. The ADN also indicated that prior to administering the medication to Resident #2, she failed to check the Physician's order, Medication Administration Record, [REDACTED]. In addition, the ADN stated she failed to check Resident#2's name wrist band and she was not supposed to administer medications she did not prepare. Review of the facility policy titled, General Guidelines for the Administration, dated 1/2019, under Procedure #3, included the following: . The nurse observes the five rights in administering each medication: a). The right resident b). The right time c). The right medication d). The right dose Under #5. Nurse identifies resident by name and by the facility identification system in place (ID bracelet, photo, etc.). Review of a second facility's policy titled Medication Incidents, dated 1/19, included under Definitions: Medication Incident: Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health professional Under Severity of Event included Incident Harm, Category L4. An incident occurred that resulted in the need for treatment or intervention and caused temporary patient harm. N.J.A.C:8:39-29.2(d)

COMPLAINT # NJ 5 Based on interviews, review of the Medical Records (MR), and other pertinent facility documentation on 11/15/2019 and 11/20/19, it was determined that the facility staff failed to safely discharge a Resident with [MEDICAL CONDITION], Stage 4 Wounds, Tube feedings, and needed continuous oxygen (O2) on 10/30/2019. The facility failed to ensure that appropriate arrangements were in place prior to discharge to ensure a safe discharge and prevent harm. The facility also failed to ensure that Durable Medical Equipment (DME) was delivered to the home prior to discharge which included; Oxygen tanks (O2), tube feeding pump, humidifier for the [MEDICAL CONDITION] (trach), Ambu bag (manual resuscitator/emergency ventilator), Nebulizer machine (for administration of breathing treatments), Suction Machine, and [MEDICAL CONDITION] (inhalation/exhalation pressure)/C-Pap Machine (continuous positive airway pressure), as well as supplies for these. The facility also failed to provide adequate education with return demonstration to the care giver to ensure that the Resident would receive appropriate care prior to discharge in the areas of [MEDICAL CONDITION] care and suctioning, Jejunostomy tube feedings (J-tube), Stage 4 wound care, [MEDICAL CONDITION]/C-Pap instructions, Nebulizer Treatments, Oxygen use and Humidification, as well as follow the facility's own policy titled Discharge Planning: Discharge Planning and Instructions, for 1 of 5 sampled residents, (Resident #3). On 10/30/2019, Resident #3 was discharged to home without the resident's son receiving appropriate education for [MEDICAL CONDITION] care, Stage 4 wound care, Jejunostomy Feeding, and the use of [MEDICAL CONDITION]. As well as no Oxygen therapy education, and no Oxygen in the home. Resident #3 arrived home and was immediately transferred to the hospital. This deficient practice placed Resident #3, as well as all residents pending discharge to home in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the Administrator and the Director of Nursing (DON) on 11/15/2019 at 3:25 p.m. when the IJ template was provided to the Administrator. The IJ ran from 10/30/2019 until 11/15/2019 at 4:30 p.m., and was lifted when the Administrator provided an acceptable Removal Plan on 11/15/2019 at 4:30 p.m. This deficient practice is further evidenced by the following: 1. According to the facility Face Sheet, Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 7/2/2019, Resident #3 had a brief interview for Mental Status (BIMS) score of 13/15, indicating that Resident #3 had intact cognition. Review of Resident #3's Care Plan (CP) with an effective date of 7/10/2019, under Problems/Strengths revealed : Resident #3 has Stage 4 Pressure Ulcers; on the Sacrum and Left Buttock, was incontinent of bowel, has limited bed mobility and is at risk for further skin breakdown. Interventions included but were not limited to: Treatment as ordered ., Turn and reposition every 2 hours . The CP also included under Problems/Strengths; Resident #3 has a [MEDICAL CONDITION] and is at risk for increased secretions/congestion and [MEDICAL CONDITION]. Interventions included but were not limited to: Respiratory Management/[MEDICAL CONDITION] care per protocol, suction to remove thick secretions PRN, (As necessary when required), monitor amount, color, odor, and consistency of sputum. The CP further revealed under Problems/Strengths: Resident #3 is at risk for alteration in nutrition/hydration due to being NPO (nothing by mouth) secondary to dysphagia (Difficulty swallowing), and vent (ventilator) dependence, requires tube feeding for nutrition and hydration support . Interventions included but were not limited to: Monitor weight trends, Provide tube feeding [MEDICATION NAME] 1.5 at 60 ml (milliliters)/hr x 16 hours or until total volume of 960 ml is administered. Start tube feeding at 6 p.m. Provide Advanced Mechanical soft tray for breakfast and lunch with Passy Muir valve (one way speaking valve commonly used to help patients with [MEDICAL CONDITION] speak) in place. The CP also revealed that Resident #3 has episodes of physical behavioral symptoms as evidenced by : pulling out Trach, and trying to climb out of bed during care, pushing care giver related to DX (Diagnosis) of [MEDICAL CONDITION], Anxiety Disorder, and Depression. The CP further revealed under: Problems/Strengths: revised date 4/17/2019, Resident #3 requires assistance with discharge planning to another facility. Interventions included but were not limited to: Assist with resident's family's understanding and acceptance of treatment goals and discharge plan. Order Visiting Nurse Services, Durable Medical Equipment and transportation as needed, Dietician to provide diet instructions, Nursing /MD (physician) to instruct the resident/family /primary care person regarding medication (dose, use, side effects, rationale) and treatments. Assure that continuity of care is maintained by giving a detailed summary of care needs when discharged . Encourage resident/ family to express feelings, concerns, preferences related to placement, limitations and discharge plan. Review of the MD Monthly Progress Note, dated 9/11/2019, revealed the following : Pt (Patient) is awake/alert, communicating well, asking to go home, wants more privacy .will discuss with Psychiatry, will continue [MEDICATION NAME] prn for anxiety continue psyche (psychiatric) meds (medications) per orders. No GRD (Gradual Dose Reduction for psyche meds) at this time. Continue with feeding/Aspiration (choking) precautions. Review of the Physician order [REDACTED].#3's discharge were as follows: O2 (Oxygen ) supply 2 L (liters) and humidification, Home Care Services, Normal Saline flushes (to clear the wound), [MEDICAL CONDITION]/C-Pap machine, 2 Liter O2, 50 ml Twister Syringe, [MEDICATION NAME] 1.5 at 60 cc (ml) hr X 16 hrs (hours), Foam Dressing 4x4 #90 (supply 90), Gauze 4x4 5 boxes, Pill Crusher #1,Tube feeding tubing #30, 6x6 sponges #5 boxes, Inner Cannulas (trach) #7 [MEDICATION NAME], Ambu Bag, Nebulizer kit #30, [MEDICAL CONDITION] #7 cuffed, [MEDICAL CONDITION] collar, Suction Machine #1 and kit, [MEDICATION NAME] Nebulizer 1.25 mg (milligrams)/3 mg vial q (every) 4 hours x1month, tube feeding tubing #30,[MEDICAL CONDITION] 50 % O2, [MEDICAL CONDITION] 10/5 28% NC (Nasal Cannula). Review of a Interdisciplinary Progress Notes (IPN) dated 10/21/2019 02:36 p.m. revealed : The SW (Social Worker) informed resident's son that as per Home Care Service they will provide service 3 days a week, therefore the son has to either pay a private nurse to cover for the remaining days of the week or a family member should be trained, the son declined but stated that he will start Medicaid application in NY. Per the note, the SW educated him on the importance of a safe and well planned discharge. Review of IPN dated 10/23/2019 at 2:34 p.m., revealed The IDCP (Interdisciplinary Care Plan) Team met today for a conference call with Resident #3's son . to inform him about his mother's intricate medical care upon her discharge. Nursing, Rehab (Rehabilitation), Respiratory, and Nutrition Services explained to him the care that his mother is currently receiving in this facility and what will be needed when she is discharged home. His questions and concerns were addressed to his satisfaction . Review of IPN dated 10/23/2019 at 3:06 a.m., revealed continue of 1:1 supervision and camera monitoring for [MEDICAL CONDITION] tubing, [MEDICAL CONDITION] in use . Review of IPN dated 10/29/2019 at 2:37 p.m., Respirations unlabored. Suction as needed for copious amount of white thick secretions. Scheduled for discharge tomorrow as per SW resident son is coming tomorrow for discharge instruction. Pick up by (transport) at 11 AM. Review of IPN 10/30/2019 at 4:27 p.m. revealed: the nurse documented that 10:30 AM met with resident's son to give discharge instructions on administration and purpose for medication. The nurse also documented that the son did not want Resident #3 on psyche meds; the [MEDICATION NAME] and [MEDICATION NAME] and wanted them to be discontinued because he did not want his mother to be sleeping all day. The IPN continued that the son was also informed of the Respiratory treatment and care that would have to be done to maintain a patent airway, about oral care, incontinent care, wound care, and to have resident in upright position for meals. The nurse documented that The [MEDICAL CONDITION] has to be on at night and in the day oxygen [MEDICAL CONDITION], He was also told that the Respiratory company will give further Respiratory teaching. Son expressed that he understood. Resident left at 11:40 am via ambulance, no acute distress noted. There was no documentation to indicate that beyond verbal instruction, that any demonstration of the above occurred at that time. A review of the documentation in the Interdisciplinary DischargeSummary dated 10/28/19, included Resident #3's medication list. The documentation was signed on the last page and dated 10/30/19. However, there was no documentation regarding discharge instructions/education and/or return demonstration of any of Resident #3's care needs. Review of IPN dated 10/30/2019 at 5:07 p.m., revealed 1:35 PM informed by charge nurse that (son) called to say that no one brought oxygen to the house for his mother. I spoke to EMT (Emergency Medical Technician) for Rapid Response Ambulance. He said there are two ambulances at the house and all they need is for the Doctor to fax (facsimile) an order for [REDACTED]. During an interview on 11/15/2019 at 10:18 a.m., the Charge Nurse (CN) stated that the process for determining when a resident can be discharged back to the community is upon admission we do a discharge process most of the time they are Long Term Care. Sometimes the family wants to bring resident home, we start at the IDC (Interdisciplinary Care) meeting, Nursing, Social Worker, MDS (Minimum Data Set), PT (Physical Therapy), Dietary, the final say is with Doctor. We get tentative date for discharge, most of time family members come in weeks before discharge. We give teaching, especially [MEDICAL CONDITION], educate, turn, suction, if something happens who do they call. The CN further stated that they involve the resident/ POA (Power of Attorney) in the discharge planning process by; We give them teaching, they go to IDC meeting if family can't come they do telephone conference. The CN continued with wound care, Meds, feeding, falls to Nursing, Respiratory Therapy would teaching about suctioning,[MEDICAL CONDITION], what to do in [MEDICAL CONDITION], oxygen therapy. The CN added that son (Resident #3's) was called several times to go to IDC care meetings but he never showed up .The only teaching we did, Nurse Manager did, was day of discharge, she reviewed meds one by one, gave him wound care education, she didn't show him how to do it, she verbalized the wound care. The CN also stated that no one instructed the son on tube feedings at that time, and that I thought they had a Home Health Aide (HHA) coming and the HHA would do education, Resident #3 ate PO (by mouth) lunch. During a telephone interview on 11/15/2019 at 10:45 a.m., the Director of Social Services (DSS) stated that Resident #3's son was involved in a conference call for discharge planning. The DSS further stated that they spoke to a representative from the ER (emergency room ) that Resident #3 was sent to after discharge, who asked if she was the person that set up the discharge for Resident #3. The DSS said they were not, the ER representative said that Resident #3 was in the ER because there was not appropriate oxygen at the home. The DSS stated that the son called after discharge and said he was with the ambulance taking Resident #3 to the hospital. The DSS also stated: the son did not know his mother needed oxygen in home, he thought everything would be set up. During an interview with the SW on 11/15/2019 at 11:15 a.m., the SW stated that the process for determining when a resident can be discharged back to the community depends on; Medical state, if person has a place to go, family support, if Doctor (DR.) says it's okay, if the team says person can go, if the family insists and the DR says no, we have a team meeting with family. If they still insist they want to take person home we discharge. At the meeting we talk why DR said no. The SW also stated that they involve the resident/POA in the discharge planning by; we call ahead of time from beginning, make sure they are involved every step. The SW also stated as far as making referrals to local agencies to ensure residents that need Home Health Care receive it I do Home Care, Meals on Wheels, when I involve Home Care everyone has different needs, if they accept (Home Health Care) Insurance. The SW stated the facility provides education to resident or care provider regarding care and treatments that are needed post discharge by; we invite family members to come in and be educated for a couple weeks, the care giver would be taught.[MEDICAL CONDITION] would be Respiratory Therapy's job, Tube feedings would be Dietary, Wounds would be Wound Care Nurse. The SW also stated that when the family requested to take (Resident #3) home, I insisted because Home Care only covered 3 days a week, so I told the son to come in for education and training, he said; I will send someone, a nurse he knows, neighbor, family member. I kept telling him we need someone to train, he said; I will come day of discharge to get trained at 8:00 a.m He came in 11:00 a.m. said I couldn't make it, traffic. The ambulance was already here waiting for (Resident #3) so he took her home. The SW went on to state that the resident was discharged without the son being trained. The SW further stated that Resident #3 was not discharged with the appropriate planning because he was not here for the training. The SW further stated that there was no Oxygen when Resident #3 got home because the Respiratory Director said (Resident #3) was going home with what (Resident #3) had here. The SW stated that I faxed the script (for oxygen) the 29th, or 28th of October to Home Health Care they received it. They were coming to house November 1st, .I believed that Resident #3 had enough oxygen to last til next day. The SW stated that they knew it was not a safe discharge, he said that day he would be here 8:00 a.m., he kept saying someone would come to get trained. I was at a CP meeting for another resident when I came down, (Resident #3) was on a stretcher. I asked him were you trained because you said you were going to be trained for 4 hours, he said; no I wasn't trained; they just left. The SW said they did not delay or stop the discharge because he (the son) insisted to being discharged . During a telephone interview on 11/15/2019 at 11:45 a.m., the Registered Nurse Unit Manager (UM), stated that when the son arrived Resident #3 was already dressed, she did wound care in the office I wet the gauze showed him how to apply the NACL (Sodium Calcium) Algonate, and self adhesive dressing. Wound care was done when he got there so I opened the packages demonstrated but not on the resident. The UM further stated [MEDICAL CONDITION] was done already, I really don't know if anyone [MEDICAL CONDITION]. but the UM did not. The UM showed the son how to give a tube feeding by I showed him in my office how to do it. (Resident #3) had a pump at the facility, he said he didn't want her hooked up to anything, we had a big syringe. The UM did not have the son do return demonstration of the feeding. During an interview on 11/15/2019 at 1:00 p.m., the Dietician stated that we had a conference call we talked about the volume and rate (of the feeding), I asked if he had a machine (pump) he said we would talk to the caregiver, he said he was hiring someone to come in to care for her. During an interview on 11/15/2019 at 2:30 p.m., the Respiratory Therapy Director (RT) stated that they do not order oxygen for residents that are discharged the SW does. The RT further stated that typically Respiratory Therapy [MEDICAL CONDITION] and suctioning teaching if here and available, we can educate 24/7, but did not know who did Resident #3's suctioning [MEDICAL CONDITION] education, but it is typically documented on treatment sheets,[MEDICAL CONDITION] sheets, could be on [MEDICAL CONDITION] sheet also. The RT also stated that 2 tanks of oxygen at 2 liters per minute continuously would last approximately 24 hours. At 3:30 p.m., on 11/15/2019, the RT returned and stated they could not find any documentation that Resident #3's son was given any instructions to care for the trach, suctioning, or [MEDICAL CONDITION]. A review of a facility policy titled Discharge Planning: Discharge Planning and Instructions, revised date : 2/19 revealed under Responsibility: With the resident, family, responsible person, the team assesses the discharge plan-Social Services provides for discharge-transportation and any durable medical equipment, home care and nursing services, any P.T.(Physical Therapy), O.T. (Occupational Therapy), or S.T. (Speech Therapy), as are appropriate. Resident #3 was transported from the home via ambulance to a Hospital. This placed Resident #3, as well as all residents planning to be discharged in an Immediate Jeopardy (IJ) situation. The IJ was identified and reported to the Administrator and the Director of Nursing (DON) on 11/15/2019 at 3:25 p.m., and was lifted when the facility provided an acceptable Removal Plan on 11/15/2019 at 4:30 p.m. The removal plan was verified on 11/20/2019, day two of the survey. NJAC 8:39-5.4(b) THIS DEFICIENT PRACTICE CONTINUES at a D LEVEL.

Based on observation, interview, and record review, it was determined that the facility failed to provide a safe environment for a cognitively impaired resident with a [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. This deficient practice was identified for 1 of 30 residents sampled for incidents/ accidents, Resident #27, as evidenced by the following: On 4/20/16 at 9:45 a.m. the surveyor observed Resident #27 during medication pass. The resident said that s/he had a headache and had been very dizzy since the last fall when the resident hit his/her head. On 4/25/16 at 12:25 p.m. the nurse said that the resident was confused at times and used a seat belt for safety. At 12:43 p.m. the surveyor observed the resident seated in a wheelchair in the dining room awake and alert. The resident stated that s/he did not know why s/he had to be at the facility. On 4/25/16 at 1:00 p.m. the surveyor reviewed the residents medical record. The resident had [DIAGNOSES REDACTED]. On 9/11/15 the Interdisciplinary (IDC) team assessed the resident utilizing a Significant Change Minimum Data Set (MDS), an assessment tool, as being cognitively impaired, requiring the extensive assistance of 2 staff members for transfers, bed mobility, and the resident did not ambulate. The IDC team further assessed the resident as having Delirium including inattention and disorganized thinking. According to a Quarterly MDS of 3/5/15 the IDC team assessed the resident as being cognitively impaired, non ambulatory, and required the extensive assistance of 1 staff member for toileting. On 4/26/16 at 9:15 a.m. the surveyor reviewed the resident's Occurrence Reports. Review of an Occurrence report dated 8/27/15 at 8:30 p.m. indicated the resident was attempting to get up from the toilet, when he/she lost balance and fell . The assigned aid was in the room making his/her bed. Pt (Patient) complained of right hip, right leg pain. Superficial abrasion on the right flank. According to a CNA statement of 8/27/15 at 8:30 p.m., the CNA left the resident in the bathroom, went to place the call bell when suddenly the CNA heard a boom and went in to the bathroom and found the resident sitting on the floor. The CNA asked the resident if they had pain, and the resident complained of pain on the right leg. The nurse assessed the resident and found that the resident sustained [REDACTED]. An X-ray of the resident was done and the resident was diagnosed with [REDACTED]. On 4/26/16 at 10:10 a.m. the Director of Nursing (DON) told the surveyor that the CNA was making the resident's bed while the resident was in the bathroom. She said that the resident should not have been left alone in the bathroom. The resident had a [DIAGNOSES REDACTED]. Resident #27 had stood and fallen on 4/7/16 which resulted in a laceration requiring 3 sutures. On 4/26/16 at 10:20 a.m. the residents CNA stated that the resident continued to attempt to get up. She said that the resident must be supervised at all times and cannot be left alone. Resident #27's care plan contained interventions dated 10/29/14 to move resident near the nursing station for closer monitoring as resident has tendency to get up without asking for assistance and have staff sit beside resident when in dayroom. These interventions reflect that resident will stand without asking for assistance. On 4/26/16 at 10:33 a.m. the surveyor observed the resident in the dining room sitting in a wheelchair with an alarming seat belt in use. The resident stated that s/he was not aware of the fall or fractured hip of 8/27/16. On 4/26/16 at 11:18 a.m. the survey team met with the Administrator and DON and made them aware of the concerns with the residents falls. NJAC 8:39 27.1(a)

Based on interviews, review of documentation and other pertinent facility documentation, it was determined that the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of disease and infection. In addition, the facility failed to follow their own policy on Scabies. This deficient practice was evidenced by: Medical records were reviewed and interviews were conducted on [DATE] unless otherwise noted. 1. Resident #1, resides on unit ,[DATE] is ambulatory and walks around the unit. Review of interdisciplinary progress notes (IPN), dated [DATE] revealed, Resident complains of itchiness. Small rashes noted on lower abdomen and lower extremities rashes IPN dated [DATE], resident complained of itchiness. Small rashes on lower abdomen, lower back and lower extremities. The physician ordered [MEDICATION NAME] (mild corticosteroid) cream to be applied twice a day. In addition, the physician said "no need for dermatology consult at this time". Reported to Infection Control staff. IPN dated [DATE], rashes on lower abdomen, lower back and both lower extremities resolved. IPN dated [DATE], noted with rash to abdomen and extremities...Dermatology consult and [MEDICATION NAME] (corticosteroid) cream ordered. IPN dated [DATE], resident had appointment with Dermatologist ...shave biopsy done results will be ready in about 1 week, no new orders at this time. As evidenced by the IPN, the staff failed to follow up on the results of the shave biopsy until [DATE]. At that time the physician's office said that they would fax the results tomorrow. The results were not available until [DATE], with a [DIAGNOSES REDACTED]. The physician ordered [MEDICATION NAME] (scabicidal), at bedtime and shower in the morning. [MEDICATION NAME] treatment to be repeated in one week. 2. Resident #2, was readmitted from acute care on [DATE] to unit ,[DATE]. The resident is non ambulatory and requires total care. IPN dated [DATE], revealed, rash and itching noted to both hands. The physician ordered [MEDICATION NAME] (corticosteroid) 1% cream to both hands two times a day for 14 days. IPN dated [DATE], rash and itching persists. IPN dated [DATE], rash and itching persists. IPN dated [DATE], noticeable rashes around the trunk and arms. The physician was made aware, [MEDICATION NAME] (scabicidal) cream was applied and patient to be washed in the morning. IPN dated [DATE], rashes on the lower abdomen and bilateral hands. IPN dated [DATE], rash and itching persists. IPN dated [DATE], [MEDICATION NAME] (scabicidal) cream was ordered to entire body. 3. Resident #3, resides on unit ,[DATE] and ambulates independently. IPN dated [DATE], Resident returned from dermatology clinic. The physician ordered Eurax (scabicidal lotion )(454 grams), apply neck to toes after a warm shower x 4 nights to clear the infection. IPN dated [DATE], Resident returned to unit from dermatology office. the physician ordered [MEDICATION NAME] (corticosteroid) cream to affected areas (abdomen and chest) two times a day for 8 weeks and [MEDICATION NAME] ([MEDICATION NAME]), 10 mg 1 tab at bedtime for 80 days. IPN dated [DATE], Quarterly Review Note: The resident is being followed up by a dermatologist due to presence of contact dermatitis. IPN dated [DATE], Resident returned to unit from dermatology clinic ...with recommendation... [MEDICATION NAME] (scabicidal) lotion after a good shower at night x 4 nights from neck to toes. IPN dated [DATE], Resident seen by dermatologist yesterday with new prescriptions for rash all over his body. Start on Eurax (scabicidal) lotion tonight after a warm shower x 4 days. IPN dated [DATE], Resident is on Eurax (scabicidal) skin treatment x 4 days after warm shower, today is day 3 some progress is noted. 4. Resident #4, resided on unit ,[DATE] and was transferred to unit ,[DATE] on [DATE]. The resident is non-ambulatory and requires assistance with care. IPN dated [DATE], skin assessment done. Resident noted with chest and back rash. The physician ordered [MEDICATION NAME] (corticosteroid) cream. IPN dated [DATE], to dermatology appointment. Consultation [DATE] at 2:45 PM, with the dermatologist who states, "This patient needs to be treated with Eurax (scabicidal) lotion for 4 nights neck to toes after a warm shower... Dx: Scabies". 5. Resident #5, resides on unit ,[DATE]. IPN dated [DATE], primary Certified Nursing Assistant (CNA) assisted resident to toilet, called nurse to see rash on resident's body. Nurse observed rash to chest, left lateral abdomen and to bilateral lower forearm. Physician notified and ordered [MEDICATION NAME] (corticosteroid) lotion to chest area, bilateral forearms and abdomen BID x 30 days. IPN dated [DATE], Physician examined the resident and wrote order to discontinue [MEDICATION NAME] (corticosteroid) lotion to rash, start [MEDICATION NAME]. IPN dated [DATE], rashes to the arms persist. IPN dated [DATE], slight improvement to rash on left upper extremity. IPN progress notes dated [DATE], skin rash not resolved, physician ordered dermatology consult. IPN dated [DATE], stated, resident had biopsy done on chest {LUE} today and order was given for [MEDICATION NAME] (scabicidal) treatment and to be repeated in one week. IPN dated [DATE], resident has new order for [MEDICATION NAME] (scabicidal) 5% cream for rash, and is applied to entire body. 6. Resident #6 resides on unit ,[DATE]. IPN dated [DATE], she has generalized body rash [MEDICATION NAME] (mild corticosteroid) and Topicort (corticosteroid) cream. IPN dated [DATE], seen by physician, dermatology consult ordered. IPN dated [DATE], resident came back per stretcher from dermatology consult... [MEDICATION NAME] (antifungal) and Aclovent (corticosteroid) cream to be applied to affected area two times a day x 2 weeks. IPN dated [DATE], resident came back earlier from Derm consult with new recommendation. MD aware and approved recommendation. Eurax (scabicidal) cream and [MEDICATION NAME] (corticosteroid) cream application started for body rashes. IPN dated [DATE], returned from Derm appointment with a [DIAGNOSES REDACTED]. IPN dated [DATE], Quarterly note "...She has generalized body rash..." 7. Resident #7 resides on unit ,[DATE], is non ambulatory and requires assistance with care. IPN dated [DATE], rash noted all over the body, Dermatology consult ordered. IPN dated [DATE], went to dermatologist. [DIAGNOSES REDACTED]. Orders received were Eurax (scabicidal) lotion to be applied from neck to toes after a warm shower x 4 nights. IPN dated [DATE], returned from dermatology consult with new orders for [MEDICATION NAME] (corticosteroid) to be applied to affected areas two times a day for 2 months. 8. Resident #8 resides on unit ,[DATE]. IPN dated [DATE], resident noted with small red pustules on chest and extremities. M.D. ordered [MEDICATION NAME] (corticosteroid) cream. IPN dated [DATE], small redden pustules on chest and extremities worsen. [MEDICATION NAME] 875 mg two times a day for 14 days was ordered. IPN notes dated [DATE], returned from dermatology office, shave biopsy done, papule on left arm. Physician recommended [MEDICATION NAME] (corticosteroid) cream BID. IPN dated [DATE], Dermatology Report: Subacute Spongiotic Dermatitis. Consistent with eczema or contact dermatitis, physician ordered [MEDICATION NAME] (scabicidal) cream tonight and to repeat on ,[DATE]. IPN dated [DATE], [MEDICATION NAME] (scabicidal) cream applied last night shower given this morning. Facility could not provide documentation that the policy on scabies was followed. 9. Resident #9 resides on unit ,[DATE] is non ambulatory and requires assistance with care. IPN dated [DATE], resident noted with a rash on her body, red raised pus filled papules, mostly on extremities. Physician notified and ordered [MEDICATION NAME] (corticosteroid) Cream two times a day for 10 days and [MEDICATION NAME] 500 mg two times a day for 10 days. IPN dated [DATE], resident noted with rash to extremities, red pustules varying in size on extremities and upper back. IPN dated [DATE], Dermatology consult ordered Discontinue previous [MEDICATION NAME] (corticosteroid) cream order. Apply [MEDICATION NAME] (corticosteroid) cream to entire body twice a day for 14 days. IPN dated [DATE] stated, Infection control staff made aware about rash on entire body. IPN dated [DATE], placed on [MEDICATION NAME] 875 mg po two times a day for 10 days. IPN dated [DATE] stated, resident is on antibiotic for body rashes with pustules. IPN dated [DATE], unable to go to dermatology consult due to transportation problem. IPN dated [DATE], went to dermatologist. New orders, D/C [MEDICATION NAME] (corticosteroid) cream, and start [MEDICATION NAME] (corticosteroid) ointment two times a day to body rashes. IPN dated [DATE], dermatology office reported that resident biopsy result ready. The rash may be drug eruption or scabies. The physician ordered [MEDICATION NAME] (scabicidal) cream order. IPN dated [DATE], rashes on entire body persists with treatment. [MEDICATION NAME] (scabicidal) ordered again to be applied to entire body from neck down to the toes. IPN dated [DATE], resident still has papular eruption on body, especially elbows, thighs. Presumably she was treated with [MEDICATION NAME] (scabicidal) to R/O scabies. Since there is no response, this biopsy is most consistent with drug eruption. IPN dated [DATE], physician said he does not want to discontinue all resident's medications. IPN dated [DATE], resident body rash still persists, especially more rashes on resident thighs, buttocks and back. Physician examined resident and determined that rash is not from drug reaction. IPN dated [DATE], [MEDICATION NAME] (scabicidal) treatment completed this shift. 10. Resident #10 resides on unit ,[DATE]. The resident is non ambulatory and requires assistance with care. IPN dated [DATE], grouped rash to left side of upper back noted Physician ordered [MEDICATION NAME] (corticosteroid) cream to effected area two times a day for 2 weeks. IPN dated [DATE], resident still noted with rashes on upper back . IPN dated [DATE], per physician, continue Wescort (corticosteroid) cream to the left upperback two times a day for 14 days for rashes and dermatology consult . IPN dated [DATE], resident back from dermatologist, [MEDICATION NAME] (antifungal) cream with [MEDICATION NAME] (corticosteroid) cream ordered to apply two times a day to affected areas . IPN dated [DATE], returned from dermatology consult ...new orders are the following: [MEDICATION NAME] (antibacterial) solution apply to affected area in the body (back and left arm) daily in AM and [MEDICATION NAME] (antifungal) [MEDICATION NAME] (corticosteroid) mix apply to affected area (back and left arm) at HS. IPN dated [DATE], resident came back from derm consult ...Apply Eurax (scabicidal) lotion neck to toes after a warm shower x 4 nights. 11. Resident #11 resides on unit ,[DATE]. IPN dated [DATE], consultation with dermatologist. Dermatologist states, "this patient is in the beginning stage of skin eruption. Please treat this patient with Eurax lotion for the next four nights". IPN dated [DATE], resident returned from Dermatology clinic with order for [MEDICATION NAME] (corticosteroid) cream. Consultation on [DATE] from Dermatology clinic states, "...Please apply Eurax (scabicidal) lotion for 4 nights neck to toes & [MEDICATION NAME] (corticosteroid) BID to affected skin". 12. Resident #12 resides on unit ,[DATE]. The resident is non ambulatory and requires assistance with care. IPN dated [DATE] , resident observed with rashes on her right upper back, left thigh and leg. IPN dated [DATE] stated, rashes on right upper back, left thigh and leg persists. [MEDICATION NAME] (corticosteroid) cream as ordered. Infection control staff made aware of resident rashes. IPN dated [DATE], resident has rashes on right upper back, left thigh and leg. Continue to apply [MEDICATION NAME] (corticosteroid) cream twice a day for 14 days for rashes. IPN dated [DATE], resident to dermatology appointment, shave biopsy done. IPN dated [DATE], rashes on right upper back, left thigh and left leg still persists. Treatment order completed. Also observed rashes on arms... apply [MEDICATION NAME] (corticosteroid) cream two times a day until resolved. IPN dated [DATE], "...biopsy result showed insect bite like scabies. ...Left message to infection control nurse answering machine...". [MEDICATION NAME] (scabicidal) cream applied to entire body rashes from neck down to the soles of the feet . 13. Resident #13 resides on unit ,[DATE]. The resident is non ambulatory and requires assistance with care. IPN dated [DATE], rash noted to resident right and left upper back. IPN dated [DATE], new order of [MEDICATION NAME] (corticosteroid) cream to right upper back twice a day for 7 days. IPN dated [DATE], skin rash noted to upper back and bilateral arm ...new order [MEDICATION NAME] (corticosteroid) cream to skin rash twice a day for 14 days. IPN dated [DATE], rashes on back and both upper extremity still persist, dermatology consult ordered. IPN dated [DATE], multiple excoriations of the skin. Orders given to mix 60 grams each of [MEDICATION NAME] (antifungal) cream and [MEDICATION NAME] (corticosteroid) cream and apply to affected area two times a day for 3 week and Eurax (scabicidal) lotion 454 grams to be applied from neck to toes after warm shower x 4 nights. 14. Resident #14 resides on unit ,[DATE]. The resident is non ambulatory and requires assistance with care. IPN dated [DATE], rash with raised red bumps on lower back and thigh area. IPN dated [DATE], rash on resident's buttocks, lower back and thigh area. Dermatology consult ordered. IPN dated [DATE] stated, "...resident returned from derm appointment. MD could not look at rash on resident's buttocks, lower back and thighs because he needed two people to examine him. [MEDICATION NAME] (mild corticosteroid) cream 2.5% ordered twice daily to rashes for 2 weeks". IPN dated [DATE], examined by physician for body rash. No new order. IPN dated [DATE], resident went to dermatologist's office for rashes on chest, back, arms and legs. MD will defer treatment at this time as patient is not uncomfortable at this time. IPN dated [DATE], resident had shower post [MEDICATION NAME] (scabicidal) treatment. Will continue to monitor resident. There is no explanation in the resident's chart as to why this medication was ordered. IPN dated [DATE], resident observed with rashes on his abdomen area and right side of the upper body. [MEDICATION NAME] (corticosteroid) cream ordered two times a day for 7 days. IPN dated [DATE], post [MEDICATION NAME] (scabicidal) TX shower was given to resident this AM. 15. Resident #15 resides on unit ,[DATE]. The resident ambulates independently. IPN dated [DATE], physician made aware of residents rash to arm, legs and trunk. New order for [MEDICATION NAME] (corticosteroid) cream two times a day for 7 days and dermatology consult . IPN dated [DATE], returned from dermatology consultation which states, Dx; Scabies, treat with Eurax (scabicidal) lotion neck to toes for 4 nights following warm shower. 16. Resident #16 resides on unit ,[DATE]. The resident ambulates independently. IPN dated [DATE], resident c/o dry, itchy feet and rash noted. IPN [DATE], resident c/o rash on skin inside legs and groin area. IPN dated [DATE], resident went to visit dermatology who ordered to apply [MEDICATION NAME] (scabicidal) cream at bed time to whole body below the chin. Wash off after 8 hours. Repeat after 1 week. Consultation [DATE] from dermatology, "...Scrapings probably (+) for ova - no adult mite seen. Imp Scabies (certainly clinically). Plan [MEDICATION NAME] (scabicidal) cream Apply HS to whole body below the chin. Repeat after 1 week". 17. Resident #17 resides on unit ,[DATE]. IPN dated [DATE], rash on left side and both arms. IPN dated [DATE], Quarterly Review Note: "... Her skin remains intact, itchy rash was observed on inner aspect of right upper arm extending to the right side of her trunk. No skin opening was observed and rash is light pink and dry. Advised to avoid scratching. ...". IPN dated [DATE], resident observed with rashes on upper body, mostly on right upper side of the body and axilla. Complaining of itchiness ...Resident on Westcort (corticosteroid) cream two times a day for 10 days and reassess. IPN dated [DATE], noted rash on both arms, chest, and back. Areas red and raised, noted scratching at intervals. moisture cream applied with some relief. To follow up with M.D. in AM. IPN dated [DATE], body rash persist, complaining of itchiness, physician ordered dermatology consult. IPN dated [DATE] stated, "scrapping could be anthropod bite" IPN dated [DATE], [MEDICATION NAME] (scabicidal) treatment completed this shift. 18. Resident #18 resides on unit ,[DATE]. The resident was non ambulatory and required assistance with care. Dermatology consult dated [DATE] stated, "this patient has Psoriasis which is out of control". Topicort cream was ordered by the physician. Allergy and Immunology consult dated [DATE], patient has had a pruritic rash for about one year. The patient was seen by a Dermatologist who considered the possibility of psoriasis. Assessment by the Allergist revealed the neck and trunk covered with confluent [DIAGNOSES REDACTED]tous rash. The lesions on the thighs and lower legs are not raised and less confluent. [DIAGNOSES REDACTED]. IPN dated [DATE], resident is noted with a white rash to hands, feet, calves, thighs, chest back and head. Cream ordered. 19. Resident #19 resides on unit ,[DATE], he is the room mate of resident #15 who was diagnosed with [REDACTED]. Resident #19 is non ambulatory and requires assistance with care. IPN dated [DATE], has chronic Dermatitis of the lower extremities that still persists. He was seen by Dermatologist on [DATE] who ordered Cloderm (topical steroid) cream to be applied three times a day. IPN dated [DATE], Physician aware of rash areas to trunk, back arm and legs. New order for [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] (corticosteroid) cream and a dermatology consult. Dermatology consult dated [DATE] stated, "this patient suffers with atopic dermatitis, please apply Cloderm (topical steroid) cream three times a day and give [MEDICATION NAME] 10 mg three times a day for 2 months". This is the roommate of Resident #15 who was diagnosed on the the same day ([DATE]), with Scabies. Resident #15 was treated with Eurax (scabicidal), however, the facility provided no evidence that this resident and direct contact staff were also treated as per the facility policy. 20. Review of the facility Infection Control Council meeting minutes dated [DATE], revealed "...New Business - LTC bug issues, comprehensive extermination process taking place in Unit ,[DATE] ...". Infection Control Council meeting minutes dated [DATE], revealed "...New Business - Rashes in LTC division, several residents in LTC with rashes, rashes that are all different; some have been treated empirically for scabies, residents have been sent out to outside dermatologist(s), staff with rashes have been sent to EHS with no confirmation of scabies, EVS notified to inspect units for possible bedbugs, there has been no recent change in any of the products used ...". Infection Control Council meeting minutes dated [DATE], revealed "...Employee skin eruptions, a Task Force was created and convened in mid July, the IC department has maintained an ongoing investigation of these skin eruptions, which are non-infectious in nature, the IC department is also working in conjunction with EHS, HR and the BCDOH, employees from different departments are being evaluated for skin eruptions, the types of lesions have been noted to be different as well as the dates of onset, environmental factors are also being investigated, a memo from BRMC President sent on [DATE] explaining situation and steps to follow, a skin care protocol is to be instituted in the LTC division ...". 21. Review of the facility policy titled "Scabies - Confirmed ... Definition ...Diagnosis - To make a specific/definite [DIAGNOSES REDACTED]. Based upon strong clinical suspicion, the patient can be treated empirically. ...Confirmed Scabies [DIAGNOSES REDACTED]. Should be confined to his/her room during the treatment period. The resident must be treated as well as all close contacts and care givers". 22. The surveyor conducted interviews at 11:20 AM, with the Infectious diseases nurse (ID), the Assistant Director of Nursing (ADON), and the AVP of Quality Management. The ID nurse stated that when residents have a positive scrapping for scabies the facility policy is followed. She went on to say, that the policy is not followed if the [DIAGNOSES REDACTED]. The ADON stated that a confirmed case of scabies can be made by a physician without a scrapping. Whenever, a confirmed case of scabies is made the facility policy should be followed. The AVP also acknowledged that a [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. There were 19 residents who were reviewed who had developed a rash from [DATE] until [DATE]. These 19 residents reside in 5 different units of this facility as follows; 4 residents reside in unit ,[DATE], 3 residents reside in unit ,[DATE], 4 residents reside in unit ,[DATE], 1 resident resided in unit ,[DATE] (expired on [DATE]), and 7 residents reside in unit ,[DATE]. On unit ,[DATE], 6 residents were diagnosed with [REDACTED].#8, #9, #12, #16 and #17. The facility policy was not followed for Residents #1, #8, #9, #12, and #17, by not treating those residents and their close contacts as well as their care givers. The first time the facility policy was followed was on [DATE] for #16. At that time, the entire ,[DATE] unit, residents and staff were treated. On unit ,[DATE], 2 residents were diagnosed with [REDACTED].#15. The facility policy was not followed for either resident, by treating these residents' close contacts as well as their care givers. On unit ,[DATE], Resident #2 had been treated with [MEDICATION NAME] X 2, per physician orders. On unit ,[DATE], Resident #3 was treated with Eurax and #5 was treated with [MEDICATION NAME], per physician orders. On unit ,[DATE], Resident #6, #7, #10 and #13 were treated with Eurax, per physician orders. On unit ,[DATE], Resident #11 was treated with Eurax, per physician orders. On unit ,[DATE], Resident #14 was treated with [MEDICATION NAME], per physician orders. These residents were treated for [REDACTED]. NJAC 8:,[DATE].4(d)(e)(f)(g)