Every finding on record at Careone at Middletown

Based on interview and document review it was determined that the facility failed to have a system in place to ensure quarterly financial statements were provided to residents or resident representative (RR) for residents who maintained Personal Needs Accounts (PNA) with the facility. This deficient practice was identified for 3 of 3 residents and affected all 42 residents identified as maintaining a facility PNA account.The evidence was as follows:On 05/18/26 at 10:28 AM, the surveyor conducted a resident council meeting with 5 residents. When asked if the residents were provided with quarterly financial statements for their PNA accounts, One of five residents (Resident #69) had PNA funds held by the facility, and stated No, the facility had never provided them with a quarterly financial statement. Resident #69 further stated that a quarterly statement would be helpful because they would know how much money they had in their account. On 5/18/26 at 11:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of all PNA balances as of 5/18/26. The Trial Balance listed 42 total PNA accounts with a balance of $19,849.61. On 05/19/26 at 9:10 AM, the surveyor interviewed Resident #29 regarding their PNA account. Resident #29 stated that they did not know how much money they had in their account and they had never received a quarterly statement regarding their PNA account. On 05/19/26 at 9:34 AM the surveyor interviewed the Business Office Manager (BOM) who stated that residents and/or Resident Representatives (RR) were not provided with a quarterly financial statement for PNA accounts. The BOM further added if they had asked for a quarterly financial statement the facility would have provided it. On 05/19/26 at 10:56 AM, the surveyor interviewed Resident #76's (RR). The RR stated that a facility representative had called them today and stated that Resident #76 had a lot of money and Resident #76 needed new clothing and shoes. The RR stated that they had not received any quarterly statements regarding the PNA account. They further stated that they were aware that the Medicaid benefit would be in jeopardy due to a high PNA balance but they had relied on the facility to inform them of the balance because they didn't keep track of the balance. The RR confirmed that they had not received a quarterly financial statement regarding the PNA account but they would have liked to receive one because it would have been good to know the account balance so they could keep track of the amount. On 05/26/26 at 10:39 AM, the surveyor interviewed the LNHA. The LNHA stated that they were not aware that the Residents/RR had not received quarterly financial statements for PNA accounts. The LNHA stated that he was responsible to ensure that the facility process for statements was happening. A review of the Resident Trust Account policy last revised 2016, revealed a Purpose Statement: The center, acting in a fiduciary role, will safeguard the Resident's Personal Fund and provide for accurate record keeping in accordance with State and Federal regulations. The policy did not indicate a process for providing quarterly financial statements. NJAC 8:39-9.5(a)

Based on interview and review of documentation it was determined that the facility failed to have a system in place to ensure residents or resident responsible parties were notified that the funds held by the facility in their Personal Needs Account (PNA) reached the $2,000 maximum Supplemental Security Income (SSI) or $200 less of the maximum which could jeopardize their eligibility for SSI or Medicaid. This deficient practice was identified for 2 of 2 (Resident #29 and Resident # 76) reviewed for PNA, and affected all 42 residents who had a PNA account held by the facility. The evidence was as follows:On 5/18/26 at 12:00 PM, a review of the facility provided Trial Balance report revealed one resident PNA balance was over the $2,000 SSI maximum and one of the balances were over $1,800 which was $200.00 less than the $2,000 maximum. The account balances were as follows:-Resident #29's PNA reflected a PNA balance of 3,155.97.-Resident #76's PNA reflected a balance of $1,938.69. On 05/19/2026 at 9:10 AM, the surveyor interviewed Resident #29. Resident #29 stated that they had received $50 per month from their PNA account, however they were waiting for this month's $50. Resident #29 stated that they used to go to the business office to request their PNA money, but it became more difficult for them because they had become less mobile. Resident #29 stated that the last purchase they had made using their PNA funds was purchasing a couple snacks from the facility vending machine. Resident #29 stated that they also made a $25 charitable donation. Resident #29 stated that they only had two house dresses [casual pull on dress]. Resident #29 stated they had four but two of them were so old and thin that you could see through them. They would have liked to buy more but they would have needed help to figure out how to purchase the items. On 05/19/26 at 9:25 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who cared for Resident #76 who was confused, and was non interviewable by the surveyor. The CNA informed the surveyor that Resident # 76 had one pair of slip-on shoes that the facility provided from a donation box. The CNA also stated, we had gone down to see if we could find [Resident #76's] shoe size, unfortunately, we have not been able to find their shoes size. The CNA stated the resident could have used a pair of shoes with some grip. The CNA stated that would have helped when Resident # 76 was transferred from the bed to the chair. On 05/19/26 at 9:34 AM, the surveyor interviewed the Business Office Manager (BOM) about the PNA process. The BOM stated that if a resident received Medicaid benefit their PNA account could not exceed $2,000, because the resident's income would had gone over the limit for Medicaid, and they could have lost their Medicaid. The BOM was unable to explain a process to manage PNA funds to ensure residents did not lose their Medicaid. The BOM also stated that she thinks the last time Resident #29 purchased new clothing items was last summer. The BOM stated that Resident #76's PNA balance of $1938.69 was an acceptable balance, and their Resident Representative (RR) would have informed the facility what items Resident #76 needed. The BOM stated I haven't asked the CNA or nurse if Resident #76 needed any items, I go through the RR. The BOM also stated that the facility was not aware that the staff obtained slip-on shoes for Resident #76 from the facility donation bin. On 05/19/26 at 10:56 AM, the surveyor interviewed the RR for Resident #76. The RR stated that a facility representative had just called them today and stated that Resident #76 had a lot of money, and Resident #76 needed new clothing and shoes. The RR stated that during the Care Plan meetings the facility would usually inform them if Resident #76 needed any items. The RR was not aware that Resident #76 needed shoes. On 05/26/26 at 10:39 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The LNHA stated that he was not aware the facility did not notify the residents or RR that the funds in their PNA account reached the $2,000 maximum SSI, or $200 less of the maximum which could jeopardize their eligibility for SSI or Medicaid. NJAC 8:39-9.5

Based on observation, interview, and record review, it was determined that the facility failed to ensure a) adequate supervision was provided to a resident with documented behaviors of wandering into other residents rooms (Resident #26), b) targeted fall interventions were identified and implemented in response to falls, and c) current care plan interventions to prevent accidents were implemented. This deficient practice occurred for 2 of 3 residents reviewed (Resident #23 and #26) for accidents and was evidenced by the following: 1. On 5/19/26 at 8:20 AM, the surveyor toured the unit where Resident #23 resided and observed the resident in bed, and the Certified Nurse Aide (CNA) was in the room and informed the surveyor that the resident was confused.On 5/19/26 at 9:00 AM, the surveyor observed Resident #23 in their room, Resident #23 was alert but could not answer the surveyor's inquiries.On 5/20/26 at 10:30 AM, the surveyor observed Resident #23 ambulating and wandering in the hallway, The resident asked the surveyor to assist them in locating their room. The Unit Manager was in the hallway at that time, and assisted Resident #23 to their room. On 5/22/26 at 8:45 AM, the surveyor observed Resident #23 in the dayroom with three other residents and there were no staff in attendance.A review of Resident #23's medical record at that time revealed the following: Resident #23 was admitted to the facility with diagnoses which included but were not limited to: cerebral ischemia, chronic kidney disease and other frontotemporal neurocognitive disorder.The Quarterly Minimum Data Set (MDS) dated 02//28/26 an assessment tool used by the facility to prioritize care reflected that Resident #23 had a BIMS Score of 13 out of 15 which was indicative of intact cognition. On 5/22/26 at 9:30 AM, the surveyor interviewed the CNA assigned to Resident #23. The CNA informed the surveyor that Resident #23 was confused at times, had a Foley catheter in place, wore a leg bag during the day. Further review of the electronic medical record (EMR) revealed that Resident #23 sustained two falls at the facility on 11/2/25 at 8:00 PM, and 11/19/25 at 7:30 PM.On 5/22/25 the surveyor requested the fall investigation and the fall Care Plan from the Director of Nursing.The following was documented in the progress notes in the EMR:On 11/2/25 at 8:00 PM, the staff heard Resident #23 yelling for help. The resident was found on the floor in the bathroom. The resident informed the staff that they needed to have a bowel movement and transferred themselves to the bathroom.On 11/19/25 at 7:30 PM, Resident #23 was found on the bathroom floor. The resident stated that they needed to have a bowel movement and transferred themselves to the bathroom. A review of the Comprehensive Care Plan had a Focus for falls with the Goal of minimizing falls. The interventions included: Frequent rounds to anticipate needs and ensure safety. Rounds to assist with toileting. Reinforce the need to call for assistance,On 5/23/26 at 11:30 AM, the surveyor reviewed the fall investigations and the Care Plan (CP) along with the DON. The DON stated that the causal factor for each fall should be identified, and the Care Plan had to be revised after the falls to implement or revise interventions that would prevent further falls. The surveyor reviewed the CP with the DON and we both observed that there were no revisions made to the CP after the falls that occurred. The Interdisciplinary notes had reflected that the CP was updated, and the CP was last updated 8/26/25. There was no documentation that was identified that Resident #23's falls that occurred prior to going to bed while trying to use the bathroom had been addressed and there were no revisions to the CP. 2. On 5/19/26 at 9:30 AM, the surveyor observed Resident # 26 in their room, the resident stated that they had to make their bed. The CNA, who was at the bedside and informed the surveyor that Resident #26 required assistance with care.On 5/20/26 at 8:55 AM, the surveyor observed Resident #26 in the dayroom, eating breakfast, the resident then ambulated out of the dayroom shortly after and proceeded to enter another resident room next to the dayroom. A CNA then redirected the resident to the dayroom. There were no staff in attendance when the CNA redirected the resident back to the dayroom, and four other residents were also observed in the dayroom. On 5/20/26 at 11:00 AM, the surveyor reviewed Resident #26's medical record which revealed the following:The admission face sheet (an admission summary) reflected that Resident #26 was admitted to the facility with diagnoses which included but were not limited to: Unspecified Dementia severe without behavioral disturbance, mood disturbance and anxiety. The Quarterly Minimum Data Set (MDS) dated 02//26/26, an assessment tool used by the facility to prioritize care, reflected that Resident #26 was severely cognitively impaired. Resident #26 scored 5 out 15 on the Brief Interview for Mental Status.Review of Resident #26's Comprehensive Care plan provided by the facility on 5/25/26, revealed: A focus area: Resident #26 was at high risk for falls related to impaired balance, poor coordination and medication side effects. Initiated 9/07/25. The goal was to minimize risk for injury related to falls.The interventions included:Ensure that I do not wander into residents' rooms.Redirect me when wandering into other residents' rooms.Provide assistance with transfer and ambulate as needed.Therapy evaluation and treatment as ordered.The following incidents were documented in the Electronic Medical Record:The surveyor reviewed a 09/27/25 nursing Progress note documented at 1:40 PM that indicated the following: Resident in room [ROOM NUMBER] contacted this writer and reported that that Resident #26 was sitting on the floor in their room.The fall note indicated that Resident #26 went to room [ROOM NUMBER] and picked up a stuffed animal, and when the other resident tried to take it back, Resident #26 slapped the other resident. Resident #26 then lost their balance and fell onto the floor.On 11/17/25 at 2:30 PM, the resident sustained an unwitnessed fall in the activity room. The statements provided indicated that Resident #26 was sitting in the dayroom with peers coloring. Resident #26 stood up to reach for the chair, lost their balance and fell.Another incident dated 12/11/25 timed 2:45 AM, revealed that Resident #26 reported that their roommate slapped them. During an interview with the other resident, they stated that Resident #26 kept coming into their room and disturbing them during the night and they had reported the concerns to the staff.On 1/1/26 Resident #26 was left unsupervised in the dining room and had a physical altercation with another resident. The investigation was not provided. The DON stated that she could not locate the investigation. Another fall incident dated 2/22/26 timed 1:50 PM, revealed that Resident #26 was found on the floor in the room, sustained some redness to the midback which measured 1 centimeter x 1 centimeter (cm).On 5/20/26 at 11:40 AM, the surveyor again observed Resident #26 in the dayroom along with four other residents, there were no staff in attendance. During an interview with the Activity Staff (AS) at that time, she stated that she thought another staff member was assigned to the dayroom for monitoring residents.On 5/21/26 at 12:30 PM, the surveyor requested all investigations, Fall Risk Assessments for Resident # 26 for review from the Director of Nursing (DON).On 05/22/26 at 10:30 AM, the following were provided by the DON: Fall Risk Assessment on admission dated 08/22/25, reflected that the facility identified Resident #26 as a high fall risk. Resident #26 received a score of 10. Category: High Risk.The Fall Risk assessment dated [DATE], reflected that Resident #26 was not a high fall risk, Resident #26 received a score of 2. Category: not applicable. The Director of Nursing could not comment on the score when prompted to explain why it changed.The Fall Risk assessment dated [DATE], Resident #26 received a score of 8. Category: Not applicable.Resident #26 sustained a fall on 1/1/26, and upon surveyor inquiry, the investigation was not provided. The DON informed the surveyor that she could not locate the incident that occurred or the investigation.On 5/22/26 at 9:30 AM, the surveyor reviewed all of the provided fall incidents along with the fall risk assessments score with the DON. The DON confirmed that Resident #26 was a high fall risk and could not comment on the Fall Risk assessment scores that did not specify a high fall risk.On 05/26/26 at 10:39 AM, the survey team conducted a meeting with the DON and Licensed Nursing Home Administrator (LNHA) and further informed them of the above concerns and at 12:38 PM, the DON and LNHA met with the survey team for the exit conference and no additional pertinent information was provided. A review of the facility policy for Falls-Clinical protocol last revised, March 2018, under treatment and management revealed the following:Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls, and to address the risks of clinically significant consequences of falling.Under monitoring and follow-up, the following were noted: If the individual continues to fall, the staff and physicians will reevaluate the situation and reconsider possible reasons for the residents' falling (instead of, in addition to those that have already been identified) and also reconsider the current interventions. No specific interventions were implemented to prevent recurrence. NJAC 8:39-27.1 (a)

Complaint #NJ 3001928Based on observations, interviews and record reviews, it was determined that the facility failed to ensure that a resident was assessed for the appropriate call bell device and the device was within the resident's reach. This deficient practice was identified for 1 of 2 residents reviewed for call bell (Resident #62) and was evidenced by the following:On 5/19/26 at 8:59 AM, the surveyor observed Resident #62 in bed, their eyes were closed, and the call bell was observed on the bedside table and out of reach of the resident.On 5/22/26 at 8:26 AM, the surveyor observed Resident #62 in bed, and the call bell was again observed on the bedside table in the same manner as observed on 5/19/26 at 8:59 AM.On 5/22/26 at 8:40 AM, the surveyor accompanied the Licensed Practical Nurse/ Unit Manager (LPN/UM) to the room, and the LPN/UM verified that the call bell was not accessible to the resident.The surveyor asked the UM if Resident #62 could access the call bell, the UM stated, No. The UM stated that Resident #62 was very limited and could not reach the call bell on the bedside table. On 5/22/26 at 11:30 AM, the surveyor reviewed Resident #62 electronic medical record which revealed that Resident #62 was admitted to the facility with diagnoses which included, but were not limited to; muscle weakness, difficulty in walking, other lack of coordination and major depressive disorder. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #62 required extensive assistance with toileting, bed mobility and transfers, had limitations in the functional ability of their extremities, and was frequently incontinent of bowel and bladder. The MDS also indicated the resident had moderate cognitive impairment, as Resident #62 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the care plan dated included a focus for Activity of Daily Living Self Care deficit related to disease process (dementia, mood disorder and adjustment disorder). Another focus was for falls related to medication side effects. Two of the listed approaches included for staff to keep commonly used items within easy reach and reinforce the need to call for assistance. Initiated 03/12/25. On 5/19/26 at 9:35 AM, the surveyor asked the resident if they could activate the call bell, the resident ran their hands across the bed sheet and could not locate the call bell.On 5/22/26 at 10:51 AM, the surveyor entered the room with the LPN/UM and inquired where the call bell should be located for the resident to be able to use it to indicate the needed assistance. The LPN/UM stated that the call bell should be within reach and confirmed that Resident # 62 could not reach the call bell was located on the bedside table. The LPN/UM placed the call bell next to the resident and instructed the resident to activate the call bell. Resident #62 was unable to activate the call bell and as observed with tremors and deformities of both of their hands. The UM stated that she had not been aware that Resident #62 was unable to activate the call bell.On 5/22/26 at 11:15 AM, the surveyor interviewed the resident regarding the call bell placement. Resident #62 stated that sometimes they could not locate the call bell, and that they would yell for assistance or wait for someone to come to the room. On 5/22/26 at 11:30 AM, after surveyor inquiry, the LPN/UM called the Maintenance Director (MD) and requested that the call bell be switched to a tap bell (a pad type device). The MD entered the room and switched the call bell to a tap bell and placed the tap bell on the bed. During an interview with the MD, he stated that usually the nurse would inform the maintenance department if a resident needed a tap bell instead of a regular call bell. The MD stated he was made aware, only today that Resident #62 needed a tap bell. The facility did not inform or explain to Resident #62 how to operate the tap bell when it was placed on the bed. Prior to exiting the room the MD asked the resident to press the tap bell, and the resident stated, Is it my phone. The MD informed Resident #62 that was a tap bell. On 5/22/26 at 11:50 AM, the surveyor again interviewed the LPN/UM and inquired regarding how residents were assessed for call bell devices. The LPN/UM stated that all residents were assessed upon admission, and the call device was checked as needed. The LPN/UM stated that the staff did not report that Resident #62 was unable to activate the call bell. The surveyor then inquired regarding who was responsible to ensure that all residents were provided with the appropriate call bell device to ensure they were able to call for assistance. The UM stated that we (referring to staff) were responsible to ensure that residents call devices were functional and accessible. The UM stated that the CNAs did not report that Resident #62 could not press the call bell. On 5/22/26 at 12:51 PM, the surveyor interviewed the CNA who cared for Resident #62, she stated that Resident #62 would yell and scream and would not press the call bell. She was not aware that Resident #62's tremors and deformities could prevent them from using the call bell.A review of the facility's policy titled, Activities of Daily Living (ADL), Supporting. Revealed under Policy Statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, including appropriate support and assistance with: communication and any functional communication system. On 5/26/26 at 11:30 AM, the team met with the Licensed Nursing Home Administrator and the Director of Nursing and presented the above concerns, no additional information was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate and timely incontinence care for residents who were dependent on staff assistance for care. This deficient practice was identified for 2 of 3 residents (Resident # 22 and Resident #62) reviewed for activities of daily living (ADL) care and was evidenced by the following: included:On 5/18/22 at 10:00 AM, the surveyor toured the unit and inquired regarding the care received by Resident #22 who informed the surveyor that during the 3:00 PM-11:00 PM shift incontinence care was not provided in a timely manner. The resident stated, you have to urinate 3 to 4 times in the brief before you can get changed.1. On 5/19/26 at 9:15 AM, the surveyor observed Resident #22 lying in bed in their room. The CNA informed the surveyor that Resident #22 had breakfast already.On 5/19/26 at 9:19 AM, the surveyor returned to the room; the resident informed the surveyor that they were wet and required to be changed. The surveyor then asked the CNA to assist with a care observation. During the care observation, Resident #22 was observed soaked with urine and the bedding was also soiled and yellow stained.The surveyor then asked the resident when the last time they had received incontinence care, Resident #22 stated they received care around 5:00 AM on 5/19/26 (4 hours prior).On 5/19/26 at 9:35 AM, the surveyor continued the tour and entered Resident #62's room and during the observation of the Certified Nurse Aide (CNA) providing Resident #62 with care. The incontinent brief was observed soaked with urine. Resident #62 also had a dressing to the sacral area that was soaked with urine. Resident #62 could not comment on the last time they had received incontinence care.On 05/19/26 at 10:30 AM, the surveyor interviewed the CNA who cared for Resident #62. The CNA acknowledged that she did not provide any incontinence care to the resident since they began their shift. She stated she had to wait for the nurse to be available to change the sacral dressing.On 5/20/26 at 10:30 AM, the surveyor reviewed Resident #22's electronic medical record which revealed that Resident #22 was admitted to the facility with diagnoses which included but were not limited to; difficulty walking, morbid severe obesity, pain in right hip and post-traumatic stress syndrome.A review of Resident #22's most recent quarterly Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 03/08/26, documented the resident required extensive assistance with most activities of daily (ADL) including incontinence care. Resident #22 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) which revealed that Resident #22 had intact cognition. The resident was incontinent of bowel and bladder and required incontinence briefs. Review of Resident #22's care plan was dated 12/02/25, and revealed they had an ADL/self-care performance deficit related to disease process (major depression, schizophrenia and post-traumatic stress syndrome. The goal was for Resident #22 to maintain existing ADL self-care performance. Resident #22 would be clean, dressed and well-groomed daily. The interventions included: Assist with daily hygiene, grooming, dressing, eating and oral care as needed. Assist with bathing and shower as needed. 2. Resident #62 was admitted to the facility with diagnoses which included but were not limited to: Resident #62 was admitted to the facility with diagnoses which included but were not limited to; muscle weakness, difficulty in walking, other lack of coordination and major depressive disorder. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 required extensive assistance with toileting, bed mobility and transfers, had limitations in the functional ability of their extremities, and was frequently incontinent of bowel and bladder. The MDS indicated the resident had moderate cognitive impairment, Resident #62 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the care plan dated 03/13/25, included a focus for ADL Self Care deficit related to disease process (dementia, mood disorder and adjustment disorder. Initiated 03/13/25. The goal was for Resident #62 to maintain existing ADL self-performance. The interventions included, assist to bathe and shower as needed, assist with daily hygiene, grooming, dressing, oral hygiene and eating as needed. Resident #62 also had a care plan for urinary incontinence related to impaired mobility.Initiated 04/28/25. The goal was for Resident #62 to be free from skin breakdown. Initiated 04/28/25. The interventions included: Provide assistance with toileting or provide incontinence care as needed. Initiated 05/22/25. On 5/22/26 at 12:02 PM, the surveyor interviewed the Director of Nursing (DON) regarding the above concerns with incontinent care. The DON stated that incontinence care was to be provided every 2-3 hours and as needed. The DON stated some residents were to receive incontinence care more frequently based on request. The DON further stated that staff were to provide incontinence care before meals to ensure the residents were not soiled. The surveyor then inquired who was responsible to ensure that residents received incontinence care in a timely manner. The DON stated the nurses and the Unit Managers were responsible.On 05/26/26 at 10:39 AM, the survey team conducted informed the DON and Licensed Nursing Home Administrator (LNHA) of the above concerns and at 12:38 PM, the DON and LNHA met with the survey team for the exit conference and no additional pertinent information was provided. A review of the facility's policy titled, Activities of Daily Living (ADLs) Supporting, last revised 3/2018, revealed the following:Policy Statement:Residents will be provided with care and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Policy for Urinary Incontinence -Clinical Protocol revealed under TreatmentAs appropriate, based on assessment of the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to improve the individual's continence status. NJAC 8:39-27.1 (a) 2; (g)(h)

Complaint # 2600008 Based on interviews, record review and review of pertinent facility documents, it was determined that the facility failed ensure that a Registered Nurse (RN) documented a resident's assessment after a fall occurred. This deficient practice was identified for 1 of 2 residents reviewed for falls (Resident #101).This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 05/19/26 at 10:45 AM, the surveyor, as part of a complaint investigation into a fall that occurred on 08/06/25, requested a facility fall investigation for Resident #101 from the Director of Nursing. On 05/20/26 at 11:20 AM, the surveyor reviewed the closed medical record for Resident #101. A review of the resident's admission record (admission summary) revealed diagnoses which included but not limited to; muscle weakness(a perceived or actual decrease in ability to generate force in one or more muscles), macular degeneration (a leading cause of vision loss in adults over 50, affects in the macular in the central part of the retina, resulting in blurred or loss of central vision while leaving peripheral (side) vision intact.), and difficulty in walking. A review of the Nursing Note (NN) dated 08/06/2025 at 5:00AM, which revealed the following: Heard noise from resident's room, observed resident on the floor lying on their back, next to bed. Neuro checks initiated. Hematoma noted to back of head. MD contacted, awaiting response. Spoke with daughter {name redacted} and made aware. DON notified. Resident lack safety awareness and insist on taking themselves to bathroom without staff assistance. Plan of care ongoing. The note was signed electronically by a Licensed Practical Nurse (LPN). They were no signature of a Registered Nurse in the electronic medical record.A review of a Change of Condition note dated 8/6/25 at 05:08 AM, revealed that the resident had an unwitnessed fall. Noted a change of condition which started on 08/06/25. Note revealed that the resident was on no anti-coagulant therapy, resident had orders for following Advanced care planning which included: Do Not Resuscitate (DNR). Resident's vitals which included Blood Pressure (BP) 152/81, Pulse 88, oxygen saturation 95% and the resident had no changes in mental status. The Changed of Condition note was electronically signed by the LPN. They were no electronic signature from a Registered Nurse.A review of the facility's Fall Investigation for Resident #101 revealed that the resident had a fall on 08/06/25 at 04:20 AM. The incident report revealed under Nursing Description that a Certified Nursing Assistant (CNA #1) heard a noise from the resident's room. The CNA observed the resident on the floor. The resident was next to their bed and was lying on their back. Resident #110 told the Licensed Practical Nurse (LPN#1) that they were attempting to go to the bathroom. Under the section titled Immediate Action Taken a Licensed Practical Nurse (LPN) wrote the following: Assessment completed, observed hematoma to back of head. Initiated neuro checks, no abnormalities noted. Assisted to bathroom and back into bed. Hourly safety checks and to anticipate needs. The investigation report included a statement from the CNA which revealed that the resident was assisted back to bed by both the CNA and a nurse. The Fall investigation was signed and dated.On 05/26/26 at 9:25 AM, the surveyor interviewed LPN #1 who couldn't recall, Resident #101's fall from 8/6/25. The surveyor asked LPN#1 what she would do if a resident fell and hit their head. LPN#1 stated that she would call a RN to assess the resident and if no RN was available that she would stay with the resident and have the CNA call for paramedics. On 05/26/26 at 9:35 AM, the surveyor left a message with the CNA who never returned the surveyor's call, On 5/26/26 at 10:50 AM, the surveyor presented the above concern to the Licensed Nursing Home Administrator and the DON. The DON stated that an LPN can evaluate a resident who had a fall but only a Registered Nurse (RN) could assess a resident. When the surveyor pointed out that the facility investigation report revealed that the LPN and CNA transferred the resident back to bed after the fall. The DON stated that an LPN was not allowed to transfer a resident back to bed after a fall until the resident is assessed by an RN. DON and the LNHA both stated that they were a RN in the building at the time of the fall, but both also stated that they had no documentation from the RN regarding Resident #101's fall. No further information was provided. A review of a facility Job Description titled Registered Nurse dated 07/2024, included the following duties and responsibilities: Provide oversight of Certified Nursing Assistants (CNA) and licensed nurses as directed by the Director of Nursing. Monitor residents for developments of acute changes of condition including confusion, fever, difficulty breathing. Increased pain, difficulty with urination, loss of appetite, constipation, diarrhea, vision and hearing loss, general malaise or decrease range of motion (ROM); conduct assessments and notify the provider as needed. Maintain documentation of all nursing care and services provided to the residents; use nurse's notes, flow sheets and electronic medical records according to facility protocols. Provide nursing care that is trauma-informed and sensitive individual experiences and triggers. N.J.A.C. 8:39-3.2 (a), (b); 27.1 (a)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for removal of a BIPAP (Bilevel Positive Airway Pressure- a type of non-invasive mechanical ventilation that delivers two different pressurized air levels through a mask) and ensure accuracy for the orders to change a BIPAP mask and tubing. This deficient practice was identified for 1 of 1 resident (Resident #9) reviewed for respiratory care and was evidenced by the following: On 5/18/26 at 10:40 AM, during an initial tour, the surveyor observed Resident #9 lying in their bed. A BIPAP machine was on their nightstand. The surveyor then reviewed the Electronic Medical Record (EMR) for Resident #9 which reflected the following: A review of the admission Record (an admission summary) reflected the resident was admitted with diagnoses which included but were not limited to; interstitial pulmonary disease (a condition that causes inflammation and scarring of lungs), chronic obstructive pulmonary disease (COPD, a progressive lung disease characterized by persistent airflow limitation), and congestive heart failure (CHF, a chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts). A review of the quarterly Minimum Data Set (MDS, a resident assessment and care screening tool) dated 3/26/26, reflected a Brief Interview for Mental Status (BIMS) of 15 out of 15, which indicated the resident was cognitively intact. The MDS further reflected the resident was receiving non-invasive mechanical ventilation. A review of the Individualized Comprehensive Care Plan (ICCP) reflected a Focus area Has/At risk for respiratory impairment related to sleep apnea, acute respiratory failure, obesity, heart failure. An associated intervention was BIPAP use per physician orders. A review of the Physician Orders (PO's) and associated Medication Administration Record (MAR) for May 2026 and Treatment Administration Record (TAR) for May 2026 reflected the following findings under the order group for BIPAP: A PO indicated at bedtime for respiratory distress apply.BIPAP. Start date 4/7/26. The MAR reflected the hour for administration was 2100 (9 PM military time). There were nurse's initials and a checkmark for every date in the month of May up to date of surveyor review. A PO indicated every night shift every 6 month(s) starting on the 1st for 1 day(s) for respiratory distress change mask and tubing every 6 months. Start date 5/1/26. The MAR reflected the hour for administration was Night. There were a nurse's initials and checkmark for the date of 5/1. A PO indicated in the morning for respiratory failure wash mask daily with soap and warm H2O (water), rinse thoroughly with warm H2O and allow to dry. Start date 4/8/26. The MAR reflected the hour for administration was 0600 (6 AM military time). There were nurse's initials and a checkmark for every date up to the date of surveyor review. A PO indicated change BIPAP mask and tubing monthly on the first. In the evening every 1 month(s) starting on the 1st for 28 day(s) for monthly maintenance. Start date 5/1/26. The TAR reflected the hour for administration was 2000 (8 PM military time). There were nurse's initials and a checkmark for every date up to the date of surveyor review. On 5/20/26 at 12:31 PM, the surveyor interviewed the Registered Nurse (RN) #1 who stated she had Resident #9 on her assignment and was familiar with the resident. RN #1 stated Resident #9's BIPAP was put on at night and was already off in the morning by the time she started her shift at 7:00 AM. RN #1 did not know what time the BIPAP mask was removed. On 5/20/26 at 12:42 PM, the surveyor interviewed Resident #9 in their room. Resident #9 stated their BIPAP mask was put on by their nurse at night and taken off in the morning around 5 or 6 AM by the nurse. On 5/20/26 at 12:45 PM, the surveyor interviewed the subacute Unit Manager, Licensed Practical Nurse (UM/LPN) #1 who stated for a resident receiving BIPAP treatment, there should be PO to apply the BIPAP at bedtime and a PO to remove it in the morning. There should also be a PO to change the mask and tubing. In the presence of the surveyor, UM/LPN #1 reviewed the Electronic Medical Record (EMR) for Resident #9. UM/LPN #1 stated there was an order to place the BIPAP at 9 PM and acknowledged there was not an order indicating what time to remove the BIPAP. She stated there was an order to wash it at 6 AM and added, You would have to remove it to wash it. UM/LPN #1 continued to review the PO's for Resident #9. She stated per the PO, the BIPAP mask and tubing was to be changed every 6 months. She stated she would have to check the policy to confirm if this was their protocol. UM/LPN #1 then reviewed the TAR and acknowledged an order to change the mask and tubing had the nurse's initials every day for the month of May 2026, up to the date of review. She stated if the nurse's initials were on the (TAR) that meant that the nurse administered the treatment ordered. She acknowledged the nurses' initials on the TAR meant they changed the mask and tubing every day and stated that was not the proper facility protocol. On 5/21/26 at 10:19 AM, the surveyor interviewed the Director of Nursing (DON) regarding the above. The DON, in the presence of the surveyor, reviewed the EMR including BIPAP PO's, MARs, and TARs for Resident #9. The DON acknowledged there was no PO to remove the BIPAP at any time after it was applied at night. She stated, We clean it in the morning, so it (an order to remove) should be in with that order. After reviewing the PO's with the DON she acknowledged the order to wash the mask did not include an order to remove the BIPAP. The DON then acknowledged there were two separate orders for changing the BIPAP mask and tubing; One indicated every night shift every 6 months, the other indicated every evening every 1 month. The DON stated their BIPAP tubing was changed monthly but would check the policy and speak with the Respiratory Therapist for their recommendations. The DON stated the nurse who entered the PO into the EMR put the order in wrong, which resulted in the nurses signing (initials) on every date of the month. The DON acknowledged, That meant they did it every day. But I know they didn't do it because we don't have enough supplies for that. On 5/21/26 at 11:15 AM, the DON in the presence of the surveyor, spoke with the Respiratory Therapist (RT) via phone call. The RT stated he was familiar with Resident #9 and her use of BIPAP. He stated his recommendation was for the mask and tubing to be changed monthly. The RT stated the equipment should never go 6 months without being changed, the maximum was 3 months in certain situations. After the phone call ended, the DON acknowledged Resident #9's BIPAP orders needed to be corrected and re-written. On 5/26/26 at 10:39 AM, the survey team met with the Administrator and DON to present the above findings. The DON acknowledged the PO's for Resident #9 regarding the BIPAP needed to be changed to specify each task including removal of the BIPAP, and the timeline corrected for care and maintenance of the equipment. The surveyor reviewed the facility provided policy for CPAP/BIPAP support dated 2001 which reflected the purpose was to . 2). Improve arterial oxygenation (PaO2) in residents with respiratory insufficiency.3). Promote resident comfort and safety. Documentation guidelines included to document the following in the resident's medical record. Time.was started and duration of the therapy. The surveyor reviewed the facility provided policy for Oxygen Administration dated 2001 which reflected the purpose was to provide guidelines for safe oxygen administration. Preparation included to verify there was a physician's order for the procedure. Review the physicians orders or facility protocol for oxygen administration. Documentation guidelines included after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record. 1). The date and time the procedure was performed. 4). The frequency and duration of the treatment. NJAC 8:39-25.2(c)3

Based on observation, interview and document review it was determined that the facility failed to failed to maintain the kitchen environment and equipment in a sanitary and properly functioning manner to prevent potential contamination and or the spread of potential food borne illness. This deficient practice was evidenced by the following: On 01/07/25 at 9:51 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: 1. The metal baffles that were inside of the exhaust hood, and above the cooking battery, were visibly soiled with black debris in the slats of the baffles. There was visible grease and grime located on the bottom of the baffles and there was grease type droplets affixed to the opposite inside of the hood. At that time the surveyor interviewed the FSD who confirmed the findings and the surveyor asked the FSD if there was a cleaning schedule to remove and clean the baffles. The FSD state I am working on a cleaning schedule. The nozzles of the fire suppression system in the hood was also observed covered in a grease like substance. 2. The surveyor proceeded to wash hands in the only hand washing sink in the kitchen. The sink water out of the hot faucet felt cold. The surveyor asked the FSD to take the temperature with the facility's calibrated thermometer. The FSD held a thermometer under the running hot water and the thermometer was 74 degrees Fahrenheit. There was a sign affixed above the hand washing sink that revealed: All Employees Must Wash Hands Before Returning to Work, and Wet hands with hot water with a temperature between 90 and 110 degrees Fahrenheit. The surveyor asked the FSD if it was okay if the water was below the required temperature to wash the hands. The FSD stated the cold water won't take off bacteria. 3. Under a stainless steel table opposite of the cooking area the insulated tray lids were stacked with food covering side open and unprotected under a visibly soiled stainless steal table. The Cleaning Policy, undated, provided by the Liscensed Nursing Home Administrator revealed: 2. Surfaces must be cleaned with a sanitizing agent /solution . 4. Grid panels in the fire suppression hood over the stove will be removed and run through the dish machine once a month. NJAC 8:39-17.2(g)

Based on observations and interviews between 01/08/2025 and 01/10/2025 in the presence of the Maintenance Assistant (MA), Regional Director of Maintenance (RDOM) and Senior Regional Director of Maintenance (SRDOM), it was determined that the facility failed to ensure that the resident call bell system properly functioned .This deficient practice had the potential to affect all residents and was evidenced by the following: An observation on 01/09/2025 at 10:14 AM revealed, when the call bell was tested for room [ROOM NUMBER], it did not send a signal of activation to the nurse's station on unit 3. The call bell annunciator was showing an ERROR CONNECTIVITY signal at the desk. An observation at 10:22 AM revealed, when the call bell was tested for room [ROOM NUMBER], it did not send signal of activation to the nurse's station on unit 3. Upon further investigation, The SRDOM push the cord on the annunciator in and stated that the cord was not all the way in. An observation at 11:01 AM revealed, when the call bell was tested for room [ROOM NUMBER], it did not send signal of activation to the nurse's station on unit 2. Upon further investigation, the RDOM noticed that the annunciator at the nurse's station was unplugged and not powered on. The RDOM proceeded to plug the annunciator in and power it on. The facility's Administrator was informed of the deficient practices at the Life Safety Code exit conference on 01/10/25 at 12:30 PM. N.J.A.C 8:39-31.2 (e)

Based on observation, interview and record review it was determined that the facility failed to update resident Care Plans for Activities for 2 of 2 residents reviewed for activities (Resident #26 and Resident #2). The deficient practice was evidenced by the following: a) On 01/06/25 10:46 AM, Resident #26 was observed in bed and was alert. The surveyor tried to engage the resident in conversation and the resident spoke Spanish. There were no activities observed in progress in the room, or any Spanish language materials for the resident. On 01/06/25 at 12:24 PM, the surveyor interviewed the Certified Nurse Aide (CNA) assigned to resident #26. There was a sheet observed with boxes in Spanish and Pictures to help communicate with the resident and was located on the bedside table. The surveyor asked if that was how she communicated with the Resident and the CNA stated, not everything was on there and stated no CNAs speak Spanish. The surveyor asked what the resident liked to do and the CNA stated she didn't know what the resident like to do. On 01/06/25 at 2:00 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #26 which revealed: the Adminssion Record documented diagnoses which included, but were not limit to Sepsis, Metabolic Encephalopathy and Acute Kidney Failure. The Admission Minimum Data Set, dated dated dated [DATE], revealed that the Resident's preferred language was Spanish, and Yes was checked for needing or wanting an interpreter to communicate with the doctor of health care staff. Section F0800 revealed that the Staff Assessment of Daily and Activity Preferences were left blank. The Brief Interview for Mental Status section revealed the resident scored 3/15 which indicated the resident was severely cognitively impaired. A Care Plan Focus for Activities initiated 12/30/24 revealed, Enjoys activities such as music, crafts and television. The Goal is Will actively participate in independent activities of choice daily, Date Initiated: 12/30/2024, Target Date: 01/12/2025. The Interventions included, Assist to transport to and from activities of choice, Date Initiated: 12/30/2024, Provide supplies/materials for leisure activities as needed/requested, Date Initiated: 12/30/2024. The Activity Evaluation, singed by the AD on 12/30/24 documented that the the Language Spoken was English, and speech was Clear. The Activity Evaluation revealed the following; Current Interests: Crafts/Arts/Hobbies, Music, TV Program Viewing Radio, Talking and Conversing, Spending Time Outdoors, Watching Movies and Favorie Movie section was left blank, and Parties and Social Events. On 01/08/25 at 11:45 AM, the surveyor interviewed the AD regarding if there was any documentation regarding attendance in activities. The AD stated that only for the Long Term Care Residents, and it was not for the activity program attendance. The AD stated Resident #26 was considered sub-acute and she did not include the sub-acute residents. The surveyor asked were there any programs developed for cognitively impaired residents including sensory programs. The AD could not provide the survey team with any sensory programs or activities that were scheduled for the residents. The surveyor asked the AD about Resident #26 activities since the resident only spoke Spanish and the Care Plan did not speak to any Spanish activities and the Activity Evaluation indicated the resident spoke English. The AD stated that she must have gotten the information from somewhere else. The AD was unable to provide any information on Resident #26 being provided activities in their native language and related to their cognitive status. 38079 b) On 01/05/25 at 7:26 AM, Surveyor #2 toured the Station 3 nursing unit and observed a large Activity calendar by the unit day room. The activity calendar failed to include all times and locations of activities. Also during tour, Surveyor #2 observed Resident #24 sleeping in their room. On 01/06/25 at 11:49 AM, Resident #24 was observed in their room watching television (TV), and there were also residents in the day room observed watching TV. On 01/07/25 at 9:27 AM, the resident's direct care CNA stated that the resident was independent but needed prompting. He stated Resident #24 would come out of their room and liked to watch TV and sports. A review of the Admission Record revealed Resident #24 had been admitted in 2017 and readmitted in 2021. Resident #24 had diagnoses which included but were not limited to; Bipolar (a mental illness with extreme mood swings); dementia, and muscle weakness. A review of the annual MDS dated [DATE], included a BIMS of 04 out of 15 indicating severe cognitive impairment; Section D Mood revealed 0 never for social isolation; Section F Preferences for Customary Routine and Activities documented it was 1 Very Important to go outside, participate in religious services and 2 Somewhat Important to listen to music, be around animals, keep up with the news. A review of the resident-centered care plan included but was not limited to; Focus area initiated 12/22/2020 and revised 12/22/2020, Prefers not to attend group activities prefers independent activities. A Goal initiated 12/22/2020 and revised 11/20/24, Will sometimes be a passive observer. Goal: will participate in activities of choice such as watching television, wheeling around facility, and engaging in conversation with staff and residents. Intervention dated 8/7/21, encourage participation in activities of interest, and dated 12/22/20, provide information on activity programs on a regular basis and to respect choice in regard to limited/no activity participation. No interventions were revised after 12/22/2020. A review of the facility provided most recent. Activity Evaluation was dated 01/28/2024 and not filled out. The Activity Evaluation included but was not limited to; background, Spiritual involvement, Preferences, 22 categories of activity preferences, adaptions required (i.e.: reminders, assistance, leisure cart visits, sensory, one to one, dementia programs), and mode of transportation. A review of the facility provided Care Conference Notes effective 12/17/24, revealed recreation department did not attend and there was no summary or update of Resident #24's activity preferences. A review of the facility provided Care Conference Notes effective date 10/30/23, included but was not limited to; enjoys time outdoors, family call often, enjoys watching TV, passive observer and sometimes participates in activities, and has been attending more programs in the main dining room. A review of the January 2025 Individual Participation Record revealed codes to be used to record resident activity. The form included A=active, P=passive, R=refused, W=leaves and returns, I=individual, and O=off unit. The form included 21 categories of activities and noted that Resident #24 was marked A in four categories inconsistently and no other codes were entered to indicate if the resident was a passive observer or was invited and refused. On 01/08/25 at 11:49 AM, the Activities Director stated that Resident #24 enjoyed music events and live music. The Activities Director further indicated there was no documentation regarding Resident #24's activity attendance or preferences. A review of the facility provided policy, Care Plans, Comprehensive Person-Centered edited 04/25/22, included but was not limited to; Statement . includes measurable objective and timetables . 2. interventions are derived from a thorough analysis of the information gathered as part of a comprehensive assessment. 7. The process will: . b. includes an assessment of strengths and needs and c. personal and cultural preferences . 8. The . care plan will: b. describes services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being . 13. Assessments are ongoing and care plans are revised as information about the resident and residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: . b. when the desired outcome has not been met, c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly in conjunction with the required quarterly MDS assessment. A review of the facility provided Activity Director job description signed and dated 06/12/2020, included but was not limited to; Purpose . to assure an ongoing program of activities is designed to meeting in accordance with the comprehensive assessment, the interests . mental and psychosocial well-being of each resident. Ensure all activity notes are informative and descriptive of the services provided and the resident's response to the service. On 01/08/25 at 1:43 PM, the above concerns were addressed with the facility administration and the Director of Nursing acknowledged Resident #24's care plan should have been reviewed and revised since 2020. The facility had no additional information to provide. NJAC 8:39-11.2; 27.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a) follow Contact isolation precautions for a resident who was on Transmission Based Precautions (TBP) (Resident #42), b) ensure that resident's indwelling urinary catheter drainage bag was stored properly for 1 of 1 resident reviewed for urinary catheter (Resident #47), and c) perform hand hygiene during meals according to the facility policy. This deficient practice occurred on 2 of 3 resident units (Section 1 & 2) and was evidenced by the following: 1. On 1/5/24 at 7:19 AM, during the initial tour, the surveyor observed a Contact Precaution signage and personal protective equipment (PPE; equipment (gowns, gloves, masks, etc. worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) bin hanging on Resident #42's door. The surveyor observed that the signage indicated Everyone must: Put on gloves before room entry. Put on gown before room entry. On 1/6/25 at 12:36 PM, the surveyor observed a Certified Nursing Assistant (CNA) in Resident #42's room. The CNA was not observed wearing a gown and gloves while in the resident's room as the sign on the door indicated. At that time, the surveyor conducted an interview with the CNA upon exiting Resident #42's room. The CNA confirmed that she was not wearing a gown and gloves upon entering Resident #42's room. The CNA stated it was important to put on PPE before entering a Contact precaution room to protect oneself from what the resident had. The CNA stated, I just went to drop off the lunch tray and I did not have to put on PPE. After reading the posted signage, the CNA further stated they (the unit manager [UM]) told us we have to put on a gown and gloves when we are feeding a resident. I wasn't feeding the resident. I just went to drop off the tray and came out. Later, the CNA stated, I should have put it on as per the signage. At 1/6/25 at 12:43 PM, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated the Contact precaution signage meant that gown and gloves were to be worn at all times and anytime you walked into the Contact isolation room. The LPN/UM stated it was important to put on gown and gloves to protect self and the residents. The surveyor notified the LPN/UM of the above-mentioned observations and the LPN/UM stated that the CNA should have had the gown and gloves on before she entered Resident #42's room. The surveyor reviewed the medical records for Resident #42 which revealed the following: The Admission Record (AR, admission summary) reflected that the resident was admitted to the facility, had diagnoses which included but were not limited to Crohn's disease (a chronic [long duration and generally slow progression] inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition), irritable bowel syndrome (a common condition that affects the stomach and intestines), ulcerative colitis (an inflammatory bowel disease, that causes irritation, inflammation, and ulcers in the lining of your large intestine (also called your colon), and major depressive disorder. The Order Summary Report (OSR) indicated a physician order Contact isolation every shift for HSV-1 (a viral infection that causes genital and oral herpes) with a start date of 12/23/24. On 1/9/25 at 9:37 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated it was important to utilize PPE before entering the Contact precaution room for infection control. The IP acknowledged that the CNA should have worn PPE upon entry and when she delivered the lunch tray. A review of the facility provided Employee In-Service Education dated 5/1/24, Topic: Infection Control: Hand Washing, PPE, EBP, Donning & doffing revealed that above mentioned CNA attended. A review of the facility provided Job Responsibilities for Certified Nursing Assistant (CNA) under Duties and Responsibilities included: Follow established infection prevention and control procedures. A review of the facility policy titled Isolation - Categories of Transmission-Based Precautions (TBP) revised 9/22 included under Policy Statement: TBP are initiated when a resident develops signs and symptoms of a transmissible infection and is at risk of transmitting the infection to other residents. Under Policy Interpretation and Implementation 5a.) The signage informs the staff of the type of CDC (centers for disease control and prevention) precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room. 2. On 1/5/25 at 8:13 AM, during initial tour, the surveyor observed Resident #47 watching TV in their bed. Resident had a urinary drainage bag placed on bedframe to their left side of the bed. On 1/6/25 from 11:58 AM through 1:25 PM, the surveyor observed Resident #47 in bed. At that time, the surveyor observed resident's urinary drainage bag resting on the floor. The drainage bag was not secured to the bedframe. At 1:29 PM, during an interview with the surveyor, the CNA stated if a resident has a urinary catheter. The CNA stated the drainage bag would be below the bladder and secured on the frame of the bed (bedframe). The CNA stated if she observed a urinary drainage bag on the floor, she would notify resident's nurse. The surveyor then accompanied the CNA to resident #47's room and both observed resident's urinary drainage bag on the floor. The CNA donned PPE and picked up resident's urinary drainage bag and secured on the bed frame. The CNA stated she would notify resident's nurse and change the privacy bag. On 1/6/25 at 1:57 PM, during an interview with the surveyor, the LPN stated the urinary bag would be placed on a hook on the bedframe, so it doesn't touch the floor for infection control. The LPN further stated if the urinary bag touched the floor or was on the floor, she would notify resident's physician and get an order to change the bag. On 1/6/25 at 2:07 PM, during an interview with the surveyor, the LPN/UM stated the urinary drainage bag would be placed on the bed frame and it should not touch the floor due to risk of infection. The surveyor notified of the above-mentioned observations and concern regarding resident's urinary bag between the time of 11:58 AM - 1:50 PM. The surveyor then reviewed the medical records for Resident #47 which revealed the following: The AR reflected that the resident was admitted to the facility, had diagnoses which included but were not limited to type 2 diabetes mellitus with other circulatory complications, history of falling, obstructive and reflux uropathy (when urine can't flow (either partially or completely) through your ureter, bladder, or urethra due to some type of obstruction [blockage]). A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/7/2024 included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of MDS, Section H for bladder and bowel reflected Resident #47 had an indwelling catheter. A review of the OSR indicated a physician order, dated 11/08/24 for Insert #16fr (size of catheter) 10 cc (milliliters) [Name redacted] catheter. A review of Resident #47's care plan included the following focus area with an initiated date of 11/26/2024: Use of indwelling urinary catheter related to disease process secondary to obstructive uropathy. On 1/8/25 1:44 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The surveyor notified of the above-mentioned concerns. On 1/9/25 at 9:37 AM, during an interview with the surveyor, the IP stated urinary bags should be secured on the bedframe. The surveyor mentioned Resident #47's urinary bag concerns to the IP. The IP further stated, There is no excuse. It (urinary drainage bag) shouldn't be on the floor. A review of the facility provided Employee Competency Assessment for Catheter Care, Urinary, dated 7/15/24, did not reflect any comments or concerns for the CNA. A review of the facility policy titled Catheter Care, Urinary revised 8/22 included under Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. 27193 3. On 01/06/25 at 11:49 AM, the surveyor reported to the subacute Unit to observe the lunch meal. The surveyor observed a Certified Nursing Assistant (CNA) approaching the dietary cart, picked up a tray, delivered the tray to Resident #58, assisted with setting up the resident. Posted signage was observed on the door to caution staff to wash hands prior to enter and exiting the room, and to wear Personal Protective Equipment during care. The CNA then exited the room without performing hand hygiene. The CNA then went to the dietary cart picked up another meal tray, delivered the tray to another resident on Enhanced Barrier Precaution without washing their hands first. On 01/06/25 at 1:30 PM, the surveyor interviewed the CNA who stated that she entered the room, delivered the tray and did not perform any care to the resident. The surveyor then showed to the CNA the signage posted at the door, and the CNA did not have any comment. At that time the surveyor reviewed the Electronic Medical Record (EMR) for Resident # 58 was admitted to the facility with diagnoses which included but were not limited to, muscle weakness, immunodeficiency, aftercare following joint replacement surgery. Resident #58 had a wound to the left leg and was placed on Enhanced Barrier precautions. On 01/07/25 at 1:45 PM, the surveyor interviewed the Infection Control Nurse who stated that all staff had been educated on Infection Control Prevention. On 1/9/25 at 10:41 AM, the survey team met with the LNHA, and DON for the Exit Conference, and facility management did not provide any additional information and did not refute the findings. NJAC 8:39-19.4(1,2), 27.1(a)

38079 Based on observation, interview, and review of pertinent documents it was determined that the facility failed to ensure a system was in place to inspect the emergency crash carts (ECC) for expiration dates and placement. This deficient practice was identified on 3 of 3 Resident Sections (1,2,3) and was evidenced by the following: On [DATE] at 12:17 PM, Surveyor #1 and Surveyor #2 were on Section 1 unit. The Automatic External Defibrillator (AED) was located in a cabinet on the wall. Across from the AED, the ECC was located. At that time, the Licensed Practical Nurse Infection Preventionist (LPN IP) was on the unit. Surveyor #2 inspected the ECC and found it was locked. There were items on top of the ECC which included the checklist. A review of the ECC checklist revealed the following items were not documented as having been checked: AED, suction machine, suction canister, Intravenous (IV) kit, back board, flashlight with batteries, extension cord, oxygen tank, gloves, [name redacted] suction tube, oral airway, and isolation gowns. Surveyor #2 observed a resuscitation bag hanging on the ECC which was not included in the checklist and there were no instructions on the checklist. The LPN IP stated that the checklist should be checked and signed daily and that there was no reason why it was not. He further stated the facility did not have a policy or procedure for inspecting the ECC. On [DATE] at 7:48 AM, Surveyor #2 observed the ECC and checklist on Section 3. The LPN stated the process was for the staff to make sure everything is there. She stated the pharmacy replaces supplies but did not know who was responsible to check expiration dates. A review of the ECC checklist revealed a lock number for the lock on the cart and lines through the rest of the items. There were no instructions on the checklist. On [DATE] at 9:02 AM, the Licensed Nursing Home Administrator (LNHA) stated there was no policy and procedure for staff to use to check the ECC. The LNHA acknowledged that the staff were signing the bottom of the checklist but there was no procedure for them to follow regarding what to check for. On [DATE] at 9:18 AM, Surveyor #2 was on Section 1 and observed the Registered Nurse (RN) Supervisor by the ECC. The RN Supervisor stated that there was no policy, and she could not inform the surveyor what the staff would be checking for. The RN Supervisor further stated without a policy there was no way for sure to know who was responsible. She lastly stated that the ECC should be checked. On [DATE] at 10:30 AM, Surveyor #3 was on Section 1 and observed the RN opening the ECC. Surveyor #3 inspected the ECC along with the RN. It was noted that the resuscitation bag hanging on the top of the cart was dated [DATE] and had expired [DATE]. Inside the ECC, it was noted that two IV insertion kits had expired [DATE]. The RN revealed that the facility had to check and ensure the emergency cart was locked only and that once a month the 11 PM - 7 PM shift staff would open and check the items inside the emergency cart. On [DATE] at 11:00 AM, Surveyor #2 inspected the ECC on Section 2. The ECC was locked, and the checklist was on top. There were no instructions on what to inspect for on the checklist. The checklist had a lock number and line through all items and did not include inspection of the resuscitation bag. On [DATE] at 1:43 PM, the facility administration was made aware of the concerns. On [DATE] at 10:00 AM, the facility administration informed the survey team that they were still waiting on a policy and procedure for the ECC. The facility informed the survey team that they did create a new ECC checklist. When reviewed, it was noted that the new list did not include inspection of the resuscitation bag. NJAC 8:,d+[DATE].1; 29.4

Based on observation, interview, and review of pertinent documentation, it was determined that the facility failed to a.) ensure activity assessments accurately reflected the needs of all residents and appropriate activities were provided for a non-English speaking resident (Resident #26), and b.) complete a yearly activity assessment and activity monitoring to determine the meaninful interests of a resident (Resident #24), hobbies, and cultural preferences. This deficient practice occurred for 2 of 2 residents reviewed for resident activities and was evidenced by the following: a) On 01/05/24 at 12:47 PM, the surveyor observed Resident #26 sitting in the wheelchair in the Day Room of Station 1. Resident #26 was at a table by themselves, next to a wall, awake and alert with no activities observed in front of the resident, and no activity staff were present. Three other residents were observed in front of a television at another table. At that time, three staff were observed at the nursing desk and there was no resident activity in progress. On 01/06/24 at 11:30 AM, the Liscensed Nursing Home Administrator (LNHA) provided six months of activity calendars and included a weekly January nativity sheet. The scheduled activities for 01/06/24 were Morning Trivia at 10:15 AM on Statio 2 and 3, Bingo and Lunch 11:30 AM in the Dining Room and the Gab [NAME] at 2:15 PM There was nothing scheduled for the entire day for Station #1. On 01/06/25 10:46 AM, Resident #26 was observed in bed and was alert. The surveyor tried to engage the resident in conversation and the resident spoke Spanish. There were no activities observed in the room, or any Spanish language materials for the resident. On 01/06/25 at 10:52 AM, the surveyor observed the three residents in front of the television on Station #1 Day Room. The Activity Director asked if any residents wanted to play Bingo and one resident agreed to go to Bingo. The other two Residents remained in the Station 1 Day Room in front of the television with no other activities planned for Station 1. On 01/06/25 at 12:24 PM, the surveyor interviewed the Certified Nurse Aide (CNA) assigned to resident #26. There was a sheet observed with boxes in Spanish and Pictures to help communicate with the resident and was located on the bedside table. The surveyor asked if that is how she communicated with the Resident and the CNA stated, not everything was on there, and stated no CNAs speak Spanish. The surveyor asked what the resident liked to do and the CNA stated she didn't know what the resident like to do. On 01/06/25 at 1:41 PM, Resident #26 observed in the Station 1 day room, at the end of the table by the television, sitting at a table with other residents and Resident #26 was sleeping while the television was on and no activities were in progress. On 01/06/25 at 2:00 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #26 which revealed: the Adminssion Record documented diagnoses which included, but were not limit to Sepsis, Metabolic Encephalopathy and Acute Kidney Failure. The Admission Minimum Data Set, dated dated dated [DATE] revealed that the Resident's preferred language was Spanish, and Yes was checked for needing or wanting an interpreter to communicate with the doctor of health care staff. Section F0800 revealed that the Staff Assessment of Daily and Activity Preferences was left blank. The Brief Interview for Mental Status section revealed the resident scored 03 out of 15 which indicated the resident was severely cognitively impaired. A Care Plan Focus for Activities initiated 12/30/24 revealed, Enjoys activities such as music, crafts and television. The Goal is Will actively participate in independent activities of choice daily, Date Initiated: 12/30/2024, Target Date: 01/12/2025. The Interventions included, Assist to transport to and from activities of choice, Date Initiated: 12/30/2024, Provide supplies/materials for leisure activities as needed/requested, Date Initiated: 12/30/2024. The Activity Evaluation, singed by the AD on 12/30/24 documented that the the Language Spoken was English, and speech was Clear. The Activity Evaluation revealed;ed the following Current Interests: Crafts/Arts/Hobbies, Music, TV Program Viewing Radio, Talking and Conversing, Spending Time Outdoors, Watching Movies and Favorie Movie section was left blank, and Parties and Social Events. On 01/08/25 at 11:45 AM, the surveyor interviewed the AD regarding if there was any documentation regarding resident attendance in activities. The AD stated that only for the Long Term Care Residents, and not for the activity program attendance for the sub-acute residents and Resident #26 was considered sub-acute. The surveyor asked were there any sensory type programs developed for cognitively impaired residents. The AD could not provide the survey team with any sensory type activity programs or activities that were scheduled for the residents who were cognitively impaired. The surveyor asked the AD about Resident #26 activities since the resident only spoke Spanish and the Care Plan did not document any Spanish activities and the Activity Evaluation indicated the resident spoke English. The AD stated that she must have gotten the information from somewhere else. The AD was unable to provide any information on Resident #26 being provided activities in their native language or related to their cognitive status. 38079 b) On 01/05/25 at 7:26 AM, Surveyor #2 was touring Section 3 unit and observed Resident #24 sleeping on their right side in bed. Surveyor #2 observed a very large activities calendar by the unit day room and a large television in the unit day room. The large activities calendar failed to include the times or locations of the activities. On 01/06/25 at 11:49 AM, Surveyor #2 observed Resident #24 in their room watching television. On 01/07/25 at 9:26 AM, Resident #24 was observed in bed sleeping on their right side. On 01/07/25 at 9:27 AM, the direct care Certified Nursing Assistant (CNA) stated that often Resident #24 was independent but needed prompting. He stated Resident #24 did come of the room and liked to watch television and sports. On 01/08/25 at 9:45 AM, Resident #24 was observed in the unit day room watching television with other residents. There were no activities going on at that time. Resident #24 next self-propelled off the unit. A review of Admission Record revealed that Resident #24 was admitted to the facility with diagnoses which included but were not limited to; bipolar (a mental illness characterized by extreme mood swings), dementia, and muscle weakness. A review of the annual Minimum Data Set (MDS) an assessment tool used to facilitate care dated 10/26/24, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 04 out of 15 indicating severe cognitive impairment; Section D Mood revealed 0 never for social isolation; Section F Preferences for Customary Routine and Activities documented it was 1 Very Important to go outside, participate in religious services and 2 Somewhat Important to listen to music, be around animals, keep up with the news; a review of the resident-centered care plan included but was not limited to; wandering through facility - attempts to minimize excess stimulation and provide supervision during recreation programs, indicators of depression/sadness - attempt to involve in activities respecting choice and preferences dated 12/22/20, and Prefers not to attend group activities prefers independent activities such as watching television, wheeling around facility and engaging in conversation with staff and residents - encourage participation in activities of interest dated 08/07/21. A review of the facility provided most recent Activity Evaluation was dated 01/28/2024 and not filled out. A review of the January 2025 Individual Participation Record revealed codes to be used to record resident activity. The form included A=active, P=passive, R=refused, W=leaves and returns, I=individual, and O=off unit. The form included 21 categories of activities and noted that Resident #24 was marked A in four categories inconsistently. There were no other codes entered to indicate if the resident was a passive observer or was invited and refused activities. On 01/08/25 at 11:49 AM, the Activities Director (AD) was in the conference room with two surveyors and stated that if a resident participated in an activity, there would not be documentation. She further stated there was no documentation if a resident was offered or refused to participate. When asked if the resident was offered should their form include an R for refused, the AD stated you are right, it is not done. I don't have an answer for that. The AD stated Resident #24 liked to go to music events and live music, but it was not documented anywhere that the resident was invited to any of those types of activities. A review of the facility provided policy, Activity Programs revised 2018, included but was not limited to; a. to support the well-being of residents and to encourage independence and community interaction; 5. designed to encourage maximum individual participation and . individual resident's needs; 9. All activities are documented in the resident's medical record. 13. residents are encouraged . to participate in scheduled activities. A review of the facility provided policy, Group Programs and Activities Calendar revised June 2018, included but was not limited to; 3. Residents are encouraged to participate in all group activities, especially those best suited for their interests and physical, mental, and emotional needs. The Activity Director Job Descrtiption revealed: The primary purpose of your job description is to plan, organize, develop and direct the overall operation of the Activity Department in accordance with current federal, state, and local standards, guidelines and regulations, our established polices and procedures, and as may be directed by the Aedministrator an d/or Activit Consultant, to assure that on on-going program of activities is designed to meet in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The above concerns were discussed with the facility administration on 01/08/2025, and the facility had no additional information to provide. NJAC 8:39-7.2; 7.3

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to follow the physician orders for medications (meds) that required parameters. This deficient practice occurred for 1 of 18 residents (Residents #62) reviewed for medications and was evidenced by the following: This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/5/25 at 8:49 AM, the surveyor observed Resident #62 eating breakfast in their wheelchair and the resident informed the surveyor that they had received all their medications. The surveyor reviewed Resident # 62's electric medical records (EMR) that revealed the following: The Admission Record (AR; admission summary) revealed that Resident #62 had diagnoses that included but were not limited to, acute kidney failure (a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), repeated falls, and muscle weakness. A quarterly Minimum Data Set (qMDS) an assessment tool used to facilitate management of care, with an Assessment Reference Date (ARD) of 12/3/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #62 scored a 11 out of 15, which indicated the resident was moderately cognitively impaired. A review of the Order Summary Report (OSR) reflected that Resident #62 had an active Physician Order (PO) dated 6/27/24 for a med: Midodrine HCL (hydrocholoride) Oral Tab 10 mg- Give 1 tablet by mouth every 8 hours for Hypotension (low blood pressure [BP]); HOLD if SBP [systolic BP] > 120, with a start date of 6/27/24. The corresponding PO was transcribed into the September 2024 through January 2025 electronic Medication Administration Record (eMAR). Further review of the September 2024 - January 2025 eMARs for Resident #62 revealed that nurses signed and reflected a checkmark which means that the med was administered when the med should have been held for a SBP that was greater than 120 according to the PO, for the following dates and times: Date Time SBP 9/4/24 2:00 PM 125/89 9/7/24 2:00 PM 128/73 9/19/24 10:00 PM 129/69 9/20/24 10:00 PM 129/76 10/30/24 6:00 AM 122/67 10/30/24 10:00 PM 127/72 10/31/24 10:00 PM 124/65 11/11/24 6:00 AM 122/60 12/7/24 2:00 PM 121/68 12/16/24 2:00 PM 121/69 12/16/24 10:00 PM 140/71 1/1/25 10:00 PM 121/67 During an interview with the surveyor on 1/7/25 at 10:32 AM, the Licensed Practical Nurse (LPN#1) stated, Midodrine was for hypotension (for low BP) and if the BP was higher than 120, then we would hold the medication because it would bring the BP higher. The LPN further stated, we would check BP before administering the medication. During an interview with the surveyor on 1/7/25 at 10:48 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #1) stated, Midodrine is used to raise the BP. The LPN/UM #1 stated the process was to check Vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure) first and if the BP >120, then the medication would be held. The surveyor informed the LPN/UM #1 of the above concerns for Resident #62. The LPN acknowledged that the medication should have held when the BP> 120. On 1/8/25 1:44 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The surveyor notified of the above-mentioned concerns for Resident #62. A review of the facility provided Job Responsibilities for Licensed Practical (Vocational) Nurse (LPN)/ (LVN) under Duties and Responsibilities included: Administer medications within the scope of practice and according to practitioner orders. Report adverse consequences, side effects or any medication errors. A review of the facility policy titled Administering Medications revised 4/19 included under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Under section Policy Interpretation and Implementations- 4.) Medications are administered in accordance with prescriber orders, including any required time frame. On 1/9/25 at 10:41 AM, the survey team met with the LNHA, and DON for the Exit Conference, and facility management did not provide any additional information and did not refute the findings. NJAC 8:39-11.2(b), 27.1 (a), 29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary services to maintain adequate grooming for a resident who was dependent on the staff for activities of daily living. This deficient practice was observed for 1 of 19 residents reviewed for care (Resident #125) and was evidenced by the following: On 01/05/25 at 9:07 AM, the surveyor observed Resident #125 lying in bed. Resident #125's facial area was covered with long thick facial hair. Resident #125 was positioned on the left side and the head of the bed was slightly elevated. On 01/05/25 at 11:30 AM, the surveyor observed the resident still laying on the left side as observed at 9:07 AM. The surveyor left the room and reviewed the assignment sheet. The surveyor located the Certified Nursing Assistant (CNA #1) assigned to Resident #125. CNA #1 entered the room with the surveyor and stated that she was caring for another resident and had not provided care yet to Resident #125. On 01/05/25 at 11:45 AM, in the presence of the surveyor, CNA #1 provided incontinence care to the resident, adjusted the bed linen and exited the room. The surveyor returned to the room at 12:45 PM, Resident #125 was still in bed. On 01/05/25 at 1:00 PM, the surveyor interviewed CNA #1 who stated that Resident #125 was dependent on staff for all activities of daily living. CNA #1 stated that Resident #125 had been at the facility for a few days, refused to eat and had not been out of the bed. On 01/06/25 at 8:15 AM, the surveyor observed Resident #125 in bed, positioned on the backside with the head of the bed slightly elevated. The surveyor observed the resident still with long thick facial hair. On 01/06/25 from 10:15 AM to 11:30 AM, the surveyor sat in the room, the resident was still in bed as observed at 8:15 AM, no staff entered the room during the observation. On 01/06/25 at 11:30 AM, the surveyor reviewed the Admission Record which indicated that Resident #125 was admitted to the facility with diagnoses which included but were not limited to: frontal lobe and executive function deficit following non traumatic intracerebral hemorrhage, hypertension, unspecified dementia without behavioral disturbances, and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE], an assessment tool use by the facility to prioritize care, reflected that Resident #125 had a Brief Interview for Mental Status (BIMS) of 03 indicative of severe cognitive impairment. The MDS further assessed that Resident #125 required total staff assistance for personal hygiene, including combing hair, brushing teeth and eating. On 01/07/25 at 8:20 AM, the surveyor observed that Resident #125 was in bed, and still observed with thick facial hair. The resident could not answer any questions when approached. On 01/07/25 at 8:48 AM, the surveyor observed Resident #125 in bed and the face was still covered with thick facial hair. On 01/07/25 at 9:44 AM, the surveyor inquired through the Unit Manager (UM) regarding who supervised the care. The UM stated, that the nurses and the UM were to make rounds and ensure that the the CNAs cared for the residents. The UM stated that she did not notice the facial hair on Resident #125. On 01/07/25 at 11:45 AM, the surveyor interviewed again CNA#1 who cared for Resident #125 on 1/5/25 and 1/6/25. The CNA confirmed that Resident #125 was totally dependent on staff for care. When inquired regarding the facial hair observed for the last 3 days even after she had provided care to Resident #125, CNA #1 stated that she observed the facial hair and was not aware that she could shave the resident. The CNA added that she had been working at the facility and had never shaved or assisted a resident with shaving. On 01/07/25 at 12:30 PM, the surveyor observed another CNA transferring Resident #125 to the Dayroom. Resident #125 was neatly dressed, and their grooming was tending to. There was no facial hair. Resident #125 had their eyes open and was smiling. On 01/08/25 at 8:46 AM, during a second interview with the UM, she stated that the CNAs were responsible for shaving the residents. The UM further added, that any staff can supervise the care. She was not aware that Resident #125 had facial hair. On 01/08/25 at 9:49 AM, the surveyor interviewed CNA #2 who cared for Resident #125 on 01/07/25. The CNA stated, When she entered the room on 01/07/25 at 8:40 AM, she observed the resident with thick facial hair, she thought that the resident was a [a different gender], and she went to the nurse's station and informed the Unit Manager. CNA #2 stated that she had to use four razors and asked another CNA to assist with the shaving. The CNA stated, I could not believe that the resident had been here and had not been shaved. I had to do it. On 01/08/25 at 11:06 AM, the above concerns were discussed with the the Licensed Nursing Home Administrator (LNHA), who provided the policy for shaving and stated that the CNA should know that she can shave the residents. On 01/08/25 at 12:05 PM, the surveyor reviewed the CNA assignment/computer tablet which reflected the resident had a self-care performance deficit and required staff assistance for personal hygiene. On 01/08/25 at 2:15 PM, the surveyor discussed the above observations and concerns with the Administrator and the Interim DON and required the policy for ADL and shaving. On 01/09/25 at 9:45 AM, the LNHA provided the policy titled, Shaving the Resident last revised 2/2018. The following were noted: Purpose: The purpose of this procedure is to promote cleanliness and to provide skin care. The Activities of Daily Living (ADL) Supporting contained the following: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. On 01/09/24 at 11:10 AM the surveyor reviewed the yearly competency evaluation for the CNA and verified that all CNAs received competency evaluation on Shaving. NJAC 8:39-27.1 (a)

Complaint#: NJ00181485 Based on observation, interview, and record review and review of other facility documentation on 12/23/24 and 12/24/24, it was determined that the facility failed to develop and implement baseline care plan (BCP) within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident. This practice was identified for 1 out of 6 residents (Resident #1) reviewed. This deficient practice was evidenced by the following: Resident #1 was not in the facility at the time of the survey. A closed medical record review was conducted. The surveyor reviewed the Admission Record which revealed that Resident #1 was admitted with the diagnoses which included but were not limited to spinal stenosis (spaces inside the bones of the spine that get too small), atherosclerotic heart disease, type 2 diabetes. Review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 11/21/24, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. Further review of the MDS dated revealed that the resident scored a 10 on the Resident Mood Interview which indicated moderate depression. A closed record review on 12/23/24 indicated no BCP was initiated for mood. On 12/23/24, at 12:50 P.M., during an interview with the Director of Social Services (DSS), the DSS stated that it was her responsibility to assess section D, also known as PHQ2, of the MDS which reflected the mood score of the resident. The DSS stated that she referred the resident for psychological services. The DSS was unable to provide documentation of the referral or that services were provided. The DSS did not provide a BCP that reflected an intervention for mood. On 12/24/24, at 10:14 A.M., during a follow-up interview with the DSS, she stated that a mood score of 10 was high. She stated, A score of 10 notes signs and symptoms of depression. The DSS stated that she became aware that no documentation existed that the psychologist made any attempts to see the resident after surveyor interview. The DSS further stated a mood care plan should have been initiated to address the mood score of 10. On 12/24/24, at 2:52 P.M., during an interview with the Administrator and Nurse Educator, the Administrator stated, If a screening is completed and a concern is identified then the resident is followed up with a referral and a care plan. He also stated that There should be a formal record of all referrals made to the Psychologist and that all attempts by the Psychologist be documented. Review of the facility's Director of Social Services job description, revised in November 2010, revealed that the DSS, .Develop a written plan of care for each resident that identifies the social problems/needs of the resident and the goals to be accomplished for each problem/need identified . Review of the facility's Care Plans-Baseline policy, revised in March 2022, reflected that a Baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. The policy further revealed under the Policy Interpretation and Implementation section that a baseline care plan, .must include the minimum healthcare information necessary to properly care for the resident, including but not limited to the following .d. therapy services; e. Social Services . NJAC 8:39-11.2(d)

Complaint#: NJ00181485 Based on observation, interview, and review of medical records and other pertinent facility documentation on 12/23/24 and 12/24/24, it was determined that the facility failed to maintain a safe enviornment, keep a resident free from hazards, and provide the necessary monitoring and supervision for a resident who was found to have ligature marks around the neck. This deficient practice was identified for 1 of 6 residents (Resident #1) reviewed and was evidenced by the following: Resident #1 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the Admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: spinal stenosis (spaces inside the bones of the spine that get too small), atherosclerotic heart disease, and Type 2 diabetes. Review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 11/21/24 indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. Further review of the MDS revealed that Resident #1 scored a 10 on the Resident Mood Interview (RMI), indicating that the resident was moderately depressed. Further review of the medical record did not indicate that a psychological assessment was completed. The surveyor reviewed the Incident Report, dated 12/7/24, which revealed that the call bell cord had been disconnected from the wall and was wrapped around the resident's neck. The report further revealed that the resident stated that, .[his/her] efforts of self-harm were intentional . A note under the Mental Status section revealed, Ligature marks noted to patients' neck. On 12/30/24, at 11:06 A.M., the surveyor interviewed the Certified Nurse Assistant (CNA) who responded to the incident via telephone. The CNA stated that she was regularly assigned to the resident and that on the morning of the incident she reported to the floor and noted that the resident's call bell was ringing. She stated that she could not recall how long it had been ringing. The CNA stated that she responded to the room and called out the resident's name. She further stated that the resident did not respond, and she saw that the resident was lying in bed underneath the blanket. The CNA stated she pulled the blanket back and began screaming when she saw that the call bell cord was unplugged from the wall, The cord was wrapped twice around [his/her] neck and was tied in the back of [his/her] head. The CNA stated that she screamed for help as she began to untie the cord. She further stated that the resident was unresponsive but that once the nurse arrived, they shook the resident who then, came out of it. The CNA stated that once the cord was fully removed from the resident's neck a ring was visible, [He/She] had a whole ring around his neck. On 12/30/24, at 11:25 A.M., the surveyor reached the Administrator via telephone. The Administrator stated that he was contacted on the morning of the incident by the Director of Nursing (DON). He stated that he and the DON collaborated to ensure that all aspects of the investigation were initiated and completed. The Administrator stated that the call bell had been unplugged from the wall and that this can sometimes happen inadvertently by the raising or lowering of the bed. The Administrator further stated that the call bell cord involved in the incident did not require repair, it was plugged back into the wall. The Administrator stated he could not recall if the resident suffered any injuries as a result of the incident, however, if there were any, It would be noted on the incident report. N.J.A.C. 8:39-27.1(a)

Complaint#: NJ00181485 Based on interviews, review of the medical records, as well as review of other pertinent facility documentation on 12/23/24 and 12/24/24, it was determined that the Director of Social Services (DSS) failed to develop and implement policies and procedures for the identification of medically related social and emotional needs for a resident and assist a resident in obtaining needed services from outside entities, as required by the facility's job description for the Director of Social Services. This deficient practice was identified for 1 of 6 residents (Resident #1) reviewed and was evidenced by the following: Resident #1 was no longer at the facility at the time of the survey. A closed record review was conducted. A review of the Admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: spinal stenosis (spaces inside the bones of the spine that get too small), atherosclerotic heart disease, and Type 2 diabetes. Review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 11/21/24 indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. Further review of the MDS revealed that Resident #1 scored a 10 on the Resident Mood Interview (RMI), indicating that the resident was moderately depressed. Further review of the resident's record did not indicate if Resident #1 was referred for a psychological assessment nor if an assessment was completed. The surveyor reviewed the facility's Service Agreement with the psychologist, dated 06/14/2019, which revealed under the II. Functions and Responsibilities of the Facility section that The facility shall provide a designated staff person to act as a primary contact and coordinator for [name of contracted provider]. On 12/23/24, at 10:14 A.M., during an interview with the surveyor, the Director of Social Services (DSS) stated that it was her responsibility to assess section D of the MDS which reflected the mood score of the resident. She further stated that Resident #1 scored a 10 on the RMI and that she referred the resident for psychological services. The facility did not provide documentation of the referral or that services were provided. On 12/23/24, at 1:17 P.M., during an interview with the surveyor, the Psychologist stated that she recalled attempting to see the resident several times but was not successful. On 12/23/24, at 2:26 P.M., during an interview with the resident's Medical Doctor (MD), the surveyor asked the MD if a resident that scored a 10 on the RMI should have had a psychological assessment, the MD stated, If there was a flag on his assessment, he definitely should have been monitored. On 12/24/24, at 10:05 A.M., during an interview with the surveyor, the Administrator stated that the DSS was the primary contact with the contracted psychologist. On 12/24/24 at 10:14 A.M., during a follow-up interview with the surveyor, the DSS stated that a mood score of 10 was high. She stated, A score of 10 notes signs and symptoms of depression. The DSS stated that she referred Resident #1 to the Psychologist verbally. She further added that if she had not seen the resident, she would have sent an email. The DSS also stated that she was the facility's primary contact for the Psychologist. She stated that all meetings between her and the Psychologist were verbal and that they would discuss who the Psychologist saw and who she had not seen. She further added that occasional emails were sent, but that nothing was in writing as they would discuss multiple residents at a time. On 12/24/24, at 2:34 P.M., during a follow-up interview with the surveyor, the DSS stated, At this time, there is no formal tracking of resident's identified as needing a [psychological] assessment/evaluation, and whether or not those are being completed, and/or if they are effective. On 12/24/24, at 2:52 P.M., during an interview with the Administrator and the Nurse Educator, the Administrator stated that it is the expectation that if a screening identified a concern, the resident would be followed up by a referral. They further stated that all referrals made to the contracted psychologist should be documented. The surveyor asked the Administrator about the DSS' above statement regarding the lack of formal tracking of resident's psychological referrals, completion of those referrals, and their efficacy, to which the Administrator stated that he was just made aware of this and that, There should be a formal record of all referrals made to the contracted psychologist that includes follow-up as to whether or not the psychologist evaluated the resident and if the provided services were effective. The surveyor reviewed the Job Description for Director of Social Services, revised November 2010, under Administrative Functions: .Develop and implement policies and procedures for the identification of medically related social and emotional needs of the resident . Provide consultation to members of our staff, community agencies, etc., in efforts to solve the needs and problems of the resident through the development of social service programs . Work with the facility's consultant as necessary and implement recommended changes as required . Make written and oral reports to the Administrator concerning the operation of the social service department . NJAC 8:39-27.1(a), 39.4(e)(h)(i)

Complaint#: NJ00181485 Based on observation, interview and review of medical records and other pertinent facility documents it was determined that the facility failed to maintain accurately documented and complete medical records in accordance with acceptable standards and practice by a.) not documenting attempts to complete psychological assessment and b.) not documenting weights for a new admission. This deficient practice was identified for 1 of 6 residents (Resident #1) as evidenced by the following: Resident #1 was not at the facility at the time of the survey. A closed medical record review was conducted. The surveyor reviewed the Admission Record which revealed that Resident #1 was admitted with the diagnoses which included but were not limited to spinal stenosis (spaces inside the bones of the spine that get too small), atherosclerotic heart disease, and type 2 diabetes. Review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care dated 11/21/24 indicated that Resident# 1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition. Further review of the MDS revealed that the resident scored a 10 on the Resident Mood interview which indicated moderate depression. The surveyor reviewed the resident record progress notes which revealed the following: -There were no admission weekly weights for the weeks of 11/22/24 and 11/29/24, and there was no documentation indicating why they were not obtained. -There was no documentation that the Psychologist attempted to assess the resident. On 12/23/24, at 1:17 P.M., an interview was conducted with the Psychologist who stated she attempted to see the resident several times but was not successful. She stated that every time she went to his room he was sleeping. No documentation was provided to the surveyor indicating that the Psychologist attempted to see the resident. On 12/24/24, at 10:51 A.M., an interview was conducted with the Registered Dietician (RD) who stated, that New admissions are to be weighed weekly for four weeks. The RD stated that she typically followed up with weekly weights. If the weights were not obtained, the RD stated she would have followed up to see the reason why they were not obtained. In the presence of the surveyor, she reviewed the weight record for Resident# 1 and stated that two weights were missing. On 12/24/24, at 2:52 P.M., during an interview with the Administrator and the Nurse Educator, the Administrator stated, Weights should be done at admission and then weekly. When the surveyor asked what the expectation of the facility is regarding documenting referrals for the Psychologist he stated, The expectation is that all recommendations to Psychologist should be documented, and all the attempts made by the Psychologist should be documented. Both the Administrator and the Nurse Educator stated that, All documentation should be in the system. When the surveyor asked why this is important the Administrator stated, It is important to make sure it was documented, if it wasn't documented it wasn't done. The surveyor reviewed the facility's Weight Assessment and Intervention policy, revised March 2022, which revealed under the weight assessment section that, Residents are weighed upon admission and at intervals established by the interdisciplinary team such as weekly for four weeks and then monthly unless otherwise indicated. The surveyor reviewed the facility's Service Agreement with the psychologist, dated 06/14/2019, under the Functions and Responsibilities section revealed that .all respective medical record documentation including assessment and progress notes . would be maintained according to facility policy. The surveyor reviewed the facility's Charting and Documentation policy, revised July 2017, revealed under the Policy Statement section that, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical record, physical, functional or psychosocial shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. NJAC 8:39-35.2(d)(f)

Complaint #: 168416 Based on interview and review of facility documents it was determined that the facility failed to conduct a thorough investigation to address an allegation of abuse according to their Reporting and Investigating Policy. This deficient practice was identified for 1 of 6 residents (Resident #2), and was evidenced by the following: Resident #2 no longer resides at facility, on 12/23/24, a closed record review of Resident #2's medical record was completed. The surveyor reviewed Resident #2's clinical record. The Admission Record indicated that Resident #2 was admitted to the facility with diagnoses which included but not limited to: Anxiety Disorder (a mental health condition that causes excessive and uncontrollable feelings of fear or worry that can interfere with daily life), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Muscle Weakness, Difficulty in Walking, and Presence of Artificial Eye. The Minimum Data Set (MDS) an assessment tool dated 10/09/2023, revealed that Resident #2 required substantial maximal assist with ADLs and transfers. Resident #2 scored 6 on the Brief Interview for Mental Status (BIMS) which indicated that Resident #2 had some cognitive impairment. On 12/23/24, the Administrator provided a copy of the Reportable Event Record dated 10/13/23, and a copy of the incident report for a fall that occurred on 10/10/23. A review of the progress note dated 10/10/23 at 12:37 revealed Resident #2 was found lying on the floor beside their bed with their head under their wheelchair. The progress note stated that, Resident #2 told staff that they were trying get up from their wheelchair and get into bed. According to a progress note dated 10/12/23 at 10:45, the resident had a change in condition related to complaints of nausea after a fall 2 days ago. The nurse notified the doctor, and the resident was sent out to the hospital using non-emergent transfer. A review of the progress note dated 10/12/23 at 21:19 revealed that when Resident #2's nurse called hospital for an update on the resident's status, the hospital staff stated that resident informed them that they were pushed, an investigation was completed by Acute Hospital Social Workers, and the allegation was denied by Resident #2's family member. The resident was then discharged from the hospital and sent back to the facility. No further documentation for the investigation was provided. During an interview with Surveyors on 12/24/24 at 10:14 a.m., the Director of Social Services (DSS), stated that allegations of abuse were handled in collaboration with the Administrator and Director of Nursing (DON). She stated that she would talk with the resident that made that allegation of abuse and collect their statement. She stated that she does not speak with other residents. She stated she was not hired during the time of Resident #2's abuse allegation. During an interview with Surveyors on 12/24/24 at 2:52 p.m., the Administrator stated that after an allegation of abuse, it is their policy to separate the victim and the staff member. The staff member would be suspended pending investigation, police would be called, skin assessments would be completed, witness statements would be collected from other alert and oriented residents. Administrator stated he became aware of the allegation of abuse, after he gathered the documentation for Resident #2. The administrator stated he was aware that the provided investigation was not complete. A review of the facility's policy presented by the Administrator, titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, with a revision date of September 2022, included but was not limited to the following: under the heading for Policy Statement, it states, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under the heading for Investigating Allegations, the policy states, 7. The individual conducting the investigation as a minimum: .d. interviews the person(s) reporting the incident; e. interview any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative .h. interviews staff members (on all shifts) who have contact with the resident during the period of the alleged incident .l. documents the investigation completely and thoroughly. N.J.A.C: 8:39-4.1 (a) 5