Every finding on record at Careone at Oradell

Based on observation, interview, and review of facility documents, it was determined that the facility failed to maintain the kitchen exhaust hood system in good repair and free of structural defects that could compromise fire safety. This deficient practice had the potential to affect all 122 residents in the facility by increasing the risk of fire and smoke spreading behind the kitchen exhaust hood and was evidenced by the following:On 5/6/26 at 10:00 AM, the surveyor conducted a tour of the facility kitchen with the Food Services Director (FSD). During the kitchen tour, the surveyor observed the stainless steel exhaust hood located above the cooktop. Two sections of the hood had gaps measuring greater than approximately one-half inch where the panels joined. One of the hood sections was significantly dented along the side, preventing the adjoining sections from fitting tightly together. On 5/6/26 at 10:30 AM, the surveyor interviewed the FSD regarding the gaps in the exhaust hood who acknowledged the concern and stated he understood that flames or heat from the stove could rise into the hood and enter through the gaps into the area behind the hood. The FSD further stated he would address the issue. On 5/11/26 at 9:25 AM, the surveyor conducted a follow-up kitchen observation with the FSD and the Regional FSD (RFSD). The surveyor observed that the gaps in the exhaust hood were still present and had not been repaired. During a follow-up interview on 5/11/26 at 9:25 AM, the FSD stated he had noted the concern on 5/6/26, and intended to repair the hood, but had not yet done so. The RFSD stated he would order replacement hood sections to correct the damaged panel. The surveyor observed the RFSD adjusted the hood panels and was able to close one of the two gaps; however, a second gap remained due to the dented hood section. A review of the facility's Sanitization Policy, revised November 2022, included, all utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. The policy further included, Glaze and cracked, damaged or broken equipment that cannot be repaired is discarded. These policy provisions required that kitchen equipment, including the exhaust hood system, be maintained in good repair and free of structural defects that could interfere with safe operation and proper cleaning. On 5/11/26 at 9:25 AM, the RFSD and the FSD acknowledged that the kitchen exhaust hood was not maintained in good repair and that the damaged and separated sections required replacement. On 5/13/26 at 11:49 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing regarding the kitchen exhaust hood concerns. The LNHA acknowledged that the kitchen exhaust hood sections were not reassembled correctly after cleaning and stated that when the hood sections were removed for cleaning and reassembled, they were not put back properly, resulting in gaps between the hood panels. NJAC 8:39-17.2(e); 31.2(e)

NJ #298824 Based on observation, interview, and record review it was determined that the facility failed to maintain the privacy for 4 of 4 residents (Resident #12, Resident #66, and 2 unsampled residents) during resident council meeting by 2 of 2 Recreation Aides and dignity of 1 of 4 residents (1 unsampled resident) during incontinence round and 1 of 4 residents (Resident #12) with regard to their personal care.The deficient practice was evidenced by the following. 1.On 5/6/26 at 10:10 AM, Surveyor #1 (S #1) and Surveyor #2 (S #2) met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) during an entrance conference meeting. The LNHA and DON agreed to set up the resident council meeting on 5/11/26 at 10:30 AM. The LNHA stated that he would notify Unsampled Resident #1 (UR #1) of the resident council meeting and the other residents who would be attending the meeting of the date and time. He further stated that meeting would be on the 2nd (second) floor of the small activity room. S #1 asked for copy of resident council list of residents who would attend and the copy of the last three months' minutes to be provided to S #1 tomorrow (5/7/26). On 5/11/26 at 9:49 AM, S #1 followed up with the LNHA with the list of residents who would be attending the resident council meeting, and he stated that he would get back to S #1. On 5/11/26 at 10:00 AM, the DON provided a list of residents who would be attending the resident council meeting that included UR #1, Unsampled Resident #2 (UR #2), Resident #12, and Resident #66. On 5/11/26 at 10:25 AM, S #1 went to the 2nd floor activity room and met UR #1 and the Director of Recreation (DR). The DR informed S #1 that the rest of the residents were on their way to the meeting. The DR asked S #1 if she was needed in the meeting and S #1 notified the DR that the resident council meeting would be only between S #1 and the residents that required privacy, then, the DR left the room and closed the two doors. On 5/11/26 at 10:50 AM, UR #2 entered the room and stated that they thought the meeting was set at 10:30 AM, and asked as to why there were only two residents in the meeting. UR #1 and UR #2 agreed to start the resident council meeting. After 10 minutes, Resident #12 and Resident #66 entered the room. Resident #12 informed S #1 that they were not aware the meeting would start at 10:30 AM, not until today, and was rushed to the meeting by the staff even though they did not wash their face yet. 2. On that same date at 11:12 AM, during the resident council meeting, Recreation Aide #1 (RA #1) entered the room without knocking. At that same time, after RA #1 left the room, Resident #66 stated that they experienced that some staff entered their room without knocking first and that did not bother them. Resident #66 further stated that the staff did not knock probably due to familiarity. Furthermore, UR #2 stated that a lot of times the door was open in their room, staff saw the resident incident the room, the staff would enter the room without knocking. UR #2 confirmed it happened to them as well. At 11:25 AM, Recreation Aide #2 (RA #2) entered the room without knocking on the door while the resident council meeting was on going. RA #2 entered the room with a backpack bag and stayed inside the room for about three minutes while he was fixing his ID (identification) card and personal stuff. Afterward, S #1 notified RA #2 of the ongoing meeting with four residents and requested privacy, and then RA #2 left the room. On 5/11/26 at 12:41 PM, S #1 met with the DR and the Director of Social Services (DSS), and S #1 notified of the above concerns with regard to the timeliness of the meeting, that Resident #12 was unable to wash their face prior to the resident council meeting, and two Recreation Aides who entered the closed door meeting without knocking. On that same date and time, the DR stated, I was notified this morning of the resident council meeting and was asked who should be in the meeting. The DR further stated that residents' dignity and privacy should have been respected. 3. On 5/12/26 at 9:55 AM, S #1 was accompanied by the Infection Preventionist Nurse (IPN) during incontinence round of Unsampled Resident #3 (UR #3) inside their room. UR #3 voiced out concern with regard to their privacy curtain which was unable to fully cover their area (inside the room) when the IPN was about to check their incontinence brief. The IPN acknowledged the concern of UR #3 and stated that she would ask someone to replace the privacy curtain. Afterward, the IPN then proceeded to the incontinence care with the assistance of a male Certified Nursing Aide (CNA). S #1 also notified the IPN of the concern with the metal part of the privacy curtain that they were not all properly hooked. On 5/12/26 at 11:00 AM, the survey team met with the LNHA and DON, and S #1 notified them of the above findings and concerns. On 5/13/26 at 11:48 AM, the survey team met with the DON and the LNHA stated that there was a miscommunication of the time of resident council meeting, and care was rendered to Resident #12 after surveyor's inquiry. He further stated that education was provided to recreation aids about knocking prior to entering the room. A review of the facility's Resident Rights Policy that was provided by the DON, with a revision date of October 2025, revealed that, employees shall treat all residents with kindness, respect, and dignity. A review of the facility's Dignity Policy that was provided by the DON, with a revision date of October 2025, revealed that, residents are treated with dignity and respect at all times.Policy Interpretation and Implementation:Each resident is care for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.5. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to:a. Maintain personal grooming styles.6. Residents' private space and property are respected at all times.7. Staff are expected to knock and request permission before entering residents' rooms.11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. On 5/13/26 at 1:37 PM, the survey team met with the LNHA DON, and the Regional Nurse of Clinical Services, and there was no additional information provided by the LNHA and the DON. N.J.A.C. 8:39-4.1(a)(12,16,22, 24), 27.1(a)

REPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 2 of 2 floors and 1 of 2 dining rooms (1st floor private dining room), and was evidenced by the following: The deficient practice was evidenced by the following: 1. On 5/7/26 at 10:28 AM, Surveyor #1 (S#1) and Surveyor #2 (S#2), conducted a facility tour. Both surveyors observed the 1st floor private dining area in the presence of the Regional Director of Environment Services (RDES), which revealed a ceiling return air vent with dust accumulation. The RDES confirmed the air vent needed to be cleaned for fire safety. The surveyors were joined by the Maintenance Director (MD) of the facility, and the Food Service Director (FSD) who was setting up the private dining room. The FSD stated that the private dining room was used by residents for breakfast club on Tuesdays, Wednesdays, and Thursdays, and all observed the baseboard heater/air conditioner unit against the wall which revealed dry leaves and one can tab on top of the coils. The MD confirmed that the unit should be kept clean for fire safety. On that same date and time, both surveyors, in the presence of the MD toured the 1st (first) floor, 1 North Nursing Unit lounge room. A Certified Nursing Assistant (CNA) who was present in the lounge room stated that families and residents use the room. The MD, S #1 and S #2 observed the heater/air conditioner unit in the room with dust and dried leaves on top; a broken wall table; a fish tank which revealed a cabinet underneath with thick accumulation of dust and torn papers. The MD confirmed that they all should be cleaned and would fix the broken table. Then, both surveyors and the MD toured the bathing room area in the 1 North Nursing Unit which revealed a shower with the privacy curtain dangling on some parts due to seven loose hooks; observed a towel dispenser not working, and all observations confirmed by the MD. A tour of the 2nd floor, 2 South Nursing Unit, bathing room area revealed: shower #1 cubicle with no privacy curtain, shower #2 cubicle the light was not working, and shower #4 cubicle revealed a shower vent with blackish substances and dust accumulation. The MD confirmed all findings. Afterward, both surveyors and MD observed the 2nd (second) floor Main Dining Area with 17 residents and three activity aides during an activity. The surveyors observed an air vent ceiling cover with three brownish residues; the 2nd window from the left side of the room revealed the windowsill was chipped; the steam table area observed the bottom corner with peeling wood; and observed the bottom, wall molding near the entrance door, and kitchen area splattered with brownish substances. On 5/12/26 at 10:59 AM, the survey team met with the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S #1 notified them regarding environmental concerns found during facility tour. On 5/13/26 at 11:48 AM, the survey team met with the DON and the LNHA stated the private dining area and units identified by the surveyors during environmental tour were cleaned; 2nd floor showers fixed; towel dispenser fixed; and main dining room issues were fixed (after S #1's inquiry). The LNHA did not provide additional information. 2.On 5/12/26 at 9:17 AM, S #2 toured the 2nd floor and observed Unsampled Resident #1 (UR #1) seated in a wheelchair inside their room. UR #1's floor near the foot of the bed and the floor under the bed near the head area, both with blackish and grayish substances. UR #1 stated that they did not know how long it was been like that and the last time it was cleaned. On 5/12/26 at 9:38 AM, S #2 was accompanied by Certified Nursing Aide #1 (CNA #1) and Certified Nursing Aide #2 (CNA #2) during the tour in the 2nd floor, observed Unsampled Resident #2 (UR #2) and Unsampled Resident #3's (UR #3) ceiling vents with accumulation of grayish substances. S #2 also observed the floor tiles near the airconditioned system (near the window) was blackish and with accumulation of grayish substances which were confirmed by both CNAs. On 5/12/26 at 11:00 AM, the survey team met with the LNHA and DON, and S #2 notified them of the above findings and concerns. On 5/13/26 at 1:37 PM, the survey team met with the LNHA DON, and the Regional Nurse of Clinical Services, and there was no additional information provided by the LNHA and the DON. A review of the facility's Homelike Environment Policy, with a revision date of 2/2021, revealed under policy statement .Residents are provided with a safe, clean, comfortable and homelike environment .Under Policy and Implementation . #2 revealed a.) clean, sanitary and orderly environment. b.) comfortable yet adequate lighting. #4 a.) sufficient general lighting in resident-use areas. NJAC 8:39-31.2 (e), 31.4(a)(f)

NJ #2601805, #2966040, and 2734209Based on interview and review of facility documentation, it was determined that the facility failed to follow its Grievances/Complaints, Filing policy and procedure by failing to; a.) conduct a formal investigation of a grievance filed by a resident and followed through, b.) prompt efforts to resolve grievances to the satisfaction of the resident, and c.) actions on such issues responded to in writing, including rationale for the response. This deficient practice was identified for 2 of 3 months of resident council meeting minutes.This deficient practice was evidenced by the following: On 5/11/26 at 9:49 AM, the surveyor reviewed the last three months' resident council minutes (RCM) that were provided by the Licensed Nursing Home Administrator (LNHA) that included but were not limited to, and revealed: A review of the 2/24/26 RCM included information that Unsampled Resident #1 (UR #1) had concerns about aides being loud and disruptive and displayed the lack of consideration during the night shifts. UR #1 also had concern with 11:00 PM – 7:00 AM (11-7 shift) Certified Nursing Aides (CNAs) not performing their tasks efficiently. A review of the 3/17/26 RCM included information that the previous meeting held on February 2026, was read by the Director of Recreation (DR). There was no documented evidence that the concerns of UR #1 were addressed. A review of the 4/21/26 RCM included information that residents had issues with: -A resident stated there was no proper communication. -Staffing at the weekend continued to be a serious issue. -A resident stated some of the care partners (also known as a CNA) walk past the rooms on their phone and do not assist or answer the call bell. Further review of the 4/21/25 RCM revealed that the Director of Nursing (DON) will investigate and in-service the aids on cell phone usage during shifts. The above RCM did not include information that the facility had conducted a formal investigation of a grievance filed by residents and followed through for concerns of residents with regard to UR #1's concerns about aides being loud and disruptive and displayed the lack of consideration during the night shifts, and the concern that the 11-7 shift CNAs did not perform their tasks efficiently; nor a resident stated there was no proper communication, and staffing at the weekend continued to be a serious issue. Furthermore, there was no documented evidence that there were prompt efforts to resolve grievances to the satisfaction of the resident(s) and actions on such issues responded to in writing, including rationale for the response. On 5/11/26 at 10:50 AM, during the resident council meeting of the surveyor with Resident #12, Resident #66, UR #1, and Unsampled Resident #2 (UR #2), the residents had concerns with call bell response that were affecting the toileting and care of the residents. UR #1 stated that some of the concerns brought out during last three months resident council meeting continued to be an issues and the facility management verbal respond was we are working on it. The residents confirmed there were no written resolution provided for their concerns. A review of the provided binder for Grievance for 2026 revealed that there was no documented evidence that the concerns in the RCM on 2/24/26 and 4/21/26 were investigated, had a written resolution, and filed. On 5/11/26 at 12:41 PM, the surveyor met with the Director of Recreation (DR) and the Director of Social Services (DSS), and the surveyor asked them about the facility's process with regard to grievance. The DSS stated he was responsible for grievances, and he was the Grievance Officer. The DSS further stated that anyone could write grievance not only the Social Worker (SW), and whoever initiated the grievance, the form would be then given to the SW as the gatekeeper of the form. He also stated, when we received the form, we try to resolve in timely manner. At that same time, the surveyor asked the DSS what was considered a grievance, and the DSS responded, any concerns or complaints coming from residents or family members were considered a grievance needed to be investigated, resolved, and filed. The DSS confirmed that whatever in the white grievance binder provided to the surveyor was the grievance that were filed. On that same date and time, the surveyor notified the concern that the RCM on 2/24/26 and 4/21/26 concerns of the residents had no documented grievances in the file provided and that UR #1 confirmed that there were no documented resolution provided to them. The DSS confirmed that the concerns of the residents in the resident council meeting were considered grievances and acknowledged should have been filed as a grievance. Furthermore, the DR informed the surveyor that I did not file the grievance because the DON was present during the resident council meeting. The DR also confirmed that there were no written resolution of the residents' concerns and acknowledged that there were no other documentation of residents' concerns except the provided RCM. The DSS stated that grievance should be done to ensure that residents being satisfied and also as customer service to the residents. On 5/11/26 at 1:26 PM, the surveyor interviewed the DON regarding process with RCM when there was a concern brought by residents during the meeting if that would be considered a grievance. The DON stated that there was a form that the DR had utilized. The DON further stated that she was unsure if the DR handed the form to the SW. At that same time, the surveyor notified the DON of the above findings and concerns with the RCM that were not documented in the grievance, not filed as a grievance, and no written resolution that was provided to the residents, or there was a decision accepted by the residents. The DON stated I understand what you mean, and it was upsetting 100% that there was no grievance filed and seeing the grievance binder. She also stated that she was aware of the grievance regulation. On 5/12/26 at 11:00 AM, the survey team met with the LNHA and DON, and the surveyor notified them of the above findings and concerns. On 5/13/26 at 11:48 AM, the survey team met with the DON and the LNHA stated that education was completed on 5/11/26 with Social Services and DR regarding grievance process and policy. A review of the facility's Grievances/Complaints, Filing Policy that was provided by the DON, with an edited date of 6/23/22, revealed under policy statement, residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation. 3.All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. 12. b. A written summary of the investigation will also be provided for the resident, and a copy will be filed in the business office. 14. The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. On 5/13/26 at 1:37 PM, the survey team met with the LNHA DON, and the Regional Nurse of Clinical Services, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-4.1(a)12; 13.2(c)

Based on observation, interviews, record review, and review of facility provided documents, it was determined that the facility failed to provide written information to the resident or the Resident Representative (RR) that explained the reserve bed payment policy. This deficient practice was identified for 3 of 4 residents, (Resident #4, #67, and #136), reviewed for discharge process. The deficient practice was evidenced by the following: 1. On 5/6/26 at 11:42 AM, Surveyor #1 (S#1) observed Resident #4 in the 2nd (second) floor main dining/activity room, sitting on a wheelchair (w/c), talking to other residents. On 5/11/26 at 9:32 AM, S #1 reviewed the medical records of Resident #4. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included but not limited to; osteoarthritis of knee, presence of right artificial knee joint, and type 2 diabetes mellitus without complications. A review of the modified Quarterly Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, with an Assessment Reference Date (ARD) of 11/1/25, revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A review of a Discharge Return Anticipated (DRA) MDS with an ARD of 12/12/25, revealed an acute transfer to the hospital. A review of the nursing progress note (PN) dated 12/12/25, created by License Practical Nurse #1 (LPN #1) revealed resident was admitted in the hospital for shortness of breath (SOB) and Influenza (Flu-contagious respiratory illness). A review of the hard chart and the electronic medical record (eMR) revealed no bed hold notification given to Resident #4 or RR and no information of bed hold reserve payment. S#1 reviewed the nursing PN and no notification found. On 5/11/26 at 11:06 AM, S#1 interviewed the Assistant Director of Nursing (ADON), who stated Resident #4 went to a vascular appointment, had an SOB, and was sent to the hospital from the doctor's office. The ADON further stated that Resident #4 was admitted for flu and came back to the facility on [DATE]. S #1 asked the ADON if the bed hold notification was given by the facility and he stated he was unsure. On 5/11/26 at 11:20 AM, S #1 asked Resident #4 regarding the above acute transfer to the hospital and they stated, No, I was not notified of bed hold in December when I went to the hospital. On 5/11/26 at 11:37 AM, S #1 interviewed the admission Director (AD) and asked if a bed hold notification and reserve payment information were given for the 12/12/25 acute transfer. The AD stated that when a resident left for the hospital, she would verbally inform them (RR) or tell them (RR) over the phone. She stated that she did not provide one for Resident #4 because the resident was a Long-Term Care resident. S #1 asked the AD if she was familiar with the bed hold regulation and she stated she had always been familiar with the bed hold regulation but it was just brought to her attention three weeks ago that she needed to give a written form and the amount of reserve payment because she never did that before. On 5/12/26 at 10:59 AM, the survey team met with the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S #1 notified them of above concerns regarding written notification of bed hold and reserve payment for acute transfers. On 5/13/26 at 11:48 AM, the survey team met with the DON and the LNHA stated that education was provided to the admission department (after surveyor inquiry). 2.On 5/6/26 at 10:58 AM, Surveyor #2 (S #2) observed Licensed Practical Nurse #2 (LPN #2) with surgical mask and gloves in used while inside Resident #67's room assisting two EMTs (Emergency Medical Technician is a certified healthcare professional who provides basic, out-of-hospital emergency care and transportation for critical patients) with gloves while transferring the resident from bed to stretcher. Resident #67 was transported out with a basin while vomiting. On 5/6/26 at 11:03 AM, the orientee Registered Nurse ([NAME]) in the presence of LPN #2 informed S #2 that the resident was transported to the hospital due to vomiting. A review of the AR of Resident #67 revealed diagnoses which included but not limited to other fracture of right femur (the thigh bone located in the right leg, extending from the hip to the knee) initial encounter for closed fracture and diffuse large b-cell lymphoma (a type of blood cancer that develops in the lymphatic system when abnormal B white blood cells multiply and form tumors), unspecified site. A review of the modified comprehensive MDS, with an ARD of 4/15/26, revealed a BIMS score of 14 out of 15, which indicated an intact cognition. A review of the SBAR (stands for Situation, Background, Assessment, and Recommendation, a structured, standardized communication framework used in healthcare to convey critical patient information concisely and efficiently) Change in condition form in the eMR dated 5/6/26, included information that Resident #67 had two episodes of projective vomiting, weakness with confusion compared to baseline, doctor was notified, and provided an order to be transferred to the hospital. A review of the Notice of Transfer to Acute Care Facility (NTACF) dated 5/6/26, including the notice to the resident and RR about the hospital transfer. The NTACF did not include bed hold reserve payment. On 5/7/26 at 9:45 AM, S #2 reviewed the chart of Resident 67 in the presence of Licensed Practical Nurse #3 (LPN #3), who informed S #2 that the resident had not returned yet from hospital. There was no bed hold notice printed in the chart. LPN #3 informed S #2 that the bed hold notice transfer notice was in the eMR, and there was no other documentation except for that. 3. On 5/7/26 at 9:36 AM, Surveyor #3 (S #3) reviewed the medical records of Resident #136. A review of Resident #136's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia and hemiparesis following cerebral infarction (complete paralysis and partial weakness, which are common, often overlapping, motor deficits affecting one side of the body following a stroke, caused by damage to brain areas controlling movement), and end stage renal disease (ESRD, or stage 5 chronic kidney disease, occurs when kidneys function below 10-15%, making them unable to sustain life). A review of Resident #136's PN included the following note dated 2/27/26: At approximately 1600, pt (patient) transferred to [name redacted] Hospital per RR's request after pt refused scheduled dialysis treatment. A review of Resident #136's eMR included a letter to the RR dated 2/27/26, which included that the resident was transferred to the hospital per RR request and that every resident was entitled to a ten-day bed-hold privilege. The letter did not include the bed hold reserve payment amount. On 5/7/26 at 9:53 AM, S #3 interviewed the AD who stated that the resident and RR were emailed an admissions agreement with bed hold information. She added that she discussed the bed hold process with the resident and RR. The AD stated that when a resident was transferred to the hospital, that she called the RR and reminded them of the bed hold process. The AD showed S #3 the new form that was part of the admission. She stated that she would write the amount of rate on admission. She stated that anything after admission was done by the nursing department. The AD stated that there were different rates for sub acute, long term care, and private pay. On 5/7/26 at 10:16 AM, S #3 interviewed Licensed Practical Nurse #4 (LPN #4), who stated that when a resident was transferred to the hospital that there was a preprinted form in the computer with transfer reason and bed hold policy which was emailed or given to RR. On 5/7/26 at 10:48 AM, S #3 interviewed the Licensed Practical Nurse/Unit Manager of 2 South who stated that she was not sure about the bed hold. On 5/7/26 at 10:54 AM, S #3 interviewed the DON who stated that about two weeks ago they started a new process/form for bed hold and that the AD got the signature on admission. The DON stated that when a resident was sent to the hospital that the nurses gave the acute transfer form that notified the resident about the 10 day hold. The DON stated that the business office notified the resident about the rate by phone call and then sent the two pages form with the rate to the resident and then the resident would have to sign it. S #3 asked if the new form was part of the medical record and if any form had been filled out for any residents. The DON stated that she was unsure. On 5/7/26 at 11:20 AM, S #3 interviewed the Business Office Manager (BOM) who stated that the AD gave the bed hold notice on admission and that they had a new form that was started and that admission would be in charge of it. The BOM stated that if the AD was not able to do it after a transfer then she would do the follow up. The BOM stated that it had just been started and that she had not done any yet. The BOM stated that it was not her responsibility to the bed hold after a transfer and that she was the follow up if the AD was unable to do it. On 5/12/26 at 11:32 AM, S #3 notified the LNHA and DON, the concern that Resident #136's bed-hold notification did not contain the required bed hold reserve payment information. On 5/13/26 at 12:15 PM, in the presence of the DON, the LNHA stated that education was provided to the business office and AD on 5/7/26 regarding the bed hold process. The LNHA did not provide any additional information. A review of the facility's Bed-Holds and Returns Policy with a revised date of October 2022, included the following: 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). 4. The written bed-hold notices provided to the residents/representatives explain in detail: a. the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; b. the reserve bed payment policy as indicated by the state plan (for Medicaid residents); c the facility policy regarding bed-hold periods; d. the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and. N.J.A.C. 8:39-5.1 (a); 5.3(b); 5.4(c)

REPEAT DEFICIENCYComplaint NJ #2601805, #2727668, #2734209, and #2966040Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) residents received timely and appropriate incontinence care for 6 of 8 residents (Residents #12, #17, #66, and Unsampled Residents #1, #2, and #4) and b.) staff responded to call bell timely for 2 of 33 residents (Residents #17 and #110) observed, to achieve their highest practical wellbeing. This deficient practice was evidenced by the following: On 5/11/26 at 9:49 AM, the surveyor reviewed the last three months' resident council minutes (RCM) that were provided by the Licensed Nursing Home Administrator (LNHA) that included but were not limited to, and revealed: A review of the 4/21/26 RCM included information that residents had issues with: -A resident stated there was no proper communication. -Staffing at the weekend continued to be a serious issue. -A resident stated some of the care partners (also known as a Certified Nursing Aide or CNA) walk past the rooms on their phone and do not assist or answer the call bell. Further review of the 4/21/25 RCM revealed that the Director of Nursing (DON) will investigate and in-service the aids on cell phone usage during shifts. On 5/11/26 at 11:28 AM, during the resident council meeting of the surveyor with Residents #12, #66, Unsampled Resident #1 (UR #1), and Unsampled Resident #2 (UR #2), the residents had concerns with call bell response that were affecting the toileting and care of the residents. UR #1 stated that some of the concerns continued to be an issues and the facility management verbal respond was we are working on it. On 5/11/26 at 1:22 PM, the surveyor reviewed the CNA accountability tasks of four residents that were mentioned by UR #1 during resident council meeting with concerns call bell response and toileting assistance in the electronic medical records and revealed: -Unsampled Resident #3 (UR #3)=the following days did not have three shifts documentation of bladder incontinence/toilet for 30 days lookback period: 4/14/26, 4/15, 4/18, 4/21, 4/22, 4/23, 5/3, and 5/5/26. The resident also cared planned for bladder incontinence. -Unsampled Resident #4 (UR #4)=the following days did not have three shifts documentation of bladder incontinence/toilet for 30 days lookback period: 4/18/26, 4/19, 4/21, 5/3, and 5/5/26. The resident also cared planned for bladder incontinence. -Unsampled Resident #5 (UR #5)=the resident was care planned for indwelling catheter. -Unsampled Resident #6 (UR #6)=the following days did not have three shifts documentation of bladder incontinence/toilet for 30 days lookback period: 4/18/26, 4/23, and 5/3/26. The resident also cared planned for bladder and bowel incontinence. On 5/12/26 at 9:17 AM, the surveyor toured 2 North unit and observed UR #3 seated in a wheelchair inside their room, who stated that there was concern with short staffing for a while that affected call bell response and toileting. UR #3 further stated the most recent one was last night at 2:00 AM, they rang for more than 20 minutes, and no one responded. On 5/12/26 at 9:38 AM, the surveyor with Certified Nursing Aide #1 (CNA #1) and CNA #2 accompanied the surveyor inside UR #6's room. UR #6 informed the surveyor that CNAs worked hard even though they were shorthanded almost every day and every shift. Outside UR #6's room, the surveyor interviewed CNA #1, who informed the surveyor that today she had eight residents in her assignment, had been eight since the survey team was at the facility, but prior to survey team's visit, they had 12 residents in her assignments, and worse in the weekends. On 5/12/26 at 9:55 AM, the surveyor went to the 2 South nursing station and observed Resident #17 in the call bell monitor was on for 14 minutes. The surveyor asked the Infection Preventionist Nurse (IPN) to accompany the surveyor to Resident #17's room. On that same date and time, both the surveyor and the IPN observed Resident #17 on bed with call light on and wanted the incontinence brief to be changed. The IPN checked the resident's incontinence brief, and both surveyor and IPN observed the incontinence brief was soaked wet with urine and smelled urine inside the room. The IPN confirmed the smell of urine and incontinence brief was soaked with urine, and she stated that the resident should have been changed. On 5/13/26 at 9:01 AM, the surveyor asked CNA #3 to accompany the surveyor to UR #4's room for incontinence round. CNA #3 repositioned UR #4 and both CNA #3 and the surveyor observed UR #4 with double incontinence briefs soaked with urine and feces up to resident's back. CNA #3 confirmed that the resident did not look like was changed yet since this morning and stated could not speak of why the resident had two incontinence briefs. At that same time, UR #4 stated that they did not ask for double incontinence briefs, and it was the CNA who placed it. UR #4 was unable to identify the CNA who put the double incontinence briefs. On 5/13/26 at 9:09 AM, the surveyor notified the IPN about the above concern with UR #4's double incontinence briefs soaked wet with urine and feces up to resident's back. The IPN stated that the resident should not have double incontinence briefs. On 5/12/26 at 11:00 AM, the survey team met with the LNHA and DON, and the surveyor notified them of the above findings and concerns. On 5/13/26 at 11:48 AM, the survey team met with the DON and the LNHA stated that he spoke to the residents about the efforts to attract new staff and the facility's continued hiring process. The LNHA further stated that we have continued to hire new staff and educate on the need to answer call lights in a timely manner, education started on 5/12/26, and was on going for incontinence care. A review of the facility's Staffing, Sufficient and Competent Nursing Policy that was provided by the Regional Nurse of Clinical Services (RNCS), with a revision date of March 2026, revealed, the facility provides sufficient nursing staff with appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Staffing levels are routinely reviewed and adjusted to meet or exceed current federal and state long-term care requirements, ensuring compliance with applicable regulations. Policy Interpretation and Implementation. 2.Licensed nurses and CNAs are available 24 hours a day, seven days a week to provide competent care services including: a. ensuring resident safety. d. responding to resident needs. 6. Nurse aides/nursing assistants are individual providing nursing or related services to residents in the facility, including those who provide services through an agency or under a contract with the facility. 8. Factors to considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitations of the resident population, and acuity. 9. Minimum staffing requirements imposed by state or federal regulations, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determination of sufficient and competent staffing. A review of the facility's Activities of Daily Living (ADL), Supporting Policy that was provided by the LNHA, with a revision date of March 2018, revealed, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation. 2.including appropriate support and assistance with: Hygiene. Elimination (toileting) . On 5/13/26 at 1:37 PM, the survey team met with the LNHA DON, and the RNCS, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-25.2(b); 27.2(h)

Based on interview and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for 2 of 3 residents (Resident #4 and #11) reviewed for beneficiary notifications.The deficient practice was evidenced by the following:On 5/6/26 at 11:33 AM, the License Nursing Home Administrator (LNHA) presented the surveyor with a list of residents who were discharged (d/c'd) from the facility within the last six months and should have received Advance Beneficiary Notices (ABNs). On 5/12/26 at 12:30 PM, the surveyor provided the Director of Nursing (DON) list of three residents for beneficiary review.On 5/13/26 10:28 AM, the surveyor reviewed the three randomly chosen residents who were d/c'd from a Medicare Part A stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. The surveyor reviewed their ABNs which revealed:A review of Resident #4's ABN which revealed, a Medicare Part A skilled service starting date of 12/21/26, with a last covered day (LCD) of Part A service on 1/30/26. Resident #4 continued to stay at the facility. The facility provided the resident representative (RR) with the required SNF ABN form which revealed beginning on 1/31/26, the resident would be responsible for paying out of pocket for Physical Therapy (PT) and Occupational Therapy (OT) services that insurance would not cover. The SNF ABN also indicated, We estimate that these services will cost you $MLTSS-custodial per day/item or service. There was no specified estimated amount indicated for each service on the form. The RR electronically signed the SNF ABN on 1/28/26. A review of Resident #11's SNF ABN which revealed a Medicare Part A skilled service starting date 3/1/26, and an LCD of 4/24/26. The resident stayed in facility. The facility provided the RR with the required SNF ABN form which revealed beginning on 4/25/26, the resident would be responsible for paying out of pocket for PT and OT, and OTHER (not specified what other was) services that insurance would not cover. The SNF ABN also indicated, We estimate that these services will cost you $MLTSS-custodial per day/item or service. There was no specified estimated amount indicated for each service on the form. On 5/13/26 at 11:12 AM, the surveyor interviewed the lead Minimum Data Set Coordinator (MDSC) in the presence of the Director of Social Work. The MDSC confirmed that she was responsible for the ABNs. The surveyor asked the MDSC if the residents and RR were informed of the dollar amount for each service listed on the ABNs and what does OTHER service meant. The MDSC stated that they did not discuss the rate because it was the business office who discussed the rates. The surveyor asked if she was familiar with the regulation and should the estimated/dollar amount of services be listed on the ABN forms. The MDSC confirmed she was not sure of the regulation and that the dollar amount for each service should be specified on the form.On 5/13/26 at 12:20 PM, the surveyor notified the LNHA and the DON regarding the above concerns with the SNF ABNs for the two residents.On 5/13/26 at 1:17 PM, in the presence of the survey team, the LNHA, DON, and the Regional Nurse of Clinical Services (RNCS) confirmed the rates were missing on the forms and that would be taken care of that day. The surveyor asked what the importance of the dollar amount on the forms and the RNCS stated, so the residents and the RR would know their responsibility.A review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices Policy, with a revision date of September 2024, revealed under SNF ABN (CMS form 10055) . #2. The SNF ABN provides information to the resident so that he or she can decide whether to get the care that may not be paid for by Medicare and assume financial responsibility.The facility policy did not include the notification of estimated dollar amount that services will cost the residents.NJAC 8:39-5.4(b)(c)

Based on observations, interviews, review of medical records, and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' preferences and goals and address the resident's medical and psychosocial needs. This deficient practice was identified for 2 of 28 residents (Residents #2 and #22) reviewed for a care plan. This deficient practice was evidenced by the following:1. On 5/13/26 at 9:00 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #2. The admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to, Post-Traumatic Stress Disorder (PTSD), Chronic (a mental health disorder that may develop in people after they experience or see a traumatic event). A review of Resident #2's Care Plan (CP), initiated 2/20/26, revealed that Resident #2's PTSD was not included in the CP. On 5/13/26 at 9:39 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1), who confirmed Resident #2 had PTSD, and acknowledged that the resident's CP did not include PTSD. LPN #1 stated that PTSD would have to be included in the CP. At that same time, the surveyor interviewed the Minimum Data Set Specialist (MDSS). The MDSS stated that Resident #2's PTSD was not specifically included in the resident's CP. On 5/13/26 at 11:50 AM, in the presence of the survey team, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). A review of the facility's Care Plans, Comprehensive Person-Centered Policy, revised March 2022, revealed the following:-The comprehensive, person-centered CP is informed by a resident's physical and psychosocial needs, including those related to past traumatic events.-Services provided for or arranged by the facility and outlined in the comprehensive CP are trauma-informed. 2. On 5/6/26 at 11:59 AM, the surveyor observed Resident #22 in bed, alert and oriented. Resident #22 stated they go three days a week to dialysis (a treatment that removes waste and excess fluid from the blood when the kidneys are not able to perform that function). Resident #22 stated that the transportation picked them up from the facility around 10:30 AM and returned to the facility around 5:30 PM, and depending on the timing of transportation. Resident #22 further stated the facility usually did not give them food to go with them to dialysis, and they were hungrier as a result. On 5/7/26 at 1:52 PM, the surveyor interviewed LPN #2. LPN #2 stated Resident #22 dialysis days on Tuesdays (Tue), Thursdays (Thurs), and Saturdays (Sat) around 11:00 AM, and returned to the facility between 4:00 PM and 5:00 PM, depending on when transportation picked them up and dropped them off. LPN #2 stated Resident #22 consistently refused a to-go lunch from the facility to bring with them to dialysis. LPN #2 stated they asked Resident #22 every time if they wanted a to-go lunch, and LPN #2 could not recall a time the resident said yes. A review of Resident #22's AR revealed that the resident was admitted to the facility with diagnoses that included, but were not limited to, End Stage Renal Disease (ESRD, also known as kidney failure) and dependence on renal dialysis. A review of the Order Summary Report for Resident #22 revealed an order with a start date of 3/12/26, Hemodialysis Diagnosis: ESRD Dialysis Days and Time: Tue-Thurs-Sat. 12 PM Chair Time. Pick up time: 11 AM. Every day shift every Tue, Thu, Sat for Dialysis. A review of the admission MDS (Minimum Data Set), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/15/26, revealed that Resident #22 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderately impaired cognition. A review of Resident #22's CP, initiated 3/9/26, revealed that the CP did not document that the resident was refusing food from the facility to bring with them to dialysis. On 5/12/26 at 11:00 AM, in the presence of the survey team, the surveyor discussed the concern with the LNHA and DON. On 5/13/26 at 11:54 AM, the DON stated that refusal of care should be in the CP. A review of the facility's Care Plans, Comprehensive Person-Centered Policy, revised March 2022, revealed the following:-The comprehensive, person-centered CP describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. NJAC 8:39-11.2(e); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure physician services met professional standards of practice by failing to obtain and document a clinical evaluation addressing the risk versus benefit of continuing combined therapy with antidepressant and antipsychotic medications after the consultant pharmacist identified an increased risk for falls. This deficient practice was identified for 1 of 28 residents (Resident #7) reviewed for physician services 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. On 5/7/26 at 10:05 AM, the surveyor observed Resident #7 in their room seated on the side of his bed with a walker present. On 5/12/26 at 9:54 AM, the surveyor reviewed the medical record for Resident #7. A review of the admission Record or face sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side, type 2 diabetes mellitus, and unspecified psychosis not due to a substance or known physiological condition. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 2/28/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident required extensive assistance with activities of daily living, had a history of falls, and exhibited behaviors including paranoia, yelling, and use of derogatory or offensive language. A review of the Order Summary Report, dated as of 5/13/26, included the following active physician orders (PO):A PO, dated 11/21/25, quetiapine fumarate (antipsychotic) 25 milligram (mg) tablet (tab), give three tablets (tabs) (=75 mg) by mouth in the evening for bipolar disorder.A PO, dated 1/23/25, for sertraline hydrochloride (antidepressant) 100 mg, give one tab by mouth in the evening for depression.A PO, dated 4/3/26, for behavior tracking for derogatory slurs and offensive language every shift.A PO, dated 10/23/25, for behavior monitoring for paranoia every shift.On 5/13/26 at 10:12 AM, the surveyor reviewed the Consultant Pharmacist (CP) recommendations dated 4/7/26. The CP documented, Sertraline, when used with Seroquel, may increase the risk of falls. Recent fall noted March 2026. If continuing present therapy, please document the risk vs. benefit. The same form indicated the physician accepted the recommendation, and a telephone order was documented with the physician's and nurse's names. Further review of the medical record revealed there was no psychiatric evaluation, physician progress note (PN), or nurse practitioner note documenting an assessment of the risks and benefits of continuing sertraline and quetiapine therapy after the 4/7/26 CP's recommendation. The most recent psychiatric evaluation in the Documents section of the electronic medical record was dated 2/19/26, prior to the CP's recommendation. The PO for sertraline and quetiapine remained active as of 5/13/26. On 5/13/26 at 10:25 AM, the surveyor reviewed physician and nurse practitioner PN dated 4/27/26 and 5/8/26, both notes documented that medications (meds) were continued, neither note addressed the CP's recommendation or included documentation of the clinical rationale and risk-versus-benefit analysis for continuing the combined sertraline and quetiapine therapy. On 5/13/26 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) regarding the absence of documented follow-up to the CP's 4/7/26 recommendation to complete and document a risk-versus-benefit evaluation for the continued use of sertraline and quetiapine. The DON was unable to provide a psychiatric evaluation, physician PN, or other medical provider documentation addressing the recommendation. No additional information was provided. On 5/13/26 at 11:49 AM, the Licensed Nursing Home Administrator (LNHA) and the DON in the presence of the survey team, provided no additional information regarding the follow-up addressing the CP's recommendation to evaluate and document the risk versus benefit of continuing sertraline and quetiapine therapy. NJAC 8:39-11.2(b); 35.2(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to; a) ensure an air mattress was on and functioning, b) accurately document the skin observation, and c) clarify a physician' order for wound treatment for 1 of 1 resident reviewed for Pressure Ulcer (PU) (Resident #3).This deficient practice was evidenced by the following: On 5/6/26 at 10:06 AM, the surveyor observed Resident #3 lying in a low to the ground bed with an air mattress machine attached to the end of the bed which was not on and functioning. On 5/6/26 at 11:40 AM, the surveyor reviewed Resident #3's electronic medical record. A review of Resident #3's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic obstructive pulmonary disease (COPD, is a progressive, treatable lung disease-commonly caused by smoking or long-term irritant exposure-that restricts airflow, causing chronic bronchitis and emphysema) and type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar caused by insulin resistance, where body cells do not respond effectively to insulin, and a relative lack of insulin production). A review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 3/17/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #3's cognition was severely impaired. Further review reflected that the resident had 1 unstageable PU that was not present on admission and that a pressure reducing device for bed was used. A review of Resident #3's May 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) did not include an order for air mattress. A review of Resident #3's paper medical record included an order dated 3/9/26 for an air mattress. On 5/6/26 at 1:51 PM, the surveyor requested a timeline of Resident #3's facility acquired wound(s). On 5/7/26 at 10:12 AM, the surveyor observed Resident #3 asleep in a low to ground bed and the air mattress machine was not powered on and functioning. On 5/7/26 at 10:26 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #3 had a PU and had an air mattress. She added that they check the air mattress and that it beeped sometimes if the weight was high or low. On 5/7/26 at 10:30 AM, the surveyor and LPN entered Resident #3's room and she confirmed that the air mattress was not on. On 5/7/26 at 10:36 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) regarding process for air mattress. The LPN/UM stated that an order was in the electronic medical record (eMR) and that maintenance provided the air mattress. The surveyor and LPN/UM entered Resident #3's room and the LPN/UM confirmed that the air mattress was not on. The surveyor asked the LPN/UM if the air mattress should be checked every shift and the LPN/UM stated that she would have to check. On 5/7/26 at 11:02 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the air mattress was usually an order and that the nurse would notice if it was not working. The surveyor showed the DON the picture of Resident #3's air mattress not being on. On 5/7/26 at 11:33 AM, the surveyor further reviewed Resident #3's May 2026 eMAR and eTAR which included the following order: Weekly Skin Check. Complete Skin check under Forms Tab every day shift every Tue (Tuesday) with a start date of 11/25/26. A review of the eMR under the Forms Tab included a skin observation tool that the nurse documented on 3/24/26, 4/7/26, 4/14/26, and 4/21/26 that the resident had no skin breakdown. A review of the facility provided timeline of Resident #3's PU included the following:Sacrum and coccyx unstageable from 2/16/26 until present.Left buttock and Right buttock MASD (moisture associated skin damage) from 2/16/26 until 4/21/26.Right calf vascular from 2/16/26 until present.Left calf vascular from 2/16/26 until 4/28/26.Right heel vascular from 1/20/26 until 4/28/26.The nurse documented the skin observation tool incorrectly. On 5/7/26 at 12:18 PM, the surveyor interviewed the LPN/UM who stated that the nurse assessed the skin weekly and filled out in the eMR a skin observation form and there was an order in the eTAR weekly. She added that the expectation of that form was to document if a new wound, no new breakdown or previously noted breakdown. The surveyor asked the LPN/UM to view Resident #3's skin observation tool that was dated 4/21/26. The LPN/UM confirmed that the form had no skin breakdown. The surveyor asked the LPN/UM if the form should have no skin breakdown that if the resident had PUs, and the LPN/UM did not provide an answer. Further review of Resident #3's May 2026 eMAR and eTAR included the following order: Apply Ponds cold cream to wound then wash wound daily with N.S. (normal saline) dry with paper towel. Apply procardia cream with Q tip to the periphery of wound. apply single layer xeroform, mepilex occlusive dressing. Hold days therapy requiring cycling and walking. at night, moon boots and pillows under calves. two times a day for Wound care Procardia is the patients own medication with a start date of 1/20/26.The order did not specify the site of the wound. On 5/12/26 at 10:45 AM, the surveyor interviewed the Director of Nursing (DON) who stated that an order should have the site. The surveyor notified the DON that Resident #3's wound order did not have a site. The DON stated that it should have a site. On 5/12/26 at 11:30 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON, the concern that Resident #3s air mattress was observed to be not be powered on and functioning; a wound care order did not indicate the site of the wound and was not clarified prior to surveyor inquiry; and the weekly skin observation form was not documented to reflect the residents wounds. On 5/13/26 at 12:13 PM, in the presence of the DON, the LNHA stated that on 5/12/26 (after surveyor inquiry) the DON contacted Resident #3's physician for clarification of the wound treatment order. The LNHA stated that education regarding air mattress functioning was started and ongoing. The LNHA stated that staff education was started on 5/12/26, and ongoing for accuracy and completion of skin observations. He added that the LPN that documented the skin observation tool understood no breakdown as no new breakdown. The LNHA did not provide any additional information. A review of the facility's Support Surface Guidelines Policy with a revised date of September 2013, included the following:PurposeThe purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.Interventions/Care Strategies1. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, static air, alternating air, gel, or air-loss device, when lying in bed.The policy did not contain any information on orders or checking the air mattress for functioning. A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol Policy with a revised date of April 2018, included the following:Assessment and Recognition2. In addition, the nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width an depth, presence of exudates or necrotic tissue;Treatment/Management1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.) and application of topical agents. N.J.A.C. 8:39-27.1

Based on observation, interview, and record review, it was determined that the facility failed to, a.) ensure appropriate care and services for a resident receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG tube-a feeding tube inserted through the abdominal cavity directly into stomach or small intestine to provide nutrition) by securing the external tube and provide skin care to the PEG tube site and failed to b.) ensure the resident's care plan reflected care and services for the PEG tube site. This deficient practice was identified for 1 of 2 residents (Resident #11), reviewed for enteral tube feeding (TF).This deficient practice was evidenced by the following:On 5/6/26 at 11:27 AM, the surveyor observed Resident #11's room with Enhanced Barrier Precaution (EBP) signage and Personal Protective Equipment (PPE) on the door, and alcohol-based hand sanitizer (ABHS) on the wall. Observed the License Practical Nurse (LPN), entered the resident's room with the lunch tray which consisted of pureed food and thin liquids. The surveyor observed the resident self-feed, and resident stated to the surveyor appetite was good. The LPN stated the resident ate by mouth, consumed meals above 65%, and also received Jevity 1.5 bolus TF at night. On 5/11/26 at 10:43 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the TF was new, was not eating in the hospital, and that was why they inserted the TF. The RN also stated that the resident's appetite was 75% for breakfast and lunch.On 5/11/26 at 4:39 PM, the surveyor reviewed the medical records of Resident #11. A review of the admission record or face sheet (an admission summary) revealed diagnoses which included but were not limited to; acute respiratory failure with hypoxia, encounter for attention to gastrostomy, and dysphagia (difficulty swallowing).A review of the modified Significant Change/Medicare 5 Day Minimum data Set (MDS), an assessment tool which facilitates the plan of care, with an Assessment Reference Date (ARD) of 3/6/26, revealed a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicated severe cognitive impairment. The MDS also included that the resident was eating with supervision assistance, with TF, and mechanically altered diet were coded.A review of the resident's care plan (CP) reflected nutrition via PO (by mouth) diet and TF, revised on 3/2/26; feeding tube/potential for complications of feeding tube use related to dysphagia, date initiated 3/2/26; at risk for skin breakdown related to G-tube site. Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. notify physician as needed (PRN), date initiated 3/2/26. Further review of the CP revealed there was no intervention/treatment for PEG site care or for securing the tube.A review of the physician orders revealed enteral feed in the evening Jevity 1.5, 237 ml (milliliters) at bedtime (bolus/gravity) -Revision Date 4/22/26. There was no order for PEG tubing site care and no order for securing the tube.On 5/12/26 at 9:30 AM, in the presence of the RN, the resident gave permission to observe the PEG tube site. The RN showed the surveyor the PEG tube site and the surveyor observed, no redness, no drainage, no dressing noted on tube site, and tube was hanging from abdomen, and not secured. The surveyor asked the RN what the process for PEG tube site care for any resident with a TF was, even those with a bolus feeding only, and she stated that any resident with a TF, the PEG site should be cleaned with saline, then apply slit gauze or dry dressing, and usually done every shift. On that same date and time, the RN stated she did not know why the resident did not have a dressing. The RN further stated, the area was open so would need to protect that from any infection. The surveyor and the RN reviewed the electronic treatment administration record (eTAR) and the resident's CP, and the RN confirmed there was no order for treatment for that area, no order to secure the tube and no CP for treatments. At that time, the RN approached the Assistant Director of Nursing (ADON), who was in the nursing unit at that time. The ADON stated, the nurse who admitted the resident was responsible for ordering treatments. The surveyor asked the RN and ADON if they were familiar with the regulation for PEG tube and skin care. The ADON replied that he was familiar with the regulation to keep the tube secure and make sure it was not tangled, and to monitor for skin care. The surveyor asked how Resident #11's TF being kept secured and ADON replied, by keeping the tube on the belly and have the gown over it, he confirmed they did not put any dressing to secure the tube. The ADON further added that there was no order for treatment because the resident only had bolus feeding once a day and did not need one. The surveyor asked what happened when the resident moves in bed, and during care if the tube was tugged at and the ADON replied, that they will monitor.On 5/12/26 at 10:59 AM, the survey team met with the License Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the concerns regarding PEG tube site care. On 5/13/26 at 11:48 AM, the survey team met with the LNHA and the DON stated the nursing staff were educated on PEG tube site care and CP was updated. DON further stated there was a physician order obtained yesterday for treatment (after surveyor inquiry). The LNHA did not provide additional information. A review of the facility's Enteral Tube Site Care Policy, effective date 1/31/13, revealed, it is the policy of this center to promote cleanliness and protect gastrostomy and other enteral tube sites from irritation, breakdown, and infection .Under Purpose .To prevent infection, irritation, and skin breakdown around the enteral tube insertion site .Under Process: #1. Verify practitioner order. #2. Review resident care plan and provide for any special needs of the resident . #7. Perform site care at least daily and as needed. #8. Follow standard precautions and center policy for clean dressing change technique .#20. Anchor gastrostomy tube to skin with hypoallergenic tape or anchor device to prevent peristaltic migration of the tube #25. Document the following: 25.1 Date and time of dressing change.NJAC 8:39-27.1(a)

Based on the observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure: a.) that the Physician's Order (PO) for pain management was clarified according to the appropriate pain level for 1 of 2 residents, (Resident #37), for as needed pain medications and b.) the PO was obtained for pain medication for 1 of 2 residents, (Resident #66), reviewed for pain management according to standards of clinical practice and facility's policies.The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 5/6/26 at 11:05 AM, the surveyor observed Resident #66 in the occupational therapy room in their wheelchair (w/c) while attending rehabilitation session. The surveyor reviewed the medical records of Resident #66 and revealed: A review of the admission Record (AR) or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD) with exacerbation, pulmonary hypertension (a serious, chronic condition characterized by high blood pressure in the arteries of the lungs) unspecified, type 2 diabetes mellitus without complications, and obstructive sleep apnea (a common, serious sleep disorder where breathing repeatedly stops and starts because throat muscles relax, causing the airway to collapse during sleep) (adult). A review of the comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 2/3/26, reflected a brief interview for mental status (BIMS) score of 14 out of 15, which reflected that the resident was cognitively intact. The MDS also included that the resident received pain medication (med) regularly. A review of the May 2026 electronic Med Administration Record (eMAR) revealed a transcribed PO of lidocaine patch 4% apply to lower back topically one time a day for pain management, apply for eight hours in a 24 hours period max (maximum) dose = 2 patches external use only remove per schedule and remover per schedule with a start date of 3/22/26. A review of the Progress Notes that was electronically signed by Physician #1 (P #1), with an effective date 2/1/26 at 11:30 PM, revealed that Resident #66 was seen resting in bed with c/o (complained of) BL (bilateral) LE (lower extremity) pains and lower back pain. On 5/11/26 at 9:23 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1) regarding resident's lidocaine patch order. LPN #1 informed the surveyor that the order for lidocaine patch was for resident's lower back and right knee. LPN #1 then reviewed and showed the PO from the electronic medical record, and the LPN stated she did not know as to why there was no order for lidocaine patch for right knee. On that same date and time, LPN #1 left the med cart and went to the nursing station to check the resident's chart to find the telephone order for right knee patch, which the LPN claimed there should be a PO for it. She further stated that it was Physician #2 (P #2) who ordered the lidocaine patch for the right knee. At that time, P #2 arrived and confirmed in the presence of LPN #1 that he ordered the lidocaine patch to the right knee for pain. The surveyor notified the concern that there was no PO for lidocaine patch to right knee, and P #2 responded that he would order the lidocaine patch. On 5/11/26 at 9:34 AM, the surveyor notified the Director of Nursing (DON) in the presence of LPN #1, and the Clinical Service Coordinator (CSC) of the above concern with Resident #66's lidocaine patch. On 5/13/26 at 8:15 AM, the surveyor observed Resident #66 was seated in bed while eating their breakfast. The resident informed the surveyor that when he was transferred from hospital to the facility the order for lidocaine patch was ordered to the lower back. At that same time, the resident stated that they could not remember when the order for right knee lidocaine patch was ordered, they remembered it was when one time they could not stand up and knees buckled due to right knee pain, and that was the time the nurse had administered the lidocaine patch. Resident #66 added that there was only one patch ordered so there were days it was applied to the lower back and some days to the right knee. The resident also stated that the receptionist of the facility, who was also their personal aide for years knew about the right knee patch. On 5/13/26 at 11:16 AM, the surveyor interviewed the Receptionist who stated that she was the companion of Resident #66 for 10 years. She further stated that she remembered that it was probably three weeks ago when the nurse had started administering the lidocaine patch to resident's right knee. On 5/12/26 at 11:00 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON, and the surveyor notified them of the above findings and concerns with regard to Resident #66's pain management. On 5/13/26 at 11:48 AM, the survey team met with the LNHA, and the DON stated that Resident #66 was assessed after surveyor's inquiry and with no complaints of pain. The DON further stated that LPN #1 reached out to the physician for order on 5/11/26 for the right knee lidocaine patch. The surveyor then notified the LNHA and DON that up to this time the order for lidocaine patch to the right knee was not ordered. 2.On 5/11/26 at 1:50 PM, the surveyor observed Resident #37 in the designated area for smoking. A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; chronic kidney disease unspecified, COPD unspecified, pain in left shoulder, acquired absence of left great toe, and pain in right leg. A review of the cMDS with an ARD of 4/9/26, reflected a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. The cMDS also included that the resident had frequently experienced pain during the lookback period of five days and as needed (PRN )pain medications (meds) were administered. A review of the May 2026 eMAR revealed the following PO: -Acetaminophen tablet (tab) 325 mg (milligram), give 2 tablets (tabs) by mouth every 6 hours PRN for mild pain. Do not exceed 3 grams in 24 hours. Total 650 mg. Start date 3/21/26. The above PO for Acetaminophen was plotted in the eMAR and was not administered from 5/1/26 through 5/12/26. -Oxycodone-Acetaminophen tab 5-325 mg, give 1 tab by mouth every 6 hours PRN for pain.Start date 3/31/26. The above PO for Oxycodone-Acetaminophen was plotted in the eMAR and was administered on 5/1, 5/2, 5/3, 5/7, 5/8, 5/9, 5/11, and 5/12/26. Further review of the above PRN pain meds revealed that the PO for pain management was not clarified according to the appropriate pain level or sequencing. On 5/13/26 ata 8:51 AM, the surveyor observed Resident #37 seated in a w/c eating breakfast. The resident informed the surveyor that the PRN Percocet (also known as the Oxycodone-Acetaminophen) was administered and helped with their left foot pain. On 5/13/26 at 8:53 AM, the surveyor interviewed LPN #2 who informed the surveyor that Resident #37's left foot pain was being managed well with PRN Percocet. She further stated that the resident used to have a wound on the left foot that was healed. At that same time, the surveyor notified LPN #2 of the above concern and asked if the order should have been clarified to include indication or sequencing for PRN pain meds, and LPN #2 stated that she would get back to the surveyor. On 5/13/26 at 9:11 AM, the surveyor notified the DON in the presence of the CSC about the concern of Resident #37's sequencing of PRN pain meds. A review of the facility's Pain Assessment and Management Policy that was provided by the Regional Nurse of Clinical Services (RNCS), with a revision date of April 2025, revealed, the purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain.Implementing Pain Management Strategies.6.The med regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. A review of the facility's Pain-Clinical Protocol Policy that was provided by the LNHA, with a revision date of October 2022, revealed under assessment and recognition:1.The physician and staff will identify individuals who have pain, or who are at risk for having pain.b. It also includes a review for any treatments that the resident currently is receiving for pain.Treatment/Management.2.The physician will order appropriate non-pharmacologic and med interventions to address the individual's pain.a. Pain meds should be selected based on pertinent treatment guidelines. On 5/13/26 at 1:17 PM, the survey team met with the LNHA, RNCS, and the DON stated the PRN Percocet of Resident #37 was updated to include the indication to administer for PRN moderate to severe pain. On 5/13/26 at 1:37 PM, the survey team met with the LNHA DON, and the RNCS, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure timely administration of a medication (med) for 1 of 5 (Resident #31) residents reviewed for med regimen. The deficient practice is evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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 5/7/26 at 9:31 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepared medications (meds) for Resident #31. The meds included, but were not limited to, the following physician's order (PO):-Trazodone Hydrochloride (HCl) Oral Tablet (tab) 50 mg (milligrams) Give 0.5 tab by mouth one time a day for depression half tab in morning = 25 mg Do Not Crush. The PO started on 1/17/26. On 5/7/26 at 9:31 AM, the surveyor observed the PO above was highlighted in red on the electronic medication administration record (eMAR), indicating the med was overdue. On 5/7/26 at 9:39 AM, the surveyor observed the LPN administer Trazodone to Resident #31. A review of the Medication Administration Audit Report of 4/29/26 for Resident #31 revealed the following:- Trazodone HCl Oral Tab 50 mg Give 0.5 tab by mouth one time a day for depression half tab in morning = 25 mg Do Not Crush was scheduled for 5/7/26 at 8:00 AM, was administered on 5/7/26 at 9:39 AM, and documented on 5/7/26 at 9:54 AM. On 5/7/26 at 10:00 AM, the surveyor interviewed the LPN who stated the expectation was to give a med within an hour before or an hour after it scheduled time. The LPN acknowledged that they administered Trazodone late to Resident #31. On 5/12/26 at 11:00 AM, in the presence of the survey team, the surveyor discussed the concern with the Licensed Nursing Home Administrator and the Director of Nursing. A review of the facility's Administering Medications Policy, revised April 2019, revealed, meds are administered within one hour of their prescribed time, unless otherwise specified . NJAC 8:39-29.2

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to properly store, and label with a date, medications in 1 of 2 medication rooms and 1 of 4 medication carts inspected. The deficient practice was evidenced by the following:1. On [DATE] at 10:50 AM, the surveyor inspected the medication (med) room on the 1st floor North, in the presence of the Licensed Practical Nurse (LPN). During the inspection, the surveyor found a safety needle that had expired on [DATE]. The LPN acknowledged the safety needle was expired. 2. On [DATE] at 1:33 PM, the surveyor inspected south med cart #3 on the second floor in the presence of the Registered Nurse (RN). Upon opening a drawer of the cart, the surveyor observed the following:-Resident #143's Ipratropium Bromide and Albuterol Sulfate Inhalation Solution 0.5 milligrams (mg) / 3 mg per 3 milliliters (mL) foil pouch was opened with no date on it. The foil pouch originally contained 30 vials as was written on the pouch, and there were 28 unit-dose vials remaining inside the pouch. It was written on the foil pouch, Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. -Resident #55's Budesonide Inhalation Suspension (0.5 mg/2 mL) foil pouch was opened with no date on it. The foil pouch originally contained 5 single-dose ampules as was written on the pouch, and there was 1 ampule remaining inside the pouch. It was written on the foil pouch, Once the foil pouch is opened, use the ampules within 2 weeks. On [DATE] at 1:34 PM, the surveyor interviewed the RN who stated the expectation was to label them when you open them. The RN acknowledged that the foil pouches were not labeled with the date of opening and that they should have been labeled with the date of opening. On [DATE] at 11:00 AM, in the presence of the survey team, the surveyor discussed the concern with the Licensed Nursing Home Administrator and the Director of Nursing. A review of the facility's Medication Labeling and Storage Policy, revised [DATE], revealed, labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . NJAC 8:39-29.4

Based on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices for 2 of 2 staff (Recreation Assistants) during dining observation, and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following:According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, revealed .Know how to wash hands with soap and water:Wet hands with water.Apply the manufacturer's recommended amount of product to your hands.Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet.Avoid using hot water to prevent drying of the skin.Note: Other entities recommend cleaning hands with soap and water for at least 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times and scrubbing hands and fingers with soap. On 5/7/26 at 11:31 AM, the surveyor observed the 2nd (second) floor dining room with total of 24 residents preparing for lunch that was assisted by recreation staff. The surveyor observed Recreation Assistant #1 (RA #1) performed hand washing inside the dining room for 20 seconds and turned off the faucet with bare left hand, then took a clean paper towel to dry both his hands. During an interview with RA #1, he informed the surveyor that hand washing should be performed for at least 20 seconds and turn off the faucet with clean paper towel. The surveyor then asked RA #1 if he turned off the faucet with clean paper towel and he stated usually he uses the clean paper towel to do it. The surveyor then notified the concern that the surveyor did not observe RA #1 used clean paper towel to turn off the faucet, and RA #1 did not further reply. On 5/7/26 at 11:37 AM, the surveyor observed Recreation Assistant #2 (RA #2) performed hand washing in the 2nd floor dining room laddered with soap for 10 seconds. During an interview with RA #2, he informed the surveyor that hand washing should be at least 20 seconds or sing twice the happy birthday song. RA #2 further stated that the 20 seconds start from applying soap to hands and ended when washing off hands of soap with use of water. On 5/7/26 at 11:40 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Nurse of Clinical Services (RNCS) of the concerns about RA #1 and RA #2's hand washing. On 5/13/26 at 11:48 AM, the survey team met with the DON and the LNHA stated that education was provided to two activity aides for hand hygiene and return demo (demonstration) was completed. A review of the facility's Handwashing/Hand Hygiene Policy that was provided by the DON, with a revision date of December 2025, revealed, under procedure, washing hands.2. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.3. Rinse hands with water and dry thoroughly with a disposable towel.4. Use towel to turn off the faucet. On 5/13/26 at 1:37 PM, the survey team met with the LNHA DON, and the RNCS, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-19.4(a)(1)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received care consistent with professional standards of practice, to prevent pressure ulcers, and promote healing. This deficient practice was identified for 1 of 2 residents, (Resident #197) who was identified as having a pressure right hip injury on 11/13/24, with no description of a wound, which progressed to an unstageable wound to the right hip with 30% slough (necrotic tissue that needs to be removed from the wound for healing to take place) with serosanguinous drainage. The wound measured 3 centimeters (cm) x 4 cm x 0.1 cm and was identified during routine wound rounds by a consultant on 11/20/24. The resident developed an unstageable pressure wound to the right hip on 11/20/24, which required chemical debridement when the resident was hospitalized on [DATE]. The evidence was as follows: 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. According to the National Pressure Injury Advisory Panel (NPIAP), Pressure Injury Stages, the updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer that may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . According to [name of immediate care company], Types of Wound Drainage and How to Tell When It is Serious, it's important to be able to identify different types of drainage in order to best care for wounds and discuss possible treatment options with the doctor. According to Disease and Condition, 4 Types of Wound Drainage: 1. Serous Drainage, a thin, watery, and clear substance exiting the wound is classified as serous drainage. When the wound is fresh and going through the inflammatory wound healing stages, it's perfectly normal to experience this type of drainage. If notice an overwhelming amount of serous drainage, it may indicate high bioburden or the presence of unsterilized bacteria living on the wound. 4. Serosanguineous is the most common type of drainage. It is thin, watery, and tends to be pink in color, but can also be shades of darker red. The pink/red coloring has to do with red blood cells in the fluid, a sign of capillary damage. 1. On 12/02/24 at 10:12 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) for an entrance conference. The DON informed the surveyor that residents with wounds including pressure ulcers, tube feeding, tracheostomy, dialysis, and an opening in their bodies were placed on EBP (Enhanced Barrier Precautions, are an infection control intervention to reduce MDRO (mutidrug resistant organism; are germs that are resistant to many antibiotics and can cause infections) transmission in nursing homes). The surveyor asked the LNHA and DON for list of residents with facility acquired wounds. On 12/2/24 at 11:09 AM, the surveyor observed a posted sign outside the door for EBP. Inside the room, Resident # 197 was lying on the geri chair. The surveyor reviewed the medical records of Resident #197. The Admission Record (an admission summary) revealed that the resident was admitted to the facility with the following medical diagnoses that were not limited to; unspecified dementia, contracture right knee and left knee, and abnormal posture. A review of the Braden scale (to measure risks of resident's developing pressure ulcers) dated 10/29/24, the resident scored 11 out of 23 which indicated high risk for developing pressure ulcers. The most recent comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 10/27/24, revealed that the resident's cognitive skills for daily decision-making were severely impaired. The cMDS indicated that the resident had no wounds. A review of the Resident Evaluation for admitted d 10/21/24, revealed sacrum, left heel, and right heel redness. There was no documented evidence of sacrum or left and right heel redness measurements. A review of the Resident Evaluation for readmitted d 11/25/24, revealed left heel blanchable skin ecchymosis, right heel blanchable skin ecchymosis, sacrum skin excoriation on a pressure point, and right trochanter (hip) suspected deep tissue injury (DTI). There was no documented evidence of measurements of the mentioned skin impairments on the left and right heels, sacrum, and right hip. A review of the list of residents with facility-acquired wounds provided by the LNHA on 12/02/24 at 12:10 PM, revealed two residents which included Resident #197 for sacral wound stage 2 (sore area of skin has broken through the top layer of skin (epidermis) and some of the layer below (dermis)) pressure ulcer that started on 11/20/24. A review of the wound consultation reports revealed the following: -10/23/24: recommended moisture barrier cream to bilateral buttocks and sacrum, skin prep and offload blanchable heels. There was no documented evidence that there were pressure ulcers identified for the sacrum. -11/20/24: Unstageable right hip 3 cm x 4 cm x 0.1 cm, 40% dermis, 30% slough, 30% epithelization, full thickness, serosanguineous, cleanse with saline medihoney dry dressing daily/prn (as needed), reposition side to side, monitor for changes. There was no documented evidence that there was a pressure ulcer identified for the sacrum. -11/27/24: Stage 2 right hip 3 cm x 3 cm x 0.1 cm, 100% dermis, partial thickness, cleanse with saline medihoney dry dressing daily/prn, reposition side to side, monitor for changes. There was no documented evidence that there was a pressure ulcer identified for the sacrum. A review of the physician orders (PO) revealed the following: -Calmoseptine external ointment 0.44-20.6% apply to sacrum topically every day and evening shift for redness with a start date of 10/22/24 and discontinued (d/c) on 11/22/24. -Weekly skin observations every day shift every Wed (Wednesday) 0-NO skin breakdown, 1-Previously identified wound 2-Newly identified wound with an order date of 10/22/24 and d/c order on 11/22/24. The above order for skin observations revealed that the nurse every Wed at 7:00 AM-3:00 PM (day shift) will code 0 if there was no skin impairment, code 1 if there was a previously identified wound, and code 2 if a newly identified wound was identified. -Offload heels while in bed as tolerated every shift with an order date of 10/21/24 and d/c on 11/22/24. -Optifoam to left hip every day shift for protection with a start date of 11/14/24 and d/c 11/21/24. -apply optifoam to right hip everyday shift for protection with an order date of 11/13/24 and d/c order on 11/21/24. -Cleanse Right ischium (hip) with NSS, pat dry, apply Medi-honey ointment (wound and burn gel made from honey that has antibacterial and bacterial resistant properties, meaning it prevents bacteria from building a tolerance to its beneficial effects) to the wound bed, and cover with Opti foam (is a foam dressing that has a silicone adhesive border, waterproof backing and can stay in place up to 7 days, depending on the amount of wound drainage) every day shift for Pressure with an order date of 11/21/24. -Weekly skin observations every evening shift every Thu (Thursday) 0-NO skin breakdown, 1-Previously identified wound 2-Newly identified wound with an order date of 11/25/24. -Offload heels while in bed every shift with a start date of 11/25/24. -Skin prep right heel every day and evening shift with a start date of 11/26/24. -Skin prep left heel every day and evening shift for protection with a start date of 11/26/24. -Cleanse right trochanter/hip wound with NSS (normal saline solution), pat dry, apply Medi-honey ointment, cover with optifoam dressing every day shift for wound care with a start date of 11/26/24. -Apply optifoam dressing to sacrum every day shift for protection with a start date of 11/27/24 and d/c 12/03/24 -Apply optifoam dressing to left hip every day shift for protection with a start date of 11/27/24 and d/c 12/03/24. The above PO were transcribed to the electronic Treatment Administration Record (eTAR) for November and December 2024 and revealed: -on 11/13/24, the Licensed Practical Nurse (LPN) signed the eTAR and coded 1 (previously identified wound) of the weekly skin observations for the day shift. A review of the Pressure Injury Documentation in the electronic medical record revealed: -11/21/24 at 3:23 PM, the first observation: right hip stage 2, measurement: 3 cm x 4 cm x 0.1 cm, 30% epithelial, 30% sloughed, 40%dermis, serosanguineous drainage, and electronically signed by the Registered Nurse (RN). -11/27/24 at 3:42 PM, the first observation: right hip stage 2, measurement 3 cm x 3 cm x 0.1 cm, 100% dermis, serous drainage, and electronically signed by the RN on 12/02/24 at 3:44 PM. Further review of the above medical records revealed that there was no documented evidence that the facility staff identified the right hip wound prior to the wound doctor identifying the pressure injury. The unstageable wound to the right hip was identified during the wound rounds. A review of the personalized care plan (CP) revealed that there was no documented evidence that the actual new pressure injury in the right hip was identified and initiated an intervention to promote healing and prevent further development of new pressure injury. Further review of the medical records revealed that there was no documented evidence that the physician was notified of the new pressure injury to the right hip. A review of the most recent hospitalization records revealed that Resident #197 was seen by the Advance Practice Nurse (APN) on 11/22/24, for wound evaluation. The APN documented on her assessment that the resident was dependent on mobility, and skin characteristics: right trochanter with a full-thickness wound, stage 3 pressure injury (prior to admission to the hospital) approximately 2.5 cm x 2.5 cm, wound based appeared 70% viable tissue and 30% yellow fibrinous debris, and with a scant amount of serosanguinous exudate. The APN also documented the topical care: apply collagenase to the site for enzymatic debridement and cover with a silicone dressing to promote moist wound healing and for protection, change daily. On 12/04/24 at 12:54 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of 2 North. The RN/UM informed the surveyor that it was the responsibility of the nurses to initiate a care plan upon admission, and he was responsible for updating the care plan. The surveyor notified the RN/UM of the above concerns that there was no CP initiated for the right hip pressure ulcer when it was first identified by the wound doctor on 11/20/24. The RN/UM stated, I missed it. He also confirmed that there was no stage 2 pressure injury to the sacrum and the facility-acquired wound was the right hip. At that same time, the surveyor notified the RN/UM of the concern that there was no documented evidence in the 10/21/24, admission that there was right hip skin impairment and 11/25/24, readmission resident's evaluations (assessment) that the skin impairment in the right hip was measured. The RN/UM responded that the nurse should have documented wound measurements. The RN/UM stated that the right hip had a previously healed wound which was why on 11/13/24, optifoam dressing was ordered as protection. The RN/UM further stated that he would get back to the surveyor as to why there was no documented evidence that there was a previously identified wound to the right hip. On 12/04/24 at 02:27 PM, the surveyor notified the DON of the concern that the resident's unstageable right hip wound was identified on 11/20/24, by the wound doctor during the routine wound rounds. The surveyor asked the DON why there was an order for optifoam dressing on 11/13/24, and the DON responded that there was no wound or redness on the right hip on 11/13/24, it was ordered for protection. At that same time, the DON stated that she understood the concern of the surveyor as to why the facility did not see the right hip wound, and it was the wound doctor who identified it, when the wound doctor saw the wound, it was unstageable with slough and drainage. The DON stated that she would get back to the surveyor. On 12/05/24 at 10:46 AM, the surveyor interviewed the RN regarding skin and wound assessment. The RN stated that she knew that for an open wound, the nurse should measure the wound, but she was unsure if she had to measure intact skin or intact skin impairment like redness or bruise. She further stated that it was the responsibility of the wound doctor to stage the wound every Wednesday during wound rounds. The surveyor asked the RN, what would happen for residents who developed new wounds, new admission, and readmission with wounds, who would stage the wound and document appropriate wound description to obtain the correct treatment if the wound doctor came on Wednesday only. At that same time, the RN acknowledged that she was the nurse who documented pressure injury documentation for the dates 11/21/24 and 11/27/24, for the right hip. She stated that the 11/21/24, right hip documentation was based on the 11/20/24 wound consult notes documentation. The surveyor then asked if she copied the wound documentation from the wound doctor, and why she documented stage 2 as not unstageable considering that there were no changes from the description of the wound doctor, and the RN did not respond. On 12/05/24 at 10:54 AM, the surveyor observed the wound treatment of Resident # 197 done by RN/UM and was assisted by the RN. The RN/UM read the order: to cleanse the right hip wound with NSS (normal saline solution), pat dry, apply medihoney ointment, and cover with optifoam dressing everyday shift for wound care (start date 11/26/24). The RN/UM removed the right hip dressing and informed the surveyor that the wound was beefy red, and the measurement was 0.5 cm x 0.5 cm. The RN did not perform hand hygiene in between gloves use, after direct contact to resident's environment (garbage receptacle), and prior to exiting the resident's room. The RN/UM did not disinfect the marker used to sign the dressing applied to the resident before and after use, and did not disinfect the container of medihoney that was brought inside the resident's room prior to returning inside the treatment cart. On 12/05/24 at 11:26 AM, the surveyor interviewed the LPN. The LPN confirmed that she was the nurse on 11/13/24 and 11/20/24 who signed the eTAR for a weekly skin evaluation. She stated that she coded 1 which meant that there was a previously identified wound. The LPN further stated that the previously identified wound was the right hip and she remembered it was definitely not a redness, it was more than that, it was worse and open. She further stated that on 11/13/24, she remembered that was the time the resident was moved to her side and assignment, and she did the skin evaluation and signed the eTAR. The surveyor asked why she coded it a previously identified wound that was not identified in the admission, and the LPN responded that when she notified the RN/UM at that time, the RN/UM told her that they knew about it, and they had been monitoring it and the RN/UM took care of it that was why she coded 1 as previously identified wound for the right hip. Further review of the EMR revealed the following: -The Late Entry Progress Notes (PN) with an effective date of 11/30/24, created on 12/08/24 at 4:23 PM, that was electronically signed by the Medical Doctor (MD) revealed that the right hip wound was covered with a dressing. -The PN with an effective date of 12/08/24, that was electronically signed by the MD revealed that the MD was called by the nurses on 11/13/24, that the resident had right hip pressure noted, optifoam dressing daily was ordered, the staff was advised to monitor for worsening changed of the area, wound care consult advised, and monitor for fever. -The Late Entry PN with an effective date of 11/20/24, created on 12/03/24 at 12:47 PM, that was electronically signed by the DON revealed that the RN/UM reported to her that during wound rounds with the wound team, the resident was noted with right hip pressure ulcer, 3 cm x 4 cm x 0.1 cm with small amount of serosanguineous drainage, 40% dermis, 30% slough, 30% epithelialization. Further review of the above EMR revealed that the advice of the MD on 11/13/24, to consult the wound doctor was not followed for the right hip pressure wound. On 12/05/24 at 12:25 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the concerns with Resident #197's right hip facility-acquired wound. On 12/09/24 at 11:34 AM, the survey team met with the LNHA and DON. The DON informed the surveyor that she asked the RN/UM to create another wound timeline that would include more information on Resident #197's right hip facility-acquired wound. The DON stated that the nurses should be able to assess, describe a wound, stage a wound, and relay to the doctor the wound to obtain an appropriate treatment order promptly. She further stated that the nurse should measure any skin impairment either a bruise, pressure ulcer, or skin tear as part of the assessment. At that same time, the DON stated that there was no documentation from the nurse why the order for optifoam dressing was obtained and it was missed by the nurse. The DON further stated that there was no documentation from the facility before the wound doctor identified the facility-acquired unstageable pressure injury to the right hip. The DON stated that there was a knowledge deficit on the part of the nurse on how to describe and assess the appearance of the wound, because if the nurse had seen that it should have been documented and notified the doctor to obtain a proper treatment for that skin impairment. Furthermore, the surveyor asked the LNHA and the DON if they were able to verify with the LPN that she was able to identify the right hip wound on 11/13/24, during weekly skin observation, why it was not investigated, and why the LPN did not notify the physician of the observation that the right hip was an open wound and non-intact skin. The DON stated that she would get back to the surveyor. On 12/09/24 at 01:29 PM, the surveyor interviewed the DON regarding the Pressure Injury Investigation Form (PIIF) dated 11/13/24, the PIIF revealed an investigation for right hip pressure injury with no description of the pressure injury, no measurements, and did not include what stage the wound was. In the summary, it was documented that the pressure injury was unavoidable. The PIIF instruction included in the summary was if unavoidable, a box should be checked off for a yes or a no if the physician has completed the physician documentation form or written a progress note, and it was not checked off. The DON stated that she had to ask the RN/UM who did the PIIF because she did not have a copy of the PIIF. The surveyor also notified the DON of the concern that the PIIF investigation on 11/13/24, did not match what was previously provided information of the DON and the RN/UM about the right hip and that no wound was why the order for optifoam the physician was for protection. On 12/09/24 at 01:33 PM, the DON provided a copy of the Pressure Injury investigation dated 11/20/24, which was prepared by the DON for the right hip that was identified during wound rounds, that the incident was unwitnessed, and that no statements were found. Attached to the investigation were the Pain Evaluation and Braden Scale assessment with an effective date of 11/20/24, which was electronically signed by the DON on 12/03/24. The surveyor asked the DON why the pressure injury investigation on 11/20/24, was incomplete, with no staff statements, and was not completed until 12/03/24, after the surveyor's inquiry. The DON stated that she had to get back to the surveyor. On 12/11/24 at 8:49 AM, the surveyor called and left a message for the Wound Doctor (WD#1), and the doctor did not return the call. On 12/11/24 at 10:50 AM, the surveyor interviewed WD#2 and notified that WD#1 did not return the call of the surveyor. WD#2 informed the surveyor that she was the covering wound doctor of the facility and acknowledged that WD#1 was the other doctor who was caring for the resident. WD#2 stated that she was familiar with the resident and had seen the resident since last week. She further stated that the wound team rounds were every Wednesday between 7:00 AM-9:00 AM. On that same date and time, the surveyor asked WD#2 about the identified unstageable pressure injury to the right hip on 11/20/24, and WD#2 stated that a resident would be possible to develop an unstageable open wound or intact DTI if the resident was immobilized for 6 hours that was why it was important to turn and reposition the resident. A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol Policy with a revision date of March 2014 that was provided by the DON revealed: Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. Staff will examine the skin of a new admission for ulcerations or alterations in skin . On 12/11/24 at 01:21 PM, the survey team met with the LNHA and DON for an exit conference. The facility management did not provide additional information. NJAC 8:39-27.1 (a,e)

Based on observation, interviews, and a review of facility documentation, it was determined that the facility failed to ensure that a facility wide assessment was reviewed and updated to identify the required services and procedures necessary to protect the health, safety, and welfare of all residents to ensure adequate facility resources to provide resident care and services. These failures had the potential to affect all 109 residents who currently live in the facility during the time of the survey. This deficient practice was evidenced by the following: During the entrance conference on 12/02/24 at 10:12 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) documents to complete the survey process which included but were not limited to Facility Assessment (FA). Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 109. On 12/03/2024 at 8:40 AM, the surveyor followed up with the DON regarding the requested documents during the entrance conference, and the DON responded that she would get back to the surveyor. On 12/04/24 at 10:58 AM, the surveyor met with 4 residents for the resident council meeting. Resident #79 stated that sometimes the gowns were not enough. Resident #72 stated that the facility maybe needed to order a little bit more and have the incontinence pads, the green, because at times staff was unable to find one when needed. All four residents confirmed and acknowledged the need for more supplies. On 12/05/24 at 8:39 AM, the surveyor interviewed Certified Nursing Aide #1 (CNA#1) who was in room [ROOM NUMBER] with a linen cart in front of the room. The CNA informed the surveyor that usually we have our linen cart for each CNA. She stated that today she had 9 residents and she received supplies that included but were not limited to a total of 4 towels and 5 sheets. She further stated that she had not received incontinence pads yet, because they would be delivered later, and was using the leftover from last night. She added that linen was delivered usually around 7:15 AM-7:30 AM and the incontinence pads delivered around 7:30 AM. She further stated that the green incontinence pads were the extra-large (XL), blue was the large, and white was the pull-ups. On that same date and time, CNA#1 stated that the supplies were not enough and that we could have more. She further stated that sometimes the aides go down to the laundry area to get more around 10:30 AM-11:00 AM because that was the time the laundry was finished washing and there would be available supplies. The surveyor asked the CNA how she could provide care if she had 4 towels and 5 sheets, and the CNA had no answer. On 12/05/24 at 8:45 AM, the surveyor interviewed CNA#2 from 2 South. The CNA stated that she had 8 residents today and her linen cart included but were not limited to 4 towels and 4 linens. The CNA accompanied the surveyor to the clean utility room where the CNA informed the surveyor that the incontinence pads were just delivered for 2 South and 2 North. Both the surveyor and the CNA counted the delivered incontinence pads as follows: -Large=31 pieces -XL=31 pieces -pull-ups=22 pieces There was a total of 6 packs of washcloths. At that same time, the surveyor asked the CNA how she was able to provide morning care specifically incontinence care and showers to the residents assigned to her if she only had 4 towels and 4 linens, the CNA had no response. On 12/05/24 at 8:51 AM, the surveyor interviewed CNA#3 from 2 North. The CNA informed the surveyor that she had 15 residents in her assignment today and her linen cart included but was not limited to 3 towels, 3 pieces of washcloths, 5 sheets, and 1 pad. The surveyor asked the CNA how she was able to provide morning care, showers, and incontinence care if she only had those supplies, and the CNA responded, Good question. The CNA acknowledged that it had been the same every day as what she receives for supplies. She further stated that the 2 North was a long-term care unit. The surveyor also asked was the facility management aware of the concern with supplies, the CNA responded Yes. The surveyor asked how the facility management responded to the concerns, the CNA responded that the facility management told them We are working on it. The CNA did not respond when the surveyor asked CNA#3 whom they mentioned the concerns with supplies. On 12/05/24 at 9:02 AM, the surveyor went to the laundry area and interviewed the Laundry Aide (LA) who informed the surveyor that she had been working as the LA for 7 years for 7:00 AM-3:00 PM (7-3) shift and there was another laundry person for the afternoon. The LA stated that there was a big linen cart for each shift, the one I brought for the 7-3 shift linen cart was the prepared one from last night, and that they followed the posted par level. The LA showed and provided the 7-3 shift carts and 3:00 PM-11:00 PM (3-11) shift carts for par level. The surveyor then asked the LA why there was no par level for the 11:00 PM-7:00 AM (11-7) shift and she responded that they followed the 3-11 par level for the 11-7 shift. The LA further stated that she prepared the 3-11 shift linen carts after she did the laundry. At that time, the surveyor observed the washing machines were in use and there were towels, and linens being laundered. The LA and the surveyor went to the next room (connected room) where the LA stated that was where the backup supplies were. The LA showed the big linen cart with extra pillows and clean heel booties. The LA showed the other big linen cart with 6 blankets, 18 gowns, and 27 yellow gowns. The LA informed the surveyor that the blankets and gowns were clean. She further stated that the 27 yellow gowns were being used by staff as PPE (personal protective equipment) when providing care to the residents. The LA confirmed that there were backup supplies and there was another room for emergency supplies next room. There was another blue linen cart (medium size) with supplies next to the empty big linen cart which the LA stated that the blue linen cart was for the rehabilitation (rehab) department. There were two big empty linen cart trucks in the laundry area, one had a marker for 3-11 and the other one for 11-7. Later, the surveyor and the LA went to the emergency supplies room and there were: 3 boxes of washcloths (1 box=10 dozen) 3 boxes of bath towels (1 box=5 dozen) 2 boxes of flat sheets (1 box=2 dozen) 1 box of fitted sheet (1 box=2 dozen) Furthermore, the LA informed the surveyor that the emergency supplies were only being used if in case the laundry staff filling out the big carts to be delivered in the unit did not meet the required number of supplies items in the par level. The LA confirmed the par level list below for 7-3 and 3-11 and stated that the 3-11 par will be the same for the 11-7 shift, and revealed: 7-3 shift carts par level: Items: Amount: towels 25 flats 40 fitted 12 gowns 25 blankets 140 pillowcase 20 3-11 shift carts par level: Items: Amount: towels 25 flats 40 fitted 12 gowns 10 blankets 16 washcloth 30 pillowcase 15 A review of the provided FA by the LNHA on 12/03/24 at 10:10 AM revealed that the date of assessment was 8/05/24, the reason for the assessment was for an annual review and change requiring a plan update. The FA also included the facility management who attended the meeting which were the LNHA, DON, Medical Director, Director of Social Services, and Director of Rehab. The FA review was based on the average daily census of 106. Part 3 of the FA included the facility resources needed to provide competent support and care for the resident population every day and during emergencies were based on the information and programming goals to meet the needs of the residents. In 3.9 Physical environment and building/plant included the physical resources category for non-medical supplies for soaps, cleansing products, incontinence supplies, waste baskets, bed/bath linens, communication devices, and computers that the planned changes this planning period for par levels reviewed on 8/01/24. Further review of the provided FA did not include attachments or information for par levels as specified on the 3.9 resources. A review of the provided 2 South 7-3 shift schedule for 12/05/24 by the Unit Clerk revealed that the census was 52, CNA#1 had 9 residents and CNA#2 had 8 residents. A review of the provided 2 North 7-3 shift schedule for 12/05/24 by the Registered Nurse/Unit Manager (RN/UM) revealed that the census was 61 and CNA#3 had 15 residents. A review of the provided incontinence list of the DON revealed: -CNA#1=1 resident incontinent both bladder and bowel (B & B) elimination. -CNA#2=5 residents incontinent of B & B. -CNA#3=9 residents incontinent of B & B. On 12/05/24 at 12:25 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the concerns with supplies for linens, towels, incontinence pads, and laundry area supplies that could affect the care of residents. On 12/05/24 at 01:18 PM, the LNHA, Director of Maintenance (DM), and Housekeeping Director (HD) came to meet with the surveyor, the LNHA stated that he was concerned with the surveyor's findings with care issues related to not enough supplies of the facility as reported during a team meeting with the facility. The DM confirmed the par level copies that were provided to the surveyor by the LA. The facility management confirmed that the LA was assigned to laundry and distribution of the linen supplies to the units by following the par level posted in the laundry room for 7-3 shifts. On 12/05/24 at 01:31 PM, the surveyor interviewed the LNHA regarding the FA. The surveyor asked the LNHA while presenting the FA copy that LNHA previously provided on 12/03/24, if the copy was the facility's most updated FA, and the LNHA responded that he had to check his records again. The surveyor asked where the attached information about the par level was reviewed on 8/01/24 as part of the FA, and the LNHA responded that he had to check. The surveyor then asked the LNHA why he was unsure if what he had provided on 12/03/24 was the most updated one if the documents were requested at the entrance conference on 12/02/24 and today was the 4th day of the survey already, and the LNHA had no response. Both the surveyor and the LNHA went to his office and the LNHA was unable to provide the par level copy and stated that it was probably with the DM. On that same date at 01:34 PM, the LNHA provided another copy of FA, the same copy as what was provided on 12/03/24 at 10:10 AM with no attached par level and no information about the par level. The surveyor asked the LNHA again where the par level information and he said it was probably with the DM. On 12/05/24 at 01:39 PM, the DM confirmed with the LNHA that the information that should be in the FA was the same information that was posted in the laundry area that was provided by the LA to the surveyor. On 12/05/24 at 01:42 PM, the LNHA stated that the DON would be the one to discuss further the FA. On 12/05/24 at 01:46 PM, the surveyor interviewed the DON in the presence of the Director of Quality Assurance (DQA). The surveyor asked the DON if the two provided FA (12/03/24 and 12/05/24 at 01:34 PM) were the facility's FA, and the DON stated that she had to check again will have to be back. On 12/05/24 at 02:17 PM, the DON asked for another 10 minutes to be able to provide the requested attachments for the FA. On 12/05/24 at 02:44 PM, the surveyor followed up with the DON regarding the interview and the requested documents for the FA. The DON confirmed that the 8/05/24 FA was the facility's most updated FA. The DON informed the surveyor that the facility management met on 8/05/24 because both the LNHA and the DON were new, and they wanted to discuss updates and review the FA that required changes. The DON stated that as per protocol, the facility management meets at least annually, and if there were any changes or disasters that happened that needed modification in the FA to meet the needs of the residents in the facility. At that same time, the surveyor asked the DON if the par level of the supplies met the requirements. The DON stated No, and that the FA should have updated the par level for linen supplies to meet the needs of the residents. On 12/09/24 at 11:34 AM, the survey team met with the LNHA and DON. The DON stated they were able to obtain more supplies that included towels, the par level reviewed, and should be according to the census. The DON further stated that the facility management needs to do another meeting to revise and address their FA tool based on the needs of the resident to address the par level of the linen supplies. A review of the facility's Facility Assessment Policy with a revision date of June 2024 that was provided by the LNHA revealed: An FA is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations and emergencies. Policy Interpretation and Implementation: 2. The team responsible for conducting, reviewing, and updating the FA includes but is not limited to LNHA, DON, and other department heads . Review of Available Resources: 1. The FA also includes a detailed review of the resources and personnel available to meet the needs of the resident population. This part of the assessment includes the following: beguilement and supplies (medical and non-medical) . Facility Assessment: 2. The FA is used to identify current or potential gaps in care or services due to misalignment or lack of appropriate resources. 3. The FA is also used to help the facility plan and respond to changes in the needs of the resident population, and determine budget, staffing, equipment, and supplies needed . On 12/11/24 at 01:21 PM, the survey team met with the LNHA and DON for an exit conference. There was no additional information provided and the facility management did not refute the findings. NJAC 8:39-5.1(a); 27.1

COMPLAINT# NJ178354 Based on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 2 of 2 units, (2 North and 2 South), and 1 of 22 residents, Resident #94. This deficient practice was evidenced by the following: 1. On 12/3/24 at 11:53 AM, during a tour of the 2nd floor nursing units, the surveyor observed a gray, dust or dirt like substance adhering to the air circulation vent covers on the 2 North Unit hallway. The surveyor observed 2 vent covers on the 2 North Unit. The surveyor proceeded to the 2 South unit nurses' station and observed a similar gray substance adhering to the vent cover in the ceiling over the desk area. The surveyor observed the gray dust like substance as well as stringy cobweb like material on vent covers in the hallway of the 2 South. The surveyor observed 2 vent covers on the 2 South Unit hallway. On 12/3/24 at 12:03 PM, the surveyor informed the Housekeeping Supervisor (HKS) and the Director of Maintenance (DM) of the concerns. The HKS and the DM accompanied the surveyor to the 2 North hallway, 2 South Hallway and 2 South Nurses station where the surveyor identified the air circulation vents mentioned above. The surveyor interviewed the HKS and DM. The surveyor asked if this was the normal appearance of the air vents, and the DM replied, no. The surveyor asked if this was an area that was normally cleaned, the HKS replied yes, it should be. The surveyor asked if the vents in question appeared to be clean, the HKS and DM replied, no. The surveyor asked if this could occur overnight, the HKS replied, no. The surveyor asked if this appeared to be homelike, clean, and sanitary, the HKS and DM replied no, it does not. The HKS and DM stated that the concerns would be taken care of right away. The surveyor observed housekeeping staff on ladders cleaning the air circulation vents. On 12/4/24 the surveyor interviewed the Director of Nursing (DON) and asked if there was any documentation that the air vents are cleaned regularly. The DON stated that there were no logs or documentation for cleaning of hallways or air vents by the housekeeping staff, and the only documentation that would be available was the housekeeping schedule with room assignments. 2. On 12/5/24, the surveyor observed the shower room located on Wing 1 in the 2 South nursing unit. In the shower room, the surveyor observed vinyl type disposable gloves on the floor in 2 areas, debris near the drain in one shower stall as well as a shampoo bottle on the floor. The shower room also contained lifts used for resident transfers, a wheelchair, shower chairs and shower gurneys. The floor of the shower room was observed to be completely dry. The surveyor brought Licensed Practical Nurse #1 (LPN#1), to the shower room. The surveyor asked LPN#1 if the floor was clean and the dry. The LPN#1 stated no, it was not clean, it was dry, and there should not be anything on the floors. The surveyor asked if the above items were usually stored here. LPN#1 stated, yes. On 12/9/24 the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON and discussed the above concerns. The surveyor reviewed the hybrid (paper and electronic) medical record for Resident #147 and revealed: According to the resident's list of diagnoses, the resident was admitted to the facility with diagnoses which included but was not limited to: malignant neoplasm of prostate (prostate cancer), type 2 diabetes mellitus, and hypertension (high blood pressure). The 5 Day Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 10/5/24, Section C reflected a Brief Interview for Mental Status (BIMS), an assessment test used to monitor cognition, score of 13 of 15 which indicated that Resident #147 had intact cognition. The resident reported that there was a stain on the shower room floor when they were brought for a shower. A nursing aide cleaned the floor before assisting with shower. A physician most recent discharge summary that reflected the resident left AMA (against medical advise), signed by the attending physician. 38327 3. On 12/5/24 at 8:33 AM, the surveyor observed an Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) posted sign and personal protective equipment (PPE) hung outside the door of Resident #94. Inside the resident's room, there was a Resident Representative #1 (RR#1) at the bedside. The surveyor observed Resident # 94 lying on the bed with the head of the bed elevated, eyes open, and non-verbal. On that same date and time, the surveyor observed the floor with dried brownish substances and an accumulation of grayish substances. The heater near the window with multiple plastic covers, papers, and plastic. In between the heater a space between the windowsill with an accumulation of blackish substances. The resident's nightstand table with dried whitish substances. On 12/9/24 at 9:12 AM, the surveyor observed an EBP posted sign and PPE hung outside the door. Inside the room the surveyor observed RR#2 at the bedside. The surveyor observed the floor with dried brownish substances and an accumulation of grayish substances. The windowsill and the heater were the same with an accumulation of grayish substances, plastics, and papers. The nightstand table with dry whitish substances. At that same time, RR#2 confirmed that the brownish dry substances and whitish substances on the nightstand were there for days. RR#2 stated that they visited the resident almost every day and at times other members of the family. RR#2 further stated that the blinds in the window were hard to open and the facility staff was aware because RR#2 had to ask for help to close the blinds. On 12/9/24 at 9:16 AM, the surveyor asked LPN#2 to accompany the surveyor inside the resident's room. LPN#2 stated that the assigned nurse of Resident #94 was not at the unit at that time. Inside the resident's room, both the surveyor and LPN#2 observed the floor, nightstand table, and heater area. At that same time, LPN#2 stated that the dried brownish substances on the floor were consistent with the color of the tube feeding (TF) formula. LPN#2 further stated that the grayish substances were an accumulation of dust that was on the floor and table. LPN#2 stated that he was unsure what were the dried whitish substances on top of the nightstand table. RR#2 stated that the white dried substances were from the pistol syringe (the tube used for flushing the TF) and that RR#2 knew because they saw how the nurses used it. LPN#1 also stated that the heater had multiple plastic covers from the TF pistol syringes and confirmed that there were multiple plastics and papers. LPN#2 further stated that the floor and table should have been cleaned and that there should be no plastics and papers in the heater. He stated that he would call the Housekeeper to clean the room. On 12/9/24 at 11:34 AM, the survey team met with the LNHA and the DON. The surveyor notified the facility management of the above findings and concerns for Resident #94 regarding the environment. On 12/11/24 at 11:43 AM the survey team met with the LNHA and the DON. The LNHA stated that the blinds in the resident's window were replaced. A review of the facility's Cleaning and Disinfection of Environmental Surfaces Policy dated August 2019 that was provided by the DON revealed: The policy reflected: Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. 9. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 14. Horizontal surfaces will be wet dusted regularly 15. Spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated A review of the facility's Homelike Environment Policy dated February 2021 that was provided by the DON revealed: The policy reflected: 2. a. clean, sanitary, and orderly environment. On 12/11/24 at 01:21 PM, the survey team met with the LNHA and DON for an exit conference. The facility management did not provide additional information and did not refute the findings. NJAC 8:39-31.4(a)(b)(f)

REPEAT DEFICIENCY Complaint #175734 46049 Based on observation, interview, record review and review of pertinent facility documents it was determined the facility failed to: a.) ensure a resident's medication was available and administered as scheduled for 1 of 5 residents, Resident #66, reviewed for unnecessary medications and b.) ensure residents received medications as scheduled for 2 of 22 residents (Residents #79, 87) reviewed for quality of care, in accordance with physicians' orders, and standards of practice . This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 12/3/24 at 10:01 AM, the surveyor observed Resident #66 sitting up on their bed in their room. The resident was alert, verbally responsive, and stated they had no concerns with their care in the facility. The surveyor reviewed the paper and electronic medical record (EMR) of Resident #66. The Admission Record (AR; a summary of important information about the resident) documented that the resident had diagnoses that included muscle weakness. A comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 9/25/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #66 scored a 12 out of 15, which indicated the resident had moderate cognitive impairment. Section I for Active Diagnoses indicated the resident had diagnoses that included but were not limited to Parkinson's disease and cancer. A physician's order (PO) dated 9/30/2023 documented Alprazolam 0.25 mg (milligram) tablet (tab), give 1 tab by mouth at bedtime for anxiety. The medication (med) was scheduled to be administered at 9:00 PM (9 PM). A review of the December 2024 Med Administration Record (MAR) revealed the following for the Alprazolam entry order: On 12/1/24 the nurse signed the med 9, which indicated Other/See nurses notes. On 12/2/24 the nurse signed the med as administered. On 12/3/24 the nurse signed the med 9. On 12/4/24 the nurse signed the med 9. On 12/5/24 the nurse signed the med 2, which indicated Drug Refused. On 12/6/24 the nurse signed the med 9. On 12/7/24 the nurse signed the med as administered. On 12/8/24 the nurse signed the med 2. A review of progress notes (PN) revealed the following: An administration note dated 12/1/24 by the nurse for alprazolam documented script needed, MD (Medical Doctor) aware. An administration note dated 12/3/24 by the nurse for alprazolam documented pharmacy was called, they enter in the system 12/4 at 9 PM tomorrow. An administration note dated 12/4/24 by the nurse for alprazolam documented not available [backup] under profile, called pharmacy and they said it will be added. still not available as of 9:30 PM and resident appears to be resting. An administration note dated 12/3/24 by the nurse for alprazolam documented Called pharmacy as it is not showing as available in resident profile in [backup], pharmacy said they can see it on their end and do not know why [backup] is not dispensing it. Pharmacy stated they will escalate the issue and call us back. There were no additional notes related to the alprazolam med administration. On 12/9/24 at 11:13 AM, the surveyor interviewed the Registered Nurse (RN#1) assigned to care for Resident #66. The RN stated that she received in report at shift change that the alprazolam was not being dispensed by the pharmacy. The RN stated the nurses could remove med from the [backup] machine for the residents and medications (meds) had to be listed under the resident's profile for a med to be removed. The RN further explained there was no house stock and med could not be removed from the [backup] as house stock. The RN stated the prescription for alprazolam was already sent to the pharmacy, she was not sure when and the RN/Unit Manager (RN/UM) was to follow up. On 12/9/24 at 12:15 PM, the surveyor observed Resident #66 sitting in a chair at their bedside. The resident was alert, calm, pleasant and verbalized no concerns. The resident stated they had been receiving alprazolam for a long time to help with restlessness at night. The resident reported no issues. On 12/9/24 at 12:17 PM, the surveyor interviewed the RN/UM about Resident #66's alprazolam. The RN/UM stated he was not aware of the issues with the med delivery and would follow up with the pharmacy. On 12/9/24 at 2:39 PM, the surveyor informed the Director of Nursing (DON) of the concern regarding Resident #66's alprazolam med signed as not administered for 6 of 8 days and the med not dispensed from the [backup] machine. The DON confirmed there was no house stock in the facility and stated that stat [immediate] delivery from the pharmacy could be requested if a med was not available. The DON stated she would review to provide additional information. The surveyor requested from the DON any supportive documentation including any delivery receipts and med dispensing reports for the alprazolam med. On 12/11/24 8:32 AM, the DON provided a Drug Location Reconciliation Report from 12/1/24 to 12/8/24 for Alprazolam 0.25 mg tab, and revealed 4 entries of when the medwas dispensed on 12/5/24 and 12/8/24. The list of residents did not include Resident #66. There was no additional information provided related to Resident #66's alprazolam med. On 12/11/24 at 11:43 AM, the Licensed Nursing Home Administrator (LNHA) and the DON met with the survey team. The DON called the pharmacy who were already aware of the issue of Resident #66's Alprazolam not being dispensed from the [backup] machine and addressed the issue. The DON stated that they have not gotten back to her about what happened during the time the med was not available from the [backup] machine. The surveyor asked about the entries on 12/2/24 and 12/7/24 signed as med administered to the resident as the provided report did not include alprazolam being removed for Resident #66 on those days. The DON could not speak to those days and stated she would have to follow up. The DON acknowledged the concern of the resident not receiving the med for multiple days and protocol not being followed by the nurses. The DON stated if a med was not available, the nurses should have informed her, the physician, and could have requested a stat delivery of a small quantity of the resident's med until the issue with the [backup] machine was resolved. The DON confirmed that there was no documentation that the nurses informed the physician regarding alprazolam not being available for the resident and the resident not receiving the med. The DON provided the Med Administration. The surveyor requested any additional policy related to med availability. There was no additional information provided by the facility. 2. On 12/2/24 at 10:42 AM, the surveyor observed Resident #87 sitting in bed with the head of bed elevated in their room. The resident was alert, oriented, and verbally responsive. Resident #87 reported concern at times of not receiving their morning meds at the time scheduled. The resident further explained that they did not receive their meds until the early afternoon, around 1 PM. Resident #87 stated they received med to help with dizziness which was important to them to receive on time as it had a positive effect on the rest of their day. The resident stated the meds were routine meds they received. Resident #87 recalled it occurred the past week, Saturday, Sunday, and last Monday. The resident stated they discussed their concern with Resident #79, their roommate, and they could provide additional information on its occurrence. The surveyor reviewed the paper and EMR of Resident #87. The AR documented that the resident had diagnoses that included but were not limited to, acute cystitis (a bladder infection), vertigo (dizziness), and muscle weakness. A cMDS with an ARD of 9/19/24, with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of the PO, and the November and December 2024 MAR revealed the resident was scheduled to be administered the following meds on at 8:00 AM (8 AM) and 9:00 AM (9 AM): - Potassium Chloride crystals extended-release (ER) 20 milliequivalents (MEQ) tab, give 1 tab by mouth one time a day for hypokalemia (low potassium) at 8 AM, with a start date of 9/18/24. -Folic Acid 1 mg tab, give 1 tab by mouth one time a day for supplement at 9 AM, with a start date of 9/14/24. - Lexapro 10 mg tab. Give 1 tab by mouth one time a day for depression at 9 AM, with a start date of 10/31/24. - Magnesium Oxide 400 mg tab by mouth one time a day for supplement at 9 AM, with a start date of 9/14/24. - Multi-vitamin/minerals tab, give 1 tab by mouth one time a day for supplement at 9 AM, with a start date of 9/14/24. -Vitamin B-1 100 mg tab, give 1 tab by mouth one time a day for supplement at 9 AM, with a start date of 9/14/24. - Vitamin B12 1000 mcg (microgram) ER tab, give 1 tab by mouth one time a day for supplement at 9 AM, with a start date of 9/18/24. - Meclizine 25 mg tab, give 1 tab by mouth every 12 hours for dizziness at 9 AM and 9 PM, with a start date of 11/4/24. 3. On 12/2/24 at 10:51 AM, the surveyor observed Resident #79 sitting in a wheelchair at their bedside. Resident #79 was alert, oriented, and verbally responsive. Resident #79 reported concern of occasions where morning meds were not received at their scheduled time and confirmed meds were given late on Saturday, 11/30/24 and Sunday, 12/1/24. The resident further explained they recalled it was LPN #2 and that there was no reason provided why the med was administered late and that the nurse was taking long to provide meds. Resident #79 further stated on 11/25/24 that the meds were administered late and given in the afternoon. The resident could not recall the nurse's name. In addition, Resident #79 stated on 11/29/24 their evening meds at 5:00 PM to 6:00 PM were given at 9 PM and believed LPN # 3 was the nurse. The surveyor reviewed the paper and EMR of Resident #79. The AR documented that the resident had diagnoses that included but were not limited to, peripheral vascular disease, type 2 diabetes mellitus, and hyperlipidemia (high levels of lipids or fats in the blood). A cMDS with an ARD of 9/24/24, with a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of the PO, and the November and December 2024 MAR revealed the resident was scheduled to be administered the following meds at 8 AM, 9 AM, and 5:00 PM (5 PM): - Aspirin enteric coated (EC), delayed release 81 mg tab, give 1 tab by mouth one time a day for CAD [coronary artery disease] at 9 AM, with a start date of 1/24/24. -Artificial Tears Solution 1.4%, instill 1 drop to both eyes two times a day at 9 AM and 5 PM, with a start date of 11/15/24. -Active liquid protein sugar free 15 gram/30 milliliter (ml) 30 ml two times a day for supplement at 9 AM and 5 PM, with a start date of 9/10/24. -Calcium + Vitamin D3 600-200 mg, give 1 tab by mouth two times a day for supplement at 12:00 PM and 5 PM, with a start date of 6/14/24. -Gabapentin 100 mg capsule (cap), give 1 cap by mouth two times a day for neuropathy at 9 AM and 5 PM, with a start date of 1/24/24. - Metformin ER tab, give 1 tab by mouth two times a day for diabetes at 8 AM and 5 PM, with a start date of 6/14/24. - Peridex solution 0.12%, give 15 ml by mouth two times a day at 9 AM and 5 PM, with a start date of 8/23/24. - RisaQuad (Probiotic) cap, give 1 cap by mouth two times a day for supplement at 9 AM and 5 PM, with as start date of 1/24/24. - Xarelto 2.5 mg tab, give 1 tab by mouth two times a day at 9 AM and 5 PM, with a start date of 1/24/24. - Humalog 100 unit/ml solution, injection as per sliding scale, subcutaneously before meals for diabetes mellitus at 8 AM, 12:00 PM (12 PM), and 5 PM, with a start date of 8/15/24. - Multiple vitamins with minerals tab, give 1 tab by mouth in the evening for supplement at 5 PM, with a start date of 1/24/24. On 12/3/24 at 9:28 AM, the surveyor requested from the DON the med administration audit report (MAAR) for the November 2024 and December 2024 MAR of Residents #87 and #79. On 12/3/24 at 10:34 AM, the DON provided the MAAR for Resident #87 and #79. A review of the report for Resident #87's med administration revealed the following: On 11/25/24, Resident #87's 8 AM and 9 AM meds were documented and signed as administered by RN #1 at the times of 12:48 PM to 12:50 PM. On 11/30/24, Resident #87's 8 AM and 9 AM meds were documented and signed as administered by the Licensed Practical Nurse (LPN #4) at the times of 10:19 AM to 10:22 AM. On 12/1/24, Resident #87's 8 AM and 9 AM meds were documented and signed as administered by LPN #4 at the times of 10:27 AM to 10:28 AM. On 12/2/24, Resident #87's 8 AM and 9 AM meds were documented and signed as administered by LPN #1 at the times of 10:28 AM to 10:29 AM. A review of the report for Resident #79's med administration revealed the following: On 11/25/24, Resident #79's 8 AM and 9 AM oral meds and eye drops were documented and signed as administered by RN #1 between the times of 11:55 AM to 11:56 AM. On 11/28/24, Resident #79's 5 PM oral meds and eye drops were documented and signed as administered by LPN #3 between the times of 8:46 PM to 8:55 PM. On 11/29/24, Resident #79's 5 PM oral meds and eye drops were documented and signed as administered by LPN #5 between the times of 7:55 PM to 7:56 PM. On 12/1/24, Resident #79's 8 AM and 9 AM oral meds were documented and signed as administered by RN #1 between the times of 10:25 AM to 10:26 AM. On 12/2/24, Resident #79's 8 AM and 9 AM oral meds and eye drops were documented and signed as administered by LPN #1 between the times of 10:45 AM to 10:46 AM. On 12/4/24 at 11:51 AM, the surveyor interviewed LPN#1, about the timeframe for med administration. LPN #1 stated routine meds could be given one hour before and one hour after the scheduled time. The LPN further explained that documentation should be completed after the med was administered to the resident. LPN #1 acknowledged there may be times meds were not administered at the scheduled time due to a resident may refuse at the time due or there was an emergency situation. The surveyor asked what would be the protocol for when a med was not administered within the scheduled timeframe. LPN #1 replied that a nurse note should be documented with the reason why the med was given late. There was no additional response from the LPN. On 12/5/24 at 11:10 AM, the surveyor interviewed LPN #3 about med administration. LPN #3 stated meds were to be administered 1 hour before or an hour after it was scheduled to be administered. LPN #3 further explained after meds were administered the MAR would be signed that the med was administered. LPN #3 acknowledged there were times meds would not be administered within the scheduled timeframe due to it being busy, other residents needing assistance or other emergent situations that could be going on. On 12/5/24 at 11:16 AM, the surveyor interviewed LPN #5 who stated meds could be administered an hour before and an hour after a med was scheduled to be administered. Additionally, the nurses were to document and sign the MAR after a med was administered. LPN #5 acknowledged there were times meds were not administered at its scheduled time. The LPN further explained, there could be heavy workload, and computer issues may occur which could contribute to delay in administering meds. On 12/5/24 at 11:22 AM, the surveyor interviewed RN #1 who stated meds should be given within an hour before and an hour after the med was scheduled. The RN stated the MAR should be signed the moment after the med was administered. RN #1 stated she tried to be timely with med administration and may be delayed due to an emergency or incidents out of the ordinary. On 12/5/24 at 12:25 PM, the survey team met with the DON and LNHA. The surveyor interviewed the DON about med administration. The DON stated it was expected meds were to be given within an hour before and an hour after a med was scheduled to be administered. Additionally, the DON stated the nurses were expected to document and sign the MAR as soon as the med was administered. The surveyor reviewed the MAAR with the DON who confirmed that the documentation time listed the time the nurses documented for a med and the administration time was the time when med was administered to a resident. The surveyor informed the DON and LNHA of the reported concerns from Resident #79 and Resident #87 and the review of the MAAR which indicated the meds were administered outside of its scheduled timeframe. On 12/9/24 at 11:34 AM, the DON and LNHA met with the survey team. The DON stated that she spoke with the residents about their concerns and completed a grievance. The DON acknowledged it was a concern that meds were being administered late. The specified nurses were provided 1:1 in-service education and education was being provided to the other nurses. There was no additional information provided by the facility. A review of the facility's Administering Medications Policy with a last revised date of April 2019 revealed: Under Policy Statement indicated meds were to be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation, it revealed: 7. Meds are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the med will enter the appropriate documentation code on the electronic MAR. 22. The individual administering the med initials the resident's MAR on the appropriate line after giving each med and before administering the next ones. For centers using electronic documentation, electronic signatures are utilized. N.J.A.C. 8: 39-27.1

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life specifically by honoring the resident's shower schedule and preferences for 1 of 2 residents, Resident #52, reviewed for activities of daily living. This deficient practice was evidenced by the following: On 12/3/24 at 9:50 AM, the surveyor observed Resident #52 sitting in a chair in their room dressed in well-fitted clothes. The resident was alert, oriented, and verbally responsive. Resident #52 stated for the last couple of weeks they only received a shower once a week. The resident stated that previously they had received a shower twice a week although they felt that was not enough. The resident stated that they were ambulatory and independent with ADLs (activities of daily living). On 12/3/24 10:02 AM, the surveyor interviewed the Registered Nurse/Unit Manager about showers for residents. The RN/UM stated that residents were scheduled to have showers twice a week. The RN/UM showed the surveyor a shower schedule list that was on the back of the Certified Nurse Aide (CNA) assignment binder. The RN/UM provided a copy of the shower schedule to the surveyor. On 12/3/24 at 10:15 AM, the surveyor interviewed Certified Nurse Aide #1 (CNA#1) about residents receiving showers. CNA #1 stated the binder at the nurses' station had the list based on resident's bed/room for which day and shift they were scheduled for showers. CNA #1 stated residents received bed baths daily and were to have a shower at least two times per week. The CNA explained a shower meant the resident would be taken to the bathing room for a shower and the CNAs documented in the electronic medical record (EMR) section. CNA #1 stated if the resident refused a shower or was not able to get shower, the resident would be provided a bed bath, and it would be documented in the EMR. The surveyor with CNA #1 toured the bathing room which was across from the nurses' station on the unit. The bathing room had 4 shower stalls with a shower chair in 1 of the shower stalls. On 12/3/24 at 11:54 AM, the surveyor interviewed CNA #2 who was assigned to care for Resident #52. CNA #2 stated that she knew which residents were assigned for showers on the shift by checking the EMR which would have an entry for which days the resident would have a routine shower. CNA #2 was not familiar with a binder or shower schedule at the nurses' station. CNA #2 further explained residents received bed baths every day and showers were provided at least twice a week for residents. CNA #2 confirmed a shower meant the resident would shower in the bathing room. The surveyor asked if the CNA had any residents scheduled for a shower today and if she had used the bathing room today. CNA #2 replied that she had not taken any residents to shower today and stated she only had one resident (not Resident #52) scheduled for a shower. The surveyor asked about Resident #52. The CNA replied the resident was independent and was scheduled to receive showers Fridays and Tuesdays on the 7:00 AM-3:00 PM shift. The surveyor asked if the resident had received a shower as it was Tuesday. The CNA stated she may be mistaken and would have to double check the EMR. CNA #2 reviewed the EMR and showed the surveyor the resident had a scheduled entry which indicated Resident #52 was to have showers every Monday and Thursday on the evening shift and as needed. The CNA confirmed it would be documented in the EMR if a resident was provided a shower and if they refused. On 12/3/24 at 12:03 PM, the surveyor interviewed the RN/UM about the list of residents for showers and CNA documentation of showers. The RN/UM stated it was expected for staff to bring residents to the bathing room for showers and if a resident refused a bed bath would be provided. Staff would also be expected to document if a shower was refused and a bed bath given. The RN/UM confirmed besides the shower schedule on the binder it was indicated in the EMR which residents were scheduled for showers. The surveyor toured the bathing room with the RN/UM, the shower stalls and entire bathing room floor remained dry and there was no evidence of it being used. The RN/UM acknowledged that it did not appear that the bathing room was used on the shift. The RN/UM stated that he would have to follow up with nursing staff to determine if any residents were showered. On 12/3/24 at 12:17 PM, the surveyor observed Resident #52 sitting at a table in the dayroom. The surveyor asked the resident if they received a shower today. The resident replied that they had not received a shower yet. Resident #52 confirmed the previous week when they had received a shower it was on Tuesday in the morning. On 12/3/24 at 12:47 PM, the surveyor interviewed the RN/UM about Resident #52. The RN/UM stated the resident was independent and should be able to have a shower at least twice a week if not more. The surveyor informed the RN/UM about the above concerns related to showers and Resident #52 not receiving a shower at least twice a week. The RN/UM stated it was expected for residents to have a shower twice a week, that he would in-service CNAs about shower schedules and in-service CNA#2 about the shower schedule list on the binder. On 12/3/24 at 12:50 PM, the surveyor interviewed the DON about expectations for resident showers. The DON replied that residents should have showers at least two times per week. The DON stated the shower schedule with the CNA assignment at the nurses' station indicates which residents are due for shower on shift and the CNAs were to document in the EMR, including if the resident refused. The surveyor informed the DON of the above concerns. The surveyor requested the November 2024 and December 2024 EMR documentation record for Resident #52. On 12/3/24 at 1:30 PM the DON provided a copy of the November and December 2024 EMR report for Resident #52. A review of the report revealed was no documentation of the resident receiving routine showers twice a week on assigned days. The surveyor requested from the DON any policy related showers and ADL care. On 12/3/24 at 2:05 PM, the surveyor reviewed the EMR of Resident #52. The Admission Record (a summary of important information about the resident) documented that Resident #52 had diagnoses that included hypertension, anxiety, muscle weakness, and a history of fall. A comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 9/17/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #52 scored a 15 out of 15, which indicated the resident was cognitively intact. Section GG for Functional Abilities and Goals indicated that the resident required supervision/touching assistance (E.g.-steadying, contact guard assistance, verbal cueing). A care plan with a focus on ADL care had an initiation date of 6/21/24. It included interventions that detailed: Assist of (1 person or supervise) with ADL's with an initiation date of 6/21/24; and supervise with daily hygiene, grooming, dressing, as needed with an initiation date of 6/21/24. On 12/4/24 at 8:33 AM, the DON provided the surveyor the ADL policy. On 12/9/24 at 11:34 AM, the DON and LNHA met with the survey team. The DON acknowledged the concern for Resident #52. A grievance was created, the DON spoke with the resident who reported they only got 1 shower. The DON further explained in-service education was provided to nursing staff and the protocol would be updated to ensure residents received showers. A review of the facility's Activities of Daily Living Policy with a last revised date of March 2018 under Policy Statement revealed: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Under Policy Interpretation and Implementation revealed: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . hygiene (bathing, dressing, grooming, and oral care) . and mobility (transfer and ambulation, including walking). A review of the facility's Resident Rights Policy with a last revised date of 5/30/24 under Policy Interpretation and Implementation revealed: Federal and state laws guarantee certain basic rights to all residents of this facility. These resident rights included: a. a dignified existence . e. self-determination . N.J.A.C. 8:39-4.1