Every finding on record at Complete Care at Bayshore LLC

Based on observation, interview and document review it was determined that the facility failed to maintain a comprehensive and documented Quality Assurance Program (QAPI) and a process was in place to demonstrate the facility made good faith attempts to identify and prioritize potential issues related to resident care and services, and to track and measure performance at QAPI. The deficient practice affected all residents that resided at the facility and was evidenced by the following: Refer to: F605, F607, F677, F 684, F689, F695, F755, F761, F800, F803, F804, F812, F919 On 05/08/26 at 9:43 AM, the surveyor requested the Quality Assurance Performance Improvement (QAPI) to bring in the documents from the Licensed Nursing Home Administrator (LNHA) so he may discuss with the survey team. On 05/08/26 at 11:04 AM, the LNHA and the Assistant LNHA (ALNHA) returned to discuss QAPI. The LNHA stated the facility had quarterly QAPI meetings with all the vendors and included the department heads and Medical Director and provided the sign in sheets for the last three quarters of the quarterly QAPI meeting and the most recent quarterly meeting was 4/10/26. for the most When he asked the LNHA if he had any QAPI plans related to the implementation of the new dietary management company and new systems, he stated there were none and confirmed that the took over the dietary operations one month prior in April 2026. When asked to explain the process, the LNHA stated that during the daily morning meetings the facility identified issues, and through the grievance process. When asked if the facility tracked and trended the grievances. The LNHA asked what that meant, and he stated they also had a kiosk where people could report grievances and staff could also report grievances. The surveyor further explained and asked if the facility identified any trends from the grievance process and where they were brought to the QAPI team. The LNHA stated there was no QAPI related to grievance concerns. The surveyor asked the LNHA to discuss all the current QAPI initiatives and he stated: 1. Antibiotic Stewardship.2. Employee files incomplete; a review of the QAPI plan dated 3/5/26 revealed it was discovered that a significant number of employee files were incomplete. The problem and goal were not specific and measurable. When asked the LNHA confirmed it was not and that it should be specific and measurable.3. Maintenance conducted a QAPI related to blocked areas and was dated 4/6/26. The problem was leaving supplies in front of utility panels. The QAPI was completed on 4/8/26 and was not specific and measurable.4. A QAPI related to completing dialysis forms in their entirety. And the LNHA confirmed there was nothing else related to dialysis, including ensuring that medications were provided around the dialysis schedule as identified during the survey. 5.Trayline accuracy- was not specific as the problem statement was Tray line each position has a responsibility to try to honor the client request each time and was not specific ore measurable.6.Minimu Data Set coding inaccuracy- was not specific and measurable.7.Activity staff recruitment.8.Weight changes completed by the Dietitian was specific and measurable.9.Missing physician visits. 10.Call bell response time had no data and root cause was not enough staff. There was nothing presented by the LNHA related to functioning call bells or timely incontinence care. 11. Therapy with inconsistent splints12.Personal Needs Accounts.13.Director Of Nursing- Medication hold parameters- not specific. 14.Lab report.15.Pharamacy report- not related to expired medications found on survey. 16. Annual Education.17. Nurse Aide Assignments.18.Trayline accuracy- not related to preferences. Specific or measurable.19.All CNA Tasks20.GG coding on the Minimum Data Set.21.Employee Physicals.22.Admisisons23.Bed hold24.Activity assessments were not specific or measurable and related to one-to-one visit books not being completed.25.Hoyer lifts-in front of doors26.In house pressure wounds, the problem statement was in house pressure wounds not measurable, and goal was to reduce by 1%. 27.Air mattress in proper settings28.Nurse aide not reporting skin breakdown.29.Facility Assessment.30.Fire Alarm Education.31.Nursing report communication.32.Code/Post all residents.33.Environmental.34.Elopement.35.Wet nesting in kitchen. There was nothing related to sanitation, dish machine, new menus, or recipes. 36: Late meals. The surveyor asked the LNHA if the facility tracked and trended significant events, and the LNHA stated, no. On 05/08/26 at 10:09 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Administrator in Training, [NAME] President of Clinical Services and Regional Director of Operations and reviewed the above concerns. On 05/08/26 at 12:29 PM, there was no actional information provided prior to the survey exit.The QAPI Program Plan Revised 12/19/25 revealed the Purpose: The QAPI plan outlines the five core elements of the QAI program. Quality assurance and performance improvement principles drive decision making within our organization. Decisions are made that promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas include all systems, processes and outcomes that affect resident and family satisfaction, the quality of care and services provided . NJAC 8:39-33.2(a)(b)(c)1-13(d)

Based on observation, interview, and document review, it was determined that the facility failed to ensure a) that equipment used to clean dishes and other kitchen items was utilized per manufacturer's specifications for temperature, b) foods were stored in a manner to prevent potential foodborne illness, and c) the kitchen environment and equipment was maintained in a clean and sanitary manner to prevent contamination from foreign substances and limit the potential for the development a foodborne illness. This deficient practice affected all residents who resided at the facility and was evidenced by the following: On 05/03/26at 6:28 PM-7:00 PM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD) and observed the following: -The gasket on first walk in refrigerator had a blackened soiled gasket with embedded debris and blackened areas around the gasket. When asked if had been cleaned, The FSD stated, No, it needed to be cleaned and replaced. -There ceiling vents above the exterior of the walk-in refrigerator door that had embedded dust like dark debris. -The ceiling tiles in the area by the walk-in refrigerator and extending into the kitchen -The gray fan grate inside of the walk-in had visible debris embedded on and inside the holes of the grate. -The racks that held the food inside the walk-in had areas of blacked embedded debris and the FSD stated we try to clean then one timer per week. -The 2nd walk-in refrigerator contained several racks with the metal visibly peeledseveral Racks in walk in visibly rusted and missing and peeled off finish from the racks. The FSD stated, I will tell [the Licensed Nursing Home Administrator]. -The elongated ceiling light inside the walk-in refrigerator had caked on black debris, in addition To the ceiling blackened areas. -There was a blue colored container that was visibly soiled with blackened color debris throughout that contained raw cabbage and did not contain any dates. -The floor underneath the food shelves had what appeared to be black splotched mold-like and yellow in appearance and was climbing up the back wall.-The hand washing sink in the kitchen, soiled with debris inside sink and embedded by foot pedals.-A white bin labeled rice and had debris on the outside of the bin, and debris was also on the metal table under the bin and there was darkened areas on the floor. -Splatters observed on ceiling tiles by the food preparation area of the kitchen. -The exterior of the ice machine bin had splatters on the exterior and the vent area of the ice machine had caked on dust like debris. -The dry storage room had three visibly dented vanilla pudding cans on the can rack. When the surveyor showed the cans to the FSD and asked why the dented cans were on the racks. The FSD stated, oh it was on the dented can rack and then physically moved the cans to another rack without any other cans, or labeled dented cans, and did not acknowledge that the dented cans were stored with the regular cans. -The metal racks that were used to store the food in the dry storage area were visibly soiled with embedded debris throughout on various areas of the racks. -A large container of vanilla icing was stored on a shelf in the dry storage area with icing that was visibly caked outside of the container which was labeled (opened 4/20/26) and did not contain a use by date. -The dish machine was in use and the surveyor observed food preparation items, and dishware being placed in the machine by one person and another removing the items. The surveyor, in the presence of the FSD, observed that as the racks containing dishware were being placed through the machine, the wash temperature was 147 degrees Fahrenheit (F) and 146 F. When asked the FSD what the temperature requirement was for the wash cycle, the FSD stated 150 F, and the FSD stated that our log has 150 F, and I am going to go with that. At that time the surveyor asked for the temperature log for the dish machine and the staff pointed to an empty clipboard affixed to the wall. At that time, the surveyor continued to watch the staff place dishes through the dish machine which was 146 F, 145 F and 147 F, and the surveyor then asked where the plaque was located that was affixed to the dish machine that provided the manufacture specifications to run the dish machine. The FSD did not respond to the surveyor and the surveyor then bent down and observed the specification plaque affixed to the machine with the chemical company name and model and serial number of the machine which documented: Hot Water Sanitizing 160F, Minimum Wash Tank Temperature . When the surveyor showed the FSD the plaque and then asked the FSD if 150 F for the wash temperature would have met the manufacturer temperature requirements, the FSD stated she was going to make the machine a low temperature machine. When again asked if the 150 F was meeting the 160 F requirement, the FSD confirmed it was not because it was at 149 F. On 05/06/26 at 10:31 AM, the surveyor conducted a telephone interview with the chemical company representative (CC) who stated he was contacted on 5/3/26 by the facility to look at the dish machine due to temperature issues and conducted a service call the following day. The CC stated he provided routine service to the dish machine and had never been made aware of temperature issues by the facility prior to 5/3/26. The CC also confirmed that the minimum dish machine wash temperature should be 160 F per plaque, and he stated the chemical had nothing to do with the wash temperature, only the rinse temperature override which was not malfunctioning. The CC confirmed that the wash temperature was not functioning at the appropriate level which would affect the cleaning of the items. He stated that he had never been contacted prior to 5/4/26 about the wash temp not meeting requirements. When asked about the FSD running a chemical override when she found out that the machine was not working to meet the wash temperatures, he stated that the chemical had nothing to do with the wash temperature, that was only for the rinse temp override and confirmed it was not meeting requirements. The CC provided the surveyor with a copy of a Service Visit Report for the 4/5/26 visit that revealed Request Description: Temperature at 149 F. Service Comments: I increased the washer heating element. We verified after that, that the wash cycle was running at 160+ F. On 05/08/26 at 10:09 AM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, Administrator in Training, [NAME] President of Clinical Services and Regional Director of Operations and reviewed the above concerns. On 05/08/26 at 12:29 PM, during the exit conference, no additional information was provided.NJAC 8:39-27.1(g)

Based on observation, interview and document review it was determined that the facility failed to ensure that foods were prepared utilizing standardized recipes and ensure that meals were provided to residents at an appetizing temperature. The deficient practice occurred for 10 of 10 residents who attended a residents council meeting, for 2 of 2 residents reviewed for food (Resident #69 and Resident #75) and affected the nutritional adequacy and consistency of all foods served and affected all residents who resided at the facility. The deficient practice was evidenced by the following: Based on observation, interview and document review it was determined that the facility failed to ensure that foods were prepared utilizing standardized recipes and ensure that meals were provided to residents at an appetizing temperature. The deficient practice occurred for 10 of 10 residents who attended a residents council meeting, for 2 of 2 residents reviewed for food (Resident #69 and Resident #75) and affected the nutritional adequacy and consistency of all foods served and affected all residents who resided at the facility. The deficient practice was evidenced by the following: On 5/3/26 at 7:30 PM, the surveyor interviewed Resident #69 and Resident #75 in their room. When asked about the meals both residents stated the food was not good the hot food was served cold and the food was disgusting. Resident #69 also stated they were on a puree diet. On 5/04/26 at 10:33 AM, the surveyor conducted a resident council with 10 residents, and 10 of 10 residents stated they did not receive the foods that they selected, did not receive complete meals and, and one resident stated that they only received a bowl of broccoli as a dinner meal, and all ten residents stated the hot food was delivered cold.On 5/4/26 at 11:45 AM, the surveyor observed the menu posted in the B-wing hallway that indicated the lunch meal was cheese ravioli with meat sauce, mixed vegetables and cinnamon apple slices, and then observed Residents #69 and #75 were in their room with their lunch trays in front of them. When asked Resident #75 about their lunch meal, which consisted of a plate of cheese ravioli and meat sauce and a small hot dog on the side. There were no vegetables and a small peanut butter and jelly sandwich was wrapped in plastic wrap and sliced apples were in a cup, with 4 ounces of skim milk. Resident #75 stated that was disgusting, who would eat that? The resident stated they did not select those items and did not have a copy of the menu in the room. Resident #69 had a flat pancake shaped reddish item on their trat that as touching a white flat pancake shaped item, the Diet Ticket was labeled Regular Puree with Thin liquid and Food Adds: Pureed peanut and butter and jelly sandwiches- 2. Resident #69 stated that they had a tumor in their cheek. When asked what was on the tray, the resident had no idea and stated, why don't they ever get coffee, they have no restriction. On 05/05/26 at 10:57AM, the surveyor interviewed the [NAME] in the kitchen regarding the meals that were prepared. The [NAME] stated he was mostly the breakfast and lunch cook. The surveyor asked the [NAME] if he also prepared the puree items and the [NAME] confirmed that he also prepared the puree meals. The surveyor asked if the cook utilized recipes for the puree foods and he stated, No. When asked how he would know how to make the purees, the [NAME] stated it was basically product water and thickener. When asked if the menus were new, the [NAME] stated, that we just converted to a new company and showed the surveyor the menus and explained he used them to show what had to be prepared for each item regarding the specialized diets, and he confirmed that he did not have recipes. The cook stated that the new menus started the previous month and when asked how he had prepared the puree for the current meal, he stated he added chicken, product and a little thickener. When asked if the puree food should be runny, he stated that it should not be runny and be in a pile. The [NAME] again stated that he was not provided with a recipe book, but he knew how to cook. On 5/5/26 at 11:18 AM, during the tray line production the surveyor observed the tray line in progress and staff confirmed the main meal was teriyaki chicken, steamed rice, broccoli and bread and there was a puree hot dog. All the modified consistency items had a 2- ounce blue handled scoop. On the tray line and surveyor asked the Dietary Staff (DS) what the portions for the puree items were. The Food Service Director (FSD) interjected and stated, all protein should be 2 ounces and the surveyor asked why one of the puree items had a four-ounce scoop, the FSD stated, all 2oz scoops for everything. The FSD then told the staff to have all blue 2-ounce scoops and the DS told the FSD they did not have that many, and the FSD then told the DS to change to a 2-ounce scoop.The DA plated out 2-ounce services of puree rice, puree chicken, puree hot dog and puree broccoli and the puree hot dog spread out on the plate and were touching. A 4-ounce container of milk and 4 ounce container of juice was also on the test tray that was sent to the B-wing unit. Upon the last tray served to the residents the surveyor tested the temperatures. The test meal arrived at 11:35 AM on B-Wing.The first tray was removed at 11:37 AM, and the last tray at 11:46 PM and the District Manager (DM) from the new company observed the surveyor during the test-tray observation. The surveyor asked him what the temperature standards when the food was served to the resident and stated the cold food was 40 degrees Fahrenheit (F) in the kitchen and the hot food was 135 degrees F in the kitchen. The DM did not respond when asked what the temperatures of the food should be when it reached the residents. The juice and milk were 54 degrees Fahrenheit (F) per the DM's thermometer, and the surveyor tested the milk and juice which was 53 F per the surveyor's thermometer. When asked to provide a copy of the policy for food temperatures, the DM exclaimed, palatability is not a policy! Then the surveyor then placed a teaspoon into the top of the puree rice, which was thick, and the spoon stuck straight up and did not move. The surveyor then asked the DM if that was supposed to be the consistency of the puree rice? The DM did not respond to the surveyors inquiry. On 5/5/26 at 11:56 AM, the surveyor immediately went to Resident #69 and #75's room who had their lunch meals in front of them. When asked about the food, Resident #75, had only a piece of chicken on their plate and stated, who serves just a piece of chicken? Resident #75 stated, they never received what they ordered and they never get copies of the menus to confirm what they ordered. Both meal tickets were reviewed, and the resident stated, we never get full trays. When asked if the milk and juice were at a good temperature, both residents stated, they are not cold, and that they would like it served cold.Resident #69 had two puree items on their tray and a peanut butter and jelly sandwich, although the ticket has puree peanut butter and jelly. Resident #69 asked again, they are not given a coffee with sugar? They can drink coffee; they can select their menu and never get what they select and no one comes to review the menus with them. Resident #69's meal plate had a beige item and a pink item on the plate, both touching one another and the ticket had pureed hot dog and a bun, and pureed roll hand checked with a checkmark on the meal ticket. Resident #75 had Chicken Teriyaki checked off in the manner as Resident #69's meal ticket and streamed rice and broccoli were not checked off. On 5/6/26 at 9:21 AM, the facility provided the surveyor with the Spreadsheets for the menus (portion size breakdown for nutritional adequacy) which had been requested since 5/3/26. The spreadsheets revealed the Chicken Teriyaki Puree was a 3-ounce portion, The puree rice, and puree broccoli was listed as a #8 scoop (4 ounce portion), mashed potato was listed as 4 ounce portion and there was no puree hot dog and a bun listed. None of the items were 2-ounce portion sizes as stated by the FSD.On 05/06/2026 at 1:23 PM, the surveyor conducted an interview with the Registered Dietitian (MRD) who stated she oversaw a team of Dietitians who writes the menus for a separate company that the Food Management company contracted with to purchase menus. The MRD stated she was familiar with menu requirements for the population at the facility. The MRD stated she worked only for the menu company and was not affiliated with the facility Food Service Management company and she was the one that certified the nutritional adequacy of the menu by signing them. When asked if she communicated at all with the facility, she stated that the menus were changed only if they were not locked, otherwise the facility was responsible for following the menu program and must contact the company via an 800 number to make any changes. When asked if her company provided recipes for the menus, she confirmed that there were recipes provided for the menus, including for the modified diets. When asked if it was important to follow the menus, the MRD stated there were very specific recipes and the methodology to prepare the items, it is important to use the recipes, otherwise you won't get a standardized product and that would affect the nutritional quality of the menus. On 05/08/26 at 10:09 AM, the survey team informed the Licensed Nursing Home Administrator, DON, Assistant Administrator/Administrator in Training, the Regional Director of Operation and the [NAME] President of Clinical services of the above concerns. On 05/08/26 at 1:18 PM, during the exit conference no additional pertinent information was provided. The Food Palatability policy, dated 7/14/25 revealed: Standard: Food will e prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form and texture to meet residents' needs. Guidelines: 1. The Dining Services Director and Cooks are responsible for food preparation.Menj items are prepared according to the menu, production guidelines, and standardized recipes. 3. The Proper portion sizes must be served per the menu based on volume or weight of size listed. NJAC 8:39-17.4(1-3)

Based on observation, interview and document review it was determined that the facility failed to ensure a process was in place to ensure that menus and recipes were followed and appropriate portion sizes were provided to the residents. This deficient practice was identified for 10 of 10 residents who attended a resident council meeting and for Resident #69 and Resident #75 reviewed for food, and was evidenced by the follwoing: On 5/3/26 at 7:30 PM, the surveyor interviewed Resident #69 and Resident #75 in their room. When asked about the meals both residents stated the food was not good the hot food was served cold and the food was disgusting. Resident #69 also stated they were on a puree diet. On 5/04/26 at 10:33 AM, the surveyor conducted a resident council with 10 residents, and 10 of 10 residents stated they did not receive the foods that they selected, did not receive complete meals and, and one resident stated that they only received a bowl of broccoli as a dinner meal, and all ten residents stated the hot food was delivered cold. On 5/4/26 at 11:45 AM, the surveyor observed the menu posted in the B-wing hallway that indicated the lunch meal was cheese ravioli with meat sauce, mixed vegetables and cinnamon apple slices, and then observed Residents #69 and #75 were in their room with their lunch trays in front of them. When asked Resident #75 about their lunch meal, which consisted of a plate of cheese ravioli and meat sauce and a small hot dog on the side. There were no vegetables and a small peanut butter and jelly sandwich was wrapped in plastic wrap and sliced apples were in a cup, with 4 ounces of skim milk. Resident #75 stated that was disgusting, who would eat that? The residents stated they did not select those items and did not have a copy of the menu in the room. Resident #69 had a flat pancake shaped reddish item on their tray that as touching a white flat pancake shaped item, the Diet Ticket was labeled Regular Puree with Thin liquid and Food Adds: Pureed peanut and butter and jelly sandwiches- 2. Resident #69 stated that they had a tumor in their cheek. When asked what was on the tray, the resident had no idea and stated, why don't they ever get coffee, they have no restriction. On 05/05/26 at 10:57AM, the surveyor interviewed the [NAME] in the kitchen regarding the meals that were prepared. The [NAME] stated he was mostly the breakfast and lunch cook. The surveyor asked the [NAME] if he also prepared the puree items and the [NAME] confirmed that he also prepared the puree meals. The surveyor asked if the cook utilized recipes for the puree foods and he stated, No. When asked how he would know how to make the purees, the [NAME] stated it was basically product water and thickener. When asked if the menus were new, the [NAME] stated, that we just converted to a new company and showed the surveyor the menus and explained he used them to show what had to be prepared for each item regarding the specialized diets, and he confirmed that he did not have recipes. The cook stated that the new menus started the previous month and when asked how he had prepared the puree for the current meal, he stated he added chicken, product and a little thickener. When asked if the puree food should be runny, he stated that it should not be runny and be in a pile. The [NAME] again stated that he was not provided with a recipe book, but he knew how to cook. On 5/5/26 at 11:18 AM, during the tray line production the surveyor observed the tray line in progress and staff confirmed the main meal was teriyaki chicken, steamed rice, broccoli and bread and there was a puree hot dog. All the modified consistency items had a 2- ounce blue handled scoop. On the tray line and surveyor asked the Dietary Staff (DS) what the portions for the puree items were. The Food Service Director (FSD) interjected and stated, all protein should be 2 ounces and the surveyor asked why one of the puree items had a four-ounce scoop, the FSD stated, all 2oz scoops for everything. The FSD then told the staff to have all blue 2-ounce scoops and the DS told the FSD they did not have that many, and the FSD then told the DS to change it to a 2-ounce scoop.On 5/5/26 at 11:56 AM, the surveyor immediately went to Resident #69 and #75's room who had their lunch meals in front of them. When asked about the food, Resident #75, had only a piece of chicken on their plate and stated, who serves just a piece of chicken? Resident #75 stated, they never received what they ordered and they never get copies of the menus to confirm what they had ordered. Both meal tickets were reviewed, and the resident stated, we never get full trays. When asked if the milk and juice were at a good temperature, both residents stated, they are not cold, and that they would like it served cold. There was 4 ounces of milk on the tray, although 8 ounces was printed on the meal ticket.On 5/5/26 at 1:30 PM, the surveyor interviewed the Registered Dietitian (RD) and Corporate Registered Dietitian (CRD). The surveyor shared the concerns regarding the meal observations and asked both what their involvement was with the oversight of the Dietary Department. Both stated they were not all involved with the Dietary Department (DD) which was a new management company, other than providing preferences to the DD and were responsible only to provide the nutrition assessments and other clinical services to the residents. On 05/05/26 at 1:56 PM, both the CRD and RD were again interviewed regarding the menus and recipes used by the facility and asked if they reviewed and approved them for nutritional adequacy. They both stated that the facility should be using recipes for consistency and nutritional adequacy. When asked if the residents who required altered consistency foods such as puree, should be provided with smaller portions. The CRD stated, no, it should be equal. When asked who was responsible to oversee the menus and ensure they were nutritionally adequate, the CRD stated they were not involved, but the management company should have someone to review the menus. On 5/6/26 at 9:21 AM, the facility provided the surveyor with the Menus and Spreadsheets for the menus (portion size breakdown for nutritional adequacy) which was originally requested on 5/3/26 during the entrance conference. The menu revealed 2% milk was listed. The spreadsheets revealed the Chicken Teriyaki Puree was a 3-ounce portion, The puree rice, and puree broccoli was listed as a #8 scoop (4-ounce portion), mashed potato was listed as 4-ounce portion and there were no puree hot dog and a bun listed. None of the items were 2-ounce portion sizes as stated by the FSD. A further review of the Spreadsheets revealed that 8 ounces of milk was served with breakfast and lunch. On 05/06/26 at 1:23 PM, the surveyor conducted a telephone interview with the Registered Dietitian (MRD) who stated she oversaw a team of Dietitians who wrote the menus for a separate company that the Food Management company contracted with to purchase the menus. The MRD stated she was familiar with menu requirements for the population at the facility. The MRD stated she worked only for the menu company and was not affiliated with the Food Service Management company. She confirmed that she was the one that certified the nutritional adequacy of the menu by signing them. When asked if she communicated at all with the facility to change menus, etc., she stated that the menus were changed only if they were not locked, otherwise the facility was responsible for following the menu program and must contact the company via an 800 number to make any changes. When asked if her company provided recipes for the menus, she confirmed that there were recipes provided for the menus, including for the modified diets. When asked if it was important to follow the menus, the MRD stated there were very specific recipes and the methodology to prepare the items, it is important to use the recipes, otherwise you won't get a standardized product and that would affect the nutritional quality of the menus. When asked what the menus were based off of to ensure nutritional adequacy, she stated that the menus were based off of the Recommended Dietary Intakes from the National Food and Nutritional Board. She stated that the base meal pattern was for 6 ounces of edible protein per day, 5-1/2 Cups of fruits and vegetables, 3 Vitamin A sources per week, 5-6 servings of gran/starches and 2-3 cups of milk daily. When asked if it was important to provide 8 ounces of milk vs. 4 ounces, she stated, Yes, and that her company wrote the menus, and it was up to the facility to comply with them. The MRD confirmed that compliance of the menus was facility based. The MRD stated if the menu was provided as written, the facility has to comply and it was the responsibility of the facility corporate oversight to monitor the facility compliance. The MRD further stated that my signature certified that the menu met the nutritional requirements and the compliance was up to the facility to monitor. When explained the observations of a 2-ounce scoop being used for the puree chicken vs. the #6 scoop that was listed for the puree chicken. She stated the #6 scoop was a 2/3rd cup (5.3 ounces) portion, and if the facility used a 2-ounce scoop instead that would change the nutritional adequacy of what they were offering and they would not meet the protein requirement. The MRD stated the scoop sizes were also larger for casserole. The MRD stated the facility needed to utilize the recipes and the menu as written to ensure that the nutritional adequacy of the menus. The MRD stated the facility RD's could also review the menus. On 05/08/26 at 10:09 AM, the survey team informed the Licensed Nursing Home Administrator, DON, Assistant Administrator/Administrator in Training, the Regional Director of Operation and the [NAME] President of Clinical services of the above concerns. On 05/08/26 at 1:18 PM, during the exit conference, no additional pertinent information was provided. The Person Centered Dining provided by the facility for the management company revealed: What we know .The elderly are at risk for weight loss, malnutrition, dehydration, and skin breakdown .NJAC 8:39-17.4(a)3

Based on observation, interview and document review it was determined that the facility failed to ensure staff responsible for the facility food and nutrition services necessary had the skills and competencies to ensure a) the facility was maintained in a clean and sanitary manner, b) the mechanical dish machine was functioning appropriately, c) menus were followed to ensure appropriate portion sizes were provided and recipes were utilized to ensure nutritional adequacy of the food served, and d) residents received appetizing meals. The deficient practice affected all residents who resided in the facility, placed the residents at potential nutritional risk, and at risk for potential foodborne illness.The evidence was as follows: Refer to: F803, F804, F812 On 05/3/26 from 6:28 PM-7:00 PM, the surveyor conducted an initial tour of the kitchen with the Food Service Director (FSD) and observed debris and soiled areas in the walk in refrigeration units, the food storage areas, on storage racks, on the ceiling, and on exterior of equipment, tables and the ice machine. The surveyor also observed the dish machine was in use. Food preparation items, and dishware were placed in the machine by one person and another removing the clean items. The surveyor, in the presence of the FSD, observed that as the racks containing dishware were being placed through the machine, the wash temperature was 147 degrees Fahrenheit (F) and also observed at 146 F. When the surveyor asked the FSD what the temperature requirement was for the wash cycle, the FSD stated 150 F, and the FSD stated that our log has 150 F, and I am going to go with that. At that time the surveyor asked for the temperature log for the dish machine and the staff pointed to an empty clipboard affixed to the wall. At that time, the surveyor continued to watch the staff place dishes through the dish machine which was 146 F, 145 F and 147 F, and the surveyor then asked where the plaque was located that was affixed to the dish machine that provided the manufacturer specifications to run the dish machine. The FSD did not respond to the surveyor and the surveyor then bent down and observed the specification plaque affixed to the machine with the chemical company name and model and serial number of the machine which documented: Hot Water Sanitizing 160F, Minimum Wash Tank Temperature . When the surveyor showed the FSD the plaque and then asked the FSD if 150 F for the wash temperature would have met the manufacturer temperature requirements, the FSD stated she was going to make the machine a low temperature machine. The FSD said she was going to put it in chemical sanitizing mode and took a bottle of chemical and was setting up the chemical attached to the machine. When again asked if the 150 F was meeting the 160 F requirement, the FSD confirmed it was not because it was at 149 F. On 5/3/26 at 7:30 PM, the surveyor interviewed Resident #69 and Resident #75 in their room. When asked about the meals both residents stated the food was not good the hot food was served cold and the food was disgusting. Resident #69 also stated they were on a puree diet. On 5/4/26 at 10:33 AM, the surveyor conducted a resident council meeting with 10 residents, and 10 of 10 residents stated they did not receive the foods that they selected, did not receive complete meals and one resident stated that they only received a bowl of broccoli as a dinner meal, and all ten residents stated the hot food was delivered cold. On 5/4/26 at 11:45 AM, the surveyor observed the menu posted in the B-wing hallway that indicated the lunch meal was cheese ravioli with meat sauce, mixed vegetables and cinnamon apple slices, and then observed Residents #69 and #75 were in their room with their lunch trays in front of them. When asked Resident #75 about their lunch meal, which consisted of a plate of cheese ravioli and meat sauce and a small hot dog on the side. There were no vegetables and a small peanut butter and jelly sandwich was wrapped in plastic wrap and sliced apples were in a cup, with 4 ounces of skim milk. Resident #75 stated that was disgusting, who would eat that? The residents stated they did not select those items and did not have a copy of the menu in the room. Resident #69 had a flat pancake shaped reddish item on their tray that as touching a white flat pancake shaped item, the Diet Ticket was labeled Regular Puree with Thin liquid and Food Adds: Pureed peanut and butter and jelly sandwiches- 2. Resident #69 stated that they had a tumor in their cheek. When asked what was on the tray, the resident had no idea and stated, why don't they ever get coffee, they have no restriction. On 05/5/26 at 10:57AM, the surveyor interviewed the [NAME] in the kitchen regarding the meals that were prepared. The [NAME] stated he was mostly the breakfast and lunch cook. The surveyor asked the [NAME] if he also prepared the puree items and the [NAME] confirmed that he also prepared the puree meals. The surveyor asked if the cook utilized recipes for the puree foods and he stated, No. When asked how he would know how to make the purees, the [NAME] stated it was basically product water and thickener. When asked if the menus were new, the [NAME] stated, that we just converted to a new company and showed the surveyor the menus and explained he used them to show what had to be prepared for each item regarding the specialized diets, and he confirmed that he did not have recipes, and he stated he knew how to cook. The cook stated that the new menus started the previous month and when asked how he had prepared the puree for the current meal, he stated he added chicken, product and a little thickener. When asked if the puree food should be runny, he stated that it should not be runny and be in a pile. On 5/5/26 at 11:06 AM, a person interjected themselves into the interview with the cook and when asked who he was, he stated he was the District Manager (DM) of the new food service company and he was responsible for the kitchen, and stated they had recipes. The FSD entered the kitchen from the office and placed a large book down on the counter by the cook and stated, she needed to make a change and the recipe book was in her office. The surveyor went back to interview the [NAME] regarding the book provided and he confirmed that he had not been provided that recipe book.On 5/5/26 at 11:18 AM, during the tray line production in the kitchen the surveyor observed the tray line in progress and staff confirmed the main meal was teriyaki chicken, steamed rice, broccoli and bread and there was a puree hot dog. All the modified consistency items had a 2- ounce blue handled scoop. On the tray line and surveyor asked the Dietary Staff (DS) what the portions for the puree items were. The Food Service Director (FSD) interjected and stated, all protein should be 2 ounces and the surveyor asked why one of the puree items had a four-ounce scoops in the steam table, and the FSD stated, all 2oz scoops for everything. The FSD then told the staff to have all blue 2-ounce scoops and the DS told the FSD they did not have that many, and the FSD then told the DS to change it to a 2-ounce scoop.The first tray was removed the meal truck on the B-Wing unit at 11:37 AM, and the last tray at 11:46 PM. The District Manager (DM) from the new company observed the surveyor during the test-tray observation. The surveyor asked him what the temperature standards when the food was served to the resident and he stated the cold food was 40 degrees Fahrenheit (F) in the kitchen and the hot food was 135 degrees F in the kitchen. The DM did not respond when asked what the temperatures of the food should be when it reached the residents. The juice and milk were 54 degrees Fahrenheit (F) per the DM's thermometer, and the surveyor tested the milk and juice which was 53 F per the surveyor's thermometer. When asked to provide a copy of the policy for food temperatures, the DM exclaimed, palatability is not a policy! The surveyor then placed a teaspoon into the top of the puree rice, which was thick, and the spoon stuck straight up and did not move. The surveyor then asked the DM if that was supposed to be the consistency of the puree rice? The DM did not respond to the surveyor's inquiry. On 5/5/26 at 11:56 AM, the surveyor immediately went to Resident #69 and #75's room who had their lunch meals in front of them. When asked about the food, Resident #75, had only a piece of chicken on their plate and stated, who serves just a piece of chicken? Resident #75 stated, they never received what they ordered and they never get copies of the menus to confirm what they ordered. Both meal tickets were reviewed, and Resident #75 stated, we never get full trays. When asked if the milk and juice were at a good temperature, both residents stated, they are not cold, and that they would like it served cold. There was 4 ounces of milk on the tray, although 8 ounces was printed on the meal ticket.On 5/5/26 at 1:30 PM, the surveyor interviewed the Registered Dietitian (RD) and Corporate Registered Dietitian (CRD). The surveyor shared the concerns regarding the meal observations and asked both what their involvement was with the oversight of the Dietary Department. Both stated they were not involved with the Dietary Department (DD), which was a new management company, other than providing preferences to the DD and were responsible to provide the nutrition assessments and other services to the residents. On 05/6/26 at 10:31 AM, the surveyor conducted a telephone call with the dish machine chemical company representative (CC) who stated he was contacted on 5/3/26 by the facility to look at the dish machine due to temperature issues and conducted a service call the following day. The CC stated he provided routine service to the dish machine and had never been made aware of temperature issues by the facility prior to 5/3/26. The CC also confirmed that the minimum dish machine wash temperature should be 160 F per manufacturer specification, per the plaque. When asked if placing a chemical sanitizer on the machine and placing it in low temperature mode would fix the issue with the improper wash temperature, the CC stated that adding the chemical had nothing to do with the wash temperature and stated that would only work as a high temperature rinse override, using a sanitizer, and the high temperature rinse was not malfunctioning. The CC then confirmed that the wash temperature was not functioning at the appropriate level, which would affect the machine's ability to clean the soiled items. The CC provided the surveyor with a copy of a Service Visit Report for the 4/5/26 visit that revealed Request Description: Temperature at 149 F. Service Comments: I increased the washer heating element. We verified after that, that the wash cycle was running at 160+ F. On 05/5/26 at 1:56 PM, both the CRD and RD were again interviewed regarding the menus and recipes used by the facility and asked if they reviewed and approved them for nutritional adequacy. They both stated that the facility should be using recipes for consistency and nutritional adequacy. When asked if the residents who required altered consistency foods such as puree, should be provided with smaller portions, the CRD stated, no, it should be equal. When asked who was responsible for overseeing the menus and ensuring they were nutritionally adequate, The CRD stated they were not involved, but the management company should have someone review the menus. On 5/6/26 at 12:43 PM, the Regional Director of Operations for the facility brought the Regional Director of Operations for the contracted Dietary Department (RDOD) and the DM's employee file and any education that was requested by the surveyor. When asked the RDOD her role with the Dietary Department, she started, I am an attorney The surveyor asked what qualifications, training and competencies the DM had to ensure appropriate oversight of the Dietary Department. When asked the RDOD if the DM had formal education, the RDOD stated the DM did not have a degree, and that she trained the DM. When asked what training she provided, she stated she was a Certified Dietary Manager and she trained him on how to complete a kitchen walk -through (for sanitation purposes). When asked if the DM had any nationally recognized training in food service sanitation, the RDOD stated his Serve Safe was expired. The training provided by the RDOD included online training for discrimination, harassment in the workplace, bloodborne pathogens, preventing back injuries, standard precautions and there were no other training, competencies or education provided. On 05/06/26 at 1:23 PM, the surveyor conducted a telephone interview with the Registered Dietitian (MRD) who stated she oversaw a team of Dietitians who wrote the menus for a separate company that the Food Management company contracted with to purchase menus.The MRD stated she was familiar with menu requirements for the population at the facility. The MRD stated she worked only for the menu company and was not affiliated with the Food Service Management company, and she was the one that certified the nutritional adequacy of the menu by signing them. When asked if she communicated at all with the facility, she stated that the menus were changed only if they were not locked, otherwise the facility was responsible for following the menu program and must contact the company via an 800 number to make any changes. When asked if her company provided recipes for the menus, she confirmed that there were recipes provided for the menus, including for the modified diets. When asked if it was important to follow the menus, the MRD stated there were very specific recipes and the methodology to prepare the items, it is important to use the recipes, otherwise you won't get a standardized product and that would affect the nutritional quality of the menus. When asked if it was important to provide 8 ounces of milk vs. 4 ounces, she stated, Yes, and that her company wrote the menus, and it was up to the facility to comply with them. The MRD confirmed that compliance of the menus was facility based. The MRD stated if the menu was provided as written, the facility has to comply and it was the responsibility of their corporate oversight to monitor the facility compliance. The MRD further stated that my signature certifies that the menu meets the nutritional requirements and the compliance is up to the facility to monitor. On 05/08/26 at 10:09 AM, the survey team informed the Licensed Nursing Home Administrator, DON, Assistant Administrator/Administrator in Training, the Regional Director of Operation and the [NAME] President of Clinical services of the above concerns. On 05/08/26 at 1:18 PM, during the exit conference no additional pertinent information was provided.A review of the FSD jobs description signed 3/28/26 revealed. As the FSD, you are responsible for the management, supervision and direction of the food service staff and program within the facility. In addition, the FSD is responsible for . planning and preparing of appealing and nutritious, heart-health, tasteful, fresh, food for residents and guests .Essential Job Functions included .ensures established sanitation and safety standards are maintained. A review of the DM's job description revealed Primary Duty: manages multiple facilities .according to federal/state requirements. Provides leadership, support and guidance to ensure that dietary quality standards .are met. Ensures that all required in-services are provided and documented for each employee in area of responsibility. Is able to perform the job assignments of the FSD, Dishwasher Cook, Dietary Aide Education and Experience and equivalent combination of education, training and experience will be considered. Bachelor degree in management or related field is highly preferred. Must be able to successfully complete regulatory compliance courses and identify issues and implement necessary changes. Two years experience in dietary services in a healthcare environment and personnel supervision is required. must have considerable knowledge of dietary safety/sanitation requirements and procedures. NJAC 8:39-17.4(a)3

Based on observation, interview, and document review, the facility failed to ensure a safe, comfortable, and homelike environment was provided for residents who had actual and/or expressed concerns regarding linen shortage at the facility. This deficient practice had the potential to affect all residents at the facility and was evidenced by the following: On 05/06/2026 at 11:30 AM, the surveyor reviewed the Resident Council minutes which revealed concerns regarding linen shortage for the last 3 months. The following were documented in resident council minutes: 2/27/27 linen shortage, 3/26 needs more towel, 4/30, towel and linen shortage over weekend. The resident council minutes did not reflect that the concerns with the linen shortage were resolved.Following the Resident Council meeting, the surveyor interviewed 3 alert residents over the above concerns. The residents revealed they had been complaining and reported the linen shortage to the staff. When they were asked how they knew of the linen shortage, they stated staff were unable to provide them with towels and changed their bed linen in a timely manner. One resident went on to state the concern with the linen shortage was worse over the weekend.On 5/6/26 at12:30 PM, the surveyor went to the laundry and asked the staff to provide the linen PAR (Periodic Automatic Replenishment). The laundry staff could not comment on the linen PAR and refer the surveyor to the Housekeeping Director (HD). All facilities require a 3-par system (one set in the laundry, one set in use and one set in storage) to ensure continuous services, prevent infection control and promote residents' comfort.On 5/6/26 at 1:00 PM, the surveyor interviewed the HD and inquired regarding the linen delivery system on the units. The facility is licensed for 250 beds and has a census of 145. The HD was unable to provide the amount of linen that was sent on the floor on each shift.On 05/06/2026 at 1:05 PM, the HD stated that the facility did not have a linen inventory. The surveyor then inquired regarding linen storage, the HD stated that the facility did not have linen storage. The HD stated. I can tell you, what we had, we washed them and sent them to the unit.On 5/6/26 at 1:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the facility linen inventory and requested the linen PAR for the facility. The LNHA stated that on 1/5/26 he did an inventory and was aware of the linen shortage. The LNHA provided a Baseline inventory conducted on 1/5/26 which revealed that the facility had 105 pads, 120 regular gowns, 12 bariatric gowns and 36 in storage, 90 fitted sheets and 12 in storage, 121 flat sheets, 136 blankets, 67 pillowcases, 66 washcloths and 10 dozens in storage, 60 towels. The facility ordered some sheets and towels at that time. The surveyor then asked the LNHA to provide the linen PAR based on the number of licensed beds. The LNHA was unable to show the amount of linen the facility had in house and what was needed to satisfy the linen PAR based on the number of licensed beds or the current facility census. The LNHA along with the HD could not determine what was needed based on the number of licensed beds. On 5/6/26 the LNHA provided 3 invoices 3 invoices for purchase orders submitted by the HD IN February and March 2026, for towel and flat sheets, the facility could not provide the date the shipment was received and where the linen was located. On 05/07/2026 at 12:01 PM, the surveyor interviewed a random Certified Nurse Aide (CNA) regarding the linen delivery on the unit. The CAN stated that the laundry staff delivered a linen cart in the morning but sometimes they had to call the laundry to require more linen. The CNA further stated that the bed linen was changed every other day and if the linen was soiled. The CNA stated that most of the time they do not have enough linen and had to call the HD to deliver more linen.On 5/7/26 at 12:30 AM, the surveyor interviewed 2 CANs on the 600 Units, the CNAs, stated that the bed linen was changed twice a week and if the linen was soiled. When the surveyor inquired if they had enough linen to care for the residents they stated, the weekend was a nightmare, they do not have enough linen, most of the time they will go to another floor and attempt to get sheets and towels to use for their residents, at times they had to ask the residents to wait until the laundry department could provide more linen.On 5/8/26 at 11:15 AM, the LNHA and the Regional Director of Housekeeping accompanied the surveyor to the storage room to show the linen that the facility had in stock. The Regional Director showed to the surveyor one unopened box of washcloth stored in the room. The RD stated, I thought they were towels. There was no linen in the storage room. The RD then escorted the surveyor to the clean utility room on 2 units, only to verify several blankets and pads were stored in the room.On 5/8/26 at 12:45 PM, in the presence of the survey team, the surveyor requested again the linen PAR from the LNHA, none was provided.On 5/7/26 at 2:00 PM, the LNHA provided a form titled, Linen-Par Levels. The following were documented:A linen PAR is the amount of linen needed to satisfy the daily needs of each resident.Established linen PAR allows the laundry department to provide nursing with the linens they need in the proper amounts and at the proper time. There must always be agreed-upon par, along with regularly scheduled delivery times. It is best practice that linen inventory should be a minimum of 3 times your par (the amount of linen needed to satisfy the daily needs of each resident) -and 8 times par for wash cloth.The facility shall maintain a par level of all essential linens. Inventory will be monitored to prevent shortages and ensure that any worn, stained or torn linens are removed from circulation and replaced immediately. NJAC 8:39-27.2(j)

Based on observation, interview, and record review, the facility failed to ensure that all residents had their call light easily accessible and functional. This deficient practice was identified for 2 of 2 residents reviewed on 2 of 4 resident units (B- Wing and Sub-Acute) reviewed for adequate staffing (Resident # 30 and Resident #86), and had the potential of placing all residents at risk for inability to receive assistance in a timely manner to meet their needs.The evidence was as follows: a. On 5/3/26 at 7:00 PM, the surveyor observed Resident #30 sleeping in a low bed and the call bell was not in reach of the resident, and a floor mat was to the right side of the bed. On 5/4/26 at 9:34 AM, the surveyor conducted an initial review of Resident #30's medical record which revealed the following: The admission Face Sheet (an admission summary) revealed diagnoses which included but were not limited to; cognitive communication deficit, acute respiratory failure with hypoxia, and hydrocephalus (abnormal build up of spinal fluid in the brain). On 5/4/26 at 9:48 AM, the surveyor conducted a telephone interview with the Responsible Party (RP). When asked about the resident and care, the RP stated the resident has a history of falls and had brain bleed. [NAME] asked about call bell use, the RP stated the resident was legally blind and they were unable to see the call bell and had a discussion with the facility that they would purchase a flat call bell if that would help since the resident has had falls since they were at the facility and they could not advocate for themself. On 05/04/26 at 11:12 AM, the resident was observed in bed sleeping and call bell was on the bed to the right side of the resident. On 05/05/26 at 8:30 AM, the surveyor observed Resident #30 in bed and the Certified Nurse Aide (CNA) was at the bedside setting up the meal. On 05/05/26 at 8:45 AM, a subsequent interview with the CNA revealed that Resident #30 would get out of bed every other day, Monday, Wednesday and Friday, with a mechanical lift and 2-persons to assist. When asked the CNA if the resident could press the call bell, the CNA then placed the call bell in the resident's hand and instructed the resident to press the call bell. The resident then tried to press the call bell, and it was not functioning. The CNA then confirmed that Resident #30's call bell was not functioning after she pressed the bell and it did not work. A further review of Resident #30's medical revealed a 27 page Care Plan with current and resolved Focus areas and a Focus for resident is at high risk for falls, due to history of stroke/weakness, muscle weakness, history of falls and lack of coordination, Initiated 12/30/25; Goal Resident will be free of minor injury and will not sustain serious injury through the review date, Initiated 3/31/26 with a Target Date 6/30/26. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Initiated 1/26/26. Follow facility fall protocol; Initiated 12/30/26; 1/23/26:3/11/26: 1. Continue to use floor mat, 2-Continue low height bed, 3. Re-educate resident to call for assistance prior to transfers, 4 Initiate new physical therapy screen, 5. Re-educate staff on frequent founding and fall-prevention practices; Date Initiated 1/26/26; Anticipate and meet resident's needs, Initiated 12/30/26. b. On 05/03/26 at 7:26 PM, the surveyor toured the 600 Unit- Sub-Acute (typically post hospitalization residents who required skilled nursing services) and observed Resident #86 in bed, the resident reported a delay in answering the call light by the facility and stated that during the 3:00 PM-11:00 PM shift, it could take up to an hour for the staff to answer the call light. The surveyor asked Resident # 86 to activate the call light, the resident could not reach the call light, and the roommate then activated the call light. Staff responded in 15 minutes to respond to the the call light. On 05/06/26 at 8:45 AM, the surveyor entered Resident #86's room, the resident was alert and awake and informed the surveyor that they needed to be changed. The surveyor asked the resident to activate the call light. The resident proceeded to reach for the call light, but the call light was not accessible. The surveyor left the room and informed a staff member who was sitting at the desk that Resident #86 needed assistance. The Unit Clerk entered the room and attempted to locate the call light. She could not locate the call light. The surveyor looked on the left side of the bed and observed that the call light was tied to the bed frame and was outside of the resident's view. The CNA confirmed that the call light was not accessible. On 5/7/26 at 9:45 AM, the surveyor reviewed the medical record for Resident #86. The admission Face Sheet (an admission summary) revealed that Resident #86 was admitted to the facility with diagnoses that included but not limited to unspecified fracture of lower end of right femur, cerebral Infarction, difficulty walking, muscle weakness and pain in the right knee. The admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date of 04/10/26, revealed a Brief Interview for Mental Status score of 3 out of 15, indicating that the resident had severely impaired cognition. The MDS assessment further reflected under Section GG Functional Status that Resident #86 needed assistance with all activities of daily living (ADLs) A review of Resident #86's Care Plan (CP) with an initial date of 04/17/2026, reflected a focus for decreased strength and functional activity intolerance limiting their independence with ADL's. Another focus was for falls related to gait balance problems, unaware of safety needs initiated 04/17/26. The interventions were for staff to Anticipate needs. Educate Resident/caregivers about safety reminders. On 05/06/26 at 1:30 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager regarding call light placement while residents were in bed. She stated that all residents call bells should be easily accessible. The surveyor then asked the UM where the call light should be placed if the residents were in bed. The UM stated that the call light should be on the bed or by the bed rails where the residents could reach the call bell without effort. The LPN/UM acknowledged that she was made aware that Resident #86's call bell was not accessible, so she started to educate the staff. She further stated that the CNAs and the nurses were responsible for ensuring that residents call lights were functional and within easy reach. On 05/08/26 at 10:09 AM, the survey team informed the Licensed Nursing Home Administrator, DON, Assistant Administrator/Administrator in Training, the Regional Director of Operation and the [NAME] President of Clinical services of the above concerns. On 05/08/26 at 1:18 PM, during the exit conference, the facility informed the surveyor upon surveyor identification of the broken call bell it was replaced. A work order dated 5/5/25 revealed the call bell was replaced and no additional pertinent information was provided. The Regional Director of Nursing acknowledged that Resident #86 did not have their call light easily accessible. NJAC 8:39-27.1(a); 31.8(c)9

Based on observation, interview and record review, it was determined that the facility failed to ensure residents were free from unnecessary medications and potential chemical restraints by ensuring that psychotropic drugs had documented adequate indications for use, were monitored and were necessary to treat a specific condition. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for unnecessary medication (antipsychotic drug use and a diagnosis of Alzheimer's/Dementia).This deficient practice was evidenced by the following:On 05/03/26 at 7:45 PM, the surveyor observed Resident #2 lying in bed in their room on the Ventilator (Vent) Unit, and their eyes were closed, Resident #2 was nonverbal and was attached to a mechanical ventilator (a life support device that pumps oxygen into the lungs and removed carbon dioxide when a person cannot breathe on their own). Resident #2 was observed receiving nutritional support through a tube, and a urinary catheter was observed in a dignity bag and hung on the bed rail. On 05/04/26 at 9:30 AM, the surveyor observed Resident #2 in bed, resting comfortably, their eyes were closed, and Resident #2 did not seem to be aware of their surroundings and did not engage visually the surveyor. The surveyor returned to the room at 11:30 AM and observed Resident #2 resting in the same manner as observed at 9:30 AM.On 5/6/26 at 8:30 AM, the surveyor observed the Certified Nurse Aide (CNA) in Resident #2's room. The Respiratory Therapist (RT) was also at the bedside providing care. Resident #2 was calm and did not react to receiving care.On 5/6/26 at 9:30 AM, the surveyor interviewed the CNA assigned to the Vent unit regarding Resident #2's care. The CNA stated that Resident #2 was nonverbal, used to be combative and will spit on staff during care. The surveyor then inquired if the behavior was still occurring and the CNA stated, not really.On 5/6/26 10:30 AM, the surveyor interviewed the Registered Nurse (RN) assigned to the Vent unit. The RN stated that currently Resident #2 did not have any behaviors. The Resident Representative was very involved and visited often. The RN further stated that she had been caring for Resident #2 for almost one year and had not observed any behavior. The surveyor then asked the RN what should occur to determine if a psychotropic medication was ordered to treat a condition and the condition did not persist and the nurse then stated, 'the resident should have been reevaluated for the continued use of medications. On 5/6/26 at 11:15 AM, the surveyor reviewed the medical record for Resident #2. The admission Face Sheet (admission summary) reflected that Resident #2 had diagnoses which included but were not limited to; acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, pneumonia due to other specified bacteria, dependence on respirator (Ventilator) status, Alzheimer's disease, unspecified and major depressive disorder.The surveyor then reviewed the May 2026 Physician's Order Sheet (POS) which revealed the resident had an order for Seroquel (an antipsychotic medication) 25 milligrams (mg) at bedtime and 12.5 mg in the morning for depression and mood disorder, Zoloft 75 mg daily for depression, Remeron 15 mg at bedtime for major depression and appetite stimulant, Lexapro 5 mg daily for depression.A review of May 2026 Medication Administration Record (MAR) reflected an order to monitor for behavior for psychoactive: Number of times each shift, Behaviors of: spitting on staff, restlessness observed, combativeness, aggression, outburst, refusal of care. Document non-Drug interventions: Diversional Activity, Snack, Support provided. Outcome: Effective/ Ineffective every shift document Progress Notes for any other behavior.A review of the Progress Notes (PN) from March 2026, April 2026, and May 2026 revealed that there was no documentation that Resident #2 displayed any aggressive behavior, outbursts of anger or refusal of care. All the documentation pertained to the ventilator care.The surveyor reviewed the Monthly Psychotherapeutic Drug Evaluation Form dated 12/25, 01/26, 02/26, 03/26, 04/26 and 05/26 revealed that all target behaviors were coded as zero indicating absence of behaviors.Further review of the forms failed to indicate any behavioral interventions /nonpharmacological approaches to care that were provided as part of a supportive physical/psychosocial environment that failed when the resident displayed the target behaviors being monitored. According to the documentation provided, the resident's behavior was stable for six months.The surveyor reviewed the monthly psychotropic assessment completed by the Nurse Practitioner which revealed the following: 11/04/25: Chart reviewed, history of depression and dementia. Per nursing, has decreased episodes of combativeness, and agitation, there are no s/s [sign and symptoms] of depression, or anxiety during visit. No irritability or agitation observed. Sleep is appropriate per staff. Plan: Continue Zoloft for depression, continue Seroquel. Will attempt to contact Resident Representative for care coordination and to discuss medications and treatment plan. The 12/23/25 Psychotropic Assessment revealed the following: Chart reviewed, history of depression and dementia. Resident #2 was unable to use the communication board, no signs/symptoms of depression. There was no irritability or agitation. Unable to assess suicidal/ homicidal ideations and paranoia as patient was nonverbal, but none were evident. Per staff sleep is appropriate. Continue current medications.On 4/21/26. the Nurse Practitioner (NP) documented the following: Patient's mood symptoms have been stable on his current medication regime. Will contact Resident Representative for GDR of Seroquel. There are no s/s of depression, or anxiety, no irritability or agitation observed.On 5/8/26 at 9:15 AM, the surveyor conducted a telephone interview with the NP. The surveyor inquired regarding the medication regimen and asked the NP to elaborate on the symptoms that warrantied the medication such as Seroquel, 3- antidepressants, Lexapro, Zoloft and Remeron. The NP stated that Resident #2 used to be combative with care, the medications were ordered to treat the target behaviors of combativeness, spitting and restlessness. The surveyor then asked the NP if she reviewed the monthly Psychotherapeutic Drug Evaluation Forms for the target behaviors. The NP stated No. The NP stated that she spoke with the staff and any changes in the care plan had to be discussed with the Resident Representative. She then confirmed that the drug regimen should be reviewed in the absence of the target behaviors. The NP stated that she had not been able to discuss any gradual dose reductions for the psychotropic medication. On 5/8/26 at 10:30 AM, the surveyor interviewed the Resident Representative (RR) regarding the care. The RR expressed some concerns and informed the surveyor that Resident #2 had declined mentally and physically. Resident #2 was nonverbal and did not engage anymore. The RR further stated that Resident #2 used to feed themselves and used the communication board to communicate with staff and All [they] do now is sleep all day. When inquired regarding the drug regimen, the RR stated that they were a nurse and some of the medications needed to be discontinued in the absence of the behavior. On 05/08/26 at 11:30 AM, the surveyor discussed the above concerns regarding Resident #2's medication regimen with the Regional Director of Nursing, the LNHA, and the Director of Nursing. They agreed that the medication regimen should have been reviewed in the absence of the target behaviors. No further information was provided. A review of the facility policy titled, Use of Psychotropic Medication () last revised 3/10/25 indicated the following: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. NJAC 8:39-27.1 (a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure dependent residents were provided with routine and appropriate incontinence care in a timely manner. This deficient practice was identified for 2 of 2 residents reviewed (Resident #120 and #159) for Activities of Daily Living and appropriate incontinence care. The deficient practice was evidenced by the following:a) On 5/3/26 at 8:40 PM, the surveyor toured the 600 Unit of the facility, Resident # 120 informed the surveyor that they had a Urinary Tract Infection (UTI) and it burned. Resident #120 further stated that incontinence care was not provided timely, sometimes it could take up to one hour for the staff to assist with incontinent care.The surveyor continued the tour and entered another resident room, when inquired regarding the care, the resident stated that they did not receive care timely and it occurred mostly on the 3:00 PM-11:00 PM shift. When asked to elaborate, the resident stated on the 3:00 PM-11:00 PM shift, it could take over one hour to receive incontinence care.On 5/4/26 at 9:45 AM, the surveyor asked a random Certified Nurse Aide (CNA) to assist with a care tour observation. Resident #120 was observed saturated with urine. Resident #120 informed the surveyor that they were provided with incontinence care during the prior shift (11:00 PM-7:00 AM). During an interview with the CNA assigned to Resident #120, she stated that she was on another assignment and did not check the resident prior to serving them the breakfast meal. On 05/04/26 at 10:10 AM, the surveyor observed Resident #159 in bed, upon inquiry, the resident stated that they were soiled. On 05/04/2026 at 10:30 AM, the surveyor asked a random CNA to assist with a care tour observation and Resident #159 was heavily soiled with urine and feces.The surveyor then asked the CNA if she checked the resident this morning. The CNA confirmed that Resident #159 was on her assignment and stated, I came in at 7:00 AM, I was told that Resident #159 received incontinence care earlier, I did not check the resident this morning. When asked if she felt that the resident was provided with incontinence care this morning, she stated, based on what we observed, I did not think so. The CNA stated I was on another assignment I did not provide care yet. On 5/7/26 at 10:15 AM, the surveyor reviewed Resident #120's medical record which revealed: the resident was admitted to the facility with diagnoses which included but were not limited to; muscle weakness, difficulty in walking, repeated falls, and retention of urine.A review of Resident #120's admission Minimum Data Set (MDS) an assessment tool to facilitate resident care, dated 02/18/26, documented the resident required extensive assistance with most activities of daily (ADL) including incontinence care. Resident #120 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) which revealed that Resident # 120 had intact cognition. The resident was incontinent of bowel and bladder and required incontinence briefs.Review of Resident #120's care plan dated 02/13/2026, revealed they were care planned for ADL/self-care performance deficit related to activity intolerance, fatigue and impaired balance. The goal was Resident #120 would increase their functional ability and independence with ADLs to return home with caregiver. The interventions included: Occupational therapy activity, ADL retraining, orthotic training as needed, wheelchair mobility training and physical modality as needed. Resident #120 was to be provided with incontinence care as needed.On 5/7/26 at 10:30 AM, the surveyor observed Resident #120 for incontinence care with the CNA. During the incontinence observation with the CNA, the surveyor observed Resident #120 in bed and was saturated in urine.A review of the medical record for Resident #159 revealed the resident was admitted to the facility with diagnoses which included but were not limited to; muscle weakness, difficulty in walking, unspecified dementia, acute cystitis (painful bacterial infection of the bladder).The admission Minimum Data Set Assessment (MDS) dated [DATE], reflected that Resident #159 was severely cognitively impaired. Resident #159 scored 03 out of 15, on the Brief Interview for Mental Status (BIMS).The Comprehensive undated Care Plan reflected a focus for ADL self-care performance deficit related to impaired balance. The goal was for Resident #159 to improve current level of function in ADLs, transfers and mobility and strength through the review date.The interventions included, Occupational therapy evaluation and training, ADL retraining, group therapy and wheelchair management. Another focus was for contact isolation related to infection with a multi-drug-resistant organism. Vancomycin-resistant Enterococci. (VRE). The interventions were to change Resident #159's briefs or assist with toileting, device care or use.On 05/07/26 at 9:40 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) Unit Manager (UM) and inquired regarding when incontinence care was to be offered. The LPN stated Incontinence care was to be offered every 2 hours. The LPNUM stated that incontinence care was to be offered in the morning during rounds prior to breakfast. The CNAs were to check their residents and provided incontinence care.The surveyor then asked the UM when the last in-service on incontinent care was, the UM stated that she provided an in-service last month following a complaint from a family member who visited over the weekend and observed that their loved one was saturated in urine and had not been provided with incontinence care for an extended period.On 5/8/26 at 10:30 AM, the surveyor reviewed the grievance book which revealed that on 4/19/26 a resident reported that they had to wait more than 30 minutes to be assisted with care. They needed to use the bedpan, they activated the call light and staff were not available for assistance for over 30 minutes.The above concerns were presented to the facility administrative staff on 5/8/26 at 10:30 AM. During the pre-exit conference on 5/8/26 no additional information was provided. On 5/9/26 at 10:06 the Regional Director of Nursing provided a policy titled, Perineal care, last revised 2/20/26. The policy stated, It is the practice of the facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown.NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice 2 of 28 residents (Resident #7 and Resident #135) reviewed for quality of care. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 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. a. On 5/3/26 at 7:30 PM, the surveyor observed Resident #7 who was seated in a wheelchair and watching television in their room. The surveyor reviewed the medical record for Resident #7. A review of the resident's admission record (admission summary) revealed diagnoses which included but not limited to; spinal stenosis (narrowing of spaces within the spine putting pressure on the spinal cord), Parkinson's disease (a progressive incurable neurodegenerative disorder of the nervous system that primarily affects movement), and type 2 diabetes (a chronic metabolic condition where the body resist insulin). A review of a Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 02/24/26, reflected that the resident had a brief interview for mental status score of 13 out of 15, indicating that the resident is cognitively intact. A review of the April 2026 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 04/23/26 for Doxycycline Hyclate oral tablet 100 mg, give 1 tablet by mouth two times a day for abscess for 7 days. A skilled progress note (PN) dated 4/21/26 at 11:00 PM revealed that a Family Nurse Practitioner (FNP) documented the following: Resident (age and sex redacted) was seen at the bedside today for cutaneous abscess to left lower back. Resident reports they (gender redacted) have a red bump to lower back that started several days ago. Resident reports that this has happened to them previously in the same spot and it requires I&D (incision and drainage). Resident denies fever or chills, reports pain and itching at the site. The FNP also wrote the following under physical exam: Skin: Warm and dry. 3 x 5 cm abscess with fluctuance and erythema noted to the left lumbar region. The FNP also wrote the following under plan: Cutaneous abscess (Acute unstable)- Due to resident's risk for systemic infection advised that they need a I and D of fluctuant abscess. Unable to obtain appropriate supplies (I and D tray, lidocaine 1%, packing, etc) transfer to hospital for incision and drainage of the cutaneous abscess. Start Doxycycline 100 mg bid (twice daily) po (by mouth) x (for) 7 days. A further review of the facility's PN revealed no nurses' notes from 4/11/26 through 4/22/26. A review of Resident #7's Weekly Skin Review dated 4/21/26 at 2:08 PM revealed that the resident's skin was identified as being intact. A review of Resident #7's Weekly Skin Review dated 4/14/26 at 12:16 PM revealed that the resident's skin was identified as being intact. A review of Documentation Survey Report (Task for Certified Nurse Aids) revealed under Skin Observation from 4/14/26 through 04/21/26 that the Certified Nursing Assistant documented 5 for none of the above observed (1. Skin observation 0- scratched, 1- Red Area, 2 -discoloration, 3-Skin tear, 4-Open Area, and 5-None of the above observed). A review of the facility's comprehensive care plan under the focus area Diabetes Mellitus dated 6/5/25 revealed the following intervention: Check all of body for breaks in skin and treat promptly as ordered by doctor. On 05/07/26 at 10:00 AM, the surveyor interviewed Resident #7 who stated that on 4/21/26, they were experiencing an itch in their lower back. The resident stated that they notified the nurse practitioner and told them that they were experiencing irritation in the lower back. The resident then stated that they had been experiencing irritation in the lower back for several days. After the nurse practitioner examined the resident's lower back, she stated then she decided to send Resident #7 to the hospital to get the abscess drained. On 05/07/26 at 10:30 AM, the surveyor interviewed the resident's Certified Nurse Aide (CNA) who stated that part of her job was to complete skin observations for her residents. She stated that she completed skin checks for Resident #7 but did not recall observing an abscess on the resident's lower back. The CNA further stated that if she had noticed any type of skin irritation which would include a skin tear, swelling, redness, or inflammation, that she would notify the nurse. On 05/07/26 at 11:30 AM, the surveyor interviewed Resident #7's Licensed Practical Nurse (LPN) who stated that the resident received a weekly skin assessment and was unable to explain why the abscess on the resident's lower back had not been identified and documented on the 4/21/26, weekly skin assessment. He stated that the abscess should have been identified during the nurse's weekly skin assessment and during the CNA's skin observation which were both completed on 4/21/26. On 05/07/26 at 1:20 PM, the surveyor interviewed the FNP regarding the progress note she documented on 4/21/26. She stated that she was doing her rounds when Resident #7 informed her that they had irritation in their lower back. When she examined the resident, she observed the abscess on their back and it was observed as infected and it was oozing. She stated that the abscess was 3 centimeters (CM by 5 CM and stated that it was a noticeable abscess. On 05/8/26 at 10:30 AM, the surveyor presented the above concerns to the facility's administrative team which included the Licensed Nursing Home Administrator, the Director of Nursing, [NAME] President of Clinical services, and the Regional Director of Clinical services. No additional information was provided. A review of the facility policy dated as last approved 1/1/2024 for Skin Assessment provided by the Regional Director of Clinical Services, revealed the following: A full body, or head to toe, skin assessment will be conducted by a licensed of Registered Nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment should also be performed upon any change in condition or identification of new wound (s) (i.e., pressure injury, non-pressure injuries, diabetic ulcers, skin tears, etc.). A review of the facility policy dated 10/31/2019 for Acute Condition Changes-Clinical Protocol provided by the Regional Director of Clinical Services revealed the following: Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. b. On 5/07/26 at 9:01 AM, Resident #135 was observed in the room sitting in wheelchair and was eating breakfast. The resident stated they had cataract surgery on 5/5/26. The resident further stated that on one occasion an aide did not accompany them to the appointment, and the resident was not informed why an aide did not accompany them on the appointment. On 5/07/26 at 9:08 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) Unit Manager (UM) who stated the follow-up appointment yesterday and an aide accompanied the resident for the appointment. She further stated that there were no staff that accompanied the resident on the date of the surgery and that she thought it was a miscommunication. The UM stated that an aide should have accompanied Resident #135 for the surgery appointment. On 5/07/26 at 9:37 AM, the surveyor reviewed the electronic medical record (EMR) which revealed the following: An admission record revealed diagnoses that included but not limited to; hemiplegia and hemiparesis following other cerebrovascular disease (weakness of one side of the body), difficulty walking, muscle weakness, dementia, and cataract (clouding of the lens of the eye). A quarterly Minimum Data Set (an assessment tool) dated 2/9/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15which indicated the resident was cognitively intact. The resident required supervision with transfers and ambulation short distances, and moderate assistance with toileting hygiene. The Individual Comprehensive Care Plan (ICCP) revealed a Focus area initiated 11/14/24, that addressed limited physical mobility related to weakness with an intervention of staff to provide assistance with mobility as needed. The ICCP also included a Focus area initiated 11/14/24, addressing a risk for falls related to deconditioning, muscle weakness, history of falls, lack of coordination and seizure, with interventions which included resident educated on the importance of calling for assistance prior to transfers; additional lighting provided to improve visibility related to cataract dated 1/27/26, and to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed; the resident needed prompt response to all requests for assistance dated 11/14/24. The ICCP also included a focus area dated 11/14/24, that addressed the medical diagnosis of seizure disorder and intervention of seizure precautions, which included Do not leave resident alone during a seizure, protect from injury. A review of the EMR further revealed that cataract surgery was recommended on 4/3/26, and the medical clearance was completed on 4/7/26. On 5/5/26 at 7:57 AM, the progress notes indicated that the resident was picked up at 6:00 AM, by [Name Redacted] to [Name Redacted] Medical Center for right eye surgery. On 5/5/26 at 12:34 PM, the progress notes indicated that the resident returned from [Name Redacted] Medical Center for the right eye surgery, stable. Follow-up appointment on 5/6/26 at 9:45 AM. Scheduler/all parties made aware. On 5/07/26 at 11:37 AM, the surveyor interviewed the Director of Nursing (DON), who stated if a resident had an appointment, the unit clerk scheduled the appointments. The DON stated sometimes we asked the family, and they would meet the resident at the surgery. If a resident really needed help, we could get an aide to go with a resident. She further stated, There was a lapse with that appointment. It was just missed; it was not communicated well. She also stated that she thought at one point the resident representative was going to go with the resident to the appointment. She then stated that an aide should have gone with the resident to the surgery appointment. The surveyor reviewed the facility provided policy, Transportation Policy, implemented 1/1/21, which included: Policy: For residents' convenience the facility offers transportation to doctor's appointments and emergent visits to medical centers. This policy outlines facility schedule for transportation operations and procedures for making transportation arrangements; Procedures: appointments will be scheduled by appointment in advance or emergency visit as applicable by the nursing staff. All residents and their needs will be considered for their appointments. N.J.A.C. 8:39-27.1(a); 8:39-3.2 (a), (b)

Based on observation, interview, record review, and review of pertinent documents it was determined that the facility failed to provide adequate supervision and implement specific and meaningful interventions to prevent a resident identified at high falls risks and assessed as being cognitively impaired from experiencing unnecessary falls. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #30), and was evidenced by the following. The evidence was as follows: A review of the facility policy titled; Fall Prevention Program, Date Implemented 1/2/25 revealed: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 3. The nurse will indicate in the resident's record the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's risk. 4. Provided interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. A. Provide additional interventions as directed by the resident's assessment, including but not limited to i. assistive devices, ii. increased frequency of rounds, iii. sitter if needed . vi. Alternate call system access, vii. Scheduled ambulation or toileting assistance . ix. Therapy services referral; 5 Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. interventions will be monitored for effectiveness, b. The plan of care will be revised as needed, 6. When any resident experiences a fall, the facility will: e. Review the resident's care plan and update as indicated. On 5/3/26 at 7:00 PM, the surveyor observed Resident #30 sleeping in a low bed and the call bell was not in reach of the resident, and a floor mat was to the right side of the bed. On 5/4/26 at 9:34 AM, the surveyor conducted an initial review of Resident #30's medical record which revealed the following: The admission Face Sheet (an admission summary) revealed diagnoses which included but were not limited to; cognitive communication deficit, acute respiratory failure with hypoxia, and hydrocephalus (abnormal build up of spinal fluid in the brain). On 5/4/26 at 9:48 AM, the surveyor conducted a telephone interview with the Responsible Party (RP). When asked about the resident and care, the RP stated the resident had a history of falls and had brain bleed. When asked about call bell use, the RP stated the resident was legally blind and they were unable to see the call bell and the RP had a discussion with the facility and the RP stated that they would purchase a flat call bell if that would help since the resident has had falls since they were at the facility and they could not advocate for themself. On 05/04/26 at 11:12 AM, the resident was observed in bed sleeping and call bell was on the bed to the right side of the resident. On 05/05/26 at 8:30 AM, the surveyor observed Resident #30 in bed and the Certified Nurse Aide (CNA) was at the bedside setting up the breakfast meal. On 05/05/26 at 8:45 AM, a subsequent interview with the CNA revealed that Resident #30 would get out of bed every other day, Monday, Wednesday and Friday, with a mechanical lift and 2-persons would assist. When asked the CNA if the resident could press the call bell, the CNA then placed the call bell in the resident's hand and instructed the resident to press the call bell. The resident then tried to press the call bell, and it failed to activate. The CNA then stated at that time, the call bell was not functioning. A further review of Resident #30's medical revealed a 27 page Care Plan with current and resolved Focus areas and a Focus for resident is at high risk for falls, due to history of stroke/weakness, muscle weakness, history of falls and lack of coordination, Initiated 12/30/25; Goal Resident will be free of minor injury and will not sustain serious injury through the review date, Initiated 3/31/26 with a Target Date 6/30/26. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Initiated 1/26/26. Follow facility fall protocol; Initiated 12/30/26; 1/23/26:3/11/26: 1. Continue to use floor mat, 2-Continue low height bed, 3. Re-educate resident to call for assistance prior to transfers, 4 Initiate new physical therapy screen, 5. Re-educate staff on frequent founding and fall-prevention practices; Date Initiated 1/26/26; Anticipate and meet resident's needs, Initiated 12/30/26. A review of the admission Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status Score of 9 out of 15 which revealed the resident had a moderately impaired cognition. Section GG for Functional Status revealed the resident was dependent on staff to perform toileting, dressing and bathing, and the resident was dependent on staff for transferring. A Fall Risk Assessment, Effective 12/24/25 revealed Resident #30 was identified as being at High Risk for falls. The Emergency Department Record dated 1/22/26, revealed Diagnosis: Unwitnessed Fall . A review of the admission Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 9 out of 15 which revealed the resident had a moderately impaired cognition. Section GG for Functional Status revealed the resident was dependent on staff to perform toileting, dressing and bathing, and the resident was dependent on staff for transferring. The Licensed Practical Nurse Progress Note, effective 1/22/26 at 6:52 AM revealed CNA called me into resident's room, resident was sitting on floor at the edge of bed. Resident could not state what the reason was for moving from bed .Neuro checks initiated due to unwitnessed fall. A Registered Nurse Progress Note, effective 3/10/26 at 16:16 (4:16 PM) revealed called to resident's room approximately 4:00 PM, noted sitting on floor mat, back against bed. Resident could not give account of what happened, reported lower back pain . X-Ray ordered . On 05/06/26 at 8:31 AM, Resident #30 was observed in bed, the meal tray was at the bedside. The call bell was located out of reach from resident's right hand, when asked if they could ring the call bell, they tried with the left hand and then stated No. The surveyor then requested all investigations for Resident #30 from the facility. On 05/07/26 at 12:30 PM, the surveyor interviewed the Speech Therapist (ST) about Resident #30. The ST confirmed she provided care and assessed and asked if Resident #30 had adequate vision. The ST stated, not really, the resident was able to see lights and shadows. When asked if Resident #30 was able to press the call bell she stated, Resident #30 could grab, but had weakness and doesn't have the follow through to know how to press the call bell, because they had cognitive deficits. On 5/7/26 at 1:56 PM, the Assistant Administrator provided two investigations that he confirmed were complete and had all documentation, including any documentation from witnesses. A review of the 1/22/26 Fall Reports revealed Notes: 1/23/26. Interdisciplinary Team (IDT) met to discuss unwitnessed fall and resident could not recall what happened. There were no new interventions added to the Care Plan specific to a causal factor of the fall or effectiveness of interventions reviewed. A review of the 3/10/26 Fall Report revealed under Incident Description: Social worker alerted nurse regarding resident found on the mattress on the floor . Notes that at 4:16 PM, the nurse called me to tell me the resident slid of the bed onto the floor mattress. There were no new interventions added to the Care Plan specific to a causal factor of the fall or a review of the effectiveness of the current interventions. The Speech Therapy Evaluation dated 12/29/25 revealed: Cognitive Skills: Executive Function =impaired. Oriented to =Person. Memory=Impaired; short term memory =25% . During the screen poor auditory comprehension, poor orientation, and poor sustained attention. On 05/08/26 8:51 AM, the surveyor conducted an interview with the Director of Nursing (DON) in the presence of the survey team. The surveyor asked about how the facility determined if a resident was a fall risk. The DON stated that upon admission a resident had a fall assessment completed to determine if they had a potential for falls, they completed the morse fall for every admission. The DON stated that every resident had every 2-hour rounding, and when asked where that documentation for the 2-hour rounding was located, the DON stated, we don't really document it. When asked about an order for the 2-hour rounding, the DON stated, we don't get a physician order, some of it would be in the progress notes, it depended on if the nurses document it. When asked the DON if the staff documented anything to confirm the 2-hour rounding was completed, she confirmed we don't have a specific thing we do to document the 2-hour rounding. The surveyor then asked the DON what the facility would complete for a new admission related to fall prevention. The DON stated a Care Plan was completed for fall risk and it would include using a low bed, and using the call bell. When asked how would you know if a resident was able to use the call bell, the DON stated the call bell would always be in reach, they all use it. When asked could all residents use the call bell if they had cognitive impairments, the DON stated that all residents would still be educated to use the call bells. The DON stated if a resident had a fall, they reviewed all current interventions to see if they were appropriate and the DON stated she was responsible to complete the investigation. The surveyor then asked if a resident had visual deficits would a call bell be an appropriate intervention. The DON stated, No, we would change the call bell to a tap bell or the spongy call bell. When asked if she knew if Resident #30 had visual deficits? She stated, No. When asked if she had spoken to the ST, or any therapist about the resident? The DON stated she did not speak to therapy and confirmed that she was unaware that Resident #30 had any visual deficits. The surveyor informed the DON of the observations, including the broken call bell and the inability to press the call bell, and the call bell that was out of reach. When asked the DON if she should have been aware of the visual deficits, she stated, Yes, and could not speak to why she was not aware. The DON confirmed that if she had been aware of the visual deficit for Resident #30, that she could have added other interventions such as a tap bell. On 05/08/26 at 10:09 AM, the survey team informed the Licensed Nursing Home Administrator, DON, Assistant Administrator/Administrator in Training, the Regional Director of Operation and the [NAME] President of Clinical services of the above concerns. On 05/08/26 at 1:18 PM, during the exit conference, the facility informed the surveyor upon surveyor identification of the broken call bell it was replaced. A work order dated 5/5/25 revealed the call bell was replaced and no additional pertinent information was provided. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide appropriate care and services for residents who required oxygen therapy by failing to administer oxygen according to the physician order. This deficient practice occurred for 2 of 5 residents, including a resident (Resident # 53) with a history of aspiration pneumonia (inhaling food into lungs) and acute hypoxic respiratory failure and Resident #74 reviewed for respiratory therapy and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes 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.a. On 5/3/26 at 7:00 PM, during the initial tour, the surveyor observed Resident #53 in bed sleeping, was wearing a NC and the oxygen O2 via concentrator administered O2 and it was set to 5 liters per minute (LPM). On 05/04/26 at 11:58 AM, the surveyor entered Resident #53's room, and the resident was wearing a NC and stated I cannot breathe to the surveyor and the surveyor observed the O2 was running at 5 LPM as observed on 5/3/26. The surveyor immediately went to the front desk area and observed the Licensed Practical Nurse, Charge Nurse (LPNC) and informed her of the surveyor's observations and the resident was on 5 L O2 via NC. The LPNC stated that is behavior. On 05/04/26 at 12:01 PM, the LPNC asked a nurse for a pulse oximeter (measures O2 concentration in the blood) and went toward the room, the surveyor accompanied the LPNC to the room and the surveyor asked about the statement she made, and she said, that's behavior, it is a behavior that they do all the time. The resident was observed on the NC and the LPNC confirmed that the resident was on 5 LPM O2. The resident was breathing heavily and stated, I cannot breathe to the LPNC. The LPNC took the resident's pulse oximeter reading which was 93 and 94 % saturation (95-100 % normal and low oxygen level below 95%). The LPNC tried to feed the resident from the meal tray, and the resident stated, It is hard to swallow. The surveyor then reviewed Resident #53's medical record which revealed the following: The resident had diagnoses with included, but were not limited to; Parkinson's Disease with Dyskinesia (a movement disorder), Chronic Obstructive Pulmonary Disease, Hemiplegia affecting left side and Depression. The Order Summary Report revealed a physician order dated 12/02/24 for If SpO2 (SpO2 -peripheral capillary oxygen saturation) measures the percentage of oxygen-saturated hemoglobin in the blood) is lower than 90% apply O2 at 2 L or if shortness of breath, every 8 hours as needed, head of bed elevated. The Progress nots revealed a Late Entry Physician/ Nurse Practitioner Note (NP) Effective Date: 4/30/26 at 2:18 PM revealed: No complaints, no pain, or shortness of breath . History of aspiration pneumonia (inhaling food into lungs), dysphagia and acute hypoxic respiratory failure . The 31-page Care Plan with current and resolved items was reviewed. A Focus for COPD initiated 5/10/24 with a Goal: Will be free of signs and symptoms of respiratory infections through review date, Initiated 5/10/24; Interventions included: Monitory for difficulty breathing on exertion . Monitor for signs and symptoms of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, Shortness of Breath at rest, Cyanosis (turning blue) and Somnolence (a strong, persistent desire to fall asleep or an increased duration of sleep), Initiated 5/10/24. Another Care Plan Focus for oxygen therapy resulted to ineffective gas exchange was initiated 05/31/24 with a Goal that resident will have no signs or symptoms of poor oxygen absorption through the review date, Initiated 5/31/24; Interventions included: Monitor for signs and symptoms of respiratory distress and report to physician as needed; respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color; Oxygen settings: O2 via NC (nasal cannula) at 2 L as needed for shortness of breath, Date initiated 5/31/24. Both were dated Target Date: 4/2/26, and there were no care plans related to having a behavior related to using 5 L O2 and having a behavior of not being able to breathe. The Medication Administration Record (MAR) revealed the nurse signed off that the O2 saturation level was 97 % on 5/3/26 in the evening and the as needed (PRN) O2 order for 2 L was left blank on 5/3/26 and 5/4/26 when the surveyor observed the oxygen being administered at 5 L via NC. The Comprehensive Minimum Data Set, dated [DATE] revealed the resident scored 11 out of 15 on the Brief Interview for Mental Status which indicated a moderately impaired cognition and was not coded for O2 therapy. On 05/05/26 at 9:58 AM, the Regional Clinical Supervisor (RCS) for the corporation informed the survey team that the LPNC was suspended pending investigation related to a failure in care due to a failure to follow procedures after she was notified the resident was complaining of breathing difficulty. When asked who was responsible for the 5 L O2 that did not match the physician order, the RCS stated that they did not know and were investigating it. b. On 5/6/26 at 11:35 AM, the surveyor observed Resident #74 who was in a wheelchair with a portable oxygen concentrator. The resident was with a facility staff member, and the surveyor asked the resident, who was alert and oriented, if they could check the resident's oxygen concentrator. The surveyor checked portable oxygen concentrator, per resident's approval, and the needle was situated in the red area which indicated the tank was empty. At that time, the facility staff member also acknowledged that the tank was empty. On 5/6/26 at 11:45 AM, the surveyor interviewed the A-unit Licensed Practical Nurse (LPN) who was Resident #74's nurse. The LPN acknowledged that the resident's portable oxygen concentrator was empty and stated that she just changed [their] oxygen tank, and she then stated that the resident was alert and they would tell the nurse if the oxygen tank needed to be changed. The surveyor then asked the LPN if the facility checked the resident's oxygen and she stated every morning, but she was unable to inform the surveyor why the tank was empty. The surveyor then reviewed the medical record for Resident #74 which revealed the following: A review of the admission record (admission summary) revealed diagnoses which included but not limited to; chronic obstructive pulmonary disease (a progressive, treatable disease commonly caused by smoking or long-term irritant exposure), congestive heart failure (a chronic condition where the heart muscle is too weak or stiff to pump blood efficiently, causing fluid to back-up into the lungs, legs, and body) essential hypertension (high blood pressure), and peripheral vascular disease (a slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels outside of heart and the brain). A review of a Quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 04/27/26, reflected that the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident was cognitively intact. The MDS further revealed that Resident #20 received Respiratory treatments which included oxygen therapy. A review of the May 2026 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 01/04/26 for Oxygen at 3 Liters per minute (l/min) via nasal cannula every shift for oxygen. A review of Resident #74's Individualized Care Plan had a focus that indicated the resident has behavior problem and is non-compliant with oxygen use. Resident frequent locomotion in wheelchair in and out of room which results in inconsistent oxygen therapy adherence initiated 10/09/24 with interventions that included but were not limited to; Ensure portable oxygen is functioning and accessible at all times. On 05/8/26 at 10:30 AM, the survey team presented the above concerns to the facility's administrative team which included the Licensed Nursing Home Administrator, the Director of Nursing, The [NAME] President of Clinical Services, and the Regional Director of Clinical services. No additional pertinent information was provided. A review of the Oxygen Administration Policy implemented 1/1/24 revealed the following: Policy Explanation and Compliance Guidelines: 1.Oxygen is administered under orders of a physician, except in the case of an emergency . 2. Personnel authorized to initiate oxygen therapy include physicians, Registered Nurse, LPNs and respiratory therapists. 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. monitoring for complications associated with the use of oxygen. 12 Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. NJAC 8:39-27.1 (a)

Repeat DeficiencyBased on observation, interview, and record review, it was determined that the facility failed (a) to follow Physician Orders (PO) with regards to medications with parameters for 2 of 29 residents (Resident #14 and Resident #63) reviewed for medication management (b) to properly secure a medication in one (1) of four (4) nursing units, and C). accurate reconciliation and administration of narcotic medication with potential for drug diversion .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. a). On 05/03/26 at 7:00 PM, the surveyor observed Resident #14 sitting up in bed with eyes open watching television. The surveyor reviewed the medical record for Resident #14. A review of the resident's admission record (admission summary) revealed diagnoses which included but not limited to; chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and essential (primary) hypertension (high blood pressure).A review of a significant change Minimum Data Set, an assessment tool used to facilitate the management of care, dated 03/05/26, reflected that the resident had a brief interview for mental status score of 13 out of 15, indicating that the resident was cognitively intact. A review of the May 2026 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 4/17/26 for Fludrocortisone Acetate Oral tablet 0.1 mg (Fludrocortisone Acetate), give 1 tablet by mouth one time a day for hypotension. Hold for systolic blood pressure (SBP) greater than 140.A review of the May 2026 electronic medication administration record (e-MAR) revealed the following Physician's Order (PO) dated 4/17/26 for Fludrocortisone Acetate Oral tablet 0.1 mg (Fludrocortisone Acetate), give 1 tablet by mouth one time a day for hypotension. Hold for systolic blood pressure (SBP) greater than 140. A review of the e-MAR revealed that Fludrocortisone had a plotted time for 0500 (5:00 AM) and on 5/4/26 the resident's Blood Pressure was plotted for a SBP of 148 and the medication was signed as being administered. On 5/5/26 at 11:15 AM, the surveyor in surveyor in the presence of a Licensed Practical Nurse (LPN#1) reviewed the resident's e-MAR. At that time, LPN#1 acknowledge that the resident had a perimeter to hold Fludrocortisone Acetate when the SBP was over 140. LPN#1 further acknowledge that the SBP blood pressure on 5/4/26 at 5:00 AM was 148 and the nurse should have held the medication. b). 05/03/2026 8:21 PM, the surveyor observed Resident #63 in their room, the resident who was in hospice care was observed in bed with their eyes closed and was sleeping. The surveyor reviewed the medical record for Resident #63. A review of the resident's admission record (admission summary) revealed diagnoses which included but not limited to; chronic kidney disease (long-term, progressive loss of kidney function), essential hypertension (high blood pressure), and peripheral vascular disease (a slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels outside of heart and the brain).A review of an Annual Minimum Data Set, an assessment tool used to facilitate the management of care, dated 9/05/25, reflected that the resident had a brief interview for mental status score of 3 out of 15, indicating that the resident had severe cognitive impairment. A review of the May 2026 Order Summary Report (OSR) revealed the following Physician's Order (PO) dated 1/23/26 for Amlodipine besylate oral tablet 5 mg, give 1 tablet by mouth one time a day for hypertension. Hold for SBP less than 110.A review of the May 2026 electronic medication administration record (e-MAR) revealed the following Physician's Order (PO) dated 1/23/26 for Amlodipine besylate oral tablet 5 mg, give 1 tablet by mouth one time a day for hypertension. Hold for SBP less than 110. A further review of the April and May 2026 e-MAR revealed that Amlodipine besylate 5 mg had a plotted time of 0800 (8:00 AM) and on two occasions the medication was administered when the SBP was less than 110.On 4/3/26, the resident had a documented blood pressure of 105/67. The medication was signed by the nurse as being administered with a SBP of 105.On 5/1/26, the resident had a documented blood pressure of 106/54. The medication was signed by the nurse as being administered with a SBP of 106. On 5/5/26 at 11:30 AM, the surveyor in surveyor in the presence of a Licensed Practical Nurse (LPN#1) reviewed the resident's e-MAR. At that time, LPN#1 acknowledge that the resident had a perimeter to hold Amlodipine when the SBP was under 110. LPN#1 further acknowledge that Amlodipine was administered to the resident on two occasions (4/3/26 and 5/1/26) when the SBP was less than 110. c). On 5/5/26 at 10:25 AM, the surveyor reviewed Resident #14's dialysis communication book on the A-unit and observed three tablets of Midodrine 5 mg with a package date of 5/4/26 inside the book. At that time, the surveyor interviewed LPN#2/unit manager who stated that the medication was returned by the dialysis center and when the nurse reviewed the dialysis book the medication should have been removed and destroyed in a pill buster (medication destruction system). On 5/3/26 at 7:00 PM, the surveyor observed Resident #14 sitting up in bed with eyes open watching television. The surveyor reviewed the medical record for Resident #14. A review of the resident's admission record (admission summary) revealed diagnoses which included but not limited to; chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and essential (primary) hypertension (high blood pressure).A review of a significant change Minimum Data Set, an assessment tool used to facilitate the management of care dated 3/05/26, reflected that the resident had a brief interview for mental status score of 13 out of 15, indicating that the resident was cognitively intact. A review of May 2026 OSR revealed the following PO dated 4/17/26 for Midodrine HCL Oral tablet 5 mg, give 3 tablets by mouth time a day Monday, Wednesday, and Friday for pre-treatment at dialysis. d). On 5/7/26 at 8:55 AM, a surveyor was conducting medication storage on unit-B and was doing a narcotic count in the presence of LPN#3. The surveyor observed LPN#3 signing out the narcotic inventory logbook after administering a resident's Clonazepam 1 mg tablet. At that time, the surveyor interviewed LPN#3 who acknowledge that she was signing the narcotic inventory logbook after administering the medication. LPN #3 further stated that per facility policy that all controlled substances must be long out of the narcotic inventory logbook once removed from the bingo card (medication administration system). On 5/8/26 at 10:30 AM, the surveyor presented the above concerns to the facility's administrative team which included the Licensed Nursing Home Administrator, the Director of Nursing, The [NAME] President of Clinical services, and the Regional Director of Clinical services.No additional information was provided.A review of the facility policy dated as last approved 1/1/2024 for Medication Administration provided by the Regional Director of Clinical Services, revealed the following: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 21. If medication is a controlled substance, sign narcotic book.A review of the facility's policy dated 9/1/24 for Medication Storage provided by the Regional Director of Clinical Services, revealed the following: All drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. A review of the facility's policy dated 1/1/24 for Controlled Substances Administration and Accountability provided by the Regional Director of Clinical Services, revealed the following: All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview and record review it was determined that the facility failed to properly label, dispose of and store medications in 2 of 6 medication carts and 1 of 3 medication rooms.The deficient practices was evidenced by the following: On 5/7/26 at 8:55 AM, the surveyor inspected B-Wing medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed 2 unidentifiable tablets that were loose inside the medication cart. The surveyor also observed a Fluticasone propionate nasal spray with a used by date of 2/6/26.At that time, the surveyor interviewed LPN#1 who stated that the medication carts are cleaned daily and that any loose pills should have been discarded immediately in a pill buster (medication disposal system). LPN#1 also stated that any medication that is past it's used by date should be removed from the medication cart.On 5/7/26 at 9:50 AM, the surveyor inspected the subacute unit medication room in the presence of LPN #2. The surveyor observed a tablet that was in a medication package in a bin of normal saline IV bags, a resident's Meropenem IV bag that was label with an expiration date of 5/20/26 that was stored on top of IV normal saline bags, an opened and unused syringe, 4 blood collection sets with an expiration date of 12/31/24, 37 blood collection sets with an expiration date of 2/28/25, 13 blood collection sets with an expiration date of 3/31/25, 1 blood collection vial with an expiration date of 8/31/23, 2 blood collection vials with an expiration date of 7/31/22, one blood collection vial with an expiration date of 8/31/25 and one bag of 10% dextrose 1000 ml with an expiration date of 9/2025.In the presence of surveyor, LPN#2 acknowledged that all the above medical supplies were outdated. LPN#2 was unsure how often the medication room was cleaned and inspected but believed that the responsibility of cleaning and maintaining the medication room is with the supervisors and the managers. She further acknowledges that the loose tablet and syringe should have been discarded and that the resident Meropenem IV bag should have been stored separately from the IV normal saline bags. On 5/7/26 at 10:16 AM, the surveyor interviewed the subacute unit LPN#3/Unit Manager (UM) who stated that it was the responsibility of the overnight supervisor to ensure that the medication room was maintained which included being organized and was cleaned. She stated that it was her and night supervisor's responsibility to check medication and medical supplies expiration dates. She stated that she tried to check expiration dates on Monday morning but acknowledged that they were no documentation showing that the medication room was being cleaned. LPN#3/UM further stated that they should be no expired medications in drawers or in cabinets.On 5/7/26 at 10:23 AM, the surveyor inspected the ventilator unit medication cart in the presence of a Registered Nurse (RN#1). The surveyor observed one blood draw kit with an expiration date of 2/28/25. At that time, the surveyor interviewed RN#1 acknowledge that the blood draw kit was expired and should have been removed from the medication cart.On 05/8/26 at 10:30 AM, the surveyor presented the above concerns to the facility's administrative team which included the Licensed Nursing Home Administrator, the Director of Nursing, The [NAME] President of Clinical services, and the Regional Director of Clinical services.No additional information was provided.A review of the facility's policy dated 9/1/24 for Medication Storage provided by the Regional Director of Clinical Services, revealed the following: Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels.NJAC 8:39-29.4(a)(h) and (d)

Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to have a process in place to ensure that consistent communication between the facility and the hospice provider occurred for the coordination of resident care. This deficient practice was identified for one 1 of 2 residents reviewed for hospice care (Resident #13) and the deficient practice was evidenced by the following:On 05/04/2026 12:10 PM the surveyor observed Resident #13 lying in bed watching television. Resident #13 stated that they were in no pain and comfortable. A review of Resident #13's Electronic Medical Record (EMR) revealed diagnosis of but not limited to; Idiopathic Normal pressure hydrocephalus (fluid backup in the brain with no known cause leading to neurological problems), and palliative care (care to provide symptom relief and maintain quality of life).A review of Resident's EMR revealed an order for hospice care, with an order date of 04/01/2026.A review of the significant change Minimum Data Set (SCMDS), an assessment tool used to facilitate management of care, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of four, revealing that Resident #13 had severe cognitive impairment. The SCMDS further revealed, Resident #13 was receiving hospice care while at the facility. A review of Resident #13's Care plan included a focus that revealed, Resident #13 was receiving hospice services through a hospice service with an intervention to work with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. A review of Resident #13's hospice communication binder revealed a hospice visit note report dated 3/31/2026, patient information sheet dated 3/31/2026, hospice aide care plan sheet dated 3/31/2026, an incomplete Hospice aide weekly visit record undated, a medication profile undated and NJ universal transfer form undated.On 5/6/2026 11:10 AM, during an interview with the surveyor, the Unit Manager (UM) stated that a hospice aide is provided once a week. The UM further stated that any communication documentation can be found in the resident's hospice binder. On 5/6/2026 12:15 PM during an interview with the surveyor, the Director of Nursing (DON) stated that when the hospice aide provides care, it should be documented in the resident's hospice binder. The DON further stated the UM was responsible for ensuring that the communication documentation was done. A review of the facility provided policy titled Coordination of Hospice Services implemented on 6/01/2025, revealed under Policy Explanation and Compliance Guidelines, under number 4, The facility will communicate with hospice and identify and communicate, follow and document all interventions put into place by hospice and the facility. Further review of the policy further revealed under number 6, The facility will maintain communication with hospice as it related to the resident's plan of care and serves to ensure each entity is aware of their responsibility. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to ensure a resident call bell was operationional. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #30) and was evidenced by the following: On 05/05/26 at 8:30 AM, the surveyor observed Resident #30 in bed and the Certified Nurse Aide (CNA) was at the bedside setting up the meal. On 05/05/26 at 8:45 AM, a subsequent interview with the CNA revealed that Resident #30 would get out of bed every other day, Monday, Wednesday and Friday, with a mechanical lift and 2-persons to assist. When asked the CNA if the resident could press the call bell, the CNA then placed the call bell in the resident's hand and instructed the resident to press the call bell. The resident then tried to press the call bell, and it was not functioning. The CNA then confirmed that Resident #30's call bell was not functioning after she pressed the bell and it did not work. A further review of Resident #30's medical revealed a 27 page Care Plan with current and resolved Focus areas and a Focus for resident is at high risk for falls, due to history of stroke/weakness, muscle weakness, history of falls and lack of coordination, Initiated 12/30/25; Goal Resident will be free of minor injury and will not sustain serious injury through the review date, Initiated 3/31/26 with a Target Date 6/30/26. Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Initiated 1/26/26. Follow facility fall protocol; Initiated 12/30/26; 1/23/26:3/11/26: 1. Continue to use floor mat, 2-Continue low height bed, 3. Re-educate resident to call for assistance prior to transfers, 4 Initiate new physical therapy screen, 5. Re-educate staff on frequent founding and fall-prevention practices; Date Initiated 1/26/26; Anticipate and meet resident's needs, Initiated 12/30/26. A review of the admission Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status Score of 9 out of 15 which revealed the resident had a moderately impaired cognition. Section GG for Functional Status revealed the resident was dependent on staff to perform toileting, dressing and bathing, and the resident was dependent on staff for transferring. A Fall Risk Assessment, Effective 12/24/25 revealed Resident #30 was identified as being at High Risk for falls. On 05/08/26 at 10:09 AM, the survey team informed the Licensed Nursing Home Administrator, DON, Assistant Administrator/Administrator in Training, the Regional Director of Operation and the [NAME] President of Clinical services of the above concerns. On 05/08/26 at 1:18 PM, during the exit conference, the facility informed the surveyor upon surveyor identification of the broken call bell it was replaced. A work order dated 5/5/25 revealed the call bell was replaced and no additional pertinent information was provided.

Based on observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis treatment (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) scheduled times. This deficient practice was identified for 1 of 1 residents (Resident #14) reviewed for dialysis and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The deficient practice was evidenced by the following: On 5/3/26 at 7:00 PM, the surveyor observed Resident #14 in bed with eyes open watching television and did not want to participate in an interview. The surveyor reviewed the medical record for Resident #14. A review of the resident's admission record revealed diagnoses which included but not limited to; chronic kidney disease, end stage renal disease (ESRD) (a condition which the kidneys cannot filter waste from the blood), dependence on renal dialysis (a mechanical process used to filter waste from the blood) and essential (primary) hypertension (high blood pressure). A review of a significant change Minimum Data Set, an assessment tool used to facilitate the management of care dated 3/5/26, reflected that the resident had a brief interview for mental status score of 13 out of 15, indicating that the resident was cognitively intact. A review of the resident's electronic physician's order (PO) reflected a PO for Hemodialysis on Monday-Wednesday-Friday @ (at) 5:30 AM with a start date of 4/17/26.Further review of the PO reflected the following:-a PO dated04/16/26 for Cholecalciferol oral capsule 25 MCG (1000 units), give 1 capsule by mouth one time a day for calcium absorption.-a PO dated 4/16/26 for Fenofibrate tablet 145 mg, give 1 tablet by mouth one time a day for high amount of triglycerides in blood.-a PO dated 11/23/24 for Folic acid 1 mg , give 1 tablet by mouth one time a day for Anemia- a PO dated 4/16/26 for Sucralfate tablet 1 Gram, give 1 tablet by mouth two times a day for gastric problems.A review of the May 2026 electronic medication administration record (EMAR) indicated medication administration times that occurred during the time that the resident was out of the facility at dialysis. The EMAR revealed the following:-a PO dated 4/16/26 for Cholecalciferol oral capsule 25 MCG (1000 units), give 1 capsule by mouth one time a day for calcium absorption. A plotted time of 10:00 AM and was signed as being administered.-a PO dated 04/16/26 for Fenofibrate tablet 145 mg, give 1 tablet by mouth one time a day for high amount of triglycerides in blood. A plotted time of 8:00 AM and was signed as being administered.-a PO dated 11/23/24 for Folic acid 1 mg , give 1 tablet by mouth one time a day for Anemia A plotted time of 8:00 AM and was signed as being administered.- a PO dated 04/16/26 for Sucralfate tablet 1 Gram, give 1 tablet by mouth two times a day for gastric problems. A plotted time of 10:00 AM and was signed as being administered. A review of the resident's progress notes (PN) revealed multiple notes indicating that the resident returns to the facility on dialysis days at 11:30 AM. Which included the following:A Nurses Note (NN) dated 5/4/26 at 12:47 PM, post-dialysis note: Resident returned to the facility at 11:10 AM.A NN dated 4/24/26 at 12:06 PM, Returned from dialysis about 12:30 PM. A NN dated 4/22/26 at 4:04 PM, Returned from dialysis at 12:30 PM.A PN dated 4/20/26 at 12:06 PM, post dialysis note: Resident returned to the facility at 11:30 AM.On 5/5/26 at 11:15 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) who was Resident #14's medication nurse. She informed the surveyor that Resident #14 returned from dialysis around 11:30 AM, and at that time she would administer the resident's medications. After reviewing the resident's e-MAR in the presence of the surveyor, the LPN stated that the medication should have the administration times adjusted per the time the resident returned from dialysis.On 5/8/26 at 10:30 AM, the surveyor presented the above concerns to the facility's administrative team which included the Licensed Nursing Home Administrator, the Director of Nursing, The [NAME] President of Clinical services, and the Regional Director of Clinical services.No additional information was provided.A review of the facility policy dated as last approved 6/1/2025 for Hemodialysis provided by the Regional Director of Clinical Services, revealed the following: Timely medication administration (initiated, held, or discontinued) by the nursing home and /or dialysis facility.NJAC: 8:39-11.2(b), 27.1(a), 29.2(a)(d)

Based on interviews and document review, it was determined that the facility failed to have a system in place to ensure prior to hire, all employees were pre-screened to ensure that they had not been found guilty in a court of law of abuse, neglect, or misappropriation, or had findings entered into the state nurse aide registry or against a professional license, and b) a process was in place to maintain documentation to confirm an appropriate pre-screening had occurred for all contracted facility employees which including dietary. The deficient practice was identified for 4 of 73 employee files reviewed that were provided by the facility and was evidenced by the following:On 5/3/26, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a list of all employees that were hired since last survey, including name, date of hire, title, and including contracted employees and their files including medical information. On 5/4/26 at 10:38 AM, the LNHA provided the list of employees, status, position, department, and date hired and their human resource and medical files. Between 5/4/26 and 5/8/26, the surveyors reviewed seventy-three employee files provided by the facility. Employee # 1, with a position of Social Worker and a date of hire (DOH) of 7/14/25, was noted to have a criminal background check ordered and completed on 9/5/25. Employee #2, with a position of Certified Nurse Aide (CNA) and a DOH of 1/15/25, was noted to have a criminal background check ordered on 5/7/26 with results of search pending. Employee #3, with a position of Certified Nurse Aide (CNA) and a DOH of 3/19/25, was noted to have a criminal background check ordered on 6/20/24 and results dated 6/21/24. Employee #4, with a position of District Manager for the [Name Redacted] (contracted) food service company and a DOH of 3/23/26, was noted to have a criminal background check ordered and completed on 5/6/26. On 5/07/2026 at 1:51 PM, the surveyor interviewed the Human Resource Director (HRD) who stated that she prints the criminal background check when she orders it, then she prints it again when the results come back. She further stated that a new employee should not be in the building until the criminal background check is completed. On 5/08/2026 at 10:09 AM, the survey team met with the Director of Nursing (DON), LNHA, Administrator in Training (AIT), [NAME] President of Clinical Services (VPCS), and the Regional Director of Operations (RDOO) and notified of the above concerns. On 5/08/2026 at 12:29 PM, the survey team met with the LNHA, DON, AIT, VPCS, and the RDOO. The DON handed the surveyor a packet stating, This is the employee files - it's all here.Review of facility provided policy, Employee files - New Hire - NJ, implemented 1/16/26, which included: Policy:The facility will not ask job applicants to answer medical questions, take a medical exam, or identify a disability. Current employees may be asked to undergo a medical examination under certain circumstances. Policy Explanation and Compliance Guidelines:Human Resources FileAll offers of employment are contingent upon clear results of a thorough background check. Background checks will be conducted on all final candidates and on all employees who are promoted, as deemed necessary.To include Social Security Verification, Educational Verification, Criminal History The surveyor reviewed the facility provided policy, Abuse, Neglect and Exploitation, revised 1/1/26, which included:Policy:It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.The components of the facility abuse prohibition plan are discussed herein:Screening Potential employees will be screened for a history or abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants.Screenings may be conducted by the facility itself, third party agency or academic institution.The facility will maintain documentation of proof that the screening occurred. N.J.A.C. 8:39-9.3(b)

Based on record review, staff interviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's clinical status regarding bladder function for one of five sampled residents (Resident (R) 1) reviewed for resident assessment. This failure had the potential to affect care planning, infection risk management, and the provision of necessary services.Findings include:Review of R1's admission Record located in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease, stage 3A.Review of R1'sMDS with an Assessment Reference Date (ARD) of 01/06/26, located in the EMR under the MDS tab, revealed R1 was coded as having an indwelling urinary catheter.Review of physician orders, treatment records, and nursing documentation found in the EMR revealed no evidence that R1 had an indwelling urinary catheter during the assessment period.During an interview on 04/16/26 at 12:24 PM, the Regional Nurse Clinical Supervisor (RNCS) stated that a Certified Nursing Assistant (CNA) entered incorrect information in the point of care system, which was subsequently used to complete the MDS without verification.Review of the facility's policy titled, MDS 3.0 Completion, revised 01/01/21, indicated that all disciplines were to follow the guidelines in Chapter 3 of the Resident Assessment Instrument (RAI) Manual when coding assessments.Review of the October 2024 RAI Manual, page 1-5, revealed, . An accurate assessment requires collecting information from multiple sources . information obtained should cover the same observation period . and should be validated for accuracy (what the resident's actual status was during the observation period) by the interdisciplinary team completing the assessment.

Based on interview and review of facility documents, it was determined that the facility failed to ensure that the facility-wide assessment identified the required services and procedures necessary for ventilator-dependent residents. This deficient practice was identified by the following:On 12/26/25, the surveyor requested a copy of the Facility Assessment (FA).On 12/30/25, the surveyor reviewed the FA dated completed 9/30/25.The FA under Part 1: Our Resident Profile indicated that the facility is licensed to provide care for 232 residents but did not specify that the facility has a license for 220 long-term care beds and 12 ventilator care beds.The FA under, Diseases/conditions, physical and cognitive disabilities, of the FA the facility identified under Category, respiratory system and under Common Diagnoses, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Respiratory Failure. Ventilator-dependent residents were not included.The FA under Decisions regarding caring for residents with conditions not listed above: 1.4 Complete Care at Bayshore will make every effort to make sound admission decisions regarding caring for residents with conditions not listed above. Facility administration and the clinical team will review all pertinent medical information of the pending admission. The facility team review will evaluate if the specific needs of the pending admission can be met and what resources will be needed to best meet their specific needs. The facility staff will receive continuing education of the new condition and all needed equipment (if applicable). Educational resources would not be limited to in-services education from the facility educator and will have additional educational support from any provisional vendor. Ventilator-dependent residents were not included.The FA under, Resident support/care needs, did not include ventilator-dependent residents.The FA under, Staff training/education and competencies, did not include ventilator-dependent residents.The FA under, Physical environment and building/plant needs: 3.8. Complete Care at Bayshore physical resources typically provided are listed below. Additional resources that are atypical may be provided on as-needed basis. This can be through rentals with various equipment rental agencies that the facility has a relationship with. The facility's purchasing department ensures our facility has adequate supplies through our ordering process and vendor relationships. Complete Care at Bayshore ensures equipment is maintained and monitored to protect and promote the health and safety of our residents. Ventilator-Dependent equipment was not included.On 12/29/25 at 12:07 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) with the Regional Director of Operations (RDO) and the [NAME] President of Clinical (VPC). The LNHA confirmed that the FA was up to date from 9/30/25 (?). The surveyor handed all three individuals the facility assessment and requested identification of vent specific or related assessments. The VPC stated this was covered under respiratory. The surveyor requested identification for vent specific planning and licensing, the VPC stated that overall capacity encompassed the ventilator specific licensing and was comprehensive. She further stated that the components regarding ventilator residents were present but that the FA could elaborate more.On 12/29/25 at 1:08 PM, in an interview at the exit conference that included the LNHA, RDO, VPC, Director of Nursing (DON), Regional Clinical Director (RCD) and [NAME] President of Operations (VPO), the surveyor informed the facility that there were concerns related to the FA. The VPO stated that federal regulations require one facility assessment and that there is nothing stating specifics regarding vents. She further stated that the facility would tighten up their FA but that they are not required to according to regulations.NJAC 8:39-5.1(a)

Based on observation, interviews, review of medical records and other facility documentation, it was determined that from 12/30/2021 through 03/22/2022, the facility failed to properly assess a skin opening of the left intergluteal cleft (groove between the buttocks) immediately upon identification, obtain treatment orders, and consistently implement timely interventions in adherence with the facility wound evaluation policy, physician's orders and the resident's care plan to prevent the development of a Stage 4 Pressure Ulcer. This deficient practice occurred for 1 of 2 residents reviewed, who were previously identified as being at risk for the development of a Pressure Ulcer and for Pressure Ulcer management (Resident #73). The deficient practice was evidenced by the following: Reference: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf NPUAP 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 and 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. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss On 07/19/22 at 11:14 AM, during the initial tour of the the facility, the surveyor observed Resident #73 seated in a wheelchair at the bedside. The resident stated that he/she developed a pressure ulcer about a year ago, and did not receive immediate treatment after the resident's Certified Nursing Assistant (CNA) had reported a wound that was on his/her tail bone to nursing. Resident #73 stated the pressure ulcer then grew in size and resulted in the resident being hospitalized with a diagnosis of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues, potentially leading to the malfunctioning of various organs, shock and death). Review of Resident #73's Face Sheet (an admission summary) revealed that the resident was readmitted to the facility in May of 2022, with diagnoses which included but were not limited to: Enterocolitis due to clostridium difficile (results from disruption of normal healthy bacteria in the colon, often from antibiotics but can also be transmitted from person to person by spores (bacterial cell), sepsis, unspecified open wound of unspecified buttock, urinary tract infection, neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), Type 2 diabetes mellitus (an impairment in the way the body regulates glucose (sugar) as fuel, and foot drop in the left foot (difficulty lifting the front part of the foot). Review of Resident #73's quarterly Minimum Data Set (MDS), an assessment tool dated 05/26/22, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident was cognitively intact. Further review of the MDS revealed that the resident required extensive assistance of one person for bed mobility, toileting, personal hygiene, required limited assistance of one person for transfers and had a Stage 4 pressure ulcer and was occasionally incontinent of bowel and bladder. The surveyor reviewed the resident's previous quarterly MDS dated [DATE], which identified that the resident was identified to have been at risk for pressure ulcers, and did not have a pressure ulcer, wound or any skin problems at that time. Further review of the MDS revealed that the resident had an indwelling urinary catheter (a tube placed in the bladder to allow urine to drain into a collection bag) and was occasionally incontinent of bowel. Review of Resident #73's Care Plan Activity Report (CPAR) revealed an entry dated 09/05/2018, which detailed that the resident's Skin Integrity was at risk for skin breakdown based on the Braden Scale Score (a tool for predicting pressure ulcer risk), and the score was not specified, impaired mobility, phabdomyolysis [sic.] (rhabdomyolysis, breakdown of muscle tissue that releases a damaging protein into the blood), bilateral knee surgery, lower extremity fracture repairs, gastric bypass (weight loss surgery), and anemia .Interventions included but were not limited to: Routine skin assessments twice a week. Report signs and symptoms of early skin breakdown to the wound nurse. On 08/27/2019, an intervention was added to notify the resident or POA (power of attorney) and the doctor about significant changes in skin condition or care. Use barrier cream to perineal area (the region between the thighs, bounded by the scrotum and anus in males and by the opening of the vagina and the anus in females). On 11/19/2021, the Wound Care Nurse (WCN) documented that the resident's skin remained without breakdown. Will continue current plan of care. On 02/07/2022, the WCN documented that the resident's skin integrity was well maintained, care plan reviewed and will continue. Further review of Resident #73's CPAR revealed an entry dated 03/22/2022 that was entered by the WCN and demonstrated the following: Skin Integrity: Pressure Ulcer-resident has a pressure related wound stage 4 to gluteal cleft that evolved from an atypical wound, with full-thickness tissue loss .Interventions that accompanied the entry included but were not limited to: Apply treatment to affected area as ordered. Re-evaluate periodically. Refer to Wound Specialist as needed. Refer to Wound Rounds Team as needed. Alternating pressure low air loss mattress (help treat pressure sores by providing two sets of air cells that expand and contract on an alternating basis to continually shift pressure). Minimize pressure to wounded area to maximize blood flow. Keep incontinence garment loosed [sic.] while in bed to allow air circulation to the affected area. Assess for pain at least every shift. Offer pain medication before wound treatment as needed. The WCN added a note to the entry which specified: Resident is f/u (following up) weakly [sic.] on wound rounds. Wound treatment and plan of care was adjusted to resident needs. Resident is also f/u with plastic surgeon, and was scheduled for skin reduction to facilitate wound healing. Wound is stable with no s/s (signs and symptoms) of infection .Further review of the CPAR revealed that on 03/22/22 at 11:26 AM, the WCN documented that the resident had an atypical (unusual) wound with full-thickness tissue loss to the gluteal cleft (groove that runs just below the sacrum, a triangular bone in the low back to the perineum). Review of the Progress Notes (PN) contained within the Electronic Health Record (EHR) revealed that on the following dates: -02/22/2022 at 3:44 AM -02/23/2022 at 2:34 AM -02/27/2022 at 2:32 AM -02/28/2022 at 2:41 AM -03/04/2022 at 3:12 AM -03/08/2022 at 3:14 AM -03/09/2022 at 4:05 AM Licensed Practical Nurse #1 (LPN#1) documented that Resident #73 had a wound on the left intergluteal cleft, and a wound on the right inner thigh, and indicated that a dressing was applied. On 03/22/2022 at 11:57 AM, the Licensed practical Nurse/Unit Manager (LPN/UM) documented that she was asked by the night nurse to have the Wound Care Nurse (WCN) take a look at Resident #73's butt (buttocks). The wound care nurse was made aware of the request and assessed the resident. The LPN/UM documented that the WCN then called her (LPN/UM) into the resident's room, and the LPN/UM observed that the resident had a wound on the gluteal cleft. Further review of Resident #73's PN revealed that on 03/22/2022 at 1:00 PM, the WCN documented that the resident had full-thickness tissue loss to the coccyx/gluteal cleft, that measured about 2 x 0.8 x 0.3 cm, base adipose tissue mixed with slough (dead tissue), periwound (skin surrounding the wound) with no erythema (redness), scant serous non-door [sic.] exudate. The WCN asked the resident when the wound developed? The resident stated that it had started a few weeks before the catheter was inserted. The WCN documented that the catheter was documented in January due to bilateral hydronephrosis (excess fluid in the kidney due to backup of urine). The surveyor reviewed Resident #73's paper medical record which contained a typed letter written by the resident's attending physician, dated 04/15/2022, which revealed the following: In 2007 the resident had gastric bypass and has since lost approximately 130 pounds (lbs.) Resident continued to lose weight on his/her own. The resident has had complications in relation to excess skin, and has been treated for skin infections under abdominal skin folds, the anterior medial aspects of upper legs, and most recently developed an ulcer in the gluteal cleft in relation to his/her excess skin causing friction and retention of moisture. (He/she was hospitalized from 04/01/22 until 04/06/22 for sepsis in relation to cellulitis in the upper legs). During that time, the gluteal cleft ulcer worsened, and continued to need regular daily treatment to promote wound healing. The physician requested consideration for removal of excess skin that was now medically necessary to promote wound healing, future skin infections and to provide a better quality of life. Further review of the paper medical record revealed a Consultation Report Form dated 04/27/2022, in which the Plastic Surgery Group documented that Resident #73 was seen and examined and the chart was reviewed. The Impression was: Stage IV sacral pressure ulcer with chronic granulation tissue (healing surface of wound), mild slough, some periwound maceration (skin surrounding wound was surrounded by moisture), no pus, no cellulitis (inflammation of subcutaneous connective tissue), redundant skin and subcutaneous tissue of the buttocks and lower extremities noted (s/p weight loss). Plan: Patient is not a good medical/surgical candidate for extensive skin/fat removal over buttock and flap advancements with anticipated high risk of complication including wound breakdown. Also, it was unclear if removal of excess skin/fat would expedite healing of chronic sacral ulcer. Recommend continued local care to sacral pressure ulcer and consider periwound protection of skin with barrier cream, as per wound care team. On 07/26/2022 at 11:07 AM, the surveyor interviewed the LPN/UM who stated that on 03/22/22 during the night shift, Resident #73 who was oriented, requested that the Licensed LPN #1 look at a wound on his/her gluteal cleft. LPN #1 discovered an opened wound on the resident's gluteal cleft and failed to document the finding as required. The LPN/UM stated that LPN #1 had informed her about the wound in the morning before he signed off duty, and he requested that she contact the WCN. The LPN/UM stated that to her knowledge the wound was a new opening. The LPN/UM stated that when she looked at the wound herself, it was opened. The LPN/UM stated that a review of a Skin assessment dated [DATE], revealed that a left intercleft wound was previously identified. The LPN/UM stated that Registered Nurse (RN #1) documented that the resident had a left intergluteal cleft wound and should have known the process for wound care documentation and reporting. She further stated that RN #1 should have alerted the LPN/UM at that time, as well as the doctor, WCN and supervisor. The LPN/UM stated if RN #1 had followed the policy and procedure for notification, it would have initiated a Care Link (a computerized incident report) and also a Skin Integrity Packet could have been initiated. LPN/UM acknowledged that as a result of RN #1's failure to follow the facility policy and procedures, there was a delay in reporting the resident's wound, and also in obtaining and implementing a treatment order for the wound as was required. On 07/26/22 at 1:37 PM, the surveyor interviewed the Registered Nurse/Educator (RN/E) regarding what the process would entail when a new wound was discovered. The RN/E stated that when a nurse identified a new wound they were expected to inspect the area, and then initiate a treatment based on what they observed, then they should call the doctor and validate that the treatment option was appropriate for the resident, write a PN, initiate a Care Link, and complete a Skin Packet. She stated that the facility utilized both paper and computerized incident reports which doubled the work. She then stated that the WCN also would receive a message to evaluate the, and that by that time, a treatment should have already have been initiated. The doctor and family notification and skin note were part of the Care Link. The RN/E stated that the CNA's (Certified Nursing Assistant) were also required to write a statement and document what they observed in their own words. She stated that skin assessments were completed on shower days and required a 72 hour look back to see if they could have prevented any skin injuries. The RN/E stated any finding discovered on the night shifts should have been passed onto the day shift in report which would ensure that it would be followed through. It should also have been discussed in the morning huddle (a daily clinical meeting) to ensure the supervisor could make rounds as needed and follow-up. She stated, skin issues were not just a little blurb. The RN/E further stated that if RN #1 had identified a skin issue on 02/17/22, she should have passed it on in the report, and also have documented the finding in the PN. She stated that the WCN evaluated the resident on 02/17/22 at 9:46 AM, and documented the specifics related to an upper thigh wound. The RN/E stated that the CNA who first observed the wound should have written a statement, which should have been included in the 72 hour look back. The RN/E stated that the CNAs should have lifted that skin on the resident's intergluteal cleft to clean it at the very least. The RN/E further stated that Resident #73 was a good historian, and he/she could remember what they ate last week. The RN/E stated that when interviewed, the resident had recalled that the wound had been in place on his/her bottom prior to the urinary catheter insertion which was inserted in January 2022. The RN/E stated that the wound may have developed in December 2021. The RN/E reviewed the EHR in the presence of the surveyor and stated the following: On 12/13/2021 the resident's skin was intact. On 12/30/2021, an opening was identified at the left intergluteal cleft by RN #1. The RN/E stated that further review of the EHR revealed that there were no wound related documented interventions in response to the newly discovered wound, and nothing was documented by the WCN regarding the finding. The RN/E further stated, if the resident's wound was not addressed from 12/30/2021 through 03/22/2022, that was a very long time. On 07/26/22 at 2:26 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who provided the surveyor with a typed, Investigation Summary and Conclusion dated 03/22/22 which indicated that the Event Date was 12/22/2021. The surveyor asked the LNHA for clarification about the delay in the investigation from the time of discovery of the wound and he stated he was not familiar with the investigation as it was completed under the previous LNHA. The RN/E was present and presented the surveyor with Resident #73's Clinical Assessment form which had a hand written date on it of 12/30/2021, and contained the following entry: Gluteal Abrasion was documented on the form. Review of Resident #73's Investigation Summary and Conclusion revealed that on 03/22/22, the LPN/UM documented the following: Situation: Skin Integrity: On 12/30/2021, RN #1 did a Care Link for a skin integrity opening found to the left intergluteal cleft. The Braden Score was 19, low risk .The 3-11 CNA was interviewed and the resident had something small on his/her butt back in December. The CNA reported it to the nurse and the nurse initiated a Care Link. After that, the CNA stated that she reported it to multiple nurses over the next couple of months and even told the nurses that it was getting worse. She applied peri guard (used to treat skin irritation associated with incontinence) to the area as ordered and encouraged the resident to remind the nurse to look at it when they administered medications to the resident. The following time line was included in the investigation: On 01/03/2021 a skin assessment was done and showed that the resident had a gluteal abrasion, 01/13/2022 skin assessment showed a small opening to the intergluteal cleft, 01/21/2022 urinary catheter was inserted. Prior to the urinary catheter insertion, the resident was a heavy wetter with some bowel incontinence episodes. On 02/16/2022, a skin assessment showed a left inner thigh wound, and left inner cleft wound. On 02/17/2022, RN #1 noted an opened lesion to the right inner thigh which was addressed with treatment recommended by the WCN and MD (medical doctor) and the wound healed after a few weeks. On 03/14/2022, a skin assessment was rendered and it showed redness to the area, On 03/22/2022, LPN #1 asked the LPN/UM to have the WCN look at the resident's butt. The WCN called the LPN/UM into the resident's room and she observed a full thickness wound to the coccyx/gluteal cleft and the supervisor was made aware. Further review of the Investigation Summary and Conclusion revealed the following Conclusion/Recommendations: Resident was seen by WCN for full-thickness tissue loss to coccyx (tail bone)/gluteal cleft and observed about 2 x 0.8 x 0.3 cm, base adipose (fat) tissue mixed with slough, periwound, no erythema, scant serous (thin, watery drainage) non-door [sic.] exudate (fluid that leaked out of blood vessels into nearby tissues). Santyl (helps remove dead skin and aid in wound healing) applied and covered with a 4 x 4 gentle dressing and will continue daily and as needed per MD. On 03/31/22, resident was seen by Wound Team which included Wound Care Consultant Nurse Practitioner (WCC/NP), who saw the resident and an atypical wound (no wound staging was identified) to gluteal cleft that measured 2 x 2 x 1 cm, was noted. Treatment continued. Specialty mattress updated to low air loss mattress to promote wound healing. Reinforced the importance on side lying while in bed and to keep the region clean and dry to avoid moisture trap under loose/saggy skin flaps. Care Plan discussed with the resident and nursing staff. Further review of the Investigation Summary and Conclusion revealed that on 04/01/2022, Resident #73 complained of not feeling well and the vital signs were: blood pressure: 80/58, heart rate 102, respirations 16, temperature 100.5, SPO2 (measures level of circulating level of oxygen circulating in the blood with the use of a probe placed on the fingers) on room air was 96%. The resident was sent to the emergency room and was admitted with a UTI (urinary tract infection), fever, abdominal pain and right thigh cellulitis and returned to the facility on [DATE]. The Wound Team and WCC/NP followed up on 04/07/2022, and documented an atypical wound to coccyx/gluteal cleft and noted that it had worsened s/p recent hospitalization after the resident spent three days in the Intensive Care Unit and the wound evolved into a Stage 4 Pressure Ulcer. On the day of discharge the resident had a bedside wound debridement (the removal of damaged tissue from a wound to promote wound healing). Today on assessment the wound measured 2.5 x 2 x 2 cm, slough mixed with granular tissue and bone exposed which increased the risk for osteomyelitis (bone infection) . Moderate serous exudate, no erythema to periwound, pain present .Area will be difficult to heal due to excess skin from weight loss that covered the ulcer. The resident should be seen by a plastic surgeon or general surgeon to have the skin removed to promote healing. Ongoing weekly WCC/NP follow-up to continue. On 07/26/22 at 12:58 PM, the surveyor conducted a telephone interview with LPN #1 who confirmed that he terminated his employment with the facility on 05/27/22. He stated that he recalled that,Resident #73 had a sacral wound that was a little lower than the sacrum at the top of his/her butt crack that was tucked away beneath excess skin. He stated that one of the 3:00 PM to 11:00 PM CNAs brought it to his attention, although he did not recall her name. He stated that he inspected the wound himself, wrote a report, and brought it to the attention of the LPN/UM. He stated that the report that he wrote was paper based and was filed with management. He stated that the resident complained of pain at the sight of the wound. He stated that the WCN was required to complete the wound assessment and update the residents CPAR. LPN #1 stated that he was required to document the finding in the Progress Notes (PN) which included documentation of a skin abnormality, who had been notified of the finding, and any actions that were taken. He stated that both the physician and the LPN/UM were required to be notified. The surveyor informed LPN #1 that review of the Shift Assessment that he completed on 03/22/22 at 2:30 AM, on the date that he reported the finding to the LPN/UM, revealed that he documented that the resident's skin/wounds were as follows: color appropriate to ethnicity, warm and dry and failed to document the wound or required interventions as he previously described. He stated that the Shift Assessment was documented prior to the CNA bringing the wound to his attention. The LPN#1 stated that he did not recall seeing the wound prior to 03/22/2022, and that was when he reported it. On 07/27/2022 at 10:00 AM, the surveyor conducted a phone interview with CNA #1 in the presence of the survey team. She stated that on the 3:00 PM to 11:00 PM shift she was responsible to shower the residents and to report any skin abnormalities to the nurse. CNA #1 stated that Resident #73 was assigned to her in December 2021. She stated that the resident developed a little hole on his/her sacrum and she reported it for the first time to LPN #1 because he was the resident's assigned nurse at that time. CNA #1 stated that she asked LPN #1 for permission to apply barrier cream to the area on the resident's sacrum. CNA #1 stated that she reported the finding to him, and what he did with the information was not part of her job. CNA #1 stated that she had written a statement and provided it to the LPN/UM (statement dated 03/22/2022). CNA #1 stated that LPN #1 was the first nurse that she had reported it to, and that she had also worked with RN #1 and also had reported the skin abnormality to her. CNA #1 explained that she had to lift the resident's skin in order to see the area because the resident lost a lot of weight and the resident's skin flopped on the butt. CNA #1 further explained that in order to see the wound, you must lift the resident's skin up, and then look at the area under the skin when care was provided. On 07/27/2022 at 11:15 AM, the surveyor conducted a phone interview with Resident #73's attending physician, who stated that about six months ago, the facility alerted him that the resident had a Stage I or Stage II pressure ulcer. He stated we did our best with body repositioning, but the resident had lost a lot of weight and also had neuropathy (disease that affects peripheral nerves causing numbness or weakness). He stated that he doubted that the resident's wound would heal. He stated that he last saw the wound, about four months ago, it had looked the same. The physician described the wound as an irritated area with a little bit of contamination, and had both discharge and secretions coming from the wound. He further stated that he reviewed the WCC/NP's notes, and the LPN/UM always had called him about the wound. On 07/27/2022 at 12:10 PM, the surveyor interviewed the WCC/NP via telephone. She stated that her colleague who was assigned to Resident #73 completed an initial consult with the resident on 03/24/2022, and the wound was deemed to be atypical with full thickness skin loss. She stated that the assigned NP last saw the resident on 06/23/2022, and was currently out on leave. The WCC/NP stated that she had not seen the resident in her colleague's absence since that time because the resident had orders from the surgeon, and she had wanted to avoid having two providers looking at the wound. She stated based on the notes written by the previous WCC/NP, the following wound treatment was recommended: Cleanse with normal saline solution, pat dry, lightly pack with silver alginate (treatment for at risk or infected wounds) and cover with foam dressing twice daily due to moderate drainage. She stated the wound was staged as a Stage 4 Pressure Ulcer because there was bone exposed. She stated the wound was in a difficult area, and was not necessarily a pressure injury, there was moderate loose skin and trauma related to rubbing from excess skin to the mid-gluteal cleft. The WCC/NP stated that the facility WCN also would monitor the wound but she has been on vacation. On 07/27/2022 at 12:32 PM, the surveyor interviewed Resident #73 who stated that CNA #1 first identified that she had observed a little skin tear on the resident's bottom. The resident was unable to provide the date CNA #1 observed the skin tear. The resident stated that CNA #1 kept checking it and had reported it to the nurse. The resident stated that CNA #1 and CNA #2 put cream on it and informed the assigned nurse. The resident stated that the tear had gotten bigger, and bigger and there was blood and oozy stuff when he/she wiped that area. The resident stated that by that time, it got very big and really infected and went into my leg. The resident stated that his/her blood pressure went very low ,and the vitals were off, so I was sent out to the hospital that night with a diagnosis of sepsis. Resident #73 stated, that while at the hospital, I was in the ICU and was on a strong antibiotic. The infection came around to the front of my leg from the tail bone. The resident continued, and stated the WCC/NP who was out on leave came in to see him/her a couple of weeks ago, and the facility WCN was currently on vacation. The resident was concerned that no one had looked at the wound recently except for the facility nurses. The resident further stated that the plastic surgery had been postponed as the doctor had not granted medical clearance for the resident to have the procedure. On 07/27/2022 at 1:01 PM, the surveyor interviewed the LPN/UM who reviewed the EHR in the presence of the surveyor and confirmed that Resident was #73 last seen by the WCC/NP on 07/07/2022, twenty days prior, and the WCN was also present during wound rounds on that date. The surveyor asked for clarification of the date that the resident's left intergluteal cleft wound was initially identified. The LPN/UM stated that on 03/22/2022, the DON and she typed up a statement and there was also an incident report completed related to Resident #73's sacral wound. The LPN/UM stated that the resident's primary nurse, RN #1, documented a skin abnormality on 12/30/2021, and was supposed to initiate an incident report. She stated that to her knowledge, there was no wound treatments rendered to the resident's wound between 12/30/21 and 03/22/2022. She stated that the DON was notified. She stated that both she and the facility WCN looked at the wound together, and when I saw it, I was like wow! The LPN/UM stated that when we lifted and inspected the skin, I could see that it was opened. She clarified that LPN #1 had just informed her that there was something there but I had not expected for the wound to have been opened. The LPN/UM stated that when RN #1 was interviewed during the investigation conducted on 03/22/2022, she stated that she informed the WCN via e-mail and notified her directly of the resident's wound in December 2021. The LPN/UM stated that she informed RN #1 that nursing was required to inform the Unit Manager, and she should have initiated a treatment, notified the WCN, completed a Care Link and notified the Supervisor. The LPN/UM further stated that RN #1 should have also notified the doctor, and was also required to write a PN as she was the initial nurse that had observed the wound. On 07/27/2022 at 1:28 PM, the DON presented the surveyor with another investigation that pertained to Resident #73's wound. He stated that Z-Guard (skin protectant) and a pressure relief mattress were in place for the Resident #73 prior to December 2021. He stated on 12/30/2021, it was documented that there was some opening on the resident's left intergluteal cleft in the PN. He stated that per skin assessments, a skin issue on the gluteal cleft was documented off and on. On 02/17/2022, the WCN was asked to see the resident related to a wound found on the groin area, and she did not document that she had assessed the resident's sacrum at that time, though she had discontinued the Z-Guard (skin protectant) that was previously ordered, and had added Zinc (prevents diaper rash) instead. He stated that LPN #1 verbally reported a concern on the resident's skin to the LPN/UM on 03/22/2022 and the WCN was notified. He stated that the LPN #1 documented that he could not tell if the wound was opened or the severity of the wound. The DON stated that CNA#1 documented that she notified both LPN #1 and RN #1 in December 2021. The DON stated that CNA #1 documented, I have been reported it as part of my job. He stated that RN #1 should have documented changes in the resident's skin, and a Skin Packet (form of an incident report) should have been completed so that we could have investigated the matter further. He stated that RN #1 was also required to inform the Supervisor and WCN. The physician should also have been contacted if a treatment order was needed. He stated that RN #1 failed to complete the skin packet, and as [TRUNCATED]