Every finding on record at Complete Care at Green Knoll

Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris.On 02/04/2026 9:21 AM, in the presence of the Food Service Director (FSD), the surveyor toured the kitchen and the designated garbage area and observed the following: There were multiple carboard boxes outside of the dumpster on the ground and surrounding area. The FSD stated that the area should have been cleaned by the maintenance and dietary departments. On 2/5/26 at 9:00 AM, the FSD provided the surveyor with a facility policy titled, Garbage and dumpster area policy with a revised date of 5/8/21. The policy revealed, 3. If any trash blows out of the trash can or you drop any trash on the ground or around the dumpster, you are responsible to pick it up. If you make a mess by the dumpster when throwing out garbage, you must clean it up. 4. Everyone is responsible to breakdown and throw out their own boxes. They are to be put in the small recycling bin only, not in the long dumpster. Do not throw boxes in bins unless they are broken down. On 2/9/26 at 12:56 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Clinical Director (RCD), Regional Director of Operations (DOO), and [NAME] President of Quality and Performance Improvement (VPQPI) to review concerns found during the survey. The LNHA stated all boxes need to be broken down and put into the dumpster and not left on the ground.On 2/11/26 at 12:06 PM, the surveyor met with the LHNA, DON, RCD, and DOO for exit conference. No further pertinent information was provided. NJAC 8:39-19.7

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep the call bell within residents' reach. This deficient practice was identified for 8 of 30 residents (Resident #6,15, 37, 44, 55, 139, 152 and 155) reviewed for accommodations of needs and was evidenced by the following:1.On [DATE] at 11:56 AM, the surveyor observed Resident #139 in bed wearing glasses with floor mats on both sides of the bed and the call bell on the floor not within the resident's reach. On [DATE] at 7:40 AM, the surveyor observed Resident #139 in bed with floor mats on both sides of the bed and the call bell on the floor not within the resident's reach. The surveyor reviewed the medical record for Resident #139. A review of the admission record reflected that Resident #139 was admitted to the facility with diagnoses that included but were not limited to; dementia (an umbrella term for a progressive decline in cognitive function) and diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar). A review of Resident #139's Quarterly Minimum Data Set (MDS) an assessment tool, dated [DATE] revealed the resident had a brief Interview for mental status (BIMS) score of 7 out of 15 which indicated a severe cognitive impairment. Section GG assessed Resident as being dependent on staff for Activities of Daily Living (ADL) care. A review of Resident #139's Care Plan Report (CPR) reflected a Focus area that the resident was at risk for falls dated as initiated on [DATE] with interventions that included but were not limited to; Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident must have prompt response to all requests for assistance. 2.On [DATE] at 12:00 PM, the surveyor observed Resident #37 in bed with their eyes closed and the call bell on the floor behind the dresser not within the resident's reach. On [DATE] at 12:52 PM, the surveyor observed Resident #37 in bed with the call bell on the floor behind the dresser not within the resident's reach. On [DATE] at 7:42 AM, the surveyor observed Resident #37 in bed with call bell on the floor behind the dresser. The surveyor reviewed the medical record for Resident #37. A review of the admission Record revealed the resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease and Chronic Kidney Disease, stage 3 (long-term progressive loss of kidney function). A review of the Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 3 out of 15 which indicated a severe cognitive impairment. Section GG assessed that Resident #37 required substantial maximum assistance from staff for ADL care. A review of the CPR reflected a focus area that the resident was at risk for falls with interventions that included but were not limited to; the resident needs a safe environment with .a working and reachable call light . On [DATE] at 12:56 PM, the surveyor showed the Certified Nursing Assistant (CNA) assigned to Resident #37's care (CNA #3) the call bell on the floor. CNA #3 confirmed that she should have placed the call bell within the resident's reach. On [DATE] at 7:44 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) observed the call light on the floor behind the dresser and confirmed that all call bells should be placed within the resident's reach. 3. On [DATE] at 12:15 PM, the surveyor observed Resident #55 in bed with their eyes closed and the call bell on the roommate's end table behind the privacy curtain not within the resident's reach. The surveyor reviewed the medical record for Resident #55. A review of the admission Record reflected Resident #55 was admitted to the facility with diagnoses that included but were not limited to; dependence on renal dialysis (a life-sustaining medical procedure that replaces kidney function in individuals with severe kidney failure) and hypertension (high blood pressure). A review of Resident #55's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 5 out of 15, which indicated a severe cognitive impairment. Section GG assessed that the resident required substantial/maximum assistance from staff for ADL care. A review of Resident #55's CPR had a Focus area that indicated the resident was at risk for falls with interventions that included but were not limited to; the resident needs a working and reachable call light . 4. On [DATE] at 12:38 PM, the surveyor observed Resident #152 in bed with the call bell on the floor not within the Resident's reach. The surveyor reviewed the medical record for Resident #152. A review of the admission Record reflected Resident #152 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; dementia and hypertension. A review of the Quarterly MDS dated [DATE] reflected Resident #152 had a BIMS score of 1 out of 15 which indicated severe cognitive impairment. Section GG further assessed Resident #152 was dependent on staff for ADL care. A review of Resident #152's CPR reflected a focus area resident is at risk for falls initiated on [DATE] with interventions that included but were not limited to; Ensure the resident's call light and personal items are within reach encourage the resident to use the call bell for assistance. The resident needs prompt response to all requests for assistance. On [DATE] at 12:42 PM, the surveyor showed CNA #2 152's call bell on the floor. CNA #2 confirmed that the call bell should be within the resident's reach and stated that the resident was able to use it. 5. On [DATE] at 12:55 PM, the surveyor observed Resident #44 in bed. The surveyor observed that the resident did not have a call bell. The surveyor reviewed the medical record for Resident #44. A review of the admission Record reflected that Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; diabetes mellitus and cerebral infarction (stroke that results in an area of necrotic tissue in the brain.) A review of the Annual MDS dated [DATE] reflected Resident #44 had a BIMS score of 2 out of 15 which indicated severe cognitive impairment. Section GG assessed Resident #44 required supervision or touching assistance for transfers and ambulation. A review of the CPR had a focus area resident is at risk for falls initiated [DATE] with interventions that included but were not limited to; Ensure the resident's call light is within reach and encourage the resident to use it.The resident needs prompt response to all requests for assistance. On [DATE] at 12:56 PM, the surveyor showed the CNA assigned to Resident #44's care (CNA #3) the missing call bell. CNA #3 confirmed that the call bell was missing and that all residents should have a call bell so that they are able to call for staff assistance when needed. 6. On [DATE] at 1:00 PM, the surveyor observed Resident #15 in bed with their eyes closed on a specialty mattress and the call bell under the bed not within the resident's reach. The surveyor reviewed the medical record for Resident #15. A review of the admission Record reflected Resident #15 was admitted to the facility with diagnosis that included but were not limited to; Alzheimer's Disease and hypertension. A review of Resident #15's Quarterly MDS dated [DATE] reflected the resident's cognitive skills for daily decision making were severely impaired and that Resident #15 was dependent on staff for ADL care. A review of Resident #15's Care Plan Report reflected a Focus area that indicated the resident had an ADL self-care deficit dated as initiated on [DATE] with interventions that included but were not limited to; encourage the resident to use the bell to call for assistance. On [DATE] at 1:02 PM, the surveyor showed the CNA assigned to Resident #15's care (CNA #1) the call light on the floor under the bed. CNA #1 confirmed that all call lights should be within the resident's reach. On [DATE] at 1:56 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), Regional Clinical Director, Regional Director of Operations and VP of Quality and Performance Improvement to discuss the above observations and concerns. On [DATE] at 10:55 AM, during an interview with the surveyor, the DON confirmed that all residents should have call bells and that nurses and CNAs should ensure that they are placed within the residents' reach so that they were able to summon the staff for assistance. On 2/1126 at 12:06 PM, no further information was provided. NJAC 8:39-27.1 (a); 31.8 (c) (9) 7. On [DATE] at 10:55 AM, the surveyor observed Resident #155 in their room. The resident was sitting up in bed and was watching television. The resident was alert and oriented and the surveyor asked the resident how they would contact the facility staff since the call bell system for the room is not working. The resident told the surveyor that they would ask their roommate to contact the facility staff using the roommate's call bell. The surveyor observed a tap bell on the resident's bedside table, not within reach of Resident #155. The surveyor reviewed the medical record for Resident #155. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; gastrostomy status(refers to the presence of an artificial opening (stoma) in the stomach, usually with a tube (PEG) inserted directly through the abdominal wall for long-term nutritional support) and multiple sclerosis (chronic and often disabling, autoimmune disease of the central nervous system). A review of the Quarterly MDS, dated [DATE], indicated that Resident #155 had a BIMS score of 6, which indicated that the resident's cognition was severely impaired. The MDS further indicated that Resident #155 was dependent on staff for ADL care. A review of the Resident's CPR included a focus area, Falls, with interventions that included, but were not limited to: keeping the resident's call light within reach and encouraging the resident to use it for assistance as needed. Resident #155 also needed a prompt response to all requests for assistance. 8.) On [DATE] at 11:00 AM, the surveyor observed Resident #6 in their room; the resident was seated in their bed reading. The surveyor interviewed the resident about the facility's call bell system. Resident #6 stated they would request staff assistance by using the call bell. The call bell was next to the resident, but they were unaware that the call bell system in their room was not working. The surveyor asked the resident whether the facility had given them a tap bell. The resident was unsure whether they had received a tap bell, but the surveyor and the resident couldn't locate one. A review of the admission Record reflected that the resident was admitted to the facility with a diagnosis that included but not limited to; restless leg syndrome (a common neurological disorder characterized by irresistible urge to move the legs, typically accompanied by uncomfortable crawling, tingling, or aching sensation), chronic pain syndrome (a condition where pain last 3 to 6 months beyond normal healing), and venous insufficiency peripheral (occurs when damaged or blocked veins struggle to return blood to the heart, causing venous pooling.) A review of the Quarterly MDS dated [DATE] indicated that Resident #6 had a BIMS score of 14, which indicated that the resident's cognition was intact. A review of the Resident's CPR identified a focus area, Falls, with interventions that included but were not limited to; place the call bell within reach. On [DATE] at 11:15 AM, the surveyor in the presence of the Licensed Practical Nurse/ Unit Manager (LPN/UM) searched for Resident #6's tap bell. The LPN/UM acknowledged that the call bell system for Resident #155 and Resident #6's rooms were not working. The LPN/UM found Resident #6's tap bell, which was on their roommate's nightstand, not within their reach. The LPN/UM confirmed that the two tap bells were out of reach for both residents and that both residents should have their tap bells within reach. On [DATE] at 12:30 PM, the surveyor discussed the above concerns with the facility administration team, which consisted of the Licensed Nursing Home Administrator (LNHA), Director of Nursing, Regional Clinical Director, Regional Director of Operations, and the [NAME] President of Quality and Performance Improvement. A review of the facility policy titled Call Lights dated [DATE], provided by the LNHA revealed the following: A call bell will be available within reach and operational for each resident. NJAC 8:39- 27.1(a); 31.8 (c)(9)

Based on observation, interview, record review and review of facility provided documents, it was determined the facility failed to a.) ensure the timeliness of each resident's person-centered comprehensive care plan (PCCP), that is reviewed and revised by an interdisciplinary care team, (IDCP) during the IDCP meeting with the resident and a resident representative (if applicable) every quarter, and b) updating the care plan to reflect new physician orders. The deficient practice was identified for 2 of 30 residents reviewed for Comprehensive Care Plan (Resident #11 and Resident #168). These deficient practices were evidenced by the followinga. Resident #11 On 02/4/26 at 10:45 AM, the surveyor observed Resident #11 in their room. A review of the medical records revealed Resident #11 had diagnoses which included but were not limited to; hemiplegia and hemiparesis, cerebral vascular accident (CVA) (a loss of blood flow to part of the brain), chronic obstructive pulmonary disease (condition involving constriction of the airway and difficulty or discomfort in breathing) (COPD). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of MDS submissions for Resident #11 from the facility are as follows. 02/15/26 -- in progress 11/16/25-- quarterly 08/17/25—annual, IDCP meeting not done 05/18/25-- quarterly 02/16/25— quarterly, IDCP meeting not done 11/17/24-- quarterly 08/18/24—annual, IDCP meeting not done A review of the IDCP meeting progress notes revealed that the IDCP meetings were not done according to facility policy and Center of Medicare regulations to be done quarterly following MDS schedule. For the year of 2025 there were only two IDCP meetings; 11/17/25 and 5/21/25.For the year of 2024, 11/24/24. The not completed IDCP meetings are as follows.8/17/25, 2/16/25, and 8/18/24 in accordance with MDS submissions. On 02/9/26 at 11:15 AM, the surveyor interviewed the social worker who stated, she knew the IDCP meeting should be done quarterly but sometimes things happen and they need to be canceled. When asked if documented such issue to indicate in the electronic medical record (eMR) her response was no. The system generated responses are from her adding a date or something to the MDS and the eMR auto populates a system generated system note. On 02/09/26 at 12:57 PM, the Director of Nursing (DON) stated that resident care plans are revised as needed and quarterly. The DON further stated, the care plan represents what care the resident was being provided and that the care plans were patient centered. The DON acknowledged and agreed with the surveyors' findings. On 02/10/26 at 10:12 AM, the surveyor interviewed the DON who stated that the care plan is completed by each department by discipline. Allowing it to be patient centered on admission, quarterly, and significant event timeframe. IDCP meetings are held according to MDS timing. The Care Plan is officially reviewed with the residents during their IDCP meetings. On 2/11/26 at 12:15 PM, the above concerns were addressed to the facility administration. A review of the Comprehensive care Plan policy, dated 9/1/24 and revised 3/6/25, revealed.it is the facility policy to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights.person- centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives.comprehensive care plan will be prepared by an IDC team, that includes, but is not limited to: family members, surrogate, or others desired by the resident.The comprehensive care plan will be reviewed and revised by the IDC team after each comprehensive and quarterly MDS assessment. NJAC 8:39-11.2, 12.1, 13.2 b. Resident #168 On 2/5/26 9:30 AM, the surveyor observed Resident #168 in their room watching television. During interview Resident #168 stated they go to dialysis three times per week and is on a specialized diet including a fluid restriction. On 2/5/2026 9:41 AM, the surveyor reviewed the medical records of Resident #168 which revealed diagnoses which included but were not limited to; end stage renal disease (a chronic kidney disease which includes the gradual loss of kidney function), dependence on renal dialysis (a medical treatment that performs the essential blood-filtering functions of failing kidneys by removing waste, toxins, and excess fluids from the body), and protein-calorie malnutrition (a condition characterized by a deficiency of both protein and calories to meet the body's nutritional needs). A review of the most recent comprehensive Minimum Data Set (MDS), reflected the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated a cognitively intact cognition A review of the monthly summary revealed a Physician Order (PO) dated 1/28/26, Fluid Restriction 1500 milliliters (ml): Dietary: 1080ml, Nursing 420ml: 7am-3pm = 180ml, 3pm-11pm = 180ml and 11pm-7am= 90 ml. A review of Resident #168's Care Plan (CP) revealed a CP with an initiated date of 1/23/26, I am on a fluid restriction 1500ml: Dietary: 1000ml, Nursing: 500ml, 7am-3pm = 200ml, 3pm-11pm = 200ml, 11pm-7am = 100ml. On 2/9/26 at 9:31 AM, the surveyor interviewed the Registered Dietitian (RD#1) who stated the nursing staff puts the FR and fluid breakdown in the PO initially and RD#1 will adjust the FR breakdown to accommodate the resident's specific needs and fluid requests. The nursing staff puts the FR CP into the system and the nurse will adjust the CP as needed. RD#1 stated there was a miscommunication between her and the nursing staff and that is why the CP was not updated to reflect the latest FR PO. A review of the Comprehensive care Plan policy, dated 9/1/24 and revised 3/6/25, revealed under the policy explanation and compliance guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: f. Resident specific interventions that reflect the resident's needs and preferences.5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. On 2/9/26 at 12:56 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Clinical Director (RCD), Regional Director of Operations (DOO), and [NAME] President of Quality and Performance Improvement (VPQPI) to review concerns found during the survey. The DON stated the care plans should match the physician orders in terms of the fluid restriction. On 2/11/26 at 12:06 PM, the surveyor met with the LHNA, DON, RCD, and DOO for exit conference. No further pertinent information was provided. NJAC 8:39-11.2, 12.1, 13.2

Based on observation, interview and review of facility policy, it was determined that the facility failed to maintain the confidentiality of the resident information and properly dispose of paperwork with resident information. This deficient practice was observed during kitchen observation around the dumpster area of the building.On 2/4/26 at 9:30 AM, during observation of the garbage/dumpster area and in the presence of the Food Service Director (FSD), the surveyor observed an open carboard box with multiple papers. Upon further observation and investigation, the surveyor observed multiple printed papers dated 8/12/25 and 8/18/25 that contained resident names and room numbers as well as a list of residents who were under enhanced barrier precautions ((EBP) infection control measures that require healthcare staff to wear gowns and gloves during high-contact care activities for residents at risk of or colonized with multidrug-resistant organisms.)On 2/4/26 at 9:35 AM, the Assistant Director of Nursing (ADON) confirmed the papers in the cardboard box had resident information and that paperwork should have been disposed of properly which included being placed into a designated disposable box that is later shredded by an outside company.On 2/9/26 at 9:53 AM, the surveyor interviewed the Director of Nursing (DON), who stated all paper medical records should be placed in the designated area and all records should be shredded to protect patient information. The DON was unable to state how and why the resident paperwork was incorrectly disposed of. On 2/9/26 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Confidentiality of Personal Medical Records) with a revised date of 3/6/25. The policy explanation and compliance guidelines revealed, 8. Paper notes or reminders with residents' personal or medical information shall not be left unattended or viewable by unauthorized persons. These paper notes and reminders will be disposed of in a way that will not compromise resident's personal or medical information.On 2/9/26 at 12:56 PM, the surveyor met with the LHNA, DON, ADON, Regional Clinical Director (RCD), Regional Director of Operations (DOO), and [NAME] President of Quality and Performance Improvement (VPQPI) to review concerns found during the survey. The LNHA stated the paper documents with resident information was not disposed of correctly and a facility wide in-service had been conducted.On 2/11/26 at 12:06 PM, the surveyor met with the LHNA, DON, RCD, and DOO for exit conference. No further pertinent information was provided.NJAC 8:39-4.1 (a) 18

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms. The deficient practice was observed on 1 of 3 nursing units (3rd floor) and was evidenced by the following:On 2/4/26 at 11:53 AM, the surveyor toured the 3rd floor nursing unit on the 3rd floor nursing unit and observed the following: In room [ROOM NUMBER], the heater was heavily rusted, the heating vent cover was missing, and theCove base molding was pulled away from the wall.In room [ROOM NUMBER] D, the electrical outlet was cracked.In room [ROOM NUMBER] B, the cove base molding under the sink was pulled off.In room [ROOM NUMBER], the wall behind the bed by the door had chipped paint, and the molding along the wall was cracked. The bathroom door had a large crack at the bottom.On 2/9/26 at 10:10 AM, the surveyor showed the Director of Maintenance (DOM) the above observations and concerns. The DOM stated that he was not aware of the above areas in disrepair and confirmed that they should have been repaired, as this does not provide residents with a homelike environment. On 2/9/26 at 1:56 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Clinical Director, Regional Director of Operations, and VP of Quality and Performance Improvements to discuss the above observations and concerns. A review of the facility's policy, Safe and Homelike Environment dated as reviewed 9/1/2025, reflected.In accordance with the residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS, an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 5 of 30 residents (Resident #9, #39, #111, #131 and #134) during the review of resident assessment. The MDS is a comprehensive tool, a federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 2/9/26 at 11:30 AM, the surveyor provided the MDS Coordinator/Registered Nurse (MDSC/RN) with the list of 5 residents who had not completed an MDS in over 14 days. The surveyor also requested a copy of the resident's final validation report (generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). On 2/9/26 at 12:15 PM, the surveyor interviewed MDSC/RN, who stated that she started working in the facility in November 2025 and is aware that there were MDS assessments that were late. The MDSC/RN revealed there were some MDS that were late prior to her starting. The surveyor reviewed the final validation report from CMS with the MDSC/RN, the 5 residents' MDS assessments that were not submitted within fourteen days of completion, as follows: 1. Resident #39 had an Annual MDS assessment with an assessment reference date (ARD, the last day of the observation period) of 1/1/26 but not transmitted until 1/30/26, a Modification of End of PPS Part A Stay MDS with an ARD of 7/28/25 but was not submitted until 8/17/25, a Quarterly MDS with an ARD of 7/3/25 but was not submitted until 7/20/25 and a Quarterly MDS with an ARD of 4/3/25 but was not submitted until 4/27/25. 2. Resident #9 had a Quarterly MDS with an ARD of 12/5/25 but was not submitted until 1/9/25 and an admission MDS with an ARD of 9/5/25 but was not submitted until 9/20/25. 3. Resident #111 had a Quarterly MDS with an ARD of 12/30/25 but was not submitted until 1/30/26, a Quarterly MDS with an ARD of 7/1/25 but was not submitted until 7/20/25, a Quarterly MDS with an ARD 4/1/25 but was not submitted until 4/27/25 and a Quarterly MDS with an ARD of 12/31/24 but was not submitted until 2/1/25. 4. Resident #131 had an Annual MDS with an ARD of 1/3/26 but was not submitted until 1/31/26, a Quarterly MDS with an ARD of 7/5/25 but was not submitted until 7/20/25, a Quarterly MDS with an ARD of 4/5/25 but was not submitted until 4/27/25 and an admission MDS with an ARD of 1/4/25 but was not submitted until 1/22/25. 5. Resident #134 had a Quarterly MDS with an ARD of 12/30/25 but was not submitted until 1/30/26, an Annual MDS with an ARD of 9/30/25 but was not submitted until 10/21/25, a Quarterly MDS with an ARD of 7/1/25 but was not submitted 7/20/25 and a Quarterly MDS with an ARD of 4/1/25 but was not submitted until 4/27/25. On 2/9/26 at 12:50 PM, the [NAME] President of Quality and Performance Improvement (VPQPI) provided the surveyor with a facility policy titled, MDS 3.0 Completion, with revised dated 3/2025. Under the policy explanation and compliance guidelines it was revealed, 2. admission Assessment - completed within 14 days of admission counting the day of admission as day #1.7. Transmission Requirements: a. All assessments shall be transmitted to the designated CMS system within 14 days of completion. On 2/9/26 at 12:56 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Clinical Director (RCD), Regional Director of Operations (DOO), and VPQPI to review concerns found during the survey. The DON stated Admission, Quarterly and Annual MDS should be completed within 14 days of the ARD.On 2/11/26 at 12:06 PM, the surveyor met with the LHNA, DON, RCD, and DOO for exit conference. No further pertinent information was provided.NJAC 8:39-11.1

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was accurately set and monitored according to the resident's weight and or comfort. This deficient practice was identified for 4 of 5 residents reviewed (Resident #15, # 92, 152, and #163. This deficient practice was evidenced by the following:1. On 2/4/26 at 11:09 AM, the surveyor interviewed Resident #163 in their room. Resident stated their air mattress was very stiff and caused back pain. The surveyor observed the air mattress setting at 380 lbs. During interview Resident #163 stated they weighed around 130 pounds (lbs.) At 2/4/26 at 11:12 AM, Resident #163's Registered Nurse (RN#1) entered the room, the surveyor interviewed RN#1 who stated, air mattresses should be set per the resident's current body weight and acknowledged the air mattress setting was incorrect. RN#1 stated he had not checked the air mattress setting during his shift and was unable to state if the staff has been checking the air mattress setting. The surveyor reviewed Resident #163's medical record. A review of the admission Record (AR) reflected Resident #163 was admitted to the facility with diagnoses that included but were not limited to; multiple fractures of the ribs left side (crack or break in one or more of the rib bones), anxiety (a feeling of fear, dread, and uneasiness) and history of falls. A review of Resident #163's admission Minimum Data Set (MDS), an assessment tool dated 12/19/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. A review of Resident #163's Order Summary Report (OSR) did not reflect an active Physician's Order (PO) for an Air Mattress. The OSR did reflect an a PO for , Pain assessment every shift with an order date of 1/7/26, Tramadol HCl Tablet 50 milligram (MG), Give 1 tablet by mouth every 8 hours as needed for Severe pain (7-10) Monitor for resp depression, sedation, constipation, Acetaminophen Tablet 325 MG, Give 3 tablet by mouth every 8 hours as needed for Mild Pain(1-3) to equal 650mg. Do not exceed 3 grams per day with an order date of 1/9/26, and Lidoderm Patch 5 % (Lidocaine) Apply to lower back topically in the morning for lower back pain and remove per schedule with an order date of 1/8/26. A review of the January and February Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed Resident #163's Lidoderm patch was applied daily, pain assessment was completed every shift, Acetaminophen and Tramadol were provided as ordered. On 2/6/26 at 9:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Use of support surfaces with revised date of 3/6/25. Under the policy explanation and compliance guidelines it revealed, 3. Support surfaces will be chosen by matching the potential therapeutic benefit with resident's specific situation. Considerations for utilizing specialized support surfaces: e. Risk for developing a pressure injury or at high risk for additional pressure injuries. f. Pain or discomfort. 4. The goal and preferences of the resident and/or authorized representative will be included in the plan of care and support surface selection.6. Support surfaces will be utilized in accordance with manufacturer recommendations. 7. For powered devices, or those requiring air, the licensed nurse will check each shift and prn for proper functioning and/or inflation.10. The effectiveness of support surfaces will be monitored through ongoing assessment of the resident and/or wound. Considerations for alternate surfaces include: a. Pain or discomfort associated with use. b. Development of a new pressure injury. On 2/9/26 at 12:56 PM, the surveyor met with the LHNA, DON, ADON, Regional Clinical Director (RCD), Regional Director of Operations (DOO), and [NAME] President of Quality and Performance Improvement (VPQPI) to review concerns found during the survey. The DON stated the air mattresses should be set to the resident's weight. On 2/11/26 at 12:06 PM, the surveyor met with the LHNA, DON, RCD, and DOO for exit conference. No further pertinent information was provided. 2. On 2/4/26 at 11:53 AM, the surveyor observed Resident #92 in bed with their eyes closed on a specialty air mattress. The resident's air mattress pump was set to a weight of 180-250 #'s. On 2/5/26 at 1:08 PM, the surveyor observed Resident #92 in bed with their eyes closed on a specialty air mattress. The resident's air mattress pump was set to a weight between 180-250 #'s. The surveyor reviewed Resident #92's medical record. A review of the admission Record reflected Resident #92 was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease (a progressive, irreversible neurological brain disorder that slowly destroys memory and thinking skills) and hypertension (high blood pressure, where the force of blood against artery walls is too high). A review of Resident #92's Quarterly Minimum Data Set (MDS), an assessment tool dated 12/19/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated a severe cognitive impairment. A review of Resident #92's Order Summary Report (OSR) reflected an active Physician's Order for an Air Mattress: Check for placement and functioning every shift with an order date of 12/5/25. The PO was transcribed into the February Medication Administration Record (MAR) and signed by the nurses each shift, with placement and function checked. On 2/5/26 at 1:09 PM, the surveyor asked the Licensed Practical Nurse (LPN) assigned to Resident #92's care if the gauge should be set to the resident's weight. The LPN replied yes, and further stated that the resident definitely did not appear to weigh 190 pounds but that it was the maintenance departments responsibility to set and monitor the specialty mattresses. On 2/5/26 at 1:12 PM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager on the 3rd floor stated that nursing was not responsible for monitoring the specialty mattresses. It was the responsibility of the maintenance staff and the hospice staff. The nurses called the maintenance staff if the mattress beeped, otherwise it was maintenance responsibility to ensure it was set up and working properly. 3. On 02/04/2026 at12:10 PM, the surveyor observed Resident #15 in bed with their eyes closed and positioned on their right side. The surveyor observed the Air mattress setting with 4 green circles on. On 2/5/26 at 1:00 PM, the surveyor observed Resident #15 in bed with their eyes closed and the specialty air mattress with 1 light on. The surveyor reviewed the medical record for Resident #15. A review of the admission Record reflected Resident #15 was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's Disease and hypertension. A review of Resident #15's Quarterly MDS dated [DATE] reflected the resident's cognitive skills for daily decision making were severely impaired, and that Resident #15 was dependent on staff for ADL care. A review of Resident #15's current OSR reflected an active PO for Air Mattress every shift for preventative; to check for placement and function with an order date of 3/21/25. The order was transcribed on the February Treatment Administration Record (TAR) and signed by the nurses as checked on every shift. A review of Resident #15's Care Plan Report reflected that there was no care plan initiated for the use of a specialty air mattress. On 2/5/26 at 1:02 PM, during an interview with the surveyor, the Certified Nursing Assistant (CNA #1) assigned to Resident #15's care stated that she didn't know anything about the mattress, and that maintenance checked it. 4. On 2/5/26 at 12:38 PM, the surveyor observed Resident #152 in bed on a specialty mattress. The resident was eating lunch independently and greeted the surveyor. The surveyor observed that all the lights on the mattress were on. The surveyor reviewed the medical record for Resident #152. A review of the admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia and hypertension. A review of the quarterly MDS dated [DATE] reflected that Resident #152 had a BIMS score of 1 out of 15, which indicated a severe cognitive impairment. A review of section GG indicated the resident was dependent on staff for ADL care. Section M included the resident received a pressure reducing device for their bed. A review of the current OSR reflected a PO for a low-air-loss mattress, monitor function every shift, dated as ordered 6/4/25, and transcribed onto the TAR and signed by the nurses as being monitored. A review of Resident #152's Care Plan Report reflected a Focus area that included impaired skin integrity initiated 6/13/25 with interventions that included but were not limited to; Low air Loss Mattress. A review of Resident #152's Care Plan Report reflected a Focus area that included Resident was at risk for falls r/t history of falls .with interventions that included but were not limited to; be sure the resident's call light and personal items are within reach, encourage the resident to use the call bell for assistance .the resident needs prompt response to all requests for assistance. On 2/5/26 at 12:42 PM, the surveyor interviewed CNA #2, assigned to Resident #152's care, who stated, I have no idea what the lights on the mattress are, maintenance checks it. On 2/5/26 at 12:45 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager who stated that hospice and maintenance set and monitor the specialty mattresses, not nursing. The LPN/UM further stated that when the lights were on, it meant it was set at the resident's weight, which was in the 90#'s. On 2/5/26 at 1:50 PM, during an interview with the surveyor, the Regional Maintenance Director, employed for 4 months, stated that the maintenance staff should check the specialty mattresses weekly or more often if necessary. On 2/5/26 at 1:50 PM, during an interview with the surveyor, the maintenance director confirmed that specialty mattresses were set according to the resident's weight. The surveyor asked the maintenance director about the mattresses that don't have a weight but only had small circles. The director replied that he would look into it and get back to the surveyor. The surveyor asked the director to provide the weekly monitoring sheets for the specialty mattresses, the policy, and the manufacturers' specifications. The director confirmed there was no documentation regarding the weekly monitoring of the air mattresses. On 2/9/26 at 12:30 PM, the surveyor and Director of maintenance observed Resident #92's specialty air mattress. The surveyor observed it was a new specialty mattress. The director of maintenance confirmed that the other mattress did not meet regulations and was outdated, so he replaced it with a new one and set it to 150 pounds (the resident's current weight). On 2/9/26 at 12:35 PM, the surveyor and the maintenance director observed Resident #15's specialty air mattress that did not have a weight setting, just small circles. The maintenance director stated that he was not familiar with the mattress, and was not sure what the lights indicated. On 2/9/26 at 1:56 PM, the survey team met with the LHNA, DON, Regional Clinical Director, Regional Director of Operations, and VP Quality and Performance Improvements to discuss the above observations and concerns. On 2/11/26 at 10:55 AM, during an interview with the surveyor, the DON confirmed that nurses were responsible for monitoring the specialty mattresses as they were the ones signing the Medication Administration Records and Treatment Administration Records, which indicated they were monitoring them every shift. The DON further stated that maintenance was responsible for the weekly monitoring of the specialty air mattresses and should have the inspection of the weekly rounds documented. On 2/11/26 at 12:06 PM, no further information was provided. NJAC: 8:39 27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to provide assessments of the resident's condition and to monitor for complications after dialysis treatments were received at a certified dialysis facility for 1 of 2 residents (Resident #55) reviewed for dialysis. This deficient practice was evidenced by the following:Based on observation, interview and record review, it was determined that the facility failed to provide assessments of the resident's condition and monitoring for complications after dialysis treatments were received at a certified dialysis facility for 1 of 2 residents (Resident #55) reviewed for dialysis. This deficient practice was evidenced by the following: On 02/04/2026 at 12:15 PM, the surveyor observed Resident #55 in bed with their eyes closed.On 2/9/26 at 9:50 AM, the surveyor observed Resident #55 in bed with their eyes closed. A review of the current physician's order (PO) reflected an order for dialysis, every Tuesday, Thursday and Saturday at 9:40 AM; Monitor right chest permacath site ( a long catheter inserted into a central vein for chronic hemodialysis) every shift for placement, bleeding, s/s of infection; do not wet permacath site. A review of Resident #55's admission Record reflected that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to; dependence on renal dialysis (a life-sustaining medical procedure that replaces kidney function in individuals with severe kidney failure) and hypertension (high blood pressure). A review of the quarterly Minimum Data Set (MDS) dated [DATE] reflected that the resident had a brief interview for mental status (BIMS) score of 5 out of 15 which indicated the resident had a severe cognitive impairment. Section O indicated that Resident #55 received special treatments which included hemodialysis. A review of the Resident's Care Plan reflected a focus area that indicated the resident needed hemodialysis r/t renal failure .every Tuesday, Thursday and Saturday . initiated 2/15/24 with interventions that included but were not limited to; Check right upper chest wall permacath dressing every shift .Monitor vital signs as ordered and when necessary. The surveyor reviewed the hybrid Nursing Facility/Dialysis Communication Record forms from October 2025 to February 2026 which revealed that on 10/28/25, 11/15/25 and 11/22/25 the forms were not completed by the facility nurse upon the resident's return from Dialysis. The surveyor also reviewed the resident's electronic medical which revealed there was no documentation indicating the nurse assessed Resident #55 upon return on the above dates.On 2/6/26 at 1:40 PM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) confirmed that the facility nurse who was assigned to the resident should have completed the post dialysis Facility Nurse Assessment Upon Return From Dialysis section which included Vital signs (blood pressure, heart rate, temperature, pulse oximeter) and that the dialysis access site was checked. On 2/9/26 at 1:00 PM, during an interview with the surveyor, the Director of Nursing confirmed that the facility nurses should have completed the post dialysis sections of the Dialysis Communication Record. On 2/9/26 at 1:56 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON), Regional clinical Director, Regional Director of Operations and VP of Quality and Performance Improvement to discuss the above observations and concerns. A review of the facility's Dialysis Patients policy, dated as revised 11/25, reflected .Communication between the dialysis provider and center staff should include: Written communication .Post Dialysis Protocol .Blood pressure prn/daily or as the physician orders (do not take the B/P on arm that fistula is in .Check fistula for bruit (listening to fistula) or feel for a thrill (by touching the fistula) NJAC 8:39-27.1 (a)

Repeat deficiencyBased on observation, interview, and record review, it was determined that the facility failed to a). properly label, store and dispose of medications in 2 of 7 medication carts and 1 of 3 medication room refrigerators inspected and b). failed to secure 1 of 3 emergency crash carts observed.This deficient practice was evidenced by the following: This deficient practice was evidenced by the following:a). On 02/04/26 at 09:40 AM, the surveyor inspected the 2nd floor medication cart #1 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed two (1) loose medications in tablet form (not in pharmaceutical packaging) in the 2nd drawer of the medication cart and one (1) loose medication in tablet form in the 3rd drawer of the medication cart. The surveyor also observed two bottles of Velphoro 500mg chewable tablet (supplement for dialysis) that contained no pharmacy label (required for prescription medication). The bottle contained only the resident's name, written on both bottles. At that time, LPN#1 acknowledged that the loose medication, not in an identifiable pharmacy package, should have been destroyed per facility policy. LPN#1 also stated that the two bottles of Velphoro 500 mg chewable tablets were not supplied by the pharmacy. The medication was ordered by dialysis and came to the facility in two boxes. LPN#1 acknowledged that the medication did not contain a pharmacy label.On 02/04/26 at 10:15 AM, the surveyor inspected the 1st floor medication cart #3 in the presence of LPN#2. The surveyor observed one Enoxaparin 40mg/0.4 mL injection in the medication cart that had no pharmacy label or resident name. At that time, the surveyor interviewed LPN#2, who stated that Enoxaparin 40m/0.4ml was a discontinued medication and should have been removed from the medication cart. LPN#2 further stated that all medication should contain a pharmacy label and the resident's name.On 02/04/26 at 10:25 AM, the surveyor inspected the first-floor medication room refrigerator in the presence of LPN#2. The surveyor observed that the medication refrigerator had a temperature of 50 degrees and contained a vial of influenza vaccine. A further review of the 1st-floor medication room refrigerator temperature log revealed that no temperatures were documented for 2/3/26 and 2/4/26 in the February 2026 temperature log. At that time, the surveyor interviewed LPN#2, who confirmed that the refrigerator temperature was outside the 36-to-46-degree range and that no one had documented the temperature for the last 2 days. LPN#2 also stated that the influenza vaccine should be stored at the proper temperature. b) On 02/04/26 at 10:10 AM, the surveyor inspected the first-floor nursing unit and observed an open emergency crash part; there were no residents in the vicinity. The surveyor notified the Registered Nurse (RN)/Unit Manager (UM) about the emergency crash cart, and the RN/UM acknowledged that the cart should have been locked. A review of the Manufacturer's Specifications for the following medications revealed the following:Influenza Vaccines should be stored in a refrigerator at 36 to 46 degrees Fahrenheit (2 to 8 degrees Celsius).A review of the NJ state pharmacy law revealed the following key requirements for New Jersey Prescription labels:Pharmacy information, which includes the name, address, and telephone number.Patient and Provider information that includes the full patient's name and the prescribing practitioner's name.Drug information, including the Brand name and the medication's strength.Dispensing details, which included the dispensing date of the medication.Usage instructions.Safety/expiration, which includes the use by date (earlier of one year from dispensing or the manufacturer's expiration date. On 2/10/25 at 12:45 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator, Director of Nursing (DON), Regional Director of Operations, [NAME] President of Quality and Performance Improvement, and the Regional Clinical Director.There was no additional information provided.A review of the facility's policy titled Medication Storage that was dated 9/1/24 and was provided by the DON included the following: All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Refrigerator Products: b. Temperatures are maintained within 36-46 degrees Fahrenheit. Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or designee. 8. 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) (d)

Based on interview, record review, and facility policy review, the facility failed to provide information on how to file an anonymous grievance for six of six residents (Residents (R) 18, R88, R94, R97, R95, and R128) reviewed for the grievance process of 40 sample residents. The failure had the potential to affect residents' ability to safely report concerns without fear of retaliation. Findings include: A resident group interview was conducted on 09/25/24 at 3:00 PM with six residents whom the facility identified as reliable historians. During the meeting, six of the six residents (R18, R88, R94, R97, R95, and R128) expressed that they did not know how to file an anonymous grievance. They stated that Nobody told us how to file one and We can go to the social worker to file a grievance, but not anonymous. Review of the Resident Council meeting minutes, dated 01/26/24 through 09/12/24, revealed no mention of making an anonymous grievance. During an interview on 09/25/2024 at 4:00 PM, Social Services (SS) stated that the residents could come to her to make a grievance. SS stated that she went around to most residents in the morning to see how things were going or if they had any grievances. However, she stated she never explained to the residents about filing a grievance anonymously. During an interview on 09/25/2024 at 4:10 PM, the Administrator stated that the residents could file a grievance. However, she stated she never explained to the residents about filing a grievance anonymously. She also stated there was no way to file an anonymous grievance in the facility. Review of the facility's undated policy titled, Grievance Policy and Procedure, revealed All residents, responsible parties, interested family members, and staff of [Facility Name] have the right to voice grievances that are free from interference, coercion, discrimination, or reprisal concerning: The care, treatment, and services that are or fail to be, furnished; the policies, procedures, physical condition of the facility; the behavior of other residents, responsible parties, interested family members, and staff. NJAC 8:39- 4.1(a)35 NJAC 8:39-13.2(c)

39540 42440 Based on record review, interviews, and policy review, the facility failed to provide written notice of their bed hold policy and the cost of a bed hold when residents were transferred to the hospital for five of five residents (Resident (R) 119, R87, R83, R29, and R67) reviewed for hospitalization of 40 sample residents. This failure had the potential to cause confusion or distress regarding the cost to hold a room and whether or not a resident would be able to return to the facility after hospitalization . Findings include: 1. Review of R119's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/24 and located in the MDS tab of the electronic medical record (EMR), revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS) and the staff assessment for cognition indicated moderately impaired cognition. Review of R119's Prog Note tab of the EMR revealed a note, dated 01/20/24 at 2:26 PM, which documented R119 was sent to the hospital for a sudden change in her level of consciousness. An entry dated 01/29/24, revealed R119 had returned from the hospital. Review of R119's Prog Note tab of the EMR further revealed a note, dated 04/12/24 at 10:28 PM, which documented R119 was admitted to the hospital for aspiration pneumonia. Review of R119's Census tab of the EMR revealed that R119's payor source at the facility was private pay when she was discharged to the hospital on 01/20/24 and Medicare when she was discharged to the hospital on 04/12/24. Review of R119's EMR and hard chart revealed no evidence that a bed hold policy or bed hold letter was provided to the resident representative for the hospitalization s. Review of a facility provided binder of bed hold letters revealed an undated letter to R119's representative, which revealed R119 had discharged to the hospital on 01/20/24 for altered mental status. It stated the facility would hold her bed for ten days but did not state the cost after the ten days or whether R119 would be able to return to the facility. The binder did not include a letter for when R119 was admitted to the hospital on 04/12/24. Review of the facility provided copy of the undated bed hold letter for 04/12/24 revealed R119 was discharged to the hospital for lethargy. It revealed the facility would hold her bed for ten days but did not state the cost after the ten days or whether R119 would be able to return to the facility. During an interview on 09/26/24 at 4:53 PM, the Business Office Manager (BOM) stated that R119's two discharges had no cost associated with them because she was Medicaid pending. 2. Review of R87's undated Face Sheet located under the Profile tab of the EMR, revealed R87 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Incident Reporting Application (initial reporting), dated 04/09/24 and located under the Progress Notes tab of the EMR, revealed Received report [R87] noted with physical aggression towards resident .[R87] was later sent to the hospital for further evaluation and treatment. Review of R87's EMR revealed no documented evidence that the facility provided written information regarding the facility's bed hold policy to the resident and the resident's responsible party at the time of transfer. Review of a facility provided binder of bed hold letters revealed an undated letter that did not contain the cost associated with the bed hold. 3. Review of R83's undated Face Sheet located under the Profile tab of the EMR, revealed R83 was admitted to the facility on [DATE]. Review of R83s Progress Notes, dated 05/20/24 and located in the Progress Notes tab of the EMR, revealed R83 was discharged to the hospital on 05/20/24. Review of R83's EMR revealed no documented evidence that the facility provided written information regarding the facility's bed hold policy to the resident and the resident's responsible party at the time of transfer. Review of a facility provided binder of bed hold letters revealed an undated letter that did not contain the cost associated with the bed hold. 4. Review of R29's undated Face Sheet located under the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. Review of R29s Progress Notes, dated 05/17/23 and located in the Progress Notes tab of the EMR, revealed R29 was sent to the hospital on 05/17/23. Review of R29's EMR revealed no documented evidence that the facility provided written information regarding the facility's bed hold policy to the resident and the resident's responsible party at the time of transfer. Review of a facility provided binder of bed hold letters revealed an undated letter that did not contain the cost associated with the bed hold. During an interview on 09/25/24 at 8:48 AM Social Services Director (SSD) stated, I have nothing to do with the bed hold notice transfer. The receptionist sends out the notice the next day. SSD reviewed the facility bed hold notice upon transfer and stated was familiar with the policy, but did not realize the written notice did not include the bed hold payment portion. During an interview on 09/25/24 at 8:55 AM the Administrative Receptionist (AdmRec) stated, When I come in the morning, I will run the resident census to see what residents have been transferred to the hospital and then I will send out the facility bed hold policy to the family or responsible party. The AdmRec further stated that she was not familiar with the official policy; she just sent it out. 5. Review of R67's Admission Record located in the EMR under the Profile tab, revealed an admitted [DATE] and readmission on 06/05/24 with medical diagnoses that included diabetes mellitus and end stage renal failure (ESRD). Review of R67's EMR documented R67 was emergently hospitalized on [DATE], 03/02/24, 04/08/24, and 05/29/24. Review of the EMR and paper chart lacked documentation the resident representative was notified in writing the cost-if any to hold the bed. During an interview on 09/26/24 3:57 PM, the AdmRec explained the process of notification to the family about a resident discharge. She stated each morning the Receptionist checked the census for discharges and clarified each with the Director of Nursing (DON). She stated they checked the census tab in the EMR to confirm payment status and informed the Business Office Manager (BOM) to clarify if payment for bed hold was required. She stated a copy of the facility bed hold policy was not included in the mailing to the resident representative address. The Receptionist stated she was unaware if the documentation about the bed hold notice being placed into the resident's medical record. During an interview on 09/26/24 at 4:12 PM, the BOM explained the Receptionist checked with the BOM to verify amount of payment for Medicare and private pay residents. The BOM stated they provided the amount and followed up with a call to the resident representative to confirm the bed hold. The BOM was unsure if the documentation about the bed hold and cost to hold the bed was placed in the resident's medical record. Review of the facility's policy titled, Bed Hold Notice Upon Discharge, updated 01/15/24, revealed Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: The duration of the state bed-hold policy, if any, during which the resident is permitted io return and resume residence in the nursing facility. The reserve bed payment policy in the slate plan policy, if any .The facility policies regarding bed-hold periods to include following a resident to return to the next available bed .Conditions upon which the resident would return to the facility: ln the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies. NJAC 8:39-4.1(a)32

Based on observation, interview, and facility policy review, the facility failed to ensure food prepared by the facility was served at a palatable temperature for five of six residents (Resident (R) 97, R18, R88, R94, and R128) reviewed for palatability of 40 sample residents. As a result of this deficient practice the residents had the potential for poor nutrition and weight loss. Findings include: 1. Review of R97's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. During an interview on 09/23/24 at 2:12 PM, R97 stated the food was always cold. 2. Review of R18's quarterly MDS assessment with an ARD of 06/16/24, revealed a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. 3. Review of R88's quarterly MDS assessment with an ARD of 09/02/24, revealed a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 4. Review of R94's quarterly MDS assessment with an ARD of 08/26/24, revealed a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. 5. Review of R128's quarterly MDS assessment with an ARD of 06/26/24, revealed a BIMS score of six out of 15 which indicated the resident was severely cognitively impaired. During a resident group meeting on 09/25/24 at 3:20 PM, five residents (R18, R88, R94, R97, and R128) of the six residents expressed concerns that the food was cold and tasteless for most meals. They stated they had complained at the monthly council meetings as the issues had been going on for quite a while, but they saw no changes. During an observation on 09/25/24 at 11:22 AM, Dietary Staff (Dietary) 1 checked the temperatures of the food on the steam table. The readings of the main meal included: chicken 153.2 degrees Fahrenheit (F), boiled potatoes 183 degrees F, and broccoli 184 degrees F. Dietary1 then began to plate the food. Dietary staff did not check food temperatures throughout the meal service. During an observation on 09/25/24 at 1:06 PM, Dietary1 finished plating the last resident tray and then plated a test tray of the main meal and provided a facility thermometer to check the temperatures of the food on the test tray. During an observation on 09/25/24 at 1:12 PM, dietary staff brought the wheeled, enclosed cart to the second floor, which included the test tray, and left the cart to return to the kitchen in the basement. During an observation on 09/25/24 at 1:22 PM, as staff passed the last two trays to residents, the temperatures of the food on the test tray were: chicken 130.3 degrees F, potatoes 113.3 degrees F, and broccoli 112.8 degrees F. Human Resources (HR) verified the temperature readings and tasted the food for palatability, spitting out the chicken. During an interview on 09/25/24 at 1:23 PM, HR described the food on the test tray as room temperature and stated it could definitely be warmer. During an interview on 09/25/24 at 1:36 PM, the Regional Dietary Director (RDD) stated the facility needed to do audits to determine why the food temperatures dropped. During an interview on 09/25/24 at 1:41 PM, the Dietary Manager (DM) reported the temperature drops were significant. The DM expected the temperatures to be equivalent to the temperatures displayed on an undated, untitled paper which listed desired temperatures of food by category, hot entrees, starches, and vegetables had a desired temperature range of 140-165 degrees F. The DM stated the facility used heated pellets, which held temperatures for up to 20 minutes. Review of the facility's policy titled, Food Temperature Policy, revised 08/23, revealed All hot food items must be . held and served at a temperature of at least 135 [degrees] F. Take temperatures often to monitor for safe food holding temperature ranges . at or above 135 [degrees] F for hot foods .Temperatures should be taken periodically to assure hot foods stay above 135 [degrees] F . during the portioning, transporting and delivery process until received by the individual recipient .Foods sent to the units for distribution (such as meals, .) will be transported and delivered to maintain temperatures . at or above 135 [degrees] F for hot foods. NJAC 8:39-17.4(a)

Based on observation, record review, interview, and facility policy review, the facility failed to ensure a resident's safety during transport to an outside appointment when the resident was dropped off at his personal residence instead of a safe facility return for one of three residents (Resident (R) 298) and the facility failed to ensure safe resident transfers with use of a gait belt for two of three residents (R119 and R121) reviewed for accident hazards of 40 sample residents. This had the potential to place all residents who are dependent on the facility at risk. Findings include: 1. Review of R298's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed R38 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD), muscle weakness, dysphagia, and difficulty in walking. Review of R298's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/23 located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) of three out of 15 which indicated the resident was severely cognitively impaired. Further review revealed the resident used a wheelchair for mobility and was an extensive assist of one staff with transfers. Review of R298's Care Plan located under the Care Plan tab of the EMR and dated 07/26/23, revealed the resident had impaired cognitive function. Review of R298's Patient Appointment, (hardcopy) dated 07/25/23 and provided by the facility, revealed appointment time was 1:30 PM. The pickup time was at 12:10 PM and the return time was 6:00 PM. It was noted under transport . R298 was dropped off at his home and the address of the resident's home was listed. During an interview on 09/25/24 at 4:32 PM, RN2 said R298 had a cardiologist appointment on 07/25/23 but the transportation company took the resident to his personal residence. She was unsure who notified the facility but thought someone called the transportation company and they said the personal address was the one on file as the drop-off location. She thought the facility requested that the transportation company to go back and pick up the resident and bring him to the facility, but she could not remember anything specifically. During an interview on 09/26/24 at 10:24 AM, Medical Records (MR) stated she spoke with the transport company, and they stated back on 07/25/23 the facility contacted the transportation company at 6:50 PM after the R298 did not return from his appointment. She stated the facility was informed the resident was dropped off at his personal residence. MR stated the previous staff who was the unit clerk/medical records at that time accidentally provided the transportation company with R298's personal address listed on the face sheet instead of the facility address as the drop off location. She said it was the previous unit clerk's error. During an interview on 09/26/24 at 2:25 PM, the Director of Nursing (DON) stated it was a previous Administrator and DON at the time the incident occurred, and she was unaware of what happened. 2. Review of R119's Admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting the right, dominant, side. Review of R119's quarterly MDS with an ARD of 06/28/24 and located in the MDS tab of the EMR, revealed the resident was unable to complete a BIMS and the staff assessment for cognition indicated moderately impaired cognition. R119 required substantial/maximal assistance (helper provided more than half the effort) when moving from seated position to standing and during chair/bed-to-chair transfers. Review of R119's Care Plan, last reviewed 08/05/24 and located in the Care Plan tab of the EMR, revealed no information on how R119 transferred. It directed staff to: use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, date initiated 05/09/23. During an observation on 09/25/24 from 10:45 AM to 10:57 AM, Certified Nurse Aide (CNA) 3 and CNA8 transferred R119 from her wheelchair to bed. CNA3 stood on R119's left and CNA8 on the right. Each CNA put an arm under R119's arms and grabbed the back of R119's pants at the waist with the other hand. Pulling on R119's pants and using their arms to steady R119, the CNAs stood R119 and pivoted her to sit on the edge of the bed before they assisted her to lay down for incontinence cares. Following cares, CNA3 and CNA8 then transferred R119 back to the wheelchair using the same technique and no gait belt. During an interview on 09/26/24 at 9:36 AM, CNA2 stated R119 required two staff to assist with transfers. During an interview on 09/26/24 at 9:51 AM, CNA7 reported R119 needed two staff to transfer. CNA7 stated the floor had no gait belts, but she thought one floor still used them. CNA7 stated if any changes occurred in how residents transferred, the therapy department showed the staff how to do the transfer. 3. Review of R121's Admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE]. Review of R121's quarterly MDS with an ARD of 06/20/24 and located in the MDS tab of the EMR, revealed a BIMS score of zero out of 15 which indicated the resident had severely impaired cognition. R121 required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provided less than half the effort) for transfers. Review of R121's Care Plan, last reviewed 08/05/24 and located in the Care Plan tab of the EMR, revealed an intervention, dated 12/20/2023, that R121 required the assistance of one staff for transfers. During an observation on 09/26/24 at 9:29 AM, CNA2 transferred R121 from wheelchair to bed. Without locking the wheelchair's brakes, CNA2 faced R121, placed both arms under the resident's arms, counted to three, and moved R121 from the wheelchair to the bed. CNA2 did not use a gait belt. During an interview on 09/26/24 at 9:36 AM, CNA2 stated R121 required one person to transfer. She reported she had no gait belt and was unsure if there were any gait belts on the floor she worked. During an interview on 09/26/24 at 10:12 AM, Licensed Practical Nurse (LPN) 3 stated they did not use gait belts. LPN3 stated they let the residents know what they were doing and asked them to help. During an interview on 09/26/24 at 10:31 AM, LPN5 stated the facility did not use gait belts. She stated therapy used them for training. LPN5 was unsure why the facility did not use gait belts. It's not common practice at any facility I've been at. During an interview on 09/26/24 at 11:15 AM, the Director of Nursing (DON) reported the facility did not typically use gait belts for transfers, unless therapy approved them. She thought therapy had not approved one person for gait belt use. During an interview on 09/26/24 at 11:56 AM, the Rehabilitation Director stated that when therapy had recommendations for transferring a resident, they verbally told the charge nurse to update the care plan and Kardex. The Rehabilitation Director stated when a resident had a change in how they transferred, therapy provided an in-service to the CNAs. The rehabilitation director stated unless a resident transferred with contact guard assist and responded well to verbal cues (or used a mechanical lift), she expected staff to use a gait belt for transfers. Review of the facility's undated policy titled, Safe Resident Handling revealed: The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status .Resident lifting and transferring will be performed according to the resident's individual plan of care. NJAC 8:39-33.1(d) 42440

Based on record review and interviews, the facility failed to ensure residents received alternative measures and informed consent with explained risks and benefits was obtained prior to installation for one of one resident (Resident (R) 30) reviewed for side rails of 40 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment. Findings include: Review of R30's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE]. Diagnoses included vascular dementia, depression, bipolar disease, muscle weakness, and anxiety. Review of R30's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/14/24 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident had intact cognition. Review of R30's Care Plan, initiated 08/11/24, located under the Care Plan tab of the EMR, revealed R30 had 1/4 rails to bed for turning and repositioning. Review of R30's Order Summary Report located under the Orders tab of the EMR, revealed an order, dated 02/07/24, 1/4 side rails as an enabler for turning and repositioning in bed. Review of R30's Side Rail Assessment Screening located under the Assessments tab of the EMR, dated 07/15/24, revealed no documented evidence of any alternative measures prior to installation, and no documented evidence of obtained consent for side rail usage. During an interview on 09/26/24 at 10:59 AM, Licensed Practical Nurse (LPN) 4 stated they did not try alternatives prior to side rail use for R30. She stated staff did obtain informed consent and reviewed risks vs benefits and that it would be documented in the resident's hard chart. She reviewed the hard chart and found two forms titled informed consent for use of side rails but neither were filled out or signed. During an interview on 09/26/24 at 1:42 PM, LPN2 stated when staff were assessing residents for side rail use, they asked basic questions and asked about gaps between the side rail and mattress. LPN2 stated he was unsure what alternates would have been used and stated they did not look at alternates. He stated it's either a yes, they use side rails or a no, they did not use them. During an interview on 09/26/24 at 2:16 PM, the Director of Nursing (DON) stated prior to a resident using side rails staff should obtain a consent form that was completed on admission. She stated staff explained the risks versus the benefits of using side rails and had them or their responsible party sign it. She stated they had a Quality Assurance and Performance Improvement (QAPI) that was implemented on 08/08/24 for side rail use. The DON stated they had identified they were not getting informed consents, and they were not being care planned. She stated they only obtained signed consents for the residents on the 100 halls but have not obtained signed consents from residents on the 200 and 300 halls. When she was asked why that was not completed in the last month and a half since the QAPI on side rails was implemented, she was unsure. She confirmed the QAPI did not address the facilities lack of exploring alternates prior to bed/side rail use. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication containers were labeled specific to the resident for two of six medication carts reviewed for correct labeling of medications. As a result of this deficient practice the residents had the potential for residents to receive the wrong medication. Findings include: During an observation on 09/26/24 at 5:13 PM, medication cart one on second floor revealed a box of slow-release iron pills, 45 milligrams (mg) were stored in-between medication punch cards for the resident in 223 with only the room number (223) on the box and a box of slow-release iron 45 mg pills were stored in-between medication punch cards for the resident in 224 with only the room number (224) on the box. Both rooms [ROOM NUMBERS] had residents in bed A and B. The box only had the room number without the A or B designation. During an interview on 09/26/24 at 5:13 PM, Registered Nurse (RN) 4 explained the iron pills were slow-release and the iron pills in the regular floor stock were not slow release so a separate box was placed in with the medication punch cards for the residents in 223 and 224 so the residents would get the correct dose of iron during medication pass. RN4 confirmed the resident name was not on the box, only the room number and should have had the resident name on the box, not just the room number. During an observation on 09/26/24 at 5:13 PM, medication cart two on second floor revealed a bottle of Alaway eye drops (for allergies), located in the drawer with the topical medications, with room [ROOM NUMBER]B written on the box with no resident name. During an interview on 09/26/24 at 5:13 PM, Licensed Practical Nurse (LPN) 6 confirmed the eye drops had only the resident room number and no name. LPN6 was not sure if the eye drops needed a name because they were an over the counter (OTC) medication. During an interview on 09/26/24 at 5:58 PM, the LPN4 confirmed medications with only a room number were not in compliance, including house stock OTC medications. She stated when an OTC was specific for a resident, a resident sticker (located in the front of the paper chart), should be put on the medication/or box to clearly identify the medication was for a specific resident to avoid giving a medication to the wrong resident. During an interview on 09/26/24 at 6:04 PM, the Director of Nursing (DON) confirmed all medications, including OTC, for a specific resident, should have been labeled with the specific resident name, not just the room number. Review of the facility policy titled Labeling of Medication Containers, updated 01/2024, revealed, Labels for over-the-counter drugs shall include all necessary information, such as: a. The original label, b. The resident's name, and the expiration date when applicable . NJAC 8:39-29.2 NJAC 8:39-29.4 NJAC 8:39-44.2

Complaint#: NJ163545, NJ163595, NJ163682 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 4/20/2023 & 4/24/2023, it was determined that the facility failed to protect residents from significant medication errors on 4/18/2023 at approximately 9:00 p.m. when the Licensed Practical Nurse (LPN) administered subcutaneous insulin injections instead of heparin, to two residents (Resident #1 and Resident #3) who are not Diabetics or had a Physician's Order for Insulin. During the 9:00 p.m. medication pass, the LPN assigned to Residents #1 & #3 did not verify the medication and administered the wrong medication (insulin-Admelog) instead of Heparin 5000 IU [International Unit] as ordered to both residents. At approximately 11:15 p.m., the Registered Nurse Supervisor (RNS #1) for the 11:00 p.m. to 7:00 a.m. shift found Resident #1 Unresponsive to voice or touch and was cold and clammy. Resident #1 Blood Glucose (BG) / Blood Sugar (BS) was checked, and he/she had a reading of 22 mg/dl [milligrams per deciliter]. Glucagon was given two times IM [intramuscular], but the Resident's BG still did not rise; 911 was called, and D5 [Dextrose 5% (percent)] was administered via [through] a PIV [Peripheral Intravenous line] was started by RNS #2. Resident #1 was admitted to the hospital with a diagnosis of Hypoglycemia. At approximately 11:30 p.m., RNS #1 found Resident #3 cold and clammy, moving his/her upper extremities up in the air with eyes wide open. Resident #3 BG was checked. However, the Resident's blood sugar was too low for the device to register, so the reading result was LO (LOW). 911 was called; they were already present in the building, started PIV at the antecubital space, and the 911 team infused D10 [Dextrose 10%]. Resident #3 was suctioned for excess secretions in the mouth, and the Resident's BG increased to more than 200 mg/dl after starting the IV. Resident #3 left the building at 12:15 a.m. to go to the hospital for further evaluation and was admitted with a diagnosis of Hypoglycemia. The facility also failed to follow its policies titled Administering Medications, Identifying and Managing Medication Errors and Adverse Consequences, and Physician Orders. The facility's failure to prevent Resident #1 & Resident #3 from significant medication errors placed Resident # 1, Resident #3, and all other non-diabetic residents at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant, Director of Nursing (ADON) on 4/20/2023 at 6:40 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on 4/18/2023 and continued through 4/19/2023, when the facility removed the LPN from duty that next morning at approximately 7:00 a.m., started in-servicing licensed nursing staff on medication administration, the standards of practice for safe medication administration, Insulin, and Heparin vials being stored in different drawers, and Abuse and Neglect. On 4/24/2023, the Surveyors verified the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating licensed nursing staff on medication administration, the standards of practice for safe medication administration, Insulin, and Heparin vials being stored in different drawers, and Abuse and Neglect. So, the noncompliance remained on 04/20/2023 as a level D for no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This deficient practice was identified for 2 of 9 residents (Resident #1 & #3) and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by the healthcare facilities to report incidents on 4/20/2023, with an event date of 4/18/2023 and a time of event of 11:30 p.m., revealed the following: On 4/18/2023, at approximately 11:15 p.m., Residents #1 and Resident #3 were sent to the hospital related to hypoglycemia episodes. Both were admitted with Hypothermia and Hypoglycemia. Both residents do not have diabetes; therefore, further investigation was warranted. [The] Nurse assigned to both residents on 4/18/2023 was suspended pending investigation. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Chest Pain, Unspecified Thrombocytopenia, and Unspecified Depression. According to the Minimum Data Set (MDS), an assessment tool dated 04/04/2023, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. Resident #1 only needed supervision and one-person physical assist with most Activities of Daily Living (ADLs). Further review of the MDS showed under Section N Medications revealed Under N0350. Insulin included: that Resident#1 was not on Insulin and had no order for Insulin. The MDS also showed Under N0410. that the Resident was on Anticoagulant ( .heparin, or low molecular weight heparin) therapy. A review of Resident #1's Medication Error Report (MER) dated 4/19/2023 and signed by the Attending MD (Medical Doctor)/[Physician], LNHA [Licensed Nursing Home Administrator], the Assistant Director of Nursing, and the Director of Nursing included the following: Date of error: 4/18/23 [2023], Time of Error: 9 [:00] PM [p.m.], Physician Notified [,] Yes date/time: 4/19/23, DON/Supervisor/Manager notified? Yes, Name: DON date/time: 4/19/23, Resident representative/Family notified? Yes[,] date/time: 4/19/23 5:30 p [p.m.] [,] Medication ordered: Heparin 5000 IU [,] Description of the error-record name of the medication, dose, route and time(s) administered: insulin-Admelog [,] Outcome to the resident (provide details including care provided after error): BS [Blood Sugar] dropped sent to ER [emergency room ] via 911. Under Assessment and Summary of Medication Error, included: Under Type of Error, wrong medication. Under Reason For Error, revealed Other: did not verify medication [.] Under Corrective action taken: revealed staff education -LPN suspended pending outcome of the investigation Under Measures taken to prevent the recurrence of similar errors: included: insulin vials changed to pens-insulins + [and] heparin in separate areas of med [medication] cart [.] Under Signatures [,] Title [,] Date included: Person making error LPN [,] 4/19/23[;] Person reporting error LPN/ADON[,] 4/19/23, DON [,] RN DON [.] A review of Resident #1's New Jersey Universal Transfer Form (NJUTF) revealed Date of Transfer: 4/19/2023 and Time of Transfer 12:00 a.m. Reason for Transfer: included: Pt [patient/resident] found unresponsive [,] skin cold, clammy [,] Blood Sugar -22-glucagon x 2 given [.] A review of Resident #1's Order Summary Report (OSR) Active Orders as of 04/18/2023 revealed the following Physician Orders (POs): Heparin Sodium (Porcine) Injection Solution 5000 UNIT/ML (milliliters) (Heparin Sodium (Porcine) inject 1 ML (milliliters) every 12 hours for DVT (Deep Vein Thrombosis) prophylaxis. It may increase the risk of bleeding. Please observe for any bruising, dark urine, and black, tarry stools dated 3/29/2023. A review of Resident #1's Medication Administration Record (MAR) dated 04/1/2023-04/30/2023 reflected that the LPN administered the above POs as ordered on 4/18/2023 at 9:00 p.m. A review of Resident #1's Progress Notes (PNs) revealed the following: On 04/19/2023 at 6:42 a.m., the PNs written by RNS #1 revealed at 11:15 p.m., this nurse noted [the] Resident [Resident #1] cold and clammy. Unresponsive to voice or touch. BS [Blood Sugar] 22 Glucagon given x2 and noted BS no [not] rising. 911 was called, and D5 [Dextrose 5%] was started via PIV (Peripheral Intravenous line). When 911 arrived, his/her BS increased to 125. he/she left the building at 11:30 p.m. On 4/19/2023 at 7:10 a.m., the PNs written by RNS #1 revealed: .the NP (Nurse Practitioner) at the hospital called and confirmed [the] resident admitted to [the] hospital for further evaluations. 2. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Unspecified Organism Sepsis, (Generalized) Muscle Weakness, and Malignant Neoplasm of Unspecified Ovary. According to the MDS dated [DATE], Resident # 3 had a BIMS score of 15/15, which indicated the Resident was cognitively intact. The MDS showed Resident #3 needed extensive assistance and one-person physical assist with most ADLs and needed extensive assistance with two-person assistance with bed mobility, transfer, and personal hygiene. Further review of the MDS showed under Section N Medications revealed Under N0350. Insulin included: that Resident#1 was not on Insulin and had no order for Insulin. The MDS also showed Under N0410. that the Resident was on Anticoagulant ( .heparin, or low molecular weight heparin) therapy. A review of Resident #3's Medication Error Report (MER) dated 4/19/2023 and signed by the Attending MD (Medical Doctor)/[Physician], LNHA [Licensed Nursing Home Administrator], the Assistant Director of Nursing, and the Director of Nursing included the following: Date of error: 4/18/23 [2023], Time of Error: 9 [:00] PM [p.m.], Physician Notified [,] Yes date/time: 4/19/23, DON/Supervisor/Manager notified? Yes, Name: DON date/time: 4/19/23, Resident representative/Family notified? Yes[,] date/time: 4/19/23 5:30 p [p.m.] [,] Medication ordered: Heparin 5000 IU [,] Description of the error-record name of the medication, dose, route and time(s) administered: insulin-Admelog . [,] Outcome to the resident (provide details including care provided after error): BS [Blood Sugar] dropped sent to ER [emergency room ] via 911. Under Assessment and Summary of Medication Error, included: Under Type of Error, wrong medication. Under Reason For Error, revealed Other: did not verify medication [.] Under Corrective action taken: revealed staff education -LPN suspended pending outcome of the investigation Under Measures taken to prevent the recurrence of similar errors: included: insulin vials changed to pens-insulins + [and] heparin in separate areas of med [medication] cart [.] Under Signatures [,] Title [,] Date included: Person making error LPN [,] 4/19/23[;] Person reporting error LPN/ADON[,] 4/19/23, DON [,] RN DON [.] A review of Resident #3's NJUTF revealed Date of Transfer: 4/19/2023 and Time of Transfer 12:15 a.m. [a.m.] [,] Reason for Transfer: included Pt found cold + [and] clammy [,] Hypoglycemic episode [,] BS reads Lo [low]. A review of Resident #3's OSR, Active Orders as of 04/18/2023, revealed the following POs: Heparin Sodium (Porcine) Solution 5000 UNIT/ML[.] Inject 5000 units subcutaneously every 8 hours for clotting prevention[.] It may increase the risk of bleeding. Please observe for any bruising, dark urine, and black, tarry stools. A review of Resident #3's MAR dated 04/1/2023-04/30/2023 reflected that the LPN administered the above POs as ordered on 4/18/2023 at 10:00 p.m. A review of Resident #3's PNs revealed the following: On 4/19/2023 at 8:24 a.m., the PNs written by RNS #1 revealed, This nurse found resident cold and clammy, moving his/her upper extremities up in [the] air with eyes wide open. BG checked and read LO [LOW] PIV antecubital, D10 [Dextrose 10%] started by the 911 team present in the building. Suctioned Resident for excess secretions in his/her mouth. Resident BG up to more than 200 after IV started. Resident [#3] left [the] building at 12:15 a.m. to go to the hospital for further evaluation. NP called and notified us that [the] Resident will be admitted . This nurse notified the Family of [the] change in condition. A review of the LPN's Agency Account included: the date of Tue [Tuesday] 4/18 [4/18/2023] revealed In 2:50 p.m. [p.m.] and Out 7:08 a.m. [a.m.], indicating the LPN worked on the evening and overnight shift from 4/18/2023 through 4/19/2023. A review of the Individual One-On-One Inservice for the LPN dated 4/19/2023, and signed by the LPN and the ADON revealed Under Issue in-serviced on: Med [Medication] Pass [.] Under Education given: included: Being prepared, right resident, right drug [,] observe precautionary warnings, right time [,] correct technique, right route A review of the LPN's Statement dated 4/19/2023 revealed on 4/18/2023 on the 3:00 p.m.-11:00 p.m. shift, at the beginning of the overnight shift, 3 residents on his post developed hypoglycemia conditions that required EMT interventions. The three patients [residents] were on heparin; only one was diabetic. He recalled checking the brown bottle containing the vials of heparin to confirm the medication, but its [it is] possible that actually, it was [were] insulin vials mistakenly placed in the bottle. He didn't recall confirming or checking what was on the label of the bottle. During a telephone interview on 4/20/2023 at 2:15 p.m., RNS #1 stated, she was the Supervisor on duty. RNS #1 explained around 11:00 p.m.-11:15 p.m., she heard moaning, saw Resident #1, and observed him/her; he/she was cold, clammy, and sweaty. She thought the Resident had a blood sugar [BG] / Hypoglycemia issue and checked his/ her blood sugar and vitals. The blood sugar was low, and the first dose of Glucagon was given. However, the BS was not going up, so another nurse started an IV on the patient [Resident] on D5 [dextrose]. She continued to say the blood sugar was improving, when 911 came, blood sugar went to 75 mg/dl, we [nurses] just hung IV, at that time the Resident was responsive, talking [but] very tired, then 911 came and took him/her to the emergency room (ER) .the Nurse Supervisor (RNS #2) [was] talking that Resident #1 was responsive, talking and alert, had eaten and he/she had no issues prior to this incident. When the Surveyor asked RNS #1 about Resident #3, she stated I saw the Resident eyes wide open, hands moving in the air, unresponsive, cold, and clammy. The Resident's BG was checked, was low, and showed no number; it just read low, I wanted to start a line, another [nurse] checked blood pressure, another [nurse] called 911, he/she was moving his/her arms, 911 team came and started antecubital IV at D10 (Dextrose 10%). She continued to say his/her blood sugar went to 200 mg/dl. The RNS further stated that the LPN who cared for Resident #3 was the same nurse who cared for Resident #1. The Resident was not a diabetic . then 911 took him/her [to the hospital] for further evaluation. During an interview on 4/20/2023 at 4:35 p.m., the DON stated the status of the LPN is he is suspended pending investigation. [The] Nurse worked a double shift on 4/18/2023, the 2:30 p.m.-10:30 p.m. shift and the 10:30 p.m.-6:30 a.m. shift, the last time he worked. The med [medication] error was on 4/18/2023 at 9:00 p.m., and it was addressed the next morning. She further stated that when the incidents occurred, corporate came in, and we immediately investigated that there was a possibility of what happened with the medications. In the same interview, the DON stated, [the] nurse (LPN) said this is [a] possibility what could've happened with [the] heparin and Insulin. I did not want him working on the floor, [due to the] possibility that Insulin was given instead of heparin to the residents sent out on low blood sugar. The medication error report is the incident report for medication. We are still investigating the incidents so we can have a solid plan moving forward. Corporate is still here. We are checking all residents on heparin and on Insulin. We are switching all insulin vials to insulin pens are in process . the investigation is still ongoing During an interview on 4/20/2023 at 5:05 p.m., the Regional Director, in the presence of the Regional Clinical Director (RCD), stated, We [the facility] reported to DOH yesterday started investigation for medication administration for all staff on [the] Rights of Medication [dated] 4/19/2023. We switched all insulin vials to pens starting yesterday. We increased glucagon inventory. We immediately suspended the nurse. He (LPN) had a med [medication] pass post orientation, and he passed. In the same interview, the RCD stated we did an additional audit that all diabetic residents had a bedtime snack. The Regional Director stated we started med [medication] pass competencies with all nurses yesterday .provided education on syringes. We self-identified and self-reported [it] was isolated to one employee. The RCD continued to say we worked on it immediately, on basics, in-services were done on Abuse and Neglect on 4/20/2023, and [are] still in progress. In-service done on 4/19/2023 on insulin and heparin vials are not to be stored in the same drawers. All in-services were started and ongoing. We are still investigating, not concluded yet. During an interview on 4/24/2023 at 10:28 a.m., the ADON/Infection Preventionist (IP) stated RNS #1 called me [to say] we have three residents going out to [the] hospital. Supervisors always call [me] when sending out [residents to the hospital]. [The] Residents [were] sent out for Hypoglycemia on 4/19/2023. RNS #1 called me at approximately 1:30 a.m., and we talked about who was the nurse (LPN) and RNS #1 finished the med pass, and she checked other residents on the LPN's assignment with no issues. She then emailed the Administrator and the DON about the error. The LPN was [taken] off the [medication] cart at 1:30 a.m. by RNS #1. He took blood pressure but no medications and was sent home at the end of the shift. At approximately 2:00 a.m., I looked at all the Medication Administration Records (MARs) for all 3 residents. At 7:00 a.m., I was on the phone with the DON, the Regional Clinical [Supervisor], and Administrator. Then at approximately 8:00-9:00 a.m., the investigation was started. During the same interview, the ADON/IP stated she asked the LPN about the incident on 4/19/2023 since he was due to return at 2:30 p.m. to start the shift. According to the ADON/IP, the LPN said he probably made an error since he wasn't paying attention, so we educated him. He signed off on it, and I told him he was suspended pending investigation. I think the investigation is ongoing. I'm doing education. [The] LPN was trained prior [to the incidents] in medication pass; he missed a right of medication. The DON notified the doctor [Physician] and Family. In the same interview, she continued to say, I started education that day on Abuse, and Neglect is the whole building, [the] 9 Rights of medications, syringes, heparin & insulin vials are in separate drawers in the med [medication] cart, but now insulin pens are in place, we, nurses triple checked the heparin and Insulin, nurses did med pass and insulin pen competencies. All new hires are being med passed. During a telephone interview on 4/24/2023 at 11:53 a.m., when the Surveyor asked him what happened concerning the medications, the LPN stated, Resident #1 got meds [medications] at the end of the 3:00 p.m. -11:00 p.m. shift. He further stated that Resident #1 acted out with moaning sounds; he was unsure of the time. The BS was low, started [an] IV line [and] called 911. Later on, we discovered, Resident #3 was showing signs of not acting OK, he/she was moving [his/her] arms around in an abnormal way, so we [me & RNS #1] and RNS #2, a whole team of nurses checked everything to include: vital signs, heart rate was high, blood sugar was dropping. Then, EMT (emergency medical team) was there [and] helped, [blood] sugar was 214 and took him/her to hospital. In the same telephone interview, the LPN continued to say, [I] look in [the medication] cart for heparin, look at the bottle. I know I picked up [the] heparin bottle; it's possible that I mixed it up. The LPN explained, When I picked up the bottle and vial, it may be possible I picked up the insulin bottle. All the 10 ML (milliliters) vials are the same. [The] heparin vials were mixed up in the cart, in brown bottles, [it was] not separated. The vial is in [a] brown bottle. All just mixed up on the cart. I might not have looked at the vial. When I took it out of the drawer, it's possible I didn't look at it. During a telephone interview on 4/24/2023 at 12:20 p.m., RNS #2 stated, around 11:15 p.m., we [the nurses] heard [a] moaning noise, checked the rooms, and found Resident #1 cold, clammy, and sweaty. The BS was checked, and it was 22. She further stated that Glucagon was given x1 (once), and then the BS went up to 27 and then 29 the second time. 911 was called, D5 (Dextrose 5%) solution IV was started, and the BS increased to 48. During an interview on 4/24/2023 at 2:12 p.m., the Surveyor asked the DON about the breakdown, which led to Residents #1 and 3 receiving Heparin instead of Insulin. She replied, I couldn't identify the breakdown. As we investigated, he (LPN) said it was a possibility he didn't practice the 9 [nine] rights of medication During a post-survey telephone interview on 4/26/2023 at 1:16 p.m., the Physician, Medical Director, stated he consulted with the hospital Endocrinologist. The Medical Director explained to the Surveyor, According to the Endocrinologist, once you give glucose, it shows up as Insulin in your system. Both residents were given IV Glucose, so the lab results are the same. Glucose shows as Insulin in the lab results. During the same interview, when the Surveyor asked about Resident #1's low blood sugar before the glucose was given, the Medical Director stated, Most likely [the] medication error was Insulin, but we cannot test for Insulin due to glucose being given . He further stated other causes were ruled out; the only cause of the Hypoglycemia is Insulin, by exclusion. Resident #3 was in [the] same situation as Resident #1. A review of the facility policy titled Administering Medications with an updated date 10/2022 revealed the following: Under Policy Statement: included: Medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation included: .5. The individual administering the medication must check the label against the Physician's order to verify the right Resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. A review of the facility policy titled Identifying and Managing Medication Errors and Adverse Consequences with a revised April 2022 date revealed the following: Under Policy Statement: included: The Staff and practitioner shall try to prevent medication errors and adverse medication consequences and shall strive to identify and manage them appropriately when they occur. Under Policy Interpretation and Implementation included: 1. The staff and practitioner shall strive to minimize adverse consequences by a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; b. Defining the appropriate indications for use; . A review of the facility policy titled Physician Orders with a revised date of December 2022 revealed the following: Under Policy included: Medication and treatment orders will be accepted only from authorized, credentialed physicians or from other authorized, credentialed practitioners in accordance with state regulations regarding prescriptive privileges. Under Purpose, included: To ensure all medication and treatment orders are received from a credentialed practitioner before implementing. Under Process included: Type of Order: 1. Admission, Interim, Re-admission, and Renewal Orders: 2. Must be written on the appropriate Physician Order Sheet and Interim Plan of Care; 3. IV (intravenous) orders must be written on the appropriated IV Protocol Sheet (Central, Mid-line, or Peripheral) . N.J.A.C.: 8.39-29.2 (d)

Complaint#: NJ163545, NJ163595, NJ163682 Based on interviews, medical records review, and other pertinent facility documentation on 4/20/2023 and 4/24/2023, it was determined that the facility failed to implement a comprehensive care plan for residents on anticoagulant medications for 2 of 9 residents (Resident #2 & #3). The facility also failed to follow its policy titled Care Plans, Comprehensive Person-Centered. This deficient practice was evidenced by the following: Review of the Electronic Medical Records was as follows: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Unspecified Organism Sepsis, Type 1 Diabetes Mellitus with Ketoacidosis without Coma, Type 2 Diabetes Mellitus With Diabetic Nephropathy and Unspecified Hereditary and Idiopathic Neuropathy. According to the Minimum Data Set (MDS), an assessment tool, dated 03/24/2023, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #2 needed limited assistance and one-person physical assist with most Activities of Daily Living (ADLs). The MDS also showed Under N0410. Medications Received revealed Indicate the number of Days the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days . included: Enter Days 6 for E. Anticoagulant ( .heparin, or low molecular weight heparin). A review of Resident #2's Order Summary Report (OSR), Active Orders as of 04/18/2023 revealed the following Physician Orders (POs): Heparin Sodium (Porcine) Solution 5000 UNIT/ML[.] Inject 5000 units subcutaneous every 8 hours for clotting prevention[.] It may increase the risk of bleeding. Please observe for any bruising, dark urine, and black, tarry stools dated 02/01/2023. A review of Resident #2's Care Plan (CP) showed no CP was developed, and no interventions were in place for Heparin (an anticoagulant medication). 2. According to the AR, Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Unspecified Organism Sepsis, (Generalized) Muscle Weakness, and Malignant Neoplasm of Unspecified Ovary. According to the MDS dated [DATE], Resident # 3 had a BIMS score of 15/15, which indicated the Resident was cognitively intact. The MDS also showed Resident #3 needed extensive assistance and one-person physical assist with most ADLs and needed extensive assistance with two-person assistance with bed mobility, transfer, and personal hygiene. The MDS also showed Under N0410. Medications Received revealed Indicate the number of Days the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days . included: Enter Days 7 for E. Anticoagulant ( .heparin, or low molecular weight heparin). A review of Resident #3's OSR, Active Orders as of 04/18/2023, revealed the following POs: Heparin Sodium (Porcine) Solution 5000 UNIT/ML[.] Inject 5000 units subcutaneous every 8 hours for clotting prevention[.] It may increase the risk of bleeding. Please observe for any bruising, dark urine, and black, tarry stools. A review of Resident #3's CP showed no evidence of a CP being developed and no interventions in place for Heparin (an anticoagulant medication). During an interview on 4/24/2023 at 10:59 a.m., the Registered Nurse (RN) who cared for Resident #2 stated, If a resident is on heparin, it [the medication] should be on the CP. She further stated that the CP is an informative guideline, and all residents on blood thinners should be carefully planned for it. During a telephone interview on 4/24/2023 at 12:20 p.m., the RN Supervisor stated, If a resident is on heparin, it should be on the CP. She further stated the CP is anything the patient [Resident] has; it is the Resident's plan of care. During an interview on 4/24/2023 at 1:40 p.m., the Unit Manager/Licensed Practice Nurse (UM/LPN) stated the CP's purpose is to manage the patient's [Resident's] care. When the Surveyor asked the UM/LPN if Heparin should be on the CP, he stated, Yep, it [Heparin] should be on the care plan. During an interview on 4/24/2023 at 2:12 p.m., the DON stated, Heparin or anticoagulants [medications] should be on the CP with interventions. A review of the facility policy titled Care Plans-Comprehensive Person-Centered dated October 2022 revealed the following: Under Policy Statement included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement for each resident. Under Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental, and psychosocial well-being; . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the Resident's condition change. 14. The Interdisciplinary Team must review and update the care plan: .When the Resident has been readmitted to the facility from a hospital stay; N.J.A.C.: 8.39-27.1 (a)

Complaint#: NJ163545, NJ163595 Based on observation, interview, medical record review, and other pertinent facility documents on 4/20/2023 and 4/24/2023, it was determined that the facility failed to maintain Professional Standards of practice by not a). administering medication according to Physician's Orders, and b). following the Pharmacy's cautionary warnings. The facility also failed to follow its policies titled Administering Medications, Charting and Documentation, and Physician Orders. This deficient practice was identified for 2 of 9 residents (Resident #7 and #8) reviewed for standards of practice. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/24/23 at 9:20 a.m., the Surveyor observed the Licensed Practical Nurse (LPN) during medication administration. While the LPN prepared the medication for Resident #7, she informed the Surveyor that Resident #7's prescribed order for Megestrol Acetate Suspension of 10 milliliters by mouth once daily for poor appetite was unavailable to be administered. The LPN informed the Surveyor that she would call the Pharmacy for a refill order and notify the Physician after completing medication administration to all her residents so that she is only making one call. The LPN noted the missing medication on a notepad on the medication cart. The LPN also told the Surveyor that she would make a note [document] in the resident's electronic medical record (EMR) of the unavailable medication and the Physician's notification. On 4/24/2023 at 9:20 a.m., the Surveyor observed the LPN prepare medications for Resident #7 in the following order: Amiodarone HCL (hydrochloride) Oral Tablet 100 MG. Give 1 tablet by mouth daily for Chronic Afib (Atrial fibrillation). Eliquis Tablet 2.5 MG 1 tablet by mouth twice daily for Chronic Afib. Bethanechol Chloride oral tablet 5 MG. Give 1 tablet by mouth three times daily for Urinary Retention. Synthroid 50 MG. Give 1 tablet by mouth in the morning before meals for Hypothyroidism. Lipitor Oral Tablet 10 MG. Give 1 tablet by mouth at bedtime for Hyperlipidemia. Multiple Vitamins-Minerals Tablet. Give 1 tablet by mouth daily for Supplement. 1. According to the Admission Record (AR), Resident #7 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Anemia, Chronic Kidney Disease, Acute Respiratory Failure, and Unspecified Severe Protein-Calorie Malnutrition. Review of the Minimum Data Set (MDS), an assessment tool dated 3/9/2023, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the resident had severe cognition. The MDS also showed Resident #7 was dependent on staff for all Activities of Daily Living (ADLs). A review of the Order Summary Report (OSR) for Resident #7, dated 4/1/2023 through 4/30/2023, revealed the following Physician Orders (POs): Megestrol Acetate Suspension 400 MG/10 ML give 10ML by mouth one time a day for Poor Appetite dated 2/15/2023. Amiodarone HCL Oral Tablet 100 MG. Give 1 tablet by mouth daily for Chronic Afib, dated 1/25/2023. Eliquis Tablet 2.5 MG 1 tablet by mouth twice daily for Chronic Afib dated 1/25/2023. Bethanechol Chloride oral tablet 5 MG. Give 1 tablet by mouth three times daily for Urinary Retention dated 3/23/2023. Synthroid 50 MG Give 1 tablet by mouth in the morning before meals for Hypothyroidism dated 1/25/2023. Lipitor Oral Tablet 10 MG. Give 1 tablet by mouth at bedtime for Hyperlipidemia dated 2/3/2023. Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth daily for Supplement dated 1/25/2023. Review of Resident #7's Electronic Medical Record (EMR) showed no documentation that the Pharmacy was notified for a Megestrol Acetate Suspension 400 MG/10 ML refill. There was no documentation that the Doctor was notified about the unavailable medication. The EMR also showed no evidence of weight loss during the review period. The Surveyor attempted to interview the resident (Resident #7) but was unable due to the resident's cognition. On 4/24/2023 at 9:40 a.m., the Surveyor observed the LPN prepare medications for Resident #8 in the following order: Benztropine Mesylate Oral Tablet 1 MG. Give 1 tablet by mouth daily for Parkinson's. Doxazosin Mesylate Tablet 1mg. Give 1 tablet by mouth daily for Hypertension (HTN). Enulose Solution 10 GM (Gram)/15 ML (Milliliter). Give 15 MG by mouth for Constipation. Isosorbide Mononitrate ER (Extended Release) Oral tablet 24 Hour 60 mg. Give 1 tablet by mouth daily for HTN . DO NOT CRUSH OR CHEW. Lidocaine External Patch 4 percent (%) apply to both knees topically for Pain. MiraLAX Oral Packet 17 GM mix with 4-6 ounces of water or juice by mouth for Constipation. Multiple Vitamin Tablet. Give 1 tablet by mouth daily for Supplement. Colace Sodium 100 MG Tablet 1 tablet by mouth twice daily for Constipation. Fluticasone-Salmeterol 1 inhalation for Asthma rinse mouth after use for Asthma. Topiramate 25 MG Tablet. Give 1 tablet by mouth twice daily for Seizure Disorder. Vitamin D 1000 units. Give 2 tablets by mouth daily for Supplement. The LPN crushed each pill separately, emptied it into separate cups (30 ml cup), and added apple sauce in each cup in the same order the pill was removed from the medication cart. The LPN informed the Surveyor she was ready to administer the medications and walked towards Resident #8 for administration. At that time, the Surveyor stopped and requested the LPN return to the medication cart. The Surveyor and LPN reviewed the electronic Medication Administration Record (eMAR) against the bingo cards (blister packets containing the medications). The eMAR revealed Isosorbide Mononitrate ER oral tablet Extended Release 24 Hour 60 mg for HTN . DO NOT CRUSH OR CHEW. The Surveyor asked the LPN if she followed the cautionary warning regarding the crushed Isosorbide Mononitrate ER 60 MG. The LPN removed the cup containing the crushed Isosorbide Mononitrate from the rest of Resident #8's medications and administered the other medications as ordered. 2. According to the AR, Resident #8 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Unspecified Anemia, Essential Hypertension, Major depressive Disorder, and Mild Intellectual Disabilities. Review of the MDS dated [DATE], Resident #8 had a BIMS score of 4/15, which indicated the resident was cognitively impaired. The MDS also showed Resident #8 was dependent on staff for all ADLs. Review of the OSR for Resident #8 dated 4/1/2023 through 4/30/2023 revealed the following POs: Lidocaine External Patch 4 % (Lidocaine). Apply to both knees topically one time a day for Pain and remove as scheduled, dated 3/14/2023. Benztropine Mesylate Oral Tablet 1 MG. Give 1 tablet by mouth daily for Parkinson's, dated 3/9/2023. Doxazosin Mesylate Tablet 1 MG. Give 1 tablet by mouth daily for Hypertension (HTN), dated 3/9/2023. Enulose Solution 10 GM/15 ML (Milliliter). Give 15 ml by mouth for Constipation, dated 3/9/2023. Isosorbide Mononitrate ER oral tablet Extended Release 24 Hour 60 mg. Give 1 tablet by mouth daily for HTN . DO NOT CRUSH OR CHEW, dated 3/9/2023. MiraLAX Oral Packet 17 gm mix with 4-6 ounces of water or juice by mouth for Constipation, dated 3/9/2023. Multiple Vitamin Tablet. Give 1 tablet by mouth daily for Supplement dated 3/9/2023. Colace Sodium 100 MG Tablet. Give 1 tablet by mouth twice daily for Constipation, dated 3/9/2023. Fluticasone-Salmeterol 1 inhalation for Asthma rinse mouth after use for Asthma, dated 3/9/2023. Topiramate 25 MG Tablet. Give 1 tablet by mouth twice daily for Seizure Disorder, dated 3/9/2023. Vitamin D 1000 units. Give 2 tablets by mouth daily for Supplement dated 3/9/2023. May Crush or Open capsules and place in food or liquid according to pharmacy guidelines dated 3/9/2023. During an interview on 4/24/2023 at 10:00 a.m., the LPN acknowledged the cautionary warning for the medication and stated, The pill [Isosorbide Mononitrate] should not have been crushed, I should have followed the pharmacy warning [ DO NOT CRUSH OR CHEW]. She continued to say the Doctor [Physician] should have been notified about the Pharmacy's cautionary warning and a substitute order or an order to change the pill to liquid if available. The LPN further stated, I would have given the medication if you didn't stop me. During a second interview on 4/24/2023 at 10:43 a.m., the LPN informed the Surveyor that she had notified the Unit Manager/Licensed Practical Nurse (UM/LPN) about the unavailable dose of the Megestrol Acetate Suspension 10 ML and stated, I thought the UM/LPN had called the Pharmacy to reorder the medication. The LPN continued to say the process of reordering an unavailable medication is for the administering Nurse to contact the Pharmacy for a refill and notify the prescribing Doctor [Physician] of the unavailable medication. She further stated that the Doctor might give a verbal order for a substitute medication or a hold order until the medication is delivered from the Pharmacy. When asked by the Surveyor if the Pharmacy was called or if the Doctor was notified, the LPN stated, No, I did not call the Pharmacy for a refill for Resident #7's Megestrol Acetate Suspension 400 MG/10 ML or notify the Doctor about the unavailable dose. She further stated that this should all be documented in the resident's EMR. During an interview on 4/24/2023 at 1:40 p.m., the UM/LPN stated, the Nurse on the cart is expected to call the Pharmacy if a medication is unavailable during a medication administration pass. He also said, This should be done immediately during the medication administration pass if a medication is unavailable. When asked by the Surveyor what the LPN should have done when she did not have the medication, he stated that if a medication is unavailable during medication administration, the LPN is expected to call the Pharmacy for a STAT refill, notify the Doctor to obtain a substitute order if available in the back-up box, if not obtain a hold order from the Doctor until the medication is delivered from the Pharmacy. The UM/LPN further stated this should all be documented by the LPN in the resident's EMR. In the same interview, when asked by the Surveyor what the LPN should have done regarding the pharmacy cautionary warning, the UM/LPN stated, We [Nurses] have to follow the cautionary warning from the pharmacy as listed on the eMAR. He further stated if a resident has an order to crush all medications and a particular medication cannot be crushed, the LPN is expected to notify the Doctor about the warning [DO NOT CRUSH OR CHEW] and obtain a substitute medication that can be crushed. During an interview on 4/24/2023 at 5:42 p.m., the DON stated, If a medication is unavailable during medication administration, the Nurse should immediately call the Pharmacy for a refill order and request a STAT delivery. The Nurse should also call the Doctor to obtain a substitute or hold the order for that medication until delivered from the Pharmacy. She further stated, This should all be documented in the Resident's EMR. In the same interview, the DON stated, If there is a cautionary warning for a medication [DO NOT CRUSH OR CHEW], I expect it [the medication] not to be crushed. She further stated, The LPN should reach out to the Doctor [Physician]and obtain an order for a substitute medication that can be crushed if there is a cautionary warning for a particular medication. During the post-survey telephone interview on 4/28/2023 at 12:11 p.m., the Pharmacist stated that Resident #7's Megestrol Acetate Suspension 400MG/10ML was last reordered and delivered to the facility on [DATE]. The Pharmacist further stated that the Megestrol Acetate Suspension 400MG/10ML is past due for a refill, and a refill request has not been received from the facility since last filled on March 22, 2023. Review of the facility's undated Policy titled Charting and Documentation under Policy revealed . All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility policy last updated 10/2022 titled Administering Medications under Policy revealed . 2. Medications must be administered in accordance with the orders, including any time frame. 5. The individual administering the medication must check the label against the Physician's order to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. A review of the facility policy titled Physician Orders with a revised date of December 2022 revealed the following: Under Policy included: Medication and treatment orders will be accepted only from authorized, credentialed physicians or from other authorized, credentialed practitioners in accordance with state regulations regarding prescriptive privileges. Under Purpose, included: To ensure all medication and treatment orders are received from a credentialed practitioner before implementing. NJAC 8:39-27.1(a) NJAC 8:39-11.2(b)

Based on interviews, record review, facility policy review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, it was determined the facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the assessment reference date (ARD) for 2 (Resident #5 and Resident #15) of 4 sampled residents reviewed for timeliness of MDS assessments. Findings included: 1. Review of an Admission Record revealed Resident #15 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/05/2022 revealed the MDS was signed by the Registered Nurse (RN) as completed on 09/26/2022. 2. Review of an Admission Record revealed Resident #5 had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of a quarterly MDS with an assessment reference date of 07/26/2022 revealed the MDS was signed by the RN as completed on 09/26/2022. During an interview on 09/28/2022 at 2:47 PM, the Director of Nursing (DON) stated she was not aware the MDS assessments were being completed late. She indicated she expected the MDS assessments to be completed timely. During a follow-up interview on 09/29/2022 at 8:51 AM, the DON confirmed Resident #5's quarterly MDS was completed on 09/26/2022 and acknowledged this was late. During an interview on 09/28/2022 at 3:03 PM, the Administrator stated he expected the staff to follow the Centers for Medicare and Medicaid Services (CMS) regulations and complete the MDS assessments in a timely manner. The Administrator indicated the reason the assessments needed to be completed in a timely manner was to ensure the residents were receiving the care that was needed. During an interview on 09/29/2022 at 1:18 PM, the MDS Coordinator indicated she started to conduct MDS assessments as a new employee of the facility three months ago. The MDS Coordinator indicated when she started to work in the facility, the goal was to catch up on the assessments that were missed or not transmitted. She acknowledged there was a problem with the completion of MDS assessments and stated to resolve the problem, she was going to start running a weekly report to catch the problem. During an interview on 09/29/2022 at 9:00 AM, the Administrator stated there would be changes in the MDS personnel and that the assessments would be completed and transmitted timely. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed the MDS completion date (Item Z0500B) must be no later than 14 days after the assessment reference date (ARD). Review of an undated facility policy titled, MDS Completion and Submission Timeframe revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy also indicated, Timeframes for completion and submission of assessment is based on the current requirements published in the Resident Assessment Instrument Manual. New Jersey Administrative Code S 8:39-11.1

Based on interviews, record review and facility policy review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed when a new mental illness was diagnosed for 1 (Resident #55) of 3 sampled residents reviewed for PASSR. Findings included: Review of an Admission Record revealed the facility admitted Resident #55 on 03/23/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan, dated as initiated on 03/11/2019, revealed Resident #55 was risk for complications related to the use of [CONDITION(S)] drugs for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. The MDS further revealed the resident had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #55's clinical record revealed no evidence a Level II PASRR was completed after the resident received new mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/28/2022 at 9:26 AM, the Social Worker (SW) stated she and the Director of Social Services oversaw PASRRs and did not know what should happen with the PASRR when a resident received a new mental illness diagnosis. During an interview on 09/28/2022 at 9:35 AM, the Director of Social Services acknowledged Resident #55 received new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the Director of Social Services, she did not redo the PASRR when a resident was diagnosed with a new mental illness. During an interview on 09/28/2022 at 2:49 PM, the Director of Nursing (DON) stated the facility used PASRRs to make sure residents were being placed in the proper facility for the care needed. Per the DON, when a resident was diagnosed with a new mental illness, a PASRR Level II screening was supposed to be completed. During an interview on 09/28/2022 at 3:06 PM, the Administrator stated he expected staff to follow the guidelines provided by the Centers for Medicare and Medicaid Services (CMS) and complete the PASRR Level II when there was a new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . New Jersey Administrative Code S 8:39-28.1(c)