Every finding on record at Complete Care at Harborage LLC

Based on observations, interviews, review of medical records, and review of pertinent facility documents on 5/18/26, it was determined that the facility failed to ensure that a cognitively impaired resident who had a tracheostomy and was ventilator dependent was free from physical abuse. On 5/10/26, the police notified the facility of an allegation of abuse by a Respiratory Therapist (RT). The Licensed Nursing Home Administrator (LNHA) was shown a video by the police that was taken by a hidden video camera that was placed in the resident's room by their family member. The RT was suspended immediately and did not return to the facility. The facility self-corrected and put themselves back in compliance to prevent serious harm from occurring or recurring on 5/11/26 when facility staff were educated on facility abuse policies.The IJ was Past Non-Compliance (PNC). This deficient practice was identified for 1 of 4 residents (Resident #1) reviewed for abuse.The deficient practice was evidenced by:A review of the facility's policy on Abuse, Neglect, and Exploitation, with a reviewed/revised date of 5/10/2026, included under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish [ .] Physical Abuse includes, but is not limited to hitting, slapping, punching [ .] Staff includes [ .] contractors, [ .] caregivers who provide care and services to residents on behalf of the facility [ .] including therapy [ .]. Under Policy Explanation and Compliance Guidelines: [ .] 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Under The components of the facility abuse prohibition plan are discussed herein: [ .] III. Prevention of Abuse, Neglect, and Exploitation [ .] D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect [ .] H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. A review of the Reportable Event Record/Report (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 5/11/26, included the date and time of event: 5/10/26 at 12:00 PM. The FRE further revealed under Narrative that on 5/10/26 at approximately 12:00 PM, the facility was made aware by law enforcement of an alleged staff to resident abuse. A RT was identified and immediately suspended pending investigation. The resident (Resident #1) was immediately assessed by nursing staff with no new findings. A review of the facility's Investigational Summary and Conclusion (ISC) report revealed under Description of Event: On 5/10/2026 at approximately 12 PM, the facility was made aware by law enforcement of an alleged abuse as they indicated they reviewed video footage. The ISC further revealed that the RT was interviewed and denied any abuse. Additional staff were interviewed without concerns identified. Under Conclusion the ISC revealed the RT was not returned to the facility based on the reviewed video footage as it demonstrated behaviors that are not consistent with facility policy. The surveyor reviewed the video footage from the police department. Videos were received for 4/28/26, 5/1/26, and 5/2/26. A review of footage dated 4/28/26, lasted 1:54 [1 minute and 54 seconds], revealed: - At 11:38 PM, RT observed in view of the camera; Resident #1 in bed; RT noted on the left side of the resident's bed and appeared to be connecting the resident's tubing to their tracheostomy tube; Resident #1 raised their right hand; RT pushed the resident's hand down. - At 11:39 PM, the RT threw a towel on the resident's face; the resident removed the towel from their face with their right hand; RT threw the towel back on resident's face; the resident again removed the towel from their face with their right hand; RT threw the towel on resident's face in total of four times and each time the resident removed it with their right hand. A review of footage dated 5/1/26, lasted 1:58 [1 minute and 58 seconds], revealed:- At 11:44 PM, RT observed in view of the camera; Resident #1 noted in bed; RT noted standing on the left side of the resident's bed; RT noted pulling resident's hands by the wrists, arranged the resident's pillow, held the resident's head by the back, and let it drop on the pillow; RT was then observed using their hand to hit the resident on their left side of face and afterwards, proceeded to connect the tubing to the resident's tracheostomy; RT was then noted holding the resident's raised right hand and appeared to twist and bend the resident's hand back; Resident #1 noted with facial grimacing and pulling hand away. - At 11:45 PM, RT was observed to have held the resident's left hand by the wrist and appeared to squeeze and bend the hand; RT was then observed to push the resident's left arm down and throw a towel on the resident's face, squeezing the towel on the resident's face; Resident #1 noted to be gasping for air. - At 11:46 PM, RT was observed checking the tubing connections and seen hitting the resident on their right side of the face; RT then left and disappeared from the screen. A review of footage dated 5/2/26, lasted 15 seconds, revealed:-At 3:32 AM, RT observed in view of the camera; Resident 1 noted in bed; RT noted standing on the right side of the resident's bed; RT was then observed to have held the resident's right hand and forcibly held it down on the bed. A review of footage dated 5/2/26, lasted 31 seconds, revealed: -At 5:58 AM, RT observed in view of the camera; Resident #1 noted in bed; RT noted standing at the side of the resident's bed; Resident #1 was observed with their right hand raised and waving; RT then hit the resident on their right side of head, pushed down the resident's right hand, squeezed the fingers, and bent Resident #1's hand for 14 seconds; Resident #1 noted with facial grimacing of pain. The surveyor reviewed the medical record of Resident #1. A review of Resident #1's admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses which included but are not limited to chronic respiratory failure with hypoxia (a medical condition that a specific part of body does not receive enough oxygen to function properly), chronic obstructive pulmonary disease (COPD), adjustment disorder with anxiety, tracheostomy status, and gastrostomy status. A review of the Minimum Data Set (MDS), an assessment tool dated 2/4/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated the resident's cognition was severely impaired. The MDS further revealed that the resident required total assistance from staff in the completion of their Activities of Daily Living (ADLs). A review of the resident's care plan report (CP) included the following Foci (Problem areas/needs):Resident #1 has impaired cognitive/communication function s/p (status post) CVA (cerebrovascular accident; stroke), chronic respiratory failure, initiated 6/13/24. Interventions included but were not limited to: ask yes/no questions in order to determine resident's needs; keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, and present just one thought, idea, question or command at a time.Resident #1 is at risk for developing pressure ulcers, skin breakdown, and bruising r/t (related to) holding tightly to side rail during peri care, increased agitation, swinging, decrease mobility, incontinence, and anticoagulation medications, initiated 6/13/24. Interventions included but were not limited to: report any skin redness/impaired integrity areas, resident's skin will be assessed on a weekly basis and document findings on a weekly skin assessment. monitor/document location, size and treatment of skin injury, and report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration (the softening and breaking down of tissue due to prolonged exposure to moisture), etc. to MD (physician). Resident #1 is resistive to care r/t anxiety episodes of pulling out trach, initiated 2/26/25. Interventions included but were not limited to: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care.Resident #1 uses psychotropic medications anti-anxiety meds r/t anxiety and behavior of flailing her arms and contracted hand resulting in unintentional injuries to face, arms, and hands, initiated 12/4/24. Interventions included but were not limited to: remove unnecessary environmental triggers, provide calm environment, reduce excessive noise/stimulation, and maintain calm structured environment.Resident #1 is on ventilator dependent r/t respiratory failure; resident has a trach due to respiratory failure, initiated 6/13/24. A review of Resident #1's hospital Emergency Department (ED) records dated 5/11/26 showed the admitting diagnosis of subdural hematoma (A life-threatening collection of blood between the brain and the skull's tough outer covering (Dura mater), usually caused by a head injury). Under Chief Complaint: Patient presents with: Contusion, Multiple, Face, L [left] chest, R [right] arm. The ED records further showed a CT (Computed tomography scan; an imaging test that combines a series of x-rays with computer processing to create detailed 3D cross-sectional images of bones, organs, and soft tissues) Head without contrast (dye) dated 5/11/26 at 11 PM with results which indicated, Right convexity (a curved or outward-bulging surface) subdural hematoma.On 5/18/26 at 2:24 PM, the surveyor interviewed the LNHA and the Director of Nursing (DON). The LNHA stated he only saw 1 video, which was under 1 minute, but there were more. The LNJA further stated that in the video the RT showed actions not to our expectations nor consistent with our abuse policy. The LNHA was unaware a family member had placed a camera until the police came.The facility addressed the situation by reeducated the facility staff on abuse policies and procedures, initiated 5/10/26 and completed 5/11/26; all new staff or any staff on leave to be educated prior to first shift, initiated 5/10/26; skin assessments completed on all residents, with no findings; review of all incident/accident reports; chart audits conducted on all the RT's residents from the date of hire to the present; all residents interviewed, if not cognitively intact, PHQ-2 PHQ-2 (Patient Health Questionnaire-2; a brief, 2 item tool used to identify potential major depressive disorder) conducted, with no concerns reported; audits to be conducted by interviewing 5 staff members daily x 1 week, then weekly x 4 weeks, then monthly x 2 months to ensure staff comprehension of the policy; audits to be conducted to observe staff to resident interactions, 5 staff members per unit daily x 1 week, then weekly x 4 weeks, then monthly x 2 months, and audits to be conducted by interviewing 5 residents per unit daily x 1 week, then weekly x 4 weeks, then monthly x 2 months to ensure residents feel safe within the facility and can voice any concerns. The IJ began 5/10/26 at 12 PM when the police notified the facility of the video footage.The IJ is Past Non-Compliance (PNC). The surveyor verified the implementation of the Removal Plan on-site on 5/18/26 and determined that there is sufficient evidence that the facility self-corrected the noncompliance on 5/11/26 and is in substantial compliance at the time of the current survey for the specific regulatory requirements for F 600. N.J.A.C. 8:39- 4.1(a)5

Based on interviews, record review, and review of pertinent facility documentations on 5/18/26, it was determined that the facility failed to ensure complete and thorough investigations to rule out abuse were done for multiple incidents of resident injury dated 3/21/26 and 4/16/26 for Resident #1 and an incident dated 4/15/26 for Resident #3. This deficient practice was identified for 2 of 4 residents reviewed for abuse and neglect, Resident #1 and Resident #3.The deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #1.A review of Resident #1's admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses, which included but are not limited to chronic respiratory failure with hypoxia (a medical condition that a specific part of body does not receive enough oxygen to function properly), chronic obstructive pulmonary disease (COPD), adjustment disorder with anxiety, tracheostomy status, and gastrostomy status. A review of the Minimum Data Set (MDS), an assessment tool dated 2/4/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated the resident's cognition was severely impaired. The MDS further revealed that the resident required total assistance from staff in the completion of their Activities of Daily Living (ADLs). A review of the resident's care plan report (CP) included the following Foci (Problem areas/needs):Resident #1 has impaired cognitive/communication function s/p (status post) CVA (stroke), chronic respiratory failure, initiated 6/13/24. Interventions included but were not limited to: ask yes/no questions in order to determine resident's needs; keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, and present just one thought, idea, question or command at a time.Resident #1 is at risk for developing pressure ulcers, skin breakdown, and bruising r/t (related to) holding tightly to side rail during peri care, increased agitation, swinging, decrease mobility, incontinence, and anticoagulation medications, initiated 6/13/24. Interventions included but were not limited to: report any skin redness/impaired integrity areas, resident's skin will be assessed on a weekly basis and document findings on a weekly skin assessment. monitor/document location, size and treatment of skin injury, and report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration (the softening and breaking down of tissue due to prolonged exposure to moisture), etc. to MD (physician). Resident #1 is resistive to care r/t anxiety episodes of pulling out trach, initiated 2/26/25. Interventions included but were not limited to: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care.Resident #1 uses psychotropic medications anti-anxiety meds r/t anxiety and behavior of flailing her arms and contracted hand resulting in unintentional injuries to face, arms, and hands, initiated 12/4/24. Interventions included but were not limited to: remove unnecessary environmental triggers, provide calm environment, reduce excessive noise/stimulation, and maintain calm structured environment.Resident #1 is on ventilator dependent r/t respiratory failure; resident has a trach due to respiratory failure, initiated 6/13/24.The surveyor requested for the incidents/accidents (I/A) reports for Resident #1 from March 2026 to date of survey.A review of a facility document labeled Date of Incident reporting: 4/16/2026, Incident Investigation Summary and Conclusion revealed Resident #1 was noted to have a large bruise to the left cheek. A further review revealed that upon assessment and staff interview, it was reported that several days prior the resident attempted to pull at their tracheostomy tubing and accidentally struck themself in the face multiple times during the episode. Under Conclusion revealed no evidence of abuse, neglect, or staff misconduct was identified. A review of a PN dated 4/16/26 at 12:52 PM documented During rounds noted skin discoloration on left cheek down to [Resident #1's] neck [ .] resident [ .] can't recall what happened.The I/A report did not indicate what interventions were to be put in place to prevent further injury.A review of a PN dated 3/21/26 at 4:39 PM documented the resident came back to the unit from ER [emergency room] for GT [gastrostomy tube] placement via stretcher, accompanied by Respiratory Therapist (RT) and CNA (certified nursing assistant). The PN further revealed, resident noted to the L (left) side of the cheekbone ecchymosis (bruise) noted, will continue to monitor, no new order received.There was no I/A report or investigation of the 3/21/26 event given to the surveyor. The surveyor reviewed the medical record of Resident #3. A review of Resident #3's AR, an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses which included but are not limited to non-traumatic intracerebral hemorrhage (bleeding into the brain tissue; a type of stroke), atrial flutter, gastrostomy status, respiratory failure, and tracheostomy status.A review of the MDS, an assessment tool dated 2/17/26, revealed the resident had short- and long-term memory problems and had severely impaired cognitive skills. The MDS further revealed the resident required total assistance from staff in the completion of their Activities of Daily Living (ADLs).A review of the resident's care plan report (CP) included the following Foci (Problem areas/needs):Resident #3 requires tube feeding r/t dysphagia [difficulty swallowing], anoxic brain injury (a severe type of brain injury caused by a total lack of oxygen to the brain), vented tracheostomy initiated 11/7/25. Interventions included but were not limited to: NPO (nothing by mouth). Impaired gas exchange respiratory failure, mechanical ventilation initiated 11/6/25. Interventions included but were not limited to: maintain ventilator settings per orders.Resident #3 has an ADL self-care performance deficit r/t vegetative state, initiated 11/6/25. Interventions included but were not limited to: the resident is totally dependent on nursing staff for nutrition administration.Resident #3 has impaired cognitive loss due to CVA, anoxic brain, and is unable to communicate initiated 12/1/25. Interventions included but are not limited to: discuss concerns about confusion, disease process, NH (nursing home) placement with husband. Resident #3 has potential/actual impairment skin integrity r/t presence of PEG (Percutaneous Endoscopic Gastrostomy tube; a medical device inserted directly through the abdominal wall into the stomach to provide a direct route for delivering liquid nutrition, hydration, and medications to individuals who cannot safely chew or swallow), tracheostomy and impaired mobility, resident witnessed leaning on side rail, pillow added for side to help prevent bruising or injury initiated 11/6/25. Interventions included but were not limited to: report any skin redness/impaired integrity areas to my nurse.The surveyor requested the I/A reports for Resident #3 from March 2026 to date of survey. A review of a facility document labeled Date of incident 4/15/2026, Re: [Resident #3], Skin Injury Investigation revealed that during routine nursing assessment, resident was observed leaning toward the side rail of the bed with forehead resting against the rail. A small bruise/discoloration to the forehead area was noted upon repositioning. A further review revealed the investigation findings indicated the bruise was consistent with accidental contact/pressure against the side rail related to the resident's positioning behavior and anti-coagulant use.The I/A report contained one staff statement from the nurse who assessed the resident. There were no other staff statements supplied to the surveyor.A review of the facility's policy on Abuse, Neglect, and Exploitation, with a reviewed/revised date of 5/10/2026, included under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source[.]. Under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: [.] b. Establish policies and procedures to investigate such allegations[.]. Under V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse neglect or exploitation occur.N.J.A.C. 8:39-13.4(c)2ii

Based on interviews, record review, and review of pertinent facility documentations on 5/18/26, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) potential abuse related to multiple incidents of resident injuries of unknown origin dated 3/21/26 and 4/16/26 for Resident #1 and dated 4/15/26 for Resident #3. This deficient practice was identified for 2 of 4 residents reviewed for abuse and neglect, Resident #1 and Resident #3.The deficient practice was evidenced by the following: The surveyor reviewed the medical record of Resident #1.A review of Resident #1's admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses which included but are not limited to chronic respiratory failure with hypoxia (a medical condition that a specific part of body does not receive enough oxygen to function properly), chronic obstructive pulmonary disease (COPD), adjustment disorder with anxiety, tracheostomy status, and gastrostomy status. A review of the Minimum Data Set (MDS), an assessment tool dated 2/4/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated the resident's cognition was severely impaired. The MDS further revealed that the resident required total assistance from staff in the completion of their Activities of Daily Living (ADLs). A review of the resident's care plan report (CP) included the following Foci (Problem areas/needs):Resident #1 has impaired cognitive/communication function s/p (status post) CVA (stroke), chronic respiratory failure, initiated 6/13/24. Interventions included but were not limited to: ask yes/no questions in order to determine resident's needs; keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion, and present just one thought, idea, question or command at a time.Resident #1 is at risk for developing pressure ulcers, skin breakdown, and bruising r/t (related to) holding tightly to side rail during peri care, increased agitation, swinging, decrease mobility, incontinence, and anticoagulation medications, initiated 6/13/24. Interventions included but were not limited to: report any skin redness/impaired integrity areas, resident's skin will be assessed on a weekly basis and document findings on a weekly skin assessment. monitor/document location, size and treatment of skin injury, and report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration (the softening and breaking down of tissue due to prolonged exposure to moisture), etc. to MD (physician). Resident #1 is resistive to care r/t anxiety episodes of pulling out trach, initiated 2/26/25. Interventions included but were not limited to: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care.Resident #1 uses psychotropic medications anti-anxiety meds r/t anxiety and behavior of flailing her arms and contracted hand resulting in unintentional injuries to face, arms, and hands, initiated 12/4/24. Interventions included but were not limited to: remove unnecessary environmental triggers, provide calm environment, reduce excessive noise/stimulation, and maintain calm structured environment.Resident #1 is on ventilator dependent r/t respiratory failure; resident has a trach due to respiratory failure, initiated 6/13/24. The surveyor requested for the incidents/accidents (I/A) reports for Resident #1 from March 2026 to date of survey.A review of a facility document labeled Date of Incident reporting: 4/16/2026, Incident Investigation Summary and Conclusion revealed Resident #1 was noted to have a large bruise to the left cheek. A further review revealed that upon assessment and staff interview, it was reported that several days prior the resident attempted to pull at their tracheostomy tubing and accidentally struck themself in the face multiple times during the episode. Under Conclusion revealed no evidence of abuse, neglect, or staff misconduct was identified. A review of a facility document titled #1613 Skin Injury dated 4/16/2026 02:35 [2:35AM] revealed under Nursing Description, Resident noted with large bruise to L cheek[ .]. The document further revealed under Resident Description that the resident was unable to give a description. Under Was this incident witnessed was N. A review of a PN dated 4/16/26 at 12:52 PM documented During rounds noted skin discoloration on left cheek down to [Resident #1's] neck [ .] resident [ .] can't recall what happened.The 4/16/26 incident was not reported to the NJDOH.A review of a PN dated 3/21/26 at 4:39 PM documented the resident came back to the unit from ER [emergency room] for GT [gastrostomy tube] placement via stretcher, accompanied by Respiratory Therapist (RT) and CNA (certified nursing assistant). The PN further revealed, resident noted to the L (left) side of the cheekbone ecchymosis (bruise) noted, will continue to monitor, no new order received.The 3/21/26 incident was not reported to the NJDOH.The surveyor reviewed the medical record of Resident #3. A review of Resident #3's AR, an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses which included but are not limited to non-traumatic intracerebral hemorrhage (bleeding into the brain tissue; a type of stroke), atrial flutter, gastrostomy status, respiratory failure, and tracheostomy status.A review of the MDS, an assessment tool dated 2/17/26, revealed the resident had short- and long-term memory problems and had severely impaired cognitive skills. The MDS further revealed the resident required total assistance from staff in the completion of their Activities of Daily Living (ADLs).A review of the resident's care plan report (CP) included the following Foci (Problem areas/needs):Resident #3 requires tube feeding r/t dysphagia [difficulty swallowing], anoxic brain injury (a severe type of brain injury caused by a total lack of oxygen to the brain), vented tracheostomy initiated 11/7/25. Interventions included but were not limited to: NPO (nothing by mouth). Impaired gas exchange respiratory failure, mechanical ventilation initiated 11/6/25. Interventions included but were not limited to: maintain ventilator settings per orders.Resident #3 has an ADL self-care performance deficit r/t vegetative state, initiated 11/6/25. Interventions included but were not limited to: the resident is totally dependent on nursing staff for nutrition administration.Resident #3 has impaired cognitive loss due to CVA, anoxic brain, and is unable to communicate initiated 12/1/25. Interventions included but are not limited to: discuss concerns about confusion, disease process, NH (nursing home) placement with husband. Resident #3 has potential/actual impairment skin integrity r/t presence of PEG (Percutaneous Endoscopic Gastrostomy tube; a medical device inserted directly through the abdominal wall into the stomach to provide a direct route for delivering liquid nutrition, hydration, and medications to individuals who cannot safely chew or swallow), tracheostomy and impaired mobility, resident witnessed leaning on side rail, pillow added for side to help prevent bruising or injury initiated 11/6/25. Interventions included but were not limited to: report any skin redness/impaired integrity areas to my nurse.The surveyor requested the I/A reports for Resident #3 from March 2026 to date of survey. A review of a facility document labeled Date of incident 4/15/2026, Re: [Resident #3], Skin Injury Investigation revealed that during routine nursing assessment, resident was observed leaning toward the side rail of the bed with forehead resting against the rail. A small bruise/discoloration to the forehead area was noted upon repositioning. A further review revealed the investigation findings indicated the bruise was consistent with accidental contact/pressure against the side rail related to the resident's positioning behavior and anti-coagulant use.A review of a facility document titled #1611 Skin Injury dated 4/15/2026 09:00 [9:00AM] revealed under Nursing Description, Patient noted with skin area to right forehead. The document further revealed under Resident Description that the resident was unable to give a description. Under Was this incident witnessed was N and under Description: On skin assessment no open wound noted, bruising noted. The 4/15/26 incident was not reported to the NJDOH.A review of the facility's policy on Abuse, Neglect, and Exploitation, with a reviewed/revised date of 5/10/2026, included under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under Definitions: Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source[.]. Under VII. Reporting/Response: A. The facility will have written procedures that include:[.] 1. Reporting all alleged violations to the Administrator, state agency[.] within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.N.J.A.C. 8:39-9.4(f)

Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire; a.) by not completing a prior to hiring employees for 37 of 112 employees, b.) not documenting verification of the licenses of 5 of 52 nurses hired since 12/6/24, and c.) not documenting verification of the certification of 3 of 45 Certified Nursing Assistants (CNAs), in accordance with facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy.The deficient practice was evidenced by the following: On 4/28/26, 4/29/26, and 4/30/26, Surveyor #1 reviewed the Human Resource Records (HRR) including the Criminal Background Investigations (CBI) for 87 employees hired since last recertification survey, 12/6/24. The following concerns were revealed: Employee #4 (E #74), a Registered Nurse (RN) began employment on 7/1/25, The CBI was reported 7/2/25. E #10, a Licensed practical Nurse (LPN), began employment on 9/5/25. The CBI was reported on 9/12/25. E #11, an RN, began employment on 3/12/25. The CBI was reported on 3/13/25. E # 13, an RN, began employment on 12/17/24. The CBI was reported on 12/18/24. E # 18, an RN, began employment on 12/23/24. The CBI was reported on 12/31/24. E # 21, an LPN, began employment on 9/9/25. The CBI was reported on 9/12/25. E # 24, a CNA, began employment on 3/25/25. The CBI was reported on 3/26/25. E #27, a CNA, began employment on 9/16/25. The CBI was reported on 9/18/25. E # 28, a CNA, began employment on 7/1/25. The CBI was reported on 7/2/25. E # 32, an RN, began employment on 5/28/25. The CBI was reported on 5/30/25. E #33, an LPN, began employment on 2/4/25. The CBI was reported on 2/6/25. E #35, a CNA, began employment on 9/9/25. The CBI was reported on 9/12/25. E #41, a CNA, began employment on 5/28/25. The CBI was reported on 6/4/25. E #43, an RN, began employment on 8/19/25. The CBI was reported on 8/20/25. E #47, a Housekeeper, began employment on 7/24/25. The CBI was reported on 7/26/25. E #52, an LPN, began employment on 7/1/25. The CBI was reported on 7/2/25. E #53, an RN, began employment on 8/5/25. The CBI was reported on 6/11/25. E #56, an RN, began employment on 5/8/25. The CBI was reported on . E #58, an LPN, began employment on 6/10/25. The CBI was reported on 6/19/25. E #59, a CNA, began employment on 9/16/25. The CBI was reported on 9/18/25. E #61, a CNA, began employment on 4/30/25. The CBI was reported on 5/5/25. E #63, an RN, began employment on 3/12/25. The CBI was reported on 3/14/25. E #66, a CNA, began employment on 5/28/25. The CBI was reported on 5/30/25. E #70, an RN, began employment on 5/14/25. The CBI was reported on 5/16/25. E #107, an RN, began employment on 7/22/25. The CBI was reported on 7/24/25. E #108, a Housekeeper (HK), began employment on 7/24/25. The CBI was reported on 7/28/25. E #110, a CNA, began employment on 10/7/25. The CBI was reported on 10/8/25. On 4/28/26, 4/29/26, and 4/30/26, S #1 reviewed the HRR for 52 nurses hired since the previous Department of Health Recertification Inspection on 12/6/24. The following concerns were revealed: E #3, an LPN, began employment on 8/19/25. No documentation for nursing license verification was present in the employee's file. E 11, an RN, began employment on 3/12/25. No documentation for nursing license verification was present in the employee's file. E #18, an RN, began employment on 12/23/24. No documentation for nursing license verification was present in the employee's file. E #70, an RN, began employment on 5/14/25. No documentation for nursing license verification was present in the employee's file. E #103, an LPN, began employment on 11/25/25. No documentation for nursing license verification was present in the employee's file. On 4/28/26, 4/29/26, and 4/30/26, S #1 reviewed the HRR for 45 CNAs hired since the previous Department of Health Recertification Inspection on 12/6/24. The following concerns were revealed: E #35, a CNA, began employment on 9/9/25. No documentation of Nursing assistant certification verification was present in the employee's file. E #68, a CNA, began employment on 3/2/25. No documentation for Nursing Assistant Certification verification was present in the employee's file. E #110, a CNA, began employment on 10/7/25. No documentation of Nursing assistant certification verification was present in the employee's file. On 4/30/26 at 11:15 AM, S #1 met with the Licensed Nursing Home Administrator (LNHA) and the Director of Human Resources (DHR), who both acknowledged that a number of background checks in the employee files were reported and documented after the employee's date of hire. They both acknowledged they had presented all documentation for the 112 employee files under review. On 4/30/26 at 12:38 PM, the survey team met with the LNHA and Director of Nursing (DON), and S #1 presented the above concerns with 70 employee files concerning missing and late CBI and missing licenses and certification concerns. On 5/1/26 at 11:01 AM, the survey team met with the LNHA, Administrator in Training (AIT), and the DON regarding concerns with employee files. No further information provided by the LNHA. 2. On 4/30/26 and 5/1/26, Surveyor #2 (S #2) reviewed the HRR including CBI for 25 employees who were hired since the previous Department of Health Recertification Inspection. The following concerns were revealed. E #74, a CNA, began employment on 5/28/25. The CBI was ordered on 5/30/25. E #76, a CNA, began employment on 11/4/25. The CBI was ordered on 11/4/25. E #80, a nurse, began employment on 4/2/25. The CBI was ordered on 4/4/25. E #82, a nurse, began employment on 9/30/25. The CBI was ordered on 10/1/25.6 E #86, a nurse, began employment on 2/25/26. The CBI was ordered on 2/26/25. E #89, a CNA, began employment on 6/11/24. The CBI was ordered on 6/19/24. E #91, a CNA, began employment on 7/22/25. The CBI was ordered on 7/23/25. E #92, a nurse, began employment on 1/23/25. The CBI was ordered on 1/31/25. E #95, a CNA, began employment on 9/9/25. The CBI was ordered on 9/11/25. E #96, a CNA, began employment on 9/16/25. The CBI was ordered on 9/17/25. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, updated 1/2023, indicated in Step #4 that the facility should conduct employee background checks and not knowingly employ an individual found guilty in a court of law or entered into the State Nurse Aide Registry for abuse, neglect, exploitation, misappropriation of property, or mistreatment. NJAC 8:39-4.1(a)5; 43.15

Based on interviews of facility staff and review of facility provided documentation, it was determined the facility failed to ensure and document that all Certified Nursing Assistants (CNAs) completed 12 hours of in-service training including the topics of preventing resident abuse, dementia management, and areas of weakness identified in the individual CNA's annual review for 4 of 5 CNA employees reviewed. The deficient practice was evidenced by the following: The surveyor reviewed the training records provided by the facility for five selected CNAs and revealed: -A review of the facility provided 94 attendance sheets for in-services provided to all staff members since 1/1/25, 0 of 94 attendance sheets provided included a number of credited hours or minutes assigned to the given topic. -Zero of 94 attendance sheets included a syllabus for information included or minutes from the in-service. -Zero of 94 attendance sheets indicated the in-service was for training in dementia management. On 5/1/26 at 10:55AM, the surveyor with Director of Nursing (DON) and Assistant Director of Nursing (ADON), and the ADON acknowledged that the facility did not have a register or tracking record of which CNAs completed trainings, which topics each CNA received training in and the facility had not tracked individual CNA training hours. The ADON further stated that she was aware every CNA was required to complete of 12 hours of in-service training annually, and that the subjects of dementia management and abuse prevention were to be included in that training. On that same date and time, the DON acknowledged the facility did not have written annual evaluations for 4 of the 5 CNAs to identify potential areas of weakness to include in the CNA's annual in-servicing. The DON and the ADON acknowledged that the attendance sheets for in-servicing had not included credited time for the in-service, minutes of each in-service or a syllabus of covered information and no dementia training in-services were included in the 94 attendance sheets provided to the surveyor. A review of the facility's Continuing Education Policy, dated 9/1/25, reflected, all levels of employees are expected to complete required trainings within designated time frames. It is the responsibility of each employee, volunteer, or contract staff to complete required training . On 5/1/26 at 11:15 AM the survey team met with the Licensed Nursing Home Administrator, Assistant Administrator in Training, and the DON to discuss the above concerns with documentation of CNA annual training. No new information provided by the LNHA. NJAC 8:39-43.17

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to; a.) properly label an opened blood glucose test strips, b) identify and dispose of expired biological supply, and c) properly store insulin pens, in accordance with currently accepted professional principles and facility's policy. This deficient practice was identified for 4 of 8 medication carts and 1 of 2 medication rooms inspected and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. 1. On 4/30/26 at 10:19 AM, Surveyor #1 (S #1) inspected the south/center cart on the fifth (5th) floor, in the presence of Registered Nurse #1 (RN#1) and Surveyor #2 (S #2). During the inspection, S #2 observed loose disinfecting caps for needless connectors (used to decrease the central venous catheter (hollow tube inserted into the vein) associated blood stream infection on intravenous needleless connectors). Three of the disinfecting caps had an expiration date of 4/25/26, and the original container was not found on the cart. At that time, S #1 discussed the concern with the expired disinfecting caps with RN#1. At 10:37 AM, S #1 observed an opened bottle of blood glucose (bg) test strips that did not have a written opened date. During an interview with the surveyors, RN #1 stated she was not sure when the bg test strips were opened. RN #1 also stated that it was important to know the opened date, since that was used as the reference for the expiration date. At that time, RN#1 stated she would dispose of both the disinfecting caps and the bg test strips, confirmed that the expired items should have been removed and would inform the Unit Manager (UM). A review of the manufacturer's specifications for the [brand redacted] bg test strips, under storage and handling reflected: Use within six months of first opening or the expiration date on the label, whichever comes first. 2. On 4/30/26 at 10:29 AM, S #1 inspected the medication (med) room on the 5th floor, in the presence of RN #1 and S #2. During the inspection, S #1 found an opened, half full box of the disinfecting caps with an expiration date of 4/25/26. RN #1 stated she would inform the UM of the concern and acknowledged and confirmed expired supplies should have been removed from active inventory. On 4/30/26 at 1:52 PM, in the presence of the survey team, the [NAME] President of Clinical Services (VPoCS), the Administrator in Training (AIT), the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), S #1 discussed the above concerns. On 5/1/26 at 11:00 AM, during a meeting with the survey team, the LNHA, AIT and the MDS-Coordinator, the DON stated that a facility wide audit for undated glucose test strips, expired medications (meds) and supply was conducted, to ensure all meds and supplies provided to the residents were in date. The LNHA did not provided further information. A review of the facility's Medication Storage Policy, dated/revised 4/2/26, reflected that all meds housed in the facility would be stored in the pharmacy and/or med rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 3. On 4/30/26 at 10:51 AM, S #2 inspected the cart on the 5th floor ventilation unit in the presence of the Respiratory Therapist (RT). Upon opening a drawer of the cart, S #2 observed an opened foil package containing three vials of Ipratropium Bromide 0.5 mg (milligram) and Albuterol Sulfate 3 mg Inhalation Solution. It was written on the front of the package that there were originally five vials. The opened foil package had no date of opening written on it. Upon opening another drawer of the cart, S #2 observed that the nonconductive connecting tubing had expired on 10/1/25. On 4/30/26 at 11:05 AM, S #2 interviewed the RT who stated the expectation was that the date should have been written on the opened foil package containing the three vials of Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg Inhalation Solution when it was opened. The RT acknowledged it did not have a date of opening written on it. Moreover, the RT observed and acknowledged that the nonconductive connecting tubing was expired. 4. On 4/30/26 at 12:44 PM, S #2 inspected the north cart on the third floor in the presence of RN #2. Upon opening a drawer of the cart, S #2 observed an opened box containing more than 100 disinfecting caps for needleless connectors. All the disinfecting caps had an expiration date of 2/6/25. 5. On 4/30/26 at 1:18 PM, S #2 inspected the south cart on the second floor in the presence of RN #3 and S #1. During the inspection, S #2 observed that Resident #76's Insulin Lispro Injection Solution 100 Unit/milliliter (mL) pen and Resident #5's Lantus Solostar Injection Solution 100 Unit/mL pen were in the same bag labeled with Resident #5's name and med label. There was no bag labeled with Resident #76's name and med label. On 4/30/26 at 1:20 PM, S #2 interviewed RN #3 in the presence of S #1. RN #3 stated they did not know where the Resident #76's bag with the resident's name and med label was located. RN #3 stated they thought Resident #76 was discharged . RN #3 acknowledged that the insulin pens belonging to two different residents should not be kept together in one resident's bag. On 4/27/26 at 1:30 PM, S #2 reviewed the electronic medical record of Resident #76, which revealed the resident was still in the facility. A review of the April 2026 electronic Medication Administration Record (eMAR) for Resident #76 revealed the following: -On 4/30/26 at 7:30 AM, Insulin Lispro Injection Solution 100 Unit/mL Inject as per sliding scale subcutaneously (subq) before meals for type 2 diabetes, had a check mark with the nurse's initials and 2 units documented. -On 4/30/26 at 12:30 PM, Insulin Lispro Injection Solution 100 Unit/mL Inject as per sliding scale subq before meals for type 2 diabetes, had a check mark with the nurse's initials and 8 units documented. A review of the April 2026 eMAR for Resident #5 revealed the following: -Insulin Glargine subq Solution 100 Unit/mL Inject 20 unit subcutaneously at bedtime for diabetes mellitus had a check mark with the nurses' initials at 9:00 PM on 4/27/26, 4/28/26, 4/29/26, and 4/30/26. On 4/30/26 at 1:56 PM, in the presence of the survey team, S #2 discussed the concern with the LNHA, DON, VPoCS, and AIT. A review of the facility's Medication Administration Policy, revised 10/20/25, revealed, Identify expiration date. If expired, notify nurse manager. NJAC 8:39-29.4 (g) (h)

Complaint #2738075Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 4/29/26, the surveyors observed 4 nurses administer medications to 5 residents. There were 30 opportunities, and 4 errors were observed which resulted in a medication error rate of 13.33%. This deficient practice was identified for 2 of 5 residents (Resident #141 and #257), that was administered by 2 of 4 nurses.This deficient practice was evidenced by the following: 1. On 4/29/26 at 8:05 AM, two surveyors observed Registered Nurse #1 (RN #1) prepare medications (meds) for Resident #141. The meds included the following physician's order (PO): - Strovite One (prescription strength vitamin that included folic acid 1.67 milligrams (mg) used for treatment of megaloblastic anemia due to folic acid deficiency and anemia of nutritional deficit); one tablet (tab) by mouth one time a day for supplement. The PO started on 3/18/26. - Lidoderm Patch 5 % (Lidocaine); apply to left leg topically in the morning for pain, do not apply to sx [surgical site]. The PO started on 3/27/26. - Lidoderm Patch 5 % (Lidocaine); apply to left shoulder topically in the morning for pain, do not apply to sx [surgical site]. The PO started on 3/27/26. On 4/29/26 at 8:14 AM, in the presence of Surveyor #1 (S #1), Surveyor #2 (S #2) observed RN #1 removed an opened multivitamin (MVI) bottle from the medication (med) cart, poured one tab into a med cup. RN #1 stated it was stocked in the facility, for multiple residents use who an order, and was not sent from the pharmacy. At that time, the surveyors observed RN #1 removed two Lidocaine 4% patches from a box. RN#1 stated she would administer the oral meds first and place the patches on the resident afterwards. On 4/29/26 at 8:17 AM, RN #1 informed S #1 and S #2 that she was ready to administer the meds. On 4/29/26 at 8:18 AM, S #2 observed RN #1 placed the Lidoderm 4% patches back in the med cart and locked the med cart. On 4/29/26 at 8:19 AM, S #2, in the presence of S #1, observed RN #1 enter Resident #141's threshold for administration. S #2 stopped the med pass and requested to speak with RN #1 outside the resident's room to review the eMAR and the PO. At that time, RN #1 informed the surveyors that the MVI was requested from central supply and was an over the counter (OTC) med. RN #1 also stated that on 3/19/26, the PO did not arrive, she called the pharmacy at that time and further stated that she was instructed to substitute the PO Strovite One with an OTC MVI (contained zero amount of Folic Acid). At that time, RN #1 stated that she did not document the conversation with the pharmacy and did not inform the prescriber that Strovite One had not arrived on 3/19/26. The RN stated she would call the prescriber, call the pharmacy, inform the Unit Manger and the Assistant Director of Nursing (ADON). On 4/29/26 at 8:24 AM, RN #1 informed S #2 that she would dispose of the MVI into the drug disposal solution. At that time, RN #1 was observed removing the MVI from the med cup and disposed of the MVI inro the drug disposal solution. Refer to F755. 2. On 4/29/26 at 8:30 AM, In the presence of S #1, S #2 observed RN #1 remove the Lidocaine 4% patches from the med cart and dated a patch. At that time, RN #1 stated that she had the wrong strength and threw both patches into the trash, locked the med cart and left to obtain Lidocaine 5% patches. On 4/29/26 at 8:40 AM, RN #1 returned to the med cart and stated that the Lidocaine 5% was not available and that the Unit Manager called the prescriber and the new order would be entered as an alternative. At that time, S #2 observed RN #1 prepare the patches from the new PO that reflected: - Lidocaine Patch 4 % (Lidocaine); apply to left leg topically, one time only, for pain until 4/29/26 at 11:59 PM. The PO started on 4/29/26. -Lidocaine Patch 4 % (Lidocaine); apply to left shoulder topically, one time only, for pain until 4/29/26 at 11:59 PM. The PO started on 4/29/26. On 4/29/26 at 8:47 AM, RN #1 informed S #2 she was ready to administer the patches, turned and entered Resident #141's room for administration. At that time, S #2 asked to speak with RN #1 outside of the resident's room. On 4/29/26 at 8:49 AM, in the presence of S #1, S #2 and RN #1 reviewed the eMAR together. When asked how the RN knew how many patches to administer and where the specified location on the left leg and left shoulder should be placed, RN #1 confirmed and acknowledged that the orders for Lidoderm 5% and Lidocaine 4% were incomplete, should have had a specified quantity and specific location on the leg and on the shoulder. RN #1 also stated that she asked the resident where they wanted the patches applied, the resident had no surgical site and could not say how the pain was managed when the specific location was undefined, for prescriber assessments of muscular, joint or nerve issues and referred pain. On 4/30/26 at 1:52 PM, in the presence of the survey team, the [NAME] President of Clinical Services (VPoCS), the Administrator in Training (AIT), the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), S #2 discussed the above concerns that from 3/29/26, Strovite One was signed administered on the eMAR yet was not received from the pharmacy. At that time, S #2 requested evidence to support that Strovite One was received, the pharmacy and the physician were contacted. S #2 also discussed the concern with the PO for Lidoderm that did not include the quantity of patches to be administered to the leg and shoulder and did not include a specified location on the leg and shoulder for proper pain management. On 5/1/26 at 11:00 AM, during a meeting with the survey team, the LNHA, AIT and the MDS-Coordinator, the DON stated that all nurses who were involved with the med pass errors were re-educated. At that time, the DON also stated that the pharmacy had informed RN #1 that Strovite One and the OTC MVI were interchangeable. At that time, S #2 requested evidence that the pharmacy recommended the interchange and that the prescriber was informed and approved the change. No further information was provided. A review of the facility's Medication Administration Policy, dated/revised 9/1/25, included to correct any discrepancies and required reporting to the nurse manager. Additionally, staff were to ensure the six rights of med administration were followed, which involved administration to right resident, right drug, right dosage, right route, right time, and right documentation. A review of the facility's Medication Orders Policy, dated/revised 9/1/25, under Elements of Med Order included that dosage, strength of med is involved right resident, right drug, right dosage, right route, right time, and right documentation. 3. On 4/29/26 at 9:06 AM, two surveyors observed RN #2 prepare meds for Resident #257. The meds included, but were not limited to, the following PO: -Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) give 30 ml (milliliters) by mouth 2 times a day for at risk for malnutrition for 15 Days. The PO started on 4/26/26. On 4/29/26 at 9:08 AM, in the presence of S #2, S #1 observed RN #2 pour Pro-Stat Oral Liquid from the bottle into a med cup while holding the med cup in the air. After RN #2 finished pouring the liquid into the med cup, RN #2 closed the bottle and returned the bottle to the drawer in the med cart. S #1 and S #2 observed the med cup on a flat, level surface and read the meniscus (the curved surface of the liquid) at eye level. S #1 and S #2 saw that the liquid measured below 30 ml. RN #2 confirmed they were ready to administer the med. S #1 asked RN #2 if the liquid measured 30 ml, and RN #2 stated that it did not measure 30 ml. RN #2 acknowledged that they should have poured the liquid into the med cup while the med cup was on a flat surface rather than in the air. RN #2 added more Pro-Stat Oral Liquid to the med cup to reach 30 ml. On 4/29/26 at 9:40 AM, S #1 observed RN #2 administer Pro-Stat Oral Liquid to Resident #257. After RN #2 administered the med, S #1 and S #2 observed that there was still liquid left in the cup. On 4/29/26 at 9:42 AM, RN #2 threw out the cup, containing the remaining liquid, in the garbage. S #1 interviewed RN #2 who acknowledged they did not administer the full dose of the liquid to Resident #257. RN #2 stated they should have given it to the resident with a spoon. On 4/30/26 at 1:56 PM, in the presence of the survey team, S #1 discussed the concern with the LNHA, DON, VPoCS, and AIT. They did not provide a verbal response at that time. A review of the facility's Medication Administration Policy, revised 10/20/25, revealed, the following -Ensure that the six rights of med administration are followed: Right resident, Right drug, Right dosage, Right route, Right time, Right documentation. -Administer meds as ordered in accordance with manufacturer specifications. Provide appropriate amount of food and fluid. NJAC 8:39-11.2(b), 29.2(d)

Complaint #2643214 Based on observation, interview, and record review, it was determined that the facility failed to ensure consistent a.) accountability, b.) disposition (destruction) of the controlled dangerous substance (narcotic; medications, with high potential for abuse, were tracked with detail) for 2 of 8 medication carts inspected, and c.) properly dispose of non-narcotic medications, identified during the medication pass observation of 4 nurses who administered medications to 5 residents. The deficient practice was evidenced by the following: 1. On [DATE] at 11:53 AM, in the presence of Registered Nurse #1 (RN #1), Surveyor #1 (S #1) began the narcotic medication (med) inspection, which was stored in a mounted, double locked portion of the med cart (narcotic box) located on the South side of the fourth floor. A review of the shift-to-shift accountability log reflected that both nurses had signed, and no discrepancies were noted that morning. At that time, S #1 and RN #1 reviewed the Controlled Drug Administration Record (a declining inventory log (DIL) for Resident #258's Hydromorphone (a narcotic, pain reliver) reflected 18 tablets (tabs) remained and was compared against the corresponding bingo card (a multidose card containing individually packaged medications) that contained 17 pills. RN #1 stated that he had administered the Hydromorphone to Resident #258, and did not sign the DIL when he removed the med from the bingo card and again did not sign after he had administered the Hydromorphone that morning. S #1 and RN #1 reviewed the electronic Administration Record (eMAR) together that reflected an order for Hydromorphone 4 milligram (mg), to be given one tablet (tab) every 8 hours as needed (PRN), started on [DATE], and revealed that it was administered on [DATE] at 8:08 AM. The concern that three hours and 45 minutes had passed from the time of administration and observation was discussed with RN #1. 2. At that time, S #1 observed the DIL for Resident #258's Oxycodone -Acetaminophen 10/325 mg (milligram) (Oxy/APAP; a narcotic pain reliver) reflected 13 tabs remained and was compared against the corresponding bingo card that contained 12 pills. S #2 and RN #1 reviewed the eMAR together that reflected an order for Oxy/APAP 10 /325 mg to be given every 12 hours PRN for breakthrough pain and revealed an administration for that day was not signed as administered on the eMAR. The Oxy/APAP 10/325 mg pill was found in a med cup, in the med cart, was not in the mounted, double locked portion of the med cart and was unlabeled. At that time, RN #1 stated that he had removed one pill from Resident #258's inventory for administration but the resident had refused and requested for the Hydromorphone. When asked why the removal, the refusal was not documented, a response was not provided. When asked why the Oxy/APAP was not disposed, RN #1 stated that he needed two signatures but could not state why he had not asked to speak with another nurse on duty for proper disposal of the med. When asked when the DIL should be signed, RN #1 stated that the DIL should have been signed when he removed the narcotics from Resident #258's inventory. On [DATE] at 12:06 PM, in the presence of S #1, and RN #1, the Assistant Director of Nursing (ADON) confirmed the removal of the med should have signed on the DIL, refusal of the med administration should have been documented on the eMAR, after the refusal of the Oxy/APAP the pill should not have been stored in the med cart, and instead should have been disposed by two nurses then recorded. 3. On [DATE] at 8:30 AM, during the med pass observation, in the presence of Surveyor #2 (S #2), S #1 observed RN #2 removed two Lidocaine 4% patches from the med cart and dated a patch. At that time, RN #1 stated that she had the wrong strength and threw both patches into the trash, locked the med cart and left to obtain Lidocaine 5% patches. On [DATE] at 8:56 AM, during an interview with the surveyors, the Unit Manager (UM) could not state where the Lidocaine 4% patches should have been disposed of and stated she would get back to the surveyors with the answer. On [DATE] at 8:57 AM, during an interview with the surveyors, RN #1 was asked by S #2 asked where meds such as Lidocaine 4% be disposed of. At that time, RN #1 stated that it should have been disposed of in the drug disposal solution. On [DATE] at 1:52 PM, in the presence of the survey team, the [NAME] President of Clinical Services (VPoCS), the Administrator in Training (AIT), the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), S #1 discussed the above concerns with narcotic medications (meds) Hydromorphone and Oxy/APAP for Resident #258 that were not logged on the DIL, refusal that was not documented on the eMAR, the one tab of Oxy/APAP in a med cup, unlabeled stored in the med cart, and the failure to dispose of the Oxy/APAP after the resident's refusal and the failure to dispose of the Lidocaine in the drug disposal solution. On [DATE] at 11:00 AM, during a meeting with the survey team, the LNHA, AIT and the MDS Coordinator, the DON stated that the DIL should have been signed immediately after a narcotic med was removed from the resident's inventory and that the nurses were re-educated on the process for documentation on the DIL and the destruction of narcotic meds and non-narcotic meds. A review of the facility's Controlled Substance Administration and Accountability Policy, dated/revised on [DATE], included that The Controlled Drug Record (or other specified forms) serves the dual purpose of recording both narcotic disposition and patient administration. A review of the facility's Destruction of Unused Drugs Policy, dated/revised [DATE], included that all unused, contaminated, or expired prescription shall be disposed of in accordance with state laws and regulations. Our facility utilizes [brand redacted; drug disposal solution] Destroy unused, non-returnable meds. 4. On [DATE] at 10:11 AM, S #2 observed the Licensed Practical Nurse (LPN) remove controlled meds from Resident #116's bingo cards. The meds included the following physician order (PO): -Alprazolam tab 0.5 mg, give 1 tab by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for anxiety, giive prior to dialysis. The PO started on [DATE]. -Oxycodone Hydrochloride (HCl) oral tab 5 mg, give 1 tab by mouth every 12 hours PRN for moderate to severe pain (4-10). The PO started on [DATE]. The LPN did not sign the DIL when they removed the meds from the bingo cards. On [DATE] at 10:13 AM, S #2 observed the LPN administer the meds to Resident #116. The LPN still had not signed the DIL after administering the meds. On [DATE] at 10:22 AM, S #2 observed the LPN prepare meds for the next resident, Resident #208. The LPN still had not signed the DIL for Resident #116's meds. On [DATE] at 10:28 AM, S #2 interviewed the LPN who stated they should have signed the DIL right away. On [DATE] at 1:56 PM, in the presence of the survey team, S #2 discussed the above concerns with the LNHA, DON, VPoCS, and AIT. On [DATE] at 11:00 AM, during a meeting with the survey team, the LNHA, AIT and the MDS-Coordinator, the DON stated that the DIL should have been signed immediately after a narcotic med was removed from the resident's inventory. A review of the facility's Medication Administration Policy, revised [DATE], revealed, if med is a controlled substance, sign narcotic book upon removal from inventory. 5. On [DATE] at 10:22 AM, S #2 observed the LPN prepare meds for Resident #208. On [DATE] at 11:45 AM, the LPN administered the meds to the resident. Two orders remained on the LPN's computer screen highlighted in red and were overdue. The meds that remained included the following PO: -Novolog Injection Solution 100 Unit/mL (unit/milliliters) inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units call MD (Medical Doctor) if less than 70 or greater than 350, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) (a disease characterized by high levels of blood sugar). The PO started on [DATE]. -Lantus Subcutaneous Solution 100 Unit/mL Inject 18 unit subcutaneously one time a day for DM. The PO started on [DATE]. On [DATE] at 11:46 AM, S #2 asked the LPN why the meds listed above remained on the screen and were overdue. The LPN stated they already administered the meds earlier that day but did not sign that they administered them in the eMAR. The LPN stated further that they should not be administering meds without signing for them so that the documentation and time will be correct. A review of the Medication Administration Audit Report of [DATE] for Resident #208 revealed the following: -Novolog Injection Solution 100 Unit/mL was scheduled for [DATE] at 7:30 AM, administered on [DATE] at 9:00 AM, and documented on [DATE] at 11:57 AM. -Lantus Subcutaneous Solution 100 Unit/mL was scheduled for [DATE] at 9:00 AM, administered on [DATE] at 8:06 AM, and documented on [DATE] at 11:48 AM. On [DATE] at 1:56 PM, in the presence of the survey team, S #2 discussed the above concerns with the LNHA, DON, VPoCS, and AIT. They did not provide a verbal response at that time. A review of the facility's Medication Administration Policy, revised [DATE], revealed the following: -Sign MAR after administered. -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. NJAC 8:39-11.2(b); 27.1(a); 29.2(d); 29.4(a), (b)2

Based on interviews of facility staff and a review of facility provided documentation, it was determined that the facility failed to ensure the Certified Nursing Assistants employed by the facility received an annual evaluation of their work performance facilities residents for 4 of 5 employees reviewed. The deficient practice was evidenced by the following: On 4/29/26 at 12:30 PM, the surveyor requested from the Director of Nursing (DON) the annual performance evaluations for five Certified Nursing Assistants (CNA) selected from a roster of active employees provided by facility. On 5/1/26 at 10:45AM, the DON confirmed the performance evaluations for 4 of the 5 selected employees did not have written annual evaluations: Employee #1 (E1), CNA hired on 2/24/14. No performance evaluation on file.E #2, CNA hired on 1/11/23. No performance evaluation on file.E #3, CNA hired on 12/17/24. No performance evaluation on file.E #4, CNA hired 6/19/24. No performance evaluation on file. A review of the facility's Evaluation Process Policy, dated 9/1/25, reflected, it is the policy of the facility to review the work performance of employees with a formal written evaluation . On 5/1/26 at 12:05 PM, the surveyor met with Licensed Nursing Home Administrator and the DON to discuss concerns with performance evaluations for CNAs. The DON confirmed 4 of the 5 CNAs employee files requested did not have documentation of evaluations and were required to have an annual evaluation on file every year. NJAC 8:39 13.4; 25.4(b); 43.17

Based on interviews of facility staff and a review of facility provided documentation, it was determined that the facility failed to ensure the nursing staff possessed and maintained the appropriate competencies and skills to provide nursing care to the facilities residents for 5 of 5 nursing employees reviewed. The deficient practice was evidenced by the following: On 4/29/26 at 12:30 PM, the surveyor requested documentation of nursing competencies and annual performance evaluations for five nurses selected from the facility provided active employee roster. On 5/1/26 at 9:45 AM, the Assistant Director of Nursing (ADON) provided 94 Inservice sign in sheets conducted since 1/1/25. The in-service sheets reflected a topic, 0 of 94 sheets reflected nursing competencies performed, a syllabus of information or skills presented, skill assessments or minutes from the in-service. 0 of 94 in-service sheets included a time of the in-service or hours credited to the attendees of the in-service. On 5/1/26 at 10:45AM, the Director of Nursing (DON) in the presence of the ADON acknowledged no other in-servicing or competencies were available for the five selected nurses and no annual performance evaluations were available for the five nurses. The DON acknowledged 0 of 94 Inservice attendance sheets reflected nursing competencies performed, a syllabus of information or skills presented, skill assessments or minutes from the in-service. The DON acknowledged the facility policy to evaluate nursing employees and that nurses should have an evaluation performed at least annually and competencies for job skills as needed. The DON and ADON confirmed the following: Employee #1 (E#1), a Registered Nurse (RN), hired on 1/30/24 had no competencies or evaluations on file.E #2, a Licensed Practical Nurse (LPN), hired on 11/29/21 had no competencies or evaluations on file.E #3, an LPN, hired on 8/10/20 had no competencies or evaluations on file.E #4, an LPN, hired on 6/15/92, had no competencies or evaluations on file.E #5, an RN, hired on 5/30/23, had no competencies or evaluations on file. On 5/1/26 at 11:15 AM, the survey team met with Licensed Nursing Home Administrator (LNHA), Administrator in Training, and the DON to discuss the concerns with nursing competencies. The LNHA did not provide additional information. A review of the facility's Evaluation Process Policy, dated 9/1/25, reflected, it is the policy of the facility to review the work performance of employees with a formal written evaluation . NJAC 8:39-25.1; 25.2(a), (b); 26.1

Complaint #260384Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to; a.) ensure a timely initial nursing assessment was completed, b.) ensure physician ordered medication was administered, and c.) ensure hospice services were documented, communicated, and coordinated in accordance with the resident's plan of care and standards of clinical practice. This deficient practice was identified for 2 of 2 residents (Resident #11 and Resident #249) reviewed for quality of care, and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 4/29/26 at 11:05 AM, the surveyor reviewed the closed record of Resident #249. A review of the admission Record (AR) or face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses included, but were not limited to; atrial fibrillation, cerebral infarction (stroke), type 2 diabetes mellitus, hypertension, and dementia. A review of the resident's medical record revealed there was no initial nursing assessment was completed on 8/8/25, not until 8/11/25. A review of the progress notes (PN) revealed no nursing documentation was completed on 8/8/25, 8/9/25, and 8/10/25, to establish the resident's baseline status upon admission. A review of the electronic Medication Administration Record (eMAR) revealed a physician's order (PO) dated 8/17/25, lomotil oral tablet (tab) 2.5-0.025 milligrams (mg), to be given one tab by mouth every 12 hours as needed (PRN) for diarrhea after stool for Clostridium difficile (C-diff) had been collected for one day. Further review of the eMAR revealed no signature indicating that the medication (med) was administered. Further review of the PN revealed no documentation explaining why the med was not administered or omitted. On 4/30/26 at 11:40 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON) and the survey team, was made aware that the initial nursing assessment was not completed timely and that the physician-ordered Lomotil med was not administered as ordered. A review of the facility's Medication Administration Policy, dated 9/1/24, included, medications (meds) are administered. as ordered by the physician and in accordance with professional standards of practice.The policy further included, ensure that the six rights of med administration are followed. including right time and right documentation. 2. On 4/28/26 at 8:30 AM, the surveyor observed Resident #11 lying in bed with the call bell within reach. The surveyor reviewed the medical record for Resident #11. A review of the AR revealed the resident had diagnoses which included, but were not limited to; Alzheimer's disease, chronic kidney disease, peripheral vascular disease, and functional quadriplegia. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/12/26, reflected a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was receiving hospice services. A review of the resident's individual comprehensive care plan (CP), dated 3/18/26, included a focus area that the resident was on hospice care with poor appetite and difficulty chewing and swallowing. Interventions included assisting the resident with meals, encouraging fluids, and providing nutritional supplements. A review of the Order Summary Report (OSR), dated as of 4/28/26, included the PO dated 3/3/25, for hospice evaluation and treatment with no directions specified. On 4/28/26 at 11:01 AM, the surveyor interviewed the Registered Nurse (RN) who stated, when the hospice nurse has a recommendation it is verbally communicated to the nurse. The RN further stated hospice documentation was located in the Misc (miscellenous) section; however, she could not locate weekly hospice visit documentation. On that same date and time, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated, the Hospice nurse visits weekly. The RN/UM further stated there was no hospice binder kept at the nursing station, and that all documentation was completed in the electronic medical record (eMR). On 4/28/26 at 12:10 PM, the surveyor reviewed of Misc section in the eMR, revealed hospice nursing notes; however, further review revealed gaps in hospice nursing documentation, including no consistent weekly documentation in the facility's eMR despite the resident receiving ongoing hospice services. On 4/28/26 at 12:16 PM, the surveyor interviewed the DON and [NAME] President of Clinical Services (VPoCS), who provided hospice nurse notes from the hospice agency that were not included in the facility's eMR. They stated that the hospice nurse was having difficulty uploading his notes. The DON further stated, the nurses will communicate verbally when needed regarding communication between hospice and facility staff. On 4/30/26 at 9:00 AM, the surveyor conducted a follow-up interview with the Hospice Nurse who stated he had not consistently provided weekly documentation and was unaware the facility required each weekly visit to be documented in the medical record. On 4/30/26 at 9:30 AM, the surveyor conducted a follow-up interview with the Hospice Agency Administrator who stated hospice documentation was maintained in their own system and that expectations for documentation in the facility's record were unclear. On 4/30/26 at 9:42 AM, the DON, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, acknowledged that hospice documentation was not consistently maintained in the facility's medical record and that communication between hospice and facility staff was not clearly defined. A review of the facility's Coordination of Hospice Services Policy, dated 9/1/24, included, the facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility .The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities . A review of the facility's Conducting an Accurate Resident Assessment Policy, dated 9/1/24, included, qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline.Information provided by the initial comprehensive assessment establishes baseline data for the ongoing assessment of resident progress . A review of the facility's admission of a Resident Policy, dated 2/26/25, included, upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol . On 5/1/26 at 12:10 PM, the DON, in the presence of the LNHA, stated, A binder is to be used going forward for weekly hospice nursing visits to be documented. NJAC 8:39-27.1

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure services provided met professional standards of practice by failing to follow the physicians orders for 3 of 38 residents (Residents #9, # 35, and #213) reviewed. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case-finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 4/27/26 at 9:16 AM, Surveyor #1 (S #1) observed Resident #9 seated up in bed and stated that they had been in the facility for two years. A review of Resident #9's admission Record (AR) or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to heart failure (chronic, progressive condition where the heart muscle cannot pump blood efficiently, often caused by coronary artery disease, high blood pressure, or heart attacks) and hypertension (high blood pressure). A review of Resident #9's most recent comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 3/3/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of Resident #9's April 2026 electronic Medication Administration Record (eMAR) reflected the following physician order (PO): -Measure blood pressure (BP) supine (lying horizontally, with the face and torso facing up) and sitting upright every shift with an order date of 4/23/25. Further review of the above PO reflected that there were two rows labeled BP for each shift but there was no indication which row was for the supine BP and which row was for the sitting BP. In addition, the top row of BP's for day shift did not have a BP result recorded, there were NA and one number (not a 2 number BP result); for the evening shift there was 1 BP on 4/23/26, and the rest were NA or one number; for the night shift there were no BP results recorded, there were NA or one number. A review of the chart codes did not indicate what NA stood for. A review of Resident #9's May 2025 eMAR reflected the same BP order with a discontinued (dc'd) date of 5/23/25. Further review reflected the two rows labeled with BP with no indication which row was for supine and which row for sitting. In addition, the top row of BP's for the day shift included 1 BP result on 5/8/25, and the rest were either NA or one number; for the evening shift there were 2 BP results and the rest were wither NA, one number or letters; for the night shift there were 7 BP results and the rest were either NA, one number or letters. A review of the chart codes did not indicate what NA stood for. On 4/30/26 at 11:24 AM, S #1 interviewed the Director of Nursing (DON) regarding the order for BP. S #1 asked if the expectation was to follow the PO. S #1 showed the DON Resident #9's April and May 2025 eMAR. S #1 asked how it was determined which row was for which BP, and the DON stated that the top would be supine and bottom would be sitting. S #1 asked about the documented NA for most of the top row and what the NA meant and if there should have been documentation why there was not a BP result. The DON stated that he would have to ask the nurse and get back to S #1. On 4/30/26 at 12:44 PM, S #1 notified the Licensed Nursing Home Administrator (LNHA), DON, Administrator in Training (AIT), and [NAME] President of Clinical Services (VPoCS) the concern that Resident #9's PO for BP measurement while supine and sitting was not followed in April and May 2025. On 5/1/26 at 11:29 AM, in the presence of the LNHA and AIT, S #1 asked the DON if there was additional information regarding Resident #9's PO The DON stated that he was going to check on the NA. The LNHA and DON did not provide any additional information. 2. On 4/30/26 at 9:33 AM, Surveyor #2 (S #2) reviewed the electronic medical record (eMR) of Resident #35. The AR revealed Resident #35 had diagnoses that included, but were not limited to, end stage renal disease and type 2 diabetes mellitus. A review of the quarterly MDS with an ARD of 4/1/26, reflected a BIMS score of 15 out of 15, which indicated the resident was cognitive intact. A review of the PO dated 10/25/25, indicated midodrine 5 milligram (mg) tablet (tab), give 1 tab by mouth every 12 hours as needed (PRN) for hypotension (low BP) if SBP (Systolic blood pressure; the top number in a BP reading which measures the maximum pressure in your arteries when the heart beats] was less than 85. The order was dc'd on 4/18/26. A PO dated 4/18/26 indicated midodrine 10 mg tab, give 1 tab by mouth every 12 hours PRN for hypotension. The order did not include BP parameters to indicate when the medication (med) should be administered to the resident. A review of the April 2026 eMAR revealed the PRN midodrine 10 mg order entry did not include BP parameters. A review of the Nurse Practitioner progress note (PN) dated 4/18/26 at 2:55 PM, revealed Resident #31 's midodrine order was increased to 10 mg with parameters to hold midodrine if BP was greater than or equal to 110/60. A review of the nurse PN dated 4/18/26 at 3:28 PM, revealed new orders were received and transcribed to discontinue previous order for Midodrine 5 mg and a new order for midodrine 10 mg tab was initiated with parameters holding the med if SBP is less than or equal to 110 and/or [diastolic BP; the bottom number in a BP reading which measures the pressure in your arteries when the heart rests between beats] is less than or equal to 60. The midodrine order transcribed did not include any parameters. On 4/30/26 at 10:33 AM, S #2 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) who stated midodrine orders should have parameters included for the nurses to know when to give the med. S #2 notified the LPN/UM about the concern for Resident #35's midodrine order having no parameters, and the LPN/UM acknowledged the PRN midodrine order should have parameters and would clarify the order with the physician. On 4/30/26 at 12:38 PM, S #2 notified the LNHA, the DON, the VPoCS, and the AIT of the concern for Resident #35's midodrine order having no parameters. There was no verbal response by the facility at this time. On 4/30/26 at 12:42 PM, S #2 interviewed the Registered Nurse (RN) who was assigned to care for Resident #35 about midodrine med orders. The RN stated that midodrine orders should have parameters. The RN further explained the PO indicated when a med should be held as per order parameters. At that same time, S #2 with the RN reviewed Resident #35's PRN midodrine order. The RN acknowledged the order did not have parameters and could not speak to why there were none included. On 5/1/26 at 10:59 AM, the LNHA, the DON, and the AIT, met with the survey team. The DON stated that in-service education and auditing was ongoing regarding midodrine med administration. There was no additional information provided by the LNHA. A review of the facility's Med Administration Policy, with a last revised date of 9/1/25, which revealed under policy, medications (meds) are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 3. On 4/28/26 at 9:00 AM, Surveyor #3 (S #3) observed Resident #213 was receiving oxygen via nasal cannula through a concentrator. S #3 reviewed the medical record for Resident #213. A review of the AR revealed the resident had diagnoses which included, but were not limited to; pleural effusion (fluid buildup around the lungs), heart failure, chronic respiratory failure with hypoxia, and end-stage renal disease requiring dialysis. A review of the resident's cMDS with an ARD of 4/14/26, reflected a BIMS score of 4 out of 15, which indicated the resident's cognition was severely impaired. A review of the resident's individual comprehensive care plan, dated 4/28/26, included a focus area for meal management related to end-stage renal disease, moderate malnutrition, and chewing difficulties. Interventions included nutritional supplements, including Pro-Stat 30 milliliters two times daily, monitoring intake, and one-to-one meal assistance. A review of the Order Summary Report (OSR), dated as of 4/28/26, included the PO dated 4/10/26, for Pro-Stat oral liquid (amino acid-protein hydrolysate) 30 milliliters by mouth two times daily for malnutrition. A review of the eMAR revealed the Pro-Stat order dated 4/10/26 was not initiated until 4/13/26. The resident did not receive Pro-Stat from 4/10/26 in the morning through 4/13/26 in the morning, resulting in five missed doses. Further review of the PN revealed no documentation explaining the delay in initiating the PO or the missed doses. A review of the facility's Med Administration Policy, dated 9/1/24, included, meds are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy further included, Ensure that the six rights of med administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation. On 4/30/26 at 11:45 AM, S #3 notified the LNHA, in the presence of the DON that the PO for Pro-Stat was not followed as written and that doses were missed without documentation for resident #213. On 5/1/26 at 11:00 AM, the LNHA and DON provided no additional information regarding the PO for Prostat not administered for 2 1/2 days. NJAC 8:39-27.1(a)

REPEAT DEFICIENCYBased on observations, interviews, and review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' goals, medical, and psychosocial needs. This deficient practice was identified for 3 of 38 residents (Residents #5, #14, and #85) reviewed for care plan. This deficient practice was evidenced by the following: 1. On 4/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #5 lying in bed awake and able to answer S #1's inquiry. On 4/28/26 at 1:09 PM, S #1 reviewed the electronic medical record (eMR) of Resident #5, which revealed the following: A review of the admission Record (AR) or face sheet (an admission summary) reflected that Resident #5 was admitted with diagnoses that included but were not limited to peripheral vascular disease (PVD, disorder of the circulatory system). A review of the most recent quarterly Minimum Data Set (qMDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 3/20/26, reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had intact cognition. Further review of the qMDS, as reflected in section N – High Risk Drug Classes: Use and Indication, revealed that Resident #5 received an anticoagulant medication (med). A review of the Order Summary Report (OSR) revealed an order of apixaban 2.5 mg (milligram) by mouth every 12 hours for DVT (Deep Vein Thrombosis, formation of blood clot) with a start order date of 1/28/26. A review of Resident #5's comprehensive Care Plan (CP) report revealed no CP for the use of anticoagulant med. On 4/29/26 at 11:28 AM, S #1 interviewed Licensed Practical Nurse #1 (LPN #1), who stated that the anticoagulant should be in the CP to monitor for the effectiveness of the med, the side effects (s/e), such as bleeding. On 4/29/26 at 11:35 AM, S #1 interviewed the LPN/Unit Manager (LPN/UM), who stated that the anticoagulant should be in the CP to monitor bleeding and the effectiveness of the med. 2. On 4/27/26 at 9:35 AM, S #1 observed Resident #85 lying in bed awake, able to answer S #1's inquiry. S #1 observed that there was an indwelling catheter (a flexible tube attached to the bladder through the urethra) hung on the side of the bed inside the privacy bag. On 4/27/26 at 10:34 AM, S #1 reviewed the eMR of Resident #85, which revealed the following: A review of the AR reflected that Resident #85 was admitted with diagnoses that included, but were not limited to, obstructive and reflux uropathy (blockage in the urinary tract). A review of the most recent qMDS with an ARD of 3/19/26, reflected a BIMS score of 3 out of 15, which indicated that the residents had severe cognitive impairment. Further review of the qMDS, as reflected in Section H – Appliances, revealed that Resident #85 had an indwelling catheter. A review of the OSR with the start date of 11/12/25, foley catheter care, and drainage. A review of Resident #5's CP report revealed no CP for the use of an indwelling catheter. On 4/29/26 at 11:55 AM, S #1 interviewed LPN #2, who stated that the indwelling catheter should be part of the CP, and it should be added in the CP. On 4/29/26 at 12:00 PM, S #1 interviewed the LPN/UM, who stated that if the resident has an indwelling catheter, it should be in the CP. On 5/1/26 11:35 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Administrator in Training (AIT), the Director of Nursing (DON), and the Licensed Practical Nurse/MDS Staff (LPN/MDSS) regarding the above concern, the LNHA did not provide further information. 2. On 4/27/26 at 6:58 AM, Surveyor #2 (S #2) observed the Certified Nursing Aide (CNA) inside Resident #14's room responded to the call bell, the resident was observed in a low bed. S #2 reviewed the medical record of Resident #14, and revealed: A review of Resident #14's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction unspecified, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing, and unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. A review of the qMDS with an ARD of 4/2/26, revealed in Section C-Cognitive Patterns a BIMS score of 6 out of 15, which reflected that the resident had severely impaired cognition. Section I-Active Diagnosis did not reflect that depression was included as resident's diagnosis. Section N-Medications (meds) revealed that the resident received antidepressant during the seven days lookback period (this period is used for most clinical items, including functional status, behaviors, and treatments). Further review of the medical records did not reflect that there were documented evidence that the resident had a CP that focused on antidepressant med or any psychoactive meds. A review of the current OSR revealed an order date on 3/11/26, Lexapro oral tablet (tab) 5 mg, give 1 tab by mouth one time a day for depression/anxiety. The above order for Lexapro was transcribed to the electronic Medication Administration record in March and April 2026, signed by nurses daily as administered at 9:00 AM. On 4/29/26 at 8:18 AM, S #2 interviewed the LPN/MDSS who informed S #2 in the presence of the Registered Nurse/MDS Coordinator (RN/MDSC), the CP initiation with regard to psychoactive meds were responsibility of nursing. S #2 then notified the LPN/MDSS and the RN/MDSC of the above findings and concerns that the resident's CP did not include information about use of antidepressant med Lexapro for the indication of depression/anxiety. On 4/29/26 at 8:35 AM, S #2 asked the DON who was responsible for initiating CP for psychoactive meds of the resident and if s/e should also be monitored. The DON responded that it was nursing who was responsible for CP and the s/e should be monitored. S #2 then notified the DON of the above concerns with Resident #14, the resident was on Lexapro with no CP and no monitoring of s/e. On 4/30/26 at 12:38 PM, the survey team met with the LNHA, DON, AIT, and [NAME] President of Clinical Services (VPoCS), and S #2 notified them of the above findings and concerns with Resident's 14's CP. On 5/1/26 at 10:59 AM, the survey team met with the LNHA, AIT, VPoCS, LPN/MDSS, and the DON stated the antidepressant CP was addressed after surveyor's inquiry. A review of the facility's Comprehensive Care Plans Policy that was provided by the AIT, with a reviewed/revised date of 3/1/25, reflected, it is the policy of the facility to develop and implement a comprehensive person-centered CP for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Policy Explanation and Compliance Guidelines.5. The comprehensive CP will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6.The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. On 5/1/26 at 12:29 PM, the survey team met with the LNHA, DON, AIT, and VPoCS for an exit conference, and the LNHA did not provide additional information. NJAC 8:39-11.2 (e)

Based on interviews and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 3 of 38 residents (Residents #10, #14, and #85) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 4/27/26 at 10:00 AM, Surveyor #1 (S #1) observed Resident #10 awake, sitting in the wheelchair (w/c), alert and oriented, able to verbalize needs to staff. On 4/28/26 at 10:07 AM, S #1 reviewed the electronic medical record (eMR) of Resident #10, which revealed the following: A review of the admission Record (AR) or face sheet (an admission summary) reflected that Resident #10 was admitted with diagnoses that included, but were not limited to, other specified depressive (feeling of sadness) episodes. A review of the recent quarterly Minimum Data Set (qMDS), with an assessment reference date (ARD) of 3/17/26, reflected a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the residents had intact cognition. Further review of the qMDS on 9/18/25 and 3/17/26, as reflected in section N – High Risk Drug Classes: Use and Indication, revealed that both qMDS did not code for the use of antidepressant medications (meds). A review of the Order Summary Report (OSR) with the start date of 11/15/22, venlafaxine capsule 75 mg (milligram) orally one time a day for depression. A review of the care plan (CP) report initiated on 9/19/23, a focused that Resident #10 had an antidepressant medication (med). On 4/29/26 at 10:50 AM, S #1 interviewed the Registered Nurse/MDS Coordinator #1 (RN/MDSC #1), who stated that venlafaxine was an antidepressant, and it should be coded as an antidepressant to both qMDS on 3/17/26 and 9/18/25. RN/MDSC#1 acknowledged that she should code the med as an antidepressant. 2. On 4/27/26 at 9:35 AM, S #1 observed Resident #85 lying in bed awake, able to answer S #1's inquiry. On 4/27/26 at 10:34 AM, S #1 reviewed the eMR of Resident #85, which revealed the following: A review of the AR reflected that Resident #85 was admitted with diagnoses that included, but were not limited to, obstructive and reflux uropathy (blockage in the urinary tract). A review of the recent qMDS with an ARD of 3/19/26, reflected a BIMS score of 3 out of 15, which indicated that the residents had severe cognitive impairment. Further review of the qMDS, as reflected in Section H – Appliances, revealed that Resident #85 has an Ostomy (including urostomy, ileostomy, and colostomy) (an opening in the abdomen that allows stool or urine to exit the body). A review of the OSR with the start date of 11/12/25, foley catheter care, and drainage. A review of the CP report initiated on 4/27/26, focused on Resident #85, who requires enhanced barrier precautions (EBP) related to an indwelling medical device. On 4/29/26 at 10:55 AM, S #1 interviewed RN/MDSC #2, who stated that she miscoded the Resident #85's urostomy in Section H of the qMDS on 3/19/26. On 5/1/26 11:35 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Administrator in Training AIT), the Director of Nursing (DON), and the Licensed Practical Nurse/MDS Staff (LPN/MDSS) regarding the above concern, and the LNHA did not provide further information. 3. On 4/27/26 at 6:58 AM, Surveyor #2 (S #2) observed the Certified Nursing Aide (CNA) inside Resident #14's room responded to the call bell, the resident was in a low bed, and no adaptive device noted to the extremities. S #2 reviewed the medical record of Resident #14, and revealed: A review of Resident #14's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction unspecified, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing, and unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. A review of the qMDS with an ARD of 4/2/26, revealed in Section C-Cognitive Patterns a BIMS score of 6 out of 15, which reflected that the resident had severely impaired cognition. Section J-Health Conditions, the resident for shortness of breath (SOB) when lying flat was coded yes. Further review of the medical records did not reflect that there were documented evidence that the resident had SOB when lying flat to indicate that the resident's coding in Section J was an accurate assessment. On 4/29/26 at 8:18 AM, S #2 interviewed RN/MDSC #3, who informed S #2 in the presence of the LPN/MDSS that she was new to her MDSC position. RN/MDSC #3 further stated that she was still learning the MDS. The LPN/MDSS informed S #2 that he was in the MDS position full time for eight years, the facility followed the RAI manual when doing MDS that included accuracy, completion, and submitting or transmitting MDS. On that same date and time, S #2 notified RN/MDSC #3 and the LPN/MDSS of the above concern that Resident #14's was coded with SOB when lying flat when there were no documented evidence to show that the resident had SOB when lying flat. On 4/30/26 at 12:38 PM, the survey team met with the LNHA, DON, AIT, and [NAME] President of Clinical Services (VPoCS), and S #2 notified them of the above findings and concerns with Resident's 14's inaccurate MDS. On 5/1/26 at 10:59 AM, the survey team met with the LNHA, DON, AIT, and LPN/MDSS stated that Resident #14's coding of SOB when lying flat was wrong, the MDS was modified to reflect an accurate MDS, and all department heads were educated about MDS accuracy. On 5/1/26 at 12:29 PM, the survey team met with the LNHA, DON, AIT, and VPoCS for an exit conference, and the LNHA did not provide additional information. NJAC 8:39-33.2(a,d)

Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 2 of 38 residents, (Resident #14 and Resident #229), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment (RAI) Manual, dated October 2025, RAI-required Assessment Summary:-The admission (Comprehensive) assessment, the MDS completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The Care Plan Completion date is no later than CAA(s) Completion date + 7 calendar days. The Transmission date is no later than Care Plan Completion date + 14 calendar days.-The Quarterly (non-comprehensive) assessment, the MDS completion date ARD (assessment reference date) + 14 calendar days. The transmission date MDS Completion Date + 14 calendar days.-The Discharge MDS assessment return not anticipated, the MDS completion date is the discharge date + 14 calendar Days. The Transmission date is MDS Completion date + 14calendar days. 1.On 4/27/26 at 6:58 AM, the surveyor observed the Certified Nursing Aide (CNA) inside Resident #14's room to respond to the call bell, the resident was observed in a low bed, and no adaptive device noted to the extremities. The surveyor reviewed the medical record of Resident #14, and revealed:A review of Resident #14's admission Record (AR) or face sheet (the admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction (a type of ischemic stroke caused by a blockage in blood vessels supplying the brain, resulting in tissue death (necrosis) due to lack of oxygen) unspecified, cognitive communication deficit, hemiplegia and hemiparesis (hemiparesis is partial weakness, allowing some movement, while hemiplegia is severe or complete paralysis on one side) following cerebral infarction affecting left non-dominant side, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing, and unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing. Resident #14's comprehensive MDS assessment with an ARD of 1/2/26, admission date of 12/26/25, Care Areas Completion date was 1/9/26 (was in red), completion date was on 1/9/26 (was in red) and was accepted (or transmitted) on 4/22/26. The comprehensive MDS was completed late, after 14 days, which should have been completed no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). Resident #14's quarterly MDS assessment with an ARD of 4/2/26, was completed on 4/17/26 (in red) and accepted on 4/22/26. The quarterly MDS was completed a day late, after 14 days, which should have been completed within ARD + 14 calendar days. 2.The surveyor reviewed the medical record of Resident #229, and revealed: A review of Resident #229's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; Parkinson's disease without dyskinesia, without mention of fluctuations, unilateral primary osteoarthritis (the most common chronic joint disease, characterized by the breakdown of cartilage-the protective tissue cushioning the ends of bones) right knee, and chronic pulmonary disease (COPD, a progressive, long-term lung disease that causes obstructed airflow, making it difficult to breathe). Resident #229's comprehensive MDS assessment with an ARD of 1/9/26, admission date of 12/24/25, Care Areas Completion date was 1/9/26 (was in red), completion date was on 1/9/26 (was in red) and was transmitted on 1/12/26. The comprehensive MDS was completed late, after 16 days, which should have been completed no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). Resident #229's Discharge MDS assessment return not anticipated (DRNA) with an ARD of 2/5/26, was completed on 3/6/26 (in red) and was not transmitted. The discharge (d/c) MDS was completed late, after 14 days. The d/c MDS was not transmitted, which should have been transmitted MDS Completion date + 14 calendar days. On 4/29/26 at 8:18 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC) who informed the surveyor in the presence of the Licensed Practical Nurse/MDS Staff (LPN/MDSS) that she was new to her RN/MDSC position. The RN/MDSC further stated that she was still learning the MDS. The LPN/MDSS informed the surveyor that he was in the MDS position full time for eight years, the facility followed the RAI manual when doing MDS that included accuracy, completion, and submitting or transmitting MDS. On that same date and time, the LPN/MDSS stated that he was aware that there were MDSs that were late and the reason for late MDSs was because some department were not able to complete their sections timely and also due to high volume of discharges at the facility. He further stated that the sections D and Q in the MDS were the responsibility of the Social Worker, Section K was for the Dietician, and the rest of the sections in MDS were the responsibility of nursing, except for Section GG which was the collaboration between nursing and rehab department. He also added that for admission MDS, you have up to 14 days to complete the MDS and another 14 days to submit, and I think it was the same way with d/c MDS. The surveyor then notified both the RN/MDSC and the LPN/MDSS about the above findings and concerns with regards to late completion and not able to transmit due MDSs. The LPN/MDSS confirmed that if the dates were in red, it meant it was late. On 4/30/26 at 12:38 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Administrator in Training (AIT), and [NAME] President of Clinical Services (VPoCS), and the surveyor notified them of the above findings and concerns with late MDSs. On 5/1/26 at 10:59 AM, the survey team met with the LNHA, DON, AIT, and LPN/MDSS stated that all department heads were educated about late MDSs. A review of the facility's MDS 3.0 Completion Policy that was provided by the LNHA, with date implemented 9/1/25, revealed, residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.Policy Explanation and Compliance Guidelines .1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 2. Types of OBRA (Omnibus Budget Reconciliation Act of 1987, in MDS refers to federal nursing home regulations establishing mandatory, standardized assessment schedules for all residents in certified facilities, regardless of payer type) Assessments.b. admission Assessment-completed within 14 days of admission counting the day of admission as day #1 .f. D/c Assessment-completed using the d/c date as the ARD, must be completed within 14 days of the d/c date/ARD On 5/1/26 at 12:29 PM, the survey team met with the LNHA, DON, AIT, and VPoCS for an exit conference, and the LNHA did not provide additional information. NJAC 8:39 - 11.1

NJ#2643214Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 1 of 32 sampled residents (Resident #221) and 1 of 6 residents (Unsampled Resident) from resident council meeting reviewed.This deficient practice was evidenced by the following: 1. On 4/27/26 at 8:35 AM, Surveyor #1 (S #1) observed Resident #221 lying in bed, the floor mat on the right side of the resident was dirty, stained, and had wet pools on it in multiple places. On 4/27/26 at 10:31 AM, S #1 made a second observation of the floor mat which was still stained and had wet pools on it in multiple places. On 4/28/26 at 12:23 PM, S #1 made a third observation of the floor mat, which was vertical by the window wall, and stained in multiple places with dried colored chunks and pieces. On 4/28/26 at 12:45 PM, S #1 interviewed Certified Nursing Assistant #1 (CNA #1) who stated they saw the floor mat was dirty on 4/27/26 and called housekeeping then. CNA #1 acknowledged the floor mat was still dirty now. On 5/1/26 at 8:50 AM, S #1 interviewed the Director of Housekeeping (DH) who stated that housekeeping cleans the rooms daily and should be wiping down the floor mats daily as part of the routine room cleaning. The DH further stated that they did not keep a log. The DH also stated that the floor mat should have been cleaned when the room was cleaned. A review of the facility's Safe and Homelike Environment Policy, revised 9/1/26, revealed, in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment.Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 2. On 4/27/26 at 8:23 AM, Surveyor #2 (S #2) interviewed the Assistant Director of Nursing (ADON) who stated that fourth floor unit census (total number of residents) was 63. On 4/29/26 at 10:30 AM, during resident council meeting with Surveyor #3 (S #3), an Unsampled Resident (UR) stated there was a shortage of towels in the morning and that they only received one towel which was not enough. The UR stated that it had been an issue for months. On 4/29/26 at 12:35 PM, the DH provided S#2 a par list for each unit. A review reflected that the cart delivered for 7-3 shift (7:00 AM-3:00 PM) had 60 towels. The amount did not provide each resident with one towel for morning (am) care when the unit census was greater than 60 residents. The list also included 15 towels that were delivered to the unit supply closet at 10, 12, and 2. The list reflected that the cart for 3-11 (3:00 PM-11:00 PM) and 11-7 (11:00 PM-7:00 AM) shifts had 60 towels on the cart. On 4/30/26 at 9:26 AM, S #2, in the presence of the Laundry Supervisor (LS) and the Maintenance Director (MD) observed the supply closet which contained the backup laundry for the facility. S #2 observed that there were no towels in the closet. S #2 then observed the laundry room which had seven laundry carts that had 15 towels on each cart and that there were approximately 45 towels on the table and an additional pile of laundry that was being folded which had just come out of the dryer. On 4/30/26 at 9:36 AM, the DH stated that 50 dozen towels were ordered this week and that it was approved by the Licensed Nursing Home Administrator (LNHA) on Monday (4/27/26, the same day the recertification survey started at 6:30 AM). The DH stated that the towels should have arrived yesterday, but they did not. On 4/30/26 at 9:47 AM, the DH stated that the expectation was that the staff were preparing the carts for 3-11 and 11-7 shifts now. She added that the expectation at the end of day was if they may still need towels for the 7-3 shift cart for the next day that those towels would be washed on 3-11 shift and then put on the 7-3 shift cart. The DH further stated that there were some days that they did not need them for the cart and that there were some days that the cart was incomplete. She added that it depended on what came back from the floors to wash and that they did purges in the rooms. On 4/30/26 at 9:50 AM, in the presence of the DH, S #2 observed that the fourth floor unit supply closet had no towels. The DH stated that a delivery of 15 towels came to the unit at 10, 12, and 2. The DH further stated that the large cart came up in the am and that the CNAs distributed the towels to the eight small linen carts (1 for each CNA's assignment of residents) and that each cart would have seven or eight towels to start. Fourth floor unit had a resident capacity of 64 which would require eight CNAs. On 4/30/26 at 10:12 AM, S #2 interviewed CNA #2 who stated that sometimes there was not enough towels that came up in the morning and that they would bring more up at 10. On 4/30/26 at 12:44 PM, S #2 notified the LNHA, Director of Nursing (DON), Administrator in Training (AIT) and [NAME] President of Clinical Services (VPoCS) the concern that they were not enough towels and that enough towels were provided for am care. On 5/1/26 at 11:19 AM, in the presence of the LNHA and AIT, the DON stated that towels were delivered yesterday. The LNHA stated that they were making sure residents were getting additional towels if they wanted. The LNHA did not provide any additional information. A review of the facility's Linen Policy with a reviewed/revised date of 9/1/25, included the following, a linen par is the amount of linen needed to satisfy the daily needs of each resident. Established linen pars allow the laundry department to provide nursing with the linens they need in the proper amounts and at the proper time. There must always be agreed-upon par, along with regularly scheduled delivery times. It is best practice that linen inventory should be a minimum of 3 times your par (the amount of linen needed to satisfy the daily needs of each resident). The facility should maintain a par level of all essential linens. Inventory will be monitored to prevent shortages and ensure that any worn, stained or torn linens are removed from circulation and replaced immediately. Bath towels-Par Level 3.0-Calculation (Per Bed) 3 per resident. NJAC 8:39-4.1(a)11; 31.3; 31.4(a)(b);

COMPLAINT NJ #2669783 and #2735273 Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure the resident representative was notified of a significant change in condition, including a fall for 1 of 2 residents (Resident #252) and a resident's death for 1 of 1 resident (Resident #250), and failed to ensure such notification was documented in the medical record for 2 of 2 residents (Resident #250 and Resident #252) reviewed for notification of change. This deficient practice was evidenced by the following: 1.On [DATE] at 11:53 AM, Surveyor #1 (S #1) reviewed the closed records of Resident #250. A review of the admission Record (AR) or face sheet (an admission summary), revealed the resident had diagnoses which included, but were not limited to; acute respiratory failure (inability to maintain adequate oxygenation), pleural effusion (fluid buildup around the lungs), anemia, heart failure, and malignant neoplasm of the bladder. A review of the progress notes (PN) included a nurse's note, dated [DATE] at 1:05 PM, which reflected the resident expired at 12:53 PM. The PN indicated hospice services were notified and that the Unit Manager (UM) and Supervisor were aware. There was no documentation in the medical record indicating that the resident's representative (RR) was notified of the resident's death. On [DATE] at 12:49 PM, S #1 conducted a telephone interview with the Hospice Agency Director (HAD) who stated, Our process is for the person who pronounces the death in the facility to notify the RR. The HAD further stated the hospice agency follows up with the RR for bereavement services. On [DATE] at 8:56 AM, S #1 interviewed the Director of Nursing (DON) who stated the UM reported that the RR was notified of the resident's death; however, the DON was unable to provide documentation to support that notification occurred. On [DATE] at 9:18 AM, S #1 interviewed the Hospice Nurse (HN) who stated, the facility is responsible for notifying the RR when a resident expires in the facility. On [DATE] at 8:21 AM, the DON provided in-service education documentation which identified an area of opportunity for the facility related to timely notification of RR for residents receiving hospice services. The documentation indicated education was provided to nursing staff regarding the importance of notifying RR immediately upon a resident's death and documenting such notification in the medical record. A review of the facility's Notification of Changes Policy, dated [DATE], included, the facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring such notification.The policy further included that death of a resident requires immediate notification and documentation. On [DATE] at 9:00 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, and the survey team, acknowledged that documentation of notification to the RR could not be provided. 2. On [DATE] at 10:31 AM, the Assistant Director of Nursing (ADON) notified Surveyor #2 (S #2) that Resident #252 was no longer in the facility. On [DATE] at 1:50 PM, S #2 reviewed the electronic Medical Records (eMR) of Resident #252, which revealed an AR that included diagnoses but not limited to; fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing, other abnormalities of gait and mobility, muscle weakness (generalized), muscle wasting and atrophy, not elsewhere classified, multiple sites, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, unspecified, acute kidney failure, unspecified, and chronic kidney disease, unspecified. A review of the comprehensive Minimum Data Set (MDS) (an assessment tool to facilitate the plan of care), with an assessment reference date (ARD) of [DATE], revealed a Brief Interview Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment; sit to stand partial/moderate assistance; and walked 10 feet partial/moderate assistance. A review of the Care Plan (CP) revealed: impaired cognitive function/dementia or impaired thought processes related to dementia, date initiated [DATE]; risk for falls related to recent falls at home, pubis fracture, gait imbalance and actual fall dated [DATE], date initiated [DATE]. A review of the nursing PN dated [DATE] at 11:03 PM, electronically signed by the License Practical Nurse (LPN), revealed the resident was found on the floor by a CNA. The LPN documented the resident was confused, denied any discomfort, no visible injuries, vital signs taken, nursing supervisor notified, put back to bed and fall precautions in placed for safety. There was no documentation to indicate the RR was notified of the fall. On [DATE] at 8:45 AM, S #2 received the fall investigation report written by the LPN dated [DATE], which revealed the RR was notified of the fall on [DATE] at 5:15 PM (18 hours and 12 minutes later). On [DATE] at 10:08 AM, S #2 interviewed the DON regarding the facility's process with regard to fall investigations. The DON stated the nurse will come in and assess the resident head to toe, if no visible injury, assisted the resident back to bed, neuro (neurological) checks were done, notify the doctor and RR, administer pain medication if there was complaint of pain, initiate a risk assessment, and would gather statements, timeline would be that shift, and then Interdisciplinary Team (IDT) will review following day for underlying conditions or potential causes. On [DATE] at 11:57 AM, the Staffing Coordinator provided the number for the LPN that was assigned to the resident the night of the fall incident. She also stated the supervisor scheduled at the time of incident was currently on medical leave. On [DATE] at 12:01 PM, S #2 interviewed the LPN regarding the fall investigation, and the LPN stated, the CNA found the resident on the floor during his rounds and told the LPN. The LPN further stated that resident was confused, vitals done, neuro checks done, skin assessed, and there were no bruises. She stated the RR, Nursing Supervisor and doctor were notified before her shift (3:00 PM-11:00 PM) was over. At that same time, S #2 asked the LPN if the RR was notified and what the process was for informing the RR. The LPN stated she would look into resident's profiles and see who was listed. She stated she called the RR first because the RR was very involved, and stated she was unsure if she called the emergency contact person #1. She further stated that the CP should be updated by the UM or supervisor, and notification of the doctor and RR should also be documented in the PN. S #2 asked the LPN as to why the emergency contact person #1 was not called first, and the LPN responded that she was new and just started. S #2 asked about the fall investigation report which was written by the LPN and indicated that the RR was notified of the fall the next day on [DATE] at 5:15 PM, and she said she did not know why. On [DATE] at 12:41 PM, S #2 interviewed the ADON regarding the [DATE] fall incident, and that RR was notified on [DATE] at 5:15 PM. The ADON stated the process was family to be called immediately and doctor when it happened. S #2 and ADON reviewed the incident report and investigation documents, and S #2 asked why the emergency contact person #1 was not called. S #2 asked if there was a period to notify the RR, and the ADON confirmed, I do not know how that happened. We call the first contact unless we can not reach them, then go to next one. It should have been documented in the PN and that RR should be notified immediately when it occurred, and notification should be immediate. On [DATE] at 1:52 PM, the survey team met with the LNHA, [NAME] President of Clinical Services (VPoCS), DON, and Administrator in Training (AIT), and S #2 notified them of concern with not notifying RR timely and emergency contact person of change in condition for an unwitnessed fall on [DATE] timely. S #2 requested the LNHA to provide documentation that primary emergency contact #1 was notified. On [DATE] at 10:59 AM, the survey team met with the LNHA, AIT, and the DON stated We completed in-service yesterday with staff regarding importance of documenting when falls, incidents happened and notifying the primary (emergency #1) contact. There was no additional documentation provided that the primary contact was aware of the fall. A review of the facility's Notification of Changes Policy, revised on [DATE], revealed, the purpose. facility promptly informs.the RR when there is a change requiring notification . Under Additional Considerations #1c. a designated family member should be notified of significant changes.especially in the case of sudden illness or accident . A review of the facility's Fall Prevention Program Policy, revised on [DATE], revealed under Policy Explanation and Compliance Guidelines #6. When a resident experiences a fall, the facility will: d. Notify physician and family. e. Review the resident's CP and update as indicated . NJAC 8:39-13.1(c),13.2(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 of 32 residents (Resident #122 and Resident #221) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 4/27/26 at 8:42 AM, the surveyor observed Resident #122 lying in bed, the resident's call device was wrapped around itself and dangled over the outlet on the wall, and out of reach of the resident. On 4/28/26 at 11:27 AM, the surveyor made a second observation of Resident #122 lying in bed. The call device was in the same position as the previous observation, out of reach of the resident. On 4/28/26 at 12:35 PM, the surveyor interviewed Certified Nursing Assistant #1 (CNA #1) and Certified Nursing Assistant #2 (CNA #2) who both observed and acknowledged the call device was out of reach of the resident. 2. On 4/27/26 at 8:34 AM, the surveyor observed Resident #221 lying in bed, the resident's call device extended across the top of the heating and air conditioning unit that was against the window wall. The call device dangled over the side of the unit, out of reach of the resident. On 4/28/26 at 12:45 PM, the surveyor interviewed CNA #1 who acknowledged the call bell was out of reach of the resident on 4/27/26. A review of the care plan report initiated on 1/28/24, revealed that Resident #221 was high risk for falls. Interventions included, but were not limited to, Be sure Resident #221's call light is within reach and encourage Resident #221 to use it for assistance as needed. Resident #221 needs prompt response to all requests for assistance. On 4/30/26 at 1:48 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, and [NAME] President of Clinical Services. The LNHA did not provide a verbal response at that time. A review of the facility's Call Lights: Accessibility and Timely Response Policy, revised 1/15/26, revealed the following:-Staff will ensure the call light is within reach of the resident and secured, as needed.-The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. NJAC 8:39-31.8(c)9

Based on observation, interview, and record review, it was determined that the facility failed to ensure the urinary catheter bag was covered. This deficient practice was identified for 1 of 3 residents who had urinary catheters (Resident #122), and was evidenced by the following:On 4/27/26 at 8:42 AM, the surveyor observed that Resident #122 had a urinary catheter bag that was uncovered. On 4/27/26 at 9:30 AM, the surveyor reviewed the electronic medical record of Resident #122. The admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to, other neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by damage to the nerves that control bladder function). A review of the Order Summary Report revealed an order dated 2/25/26, Patient has indwelling Suprapubic catheter. Size: 20 Fr (french (or French Gauge/Scale), which represents the outer diameter of a catheter or medical tube) balloon size: 10 cc (cubic centimeter) every shift for diagnosis of neurogenic bladder. Check for placement and patency every shift. On 4/28/26 at 12:55 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that a privacy bag for the urinary catheter bag was always required. They also noticed on 4/27/26 that there was no privacy bag. The LPN acknowledged that the urinary catheter bag had been left uncovered. On 4/30/26 at 1:48 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, and [NAME] President of Clinical Services. The LNHA did not provide a verbal response at that time. A review of the facility's Appropriate Use of Indwelling Catheters Policy, revised 1/15/26, did not address the covering of urinary catheter bags. NJAC 8:39-4.1(a)12

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure grievances were documented on the facility grievance form and responses were documented according to facility policy. This deficient practice was identified for 1 of 38 residents (Resident #9) reviewed. This deficient practice was evidenced by the following: On 4/27/26 at 9:16 AM, the surveyor observed Resident #9 who was seated up in bed and stated that they had been in the facility for two years. A review of Resident #9's admission Record (AR) or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to heart failure (chronic, progressive condition where the heart muscle cannot pump blood efficiently, often caused by coronary artery disease, high blood pressure, or heart attacks) and hypertension (high blood pressure). A review of Resident #9's most recent comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 3/3/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated that the resident's cognitive status was intact. A review of Resident #9's Progress Notes (PN) included the following note dated 2/19/26: observed in bedroom yelling and expressing dissatisfaction with the facility and staff assignments. I am going to continue to call the state. Resident was asked to clarify specific care issues and did not identify unmet clinical care needs but reiterated demand to have the same CNA (certified nursing assistant) assigned daily. The resident was informed that all CNAs were trained and competent to meet their needs and that while consistent assignment will be accommodated when feasible, it cannot be guaranteed due to staffing requirements. Resident was educated on their right to voice grievances and contact outside agencies. On 4/29/26 at 9:45 AM, the surveyor reviewed the facility provided grievance binder for 2025 and 2026. There was no grievance listed for Resident #9. On 4/29/26 at 11:02 AM, the surveyor interviewed the CNA about complaints. The CNA stated that most residents do not complain but that Resident #9 did complain and that she reported it to the nurse. On 4/29/26 at 11:08 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding complaints. The ADON stated that they had a customer relation staff that went to the residents and they gave their complaints to her and she would write them and give to the department. The ADON added that they had to put what they did to resolve issue, makes rounds. The ADON stated that if someone complained to a CNA that they would tell her, the unit manager or Director of Nursing (DON) and would write a grievance. On 4/29/26 at 11:52 AM, the surveyor asked the ADON if they kept a log of grievances. The ADON stated the Licensed Nursing Home Administrator (LNHA) kept it. On 4/29/26 at 12:13 PM, the surveyor interviewed the patient relations who stated that she went around daily and ask residents if they had any concerns. She stated that she brought the grievance to the Social Worker (SW) and the SW followed up. She added that the Social Services Director (SSD) filled out the grievance form. On 4/29/26 at 12:17 PM, the surveyor interviewed the SSD who stated that when there was a concern or grievance that they would interview the resident and if a grievance or concern, then they would write it up and forward to appropriate department. The SSD stated that nursing may document the issue in the PN but that she did not and that there was a log kept. She added that the LNHA signed off on all grievances. On 4/30/26 at 10:47 AM, the surveyor showed the SSD Resident #9's PN dated 2/19/26. The SSD stated that she was not aware of that situation or directly involved. The surveyor asked the SSD if a grievance should have been filled out. The SSD stated that usually if something goes above in house, that they did not usually do a separate grievance. On 4/30/26 at 11:01 AM, the surveyor interviewed the ADON regarding Resident #9's PN dated 2/19/26. The ADON stated that the DON and herself went in the room and addressed the concern and that she thought the DON notified the Ombudsman. The surveyor asked if the expectation was for the resident's concern to be written as a grievance. The SSD stated that she did not write a grievance but that she notified the DON and that she was not sure if it was written and put in the book. The ADON stated that Resident #9 often complained about the CNA and the facility. The ADON stated that they try to give the resident a consistent CNA if they could. The surveyor asked the ADON if Resident #9's complaints would be considered grievances. The ADON stated that the problem was that it was almost every day. On 4/30/26 at 11:13 AM, the surveyor interviewed the DON regarding the grievance process. The DON stated that if a resident had a concern/grievance voiced then someone would write up a grievance form. He added that anyone could write it. The DON stated that generally it was given to Social Services (SS) and they brought it to the team. When it was resolved it went back to SS and the resident or resident representative (RR) notified and placed in the grievance binder. The surveyor asked if all complaints were put in the grievance binder. The SSD stated that it depended and that if it was a concern or if it was a want was possible it was a grievance. The surveyor asked the DON about Resident #9, and that there were no grievances in the log for Resident #9. The DON stated that they had called the Ombudsman and that they had made a folder for him to review. On 4/30/26 at 11:23 AM, in the presence of the DON, the SSD stated that Resident #9 did not contact her and that the resident went higher and notified the ombudsman. The SSD stated that she never wrote a grievance. On 4/30/26 at 12:44 PM the surveyor notified the LNHA, DON, Administrator in Training (AIT) and [NAME] President of Clinical Services (VPoCS) the concern that Resident #9's grievance documented in the PN was not documented as a grievance in the facility binder and that there were no documented grievances for Resident #9 in the 2025 and 2026 binders. On 5/1/26 at 11:26 AM, in the presence of the LNHA and AIT, the DON stated that Resident #9 bypassed facility staff for a lot of things and called the ombudsman. The surveyor asked if the resident had concerns were they not to be documented as a grievance. The DON stated that it was different with Resident #9. The surveyor asked how the facility determined what a grievance was. The LNHA stated that a complaint was generally given to the SW and written as a grievance. The DON stated that they had an ambassador that made rounds daily and tried to resolve any issues immediately. The LNHA did not provide any additional information. A review of the facility's Resident and Family Grievances Policy with a reviewed/revised date of 2/10/26, included the following:Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal.Policy Explanation and Compliance Guidelines:2. The Grievance Official is responsible for overseeing the grievance process' receiving and tracking grievances through to their conclusion; leading any necessary investigation by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations.10. Procedure:b. The staff member receiving the grievance will record the nature and specifics.on the designated grievance form, or assist.to complete the form.c. Forward the grievance form to the Grievance Official as soon as practicable.d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.e. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation.11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. N.J.A.C. 8:39-4.1(a)(35);13.2(c)

Based on interview, record review, and review of pertinent documentation on 01/03/24, 01/05/24, and 01/08/24, it was determined that the facility was in an active COVID-19 outbreak status on 10/2/23, failed to prevent the spread of COVID-19, a highly contagious virus for the following: a.) failing to perform contact trace (CT) of the employees and residents who were exposed to COVID-19 virus, b.) failing to consistently test exposed residents and employees. c.) failing to ensure that the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidance were implemented to limit the spread of the infectious disease, and to put into effect the facility's policy titled Emergent Infectious Disease (COVID-19) Outbreak Plan V11 to prevent the spread of Covid-19 which is a highly contagious virus. Reference: CDC, COVID-19, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Updated May 8, 2023, indicated the following .Perform SARS-CoV-2 Viral Testing, Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test [rapid test] instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period . Testing considerations for healthcare facilities with an outbreak of SARS-CoV-2 are described below. The yield of screening testing for identifying asymptomatic infection is likely lower when performed on those in areas with lower levels of SARS-CoV-2 community transmission. However, these results might continue to be useful in some situations (e.g., when performing higher-risk procedures, admitting/caring for patients who are moderately to severely immunocompromised, or for the HCP [Health Care Provider] caring for such patients) to inform the type of infection control precautions used (e.g., room assignment/cohorting, or PPE used) and prevent unprotected exposures. If implementing a screening testing program, testing decisions should not be based on the vaccination status of the individual being screened. To provide the greatest assurance that someone does not have SARS-CoV-2 infection, if using an antigen test instead of a NAAT, facilities should use 3 tests, spaced 48 hours apart, in line with FDA recommendations. In general, performance of pre-procedure or pre-admission testing is at the discretion of the facility. Performance of expanded screening testing of asymptomatic HCP without known exposures is at the discretion of the facility . Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and Others Healthcare facilities should have a plan for how SARS-CoV-2 exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed. If healthcare-associated transmission is suspected or identified, facilities might consider expanded testing of HCP and patients as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. For example, in an outpatient dialysis facility with an open treatment area, testing should ideally include all patients and HCP. Depending on testing resources available or the likelihood of healthcare-associated transmission, facilities may elect to initially expand testing only to HCP and patients on the affected units or departments, or a particular treatment schedule or shift, as opposed to the entire facility. If an expanded testing approach is taken and testing identifies additional infections, testing should be expanded more broadly. If possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days. Guidance for outbreak response in nursing homes is described in setting-specific considerations below. Healthcare facilities responding to SARS-CoV-2 transmission within the facility should always notify and follow the recommendations of public health authorities . Nursing Homes .The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period . According to the progress note in the medical record, it revealed that on 10/02/23, Resident #1, who resided on the second floor, had signs and symptoms of lethargy, generalized weakness and loss of appetite. The resident was given a Rapid COVID-19 test on the same day and the result was positive. According to the CDC guidelines and the Local Health Department (LHD) facility was to initiate the 3 series of viral tests on 10/02/23. a.) The facility's Infection Control Preventionist (ICP#1) identified that nine staff members were exposed to Resident #1 prior to the resident testing positive for COVID-19 on 10/2/23. The staff members were Licensed Practical Nurses (LPNs) #2, #3, and #5, and Certified Nursing Assistants (CNA) #2, #3, #4, #5, #6, and #7. All 9 staff members were rapid tested for COVID-19 on 10/03/23 and 10/04/23, however, testing was not repeated on Day 3 and Day 5 post exposure and so the 9 staff members continued to provide care to other residents. On 12/12/23, facility conducted Broad Based Approach Testing (BBAT) but failed to complete the 3 series of CDC testing recommendations for all residents on Day 1, 3, and 5 for COVID-19. b.) When Residents #2 , #3, #4, #5, and #6 tested positive for COVID -19 virus on 10/7/23, 10/8/23, 10/9/23, 10/11/23 and 10/13/23, the facility failed to initiate CT to identify staff who provided care for 5 residents on the second floor to prevent the spread of COVID-19 virus, In addition, the facility failed to CT and test exposed residents from COVID-19 virus when on 11/01/23, 11/06/23, and 11/24/23, 2 staff members, LPN #3 and #4, who provided care on the second floor and one rehab staff (Rehab #1) received rapid testing and results were positive for COVID-19. The facility had a total of 55 residents and 34 staff who tested positive for COVID-19 virus that started on 10/02/23. The facility failure to complete the recommended series of 3 viral tests, conduct contact tracing upon the identification of COVID-19 positive for staff and residents to prevent the spread of COVID-19, a contagious infectious and potentially deadly virus, posed a serious and immediate risk to the health and well-being of all staff and residents for contracting COVID-19. A serious adverse outcome was likely to occur as the identified non-compliance resulted in an Immediate Jeopardy (IJ) situation that was identified on 1/3/24 at 6:30 p.m. The removal plan was accepted and verified as implemented by the survey team during an onsite visit on 1/8/24. The IJ situation began on 10/05/23, when nine staff members who were exposed from Resident #1 who exhibited lethargy, general weakness, and no appetite were rapid tested for COVID-19 on Day 1 (10/03/23) and (10/04/23) Day 2 but no evidence of testing after this date. The non-compliance remained on 1/3/24 for F880 at level E, with no actual harm with the potential for more than minimum harm that is not immediate jeopardy. On 1/3/24 at 8:51 a.m., during the entrance conference, the Director of Nursing (DON) and Nurse Educator (NE) informed the surveyors that the facility was experiencing an outbreak of COVID-19 which began on 10/2/23. The facility currently had 3 positive COVID-19 residents. The DON stated that the facility had been communicating with the LHD and had been receiving and following the LHD's recommendation. The surveyors were provided with the facility's ongoing line listing (LL), a document that is transmitted to the Department of Health and lists all COVID-19 cases during an outbreak, and a copy of the CT for Resident #1 who tested positive for COVID-19 on 10/2/23. The LL indicated a total of 55 residents and 34 employees were tested positive for COVID-19. The surveyors reviewed the CT provided by the facility on 1/3/24. The CT revealed that LPNs #2, #3, and #5, CNAs #2, #3, #4, #5, #6, and #7 were exposed from Resident #1 and tested on Day 1. The CT did not indicate that the aforementioned CNAs and LPNs continued to be tested and this was not in accordance with the LHD recommendation, CDC guidelines, and facility policy. The surveyors conducted an interview with the DON, Regional ICP (RICP) and ICP #2 on 01/3/24 at 4:08 p.m., the ICP #2 stated that she started working with facility on the first week of September 2023 in the title of a staff nurse and started in the present title as an ICP on 10/28/23 after she took Infection Control classes from 10/23/23 to 10/27/23. ICP #2 further stated that ICP #1 last day was 10/3/23. DON stated that she was ICP certified and that she was overseeing the infection control and prevention after ICP #1 left (started on 10/4/23). The DON and ICP #2 stated that the CT was initiated on 10/3/23 by ICP #1. The DON and ICP #2 were unable to explain the reason why the 3 series of testing was not completed to the exposed staff from 10/2/23. The DON and ICP #2 revealed that the CT was not performed when Residents #2, Resident #3, Resident #4, Resident #5, and Resident #6 tested positive on 10/7/2023, 10/8/23, 10/9/23, 10/11/23 and 10/13/23, and when 3 staff members on 11/01/23, 11/06/23, and 11/24/23 tested positive for COVID-19. According to the DON everything fell into the cracks, I thought the staff, Unit Managers would know and would do the testing and contact tracing. The DON admitted that when the staff who were exposed on 10/2/23 were tested on day 1, there were no further testing was done. In addition, the DON stated that there was no documented evidence that the CT was done when 5 residents (Residents #2, #3,#4, #5 and #6) tested positive on 10/7/2023, 10/8/23, 10/9/23, 10/11/23 and 10/13/23. The DON and RICP stated it is important to CT and to test the identified exposed resident/staff to stop further exposure and eliminate transmission of Covid-19 among residents and staff. The DON and ICP #2 were aware that on 11/1/23, 11/6/23, and 11/24/23, three facility employees respectively tested positive for Covid-19, the DON stated, contact tracing and testing was done but there's no documentation to prove that it was done. The surveyors conducted an interview with ICP #2 on 1/3/24 and 1/5/24. The ICP confirmed the aforementioned cases of COVID-19. The ICP was unable to provide documented evidence that the staff who were exposed from Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 were CT and tested for COVID-19 in the accordance with the CDC guidelines and the facility policy. In addition, during the interview with the ICP on 1/5/23 at 10:05 a.m., she explained that BBAT was initiated for the whole building (for all staff and resdients) because they were unable to perform CT. On 12./11/23, there were many staff and residents who tested positive, so CT was not done at this time. According to the ICP, the staff had been educated to test for COVID-19, however, the testing was not consistently done to detect the virus before providing care to the residents. The electronic-mail (e-mail) communication from LHD on 10/3/23 at 11:16 a.m. indicated that the facility was in an outbreak. The LHD email was sent to ICP #1, DON, ICP #2, and the Administrator. The LHD instructed the facility to Conduct contact tracing on all resident and staff cases. Conduct testing of close contacts as appropriate (on days 1, 3, and 5). Be sure to follow all applicable federal and state directives. Included in the email was an Outbreak Management Checklist for COVID-19 in Nursing Homes and other Post-acute Care Settings The checklist under Screening, Testing, & Response Outbreak Intervention 1. Review outbreak response plans for SARS-CoV-2 and other respiratory pathogens to support containment and response efforts . Under Contact Tracing or Broad-based Approach Outbreak Intervention 1. Facilities should perform contact tracing to identify all high-risk staff exposures and close contact encounters with patients/residents .2. Contact tracing approach: Perform SARS-CoV-2 viral testing for all patients/residents identified as close contacts and all staff who have higher-risk exposures, regardless of vaccination status, who have not been previously positive within the past 30 days. Asymptomatic patients/residents and staff with close contact or higher-risk exposures should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately but not earlier than 24 hours after exposure and, if negative, 48 hours after the first negative test. If negative, again 48 hours after the second negative test. This will typically be on days 1, 3, and 5 (where the day of exposure is day 0). 3. Continue performing contact tracing if testing reveals additional cases .5. Broad-based approach: Perform SARS-CoV-2 testing for all patients/residents and staff on the affected unit(s), regardless of vaccination status, who have not been previously positive within the past 30 days, immediately and, if negative, again 48 hours after first negative test, and if negative, again 48 hours after second negative test. 6. If additional cases are identified, testing should continue on the affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days) should be considered . The LL for COVID-19 from 10/2/23 through 12/28/23 revealed the following medical records (MR), Resident #2, who resided on the second floor tested positive for COVID-19 on 10/7/23. Resident #3, who resided on the second floor tested positive for COVID-19 on 10/8/23. Resident #4, who resided on the second floor tested positive for COVID-19 on 10/9/23. Resident #5, who resided on the second floor tested positive for COVID-19 on 10/11/23. There was no documentation to indicate that Residents #2, #3, #4, and #5 were tested to complete the 3 series of viral test from 12/12/23 when the facility performed BBAT for all staff and residents. The medical records revealed the following: Resident #6, who resided on the second floor tested positive for COVID-19 on 10/13/23. On 12/27/23 at 11:24 a.m., documented by the Speech Therapy (ST) that Resident #6 had difficulty swallowing, at 11:25 a.m., documented by LPN #2 Very congested. Productive cough. Stated unable to swallow. Wants med crushed. Temp: 97.3. [Nurse Practitioner] informed. Order received for stat [Now] CXR [Chest X-ray], at 3:36 pm, documented by LPN #2 Appetite poor. On 12/28/23 at 10:24 a.m., documented by ST that Resident #6's diet was changed to chopped solids, at 3:06 p.m., documented by LPN #2 that the CXR results was Right lower lobe infiltrate and NP was made aware. On 12/29/23 at 12:55 p.m., documented by a LPN #1 that Resident #6 was on antibiotic for Upper Respiratory Infections. On 12/31/23 at 3:53 p.m., documented by LPN #2 that the Resident was coughing. On 1/1/24, documented by the Residents Primary Physician (PP) that No specific issue reported by nursing home staff. On 1/2/24 at 9:12 a.m., documented by Unit Manager/LPN (UM/LPN #1) that Resident was congested, and secretions was increased, the NP ordered Duoneb and CXR. On 1/2/24, Resident #6 complaint of sore throat and shortness of breath, at 7:04 p.m., the facility received an order for Levaquin for infiltrate for 7 days. On 1/3/24 at 12:49 p.m., documented by the NP to start intravenous (IV) fluids. At 3:26 p.m., documented by LPN #2 that Resident #6 was on Levaquin for Upper Respiratory Infection (URI), continued coughing and family visited. At 4:07 p.m., documented by LPN #2 Status poor. Increase congestion. Neb [nebulizer] TX [treatment] on going. On LEVAQUIN .VS stable . On 1/5/24 at 4:40 p.m., the resident was tested negative for COVID-19, at 11:15 p.m., Resident #6 was sent to emergency room for having low sodium and chest congestions. Resident #6 was admitted with diagnosis of Respiratory Syncytial Virus. The facility failed to perform CT on the staff who provided care from 10/13/23 and continued to provide care to other residents. In addition, there was no documentation that 3 series of viral test was done from 12/12/23 when the facility performed BBAT to all staff and residents. Furthermore, the facility failed to test the resident for COVID-19 when symptoms manifested from 12/27/23 until 1/5/24. Resident #7, who resided on the second floor tested positive for COVID-19 on 12/16/23. Resident #8, who resided on the second floor tested positive for COVID-19 on 12/16/23. Resident #9, who resided on the second floor tested positive for COVID-19 on 12/14/23. Resident # 11, who resided on the second floor tested positive for COVID-19 on 12/14/23. Resident #12, who resided on the second floor tested positive for COVID-19 on 12/21/23 when she/he manifested nasal congestion and noted with occasional cough. Resident #14, who resided on the second floor was tested positive for COVID-19 on 12/16/23 after she developed a cough. Residents #7, #8, #9, #11, #12, and #14 had no documentation in the MR to indicate that the residents completed the 3 series of viral test from 12/12/23 when the facility performed BBAT for all staff and residents. During an interview with the surveyor on 1/3/24 at 10:24 a.m., the Respiratory Therapist (RT) revealed that he had been working in the facility and had not been tested for COVID-19 since the beginning of the outbreak on 10/2/23. A follow up interview with the RT at 11:28 a.m., the RT revealed that he was just tested today for COVID-19 and tested negative. He also stated that this was the first time the facility tested him for COVID-19 virus. On 1/3/23 at 2:53 p.m., ICP #2 verified that the RT worked on the following days 12/13/23, 12/18/23, 12/20/23, 12/26/23, and 12/27/23. The ICP confirmed that the RT was not tested on the aforementioned dates and was only tested today, 1/3/24. Review of the form Covid BinaxNow Test Results (CBTR) provided by the facility during the survey on 1/8/24, indicated a list of employees who tested for COVID-19. The form revealed that on 12/13/23, 12/18/23, 12/20/23, 12/26/23, and 12/27/23 the RT was not tested for COVID-19 and provided care on the Ventilator Unit. The facility policy titled Policy for Emergent Infectious Diseases (COVID-19) (Outbreak Plan V11), dated 05/22/23, under ASSUMPTIONS .Every disease is different. The local, state, and federal health authorities will be the source of the latest information and most up to date guidance on prevention, case definition, surveillance, treatment, and skilled nursing center response related to a specific disease threat .GOAL to protect our residents, families, and staff from harming resulting from exposure to an emergent infectious disease while they are in our care center. 2. Local Threat: a. Once notified by the public health authorities at either the federal, state and/or local level that the Emergent Infectious Disease (EID) is likely to or already has spread to the care center's community, the care center will b. activate specific surveillance and screening as instructed by Centers for Disease Control and Prevention (CDC), state agency and/ or the local public health authorities .6: Test Based Prevention Strategy .Testing of nursing home HCP .3 .CMS still expects facilities to conduct SARS-CoV-2 testing in accordance with accepted national standards, such as the CDC recommendations .5. Retesting of HCP will be completed in accordance with the CDC guidance, amended and supplemented .Testing related to (+) COVID-19 exposure and/or symptoms associated with SARS-CoV-2 (Outbreak Testing) 1. An outbreak investigation is initiated when a single new case of Covid-19 occurs among the residents or staff to determine if others have been exposed. Testing during an outbreak would be determined in accordance with CDC guidance .3. Upon the identification of a single new case of Covid-19 infection in any staff or residents, testing should begin immediately (but not earlier than 24 hours after the exposure, if known). The facility has the option to perform outbreak testing through two approaches: contact tracing, or broad-based; 1. Contact tracing approach. Identifies all patients/residents close contacts and staff high-risk exposures. All individuals with close contact and/or high-risk exposure should be tested as described below .testing reveals additional cases, contact tracing will be continued to be performed. 2. Broad-based approach. Testing is performed for all patients/residents and staff on the affected unit(s), regardless of vaccination status, who have not been previously positive within the past 30 days .Testing of Residents and Staff as follows .2. If there is a newly identified COVID-19 positive staff of resident in a facility that can identify close contacts, then: Residents: regardless of vaccination status, who had close contact with the COVID-19 positive individual must be tested . Staff: regardless of vaccination status, that had higher risk exposure with a COVID-19 positive individual must be tested . Testing is completed on Day 1 - Day 3 - Day 5 or in accordance with the recommendations by local health department (LHD). 3. If a newly identified COVID-19 positive staff or residents in a facility that is unable to identify close contacts, then: Residents: regardless of vaccination status, facility wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility) must be tested . Staff: regardless of vaccination status, facility-wide or at a group level if staff are assigned to specific location where the new cases occurred (e.g., unit, floor, or other specific area(s) of the facility) must be tested . Testing is completed on Day 1 - Day 3 - Day 5 or in accordance with the recommendations by local health department (LHD) . N.J.A.C. 8:39-19.4 (a)(e) 48617