Every finding on record at Complete Care at Monmouth, LLC

Based on observation, interviews, record review, and review of facility provided documents, it was determined that the facility failed to obtain and update physician's orders for dialysis services, care of a dialysis access site, and document care related to dialysis services, for one of one resident (Resident #2) reviewed for dialysis. This deficient practice was evidenced by the following: On 5/1/26 at 9:21 AM, during an initial tour, Resident #2 was not in their room. A housekeeper nearby stated Resident #2 was out at dialysis. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #2. A review of the Physician's Orders (PO's) had not reflected an order for the resident to receive dialysis treatments. A PO dated 3/6/26 reflected to remove dressing from right arm AV (arterio-venous) fistula (a surgically created connection between an artery and vein to allow access to the bloodstream for a person to receive hemodialysis treatment) site upon returning from dialysis every day shift every Monday, Wednesday, Friday for dialysis. On 5/5/26 at 9:08 AM, the surveyor interviewed Resident #2 in their room. The resident stated they received dialysis treatments for the past three years. They stated they have a left chest portacath (a venous catheter surgically inserted into a large vein in the neck or groin then tunneled under the skin, exiting in the chest to be used as access for hemodialysis treatment). Resident #2 stated they had a fistula in their right arm but it clotted (a blood clot forms in the fistula, blocking the blood flow and preventing its use for dialysis). The resident stated they were scheduled for a procedure to address the clotted fistula later in the month of May. At 12:06 PM, the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON acknowledged there should be a PO for dialysis services but was unable to locate a dialysis PO in Resident #2's EMR. The ADON confirmed there was a PO to change the dressing (bandage) for any bleeding at the fistula site when the resident returned from dialysis but acknowledged if the fistula was clotted, it was not being used so there would not be a dressing on it. The ADON acknowledged the resident was scheduled for a procedure to address the fistula that was clotted, and that the resident had a portacath that was being used for dialysis access. The ADON acknowledged there should be a PO for the portacath to document monitoring for signs and symptoms of infection and to make sure the dressing and surrounding skin was intact. The ADON, in the presence of the surveyor, reviewed the progress notes in the EMR for Resident #2. She acknowledged there was one progress note (4/1/26) documented in the EMR for the month of April, that pertained to the resident receiving dialysis treatments. The ADON acknowledged the nurses should document a progress note each time the resident goes to, and returns from, dialysis treatments. The ADON stated the documentation regarding nursing assessments should also be in the dialysis communication book. At 1:00 PM, the surveyor interviewed the Director of Nursing (DON) who acknowledged the resident's dialysis access site should be assessed upon their return from dialysis. He acknowledged there was not a physician's order that referenced the portacath, and he could not recall when the portacath had been inserted. At that time the surveyor requested from the DON any information from Resident #2's medical record pertaining to the date the fistula clotted, the date their portacath was inserted or any additional information regarding orders or notes about the portacath. The surveyor further reviewed the EMR for Resident #2 which reflected the following:The admission Record (admission summary) reflected the resident was admitted with diagnoses which included but were not limited to; End stage renal (kidney) disease, and dependence on renal dialysis. A review of the most recent quarterly Minimum Data Set (MDS, an assessment tool) dated 3/21/26 reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated they were cognitively intact. The MDS further reflected the resident received dialysis. A review of the Order Summary Report, a summary of all active orders as of 5/5/26, had not reflected an order for dialysis services, and had not reflected an order for assessment or care of a portacath. The summary reflected the prior reviewed order to remove dressing from right arm AV fistula site upon returning from dialysis. A review of the Treatment Administration Record (TAR) reflected nurses' initials, indicating the treatment had been administered, for removal of the dressing from right arm AV fistula site, for each Monday, Wednesday, and Friday in the month of April to current May 4th except Friday 4/17 which was blank.A review of the Individualized Comprehensive Care Plan (ICCP) with a revision date 3/11/26, reflected a focus area the resident needed dialysis, hemo (medical treatment that filters waste and excess fluids from the blood when kidneys do not function) r/t (related to) renal failure, right arm fistula. The interventions included but were not limited to check and change dressing daily at access site. Document; Dialysis M, W, F, (Monday, Wednesday, Friday.); Monitor/document/report PRN (as needed) any s/s (signs / symptoms) of infection to access site; Redness, swelling, warmth, or drainage. The surveyor reviewed the dialysis communication book (a binder containing forms filled out by dialysis center and facility staff before, during, and after each dialysis treatment to reflect resident status and care provided). The form dated 5/1/26 reflected information from the sending facility with access site status: 0 (a zero) written on the form. A review of prior forms for the month of April reflected responses to access site status as follows:4/29/26: shunt.(illegible)4/27/26: 0 (zero)4/24/26: (a checkmark)4/22/26: 0 (zero)4/20/26: section for information from sending facility was blank4/17/26: permacath (portacath) 4/15/26: permacath 0 (zero) s/s (signs / symptoms) of infection. 4/13/26: permacath 0 (zero) s/s (signs / symptoms) of infection. 4/10/26: intact; bruit & thrill + (indicators of fistula function; bruit is a swishing sound heard with a stethoscope over an artery indicating turbulent blood flow; a normal sound heard over a fistula; thrill is a vibration felt on the skin over an artery or fistula, resulting from the same turbulent blood flow heard in a bruit).4/8/26: blank4/6/26: bruit + thrill +4/3/26: bruit / thrill +4/1/26: bruit / thrill + On 5/6/26 at 11:33 AM, the surveyor made a second request, to the ADON, for information pertaining to the date Resident #2's fistula clotted, the insertion date of the resident's portacath, or any further information regarding orders or documentation regarding assessment and care of the portacath. The surveyor made the ADON aware of the above findings.On 5/6/26 at 2:30 PM, the survey team met with the Regional Director of Operations (RDO), Licensed Nursing Home Administrator (LNHA), Regional Clinical Director (RCD) and DON and presented the above concerns and requests. On 5/7/26 at 10:05 AM, the survey team met with the RDO, LNHA, RCD and DON to discuss the above concerns. The RCD stated Resident #2 had their tunneled portacath inserted on 1/21/26 during a hospitalization. She stated the portacath had been used for dialysis access since 1/23/26. The RCD stated the resident had another hospitalization and returned to the facility in March 2026. The RCD acknowledged upon the resident's return to the facility in March, the PO for the portacath was not entered into the EMR and there was no order for assessment or care of the portacath for the past two months. The surveyor reviewed the facility policy Documentation in Medical Record with reviewed/revised date 1/26/26 provided by the RCD, which reflected each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The policy Explanation and Compliance guidelines included but were not limited to 1). Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record.The surveyor reviewed the facility policy Hemodialysis with reviewed/revised date 1/26/26 provided by the RCD, which reflected the facility would provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The purpose of the policy was to assure that each resident receives care and services for the provision of hemodialysis. Including:The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received.Ongoing assessment and oversight of the resident before, during and after dialysis treatments.Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Compliance guidelines included but were not limited to.3. The facility will coordinate and collaborate with the dialysis facility to assure that: a). The resident's needs related to dialysis treatments are met.c). Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team.8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. 13. The facility will ensure that the physician's orders for dialysis include: a). The type of access for dialysis.and location; b). The dialysis schedule; c). The nephrologist name and phone number; d). The dialysis facility name and phone number; e). Transportation arrangements to and from the dialysis facility. 16. Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled. NJAC 8:39-2.9

Based on observation, interview, record review and review of facility documents it was determined that the facility failed to a.) ensure there was appropriate Transmission Based Precaution (TBP; are designed to reduce the risk of airborne, droplet and contact transmission; used to help stop the spread of germs from one person to another) sign to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 2 residents (Resident #10 and #97) reviewed for Infection Control on 1 of 2 units and b.) appropriately disinfect multiuse medical equipment for one (1) of two (2) nurses during the medication administration observation.These deficient practices were evidenced by the following: Reference: CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 Update: June 2024 REFER to F550 1.On 4/30/26 at 10:33 AM, during an initial tour, the surveyor observed Resident #97's door closed. There were Personal Protective Equipment (PPE; specialized garments or gear [protective clothing, gloves, face shields, masks etc.] worn by healthcare personnel to create a barrier between them and infectious materials) supplies were hanging in a plastic storage organizer on the door. The surveyor observed a clear visible sign in the top middle sleeve which indicated Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. The surveyor did not observe Contact and Droplet precaution sign at Resident #97's door. On 5/1/26 at 10:34 AM, the surveyor observed Resident #97's door closed. The surveyor observed PPE supplies in a plastic storage organizer hanging over the door. The surveyor observed a clear visible signage in the top middle sleeve indicating Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. The surveyor did not observe Contact and Droplet precaution sign at Resident #97's door. On 5/1/26 at 11:23 AM, the surveyor observed the green colored STOP Droplet Precautions sign indicated Everyone must: Make sure their eyes, nose, and mouth are fully covered before entering room placed in the top middle sleeve at Resident #97's door. The surveyor reviewed the Electronic Medical Record (EMR) for Resident #97. A review of the admission Record (AR; an admission summary) revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and generalized anxiety disorder (ongoing anxiety and worry that are difficult to control). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/4/26 reflected that Resident #97 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident had moderate cognitive impairment. A review of the individual comprehensive care plan (ICCP) had a focus initiated on 4/28/26 that indicated that [Name Redacted] contact/droplet precautions related to (r/t) COVID +. The ICCP interventions included: Clear signage must be posted on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves) . In addition to EBP, Implement Transmission-based precautions as necessary during an outbreak or for specific indications. For example, Droplet precautions are indicated for residents with suspected or confirmed influenza infection, and or COVID. A review of the Order Summary Report (OSR) included the following physician orders (POs): A PO dated 4/28/6 for transmission-based precautions every shift. A PO dated 4/28/26 for maintain (contact/ droplet) isolation precautions r/t COVID . Stop sign on door.Every shift. A PO dated 4/28/26 for maintain contact/droplet isolation precautions with additional CDC recommended PPE r/t COVID + (Nurse to ensure proper isolation equipment is present, sign on door. Every shift. The above PO was transcribed to the April 2026 electronic Medication Administration Record (eMAR) and signed by nurses as completed with a checkmark next to their initials. On 5/1/26 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated when the residents were on isolation (transmission-based precautions), she would make sure all PPE supplies, bleach wipes and the proper signage were at the resident's door. The LPN stated it was important so that whatever infection the resident had did not spread to others. The LPN stated signage at the door could be placed by the Unit Manager (UM) and/or by the nurses. The LPN further stated if she did not know what kind of signage was required then she would check with her UM. On 5/1/26 at 12:47 PM, the surveyor interviewed the Infection Preventionist (IP) nurse, who stated if the resident was COVID +, they required droplet precaution signage at the door. The IP stated the staff had the signs available at the nurses' station, but she was responsible for posting and ensuring that the appropriate signage was posted outside the resident's room. The surveyor informed the IP the above-mentioned concerns for Resident #97 and then she stated, I know. The IP stated the signage that Resident #97 had should not have been there, but they could be placed behind the other signage for reference. In the presence of the surveyor, the IP reviewed POs for Resident #97 and stated there should have been Droplet/contact Precaution signage at the resident's door. The IP further stated it was important to have proper TBP signage at the resident's door to stop the spread of the infection. On 5/6/26 at 12:14 PM, the surveyor made the LPN/UM aware of the above-mentioned concerns for Resident #97. The LPN/UM stated the resident should have had contact/droplet precautions sign at their door so that all the staff understood what PPE was needed before entering the room for their safety. On 5/6/26 at 12:42 PM, the surveyor made the Director of Nursing (DON) aware of the above-mentioned concerns for Resident #97. The DON stated the expectation was to have the appropriate sign indicating the correct precautions that the resident was on. In the presence of the surveyor, the DON reviewed Resident #97's POs and stated the resident should have had signs for both droplet and contact precaution on their door as that's what the orders says. 2. On 4/30/26 at 10:50 AM, the surveyor observed Resident #10 resting in their bed. The surveyor observed PPE supplies hanging in a plastic storage organizer on the door. The surveyor observed an Enhanced Barrier Precautions (EBP; designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) sign in the top middle sleeve of an organizer which was hanging outside of Resident #10's door. On 5/1/26 at 10:37 AM, the surveyor observed Resident #10 with their eyes closed, resting in bed. The surveyor observed an EBP sign placed in the top middle sleeve in the PPE hanger, which was hanging outside of Resident #10's door. The surveyor reviewed the EMR for Resident #10. A review of the AR revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; Urinary Tract Infection (UTI; an infection caused by bacteria (germs) that enter the urinary system and grow in the bladder) and Extended Spectrum Beta Lactamase (ESBL; superbug / antibiotic resistant bacteria) Resistance (fighting against). A review of the most recent comprehensive MDS, an assessment tool dated 3/28/26 reflected that Resident #10 had a BIMS score of 15 out of 15, which indicated the resident had intact cognition. A review of the ICCP had a focus initiated on 3/23/26 that indicated that [Name Redacted] has a Urinary tract Infection r/t ESBL. Interventions included: Contact isolation. A review of the Urine Culture results dated 3/19/26 revealed Escherichia coli (a type of bacteria that can cause infections in your gut, UTI) >100,000 cfu/ml (colony forming units per milliliter; measurement used to estimate the number of live, reproducing bacteria present in a liquid sample); Susceptibility (is easily affected by a disease) to follow. Presumed ESBL. This organism is considered a MDRO (multi-drug-resistant organism) . A review of the OSR included the following POs: A PO dated 3/25/26 for Resident requires Contact isolation for ESBL in urine every shift. The above PO was transcribed to the April 2026 electronic Medication Administration Record (eMAR) and signed by nurses as completed with a checkmark next to their initials. On 5/1/26 at 12:50 PM, during an interview with the surveyor, the IP stated there were no other residents on TBP other than Resident #97. In the presence of the surveyor, the IP reviewed the list of residents who were on TBP (EBP, contact/droplet) and then stated Resident #10 was on Contact precautions for active ESBL. In the presence of the surveyor, the IP reviewed the POs in EMR for Resident #10 and stated the resident was on Contact precautions due to active infection in their urine. The surveyor accompanied the IP to 1st floor to the resident's door and observed EBP sign. The IP acknowledged the signage on Resident #10's door was not correct and stated the resident should have contact isolation precaution sign as per POs and placed the correct sign on the door. The IP stated the correct sign was important to stop the spread of the infection. On 5/6/26 at 12:14 PM, the surveyor interviewed the LPN/UM who stated the resident with positive ESBL, should be on contact precautions as per PO. The LPN/UM stated it was important to have the correct sign so that the staff was aware and to protect the residents and themselves from the active infection. On 5/6/26 at 12:42 PM, the surveyor made the DON aware of the above-mentioned concerns for Resident #10. The DON stated based on the POs, the signage should have matched. The DON stated it was important to have the proper sign for safety, infection control that you are not spreading it and to break the chain of infection. On 5/6/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, the Regional Clinical Director (RCD) and the Regional Director of Operations (RDO) and made them aware of the above-mentioned findings for Resident #10 and #97. A review of the facility's policy, Transmission-Based (Isolation) Precautions date reviewed/revised 10/14/25 revealed Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission.Policy Explanation and compliance Guidelines: 9.e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room.Additionally, either the CDC category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. A review of the facility's policy, Infection Prevention and Control Program date reviewed/revised 10/14/25 revealed under Policy Explanation and Compliance Guidelines: 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.13.c. Isolation signs are used to alert staff, family members, and visitors of transmission-based precautions. 3. On 5/5/26 at 9:03 AM, during the medication administration observation, the Registered Nurse (RN #1) stated he had to take a blood Pressure (BP) prior to administering Resident #1's Metoprolol (a medication used to treat hypertension (HTN) - high blood pressure). The surveyor observed RN #1 obtain a BP using an electronic multi-use BP machine. The surveyor had not observed the RN #1 disinfect the BP cuff prior to or after obtaining the BP for Resident #1. On 5/5/26 at 9:22 AM, during the medication administration observation, RN #1 stated he had to take a BP prior to administering Coreg (a medication used to treat HTN) to unsampled resident #1. The surveyor observed RN #1 obtain a BP using the same electronic multi-use BP machine and cuff as Resident #1. The surveyor had not observed RN #1 disinfect the BP cuff prior to or after obtaining the BP for unsampled resident #1. On 5/5/26 at 10:08 AM, during the medication administration observation, RN #1 stated he had to take a BP prior to administering Midodrine (a medication used to treat hypotension) (low BP) to unsampled resident #2. The surveyor observed RN #1 obtain a BP using the same electronic multi-use BP machine and cuff as Resident #1 and unsampled resident #1. The surveyor had not observed RN #1 disinfect the BP cuff prior to or after obtaining the BP for unsampled resident #2. On 5/5/26 at 10:29 AM, during the medication administration observation, RN #1 stated he had to take a BP prior to administering Norvasc (a medication used to treat HTN) to unsampled resident #3. The surveyor observed RN #1 obtain a BP using the same electronic multi use BP machine and cuff as Resident #1, unsampled resident #1 and unsampled resident #2. The surveyor had not observed RN #1 disinfect the BP cuff or machine prior to or after obtaining the BP for unsampled resident #3. On 5/5/26 at 10:41 AM, the surveyor interviewed the RN #1 at the medication cart. RN #1 stated that the electronic BP machine was a facility BP machine used to take vital signs on all residents. RN #1 explained that the machine and BP cuff were disinfected by using the antibacterial wipes being kept in a basket attached to the BP machine. RN #1 further explained that he also had bleach wipes he could use that were kept on the medication cart to disinfect the BP machine and cuff. RN #1 stated the BP machine was to be disinfected after use on each resident. RN #1 acknowledged he had not used the wipes to disinfect the BP cuff in between the four (4) residents observed by the surveyor during medication administration. RN #1 then stated he was going to clean the BP machine and cuff prior to the next resident. RN #1 added Those residents had no infections going on referring to the four residents observed during the medication administration observation. On 5/5/26 at 2:04 PM, the surveyor interviewed the DON who stated he would expect the nurses to clean a multi-use BP machine and cuff prior to each use. On 5/7/2026 at 10:04 AM, the survey team met with the facility administrative team. The DON stated RN #1 was inserviced on cleaning multi-use equipment after use on each resident after surveyor inquiry. The DON added RN #1 was a per diem employee and had been inserviced on the proper procedures for infection control during the medication administration when he was oriented on 1/28/26. The facility policy Cleaning and Disinfection of Resident-Care Equipment, dated as reviewed/revised 10/14/25, provided by the DON, reflected Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. In addition, Reusable multiple-resident items are items that may be used multiple times for multiple residents. Examples include stethoscopes, blood pressure cuffs, feeding tube pumps and oxygen concentrators. The policy also included Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include:.Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.Multiple-resident use equipment shall be cleaned and disinfected after each use. NJAC 8:39-19.4(a)(2)

Based on observation, interview, record review and review of facility documents it was determined that the facility failed to maintain the dignity of a resident who required contact/droplet isolation precautions signage related to COVID + (positive) status. This deficient practice was identified for 1 of 2 residents (Resident #97) reviewed for infection control. This deficient practice was evidenced by the following:Refer to F880On 4/30/26 at 10:33 AM, during an initial tour, the surveyor observed Resident #97's door closed. There were Personal Protective Equipment (PPE; specialized garments or gear [protective clothing, gloves, face shields, masks etc.] worn by healthcare personnel to create a barrier between them and infectious materials) supplies hanging in a plastic storage organizer on the door. The surveyor observed visible signage in the top middle sleeve of the organizer that stated: Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. On 5/1/26 at 10:34 AM, the surveyor observed Resident #97's door closed. The surveyor observed PPE supplies in a plastic storage organizer hanging over the door. The surveyor observed visible signage in the top middle sleeve indicating: Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19. On 5/1/26 at 11:23 AM, the surveyor observed Resident #97's door signage was replaced with a green colored Droplet Precautions Signage.The surveyor reviewed the Electronic Medical Record for Resident #97.A review of the admission Record (an admission summary), revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and generalized anxiety disorder (ongoing anxiety and worry that are difficult to control). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 4/4/26, reflected that Resident #97 had a Brief Interview for Mental Status score of 11 out of 15, which indicated the resident had moderate cognitive impairment. A review of the individual comprehensive care plan (ICCP) had a focus initiated on 4/28/26 that indicated that [name redacted] contact/droplet precautions related to (r/t) COVID +. A review of the Order Summary Report included the following physician orders (POs):A PO dated 4/28/26 to maintain (contact/ droplet) isolation precautions r/t COVID . Every shift. A PO dated 4/28/26 for transmission-based precautions every shift. On 5/1/26 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated when the residents were on isolation (transmission-based precautions), she would make sure all PPE supplies, bleach wipes and the proper signage were at the resident's door. The LPN stated it was important so that whatever infection the resident had did not spread to others. The LPN then stated that the signage at the door could be placed by the Unit Manager (UM) or the nurses. The LPN further stated that if she did not know what kind of signage was needed, she would check with her Unit Manager (UM). On 5/1/26 at 12:47 PM, the surveyor interviewed the Infection Preventionist (IP) nurse, who stated if a resident was COVID +, they required droplet precaution signage at the door. The IP stated the staff had the signs available at the nurses' station, but she was responsible for placing and ensuring the appropriate signage was posted outside of a resident's room. The IP stated the identifying signage that Resident #97 had during the surveyor's initial tour should not have been there but could be placed behind the droplet signage for reference. The IP stated you have to give privacy and maintain the resident's dignity. The IP further stated that for COVID + resident, you need to have proper Droplet/Contact Precaution signage at the doorway.On 5/6/26 at 12:14 PM, the surveyor made the Licensed Practical Nurse/Unit Manager (LPN/UM) aware of the above concerns for Resident #97. The LPN/UM stated it was not acceptable to have that signage at the resident's door due to dignity, resident rights, and privacy. On 5/6/26 at 12:42 PM, the surveyor made the Director of Nursing (DON) aware of the above concerns for Resident #97. The surveyor showed the DON the copy of the signage and he acknowledged that the identifying signage should have not been there (at Resident #97's door). The DON further stated the signage had the diagnosis (COVID+) on there and they should provide the resident with privacy and dignity. On 5/6/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, the Regional Clinical Director (RCD) and the Regional Director of Operations (RDO) and made them aware of the above-mentioned findings for Resident #97. A review of the facility's policy, Promoting/Maintaining Resident Dignity date reviewed and revised 2/10/26 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for reach resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity . 12. Maintain resident privacy.A review of the facility's policy, Confidentiality of Personal and Medical Records date implemented 9/1/24 revealed Policy: This facility honors the resident's right to secure and confidential personal and medical records. This includes the rights to confidentiality of all information contained in a resident's records. Policy Explanation and Compliance Guidelines: 5. Information regarding one resident should not be shared with other residents or visitors. 6. Facility staff should exercise caution during . in the use of signs or care reminder information that may be posted in a resident's room. NJAC 8:39-4.1(a) 12

Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop an Individualized Comprehensive Care Plan (ICCP) to address the needs of a resident who received antibiotic therapy (medicines that fight bacterial infections) for cellulitis (a serious bacterial infection of deeper layers of the skin). This deficient practice was observed for one 1 of 18 residents (Resident #9) reviewed for antibiotic therapy.This deficient practice was evidenced by the following:On 4/30/26 at 10:49 AM, the surveyor observed Resident #9 sitting in their wheelchair. The resident was cooperative and did not present any care concerns. The surveyor reviewed the electronic medical records (EMR) for Resident #9. A review of the admission Record face sheet (an admission summary) reflected that Resident #9 was admitted to the facility with diagnoses which included but were not limited to; essential (primary) hypertension (HTN; high blood pressure that develops over time without a direct, identifiable medical cause), cellulitis (bacterial skin infection) of right lower limb (leg) and cellulitis of left lower limb.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 2/17/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating that the resident's cognition was severely impaired. Further review of the MDS indicated that Resident #9 received antibiotics at the facility.A review of the Order Summary Report (OSR) revealed a Physician Order (PO), dated 2/17/26, for doxycycline hyclate Oral Capsule 100 mg (milligram) give 100 mg by mouth two times a day for skin infection - cellulitis until 2/25/26 11:59 PM. A review of the February 2026 Medication Administration Record (MAR) revealed that Resident #9 received doxycycline 100 mg by mouth two times a day from 2/17/26 through 2/25/26.A review of the ICCP revealed a Focus which indicated that the resident had a diagnosis of Onychomycosis (fungal infection of the toe nails/fingernails) date initiated 2/17/26, [Name Redacted] uses antidepressant medication related to (r/t) depression date initiated 2/25/26, the resident has depression r/t dementia, date initiated 2/16/26, [Name Redacted] has potential/actual impairment to skin integrity to the BLE (Bilateral lower extremities) bruises and BLE dry skin r/t fragile skin, date initiated 2/13/26. Further review of the ICCP did not reveal a focus or any interventions listed for antibiotics and/or for BLE cellulitis.On 5/6/26 at 10:58 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated the purpose of the ICCP was to track the resident's progress. The LPN further stated for the residents at Long Term Care, staff want to know the resident's baseline and need to have a goal for the residents to return to their normal activities of daily living (ADL). The LPN stated that ICCPs could be updated daily as the residents were making progress. The LPN stated the ICCP would include falls, functional status with ADLs, skin integrity, pain, bizarre/refusal behaviors, medications, and if the resident had a catheter, etc. The LPN stated the Unit Manager (UM) was responsible for updating the ICCPs but if something had happened during their shift, the nurse would initiate and update the ICCP and write an interdisciplinary note. On 5/6/26 at 11:51 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated the basic ICCPs for falls, pain, skin, ADLs were initiated on admission and the next day during the morning meeting, as a group, staff would look into the charts and make a ICCP according to resident's needs. The LPN/UM stated they would review and Care Plan the resident's medications, like anticoagulants (blood thinners), hypertension (high blood pressure) medications, antipsychotics (type of psychiatric medications) and antibiotics. The LPN/UM stated if the resident had an ongoing infection, the ICCP would include EBP (Enhanced Barrier Precautions- designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) and if the resident was on oral or intravenous (IV) antibiotics. The surveyor made the LPN/UM aware of the above-mentioned concerns for Resident #9. The LPN/UM stated there should have been a ICCP for the resident if they were on PO (by mouth) abt (antibiotics). On 5/6/26 at 12:42 AM, the surveyor made the Director of Nursing (DON) aware of the above-mentioned concerns for Resident #9. The DON stated the ICCP was a way to communicate between all staff in different departments. The DON stated the importance of the ICCP was to provide staff information regarding the resident's care.On 5/6/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, the Regional Clinical Director (RCD) and the Regional Director of Operations (RDO) and made them aware of the above-mentioned findings for Resident #9.A review of the facility's policy, Comprehensive Care Plans date revised 3/1/25, revealed Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs and preferences .6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. N.J.A.C. 8:39-11.2 (d)(e)(1)(2)

Based on observation, interview, medical record review, and review of pertinent facility documents, it was determined that the facility failed to revise a comprehensive care plan with interventions for a resident who alters the settings on an oxygen concentrator (device that delivers oxygen). This deficient practice was identified for 1 of 38 residents (Resident #74) reviewed for care plans.This deficient practice was evidenced by the following:On 4/30/26 at 10:13 AM, the surveyor observed Resident #74 lying in bed receiving oxygen (O2) via nasal cannula tubing (n/c - device that delivers additional oxygen through the nose) connected to an O2 concentrator administering 8 liters per minutes (lpm). On 5/1/26 at 9:11 AM, the surveyor observed the O2 concentrator administering 8 lpm of oxygen to the resident. The resident stated I don't touch it, the nurses touch it. I feel better when I wear it (O2), but it dries me out. On 5/1/26 at 10:16 AM, the surveyor brought the O2 concentrator setting to the attention of the Assistant Director of Nursing (ADON). The ADON verified that the O2 concentrator was set at 8 lpm and turned the setting down to 2 lpm. At this time the ADON educated the resident to use the call bell for assistance. The ADON then stated to the surveyor that the nurses should check the setting on the O2 concentrator when they check the resident's vital signs each shift and periodically. The surveyor reviewed the electronic medical record (EMR) for Resident #74. A review of the admission Record (an admission summary) reflected diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD - lung disease that makes breathing difficult), chronic respiratory failure (lungs cannot get enough oxygen into the blood), and anxiety (feeling of tension and worried thoughts).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/29/26, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. A further review of the MDS revealed that the resident needed oxygen therapy and was independent or needs supervision with self-care and mobility.A review of the individualized comprehensive care plan (ICCP) included a focus area dated 12/4/23, the resident had COPD with an intervention for O2 via nasal cannula 2L/min continuous. Further review of the ICCP revealed a focus area dated 12/12/23 and revised 12/4/24, with a target date 3/25/26, the resident received oxygen therapy related to COPD. The resident was noncompliant with the prescribed order and at times is seen increasing the O2 rate on the concentrator. The ICCP interventions included; Educate the importance of being compliant with the prescribed O2 order; Encourage or assist with ambulation as indicated; For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus; Give medications as ordered by physician and monitor/document side effects and effectiveness; Monitor for signs and symptoms of respiratory distress and report to MD as needed; OXYGEN SETTINGS: O2 via nasal cannula @ 2L continuous Revision on 01/28/2026; Provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress.A review of the Order Summary Report revealed physician's orders (PO) for: An order dated 4/28/26 Vital signs every shift.An order dated 4/28/26 Oxygen at 2L/min via nasal cannula continuously every shift.A review of the progress notes in the EMR revealed the following:A health status note dated 1/30/26 Resident noted to be confused and mildly disoriented towards end of shift .On-coming nurse states that whenever resident removes oxygen resident becomes confused. An encounter note dated 3/26/26 .-Monitor patient closely throughout shift for shortness of breath or increased wheezing - Continue oxygen at 2 L via nasal cannula; Chronic respiratory failure - Continue oxygen at 2 L, do not turn it up .On 5/1/26 at 11:04 AM, the surveyor interviewed the Director of Nursing (DON) who stated the resident is care planned for adjusting and raising the O2. The DON further stated, I don't know why the resident does that. On 5/5/26 at 12:48 PM, the surveyor interviewed the DON who stated there are concentrators in the building that max out at 5 lpm. The DON also stated the resident should be checked frequently to ensure the O2 concentrator is set to the ordered 2L/min. A review of the facility's provided Oxygen Administration policy, last revised 1/7/25 included Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: .4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: .c. Equipment setting for the prescribed flow rates .12. Staff shall notify the physician of any changes in the resident's condition, including .oxygen concentrations, or evidence of complications associated with the use of oxygen.A review of the facility's provided Comprehensive Care Plans policy, last revised 3/1/25 included Policy Explanation and Compliance Guidelines: .3 .f. Resident specific interventions that reflect the resident's needs and preferences .6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. N.J.A.C. 8:39-11.2(h)

Based on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to 1.) obtain physician orders to ensure that a resident received the appropriate care to maintain a centrally inserted intravenous catheter (CVC) (a long, flexible tube inserted into a large vein that goes near the heart for long-term intravenous (IV) antibiotics), 2.) develop and implement a comprehensive person-centered care plan (ICCP) for a resident with a CVC and 3.) discontinue a CVC after the completion of IV antibiotics consistent with professional standards of practice. This deficient practice was identified for 1 of 1 resident (Resident #5) reviewed for IV therapy. The deficient practice was evidenced by the following:On 5/6/26 at 9:41 AM, the surveyor observed Resident #5 resting in their bed. The surveyor observed a capped tip of thin tube coming out of the right side of their gown. The surveyor asked the resident what that was for. The resident showed the surveyor their right-side chest wall with an IV catheter that had a transparent dressing. The bottom part of the dressing was loose and curled up. The surveyor was unable to read the date. There were no medications or fluids infusing through the CVC line during this observation. The resident stated, I was receiving antibiotics through this and have not had any for weeks. The resident further stated I am not sure when they (the nurses) will take it out.The surveyor reviewed the Electronic Medical Record (EMR) for Resident #5.A review of the admission record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but not limited to; Benign prostatic hyperplasia (a benign (not cancer) condition in which the prostate gland is larger than normal) with lower Urinary tract symptoms (a group of bladder-related issues that make it difficult to store or release urine), polyneuropathy (damage to many nerves at the same time) and Extended Spectrum Beta Lactamase (ESBL; common antibiotic-resistant bacteria known as 'superbugs') resistance. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 4/1/26, revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, indicating that the resident had intact cognition. Further review of the MDS revealed the resident had IV Access and had received antibiotics during the last 7 days or since admission but it did not indicate what type of IV Access it was; (Peripheral (an IV inserted in a small vein), Midline (a vascular access device intended for placement into a peripheral vein in the upper arm], and/or a Central (IV inserted in a large vein in the chest through a vein in a patient's neck).A review of the ICCP revealed a focus area that the resident was on antibiotic therapy; Invanz related to [r/t] ESBL and ECOLI (a type of bacteria that normally lives in your intestines), initiated on 3/26/26. There was no ICCP developed and implemented for the CVC.A review of the order summary report (OSR) revealed the following physician's orders (POs):Ertapenem Sodium (Invanz) Solution Reconstituted 1 GM (gram)- use 1 gram intravenously in the morning for ESBL in urine for 1 day. Order dated 3/26/26 with End date 3/27/26; Ertapenem Sodium Solution Reconstituted 1 GM- use 1 gram intravenously in the morning for ESBL in urine for 1 day. Order dated 3/27/26 with End date 3/28/26; Ertapenem Sodium Solution Reconstituted 1 GM- use 1 gram intravenously in the morning for ESBL in urine for 2 days. Order dated 3/26/26 with End date 3/28/26. Further review of the OSR, did not reveal a PO to flush the CVC line, to monitor for signs and symptoms (S&S) of infection, to change the CVC line dressing, or to discontinue the CVC line after the completion of IV antibiotics.A review of the March 2026 electronic Medication Administration Record (eMAR) revealed that Resident #5 was given Ertapenem 1 gram IV once a day for one (1) day on 3/26/26 for ESBL in urine. Further review of the eMAR did not reveal documentation for IV/CVC line dressing changes or IV/CVC line flushes. A review of April 2026 eMAR did not reveal documentation for IV/CVC line dressing changes or IV/CVC line flushes. A review of the progress notes revealed a physician note dated 3/25/2026 at 11:05 pm, the patient is seen for admission visit.discharge planning was coordinated for transfer to a rehabilitation facility, with approval for subacute rehab placement and arrangements for tunneled catheter placement for ongoing IV antibiotics.On 5/6/26 at 10:58 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated if a resident was admitted with a central line, they would have a care plan (CP) for central line care. The surveyor inquired if Resident #5's had central line, and the LPN stated she was not told by the previous nurse if the resident had any type of IV access. In the presence of the surveyor, the LPN reviewed Resident #5's EMR and confirmed she did not see POs or progress notes for IV access. On 5/6/26 at 11:35 AM, the surveyor interviewed the LPN/Unit Manager (UM) who stated if a resident had a peripheral IV, PICC line or a midline, they would have POs to maintain patency, flushes, dressing change for the IV site. The LPN/UM stated, we have to change the IV site dressing within 24 hours of admission and then weekly as per policy. The LPN/UM stated they would get POs to discontinue the IV line once (after) the resident had completed their IV antibiotics; they would monitor the resident for 3 days after the completion for any S&S of infection before discontinuation of the IV line. In the presence of the surveyor, the LPN/UM reviewed Resident #5's EMR and confirmed there were no POs for IV/CVC line care and further stated I would know if [name redacted] had an IV line on admission because I do skin assessments on the second day on all new admissions. In the presence of the LPN/UM, the surveyor reviewed the paper copy of the New Jersey Universal Transfer Form (a form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs) dated 3/25/26 which revealed the resident had a PICC (peripherally inserted central catheter-usually insert in the upper arm) checked off as IV access upon discharge from the hospital. The surveyor accompanied the LPN/UM to Resident #5's room. The LPN/UM confirmed the resident had a right chest central line and the dressing was folded and loose at the bottom. The LPN/UM stated it looked like the dressing had a date but was unable to read it. The LPN/UM confirmed there was no CP for IV-line maintenance. The LPN/UM stated there should have been POs for IV-line flushes and dressing changes. The LPN/UM further stated the IV line should have been included in the CP. The LPN/UM reviewed EMR and confirmed the resident had a dose of IV antibiotics on 3/26 and further stated the physician should have been made aware after the completion of IV abt. On 5/6/26 at 12:42 PM, the surveyor made the Director of Nursing (DON) aware of the above-mentioned concerns for Resident #5. The DON stated there should have been POs to maintain the central IV line, to know how often to flush it to keep the line patent, to monitor the site for signs and symptoms of infection, and for dressing change for infection prevention.On 5/6/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Clinical Director (RCD) and the Regional Director of Operations (RDO) and made them aware of the above-mentioned findings.A review of the facility's policy Care and Maintenance of Central Venous Catheter revised 1/15/2026, revealed Policy: The facility will adhere to accepted standards of practice regarding the are and maintenance of central venous catheters.2. Document the indication for use, insertion date, and type of catheter in resident's medical record. Obtain physician orders for specific care and maintenance instructions.5. Assess the central line daily: a. Assess the site for signs of infection.b. Ensure the dressing is clean, dry and intact. c. Verify that the line is functional (i.e. flushes). d. Verify the line is still needed.9. Document activities in nurses' notes and/or Medication Administration Record. A review of the facility's policy, Peripherally Inserted Central Catheter Flushing, Locking, Removal date implemented 2/10/26 revealed Policy: It is the policy of this facility to ensure that peripherally inserted central catheters (PICC) are flushed, locked and removed consistent with current standards of practice. Compliance Guidelines: 9. The frequency for flushing and locking . If no IV therapy is being infused, the facility may follow these guidelines or as per facility/pharmacy protocol: a. Nonvalved PICC- every 24 hours; b. Valved PICC- at least weekly. 11. Removal of a PICC will occur at the end of therapy.or when deemed no longer necessary. Obtain a physician's order for removal.A review of the facility's policy, Documentation in Medical Record date revised 1/26/26 revealed Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy explanation and compliance guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service.4. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. C. Documentation shall be timely. NJAC 8:39-25.2 (5)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice when administering oxygen therapy, incentive spirometry and maintaining oxygen tubing (replace current tubing with new tubing) per physician orders. This deficient practice was identified for 2 of 4 residents (Residents #33 and #74) reviewed for respiratory care.Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.The deficient practice was evidenced by the following: On 4/30/26 at 10:13 AM, the surveyor observed Resident #74 in bed with oxygen (O2) via nasal cannula tubing (NC - device that delivers additional oxygen through the nares), with tubing connected to an O2 concentrator (mechanical device that delivers oxygen at a regulated rate via inhalation through connected tubing). The surveyor observed an O2 concentrator tank on the back of the resident's wheelchair with the NC tubing attached, undated and hanging down the back of the wheelchair, touching the floor. The surveyor then witnessed a staff member bring an incentive spirometer (a handheld medical device that helps improve lung function) into the room and place it on the bedside table while the resident was in the bathroom. When the resident returned, the surveyor inquired about the incentive spirometer. The resident was not aware that it was on the bedside table and stated they did not know what it was or how to use it. On 5/1/26 at 9:11 AM, the surveyor observed Resident #74 sitting on the side of the bed with the incentive spirometer on the bed next to them. The resident stated, I just got my incentive spirometer yesterday. I use it, but I am not sure if it helps. On 5/1/26 at 10:37 AM, the surveyor observed the NC tubing connected to the residents O2 tank lying on the floor and undated. The surveyor reviewed the electronic medical record (EMR) for Resident #74. A review of the admission Record (admission summary) revealed diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD-a progressive lung disease that makes it difficult to breathe), chronic respiratory failure (a long-term condition where the lungs cannot maintain adequate oxygen levels), and anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/9/26, indicated the resident had a brief interview for mental status (BIMS) of 13 out of 15 indicating the resident's cognitive function was intact. A further review reflected shortness of breath with exertion, and oxygen therapy. A review of the resident's individual comprehensive care plan (ICCP) included focus areas dated 4/30/26, for oxygen therapy and nebulizer treatments (a medical device that converts liquid medication into a fine mist so it can be inhaled directly into the lungs through a mouthpiece or face mask) related to COPD, both with listed interventions for O2 via nasal cannula/nasal prongs at 2 Liters/minute continuously. Another focus area for respiratory therapy dated 5/1/26, included a goal for improvement in pulmonary function related to COPD. Interventions included: educate resident on the benefits of using an incentive spirometer; encourage resident to use spirometer to promote lung expansion and prevent atelectasis (the collapse of a lung or part of a lung); provide incentive spirometry as ordered; and reevaluate effectiveness of spirometry as needed and each quarter. A review of the Order Summary Report (OSR) included the following physician orders (PO): A PO, dated 4/28/26, for Incentive Spirometry: 1. Assist patient to place mouthpiece in mouth, and seal lips around it. 2. Instruct to breathe slowly and deeply. Raise piston towards top of column. 3. When patient cannot inhale any longer, remove mouthpiece from mouth and hold breath as long as possible before exhaling normally. **Cough between breath every shift to promote pulmonary function for 30 Days. A PO, dated 4/28/26, to apply oxygen per nasal cannula/mask at 2 liters/minute to keep oxygen sats > or equal to 90 % **Keep bagged when not in use** every shift. A PO, dated 4/29/26, for oxygen tubing change weekly. Label each component with date and initials every night shift every Wednesday. A review of the residents' April and May 2026 Medication Administration Record (MAR) revealed: An order dated 4/28/26 for Incentive Spirometry .every shift, was signed out and filled out by nurses on every shift 4/28/26, 4/29/26, and 4/30/26. On 5/1/26 the evening shift was not filled out; on 5/2/26 the day, evening, and night shifts were not filled out; on 5/3/26 the evening shift was not filled out, and the night shift was not signed out; on 5/4/26 the night shift was not filled out; and on 5/5/26 the evening shift was not filled out. On 5/1/26 at 10:16 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who was also the acting unit manager for the day. The ADON stated Resident #74 used to be on as needed O2 but was now on continuous oxygen via NC. The ADON also stated Resident #74 had an oxygen concentrator and an oxygen tank on their wheelchair for O2, with long tubing in the room and shorter tubing on the tank. When the resident transfers from the bed to the wheelchair and back, the resident does not change to the correct tubing. The ADON continued that Resident #74 had been educated several times to use the call bell for assistance. The ADON further stated that the tubing and O2 settings should be checked when the staff is obtaining Resident #74's vital signs and periodically. On 5/7/26 at 10:04 am, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Clinical Director (RCD), and the Regional Director of Operations (RDO), and the survey team, acknowledged that the resident's physician orders should have been followed as ordered. 2. On 4/30/26 at 11:00 AM, during the initial tour of the facility, the surveyor observed Resident #33 in the activity room with other residents and staff. Resident #33 was seated in a wheelchair with an oxygen canister (a portable pressurized container that provides supplemental oxygen at a regulated rate via inhalation through connected tubing) in a cloth holder on the back of their wheelchair. There was no oxygen tubing connected to the oxygen canister. The resident was not receiving oxygen at this time. On 4/30/26 at 11:26 AM, at the door to Resident #33's room, the surveyor heard the sound of an oxygen concentrator. Resident #33 was not in their room at that time. The surveyor observed an oxygen concentrator next to their bed, with nasal cannula tubing lying on top of the resident's bedspread and connected to the concentrator. The concentrator flow rate was set at 3.5 Liters per minute (LPM). On 4/30/26 at 11:33 AM, the surveyor observed Resident #33 in their wheelchair on the second-floor dining room with other (unsampled) residents and staff. The surveyor observed an oxygen canister on the back of Resident #33's wheelchair. There was no oxygen tubing connected to the canister. Oxygen tubing was not observed on the resident or their wheelchair. On 4/30/36 at 1:41 PM, the surveyor observed Resident #33 in their wheelchair propelling themselves in the hallway. The surveyor observed an oxygen canister on the back of their wheelchair. The flow rate was set at 0.5 LPM. The surveyor did not observe oxygen tubing on the resident or connected to the canister. On 5/1/26 at 9:24 AM, the surveyor observed Resident #33 in their bed with their breakfast tray in front of them. The resident stated they were finished, and breakfast was good. The resident did not have their nasal cannula on. The surveyor observed the oxygen concentrator against the wall next to their bed. The oxygen concentrator was off and the nasal cannula tubing was draped over the machine. The surveyor observed a piece of tape wrapped around the oxygen tubing with a handwritten date of 4/2/(writing illegible). The surveyor reviewed the Electronic Medical Record which reflected Physician's Orders dated 4/15/26 to Apply oxygen at 2 LPM via nasal cannula every shift and Oxygen tubing change weekly, Label each component with date and initials every night shift every Wednesday. On 5/1/26 at 10:08 AM, during an interview with the Regional Clinical Director (RCD), the RCD stated that all of Resident #33's PO's were renewed on 4/15/26 due to an issue with their insurance. The RCD stated that orders dated 4/15/26 were not new orders. The surveyor reviewed Resident #33's EMR a second time, which reflected the resident had both of the above referenced PO's (oxygen at 2 LPM and oxygen tubing change) since 2024. On 5/1/26 at 10:51 AM, the surveyor observed Resident #33 in the activity room with their nasal cannula on. Their oxygen canister was set at 2 LPM. The dated tape on the tubing was 4/2/(illegible). The surveyor interviewed LPN #1 who stated that it was her first day caring for Resident #33 on her assignment. LPN #1, with the surveyor, went to the activity room and observed the nasal cannula tubing on the back of Resident #33's wheelchair. LPN #1 stated she had not looked at the tubing that morning and did not put the resident into their wheelchair or into the activity room. On 5/1/26 at 11:05 AM, the ADON, with the surveyor, went to the activity room and observed the nasal cannula tubing on Resident #33. The ADON acknowledged the date written on the tubing was 4/2, and that date indicated the last time the nasal cannula tubing was changed. The ADON stated, As of tomorrow that would be a month ago. The ADON stated the oxygen tubing should have been changed weekly, on Wednesday nights, and that she would change it right away. On 5/5 26 at 9:22 AM, the surveyor observed Resident #33 in their bed. The surveyor did not observe nasal cannula tubing on the resident. On 5/5/26 at 9:46 AM, the surveyor interviewed LPN #2 who stated she gave Resident #33 their medications that morning, the resident ate their breakfast and would be getting out of bed soon, if they weren't already. LPN #2, with the surveyor, observed Resident #33 in their bed; an oxygen concentrator was against the wall next to the resident's bed, turned off, with the nasal cannula tubing coiled inside of a plastic bag on the concentrator. LPN #2 stated Resident #33 used oxygen prn (as needed) and at night. LPN #2 acknowledged the resident was not wearing the nasal cannula when she (LPN #2) saw the resident earlier that morning, and she did not put oxygen on the resident because she doesn't have it on when she eats. On 5/5/26 at 9:48 AM, LPN #2, in the presence of the surveyor, reviewed the EMR for Resident #33. LPN #2 acknowledged the orders for oxygen every shift, then added, but they take it off themselves and we have to direct them to put it back on. LPN #2 acknowledged that Resident #33 was physically unable to turn off the concentrator or coil the nasal cannula into a plastic bag and place it on the concentrator against the wall. LPN #2 acknowledged she should have placed the nasal cannula on Resident #33 earlier that morning. LPN #2, in the presence of the surveyor, returned to Resident #33's room and applied the oxygen at 2 LPM via nasal cannula. The surveyor reviewed the complete EMR for Resident #33. A review of the admission Record face sheet (admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD, an ongoing condition of damage to the lungs resulting in swelling and irritation of the airways), and peripheral vascular disease (PVD, a slow progressive disorder of the blood vessels that supply limbs and organs). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 2/11/26, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. A further review of section O Special treatments, procedures and programs reflected that Resident #33 received oxygen therapy while a resident. A review of the individualized comprehensive care plan (ICCP) report reflected a focus area with revision date 12/3/24, indicated the resident had oxygen therapy r/t (related to) ineffective gas exchange; COPD. The associated interventions included if the resident is allowed to eat, oxygen still must be given to the resident via nasal cannula, revision 9/17/24; Oxygen settings: O2 via nasal prongs at 2L continuously, revision 9/17/24. A review of the Order Summary Report, a summary of all active orders as of 5/1/26, reflected the prior reviewed Physician's Order (PO) to apply oxygen at 2LPM via nasal cannula every shift, and the prior reviewed PO for oxygen tubing change weekly label each component with date and initials every night shift every Wednesday. A review of the Treatment Administration Record (TAR) for the months of April and May reflected the following: The PO for oxygen at 2 LPM had nurse initials, indicating the treatment was administered, on every shift of every day for the month of April and May up to and including the morning of surveyor review on 5/7/26. The PO for oxygen tubing change had nurse initials on April 1, 8, 15, 22, 29, and May 6. On 5/6/26 at 3:13PM, the survey team met with the Regional Director of Operations (RDO), the Licensed Nursing Home Administrator (LNHA), the Regional Clinical Director (RCD) and the Director of Nursing (DON) to present the above findings. On 5/7/26 at 10:05 AM, the DON, in the presence of the RDO, LNHA, RCD and the survey team, acknowledged that the resident's physician order should have been followed as ordered. A review of the facility's Oxygen Administration policy reviewed and revised 1/7/25 reflected oxygen was administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The Policy Explanation and Compliance Guidelines: reflected the following: 1. Oxygen is administered under orders of a physician. 4. The resident's care plan shall identify the interventions for oxygen therapy, based on the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system b. When to administer, such as continuous or intermittent. c. Equipment setting for the prescribed flow rates. 5. Other infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. e. Keep delivery devices covered in plastic bag when not in use. 11. Staff shall monitor for complications associated with the use of oxygen and take precautions to prevent them. 12. Staff shall notify the physician of any changes in the resident's condition, including changes in bital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. NJAC 8:39-11.2 (b)(f); 27.1 (a)(b)

Repeat DeficiencyBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure medications (meds) were administered in the allotted timeframe for 1 of 1 resident (Resident # 8) reviewed for medication administration times.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 4/30/26 at 11:23 AM, during an initial tour, the surveyor observed Resident #8 resting in their bed. Resident #8 stated that the nurses would take a while to administer all their medications (meds). Resident #8 further stated there were a lot of agency staff and that was one of the reasons that their meds were being administered late. The surveyor reviewed the hybrid Medical Record (MR; paper and electronic MR) for Resident #8. A review of the admission Record (an admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; Major depressive disorder (persistently low or depressed mood), Malignant neoplasm (a cancerous tumor characterized by uncontrolled cell growth, invasion of nearby tissues, and the potential to spread) of Endocervix (cervical cancer), anxiety disorder and Encephalopathy (damage or disease that alters brain function). A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 4/5/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that Resident #8's cognition intact. Further review of the MDS indicated that the resident received antianxiety (used to reduce worried feeling), antidepressant (medications used to treat depression), opioid (a class of drug used to reduce moderate to severe pain) and anticonvulsant (a type of drug that is used to prevent or treat seizure or convulsions) medications. A review of the individualized comprehensive care plan (ICCP) included a focus care area, created on 10/2/25, [Name Redacted] uses anti-anxiety medications r/t (related to) adjustment issues, pain, CA (cancer). Interventions included but were not limited to: Administer Anti-anxiety medications as ordered by physician. Further review of the ICCP included a focus care area, created on 10/2/25, [Name Redacted] uses antidepressant medication r/t depression. Interventions included administering antidepressant medications as ordered by physicians. A focus area initiated on 10/1/25, included [Name Redacted] has chronic (long lasting) pain r/t cancer of endocervix and liver. Interventions included to administer analgesia (medications that relieve pain) as per orders.A review of Resident # 8's Order Summary Report (OSR) included the following physician orders (PO): A PO dated 3/30/26 for alprazolam 2 milligram (mg) - give one tablet by mouth every 6 hours for anxiety/agitation. A PO dated 4/17/26 for alprazolam 2 milligram (mg) - give one tablet by mouth every 4 hours for anxiety. A PO dated 4/6/26 for cyclobenzaprine HCL (Hydrochloride) 10 mg- give one tablet by mouth two times a day for muscle spasm relief. A PO dated 11/3/25 for dicyclomine HCL 20 mg- give one tablet by mouth three times a day for treatment of functional/irritable bowel syndrome.A PO dated 12/1/25 for MS (Morphine Sulfate) Contin Extended Release (ER) 100 mg- give one tablet by mouth every 12 hours for severe painA PO dated 10/19/25 for phenobarbital 97.2 mg-give one tablet by mouth at bedtime for seizure disorder.A PO dated 1/28/26 for potassium chloride ER 20 MEQ (milliequivalent)-give one tablet by mouth one time a day for hypokalemia (abnormally low levels of potassium in the blood).A PO dated 10/25/26 for Protonix Delayed Release 40 mg-give one tablet by mouth two times a day for GERD (a chronic condition where stomach acid frequently flows back into the esophagus, the tube connecting the mouth and stomach)A PO dated 10/14/25 for Prozac 20 mg-give one capsule by mouth one time a day for depression (a constant feeling of sadness and loss of interest).A review of the April 2026 Progress Notes (PNs) revealed no documentation regarding Resident #8's medications not being administered as scheduled per PO's. A review of the facility Medication Administration Audit Report (MAAR), dated 4/11/26 through 4/30/26, revealed the following:On 4/12/26:1.Potassium Chloride ER 20 MEQ one tablet, scheduled for 9:00 AM was administered at 10:44 AM.2.Dicyclomine HCL 20 mg one tablet, scheduled for 9:00 AM was administered at 10:44 AM.3.Prozac 20 mg two capsules, scheduled for 9:00 AM were administered at 10:44 AM.4.MS Contin ER 100 mg one tablet, scheduled for 9:00 AM was administered at 10:44 AM.5.Cyclobenzaprine HCL 10 mg one tablet, scheduled for 9:00 AM was administered at 10:44 AM. 6.Xanax 2 mg one tablet, scheduled for 12:00 PM was administered at 1:01 PM.On 4/13/26:1.Potassium Chloride ER 20 MEQ one tablet, scheduled for 9:00 AM was administered at 10:41 AM.2.Dicyclomine HCL 20 mg one tablet, scheduled for 9:00 AM was administered at 10:41 AM.3.Prozac 20 mg two capsules, scheduled for 9:00 AM were administered at 10:41 AM.4.Cyclobenzaprine HCL 10 mg one tablet, scheduled for 9:00 AM was administered at 10:41 AM.On 4/16/261. Xanax 2 mg one tablet, scheduled for 6:00 PM was administered at 7:20 PM.On 4/18/261.Xanax 2 mg one tablet, scheduled for 8:00 AM was administered at 9:11 AM.2.Xanax 2 mg one tablet, scheduled for 12:00 PM was administered at 1:08 PM.3.Xanax 2 mg one tablet, scheduled for 4:00 PM was administered at 5:02 PM.On 4/20/261.Xanax 2 mg one tablet, scheduled for 12:00 AM was administered at 1:03 AM.On 4/21/261.Xanax 2 mg one tablet, scheduled for 8:00 AM was administered at 9:29 AM. On 4/23/261.Xanax 2 mg one tablet, scheduled for 12:00 AM was administered at 1:08 AM.2.Xanax 2 mg one tablet, scheduled for 4:00 PM was administered at 5:13 PM.On 4/24/261.Xanax 2 mg one tablet, scheduled for 12:00 AM was administered at 1:17 AM.2.Xanax 2 mg one tablet, scheduled for 12:00 PM was administered at 1:37 PM.On 4/25/261.Xanax 2 mg one tablet, scheduled for 4:00 AM was administered at 5:49 AM.On 4/26/261.Xanax 2 mg one tablet, scheduled for 8:00 PM was administered at 9:01 PM.On 4/27/261.Xanax 2 mg one tablet, scheduled for 4:00 AM was administered at 5:38 AM.2.Potassium Chloride ER 20 MEQ one tablet, scheduled for 9:00 AM was administered at 10:21 AM.3.Dicyclomine HCL 20 mg one tablet, scheduled for 9:00 AM was administered at 10:19 AM.4.Prozac 20 mg two capsules, scheduled for 9:00 AM were administered at 10:19 AM.5.MS Contin ER 100 mg one tablet, scheduled for 9:00 AM was administered at 10:21 AM.6.Cyclobenzaprine HCL 10 mg one tablet, scheduled for 9:00 AM was administered at 10:19 AM. 7.Xanax 2 mg one tablet, scheduled for 12:00 PM was administered at 1:07 PM.8.Xanax 2 mg one tablet, scheduled for 4:00 PM was administered at 5:31 PM.On 4/29/261.Xanax 2 mg one tablet, scheduled for 8:00 AM was administered at 9:34 AM.On 4/30/261.Xanax 2 mg one tablet, scheduled for 4:00 AM was administered at 5:34 AM.2.Xanax 2 mg one tablet, scheduled for 8:00 AM was administered at 9:45 AM.3.MS Contin ER 100 mg one tablet, scheduled for 9:00 PM was administered at 10:14 PM.4.Cyclobenzaprine HCL 10 mg one tablet, scheduled for 9:00 PM was administered at 10:12 PM.5.PHENobarbital 97.2 mg one tablet, scheduled for 9:00 PM was administered at 10:14 PM.On 5/6/26 at 11:07 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated the process for med administration was to always make sure they are following the five (5) resident rights: the right dose, right patient, right time, right route (by mouth) and right medication. The LPN further stated the meds could be administrated one hour before and one hour after the due time. The LPN stated that meds should always be given on time because certain meds are given with food or before food and that was why meds were ordered timely. The LPN further stated if meds were due at 9 AM and were not given until 10:30 AM for any reason, then she would call the doctor and get an okay to administer them, either they approve it or don't. The LPN stated she would document it in a progress note. On 5/6/26 at 11:15 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated the process for med administration was to follow five (5) rights: the right medication, right dose, right route, right patient, and right time. The LPN/UM stated that meds could be administered 1 hour before and 1 hour after. The LPN/UM stated if she was running late with a resident's meds, like if they were due at 9 AM and were not given until 10:30 AM, she would speak with the facility's in-house Nurse Practitioner (NP) or call the resident's physician immediately to check if it was still okay to give the meds at that time. The LPN/UM stated it was important to administer meds on time because some of the meds had parameters such as blood pressures and some need to be given with meals or after meals as ordered by the physician. The LPN/UM stated the expectation from the nurses was to call the doctor if the meds were late, meaning outside of the one hour administration window. The surveyor made the LPN/UM aware of the above-mentioned findings for Resident #8. The surveyor reviewed Resident #8's April MAAR with the LPN/UM and she stated it was unacceptable when the meds were administered outside the 1 hr window. On 5/6/26 at 12:42 PM, the surveyor made the Director of Nursing (DON) aware of the above-mentioned concerns for Resident #8. The DON stated the meds could be given an hour before or an hour after the scheduled time. The DON stated the expectation from the nurses was to notify the doctor or the NP if meds were late over an hour and document whatever the doctor's response would be. The DON acknowledged that it was not acceptable to administer meds late. On 5/6/26 at 2:41 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the DON, the Regional Clinical Director (RCD) and the Regional Director of Operations (RDO) and made them aware of the above-mentioned findings for Resident #8. A review of the facility's policy, Medication Administration date reviewed and revised 10/20/25 revealed Policy: Medications are administered by licensed nurses, .as ordered by the physician and in accordance with professional standards of practice. Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: e. Right time f. Right documentation. N.J.A.C. 8: 39-27.1

Based on observations, interviews, review of the medical record, and review of other facility documentation, it was determined that the facility failed to respond timely to the monthly Consultant Pharmacist (CP) recommendations. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #14). The deficient practice was evidenced by the following:On 4/30/2026 at 11:24 AM, during the initial tour, the surveyor went to Resident # 14's room. The resident was lying in bed, awake, alert, and stated the staff was friendly and competent. On 5/1/2026 at 9:58 AM, during a follow up tour, the surveyor observed Resident #14 sitting on the bed, in their room. The surveyor reviewed the electronic medical record (EMR) for Resident #14 A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; central pain syndrome (pain initiated or caused by a primary lesion or dysfunction in the central nervous system), generalized Anxiety disorder ( excessive, ongoing worry that are difficult to control and interfere with day-to-day activities), schizoaffective disorder (a serious mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, along with symptoms of a mood disorder, such as mania and depression), migraine, unspecified, not intractable, without status migrainosus (a headache that can cause intense throbbing pain or a pulsing feeling, usually on one side of the head), unspecified osteoarthritis (condition that causes joints to become painful and stiff), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 3/5/2026, indicated the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. A further review revealed the resident was receiving pain medications. A review of the individualized comprehensive care plan (ICCP) revealed a focus area of risk for pain in the back, and leg pain neuropathy, dated 10/14/2025. The ICCP interventions included but were not limited to; administering medication as ordered. A review of the pharmacy consultant recommendations (PCR) dated 4/13/2026 revealed the following:-Documented pain level of 2 and 0 do not match PRN (as needed) tramadol indication of severe. Please review.-Please clarify the order for PRN Tylenol for fever. Supplemental documentation for temperature is missing. A review of the April 2026 Medication Administration Record (MAR) revealed the following:-An active physician order for tramadol HCI Oral tablet 100 MG (milligram) Give 1 tablet by mouth every 8 hours as needed for severe pain (8-10).On 4/15/2026, was signed as administered at 7:54 AM for a pain level of 2.On 4/17/2026, was signed as administered at 8:43 AM for a pain level of 6.On 4/18/26, was signed as administered at 8:23 AM for a pain level of 2.On 4/19/2026, was signed as administered at 7:59 AM for a pain level of 2.On 4/20/2026, was signed as administered at 1:32 PM for a pain level of 0.On 4/22/2026, was signed off as administered at 7:59 AM for a pain level of 2.On 4/25/2026, was signed as administered at 7:58 AM for a pain level of 2.On 4/26/2026, was signed as administered at 8:38 AM for a pain level of 2.On 4/28/2026, was signed as administered at 6:29 AM for a pain level of 6.On 4/29/2026, was signed as administered at 8:32 PM for a pain level of 6.On 4/30/2026, was signed as administered at 4:54 AM for a pain level of 6. -An active physician order for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth every 6 hours as needed for fever, temp greater than 100.4 Give 2 tabs = 650 MG. Order date 10/22/2025. Further review had not revealed any update to reflect a supplemental area for documenting fever. On 5/6/2026 at 10:26 AM, the surveyor interviewed the Director of Nursing (DON), who stated the Unit Managers (UM) usually update the PCRs, but we do not currently have a UM, so multiple nurses have been helping out. The DON acknowledged the dates and the pain levels of 0, 2, and 6 that were not indicative of severe pain of 8-10. The DON further stated that the Tramadol should not have been administered based on the pain level. The nurse should have administered either Tylenol for the pain levels of 2, and Ibuprofen should have been administered for the pain level of 6. On 5/6/2026 at 12:48 PM, the surveyor attempted to reach the pharmacy consultant via telephone with no response. On 5/6/2026 at 1:33 PM, the surveyor interviewed the DON regarding how long the response time should be after the PCR was received. The DON stated, I have to check the policy. I am not 100% sure. On 5/6/2026 at 1:41 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that she assessed the resident and the pain level, and checked the order prior to pain medication administration. The surveyor showed LPN #1 Resident #14's MAR for the month of April 2026, and she acknowledged that she had not followed the physician order. LPN #1 further stated that she should have given Tylenol instead so we are not overmedicating the resident. On 5/6/2026 at 2:42 PM, in the presence of the survey team, the surveyor made the Licensed Nursing Home Administrator, the DON, the Regional Clinical Director, and Regional Director of Operations aware of the above concerns. A review of the facility's policy Pharmacy Services dated 9/1/2024, revealed Policy: It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with the state and federal requirements, and reflect current standards of practice. Compliance Guidelines . 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with the state and federal requirements, and reflect the current standards of practice. 4. The licensed pharmacist will collaborate with the facility leadership and staff to coordinate pharmaceutical services within the facility, guide development and evaluation of pharmaceutical services procedures, and help the facility identify, evaluate, and resolve pharmaceutical concerns which affect resident care, medical care, or quality of care such as the: a). Provision of consultative services by a licensed pharmacy as necessary . A review of the policy Addressing Medication Regimen Review Irregularities date 9/1/2024, revealed Policy: It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. Policy Explanation and Compliance Guidelines: 1. The facility will utilize a systematic approach for reviewing each resident's medication regimen which includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. 2. The medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month . 8. Upon conducting the MRR, the pharmacist may identify and report irregularities in one or more of the following categories: g. Presence of medication errors or the risk of such errors. NJAC 8:39-29.3 (1)

Complaint: NJ184628 Based on interviews, record review, and review of other pertinent facility documentation on 04/15/2025, it was determined that the facility failed to provide a) Individual Patient Controlled Substance Administration Record for a resident (Resident #3) b) facility failed to document refusal on the Electronic Medication Administration Record (eMAR). The facility also failed to follow its policies titled, Medication Administration and Documentation in Medical Record. This deficient practice was identified for one of three residents, Resident #3. This deficient practice was evidenced by the following: Review of the Electronic Medical Record (EMR) was as follows: According to Resident #3's admission Record (AR), the resident was admitted to the facility with diagnoses that included but were not limited to: Amyotrophic Lateral Sclerosis (ALS) (nervous system disease that weakens muscles), Anxiety disorder, Chronic Pain Syndrome, Schizoaffective Disorder, Bipolar Disorder, and Adult Failure to Thrive. According to the Minimum Data Set (MDS), an assessment tool dated 01/14/2025, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. According to Resident #3's Order Summary Report (OSR) Active Orders as of 04/01/2025, the OSR revealed a physician order for the following medications: Lorazepam Oral Concentrate 2MG/ML (milligram/milliliter). Give 1 ml by mouth every 6 hours(hrs.) at 12:00 A.M, 06:00 AM, 12:00 P.M and 06:00 P.M for agitation/anxiety with a start date of 05/06/2024. Methadone HCL Oral Concentrate. 10 MG/ML. Give 7 ml by mouth every 8 hrs at 06:00 A.M, 02:00 P.M, and 10:00 P.M for Chronic intractable pain ALS. Morphine Sulfate Oral Concentrate 20 MG/ML. Give 1.25 ML by mouth every 3 hours for Chronic intractable pain ALS 1.25ml=25mg at 12:00 A.M, 03:00 A.M, 06:00 A.M, 09:00 A.M, 12:00 P.M, 03:00 P.M, 06:00 P.M an 09:00 P.M. Review of Resident #3's eMAR showed the orders were not signed by staff on the following dates and times. Lorazepam Oral Concentrate 2MG/ML. Give 1 ml by mouth every 6 hrs., on 03/23/2025 at 06:00 P.M. Methadone HCL Oral Concentrate. 10 MG/ML. Give 7 ml by mouth every 8 hrs., on 03/12/2025 at 02:00 P.M. and 03/23/2025 at 10:00. P.M Morphine Sulfate Oral Concentrate 20 MG/ML. Give 1.25 ML by mouth every 3 hrs. on 03/23/2025 at 06:00 P.M and 09:00 P.M. A review of Resident #3's Progress Notes (PNs) from 03/24/2025 written by the Licensed Practical Nurse (LPN)/Unit Manager (UM) for Resident #3 documented, As reported from nursing staff resident refused the nurse to administer his/her midnight medication on 3/24/25. In a second PNs, regarding 3/23/25 medications for Resident #3, there was clarification that the refused medications were for the 11:00 P.M - 07:00 A.M shift. The PNs show Resident #3 refused his/her medications, however there were blanks on the eMAR. During an interview on 04/15/2025, the LPN/UM, stated that there shouldn't be any blanks on the eMAR and that the nurse administering the medication was responsible for signing the eMAR. The LPN/UM stated, If the resident refuses a medication, the proper code should be pressed and a progress note should be included. The LPN/UM confirmed the missing signatures by staff for Resident #3 on 03/23/2025 and acknowledged the nurse administering the medications did not follow the facility's policy for documentation. Surveyor attempted to interview nurse who worked on 03/23/2025 and was unable to, therefore the DON was interviewed. During an interview on 04/15/2025 at 02:48 P.M, with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), the DON stated that she doesn't expect blanks on the eMAR and that the unit managers are responsible to ensure that there are no blanks. She also stated that whoever administered the medication is responsible for filling out the eMAR and it should be signed immediately after a medication is given. She acknowledged the blanks on the eMAR for 03/23/2025 and that refusal of medications should be documented as well. She also stated that the facility's policies for medication administration and documentation was not followed. The surveyor requested Individual Patient Controlled Substance Administration Record sheets for Resident #3's medications of Lorazepam, Methadone, and Morphine Sulfate for 03/12/2025 and 03/23/2025. Reviewed Individual Patient Controlled Substance Administration Record for Methadone on 3/12/2025 and it showed that the 02:00 P.M dose was administered. The facility failed to provide the requested Individual Patient Controlled Substance Administration Record for Lorazepam, Methadone, and Morphine Sulfate for 03/23/2025. During an offsite telephone interview with the DON on 04/16/2025 at 04:16 P.M, she stated, Declining sheet should be available to surveyors and typically the original goes into the patient's chart. The DON acknowledged that Resident #3's Individual Patient Controlled Substance Administration Records were not available and they failed to follow their policy. Review of the facility's document titled Documentation in Medical Record, implemented on 10/01/2024, revealed under Policy Explanation and Compliance Guidelines: licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Review of the facility's document titled Medication Administration, implemented on 09/01/2024, revealed Medication Administration: 21. Sign MAR after administered. For those medications requiring vital signs, record vital signs on the MAR. 22. Report and document any adverse side effects or refusals. NJAC 8:39-35.2 (d) NJAC 8:39-35.2 (g)

Complaint #: NJ182074, NJ182526 Based on observations, interviews, medical record review, and review of other pertinent facility documentation on 01/23/2025 and 1/27/2025, it was determined that the facility failed to follow standards of clinical practice for Physician Orders (POs) for medication administration and follow the Care Plan (CP) interventions for a resident (Resident #2). The facility also failed to follow its policy titled Medication Administration. This deficient practice was identified for 1of 8 residents reviewed for medication administration 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to Resident #2's Admission Record (AR), the resident was admitted with diagnoses that included but were not limited to: Adult Failure to Thrive (decline in physical and mental functioning), Anxiety (feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Depression (loss of pleasure or interest in activities for long periods of time), and Chronic Pain Syndrome. According to the Minimum Data Set (MDS), an assessment tool dated 01/14/2025, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS also revealed a diagnosis of Chronic Pain Syndrome and Anxiety. According to Resident #2's CP with an initiated date of 10/18/2023, under Focus revealed: I have chronic pain r/t (related to) ALS, under Intervention: The resident (Resident #2) pain is alleviated by: scheduled Methadone and Morphine. According to Resident #2's Order Summary Report (OSR) Active Orders as of 01/27/2025, the OSR revealed a physician order for the following medications: Lorazepam Oral Concentrate 2MG/ML (milligram/milliliter). Give 1 ml by mouth every 6 hours(hrs.) at 12:00 A.M., 6:00 A.M., 12:00 P.M., and at 6:00 P.M. for agitation/anxiety with a start date of 05/06/2024. Review of Resident #2's Electronic Medication Administration Record (eMAR), the aforementioned orders were not administered on the following dates and times. Lorazepam Oral Concentrate 2mg/ml give 1 ml by mouth every 6 hrs., on 01/21/2025 at 6:00 A.M., and on 01/22/2025 at 6:00A.M. Review of Resident #2's Individual Patient Controlled Substance Administration Records (declining inventory used for narcotics) for Lorazepam and Morphine, there was no evidence of administration on the dates above. Review of Resident #2's progress notes for the mentioned dates, there was no documentation of harm to the resident due to not receiving their medications as ordered. On 01/27/2025, at 1:36 P.M., during an interview with the surveyor, the Licensed Practical Nurse (LPN), stated the expectation is for the nurse to follow the POs for medication administration for the residents. She further stated, if a medication is administered, the nurse should immediately initial the eMAR. The LPN stated, if a medication is not administered for any reason, the physician and family should be notified, and the reason should be documented in the resident's progress notes in point click care (PCC). When presented with Resident #2's eMAR for 01/2025, the LPN confirmed the missing initials. On 01/27/2025, at 2:00 P.M., during an interview with the surveyor, the Interim Director of Nursing (DON) stated it was important to administer medication as ordered because of consistency and compliance. The DON said if a medication is administered, it should be immediately documented by the administering nurse in the resident's eMAR. She further stated if a medication is not administered, the resident's physician and family should be notified, and it should be documented in the progress notes in PCC. The DON stated, there would be no other place to document except in PCC. The DON stated her expectation would be for all nurses to administer medications as ordered. When presented with Resident #2's eMAR for 01/2025, the DON confirmed the blank spaces for Lorazepam and Morphine. She further said blank spaces would indicate a medication was not administered as ordered. Review of the facility policy titled Medication Administration with a revised date of 09/01/2024. Under Policy reveals: mediations are administered by licensed nurses, or 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. Under Policy Explanation and Compliance Guidelines: #20. Sign MAR after administered. For those medications requiring vital signs, record vitals onto the MAR. NJAC 8:39- 11.2 (b)

NJ Complaint #: 174208 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/3/24 at 9:41 AM, the surveyor, accompanied by the Food Service Director (FSD), toured the facility's kitchen. The following was observed in the kitchen freezer: One unlabeled, undated opened box of hotdogs/kielbasa, which was opened, the plastic bag inside the box also opened exposing the hotdogs/kielbasa links, which had the appearance of freezer burn, to air. One opened 15-pound box of single slice bacon. The plastic bag inside the box was also opened and exposing the bacon to air. At that time, the FSD stated that those items should not be stored like that. At 9:55 AM, the surveyor observed the following in the walk-in refrigerator: Sliced turkey deli meat wrapped in clear plastic wrap, which was approximated by the FSD to be a quarter pound, labeled and dated with a use by date of 12/2. The FSD stated the turkey should have been discarded. At 10:11 AM, the surveyor observed the following on the spice/dry storage rack in the food preparation area: A four-quart plastic container with a green lid, unlabeled and undated, approximately a quarter full of an unidentifiable white powder. The FSD identified this as instant mashed potato mix. One opened 16-ounce (oz) container of garlic powder, one opened 16 oz container paprika powder, and one opened 32 fluid oz bottle of browning seasoning sauce, all undated. At that time, the FSD stated those items should have all been labeled and dated with date opened and expiration date. On the canned goods rack were the following dented cans: One number 10 can of mandarin orange slices and one number 10 can of grape jelly. The FSD stated that dented cans should have been removed from this rack and stored with the dented cans in the dry food storage room. On 12/9/24 at 11:02 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant LNHA (ALNHA), and the Regional Director of Operations (RDO), acknowledged the findings observed by the surveyor in the kitchen. A review of the facility's Frozen Food Storage Policy with revised date of November 2024 included but was not limited to 3. Boxes are labeled with the date received and kept closed until use. 4. When a box or container is opened, it is labeled with an open date and securely covered to prevent frost accumulation and freezer burn. A review of the facility's Refrigerated Food Storage Policy with revised date of November 2024, included but was not limited to 4. When a box or container is opened, it is labeled with an open date and securely covered to preserve food quality and avoid physical, chemical, or bacterial contamination. 5. Food can be stored in the refrigerator for time periods according to refrigerated food storage charts and/or manufacturer's instructions. A review of the facility's Dry Food Storage Policy with a revised date of October 2024 included but was not limited to products opened are marked with 'open' and 'use by' date label. A review of the facility's Dented/Compromised Cans Policy dated October 2023 included but was not limited to dented cans are stored in a separate location from the regular food supply. Food from a dented can has been compromised and considered contaminated. NJAC 8:39-17.2(g)

Based on interview, review of facility policy, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to complete reference checks on employees before their start date. The deficient practice was identified for 5 of 10 employees reviewed for new hires (Employee #3, #6, #8, #9 and Employee #10), and was evidenced by the following: A review of facility's Abuse Policy dated 9/1/24, included in the section titled Screening Components that it is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include 1. verification of references shall be conducted on potential employees .3. The facility will maintain documentation of proof that the screening occurred. On 12/3/24 at 12:47 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) ten newly hired employee personnel files who were hired since the facility's last standard survey who were still employed or terminated. A review of employee personnel files revealed the following: For Employee #3, Certified Nursing Assistant (CNA) with a start date of 10/24/23, there was no evidence of a reference check prior to the start of employment. For Employee #6, a Licensed Practical Nurse (LPN) with a start date of 1/2/24, there was no evidence of a reference check prior to the start of employment. For Employee #8, a CNA with a start date of 3/20/24, there was no evidence of a reference check prior to the start of employment. For Employee #9, a Registered Nurse (RN) with a start date of 2/13/24, there was no evidence of a reference check prior to the start of employment. For Employee #10, a Dietary Aide with a start date of 1/30/24, there was no evidence of a reference check prior to the start of employment. On 12/5/25/24 at 11:57 AM, the surveyor interviewed the Human Resources Director (HRD) about the facility's screening process for new hires, and the HRD stated the facility should follow their hiring policy and all new hires should have a completed reference check prior to their first day of employment. On 12/9/24 at 10:35 AM, the LNHA in the presence of the Director of Nursing (DON), Regional Director of Operations (RDO), and survey team acknowledged the missing pre-employment checks. The LNHA confirmed every employee should have a criminal background and reference check prior to employment. NJAC 8:39-4.1(a)(5); 9.3(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) respiratory equipment was stored and dated properly and b) ensure a physician's order was in place for a resident who received oxygen. This deficient practice was identified for 3 of 3 residents reviewed for respiratory care (Resident #19, Resident #54, and Resident #239), and the evidence was as follows: 1. On 12/3/24 at 10:38 AM, the surveyor observed Resident #19 in the bathroom performing morning care. At that time, the surveyor observed on the resident's bedside an oxygen (O2) concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) that was turned off and the nasal cannula (NC) tubing (a thin, flexible tube with two prongs that delivers oxygen through the nose) was draped across the top of the O2 concentrator. The tubing was not labeled or dated when it was changed, and it was not stored in a protective covering. On 12/4/24 at 11:25 AM, the surveyor reviewed the medical records for Resident #19. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but not limited too; acute and chronic congestive heart failure (CHF; chronic condition where the heart can't pump blood efficiently), acute and chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body), and obstructive sleep apnea (when the throat muscles relax and block the airway). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 10/14/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the individualized comprehensive care plan included a focus area dated 5/16/22, and revised 6/13/22, for altered respiratory status and difficulty breathing related to (r/t) diagnosis (dx) of obstructive sleep apnea. Interventions include to administer oxygen therapy via a NC at two liters per minute (2 lpm) as needed (PRN). A review of the active Order Summary Report (OSR) reflected a physician's order (PO) dated 12/3/24, to change O2 tubing when in use weekly on Wednesdays on the 11:00 PM to 7:00 AM (11-7) shift or PRN. A review of the corresponding Treatment Administration Record (TAR) revealed that the nurses were signing for the changing of the O2 tubing weekly on Wednesdays. On 12/5/24 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that staff were expected to follow the facility's policy and change the O2 tubing as reflected on the physician's orders and on the TAR. The LPN/UM stated the facility had the policy in place to prevent contamination and infection from old, dirty, or broken tubing. The LPN/UM stated when the nursing staff changed the tubing, they were supposed to label, initial, and date it to ensure accountability and allows the rest of the facility staff to know it was done. On 12/6/24 at 11:10 AM, the surveyor interviewed the Infection Preventionist (IP), who stated that the nursing staff changed any respiratory tubing every Wednesday night on the 11-7 shift. The IP stated that staff labeled the tubing with the date and their initials, and they provided a labeled and dated respiratory bag so the tubing can be placed in it when not in use to prevent contamination and infection. The IP stated proper storage of the respiratory equipment prevented infection, and daily rounds were done by management to ensure policy was followed and that something was not missed. On 12/9/2024 at 12:34 PM, the surveyor informed the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and Regional Director of Operations (RDO) the above concern. 2. On 12/3/24 at 10:44 AM, the surveyor observed Resident #54 lying in bed receiving O2 through a NC tubing. The tubing was labeled and dated 11/21/24, which indicated the tubing was in use for twelve days. At that time, the surveyor did not observe an O2 tubing storage bag. On 12/4/24 at 12:15 PM, the surveyor reviewed the medical record for Resident #54. A review of the Admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included but not limited too; chronic obstructive pulmonary disease (COPD; a group of lung diseases that damage the airways and air sacs in the lungs, making it hard to breathe). A review of the quarterly MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. A review of the ICCP r included a focus area dated 5/16/22, and revised 12/12/23, for oxygen therapy r/t COPD. Interventions included; to administer O2 therapy via NC at 2 lpm. A review of the active OSR reflected a PO dated 8/21/24, to change O2 tubing weekly, label, date, and initial each component every night shift on Wednesdays. On 12/5/24 at 11:05 AM, the surveyor interviewed the LPN/UM, who stated that staff were expected to follow the facility's policy and change the O2 tubing as reflected on the physician's orders and on the TAR. The LPN/UM stated the facility had the policy in place to prevent contamination and infection from old, dirty, or broken tubing. The LPN/UM stated when the nursing staff changed the tubing, they were supposed to label, initial, and date it to ensure accountability and allows the rest of the facility staff to know it was done. On 12/6/24 at 11:10 AM, the surveyor interviewed the IP, who stated that the nursing staff changed any respiratory tubing every Wednesday night on the 11-7 shift. The IP stated that staff labeled the tubing with the date and their initials, and they provided a labeled and dated respiratory bag so the tubing can be placed in it when not in use to prevent contamination and infection. The IP stated proper storage of the respiratory equipment prevented infection, and daily rounds were done by management to ensure policy was followed and that something was not missed. On 12/9/2024 at 12:34 PM, the surveyor informed the DON, LNHA, and RDO the above concern. A review of the facility's Oxygen Administration policy dated 9/1/24, included .5 .d) change O2 delivery tubing per facility policy and as needed if they become soiled; e) keep delivery devices covered in a plastic bag when not in use . 44833 3. On 12/3/24 at 10:51 AM, the surveyor observed Resident #239 in bed resting. The resident had a tracheostomy tube (trach; a tube that is inserted into a surgically created opening in the windpipe to help a person breathe) with a clear plastic mask used to deliver oxygen over top of the trach that was connected to a hose that was connected to an oxygen concentrator at the resident's bedside. The concentrator was set to deliver oxygen at 2 lpm to the resident. On 12/4/24 at 10:39 AM, the surveyor reviewed Resident #239's electronic medical record (EMR). A review of the Admission Record face sheet reflected that the resident was admitted to the facility with diagnosis which included but was not limited to; tracheostomy, end stage renal disease, and aphasia (inability to communicate verbally). A review of the physician's Order Summary Report did not include a physician's order for oxygen administration. A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area that the resident had a tracheostomy and interventions included but were not limited to; oxygen to be administered via tracheostomy collar as ordered. A review of the Progress Notes included an Admission Summary note dated 11/29/24 at 4:37 PM, which included the resident's vital signs and indicated the resident had a blood oxygen saturation level of 97% while being administered oxygen at a rate of 8 lpm. A review of the November and December 2024 Medication Administration Record (MAR) did not include that the nurse's were signing for the administration of oxygen. On 12/6/24 at 11:43 AM, the surveyor interviewed the Director of Nursing (DON), who stated that residents who used of oxygen required a physician's order for the use. At that time, the DON reviewed Resident #239's physician's orders and confirmed that there were no order for the administration of oxygen, and the resident received oxygen. On 12/9/24 at 11:02 AM, the DON, in the presence of the survey team, the LNHA, Assistant LNHA, and RDO, who acknowledged that Resident #239 was supposed to have an order for oxygen in place and did not. A review of the facility's Oxygen Administration policy dated 9/1/24, included .oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control . NJAC 8:39-11.2(b); 27.1(a)

NJ Complaint # 174208 Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to serve meals in a dignified, home-like manner by using disposable containers to serve food for residents who dinned in 1 of 2 main dining rooms (second floor). The deficient practice was evidenced by the following: On 12/3/24 at 12:10 PM, the surveyor observed residents in the second floor main dining room being served lunch from the on-site serving station/steam table and being plated on reusable plates and silverware. Once lunch was served to all residents present in the dining room, the surveyor observed that four (4) out of the 14 residents were served lunch on red plastic disposable plates. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was present in the room, regarding the disposable plates, and LPN #1 stated that there were not enough reusable plates brought up from the kitchen to serve all the residents in the main dining room. On 12/3/24 at 12:23 PM, after completing entree service for the resident's lunch, the Chef went to the main kitchen to obtain desserts for the residents in the second floor main dining room. The Chef returned with a tray of individually wrapped sliced cake that were plated on disposable plates. The Chef then proceeded to serve each resident in the dining room a slice of cake by placing the individually wrapped slices on the table in front of them. No staff members were observed assisting residents to remove the plastic wrap off the cake slices. On 12/5/24 at 12:24 PM, the surveyor in the presence of the contracted dietary Corporate Compliance Officer (CCO) observed one resident (unsampled) in the main dining room of the second floor eating lunch off of a red plastic disposable plate, while two other residents at the table were eating off of reusable plates. The surveyor at that time asked the CCO about the use of the disposable plates, and the CCO approached the Chef in the dining room who stated that he ran out of regular plates and that he always had disposable plates as backup because the kitchen did not provide enough plates for the meal service. On 12/5/24 at 12:35 PM, the surveyor interviewed the CCO, who stated that residents should not be served on disposable plates because it was a dignity issue and the facility needed to maintain a home-like environment. On 12/6/24 at 11:53 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that the residents in the main dining room should have all been served in the same manner using reusable plates and silverware because it was a dignity concern with dining. On 12/9/24 at 11:02 AM, the LNHA, in the presence of the survey team, the Director of Nursing (DON), and Assistant LNHA (ALNHA), stated that the kitchen should have provided more than the anticipated amount of plates needed for the residents meal service, and the Chef should have called the kitchen to request additional plates. A review of Dining Service Tray Presentation policy dated revised 10/2023, included .residents will eat their meals in a dignified home-like environment. Disposable plates, containers, utensils will not be used for meal service .the director of each account is responsible for keeping inventory and purchase non-disposables to maintain adequate supply . NJAC 8:39-17.2(e)

Complaint NJ #: 172455; 173605 Based on interview and review of pertinent facility documents, it was determined that the facility failed to a) ensure the New Jersey Universal Transfer Form (UTF) used to communicate with the receiving long-term care (LTC) facility where a resident was being transferred was complete and b) complete the physician discharge summary. The deficient practice was identified for 1 of 3 resident reviewed for discharge (Resident #289), and was evidenced by the following: Reference: NJ.gov: https://www.nj.gov/health/forms/hfel-7instr_1.pdf: INSTRUCTIONS FOR COMPLETING THE NEW JERSEY UNIVERSAL TRANSFER FORM dated August 2011, The purpose of the New Jersey Universal Transfer Form: A form that communicates pertinent, accurate clinical patient care information at the time of a transfer between health care facilities/programs. It conveys the patient information required under federal regulations and conveys specific facts that the physician and nurse need to begin caring for a patient. The word patient is used throughout the form but refers to resident/client or the terminology used by a specific facility or program. Complete all boxes #1 - 29. b) A licensed healthcare facility or program shall complete all sections of the Universal Transfer Form, to the best of the licensed healthcare facility or program's ability. 1. The Universal Transfer Form is not complete if medication information is not attached. (c) A licensed healthcare facility or program shall send a completed, paper copy of the Universal Transfer Form with a patient when a patient is transferred. (d) A licensed healthcare facility or program shall retain a completed copy of the Universal Transfer Form sent with a patient when a patient is transferred as part of the patient's medical record . On 12/04/24 at 10:30 AM, the surveyor reviewed the closed medical record for Resident #289. A review of the Admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; cerebral infarct (ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply), hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild loss of strength or weakness on one side of the body), and dysphagia (difficulty in swallowing). A review of the Progress Note (PN) dated 10/2/23 at 2:17 PM, indicated Resident #289 had been transferred to another [name redacted LTC] facility closer to family member. All the resident's belongings were packed and transferred with resident in private vehicle. A review of the UTF dated 10/2/23, instructed on the top of the form Items 1 - 29 must be completed, revealed the following: only 9 of 29 specific areas were completed (#1, #2, #3, #4, #5, #7, #9, #13, and #24) and the remaining areas were blank which included: #6 code status, #8 reason for transfer, #10 restraints, #11 respiratory needs, #12 isolation precautions, #14 sensory issues, #15 skin conditions, #16 diet, special (dysphagia), #17 intravenous (IV) access, #18 personal items sent, #19 attached documents i.e. medical records and discharge summary but not limited to, #20 at risk alerts, i.e. falls, pressure ulcer, aspiration precautions but not limited to, #21 mental status, #22 Preadmission Screening Resident Review (PSARR) level, #23 physical therapy/occupational therapy/speech therapy functioning, #25 bowel, #26 bladder, #27 sending facility contact, #28 form filled out by, and #29 form completed by. The medical record did not include a discharge summary. On 12/5/24 at 9:00 AM, the surveyor interviewed the Director of Nursing (DON), who stated if a resident was transferred, the staff completed the UTF and made copies of the record for the receiving facility which include but not limited to; the resident's discharge summary. On 12/6/24 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON and survey team, acknowledged that Resident #289's UTF was not complete and the resident's discharge summary was not completed. A review of the Discharge Planning Processpolicy dated 9/1/24, included .10. the facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e. another Long-Term Care Facility SNF) that will meet the resident's needs, goals, and preferences .12. all relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment . NJAC 8:39-4.1(a)31

Based on observation, interview, and record review it was determined that the facility failed to develop an individualized comprehensive care plan (ICCP) for a resident with a new left below knee amputation who was receiving wound care to a surgical site. This deficient practice was identified for 1 of 22 residents reviewed for comprehensive care plans (Resident #189), and was evidenced by the following: On 12/3/24 at 10:40 AM, during the initial tour of the facility the surveyor observed Resident #189 out of bed sitting in a wheelchair. The resident told the surveyor that they were receiving therapy on the left leg, showing the surveyor that the resident had a below knee amputation. The surveyor reviewed the medical record for Resident #189. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted with medical diagnoses which included; acquired absence of left leg below the knee, diabetes mellitus (high blood sugar), repeated falls, and acute kidney failure. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/22/24, indicated the resident had a Brief Interview of Mental Status (BIMS) score 15 out of 15, meaning the resident was cognitively intact. A review of Section GG, Functional Status, revealed that the resident had an impairment of the left lower extremity. A review of the Physician Order Summary included a physician's order (PO) dated 11/26/24, to cleanse the left below knee amputation with saline, dry, apply xeroform (non-adherent gauze to promote healing), and an ace wrap to stump daily. A review of the corresponding Treatment Administration Record (TAR) revealed that Resident #189 was receiving daily wound care to the left leg surgical wound. A review of the ICCP did not include a left below knee amputation, surgical wound, or impaired skin integrity. On 12/5/24 at 12:13 PM, the surveyor interviewed the Director of Nursing (DON) regarding baseline/comprehensive care plans. The surveyor asked what would be included in the electronic medical record (EMR) if a resident was admitted with a surgical wound, and the DON stated the surgical wound would be noted on the admission assessment, in the physician orders, and included in the ICCP. The surveyor asked what the focus would be on the ICCP, and the DON stated impaired skin integrity. The surveyor asked if a new left leg amputation should be part of the ICCP, and the DON confirmed yes. A review of the Comprehensive Care Plan policy dated 9/1/24, included it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights to meet a residents medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment . NJAC 8:39-11.2(e), 27.1(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to a) revise an individual comprehensive care plan (ICCP) for a resident with a fracture following a fall, and b) revise an (ICCP) for a resident after a fall. This deficient practice was identified for 2 of 2 residents reviewed for falls (Resident #14 and Resident #55), and was evidenced by the following: 1. On 12/3/24 at 9:50 AM, during the initial tour of the facility, the surveyor went to see Resident #55 and was informed that the resident was hospitalized . On 12/9/24 at 10:23 AM, the surveyor reviewed the medical record for Resident #55. The medical record indicated that the resident was readmitted back to the facility on [DATE]. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; fracture right hip joint, muscle weakness, diabetes mellitus (high blood sugar), and difficulty in walking. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/14/24, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, meaning the resident had a moderately impaired cognition. A review of Section GG, Functional Status, indicated that the resident was completely dependent on staff for transfers and mobility. A review of Section J, Pain Assessment, revealed the resident did not have any falls since admission/entry or reentry to the facility. A review of the Order Summary Report included a physician's order (PO) dated 1/15/24, to always have bed in lowest position and bedside floor mats when in bed. An additional PO dated 12/8/24, indicated the resident could bear weight to right lower extremity. A review of the post falls assessment dated [DATE], indicated following the resident's fall, the resident was a high risk for falls. A review of the ICCP included a focus area dated 11/13/23, and last revised on 6/26/24, that the resident was a moderate risk for falls related to gait/balance problems, poor safety awareness and impulsive behaviors. Interventions included to; keep bed in lowest position, bedside floor mats, and therapy to evaluate and treat. The care plan goals were that the resident would be free from falls and the resident would be free from minor injury. The goals were updated on 12/9/24, after the surveyor inquiry. On 12/9/24 at 12:15 PM during an interview with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor asked if the ICCP should be updated with new interventions following a fall, and the DON responded confirmed yes, that it should be updated with new interventions put in place. 49094 2. On 12/3/24 at 11:00 AM, during the initial tour of the facility, the surveyor observed Resident #14 sleeping in a recliner chair in their bedroom. On 12/4/24 at 12:13 PM, the surveyor observed Resident #14 lying in bed sleeping. The surveyor observed fall mats located on both sides of the resident's bed and the resident's bed was in low position with the call device within reach. On 12/4/24 at 1:13 PM, the surveyor reviewed the medical record for Resident #14. A review of the Admission Record Face sheet reflected that the resident was admitted to the facility with diagnoses that included but not limited to; chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe), type 2 diabetes mellitus (pancreas does not make enough insulin), bradycardia (condition where your heart beats fewer than 60 times a minute), and congestive heart failure (when your heart can not pump enough blood to meet the body's need). A review of the most recent comprehensive MDS dated [DATE], indicated the resident had a BIMS score of 8 out of 15, indicating a moderately impaired cognition. A further review in Section GG, Functional Abilities, reflected the resident was completely dependent for transfers and mobility. A review of the Order Summary Report included a PO dated 4/27/23, for bedside floor mats at all times when in bed. A review of the facility's incident and accident reports revealed that Resident #14 had falls on 6/22/24, 6/28/24, 7/6/24, and 9/12/24. A review of the ICCP included a focus area dated 9/12/22, that the resident was at risk for falls related to impaired mobility, impaired gait, and balance, independent minded and does not always call for assistance when needed, behaviors of sliding out of bed, rolling out of bed, and putting their self out of bed onto the floor mats. Interventions included but not limited to; floor mats in place at all times, bed in lowest position when in bed, educate resident to use the grabber for items out of reach, and review information on past falls and attempt to determine the cause of the falls. The ICCP did not include any new interventions put into place after the falls that occurred on 6/22/24, 6/28/24, and 9/12/24. During an interview with the surveyor on 12/5/24 at 11:20 AM, the Director of Nursing (DON) identified that a ICCP should be updated with interventions as changes occurred, quarterly, and annually. The DON further stated that when there was a fall, the ICCP was updated with new interventions. The DON acknowledged that Resident #14's ICCP was not updated after the falls on 6/22/24, 6/28/24, and 9/12/24. A review of the facility's Fall Prevention Program policy dated implemented date 9/1/24, included . 6. each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 7. When any resident experiences a fall, the facility will . e. Review the resident's care plan and update as indicated . A review of the facility's Care Plan Revisions Upon Status Change policy dated implemented 9/1/24, included .2. Procedure for reviewing and revising the care plan when a resident experiences a status change . d. The care plan will be updated with the new or modified interventions . NJAC 8:39-27.1(a)

NJ Complaint # 172281 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain professional standard of practice by a) ensuring medications were administered in a timely manner in accordance with the resident's physician's order for Resident #48, and b) ensuring proper medication management by borrowing medications from one resident's supply to administer to another resident for Resident #60 and Resident #4. This deficient practice was identified for 3 of 21 residents (Resident #48, Resident #60 and Resident #4) reviewed for professional standards of practice. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, 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 casefinding; 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. During initial tour on 12/4/24 at 12:15 PM, the surveyor observed two nurses exiting Resident #48's bedroom. The nurse stated the resident just received their 12:00 PM medications and did not want to be bothered at this time. The surveyor reviewed the medical record for Resident #48. A review of the Admission Record Face sheet (an admission summary) reflected that Resident #48 was admitted to the facility with diagnoses which included, but not limited to; chronic pain syndrome (pain that persists for weeks or years and interferes with daily life), anxiety disorder (feeling of fear, dread, and uneasiness), bipolar disorder (mental health condition that causes extreme mood swings), and adult failure to thrive (decline in older adults that includes decreased appetite, inactivity, weight loss). A review of the most recent significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 10/16/24, reflected the resident had a brief interview for mental status score of 15 out of 15, indicating that the resident had an intact cognition. Further review in Section J Health Conditions reflected the resident received scheduled pain medication. A review of the Order Summary Report included a physician's order (PO) dated 2/27/24, for methadone HCL oral concentrate 10 milligram per milliliter (mg/ml) (narcotic used to treat pain) give 5.8 ml by mouth every 8 hours for chronic intractable pain. May wake for administration. The Order Summary Report also included a physician's order dated 2/5/24, for lorazepam concentrate 2 mg/ml give (used to treat anxiety) 1 ml by mouth every 6 hours for anxiety/agitation. Further review of the Order Summary Report revealed an order dated 2/26/24, with a discontinued date of 3/4/24, for morphine sulfate solution 20 mg/ml (used to treat moderate to severe pain) give 2.5 ml by mouth every 3 hours for chronic intractable pain. Hold for sedation. There was a new physician order dated 3/4/24, for morphine sulfate solution 20 mg/ml give 2.5 ml sublingually every 3 hours for chronic intractable pain. A review of the corresponding Medication Admin Audit Report revealed the morphine sulfate solution 20 mg/ml was administered outside of the parameters (3) three times on 3/3/24, (1) one time on 3/4/24, (5) five times on 3/5/24, (2) two times on 3/6/24, (5) five times on 3/7/24, (2) two times on 3/8/24 and (1) one time on 3/9/24. The methadone HCL oral concentrate 10 mg/ml was administered outside parameters (2) two times on 3/3/24, (1) one time on 3/4/24, (2) two times on 3/5/24 and (1) one time on 3/7/24. The lorazepam concentrate 2 mg/ml was administered outside of parameters (1) one time on 3/3/24, (2) two times on 3/5/24, (3) three times on 3/7/24, and (1) one time on 3/8/24. On 12/6/24 at 11:35 AM, the surveyor asked the Director of Nursing (DON) in the presence of the survey team what were the time frames for administering medications, and the DON stated medications can be administered an hour before or after the physician order. The DON acknowledge that 9 AM medications given after 10 AM were considered late. On 12/9/24 at 11:05 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON, Regional Clinical Nurse, LNHA in training and the survey team, stated that if the nurse is administering medications outside the parameters, they need to document the reason. The DON stated the importance of administering the medication on time was to prevent the potential of an overdose. A review of the facility's Medication Administration implemented on 9/1/24, included compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 2. On 12/5/24 at 8:35 AM, during medication administration observations, the surveyor observed Licensed Practical Nurse #1 (LPN #1) dispensing and preparing to administer medication to Resident #60. During the process of medication administration, after showing the surveyor the medication cards (Bingo card containing individually packaged pills), one at a time, for observation, the LPN #1 dispensed one Depakote Sprinkles oral capsule delayed release 125 milligrams (mg) into a small plastic medication cup. The LPN #1 proceeded to retrieve the second medication escitalopram oxalate 10 mg tablet (used to treat depression and anxiety) when the LPN #1 recognized Resident #60 did not have this medication in the medication cart. The LPN #1 then stated, I will have to borrow the medication from another resident. The LPN #1 also stated she should not be borrowing medication from another resident, but I don't have back up medication on the medication cart. The LPN #1 further stated that back up medications were located in the medication room. LPN #1 found the escitalopram oxalate 10 mg tablet in Resident #68's medications. LPN #1 then dispensed the medication into the small plastic medication cup. LPN #1 administered the medications to Resident #60. On 12/5/24 at 8:50 AM, during medication administration observation, the surveyor observed LPN #1 as she prepared 15 medications for Resident #4. Included in these medications was metformin HCL 500 mg oral tablet (used to treat high blood sugar levels). When LPN #1 went to retrieve the medication from the resident's medication cards, LPN #1 stated Resident #4 did not have this medication in the medication cart and she would have to borrow it from another resident. LPN #1 then proceeded to borrow the metformin HCL 500 mg oral tablet from Resident #82. LPN #1 then administered all 15 medications to Resident #4. LPN #1 then stated, we aren't supposed to borrow medications from another resident, but I don't have backup medications on the medication cart. The surveyor reviewed the medical records for Resident's #60, #68, #4 and #82. a.) A review of the Admission Record Face sheet (an admission summary) reflected that Resident #60 was admitted to the facility with diagnoses that included, but not limited to; hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), major depressive disorder (depressed mood or loss of interest in activities) and dementia (loss of cognitive functioning). A review of Resident #60's most recent quarterly Minimum Data Set (MDS), an assessment tool dated 11/17/24, indicated the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. A review of the Order Summary Report for Resident #60 included a physician's order (PO) dated 10/24/23 for escitalopram oxalate Tablet 10 mg give one tablet by mouth one time a day for depression. b.) A review of the Admission Record Face sheet (an admission summary) reflected that Resident #68 was admitted to the facility with diagnoses which included, but not limited to; major depressive disorder (depressed mood or loss of interest in activities), dementia (loss of cognitive functioning) and muscle weakness. A review of Resident #68's most recent annual MDS dated [DATE], indicated the resident had a BIMS score of 10 out of 15, indicating the resident had moderately impaired cognition. A review of the Order Summary Report for Resident #68 included a physician's order (PO) dated 10/31/23, for escitalopram oxalate tablet 10 mg give one tablet by mouth one time a day related to major depressive disorder. c.) A review of the Admission Record Face sheet (an admission summary) reflected that Resident #4 was admitted to the facility with diagnoses which included, but not limited to; hypertension (high blood pressure), hyperlipidemia (abnormally high levels of fats (lipids) in the blood), and multiple sclerosis (chronic autoimmune disease that damages the central nervous system). A review of Resident #4's most recent quarterly MDS dated [DATE], indicated the resident had a BIMS score of 8 out of 15, indicating that the resident had moderately impaired cognition. A review of the Order Summary Report for Resident #4 included a physician's order (PO) dated 9/21/24, for metformin HCL oral tablet 500 mg give one tablet by mouth one time a day for diabetes mellitus. d.) A review of the Admission Record Face sheet reflected that Resident #82 was admitted to the facility with diagnoses which included, but not limited to; hypertension (high blood pressure), anxiety disorder (feeling of fear, dread, and uneasiness), bipolar disorder (mental health condition that causes extreme mood swings), and polyneuropathy (disease that affects peripheral nerves, causing weakness, numbness, and pain). A review of Resident #82's most recent quarterly MDS dated [DATE], indicated the resident had a BIMs score of 15 out of 15, indicating the resident had cognitively intact cognition. A review of the Order Summary Report for Resident #82 included a physician's order (PO) dated 11/18/24, for metformin HCL oral tablet 500 mg give one tablet by mouth one time a day for diabetes mellitus. On 12/5/24 at 9:08 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that when a medication was not available the nurse was to check the back up medication in the pyxis (automated medication dispensing system). The ADON stated if its not in the pyxis, the nurse should call the pharmacy to see if it can be ordered STAT (immediately) and also notify the physician. The ADON further stated that a nurse should never borrow a medication from another resident. On 12/5/24 at 9:15 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurse should check the pyxis if they run out of a medication. The DON also stated that if the medication was not in the pyxis, the nurse should notify the physician, get a new order if needed and follow up with the pharmacy. The DON further stated the nurse would notify the resident and the residents representative. DON then proceeded to state that medications should not be borrowed from one resident for another. On 12/6/24 at 11:35 AM, during an interview with the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Clinical Nurse, LNHA in training and the survey team, stated that if a nurse runs out of a medication, they are to check the pyxis for back up. If there was no back up, the nurse is to notify the physician, pharmacy, and the resident. The DON stated the nurse should not borrow medications from another resident. The DON further stated that borrowing medications from another resident can cause that resident to run out of their medication. A review of the facility's Medication Administration implemented on 9/1/24, included compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. NJAC 8:39-29.2(d)

Based on observations, interviews, and review of pertinent facility documentation it was determined that the facility failed to provide pressure ulcer prevention and skin protective devices as ordered by the physician. This deficient practice was identified for 1 of 2 residents (Resident #85) reviewed for pressure ulcers and was evidenced by the following: On 12/3/24 at 11:05 AM, during the initial tour of the facility the surveyor observed Resident # 85 in the bed. Resident #85 told the surveyor they were receiving physical therapy but could not wear shoes because of a sore on their right heel. The surveyor asked if it had healed and the resident stated, one nurse said it was closed, and one said it was open a little bit. On 12/4/24 at 11:00 AM, the surveyor observed Resident #85 in bed. The resident did not have a low air loss mattress or heel boots in place. On 12/5/24 at 10:00 AM, the surveyor reviewed the medical record. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted with medical diagnoses which included but was not limited to infection due to indwelling urinary catheter, difficulty in walking, hypertension (high blood pressure), and acute kidney failure. A review of the Admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 11/12/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that the resident was cognitively intact. Review of Section M of the MDS for skin assessment indicated the resident had a stage three (wound with full thickness loss of tissue) pressure ulcer and was at risk for the development of pressure ulcers. A review of the Physician Order Summary (PO) revealed an order dated 11/5/24, to offload heels when in bed, a PO dated 11/19/24, for a customized shoe for the left foot, a PO dated 11/11/24, for foam heel protector boots to the left foot and a PO dated 11/12/24, for wound care consult. A review of the current resident care plan revealed a focus area for actual impairment to skin integrity of the left heel. The care plan was initiated on 11/21/24. Interventions included to educate resident and family of causative factors and measures to prevent skin injury, follow facility protocols for treatment of injury and identify potential causative factors and eliminate/resolve where possible. A review of the wound consult dated 11/13/24, showed the resident had a documented left heel pressure ulcer measuring 0.5 cm (centimeter) by 0.5 cm. The resident also had a right buttock stage three wound measuring 1 cm x 0.5 cm. The wound care consult recommended a low air loss mattress and pressure relieving heel boots while in bed. Review of the 12/4/24, wound consultant note recommended to continue offloading measures. On 12/5/24 at 12:28 PM, the resident was observed in bed. The resident was not on a low air loss mattress and the resident did not have pressure relieving boots. The surveyor asked if resident had special boots for leg elevation while in bed and the resident stated, No, they use a pillow sometimes. The surveyor asked the resident if they were offered a special mattress, and the resident told the surveyor no. The surveyor then asked the resident if the facility fitted them for a special shoe and the resident stated no. The resident pointed to their own slip-on plastic shoes on the nightstand and said they were their shoes. On 12/5/24 at 1:31 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) caring for Resident #85. The surveyor asked if the resident wore pressure relieving boots, and she stated, no, we offload with a pillow. The surveyor then asked the LPN if the resident had a low air loss mattress, and the LPN stated no. On 12/6/24 at 12:10 PM, during an interview with the Director of Nursing (DON) regarding the recommendations made by the wound care consultants. The DON stated that the recommendations were reviewed by the Unit Manager and were then carried out. The surveyor asked why the resident would need a low air loss mattress, heel boots, or prescribed a shoe and the DON stated to prevent worsening of the wound or to prevent new pressure ulcers. On 12/9/24 at 1:00 PM, the surveyor reviewed the policy titled, Pressure Injury Prevention and Management, dated 9/1/24. The policy included that the facility was committed to the prevention of avoidable injuries, unless clinically unavoidable and is to provide treatment and services to heal the pressure ulcer and prevent development of additional pressure ulcers. NJAC 8:39-27.1 (e)

Complaint #: NJ 162301 Based on observation, interviews, review of the medical records (MRs), and other facility documentation on 3/14/23, 3/16/23, and 3/21/23, it was determined that the facility failed to implement their policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating to prevent reoccurrence of a resident-to-resident inappropriate touching by Resident #3 and to protect 2 of 2 sampled residents (Resident #1 and Resident #2). Approximately 2 weeks prior to 3/7/2023, Certified Nursing Assistant (CNA #1) witnessed Resident # 3 hug and kiss Resident #1 on her/his face in the unit hallway, Resident #1 has diagnoses of Deafness and Autism, had moderately impaired cognition and was able to communicate via writing and non-verbal gestures. Although, according to CNA #1, the incident was reported to the nurse, there was no indication that staff notified facility Administration at the time of the incident. In addition, there was no indication the resident was assessed, or interventions was put in place to prevent future occurrences of inappropriate touching by Resident #3. Subsequently, another witnessed incident of inappropriate touching by Resident #3 was reported on 3/7/23 by CNA #1. On 3/7/23 CNA #1 heard Resident #3 in Resident #2's room saying to Resident #2 kiss me, kiss me. Resident #2 has a diagnosis of Dementia and had severely impaired cognition. The CNA entered the room and observed Resident #3 was kissing Resident #2 on the face while Resident #2 was moving his/her head from left to right. The CNA separated the residents and reported the event to the nurse who reported the incident to the ADON on 3/7/23. An investigation was initiated for the 3/7/23 incident. Resident #3 was monitored for three days, continued to wander and remained on the same unit with the alleged victims Resident #1 and Resident #2 until 3/14/23. Resident #3 was evaluated by Statewide-Clinical Outreach Program for the Elderly (SCOPE) who determined that Resident #3 does not appear to be an immediate threat to self or others at the time of the assessment on 3/8/23. The facility's failure to report and initiate interventions to address the behavior displayed by Resident # 3 approximately 2 weeks prior to the incident on 3/7/23 posed a serious and immediate threat to the safety and well-being of Resident #1, #2, and placed all residents on the unit at risk of inappropriate touching by a resident. This resulted in an IJ which began approximately 2 weeks prior to the 3/7/23 incident. The facility was notified of the IJ on 3/14/23. The IJ was removed on 3/14/23. The facility provided an acceptable removal plan and was verified on-site by surveyors on 3/21/23. This deficient practiced was evidence by: On 3/14/23, 3/16/23, and 3/21/23, the surveyor reviewed the MR of Resident #1, Resident #2, and Resident #3. 1. According to the Admission Record (AR), Resident #1 was admitted to the facility on [DATE], with diagnoses which included but were not limited to; Encounter for Autism Screening and Deaf Nonspeaking. The Minimum Data Set (MDS), an assessment tool dated 1/12/23, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 12 which indicated cognition was moderately impaired and was independent with Activities of Daily Living (ADLs). A Care Plan (CP), initiated on 4/12/22, reflected that Resident #1 had a communication deficit due to being deaf, mute, and autistic. The CP further included that Resident #1 can be frightened when he/she met someone for the first time or does not know the person. 2. According to the AR, Resident #2 was admitted to the facility on [DATE], with a diagnosis which included but were not limited to; Dementia. The MDS, dated [DATE], revealed Resident #2 had a BIMS score of 3, which indicated a severely impaired cognitive status and was independent with ADLs. A CP, initiated on 4/5/22, included that Resident #2 had impaired cognition related to Dementia and can explore the unit safely by walking. 3. According to the AR, Resident #3 was admitted to the facility on [DATE], with diagnoses which included but were not limited to; Depression, Personality Disorder, and Anxiety Disorder. The MDS, dated [DATE], revealed Resident #3 had a BIMS of 15 which indicated cognition was intact and was independent with ADLs. A CP, initiated and revised on 4/16/22 indicated that the resident had the tendency to be verbally abusive and physically aggressive towards others related to anger and gets easily frustrated. Interventions included but was not limited to: Monitor/document/report as needed any sign and symptom of resident posing danger to self and others. Review of the investigation summary (IS) dated 3/8/23, revealed that on 3/7/23 at 3:30 pm, Certified Nursing Assistant (CNA #1) witnessed Resident #3 being affectionate to Resident #2. The CNA also reported that (date unknown) she witnessed the same, Resident #3 had the same behavior towards Resident #1. The IS further revealed that the CNA revised her statement all she saw was Resident #3 kiss Residents #1 and #2 on the face but not necessarily in an inappropriate manner. Furthermore, the IS conclusion indicated that there were no acts of sexual inappropriateness from Resident #3 to Resident #2 and Resident #1. Resident #3 was educated not to have any physical contact with any resident that might be perceived as sexual inappropriateness. Additionally, if [he/she] feels that certain residents are not receiving enough care to report it to nursing authority in building. Included in the IS was CNA #1's statement, undated. The IS reflected an incident on 3/7/23 at 3:45 pm, the CNA was in the hallway and heard Resident #3 saying give me a kiss. The statement further indicated that the CNA witnessed Resident #3 kissing Resident #2 in his/her room. CNA #1 asked Resident #3 not to kiss Resident #2. Resident #3 left the room. Included in the IS, Resident #1's written interview, undated, indicated that Resident #1 was questioned, [Resident #3] said that [he/she] hugged you because [he/she] cares about you, is that accurate? Resident #1 circled yes. Did [he/she] kiss you on lips or face? Resident #1 circled neck. Included in the IS was Resident #3's statement dated 3/8/23, which indicated on: 3/7 [3/7/23] 1. My next door Resident [Resident#2] seemed very disturbed and I put my arms around [her/him] and gave [him/her] a slight kiss on [his/her] farhead [forehead]. This eased [his/her] stress and that was it. 3/6 [3/6/23] 2. With the [Resident #1], I also put my arms around [his/her], as [he/she] was very stressed and gave [him/her] a slight kiss on the right side of [his/her] head .This is the only time these incidents have happened. Included in the IS, an undated statement from the Unsampled Resident #4 (UR4), who had intact cognition. UR4 indicated on 3/7/23 at 3:30 pm [Resident #2] is a dementia resident [she/he] can become confuse agitated and aggressive. [Resident #3] lives next door to [Resident #2] and calls [her/him] [mama/[NAME]]. They have a friendly relationship. On March 7th at about 3:30 pm [Resident #2] became agitated. I am [unsampled Resident #4] and live across the hall from [Resident #2 and Resident #3]. [Resident #2] does not interact socially unless [she/he] must. [He/She] spends all her time pacing up and down the hallways. When [Resident #2] became agitated - I got up to see what was wrong, coming out of my room. [Resident #3] also responded to [her/his] agitation coming forward to be helpful. What's wrong Mama? Do you need a hug?: [Resident #3] leaned forward - [he/she] did not hug, [he/she] did not kiss [Resident #2]. I looked for a sweater for [her/him]. [Resident #3] left the room and I followed. Neither a hug or a sweater or a kiss would have helped [Resident #2]. Respecting [her/his] wishes-[Resident #3] said - Ok [mama/[NAME]] I will leave you alone . The surveyor conducted an interview with UR4 on 3/16/23 at 1:35 pm, the UR4 confirmed what was written on the IS. However, UR4 stated that [Resident #2] likes [Resident #3], this incident was not new, [he/she] has been kissing and hugging [him/her]. The UR4 further stated that [she/he] did not report that Resident #3 had been kissing and hugging Resident #2 because the staff knew about it. The CP for Resident #3, initiated and revised on 3/8/23 (two weeks after the initial unreported incident), indicated that Resident #3 had a behavior of hugging peers when comforting them. Interventions which included but were not limited to; assist me with developing more appropriate methods of coping and interacting .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed. Monitor behavior episode and attempt to determine underlying cause. Consider location, time of day, person involved, and situation. Document behavior and potential causes. Review of Resident #3's Statewide-Clinical Outreach Program for the Elderly (S-COPE), dated 3/8/23 at 11:15 am, the SCOPE indicated that Client was referred by SW [Social Worker] .after she discovered that Client made physical contact with a [male/female] resident without consent on 03/07/2023. Client reportedly kissed [male/female] resident on the forehead. [Male/Female] resident has dementia .According to staff, about a week prior Client put [his/her] arms around another [male/female] residents who appeared to be distressed and kissed [him/her] on the forehead as well. Client reported that [he/she] put [his/her] arms around [male/female] resident to calm [him/her]. Both [male/female] residents have dementia. According to Administrator, Client has no history of unwarranted sexual behavior or physical contact prior to this incident. It is unclear whether Client was informed of LTCF's [Long Term Care Facility] policy on sexual behavior after the first incident, but [he/she] was informed after the second incident. Client stated that [he/she] was not aware [he/she] was breaking the rules and would not do it again .Client is wheelchair-bound .Client was seated in an electronic wheelchair and reported being able to ambulate to a limited degree . The SCOPE further indicated that Resident #3 had Minimal Depression and with mild cognitive impairment and under Clinical Impression: Client does not appear to be an immediate threat to himself/herself or others at the time of this assessment. Client appears to have been unaware of LTCF's policy on sexual behavior. Client appeared to have the intention of showing affection and/or calming a distressed resident .Stabilization Recommendations: 1. Provide Client with policy on sexual behavior with residents and educate [him/her] on terms. Educate Client on appropriate ways of showing affection that are in line with policy. 2. Utilize line of sight supervision when Client is in close proximity to other residents. Prompt Client to maintain boundaries when appropriate. 3. Encourage Client to come to staff to report if Client notices residents in distress. 4. S-COPE recommends staff training on Managing Sexually Inappropriate Behavior in Long-Term Care . There was no staff education regarding Managing Sexually Inappropriate Behavior in Long-Term Care . documented until 3/15/23. Review of Resident #1's Psychiatric Evaluation (PE), undated, written by Psychiatry Nurse Practitioner (NP #1), indicated that Resident #1 was referred for evaluation for an allegation of inappropriate contact by another resident. The NP described Resident #1 can communicate by lifting thumbs up. The PE indicated that Resident #1 generally is easily frustrated. The PE indicated When asked [Resident #1] if [she/he] had any physical contact with another resident like hug or a kiss, [she/he] started pointing to writer [NP #1] frustrated [she/he] then produced a facility pamphlet and pointed to a female resident picture, made a gesture of two pinky fingers intertwined. When asked if this resident had any physical contact with her/him she/he became frustrated waving [his/her] hands [.] When asked if [she/he] felt safe at the facility [she/he] lifted hand thumbs up. The NP further indicated that Resident #3 was unable to describe or provide any details regarding the incident. During the conversation with the NP, Resident #1 became frustrated and walked away. Review of Resident #2's PE, dated 3/15/23, written by NP #1, indicated that Resident #2 was referred for an evaluation for an allegation of physical contact by Resident #3. The NP further indicated that Resident #2 suffers from Dementia, confused to place, time, and situations. Resident #2 was unable to provide meaningful answer and insight and judgement were poor. Review of Resident #3's PE, dated 3/15/23, written by NP #1, indicated that Resident #3 was referred to evaluate for hugging and giving a kiss to 2 residents. The NP educated Resident #3 on importance of personal boundaries and no physical contact with other residents. The MR for Resident #1 had no indication the resident was assessed, or interventions was put in place approximately 2 weeks prior to 3/7/2023 incident to protect future occurrences of inappropriate touching by Resident #3. The MR for Resident #2 had no indication the resident was assessed for the 3/7/23 incident until 3/8/23. Furthermore, the MR/CP did not indicate that interventions were put in place to protect Resident #2 from inappropriate touching by Resident #3 until 3/15/23. The MR for Resident #3 had no indication that interventions were put in place to prevent future occurrences of inappropriate touching by Resident #3 approximately 2 weeks prior to the 3/7/23 incident. The MR indicated that on 3/14/23 at 10:51 pm, Resident #3 was moved to the second floor. The MR had no documented evidence that Resident #3 was being monitored from approximately 2 weeks prior to 3/7/23 to prevent a reoccurrence on 3/7/23. During the tour of the unit on 3/14/23 from 10:05 am to 11:00 am, the surveyor observed Resident #2 wandering/ambulating in the unit. The surveyor further observed that Resident #2 and Resident #3's room were at the end of the hallway which was not visible from the nurse's station. The surveyor attempted to interview Resident #1 on 3/14/23 and 3/16/23. The resident was given a marker and paper to write his/her response. The surveyor used the computer and paper and marker to communicate to the resident. The surveyor wrote on paper Resident #1 was asked if Resident #3 had physical contact like hug and a kiss? Resident did not reply, instead, Resident #1 started showing pamphlets and pointing people on the picture. The surveyor asked who are the residents on the pictures? Resident #1 raised his/her hands with thumbs up. The surveyor asked another question. When is your birthday? Resident #1 walked away to his/her drawer and showed pictures, the resident gestured to type the names written on multiple pictures. The resident can easily be distracted and unable to participate during the interview. When the surveyor began questioning about the incident happened two weeks prior to 3/7/23, Resident #1 became frustrated, pointed at the door, and gestured to leave the room. During an interview with the surveyor on 3/14/23 at 11:43 am, Resident #3 stated that he/she was just being helpful to my neighbors, [Resident #3] tried to give them compassion by showing them by reassurance that everything will be ok. Resident #3 further explained that a few weeks ago, before the incident with Resident #2 [unable to recall time and date] I tried to help [Resident #1] because [he/she] was fighting with another resident. It happened in the hallway, I hugged and kissed [him/her] on the forehead. Furthermore, the resident stated that he/she also did the same thing with Resident #2. Resident #2 was in her/his room and was upset, Resident #3 stated that he/she approached Resident #2 and put Resident #3's arms around Resident #2 and kissed Resident #2 on the forehead. Resident #3 revealed that a few days after the incident on 3/7/23, the administrator had said you can't interact with other residents like giving them kiss and hug. During an interview with the surveyor on 3/14/23 at 12:57 pm, CNA #1 revealed that on 3/7/23 around 3:45 pm, she heard a resident saying, kiss me, kiss me from Resident #2's room. CNA #1 entered Resident #2's room and witnessed Resident #3 kissing Resident #2 on his/her face and Resident #2's head was moving from left to right. The CNA instructed Resident #3 not to kiss Resident #2. Resident #3 said okay, okay and left the room. CNA #1 reported the incident to the nurse. The CNA further revealed that approximately 2 weeks ago, prior to the 3/7/23 incident (unable to recall exact date) she witnessed Resident #3 hug and kiss Resident #1 on her/his face in the unit hallway. The CNA further stated that Resident #1's back was against the wall and Resident #3 was standing Infront of Resident #1 kissing and hugging her/him. The CNA added that Resident #1's face appeared fearful/afraid and not happy that he/she was being kissed or hugged. CNA #1 instructed Resident #3 to stop hugging and kissing Resident #1. Resident #3 walked away. The CNA reported the incident to an agency nurse on the same day. The CNA was unable to recall who was nurse that she reported the incident on 2 weeks prior to 3/7/23. During an interview with the surveyor on 3/14/23 at 1:40 pm, the Assistant Director of Nursing (ADON), Director of Nursing (DON) and LNHA, the ADON stated that on 3/7/23 (unknown time), the Licensed Practical Nurse (LPN #1) reported that Resident #3 was in Resident #2's room, stood up and kissed him/her. The ADON further stated that she did not interview Resident #2 because he/she does not speak English and has diagnosis of Dementia. The ADON also revealed that the CNA witnessed a similar incident that occurred approximately 2 weeks ago, prior to the 3/7/23 incident involving Resident #3 and Resident #1. The ADON stated that on 3/7/23, she asked Resident #1 in writing saying, Did [Resident #3] tried to kiss you? According to ADON Resident #1 immediately put her/his head down and started crying. The ADON wrote again I want to help you; you can tell me if anything happened, and Resident #1 had the same reaction. The ADON stated that she reported the incident to the DON on 3/7/23. The DON confirmed that on 3/7/23 she was made aware of the first incidents that occurred prior to the 3/7/23 incident involving Resident #3 and Resident #1 and the incident that occurred on 3/7/23 involving Resident #2 and Resident #3. The DON instructed the Unit Manager (UM)/LPN #2 to monitor Resident #3 and the investigation started on 3/8/23 by the LNHA. The DON confirmed that she did not report the incident on 3/7/23 to NJDOH. During an interview with the surveyor on 3/14/23 at 2:16 pm, the UM/LPN #2 confirmed that she was made aware on 3/7/23 of the incidents that happened approximately 2 weeks ago involving Resident #1 and Resident #2, and on 3/7/23 involving Resident #2 and Resident #3. The UM/LPN #2 stated that she did not initiate the investigation because the DON said that she will take care of it tomorrow. The UM/LPN #2 further stated that she did not update the Resident #1 and Resident #3's CP because she was not aware of 3/7/23 incident. During an interview with the surveyor on 3/16/23 at 10:10 am, the SW stated that on 3/8/23 she was made aware of the incidents by the LNHA and DON of the incident involving Resident #2 and Resident #3 that occurred on 3/7/23, and the incident with Resident #1 and Resident #3 that occurred approximately 2 weeks prior to the 3/7/23 incident. According to the SW, during the interview with the SW and LNHA on 3/8/23 (unable to recall exact time), Resident #3 could not remember if there was physical touch between Resident #2 and Resident #3, the LNHA asked did you kiss or hug [Resident #2]?, Resident #3 replied ok something happened, I might have hugged and kiss [Resident #2] by giving my support and I was comforting [him/her]. Furthermore, the SW revealed that Resident #3 stated that he/she also put his/her arms around Resident #1 [unable to recall exact time and date]. During an interview with the surveyor on 3/14/23 at 12:15 pm, the LNHA and the DON revealed that the facility had investigated an incident on 3/7/23 when CNA #1 witnessed Resident #3 was kissing and hugging Resident #2 on his/her face. The LNHA further revealed that he educated Resident #3 not to physically touch residents as that might be perceived as sexually inappropriate. The LNHA stated the incident was not reported to the NJDOH because the original statement from the staff and Resident #3 were no sexual nature and there was no context of sexual abuse. During an interview with the surveyor on 3/14/23 at 1:37 pm, the Licensed Nursing Home Administrator (LNHA) revealed that the incident involving Resident #1 and Resident #3 was not investigated because CNA #1 was unable to recall exact date and whom she reported the incident two weeks prior to 3/7/2023. The LNHA added it's a dead end. Review of the facility SELF-STUDY ORIENTATION PACKET, indicated under ABUSE/NEGLECT/ELDER JUSTICE/PEGGY'S LAW .to report any incidents or aggression or any indication of abusive behaviors. Protect residents immediately and report any cases of abuse to the Administrator immediately. This is everyone's responsibility. Notify Abuse Officer - - THE ADMINISTRATOR immediately!! Thoroughly investigate - - statements from everyone Reported immediately to state agency and law enforcement officials when appropriate . The facility policy titled; Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated 9/22/22, indicated All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Reporting Allegations to the Administrator and Authorities 1. If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying /likening the facility; b. The Local/state ombudsman; c. The resident's representative .Law enforcement officials; f. Attending physician; and .3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone .All allegations are thoroughly investigated NJAC 8:39 - 4.1 (a) (5)