Every finding on record at Complete Care at Regent LLC

Based on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure each resident who was at risk for elopement was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building. Specifically, the facility failed to: a.) ensure the order and care plan included a function check of the wander guard for 1 of 3 residents (Resident #55), b.) test the battery status of the wander guards weekly as per the recommendation of the manufacturer for 3 of 3 residents (Resident #2, Resident #55, and Resident #97), and c.) have a policy/procedure in place for the wander guard bracelet or system used by the facility for 3 of 3 residents (Resident #2, Resident #55, and Resident #97). This deficient practice was evidenced by the following: 1. On 7/21/26 at 10:40 AM, the surveyor observed Resident #2 sitting on the bed and had a wander guard (wearable device that triggers alarms or locks doors to prevent unsupervised exits) on their right wrist, and it was blinking red. On 7/21/26 at 10:55 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1), who stated the wander guard should be green. LPN #1 further stated that red blinking was a warning sign that the resident was out of the range of motion. On 7/21/26 at 11:05 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that a blinking green light on the wander guard meant the battery was working. The RN/UM further stated that when the resident gets closer to the elevator, it turns red. On 7/21/26 at 11:10 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated the wander guard was never green, and it was always red. The ADON stated they had to do an in-service for the unit. The ADON further stated that if the resident was near the elevator, the elevator would beep unless someone entered the code. A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/26/26, revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated severely impaired cognition. Further review of the MDS reflected that the resident used a wander/elopement alarm daily. 2. On 7/21/26 at 12:03 PM, the surveyor observed Resident #55 sitting on the bed and had a wander guard on their left ankle, and it was blinking red. On 7/21/26 at 12:50 PM, the surveyor reviewed the medical records of Resident #55, which revealed: A review of the admission Record (AR) or face sheet (an admission summary) revealed the resident had diagnoses that included, but were not limited to; Alzheimer's Disease (a brain disorder that causes memory loss) with late onset and dementia (a loss of memory and thinking abilities) in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. A review of the quarterly MDS (qMDS) with an ARD of 7/9/26, revealed a BIMS score of 7 out of 15, which indicated severely impaired cognition. Further review of the qMDS reflected that the resident used a wander/elopement alarm daily. A review of the Order Summary revealed a physician order (PO), check wander guard placement to left lower extremity every shift. The order started on 6/4/26. The above PO did not include to check the function of the wander guard. A review of the individualized comprehensive care plan (CP) included that the resident was an elopement risk/wanderer related to (r/t) disoriented to place, resident wanders aimlessly, with an initiated date of 6/4/26. Interventions that were initiated on 6/4/26, included, but were not limited to; monitor location every shift [of the wanderguard], document wandering behavior, and attempted diversional interventions in behavior log. The CP did not include to check the function of the wander guard. On 7/24/26 at 12:18 PM, the surveyor discussed the above concerns with the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS). The VPCS confirmed that the PO should state to check the placement and function of the wander guard. On 7/27/26 at 11:26 AM, the survey team met with the LNHA, and the VPCS stated they corrected the order to include placement and function, and they in-serviced the staff. 3. On 7/21/26 at 10:43 AM, the surveyor observed Resident #97 seated on a chair at a table in the dayroom. A review of Resident #97's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia and other frontotemporal neurocognitive disorder (a progressive brain disease affecting the frontal and temporal lobes, commonly causing changes in behavior, personality, and language rather than early memory loss). A review of Resident #97's most recent qMDS with an ARD of 6/5/26, reflected that the resident had a BIMS score of 5 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the qMDS reflected that the resident used a wander/elopement alarm daily. A review of Resident #97's individualized comprehensive CP included that the resident was at risk for an elopement and wandered aimlessly due to Alzheimer's with an intervention that included but was not limited to wander alert: wander guard device to right hand # Model A-4622-3207, check for functioning and placement every shift. A review of Resident #97's July 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) included the following PO: Wander Alert: Wander guard Device to right hand # Model A4622-3207, check for placement and function every shift every shift, with an order date of 4/29/26. Further review reflected that the nurses were marking y or yes to indicate that they checked for placement and function every shift. The night shift nurse on 7/4/26 wrote n. On 7/22/26 at 10:37 AM, the surveyor interviewed LPN #2 about how the wander guard function was tested. LPN #2 stated that every shift they checked the placement and function by observing the red light on the wander guard bracelet. He added that if the red light was on then it working. On 7/23/26 at 10:51 AM, LPN #3 informed the surveyor that if a resident at risk for elopement during assessment, a wander guard would be placed, and we check placement of the wander guard. On 7/23/26 at 11:02 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that they checked the wander guard bracelet function by checking that the red light was blinking [on the bracelet]. On 7/24/26 at 9:55 AM, the surveyor interviewed the LPN/UM, who stated that he thought that something was ordered for check wander guard function, and that they checked the battery by the blinking light [on the bracelet]. He further stated that he would get back to the surveyor as to why there was no PO for checking the wander guard function. On 7/24/26 at 10:01 AM, the surveyor interviewed the ADON in the presence of the Regional Nurse regarding checking the wander guard battery status. The ADON stated that they had a [name of machine] (device used with the wander guard bracelet/system) which was used activate and showed functioning. The ADON stated that she checked the battery with the use of the machine weekly. The ADON further stated that she did not have documentation or log that would show accountability that battery check was done weekly. The ADON stated that she was going to check them all and document the status of the battery for the residents. On 7/24/26 at 12:51 PM, the surveyor notified the LNHA and the VPCS the concern that Resident #97's wander guard bracelet was not tested for battery status weekly as recommended by the manufacturer, a nurse wrote n for the placement and function order, and the facility did not have a policy or procedure for the wander guard bracelet/system. On 7/27/26 at 11:22 AM, in the presence of the LNHA, the VPCS stated that staff were in-serviced on the wander guard with battery. The VPCS further stated that she spoke with the nurse that wrote the no, and that the nurse wrote the n by mistake and that the resident always had the wander guard bracelet on and had the blinking light. The LNHA did not provide any additional information. A review of the facility provided email from the wander guard sales representative dated 4/29/26, included the following: The [name] machine is used to turn the tags on/off, check battery percentage, and tag warranty. -if they are using the legacy tags, they can confirm the tag is on if the red LED light is blinking (if the tag is not dead). A review of the facility provided manufacturer's instruction for use manual, dated August 2014, included the following: Under Chapter 3: Tags, [name], [name], & [name] of machines. Visual Pulse LED: The Visual Pulse LED (red light on bracelet/tag) indicates the tag's current mode by displaying corresponding light patterns as shown in the following table: table indicated that if no light pattern the tag was off; light blinking that the tag was active but not in zone; light was steady that the tag was active and in zone. Testing Tags: tags are powered by an internal battery. Over the course of normal operation, tags eventually lose battery power and the whole tag will need to be replaced. The tag battery is not replaceable. For maximum protection of residents, company recommends that tags be tested on a weekly basis. There are many ways to test tags:.Use a [name]/[name] of machines; Check tags visual pulse LED, if present. The [name] machine: Activating/Deactivating Tags; Testing Tags. Testing Tags: Testing a Tag for ID, Battery Level, & Warranty Date.To test a tag while it is being worn:.2) Hold the [name] machine up to and within 3 inches of the tag.3) If the tag has a low battery, the screen will display the letters LB (low battery) next to the tag number. In this case, you must replace the tag immediately. Never use a tag with a low battery. Under Chapter 11: FAQ (frequently asked questions) & Troubleshooting Tags:.How often should I check a tag's battery with my [name] of machine? .Periodic weekly testing of tags for long-term patients is also recommended. A review of the facility's Elopements and Wandering Residents Policy, dated 9/1/25, included the following: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The policy did not contain any information on the wander guard bracelet or system used by the facility. The facility did not provide a policy for the wander guard bracelet/system. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices to prevent and control the spread of infection. Specifically, the facility failed to: a.) follow neutropenic precautions for 1 of 1 resident1 (Resident #1), b.) follow enhanced barrier precautions (EBP) for 1 of 2 residents (Resident #82), and c.) ensure water management plan was followed after a presumptive healthcare-associated Legionnaire's disease was identified. This deficient practice was evidenced by the following: Reference: Centers for Disease Control (CDC) Clinical Guidance for Legionella Infections, dated 6/9/25, included the following: For Health Care Providers, Key points: Legionnaires' disease can't be clinically or radiographically distinguished from pneumonia due to other pathogens. Appropriate testing must be performed to make the correct diagnosis and inform treatment decisions. The first-line treatment for healthcare-associated or community-acquired pneumonia doesn't always include Legionella-directed antibiotics. Defining the incubation period. For case investigation purposes, public health officials collect exposure histories for the 14 days before date of symptom onset. Indications for Legionnaires' disease testing. Testing for healthcare-associated Legionnaires' disease is especially important if any of the following are identified in a healthcare facility: Healthcare-associated Legionnaires' disease diagnosis in the last year. Positive environmental tests for Legionella. Recent changes in water quality that may lead to Legionella growth. 1. On 7/22/26 at 1:12 PM, the surveyor interviewed the Director of Maintenance (DM) and the Regional Maintenance Director (RMD) regarding the facility's water management plan. The RMD stated that the facility recently had a suspected legionella case for one of their residents (Unsampled Resident #5) that the local health department (LHD) notified them of. The RMD stated that the LHD notified them that the in house water testing kits that the facility had been using was not the preferred ones, and that they had just hired a water management consultant who was now going to test their water. The RMD further stated that the LHD had given recommendations and that they just had a walk through recently with the LHD. The RMD also stated that their own inhouse water tests that were previously done were negative [for legionella] but that a resident (Unsampled Resident #5 (UR #5)) went out to hospital and the hospital did contact tracing and LHD were here last week. The surveyor requested the last testing result, any emails/letters from LHD and new water management consultant and a copy of their water management plan. On 7/23/26 at 9:31 AM, the surveyor interviewed the RMD and Infection Preventionist/Registered Nurse (IP/RN). The RMD stated that they were notified in June that there was a presumptive healthcare associated legionella infection. The RMD stated that they received a phone call from LHD with recommendations to not use tap water, turn off ice machine, and use bottled water which they implemented. The RMD stated that they received an official call with LHD on 6/26/26, and that they told them to go back to the water and ice and that they recommended point of use filters for showers and hire water management consultant. The RMD stated that they installed the filters before they got the letter from LHD on 6/30/26. The RMD stated that the LHD came for a walk through of the facility on 7/15/26, which included looking at the boiler, piping and dead legs and asked about flushing pipes. The RMD stated that they were still waiting for the report and that they would implement any other recommendations at that time. The RMD stated that they had done everything the LHD had told them to do so far. On that same date and time, the surveyor asked what was done on the clinical side, and the IP/RN stated that they were able to resume and accept residents on aspiration risk and that she reviewed the antibiotic (ABT) stewardship binder to determine if any residents had pneumonia or pneumonia like infection for a six months lookback period. The IP/RN stated that there was no resident that had a facility acquired pneumonia. The IP/RN stated that UR #5 was the suspected case. The surveyor asked if UR #5 had a roommate prior to the resident's hospitalization, and the IP/RN stated that she was fairly new in her position as IP and that she would have to check. The surveyor asked what the expectation would be if there was a roommate, and the IP/RN stated that she would have to get back to the surveyor. The surveyor asked for a copy of the bed board for UR #5's room. The IP/RN stated that the LHD called from outside to let us know of the infection. The surveyor asked if the facility did their own contact tracing or investigation. The RMD stated that he did not think that the LHD wanted them to do anything and that the LHD did it with them. The surveyor asked what was done according to their facility water management plan. The RMD stated that they performed the flushes. The IP/RN stated that residents at risk [for aspiration] were not given facility water and ice. The IP/RN further stated that they did not perform any contact tracing and that UR #5 went to the hospital on 6/10/26. A review of the facility provided Midnight Census Report reflected that UR #6 was UR #5's roommate. A review of the facility provided LHD Template: Notification Letter to a Healthcare Facility Regarding a Presumptive Healthcare-Associated Case of Legionnaires' Disease, dated 6/22/26, included the following: On 6/11/26, LHD received a report of a patient who meets the public health criteria for presumptive healthcare-associated Legionnaires' disease (LD), given that they were a resident for 10 or more days during the 14 days before onset of symptoms. The identification of a presumptive healthcare-associated LD case raises concerns about potential ongoing Legionella transmission within your facility. To minimize any risk of continued transmission, the LHD and the New Jersey Department of Health recommend a full outbreak investigation, in collaboration with your facility's infection control, building maintenance, administration and risk management teams. Please provide your availability for a one-hour conference call within the next five business days.In the meantime, please take the following actions to identify any additional healthcare-associated cases of LD. Immediately notify the LHD if you discover other diagnoses among residents, staff or visitors. We also recommend implementing immediate control measures to minimize the risk of Legionella exposure for building occupants. Further recommendations will follow upon receipt of the Facility Background Assessment Tool. The letter included Case Surveillance recommendations and Immediate Control Measures. A review of the facility provided undated Water Management Plan included the facility water system and control measures and corrective action. The plan also included the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/17, which included the following: Healthcare Facilities.if a case of healthcare associated Legionnaires' disease is discovered in a healthcare facility: Make sure the person with expertise in infection prevention on your team is aware. Important: Tell clinicians so they can test patients with healthcare-associated pneumonia for Legionnaires' disease with both culture of lower respiratory secretions and the Legionella urinary antigen test. Identifying & Investigating Legionnaires' Disease Cases. A healthcare facility's water management program to limit Legionella growth and spread should include the actions to take when a patient is diagnosed with Legionnaires' disease or environmental triggers occur. On 7/23/26 at 12:15 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that they had a meeting with the LHD and state regarding a resident that tested positive for legionella. She added that they asked the LHD when they called us if there was anything they had to do and that they would call them back. The surveyor asked if any notifications were sent out. The ADON stated that she would have to ask about that. On 7/23/26 at 12:22 PM, the surveyor asked the IP/RN if they followed their water management plan, and the IP/RN stated that they were waiting on LHD additional recommendations. She further stated that they did what the LHD told them to do so far. The surveyor asked if any of the clinicians were notified to test anyone that has signs or symptoms. The IP/RN stated that the LHD did not tell us who to notify. The IP/RN stated that the LHD did not tell them anything about notifying the doctors about the legionella results. The IP/RN further stated that they were waiting on the LHD for any further recommendations. On 7/24/26 at 12:54 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS) the concern that the facility did not follow their water management plan and did not notify clinicians to test residents for Legionnaires' disease if they had signs or symptoms of pneumonia in accordance to the facility's water management plan. The VPCS stated that they did look back and reviewed in morning meeting that no one had signs or symptoms. On 7/27/26 at 11:22 AM, in the presence of the LNHA, the VPCS stated that they were doing what the LHD told them. She added that if anyone had signs or symptoms that they would be tested and that she reviewed on Friday to make sure there was no one with symptoms. The LNHA did not provide any additional information. There was no additional emails or letters provided to the surveyor from the LHD. A review of the facility's Water Management Program Policy, with a reviewed/revised date of 10/14/25, included, it is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens. in the facility's water systems based on nationally accepted standards (e.g. CDC .).Definite healthcare-associated Legionnaires' disease refers to a case of Legionnaires' disease in a resident who spent the entire 10 days prior to onset of illness in facility.14. Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years. 2. On 7/21/26 at 10:54 AM, the surveyor observed a green sign titled, Protective/ Reverse Isolation, that was posted on the wall beside the door, outside Resident #1's room. The sign was posted directly under the room number and resident's name on the wall. It was written under the title on the sign, (Reverse barrier nursing, for patients who are immune-compromised. (Organ transplant, neutropenia, cancer, etc). Instructions on the sign included but were not limited to, Door is closed at all times. On 7/21/26 at 10:55 AM, the surveyor observed the resident was sitting in a wheelchair beside the bed inside their room, and the door was kept open. On 7/22/26 at 11:05 AM, the surveyor made a second observation that the resident's door was open. On 7/23/26 at 9:45 AM, the surveyor made a third observation that the resident's door was kept open while the resident was inside the room. On that same date and time, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1), who stated that the sign with rules to protect the resident was found right outside the room. After reading the sign, LPN #1 acknowledged that the door should have been closed at all times. LPN #1 further stated the reason they did not close the door was that they were used to seeing the other sign for EBP. LPN #1 observed the resident's door was open, and then LPN #1 closed the door after surveyor's inquiry. A review of the admission Record (AR) or face sheet (an admission summary) revealed the resident had diagnoses that included, but were not limited to, primary central nervous system lymphoma (a disease in which cancer cells form in the lymph tissue of the brain and/or spinal cord). A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 4/21/26, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderately impaired cognition. A review of the Order Summary Report (OSR) revealed a physician order (PO), maintain protective isolation for neutropenia (a condition in which there is a low level of neutrophils, a type of white blood cell that fights infections) every shift for infection prevention. The order started on 5/1/26. A review of the individualized comprehensive care plan (CP) revealed the resident was receiving by mouth ABT for neutropenia, with an initiated date of 4/17/26. Interventions initiated on 4/17/26, included but were not limited to, implement neutropenic precautions as ordered. 3. On 7/22/26 at 11:22 AM, the surveyor observed a sign titled EBP that was posted on the wall beside the door, outside Resident #82's room. The sign was posted directly under the room number and resident's name on the wall. It was written under the title on the sign, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. On 7/22/26 at 11:39 AM, the surveyor observed Resident #82 lying in bed with a tracheostomy (trach) tube (a tube inserted into the opening made in the windpipe to help someone breathe) and did not appear to be in distress. At this time, the surveyor observed that LPN #2 suctioned (a procedure that helps clear mucus secretions in people with a trach) the trach without wearing a gown. On 7/22/26 at 11:50 AM, the surveyor interviewed LPN #2, who acknowledged they did not wear a gown while suctioning the trach. LPN #2 further stated they think they were supposed to wear a gown. LPN #2 stated the reason they did not wear a gown was, I have to suction [the trach] every half an hour and have 35 patients. On 7/22/26 at 11:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM), who confirmed that the nurse must gown up to suction the trach due to body fluids coming out from the trach. A review of the AR revealed the resident had diagnoses that included, but were not limited to; type 2 diabetes mellitus with hyperglycemia (a disease in which blood sugar levels are higher than normal because the body does not make enough insulin or use it the way it should), essential (primary) hypertension (high blood pressure), trach status (a procedure that creates an opening in the neck), and gastrostomy status (a procedure that creates an opening into the stomach). A review of the comprehensive MDS with an ARD of 7/14/26, revealed that the resident was rarely understood. A review of the OSR for the resident revealed an order, EBP for PEG (Percutaneous Endoscopic Gastrostomy; a procedure in which a tube in inserted into the stomach) every shift for Infection prevention. The order started on 7/9/26. On 7/24/26 at 12:18 PM, the surveyor discussed the above concerns with the LNHA and VPCS. A review of the facility's Neutropenic Precautions Policy, reviewed/revised 10/14/25, revealed, it is the policy of this facility to ensure that residents that require neutropenic precautions are protected from the risk of infection based on current standards of practice. The nurse will obtain and verify the PO for neutropenic precautions and place signage outside the resident's door informing staff, residents and visitors of the precautions. Utilize standard precautions with the additional precautions noted. CP accordingly. Staff, visitors, and other residents will adhere to the guidance of the precautions to help protect the affected resident. The resident should be placed into a single-resident room with the door shut. Avoid crowded places. A review of the facility's Enhanced Barrier Precautions Policy, reviewed/revised 10/1/25, revealed, it is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. Definitions: EBP, refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. High-contact resident care activities include, but are not limited to, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripherally inserted central catheter (PICC) lines, midline catheters. NJAC 8:39-19.4

Based on observation, interview, and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times. This deficient practice was identified for 1 of 1 resident (Resident #4), reviewed for dialysis services.The deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 7/21/26 at 10:40 AM, the surveyor observed Resident #4 in the hallway able to self propel their wheelchair, who stated they go to dialysis on M (Monday)-W (Wednesday)-F (Friday) at 5:45 AM, and returned to the facility around 10:30 AM.On 7/22/26 at 3:30 PM, the surveyor reviewed the electronic medical records of Resident #4.A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included but not limited to; type 2 diabetes mellitus (DM) with proliferative diabetic retinopathy with macular edema, bilateral, end stage renal disease (ESRD), and dependence on renal dialysis.A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/1/26, revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS reflected that the resident had diagnosis of ESRD and on dialysis (procedure which removes waste and excess fluid from the blood).A review of the care plan (CP) revealed ESRD requiring hemodialysis (HD) three times per week via left arm AV (arteriovenous) fistula (LAVF).date initiated 12/26/23, on continuous glucose monitor, date initiated 7/1/26, diabetes mellitus and diabetic retinopathy, date initiated 9/20/23, and impaired visual function related to cataracts to right and left eye, date initiated 6/16/26.A review of the physician orders (PO) and nursing progress notes (PN) revealed:-HD via LAVF due to ESRD three times a week. [Name Redacted] dialysis center M-W -F pick up at 5:25 AM, chair time 6:00 AM x 4 hours . in the morning every M, W, F for dialysis -Order Date 6/10/26.-Apply [brand name] sensor to the back of upper arm area and change sensor every 10 days rotating sites, and PRN (as needed) if dislodged, malfunctioning one time a day every 10 day(s), ordered 7/2/26. The electronic Medication Administration Record (eMAR) reflected the time was plotted for 9:00 AM, and was signed by the nurses in the facility that it was administered on Wednesday 7/8/26 at 9AM (the resident was at dialysis center at this time).-Prednisolone Acetate Ophthalmic Suspension 1 %. Instill 1 drop in both eyes three times a day for post-surgery until 7/30/26, ordered 7/17/26.The eMAR reflected it was plotted for 9:00 AM, and on Monday 7/20/26, and Wednesday 7/22/26, it was marked as #7 (see PN).A review of the nursing PN revealed there were no nursing notes documented on 7/20/26, and on 7/22/26 the PN revealed resident was out for HD.-Humalog Injection Solution 100 unit/ml (milliliters) inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Notify MD (Medical Doctor) if blood sugar (BS) is less than 70 or higher than 400, subcutaneously before meals and at bedtime for DM, order date 6/30/26.A review of the eMAR revealed it was plotted at 7:00 AM, and signed every M-W-F with a BS value while the resident was in HD center (7/1/26, 7/3/26, 7/6/26, 7/8/26, 7/10/26, 7/13/26, 7/15/26, 7/17/26, 7/20/26, and 7/22/26), a total of 10 days.On 7/23/26 at 11:17 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), in the presence of a staff License Practical Nurse (LPN) regarding the process for medication (med) administration for residents on dialysis. The ADON (also a Registered Nurse) stated that usually medications (meds) were put in around the dialysis time. The ADON further stated we usually administered meds when the resident returned from HD. At that same time, both the ADON and the LPN reviewed the eMAR, and both confirmed meds should not have been given at those times. The ADON/RN further stated that the resident was not at the facility those times that the eMAR was signed for meds as administered.On 7/24/26 at 12:54 PM, the survey team met with the License Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS), and the surveyor notified them of the above findings and concerns that Resident #4's meds were not accommodated according to the resident's HD days and times. On 7/27/26 at 11:23 AM, the survey team met with the LNHA and the VPCS stated the orders were updated to schedule around dialysis time after surveyor's inquiry.On 7/27/26 at 12:05 PM, during the exit conference with the VPCS, and the LNHA did not provide additional information.A review of the facility's Hemodialysis Policy, date revised 9/1/25, revealed under Compliance Guidelines: #5 The licensed nurse will.include but not limit itself to: a. Timely med administration.by the nursing home.A review of the facility's Medication Administration Policy, date revised 9/1/25, revealed under Policy Explanation and Compliance Guidelines: #10. Ensure that the six rights of med administration are followed: e) Right time.NJAC 8:39-11.2(b), 27.1(a), 29.2(d)

REPEAT DEFICIENCYBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure a resident had reasonable access to the facility call system, by failing to maintain the call bell within the resident's reach. This deficient practice was identified for 2 of 32 residents (Resident #13 and Resident #123) reviewed for call bell accessibility, and was evidenced by the following: 1. On 7/22/26 at 9:35 AM, the surveyor observed Resident #13 lying in bed. During an interview, Resident #13 stated that they needed to go to the bathroom. The surveyor observed the resident's call bell positioned behind the resident at the top of the bed, and out of her reach. When the surveyor asked Resident #13 if they knew where their call bell was, the resident stated, No. At that same time, the surveyor requested an assistance from Licensed Practical Nurse #1 (LPN #1), who was assigned to Resident #13. The LPN/Unit Manager (LPN/UM) subsequently entered the resident's room. The LPN/UM observed and acknowledged that the call bell was not within Resident #13's reach and was not accessible to the resident. On 7/22/26 at 10:29 AM, the surveyor reviewed the medical record for Resident #13. A review of Resident #13's admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included but were not limited to; type 2 diabetes mellitus, paranoid schizophrenia, bipolar disorder, anxiety disorder, uninhibited neuropathic bladder, and peripheral autonomic neuropathy. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Further review of the MDS revealed the resident had experienced a decline in functional mobility. On 7/24/26 at 10:04 AM, the surveyor interviewed the Director of Rehabilitation/Occupational Therapist and Regional Rehabilitation Manager, who stated that the resident had experienced a decline in function, and that an assessment dated [DATE], determined she was unable to sit unsupported for 30 seconds, and that the resident required bedside care, and was receiving rehabilitation for muscle weakness and endurance. On 7/27/26 at 12:10 PM, the Licensed Nursing Home Administrator (LNHA) acknowledged that Resident #13's call bell should have been maintained within their reach and accessible so that they could summon staff for assistance. 2. On 7/21/26 at 9:53 AM, the surveyor observed Resident #123 seated in a wheelchair in their room that was positioned at the foot of the resident's bed. Resident #123 stated that they had to wait sometimes for someone to come when they had to go to bathroom. Resident #123 then added that they needed to go to the bathroom. The surveyor observed that Resident #123's call bell was on the floor between the head of the bed and the bedside dresser. Resident #123's call bell was not within reach for the resident to use. On 7/21/26 at 9:55 AM, the surveyor interviewed LPN #2, who stated that the expectation was to have the call bell within reach of the resident. The surveyor asked LPN #2 to go to Resident #123's room and he confirmed that Resident #123's call bell was not within their reach. A review of Resident #123's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; hypertension (high blood pressure) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and acts). A review of Resident #123's most recent quarterly MDS with an ARD of 4/20/26, reflected that the resident had a BIMS score of 13 out of 15, which indicated that the resident's cognition was intact. On 7/24/26 at 12:50 PM, the surveyor notified the LNHA and [NAME] President of Clinical Services (VPCS) the concern that Resident #123's call bell was not within reach during the initial tour and that the resident informed the surveyor that they needed to go to bathroom. On 7/27/26 at 11:22 AM, in the presence of the LNHA, the VPCS stated that staff were in-serviced on call bells. The LNHA did not provide any additional information. A review of the facility's Call Lights: Accessibility and Timely Response Policy, with a reviewed/revised date of 1/15/26, included the following: Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call light is within reach of resident and secured, as needed. N.J.A.C. 8:39-27.1(a)

Complaint #2691795Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide notification to the resident representative regarding resident status and change in condition for 1 of 2 residents (Resident #172) reviewed. This deficient practice was evidenced by the following: On 7/21/26 at 9:28 AM, during an initial meeting with the survey team, the Regional Administrator, who stated he was the current acting Licensed Nursing Home Administrator (LNHA). The LNHA provided the surveyors with access to the electronic medical records (eMR) and stated all medical records were in the eMR, there were no paper medical records for review.The surveyor reviewed the eMR for Resident #172, and revealed:A review of the admission Record (AR) or face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, constipation, insomnia, and hypertension. Further review of the AR reflected the Resident Representative (RR) was emergency contact #1, and with a phone number listed. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 7/23/25, reflected the resident had unclear speech, was rarely/never understood, and rarely/never understood others. Section C (cognitive patterns), reflected a staff assessment for mental status, which revealed that the resident had both short-term and long-term memory problems, and cognitive skills for daily decision making were severely impaired - never/rarely made decisions. A review of the progress notes (PN), a nursing admission note [date redacted] at 2:51 PM, reflected the resident arrived via wheelchair from home, assessment completed, vital signs taken, skin color was normal, alert, oriented to person only [not place or time]. A review of the PN, nurses noted dated 8/11/25 at 3:30 PM, reflected resident vomited x 1, poor appetite. MOM (milk of magnesia) and suppository administered. No BM (bowel movement) noted. Endorsed to incoming nurse to continue monitoring.A review of the PN, nurses note dated 8/12/25 at 9:17 AM, reflected abd (abdominal) x-ray results, the physician was notified with orders for bowel rest, start an IVF (IV fluids) for hydration, stat (immediate) blood work, repeat abd xray, and kept NPO (nothing by mouth). The PN also reflected that the RR was unable to reach. Further review of the above PN revealed that there was no attempt to call nor notify the RR of the change in condition of the resident on 8/11/25, nor further attempt to notify the RR when the abd x-ray results received and the physician had new orders. A review of the PN, physician note dated 8/12/25 at 10:10 AM, revealed that the physician documented that he was called today with abnormal x-ray results showed mild ileus versus early distal obstruction. The physician further documented that review of 8/8/25 laboratory (lab) results showed wbc (white blood cell count, a test that measures the infection-fighting cells in blood. It is a standard part of a routine Complete Blood Count (CBC) of 11.1 (normal range 4-11). The PN reflected that the plan of care for NPO, IVF, and repeat abd x-ray were discussed and reviewed with the resident and nursing.A review of the PN, physician note dated 8/14/25 at 9:50 AM, reflected a urinary tract infection (UTI) and plan to start Rocephin 1 gm IV daily for 5 days depends on the sensitivity (resistance to antibiotics). Start Reglan 5 mg 1 tab by mouth every 8 hours and the resident will be NPO. Further review of the PN of the physician reflected that plan of care was discussed with the resident who was cognitively impaired and there was no documented evidence that the RR was notified of the plan of care on 8/12/25 and 8/14/25.A review of the weekly skin evaluation dated 8/22/25 at 6:51 PM, reflected skin impairments in the perianal area and posterior head that were previously identified, and plan of care was in placed.Further review of the eMR revealed there was no documented evidence that the physician nor the RR were notified of the skin impairments that were identified on 8/22/25. A review of the PN, physician note dated 8/27/25 at 11:00 AM, reflected a plan which included a discharge (d/c) on 8/28/25 to home. The PN included a documentation that the plan for d/c was discussed with the social service team on 8/27/25, and the plan of care was reviewed with the patient and nursing. A review of the PN, nurses note dated 8/28/25 at 8:11 PM, reflected resident was discharged home via [company redacted] ambulance.Further review of the eMR did not reflect nursing communication with the RR with regard to d/c plan. There was no documented evidence that the SW had reached out to the RR for d/c plan.On 7/24/26 at 12:07 PM, the surveyor interviewed the SW, who stated she was the only SW employed by the facility at this time. She stated Resident #172 was assigned to a different SW who was no longer employed at the facility. The SW stated the process in her role was to see residents on admission, for any forms that need to be signed, any family meetings, then at quarterly care plan (CP) meetings. On that same date and time, the SW reviewed the eMR for Resident #172, and acknowledged there was no assessment and no notes from a SW during the resident's stay at the facility. The SW further stated she recalled speaking to the RR herself, but could not produce a note to reflect an interaction with the RR. The SW confirmed that the resident was cognitively impaired and all communications should be addressed to the RR.On 7/24/26 at 12:24 PM, the survey team met with the LNHA and the [NAME] President of Clinical Services (VPCS) acknowledged there should have been nurses notes to reflect the RR was made aware of changes in the resident's status, particularly with regard to skin, bowels and bladder, NPO status, lab testing, and IV fluids and medication. On 7/27/26 at 11:22 AM, the survey team met with the LNHA and the VPCS stated the SW who was assigned to Resident #172 was no longer there. The VPCS further stated she spoke to the prior Unit Manager (UM) by phone who said she spoke to the RR often but nothing was documented. A review of the facility's Notification of Changes Policy, implemented 3/20/25, reflected the purpose of the policy was to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the RR when there is a change requiring notification. Compliance guidelines reflected circumstances requiring notification to include:.2. Significant change in the resident's physical, mental or psychosocial condition. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. discontinuation of treatment due to adverse consequences, acute condition, exacerbation of chronic condition. 4. A transfer or d/c of the resident from the facility.Additional considerations reflected 2. Residents incapable of making decisions: a. the representative would make any decisions that have to be made.A review of the facility's job description for SW which included a section titled Major Duties and Responsibilities. This included.The SW will contribute to.social services goals and approaches to the comprehensive CP.Accurately and completely document social service actions and interactions in each resident's medical record.A review of the facility's job description for Registered Nurse which included a section titled Major Duties and Responsibilities. This included.Assesses changes in residents' status, notifying the physician and RR and documenting accordingly.A review of the facility's job description for Licensed Practical Nurse which included a section titled Major Duties and Responsibilities. This included.Monitor for changes in resident's status, notifying the physician and RR and documenting accordingly.NJAC 8:39-4.1 (a)2; 13.2(a)

REPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified as 1 of 1 dining area (4th floor), 2 of 2 shower rooms (4th floor), 1 of 32 residents' rooms (Resident #12), and was evidenced by the following:1. On 7/21/26 at 10:32 AM, the surveyor observed 4th (fourth) floor unit dining room, just across the nursing station, there were total of 11 residents while recreational activity was ongoing with one Activity Aide (AA). The surveyor observed inside the dining room, sticky floor, the floor molding and floor tiles with blackish accumulation, which the floor molding extended to the wall with brown dried substances. There was a black cabinet with whitish substances stained on the lower part, the center ceiling vent and surrounding ceiling tiles with accumulation of blackish stained and substances, there were scattered pieces of paper, plastic, wrappers of sugar on the floor, next to the entry way to the dining area a dust pan and a broom next to the table and telephone. There were peeling off of wall paper surrounding the dining area, the wall air condition (aircon) vent with two metal grills with heavy accumulation of grayish to blackish substances, and the window sill with wooden part uneven.Afterward, the AA acknowledged all the above surveyor's concerns and stated that it was a while that the room was thoroughly cleaned. The AA further stated the room was dirty, and should fix the walls and the ceiling. 2. On 7/21/26 at 10:38 AM, the surveyor observed prior to entering Resident #12's room, the floor molding with blackish substances, the floor was sticky, the side table upon entry with heavy accumulation of unknown orange, brownish, and blackish color in the metal part on the bottom area.Inside the resident's room, the surveyor observed the floor molding with gaps and the peeling of wall paper that was near the toilet room. Inside the toilet room, the surveyor observed the floor with heavy accumulation of blackish and brownish substances, the floor molding above peeling off wall paper, with blackish accumulation around, the floor tiles beneath the toilet seat was uneven, and there were no paper towels. On 7/21/26 at 10:41 AM, the surveyor asked the Housekeeper (HK) to go with the surveyor inside Resident' #12's room. Inside Resident #12's room, the HK confirmed that the floor needed to be stripped because even though it was swept daily, it did not clean that much. The HK further stated that she was responsible for cleaning the room, but the side table should have been replaced for a new one because she would not clean the vomit that was on the bottom metal part of the side table because of infection. She confirmed the wall was peeling off and the molding was dirty, and toilet room uneven floor tiles not her responsibility. She further confirmed there were no paper towels.On 7/21/26 at 10:45 AM, the surveyor asked the Licensed Practical Nurse/Unit Manager (LPN/UM) to accompany the surveyor inside Resident #12's room. Inside Resident #12's room, the LPN/UM confirmed the above concerns with the floor, floor molding, side table of the resident which she stated disgusting, the wall paper peeling off, gaps in the floor molding, inside the toilet room floor tiles wall paper peeling off, and no paper towels.At that same time, the roommate of Resident #12 confirmed that the room was dirty, and had no paper towel for few days. The LPN/UM stated that she would notify the management about the concern. The LPN/UM further stated, definitely the room needed deep cleaning, and did not look like it was deep cleaned recently. 3. On 7/21/26 at 10:48 AM, both the surveyor and the LPN/UM toured Bathing 1 (also known as the shower room), and the LPN/UM confirmed the shower room being used by residents for showers. Both observed upon entry, on the left side, 1st (first) cubicle, which was the toilet area, the ceiling vent with accumulation of grayish substances, and the LPN/UM stated that was dust. The wall aircon/heater wall paper was peeling off and blackish in color. There were stocks of boxes and black bags inside the shower room, near the window, which the LPN/UM stated were residents' personal stuff.Afterward, both the surveyor and the LPN/UM went to the next room, Bathing 2 (another shower room) and observed upon entry, there were missing and broken floor tiles, which the LPN/UM confirmed that there should be no missing and broken tiles on the floor to prevent fall incidents of residents and staff. The shower bed padding was peeling off and was confirmed by the LPN/UM, who acknowledged that they should be fixed to promote safety and prevent infection with the residents. The 1st cubicle to the right upon entering the door was the toilet area with aircon/heater wall paper blackish in color. The 3rd (third) cubicle with shower chair and a blanket on the floor, the LPN/UM stated that was probably used to wipe the floor and should not leave there.On 7/21/26 at 10:55 AM, the surveyor and the LPN/UM went to the 4th dining room (also known as the activity room), and both observed the concern with the sticky floor tiles, blackish substances around the floor molding, the wall with dried brownish substances, the black cabinet with whitish substances on the bottom area, the window area peeling of wall paper and wooden area, the ceiling vent and ceiling tiles around in the middle of the dining area blackish in color, and the center and around the area of the floor tiles inside the dining room with accumulation of blackish substances, which she confirmed dust, and should have been cleaned.On 7/21/26 at 11:10 AM, the surveyor interviewed the contracted Director of Environment Services (DES), and the surveyor notified the DES of the above findings and concerns with the 4th floor dining room, 4th floor shower rooms, and Resident #12's room. The DES stated that it was their department responsibility to clean the rooms, shower rooms, dining areas, but the wall papers and tiles would be the maintenance department. She confirmed that the floor should have been stripped I could tell it has been a while it was not stripped, it would be a project when we took over 7/6/26. On 7/22/26 at 8:24 AM, the DES approached and informed the surveyor in the presence of the 4th floor Unit Clerk that she addressed the surveyor's concerns in the 4th dining room, and confirmed it was dusty and needed cleaning.On 7/23/26 at 12:56 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS), and the surveyor notified them of the above concerns with Resident #12's room, 4th floor shower rooms, and 4th floor dining room. A review of the facility's Safe and Homelike Environment Policy, date reviewed 9/1/25, that was provided by the Regional Nurse, revealed, in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment.This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.Definitions.Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas.Orderly is defined as an uncluttered physical environment that is neat and well-kept. Sanitary includes but is not limited to; preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in completion of the activities of daily living.Policy Explanation and Compliance Guidelines.3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.9. General Considerations:a. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms needing cleaning to Housekeeping Department.f. Report any unresolved environmental concerns to the Administrator.On 7/24/26 at 12:18 PM, the survey team met with the LNHA, and the VPCS stated, we did a QAPI (quality assurance performance improvement) after surveyor's inquiry and notified the DES with regard to the environment concerns.NJAC 8:39-31.2(e); 31.4(a)(c)(f)

Based on interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure grievances were documented on the facility grievance form and responses were documented according to facility policy for 1 of 32 residents sampled (Resident #150). This deficient practice was evidenced by the following:On 7/21/26 at 10:20 AM, the surveyor interviewed Resident #150, who was seated up in their bed, and who stated that they have had concerns in the past with the care that was given by the Certified Nursing Aides (CNA) which included not giving incontinent care in a timely manner, not giving incontinent care appropriately, and dropping their computer. Resident #150 further stated that they had notified staff, which included but was not limited to the day shift CNA and Social Worker (SW) of their concerns, and that some were taken care of but that some they were still waiting on. A review of Resident #150's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; type 2 diabetes mellitus (a chronic condition where the body resists insulin or does not make enough insulin, leading to high blood sugar) and anemia (a common blood condition where your body lacks enough healthy red blood cells or hemoglobin to carry needed oxygen to your tissues, leading to tiredness and weakness).A review of Resident #150's most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 4/23/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact.A review of Resident #150's SW Progress Notes did not include any documented evidence of any concerns or grievances.On 7/23/26 at 10:34 AM, the surveyor interviewed the CNA, who stated that Resident #150 had complained to him the past about the care received on other shifts. The CNA further stated that Resident #150 had told someone about it and that the CNA had been switched.On 7/23/26 at 12:18 PM, the surveyor interviewed the 2nd (second) floor Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that Resident #150 wanted care a certain way but that they could only pat dry and that their was an issue with the computer that they were working on. The LPN/UM further stated that issues were resolved.On 7/23/26 at 12:51 PM, the surveyor reviewed the facility provided grievance binder for 2025 and 2026. There was no documented evidence in the grievance log for any of the grievances/concerns that Resident #150 had. A review of the grievances listed were for broken or missing items of other residents. There were no documented care issues.On 7/24/26 at 9:17 AM, the surveyor interviewed the SW, who stated that for grievances there was a form that was filled out by her or nursing staff which included resident complaints about missing items, equipment not working, inappropriate behavior and proper care. The SW stated that she would go and speak to resident and write it on the form and then start an investigation and provide it to the administrator or nursing. The SW stated that she would write the incident in the log and put the form in the binder. She added that she kept rewriting the log paper because she had forgotten to put one in the log. The SW further stated that some concerns may get resolved and not put in the log. She added that it depended on if it was minor and resolved at the same moment, it may not be in the log but if it needed an investigation, it needed to be addressed.On that same date and time, the surveyor asked the SW if Resident #150 had any concerns. The SW stated that she had been talking to Resident #150 about concerns with their laptop that was in the process of getting fixed. The SW further stated that the concern just came up this week and had not been able to write it yet because she was the only SW at the facility for the last four weeks. The SW stated that Resident #150 had told the SW that one of the CNA had not cleaned the resident properly. The surveyor asked the SW if that concern should have been in the grievance log, and the SW stated that it should have been there, but that she did not put it. She added that she would put in the log by Monday and that she was going to see the resident today. The SW also stated that she tried to take care of the residents but that there was only one of her and 160 of them.On 7/24/26 at 11:33 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that if a resident had a grievance or concern then the SW would to resident or their representative. She added that the SW brought the concern up to morning meeting or to nursing or administration. The ADON stated that they had a form for grievances which would include concerns with missing items, broken equipment and care. The ADON further stated that if a resident complained about care that it would go to the manager and then the SW.At that same time, the ADON stated that she knew about the computer issue recently and that it was discussed in morning meeting, and they were working on the computer. The surveyor asked the ADON if there was an issue with a CNA. The ADON stated that if there was an issue with a CNA that they would ask the resident and that if they were not comfortable with the resident then they would not have that CNA take care of that resident. The surveyor asked the ADON if a residents concerns should have a grievance form, and the ADON stated that the concerns should have a form even though they were addressed.On 7/24/26 at 12:54 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS) the concern that Resident #150's concerns with care and their computer were not documented as a grievance.On 7/27/26 at 11:22 AM, in the presence of the LNHA, the VPCS stated that staff were in-serviced on grievances, how to report and that they should be documented. The LNHA did not provide any additional information.A review of the facility's Resident and Family Grievances Policy, dated 9/1/25, included the following:1. The SW has been designated as the Grievance Official.2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility.issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 3. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC facility stay.9.d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.N.J.A.C. 8:39-4.1(a)(35)

Complaint #2691795Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to implement an effective discharge planning process for 1 of 2 residents (Resident #172) reviewed for discharge. This deficient practice was evidenced by the following:On 7/21/26 at 9:28 AM, during an initial meeting with the survey team, the Regional Administrator stated he was the current acting Licensed Nursing Home Administrator (LNHA). The LNHA provided the surveyors with access to the electronic medical records (eMR) and stated all medical records were in the eMR, and there were no paper medical records for review.The surveyor reviewed the eMR for Resident #172, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, constipation, insomnia, and hypertension. The AR further reflected the Resident Representative (RR) was emergency contact #1, and with a phone number listed. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 7/23/25, reflected the resident had unclear speech, was rarely/never understood, and rarely/never understood others. Section C (cognitive patterns) revealed a staff assessment for mental status reflected both short-term and long-term memory problems, and cognitive skills for daily decision making were severely impaired - never/rarely made decisions.A review of the discharge (d/c) MDS [d/c date redacted] reflected the d/c status was to home/community. Section C reflected cognitive skills for daily decision making were severely impaired.A review of the Care Plan (CP) revealed no documented evidence that d/c planning was included in the CP. A review of the progress notes (PN), physician note dated 8/27/25 at 11:00 AM, reflected a plan to d/c the resident on 8/28/25 to home. The PN reflected that the physician discussed with the social service team on 8/27/25, and it was also reviewed and discussed with the resident and nursing. A review of the Physician Order Summary did not reflect an order to d/c the resident to home.A review of the PN, nurses note dated 8/28/25 at 8:11 PM, reflected resident was discharged home via [company redacted] ambulance. The resident left facility breathing easy and unlabored, no pain, and all resident's belongings given to driver including medications brought in upon admission. Further review of the eMR revealed no documented evidence that the RR was notified of the d/c plan, nor there were social services PN to reflect ongoing communication with the RR and the d/c plan. There was no note to reflect the RR was notified of the d/c, or provided with d/c instructions. On 7/24/26 at 12:07 PM, the surveyor interviewed the Social Worker (SW), who stated she was the only SW employed by the facility at this time. The SW further stated Resident #172 was assigned to a different SW who was no longer employed at the facility. The SW stated the process in her role was to see residents on admission, for any forms that need to be signed, any family meetings, then at quarterly CP meetings. The SW stated any phone calls or conversations with the RR would be in the PN. On that same date and time, the SW reviewed the eMR for Resident #172, and acknowledged there was no SW assessment, no SW notes for the entire time of the resident's stay at the facility. The SW further stated she herself did the d/c for this resident for [DC date redacted]. The SW directed the surveyor to the location in the resident's eMR that contained the d/c plan documentation file. The SW stated that the d/c summary was never closed (locked) by the nurse though, and the SW explained that meant the form was not completed and could not be printed out. The SW could not produce a note to reflect a conversation with the RR and could not recall any other conversation with the RR. On 7/24/26 at 12:24 PM, the survey team met with the LNHA and the [NAME] President of Clinical Services (VPCS) acknowledged the SW should have seen the resident on admission, and been in communication with the RR. The VPCS further stated the resident or RR should have been provided with written d/c instructions upon d/c. On 7/27/26 at 11:22 AM, the survey team met with the LNHA and the VPCS stated the SW who was assigned to Resident #172 was no longer there. There was no further information was provided as to why no SW documentation was done for the resident. The VPCS stated she spoke to the prior Unit Manager by phone who said she spoke to the RR often but nothing was documented. There was no further information was provided with regard to the incomplete d/c instructions.A review of the facility's Discharge Planning Process Policy, reviewed/revised 3/1/25, reflected it was the policy of the facility to develop and implement an effective d/c planning process. The definition of d/c planning was a process that generally begins on admission and involves identifying each resident's d/c goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful d/c. The procedure reflected.2.a. Initial information and discharge goals will be included in the resident's baseline CP. 5. If d/c to community is a goal, an active d/c CP will be implemented and will involve the interdisciplinary team, including the resident and/or RR.12. The evaluation of the resident's d/c needs and d/c plan will be completely documented on a timely basis in the clinical record. 13. The results of the evaluation and the final d/c plan will be discussed with the resident or RR. All relevant information will be provided in a d/c summary to avoid unnecessary delays in the resident's d/c or transfer, and to assist the resident in adjustment to his or her new living environment. 14. Education needs, as identified in the d/c plan, will be provided to the resident and/or family member prior to d/c. A review of the facility's job description for SW included a section titled Major Duties and Responsibilities.The SW will contribute to.social services goals and approaches to the comprehensive CP.Facilitate residents' safe transition back into the community through interdisciplinary d/c planning and arrangement of community based services and follow-up care. Accurately and completely document social service actions and interactions in each resident's medical record.NJAC 8:39-5.4

Based on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of nursing practice, by failing to a.) clarify the psychiatrist recommendation for a resident on an antipsychotic medication for 1 of 5 residents (Resident #11) reviewed for unnecessary medications, b.) ensure residents had their name bands for 1 of 32 sampled residents (Resident #16) and 4 of 4 unsampled residents (Unsampled Residents #1, #2, #3, and #4), and c.) follow the physician's order with regard to weight monitoring for 1 of 3 residents (Resident #71) reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 7/21/26 at 10:06 AM, the surveyor observed Resident #11 in their room, lying in bed with eyes closed. On 7/21/26 at 3:29 PM, the surveyor reviewed the electronic medical records (eMR) of Resident #11, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnose which included but not limited to; schizoaffective disorder (a chronic mental health condition), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, unspecified; major depressive disorder, recurrent, severe with psychotic symptoms, unspecified psychosis not due to a substance or known physiological condition, and gastrostomy status (a surgical opening to the abdominal skin to the stomach to place a feeding tube-PEG tube). A review of the comprehensive Minimum Data set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 5/19/26, revealed a Brief Interview Mental Status (BIMS) score of 3 out of 15, indicating severe impaired cognition. The MDS reflected physical behavioral symptoms that occurred 1 to 3 days, other behavioral symptoms occurred 1 to 3 days, impacted resident and others, rejection of care 1 to 3 days, and antipsychotic medication (med) received on a routine basis. A review of the resident's care plans (CP) reflected, Resident #11 had impaired communications skills related to (r/t) dementia with BIMS score of 3, schizoaffective disorder, depression with psychotic disorder and anxiety, date initiated 5/20/26. The CP also included a focus on behavior problem of confabulation r/t disease process schizoaffective disorder.exhibiting behaviors of crying, fighting with staff, refusing medications (meds)/care, hitting staff, date initiated 11/14/24. The CP focus on psychotropic meds r/5]t behavior management secondary to disease process of schizoaffective disorder, date initiated 5/12/26. A review of the physician orders (PO) revealed an order on 6/8/26, for olanzapine oral tablet (tab) 10 mg (milligram), give 1 tab via PEG-tube (percutaneous endoscopic gastrostomy tube, is a medical device placed directly through the skin of the abdomen into the stomach to deliver nutrition, fluids, and meds) two times a day for schizoaffective disorder. A review of the Psychiatry consult dated 6/8/26, revealed a note from the Nurse Practitioner (NP) stating, per request for consultation met with the resident for ongoing presentation of behavioral disturbances, agitation mood, confusion, delusional episodes, resistance to care, and aggressiveness behavior. The NP recommended olanzapine 20 mg via peg-tube bid (twice a day) for schizoaffective disorder. There was no nursing progress note (PN) documented that the recommendation from the NP for 20 mg of olanzapine and the PO for 10 mg were clarified on that date. On 7/22/26 at 11:52 AM, the surveyor interviewed the 3rd (third) floor License Practical Nurse/Unit Manager #1 (LPN/UM #1), who stated the psychiatry doctor usually writes the orders, they write a script or they verbally tell the nurses. Both the surveyor and the LPN/UM reviewed the PO for olanzapine and the psychiatry consult on 6/8/26, and LPN/UM #1 stated there was a discrepancy with the PO and what the NP recommended. LPN/UM #1 further stated that the NP probably told the nurse at that time verbally that it should be olanzapine 10mg, and should have been clarified. On 7/22/26 at 12:03 PM, the surveyor and the LPN/UM both called the NP with regard to above concerns. The NP stated, I made a mistake on the 6/8/26 consult note, and was not aware of it until surveyor's inquiry (44 days later). The NP further stated that the order should be 10 mg, and the resident had some improvement with behaviors on olanzapine. The NP added that the PO was correct, not the notes, and the NP confirmed he did not document that an error. On 7/22/26 at 1:10 PM, the surveyor interviewed assigned Licensed Practical Nurse #1 (LPN #1), who stated that she was the responsible nurse on 6/8/26, when the NP came and made a recommendations, notified the physician of the recommendations, and transcribed the PO. LPN #1 further stated that if there were discrepancies with the recommendations and PO, it should have been clarified, and LPN #1 was unable to remember what had happened on 6/8/26, as to why the PO was different on what what was recommended by the NP. On 7/24/26 at 1:05 PM, the surveyor notified the License Nursing Home Administrator (LNHA) and the [NAME] President of Clinical Services (VPCS) with regard to above concerns. On 7/27/26 at 11:23 AM, the survey team met with the LNHA and the VPCS stated they spoke to the NP, they followed PO, it was a transcription error, and nurse clarified the order with the primary physician. A review of the facility's Consulting Physician/Practitioner Orders Policy, date reviewed/revised 5/14/26, revealed under Policy Explanation and Compliance Guidelines: #2. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a) Call the attending physician to verify the order; b) Document the verification order; c) Follow facility procedures for verbal or telephone orders including: noting the order. A review of the facility's Verbal Orders Policy, date reviewed/revised 9/1/25, revealed under Policy Explanation and Compliance Guidelines: #2. Use clarification questions to avoid misunderstandings. 2. On 7/21/26 at 9:50 AM, during initial tour of the 2nd (second) floor unit, the surveyor observed residents seated in the dayroom. The surveyor observed Resident #16 seated in a high back wheelchair (wc) with both arms visible. The surveyor did not observe that Resident #16 had an identification (id) band on either arm. The surveyor observed other residents in the dayroom that did not have id bands visible on their arms. On 7/21/26 at 12:59 PM, the surveyor interviewed LPN #2, who stated that he used the residents bracelet, name on door and picture in computer to identify residents. LPN #2 further stated that the residents had an id band on their wrists. LPN #2 stated that when they see a resident that did not have their id band on, then they notify the Unit Clerk (UC), and the UC would get a new one to put on. LPN #2 confirmed that Resident #16 did not have an id band. On 7/21/26 at 1:02 PM, the surveyor interviewed the 2nd floor LPN/UM #2, who stated that they used the id band, their picture and call a staff member in identifying a resident. LPN/UM #2 further stated that most of the times the residents had an id band but that some had a CP that indicated that they removed the id band. LPN/UM #2 stated that as soon as staff know that the id band was removed then they reapply the id band. LPN/UM #2 also stated that he told the staff like the recreation staff that if they do not see the id band that they should tell so it could be reapplied. He added that when the staff told him then he would reapply the band. A review of Resident #16's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Alzheimer's disease (a progressive brain disorder that causes memory loss, worsening confusion, and changes in behavior) and epilepsy (a common chronic brain disorder defined by two or more recurring, unprovoked seizures caused by sudden bursts of abnormal electrical activity in the brain). A review of Resident #16's most recent quarterly MDS (qMDS) with an ARD of 5/11/26, reflected that the resident's cognitive skills for daily decision making were severely impaired. A review of Resident #16's individualized CP did not include any information about the resident removing their id band. On 7/21/26 at 1:09 PM, LPN/UM #2 confirmed that Resident #16 did not have a CP for removing id band. On 7/21/26 at 1:20 PM, the surveyor asked LPN/UM #2 to check some of the other residents in the dayroom for id bands. Unsampled Resident #1 (UR #1) did not have an id band. UR #2 did not have an id band. UR #3 did not have an id band. UR #4 did not have an id band. LPN/UM #2 stated that some of the UR's had a CP that the resident removed the id band. LPN/UM #2 stated that even though they had a CP that as soon as they were aware that they did not have an id band that they would put a new id band on. LPN/UM #2 further stated that he kept extra id bands with resident names on them in his office. On 7/24/26 at 12:52 PM, the surveyor notified the LNHA and the VPCS the concern that Resident #16, UR #1, UR #2, UR #3 and UR #4 did not have id bands and that Resident #16 did not have a CP that indicated the resident removed the id band. The VPCS stated that staff can use pictures or other staff members to identify residents. The LNHA did not provide any additional information. The facility did not have a policy on id bands. A review of the facility's Following Physician Orders Policy, with a reviewed/revised date of 9/1/25, included the following .4. The individual administering meds must verify the resident's identity before giving the resident his/her meds. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medial record; and c. if necessary, verifying resident identification with other facility personnel. 3. On 7/21/26 at 10:14 AM, the surveyor observed Resident #71 asleep in bed. A review of Resident #71's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; congestive heart failure (serious condition where the heart cannot pump blood well, causing fluid to build up, shortness of breath, and swelling in the body) and dementia (a decline in memory, thinking, and social abilities that interferes with daily life). A review of Resident #71's most recent qMDS with an ARD of 6/10/26, reflected that the resident had a BIMS score of 7 out of 15, which indicated that the resident's cognition was moderately impaired. A review of Resident #71's July 2026 electronic Med Administration Record (eMAR) included the following: Daily Weight-Notify the physician for a weight (wt) gain of 2 pounds (lbs) or more within 24 hours and/or 5 lbs or more within one week-in the morning with an order date of 1/28/26. The nurses made a check mark that indicated the order was administered. There was no wt indicated on the eMAR. Further review reflected that on 7/4/26, 7/5/26, 7/6/26, 7/8/26, and 7/19/26, the nurse did not indicate that the PO was followed. A review of Resident #71's wt section in the eMR included the following: 7/9/26 at 6:42 AM, the wt was 162.5 lbs via (by way of) wc 7/8/26 at 6:38 AM, the wt was 160.0 lbs via wc 7/7/26 at 6:22 AM, the wt was 159.4 lbs via wc 7/6/26 at 6:44 AM, the wt was 160.0 lbs via wc 7/5/26 at 6:45 AM, the wt was 160.6 lbs via wc 7/2/26 at 6:23 AM, the wt was 162.4 lbs via wc 7/1/26 at 12:00 AM, the wt was 162.4 lbs via wc There were no weights (wts) listed for 7/3/26, 7/4/26, and 7/10/26 through 7/23/26. A review of Resident #71's CNA (Certified Nursing Aid) task section of the eMR included the following: Daily wt, obtain wt, and give to nurse. There was no documented wts in this section. On 7/23/26 at 10:18 AM, the surveyor interviewed CNA #1, who stated that for wts there was a specific order for wts, and that the monthly was done at the beginning of the month. She added that if it was daily, she placed it in the kiosk for the eMR but that she was not the one that obtained Resident #71's daily wt. On 7/23/26 at 10:48 AM, the surveyor interviewed LPN #3, who stated that wts were done monthly, weekly and daily for CHF. She added that wts that were monthly was done by the CNA and that the nurse mostly did the daily wt. LPN #2 further stated that the wts were documented in the eMR under wt section. LPN #2 also stated that Resident #71's wts were done early in the morning during the shift before hers. On 7/23/26 at 10:53 AM, the surveyor interviewed LPN/UM #2, who stated that for monthly wts they had a binder that the wts were written in first and then put in the eMR. LPN/UM #2 stated that daily wts were done on 11-7 shift and documented in the eMR. LPN/UM #2 further stated that the process before was the wt was listed on the eMAR but that they changed the process and would get back to the surveyor with the new process. LPN/UM #2 confirmed that Resident #71's last wt in the eMR was 7/9/26, and that there were blanks on the eMAR. LPN/UM #2 stated that there should be a wt listed. On 7/24/26 at 12:52 PM, the surveyor notified the LNHA and the VPCS the concern that Resident #71's PO for daily wts was not followed. On 7/27/26 at 9:09 AM, the surveyor via telephone, interviewed CNA #2, who stated that she obtained Resident #71's wt when she was assigned to the resident and wrote it on a paper at the desk and gave it to the nurse. On 7/27/26 at 11:22 AM, in the presence of the LNHA, the VPCS stated that staff were in-serviced on obtaining wts and not having blanks. The LNHA did not provide any additional information. A review of the facility's Weight Monitoring Policy, with a reviewed/revised date of 9/1/25, included the following .5. A wt monitoring schedule will be developed upon admission for all residents: a. Wts should be recorded at the time obtained.d. if clinically indicated-monitor wt daily. 6. Wt Analysis: The newly recorded resident wt should be compared to the previous recorded wt. N.J.A.C. 8:39-27.1(a); 29.2(b)(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, by failing to ensure that the resident's condition was assessed by appropriate disciplines, interventions were implemented timely, and documentation reflected care of the resident during their stay. This deficient practice was identified for 1 of 2 residents, (Resident #13), reviewed for quality of care, and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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 7/22/26 at 9:35 AM, the surveyor observed Resident #13 lying in bed. During an interview, Resident #13 stated that they needed to go to the bathroom and needed to move their bowel. On that same date and time, the surveyor notified the assigned Licensed Practical Nurse (LPN), who stated to Resident #13 that they were wearing an incontinence brief, and could have the bowel movement in the brief. At that same time, the surveyor subsequently requested assistance from the LPN/Unit Manager (LPN/UM). The surveyor heard the LPN/UM told Resident #13 that they were wearing an incontinent brief, and could have the bowel movement in the brief. Afterward, the surveyor asked whether Resident #13 was normally assisted to the bathroom for bowel movements, and the LPN/UM stated that she was unsure and would check. The LPN/UM returned and stated that the Certified Nursing Assistants were busy. The surveyor observed the LPN/UM attempted to locate a bedpan for Resident #13. Furthermore, the LPN/UM was unsure if the resident should use a bedpan in accordance with resident's care plan (CP), and informed the surveyor that she had to check and would get back. On 7/22/26 at 10:29 AM, the surveyor reviewed the medical record for Resident #13. A review of Resident #13's admission Record or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; type 2 diabetes mellitus, paranoid schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, uninhibited neuropathic bladder, and peripheral autonomic neuropathy. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. A review of Resident #13's care plan (CP) revealed a focus area that the resident had full fecal incontinence related to (r/t) decreased mobility, generalized weakness, and neurological/functional impairment. The CP identified goals that bowel incontinence episodes would be managed according to facility protocol and that the resident's comfort and dignity would be maintained. Interventions included providing prompt incontinence care after each episode. Further review of the CP revealed a focus area that Resident #13 was at risk for constipation r/t decreased mobility and side effects of psychotropic medications. The CP included goals for the resident to pass soft, formed stool and have a normal bowel movement (BM). Interventions included encouraging Resident #13 to sit on the toilet to evacuate their bowels if possible and following the facility bowel protocol for bowel management. On 7/22/26 at 11:34 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) and Regional Nurse regarding Resident #13's bowel and toileting care. The ADON stated that Resident #13 was incontinent and was offered a bedpan. The ADON further stated that the resident required a Hoyer lift and could not currently be transferred to the toilet. The ADON also stated that the resident previously used the toilet and that therapy would be consulted regarding whether the resident could safely use the toilet. The ADON and Regional Nurse acknowledged that the CP might need to be updated to reflect the resident's current functional status. On 7/24/26 at 10:04 AM, the surveyor interviewed the Director of Rehabilitation/Occupational Therapist (DR/OT) and Regional Rehabilitation Manager (RRM), who stated that Resident #13's current core stability made use of the toilet unsafe and that bedside toileting was more appropriate. Both the DR/OT and RRM explained that bedside toileting included use of a bedpan. A review of the facility's Bowel and Bladder – Incontinence Policy, implemented 9/1/25, included that, based on the resident's comprehensive assessment, residents who were incontinent would receive appropriate treatment and services. The policy further included that residents who were incontinent of bowel or bladder would receive appropriate treatment to prevent infections and restore continence to the extent possible. A review of the facility's Provision of Quality Care Policy, implemented 9/1/25, included that, based on comprehensive assessments, the facility would ensure residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered CP, and the resident's choices. The policy further included that each resident would be provided care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and that qualified persons would provide care and treatment in accordance with the resident's CP. A review of the facility's Comprehensive Care Plans Policy, implemented 9/1/25, included that the facility would develop and implement a comprehensive person-centered CP for each resident that addressed the resident's medical, nursing, mental, and psychosocial needs and all services identified in the comprehensive assessment. The policy further included that the comprehensive CP would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment and that qualified staff responsible for carrying out care-plan interventions would be notified of their roles and responsibilities. On 7/27/26 at 12:00 PM, the [NAME] President of Clinical Services and the Licensed Nursing Home Administrator acknowledged that when Resident #13 communicated a need to have a BM, staff should have assessed and provided the resident with the appropriate toileting assistance in accordance with their current needs and CP. NJAC 8:39-11.2; 27.1

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a resident with an existing stage 4 pressure injury received necessary treatment and services to promote healing and prevent further pressure injury by failing to: a.) ensure a pressure-reducing air mattress was set according to the resident's weight and b.) ensure the pressure-reducing air mattress remained powered and operational while the resident was in bed. This deficient practice was identified for 1 of 2 residents (Resident #7) reviewed for pressure injuries, in accordance with facility's policy and standards of clinical practice, 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.On 7/22/26 at 10:00 AM, the surveyor observed Resident #7 lying in bed on a pressure-reducing air mattress. The surveyor observed that Resident #7's pressure-reducing air mattress control unit was set at 300 pounds (lbs), the maximum weight (wt) setting.On 7/22/26 at 10:10 AM , the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who observed the air mattress control unit with the surveyor and confirmed that the mattress was set to the maximum wt setting of 300 lbs. Following the interview, the surveyor observed that the air mattress setting had been changed to 120 lbs.On 7/22/26 at 10:37 AM, the surveyor reviewed Resident #7's medical record.A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; stage 4 pressure ulcer (a deep wound featuring full-thickness skin and tissue loss with exposed bone, muscle, or tendons) of the sacral region, vascular dementia, acute and chronic respiratory failure with hypoxia, and acute on chronic diastolic heart failure.A review of Resident #7's quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 6/5/26, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Further review of the MDS identified that Resident #7 was at risk for pressure ulcers/injuries and had one unhealed Stage 4 pressure ulcer/injury. The MDS further identified the use of a pressure-reducing device for the bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, and pressure ulcer/injury care.A review of Resident #7's individual comprehensive care plan (CP) revealed a focus area that the resident had an actual skin integrity impairment of the coccyx extending to the left gluteal region and was at risk for further skin impairment due to weakness, reduced mobility, use of a Foley catheter, diabetes mellitus, heart failure, chronic pain, depression, and incontinence. Interventions included use of a pressure-relieving/reducing mattress while in bed, pressure reduction and turning/repositioning precautions, offloading of pressure areas, and monitoring of the skin impairment for healing and complications.A review of the resident's Weights (wts) and Vitals revealed a wt of 129.8 lbs, documented on 7/6/26.On 7/22/26 at 11:00 AM, the surveyor observed Resident #7 lying in bed while receiving a nebulizer (neb) treatment and noted that the pressure-reducing air mattress appeared to be turned off. The surveyor asked the LPN/UM to assess the mattress, and the LPN/UM determined that the air mattress had been unplugged from the electrical outlet so that the neb could be plugged in. The LPN/UM acknowledged that the air mattress should not have been unplugged while Resident #7 was lying on it.Afterward, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to Resident #7, who confirmed that she had unplugged the pressure-reducing air mattress to plug in the neb for the resident's treatment and acknowledged that this was an error.A review of the facility's Use of Support Surfaces Policy, implemented 9/1/25, included that support surfaces would be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. The policy further included that specialized support surfaces would be selected based upon the resident's medical condition, size and wt, mobility and activity levels, presence of pressure injuries, and risk for developing a pressure injury. The policy further included that support surfaces would be utilized in accordance with manufacturer recommendations and that the effectiveness of support surfaces would be monitored through ongoing assessment of the resident and/or wound.On 7/27/26 at 12:00 PM, the [NAME] President of Clinical Services and the Licensed Nursing Home Administrator, in the presence of the survey team, provided documentation that education was completed for the Nursing staff on the setting the resident's wt on the air mattress control unit and acknowledged that Resident #7's pressure-reducing air mattress should have been set according to the resident's actual wt and should have remained plugged in and operational while the resident was lying in bed.NJAC 8:39-25.2(b); 27.1(e)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure respiratory care was provided in accordance with professional standards of practice and facility policy by administering oxygen therapy to a resident without a physician order and without obtaining an order following administration. This deficient practice was identified for 2 of 4 residents (Resident #13 and Resident #82) reviewed for respiratory care, and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 7/21/26, the surveyor observed Resident #13 lying in bed, with an oxygen (O2) concentrator was present at the resident's bedside, and O2 tubing with a nasal cannula (n/c). On 7/22/26 at 9:35 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding the O2 concentrator observed in Resident #13's room on 7/21/26. The LPN/UM stated the resident did not currently need O2 because the resident's O2 saturation (sat) was 96% on room air. The LPN/UM confirmed that there was no physician order (PO) for O2. The LPN/UM further stated that the O2 may have been placed in the resident's room overnight and acknowledged that the O2 administration should be documented. On 7/22/26 at 10:29 AM, the surveyor reviewed Resident #13's electronic medical record (eMR). A review of Resident #13's admission Record (AR) or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; type 2 diabetes mellitus, paranoid schizophrenia, bipolar disorder, anxiety disorder, uninhibited neuropathic bladder, peripheral autonomic neuropathy, and hypertension. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. A review of Resident #13's PO as of 7/22/26, revealed no order for O2 therapy. A review of the progress notes (PN), a nurse's note dated 7/19/26 at 2:37 PM, which documented that Resident #13 was in bed, had no shortness of breath, had an O2 sat of 94%, and was receiving O2 at 2 liters per minute (lpm) by n/c. Further review of the medical record revealed no PO corresponding with the documented administration of O2 at 2 lpm by n/c on 7/19/26. On 7/22/26 at 11:34 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) and Regional Nurse. The ADON stated that a resident needed an order for O2, except in an acute situation when a nurse could initiate O2 and then obtain a PO afterward. The ADON confirmed the expectation was that an order would be obtained when O2 therapy was initiated. A review of the facility's Oxygen Administration Policy, included that O2 would be administered to residents who required it consistent with professional standards of practice, comprehensive person-centered care plans, and resident goals and preferences. The policy further included that O2 was administered under the orders of a physician, except in an emergency, and when O2 was initiated during an emergency, an order for O2 would be obtained as soon as practicable after the situation was under control. The policy further included that staff would document the initial and ongoing assessment of the resident's condition warranting O2 therapy and the resident's response to O2 therapy. The resident's care plan (CP) was to identify interventions for O2 therapy based upon assessment and orders, including the type of O2 delivery system, whether O2 was continuous or intermittent and when it was to be discontinued, the prescribed flow rate, O2 sat monitoring, and monitoring for complications. A review of the facility's Medication Monitoring Policy, implemented 9/1/25, included that licensed nurses were responsible for verifying orders upon receipt and adhering to facility policies and current standards of practice for administration and monitoring of medications and treatments. On 7/27/26 at 12:05 PM, the Licensed Nursing Home Administrator (LNHA) acknowledged that Resident #13 should not have received ongoing O2 therapy without a PO and that, if O2 had been initiated for an acute or emergency condition, staff were required to obtain an order as soon as practicable and document the resident's assessment and response to the O2 therapy. 2. On 7/21/26 at 11:28 AM, the surveyor observed Resident #82 lying in bed with a tracheostomy (trach) tube (a tube inserted into the opening made in the windpipe to help someone breathe) and was receiving O2. The surveyor observed that the O2 flow meter was set at 5 lpm. A review of the AR revealed the resident had diagnoses that included, but were not limited to; type 2 diabetes mellitus with hyperglycemia (a disease in which blood sugar levels are higher than normal because the body does not make enough insulin or use it the way it should), essential (primary) hypertension (high blood pressure), tracheostomy status (a procedure that creates an opening in the neck), and gastrostomy status (a procedure that creates an opening into the stomach). A review of the comprehensive MDS with an ARD of 7/14/26, revealed that the resident was rarely understood. A review of the Order Summary Report (OSR) for the resident revealed orders that included but were not limited to the following: -Trach Collar at 5% O2 continuously every shift. The order started on 7/7/26, and was discontinued on 7/21/26. -Trach Collar at 35% O2 continuously every shift. The order started on 7/21/26. There was no PO in the OSR that included the O2 flow rate. A review of the physician's PN from the hospital, dated 7/6/26, under Vitals, revealed lpm unknown. On 7/22/26 at 11:26 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1). Both the surveyor and LPN #1 observed that the resident was receiving O2. At that same time, LPN #1 reviewed the eMR of resident #82, LPN #1 stated there should be a PO with the O2 flow rate for the resident, and confirmed there was no order that included the O2 flow rate. On 7/22/26 at 11:59 AM and 7/23/26 at 9:45 AM, the surveyor observed Resident #82 lying in bed with a trach tube and was receiving O2 and the O2 flow meter was set at 5 lpm. On 7/23/26 at 9:48 AM, the surveyor interviewed LPN #2. Both the surveyor and LPN #2 observed the resident was receiving O2, and LPN #2 confirmed the O2 flow rate was set at 5 lpm. LPN #2 further stated it was important to include the lpm in an order because they would not know where the O2 should be set without it. LPN #2 acknowledged that they were not able to check if the O2 was set correctly without an order for the O2 flow rate. On 7/23/26 at 12:03 PM, the surveyor interviewed the Respiratory Therapist (RT) via phone call who was a consultant at the facility. The RT stated that Trach Collar at 5% O2 continuously every shift was not a valid order. In addition, the RT stated that Resident #82 should receive 4 lpm of O2, and he told this to the nursing staff when the RT did their initial assessment. The RT further stated that it was important to include the Fraction of Inspired O2 (FiO2; the percentage of O2 a person inhales) and O2 flow rate in lpm in the order. The RT stated they did not enter the orders into the eMR. On 7/24/26 at 12:18 PM, the surveyor discussed the concerns with the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS) regarding the invalid order of trach collar at 5% O2 continuously every shift, the incomplete order of trach collar at 35% O2 continuously every shift, that the facility did not clarify the resident's lpm from the hospital, and that the resident was receiving 5 lpm of O2 when the RT stated they should receive 4 lpm of O2. On 7/27/26 at 11:26 AM, the survey team met with the LNHA and the VPCS stated there was no change in the resident's respiratory status despite the order not being entered correctly. The VPCS also stated that education was provided regarding how to enter the O2 orders correctly. The VPCS provided the surveyor with a copy of the in-service dated 7/24/26. The topic of the in-service was Orders. The in-service included, but was not limited to; all residents on O2 must have orders from their provider and all trach orders should include FiO2 and lpm. A review of the facility's Oxygen Administration Policy, last reviewed/revised 5/1/26, revealed, O2 is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered CP, and the resident's goals and preferences. O2 is administered under orders of a physician, except in the case of an emergency. The resident's CP shall identify the interventions for O2 therapy, based upon the resident's assessment and orders, such as, but not limited to: equipment setting for the prescribed flow rates. NJ 8:39-25.2(c)3, 4

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate administration of a medication to Resident #61, administered by 1 of 2 nurses, identified during the medication pass observation.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 7/24/26 at 9:41 AM, the surveyor observed the Licensed Practical Nurse (LPN) preparing medications (meds) for Resident #61. The meds included, but were not limited to, the following physician's order (PO):Cholecalciferol (also known as vitamin D3, a form of vitamin D) tablet (tab) 1000 unit give 1 tab by mouth one time a day for Vitamin D Deficiency. The PO started on 4/23/25.On 7/24/26 at 9:56 AM, the LPN stated that cholecalciferol was vitamin B-12. The surveyor observed that the LPN opened a bottle of vitamin B-12 1000 microgram (mcg) tablets (tabs) and put one tab from the bottle in a medicine (med) cup for the resident. On 7/24/26 at 10:02 AM, the LPN informed the surveyor that they were ready to administer the meds to Resident #61.On 7/24/26 at 10:04 AM, the surveyor observed that the LPN entered Resident #61's threshold for administration and was about to administer the meds. The surveyor stopped the med pass and requested to speak with the LPN outside the resident's room to review the electronic medical records (eMR) and the PO. The LPN reaffirmed that cholecalciferol was vitamin B-12. When the surveyor asked the LPN if they could confirm that, the LPN searched for the information on the LPN's phone, and then, the LPN stated that cholecalciferol was vitamin D3, not vitamin B-12. The LPN acknowledged that the LPN was about to administer the wrong med to the resident.A review of the admission Record or face sheet (an admission summary) revealed that Resident #61 had diagnoses that included, but were not limited to; chronic kidney disease, unspecified (CKD; a condition in which the kidneys are damaged and cannot filter blood as well as they should) and type 2 diabetes mellitus with unspecified complications (a disease characterized by high levels of blood sugar).A review of the quarterly minimum data set (MDS), an assessment tool), with an Assessment Reference Date (ARD) of 4/15/26, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which reflected that the resident's cognition was intact.On 7/24/26 at 12:18 PM, the surveyor discussed the above concern with the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS).On 7/27/26 at 11:26 AM, the survey team met with the LNHA and the VPCS stated they did a one-to-one in-service with the LPN.A review of the facility's Medication Administration Policy, reviewed/revised 9/1/25, revealed, the meds are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure that the six rights of med administration are followed: right resident, right drug, right dosage, right route, right time, right documentation. Compare med source (bubble pack, vial, etc.) Med Administration Record (MAR) to verify resident name, med name, form, dose, route, and time.NJAC 8:39-29.2(d)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to prevent the accumulation of refuse and prevent the feeding of pests/animals in order to maintain the outdoor garbage storage area in a sanitary condition, and was evidenced by the following:On 7/23/26 at 8:54 AM, the surveyor conducted a tour with the Food Service Director (FSD) of the outside garbage area where the dumpster was located. Upon exiting the building the surveyor observed, on the sidewalk against the building, two large bins on wheels, with openings at the front, full of cardboard. These were identified by the FSD as bins for recycling cardboard. The surveyor and the FSD then observed two stacked cardboard boxes next to the recycling bins, on top of the boxes there were three cans with cat food labels, two cans were sealed, and one can was open with brown soft material inside. There was a large open styrofoam cup next to the cat food cans. On the sidewalk, there was a grassy area adjacent, the surveyor observed seven black wheeled garbage collection bins, some upright and some lying on their sides. The surveyor also observed what appeared to be white type tubing in a rectangular shape with dark blue netted cloth stretched on it (later identified as a laundry bin) lying on its side.At that same time, both the surveyor and the FSD observed a white and brown cat sleeping on the netted cloth. The FSD acknowledged the above observations and stated her staff goes directly to the dumpster with their garbage. She further stated she thought the black garbage collection bins were all broken and needed to be removed. The FSD also stated that was housekeeping and maintenance departments, the bins were not used by kitchen staff. The FSD acknowledged the observation of the cat, and cans of cat food, and stated those were not supposed to be in that area and could potentially attract other animals that could carry disease. She stated she was not aware of anyone putting cat food in the garbage area. On 7/23/26 at 9:35 AM, the surveyor interviewed the Director of Environmental Services (DES) in the presence of the District Manager for Environmental Services (DMES). Both the DES and the DMES acknowledged they saw the cans of cat food in the garbage area earlier this morning. The DMES stated she removed the cans of cat food prior to this interview with the surveyor. The DES acknowledged she was aware that a cat was being fed by staff for as long as I have been here, and was unable to identify who the staff was. The DES acknowledged having open food, and animals, could bring in other animals and pests. Furthermore, the DES stated all of the black bins in the area were broken and not in use. She further stated that the housekeeping department used that type of black garbage collection bin. In the presence of the surveyor and the DMES, the DES observed and acknowledged that extra individual garbage cans of a tan color, and additional garbage collection bins, were being stored along an outside wall, outside of a double door which was locked from the outside. The DES stated she did not know what area of the facility was behind that doors. The DES further stated the garbage cans and additional garbage collection bins were in use, and would be taken into the facility as needed. The DES and DMES both acknowledged the accumulation of bins on the grassy area and sidewalks created a cluttered environment that could harbor pests or animals.On 7/23/26 at 9:54 AM, the surveyor in the presence of the Regional Maintenance Director (RMD) interviewed the Maintenance Director (MD), who acknowledged there were multiple broken garbage bins in the outdoor garbage area, on the sidewalk and grass. The MD stated he was waiting for a larger dumpster to be delivered to dispose of all large items. The MD acknowledged the broken bins had been there a while, and he had to wait for administrator approval. The MD further stated the request was put in on Monday (3 days prior to surveyor interview). The MD stated all items were usually lined up along the wall but with recent weather may have blown around. At that same time, the MD stated he tried to go daily to make rounds and had cleaned up the area on Monday. The MD acknowledged he was aware of cats in the area and cans of cat food being left out to feed them. He further stated he did not know who was leaving the cans there but would throw it away each time he saw it. He did not do anything else to prevent the feeding or cat presence in the area. The MD acknowledged having cats and cat food could attract other animals or pests, and the area needed to be kept clean for the well-being of the residents. The MD stated he believed cat food was being placed outside for longer than I have been here. On 7/24/26 at 12:19 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the [NAME] President of Clinical Services (VPCS) stated in response to the above concerns identified by the surveyor, the facility put a tracking tool together, and a process in place to start tackling all of the concerns. On 7/27/26 at 12:05 PM, the survey team met with the VPCS during an exit conference, and the LNHA did not provide additional information. A review of the facility's Disposal of Garbage and Refuse Policy, with a date implemented 9/1/25, reflected the facility shall properly dispose of garbage and refuse. The policy explanation and compliance guidelines reflected.7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers.Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8.Garbage should not accumulate or be left outside the dumpster. 9. The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse. 10. Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.NJAC 8:39-19.7(a),(b),(f)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to provide documented evidence that written notification to the beneficiary or Resident Representative when the resident was discharged from Medicare Part A services on their Notice of Medicare Non-Coverage (NOMNC) were completed thoroughly and of the potential liability charges for services not covered, with benefit days remaining provided for them to choose which option they wanted on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) Forms for 2 of 3 residents reviewed for beneficiary notice (Residents #98 and #161).This deficient practice was evidenced by the following:On 7/23/26 at 10:52 AM, the surveyor reviewed the facility provided NOMNC and SNFABN Forms for Resident #98 and Resident #161, that was provided by the Regional Nurse, which revealed the following:1. A review of the Skilled Nursing Facility (SNF) Beneficiary Notification Review form that was filled out by the facility, Resident #98 did not require an ABN, disenrolled, continued treatment under new payor source, and went to the hospital on 7/14/26. Further review of the electronic medical records revealed that Resident #98 was on Medicare from 7/1/26, and stopped billing under Medicare on 7/14/26, when the resident was hospitalized . Further review of the SNF Beneficiary Notification Review form that was filled out by the facility revealed that Resident Representative (RR) gave verbal acknowledgment via phone. There was no information about who obtained the verbal consent.A review of Resident #98's NOMNC revealed that on 7/8/26, Medicare coverage of current SNF services would end. There was additional handwritten information that the resident was cognitively impaired and unable to sign, the RR name and date 7/5/26 were included. There was no further information about who obtained the verbal consent nor a witness for the phone conference. 2. A review of Resident #161's SNFABN form had information that beginning on 2/18/26, Resident #161, may have to pay out of pocket for Physical Therapy, Occupational Therapy, and Daily Skilled Nursing Care, these cares were no longer occur daily, as a result, Medicare may not pay for the resident's inpatient SNF due to a reason that the resident reached maximum potential. The estimated amount for the services that would cost Resident #161 was left blank for per day/item or service. There was handwritten information that the resident refused to sign the SNFABN form. There was no information as to who obtained the information that the resident refused to sign the form nor an information of a witness.A review of Resident #161's NOMNC revealed that on 2/17/26, Medicare coverage of current SNF services would end. There was additional handwritten information that the resident refused to sign and date 2/13/26 were included. There was no further information about who obtained the refusal nor a witness during the time the NOMNC was presented to the resident. On 7/23/26 at 12:56 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPCS), and the surveyor notified them of the above concerns with Residents #98 and #161's NOMNC and ABN. The surveyor asked for facility's policy regarding beneficiaries.A review of the facility's Advance Beneficiary Notices Policy, date implemented 6/24/26, that was provided by the VPCS, revealed, it is the policy of the facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines:8. The Social Work Director, or designee, is responsible for issuing notices.9. The facility shall issue a notice each time, and as soon as possible, it makes the assessment that Medicare payment certainly or probably will not be made .11. Beneficiary refusals to sign: a. Explain to resident/RR they cannot properly refuse to sign the ABN at all and still demand the item or service. Explain their rights to request a demand bill (and follow facility procedures for demand billing).b. Have a second facility representative witness the provision of the ABN and the beneficiary's refusal to sign and sign an annotation on the ABN attesting to having witnessed said provision and refusal.On 7/24/26 at 12:18 PM, the survey team met with the LNHA, and the VPCS stated that education was provided to the Social Worker regarding the process of completing an ABN.NJAC 8:39-4.1(a)(8), 5.1

Based on observation and interview on 1/27/2025 in the presence of the Director of Maintenance (DM), it was determined that the facility failed to ensure that the devices used to identify call bell notifications were functioning properly. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation at 1:28 PM, revealed that the call bell system did not give audible or visual notification of the activation of the call bell system at the nurse's station when it was test for room [ROOM NUMBER]. Upon further investigation by the DM, it was discovered that the call bell annunciator at the nurse's station was not plugged in. In an interview at the time, the DM confirmed that the call bell annunciator panel was unplugged, and confirmed that with the annunciator panel unplugged, any activation of the call bell system from any room on floor 4 would not be heard or seen at the nurse's station. The DM plugged the call bell annunciator back in and informed the nursing staff that they had to be careful not to unplug it. The facility's Administrator was informed of the deficient practices at the Life Safety Code exit conference on 1/29/2025 at 12:00 PM. N.J.A.C 8:39-31:2(e)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: 1. On [DATE] at 9:16 AM, the surveyor, in the presence of the Food Service Director (FSD) observed the following during the initial kitchen tour: On a shelf in a refrigerator, there was an opened pack of shredded mozzarella cheese. The pack had an open date of [DATE] and a use by date of [DATE]. The FSD stated that the pack of cheese should not be there and took it out to be discarded. The FSD further explained the item was good for seven days after opening and that all dietary staff were responsible for ensuring expired food items were removed. 2. On [DATE] at 10:19 AM, the surveyor, in the presence of the FSD conducted a follow up tour in the kitchen. The surveyor observed Dietary Staff (DS) #1 with their hair sticking out of their hairnet on the sides behind their ears. DS #1 was serving fruits in individual cups for lunch. The surveyor asked the FSD about the observation. The FSD acknowledged all hair should be restrained in the hairnet and told DS #1 to fix her hairnet. DS #1 removed her gloves and stepped out of the food preparation area to adjust their hairnet. 3. On [DATE] at 11:26 AM, the surveyor observed tray line preparation in the kitchen. The surveyor observed DS #2 who wore a surgical mask down toward their chin, with their mustache exposed. The surveyor asked the FSD about the observation of DS #2. The FSD acknowledged his mustache should be covered. The FSD instructed DS #2 to put up his mask to cover his mustache. 4. On [DATE] at 11:28 AM, the surveyor observed DS #1 dispose removed gloves in the garbage, then went to the counter, grabbed new gloves, donned the gloves and went back to prepare for tray line to start. The surveyor asked the FSD if hand hygiene should be performed between changing gloves. The FSD replied yes. The surveyor notified the FSD about the observation of DS #1. The FSD called over DS #1 who stated that she had washed her hands twice prior to changing her gloves. The surveyor notified DS #1 of the above observation and asked if she washed her hands between the changing of the gloves. DS #1 acknowledged that she did not wash her hands at that time. DS #1 doffed (removed) her gloves and went to wash her hands. On [DATE] at 2:18 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the [NAME] President of Clinical Services (VPoCS), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) of the observed concerns during the kitchen tour. On [DATE] at 10:57 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) #1 about the unit nutrition refrigerator for residents. LPN #1 stated items should be dated and labeled with the resident's name for personal food items. LPN #1 further explained food items were thrown out after two days from the written date. The surveyor inspected the third-floor unit nutrition refrigerator with LPN #1 and observed the following: 5. On the door of the refrigerator was an opened two cal HN (a nutritional supplement) plastic bottle which was dated [DATE] and had no name written on it. LPN #1 stated it was a supplement for a resident but was unsure for which resident. 6. In the freezer of the refrigerator, there were two 32-ounce (oz) Styrofoam cups filled with a berry-colored solid frozen item. Both cups were undated and unlabeled with a resident's name. LPN #1 did not know who the cups belonged to. The LPN acknowledged the items should have been labeled with a name and dated. LPN #1 removed the cups to be disposed. On [DATE] at 11:00 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of the third-floor unit. The RN/UM stated that food items in the nutrition refrigerator should be labeled with the resident's name and dated. The RN/UM further explained food items were to be removed after 48 hours. The surveyor inspected the refrigerator with the RN/UM. The surveyor asked about the two cal HN, the RN/UM stated she was not sure if the supplement was being used for one resident or as a house stock item for multiple residents. 7. In the bottom left drawer of the refrigerator, a store recycling bag was labeled with Resident #75's name and dated [DATE]. Inside of the bag there were two boxes of microwavable frozen food products. The surveyor asked RN/UM about the frozen food items found in the refrigerator section. The RN/UM stated that she was not sure if the food items needed to be kept in the freezer or if the items were ok to be left in the refrigerator. 8. In the bottom right drawer of the refrigerator, there was a blue colored bag which had a plastic container of blueberries. The blueberries container was labeled [DATE] and there was no name on the food item. The RN/UM could not say who the item belonged to. The RN/UM stated that she would follow up. 9. On [DATE] at 11:10 AM, the surveyor inspected the second-floor refrigerator with LPN #2. The surveyor observed the inside of the refrigerator was dark. The light bulb fixture in the refrigerator was hanging downward from the ceiling and was empty. The LPN could not speak to what happened to the light fixture and stated it would be expected for maintenance to be notified of issue. LPN #1 was not sure if maintenance was aware of the issue. 10. On [DATE] at 11:20 AM, the surveyor inspected with the LPN/Unit Manager (LPN/UM) the fourth-floor refrigerator. The thermometer in the refrigerator read 28 degrees Fahrenheit (F). The surveyor asked the LPN/UM about the normal range for refrigerator temperatures. The LPN/UM checked the refrigerator temperature log sheet attached to the refrigerator. The LPN/UM replied, the acceptable range as indicated on the log was 34 to 40 degrees F. The LPN/UM acknowledged the temperature of 28 degrees F was outside of the expected normal range and it was protocol to notify maintenance. The LPN/UM stated she would inform the maintenance department to check and adjust the temperature. The LPN/UM provided a copy of the January refrigerator temperature log which was posted on the refrigerator. On [DATE] at 11:45 AM, the surveyor interviewed the DON about the nutrition refrigerators on the unit. The DON stated dietary were responsible for cleaning out and checking the refrigerators for outdated items. The DON explained the night shift nurses were responsible for checking refrigerator temperatures and if any issues with the refrigerators, maintenance would be informed. The surveyor informed the DON of the above observations for the unit nutrition refrigerators. The DON accompanied the surveyor to the 3rd floor unit refrigerator regarding observations. The two frozen food packages observed included the direction, keep frozen on their packaging. The DON acknowledged the food items should be kept in the freezer as instructed. The DON stated he would follow up on the surveyor's observed concerns to provide additional information. On [DATE] at 12:01 PM, the surveyor reviewed the Temperature (temp) Log for the fourth-floor nutrition refrigerator which revealed the following: The form indicated Refrigerator minimum/maximum range 34 to 40 [degrees] Fahrenheit. -On [DATE] the refrigerator temp was documented as 33 degrees. The adjustment/corrective action section was blank. -On [DATE] the refrigerator temp was documented as 30 degrees. The adjustment/corrective action section was blank. On [DATE] at 12:11 PM, the surveyor interviewed LPN #2 on the fourth floor who stated if there were maintenance issues, the nurse supervisor would be made aware, maintenance would also be contacted, and there was a maintenance log book kept at the nurses' station. The maintenance staff checked the log book during their rounds on the unit. A review of entries in the maintenance log book for [DATE] revealed one entry related to a refrigerator on the unit, dated [DATE], that documented Refrigerator to cold please check. For the entry the Corrective Measure portion was left blank. There were no other entries related to refrigerators. On [DATE] at 1:17 PM, the LNHA, VPoCS, and the DON met with the survey team. The VPoCS stated the FSD did in-service education to dietary staff on hair restraints, handwashing, and expired cheese item found. The surveyor notified the LNHA, VPoCS, and the DON of the above concerns observed with the nutrition refrigerators. On [DATE] at 10:32 AM, the LNHA, the DON, and the VPoCS met with the survey team. The VPOCS acknowledged the frozen food items should have been stored in the freezer and the resident as well as staff were educated. In-service education was provided to nursing staff was provided about appropriate labeling of items placed in the refrigerators. The refrigerator on the 4th floor was replaced with another refrigerator as the temp was not able to be adjusted within the normal range. The light for the second-floor refrigerator was fixed. There was no additional response provided by the facility. A review of the facility's Labeling and Dating System Protocol, with a last revised date of [DATE]. The policy indicated opened sliced, or shredded cheese were good for one week from their open date. A review of the facility's Media, Uniform and Hairnet Policy, with a last revised date of [DATE]. Under Procedure, it documented .Hair nets are worn and completely cover hair from front to back .Facial hair coverings will be worn to cover any facial hair . A review of the facility's Handwashing/Hand Hygiene Policy, with a last updated date of [DATE]. Under Policy Interpretation and Implementation indicated hand hygiene to be performed after removing gloves. The policy also indicated .The use of gloves does not replace hand washing/hand hygiene . A review of the facility's Refrigerators and Freezers Policy, with a last reviewed date of [DATE]. Under Policy Interpretation and Implementation documented: 1. Acceptable temp ranges are 36 to 40 degrees F for refrigerators . 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temp will be recorded on the tracking sheet, including the repair personnel and/or department contacted. 6. All food shall be appropriately dated to ensure proper rotation by expiration dates .Expiration dated on unopened food will be observed and use by dates indicated once food is opened. 7. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expires or past perish dates. NJAC 8:,d+[DATE].2(g)

Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the residents or resident representative written notification of the facility's bed hold policy for 4 of 5 residents, (Residents #12, #84, #94, and #97), reviewed for hospitalizations. This deficient practice is evidenced by the following: 1. On 1/27/25 at 10:59 AM, Surveyor #1 (S#1) observed Resident #12, seated on the side of the bed and informed the surveyor that they were a short-term resident and had been in and out of the facility for more than three times hospitalizations due to a heart condition. The surveyor reviewed the medical records of Resident #12, and revealed the following: The admission Record (AR, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; cardiac arrhythmia (irregular heartbeat) unspecified, unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), essential hypertension (elevated blood pressure), and type 2 diabetes mellitus without complications. A review of the Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 8/16/24 and 9/10/24, revealed in Section A Identification Information, Resident #12 had unplanned hospital transfers. A review of the quarterly MDS (qMDS) with an ARD 11/20/24, under Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 15 of 15, which reflected that the resident had intact cognition. 2. On 1/27/25 at 10:14 AM, Surveyor #2 (S#2) observed Resident #94, in bed with the head of the bed elevated. A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; aphasia (an impairment in a person's ability to comprehend or formulate language because of damage to specific brain regions) following cerebral infarction (stroke), unspecified atrial fibrillation, and essential hypertension. A review of the MDS, with an ARD of 12/18/24, under Section A, reflected that the resident had unplanned hospital transfer. Further review of the medical records revealed that there was no documented evidence that the written bed hold notifications were given to the Resident or Resident Representative (RR) of Residents #12 and #94. On 1/28/25 at 2:51 PM, S#1 asked the Director of admission (DA) about the bed hold notifications for Residents #12 and #94, and the DA informed the surveyor that she had a binder for bed hold notices. The DA reviewed her binder for bed hold notices, and the DA stated that she probably had it in another binder in the other room. At that time, S#1 and the DA went to another room and the DA looked for the other binder. The DA then stated that she could not find the binder, and the DA agreed to had 15 minutes to look for the other binder. She further stated that she would get back to the surveyor. On 1/28/25 at 3:01 PM, the DA provided the two-bed hold notices for Resident #12 and one bed hold notice for Resident #94, and the DA confirmed that she found the other binder where she found the missing bed hold notices of two residents. Inside the DA's room, the DA was unable to show the other binder, and the DA stated that there was no other binder. At that same time, the DA confirmed that Resident #94's bed hold notice was done after the surveyor's inquiry. A review of the provided Bed Hold Notice for Resident #12 revealed: -for the date 8/15/24, verbal consent was obtained from RR. -for the date 9/11/24, verbal consent was obtained from RR. Further review of the above 8/15/24 and 9/11/24 revealed that the notice forms did not include information about the rate of the rooms and no written notifications. There was a discrepancy on the notice provided for the date 8/15/24, versus the date the resident was transferred to the hospital which was on 8/16/24. On 1/29/25 at 1:16 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and [NAME] President of Clinical Services (VPoCS), and the surveyor notified them of the above findings and concerns. S#1 asked the facility team, what was the facility's process and protocol with regard to providing bed hold notification and if the facility provided the Resident and/or the RR notification in written form. The VPoCS stated that we just recently started the written notification for a bed hold and to be honest, the facility was doing verbal notifications before. A review of the facility's Bed Hold Notice Upon Transfer Policy, with a reviewed date of 12/2024, that was provided by the Assistant DON reflected that a time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the RR written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Policy Explanation and Compliance Guidelines: 1. Before a resident is transferred to the hospital .the facility will provide the resident and/or RR written information that specifies . b. The reserve bed payment policy in the state plan policy, if any On 2/3/25 at 12:05 PM, the survey team met with the LNHA, DON, and VPoCS for an exit conference, and there was no additional information provided by the facility. 3. On 1/28/25 at 11:28 AM, Surveyor #3 (S#3) observed the Resident #84 lying in bed. The resident stated, I came here because of my legs, and I go to the hospital I take care of myself. A review of the Resident's #84 medical record revealed diagnoses which included but not limited to urinary tract infection (UTI), spinal stenosis (a condition where the spinal canal becomes narrowed). A review of the qMDS with an ARD of 11/8/24, revealed a BIMS score of 15 out of 15 indicating intact cognition. A review of the medical record revealed a hospitalization on 12/30/24 for bacteremia likely due to UTI, which resolved with antibiotic on 1/13/24. On 1/29/25 at 9:18 AM, S#3 requested for the bed hold binder from the DA, and the DA provided one binder from 2024-2025. The DA stated, I do not have any other binder for those years. At that same time, S#3 reviewed the bed hold binder that was provided which revealed notices from 11/13/24-1/17/25 were incomplete: signatures from resident and family representative missing; and private pay rates not filled out. The bed hold policy notice for Resident #84 not found in the binder. On 1/29/25 at 10:11 AM, S#3 interviewed the DA, regarding bed hold policy notification. The DA stated, We are obligated to offer for that bed to be held in their absence. We are supposed to hold bed for 10 days and even after 10 days, we're obligated to hold the bed. The first thing we do is call the family if they want the bed hold, write who I spoke to on the Bed-Hold Notice form, I give them the verbal amount over the phone and not really fill that part out on the form. I put their name under signature as verbal notification and recently I started to e-mail the responsible party after I fill out the form and send that to the responsible party. I try to notify family two ways, call them and e-mail them, I started this on January 13th, 2025. Furthermore, the DA stated that prior to that I always called family and not give written notification. As far as policy, call them on the phone, document the call and create a bed hold book. She further stated that as far as I know the regulation to notify family was to use that form, call the family and do a verbal over the phone, that was the way I've been doing it. At that time, S#3 reviewed the facility policy for bed hold notification with the DA. The DA confirmed that the notices were not being completed properly. The DA stated, I will look at that because I thought I was doing it right. I didn't know it was supposed to be a written notification. On 1/29/25 at 10:33 AM, S#3 requested for the bed hold notice for Resident #84 which was not in the binder. The DA confirmed the bed hold notice was not in the binder, and stated, I don't know what happened to this one. I have to look for that resident's notice. 4. On 1/28/25 at 10:47 AM, S#3 observed the Resident #97 in the activity room sitting on a wheelchair, attending mass service. A review of the Resident's #97's medical record revealed diagnosis which included but not limited to syncope and collapse (a brief loss of consciousness). A review of the medical records also revealed that the resident had a hospital transfer on 10/5/24. A review of the most recent qMDS revealed a BIMS score of 4 out of 15 indicating severe impaired cognition. On 1/29/25 at 10:33 AM, S#3 requested from the DA for the bed hold notice for Resident #97 which was not found in the binder. The DA confirmed the bed hold notice was not in the binder. I don't know what happened to this one. On 1/29/25 at 1:37 PM, S#3 notified the DON, VPoCS, and the LNHA of the above concerns regarding missing bed hold notices including notification forms not filled out properly (no signatures from resident/family and pay rates missing). The surveyor asked what the policy is for bed hold notices and the VPoCS confirmed, They're calling family and not sending written notification before, and we recently in-serviced the DA to within 24 hours e-mail them and give written notification which started this month. On 1/29/25 at 2:20 PM, the DA stated, I was looking for you about the notices. The resident was alert and oriented, they always calls the building to let us know to hold the bed. It's a verbal with the resident, I couldn't find the letter. I just started giving the written notices. There was no bed hold notices provided for the Resident #84 and the Resident #97. On 1/29/25 at 2:30 PM, S#3 reviewed the facility's policy and procedure titled, Bed Hold Notice, dated 12/2024 which revealed, .the facility will provide within 24 hours written notice of the facility's bed hold policies, as stipulated in the State's plan. On 2/3/25 at 10:34 AM, the VPoCS stated, As far as the bed hold notice, we did speak to the DA. She already started the e-mail process of notifications to the families or submitting the notification in person if family is here and for notification to be filled out completely including the rates on the form. N.J.A.C. 8:39-5.1 (a), 5.2 (a)

Based on observation, interview, and review of other facility documentation, it was determined the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 3 of 3 units, (2nd, 3rd, and 4th units) and 2 of 2 residents' rooms. This deficient practice was evidenced by the following: 1. On 1/27/25 at 1:58 PM, during the initial tour of the 4th floor nursing unit, the surveyor observed a gray, dust or dirt-like substance adhering to the air circulation vent covers on the 4th floor unit in the hallways and above the nursing station. The surveyor observed four vent covers in the 4th floor hallways and one vent cover above the nursing station. On 1/28/25 at 9:30 AM, the surveyor observed the vent covers on the 2nd and 3rd floors. The surveyor observed that the vent covers on the 2nd and 3rd floors also had a gray, dust or dirt-like substance accumulated on them. The surveyor asked the Director of Nursing (DON) who was responsible for the cleaning of the air vents. The DON stated that maintenance was the department responsible. On 1/28/25 at 10:27 AM, the surveyor interviewed the Director of Maintenance (DM) on the 4th floor. The surveyor asked the DM if the maintenance department was responsible for cleaning the air vents and when was it done. The DM stated, yes, it was done by maintenance and should be done monthly. On that same date and time, the surveyor showed the DM the air vents located on the 4th floor and asked if they were considered clean. The DM stated no, they do not look clean. The surveyor asked if the amount of material on the vents looked like it could accumulate within a few days. The DM stated, no, it would take a while to build up. The surveyor asked if the condition of the air vents would be considered homelike, clean and sanitary. The DM stated no they were not. The surveyor asked the DM if it was likely that the air vents on the other floors were in the same condition. The DM stated, they probably were dirty as well, I have to check with my staff to see why they were not being cleaned, they should be cleaned with a vacuum. On 1/28/25 at 2:00 PM, the survey team met with the DON, Assistant Director of Nursing (ADON), Licensed Nursing Home Administrator (LNHA) and [NAME] President of Clinical Services (VPoCS) to discuss concerns. The facility did not provide any further pertinent documentation. 38327 2. On 1/27/25 at 10:58 AM, during the initial tour, the surveyor observed room [ROOM NUMBER]'s toilet vent with an accumulation of grayish substances. At that time, there were two residents inside the room, Resident # 23 and Resident # 8. On 1/28/25 at 11:21 AM, the surveyor with the Registered Nurse (RN) went to see room [ROOM NUMBER]'s toilet and both observed an accumulation of grayish substances on the vent. The RN stated that the vent should have been cleaned by housekeeping, and she confirmed that the grayish substances were the accumulation of dust. 3. On 1/27/25 at 10:59 AM, during the initial tour, the surveyor observed room [ROOM NUMBER]'s toilet tissue paper holder broken. The surveyor observed Resident #12 was inside the room seated on the side of the bed. On 1/28/25 at 11:13 AM, the surveyor observed Resident #12 lying on the bed, awake, and denied care concerns. The surveyor observed the toilet room with broken tissue paper holder, same as yesterday's observation. 4. On 1/28/25 at 10:42 AM, the surveyor observed the elevator vent with an accumulation of grayish substances. At that same time, the staff and a resident were inside the elevator. On 1/29/25 at 1:16 PM, the survey team met with the LNHA, DON, and VPoCS. The VPoCS stated that we addressed the vents and put the process in place for cleaning. The surveyor notified the concern also with the elevator's dusty vents, and the VPoCS responded that she would look at it as well. On 2/03/25 at 8:22 AM, the surveyor followed up the concerns with Resident #12's broken toilet tissue paper holder and the elevator vent, and the DON responded that resident#12's toilet tissue paper holder was done and fixed the same day the surveyor mentioned it. He further stated that the concerns with dusty vents in the elevator and room [ROOM NUMBER] toilet were all cleaned after the surveyor's inquiry. A review of the facility's Environment Policy, with a reviewed date of 1/2025, that was provided by the VPoCS on 1/30/25 at 10:10 AM revealed: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Definitions: Environment refers to any environment in the facility that is frequented by residents, including the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas . Orderly is defined as an uncluttered physical environment that is neat and well-kept . Policy Explanation and Compliance Guidelines: 3. Housekeeping and Maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment . The policy did not reflect any mention of air vents, cleaning of vents or other areas. On 2/03/25 at 12:05 PM, the survey team met with the LNHA, DON, and VPoCS for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-31.4(a)(b)(f)

Based on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for 5 of 8 newly hired licensed staff reviewed, Staff Member (SM) #1, #4, #5, #6, and #7 evidenced by the following: On 1/28/25 at 11:12 AM, the surveyor reviewed ten randomly selected newly hired employee files. The review for license verification for eight of the new licensed employees revealed the following: 1. A review of Staff Member #1 (SM#1), a Certified Nursing Assistant (CNA #1), hired on 5/30/24, had a New Jersey Department of Health (NJDOH) online Public Registry license verification printout (used to verify the status of a CNA's license and to check the nurse aide registry) which did not include the date that the verification was done. There was no documented evidence that SM#1's license was verified prior to the date of hire (doh). 2. A review of Staff Member #4 (SM#4), a CNA, hired on 6/20/24, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. There was no documented evidence that SM#4's license was verified prior to the doh. 3. A review of Staff Member #5 (SM#5), a CNA, hired on 6/13/24, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. There was no documented evidence that SM#5's license was verified prior to the doh. 4. A review of Staff Member #6 (SM#6), a CNA, hired on 2/22/24, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. There was no documented evidence that SM#6's license was verified prior to the doh. 5. A review of Staff Member #7 (SM#7), a CNA, hired on 9/20/24, had a NJDOH online Public Registry license verification printout which did not include the date that the verification was done. There was no documented evidence that SM#7's license was verified prior to the doh. On 1/28/25 at 12:28 PM, the surveyor interviewed the Director of Human Resources ([NAME]) regarding the process for license verification. The [NAME] stated that she would ask for a copy of their license and verify it on the NJDOH online Public Registry prior to the doh. The surveyor asked if the date that the verification was on the printout. The [NAME] stated that she was not sure. The [NAME] then viewed one of the printouts and stated that she did not think the date was on the printout. On 1/29/25 at 10:07 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Regional LNHA, Director of Nursing (DON) and [NAME] President of Clinical Services (VPoCS) the concern that SM#1, SM#4, SM#5, SM#6 and SM#7 did not have documented evidence of the date that their license was verified. On 1/29/25 at 1:41 PM, in the presence of the LNHA and DON, the VPoCS stated that she called the license verification site and they stated that the date was not printed from the website and that the computer that is printing it would have to have the header and footer setting for the date to be printed on the printout. She added that she did not know that. The VPoCS stated that we verify license prior to the doh and that it was part of their process. The facility could not provide documented evidence that the licenses were verified prior to their doh. The facility did not provide any additional information. A review of the facility's Abuse, Neglect and Exploitation Policy with a adopted date of 6/2024, included the following: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credential's checks shall be conducted on potential employees 3. The facility will maintain documentation of proof that the screening occurred. A review of the facility's Onboarding/Background Check Policy and Procedure with a revised date of 10/2024, included the following: License/Certification Verification: confirms the applicant's license/certification is in good standing with no pending or prior investigations. (if applicable) N.J.A.C. 8:39-43.15(a)