Every finding on record at Coral Harbor Rehabilitation and Healthcare Center

Complaint #2790808Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) ensure a Registered Nurse (RN) immediately assessed a resident who had fallen and complained of pain. On [DATE], Resident #3 had an unwitnessed fall. The Licensed Practical Nurse (LPN #1) responded to the fall and did not call an RN to assess the resident. The resident complained of pain and was transferred back to bed by two Certified Nursing Assistants (CNAs). On [DATE], 4 days later, the resident was transferred to the emergency room (ER) for an unrelated medical concern and was diagnosed with a right hip fracture. The facility further failed to b.) ensure that a resident (Resident #10) who experienced an acute change and decline in their medical condition was properly assessed and treated in a timely manner. This deficient practice was identified for 2 of 2 residents (Resident #3 and Resident #10) reviewed for quality of care and was evidenced by the following:Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 [DATE] at 10:48 AM, during the initial tour of the facility, the surveyor observed Resident #3 in the activities room on the second floor. The resident was seated on a recliner with a mechanical lift pad beneath their back. The surveyor observed the resident's right arm to be flexed at the wrist and elbow areas and the resident's right hand rested on their right collar bone. The resident was speaking to other residents who were seated at their table. On [DATE] at 9:39 AM, the surveyor observed the resident in bed with no fall mat on either side of the bed. Their right forearm was flexed at the elbow and wrist with the resident's right hand resting on their right collar bone. The resident's feet were observed to be pointing outward. On that same date and time, the surveyor interviewed the resident who stated that they fell in the facility three times, with one fall that resulted with them hurting their right knee. The resident showed the surveyor how they grabbed the left grab bar on the bed with their left arm to pull themselves up in bed, but ended up sliding to the floor on the left side of the bed, falling on their face, and hurting their right knee. The resident stated that they were alone when the incident occurred. The resident stated that CNA #2 came to check on them and called the unit nurse. The resident further stated that CNA #2 picked them up and denied that they were transferred to bed from the floor by mechanical lift. The resident stated that they were already in bed when the nurse came to take their BP (blood pressure). The resident stated that they experienced pain on the right knee including the right hamstring area when they fell. The resident stated that only one nurse came to check on the resident after the fall. The surveyor reviewed the medical record for Resident #3. A review of the admission Record (an admission summary), reflected that Resident #3 was readmitted to the facility with diagnoses which included but were not limited to the following: fracture of the right femur, suicidal ideations, and quadriplegia (paralysis of both arms and legs). A review of the most current quarterly Minimum Data Set (MDS), an assessment tool dated [DATE], reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the resident's behavioral symptoms did not reveal any rejection of care. A review of the resident's functional limitation in the range of motion reflected the resident had an upper extremity (shoulder, elbow, wrist, hand) impairment to one side. The lower extremity (hip, knee, ankle, foot) was coded 0 or no impairment. A review of the resident's functional abilities in the MDS reflected that the resident was dependent on staff for all their activities of daily living including transfers to and from bed to chair and vice versa. Being dependent on transfers means that the assistance of 2 or more helpers is required for the resident to complete the activity. A review of the resident's health conditions did not capture the resident's fall on [DATE], when the resident sustained a fracture of the right hip. A review of the individual comprehensive care plan (ICCP) included a focus area for risk of falls related to limited mobility and seizures created on [DATE]. The interventions included the following: Fall mat(s) to (Specify: Right, Left, Both) side(s) of the bed at all times when the resident is in bed initiated on [DATE]. The ICCP also specified that the resident transfers with assistance from 2 (two) staff members. A review of the Order Summary Report (OSR) active as of [DATE], revealed the following physician orders: Acetaminophen Tablet 325 mg. Give 2 tablets by mouth every 6 hours as needed for general discomfort for total dose of 650mg. Do not exceed 3 grams per 24 hours started on [DATE] and discontinued on [DATE], S/P (status post) fall documentation x (for) 72 hours every shift for s/p fall for 3 Days, shift note regarding fall, VS (vital signs) per shift, neuro checks every shift started on [DATE]. A review of the corresponding Medication Administration Record (MAR) in February 2026, revealed that the resident was maintained with zero pain level except on the following dates when acetaminophen 650 mg was administered to them: on [DATE] at 4:00 PM for pain level of 3/10, on [DATE] at 5:00 PM for pain level of 3/10, and on [DATE] at 12:27 AM for pain level of 4/10. The MAR also reflected that the resident refused their day shift medications on [DATE], prior to the fall. A review of the Progress Notes (PN) revealed on [DATE] at 2:53 PM, LPN #3 documented that the resident refused all their morning medications. At 3:32 PM, the nurse documented that the resident's physician was contacted because of the resident's refusal of medications and a urine output of 100 cc (cubic centimeter) on the day shift. The physician gave a telephone order to rehydrate the resident with intravenous (IV) fluid and laboratory work ups to include CBC/ CMP (Complete Blood Count [ a blood test that measures the type and number of cells in the blood] / Comprehensive Metabolic Panel [ a blood test that measures different substances in the liver and kidney ] ) and urinalysis with culture and sensitivity. A request for vascular access (a short-term access for fluid or medication through insertion of a tube in the artery or vein) was placed with [name of service redacted]. Further review of the PN revealed that on [DATE] at 3:30 PM, LPN #4 documented that the resident had an unwitnessed fall. LPN #4 checked the resident's vital signs, evaluated their skin and pain level, administered acetaminophen 650 mg by mouth for mild pain, 3/10, initiated neurological checks, placed the bed in the lowest position, placed the call bell within reach of the resident, and notified the resident's physician. LPN #4 also completed the fall risk evaluation, skin check, and pain evaluation forms in the EMR (electronic medical record). There was no documentation to indicate that an RN assessed the resident or range of motion was assessed and compared to the resident's baseline. There were no documented routine assessments for the resident's neurological status to include the level of consciousness, pupillary response, motor strength, speech pattern, facial symmetry that were assessed and performed on a scheduled basis within the PN. Further review of the PN revealed a health status note from Resident #3's physician entered on [DATE] at 9:38 AM, with a specified Date of Service on [DATE], did not include any reference to the resident's fall on [DATE]. A review of the progress notes after the resident's fall revealed that on [DATE], the resident verbalized to the staff that they were going to kill themselves if their family members would not be in the facility in 5 minutes. The resident was transferred to the hospital for further evaluation which showed an acute impacted fracture of the right hip. The resident was managed conservatively without surgical intervention since the resident was bedbound. The resident was readmitted to the facility on [DATE]. A review of a Facility Reportable Event (FRE) submitted to the New Jersey Department of Health (NJDOH) on [DATE] revealed that on [DATE], the resident was transferred to the emergency room for behaviors and upon assessment was diagnosed with a right hip fracture. A review of the facility's undated investigation concluded that the resident sustained the hip fracture from the fall on [DATE], which went undetected because of the resident's comorbidities. Abuse was ruled out. A review of the facility nursing schedule on [DATE], revealed there were two RNs (RN #1, RN #2) present in the facility on the day shift at the time of the resident's fall. On [DATE] at 11:45 AM, the surveyor conducted a telephone interview with CNA #2 who stated that on [DATE], the resident threw themselves on the floor. The surveyor asked CNA #2 if they transferred the resident back to bed from the floor. CNA #2 stated that the resident was already in bed. CNA #2 told the surveyor that they wrote a statement regarding the fall. A review of the CNA #2's statement revealed that she put the resident back to bed after the nurse checked the resident's vital signs. On [DATE] at 9:18 AM, the surveyor conducted a telephone interview with Resident #3's physician who stated that on [DATE], they received text messages from LPN #4 and LPN #3 regarding the resident's refusal of medications, decreased urine output and ordered IV fluids and urinalysis with culture and sensitivity tests. The physician stated they also received a message at 4:00 PM, that the resident rolled out of bed. The physician stated that it was their medical judgement not to order a radiology exam. On [DATE] at 9:31 AM, the surveyor attempted to conduct a telephone interview with LPN #3 but was unable to. On [DATE] at 12:38 PM, the surveyor interviewed RN #1 who stated that LPNs and RNs assess residents who fall in the facility. RN #1 confirmed that they did not assess Resident #3 on [DATE]. On [DATE] at 12:39 PM, the surveyor interviewed CNA #4 who stated that it was the facility protocol to call for help when a resident falls. On [DATE] at 3:31 PM, the surveyor conducted a telephone interview with LPN #4 who stated that they assessed Resident #3's vital signs, skin for redness and swelling, and for pain. The LPN also stated that they witnessed CNA #2 and CNA #3 picked up the resident from the floor. The surveyor asked LPN #4 whether they had seen the CNAs use the mechanical lift to transfer the resident. LPN #4 stated that they had not seen the CNAs use the lift to transfer the resident to bed. LPN #4 stated they did not call another nurse or an RN to assess the resident post fall. A review of LPN #4's written statement on [DATE], revealed that the resident was placed in bed by the CNAs. On [DATE] at 4:21 PM, the surveyor conducted a telephone interview with RN #2 who stated that they worked in the facility during the day shift of [DATE] on second floor. RN #2 stated that they were not called to assess Resident #'3's fall during their shift. RN #2 stated that the facility protocol was for LPNs and RNs to assess the residents who fell. On [DATE] at 10:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated that LPNs can assess the residents who fall if there were no RNs in the building. When the RNs come in, then they could assess the residents at that time. A review of the facility policy revised in [DATE], titled Fall – Clinical Protocol indicated under Assessment and Recognition the following: 2) In addition, the nurse shall assess and document/ report the following: a. Vital signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc. d. Change in condition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy, and j. All active diagnosis. 4) The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications associated with increased falling risk) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant). Part 2 2.) On [DATE] at 9:42 AM, Surveyor #2 reviewed the closed record of Resident #10. A review of the admission Record (an admission summary), revealed that the resident was admitted to the facility with diagnoses which included but were not limited to: acute respiratory failure with hypoxia (deficiency in the amount of oxygen reaching the tissues), heart failure, unspecified, other gram-negative sepsis (a severe, systemic infection characterized by an sudden onset of symptoms such as fever and chills, and requires prompt diagnosis and treatment), and Extended Spectrum Beta Lactamase (ESBL) Resistance (Enterobacterales (a group of bacteria that are resistant to most antibiotics), difficulty in walking, and presence of other cardiac implants and grafts. A review of the comprehensive Minimum Data Set (MDS), dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS revealed that the resident had active diagnoses which included septicemia (blood poisoning, caused by bacteria and their toxins) and Multidrug-Resistant Organism (MDRO, bacteria that are resistant to at least three families of antibiotics). A review of the resident's individual comprehensive care plan (ICCP) included a focus area with a cancelled date of [DATE], which indicated the resident was at risk for respiratory complications r/t (related to) COPD (Chronic Obstructive Pulmonary Disease, a condition involving constriction of the airways and difficulty or discomfort in breathing). The Goal included: My risk for respiratory complications and infections will be mitigated (making something bad less severe) through the review date. Interventions included: Monitor vital signs, including oxygen saturation, as ordered an/or clinically indicated. Report abnormal findings to the practitioner. Document findings and interventions. Further review of the ICCP included a focus area with a cancelled date of [DATE], which indicated the resident Required supplemental oxygen r/t COPD. Goals included: I will remain free of symptoms and complications of low oxygen levels, such as shortness of breath, dizziness, tachycardia (rapid heart rate above 100), headache through review date. Interventions included: Monitor vital signs, including pulse oximeter (a probe placed on the index finger to measure the amount of circulating oxygen levels in the blood), as ordered and clinically RN (Registered Nurse) Licensed Practical Nurse (LPN) indicated. Report abnormal findings to practitioner. Document findings and interventions. Further review of the ICCP included a focus area with a cancelled date of [DATE], which indicated the resident had an indwelling urinary catheter r/t BPH, benign prostatic hyperplasia (BPH, a condition in men related to an enlarged prostate (a gland surrounding the neck of the bladder). Interventions included: Monitor for signs and symptoms of UTI (urinary tract infection) such as .fever, chills, altered mental status, change in behavior .Report abnormal findings to Practitioner; Document findings and interventions. A review of the Order Summary Report including the following Physician's Order (PO): A PO, dated [DATE], for DNR (Do Not Resuscitate) (revive). A PO, dated [DATE], for DNI (Do Not Intubate) (a life-saving procedure to keep your airway open). A review of the electronic medical record (EMR) revealed a Health Status Note (HSN) effective on [DATE] at 00:56 AM (12:56 AM) that was written by Licensed Practical Nurse (LPN # 5) included the following: Upon doing round [sic] at 11:30pm, found resident in bed shaking very seriously, obtain vital sign bp (blood pressure) was 165/111, HR (heart rate) 111, R (respirations) 24, temp 98.7, unable to obtain oxygen saturation, slightly unconscious, not responding to verbal commands as usual, after one and half hour recheck vitals with another nurse, reading obtain [sic] bp 150/79, HR 110, temp 98.7, still unable to read oxygen saturation, call placed to MD (Medical Doctor) to relayed [sic] pt condition unable to reach him, 911 call and relayed pt condition, he/she was pick up at 12:50 am will continue to follow up with pt while sent to hospital for further evaluation. Further review of the EMR revealed a Health Status Note with an effective date of [DATE] at 1:25 (AM) revealed, Doctor [name redacted] call back at 1:15 am, and ordered to send pt out to ER for evaluation. Further review of the EMR revealed a HSN with an effective date of [DATE] at 15:14 (3:14 PM) that was written by the Director of Nursing (DON) included: Pt admitted to [hospital name redacted] for sepsis. On [DATE] at 10:38 AM, the surveyor phoned LPN # 5 in the presence of the survey team and conducted an interview via speakerphone with her permission. The surveyor reviewed the HSN dated [DATE] at 12:56 AM aloud with LPN #5. LPN #5 stated that she had taken the resident's vital signs and her supervisor, was there. LPN #5 was unable to state the name of the supervisor when asked and the documentation within the resident's EMR did not indicate the presence of a nurse supervisor. LPN #5 stated that she called the MD and received no response, so we decided to call 911. LPN #5 stated that she returned to the resident's room with a Registered Nurse (RN #3), who was another nurse on the unit, and we rechecked the resident's vital signs. LPN #5 stated that the resident's hands were cold, and the pulse oximeter could not read the resident's oxygen level reading. LPN #5 stated that we called 911 and they said that they were coming. When the surveyor asked LPN #5 why she had waited one and a half hours to recheck the resident's vital signs with another nurse after she documented that at 11:30 PM, she found the resident shaking very seriously, slightly unconscious, not responding to verbal commands, unable to obtain oxygen saturation, with a blood pressure reading of 165/111, HR 111, R 24? LPN #5 stated that she could not remember the time frames. LPN #5 stated that the second time that she went to see the resident the resident had stopped shaking. When the surveyor asked LPN #5 if the resident resumed consciousness at any point she stated, Yes, the resident came around before 911 came. When the surveyor asked LPN #5 if she had ever received any education or training related to sepsis she stated, No. On [DATE] at 12:48 PM, the surveyor attempted to reach interview RN #3 via telephone, but was unable to reach her. On [DATE] at 9:32 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2) who stated that Resident #10 should have been placed on oxygen immediately, and a code should have been called to the resident's room because the more hands to care for the resident, the better. LPN/UM #2 stated that if LPN #5 could not get a pulse oximetry reading on the resident, the resident should have been sent out via 911 and then called the physician. LPN/UM #2 stated that a nurse should have remained with the resident as the resident could have become unresponsive. LPN/UM #2 stated that the resident's first set of vital sighs were very high and she should not have waited. LPN/UM #2 stated that the blood pressure (BP) was very elevated ate 165/111, and heart rate was elevated at 111, and respirations were 24, all signs and symptoms of possible sepsis or stroke. LPN/UM #2 stated that a code should have been called and all nurses and the RN should have responded. LPN/UM #2 stated that she could not tell if a code were called or if the resident were assessed by an RN from the Progress Note that LPN #5 had written because her note just indicated that she brought another nurse in, but it did not say if it were an RN or not. LPN/UM #2 stated the facility did have a sepsis protocol and she was educated regarding the protocol upon hire. On [DATE] at 9:46 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the facility sepsis protocol included if a resident were identified with an elevated temperature, with a wound, or an altered mental status, there was a criteria to follow, and we sent the residents to the hospital very quickly, because sepsis was very fast acting. The ADON stated that the resident could have died in an hour and a half and it was definitely an inappropriate action that LPN #5 had taken. The ADON stated, That is a delay in care. The ADON stated that the nurse who went with LPN #5 into the room to recheck the resident's vital signs also should have written a note and documented that she assessed the resident. The ADON stated that LPN #5 either should have did the sepsis protocol or called for help. The ADON stated, Shaking very seriously, slightly unconscious, it is in the documentation that the resident presented as if they needed immediate medical attention and absolutely should not have had to have waited an hour and a half. On [DATE] at 9:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #10 was admitted to the facility on intravenous antibiotics after they had become septic in the hospital and after we removed the midline catheter (a thin, flexible tube inserted into a large vein in the upper arm, with the tip resting below the shoulder) and the resident became septic again. The DON stated that the doctor should have been called immediately. The DON stated LPN #5 was a nurse and should have taken accountability for her patient because she would not have let it get that far. The DON read the HSN and stated that slightly unconscious could have indicated that the resident was having a stroke and she should have dealt with it right away and called the doctor and the hospital. The DON stated, You do not wait an hour. I am sorry. Yes, I would have to say there was a delay in treatment, and there could have been permanent effects, and damage, especially if it were a stroke. The DON stated we have a sepsis protocol, and we are to get them out the door as soon as possible if they have sepsis because the hospital is right across the street. At that time, the DON stated the nurse who accompanied LPN #5 into see Resident #10 definitely should have written a note to document their findings and what they did about it. The DON stated that the resident survived, but did not return here, as the resident was actually getting ready to go home from here prior to hospitalization. On [DATE] at 11:36 AM, in a later interview with the DON, the DON stated that she confirmed that the resident was admitted to the hospital on [DATE] at 1:20 AM. The DON stated she interviewed LPN #5 who maintained that it was a half hour, and not an hour and a half before she had another nurse confirm the resident's vital signs with her. The DON stated that LPN #5 maintained that she remained with Resident #10 and rubbed the resident's hands in an effort to get them warm enough to obtain a pulse oximetry reading. When the surveyor asked if LPN #5 if she should have waited a half hour to seek the help of another nurse the DON stated, No, LPN #5 should have sought help immediately. The DON confirmed that there was a delay in seeking a higher level of medical treatment which could have negatively affected the resident. A review of an ED (Emergency Department) Note dated [DATE] at 1:20 AM, revealed, Received pt to ED .in stretcher. A&Ox3 (awake, alert, and oriented x 3). Pt is diaphoretic (perspiring) and SOB (short of breath) upon arrival. Pt placed on 6 L NC (six liters of oxygen via nasal cannula (plastic tubing placed in the nostrils for oxygen delivery) .Pt connected to heart monitor, NIBP (non-invasive blood pressure), and continuous pulse oximetry. No acute distress noted at this time. Pt expressing no needs at this time Further review of the ED Care Time line revealed: 2/21 admitted to Surgical Trauma Intensive Care Unit from ED 0700, .Cystoscopy (a procedure to view the inside of the bladder), Right Retrograde Pyleogram (a test to evaluate the urinary system for blockage), Bladder Stone Removal, Right Ureteral Stent Placement (procedure that opens a blocked tube that carries urine from the kidney to the bladder), Foley Catheter Placement (a tube placed into the urethra to empty urine from the bladder) discharged on [DATE]. A review of the facility, Change in a Resident's Condition or Status Revision Date February 2021, included: The nurse will notify the resident's attending physician or physician on call when there has been a (an): .significant change in the resident's physical/emotional/mental condition; .need to transfer the resident to a hospital/treatment center; NJAC 8:39:11.1, 27.1(a)

Based on an interview and review of other pertinent facility documentation, it was determined that the facility failed to fully implement the antibiotic stewardship program, including ongoing monitoring and use of surveillance criteria when antibiotics were prescribed.This deficient practice was identified for 5 of 5 months of antibiotic stewardship records reviewed and was evidenced by the following:On 5/5/2026 at 11:19 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics were used only when necessary and appropriate). The IP stated that the facility used the McGeer's and Loeb's criteria (clinical and laboratory findings used to define and track infections) for each resident when an antibiotic was prescribed, to ensure that each resident met the criteria for antibiotic usage. She further stated that when a resident was started on antibiotics, they initiated the screening. She added that nursing would document any signs and symptoms of an infection. The system would then determine if the resident met the criteria for the antibiotics. She stated that if the criteria was not met, they would notify the physician. She also noted that sometimes the antibiotics were started before the culture and sensitivity (C&S) came back, because the doctor did not want to wait. The IP stated that it did not occur that often, as the Medical Director tried to educate the providers to make sure the residents were screened properly before they were started on antibiotics. The IP also stated that she has been providing education to the nurses that when they got an order for a chest X-ray, labs, urinalysis, wound culture, or anything that could possibly require an antibiotic, they should initiate the McGeer's criteria.At that time, the surveyor reviewed the antibiotic log (a log containing residents who were prescribed antibiotics). The IP stated that the corporate office provided her with the log on 5/4/2026. The surveyor randomly selected 10 residents who were prescribed antibiotics from October 2025 through April 2026 and the following was identified:Resident #35, was started on Amoxicillin-Pot Clavulanate tablet 500 milligrams (MG) 4/30-5/5/2026 for a urinary tract infection. There was no documented evidence that the McGeer's Criteria was completed.A further review of the Resident #35's, medical record revealed that the resident was also started on Amoxicillin-Pot Clavulanate tablet 500 milligrams (MG) on 3/30/2026 through 4/2/2026, for an upper respiratory infection. A further review of the antibiotic tracking log did not include an entry for that event.Resident #75, was started on cephalexin 500 mg, 4/8/2026 through 4/14/2026 for a wound infection. A review of McGeer's criteria revealed that it was completed on 5/5/2026. At that time, the IP stated she backtracked, and noticed that the McGeer's was not completed at the time that Resident #75 was started on the antibiotic, so she completed it yesterday (5/5/2026), after surveyor inquiry.Resident #33, was started on antibiotics 4/4/2026 through 4/9/2026 for a urinary tract infection. There was no documented evidence that the McGeer's was completed.Resident #9, was started on Levaquin 500 mg 3/11/2026-through 3/18/2026 for an upper respiratory infection. There was no documented evidence that McGeer's was completed.Resident #91, was started on cephalexin 250 mg, 2/2/2026 through 2/7/2026 for bilateral arm cellulitis. There was no documented evidence that McGeer's was completed.Resident #117, was started on Macrobid 100 mg, 1/11/2026 through 1/17/2026 for a urinary tract infection. There was no documented evidence that McGeer's was completed.Resident #63, was started on piperacillin 3.375 grams on 3/23/2026 for sepsis protocol. There was no documented evidence that McGeer's was completed. A further review of the medication administration record (MAR) revealed that Resident #63 was started on Macrobid 100 mg, 3/23/2026 through 3/30/2026 for a urinary tract infection. A Further review of the Antibiotic tracking log did not include the Macrobid.Resident #49, was started on cephalexin 500 mg, 3/24/2026 through 3/26/2026 for a UTI. There was no documented evidence that McGeer's was completed. A further review of the antibiotic tracking log did not include an entry for that event.Resident #119, was administered Zosyn intravenous solution 3-0.375 gram/ml, 3/27/2026 through 4/1/2026, for a wound infection. There was no documented evidence that McGeer's criteria was completed.On 5/07/2026 at 9:16 AM, the Director of Nursing (DON) stated that they had to make sure the resident was qualified to receive the antibiotics. She further stated that the McGeer's criteria would be initiated prior to the resident starting the antibiotics. She added that she wanted to make sure the resident actually needed the antibiotic because they did not want people on antibiotics unnecessarily. She added that the previous IP was terminated due to not following the policies and procedures related to infection control.A review of the facility's Antibiotic Stewardship-Review and Surveillance of Antibiotic Use dated December 2016, Antibiotic usage and outcome and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form NJAC 8:39-19.4(c) (d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide the provision of respiratory care in accordance with professional standards of practice specifically by: a.) not having a physician's order for oxygen administration. b.) not storing an oxygen mask and nasal cannula (NC, a tube used to deliver supplemental oxygen directly into a patient's nostrils) in a protective bag and c.) not ensuring that oxygen equipment, and the humidification bottle was dated.The deficient practice was identified for 2 of 3 residents (Residents #7, and Resident #8) reviewed for Respiratory Care and was evidenced by the following:1.) On 5/3/2026 at 11:02 AM, during the initial tour of the facility, the surveyor observed Resident #7 in their room and the resident received oxygen via nasal at 2 (two) liters per minute (lpm) delivered via a concentrator (A device used to deliver supplemental oxygen.) The surveyor noted that the humidification bottle (a refillable container attached to an oxygen concentrator that added moisture to the dry, concentrated oxygen before it reached the user) was not labeled or dated. When the surveyor asked the resident how often the staff changed the humidification bottle, the resident stated, They do not change it, I take care of it myself. At that time, the surveyor observed that next to the resident's bed there was an oxygen nasal cannula hanging off of the side of the resident's wheelchair that was connected to a portable oxygen tank. The nasal cannula was not in a protective bag, was exposed to air, and was not dated. When interviewed the resident confirmed with the surveyor that they used the oxygen when they were in their wheelchair. On 5/4/2026 at 12:00 PM, the surveyor observed Resident #7's nasal cannula was hanging on the resident's wheelchair and was not in a protective bag, was exposed to air, and was not dated.The surveyor reviewed the Electronic Medical Record (EMR) for Resident #7.A review of the admission Record, an admission summary, revealed that Resident #7 was admitted to the facility with diagnoses which included, but were not limited to: chronic obstructive pulmonary disease (COPD) (a condition involving constriction of the airway making it difficult to breathe), acute respiratory failure with hypercapnia (AHRF) (occurs when the lungs cannot breathe deeply or quickly enough to remove carbon dioxide (CO2), causing it to build up rapidly in the blood), chronic respiratory failure with hypercapnia (a long-term condition where the lungs cannot adequately remove carbon dioxide (CO2) from the blood, leading to high (CO2) levels (hypercapnia). A review of the most recent comprehensive Minimum Data Set (MDS), dated [DATE], an assessment tool used to facilitate a resident's care, indicated that the Resident scored 15 out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident was cognitively intact. Further review of the MDS revealed that the Resident was on oxygen.A review of the resident's individual comprehensive care plan (ICCP) included a focus area revised on 5/11/2022, that the resident has oxygen therapy related to ineffective gas exchange. Interventions included: administer oxygen per order, monitor for signs and symptoms of respiratory distress and report to MD (Medical Doctor) as needed initiated on 6/2/2023. A Focus area, dated 8/19/2019, that the resident has COPD. Interventions included: give oxygen therapy as ordered by the physician, monitor for signs and symptoms of respiratory insufficiency. Further review of the care plan failed to include interventions for the use and care of the humidification equipment. A review of the Treatment Administration Record (TAR) reflected a physician's order (PO) dated 04/18/2023, for O2 (oxygen) at 2 liters continuous via nasal cannula every shift. A physician's order, dated 5/1/2022, for oxygen tubing changed and dated on 11-7 shift every Sunday. On 5/4/2026 at 12:04 PM, Licensed Practical Nurse (LPN#1) accompanied the surveyor into the resident's room. During an interview with the surveyor, LPN#1 verified that the humidification bottle in the resident's room was not dated. The surveyor asked LPN #1 if the humidification bottle should be dated and LPN#1 stated, Yes, it should be dated. The surveyor asked LPN#1 what the process was for refilling and changing the humidification bottle and LPN#1 responded that the humidification bottle was refilled by staff as needed and changed weekly and as needed on the 11-7 shift.On 5/4/2026 at 1:10 PM, during a later interview with LPN #1 regarding the resident's oxygen nasal cannula, LPN#1 verified that the nasal cannula that was connected to the portable oxygen tank on the resident's wheelchair and was not dated and was exposed to air. The surveyor asked LPN#1 what the process was for storing and changing the nasal cannula and LPN#1 stated the nasal cannula should be changed weekly on the 11-7 shift and as needed. LPN#1 further stated the nasal cannula should be dated and stored in a dated bag on the wheelchair when not in use.On 5/6/2026 at 12:57 PM during an interview with the surveyor in the presence of the LNHA and survey team, the Director of Nursing (DON) stated, The resident's nasal cannula tubing should have been dated and stored in a bag when not in use, and the humidification bottle should have been changed and dated.2.) On 5/3/2026 at 10:32 AM, the surveyor observed that Resident #8 was not in their room. The surveyor observed an oxygen mask with tubing lying on the resident's bed exposed to air, no protective bag was noted, and there was no date on the oxygen tubing.On 5/4/2026 at 11:50 AM, the surveyor observed that Resident #8 was not in their room. The surveyor observed an oxygen mask with tubing lying on the resident's bed and it was not dated and was not in a protective bag.On 5/5/2026 at 1:01 PM, the surveyor observed an oxygen mask with tubing lying on the resident's bed, and it was not in a protective bag, and was not dated.On 5/6/2026 at 9:00 AM, the surveyor reviewed the electronic medical record for Resident #8. A review of Resident #8's admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Sleep apnea unspecified, (a common, serious disorder where breathing repeatedly stops and starts during sleep), Heart failure unspecified, (a chronic condition where the heart muscle is too weak or stiff to pump efficiently, and cannot meet the body's needs for oxygen). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/12/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was on oxygen therapy.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/2/2026, that the resident used supplemental oxygen at bedtime. Interventions included: add humidity to oxygen as needed; monitor pulse oximeter, as ordered and clinically indicated. A Focus area, dated 12/26/2025, included the resident is at risk for respiratory complications related to sleep apnea. Interventions included: Monitor vital signs including oxygen saturation, as ordered and/or clinically indicated, administer respiratory treatments and inhalants as ordered, keep respiratory equipment clean, and change disposable equipment per facility policy.A review of the Order Summary Report (OSR) revealed there was no physician's order (PO) for supplemental oxygen as required. A review of the progress notes included a Health Status Note, dated 11/9/2025 at 22:33 (10:33pm), written by Licensed Practical Nurse (LPN #6) which indicated that: 9:30 pm resident complained of difficulty breathing; Vital signs stable; Pulse oxygen level+82-86%; oxygen via face mask applied at 3-6Liters Per Minute; Pulse oximeter level increased to 96%; alert and oriented x3; 9:45pm ambulance arrived; 10:05 pm resident transported to (name redacted) emergency room alert and responsive; 10:18 pm Dr. [NAME] notified; 10:32pm resident's son notified.On 5/5/2026 at 1:01 PM, during an interview with the surveyor regarding oxygen use Resident #8 stated, I have been using the oxygen at bedtime as needed for about five days a week for six months. Resident #8 stated that he/she started on the oxygen when they had an episode of shortness of breath and was sent to the emergency room about six months ago and has been using it ever since they returned from the hospital.On 5/6/2026 at 9:32 AM, LPN #1 accompanied the surveyor into the resident's room to verify and observe the oxygen concentrator and oxygen mask which had soiled strings attached, with tubing not dated, and no protective cover. The surveyor asked LPN #1 if there was an order for oxygen and LPN#1 checked in the resident's electronic medical record (EMR) and stated that there was not an order. The surveyor asked LPN #1 if there should be an order for oxygen and what was the process for oxygen use. LPN #1 stated, First you need an order for oxygen, and an order for the tubing for the oxygen to be changed weekly and as needed for infection control.On 5/6/2026 at 9:35 AM, during an interview with the surveyor the Licensed Practical Nurse/Unit Manager (LPN/UM #1) verified there was no order for oxygen for Resident #8. LPN/UM #1 further stated There should have been an order for the oxygen and the oxygen tubing to be changed weekly and PRN (as needed).On 5/6/2026 at 12:57 PM, during an interview with the surveyor in the presence of the LNHA and the survey team, the Director of Nursing (DON) stated, Resident # 8 should have had an order for the oxygen.A review of the facility's Oxygen Administration policy, revision date October 2010, did not address dating, changing of oxygen tubing or how to store oxygen tubing when not in use.A review of the facility's Medication Orders policy, revision date November 2014, revealed the purpose is to establish uniform guidelines in receiving and recording of medication orders. Oxygen orders- when recording orders for oxygen, specify the rate of flow, route and rational. Example: Oxygen 3L/min per nasal cannula as needed for shortness of breath. NJAC 8:39-27.1(a)

Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to adjust a resident's medication administration schedule to accommodate dialysis treatments. This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for dialysis services. This deficient practice was evidenced by the following:On 5/3/2026 at 10:07 AM, the surveyor observed the resident awake in bed. A tray containing covered dishes was in front of him/her. The resident appeared weak. The resident stated that they went to dialysis (a life-sustaining medical treatment that performs the function of failing kidneys by filtering wastes, toxins, and excess fluid from the blood).The surveyor reviewed the medical record for Resident #6.A review of the admission Record (an admission summary) reflected that Resident #6 was admitted to the facility with diagnoses which included but were not limited to the following: dependence on dialysis, anemia (a blood condition where you lack enough healthy red blood cells or hemoglobin to carry oxygen to your body's tissues) in chronic kidney disease, and end-stage kidney disease.A review of the most current quarterly Minimum Data Set (MDS), an assessment tool dated 3/24/2026, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident was on dialysis services.A review of the Order Summary Report (OSR) with active orders as of 5/5/2026, included the following physician's orders (PO):A PO, dated 4/7/2026, for Clonidine HCl oral tablet 0.3 mg (milligram). Give 1 tablet by mouth every 8 hours for high blood pressure.A PO, dated 4/7/2026, for Sevelamer carbonate oral tablet 800 mg. Give 1 tablet by mouth three times a day for high amount of phosphate in the blood.A PO, dated 4/8/2026, for Dialysis Schedule: M W F (Monday, Wednesday, Friday) Dialysis Site: [name redacted] Chair Time: 10 am.A review of the corresponding Medication Administration Record (MAR) for the months of April 2026 and May 2026, revealed the resident did not receive the Sevelamer carbonate 800 mg tablet pending delivery from the pharmacy on the following dates and times:9:00 AM - 4/8/26, and 4/9/261:00 PM - 4/8/265:00 PM - 4/8/26, and 4/9/26A review of the corresponding Medication Administration Record (MAR) for the months of April 2026 and May 2026, revealed the resident did not receive the Sevelamer carbonate 800 mg tablet because the resident was at dialysis on the following dates and times:9:00 AM - 4/10/26, 4/13/26, 4/16/26, and 5/6/261:00 PM - 4/10/26, 4/13/26, 4/15/26, 4/17/26, 4/22/26, 4/24/26, 5/1/26, and 5/4/26A review of the corresponding Medication Administration Record (MAR) for the months of April 2026 and May 2026, revealed the resident did not receive the Clonidine HCl 0.3 mg tablet because the resident was at dialysis on the following dates and times:2:00 PM - 4/8/26, 4/10/26, 4/13/26, 4/15/26, 4/17/26, 4/22/26, 4/24/26, 4/29/26, 5/1/26, 5/4/26, and 5/6/26A review of the progress notes (PN) revealed no documented communication to the physician about the doses missed for Sevelamer and Clonidine.On 5/5/2026 at 11:50 AM, during an interview with the surveyor, Registered Nurse (RN #1) stated that the resident goes out to dialysis and does not return until 3:30 pm. RN #1 stated that the numerical code #3 in the electronic medical record (EMR) meant the resident was out of facility on dialysis and did not take the medication. RN #1 also stated that the numerical code #22 in the EMR means that the medication was not administered. RN #1 explained that when the residents missed their medications, the nurses have to reorder medications from the pharmacy, make the physician aware, and document these in the progress notes of the EMR.On 5/5/2026 at 12:25 PM, the surveyor asked the Licensed Practical Nurse/Infection Preventionist (LPN/ IP) for the resident's laboratory results. LPN/IP stated that the facility did not have great communication with the dialysis center. LPN/ IP stated that the dialysis center was supposed to put the laboratory results in the communication book. LPN/IP stated that the facility asked the dialysis center several times. On 5/6/2026 at 9:43 AM, the surveyor called the dialysis center's main contact number and was unable to leave a message because the number was not in service.On 5/6/2026 at 10:36 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the Consultant Pharmacist (CP) reviewed all their admission orders and subsequently monthly, or if they had a resident with a change of condition. The DON also stated that the CP had access to the EMR and MAR. The DON stated that medications should be administered within one hour, before and after the ordered time. The DON stated that residents who go out of the facility for dialysis should have two separate orders for their medications, one on dialysis days and another one for non-dialysis days. The DON stated that if residents missed medications, the nurses have to call the physician and see if the medication would be put on hold.On 5/6/2026 at 10:45 AM, during an interview with the surveyor, the CP stated that when the residents missed medications, the staff should talk to the physician. The CP stated that medication administration schedule should work around the dialysis schedule.A review of facility's Administering Medications policy, revised in April 2019, included: Under Policy Interpretation and Implementation the following: 7) Medications are administered within one hour of the prescribed time, unless otherwise specified (for example, before and after meal orders).NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a medication was administered per the physician's order (PO) within the required timeframe. This deficient practice was identified for 1 of 1 resident (Resident #15) reviewed for insulin and was evidenced by the following:On 5/5/2026 at 11:10 AM, the surveyor observed Resident #15 in the room in bed. The resident was fully dressed and well groomed. The surveyor asked the resident if they received their medication daily and they responded Yes. When the surveyor asked if the medications were administered timely, the resident told surveyor they do not remember. The surveyor then asked the resident if they had received insulin the morning of the interview and the resident stated they could not remember.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to diabetes (high blood sugar), low back pain, and anxiety disorder. The resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/3/26, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, which meant the resident was cognitively intact. Section I, active diagnoses showed the resident had a diagnosis of diabetes. A review of the resident's individual comprehensive care plan (ICCP), dated 5/24/24, included a focus area for diabetes. Interventions included giving diabetes medication as ordered by the doctor. A review of the physician's order (PO), dated 3/13/26, showed the following insulin orders: Insulin Lispro Injection Solution 100 UNIT/Milliliter (ML) (Insulin Lispro) Inject subcutaneously two times a day for diabetes Inject as per sliding scale: if 0 - 150 = 0 units Check blood Sugar 3 times per day before meals and at HS (hours of sleep). Call physician for blood sugars above 400; 151 - 200 = 4 unit; 201 - 250 = 6 unit; 251 - 300 = 8 unit; 301 - 350 = 10 unit; 351 - 400 = 12 unit; 401+ Call MD, subcutaneously two times a day 8:30 AM and 4:30 PM for DM (diabetes mellitus) Type 2 -Start Date 3/13/2026 On 5/6/2026 at 12:07 PM, the surveyor reviewed the medication audit report: For the months of April 2026 and May 2026. The surveyor noted the following medication administration times for the resident's prescribed insulin: 4/1/26 8:30 AM insulin administered at 10:10 AM4/3/26 8:30 AM insulin administered at 10:20 AM4/7/26 8:30 AM insulin administered at 11:30 AM4/8/26 8:30 AM insulin administered at 10:47 AM4/10/26 8:30 AM insulin administered at 11:19 AM4/11/26 8:30 AM insulin administered at 11:04 AM4/12/26 8:30 AM insulin administered at 9:57 AM4/13/26 8:30 AM insulin administered at 11:19 AM4/14/26 8:30 AM insulin administered at 10:22 AM4/17/26 8:30 AM insulin administered at 12:20 PM4/19/26 8:30 AM insulin administered at 10:14 AM4/21/26 8:30 AM insulin administered at 10:29 AM4/22/26 8:30 AM insulin administered at 11:36 AM4/23/26 8:30 AM insulin administered at 11:43 AM4/24/26 8:30 AM insulin administered at 10:14 AM4/25/26 8:30 AM insulin administered at 10:52 AM4/26/26 8:30 AM insulin administered at 11:55 AM4/27/26 8:30 AM insulin administered at 9:41 AM4/28/26 8:30 AM insulin administered at 10:57 AM4/29/26 8:30 AM insulin administered at 10:55 AM5/4/26 8:30 AM insulin administered at 12:09 PM5/5/26 8:30 AM insulin administered at 11:34 AM5/6/26 8:30 AM insulin administered at 2:10 PM On 5/7/26 at 9:10 AM, the surveyor reviewed the policy titled, Administering Medications, the policy was dated April 2019. Number four in the policy indicated that medications are administered in accordance with the prescriber orders, including any required time frame. Number seven indicated that medications are administered within one hour of their prescribed time, unless otherwise specified.On 5/7/26 at 10:15 AM, during an interview with the Director of Nursing (DON), she acknowledged the late medication administration and told the surveyor that it was one specific nurse who was administering medications late. NJAC 8:39-29.2

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a significant change assessment was completed for Resident #43, 1 of 30 residents reviewed for an evaluation of a significant change in the resident's condition. This deficient practice was evidenced by the following:A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to inclusion body myositis (progressive muscle disease), hypertension (high blood pressure), and chronic pain syndrome.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 3/31/26, indicated that Resident #43 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated that the resident had moderate cognitive impairment. Section O, special procedures indicated the resident was receiving hospice services since admission. A review of Resident #43's Individual Comprehensive Care Plan (ICCP) initiated on 3/25/26, showed a focus area of terminal prognosis. Interventions included but were not limited to receiving hospice services. A review of the admission hospice documentation showed the resident was admitted under [provider name redacted] Hospice Service Provider #1 on 3/24/26. Further record review revealed that on 4/13/26 the physician ordered hospice to evaluate and treat using [provider name redacted] Hospice Services Provider #2. The surveyor then reviewed the facility notification to admit to [provider name redacted] Hospice Services Provider #2 dated 4/13/26. The surveyor reviewed the MDS list within the resident's electronic medical record (EMR) and could not locate a significant change MDS when the hospice companies changed. On 5/7/2026 at 9:33 AM, the surveyor interviewed the Regional Minimum Data Set Coordinator regarding the need for a significant change MDS when a resident changed hospice companies. The RMDSC stated, Yes, a significant change is supposed to be done. NJAC 8:39-11.2 (i)

Based on observation, interview, review of medical records and other pertinent facility documentation, it was determined that the facility failed to develop and implement an Individualized Comprehensive Care Plan (ICCP) for a.) a resident on contact precautions (Resident #114) and b.) a resident who utilized an abdominal binder and a heel relief shoe (Resident #28). This deficient practice was evidenced by the following:1.) On 5/3/2026 at 10:52 AM, during tour, the surveyor observed transmission-based precaution signage posted on Resident #114's door and a personal protective equipment (PPE) cart located outside the resident's room. The nurse assigned to the medication cart outside of the resident's room stated that Resident #114 was on contact precautions (infection control measures used to prevent the spread of infection) for MRSA (Methicillin-resistant Staphylococcus aureus) in the blood and was on intravenous (IV) antibiotics. A review of the admission Record (an admission summary) indicated that Resident #114 had diagnoses which included but were not limited to bacteremia (infection of the blood), and chronic obstructive pulmonary disease (COPD, a group of progressive, long-term lung diseases). Resident #114 was recently admitted to the facility and did not yet have an Minimum Data Set (MDS) assessment completed, as it was not due at the time of review. On 5/04/2026 at 10:39 AM, the surveyor was unable to observe or interview Resident #114 because the resident was out to a medical appointment. The surveyor again observed the contact precaution sign posted on the resident's door and a PPE cart outside the resident's room that contained gloves, gowns, masks. The surveyor reviewed the resident #114's medical records which revealed the following information: A review of the Medication Administration Audit Report dated 4/26/2026 reflected a physician's order (PO) for contact precautions every shift related to MRSA. A review of the Interdisciplinary Comprehensive Care Plan (ICCP) indicated that the resident had a diagnosis of MRSA; however, there was no documentation indicating the resident was on contact precautions or TBP (transmission based precautions, specialized infection control measures used in healthcare settings for patients known or suspected to be infected with highly transmissible pathogens). On 5/6/2026 at 9:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2) who stated that she was unsure whether the ICCP should include documentation regarding contact precautions or TBP. LPN #2 stated the unit manager and the Assistant Director of Nursing (ADON) were responsible for updating the ICCP. On 5/6/2026 at 9:30 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that ICCPs were developed by the floor nurses, unit managers and ADON. The ADON stated ICCPs should be individualized and include pertinent resident-specific information, including interventions necessary to provide appropriate care. The ADON further stated that if a resident was on transmission- based precautions, the information should be included in the care plan, including specific type of precautions implemented. On 5/6/2026 at 9:45 AM, the surveyor interviewed the Infection Preventionist (IP) who stated that any discipline could update and add interventions to the ICCP. She explained that it was important to have pertinent information to be included on the care plan to ensure staff were able to appropriately manage the resident care needs. She further stated that transmission-based precautions should be included in the resident's plan of care. The IP reviewed Resident #114 care plan and confirmed that the resident was on contact precautions. The IP stated that contact precautions should have been included in the resident's care plan. On 5/07/2026 at 10:32 AM, during exit conference and in the presence of the survey team, the Director of Nursing (DON) confirmed that Resident #114's care plan had not been developed and updated to include contact precautions. Refer to citation F0658. 2.) On 5/3/2026 at 10:58 AM, the surveyor observed Resident #28 awake in bed wearing a partially secured abdominal binder and a black medical shoe on their right foot. On 5/4/2026 at 10:02 AM, the surveyor made a follow-up visit with Resident #28 who was observed awake in their bed with the abdominal binder and black medical shoe on their right foot. Resident #28 stated that they were waiting for their back brace from the therapy department and would soon be discharged . On 5/5/2026 at 9:30 AM, the surveyor reviewed the resident's electronic medical record (EMR). A review of the admission Record, an admission summary, included that the resident had difficulty in walking, and other abnormalities of gait and mobility. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. It further revealed that Resident #28 had an unhealed pressure ulcer. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/16/2026, that the resident had a deep tissue injury to the right heel. Interventions included: Elevate/Offload my heels when in bed, administer treatments as ordered, and monitor effectiveness. A review of the Physician Orders did not include an order for the black medical boot. A review of the Physician Orders did not include an order for the abdominal binder. On 5/5/2026 at 12:14 PM, the surveyor conducted another follow-up visit with Resident #28 who again was observed in bed with the medical boot on their right foot. The resident stated that the boot protected their heel. The resident stated that their heel had gotten a lot better. The resident added that they wore the boot all the time although the nurses informed them that it did not have to be worn in bed. The resident further stated that they needed to be ready if they had to go to the restroom because it would take a lot of time to put the boot on due to their back issues. On 5/5/2026 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #3) who stated Resident #28 should have a physician's order for the medical boot and the abdominal binder that they were wearing. At that time, she pulled up Resident #28's medical record in the computer and stated that she did not see the physician's order and a place to sign that the nurse ensured that they were wearing both devices. She stated that there should be documentation that the skin was being checked daily. She further stated that any assistive devices should be included on the ICCP. On 5/5/2026 at 12:35 PM, the surveyor interviewed the Director of Rehabilitation (DOR), who identified the black medical boot as a [name redacted] Heel Relief Shoe (a specialized orthopedic device designed to treat heel injuries by eliminating pressure) that Resident #28 was given on a prior admission to the facility, and was readmitted to the facility with it. He stated that upon the resident's readmission, nursing should have obtained a physician's order for the heel relief shoe. He stated that nursing should have also updated the care plan to include the heel relief shoe. He stated that Resident #28 was recently issued an abdominal binder to support their back while they waited for a back brace to arrive. The DOR further stated that nursing should have also obtained a physician's order for the abdominal binder and also included it in the resident's care plan. On 5/6/2026 at 9:34 AM, the surveyor interviewed the Director of Nursing (DON) who stated, always have to have an order that they can wear it, referring to the abdominal binder and the heel relief shoe. She noted that as soon as the resident wanted to wear the heel relief shoe and abdominal binder, the nurse should have contacted the physician to obtain an order. She further stated that the therapy department would let the nursing department know when an assistive device was given to the resident, then they would reach out to the doctor. The DON further stated, anytime something changes, they would refresh the staff on how to care for the resident. She also stated that the care plan was updated quarterly and as needed and should have been updated by the nurse. A review of the facility's Assistive Devices and Equipment policy, revision date February 2021, included: Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. A review of the facility policy dated March 2022 and titled, Care Plans, Comprehensive Person-Centered included: measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated that the care plan describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental and psychosocial well-being. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications and biologicals were stored and labeled properly in medication carts. This deficient practice was identified for 1 of 2 medication carts reviewed under the Medication Storage and Labeling Task. The deficient practice was evidenced by the following: On 5/5/2026 at 1:12 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1) checked medication cart #1 on the second floor. During the inspection the surveyor observed the following: One tube of Hydrocortisone cream 2.5%, more than half used, with no label and were not dated. Sodium Chloride 5% eye ointment tubes, with no labels and were not dated. Cyclosporine 0.05%, 2 (two) eye droppers, with no resident names and were not dated. Three refresh eye drop tubes were on the bottom of the cart drawer, with no labels and were not dated. One 10-ounce bottle of Magnesium Citrate, opened with approximately one quarter of the bottle left, with no label and was no dated. When interviewed at that time, LPN #1 acknowledged the items were unlabeled and undated and stated that they should have labels. LPN #1 told the surveyor she would discard the items. The surveyor reviewed the consultant pharmacy medication cart audits for the first and second floors, dated 5/3/26. Both audits were marked as No for all drugs properly labeled. The surveyor reviewed the policy titled, Medication Storage dated August 2021. Number 9 of the policy indicated that all medications will be kept in their original containers and will be properly labeled and identified. NJAC 8:39-29.4 (a)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to maintain a Hospice Communication Record which included a Certified Nursing Assistant (CNA) care plan for 1 of 1 resident (Resident #43) reviewed for Hospice Services. This deficient practice was evidenced by the following: On 5/05/2026 at 10:27 AM, the surveyor observed Resident #43 in bed. The resident told the surveyor that they do not get out of bed due to being paralyzed. During the observation the resident appeared well groomed and was dressed in personal clothing. The resident stated a hospice aide came to the facility to provide care. On 5/6/2026 at 9:35 AM, the surveyor requested the hospice communication binder for Resident #43. The Assistant Director of Nursing (ADON) provided the surveyor with the resident's paper chart. The surveyor located a hospice consent form signed by the resident and the physician orders for hospice. There was a communication sheet with a nursing recommendation dated 3/24/26. The surveyor could not locate a care plan or any other documentation that pertained to hospice services. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; inclusion body myositis (progressive muscle disease), hypertension (high blood pressure), and chronic pain syndrome.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 3/31/26, indicated that Resident #43 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which meant the resident had moderate cognitive impairment. Section O, special procedures indicated the resident was receiving hospice services. A review of Resident #43's Individual Comprehensive Care Plan (ICCP) initiated on 3/25/26, showed a focus area of terminal prognosis. Interventions included but were not limited to receiving hospice services through [name redacted] Hospice Services. On 5/6/26 at 9:45 AM, the surveyor asked the ADON how often the nurses and nursing assistants (CNAs) from the hospice company came to see Resident #43. The ADON stated the CNA usually came to the facility four to five times per week. The surveyor asked to see the hospice CNA care plan, and she stated she was not sure the aide was care planned. The ADON told the surveyor that the clinical leader from hospice was in to see the resident on 5/4/26. The surveyor requested the documentation from the hospice clinical leader visit and the ADON could not locate the documentation. On 5/6/2026 at 9:57 AM, the surveyor went in to see Resident #43 who was awake and in bed. The resident, who was aware they were receiving hospice services, was asked by the surveyor if a CNA from the hospice company came to the facility to assist the resident. The resident stated, Supposedly two times a week, I need that aide. The surveyor asked if they were coming twice weekly and the resident told the surveyor it was hard to say. Resident #43 told the surveyor that the hospice nurse was at the facility and told the resident the hospice agency was short staffed, and they were trying to get help. On 5/7/26 at 10:15 AM, the facility provided the surveyor with a copy of the hospice care plan. The care plan was received via fax on 5/7/26 from the hospice agency after surveyor inquiry. On 5/7/2026 at 10:20 AM, during an interview with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor asked if a hospice care plan should be available on the nursing unit for the resident. The DON responded, Absolutely. On 5/7/26 at 12:10 PM, the surveyor reviewed the facility's, Hospice Program policy, dated July 2017, which included; Number 10 of the policy indicated that the facility was responsible for communicating with the hospice provided and documenting such communication to ensure the needs of the resident are addressed. NJAC 8:39-27.1(a)

Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection: a.) by ensuring proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) b.) during the provision of a wound treatment for a resident with a stage 4 pressure ulcer wound (full-thickness tissue loss with exposed bone, tendon, or muscle) and c.) by failing to clean and disinfect a blood pressure cuff after use between residents and perform hand hygiene after resident contact during the medication pass observation. This deficient practice was identified for 1 of 2 residents (Resident #112) reviewed for antibiotic usage, 1 of 1 resident (Resident #63) reviewed for pressure ulcer (PU)/injury, and for 1 of 2 nurses on 1 of 2 nursing units (Second Floor) observed during the medication pass observation. This deficient practice was evidenced by the following: Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal. CDC recommendations for Hand Hygiene: Updated February 27, 2024 :https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations 1.) On 5/3/2026 at 10:28 AM, during a tour of the nursing unit, the surveyor observed Resident #63's room. There was no signage for Enhanced Barrier Precautions (EBP) (an infection control strategy focused on reducing the spread of multidrug-resistant organisms [MDRO] in nursing homes) in the doorway. There was no PPE (Personal Protective Equipment) immediately available near the room. The surveyor observed the resident awake in bed. The resident's low air-loss mattress was set at normal pressure. On 5/4/2026 at 11:15 AM, the surveyor observed the resident's room. There was no signage for EBP and there was no PPE immediately available near the room. On 5/6/2026 at 9:52 AM, the surveyor observed Registered Nurse (RN #1) perform the administration of a wound treatment for the resident's sacral wound and was assisted by Certified Nursing Assistant (CNA #5). During the wound care observation, the surveyor observed the RN and CNA performed hand hygiene with sanitizer and donned (put on) disposable gown and gloves outside the resident's room. The RN inserted a washable linen under the resident as a liner. The RN stated that the facility does not use disposable chucks. The resident was turned to their left side. The RN unpeeled the bordered foam dressing and removed several soiled gauze sponges from the resident's sacral area and discarded them in the trash bin that was lined with a clear plastic bag. The surveyor observed the resident's sacral wound to be opened, concave (curved inwards) in shape, it was very deep with exposed muscle, tendon and what appeared to be a bony prominence. The RN stated that wound consultants measure the wound. The surveyor noted that the supplies needed for the treatment were not yet assembled by the bedside. The resident was allowed to turn onto their back with the wound touching the washable linen beneath them. RN #1 doffed (removed) their gloves and gown and washed their hands for 20 seconds. The nurse left the room and took the treatment cart from the nurses' station and positioned it by the doorway of the resident's room. The nurse pulled several pairs of clean gloves from the box and put them in their right pocket of their scrub uniform. The nurse left the treatment cart and returned to the nurses' station to get a marker. When the nurse reached the treatment cart again, they took one opened and one unopened container of non-sterile gauze sponge, an unopened bottle of saline solution and placed them on top of the treatment cart. The RN donned a new pair of gloves without washing or sanitizing their hands. The RN reached the overbed table and cleaned it with bleach wipes. The RN placed a disposable liner on top of the table and placed the saline solution, gauze sponges, and bordered foam dressings on top. The RN removed the gloves from her pocket and placed them on top of the liner. The resident was turned again by the RN to their left side assisted by the CNA. Without doffing (removing) or changing their gloves and first performing hand hygiene, the nurse soaked several gauze sponges with saline solution. The nurse patted down the inside cavity of the wound repeatedly using the same gauze sponges then discarded the gauze sponges in the trash bin. Without doffing or changing their gloves and performing hand hygiene, the nurse pulled non-sterile gauze sponges from the half-full container and packed the wound with three pieces of gauze. The surveyor did not observe the nurse moisten the gauze before she packed the wound. The nurse picked up the bordered foam dressing from the table and applied it on the wound. The nurse reinforced the dressing with another bordered foam dressing. The nurse then doffed their gloves and washed their hands in the bathroom for 24 seconds. The nurse then pulled gloves from her pocket and donned them. The nurse wrote the date on the bordered foam dressing on the resident's back. The nurse threw all materials that were used in the trash bin. The nurse doffed their gloves and washed their hands for 21 seconds. The nurse tied the plastic trash bag, touched the resident again to pull the washable linen out from beneath the resident. The CNA assisted the resident to reposition in bed. The surveyor reviewed the medical record for Resident #63. A review of the admission Record indicated that Resident #63 was admitted to the facility with diagnoses that included but were not limited to spondylosis (age-related wear and tear of the spinal discs), hypertension, and muscle weakness. There was no diagnosis related to any skin impairment. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/24/2026, revealed that the resident had a stage 4 PU upon admission and that the resident received PU care. A review of the Order Summary Report (OSR) active as of 5/5/2026 indicated the following physician orders: Clean the sacrum with NSS (normal saline solution), pat dry. Apply saline moisten (sic) gauze to site and cover with a CDD (clean, dry, dressing) daily, every day shift for wound care Enhanced Barrier Precautions R/T chronic wounds every shift A review of the individual comprehensive care plan revised on 4/17/2026, reflected a focus area for multiple skin impairments including a stage 4 pressure ulcer from the sacrum to the buttocks. The following interventions were included: Monitor and document changes in skin status such as: appearance, color, wound healing, s/sx (signs/ symptoms) of infection, changes in wound size or stage, to physician or designee as clinically indicated initiated on 10/16/2025 Monitor and document wound healing. Measure length, width, and depth (where possible). Assess and document status of wound perimeter, wound bed, and healing progress. Report changes in wound to physician or designee as clinically indicated initiated on 10/16/2025 On 5/6/2026 at 10:20 AM, during an interview with the surveyor, the RN stated that the gauze they used to pack the wound was a clean dressing and that the wound did not need a sterile dressing. The surveyor asked the nurse if they should have used sterile gloves to touch the cavity of the wound. The RN stated no. The surveyor asked the nurse if they should have changed their gloves and performed hand hygiene between touching the soiled gauze sponges and touching the clean sponges to pack the wound, and the RN stated that they did that. The surveyor stated that they did not observe that. On 5/6/2026 at 10:36 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that pressure ulcers qualified for EBP use during direct care activities. The DON also stated that the facility used sterile gauze and gloves if ordered by the physician. On 5/7/2026 at 8:19 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that their process for doing a wound treatment to a stage 4 pressure ulcer would be the following: I would prep my service area, I use the bedside table, put clean barrier, gather all my supplies, wash hands, explain to the resident, remove the soiled dressing. I would change gloves and wash my hands. I would put on clean gloves, clean the site. I would wash my hands again, put on clean gloves. I would apply the treatment to site with new gloves. I would pull gloves from the glove box, unless the doctor orders sterile dressing. That is our best practice. A review of the facility policy reviewed in April 2024, titled Wound Treatment included the following under Steps in the Procedure: 1) Disinfect overbed table; 2) Perform hand hygiene; 3) Use disposable cloth to establish clean field on resident's overbed table; 4) Prepare supplies on the clean field on resident's overbed table; 5) [NAME] dressing label or tape with date, time, and initials; 6) Prepare a plastic bag or wastebasket for discarded materials; 7) Position resident to provide access to affected area. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites, as needed; 8) Perform hand hygiene and put on clean gloves; 9) Remove soiled dressing and discard into designated container; 10) Remove gloves and perform hand hygiene; 11) Put on clean gloves; 12) Evaluate the appearance of the wound and surrounding skin; 13) Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward); 14) Apply treatment as ordered. Use sterile tongue blades/ applicators to remove ointments and creams from their containers; 15) Apply dressing as ordered; 16) Apply prepared label with date, time, and initials to dressing; 17) Reposition the resident if necessary; 18) Discard disposable items into appropriate receptacle. Remove gloves and discard; 19) Perform hand hygiene; and 20) Disinfect reusable supplies as indicated.Return reusable supplies to treatment cart. 2.) A review of the admission Record (admission summary) indicated that Resident #112 was admitted to the facility with the diagnoses that included but was not limited to orthopedic aftercare. An admission Minimum Data Set (MDS), an assessment that facilitates a resident's care, was not due at this time and was not able to be reviewed. A review of Resident #112's Individual Comprehensive Care Plan (ICCP), dated 4/25/26, indicated that the resident had a wound and had the potential for pain and also had an intravenous (IV) access site for IV therapy. On 5/3/2026 at 10:11 AM, the surveyor observed Resident #112 lying in bed. The resident was interviewed at this time and stated that they were on IV antibiotics for a wound infection of their right foot. The surveyor did not observe signage posted on the resident's door that indicated that the resident was on EBP, nor did the surveyor observe any personal protective equipment (PPE) such as gloves, gowns or masks readily available for use for providing resident care. A review of the residents' electronic medical records (EMR) revealed the following information: A review of the physician's order (PO), dated 4/27/2026, indicated that Ceftriaxone Sodium Solution (antibiotic) reconstituted 2 GM was to be provided intravenously in the evening for osteomyelitis (bone infection) until 6/1/2026. A review of the PO, dated 5/1/26, indicated that Dakin's solution 0.125% was to be applied topically to the right heel one time a day for wound care moist to dry dressing. The surveyor did not observe a PO or a ICCP documented in the residents' EMR for EBP. On 5/4/2026 at 10:05 AM, the surveyor observed the resident lying in bed and the resident stated that they were doing OK. The resident had no concerns at that time. The surveyor had a second observation and there was no signage posted on the resident's door that indicated the resident was on EBP. There was also no PPE readily available for use outside of the resident's room. On 5/4/2026 at 10:11 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #112 was alert and oriented to person, place and time. She stated that the resident required substantial assistance with washing and dressing and was incontinent of bladder and bowel. She explained that the resident was on IV antibiotics for an infection and had a dressing on their right foot. CNA #1 revealed that while providing direct resident care to Resident #112, she wore gloves for standard precautions but did not wear a gown or mask while caring for the resident. She further explained that if Resident #112 was on EBP, a sign would be posted on the resident's door, and a PPE cart would be outside the resident's room that contained gowns and gloves. She stated that signage was how she was informed residents were on transmission-based precautions and EBP. CNA #1 confirmed that this did not occur for Resident #112. On 5/4/2026 at 10:17 AM, the surveyor interviewed the resident primary care Licensed Practical Nurse (LPN #2) who stated that Resident #112 was a new admission to the facility, was diabetic and was on insulin and IV antibiotics. She stated that Resident #112 had a midline in the left upper arm and had a right heel wound. She further explained that when a resident was on EBP, staff had to wear gloves and gowns when providing direct resident care. She stated that she was not aware that the resident was not on EBP and that she would notify the unit manager. On 5/4/2026 at 10:26 AM, the surveyor interviewed the LPN Unit Manager/Infection Preventionist (IP) who stated that EBP was required for any residents with internal access to the body (catheter, peripherally inserted central catheter (PICC) lines, wounds, midline catheters, and dialysis). She stated that an orange sign would be posted on the resident's door to inform family, staff, and visitors what type of precautions and PPE was required before entering the resident's room. She stated that according to the facility policy a physician's order was required for EBP. The IP further stated that a care plan was also required when a resident was on EBP. The IP accompanied the surveyor to the resident's room and confirmed that Resident #112 did not have signage posted on the door to inform staff, visitors or family that the resident was on EBP and PPE was not readily available in a cart outside of the resident's room for staff and visitors to utilize if caring for the resident. On 5/4/2026 at 11:05 AM, the surveyor requested a copy of the resident's ICCP to review. EBP was documented on the ICCP after surveyor inquiry. On 5/6/2026 at 9:30 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that ICCPs were developed by the floor nurses, unit managers and ADON. The ADON stated ICCPs should be individualized and include pertinent resident-specific information, including interventions necessary to provide appropriate care. The ADON further stated that if a resident was on transmission- based precautions, the information should be included in the care plan, including specific type of precautions implemented. The ADON stated that EBP should be specified on the resident's care plan and signage should be posted on the resident's door. This signage would indicate to family, staff and visitors what type of precautions and what type of PPE should be worn when caring for the resident. On 5/7/2026 at 10:24 AM, the Director of Nursing (DON) confirmed that Resident #112 did not have an order for EPB or an ICCP. She also confirmed that the ICCP needed to be updated to include EBP. She also confirmed that signage should be posted on the resident's door and a PPE cart should be outside the resident's room. A review of the facilities Enhanced Barrier Precautions policy, dated April 2025, indicated that EBP was utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. -A resident is infected or colonized with a CDC (Centers for Disease Control)-targeted MDRO but does not have a wound or indwelling medical device or does not have secretions or excretions that are unable to be covered or contained. - A resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device and does not have secretions or excretions that are unable to be covered or contained. -Indwelling devices include central lines, urinary catheters, feeding tubes, tracheostomies (a surgically created hole through the neck and wind pipe to keep it open for breathing), peripheral IV catheters are not considered an indwelling medical device for purpose of EBP. -EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. 3.) On 5/4/2026 at 8:20 AM, the surveyor met with Licensed Practical Nurse (LPN #7) who was assigned to the High Side Medication Cart on the Second Floor Nursing Unit to observe the medication pass. At 8:22 AM, the surveyor observed LPN #7 who used an automated wrist blood pressure cuff to obtain Resident #11's blood pressure on the resident's right wrist. At 8:25 AM, LPN #7 returned to the medication cart and placed the automated wrist blood pressure cuff on top of the medication cart immediately after use without cleaning it first. LPN #7 then proceeded to access the computer to view the resident's medications in the electronic medical record (EMR) and removed the resident's scheduled medications from the medication cart for preparation without first performing hand hygiene. At 8:56 AM, LPN #7 used the automated wrist blood pressure cuff to obtain Resident #27's blood pressure on their right wrist without cleaning and disinfecting it prior to use. When finished, LPN #7 placed the automated wrist blood pressure cuff on top of the medication cart. At 9:17 AM, the surveyor interviewed LPN #7 who stated that the automated wrist blood pressure cuff should be wiped down between rooms with bleach wipes. LPN #7 further acknowledged that she had forgotten to clean the automated wrist blood pressure cuff between residents in order to prevent the spread of germs and contamination from patient to patient. At that time, LPN #7 stated that she had not realized that she had not performed hand hygiene after she had taken Resident #11's blood pressure and prepared their medications for infection control purposes. On 5/4/2026 at 11:37 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who stated that reusable equipment such as an automated blood pressure cuff should be wiped down and cleaned with a bleach wipe between residents because it should be cleaned after each use. LPN/UM #1 further stated that if it were not cleaned between residents it was an infection control issue, and you may pass on an infection to the other resident. On 5/4/2026 at 12:03 PM, the surveyor interviewed the Infection Preventionist (IP) who stated that staff should not use a hand-held automated wrist blood pressure device because they need to be cleaned and disinfected between residents and is difficult to do with this type of blood pressure cuff due to the cloth material. The IP stated that staff should instead use the rolling automated blood pressure machine which could be disinfected. The IP further stated that the only time the facility used a dedicated hand-held blood pressure cuff was for residents on isolation precautions. The IP stated that if the blood pressure cuff were not cleaned and was used on another resident there would be a concern for the spread of infection from room to room. The IP further stated that the nurse should have performed hand hygiene after she obtained a resident's blood pressure and prior to pulling the residents medications for administration for infection control purposes. The IP also stated that if the automated wrist blood pressure cuff were placed on top of the medication cart without a barrier, then the top of the cart should have been disinfected too for infection control purposes. On 5/4/2026 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurse should clean the blood pressure cuff both before and after use with bleach wipes for infection control because if somebody had something, you do not want to spread germs. The DON stated that you have to wash the blood pressure cuff down and wash your hands or at least use the hand sanitizer before you touched anything else. A review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, (adopted 2021), included: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) bloodborne pathogens standard. .Non-Critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, .Most non-critical reusable items can be decontaminated where they are used . A review of the facility's Handwashing/Hand Hygiene policy, (Revision Date 2023), included: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. .Indications for Hand Hygiene: .after touching a resident; after touching the resident's environment; NJAC 8:39-19.4(a); 27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) obtain an order for nursing care for a resident admitted with an intravenous (IV) access, b.) obtain a physician's order for an assistive device and update the care plan accordingly.This deficient practice was identified for 2 of 2 residents (Resident #28 and #110) reviewed for hydration, and wound (s), and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 5/3/2026 at 11:56 AM, the surveyor reviewed the medical record for Resident #110.A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: chronic kidney disease and symbolic dysfunctions (a range of neurological disorders affecting the ability to use, understand, or process symbols-such as spoken language, writing, or gestures. It often involves deficits in communication, spatial perception, and conceptualization resulting from brain injury, degenerative diseases like Alzheimer's, or neurodevelopmental conditions).A review of the Social Services Assessment included the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident's cognition was moderately impaired.A review of the resident's individual comprehensive care plan (ICCP) did not include IV access.A review of the Order Summary Report (OSR), did not include physician orders on how to care for an IV access.A review of the progress notes included a nurse's note (NN), dated [date of note redacted] at 2:38 PM, included, Patient arrived to the unit via stretcher. 20 to RAC (referring to a 20 gauge, IV catheter inserted to the right antecubital area).A review of Resident #110's preadmission packet, also included that the resident had a peripheral IV inserted in the right antecubital arm.On 5/4/2026 at 10:24 AM, the surveyor interviewed Registered Nurse (RN) #1, who stated that when a resident was admitted to the facility, she would take report from the sending facility. She added, if the resident was admitted from a hospital, the hospital would usually remove the peripheral IV. She further stated that she would check the IV site and the date because usually, the peripheral IVs were only good for 72 hours and it would be documented in the progress notes.On 5/6/2026 at 10:21 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated that the admitting nurse would get it in report from the hospital that the resident was being sent with a peripheral IV access. She added that the report that was given from the sending facility was usually handwritten and uploaded in the electronic medical record (EMR). At that time, the surveyor requested to view the written report that was obtained from the sending facility. The ADON pulled up Resident #110's EMR. In the EMR, there was handwritten RAC 20 (right antecubital 20 gauge catheter). She added that most of the hospitals would remove the peripheral IV if they were no longer using it and sometimes the sending facility may give it in report, but removed it prior to them sending the resident.On 5/06/2026 at 12:53 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if a resident was admitted in the facility with IV access, we would call the doctor and ask for orders to remove the IV it was not utilized. She added that if the Iv site was not cared for and was just left in , it could cause the resident to get an infection. She added that would be done upon admission to the facility, during the admission assessment.2.) On 5/3/2026 at 10:58 AM, the surveyor observed Resident #28 awake in bed wearing a partially secured abdominal binder and a black medical shoe on their right foot.On 5/4/2026 at 10:02 AM, the surveyor made a follow-up visit with Resident #28 who was observed awake in their bed with the abdominal binder and black medical shoe on their right foot. Resident #28 stated that they were waiting for their back brace from the therapy department and would soon be discharged .On 5/5/2026 at 9:30 AM, the surveyor reviewed the resident's electronic medical record (EMR).A review of the admission Record, an admission summary. included that the resident had difficulty in walking, and other abnormalities of gait and mobility.A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/27/2026, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. It further revealed that Resident #28 had an unhealed pressure ulcer.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/16/2026, that the resident had a deep tissue injury to the right heel. Interventions included: Elevate/Offload my heels when in bed, administer treatments as ordered, and monitor effectiveness.A review of the Physician Orders did not include an order for the black medical boot.A review of the Physician Orders did not include the abdominal binder.On 5/5/2026 at 12:14 PM, the surveyor conducted another follow-up visit with Resident #28 who again was observed in bed with the medical boot on their right foot. The resident stated that the boot protected their heel. They stated that their heel has gotten a lot better. They added that they wore the boot all the time although the nurses informed them that it did not have to be worn in bed. They stated that they needed to be ready if they had to go to the restroom because it would take a lot of time to put the boot on due to their back issues.On 5/5/2026 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #3) who stated Resident #28 should have a physician's order for the medical boot and the abdominal binder that they were wearing. At that time, she pulled up Resident #28's medical record and stated that she did not see the physician's order and a place to sign that the nurse ensured that they were wearing both devices. She further added that there should be documentation that the skin was being checked daily. She further added that any assistive devices should be included on the ICCP.On 5/5/2026 at 12:35 PM, the surveyor interviewed the Director of Rehabilitation (DOR), who identified the black medical boot as a [name redacted] Heel Relief Shoe (a specialized orthopedic device designed to treat heel injuries by eliminating pressure) that Resident #28 was given on a prior admission to the facility, and was readmitted to the facility with it. He further stated that upon the resident's readmission, nursing should have obtained a physician's order for the heel relief shoe. He added that nursing should have also updated the care plan to include the heel relief shoe. He added that Resident #28 was recently issued an abdominal binder to support their back while they waited for a back brace to arrive. The DOR stated that nursing should have also obtained a physician's order for the abdominal binder and also included it in the resident's care plan. On 5/6/2026 at 9:34 AM, the surveyor interviewed the Director of Nursing (DON) who stated there always have to have an order that they can wear it, referring to the abdominal binder and the heel relief shoe. She noted that as soon as the resident wanted to wear the heel relief shoe and abdominal binder, the nurse should have contacted the physician to obtain an order. She further stated that the therapy department would let the nursing department know when an assistive device was given to the resident, then they would reach out to the doctor. Subsequently, anytime something changes, they would refresh the staff on how to care for the resident. She also stated that the care plan was updated quarterly and as needed and should have been updated by the nurse.A review of the facility's Assistive Devices and Equipment policy, revision date February 2021, included: Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan.NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain a safe and sanitary environment. The deficient practice was identified for 2 of 2 units reviewed for environment.This deficient practice was evidenced by the following:On 10/24/25 at 9:25 AM, the two surveyors conducted a unit tour on the first floor and second floor units. The following was observed during the tour:1.At 9:25 AM, the surveyors observed in room [ROOM NUMBER] the floor was soiled with a dried, unknown substance. 2. At 9:40 AM, the surveyors entered room [ROOM NUMBER], and observed an unsampled resident's room, who stated their bathroom shower drain had been clogged and when they took a shower, the water did not drain well. 3. At 9:42 AM, the surveyors entered room [ROOM NUMBER] and observed a resident in their bed. There was a feeding tube machine with tube feeding bottle attached at the bedside. The surveyors observed the side rail padding was soiled with dried up tube feeding formula. 4. At 9:45 AM, the surveyors accompanied by the Certified Nurse Aide (CNA) entered room [ROOM NUMBER] and observed a dark colored debris on the surface of the bathtub. There was a piece of brown colored wet paper noted in the bathtub. The CNA stated the shower had been out of order. The CNA sent a maintenance request electronically to the maintenance department.5. At 9:49 AM, the surveyors entered room [ROOM NUMBER] and observed the brown colored laminated paper was peeling off from the top surface of a resident's nightstand by the window. The surveyors observed there were two television stands with drawers for each resident in the room and the laminated paper was peeled off from the edges on the top surfaces. 6. The surveyors observed loose handrails in the hallway on the first and second floor unit during the tour. The surveyors observed the push bars on the double doors on both units were missing the end cap brackets (a small metal piece screwed to the door) and had sharp edged openings.On 10/24/25 at 10:00 AM, during an interview with the surveyor, the Director of Environmental Services (DES) stated he was responsible for making environmental rounds daily on the units and presented any concerns during morning meetings. The surveyor informed the DES the above concerns during the tour of the units. The DES stated the staff did not report anything to him and he was not aware of the concerns.On 10/24/25 at 11:15 AM, during an interview with the surveyor, the Maintenance Director (MD) stated he made rounds daily. The surveyor inquired if he was aware of the above concerns identified during tour. The MD replied he was not aware of any of the concerns. On 10/24/25 at 2:53 PM, the surveyors met with the Licensed Nursing Home Administrator, the Regional Director of Clinical Services and the Regional Director of Specialty Program. The surveyors notified the facility management of the above concerns and findings regarding the resident bathroom showers, furniture in the resident's room, loose handrails, and the double door push bars missing their end cap brackets on the units.A review of the facility provided Homelike Environment policy with a revised date February 2021, included:Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a.) clean, sanitary and orderly environment; d.) personalized furniture and room .NJAC 8:39-31.4 (a)(b)(f)

NJ Complaint NJ #: 177087 Based on interview and review of pertinent facility documents, it was determined that the facility failed to investigate allegations of verbal abuse emailed to the facility on [DATE], by both a resident (Resident #145) and their representative, that an unidentified nurse verbally abused the resident and it was not investigated until surveyor inquiry. This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #145), and was evidenced by the following: On 1/6/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) all reportable events, grievances, accidents, and incident reports for Resident #145. On 1/7/25 at 1:15 PM, the LNHA provided the surveyor with the requested documents for Resident #145. The documentation included the following: An internal compliance hotline call from the resident dated 7/27/24. A fall accident report and investigation dated 9/26/24. A fall accident report and investigation dated 10/14/24. At that time, the surveyor asked the LNHA if those were all the reports for Resident #145 that the facility investigated, and the LNHA replied yes, as far as she was aware. On 1/9/25 at 9:04 AM, the LNHA and the Director of Nursing (DON) informed the surveyor that after the surveyor's multiple inquiries for reportable events, accidents, incidents, and grievances regarding Resident #145, they began to ask facility staff if they were aware of any other incidents that were not provided to the surveyor. The LNHA stated that the Social Worker (SW) looked through her emails and found two emails, both dated 8/7/24, one was from Resident #145 and the second from the Resident's Representative (RR). The emails both included grievances and an accusation of verbal abuse from an unnamed nurse at the facility towards the resident. The LNHA stated that the email was just found in the SW's spam/junk folder after surveyor inquiry. The LNHA acknowledged that the allegation was absolutely considered verbal abuse, and stated that the facility started an investigation into the matter which included attempting to reach out to the resident who no longer resided at the facility. On 1/9/25 at 9:58 AM, the surveyor reviewed Resident #145's medical record. A review of the resident's Transfer/Discharge Report indicated that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), need for assistance with personal care, and chronic pain. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/31/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. On 1/9/25 at 11:46 AM, the surveyor interviewed the LNHA, who stated when an allegation of abuse or grievance was reported to the facility by a resident or their representative, it was brought to the attention of the administration team. The LNHA continued if a particular person or staff member was named, then that staff member was suspended pending investigation. The LNHA stated that investigations should be completed and closed out in five days or sooner. The LNHA stated she was unsure as to why or how the emailed grievance/allegation was sent to the spam/junk folder and the facility's information technology (IT) department needed to investigate it. On 1/9/25 at 1:01 PM, the Regional Director of Operations (RDO), in the presence of the survey team, acknowledged the delay in investigating this accusation of abuse and stated, we agree that the system inhibited the ability to respond to the complaint/allegation. On 1/10/25 at 10:22 AM, the LNHA acknowledged to the surveyor, in the presence of the survey team, that the allegation of abuse that was emailed on 8/7/24, was just being investigated and followed up with now after surveyor inquiry. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated revised April 2021, included .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to; freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms .the facility would .develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents .identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident property . NJAC 8:39-4.1(a)5

Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 1 of 3 residents reviewed for dialysis (Resident #68), and was evidenced by the following: On 1/6/25 at 12:25 PM, during initial tour of the facility, the surveyor observed Resident #68 in their bedroom sleeping. On 1/7/25 at 9:00 AM, the surveyor reviewed the medical record for Resident #68. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but not limited to; end stage renal disease (kidneys have permanently lost their ability to function), chronic kidney disease (slow loss of kidney function over time), and type two diabetes mellitus (body does not use insulin properly). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 12/14/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated a cognitively intact cognition. A further review included the resident received dialysis while at the facility. A review of the Order Summary Report included a physician's order (PO) dated 12/7/24, for dialysis at [dialysis center name] on Tuesday, Thursday, and Saturday; pick up at 7:00 AM. A further review revealed a PO dated 12/7/24, to give book and bag lunch prior to leaving; check the book after arrival for communication in the morning every Tuesday, Thursday, and Saturday. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 6/18/24, that the resident needed hemodialysis related to renal failure at [dialysis center name] on Tuesday, Thursday, and Saturday. Interventions included but not limited to; monitor dialysis access site for signs and symptoms of infection, report abnormal findings to the physician or designee, monitor shunt sites for thrill and bruit (an assessment done by feeling their shunt for electric pulse that can be done with fingers or stethoscope done every shift to make sure functioning) every shift and as needed. On 1/8/25 at 10:22 AM, the surveyor reviewed Resident #68's dialysis communication book that was sent with the resident on dialysis treatment days. The communication forms were reviewed from October 2024 to January 2025. The following dialysis communication forms were not completed by the facility's nurse upon return from dialysis: 10/12/24, 10/15/24, and 10/17/24. The dialysis communication form was not completed by the dialysis center on 11/7/24. On 1/8/25 at 10:44 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated Resident #68 went out for dialysis on Tuesday, Thursday, and Saturday. LPN #1 further stated that prior to their departure, the nurse obtained vital signs, monitored the access site, and documented on the dialysis communication form that it was sent to dialysis with the resident. LPN #1 also stated that when the resident returned from dialysis, the nurse obtained vital signs, monitored the access site for drainage, checked the bruit and thrill and documented it in section three of the communication form. LPN #1 stated that if the dialysis center did not fill out their section, the facility called the center to see what they did at the dialysis center and if there were any new orders or changes. On 1/9/25 at 10:05 AM, the surveyor interviewed the Director of Nursing (DON), who stated the purpose of the dialysis communication form was to ensure communication between the facility and dialysis center. The DON further stated that when a resident went out to dialysis, the nurse was responsible to complete section one with vital signs, upon return the nurse reviewed the form and completed section three. The DON also stated that the dialysis center completed section two with weights, vital signs, labs, and new orders. The surveyor asked the DON if the dialysis center left section two blank, what should the nurse do. The DON replied, the nurse called the dialysis center to find out if there were any new orders or any concerns. The DON acknowledged that the dialysis communication forms were not filled out completely on the following dates: 10/12/24, 10/15/24, 10/17/24, and 11/7/24. On 1/9/25 at 12:49 PM, the DON, in the presence of the Licensed Nursing Home Administer (LNHA), Assistant Director of Nursing (ADON), [NAME] President of Clinical Services, and the survey team, stated the importance of the dialysis communication forms were to ensure communication between the facility and the dialysis center. The DON also stated that the dialysis center completed section two with how the dialysis treatment went, vital signs, and any new orders. The DON further stated if section two was not completed by the dialysis center, the nurse contacted the dialysis center and documented any new orders. A review of the facility's Hemodialysis Catheters - Access and Care of policy dated revised February 2023, included the nurse should document in the resident's medical record every shift as follows: .3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis . NJAC 8:39-27.1(a)

Complaint NJ #: 177087, 178121 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment by ensuring resident bathroom doors were in good repair. This deficient practice was observed in 1 of 2 nursing units and was evidenced by the following: On 1/6/25 at 12:27 PM, during initial tour of the facility, the surveyor observed the bathroom door of Resident room [ROOM NUMBER] to be deformed with a bow causing the top corner and the bottom corner of the handle side to be bowed out from the frame when the door was completely closed. Only the latch was able to fully be seated in the door frame with the top and bottom corners pulled away allowing the surveyor to see into the bathroom with the door closed. The door also had at least eight approximately half inch sized holes drilled into the door on the inside running half the length of the door from the top down. The door handle appeared to be coming off/loose from the door on the inside. On 1/9/25 at 12:08 PM, the surveyor interviewed the Director of Maintenance (DM), who stated that the facility utilized a system called TELS that all staff had access to put in work orders and inform the Maintenance Department of repairs that needed to be addressed. The DM acknowledged having knowledge of the bathroom door of Resident room [ROOM NUMBER] being in disrepair, but stated that the facility had not yet developed a plan to address it. The DM was unsure of how long it had been in its current state. The DM further stated that the facility was aware that some doors need to be replaced, specifically on the second floor, but stated we don't have anything in place for door orders. The DM acknowledged that the facility had a responsibility to ensure the building was in good repair and to look and function as good as it should in order to maintain a homelike environment for residents. On 1/9/25 at 12:52 PM, in the presence of the survey team, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who confirmed that all staff had access and knew how to use the TELS repair order system and that the Maintenance Department as well as the Regional Administration did monthly rounds of the facility to ensure all repairs were addressed. On 1/10/25 at 10:22 AM, in the presence of the survey team, the LNHA provided the surveyor with photos of the bathroom door for Resident room [ROOM NUMBER] and acknowledged it was in disrepair and he informed the surveyor that the door was replaced after surveyor inquiry. A review of the facility's Homelike Environment policy with revised February 2021, included .Residents are provided with a safe, clean, comfortable and homelike environments and encouraged to use their personal belongings to the extent possible .the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: clean, sanitary, and orderly environment . A review of the facility's Maintenance Service policy revised December 2009, included .the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . NJAC 8:39-31.4(a)

Complaint NJ #: 177087 Based on observations, interviews, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse within two hours to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #145), and was evidenced by the following: On 1/6/25 at 1:00 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) all reportable events, grievances, accidents, and incident reports for Resident #145. On 1/7/25 at 1:15 PM, the LNHA provided the surveyor with the requested documentation for Resident #145. This documentation included the following: An internal compliance hotline call from the resident dated 7/27/24. A fall accident report and investigation dated 9/26/24. A fall accident report and investigation dated 10/14/24. At that time, the surveyor asked the LNHA if that was all the reports for Resident #145, and the LNHA replied as far as she was aware, it was. On 1/9/25 at 9:04 AM, the LNHA and the Director of Nursing (DON) informed the surveyor that after the surveyor's multiple inquiries for reportable events, accidents, incidents, and grievances regarding Resident #145, they began to ask facility staff if they were aware of any other incidents that were not provided to the surveyor. The LNHA stated that the Social Worker (SW) looked through her emails and found two emails, both dated 8/7/24, one was from Resident #145 and the second from the Resident's Representative (RR). The emails both included grievances and an accusation of verbal abuse from an unnamed nurse at the facility towards the resident. The LNHA stated that the email was just found in the SW's spam/junk folder after surveyor inquiry. The LNHA acknowledged that the allegation was absolutely considered verbal abuse, and stated that the facility started an investigation into the matter which included attempting to reach out to the resident who no longer resided at the facility. On 1/9/25 at 9:58 AM, the surveyor reviewed Resident #145's medical record. A review of the resident's Transfer/Discharge Report indicated the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (COPD), need for assistance with personal care, and chronic pain. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/31/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. On 1/9/25 at 11:46 AM, the surveyor interviewed the LNHA, who stated that normally when an allegation of abuse or grievance was reported to the facility by a resident or the resident's representative, it was brought to the attention of the administration team. The LNHA continued if a particular person or staff member was named, then that staff member was suspended pending an investigation, and the facility reported the allegation to the NJDOH, the office of the Ombudsman, and if necessary to local law enforcement. The LNHA stated that investigations should be completed and closed out in five days or sooner. The LNHA stated she was unsure as to why or how Resident #145's emailed grievance/allegation of abuse was sent to the spam/junk folder and the facility's information technology (IT) department had to investigate it. The LNHA further acknowledged that it was the facility's responsibility to ensure all allegations of abuse and grievances were received timely and addressed including reported immediately. The LNHA stated that the abuse allegation was reported to the NJ DOH on 1/8/25. On 1/9/25 at 1:01 PM, the Regional Director of Operations (RDO), in the presence of the survey team, acknowledged the delay in investigating the accusation of abuse and stated, we agree that the system inhibited the ability to respond to the complaint/allegation. On 1/10/25 at 10:22 AM, the LNHA acknowledged to the surveyor, in the presence of the survey team, that the allegation of abuse which was sent on 8/7/24, was just being investigated and followed up with/reported after surveyor inquiry. A review of the facility provided policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated revised September 2022, included the following:All reports of resident abuse .are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting Allegations to the Administrator and Authorities 1. If resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. NJAC 8:39-5.1(a)

Complaint NJ #: 173483 Based on interview, medical record review, and review of other pertinent facility documentation, it was determined that the facility failed to obtain admission diet orders for a resident identified as a nutritional risk. This deficient practice was identified for 1 of 19 residents reviewed for physician's orders (Resident #146), and was evidenced by the following: A review of the admission Record face sheet (an admission summary) indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to; malignant neoplasm of the urethra (cancer of the tube that carries urine out of the body), absence of the left upper arm limb (left upper arm (LUA) amputation), and right left below the knee amputation (BKA). A review of the admission Screener (AS) dated 4/24/24, reflected that Resident #146 required assistance with activities of daily living (ADLs) and was confined to the wheelchair. The AS also reflected that the resident had a pressure ulcer located on the coccyx area. A review of the Minimum Data Set (MDS), an assessment tool, was not required to be completed for the resident. The resident resided in the facility for eight days in 2024. A review of the Physician's Order Report (POR) revealed that Resident #146 did not have a diet order. A review of the admission Nutritional Risk Assessment (ANRA) dated 4/26/24 at 10:31 AM, reflected that the Registered Dietitian (RD) assessed Resident #146 as new admission to facility after a hospitalization related to percutaneous endoscopic gastrostomy (PEG; an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) removal, a wound infection of the left foot, right BKA and LUE amputation at elbow, and stage two pressure ulcer of the coccyx (tailbone). The ANRA reflected that Resident #146 was at risk for malnutrition related to altered skin integrity, underweight body mass index (BMI; calculation of weight to height), multiple amputations, with need for a therapeutic diet and supplementation. The ARNA dated 4/26/24, indicated that Resident #146 had a pressure injury noted to coccyx on admission (stage II per hospital records) and diet was to include double protein with meals. Recommendations included to: provide diet as ordered of regular, regular textures, thin liquids, double portions; provide Ensure Plus eight ounces (8 oz) every day and monitor future tolerance/acceptance; monitor future wound reports, update to resident skin integrity; monitor resident intake, weight trends, signs and symptoms of aspiration, gastrointestinal regularity, and glycemic control; monitor resident fluid/hydration status, updated lab values, updated food preferences; provide additional assistance with meals and supplements as needed. The ANRA revealed a discrepancy related to whether the resident was to have double protein diet or a double portion diet and a diet was not prescribed by a physician on admission to the facility. A review of Resident #146's individualized comprehensive care plan (ICCP) initiated on 4/26/24, reflected that the resident had the potential for nutritional problems related to hypertension, pancreatitis, PEG removal and amputations and had a need for a therapeutic diet with supplementation. Interventions included to provide a regular diet, regular textures, thin liquids with double protein. This diet was not ordered when the resident was admitted to the facility. On 1/9/25 at 9:06 AM, the surveyor interviewed the RD, who stated that she had been working in the facility for approximately five months and did not know the resident. At that time, the RD reviewed Resident #146's electronic medical record (EMR) and confirmed that a diet was not ordered for Resident #146 at the time the resident was admitted to the facility. The RD stated that the nursing department was responsible to obtain the physician's order for Resident #146's diet on admission and explained that the importance of obtaining a physician's order was so the resident received a food tray in accordance with their diet orders from the hospital records. The RD also stated that it was important to have admission diet orders to assure that the resident received a therapeutic diet with the right texture and consistency to ensure safety. The RD reviewed the ANRA dated 4/26/24, and confirmed that the resident should have received double portions of protein for wound healing, however the recommendation documented on the nutritional risk assessment dated [DATE], indicated Resident #146 was to receive double portions of the entire meal. The RD stated that the previous dietician must have made an error in documentation and that according to the resident's tray ticket, Resident #146 was provided with the correct double protein diet. The surveyor reviewed Resident #146's food tray ticket dated 4/24/24, which indicated that the resident received a double meat diet, however a diet was not prescribed for the resident on admission to the facility. On 1/9/25 at 10:37 AM, the surveyor interviewed the Licensed Practical/Nurse Unit Manager (LPN/UM), who explained the admission process to the surveyor and stated that admission orders were to include diagnoses, the correct diet with consistencies of diet, texture of diet or if the resident was on a therapeutic diet, allergies, medications, labs, and treatments. At that time, the LPN/UM reviewed Resident #146's admission orders and confirmed that a diet was not ordered for the resident on admission. On 1/9/25 at 10:50 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that admission orders included: weights, medications, treatments, diet, skin checks, bath, and shower orders. The ADON stated that it was important to put a diet order from the physician in the EMR to ensure the resident received the correct therapeutic diet with proper texture and consistency to ensure that the resident was safe. The ADON stated that when the diet was ordered, the nurse completed a diet slip and gave it to the kitchen but must have forgotten to write the diet in the physician's orders. The ADON stated that the kitchen had a different computer system and they inputted the diet into their system so that the resident received the tray with the correct diet even though there was not a physician's order for the resident's diet. The ADON confirmed that the staff did not obtain a diet order for Resident #146 on admission to the facility. On 1/10/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) who both confirmed that residents' diet orders were required at the time of admission. A review the facility's undated Diet Order Policy included that upon admission, the resident's diet will be updated by the nursing staff based on hospital recommendations .the dietician and speech pathologist may review the recommended diet order upon admission to ensure that it is appropriate and if adjustments were to be made, the physician would be notified to approve or disapprove of the recommendations and changes to the diet would be made to the diet order following documentation in the electronic medical record (EMR) . NJAC 8:39-11.2 (a), 27.1(a)

Based on interviews, observation, and review of pertinent facility documents it was determined that the facility failed to complete individual comprehensive care plans for three residents with urinary and bowel incontinence. This deficient practice was identified for 3 of 3 resident reviewed for incontinence (Resident #42, #47, and #52), and was evidenced by the following: 1. On 1/9/25 at 9:00 AM, the surveyor conducted incontinence rounds on the Second-Floor long term care nursing unit with the Certified Nursing Assistant (CNA #1). During the incontinence rounds, CNA #1 removed Resident #47's incontinence brief which was dry and the surveyor observed that the resident had a white towel within the incontinence brief. CNA #1 told the surveyor that the resident requested a towel within the incontinence brief. The surveyor interviewed the resident who confirmed that they wanted a towel in their incontinence brief. On 1/9/25 at 10:00 AM, the surveyor reviewed the medical record for Resident #47. A review of the Admission Record face sheet (an admission summary) reflected Resident #47 was admitted to the facility with medical diagnoses that included but were not limited to; hemiplegia (left side paralysis), diabetes mellitus (high blood sugar), and muscle wasting. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 12/26/24, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, meaning the resident was cognitively intact. A review of Section H for bowel and bladder, revealed the resident was always incontinent of bowel and bladder. A review of the individualized comprehensive care plan (ICCP) included a focus area initiated on 11/1/23, for bowel incontinence. Interventions included to: check resident approximately every two hours and provide incontinence care as needed and to apply moisture barrier as needed. A further review of the ICCP included a focus area dated 11/1/23, for urinary incontinence. Interventions included to: establish voiding patterns; provide incontinence care as needed; and check resident approximately every two hours and provide incontinence care as needed. On 1/9/25 at 12:49 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding the resident with a towel in their incontinence brief. The surveyor asked how staff would know that was a resident preferred that and the LNHA stated it should be included in the care plan. 2. On 1/9/25 at 9:10 AM, the surveyor conducted incontinence rounds with CNA #1 for Resident #52. CNA #1 removed the resident's incontinence brief which revealed another incontinence brief under the first brief, and the surveyor observed the resident was laying on a third incontinence brief opened and under the resident being used as a bed pad. CNA #1 told the surveyor that the resident requested the double briefs. The surveyor asked Resident #52 if it was a preference and the resident shook their head yes. On 1/9/25 at 10:30 AM, the surveyor reviewed the medical record for Resident #52. A review of the Admission Record face sheet reflected Resident #52 was admitted to the facility with medical diagnoses which included but were not limited to; hemiplegia (right sided paralysis), cervical spine injury, anxiety disorder, and difficulty in walking. A review of the most recent comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 9 out of 15, meaning the resident had a moderately impaired cognition. A review of Section H, Bowel and Bladder, indicated the resident was always incontinent of bowel and bladder. A review of Resident #52's ICCP included a focus area dated 10/2/23, for bowel incontinence. Interventions included to provide incontinence care and apply moisture barrier as needed and to monitor the resident's bowel habits. The ICCP also included a focus area initiated 10/2/23, for urinary incontinence. Interventions included to offer toileting prior to bedtime and to check the resident approximately every two hours and provide incontinence care as needed. The ICCP did not include double briefing per the resident's request. On 1/9/25 at 12:49 PM, the surveyor interviewed the LNHA regarding Resident #52's double incontinence briefing. The surveyor asked how staff would know that was the resident's preference, and the LNHA stated it should be included in the ICCP. 45208 3. On 1/9/25 at 9:00 AM, the surveyor conducted incontinence rounds on the Second-Floor long term care nursing unit with the Registered Nurse/Unit Manager (RN/UM). During the incontinence rounds, the RN/UM removed Resident #42's incontinence brief which was dry. The surveyor interviewed the resident, who stated, at nighttime it is my preference to have two diapers and a towel applied between my legs. It helps me not soak the bed and I feel safer and stay dry. On the day shift, the resident preferred to wear one incontinence brief when out of bed. The RN/UM acknowledged that the staff was aware of Resident #42's preferences for incontinence care at night. On 1/9/25 at 10:58 AM, the surveyor reviewed the medical record for Resident #42. A review of the Admission Record face sheet reflected Resident #42 was admitted to the facility with medical diagnoses that included but were not limited to; muscle wasting and atrophy (thinning or loss of muscle tissue). A review of the most recent comprehensive MDS dated [DATE], revealed Resident #42 had a BIMS score of 15 out of 15, meaning the resident was cognitively intact. A review of Section H, Bowel and Bladder, revealed the resident was frequently incontinent of bowel and bladder. A review of the ICCP included a focus area dated 10/6/24, for bowel incontinence. Interventions included to: establish bowel elimination patterns, monitor bowel habits, and offer toileting assistance at the same time each day that the resident has an incontinence episode; provide incontinence care as needed; and to apply moisture barrier as needed. The ICCP also included a focus area dated 10/6/24, for urinary incontinence. Interventions included: to establish voiding patterns; offer/encourage toileting prior to bedtime; and check resident approximately every two hours and provide incontinence care as needed. The ICCP did not include double briefing or a towel between the resident's legs per the resident's request. On 1/9/25 at 12:49 PM, the surveyor interviewed the LNHA regarding resident's preferences for double incontinence briefing. The surveyor asked how staff would know that was the resident's preference, and the LNHA stated it should be included in the ICCP. A review of the facility's Care plans, Comprehensive Person-Centered policy with a revision date of March 2022, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident and includes residents stated goals . NJAC 8:39-27.1(a)

Complaint NJ #: 173135; 173483 Based on observation, interview, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to a.) obtain a physician's order for a replacement nutritional supplement after the facility identified that there was a national shortage of the resident's (Resident #146) current nutritional supplement; b.) consistently document the assessment and dressing changes to a resident's (Resident #195) peritoneal dialysis site (kidney treatment that filters waste and excess fluid from the blood using the lining of the abdomen); c.) appropriately administer intravenous (IV) antibiotic medication in accordance to the physician's order; and d.) document communication with the physician in accordance with professional standards of practice. This deficient practice was identified for 3 of 19 residents reviewed for professional standards of practice (Resident #146, #195, and #295). Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist: Reference New Jersey Statutes, 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 task and responsibilities within the framework of case finding; reinforcing the patient family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the duration of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was identified by the following: 1. A review of the Admission Record (AR) face sheet (an admission summary) indicated that Resident #146 was admitted to the facility with the diagnoses which included but was not limited to; malignant neoplasm of the urethra (cancer of the tube that carries urine out of the body), absence of the left upper arm limb (left upper arm (LUA) amputation), and right left below the knee amputation (BKA). A review of the Admission Screener (AS) dated 4/24/24, reflected that Resident #146 required assistance with activities of daily living (ADLs) and was confined to the wheelchair. The AS also reflected that the resident had a pressure ulcer located on the coccyx (tailbone) area. A review of the Minimum Data Set (MDS), an assessment tool, was not required to be completed. The resident resided in the facility for eight days in 2024. A review of the Admission Nutritional Risk Assessment (ANRA) dated 4/26/24 at 10:31 AM, reflected that the Registered Dietitian (RD) assessed Resident #146 as new admission to facility after a hospitalization related to percutaneous endoscopic gastrostomy (PEG) (an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall) removal, a wound infection of the left foot, right BKA and LUE amputation at elbow, and stage two pressure ulcer of the coccyx. The ANRA reflected that Resident #146 was at risk for malnutrition related to altered skin integrity, underweight body mass index (BMI), multiple amputations, with need for a therapeutic diet and supplementation. Recommendations from the RD included to provide Ensure Plus (a nutritional supplement) eight ounces (8 oz) daily. A review of the Physician's Order Report (POR) included a physician's order dated 4/26/24, for Ensure Plus 8 oz daily by mouth. A review of the corresponding April 2024 Medication Administration Record (MAR) reflected that the nurses were documenting that Resident #146 received the Ensure Plus and consumed 100 percent of the supplement given on 4/27/24, 4/28/24, 4/29/24, and 4/30/24. A review of Resident #146's individualized comprehensive care plan (ICCP) initiated on 4/26/24, reflected that the resident had potential for nutritional problems related to hypertension, pancreatitis, PEG removal and amputations and had a need for a therapeutic diet with supplementation. Interventions included to provide and serve nutritional supplementation as ordered: Ensure Plus 8 oz daily. The RD provided the surveyor with Resident #146's meal tickets from 4/24/24 to 5/1/24, and the nutritional supplement documented on the meal ticket indicated that the resident received a Mighty Shake. The Mighty Shake was provided to the resident every meal according to the meal ticket. There was no physician's order for the resident to receive the Mighty Shake with every meal as was written on the meal ticket. On 1/9/25 at 9:06 AM, the surveyor interviewed the RD, who stated that she had been working in the facility for approximately five months and she was unfamiliar with the resident. At that time, the RD reviewed the physician's orders with the surveyor and confirmed that Resident #146 did not have a physician's order for the Mighty Shake; the resident had a physician's order for Ensure Plus 8 oz to be given once a day. The RD stated that at that time the Ensure Plus was ordered, there was a national shortage of Ensure Plus and that the equivalent nutritional supplement would have been the Mighty Shake to be given as a substitute. The RD confirmed that an order was not obtained for the Mighty Shake and that the nurse should have discontinued the Ensure Plus supplement and ordered the Mighty Shake as the substitute. The surveyor reviewed the MAR with the RD, and she stated that she did not know why the nurses signed that the resident received the Ensure Plus when it was not available to give to the resident. The RD provided the surveyor with a letter from the company that supplied the Ensure Plus dated 4/12/24, and according to the letter the company was experiencing temporary out of stock items and that the supplement would be expected to be back in stock by mid-June or July of 2024. The RD provided the surveyor with a form titled, Acceptable Supplement Substitution policy dated January 2024, and according to this policy a Mighty Shake/health shake would have been an acceptable substitute for Ensure Plus 8 oz. On 1/9/25 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated that if nutritional supplements were needed, an order was obtained from the medical doctor (MD) and the supplement was documented on the MAR as well as how much the resident consumed. LPN/UM #1 stated that if there was a national shortage of the supplement during the time the supplement was ordered, the MD should have been notified and the original supplement should have been discontinued and the replacement supplement should have been ordered. LPN/UM #1 stated all nutritional supplements required a physician's order. LPN/UM #1 reviewed the MAR with the surveyor and confirmed that the nurses signed on the MAR that the resident received Ensure Plus as well as signed how much the resident consumed. LPN/UM #1 confirmed there was no physician's order for the Mighty Shake, and the nurses should not have documented the resident received the Ensure Plus when there was a national shortage. On 1/9/25 at 10:50 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who explained that nutritional supplements were considered medications and were ordered by the MD and signed on the MAR the amount the resident consumed. The ADON stated if there was a national shortage of a nutritional supplement at the time it was ordered for Resident #146, and the supplement was not available, the staff notified the RD who recommended to discontinue that supplement and recommended a substitution. The ADON confirmed a physician's order was required for a Mighty Shake, and that staff did not notify the RD or MD to discontinue the Ensure Plus and order the Mighty Shake. On 1/10/25 at 10:30 AM, the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA), who both confirmed that the nurses should have changed Resident #146's supplement order, even though the supplements were interchangeable, they should have changed the order to specify the supplement that the resident was provided. 40744 2. On 1/6/25 at 9:30 AM, during an interview with LPN/UM #1, the surveyor was told that Resident #195 was receiving peritoneal dialysis treatments while at the facility. The resident received treatments every evening. A review of the AR face sheet reflected that Resident #195 was admitted to the facility with medical diagnoses which included but were not limited to; end stage renal disease, hypertension (high blood pressure), heart failure, and depression. A review of the most recent comprehensive MDS dated [DATE], revealed Resident #195 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated that the resident was cognitively intact. A review of Section O, Special Procedure and Treatments, revealed the resident was a peritoneal dialysis resident. A review of the physician's orders included the following orders dated 8/1/24, for the resident: peritoneal dialysis (PD) solution 2.5% 6000 milliliter (ml) yellow bags in the evening for PD; dialysis instill two (2) 6000 ml green bags; peritoneal dialysis solution 1.5% purple bag in the evening for PD; dialysis instill one (1) purple bag solution; and peritoneal dialysis solution 2.5% dextrose (1.5%) 2,000 ml solution yellow in the evening for PD; dialysis instill 1 small yellow bag. A review of the resident's ICCP included a focus area dated 8/1/24, for peritoneal dialysis. Interventions included to: monitor dialysis access site for signs and symptoms of infection; report abnormal findings to physician or designee; and check and change dressing on dialysis access as ordered and per policy. A review of the MAR and the TAR did include the dialysis access site assessments or dressing changes as indicated in the ICCP. A review of the Progress Notes included two Nurse's Notes, one dated 10/25/24, and one dated 11/11/24, that included the dialysis access site assessments. There was no additional documentation regarding the assessment of the site. On 1/7/25 at 11:44 AM, the surveyor observed Resident #195 in the room who had just received morning care from the Certified Nursing Assistant (CNA #1). Resident #195 told surveyor they had been on dialysis for three years prior to admission to the facility. The resident then showed the surveyor the abdominal catheter (flexible tubing) used for the dialysis treatment. The catheter was secured with tape to prevent pulling. There was an undated white gauze dressing over the catheter site. On 1/8/25 at 1:49 PM, the surveyor interviewed the DON regarding care of the resident's dialysis catheter site. The surveyor asked if there should be a dressing over the site and she stated yes. The surveyor then asked if there would be a physician's order for a dressing change and the DON stated yes. On 1/10/25 at 12:30 PM, the DON showed the surveyor an order for an antibiotic ointment to the dialysis catheter site. The order did not include a dressing. The surveyor asked the DON if the order should have a dressing, and if the dressing should be dated when changed. The DON confirmed yes. A review of the facility's Peritoneal Dialysis (Continuous Ambulator) dated revised October 2010, included .catheter care and site observation .11. to apply sterile dressing of the catheter insertion site . 45208 3. On 1/8/24 at 10:00 AM, the surveyor reviewed the medical record for Resident #295. A review of the AR face sheet reflected that Resident #295 was admitted to the facility with medical diagnoses which included but was not limited to; methicillin resistant staphylococcus aureus infection (MRSA; a type of bacteria that is resistant to many antibiotics). A review of the most recent MDS dated [DATE], reflected that Resident #295 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A further review of the MDS reflected the resident used antibiotics and received IV medications as a resident. A review of the resident's ICCP included a focus area initiated on 4/13/24, and revised on 4/23/24, that the resident received intravenous therapy of daptomycin- sodium chloride intravenous solution 700-0.9 milligram (mg) per 100 ml-% (700 mg); use 700 mg (an antibiotic). Interventions included to: monitor dressing at IV insertion site daily and change as ordered; monitor/document/report to physician as needed signs and symptoms of infection at the IV site; and report to nursing if IV comes out or site appears different. The ICCP did not include to administer the antibiotic as ordered. A review of the Order Summary Report (OSR) included a physician's order (PO) dated 4/13/24, and discontinued 4/14/24, for daptomycin 700 mg IV; to administer one time a day for MRSA and discontinuation date of 4/14/24. A review of the MAR indicated the antibiotic medication daptomycin 700 mg was to be administered intravenous (IV) with a start date of 4/14/24 at 6:00 AM. The nurse's initial signature on the MAR dated 4/14/24 at 11:00 AM, indicated NA, meaning the medication was not available and the resident did not receive their daily dose of physician ordered daptomycin on 4/14/24. A review of the Progress Notes did not reflect any nursing documentation regarding the missed medication dose, and that the nurse called the physician to notify them of the missed dose or the pharmacy was contacted. The facility was unable to provide any documentation regarding the unavailable antibiotic. On 1/9/24 at 11:00 AM, the surveyor interviewed the contracted Pharmaceutical Representative (PR) liaison, who stated the pharmacy to delivered medication to the facility on the weekend once daily to the facility between 7:30 PM and 10:00 PM. The PR stated facility could request an additional delivery if a stat (immediate) medication or a specific timed medication was needed for a resident. The PR reviewed the order sent to the company for daptomycin ordered on 4/13/24, for the dose on 4/14/24 at 6:00 AM, and the PR stated that the dose did not arrive at the facility until 4/14/24 at 9:51 PM. The PR confirmed that there were no stat requests or calls to the pharmaceutical company for a rushed delivery for the daptomycin. On 1/10/25 at 9:35 AM, the surveyor interviewed the DON, who explained that the staff should have placed a call to the physician to let them know that there was a delay in administration of the medication, and documented that call in the Progress Notes. The DON stated that the nurse should have either obtained a new order or called the pharmacy to ask for a stat dose or the estimated time of arrival (ETA) for the delivery of the medication based on the physician's recommendations. On 1/10/25 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who indicated that the staff should have notified the resident's physician. The LNHA acknowledged there was a delay in medication administration, and it prolonged the resident's care. On 1/10/25 at 10:30 AM, the surveyor team met with the LNHA and DON, who both acknowledged the surveyor's concerns and no additional information was provided. A review of the facility's Physician Orders policy dated February 2014, included that licensed nurses would obtain, document, and provide care and services in accordance with orders received from the physician. The provision of care and services in accordance with physician orders would be documented in accordance with professional standards of practice . A review of the facility's Administering Medications policy dated April 2019, included medications are administered in a safe and timely manner and as prescribed .medications are administered with in one (1) hour of their prescribed time, unless otherwise specified . NJAC 8:39-11.2(b)

Based on observation, interview, review of facility medical records and other pertinent facility documents, it was determined that the facility failed to document the necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. This deficient practice was identified for 1 of 2 residents reviewed for pressure ulcers (Resident #4), and was evidenced by the following: A review of the Admission Record face sheet (an admission summary) Resident #4 was admitted to the facility with the diagnoses that included but not limited to; dementia, diabetes mellitus and severe protein calorie malnutrition. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 11/19/24, indicated that Resident #4 had severe cognitive impairment and was dependent on staff for all aspects of activities of daily living (ADLs). A review of Section M reflected that Resident #4 was at risk for developing pressure ulcers and had a full thickness stage 3 pressure area. On 1/6/25 at 12:35 PM, the surveyor observed Resident #4 lying in bed on an air mattress. The resident was unable to be interviewed due to an impaired cognition and the resident had a non-verbal status. The nurse assigned to the resident indicated that Resident #4 had a pressure ulcer on the left foot. The surveyor observed the dressing on the left foot dated 1/6/24. A review of the Weekly Skin Check dated 12/28/24, indicated the resident had a pressure ulcer on the left foot bunion area. A review of the Treatment Administration Record (TAR) dated 1/1/25 until 1/31/25, reflected a physician's order dated 12/6/24, for Medi-honey wound/burn dressing external gel (wound dressings); apply to left bunion wound topically every day shift for wound care. Cleanse left bunion wound with normal saline solution (NSS); apply Medi honey and NSS moist gauze to the base of the wound and secure with dry gauze and rolled gauze once daily. According to the TAR, on 1/4/25 and 1/5/25, there were no nurses' signatures that indicated wound care was provided to Resident #4's left bunion wound. The surveyor reviewed Resident #4's individualized comprehensive care plan (ICCP) dated 5/14/19, which indicated that the resident had a wound to the left bunion area and had the potential for pressure ulcer development. Interventions included to provide treatments per physician's orders and the staff was to monitor for effectiveness of treatments rendered. A review of the Wound Assessment Report dated 1/7/25, indicated that Resident #4 had a left foot bunion pressure area stage three and that the wound measured three centimeters by three centimeters by nine centimeters (3 cm x 3 cm x 9 cm) with a 0.20 depth and was improving without complications. On 1/8/25 at 9:17 AM, the surveyor interviewed the Registered Nurse (RN), who stated that the nurse assigned to the resident was responsible to complete wound care and then signed on the TAR the treatment was completed. The RN stated if the TAR was not signed by a nurse, it indicated that the wound care was not completed. The RN stated if for any reason the wound care was not completed, the nurse indicated no on the TAR and then documented in a progress note as to why it was not completed. At that time the RN reviewed Resident #4's TAR, in the presence of the surveyor, and agreed that the TAR dated 1/4/25 and 1/5/25, on day shift was blank and if there were no signatures from the nurse on those days, that indicated that wound care was not completed on those days. On 1/8/25 at 9:31 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that it was the responsibility of the nurse to complete the resident's wound care and document the completion on the TAR. The LPN/UM stated if signatures were missing on the TAR, it indicated that the wound care was not completed or that the nurse forgot to sign that the treatment was completed. The LPN/UM stated that it would be important to sign the TAR so that the facility could ensure the best care was rendered for the residents and documenting completion of a procedure was important to ensure that proper care was provided. On 1/8/25 at 11:48 AM, the surveyor interviewed the Director of Nursing (DON), who stated that wound care was completed per physician's orders and documented on the TAR for completion. The DON stated that it was important for the nurse to sign the TAR after wound care completion because if the nurse did not sign the TAR, it indicated that the treatment was not done as ordered by the physician. On 1/9/25 at 9:55 AM, the surveyor interviewed the LPN, who stated that she had worked on 1/4/25 and 1/5/25, and she confirmed that the TAR did not contain her signature for the resident's wound care on those days. The LPN stated that it was a crazy busy weekend and that she must have forgotten to sign out the TAR on those dates, but she remembered performing Resident #4's left bunion area treatments. The LPN acknowledged that based on standards of nursing practice, if you did not sign that a procedure was performed then it was not done. On 1/9/25 at 10:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that after a treatment was performed by the nurse, it was the nurse's responsibility to document that it was completed by putting a signature on the TAR. The ADON stated that if the TAR was blank and there was no signature that documented the treatment was performed, then the conclusion would be that the treatment was not provided to the resident. On 1/10/25 at 10:39 AM, the surveyor interviewed the DON, who stated that the nursing staff were required to sign the TAR when treatments were provided. She stated that when the nurse signed the TAR, it confirmed that the treatment was provided. A review of the facility's Wound Care policy dated 2001, included the following information should be recorded in the resident's medical record: the type of wound care given; the date and time the wound care was given; all assessment data; the signature and title of the person recording the data . NJAC 8:39-27.1 (e)