Every finding on record at Daughters of Israel Pleasant Valley Home

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, and b.) failed to sanitize and air dry steam table pans in a manner to prevent microbial growth. This deficient practice was evidenced by the following: On 3/9/26 at 11:07 AM, in the presence of the General Manager (GM) and the Executive Chef (EC), the surveyor observed the following:On the dairy side of the kitchen, on a shelf in the food preparation area, the surveyor also observed 6 spice containers with their tops opened. The GM stated these lids should be closed. On the dairy side of the dish washing area, the surveyor observed 2 large shallow steam table pans, stacked and wet nested with water between them, the surveyor also observed 3- 2/3rd sized steam table pans, stacked and wet nested with water between them. The GM stated that the steam table pans should not be stacked when wet and should have been air dried first.A review of the Labeling and Dating policy, dated 5/2023, revealed all foods are labeled, dated, and securely covered.A review of 3 Compartment sink policy, dated 5/2023 revealed dishes should be air dried and do not stack wet dishes. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) that the physician's orders were followed according to the standard of clinical practice for 4 of 4 residents, (Resident #8, 72, 108 and 114), reviewed for respiratory care, and b.) failed to provide a humidifier according to the facility's policy and procedure for one (1) of 4 residents, (Resident #108) reviewed for respiratory care.This deficient practice was evidenced by the following:1.On 3/6/26 at 10:35 AM, the surveyor observed Resident #8 in bed in their room, receiving oxygen via a nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which O2 flows) from a concentrator and the surveyor observed the oxygen flow meter was set at 3.5 liters per minute (lpm). A review of Resident #8's electronic health record (EHR) reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dysphagia (a difficulty swallowing), Cerebral infarction (a stroke) and left hemiplegia and hemiparesis (weakness and/or paralysis of left side of the body). A review of Resident #8's Annual Minimum Data Set (MDS), an assessment tool dated 2/24/26 revealed Resident #8 has severe cognition impairment and is dependent with all activities of daily living and transfers. A review of Resident # 8's physician orders revealed an order with a start date of 12/4/25 and the details of the order prescribed resident to receive oxygen via nasal canula continuously at a flow rate of 2 lpm. On 3/6/225 at 12:50 PM, the surveyor made a second observation of Resident #8 in bed in their room, receiving Oxygen via nasal canula from a concentrator and the surveyor confirmed the oxygen flow meter was set at 3.5 lpm. On 3/6/26 at 12:55 PM, the surveyor interviewed the (Licensed Practical Nurse (LPN #1) assigned to Resident #8's care. The LPN #1 confirmed that Resident #8's oxygen orders in the resident's electronic health record (EHR) indicated that oxygen was ordered for a flow rate of 2 lpm continuously. On 3/6/26 12:58 at PM, the LPN accompanied the surveyor to Resident #8's room, and the LPN #1 confirmed the resident's oxygen was flowing at 3.5 liters per minute according to flow meter on the concentrator. She readjusted the flow to the prescribed rate of 2 lpm. The surveyor asked the LPN #1 about oxygen administration for Resident #8 and the LPN #1 stated that only nurses set or adjust concentrator flow rates for oxygen and that oxygen should always be administered as ordered by physician. 2. On 3/6/26 at 10:25 AM, the surveyor observed Resident #72 awake, lying in bed with a NC on both nostrils attached to a concentrator (a device that supplies O2) running at 4 lpm. On 3/9/26 at 10:37 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #72, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #72 was admitted with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe). A review of the admission MDS, (an assessment tool used to facilitate the management of care) dated 1/29/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the residents had severely impaired cognition. Further review of the A/MDS, as reflected in section O-Special Treatments, Procedure and Program, revealed that Resident #72 was using O2 while a resident in the facility. A review of the Physician Order (PO) with the start date of 2/9/26, O2 continuously at 2 lpm via NC. A review of the care plan (CP) activity report initiated on 1/23/26 focused on the residents at risk for respiratory distress due to the diagnosis of COPD. Intervention included, but was not limited to, O2 therapy as per the physician's order. 3. On 3/6/26 at 10:52 AM and on 3/9/26 at 10:12 AM, the surveyor observed Resident #108 awake, lying on the bed, receiving oxygen at 3.5 lpm via NC attached to a concentrator. The surveyor did not observe an oxygen humidifier attached to the concentrator. On 3/11/26 at 10:32 AM, the surveyor observed Resident #108 O2 is at 4.5 lpm via nasal cannula attached to the concentrator. The surveyor interviewed the Licensed Practical Nurse (LPN#1), who is in the room with the surveyor. LPN#1 checked the O2 parameter of the resident and confirmed that it was at 4.5 lpm. LPN #1 stated that during his rounds at 7:00 AM, the O2 was at 3 lpm, and he did not know what happened next. On 3/6/26 at 1:21 PM, the surveyor reviewed the hybrid medical record of Resident #108, which revealed the following: A review of the AR reflected that Resident #108 was admitted with diagnoses that included but were not limited to congestive heart failure (CHF, the heart cannot pump blood efficiently to meet the body's needs). A review of the A/MDS dated [DATE] indicated that the facility assessed the residents' cognitive status using a BIMS score of 0 out of 15, which indicated that the residents had severely impaired cognition. Further review of the A/MDS, as reflected in section O-Special Treatments, Procedure and Program, revealed that Resident #108 was using oxygen while a resident in the facility. A review of the PO with the start date of 2/9/26, oxygen at 3 lpm via NC continuously every shift for SOB (shortness of breath). A review of the CP activity report initiated on 3/13/26 focused on the residents at risk of having complaints of dyspnea (difficulty breathing) related to the diagnosis of CHF. Intervention included, but was not limited to, O2 therapy as per the physician's order. On 3/9/26 at 12:53 PM, the surveyor interviewed LPN #2, who stated that he does not put a humidifier in Resident #108's room because there is no order. 4. On 3/6/26 at 10:41 AM, the surveyor observed Resident #114 was awake and was using O2 at 3 lpm via NC attached to the concentrator. On 3/9/26 at 10:26 AM, the surveyor observed Resident #114 in bed awake on O2 at 3.5 lpm via NC. The LPN#2 confirmed that the resident was receiving 3.5 lpm of O2 therapy and did not provide further information. A review of the AR reflected that Resident #114 was admitted with diagnoses that included but were not limited to unspecified dementia (a loss of memory), unspecified severity with psychotic disturbance. There was no recent MDS assessment available for Resident #114 in the hybrid medical record. A review of the CP activity report initiated on 3/4/26 focused on the residents at risk of having complaints of dyspnea. Intervention included, but was not limited to, O2 therapy as per the physician's order. A review of the PO with the start date of 3/3/26, oxygen at 2 lpm via NC as needed for O2 saturation less than 92%, SOB, or respiratory distress. A review of the Resident Treatment Administration Record for Resident #114 revealed that there is no record for 3/6/26 and 3/9/26 that the resident received an O2 treatment. On 3/11/26 1:54 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), Assistant LNHA, and the Director of Nursing regarding the above concern, but did not provide further information. A review of the facility policy title Oxygen Therapy, revised date of June 2025, revealed under Procedures: 1. Check the order in the resident's chart for the amount of oxygen and frequency of administration, or follow standard of practice to maintain saturation level. and 2. If oxygen is more than 3L (liters), use a humidifier bottle with sterile water to the indicated level. Date the humidifier and change it daily. NJAC 8:39-25.2(c)3

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices to prevent and control the spread of infection. Specifically the facility failed to: a) post required signage at the rooms for 9 of 9 residents reviewed for Enhanced Barrier Precautions (Resident #'s 1, 2, 4, 8, 12, 67, 108, 113, 114), b) failed to handle medications in a sanitary manner during medication administration observation and medication storage review by 1 of 3 nurses observed during medication administration and 1 of three nurses observed during medication storage review, and c) a failure to cleanse blood glucometer between uses by 1 of 3 nurses observed during medication administration. This deficient practice was evidenced by the following:1.On 3/6/25 at 10:35, the surveyor conducted initial tour of the HP nursing care unit and observed no enhanced barrier precaution (EBP) signage on door, doorway or entrance to room #HP-334, a private room of Resident #8. A review of Resident #8's electronic health record (EHR) reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Dysphagia (a difficulty swallowing), Cerebral infarction (a stroke) and left hemiplegia and hemiparesis (weakness and/or paralysis of left side of the body). A review of Resident #8's Annual Minimum Data Set (MDS), an assessment tool dated 2/24/26 revealed Resident #8 has severe cognition impairment and is dependent for all activities of daily living and transfers. A review of Resident # 8's physician orders reflected that the resident is ordered to receive no nutrition and hydration orally but received nutrition and hydration through a gastrostomy tube inserted directly through the abdominal wall into the stomach. On 3/6/26 at 1:00PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to care for Resident #8. The LPN # 1 accompanied the surveyor to room HP-334 and the surveyor asked the LPN #1 how a staff member would know a resident was on EBP and what activities and personal protective equipment (PPE) would be required to care for the resident, the LPN # 1 stated there is a bin of PPE in the doorway. The surveyor asked the LPN #1 about appropriate signage to indicate enhanced barrier precautions. The LPN # 1 stated there was no signage in use on this resident's door or doorway and she acknowledged Resident #8 was placed on EBP due to her gastrostomy tube. 2. On 3/6/26 at 10:38 AM, during a tour on a unit, the surveyor observed a clear storage bin outside of Resident #4's room. There was an orange round magnetic dot on the door frame. The bin stored personal protective equipment (PPE) gowns and other supplies. There was no signage at the door or on the bin to indicate usage of PPE. The surveyor reviewed the electronic medical record of Resident #4. A physician order dated 5/27/25 indicated EBP every shift. A review of a care plan for Resident #4 with a focus of EBP related to the presence of a wound revealed an intervention which indicated clear signage must be posted on the door or wall outside of the resident room indicating the type of precautions and required PPE. The intervention and care plan was dated 5/2/25. 3. On 3/9/26 at 10:20 AM, during a tour on a unit, the surveyor observed a clear storage bin outside of Resident #113's room. The bin stored PPE gowns and other supplies. There was an orange round magnetic dot on the door frame. There was no signage at the door or on the bin to indicate the use of PPE. The surveyor reviewed the electronic medical record of Resident #113. A physician order dated 2/13/26, indicated EBP isolation. A review of a care plan for Resident #113 with a focus of EBP related to the presence of a wound and enteral feeding tube revealed an intervention which indicated clear signage must be posted on the door or wall outside of the resident room indicating the type of precautions and required PPE. The intervention and care plan was dated 2/13/26. On 3/9/26 at 10:23 AM, the surveyor interviewed LPN # 2 assigned to the residents about the bins at the resident's door. The LPN # 2 stated the bins stored PPE supplies used by staff when providing care to residents with wounds, enteral feedings, and urinary catheters. The LPN # 2 was not sure of the name for the type of isolation precaution. The surveyor asked the LPN # 2 how staff and visitors would know what protocols to follow for the isolation precaution. The LPN # 2 replied that the PPE in bin were for staff and not visitors as they provided high contact care to residents. LPN #2 further explained that a resident with an active infection that required another type of isolation precaution there would be a sign on the door to see the nurse prior to entering the room. The surveyor asked the LPN # 2 about the orange magnetic dot on the door. The LPN # 2 replied to the surveyor they were not sure what it was for. 4. On 3/6/26 at 10:52 AM and on 3/9/26 at 10:12 AM, the surveyor observed Resident #108 awake, lying on the bed, with an indwelling catheter with a privacy bag attached to the lower side of the bed. On 3/6/26 at 1:21 PM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #108, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #108 was admitted with diagnoses that included, but were not limited to, urinary retention. A review of the admission MDS, (an assessment tool used to facilitate the management of care) dated 2/12/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the residents had severely impaired cognition. A review of the physician order with the start date of 2/6/26, check for indwelling catheter placement every shift. A review of the care plan (CP) activity report initiated on 2/8/26 focused on the residents who had an indwelling catheter due to urinary retention. 5. On 3/6/26 at 10:41 AM, the surveyor observed that Resident 114 was lying in bed awake. A review of the AR reflected that Resident #114 was admitted with diagnoses that included but were not limited to unspecified dementia (a loss of memory), unspecified severity with psychotic disturbance. There is no recent MDS assessment available for Resident #114 in the hybrid medical record. A review of the physician order to clean the sacral wound with wound cleanser, apply medihoney cover with calcium alginate daily with a start order of 3/3/26 and an EBP with an order date on 3/4/26. A review of the CP activity report initiated on 3/4/26 focused on the residents, skin breakdown located in the sacrum. intervention included, but was not limited to, monitoring for signs and symptoms of infection. There is no intervention for the EBP order. On 3/9/26 at 10:14 AM, the surveyor interviewed the LPN # 3 assigned to the HP unit regarding the EBP. She stated that the orange dot is the EBP signage, but did not provide further information regarding the orange dot. On 3/9/26 at 12:50 PM, the surveyor interviewed CNA #1 and CNA#2 from the HP unit, who stated that they do not know what the orange dot in the outside room of the resident is. 6. On 3/9/26 at 8:32 AM, the surveyor observed medication administration. The surveyor observed that the LPN # 4 did not clean or disinfect the glucometer after using it on Resident #58. On 3/9/26 at 9:15 AM, the surveyor interviewed LPN #4 who stated that they did not clean the glucometer after use because the wipes were not at their cart. However, LPN #4 stated that they cleaned the glucometer before use when they wiped down all the items on their medication cart before beginning medication administration earlier that day. The surveyor asked LPN #4 if the glucometers are shared among residents, and LPN#4 stated that each resident has their own glucometer. The surveyor observed that there was no resident label on the glucometer. There was a capital letter A written in permanent marker on the glucometer. When the surveyor asked LPN #4 how they knew this glucometer belonged to Resident #58, LPN #4 stated that this was what their supervisor told them. They did not know what the letter A meant and stated that they thought it was the resident's initial. LPN #4 acknowledged that the nurses are supposed to wipe down the glucometer before and after using them. On 3/9/26 at 1:01 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Assistant LNHA. The LNHA stated that the glucometers are shared among residents. They clarified that the letter A written on the glucometer referred to Cart A and did not refer to a resident. A review of the facility's procedure for Blood Glucose Monitoring, revised 7/2025, revealed next to number 18, Disinfect glucometer prior to storing in cart.-Dispatch wipes. On 3/9/26 at 8:40 AM, the surveyor observed that LPN #4 placed the Humalog U-100 Insulin Pen in their pocket after they administered the insulin to Resident #58. LPN #4 also dropped the insulin pen on the floor as they exited the resident's room. Then, LPN #4 placed the insulin pen back inside the plastic bag in the medication cart without cleaning or sanitizing the insulin pen. On 3/10/26 at 12:34 PM, in the presence of the survey team, the surveyor interviewed the Infection Preventionist Nurse, who acknowledged that it is not the correct practice to store medication in a pocket of clothing. The Infection Preventionist Nurse stated that LPN #4 should have cleaned and disinfected the insulin pen after they dropped it on the floor. 7. On 3/11/26 at 11:38 AM, the surveyor inspected Medication Cart B on Unit LP in the presence of the LPN #5. The surveyor observed that the Systane eye drops box labeled for Resident #32 was open, and the bottle was missing. The surveyor asked LPN #5 where the bottle was located, and LPN #5 removed the bottle from their shirt pocket. On 3/11/26 at 1:21 PM, the surveyor interviewed LPN #5 who acknowledged that it is not the correct practice to store medication in a pocket of clothing. LPN #5 stated that medications should be stored in the medication cart. On 3/11/26 at 1:33 PM, the surveyor interviewed the Registered Nurse Supervisor who stated that it is not the correct practice to store medication in a pocket of clothing. A review of the facility's Administration of Medications Procedure, revised 5/2025, revealed, Return all medications to the cart. A review of the facility's Policy, Medication Storage, revised 11/2025, revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. A review of the facility's Comprehensive Infection Control Policy revealed, It is the policy that this facility's Infection Prevention and Control Program (ICPC) is based upon information from the Facility assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. Section 1c of the policy revealed, Standard and transmission-based precautions to be followed to prevent the spread of infections. 8. On 3/6/26 at 10:13 AM, the surveyor observed that EBP signage was lacking on the door of the room for Resident #67. The surveyor observed that the resident had an indwelling catheter. A review of the electronic health record of Resident #67 revealed an order for Enhanced Barrier Precaution, originally ordered on 09/19/2025, with a schedule of Every Day at 7:00 am-3:00 pm; 3:00 pm-11:00 pm; 11:00 pm-7:00 am. Moreover, the care plan of Resident #67, effective 07/28/2025, revealed, Resident #67 requires enhanced barrier precautions related to (r/t) presence of wound and foley. Interventions included, but were not limited to, Clear signage must be posted on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves). 9. On 3/6/26 at 10:53 AM, the surveyor observed that EBP signage was lacking on the door of the room for Resident #12. A review of the electronic health record of Resident #67 revealed an order for Enhanced Barrier Precaution, originally ordered on 03/04/2026. On 3/6/26 at 11:11 AM, the surveyor interviewed the Registered Nurse #1 (RN #1). RN #1 stated that the way staff would know a resident is on EBP is by the box with the blue gowns outside the door. RN #1 was not aware of signage for EBP. On 3/10/26 at 12:34 PM, in the presence of the survey team, the surveyor interviewed the Registered Nurse Infection Preventionist (RNIP) who stated that the facility puts a bin outside the door and an orange tag on the doorpost to indicate EBP. The RNIP stated they were aware of the need for EBP signage. The facility's policy, Enhanced Barrier Precautions, revised 1/2026, did not address signage for EBP. 10.On 3/6/26 at 11:22 AM, the surveyor observed Resident #1 seated in a wheelchair in the unit day room watching television. At the same time, the surveyor observed the resident's room. There was a plastic 3 drawer bin at the entrance to the room containing disposable gowns, masks and gloves. No signage for isolation instructions was visible at the entrance to the room. A review of the resident's electronic medical record revealed the following information. The 12/31/25 admission MDS assessment tool indicated the resident was cognitively intact as evidenced by a BIMS score of 12 out of a possible 15 (Section C). The resident was admitted with 2 unstageable pressure injuries (Section M). The 1/8/26 wound consultant documented that the resident had pressure injuries to the left ankle and the right heel and skin tears to the left forearm and left lateral lower leg. The Physician's Orders report contained a 2/4/26 treatment order for a medicated topical paste to the right lateral lower leg covered with a medicated gauze and topped with a thick cover gauze pad. The Physician's Orders report did not include an order for EBP, a type of isolation used for close contact with residents who have open wounds and indwelling medical devices. The Centers for Disease Control updated its EBP recommendations in July 2022, which included requirements for signage at the entrance to resident rooms with instructions for caregivers as to what tasks are considered close contact. Close contact tasks would require the caregiver to wear a gown and gloves. 11.On 3/6/26 at 11:34 AM, the surveyor observed Resident #2 in bed with eyes closed. The surveyor observed an indwelling urinary catheter in place in a blue privacy bag. Signage for EBP instructions was not visible at the entrance to the resident room. A 3 drawer plastic bin containing personal protective equipment was located at the entrance to the room. A review of the electronic medical record included the following information. The 2/13/26 admission MDS assessment tool indicated the resident was cognitively intact as evidenced by a BIMS score of 12 out of a possible 15 (Section C) and utilized an indwelling urinary catheter (Section H). The Physician's Orders report included a 3/2/26 order for Enhanced Barrier Precautions. On 3/6/26 at 10:40 am, the surveyor interviewed the RN #2. RN#2 stated residents with indwelling urinary catheters and those with pressure injuries should be on EBP. RN#1 was unaware of the requirement for signage for EBP. On 3/9/26 at 8:31am, the surveyor interviewed CNA#3 who was unaware of the use of EBP for indwelling medical devices and open wounds. On 3/10/26 at 12:46pm, the surveyor interviewed the Registered Nurse Infection Preventionist (RNIP). The RNIP is responsible for oversight of the facility's Infection Control Program. The RNIP confirmed residents with open wounds or indwelling medical devices required EBP. She was unaware of the CDC requirement for signage alerting caregivers of the type of isolation and instructions for close contact with those residents. On 3/10/26 at 1:30 pm, the surveyor discussed the infection control concerns with the LNHA. The surveyor reviewed the facility policy titled Enhanced Barrier Precautions, initiated 3/2024 and last reviewed 3/2025. The policy failed to include the necessity for signage outside of resident rooms with EBP. The surveyor reviewed the facility document titled Infection Control and Prevention, updated 10/2025. It included instructions to place appropriate isolation signage outside of the resident's room and designated units (Step 9). NJAC 8:39-19.4(a); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 4 of the 22 residents (Resident #19, 61, 108, and #114) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 3/6/26 at 10:33 AM, the surveyor observed Resident #19 in bed awake, alert, and able to make needs known. The surveyor observed that the resident's call device was hanging on the bed, and the resident was leaning to the opposite side of the bed, where the call bell was out of reach. Resident #19 was asking where the call device was, and they stated they cannot reach it. On the same day at 12:09 PM, the surveyor observed that the resident's call device was out of the resident's reach. On 3/6/26 at 12:54 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #19, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #19 was admitted with diagnoses that included but were not limited to an unspecified dementia (loss of memory), unspecified severity, without behavior, psychotic, mood, and anxiety (excessive worry). A review of the significant change Minimum Data Set (SC/MDS), (an assessment tool used to facilitate the management of care) dated 2/3/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the SC/MDS, as reflected in section GG, revealed that Resident #19 was dependent on staff for activities of daily living (ADL). A review of the Care Plan (CP) activity report initiated on 2/12/26 focused on the residents' resistance to care, refusal of showers, refusal of repositioning, and getting out of bed. Interventions included, but were not limited to, keeping the call bell within easy reach when the resident is in bed. 2. On 3/6/26 at 10:35 AM, the surveyor observed Resident#61 asleep in bed. The call device is located hanging on top of the resident's headboard. It was clipped to the wall itself, four inches from the outlet. On the same day at 12:11 PM, the surveyor observed that the resident's call device was still hanging on top of the resident's headboard, out of the resident's reach. On 3/6/26 at 1:04 PM, the surveyor reviewed the hybrid medical record of Resident #61, which revealed the following: A review of the AR reflected that Resident #61 was admitted with diagnoses that included but were not limited to Alzheimer's disease (a disorder that affects memory, thinking, and behavior). A review of the quarterly MDS (Q/MDS) dated [DATE] indicated that the facility assessed the residents' cognitive status using a BIMS score of 3 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the Q/MDS, as reflected in section GG, revealed that Resident #61 was dependent on staff for ADL. A review of the CP activity report indicates that there are no interventions that include the call light, which should be within easy reach of the resident for assistance. 3. On 3/6/26 at 10:52 AM, the surveyor observed that Resident #108's call device was located on the floor under the bed. Resident #108 stated that they cannot find the call device because they wanted the television to be turned on. On the same day at 12:13 PM, the surveyor checked the call device of Resident #108. It was observed that the call device was still located on the floor under the resident's bed. On 3/6/26 at 1:21 PM, the surveyor reviewed the hybrid medical record of Resident #108, which revealed the following: A review of the AR reflected that Resident # 108 was admitted with diagnoses that included but were not limited to hemiplegia (a muscle weakness that affects one side of the body) following cerebral infarction (a blood clot forms in an artery in the brain) affecting the left non-dominant side. A review of the admission MDS (A/MDS) dated [DATE] indicated that the facility assessed the residents' cognitive status using a BIMS score of 0 out of 15, which indicated that the residents had severely impaired cognition. Further review of the A/MDS, as reflected in section GG, revealed that Resident #108 requires staff assistance for ADLs. A review of the CP activity report initiated on 2/8/26 focused on the residents, showing a decline in ADL activities secondary to multiple comorbidities. Intervention included, but was not limited to, keeping the call bell within reach when in the room. 4. On 3/6/26 at 10:41 AM, the surveyor observed that the Resident #114 call device was tied to the right-side rails and was hanging off the bed out of the resident's reach. It was observed that the resident was unable to reach out for the call device due to the limitation of movement in the right hand. On 3/6/26 at 1:51 PM, the surveyor reviewed the hybrid medical record of Resident #114, which revealed the following: A review of the AR reflected that Resident #114 was admitted with diagnoses that included but were not limited to unspecified dementia (a loss of memory), unspecified severity with psychotic disturbance. There is no recent MDS assessment available for Resident #114 in the hybrid medical record. A review of the CP activity report initiated on 3/4/26 focused on the residents, showing a decline in ADL activities secondary to renal cancer and progressing dementia. Intervention included, but was not limited to, keeping the call bell within reach when in the room. On 3/9/26 at 10:23 AM, the surveyor interviewed the Certified Nurse Assistant (CNA) who stated that the call device should be placed on the right side of the resident, since the left hand is contracted or weak, and the right hand is okay to reach the call bell. The CNA added that the call device should be within the resident's reach. On 3/9/26 at 10:32 AM, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident should have a call device and should be placed within their easy reach, even if the BIMS is 0, because the first cry for help is to use the call bell. On 3/11/26 at 1:54 PM, the team met with the Licensed Nursing Home Administration (LNHA), Asst. LNHA and the Director of Nursing regarding the concern above, but did not provide further information. A review of the facility policy title Call Bell Monitoring & Responsibility, revised date of August 2025, revealed under Policy: 6. Call bells are to be left within reach at all times. NJAC 8:39-31.8(c)9

Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for one resident's room (Resident # 3's room [ROOM NUMBER]) and in the hallway of the HP unit. This deficient practice was evidenced by the following: 1. On 3/6/26 at 12:32 PM, in Resident # 3's room (room [ROOM NUMBER]), the surveyor observed that approximately 10 inches of the wall paper was peeling off the wall near the bottom of the window sill. The surveyor also observed an approximately 2 inch break in the plastic corner protector on the wall in the resident's room. 2. On 03/6/26 at 11:00 AM, during the initial tour of the facility the surveyor observed the following in the hallway and common area of the HP nursing care unit: In the hallway, near the smoke doors in the area of room [ROOM NUMBER], there was an approximately 24 inch wide by 4-foot-tall area of missing wallpaper with hanging ragged edges. In the same area of the hall as the first observation, the surveyor observed a second an approximately 8 inch wide 4 foot tall area of torn missing wallpaper. On the ceiling, in the same area of the hallway, the surveyor observed several large brown colored stains on 3 ceiling tiles. In the common room marked living room for the HP nursing care unit, the surveyor observed an approximately 6 foot wide area of torn missing wallpaper above the heating baseboard unit, under the window. The exposed area of wall above the heating baseboard unit, had dried brown stains, and the baseboard heater had a crusty brown substance and dents on it. On 3/11/26 at 1:15 PM, the surveyor interviewed the Director of Building Services (DBS) regarding findings on the HP nursing care unit. The DBS reviewed photos of the surveyor's findings and discussed responsibility for repairs. The DBS acknowledged the areas of disrepair and stated his department was responsible for repairs of the facility. He stated the areas should be repaired and acknowledged the appearance of these areas in their current state detracted from the facility's homelike environment On 03/11/26 at 1:55 PM, the surveyor discussed the above concerns with Administrator, Director of Nursing (DON), and the Assistant Administrator and Administrator acknowledged the missing wall paper and stained ceiling tiles in HP hallways detracted from the facility's homelike environment. All agreed these issues should be repaired. On 3/12/26 at 11:36 AM, the surveyor discussed the above concerns for room [ROOM NUMBER] with the Administrator, Director of Nursing, and the Assistant Administrator, who also agreed these issues should be repaired. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Based on interviews and record review, it was determined that the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool used to facilitate the management of care), in accordance with federal guidelines, for 1 (one) of 22 residents (Resident #108), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 3/6/26 at 10:52 AM and on 3/9/26 at 10:12 AM, the surveyor observed Resident #108 awake, lying on the bed, with an indwelling catheter with a privacy bag attached to the lower side of the bed. On 3/6/26 at 1:21 PM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #108, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #108 was admitted with diagnoses that included, but were not limited to, a pressure ulcer of the sacral region, unstageable. A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) dated 2/12/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the residents had severely impaired cognition. Further review of the A/MDS, as reflected in section H-Bowel and Bladder, revealed that the indwelling catheter was not coded for appliances. A review of the Physician Order (PO) with the start date of 2/6/26, check for indwelling catheter placement every shift. A review of the care plan (CP) activity report initiated on 2/8/26 focused on the residents who had an indwelling catheter due to urinary retention. On 3/10/26 at 11:00 AM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDSC), who stated that she should code the Resident #108's indwelling catheter. On 3/11/26 1:54 PM, the team of surveyors met with the Licensed Nursing Home Administrator (LNHA), Asst. LNHA and the Director of Nursing regarding the above concern, but did not provide further information. NJAC 8:39-33.2 (c)5

Based on observation, interview, and record review it was determined the facility failed to ensure care and services were provided in accordance with professional standards of practice for 2 of 22 residents reviewed (Residents #1 and #11). Specifically, the facility failed to clarify a physician order resulting in duplicative treatment orders, accurately document completion of a treatment order for Resident # 1, and provide comprehensive insulin management for Resident # 11.The findings are as follows:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 3/6/26 at 11:22 AM, the surveyor observed Resident #1 seated in a wheelchair in the unit day room watching television. A review of the electronic medical record revealed the following information. The 12/31/25 admission Minimum Data Set (MDS) assessment tool indicated the resident had no cognitive deficits as evidenced by a Brief Interview for Mental Status score of 12 of a possible 15 (Section C) and was admitted with 2 unstageable pressure injuries and skin tears (Section M). The 3/2026 Physician's Orders (PO) report included a 2/4/26 treatment order for the right lateral lower leg for application of a medicated topical paste covered by a medicated gauze and covered with a thick gauze pad. Also included in the 3/2026 PO was a 3/4/26 treatment order for the right lateral lower leg for application of a lanolin and petrolatum topical ointment and wound was to be left open to air (no covering). The 3/2026 electronic Treatment Administration Record (eTAR) contained nursing documentation that both treatments were done to the same site on 3/5, 3/6, 3,7, 3/8 and 3/9. On 3/10/26 at 10 AM, the surveyor reviewed wound consultation reports. The most recent report in the electronic medical record was dated 2/24/26. The wound consultant wrote a treatment recommendation to continue applying the medicated paste, medicated gauze, and cover with a thick pad. The wound consultant documented this treatment will be done daily until discontinued. On 3/10/26 at 11:30 AM, the surveyor observed the facility Registered Nurse (RN #1) perform a wound treatment to the resident's right lateral lower leg. RN #1 applied a lanolin and petrolatum topical ointment to the right lateral lower leg and left the wound open to air. Resident #1 questioned RN #1 why he was not applying a cover dressing. RN #1 stated the resident was confusing the order with an older previous order. RN #1 completed the order and logged into the eTAR to document completion of the wound treatment. The surveyor observed in the eTAR that the treatment had been documented as having been done hours earlier. RN #1 stated I documented it as done when it was not done. I should have waited until I completed the treatment to document its' completion. On 3/10/26 at 1:44 PM, the surveyor discussed the duplicate treatment order and the nurse signed as done when the treatment was not completed with the Licensed Nursing Home Administrator (LNHA). On 3/11/26 at 10:07 AM, the LNHA responded there was a 3/3/26 wound care consultation that was not uploaded into the electronic medical record until 3/9/26. The LNHA provided a PO indicating on 3/9/26 at 4:20 PM the order for a medicated topical paste and cover dressing was discontinued. 2. A review of resident #11's Electronic Health Record reflects the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to type 2 diabetes, Chronic obstructive pulmonary disease and congestive heart failure. A review of Resident #11's Minimum Data Set (MDS), an assessment tool dated 1/20/26 reflected that the resident had a brief interview for mental status (BIMS) score 14 out of 15, which indicated minimal to no cognitive impairment. A review of the resident Plan of Care effective date of 2/23/26 reflects no focuses, interventions or goals are included to outline care for resident's type 2 diabetes. A review of resident 11's physician orders reflects the resident had an order dated 1/9/2026 prescribing Humalog U-10 insulin 100U/ml subcutaneous solution, inject by subcutaneous route before meals and at bedtime per sliding scale coverage after testing blood glucose level. Scheule every day at 8:15 am, 12:30pm, 5:15 pm and 9:00 pm. Protocol: insulin sliding scale if blood glucose equals 200-249: 2 units of Humalog insulin, 250-299: 4 units Humalog insulin, 300-349: 6 units of Humalog insulin, 350-399: 8 units of Humalog insulin, 400-449: 10 units of Humalog insulin, Above 450: 12 units of Humalog insulin and notify Physician or Nurse Practitioner. A review of Resident #11's record of blood glucose readings reveals the resident's blood glucose result documented on 2/13/26 at 9:43 pm was 473. The resident's medication administration record (MAR) reflected documentation that 12 units of Humalog were administered as ordered but no documentation was evident in the MAR or the remainder of EHR indicates the physician or Nurse Practitioner were notified of these results as required by the physician's order. On 3/12/26 at 10:40 AM the surveyor interviewed RN assigned to the care of Resident #11. The surveyor asked the RN about care plans for residents with specific disease processes, The RN agreed residents with type 2 diabetes should have care plans with focuses and interventions to manage diabetes. The RN acknowledged after consulting the EHR that Resident#11 did not have a care plan with focuses or interventions for type 2 diabetes. The RN confirmed that Resident#11 has order since 1/9/26, including directions that if the resident had a blood glucose test result over 450, the resident was to be administered 12 units Humalog insulin and that physician or nurse practitioner were to be notified of the result and the notification would be charted in the resident's EHR. On 3/12/26 at 11:03 AM, the survey met with the Director of Nursing (DON) and discussed that residents EHR does not reflect a care plan for diabetes and does not include documentation of Physician notification of a 473 blood glucose test result on 3/13/26. The DON stated she would review Resident #11's EHR and respond. On 3/12/26 at 11:45 AM, the surveyor and team met with the DON, LNHA and ALNHA, and discussed the concerns with Resident #11. The DON confirmed that the resident's EHR does not reflect documentation that physician notification occurred for the blood glucose results on 2/13/26 as ordered. The DON confirmed that no focuses or intervention were documented or included in the plan of care for Resident # 11 and that the care plan should include measures for type 2 diabetes. NJAC 8:39-27.1

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to address the recommendations made by the Consultant Pharmacist (CP) which was identified for 1 of 5 residents (Resident #113) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 3/9/2026 at 10:20 AM, the surveyor observed Resident #113 lying in their bed, alert, and verbally responsive. Resident #113 was receiving an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) via a feeding pump. The resident had a urinary drainage bag covered with a urinary privacy bag, hanging from the bottom of the bed frame.On 3/9/2026 at 10:45 AM, the surveyor reviewed the facility provided admission Medication Review (aMRR) for Resident #113 dated 2/13/26 completed by the Consultant Pharmacist (CP). The aMRR included a recommendation to clarify the resident's Flomax capsule order with the physician as the medication should be swallowed whole, not opened, crushed, or chewed; and the resident received medication via g-tube. The recommendations were unsigned to indicate the recommendations were followed up.The surveyor reviewed the electronic medical record (EMR) of Resident #113.The Resident Face Sheet (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, left leg above knee amputation.A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 2/19/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #113 scored a 3, which indicated the resident had severe cognitive impairment. In Section K (Swallowing/Nutritional Status), Resident #56 was coded as receiving nutrition through a feeding tube while a resident.A physician's order dated 2/13/26 documented tamsulosin (Flomax) 0.4 milligram (mg) capsule, give one capsule by gastrostomy tube (G-tube; a soft tube inserted through the abdomen into the stomach to provide long term nutrition, hydration, and medication) once daily.On 3/9/26 at 11:29 AM, the surveyor interviewed the Registered Nurse (RN) Supervisor, about CP recommendations who stated the Director of Nursing (DON) was responsible for reviewing and following up on CP recommendations. The RN Supervisor further explained that when the DON was absent the RN supervisor would be responsible. The surveyor asked the RN supervisor after receiving CP recommendation reports how soon it would be expected for the recommendations to be followed up. The RN supervisor replied that they would be completed within the same week and for high priority recommendations would be followed up with physician right away. The RN supervisor further explained the report would have written notations and be signed to indicate completion.The surveyor discussed Resident #113's CP recommendations and review of the EMR revealed no documentation of follow up. Additionally, the report was unsigned. The RN supervisor stated that it would have been reviewed by the DON and would follow up to provide any additional information.On 3/10/2026 at 11:03 AM, the RN supervisor informed the surveyor that they followed up with the physician regarding the CP's recommendation for Flomax yesterday and clarified the order. The RN supervisor acknowledged the recommendation was not followed up prior to surveyor inquiry. On 3/10/26 at 12:30 PM, Additional review of the aMRR revealed lidocaine 5% (Lidoderm) topical patch recommendations to time patch administration at 9am and removal at 9pm as the medication was effective for 12 hours.A review of the physician's orders and March 2026 Medication Administration Record (MAR) revealed an order dated 2/14/26 for Lidocaine 5% topical patch, apply one patch topically once daily to lower back (for low back pain); remove at bedtime. The lidocaine patch was timed for 7 AM to 3 PM and 3 PM to 11PM. On 3/10/26 at 1:56 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and Assistant LNHA of the above concerns that not all CP recommendations from 2/13/26 were followed up by the facility and the report was unsigned to indicate review by the nursing staff and physician. The LNHA stated she would discuss with the RN supervisor to provide additional information. On 3/11/26 at 10:03 AM, the LNHA, Asst LNHA, and the DON met with the survey team. The DON stated as of that morning all recommendations were followed up. The DON stated she could not speak to why the CP recommendations were not addressed prior to surveyor inquiry. The surveyor received the facility policy for aMRR. The surveyor requested any other facility policies related to CP recommendations.On 3/12/26 at 12:00 PM, the DON stated there was no additional policy related to CP recommendations. No additional information was provided by the facility.A review of the undated facility policy titled admission MEDICATION RECONCILIATION PROTOCOL AND CONTACTING OUTSIDE PCP [Primary Care Provider] which revealed under Policy: All admitted residents will have their transfer orders reviewed and reconciled The R.N. Supervisor or designate and Medical Director or designee will coordinate clarification orders.Under the policy's Procedure revealed: .2. All new admission physician orders will be faxed to pharmacy consultant for review and reconciliation.3. The R.N. Supervisor or designee will review and reconcile the discharge orders of all newly admitted admissions to [facility] within 24 hours of admission. Medication requiring clarification will be discussed with the attending physician.The policy did not further address the procedure for follow up of CP recommendation reports. NJAC 8:39-27.1 (a); 29.3

Based on observation, interview, and record review it was determined that the facility failed to: (a) properly store, and date medications in 1 of 4 medication carts and 1 of 2 medication storage rooms inspected; and (b) ensure controlled medications were stored in a separately locked, permanently affixed compartment in 1 of 3 medication carts inspected for medication storage. This deficient practice was evidenced by the following: 1. On [DATE] at 11:08 AM, the surveyor inspected the medication storage room on the HP unit in the presence of Licensed Practical Nurse (LPN) # 1 assigned to the unit. There were 2- 0.45% Normal Saline, one Liter intravenous bags which both had a manufacturer's expiration date of [DATE] stored in a cabinet. LPN #1 confirmed the IV bags were expired and removed them to be disposed. The LPN stated she was unsure of when the eye drops were opened or if it was used. The pharmacy label read refrigerate before opening. There was a Novolin R flexpen for a resident observed with a written open date of 9/1 on the plastic bag it was stored in and written on the flexpen itself. The pharmacy label on the flexpen appeared to have a written date of 9/11. The LPN #1 stated the date opened was 9/11 and not 9/1. 2. On [DATE] at 11:21 AM, the surveyor inspected medication cart A on the HP unit in the presence of LPN #2. Upon opening a drawer of the cart, the surveyor observed an opened Ipratropium Bromide 0.5 mg/Albuterol Sulfate 3.0 mg (Duoneb) foil packet containing nebulizer inhalation vials. The foil packet had a written date of [DATE] and had no resident name written on it. LPN #2 stated the date indicated when the packet was opened. The LPN #2 could not say which resident it belonged to and acknowledged it should have been stored in the resident's duoneb manufacturer box which had a label with the resident's name on it. The LPN #2 believed the duoneb medication's expiration after opening the foil packet was two weeks but was not sure. LPN #2 stated he would ask their nurse supervisor. In the same drawer the surveyor observed Resident #104's duoneb manufacturer box which had a pharmacy label with an order date of [DATE] and indicated the duoneb order was for a ten day duration. Inside the box there was an opened foil packaging containing duoneb vials with no date on it; and underneath the packaging were four attached duoneb vials not stored in a foil packaging with no date on them. In the same drawer, the surveyor observed Resident #33's duoneb manufacturer box which contained inside a single foil packet which had a written date of [DATE]. The LPN #2 removed identified items from the medication cart and stated he would follow up with the nurse supervisor. On [DATE] at 1:28 PM, the surveyor informed the Registered Nurse (RN) Supervisor of the above medication storage concerns. The RN supervisor acknowledged the IV bags in the medication should have been disposed as it expired in [DATE]. The RN supervisor was not sure of the medication's expiration after opening the foil packaging. The RN supervisor acknowledged items should be stored in a resident specific medication box and not kept loose in the drawer. The RN supervisor stated she would follow up with the Director of Nursing (DON) and the pharmacy. 3. On [DATE] at 11:38 AM, the surveyor inspected Medication Cart B on Unit LP in the presence of the LPN #3. The surveyor observed that the compartment for storage of controlled drugs was not permanently affixed to the medication cart. The surveyor was able to lift and fully remove the compartment from the medication cart. When the surveyor lifted the compartment, they observed that the compartment had no bottom, and the controlled medications were visible and accessible. On [DATE] at 11:49 AM, the surveyor interviewed LPN #3 who acknowledged that the compartment for storage of controlled drugs should be affixed and will notify their supervisor. On [DATE] at 1:33 PM, the surveyor interviewed the RN Supervisor who stated that they will follow up to provide a response regarding the above concern. On [DATE] at 1:52 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), the Assistant LNHA, and the DON of the above medication storage concerns. On [DATE] at 9:15 AM, the DON provided the surveyor a document, dated [DATE] titled Medications which need to be dated upon opening from their pharmacy consultant which listed medications and expiration after opening. The list included Duoneb, 6 pack foil packet which indicated expiration 7 days after opening; and Duoneb, 30 pack foil packet which indicated expiration 14 days after opening. On [DATE] at 11:45 AM, the DON stated to the surveyor all identified IV and nebulizer medications were disposed. There was no additional information provided by the facility. A review of the facility's policy and procedure titled, Medication Storage, with a revised date of [DATE] under Policy revealed: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The facility's Administration of Medications Procedure, Medication Administration Policy, and Medication Storage Policy and Procedure did not address the requirement of the facility to provide permanently affixed compartments for storage of controlled drugs. NJAC 8:39-29.4

Complaint #: 392826 (187404)Based on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure a.) the residents' current active care plan (CP) contained the interventions that were implemented after each resident's fall and were followed in order to prevent any additional falls for 3 of 3 residents (Residents #1, #2, and #3) reviewed for accidents and falls and b) fall investigations were thoroughly investigated and completed in accordance with the facility's practice and policy for 2 of 3 residents reviewed for falls (Residents #1 and #2). The deficient practice was evidenced by the following: 1.On 11/10/25 at 9:20 AM, Surveyor #1 (S #1) toured the Memory Unit and interviewed the Registered Nurse Supervisor (RNS), who informed S #1 that Resident #1 was at risk for falls due to cognitive impairment and had recent falls. On that same date at 9:25 AM, S #1 observed Resident #1 in the dining area, seated in a wheelchair (w/c) with other residents and able to feed self during breakfast. On 11/10/25 at 10:16 AM, S #1 asked the Executive Director (ED; also known as the Licensed Nursing Home Administrator) of Resident #1's last six months fall incident investigations and Physical Therapy (PT) notes. S #1 reviewed the medical records of Resident #1, and revealed: A review of the Resident Face Sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified dementia, unspecified severity, with psychotic disturbance, delusional disorders, and anxiety disorder unspecified. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 8/425, reflected a brief interview for mental status (BIMS) score of 5, which indicated that resident's cognition was severely impaired. A review of the Nursing Fall Risk assessment dated [DATE] revealed that the resident had history of falls 1-2x's (1 to 2 times) and total score was 15 (high risk). A review of the Nursing Post Fall Checklist revealed: On 9/15/25, Resident #1 had a fall incident in the dining room while resident stood up from the w/c, and there was no injury noted. On 9/26/25, Resident #1 had a fall incident in the dining room, ambulating unassisted, found on the floor by the nurse in front of w/c, and there was no injury. On 9/30/25, Resident #1 attempted to stood up, fell from w/c to the floor in front of dining room. On 10/1/25, Resident #1 had a fall incident in the dining room and sustained reddish/blackish bump on forehead. A review of the provided accident investigation by the Director of Nursing (DON) revealed: On 9/15/25 at 12:45 PM, Resident #1 was witnessed by Licensed Practical Nurse #1 (LPN #1) fell backward from their w/c in the dining room, no injury. The measures to prevent recurrence was to continue to provide monitoring. On 9/26/25 at 8:20 AM, Resident #1 had an unwitnessed fall in the dining room with no injury. The corrective action taken, resident was assessed for injury and medical work up. The measures to prevent recurrence was close monitoring and assess for anti-roll back w/c. There were no statements from the staff. On 9/30/25 at 11:00 AM, Resident #1 attempted to get out of w/c in the dining room, fell, and no injury. The corrective action taken, recently on rehabilitation with medications (meds) change, psychotic meds were decreased. The measures to prevent recurrence was meds management and medical work up. LPN #2 statement included that while working in the hallway, a Certified Nurse Aide (CNA) called the LPN in the dining room, and found the resident on the floor in front of their w/c. There was no statement from the CNA and other staff. On 10/1/25 at 4:40 PM, Resident #1 had an unwitnessed fall in the dining room and the resident sustained bruising to right forehead. The measures to prevent recurrence was close monitoring. There was no statements included in the fall investigation. A review of the care plan (CP) revealed that the CP was not updated or revised to include the post fall interventions, measures to prevent recurrence of fall, that were, continue monitoring, close monitoring, and anti-roll back w/c. 2. On 11/10/25 at 9:20 AM, the RNS informed S #1 that Resident #2 was at risk for falls due to cognitive impairment and had recent falls. On 11/10/25 at 9:38 AM, S #1 interviewed LPN #1, who informed S #1 that as per facility's standard of practice, when a resident had a fall incident, the nurse will initiate the investigation and utilize the incident report. He stated that there should be statements from staff who were assigned to the resident in order to determine what the resident was doing before the incident that could contributed to resident's fall. He further stated that the resident would be assessed at the time of incident, monitored every shift for three days, and all would be documented in the electronic medical records, the Resident's Representative (RR) and physician would be notified. LPN #1 added that it was the responsibility of the Nursing Supervisor to update or revise the CP of the new interventions post fall to prevent the recurrence of fall and further injury. On 11/10/25 at 9:50 AM, S #1 observed Resident #2 seated in their bed with one floormat on the right side of the bed floor and the resident was eating breakfast. There was no floormat on the left side of the bed. S #1 also observed that Resident #1 had discoloration around their right eye and dried wound on the right forehead. During the interview of S #1 with Resident #2, the resident was unable to state what happened to their right eye and forehead. The resident was unable to remember if they had fall incidents. Outside the resident's room was Certified Nursing Aide #1 (CNA #1) who informed S #1 that Resident #2 was cognitively impaired, and unable to state why the resident had right eye bruising and dried wound on right forehead, nor about fall incidents. On 11/10/25 at 9:55 AM, LPN #3 informed S #1 that she was the assigned nurse of Resident #2. LPN #3 stated that Resident #2 was cognitively impaired, was previously form subacute unit and had to moved in the memory care unit because the resident required more assistance and monitoring due to dementia. She confirmed that the resident's discoloration around the right eye and forehead was from a fall and that the resident was unable to remember what had happened. On that same date at 10:07 AM, CNA #2 informed S #1 that she was the assigned aide of Resident #2. She stated that the resident with periods of confusion, had a fall incident last weekend and sustained bruising to their right forehead and eye. She was unable to state as to why there was only one floor mat on the floor. S #1 reviewed the medical records of Resident #2, and revealed: A review of the Resident Face Sheet revealed that the resident was admitted to the facility with diagnoses that included but were not limited to; other toxic encephalopathy (a neurological disorder caused by exposure to neurotoxic substances, leading to symptoms such as altered mental status, memory loss, and visual problems), difficulty in walking not elsewhere classified, and muscle weakness (generalized). A review of the most recent comprehensive MDS, with an ARD of 10/13/25, reflected a BIMS score of 4, which indicated that resident's cognition was severely impaired. A review of the Nursing Fall Risk assessment dated [DATE] revealed that the resident's total score was 14 (high risk). A review of the Nursing Post Fall Checklist revealed: On 10/22/25, Resident #2 had an unwitnessed fall incident and sustained one centimeter long abrasion to right shin. On 11/5/25, Resident #2 had a fall incident in the dining room and sustained laceration and hematoma. A review of the provided accident investigation by the DON revealed: On 10/22/25 at 11:15 PM, Resident #2 had an unwitnessed fall, found sitting on the floor in front of their bed and sustained one cm (centimeter) long abrasion to right shin. The corrective actions taken was to place floor mattress to both side of the bed. The measures to prevent recurrence was to monitor hourly when in room. There were no statements from other staff except from the 11-7 shift nurse. On 11/2/25 at 10:40 AM, Resident #2 had an unwitnessed fall in the day room and sustained a small open area and ecchymosis area to right forehead. The corrective action taken, hip protectors in use, had resident in a supervised area at all times, and closely monitored. The measures to prevent recurrence was safety monitoring. There was no statements from staff. A review of the CP revealed that the CP was not updated or revised to include the post fall interventions, measures to prevent recurrence of fall, that were, floormats on the floor, monitor hourly when in room, supervised area at all times, and close monitoring. On 11/10/25 at 1:19 PM, the surveyors met with the ED, DON, and the Assistant Administrator in Training (AAIT), and the DON stated that it was an expectation that for the unwitnessed falls, there should be statements from staff in the accident reports. The DON further stated that the interventions in each fall incident should be in the CP. At that same time, S #1 asked the facility management what close monitoring different from continue monitoring and how the staff should follow the interventions post fall. The DON responded that the facility was unable to do 1:1 monitoring at the facility. S #1 notified the ED, DON, and AAIT of the above findings and concerns for Residents #1 and #2. A review of the CNA Documentation History Detail (CNA log) that was provided by the Registered Nurse MDS Coordinator (RNMDSC) revealed that there was no information about bilateral floor mats, hourly monitoring, and supervised at all times. On 11/10/25 at 2:13 PM, the surveyors met with the ED, DON, and AAIT, and there was no additional information provided by the ED. The DON confirmed that there were no other statements from staff for all identified fall investigations for Residents #1 and #2. 3. On 11/10/25 at 9:20 AM, Surveyor #2 (S #2) observed Resident #3 in bed eating breakfast independently. Resident #3 told S #2 that they had a stroke and had left-sided weakness. Resident #3 further stated that they had fallen a few times before the staff started using a mechanical lift for transfers. Resident #3 stated they had not fallen recently. A review of Resident #3's admission Record reflected the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), bilateral osteoarthritis of the knees, and morbid obesity. A review of the most recent MDS, with an ARD of 6/24/25, reflected that Resident #3 had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Section GG assessed that the resident required the assistance of two staff members for transfers. A review of Resident #3's comprehensive CP dated 7/24/24 and reviewed 7/26/25, included a focus area that indicated that the resident was dependent on two staff members for transfers. A review of the facility's accident/ incident nurses note dated 6/11/25 at 10:10 PM, reflected that while the nurse was preparing meds in the hall, a CNA came out from Resident #3's room and informed the nurse that the resident slid down on one knee while the CNA was trying to transfer the resident from the toilet seat to the w/c. The nurse went to the room and observed Resident #3 on the bathroom floor on their knees, crying. Resident #3 complained of pain in their right knee. All responsible parties were notified. The Nurse Practitioner ordered an X-ray of the right knee and an order for the rehabilitation department to screen for treatment from the occupational and physical therapy department. Further review revealed that Resident #3 was transferred to the hospital Emergency Department due to complaints of knee pain. All testing proved negative for injury. The resident was readmitted to the facility on antibiotics for a urinary tract infection. On 11/10/25 at 12:15 PM, S #2 conducted a telephone interview with the assigned CNA (CNA #3) who transferred Resident #3 without the assistance of a second staff member. CNA #3 stated that she was not aware that the resident required two staff members for transfers and that she should have checked the resident's plan of care before transferring them. On 11/10/25 at 1:10 PM, during an interview with S #2, the RNMDSC confirmed that Resident #3 had been care-planned as dependent on two staff members for all transfers, effective from 1/18/24 to the present. On 11/10/25 at 1:20 PM, the survey team discussed the above observations and concerns with the ED, AAIT, and the DON. The DON confirmed that CNA #3 should have followed the resident's CP for a two-person transfer. A review of the facility's Accident/Incident Report Policy that was provided by the DON, with a reviewed date of 7/2025, revealed that it was the facility's policy to document and investigate all incidents that involve residents, whether or not injury occurs.Procedure:.3. The person completing the report will interview any witnesses to the event to determine what occurred. Any witness (es) to the accident & incident (A&I) will give a written, signed statement indicating any knowledge or information they have pertaining to the incident.6. All sections of the A&I Report are to be completed.These statements will be submitted to the Supervisor after entering the statement into electronic medical records. A review of the facility's Fall Policy and Procedure that was provided by the DON, with a reviewed date of 7/2025, revealed that it was the facility's policy to document and investigate all falls that involve residents, whether or not injury occurs.Procedure:.3. The person completing the report will interview any witnesses to the event to determine what occurred. Any witness (es) to the A&I will give a written, signed statement indicating any knowledge or information they have pertaining to the incident.6. All sections of the A&I Report are to be completed.These statements will be submitted to the Supervisor after entering the statement into electronic medical records. A review of the facility's Care Planning Policy that was provided by the DON with a revised date of 1/2025, revealed that there was no information about CP update and revision. No further information was provided by the ED. NJAC 8:39-27.1 (a); 33.1(d)

Based on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received a performance review for five (5) of five (5) CNA files reviewed. This deficient practice was evidenced by the following: A review of the facility provided, Licensed annual education, competencies, and performance reviews, dated January 2023 to October 2024, did not reveal performance reviews for the five (5) randomly selected CNAs. On 10/16/24 at 11:24 AM, during an interview with the surveyor, the Human Resources Director (HRD) stated that the Director of Nursing (DON) was in-charge of education, competencies (lecture, training, pre and posttests) and performance reviews for the nursing staff. On 10/17/24 at 11:57 AM, during an interview with the surveyor, the DON stated that the performance reviews were conducted based on the results of the competencies. When a nursing staff's competencies resulted with a concern, then a performance review was conducted. The DON stated that the 5 randomly selected CNAs did not have concerns with their competencies and confirmed that the CNAs had no performance reviews on file. The DON also stated that the performance reviews for all nursing staff were based on the result of the competencies. On 10/17/24 at 1:02 PM, the surveyor requested from the DON and the Licensed Nursing Home Administrator, for the policy and procedure for the competencies and performance reviews of the nursing staff. On 10/18/24 at 9:00 AM, in the presence of two surveyors and the DON, the surveyor discussed the concern with the CNAs performance reviews that was not conducted at least every 12 months, and the education provided was not based on the performance review. A review of the facility policy provided, Employee Training and Performance Management, dated 2/6/23, included that staff were required to work competently, effectively, and safely to care for its residents. To ensure that all staff meet this requirement the following policy ensured that employees were consistently monitored and trained/educated as needed to ensure they completed their job/task successfully. No additional information was provided. N.J.A.C. 8:39-43.17 (b)

Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 3 of 3 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: The surveyor requested to review the QA meeting sign in sheets for the last 3 quarters dated September 5, 2024, July 16, 2024 and May 23, 2024, upon entrance. A review of the QA meetings sign in sheets revealed that the Infection Control Preventionist (IP) had not been in attendance for the three meetings. On 10/15/24 at 11:40 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the IP was not able to attend the QAPI meetings since that staff member works the evening shift (3-11) and is also the nursing supervisor. The DON stated that they do received reports from the IP, who meets with the DON often. A review of the Quality Assurance Performance Improvement (QAPI) Program, dated July 2024, revealed that the members of the QAPI shall include but not be limited to: Medical Director, Director of Nursing, Director of Social Services, Director of Admissions, Director of Rehabilitation, Director of Activities, Director of Admissions, and Director of Building Services. The QAPI Plan did not indicate that the IP should be in attendance. N.J.A.C. 8:39-33.1 (b)

Based on observation, interview, and record review, it was determined that the facility failed to consistently provide pharmaceutical services in accordance with professional standards to ensure a.) reconciliation and accountability of dispensed and administered controlled dangerous substance (narcotic medications, with high potential for abuse and are tracked with detail) to Resident #19, and discrepancies were identified, for the narcotic stored in the medication cart located on the high side of the LP unit, and b.) reconciliation of Controlled Drug Inventory Record (CDIR; shift to shift log, a count/signature of two (2) nurses for narcotic accountability) were consistently signed/completed for the medication cart located on the B-side of the HP unit. The deficient practice was identified for one (1) of two (2) medication carts reviewed during the medication storage and labeling task and was evidence by the following: 1.) On 10/17/24 at 9:16 AM, the two (2) surveyors and the Registered Nurse (RN) began the inspection of the narcotic medication cart inspection, which was stored in a mounted, double locked portion of the medication cart (narcotic box) located on the high side of the LP unit. In the presence, of a surveyor, and the RN, the surveyor observed that the CDIR was not signed by two (2) nurses for that day. At that time, the RN stated that she did not sign the shift-to-shift log with the 11:00 PM, to 7:00 AM shift nurse that morning, because she had noticed that the 3:00 to 11:00 PM nurse had not signed Resident #19's Individual Patient Controlled Drug Record (IPDCR; declining inventory sheet used to track removal of a controlled drug from inventory) for Tramadol 50 mg (a narcotic medication, indicated for pain) that was administered on 10/16/24 [the night before]. At that time, the RN could not explain how the two (2) nurses from the 3:00 PM to 11:00 PM shift nurse and the 11:00 PM to 7:00 AM shift nurse who conducted the shift-to-shift count for accountability on 10/16/24, did not identify the discrepancy prior to her shift. The RN informed the surveyors that she had notified the Nursing Supervisor and would let the Director of Nursing know of the shift-to-shift count discrepancy. On 10/17/24 at 9:24 AM, in the presence of a surveyor and the RN, the surveyor observed Resident #19's bingo card (blister packet which contains the medication) with a pharmacy label for Tramadol 50mg contained 10 tablets. At that time, the surveyor compared the bingo card against the IPCDR for Resident #19's Tramadol. The IPCDR log reflected a documented quantity of 11 remaining. At that time, the RN informed both surveyors that the discrepancy was that the 3:00 PM to 11:00 PM nurse had not signed the removal of the Tramadol from inventory (IPCDR log) however the nurse had signed the Medication Administration Record for 10/16/24, an attestation of administration . The surveyor reviewed the medical record for Resident #19. According to the Resident Face Sheet (an admission summary) Resident #19 was admitted to the facility with diagnosis that included but was not limited to low back pain. Further review of the qMDS reflected Resident #19 received scheduled and as needed (PRN) pain medications. The resident reported moderate level of pain intensity. Review of the quarterly Minimum Data Set (qMDS), an assessment tool dated 8/20/24, reflected a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated that the resident was cognitively impaired. Review of the electronic Medication Administration Record (eMAR) for October 2024, included a physician order for Tramadol 50 milligram (mg) by oral route every 12 hours as needed (PRN) for pain. The physician order start date was 2/12/24. The surveyor compared the eMAR against the IPCDR which reflected that the Tramadol was not signed on the IPCDR as removed from the inventory but was signed administered on eMAR on 10/16/24. Review of the eMAR for September 2024, included a physician order for Tramadol 50 milligram (mg) by oral route every 12 hours as needed for pain. The physician order start date was 2/12/24. The surveyor compared the eMAR against the IPCDR which revealed the following: -on 9/13/24 at 2:00 PM, the IPCDR was signed as removed from inventory but was not signed on the eMAR as administered. -on 9/23/24 at 8:57 PM, the IPCDR was signed as removed from inventory but was not signed on the eMAR as administered. On 10/17/24 at 1:08 PM, during an interview with two (2) surveyors, Resident #19 stated she was not in pain and confirmed receiving Tramadol last night but could not recall the other dates. On 10/17/24 at 3:07 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON, the surveyor discussed the concern regarding the missing accountability, reconciliation and discrepancy of the IPCDR log against Resident #19's eMAR. On 10/18/24 at 9:13 AM, the DON stated that she had investigated the discrepancy between the IPCDR and the eMAR. The DON stated that there were two (2) different nurses involved who both stated that the PRN medication was in fact removed from inventory but was refused by the resident. Both nurses neglected to document the refusal, and the disposal of the narcotic medications. Both nurses were given education on medication administration and narcotic protocols. The DON acknowledged the concern. 2.) On 10/17/24 at 10:17 AM, the surveyor, in the presence of another surveyor and the RN/Nursing Supervisor (RN/NS) began the narcotic medication cart inspection, located in the B-side of the HP unit. At that time, the surveyor reviewed the shift-shift log for October 2024 which reflected the following: -10/7/24 at 7:00 AM, the nurse going on duty was blank (two (2) nurses' signature was not found). -10/7/24 at 3:00 PM, the nurses going on and off duty were blank. -10/7/24 at 11:00 PM, the nurse going off duty was blank. -10/9/24 at 7:00 AM, the nurse going on duty was blank. -10/10/24 at 7:00 AM, the nurse going on duty was blank. -10/10/24 at 3:00 PM, the nurse going off duty was blank. -10/12/24 at 11:00 PM, the nurse going off duty was blank. On 10/17/24 at 3:07 PM, in the presence of the survey team, the Licensed Nursing Home Administrator and the DON, the surveyor discussed the concern regarding the shift-to-shift reconciliation of controlled dangerous substance were not consistently signed/completed. On 10/17/24 at 10:50 AM, in the presence of the two (2) surveyors, the RN/SP confirmed the missing signatures on the CDIR, and acknowledged that the shift to shift log should have been signed by two (2) nurses. The RN/NS stated that he would ensure education be provided to the nursing staff and would inform the DON of the discrepancy. On 10/18/24 at 9:58 AM, the DON stated that she had investigated the concern for the missing shift to shift signature for reconciliation of the narcotic medications. The DON stated that two (2) nurses were involved and were given education regarding the importance of the shift-to-shift reconciliation. The DON acknowledged the errors. Review of the undated, facility provided policy, Nursing Medication Administration included the following: Narcotics must be counted shift- to-shift and discrepancies should be reported to the Supervisor/ DON when noted. Narcotics need to be signed off on declining sheet at the time they are taken out of the bingo card then signed on the eMAR after resident has taken the medication. If the resident declines Med once removed it, then needs to be cosigned as wasted and a note written in progress notes. NJAC 8:39- 27.1(a), 29.2 (a) (d), 29.4 (i)(k), 29.7(c)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring proper hand hygiene was performed prior to dining services and hand wipes were used and discarded appropriately . This deficient practice was identified on 1 of 3 nursing units (HP) and evidenced by the following: On 10/10/24 at 12:00 PM, the surveyor observed twenty residents seated in the HP front dining room preparing for their lunch meal. On 10/10/24 at 12:20 PM, the surveyor observed the Certified Nursing Assistant (CNA) assisted the residents with their hand hygiene. The surveyor observed the CNA cleaned a resident's hands with hand wipes, applied a clothing protector and without performing hand hygiene, cleaned another resident's hands with a hand wipe, applied a clothing protector and without performing hand hygiene reached back into the container of hand wipes, removed 4 wipes and handed them to four different residents. The four unsampled residents cleaned their hands and handed the soiled wipes back to the CNA. The CNA discarded the 4 wipes into the trash and without performing hand hygiene applied clothing protectors to the four residents. On 10/11/24 at 11:50 AM, the surveyor observed dining services in the HP front dining room. On 10/11/24 at 11:55 AM, the surveyor observed the activity coordinator (AC) donned a pair of gloves, used a hand wipe to clean a resident's hands then tied the plastic trash bag to the back of the resident's wheelchair and discarded the gloves and wipe into the bag. The AC, without sanitizing her hands, donned a new pair of gloves, cleansed a resident's hands, and discarded the wipe and gloves in the trash bag that was tied to the back of the resident's wheelchair. On 10/11/24 at 12:05 PM, the Activity Director (AD) entered the HP front dining room, and the surveyor observed the AD remove the plastic trash bag from the resident's wheelchair. At that same time, the surveyor asked the AD if the AC should have tied the trash bag to the back of a resident's wheelchair. The AD replied that she would not have done that, but everyone is different. The surveyor asked the AD if it was an Infection Control/dignity concern. The AD did not respond to the surveyor's inquiry. On 10/11/24 at 12:08 PM, the surveyor interviewed the AC who acknowledged that she should have sanitized her hands between residents and confirmed she should not have tied a trash bag to the back of a resident's wheelchair. On 10/11/24 at 12:54 PM, the surveyor interviewed the CNA who stated that her process during dining services was to put on gloves, use a hand wipe to clean a resident's hands, discard the wipe in the trash, remove and discard the gloves, and put on a new pair of gloves to clean another resident's hands. The surveyor asked the CNA if she was in serviced to perform hand hygiene between gloves changes. The CNA replied, no. The surveyor asked the CNA why she did not follow her regular process for cleaning resident's hands yesterday as the surveyor had observed the CNA had not used gloves, nor had she sanitized her hands between residents. The CNA replied she had not practiced appropriate hand hygiene because she was nervous. The CNA acknowledged that she should have performed hand hygiene between residents. On 10/16/24 at 1:22 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The LNHA stated that the AC had been educated on proper infection control practices. On 10/17/24 at 3:03 PM, the survey team met with the LNHA and DON who confirmed that the staff should sanitize their hands between residents. A review of the facility's policy entitled, Hand Hygiene reviewed 6/24 included .Hand hygiene is considered the most important procedure for preventing the spread of infection .hand hygiene must be performed after all resident care/contact .after removing gloves and any other personal protective equipment . NJAC 8:39 - 19.4(a)(m)(n); 27.1 (a)

Based on observation and interview, it was determined that the facility failed to maintain the prior year's State of New Jersey (State) inspection results and post the location of those results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following. The surveyor conducted a group meeting on 10/16/24 at 11:00 AM with 6 alert and oriented residents chosen by the facility. Six of 6 residents stated they did not know where to find the State inspection results. The surveyor looked for the most recent State inspection results (8/10/23) on each of the 3 nursing units (LP, SP, HP) on 10/17/24 at 9:00 AM. The LP Nursing Station had a plastic binder holder affixed to the front wall of the station. The binder contained 2017 and 2018 State inspection results. The HP Nursing Station had no visible binder available at the station. The surveyor asked the nurse supervisor for the binder. The nurse looked for the binder and was unable to locate it. A few minutes later she located the binder in a closed closet behind the nursing station. The binder contained 2019 inspection results. The surveyor returned the binder to the nurse. She placed the book back into the closed closet behind the nursing station. The surveyor showed the binders to the Director of Nursing (DON) on 10/17/24 at 9:15 AM while in the HP day room. The DON confirmed the most recent inspection results of 8/10/23 were not posted in the books. She stated she would update the binders. The DON returned to the surveyor on 10/17/24 at 9:30 AM. She stated the Administrator found current inspection reports on the nursing units in a pile of other binders on the counter of the nursing stations. The surveyor did not observe binders with current inspection results in an area that would be accessible to residents, families, or the public. NJAC 8:39-9.4(b)(c)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure staff follow the physician's order for the use of side rails for 1 of 21 residents, (Resident #56) and b.) ensure staff follow the physician's order according to the facility's policies and standards of clinical practice for 1 of 3 nurses, Licensed Practical Nurse (LPN)), for 1 of 9 Residents (Resident #252) observed during medication administration. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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. 1.On 10/10/24 at 10:45 AM, the surveyor observed Resident #56 in bed with his/her eyes open with two full padded side rails in use. The resident did not respond to the surveyor and the surveyor was unable to interview the resident. On 10/18/24 at 10:35 AM, the surveyor observed Resident #56 in bed with their eyes closed. The surveyor observed two full padded side rails in use. The surveyor reviewed Resident #56's Admission Record which reflected that the resident was admitted to the facility with the diagnoses which included but were not limited to dementia and depression. The surveyor reviewed the Minimum Data Set (MDS), an assessment tool dated 5/26/24 which assessed Resident #56 had a brief interview for mental status score of 2 out of 15 which indicated a severe cognitive impairment. Further review of the MDS revealed Resident #56 was dependent on staff for activities of daily living (ADLs) and transfers from the bed to the chair. A review of Resident #56's care plan (CP) reflected a focus area for ADL function and mobility effective date 5/28/24 that included an intervention that the resident will be provided one side rail up in bed for positioning. A review of the current physician's orders (PO) reflected a PO for 1 side rail up when in bed for positioning. The CP had an original order date of 1/17/20 and a renewal date of 10/8/24. A review of the Side Rail assessment dated [DATE] indicated .Side rails are indicated and serve as an enabler to promote independence in bed mobility .side rails are not considered a restraint device .provide one side rail up in bed for positioning . A review of Resident #56's Side Rail assessment dated [DATE] indicated .Side rails are indicated and serve as an enabler to promote independence in bed mobility .side rails are not considered a restraint device .provide one side rail up in bed for positioning . A review of Resident #56's Consent form for the use of 1 side rail was signed by the resident's daughter and facility social worker and dated 12/1/21. On 10/17/24 at 11:42 AM, the surveyor interviewed the Director of Building Services who stated that the facility ordered the side rails from the original manufacturer of the bed frame. He further stated that he ordered standard size siderails. On 10/18/24 at 10:36 AM, the Director of Nursing (DON) accompanied the surveyor to resident #56's room and the DON and surveyor together observed Resident #56 was in bed with 2 full padded side rails up. The DON confirmed that the PO was for 1 side rail, a Side Rail Assessment should have been completed quarterly and a PO should have been obtained prior to the use of 2 side rails. A review of the facility policy entitled, Physician Orders dated/revised 7/10/24 reflected .A licensed professional nurse will carry out and follow orders written by the physician. 2.) On 10/16/24 at 9:47 AM, the surveyor observed the LPN prepare medications for Resident #252 that included a physician order (PO) for losartan 25 milligram (mg) tablet, give 1 tablet by oral route once daily at 9:00 AM, for hypertension with Parameters to hold for systolic blood pressure (SBP) less than 110 and a PO for metoprolol succinate ER 25mg give 1 tablet by oral route once daily, give with meals every day at 9:00 AM, with parameters to hold for SBP less than 100 and to hold for pulse less than 56 beats per minute. The LPN stated that he had already taken Resident #252's vital signs earlier that morning. The surveyor asked the LPN what time he had taken them. The LPN replied, about an hour ago, and proceeded to administer the two blood pressure medications. On 10/16/24 at 1:06 PM, the surveyor interviewed the LPN in the presence of another surveyor who acknowledged that he should have taken Resident #252's vital signs within 15 minutes of administering the blood pressure medications per facility policy. On 10/16/24 at 1:34 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON to discuss the above observations and concerns. The DON stated that the LPN should have retaken the vital signs prior to administering the medications. A review of the facility policy, Administration of Medications Procedure dated/revised 4/24, included .vital signs should be taken no more than 15 minutes prior to removal of medications from the unit dose package or bottle .after taking the vital signs necessary, the medications may be removed .offer a full glass of water or juice with the medication and ensure the resident has swallowed the medications. No further information was provided by the facility. NJAC 8:39-27.1(a), 29.2(d)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents dependent on staff for Activities of Daily Living (ADL) received personal hygiene care in accordance with the facility policy. This deficient practice was identified for 1 of 1 resident (Resident #22,) reviewed for ADL care and was evidenced by the following: On 10/10/24 at 10:49 AM, the surveyor observed Resident #22 in bed with the Certified Nursing Assistant (CNA) assigned to their care in their room. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. Resident #22 stated that he/she would like to go to the salon to have their nails cleaned and manicured. The CNA told the resident she would see if the resident was on the list to go to the salon. On 10/16/24 at 12:00 PM, the surveyor observed Resident #22 in the HP front dining room seated in a wheel chair. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. On 10/17/24 at 9:53 AM, the surveyor observed Resident #22 in bed. The surveyor observed the resident's fingernails to be long, jagged and soiled with a brown substance underneath. On 10/17/24 at 10:15AM, the surveyor, in the presence of another surveyor, interviewed the CNA. The CNA stated that CNAs were only responsible for cleaning the residents nails, but the activity staff were responsible for clipping and filing their nails. The surveyor showed the CNA Resident #22's nails. The CNA acknowledged that they were long, jagged and soiled with a brown substance underneath. The surveyor asked the CNA why she hadn't cleaned Resident #22's fingernails. The CNA did not respond to the surveyor's question. On 10/17/24 at 10:22 AM, the surveyor, in the presence of another surveyor, interviewed the Licensed Practical Nurse (LPN) assigned to Resident #22's care. The LPN stated that the CNAs were responsible for cleaning, clipping and filing resident's nails. A review of the Admission Record revealed Resident #22 had been admitted with diagnoses which included but were not limited to; dementia, end-stage heart failure, and chronic respiratory failure with hypoxia (a medical condition that occurs when there is not enough oxygen in the body's tissues.) A review of the most recent Annual Minimum Data Set (MDS) an assessment tool, dated 3/22/24, included but was not limited to; a brief interview of mental status (BIMS) score of 0 of 15 which indicated the resident had a severe cognitive impairment. Section GG documented that Resident #22 required moderate assistance with personal hygiene. A review of the Care Plan documented a focus area date effective 3/25/24, the resident required assistance with ADL care and mobility. Interventions included but were not limited to . encourage resident to participate in ADL care. On 10/17/24 at 3:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. On 10/18/24 at 8:44 AM, the DON provided the surveyor with a copy of the Salon List dated 10/10/24. A review of the list reflected that Resident #22 would go to the Salon, as requested. It further document that their last visit was 9/12/24. A review of the facility provided, Certified Nurse Aide Job Description undated, included but was not limited to; Assists resident with or performs Activities of Daily Living (ADL). A review of the facility provided, ADL policy & procedure revised 8/24, included but was not limited to; Purpose . to ensure that the residents are receiving the assistance they need from staff according to their personal preference. A review of the facility provided Resident care and infection control undated, included .nails should be cleaned and trimmed/filed when needed, this is part of day-to- day standard of care. Activities may apply polish only . NJAC 8:39-27.1(a), 27.2(g)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order and failed to ensure respiratory nasal cannula tubing was stored in accordance with infection control measures for 1 of 1 resident reviewed for Respiratory therapy, Resident #22. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/10/24 at 10:49 AM, the surveyor observed Resident #22 lying in bed with Oxygen (O2) delivered via a nasal cannula (NC) tubing attaached to the O2 concentrator at 2 liters per minute (LPM)). The surveyor observed that there was an additional NC tubing dated 10/4/24 attached to a portable O2 tank that was on the back of Resident #22's wheelchair. The NC tubing was hung over the portable tank and it was not contained in a bag. On 10/17/24 at 9:53 AM, the surveyor observed Resident #22 lying in bed with O2 delivered at 2.5L via a NC tubing attached to the O2 concentrator. The surveyor observed that additional NC tubing dated 10/12/24, was attached to a portable O2 tank on the back of the wheelchair. The NC tubing was hung over the portable tank and it was not contained in a bag. A review of Resident #22's Admission Record indicated that the resident was admitted to the facility with diagnoses that included but were not limited to; dementia, end-stage heart failure, and chronic respiratory failure with hypoxia (a medical condition that occurs when there is not enough oxygen in the body's tissues.) A review of Resident #22's most recent Annual Minimum Data Set (MDS), an assessment tool, dated 3/22/24 included; a Brief Interview for Mental Status (BIMS) score of 0 of 15 which indicated the resident had a severe cognitive impairment. Section GG documented that Resident #22 required moderate assistance with personal hygiene and Section O documented that the resident was receiving respiratory treatment which included O2 therapy. A review of the Care Plan documented a focus area effective 3/25/24 which included: Resident has a Respiratory Disorder: dyspnea (shortness of breath) related to end-stage congestive heart failure (CHF). Interventions included but were not limited to: Oxygen therapy as per physician order and to provide treatments per physician order. A review of the October 2024 Physician's Orders revealed an active physician order (PO) with an order date of 2/13/22 and renewed of 10/8/24 for: O2 at 2LPM (liters per minute) per NC every shift. On 10/17/24 at 10:15 AM, the surveyor, in the presence of another surveyor, interviewed the CNA who stated that the night shift was responsible for ensuring that the NC tubing was stored properly in a plastic bag. The surveyor asked the CNA if she should have discarded the tubing and obtained a new one since they both observed the tubing was not stored properly in a bag. The CNA confirmed that she should have discarded the contaminated tubing and obtained a new clean tubing. On 10/17/24 at 10:22 AM, the surveyor, in the presence of another surveyor, interviewed the Licensed Practical Nurse (LPN) assigned to the care of Resident #22. The surveyor showed the LPN the O2; the LPN confirmed that the O2 was infusing at 2.5 LPM and that the PO was for 2LPM. The LPN acknowledged that during his morning rounds, he should have checked that the Oxygen was infusing per the physician order and should have checked to see that the NC tubing was stored properly in a bag. On 10/17/24 at 3:03 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above observations and concerns. The DON stated the facility policy was that the O2 tubing should be stored in a bag when not in use. A review of the facility provided,RN/LPN Job Description undated, included but was not limited to .the nurses will provide safe and effective nursing care in accordance with the nursing practices and policies of the facility, NJ DOH and CMS guidelines .practices infection control according to established facility and department policies . A review of the facility provided, Oxygen Therapy policy and procedure dated/revised 6/12/24, included the following: A licensed professional nurse will administer oxygen via cannula or mask as prescribed by physician .check the order in the resident's chart for amount of oxygen and frequency of administration .change oxygen tubing and bag weekly; keep tubing in bag when not in use . On 10/18/24 at 11:30 AM, the survey team met with the LNHA and DON. No additional information was provided by the facility. N.J.A.C. 8:39- 19.4(a); 27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to promote the dignity and independence for three of three residents (Resident (R)88, R47 and R9) reviewed for dining in a total sample of 24 residents. Specifically, R88 and R47 were observed being assisted with feeding by staff standing throughout the meal service. Additionally, R9 was observed to sit and wait for lunch to be served while other residents were already served. Findings include: 1. Review of R88's Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed R10 was admitted to the facility on [DATE] with diagnoses that included Nontraumatic intracerebral hemorrhage (bleeding in the brain) and Unspecified dementia. Review of R88's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23, located in the resident's EMR under the MDS tab indicated the facility assessed R88 to have a Brief Interview for Mental Status (BIMS) score was zero out of 15, indicating R88 was severely cognitively impaired. The MDS also indicated R88 required limited assistance and one-person physical assist for eating. Review of R88's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R88 was ordered a regular diet, regular texture, thin liquids. 2. Review of R47's Admission Record, located in the resident's EMR under the Profile tab, revealed R47 was admitted to the facility on [DATE] with diagnoses that including, Senile degeneration of brain and Dementia. Review of R47's quarterly MDS with an ARD of 06/26/23, located in the resident's EMR under the MDS tab indicated the facility assessed R47 to have a BIMS score was zero out of 15, indicating R47 was severely cognitively impaired. The MDS also indicated R47 required limited assistance and one-person physical assist for eating. Review of R47's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R47 was ordered a Puree diet, with thin liquids. 3. Review of R9's Admission Record located in the resident's EMR under the Profile tab, revealed R9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia and hyperlipidemia. Review of R9's quarterly MDS with an ARD of 07/06/23, located in the resident's EMR under the MDS tab indicated the facility assessed R9 to have a BIMS score of zero of 15 which indicated the resident was severely impaired. The MDS also indicated R9 required total dependence of one staff for eating. Review of R9's Physician's Orders, located in the resident's EMR under the Orders tab, revealed R22 was ordered a regular ground-national dysphagia diet level two with thin liquids. During an observation of the lunch meal on 08/07/23 at 12:55 PM - 1:30 PM, Certified Nursing Aide (CNA)1 was observed to be standing while feeding R88 their lunch in the dining area. During an observation of the breakfast meal on 08/08/23 at 9:10 AM - 9:20 AM, Activities Coordinator (AC) was observed to be standing while feeding R47 their breakfast in the dining area. During an observation of the lunch meal on 08/08/23 at 1:01 PM - 1:30 PM, R9 was observed to be sitting at the table for 29 minutes without their meals while other residents had been served their meal. Staff were observed to ask R9 were they hungry at 1:29 PM, R9 observed nodding head yes. During an interview on 08/07/23 at 1:15 PM, CNA1 stated they normally sit when assisting with meals, but they did not have a chair. CNA1 stated it was important to sit while assisting to ensure the residents felt comfortable. During an interview on 08/09/23 at 1:20 PM, the AC stated they did not have any feeding assistance training prior to assisting with meals. The AC stated they were told to go assist with meals by a supervisor and just did it. The AC stated they were in-serviced after the meal observed on 08/08/23 by the Director of Nursing (DON) and instructed to sit or be at eye level when assisting with meals. During an interview on 08/09/23 at 1:42 PM, the DON stated that her expectations were for the residents to be served at the same time or at least around the same time as others. The DON stated if there was more than one resident that required assistance with feeding, they would have expected staff to assist residents two at a time. DON stated they also expect staff to be seated when assisting with feeding. The DON stated sitting would make the meal a more pleasurable interaction. Review of the facility's policy titled, Assisting/Feeding Residents Their Meals, revised date 11/21, revealed .4. For residents that need to be feed: a. sit next to the resident and do not stand and feed the resident . NJAC 8:39-4.1(a)12

Based on observations, interviews, and facility policy review, the facility failed to provide meals at regular times. Specifically, the facility failed to deliver resident meals in a timely manner, for three of three (Residents (R)24, R42, and R62) reviewed for meal service. This had the potential to affect residents receiving room trays, and residents eating in the LP unit's back dining room. Findings include: In an interview with the Dietary Manager (DM) on 08/07/23 at 9:30 AM, he stated the mealtimes for all dining rooms were as follows: 8:30 AM breakfast; 12:30 PM lunch; and 5:15 PM dinner. The food was prepared in the main kitchen and transported, via a heated cart, to each of the pantry kitchenettes to be served to the residents. The food arrived 45 minutes prior to each meal service and was placed on the pantry steam tables to be kept hot. 1. The following observations of the lunch meal service occurred on 08/09/23: The meal was identified to be BBQ chicken or grilled hotdog on a bun, coleslaw, corn on the cob and fresh watermelon slice. Observation of the back dining room at 11:45 AM, revealed individual coleslaw cups and watermelon slices in the refrigerator. Corn on the cob, diced carrots, mechanical soft meats, and pureed meats were in containers on the steam table. Hotdogs were being grilled outside by the kitchen staff. Twelve residents were seated outside, under the canopy, at 11:50 AM, waiting for lunch to be served. All other residents were either in their respective dining rooms or in their rooms awaiting their meals. At 12:30 PM, the BBQ chicken was placed on the outside grill to be cooked. At 12:50 PM, a container of grilled hotdogs was delivered to the back dining room. The Dietary Aide (DA)1 said she was waiting for the grilled BBQ chicken before serving the six residents seated at the tables for lunch. At 12:52 PM, the residents seated outside were served. At 12:54 PM, the first meal was served in the front dining room to a resident who chose a hotdog. The BBQ chicken was delivered to the front dining room at 12:58 PM and by 1:00 PM, all residents in the front dining room had been served their meals. At 1:02 PM, the back dining room had not started meal service as DA1 said she did not have pureed carrots, required for the pureed diets. DA1 said I cannot serve the residents until I have all the right food for the purees. At 1:10 PM, the Registered Dietician (RD) retrieved the pureed carrots from the main kitchen. At 1:23 PM, all residents in the back dining room were eating, and the last room tray was delivered on the LP wing, 53 minutes after the 12:30 PM posted mealtime. In an interview with resident (R)62, at 1:30 PM, while eating her corn on the cob, R62 said she really liked the corn on the cob, but some things are cold, at meals in reference to the long wait to be served. When asked, none of the remaining five residents in the back dining room said the food was cold. It was stated that the smell of the BBQ made them hungry. 2. The following observations of the breakfast meal service occurred on 08/10/23: At 8:15 AM, observation of the back dining room pantry kitchenette on the LP unit revealed scrambled eggs, hashbrown patties, and oatmeal on the steam table. At 8:29 AM, no residents had arrived in the dining room for breakfast. At 8:34 AM, two residents were at the tables for breakfast. At 9:00 AM, all residents in the dining room had been served breakfast, however the DA3 had to request more milk for residents who requested cold cereal, bagels for resident room trays, and more scrambled eggs as she had run out of what had been initially sent. At 9:15 AM, the last room tray was delivered on the LP unit, 45 minutes after the posted mealtime of 8:30 AM. In an interview with R42, at 9:20 AM, he said the food temperature was ok, but the trays do come late sometimes. R42 ate his breakfast in his room, in bed. In an interview with R24, at 9:25 AM, he said the breakfast was pretty good, but sometimes it's cold. R24 ate his breakfast in his room, in bed. In an interview with the DM on 8/10/23 at 9:20 AM, he said the DA1 could have served the diced carrots, just mash them, she didn't have to delay the meal service. The DM could not state why the BBQ chicken was being cooked at the time the meal should have been served. In response to the dietary staff having to ask for additional food items which delayed the meal service for breakfast, the DM said they did not supply extra food on the carts, they had the staff call the kitchen for requests. In an interview with the Clinical Nutrition Manager/RD on 08/09/23 at 2:48 PM, she stated the previous BBQ had run very well without delays in meal service. She could not state why it was so late on 08/09/23. Review of the facility's policy titled, Resident Food Services, updated 01/18, revealed Monitor delivery of meals to residents to ensure timeliness and appropriateness of service. NJAC 8:39-17.2(f)

Based on observation, interview, and record review, it was determined that the facility failed to provide adequate supervision for a resident who required extensive assistance for transfer and toilet use. The resident had a fall while unsupervised in the bathroom which resulted in a fractured hip. This deficient practice was evident for Resident #16, 1 of 13 residents reviewed for falls as follows: On 9/10/14 at 11:55 a.m. during the initial tour the unit nurse manager (UM) stated that Resident #16 was confused and had a history of [REDACTED]. The surveyor observed Resident #16 on 9/10/14 at 1:45 p.m. The resident was seated in the unit dining room in a wheelchair with a seat belt in place. On 9/11/14 at 10:40 a.m., the surveyor reviewed Resident #16's medical record. The resident was admitted to the facility in May 2014 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 5/14/14 and 8/8/14, the resident had moderate cognitive impairment and required extensive assistance of one person for transfer and toilet use. Upon admission Resident #16 was assessed to be at risk for falls and the Interdisciplinary (IDC) team developed a falls care plan on 5/6/14. The interventions included the following: schedule toileting on awaking; remind the resident to call for assistance when s/he feels the need to transfer; monitor the resident every hour; anticipate needs with regard to daily living (ADLs); evaluate pattern of falls; and investigate cause of fall immediately. A Fall Risk Evaluation was conducted on 8/11/14. The score on the evaluation was 19 indicating that the resident was at high risk for falls. (A score of 10 or above indicates high risk.) The surveyor reviewed Resident #16's fall investigation reports which revealed the following: On 5/31/14 at 4:10 p.m., a Certified Nursing Assistant (CNA) responded to an audible alarm and found the resident on the bathroom floor. The resident stated that s/he tried to go to the bathroom and fell . The resident sustained [REDACTED]. The report indicated that the contributing factors were dementia, forgetfulness with poor safety judgment, requiring assistance with transfer, and not calling for assistance when needs to transfer. The Fall Investigation Report intervention was to monitor the resident every 30 minutes to prevent recurrence. On 6/2/14 at 11:00 a.m., Resident #16 was found in front of the wheelchair in the room. The chair alarm went off and alerted the nurse. The nurse went into the room and noticed the resident had discoloration to right upper arm and lower back. The Physical Therapy (PT) provided a wedge cushion and Dycem to the resident's wheelchair to prevent recurrence. On 7/6/14 at 12:00 p.m., a CNA observed the resident was having involuntary movement and suddenly jumped from the wheelchair and fell on her/his buttock in the room. No apparent injury was noted. The intervention to prevent recurrence was to continue monitoring the resident every hour. On 7/8/14 at 12:00 p.m., the resident was found on the bathroom floor in a sitting position by the Nurse Practitioner (NP). According to the investigative report the resident attempted to toilet self. The report indicated that the contributing factors were poor safety judgment and the resident's reluctance to call for assistance. The report also included that the resident went to bathroom without assistance. No apparent injuries were noted. The NP wrote a new order for the use of a seat belt when the resident was in the wheelchair. On 7/19/14 at 7:35 a.m., the resident was found sitting in front of the bed, stating s/he was looking for a sock. No apparent injuries were noted. The interventions to prevent recurrence were to continue monitoring the resident every 30 minutes, keep the resident out of room as much as possible, and continue usage of the seat belt. On 8/25/14 at 4:35 a.m. Resident #16 had a fall in bathroom. According to the accident report a CNA assisted the resident to the bathroom then left the resident alone to respond to another resident's call bell. When the CNA came back to the bathroom the resident was found sitting on the floor by the bathroom door. A nurse conducted a body check and documented that the resident was able to do full Range of Motion in all extremities, but complained of pain to left lower back. The resident was assisted to bed and administered Tylenol 650 mg. According to a nurses' note, written at 7:45 a.m. on the same date, after the incident the resident was observed sleeping. The NP was notified of the fall and an order was received to x-ray the resident's left hip. The x-ray was done and showed a fracture of left femoral (hip). The resident was transferred to the hospital and had a surgical repair of the left hip fracture on 8/27/14. Further review of the Accident report for the fall of 8/25/14 revealed that the "Accident Reason" was "lack of supervision." On 9/16/14 at approximately 2 p.m., the surveyor interviewed the Administrator and Director of Nursing (DON), regarding the incident on 8/25/14. The DON stated "no she shouldn't have" when asked if the CNA should have left Resident #16 unattended in the bathroom. NJAC 8:39-27.1(a)