Every finding on record at Dellridge Health & Rehabilitation Center

Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 3 of 3 shower rooms in the long term care units. The deficient practice was evidenced by the following: On 4/16/26 at 9:32 AM, Surveyor #1 (S #1) toured the A side nursing unit shower room that was near the nursing station, and observed in the middle cubicle a shower chair with ripped back cover, below was two broken floor tiles, and the heater grills with heavy accumulation of brownish, rusty like substances. On 4/16/26 at 9:35 AM, S #1 went to B side nursing unit shower room near the nursing station, and observed the ceiling vent just above the sink with accumulation of grayish substances and below was the heater grills with heavy accumulation of rusty like substances brownish in color. S #1 also observed in the shower cubicle wall with an open wire outlet next to the hoyer lift battery and the weighing scale. The next cubicle was observed with broken and missing tiles on the lower wall. On 4/16/26 at 9:38 AM, outside the B side shower room, S #1 observed the Registered Nurse/Unit Manager (RN/UM), and the surveyor asked the RN/UM to accompany S #1 with the tour. At that same time, inside the shower room of B side nursing unit, S #1 showed the RN/UM the above concern with the ceiling vent which she said would ask housekeeping to clean it. S #1 also notified the RN/UM and showed concern with the lower heater, the wall with an open electrical outlet, and the broken tiles. The RN/UM had no response when asked why the wall outlet was left uncovered. On 4/16/26 at 9:41 AM, both S #1 and the RN/UM went to A side nursing unit shower room and observed the broken tiles. The RN/UM stated that there should be no broken tiles because bacteria could grow in that area. S #1 asked if there would also be a safety concern with use of wheelchair and shower chair when there were broken floor tiles, and she acknowledged the concern of the surveyor. S #1 also showed the ripped back cover of the shower chair in the same cubicle in the shower room, and she did not have a response as to why it was ripped (damaged). The RN/UM stated that the ripped back cover of the shower chair should have been changed. S #1 also showed the lower heater, and she stated she did not know if that was rust or what. On 4/17/26 at 10:00 AM, S #1 observed the A side nursing unit shower room and the broken floor tiles were not replaced or fixed. On 4/20/26 at 12:14 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S #1 notified them of the above findings and concerns. On 4/21/26 at 10:13 AM, S #1 observed there was a posted sign outside B side nursing unit shower room outside door [NAME] our appearance . that the shower room work in progress and not to use. Inside the room, the surveyor observed the middle cubicle (second cubicle shower area) still with missing and broken tiles. On that same date and time, S #1 also observed the same posted sign outside A side nursing unit shower room outside door. Inside the room the middle (2nd cubicle shower area) still with broken tiles on the floor. On 4/21/26 at 10:24 AM, S #1 interviewed the RN/UM who informed the surveyor that due to broken tiles, both A and B side nursing units shower rooms were closed and would be renovated. The RN/UM also stated that there was one shower room at the other end of B side nursing unit that residents would be using for shower. S #1, Surveyor #2 (S #2), and the RN/UM went to the end of B side nursing unit shower room and observed one shower cubicle, and there was a strong smell of urine. The RN/UM acknowledged the strong smell of urine and stated that she would ask housekeeping to clean it. On 4/21/26 at 11:59 AM, the survey team met with the LNHA, DON, Regional DON #1 (RDON1) and Regional DON #2 (RDON2), and there was no response with above concerns with the environment. A review of the facility's Quality of Life-Homelike Environment Policy that was provided by the LNHA, with reviewed date of 10/2025, reflected a policy statement, residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation .2. These characteristics include: a. Cleanliness and order .e. Pleasant, neutral scents . On 4/21/26 at 1:27 PM, during the exit conference with the survey team, DON, RDON1, RDON2, the LNHA did not provide additional information. NJAC 8:39-31.4(a)(f)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physicians' orders with regard to behavior and side effects monitoring for 5 of 5 residents (Residents #3, #7, #8, #9, and #89) reviewed for unnecessary medications and b.) clarify the physician's order according to the standard of clinical practice and facility's policies.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. 1.On 4/16/26 at 10:25 AM, Surveyor #1 (S #1) observed Resident #3 participating in activities in the recreation area with a group of residents. On 4/16/26 at 10:45 AM, S #1 interviewed Licensed Practical Nurse #1 (LPN #1) who reported that the resident has improved during the residents stay at the facility and was currently using a walker for ambulation. S #1 reviewed the medical record for Resident #3, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) revealed the resident had diagnoses which included, but were not limited to; cerebral infarction, atrial fibrillation, encephalopathy, diabetes mellitus, epilepsy, and depression. A review of the resident's comprehensive Minimum Data Set (cMDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 3/8/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the cMDS revealed the resident required behavioral monitoring related to mood and antidepressant medication (med) use. A review of the resident's comprehensive care plan (CP), dated 2/2026, included a focus area that the resident uses antidepressant med related to depression. Interventions included administering antidepressant medications (meds) as ordered, monitoring and documenting side effects (s/e) and effectiveness each shift, and monitoring and documenting behavioral symptoms (SX). A review of the Order Summary Report (OSR), dated as of 4/16/26, included the following physician orders (PO): A PO, dated 2/15/26, Behavior Monitoring: Anti Depressant Med (Specify behavior) i.e. Sadness, Crying, Withdrawn, Irritability/Anger, Isolation, Appetite change, Neglecting Self-care, Sleep disruption, Lost motivation. Then, record the corresponding Non-Pharmacological intervention(s): 1. Encouragement 2. Listen/Document Feelings 3. Psychotherapy 4. Activities of Interest 5. Communication family/friends 7. Pastoral Care and if (E) Effective (IE) Ineffective every shift for Behavior Monitoring: Anti-Depressant Med A PO, dated 3/13/26, Behavior Monitoring: catatonia (slow movement, mute, staring, or refusing to eat or drink, agitations). Record the number of times resident exhibited this behavior during the shift. Then, record the corresponding Non-Pharm intervention(s): 1. give fluids, 2. offer food, 3. redirect, 4. return to room, 5. (Specify), 6. (Specify), 7. (Specify). Document E if intervention Effective; Document N if intervention Not Effective. every shift A PO, dated 4/2/26, Behavior Monitoring: sitting in the radiator. Record the number of times resident exhibited this behavior during the shift. Then, record the corresponding Non-Pharm intervention(s): 1. give fluids, 2. offer food, 3. redirect, 4. return to room, 5. (Specify), 6. (Specify), 7. (Specify). Document E if intervention Effective; Document N if intervention Not Effective. every shift A review of the electronic Medication Administration Record (eMAR), dated from 4/1/26 - 4/30/26, revealed inconsistent documentation of behavioral monitoring: For the PO dated 2/15/26, staff documented E, not applicable, and 0. The PO did not include definitions for 0 or not applicable, and documentation of E was entered without corresponding intervention codes. For the PO dated 3/13/26, staff documented N to indicate no behavior was observed; however, the PO did not include a code for documenting absence of behaviors. Additional entries of 0 were also observed without defined meaning. For the PO dated 4/2/26, staff documented check marks (√) and X instead of recording the number of behaviors and corresponding interventions as required by the PO. On 4/17/26 at 10:58 AM, S #1 interviewed LPN #1, who stated, the behavior monitoring system is very confusing and each one is different. LPN #1 further stated she used E, not applicable, or check marks to indicate no behaviors were present because she was unsure how to document correctly. On 4/17/26 at 11:20 AM, S #1 interviewed the Director of Nursing (DON), who stated that the PO for behavior monitoring were fuzzy and that the coding system was inconsistent, making it difficult for nursing staff to document appropriately. On 4/17/26 at 11:39 AM, S #1 interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the PO should be more specific and clearer to follow. On 4/21/26 at 11:59 AM, the LNHA in the presence of the survey team, acknowledged that PO required revision and that staff education was completed to address concerns related to behavioral monitoring and documentation. A review of the facility's Psychoactive Drug Use Policy, dated/reviewed 2/2026, which included that the resident's behavior is monitored. It goes on to state, the specific behavioral problems are tracked and documented as to the number of episodes or number of hours (if for pacing, yelling, or screaming) as determined by the interdisciplinary team care plan . 2. On 4/16/26 at 9:46 AM, Surveyor #2 (S #2) observed Resident #7 in the activity room sitting in the wheelchair (w/c). Resident #7 was unable to participate in an interview. A review of Resident #7's electronic medical record (eMR) revealed that the resident was admitted with diagnoses including dementia (decline in memory, thinking and daily function severe enough to affect everyday life), psychosis (difficulty distinguishing what's real from what isn't), depression and anxiety disorder. A review of the quarterly MDS (qMDS), with an ARD of 3/1/26, indicated a BIMS score of 0 out of 15, reflecting that the resident was severely cognitively impaired. A review of the OSR dated 2/22/26-4/17/26, revealed: A PO dated 2/25/26, antipsychotic medication (med): Observe s/e: dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N&V (nausea & vomiting), lethargy, drooling, EPS (extrapyramidal symptoms) (tremors, gait issues, agitation, restlessness, involuntary movement of mouth/tongue). Document Y if s/e present; document N is s/e absent. If Y also document s/e in progress notes (PN). Every shift for routine monitoring. A PO dated 2/25/26, behavior monitoring antipsychotic med: (specify Behavior (#) exhibited/noted): 1. Itching, 2. Picking at skin, 3. Restlessness/agitation, 4. Hitting, 5. Increase in complaints, 6. Biting, 7. Kicking. Record intervention code. Document in PN if intervention ineffective. Every shift code the corresponding Non-Pharm intervention: 1. Distraction 2. Calm/Quiet environment 3. Redirect 4. Return to room.; Document: Effective (E) or (N) Not effective; (#) episodes every shift. A review of the April 2026 eMAR revealed that the PO for antipsychotic med: Observe s/e did not have a Y or N documented. April 1st through April 16th had a check mark with the Nurses initials documented. The PO for behavior monitoring antipsychotic med did not have a corresponding number or a E or N documented. April 1st through April 16th had a check mark with the Nurses initials documented. On 4/17/26 at 9:29 AM, S #2 interviewed Licensed Practical Nurse #2 (LPN #2) regarding antipsychotic med and monitoring residents for s/e and behaviors. LPN #2 stated that the documentation for monitoring s/e and behaviors was in the eMAR. LPN #2 stated that they would document in the eMAR if there were any s/e and/or behaviors and what interventions were done. In the presence of S #2 LPN #2 reviewed eMAR for Resident #7. LPN #2 acknowledged that the PO should have been followed. LPN #2 stated the nurse should have entered the number to correspond with the behavior. LPN #2 acknowledged there were no numbers documented on the eMAR, just a check mark and initials. LPN #2 stated to documented s/e, the nurse should have entered the Y if present or N if not present. LPN #2 acknowledged that it was not documented on the eMAR. LPN #2 stated that it was important to document behaviors so treatments could have been adjusted as needed. LPN #2 further added it was important to document s/e because the dose could have been too high or too low. On 4/21/26 at 9:47 AM, S #2 interviewed the Registered Nurse/Unit Manager (RN/UM), who stated that the behavior and s/e should be monitored and documented to know if the med dose was appropriate. dose. S #2 and the RN/UM reviewed eMAR record together. She acknowledged that the PO was not followed, and the documentation was incorrect. I missed fixing it I updated others but not this one. I do not know why some have it and some do not have it. The RN/UM corrected both orders in the presence of S #2. On 4/21/26 at 11:59 AM, The survey team met with the LNHA, DON, Regional DON #1 (RDON1), and Regional DON #2 (RDON2). The DON stated that they reviewed all orders for monitoring s/e and behaviors and made updates after surveyors' inquiry. The facility did not have a policy regarding following PO. 2.On 4/15/26 at 10:56 AM, Surveyor #2 (S #3) observed a posted sign outside Resident #8's door for EBP (Enhanced Barrier Precautions). Inside the room, the resident was observed seated in the bed with oxygen in use. S #3 reviewed the medical records of Resident #8, and revealed: A review of the AR or face sheet revealed that Resident #8 was admitted to the facility with diagnosis that included but were not limited to; displaced trimalleolar fracture (a severe, unstable ankle injury where all three bony prominences (malleoli) break: the lateral (fibula), medial (tibia), and posterior (back of the tibia) malleolus) of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, muscle weakness, unspecified atrial fibrillation (afib), and chronic kidney disease, stage 4 (severe). A review of the cMDS, with an ARD of 3/19/26, reflected in Section C-Cognitive Patterns that the resident had a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. Section N-Medications (meds) reflected that the resident received antianxiety, antidepressant, anticoagulant, and diuretic meds. A review of the OSR revealed the following PO that included but were not limited to: - Lexapro oral tablet (tab) 5 mg (milligram), give 3 tablets (tabs) by mouth at bedtime (HS) for depression/anxiety; 3 tabs=15 mg-Start Date 4/7/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. - Eliquis tab 2.5 mg, give 1 tab by mouth two times a day for Afib. Observe for bleeding/bruising, dark urine, black tarry stools.-Start Date 3/13/26-Hold Date from 4/9/26 to 4/10/26. - oxybutynin chloride oral tab 5 mg, give 1 tab by mouth one time a day for OAB (over active bladder) observe for anticholinergic s/e-Start Date 3/14/26-Hold Date from 4/9/26 to 4/10/26. - Alprazolam tab 0.25 mg, give 1 tab by mouth every 8 hours as needed (PRN) for anxiety for 14 days, observe for CNS (central nervous system) depression-Start Date 3/30/26. - Antianxiety med-Observe for s/e: drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document Y if s/e are present; document N if s/e are absent. If Y is documented also in the PN. every shift for routine monitoring-Start Date 3/15/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. The antianxiety med order above was signed by nurses from 4/1/26 to 4/15/26, except on 4/9/26 evening shift (coded as 6=hospitalized ) and 4/12/26 night shift (blank) with check mark code and the PO was not followed to document a Y or an N. -Anticoagulant med: Observe for s/e: discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB (shortness of breath), nosebleeds. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in PN every shift for routine monitoring-Start Date 3/13/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. The anticoagulant med order above was signed by nurses from 4/1/26 to 4/15/26, except on 4/9/26 evening shift (coded as 6) and 4/12/26 night shift (blank) with check mark code and the PO was not followed to document a Y or an N. -Antidepressant med-Observe for s/e: GI (gastrointestinal) upset, insomnia, fatigue, dizziness, dry mouth, headache. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the PN. every shift for routine monitoring-Start Date 3/14/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. The antidepressant med order above was signed by nurses from 4/1/26 to 4/15/26, except on 4/9/26 evening shift (coded as 6) and 4/12/26 night shift (blank) with check mark code and the PO was not followed to document a Y or an N. -Behavior Monitoring-AntiAnxiety med: constant calling causing distress to self-record the number (#) of times resident exhibited this behavior during the shift. Then, record the corresponding Non-Pharm intervention(s)(NPI): 1. give fluids, 2. offer food, 3. redirect, 4. return to room, 5. allow time to verbalize feelings, 6. (Specify), 7. (Specify). Document E if intervention Effective; Document N if intervention Not Effective. every shift for behavior monitoring-Start Date 3/30/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. The behavior monitoring for antianxiety med order above was signed by nurses from 4/1/26 to 4/15/26, except on 4/12/26 night shift (blank) and 5 out of 53 shifts the were coded incorrectly and did not follow the PO that if resident exhibited behavior during the shift, then record the corresponding NPI (1, 2, 3, 4, 5, 6 (specify), and 7 (specify), to document E if intervention effective and N if the intervention not effective. -s/e Monitoring: Anticholinergic s/e: Observe for s/e: dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium or hallucination. Document Y if s/e are present; document N if s/e are absent. If Y is documented also in the PN. every shift for routine monitoring- on Oxybutynin-Start Date 3/13/26-Hold Date from 4/9/26 to 4/10/26. The s/e monitoring for anticholinergic med order above was signed by nurses from 4/1/26 to 4/15/26, except on 4/9/26 evening shift (coded as 6) with check mark code and the PO was not followed to document a Y or an N. On 4/17/26 at 12:22 PM, S #3 interviewed the RN/UM regarding behavior and s/e monitoring, and she said the PO should be followed, if the PO was to document Y or N it should be documented. She further stated that if there was a documented behavior there should be a NPI in the PO that also should be followed, but if no behavior observed, then there should no NPI documented in the eMAR. S #3 then notified the RN/UM of the above findings and concerns that the PO for s/e and behavior monitoring were not followed. On 4/20/26 at 12:14 PM, the survey team met with the LNHA and the DON, and S #3 notified them of the above findings and concerns. On 4/21/26 at 1:27 PM, the survey team met with the LNHA, DON, RDON1 and RDON2 for exit conference, and there was no additional information provided by the LNHA. 3. On 4/15/26 at 11:17 AM, Surveyor #4 (S #4) observed Resident #9 inside their room seated in a w/c, and no untoward behavior was noted. On 4/20/26 at 9:00 AM, S #4 reviewed the eMR of Resident #9. The AR reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to; dislocation of internal left hip prosthesis, subsequent encounter, difficulty in walking, not elsewhere classified, muscle weakness (generalized), anxiety disorder, unspecified, depression, unspecified, and personal history of transient ischemic attack (a brief blockage of blood flow to the brain that causes stroke-like symptoms), and cerebral infarction (the death of brain tissue due to lack of blood flow) without residual deficits. A review of the cMDS, with an ARD of 4/3/26, revealed that Resident #9 had a BIMS score of 15 out of 15, which indicated intact cognition. A review of the OSR revealed orders for Resident #9 included, but were not limited to, the following: -A PO, dated 4/9/26, anticoagulant med: Observe for s/e: discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB, nosebleeds. Document Y if side effects are present; document N if s/e are absent. If Y is documented also document in PN. Directions: every shift for routine monitoring. -A PO, dated 4/9/26, antidepressant med - Observe for s/e: GI upset, insomnia, fatigue, dizziness, dry mouth, headache. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the PN. Directions: every shift for routine monitoring. -A PO, dated 4/9/26, antipsychotic med: Observe for s/e: dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N&V, lethargy, drooling, EPS SX (tremors, gait issues, agitation, restlessness, involuntary movement of mouth/tongue). Document Y if s/e present; document N if side effects absent. If Y also document s/e in PN. Directions: every shift for routine monitoring. -A PO, dated 4/9/26, behavior monitoring antipsychotic med: (Specify Behavior (#) exhibited/noted): 1. itching, 2. picking at skin, 3. restlessness/agitation, 4. hitting, 5. increase in complaints, 6. biting, 7. kicking, 8. spitting, 9. cursing, 10. racial slurs, 11. elopement, 12. stealing, 13. delusions, 14. hallucinations, 15. psychosis, 16. aggression, 17. refusing care. Record intervention code. Document in the PN if interventions are ineffective. Directions: every shift Code the corresponding Non-Pharm intervention: 1. Distraction 2.Calm/Quiet Environment 3. Redirect 4. Return to room, 5. Reposition 6. Toilet 7. Recreation/Activity. 8. Other (Specify);Document: Effective(E)or(N)Not effective;(#)Episodes for Shift. -A PO, dated 3/27/26, behavior monitoring: anti depressant med (Specify behavior)i.e. Sadness, Crying, Withdrawn, Irritability/Anger, Isolation, Appetite change, Neglecting Self-care, Sleep disruption, Lost motivation. Then, record the corresponding Non-Pharmacological intervention(s): 1. Encouragement 2. Listen/Document Feelings 3. Psychotherapy 4.Activities of Interest 5.Communication family/friends 7. Pastoral Care and if (E) Effective (IE) Ineffective. Directions: every shift for Behavior Monitoring: Anti-Depressant Med. -A PO, dated 4/16/26, s/e monitoring: anticholinergic s/e: Observe for s/e: dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium or hallucination. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the PN. Directions: every shift for routine monitoring. A review of the April 2026 eMAR revealed the following: -The PO for Anticoagulant Med: Observe for s/e did not have a Y or N documented. 4/9/26 through 4/20/26 had a check mark with the nurses' initials documented. -The PO for Antidepressant Med - Observe for s/e did not have a Y or N documented. 4/9/26 through 4/20/26 had a check mark with the nurses' initials documented. -The PO for Antipsychotic Med: Observe for s/e did not have a Y or N documented. 4/9/26 through 4/20/26 had a check mark with the nurses' initials documented. -The PO for Behavior Monitoring Antipsychotic Med did not have a corresponding number or an E or N documented. 4/9/26 through 4/20/26 had a check mark with the nurses' initials documented. -The PO for Behavior Monitoring: Anti Depressant Med did not have a corresponding number to the non-pharmacological intervention or an E or IE documented. 4/1/26 through 4/7/26 had either 0 or NA documented instead of E or IE. Moreover, 4/1/26 through 4/7/26 had NA documented for the non-pharmacologic intervention instead of a corresponding number. -The PO for s/e Monitoring: Anticholinergic s/e did not have a Y or N documented. 4/16/26 through 4/20/26 had a check mark with the nurses' initials documented. On 4/20/26 at 12:33 PM, S #4 discussed the above concerns with the LNHA and the DON. On 4/21/26 at 11:00 AM, S #4 interviewed the DON who stated the expectation was that the eMAR needs to show a yes or no for s/e, specify the behaviors exhibited, code the corresponding non-pharmacological interventions, and document the effectiveness or ineffectiveness of the interventions. A review of the facility's Administering Meds Using Electronic System Policy, revised 4/2010, revealed that as required or indicated for a med, the individual administering the med will record in the resident's medical record any complaints or symptoms for which the drug was administered, and any results achieved and when those results were observed. 5. On 4/15/26 at 11:43 AM, Surveyor #5 (S #5) observed Resident #89 seated in a w/c in the dayroom waiting for lunch to be served. On 4/16/26 at 10:31 AM, S #5 reviewed Resident #89 medical record. A review of Resident #89's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia (a decline in mental ability—such as memory, language, problem-solving, and thinking—severe enough to interfere with daily life) and anxiety (a common mental health condition characterized by excessive, uncontrollable fear or worry that interferes with daily life). A review of Resident #89's most recent cMDS, with an ARD of 3/3/26, reflected that the resident had a BIMS score of 00 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #89's April 2026 eMAR revealed the following order: Antianxiety med - Observe for s/e: drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document Y if s/e are present; document N if side effects are absent. If Y is documented also document in the PN. every shift for routine monitoring with a start date of 3/18/2026. The nurses were documenting with check marks and not the Y and N. On 4/17/26 at 12:18 PM, S #5 interviewed the Registered Nurse (RN) who stated that for s/e monitoring it should follow the order and put a y or n. S #4 notified the RN about Resident #89's order. The RN stated that there was something in the electronic system to click to have the yes or no status and that we would fix it. On 4/20/26 at 12:16 PM, S #5 notified the LNHA and DON the concern that Resident #89's s/e monitoring order was not being followed as ordered. On 4/21/26 at 12:19 PM, in the presence of the DON, RDON1 and RDON2, the LNHA stated that the order was updated and staff were educated. NJAC 8:39-11.2(b)

Based on interview and record review, it was determined that the facility failed to ensure that the resident's medical record included documentation that indicated, at a minimum, that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization for 3 of 5 residents reviewed for immunizations (Residents #6, #7, and #89). This deficient practice was evidenced by the following: 1.On 4/16/26 at 10:46 AM, Surveyor #1 (S #1) reviewed the medical record for Resident #6. A review of the admission Record (AR) or face sheet (an admission summary) for Resident #6, revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. A review of the comprehensive Minimum Data Set (cMDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 3/13/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The cMDS included that the resident was assessed for pneumococcal and influenza vaccination status and it was refused. A review of the immunization record revealed: Pneumococcal vaccine (Prevnar 20), dated 3/6/26, was documented as refused, with education provided documented as No. Influenza vaccine was documented as refused, despite the resident having a documented allergy to the influenza vaccine. On 4/17/26 at 8:30 AM, S #1 interviewed the Infection Preventionist Nurse (IPN), who stated that, education should be provided when a resident refuses a vaccine. After reviewing the documentation and speaking with nurse, the IPN further stated that, the nurse reported education was provided but was not documented. During the same interview, the IPN stated that the resident had an allergy to the influenza vaccine; however, the nurse documented the vaccine as Refused instead of indicating the resident was not eligible due to contraindication. On 4/21/26 at 12:00 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, acknowledged that education for the pneumococcal vaccine refusal was not documented correctly and that staff were re-educated regarding pneumonia and Influenza vaccine documentation. A review of the facility's Pneumococcal and Influenza Vaccination Policies reviewed 10/2025, which included, If a resident declines vaccination, education regarding the benefits and risks of the vaccine will be provided and documented in the medical record. The policies go on the say, Documentation will include whether the vaccine was administered, refused, or not indicated. 2.On 4/16/26 at 9:46 AM, Surveyor #2 (S #2) observed Resident #7 in the activity room sitting in the wheelchair. Resident #7 was unable to participate in an interview. A review of Resident #7's electronic medical record (eMR) revealed that the resident was admitted with diagnoses including dementia (decline in memory, thinking and daily function severe enough to affect everyday life), psychosis (difficulty distinguishing what's real from what isn't), depression and anxiety disorder. A review of the quarterly MDS (qMDS), with an ARD of 3/1/26, indicated a BIMS score of 0 out of 15, reflecting that the resident was severely cognitively impaired. A review of the immunizations records in the eMR, revealed that there was no documentation for offered, administered or refusal of flu and pneumonia immunizations. There was no documented evidence that the resident's representative (RR) was educated regarding the benefits and potential side effects (s/e) of influenza and pneumococcal immunization. On 4/17/26 at 11:47 AM, S #2 interviewed the IPN who stated they did not have a tracking system in place for tracking immunizations status for the residents. She further stated that the information for the immunizations for the residents was in the eMR. The IPN stated that when the residents were admitted to the facility, she documented their immunizations in her notebook. The IPN could not provide any other information including documented evidence that the RR was educated regarding the benefits and potential s/e of influenza and pneumococcal immunization. On 4/17/26 at 1:07 PM, S #2 requested immunization information for Resident #7. The IPN and S #2 reviewed the eMR together and the IPN confirmed that the information regarding immunizations was not available. The IPN stated she would look at the nursing notes. There was no further information provided by the IPN. On 4/21/26 at 11:59 AM, the survey team met with the LNHA, DON, Regional DON #1 (RDON1) and Regional DON #2 (RDON), and there was no further information provided regarding the immunization information for Resident #7. 3.On 4/15/26 at 11:43 AM, Surveyor #3 (S #3) observed Resident #89 seated in a wheelchair in the dayroom waiting for lunch to be served. On 4/16/26 at 10:31 AM, S #3 reviewed Resident #89 medical record. A review of Resident #89's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia (a decline in mental ability—such as memory, language, problem-solving, and thinking—severe enough to interfere with daily life) and anxiety (a common mental health condition characterized by excessive, uncontrollable fear or worry that interferes with daily life). A review of Resident #89's most recent cMDS, with an ARD of 3/3/26, reflected that the resident had a BIMS score of 00 out of 15, which indicated the resident's cognition was severely impaired. Further review of the cMDS reflected that the resident received the influenza vaccine in the facility for the current year's season on 1/31/25. The date administered was not in the current year's season. A review of Resident #89's eMR under immunization tab reflected that the last documented influenza vaccine was given to the resident was 1/31/25. There was no documented evidence that the influenza vaccination was offered, given or refused for the most recent influenza vaccination season. Further review reflected that other vaccinations were offered and refused by the RR and education was provided. On 4/17/26 at 9:46 AM, S #3 interviewed the IPN regarding Resident #89's influenza vaccination. The IPN viewed the eMR and confirmed that Resident #89's last influenza vaccination was given on 1/31/25, The IPN then reviewed the resident's electronic Medication Administration Records (eMAR) from September 2025-March 2026 (most current influenza vaccination season) and confirmed that an influenza vaccination was not ordered/given. The IPN stated that the vaccination was offered through a mass email system that it sent each month to the representatives. The surveyor asked the IPN if the offer or refusal and education should be documented in the resident's medical record. The IPN stated again, we do it through mass email system. On 4/17/26 at 10:19 AM, the IPN provided a copy of a mass email (multiple email addresses were listed) that was delivered to Resident #89's representative which was dated 3/9/26. The surveyor asked the IPN why the other vaccinations were listed in the eMR as refused but not the influenza. The IPN stated that she did not have an answer right now. On 4/20/26 at 12:16 PM, the surveyor notified the LNHA and DON the concern that Resident #89's was not offered the influenza vaccination or any documented evidence that it was offered and refused and education was provided. On 4/21/26 at 12:19 PM, in the presence of the DON, RDON1 and RDON2, the LNHA stated that an email was sent to the RR through a mass email system to offer the vaccination. A review of the facility's Influenza Vaccine Policy, reviewed 10/25, under Policy, to protect the health and safety of all residents in the facility, the influenza vaccine will be offered to all residents annually between October 1st to March 31st . Under procedures: 1. Yearly determination between October 1st to March 31st should be made on all residents concerning the offering of influenza vaccine.5) Document at the time of vaccine administration must be recorded on the Medication Administration Record, Resident's Immunization Record and/or progress notes.7) The administration of the influenza vaccine will be in accordance with the CDC recommendations. A review of the facility's Resident Vaccination for Pneumonia Policy dated 9/2022, Purpose: The facility will offer pneumococcal vaccination for residents to aid in preventing pneumococcal infections or disease (e.g. pneumonia) in the lungs and the blood stream caused by Streptococcus pnuemoniae. The facility will offer vaccination as currently recommended by the Center for Disease Control and Prevention (CDC) .Procedure: 1. All newly admitted , readmitted and current residents are to be offered a pneumococcal vaccine unless the immunization is medically contraindicated or the resident has already been immunized. 1. Ensure that the resident or RR is provided education regarding the benefits, risks and potential side effects associated with the vaccine. The resident or RR has the opportunity to accept or refuse the pneumococcal vaccine, and change their decision. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or RR was provided education regarding the benefits and potential risks associated with pneumococcal vaccine. Consent for administration of the pneumococcal vaccine. Date of the pneumococcal vaccination, type of the pneumococcal vaccination, including lot number, expiration date, administering provider, and the site of vaccination. If the resident did not receive pneumococcal vaccine due to medical contraindications (e.g. allergy) or refusal. The LNHA did not provide any additional information. N.J.A.C. 8:39-19.4 (i)

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure an as needed psychotropic (affecting the brain and nervous system, altering mood, thoughts, perception, and behavior) medication ordered was limited to 14 days, unless the attending physician/prescribing practitioner documents a rationale to extend the medication for 1 of 2 residents reviewed for hospice (Residents #75). This deficient practice was evidenced by the following: On 4/15/26 at 10:20 AM, the surveyor observed Resident #75 asleep in bed. On 4/16/26 at 11:51 AM, the surveyor reviewed Resident #75's medical record. A review of Resident #75's admission Record or face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anorexia (a serious, potentially life-threatening eating disorder characterized by an intense fear of gaining weight, self-starvation, and a distorted body image) and dementia (a decline in mental ability-such as memory, language, problem-solving, and thinking-severe enough to interfere with daily life). A review of Resident #75's most recent Significant change in status assessment Minimum Data Set (sMDS) (an assessment tool used to facilitate the management of care) with an Assessment Reference Date of 3/30/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #75's April 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) included the following order:Lorazepam oral concentrate 2 mg/ml (milligrams/milliliters) *Controlled Drug* give 0.25 ml by mouth every 4 hours as needed (PRN) for anxiety with an order date of 3/18/26.The order was not limited to 14 days. On 4/16/26 at 12:19 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that lorazepam PRN was ordered for 14 days and then reevaluated by the physician. On 4/16/26 at 12:23 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that for lorazepam PRN was initially ordered for 14 days and then if still needed would be ordered for 30 days. On 4/20/26 at 9:44 AM, the surveyor interviewed the Director of Nursing (DON) who stated that lorazepam PRN was initially ordered for 14 days and then renewed. On 4/20/26 at 12:19 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #75's lorazepam PRN order was not limited to 14 days and that there was no documentation of a rationale to extend the medication (med). On 4/21/26 at 12:21 PM, in the presence of the DON, Regional DON #1 (RDON1) and RDON #2 (RDON2), the LNHA stated that the staff were educated on the 14 days. A review of the facility's Psychotropic Drug Use Policy with an update reviewed date of 10/2024, included under H.2. Anxiolytics:.3. PRN order is for 14 days and MD will review when med is still needed. The LNHA did not provide any additional information. N.J.A.C. 8:39-27.1

Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the Resident or Resident Representative with a written notification of the facility's bed hold policy that included the reserve payment information for 2 of 2 residents (Residents #1 and #14) reviewed for hospitalizations.This deficient practice was evidenced by the following: 1.On 4/17/26 at 9:44 AM, Surveyor #1 (S #1) interviewed the Licensed Practical Nurse (LPN) who stated that he was the assigned nurse of Resident #14. The LPN informed S #1 that the resident was cognitively impaired, required total assistance with care, with pressure ulcer (PU), and had been in and out of the hospital where PU worsened. S #1 reviewed the medical records of Resident #14, and revealed the following: The admission Record (AR) or face sheet(an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to; PU of sacral region, stage 4, muscle weakness (generalized), difficulty in walking, not elsewhere classified, and unspecified protein-calorie malnutrition. A review of the resident's Discharge Return Anticipated Minimum Data Set (DRAMDS) revealed in Section A-Identification Information, the resident had an unplanned transfer to hospital in August 2025, October 2025, and December 2025. A review of the electronic medical records (eMR) revealed a Notification of Bed Hold Policies (NBHP) dated for 8/8/25 and 12/9/25. The NBHP had a red bold instruction to Print and give resident a copy prior to transfer out of the center. The NBHP did not include information about reserve payment and there were no responses to questions in the NBHP document. On 4/20/26 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA) provided a black binder and red folder, and he said that the black binder was the 2026 LTCO (Long-Term Care Ombudsman; is a trained advocate who investigates complaints, resolves disputes, and protects the rights of residents in nursing homes, assisted living, and other residential care facilities) notification and the red folder was for the 2025 LTCO notification. The LNHA further stated that he would get back to S #1 for the bed hold notice/notification. On 4/20/26 at 1:15 PM, S #1 followed up with the LNHA the bed hold notices, and he stated that it was with the admission Director (AD). At that same time, S #1, Surveyor #2 (S #2), and the LNHA went to the AD who was in her computer with a binder, and stated that she would still need five minutes because she was checking if everything was okay. On 4/20/26 at 1:28 PM, the AD provided S #1 the binder for bed hold notices. The AD informed S #1 and S #2 the process that when the resident was transferred to the hospital, nurses handed the resident or Resident Representative (RR) with bed hold paper, then the RR would give me a call if they wanted to hold the bed or not because the insurance would not cover the bed hold. She further stated that it was an out of pocket expense, it was the nurse to give the bed hold paper, it would be in the assessment of the nurses in the eMR the information, and then I go to my own bed hold and sent it out or I call. The AD also stated that the amount was $420 per night, the price was for all residents, and it did not matter if the resident was LTC (Long Term Care) or subacute residents. She added that for Medicaid residents we have 10 days to hold the bed. In the office of the AD, both S #1 and S #2 reviewed the eMR where the AD showed the bed hold notices versus what was provided in the printed binder. The computer list of bed hold policies (or notices) were from 6/3/25 to 1/26/26 for messages sent to residents, families, employees, or prospective families. While reviewing, the AD confirmed in the presence of the LNHA that the 12/9/25 Bed Hold Policies notification was for another resident and was not for Resident #14, there were no bed hold policies notices for dates 8/8/25 and 10/22/25. The AD also confirmed that the only bed hold notice that was in the binder was for 8/8/25. At that same time, the AD confirmed it was the nurse's responsibility in the Assessment tab in the eMR to document that the bed hold policies notices were given to the resident or RR. The AD also confirmed with the LNHA that there was no 10/22/25 and 8/8/25 bed hold notices in the computer and the printed information in the binder was for 8/8/25 that did not include reserve payment. Later on, S #1, S #2, and the LNHA went to the nursing unit to review the resident's chart and did not see the bed hold notices. The Unit Clerk claimed it should be in the chart or in the miscellaneous tab of resident's medical record in the computer. On 4/20/26 at 2:11 PM, the Registered Nurse/Unit Manager (RN/UM) informed S #1 in the presence of S #2 that when the resident was transferred to the hospital, the nurse would document in the assessment tab the bed hold notice, print it out and attached it to the discharge papers that goes to the hospital, and usually unable to ask the resident or RR to sign because of emergent transfer. The RN/UM also stated that there was no printed copy except the one in the computer, and then it will be followed up by the AD. The RN/UM also confirmed that the amount of bed hold will be discussed by the AD and she could not recall if there was a reserve payment in the bed hold notice in the assessment nor she was aware of the amount. The surveyor then asked the RN/UM for copy of bed hold notices in the assessment tab. On 4/20/26 at 2:19 PM, the RN/UM provided a printed copy of bed hold notices for 8/8/25 and 12/19/25. The RN/UM was not able to provide a copy for 10/22/25, and she said she would get back to S #1 as to why there was none for 10/22/25. S #1 reviewed with the RN/UM the printed bed hold notices and asked the RN/UM if there was a reserve payment in the notice paper, and she responded there were none. The LNHA came and stated that there were bed hold notices for Resident #14, and S #1 asked the LNHA if there were reserve payment documented, and he responded none. The LNHA further stated that they will do better next time. He also acknowledged that it should be in bed hold notices the reserve payment. 2. Surveyor #2 (S #2) reviewed the medical records of Resident #1, which revealed the following: The AR reflected that the resident was admitted to the facility with diagnoses that included, but were not limited to; bronchopneumonia (a type of pneumonia that causes inflammation in the airways, or bronchioles, and small air sacs, or alveoli, of the lungs), unspecified organism, anemia (a condition that develops when the blood produced a lower-than-normal amount of healthy red blood cells), unspecified, muscle weakness (generalized), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident #1's DRAMDS revealed in Section A-Identification Information, the resident had an unplanned transfer to hospital in March 2026. A review of the eMR revealed an NBHP dated 3/18/26. The NBHP had a red bold instruction to Print and give resident a copy prior to transfer out of the center. The NBHP did not include information about reserve payment and there were no responses to questions in the NBHP document. A review of the eMR revealed a document, Bed Hold Policy, which was a notice of emergency transfer and confirmed that on 3/18/26, Resident #1 was sent to the hospital. It did not include reserve payment. A review of the facility's Bed Hold Policy that was provided by the LNHA, with a reviewed date of 1/2026, did not include information about reserve payment. On 4/21/26 at 1:27 PM, the survey team met with the LNHA, Director of Nursing (DON), Regional DON #1 and Regional DON #2 for exit conference, and there was no additional information provided by the LNHA. On 4/21/26 at 2:01 PM, RDON2 informed S #1 in the presence of the survey team that the carefeed was only a supplemental information, and the facility should follow up with resident and/or RR. N.J.A.C. 8:39-4.1(a)(31);5.1 (a)(b)

Based on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 1 of 2 residents, (Resident #120), reviewed for facility task-resident assessment, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment Instrument (RAI) Manual, dated October 2025, RAI-required Assessment Summary:-The admission (Comprehensive) assessment, the MDS completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The Care Plan Completion date is no later than CAA(s) Completion date + 7 calendar days. The Transmission date is no later than Care Plan Completion date + 14 calendar days.-The Discharge MDS assessment return not anticipated (DRNA), the MDS completion date is the discharge date + 14 calendar Days. The Transmission date is MDS Completion date + 14calendar days. On 4/17/26 at 8:40 AM, the surveyor reviewed Resident #120's MDS in the electronic medical records, and revealed: 1.Resident #120's comprehensive MDS assessment with an ARD of 12/12/25, admission date of 12/1/25, completed date was on 12/15/25, care plan (CP) completed 12/15/25, and was lock/accepted (or transmitted) on 12/16/25. The comprehensive MDS CP and completion date were completed late, after 15 days, which should have been completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). 2. Resident #120's DRNA with an ARD of 2/17/26, was completed on 2/23/26, and was transmitted on 4/15/26. The DRNA MDS was transmitted late, after 37 days, which should have been transmitted MDS Completion date + 14 calendar days. Further review of the above MDS revealed that the 12/15/25 completion and CP were in red. The 4/15/26 transmission date for DRNA MDS was also in red. On 4/20/26 at 12:14 PM, during meeting with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor notified them of the above findings and concerns about late completion and transmission of MDS for Resident #120. On 4/21/26 at 11:10 AM, the surveyor interviewed the Regional MDS Coordinator (RMDSC) who informed the surveyor that if the completion, CP, and lock/accepted (transmission) boxes in the MDS were in red it means it was late. He further stated that for the comprehensive MDS, completion date should be within 14 days of admission date, and transmission date should be within 14 days from completion date. He added that the same with discharge MDS, transmission date should be within 14 days from completion date. He informed the surveyor that we follow the RAI Manual as our policy. On 4/21/26 at 11:59 AM, the survey team met with the DON, Regional DON #1 (RDON1), Regional DON #2 (RDON2), and the LNHA stated that for Residents #120, we provided education to the MDS Coordinators. A review of the facility's MDS Completion and Submission Timeframes Policy that was provided by the DON, with a revision date of October 2025, reflected in the policy statement, the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1. The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the RAI Manual . On 4/21/26 at 1:27 PM, the survey team met with the LNHA, DON, RDON1, and RDON2 for exit conference, and there was no additional information provided by the LNHA. NJAC 8:39 - 11.1

Based on interview 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 5 of 27 residents, (Residents #7, #8, #13, #14, and #89), reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1.On 4/17/26 at 9:00 AM, Surveyor #1 (S #1) reviewed the electronic medical record (eMR) of Resident #7 and revealed: A review of the immunization record reflected that there was no documentation for offered, administered or refusal of flu and pneumonia vaccines. A review of the MDS revealed under section O0250, that C. If influenza vaccine not received, state reason: the code entered in the assessment was 1. Resident not in this facility during this year's influenza vaccination season. Further review of the MDS section O0300 revealed that A. Is the resident's Pneumococcal vaccination up to date? the code entered in the assessment was 0. No B.the code entered in the assessment was 2. Resident offered and declined. On 4/17/26 at 10:44 AM, S #1 interviewed the Licensed Practical Nurse/MDS Coordinator (LPN/MDSC), who stated that she obtained the flu and pneumonia vaccination information from the immunization tab in the eMR, admission Record (AR), and hospital records. S #1 reviewed the information that was coded in the MDS section O with the LPN/MDSC who stated that she would have reviewed the coding again and followed up with S #1. On 4/17/26 at 12:01 PM, the LPN/MDSC stated that the assessment was modified. She further stated that Resident #7 received the pneumonia vaccine in 2020 based on eligibility status of Medicare and provided a document. A review of the document titled Eligibility Response Screen revealed Pneumococcal Conjugate dated 6/24/20. On 4/18/25 at 10:00 AM, S #1 reviewed the MDS which reflected to be modified. Review of section O0250 revealed that C. If influenza vaccine not received, state reason: the code entered in the assessment was 9. None of the above. A review of the MDS section O0300 revealed that section A. Is the resident's Pneumococcal vaccination up to date? the code entered in the assessment was 1. Yes. A review of the facility's MDS Accuracy Policy, revised October 2023, included Policy Statement: Our facility will conduct resident assessments in accordance with the current Resident Assessment Instrument .Policy Interpretation and Implementation: 1. The assessment coordinator or designee will complete MDS Assessments per accordance to the Resident Assessment Instrument and per CMS guidelines and regulations. 2.On 4/15/26 at 10:45 AM, Surveyor #2 (S #2) observed Resident #13 in the rehabilitation room participating in Physical Therapy (PT) and Occupational Therapy (OT) while seated in a wheelchair (w/c). On 4/17/26 at 10:52 AM, S #2 reviewed the medical record for Resident #13. A review of the AR revealed the resident had diagnoses which included, but were not limited to; Parkinson's disease, diabetes mellitus, chronic kidney disease, and dementia. A review of the resident's quarterly MDS (qMDS), with an assessment reference date (ARD) of 4/6/26, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed Section O (O0390 – Therapy Services) was coded No for physical therapy. A review of the resident's comprehensive care plan (CP) included a focus area that the resident required rehabilitation services to improve functional mobility. Interventions included participation in PT and OT services. A review of the Order Report (OSR), dated as of 4/17/26, included the following physician orders (PO): A PO, dated 4/4/25, for PT evaluation and treatment as indicated. A PO, dated 4/2/26, for PT three times per week for therapeutic exercise, therapeutic activities, neuromuscular reeducation, and gait training. A review of the progress notes (PN) included therapy documentation, dated 3/31/26 and 4/1/26, which indicated the resident received PT services within the 7-day look-back period of the MDS assessment. Further review of the above medical records revealed that the active PO at the time of the quarterly MDS assessment, which indicated the resident was receiving rehab services. However, the MDS did not reflect that the resident received therapy services during the 7-day look-back period. On 4/17/26 at 11:40 AM, S #2 interviewed the PT Regional Rehabilitation (Rehab) Coordinator who stated the resident had been receiving therapy services for approximately two months and was working toward returning to prior level of function. The therapist further stated the resident was discharged from therapy on 4/15/26 after reaching highest potential. On 4/17/26 at 12:20 PM, S #2 interviewed the Regional Rehab representative who stated the resident was receiving rehab services on and prior to 4/12/26. On 4/17/26 at 12:55 AM, S #2 interviewed the LPN/MDSC, who stated, it appears the quarterly MDS did not capture that the resident was receiving physical therapy during the 7-day look-back period. On 4/18/26 at 9:55 AM, S #2 reviewed again the resident's MDS and revealed that the MDS was modified to reflect that the resident received PT services. On 4/21/26 at 11:59 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, Director of Nursing (DON), Regional DON 1 (RDON1), and Regional DON 2 (RDON2) acknowledged that the MDS assessment was inaccurate and required correction. The LNHA stated that education provided to MDS coordinator and the MDS was fixed. A review of the facility's MDS Accuracy Policy and MDS Error Correction Policy, dated/revised October 2025, which included, the assessment coordinator or designee will complete MDS assessments per directions in the Resident Assessment Instrument Manual and per CMS (Centers for Medicare and Medicaid Services) guidelines and regulations.The policy goes on the state .A significant error inaccurately reflects the resident's clinical status and/or may result in an inappropriate plan of care. 3. On 4/15/26 at 10:56 AM, Surveyor #3 (S #3) observed a posted sign outside Resident #8's door for EBP (Enhanced Barrier Precautions). Inside the room, the resident was observed seated in the bed with oxygen in use. S #3 reviewed the medical records of Resident #8, and revealed: A review of the AR revealed that Resident #8 was admitted to the facility with diagnosis that included but were not limited to; displaced trimalleolar fracture (a severe, unstable ankle injury where all three bony prominences (malleoli) break: the lateral (fibula), medial (tibia), and posterior (back of the tibia) malleolus) of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, muscle weakness, unspecified atrial fibrillation, and chronic kidney disease, stage 4 (severe). A review of the comprehensive MDS (cMDS), with an ARD of 3/19/26, reflected in Section C-Cognitive Patterns that Resident #8 had a BIMS score of 15, which indicated that the resident had an intact cognition. Section O- Special Treatments, Procedures, and Programs were coded as follows: -influenza vaccination was received outside facility; -pneumococcal vaccine was offered and declined; and -COVID-19 vaccine was not up to date. A review of the immunization tab in the eMR revealed that there was no documentation to reflect information about influenza, pneumococcal, and COVID-19 vaccinations. A review of the Nursing Admission-readmission Screening dated 3/13/26, under B. Vital Signs/Immunizations/Allergies revealed: #5. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? was coded 2 (no, offered). 5a. Date of influenza vaccine. [was blank] 5b. If influenza vaccine not received, state reason: was coded 2 (received outside of this facility) 6. Is the resident's Pneumococcal vaccination up to date? was coded 2 (no, offered) 6a. Date of pneumococcal vaccine. [was blank] 6b. If pneumococcal vaccination not received, state reason. [was blank]. the choices: 1. not eligible and 2. offered and declined Further review of the medical records revealed no documented evidence that the resident was offered and declined COVID-19 vaccine(s), nor the resident was asked about their history of COVID-19 in the 3/13/26 assessment. Furthermore, there was no documented evidence that the resident had offered and declined the pneumococcal vaccine and COVID-19 vaccinations were up to date as reflected in the comprehensive MDS with an ARD of 3/19/26. On 4/16/26 at 11:24 AM, the Infection Preventionist Nurse (IPN) informed S #3 that after reviewing Resident #8's medical records, she confirmed that there were no information of resident's immunization, flu, pneumonia, and COVID in the immunization tab of the eMR. She also stated that there were information that the vaccination history of the resident was asked in the admission on [DATE] of the resident by the nurse, and no information about COVID-19. At that same time, the IPN provided a copy of the PN that she documented dated 4/16/26 at 10:24 AM, after surveyor's inquiry with a Note Text called and spoke with resident's emergency contact 1.for vaccination records.the Resident Representative (RR) said the RR will look for the record as the VA (Veterans Affair) nurse is coming tomorrow. The surveyor then asked the IPN, should the PN and information was asked to the resident or RR prior to surveyor's inquiry, and the IPN did not respond. On 4/17/26 at 10:46 AM, S #3 interviewed the LPN/MDSC regarding the MDS immunizations in Section O, and she stated that she gathered information from the immunization tab in the eMR, if not there, in the admission record, and hospital records of the resident. S #3 notified the LPNMDSC about the MDS concern for ARD 3/19/26, that the pneumococcal immunization was coded offered and declined when there was no documentation that it was offered and declined. S #3 also notified the LPN/MDSC of the concern that COVID-19 was coded not up to date when there was no documented evidence of such record, not until yesterday when the surveyor's inquiry. She said she would get back to S #3. S #3 asked whether that should be considered inaccurate MDS if there were no information about it, and she did not respond. On 4/17/26 at 11:59 AM, the LPNMDSC informed S #3 that she modified Resident #8's MDS to reflect the accurate information for resident's vaccination status on 3/19/26. 4.S #3 reviewed the medical records of Resident #14, and revealed: A review of the AR revealed that the resident was admitted to the facility with diagnosis that included but were not limited to; pressure ulcer (PU) of sacral region, stage 4, muscle weakness (generalized), difficulty in walking, not elsewhere classified, and unspecified protein-calorie malnutrition. A review of the Assessment tab in the eMR revealed an admission assessment dated [DATE], reflected in the skin evaluation that the resident had a sacrum stage 4 (a severe, full-thickness wound with extensive tissue loss, exposing muscle, tendon, ligament, cartilage, or bone) and right buttock DTI (deep tissue injury; often rapidly evolving pressure injury where soft tissue is damaged under intact skin due to prolonged pressure or shear). A review of the re-admission assessment dated [DATE] at 10:52 PM, revealed that the resident had sacral, right buttock, and left buttocks PU. The skin evaluation did not include further description of the wound to indicate the staging of the wounds (the classification of pressure injuries (bedsores) based on their depth and severity, ranging from Stage 1 (skin intact) to Stage 4 (deep tissue exposure) except for the measurements. A review of the PN, created by the Physician Assistant (PA) with an effective date of 7/28/25 at 10:00 AM, for a wound initial consult reflected that the resident had a stage 4 PU in the sacrum. A review of the PN, type: Skilled Note, with an effective date of 7/30/25 at 9:50 PM, created by the Registered Nurse (RN), with a text note that the resident with sacral wounds unstageable, peri buttocks MASD (Moisture-Associated Skin Damage, a condition where prolonged exposure to moisture leads to inflammation and erosion of the skin), right buttocks with DTI, and with no s/sx (signs/symptoms) of infection noted. Further review of the PN, type: Skilled Note, with an effective date of 7/31/25 at 2:55 PM, created by a Licensed Practical Nurse (LPN), with a note text that the resident with sacral wounds unstageable, peri buttocks MASD, right buttocks with DTI, and with no s/sx of infection noted. A review of the modified cMDS, with an ARD of 7/31/25, reflected in Section M-Skin Conditions that the resident had one stage 4 and one unstageable DTI PU that both were present on admission. A review of the qMDS with an ARD of 2/25/26, reflected that the resident had severely impaired cognition. Section M reflected that the resident had one stage 4 PU that was present on admission. Further review of the medical records revealed that Resident #14's MASD that were documented by the LPN (7/31/25) and the RN (7/30/25) were not identified in the resident's comprehensive MDS on ARD 7/31/25. There was no documented evidence as to why it was not captured in the MDS. On 4/17/26 at 9:28 AM, S #3 interviewed the LPN/MDSC in the nursing station of LTC unit regarding the MDS. The LPN/MDSC informed S #3 that the facility followed the RAI (Resident Assessment Instrument) manual when doing MDS, she was responsible for Sections A, B, some part of C with Social Worker (SW), J, L, M, N, O some part with Rehab department, P, and Section V. She also stated that for Section M-wounds in the MDS, she gather the information from the resident's medical records including the nursing notes, physician and the wound consultation notes. At that same time, S #3 notified the LPN/MDSC of the above concern with Resident #14's MASD documentations by the LPN and an RN were not reflected in the coding of the MDS specifically in the ARD 7/31/25. S #3 then asked the LPN/MDSC if that would consider an inaccurate MDS coding if the MDS did not reflect the current condition and assessment of the resident, and the LPN/MDSC stated she would review the record and would get back to S #3. On 4/17/26 at 1:30 PM, the survey team met with the LNHA and DON informed S #2 that it was the responsibility of the wound nurse (contracted) to stage the wound of the resident, and the Wound Nurse (also known as the PA) was in the facility at least once or twice a week. The DON was unable to state the specific days the PA was at the facility. The DON further stated that when a resident was admitted or readmitted at the facility, on the day of admission, the nurse describe the wound, and the second or following day, an RN would stage the wound. S #3 then notified the LNHA and DON of the above findings and concerns with Resident #14's inaccurate coding for the MDS. On 4/20/26 at 10:24 AM, the RN/MDS Coordinator (RN/MDSC) informed S #3 that they go by the PA assessment on 7/28/25, that there was no MASD that was why the MDS was not coded with MASD. She also stated that there were no documentation that the assessment of an RN on 7/30/25 was clarified that there was no MASD. S #3 then asked the RN/MDSC if part of her MDS assessment was to observe and assess resident if there was an MASD, and she responded, I do not physically look. On 4/20/26 at 10:29 AM, the DON stated that she was not familiar with MDS and unable to speak about it. She further stated that the RN who documented on 7/30/25 resigned and was not an employee of the facility anymore. On 4/21/26 at 11:59 AM, the survey team met with the DON, RDON1, RDON2, and the LNHA stated that for Residents #8 and #14, we provided education to the MDS Coordinators. 5. On 4/15/26 at 11:43 AM, S #4 observed Resident #89 seated in a w/c in the dayroom waiting for lunch to be served. On 4/16/26 at 10:31 AM, S #4 reviewed Resident #89 medical record. A review of Resident #89's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia (a decline in mental ability—such as memory, language, problem-solving, and thinking—severe enough to interfere with daily life) and anxiety (a common mental health condition characterized by excessive, uncontrollable fear or worry that interferes with daily life). A review of Resident #89's most recent cMDS, with an ARD of 3/3/26, reflected that the resident had a BIMS score of 00 out of 15, which indicated the resident's cognition was severely impaired. Further review of the cMDS reflected that the resident received the influenza vaccine in the facility for the current year's season on 1/31/25. The date administered was not in the current year's season. The cMDS was not coded accurately. A review of Resident #89's most recent qMDS, with an ARD of 12/3/25, reflected that the resident received the influenza vaccine in the facility for the current year's season on 1/31/25. The date administered was not in the current year's season. The qMDS was not coded accurately. A review of Resident #89's eMR under immunization tab reflected that the last documented influenza vaccine was given to the resident was 1/31/25. There was no documented evidence that the influenza vaccination was offered, given or refused for the most recent influenza vaccination season. On 4/17/26 at 10:40 AM, S #4 interviewed the LPN/MDSC regarding the influenza vaccination coding, and the LPN/MDSC stated that it was coded by when the season started and the email mass notification system started. S #4 asked LPN/MDSC if Resident #89's most recent aMDS and qMDS were accurate for the influenza vaccination. She stated that she would have to check. On 4/20/26 at 12:16 PM, S #4 notified the LNHA and DON the concern that Resident #89's most recent aMDS and qMDS were not accurate for the influenza vaccination status. On 4/21/26 at 12:19 PM, in the presence of the DON, RDON1 and RDON2, the LNHA stated that staff were education on accuracy. On 4/21/26 at 1:27 PM, the survey team met with the LNHA, DON, RDON1 and RDON2 for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-33.2 (d)

Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice that meet each resident's physical, mental and psychosocial needs, specifically a.) ensuring a consent was obtained and signage posted for video monitoring for 1 of 2 residents reviewed for falls (Resident #16) and b.) ensuring hospice recommendations that were not followed were clarified with the physician and medications discontinued that a hospice resident was refusing to take for 1 of 2 residents reviewed for hospice (Resident #75).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. 1. On 4/15/26 at 11:25 AM, the surveyor observed Resident #16 seated in a wheelchair in their room. The surveyor observed a video monitoring camera on the dresser. There was no signage on the door of the room or inside the room to indicate video monitoring was in the process. A review of Resident #16's admission Record (AR) or face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to hemiplegia and hemiparesis following cerebral infarction (total paralysis and weakness on one side of the body which are consequences of a stroke or cerebral infarction due to damaged brain tissue) and encephalopathy (a broad, non-specific term for any disease, damage, or dysfunction that alters brain function or structure). A review of Resident #16's most recent Discharge Return Anticipated Minimum Data Set (DRAMDS), with an Assessment Reference Date of 3/17/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review reflected the resident had a fall with major injury. A review of Resident #16's comprehensive care plan (CP) included a focus area of at risk for falls and actual falls related to impaired mobility and poor safety awareness which included but was not limited to the following intervention added 3/23/26 of video monitor at all times for safety. A review of Resident #16's April 2026 electronic Treatment Administration Record (eTAR) included the following order:Video monitor at all times, check for placement every shift. A review of Resident #16's Progress Notes (PN) included the following note dated 3/23/26:IDT (interdisciplinary team) met to discuss the fall incident that occurred on 3/17/26 around 4:45 PM. Resident was sent to ER (emergency room) and was admitted with Rt (right) thigh Hematoma. Resident returned to facility on 3/23/26, noted with five staples to scalp Rt temporal post laceration . Rt thigh hematoma, findings may reflect hematoma in the setting of recent trauma. Team recommended to apply video monitor at all times. Resident continues to be fall risk due to poor safety awareness despite of current interventions. Further review of the PN did not include any documentation that the resident representative (RR) was notified or gave permission for the video monitoring. A review of the resident's hybrid (electronic and paper) medical record did not contain a written consent from the RR for the video monitoring. On 4/17/26 at 9:57 AM, the surveyor interviewed Licensed Practical Nurse #1 (LPN #1) who stated that the resident had a recent and had a fall when the resident was located on the other unit. LPN #1 stated that the resident liked to get up in the room and that there was a video monitor in the room. LPN #1 stated that when the resident had returned from the hospital, the resident was moved to a room by the nurse station and that the resident was in an activity now. On 4/20/26 at 12:51 PM, the surveyor interviewed LPN #2 who stated that Resident #16 had video monitoring especially at night and when in the room by themselves. LPN #2 stated that the resident suffered a stroke and was very impulsive and did not make good decisions. The surveyor asked LPN #2 if there was signage for the video monitoring. LPN #2 confirmed that there was no signage for the video monitoring in Resident #16's room or door. The surveyor asked LPN #2 if there was a written consent for the video monitoring. LPN #2 stated that they had obtained verbal consent from the RR and that the RR was in agreement with the video monitoring. The surveyor, in the presence of LPN #2 reviewed Resident #16's paper medical record and did not see a written consent for video monitoring. LPN #2 confirmed that there was not a written consent for the video monitoring. The surveyor observed the monitor for Resident #16 was sitting on the counter of the nurses station. The resident was not currently in their room. On 4/20/26 at 1:01 PM, the surveyor interviewed the Director of Nursing (DON) regarding video monitoring. The DON stated that it was ok if in a private room and that if in a two-person room would have to get consent. The DON stated that if a resident was a high fall risk, then one of the interventions they used was for video monitoring if the RR was agreeable. She added that they would get written consent or verbal consent. The surveyor asked if the verbal consent would be documented. The DON stated that it would be expected to be documented. The surveyor asked the DON if there should be signage about the video monitoring that was occurring. The DON stated, something to be considered. On 4/20/26 at 1:06 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #16 had video monitoring and there was no documented evidence that a consent was obtained and that there was no signage alerting that the room was being video monitored. On 4/21/26 at 12:27 PM, in the presence of the DON, Regional DON #1 (RDON1) and RDON #2 (RDON2), the LNHA stated that the staff were educated about consent and signage for video monitoring. A review of the facility's Photography/Videography Policy with a reviewed date of 3/2026, included the following:3. Room video monitoring devices to monitor resident safety use audio/video transmitter that stays in the room, while a handheld monitor is held by staff.4. If a video monitoring device is installed in a resident's room, a sign will be posted at the room entrance to inform all residents, visitors, employees, etc., of the use of this device. The staff shall obtain signed consent from the resident's roommate or authorized representative before video monitoring starts.5. Staff must obtain written consent from the resident or resident's legal representative to have video camera in the room.6. Residents' privacy rights and dignity should always be maintained. Video monitor will be turned off when staff are providing care. Attached was an example of the Resident Video Monitoring Consent Form. The LNHA did not provide any additional information. 2. On 4/15/26 at 10:20 AM, the surveyor observed Resident #75 asleep in bed. On 4/16/26 at 11:51 AM, the surveyor reviewed Resident #75's medical record. A review of Resident #75's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anorexia (a serious, potentially life-threatening eating disorder characterized by an intense fear of gaining weight, self-starvation, and a distorted body image) and dementia (a decline in mental ability-such as memory, language, problem-solving, and thinking-severe enough to interfere with daily life). A review of Resident #75's most recent comprehensive MDS with an ARD of 3/30/26, reflected that the resident had a BIMS score of 00 out of 15, which indicated the resident's cognition was severely impaired. Further review reflected the resident received hospice services. A review of Resident #75's Hospice recommendations dated 3/18/26 included the following:D/C (discontinue) Memantine, Eliquis, Vitamin D3, Multivitamin, Cyanocobalamin, Ascorbic Acid, Methenamine, Omega.Start Memantine 5 mg (milligram) 1 tablet (tab) daily for 7 days and then DC. A review of Resident #75's March 2026 electronic Medication Administration Record (eMAR) reflected that after 3/18/26 the resident refused Ascorbic acid 8 out of 13 days; Methenamine 2 of 13 days; Multivitamin 7 of 13 days; Vitamin D 8 of 13 days. Further review reflected that Cyanocobalamin, Omega-3, Losartan and Eliquis were discontinued (d/c'd) on 3/20/26. A review of Resident #75's April 2026 eMAR reflected that the resident refused Ascorbic acid 13 out of 16 days; Methenamine 4 of 16 days; Multivitamin 13 of 16 days; Vitamin D 14 of 16 days. A review of the physician note dated 3/20/26 included the following:Hospice then 10 words that were illegible. d/c 1 illegible word & Eliquis. Family wants to keep Namenda & 1 illegible word. 3 illegible words. It did not appear that all the medications (meds) that were recommended to be d/c'd were addressed in the note. A review of the physician note dated 4/14/26 was illegible. A review of Resident #75's Progress Notes (PN) included the following note:3/18/26 16:41 PN -Note Text: Resident evaluated today by Hospice with RR at bedside. admitted to hospice with Dx of Anorexia. Recommendations given, and PMD (primary medical doctor) made aware. PMD ordered to d/c Eliquis.New orders:Morphine 20 mg/ml (milligrams/milliliters) - 5 mg SL (sublingual) Q4H (every 4 hours) PRN (as needed) for pain/SOB (shortness of breath)Lorazepam 2 mg/ml - 0.5 mg SL Q4H PRN for anxiety/restlessness.Hyoscyamine 0.125 mg/0.25 ml - 0.125 mg SL Q6H PRN for secretions.Acetaminophen 650 mg Supp (suppository) - 1 Supp Q 6H (every 6 hours) PRN for fever.Bisacodyl 10 mg Supp - 1 Supp Daily PRN for constipationPMD stated she will talk with family.Endorsed. Further review of the PN reflected that resident refused to take meds and became agitated on additional attempts to administer meds on 3/25/26, 4/7/26, 4/14/26, 4/18/26 and 4/19/26. On 4/16/26 at 12:19 PM, the surveyor interviewed LPN #3 who stated that usually the meds were d/c'd that hospice recommends. The surveyor asked LPN #3 who checked the recommendations and LPN #3 stated that she would have to get back to the surveyor on that. She added not the nurse but that maybe it was the Unit Manager or Assistant DON. On 4/16/26 at 12:23 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that for they called the primary physician with the hospice recommendations to see what should be started or discontinued. She added that sometimes the physician did not agree and that it should be documented somewhere. On 4/17/2026 at 9:16 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she had shown the hospice recommendations to the physician and that the physician would follow up with the RR. The surveyor asked the RN about the multiple refusals of the meds. The RN stated that the physician was aware that the resident refused but that the physician wanted us to try. On 4/17/26 at 9:32 AM, the surveyor asked the RN/UM to read the physician notes. The RN/UM stated that she was unsure what some of the words that were written were and that she would call the physician. On 4/20/26 at 10:00 AM, the RN/UM stated that she spoke with the physician and that she wanted to continue the medicine because the RR wanted it. The RN/UM stated that she did not ask the physician what her note specifically was but that she read each med to her. An additional review of Resident #75's PN included the following note dated 4/17/26: LATE ENTRY Spoke to PMD regarding the recommendations to d/c meds, per PMD the RR still wanted to continue Namenda and vitamin. Will continue to monitor. The clarification was done after surveyor inquiry. On 4/20/26 at 9:45 AM, the surveyor interviewed the DON who stated that when hospice makes recommendations that they notify the physician and carry them out if the physician is in agreement and the RR was involved. The surveyor asked the DON what was done if the resident refused the meds. The DON stated that she would have to check. On 4/20/26 at 12:19 PM, the surveyor notified the LNHA and DON the concern that Resident #75's hospice recommendations were not followed and the facility did not clarify the physician's documentation as to which recommendations were to be followed and that the Eliquis was d/c'd but the various supplements were not and the resident was refusing and became agitated when nurses made several attempts to administer the meds. On 4/21/26 at 12:21 PM, in the presence of the DON, RDON1 and RDON2, the LNHA stated that the physician only d/c'd the eliquis and that the physician spoke with the RR. He added that they called the doctor to confirm. The surveyor asked if the physician documentation should have been clarified prior to surveyor inquiry. The DON stated that it should have been clarified. She added that the RR requested to try to administer the meds. The LNHA stated that staff were educated. A review of the facility's Hospice Program Policy with a reviewed date of 10/2025, included the following:5. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The CP shall be revised and updated as necessary to reflect the resident's current status. The LNHA did not provide any additional information. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) an air mattress was set according to the resident's weight and b.) the medication administration record was signed in accordance with professional standards of nursing practice for 1 of 2 residents reviewed for pressure ulcer (PU) (Resident #11).This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/15/26 at 10:27 AM, the surveyor observed Resident #11 asleep in bed. The Registered Nurse/Unit Manager (RN/UM) informed the surveyor that the resident had a facility acquired PU. On 4/16/26 at 9:00 AM, the surveyor interviewed Resident #11 who stated that they received an antibiotic for the wound (PU) they had. A review of Resident #11's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to cerebral infarction (or ischemic stroke, occurs when blood flow to the brain is blocked, starving brain tissue of oxygen and causing cell death) and moderate protein-calorie malnutrition (a condition marked by inadequate intake of protein and calories, resulting in 10-20% weight loss, reduced muscle mass, and exhaustion). A review of Resident #11's most recent quarterly Minimum Data Set (qMDS) with an Assessment Reference Date (ARD) of 3/31/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the qMDS revealed that the resident had one Stage 3 PU that was not present upon admission/entry or reentry. A Review of Resident #11's April 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) included the following orders:Vancomycin HCl (hydrochloride) Intravenous Solution Reconstituted 1 gm (gram), use 1 vial intravenously one time a day for Wound infection. for 21 Days until finished with a start date of 4/8/26. The order was plotted to be administered at 6:45 AM. There was a blank for 4/9/26 and 4/13/26. The medication (med) was not marked as administered or held. Device: Mattress-Air, check for placement and functioning every shift with a start date of 5/28/25. The order did not indicate to check the setting of the air mattress. A review of Resident #11's weight was 126 pounds on 4/2/26. On 4/16/26 at 10:40 AM, the surveyor observed Resident #11's PU treatment that was performed by Licensed Practical Nurse #1 (LPN #1) and LPN #2. Following the wound treatment, the surveyor observed that Resident #11's air mattress was set at 260. The surveyor observed the resident who was not 260 pounds. LPN #1 and LPN #2 confirmed that the setting was 260. On 4/16/26 at 11:23 AM, the surveyor interviewed LPN #1 who stated that she was not really sure but that a resident's weight was taken into consideration and that she would check. On 4/17/26 at 9:12 AM, LPN #1 stated that she was not sure why the setting was up but that maybe someone touched it and that now it was set by the weight. On 4/17/26 at 9:35 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding Resident #11's antibiotic order. The RNUM stated that there should not be blanks and that if something was not administered it should have documentation as to why. She added that maybe if a trough was done they were holding it until the result. The surveyor asked if there should have been documentation for that. She stated that she would have to check. The surveyor then asked the RN/UM about air mattress process. The RN/UM stated that every shift the air mattress was checked that it was in place, functioning and set according to weight. The surveyor showed the RN/UM the picture of Resident #11's air mattress setting from the prior day. The RN/UM stated that the air mattress should have been set to the weight. On 4/20/26 at 9:42 AM, the surveyor interviewed the Director of Nursing (DON) regarding air mattress process. The DON stated that the air mattress was set on static by weight [of resident] and that the nurses were expected to check the setting every shift. The surveyor then asked the DON if a resident's eMAR should have blanks. The DON stated that unless there was a hold. The surveyor asked if there should be a code for a hold. The DON stated that there should be a code. On 4/20/26 at 12:16 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #11's air mattress was not set according to the resident's weight and that there were two blanks for the Vancomycin order. On 4/21/26 at 12:19 PM, in the presence of the DON, Regional DON #1 (RDON1) and Regional DON #2 (RDON2), the LNHA stated that all staff were educated on the air mattress and that the order was changed to include check the settings. The LNHA added that maybe it was not checked yet that shift. The LNHA stated that he received a statement from the nurse that she gave the med and that it was blank. The email statement provided was dated 4/20/26 The LNHA did not provide any additional information. A review of the facility's Manufacturer's Use Instructions for the air mattress included the following:Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. A review of the facility's Administering Medications Using Electronic System Policy with a reviewed date of 11/2025, included the following:Charting Withholding/Refusal of Medications on the eMAR16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the med shall document following the appropriate key guide in the eMAR space provided for that drug and dose. N.J.A.C. 8:39-27.1

Based on observations, interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of resident that was receiving oxygen according to the standard of clinical practice and the facility's policy and procedure. This deficient practice was identified for 1 of 1 resident, Resident #8, reviewed for respiratory care, and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 4/15/26 at 10:56 AM, the surveyor observed a posted sign outside Resident #8's door for EBP (Enhanced Barrier Precautions). Inside the room, the resident was observed seated on the bed with oxygen (O2) in use. S #3 reviewed the medical records of Resident #8, and revealed:A review of the admission Record or face sheet (an admission summary) revealed that Resident #8 was admitted to the facility with diagnosis that included but were not limited to; displaced trimalleolar fracture (a severe, unstable ankle injury where all three bony prominences (malleoli) break: the lateral (fibula), medial (tibia), and posterior (back of the tibia) malleolus) of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, muscle weakness, unspecified atrial fibrillation (afib), and chronic kidney disease, stage 4 (severe). A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/19/26, reflected in Section C-Cognitive Patterns that the resident had a BIMS score of 15 out of 15, which indicated that the resident had an intact cognition. The MDS also included that the resident received O2. A review of the Order Summary Report (OSR) revealed the following physician's order (PO) that included but were not limited to:-Check O2 saturation (sats) every shift-Start Date 3/14/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. The above PO to check O2 sats was signed by nurses every shift except on 4/12/26 at night shift. The 4/12/26 had no documentation of O2 sats and initials of the nurse. -Transmission Based Precautions: EBP for suprapubic catheter every shift-Start Date 3/13/26-Hold Date from 4/9/26 to 4/10/26. -Administer O2 at 3 L/Min (liters/minute) via NC (nasal cannula) as needed (PRN) for SOB/SPO2 (shortness of breath/Peripheral Oxygen Saturation) below 90-Start Date 3/25/26-Hold Date from 4/9/26 to 4/10/26-Hold Date from 4/13/26 to 4/13/26. A review of the above PO for O2 at 3 L/min, there were no documentation or signature of nurse(s) to indicate that the resident was administered with O2 nor was the sats obtained. A review of the Progress Note (PN) with an effective date of 4/14/26 at 10:00 PM, that was electronically signed by Licensed Practical Nurse #1 (LPN #1), with a note text that the resident was received alert and oriented at approximately 3:00 PM, seated in a wheelchair with O2 via NC.Care plan on going. A review of the PN, with an effective date of 4/15/26 at 2:06 PM, that was electronically signed by Licensed Practical Nurse #2 (LPN #2) with a note text that Resident #8 was anxious and complained of SOB; constantly pushing call bell for minor details; with disruptive behavior. New order for IV (intravenous) furosemide (diuretic) 40 mg (milligram) was ordered. Resident in bed, accompanied by the resident representative (RR). Further review of the medical records revealed that the PO for PRN 3 L/min O2 was not followed, there was no documentation that it was administered on 4/14/26 when LPN #1 documented in her PN that O2 via NC was in used. There was no documentation that the O2 was administered on 4/15/26 when the resident complained of SOB, LPN #2 did not follow the PO to administer the 3 L/min O2 for PRN SOB. On 4/16/26 at 9:53 AM, the surveyor observed Licensed Practical Nurse #3 (LPN #3) inside the resident's room while the resident seated on their bed with O2 via NC. LPN #3 informed the surveyor that the resident was on continuous O2 at 2 L/min while checking the O2 concentrator at 3 L/min (set), and LPN #3 stated that it will drop to 2 liters later. On 4/16/26 at 10:05 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who stated that she was covering for the other RN/UM. The surveyor notified the RN/UM of the concern that for two days of observation that the resident was on O2 via NC and that the electronic Medication Administration Record (eMAR) was not signed for PO of PRN O2. The RN/UM confirmed that the O2 eMAR and electronic Treatment Administration Record (eTAR) should have been signed. Later on, during the interview of the surveyor with the RN/UM, Licensed Practical Nurse #4 (LPN #4) informed the surveyor Resident #8 was on continuous O2 and the records should have been signed that it was administered. The surveyor also notified the RN/UM and LPN #4 the concern that there was no order for continuous O2 and only PRN which was not signed. On 4/16/26 at 10:31 AM, the surveyor interviewed LPN #2 who informed the surveyor that she was the assigned nurse of the resident yesterday (4/15/26) at 7-3 shift, and that the resident was on continuous O2 via NC at 3 L/min. She further stated that when she came in yesterday at 7:00 AM, the resident was on O2 already. On that same date and time, LPN #2 stated that she was a per diem nurse, had worked four times at the facility, and a floater. She indicated that the resident was on continuous O2 because the resident's O2 sats without O2 was on 88%. She was unaware that there was no standing order for O2, and that the order was a PRN. She had no response when asked why she did not sign the eMAR when O2 was used by the resident yesterday. On 4/20/26 at 12:14 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with regard to Resident #8's O2. On 4/21/26 at 11:59 AM, the survey team met with the DON, Regional DON #1 (RDON1), Regional DON #2 (RDON2), and the LNHA stated that for Residents #120, we provided education to all staff. A review of the facility's Oxygen/Nebulizer Care Policy that was provided by the DON, with a reviewed date of 10/2025, reflected in the policy, to administer O2 for the treatment of certain diseases or conditions. Policy Explanation and Procedures: 1. Care of the resident: a. obtain PO for the rate of flow and route of administration of O2 (mask, NC, etc.). On 4/21/26 at 1:27 PM, the survey team met with the LNHA, DON, Regional DON #1 (RDON1) and Regional DON #2 (RDON2) for exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-11.2(a)(b); 27.1(a)

Based on interviews and review of other facility documentation, the facility failed to ensure that the physician must include an evaluation of the resident's condition and total program of care and a decision about the continued appropriateness of the resident's current medical regimen. The primary physician's history and physical and succeeding visit notes did not reflect resident's skin impairment and pressure ulcer. This deficient practice was identified for 1 of 27 residents, (Resident #14), reviewed for physician services.This deficient practice was evidenced by the following: On 4/17/26 at 8:34 AM, the surveyor reviewed the medical records of Resident #14, and revealed the following: The admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnosis that included but were not limited to; pressure ulcer (PU) of sacral region, stage 4 (a severe, full-thickness wound involving extensive destruction, tissue necrosis, and damage to muscle, bone, or supporting structures), muscle weakness (generalized), difficulty in walking, not elsewhere classified, and unspecified protein-calorie malnutrition. A review of the modified comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/31/25, revealed that Resident #14 had one stage 4 and unstageable PUs (pressure ulcers) that were present on admission. A review of the comprehensive MDS with an ARD of 11/25/25, revealed that the resident had one unstageable PU that was present on admission. A review of the quarterly MDS with an ARD of 2/25/26, revealed that the resident had one stage 4 PU that was present on admission. A review of the Care Plan that was revised on 8/11/25, reflected that the resident had a right buttock DTI (deep tissue injury; is a serious pressure injury characterized by localized, persistent, non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin) and stage 4 sacral PU. A review of the assessment tab in electronic medical record revealed the following skin evaluation:-7/24/25, admission assessment, reflected a sacrum stage 4 and right buttock DTI. -11/12/25, readmission assessment, reflected a sacrum right and left buttocks unstageable. -12/12/25, readmission assessment, reflected a sacrum, right and left buttocks skin impairment with no staging. A review of the 2/10/26 Weekly Skin Condition revealed stage 4 sacral and bilateral buttocks mycosis (a disease or infection caused by a fungus that invades human tissues). A review of the Progress Notes (PN) with an effective date of 7/30/25 at 9:50 PM, that was electronically signed by the Registered Nurse (RN), revealed that Resident #14 with sacral wounds unstageable, peri buttocks MASD (Moisture Associated Skin Damage is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage), right buttocks with DTI, bilateral thigh with wounds, no s/sx (signs/symptoms) of infection noted. Further review of the PN with an effective date of 7/31/25 at 2:55 PM, that was electronically signed by Licensed Practical Nurse #1 (LPN #1) revealed that Resident #14 with sacral wounds unstageable, peri buttocks MASD right buttocks with DTI, bilateral thigh with wounds, no s/sx of infection noted. On 4/17/26 at 9:39 AM, the surveyor reviewed the paper chart of the resident and revealed that the resident's primary physician had a handwritten History and Physical (H&P) dated 7/24/25, documented in the physical findings skin no lesions. The succeeding visit notes dated 8/1, 8/4, 8/27 documented PUs were absent and skin no rashes, lesions, ulcers. The follow up visit notes 10/4/25, 10/24/25, 11/4/25, 11/15/25, 12/4/25, 12/18/25, 1/4/26, 1/18/26, 2/4/26, 2/15/26, 3/4/26, 3/18/26, and 4/3/26 did not identify any skin impairments. There was one visit note with handwritten information after 4/3/26, with no date and was already signed by the primary physician. Further review of the paper chart included a UTF (Universal Transfer Form) dated 12/9/25, transfer from the facility going to the hospital with a reason for transfer: failure to thrive, malnutrition, and unstageable sacral wound. The UTF was signed by the RN/Unit Manager (RN/UM). On 4/17/26 at 9:44 AM, the surveyor interviewed Licensed Practical Nurse #2 (LPN #2) who stated that he was the assigned nurse of Resident #14. LPN #2 further stated that the resident was cognitively impaired, required total assistance with care, with PU, and had been in and out of the hospital where PU worsened. At that same time, both the surveyor and LPN #2 reviewed the paper chart of the resident and LPN #2 confirmed that the primary physician did not identify any skin impairment or PU in the visit notes. LPN #2 had no response as to why the primary physician did not identify in their visit notes resident's skin impairment and PU. On 4/17/26 at 9:47 AM, the surveyor notified the RN/UM of the above findings and concern regarding the physician's H&P and succeeding visit notes did not reflect resident's skin impairment and PUs. The RN/UM checked and reviewed the resident's paper chart and stated that she did not know why the physician did not document the PU and skin impairment. She further stated that it was an expectation that the visit notes should include the resident's information about wounds in the physician notes. The surveyor asked the RN/UM who was responsibility to check the physician's visit notes, and she did not respond. On 4/17/26 at 10:19 AM, the RN/UM informed the surveyor that she called the primary physician about the surveyor's concerns regarding the visit notes, and the physician stated that even though he did not document that the resident had wounds, it did not mean that the resident had no wounds, it was just missed. The RN/UM then provided the surveyor with the phone number of the physician. Afterward, the surveyor called the physician twice and the surveyor was unable to reach the physician because the voicemail was full and unable to leave a message. On 4/17/26 at 10:26 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) that the surveyor was unable to reach the primary physician for an interview. On 4/20/26 at 12:14 PM, the survey team met with the LNHA and the Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with regard to physician's H&P and succeeding visit notes did not reflect the resident's PU and skin impairments. On 4/21/26 at 11:59 AM, the survey team met with the DON, Regional DON #1 (RDON1), Regional DON #2 (RDON2), and the LNHA did not provide additional information. A review of the facility's Physician Services Policy that was provided by the LNHA, with a revised date of 10/2025, reflected under policy statement, the medical care of each resident is under the supervision of a Licensed Physician. Policy Interpretation and Implementation.3. Physician orders and PN shall be maintained in accordance with current.regulations and facility policy.6. The attending physician shall also be responsible for initial and ongoing medical evaluations as follows.b. The physician PN shall be maintained in accordance with acceptable professional standards and practices as necessitated by the medical beneficiary's and medical condition. On 4/21/26 at 1:27 PM, the survey team met with the LNHA, DON, RDON1 and Regional DON2 for exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-23.2(b); 35.2(d)(8, 5, 6)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure the consultant pharmacist identified and reported irregularities in the medication regimen, b.) ensure duplicate and conflicting physician orders were clarified, and c.) ensure that as needed and routine orders were not duplicative or clinically appropriate. This deficient practice was identified for 1 of 27 residents (Resident #6) reviewed for orders.The deficient practice was evidenced by the following: On 4/16/26 at 10:10 AM, the surveyor observed Resident #6 in the resident's room lying in bed. The resident was alert and oriented, with the call bell within reach. The surveyor reviewed the medical record for Resident #6. A review of the admission Record or face sheet (an admission summary), revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. A review of the comprehensive Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 4/2/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the resident's comprehensive care plan (CP) revealed no interventions addressing duplicate or conflicting physician orders (PO) related to skin treatments or medication (med) monitoring. A review of the Order Summary Report (OSR), dated as of 4/16/26, included concerns with the following PO:Order #1: apply cornstarch to BL (bilateral) groin q (every) shift and PRN (as needed) every shift for protection Start Date: 3/6/26. Order #2: MASD (moisture associated skin damage), intergluteal cleft- cleanse with NS (normal saline), apply Silvadene 1% cream and cover with alginate BID (twice a day) and PRN every day and evening shift for masd Start Date: 3/7/26. Order #3: Apply cornstarch to BL breast folds, abdominal [NAME], BL groin and buttocks q shift and PRN every shift for protection for redness Start Date: 3/6/26. Order #4: Intergluteal cleft- cleanse with NS, apply alginate, change BID and PRN every day and evening shift for masd Start Date: 3/7/26. Further review revealed that the above PO included: Duplicate cornstarch orders for overlapping anatomical areas (groin, breast folds, pannus, buttocks), Overlapping wound care orders for the same anatomical site (intergluteal cleft), including multiple orders for alginate and Silvadene, and routine and PRN orders for the same treatments without clear differentiation. There was no documented evidence that the above duplicate orders were clarified. A review of the monthly medication regimen review (MMR) dated 3/12/26 documentation revealed that the Consultant Pharmacist did not identify or report these irregularities, including duplicate and conflicting PO. On 4/17/26 at 9:51 AM, the surveyor interviewed the Director of Nursing (DON), who stated she would review the documentation and follow up regarding the identified concerns. On 4/20/26 at 12:30 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the DON and survey team, acknowledged that the duplicate and conflicting PO were not identified during the monthly MRR. The DON confirmed that duplicate and conflicting PO should be identified and clarified and that the consultant pharmacist was responsible for identifying irregularities during the MRR. On 4/21/26 at 12:00 PM, the LNHA stated that the irregular orders were fixed following surveyor inquiry. A review of the facility's Pharmacy Services - Role of the Consultant Pharmacist Policy, dated/reviewed 8/2025, which included that the Consultant Pharmacist is responsible for conducting a documented monthly MRR for each resident . The policy further included that the Consultant Pharmacist is to communicate potential or actual problems related to medications, including medication irregularities, to prescribers and facility leadership . NJAC 8:39-29.3

REPEAT DEFICIENCYBased on observation, interview, and review of other pertinent facility documentation, it was determined that the facility failed to; a.) follow appropriate hand hygiene, use of personal protective equipment (PPE), and disinfect equipment for 1 of 4 nurses during medication pass observation, b.) perform hand hygiene and follow enhanced barrier precautions (EBP) for 1 of 1 staff (Housekeeper), and c.) track the extent to which staff were following the facility's policy and procedures to control infections and communicable diseases for all residents with regard to vaccinations, failed to follow appropriate infection control practices to prevent the spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 6/28/24, revealed, EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. While this guidance focuses on gown and glove use, prevention of MDRO transmission in nursing homes requires much more than just proper use of PPE. Adherence to other recommended infection prevention practices including performing hand hygiene, cleaning and disinfection of environmental surfaces and resident care equipment, proper handling of indwelling medical devices, and care of wounds is also critical. CDC and health departments continue to identify gaps in recommended infection prevention practices as part of on-site infection control assessments in nursing homes. Examples include lack of access to alcohol-based hand sanitizer in resident rooms and other care areas; lack of access to EPA-registered disinfectants at the point of use; and failure to clean and disinfect shared resident care equipment after each use. 1.On 4/15/26 at 10:58 AM, Surveyor #1 (S #1) interviewed Licensed Practical Nurse #1 (LPN #1) who informed S #1 that residents with posted sign for EBP were those residents with tube feeding (TF), wounds, and catheters. She further stated that staff must follow the posted sign instructions for EBP. On 4/20/26 at 8:41 AM, S #1 observed the Housekeeper (HK) inside room [ROOM NUMBER] (R70), in the toilet room, kneeling while picking up garbage with gloves, stood up, left the toilet room, did not perform hand hygiene, exited the room with same gloves, walked in the hallway, and discarded the garbage and used gloves in one of two compartment bins with note for garbage. At that same time, S #1 observed the HK walked away from the two compartment bins, knocked in room [ROOM NUMBER] (R64) without performing hand hygiene, and entered the room. R64 door had a posted sign for EBP. S #1 asked HK for an interview outside R64. During an interview, the HK acknowledged and stated that he came out from one of the room where he picked up garbage. He continued to state that he left the room without removing used gloves, did not perform hand hygiene, and went to the two compartment bins to dispose of the garbage and used gloves. He further stated that he went to R64 with posted sign for EBP. After the interview, the surveyor did not observe HK performed hand hygiene and continued to walk away. On 4/20/26 at 8:44 AM, S #1 notified the Registered Nurse/Unit Manager (RN/UM) of the above findings and concerns with regard to HK's hand hygiene and use of gloves in the hallway. The RN/UM stated she would talk to the HK. She further stated that the HK should have removed gloves inside the room and performed hand hygiene. On 4/20/26 at 8:46 AM, S #1 interviewed Licensed Practical Nurse #2 (LPN #2) who informed S #1 that the resident in R64 had a posted sign for EBP due to presence of foley catheter and wound. 2. On 4/15/26 at 10:56 AM, S #1 observed a posted sign outside Resident #8's door for EBP. Inside the room, the resident was observed seated in the bed with oxygen in use. S #1 reviewed the medical records of Resident #8, and revealed: A review of the admission Record (AR) or face sheet (an admission summary) revealed that Resident #8 was admitted to the facility with diagnosis that included but were not limited to; displaced trimalleolar fracture (a severe, unstable ankle injury where all three bony prominences (malleoli) break: the lateral (fibula), medial (tibia), and posterior (back of the tibia) malleolus) of right lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, muscle weakness, unspecified atrial fibrillation (afib), and chronic kidney disease, stage 4 (severe). A review of the comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/19/26, reflected in Section C-Cognitive Patterns that the resident had a BIMS score of 15, which indicated that the resident had an intact cognition. The MDS also reflected that influenza vaccine was received outside the facility, the pneumococcal vaccine was offered and declined, and the COVID-19 vaccinations were not up to date. A review of the immunization tab in the electronic medical records (eMR) was blank. Further review of the eMR revealed that there was no documented evidence that the resident or Resident Representative (RR) was provided an opportunity in writing to accept or decline the COVID-19 vaccine. A review of the paper chart revealed that there was no consent forms for influenza, pneumococcal, and COVID-19 vaccines that the resident or RR signed. On 4/16/26 at 10:05 AM, S #1 interviewed the RN/UM who stated that it was the nurse's responsibility to obtain consent for vaccinations of the resident, and it should be documented in the immunization tab of the eMR, or if not in the progress notes (PN). S #1 notified the RN/UM of the above concern that Resident #8 had no consent obtained for s in the immunization tab. The RN/UM checked eMR and stated that she did not see also that consent was obtained. On 4/16/26 at 10:11 AM, S #1 interviewed the Infection Preventionist Nurse (IPN) in the presence of LPN #2 and the RN/UM regarding immunization records. The IPN informed S #1 that it should be obtained and document it in the immunization tab of eMR, and there were no paper consent forms anymore, it was being done electronically. S #1 then notified the IPN of the concern and asked how the resident's immunization were being tracked. The IPN stated that she would get back to S #1. On 4/16/26 at 11:24 AM, the IPN informed S #1 that after reviewing Resident #8's medical records, there was no information of resident's immunization for COVID-19. She further stated that the information for influenza and pneumococcal vaccines were asked and documented in the admission of resident on 3/13/26. At that same time, the IPN provided a copy of the resident's PN dated 4/16/25 at 10:24 AM, after surveyor's inquiry, with a note text that the IPN called the RR for vaccination records. S #1 then asked the IPN, should the PN and information was asked to the RR prior to surveyor's inquiry, and the IPN did not respond. The surveyor also asked how she was able to track the immunization of the residents in the facility and who was responsible for tracking, and she responded that some she was responsible, and that she would get back to S #1 to show her notebook. On 4/16/26 at 11:54 AM, the IPN provided a copy of the printed NJ (New Jersey) Immunization Information System Patient Immunizations Administered Report for Resident #8, which was printed on 4/16/26 at 11:51 AM, by the IPN, which was obtained after surveyor's inquiry. On 4/16/26 at 12:14 PM, the IPN provided and showed the three notebooks that she claimed her tracking for immunization of residents in the facility. The IPN informed S #1 that there were no record in her three notebooks that Resident #8 was checked or tracked for vaccinations, it was missed. The IPN stated that the three notebooks were for two facilities that she covered as an IPN. Both S #1 and the IPN reviewed the three notebooks, and S #1 asked the IPN why the three notebooks were incomplete, inconsistently documented, and missed other residents. The IPN responded that the notebook was not a tracking record for immunizations, it was for state reports. Furthermore, S #1 asked how she was able to track the immunizations of residents in the facility, and she did not provide a direct response, and stated that it was also the Director of Nursing (DON) who tracked the immunization records since she was only at the facility part time, two times a week at the facility, which was every Thursday and Friday. The IPN was unable to state where the tracking was documented. On 4/16/26 at 12:23 PM, S #1 in the presence of the Licensed Nursing Home Administrator (LNHA), Regional DON #1 (RDON1) and Regional DON #2 (RDON2) asked the DON if she was tracking immunizations of residents, and the DON was unable to answer. S #1 asked who was responsible for tracking immunizations of residents and RDON1 stated that it was the IPN who was responsible for tracking. At that same time, RDON2 stated to the IPN that she should have the tracking in excel spreadsheet of residents' immunization records, and the IPN responded that she did not have an excel spreadsheet for residents, but she had for staff. On 4/20/26 at 12:14 PM, the survey team met with the LNHA and the DON, and S #1 notified them of the above findings and concerns with regard to immunization records tracking. On 4/21/26 at 1:27 PM, the survey team met with the LNHA, DON, RDON1, and RDON2 for exit conference, and there was no additional information provided by the LNHA. 3. On 4/20/26 at 10:32 AM, Surveyor #2 (S #2) observed the following during medication (med) administration: -Licensed Practical Nurse #3 (LPN #3) did not perform hand hygiene before entering Resident #90's room to administer medications (meds), including Allegra, as well as Ipratropium-Albuterol Solution via nebulizer, and to use devices on the resident, including a stethoscope (a medical instrument used for listening to sounds inside the heart, lungs, intestines, and blood vessels) and pulse oximeter (a device usually placed on a fingertip that estimates the amount of oxygen in the blood). -LPN #3 did not sanitize the stethoscope or pulse oximeter before or after use on Resident #90. -LPN #3 washed their hands for 14 seconds before exiting Resident #90's room. -LPN #3 used the same paper towel to turn off the faucet as they used to dry their hands. On 4/20/26 at 10:38 AM, S #2 interviewed LPN#3 who stated they did not perform hand hygiene before entering Resident #90's room to administer medications (meds) and use devices on the resident. Moreover, LPN #3 stated they did not sanitize the stethoscope or pulse oximeter before or after use on Resident #90. LPN #3 stated the expectation was to sanitize the stethoscope and pulse oximeter before and after use. He also stated the expectation was to wash their hands for at least 20 seconds and that it was best practice to turn off the faucet with a new, unused paper towel. On 4/20/26 at 12:33 PM, S #2 discussed the concerns with the LNHA and the DON. On 4/21/26 at 12:35 PM, S #2 interviewed the LNHA and the DON. The LNHA stated equipment should be cleaned after each use. The DON stated that handwashing should be performed for at least 20 seconds, and a clean, separate paper towel should be used to turn off the faucet. A review of the AR revealed Resident #90 had diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), Unspecified (a chronic lung disease that prevents airflow to the lungs, causing breathing problems). A review of the Order Summary revealed orders for Resident #90 included, but were not limited to, the following: -Allegra Oral Tablet (tab)180 milligrams (MG), ordered 4/14/26, with directions to give 1 tab by mouth one time a day for post nasal drip. -Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 milliliters (ML), ordered 10/20/25, with directions to inhale 3 ML orally via nebulizer two times a day for COPD. Supplementary Documentation Codes: Pre & Post Treatment Lung Sounds - C = Clear, O = Other (see progress note) Pre & Post Treatment – P (pulse), R (respiratory), and Oxygen Saturation results. A review of the quarterly MDS, with an ARD of 3/27/26, revealed that Resident #90 had a BIMS score of 13 out of 15, which indicated intact cognition. A review of the facility's Cleaning and Disinfection of Resident-Care Items and Equipment Policy, revised 10/2022, revealed resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected. Reusable resident care equipment i.e.; stethoscopes, blood pressure cuffs, glucometer machine, will be decontaminated between residents use according to manufacturers' instructions. A review of the facility's Handwashing/Hand Hygiene Policy, revised 4/2010, revealed the following: -Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions, including but not limited to, before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). -If hands are not visibly soiled, use an alcohol-based hand run containing at least 70% ethanol or isopropanol for the following situations, including, but not limited to, before and after direct contact with residents; before preparing or handling meds. -Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. A review of the facility's Administering Meds Using Electronic System Policy, revised 4/2010, revealed staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of meds. NJAC 8:39-19.4(a)(1,2,4)

Based on interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure all residents and/or resident representatives must be educated on the COVID-19 vaccine the facility offered, in a manner they could understand for 2 of 5 residents reviewed for immunizations (Residents #6 and #7). This deficient practice was evidenced by the following: 1.On 4/16/26 at 10:46 AM, Surveyor #1 (S #1) reviewed the medical record for Resident #6. A review of the admission Record (AR) or face sheet (an admission summary) for Resident #6, revealed diagnoses which included, but were not limited to; multiple sclerosis, sepsis, extended spectrum beta-lactamase resistance, acute kidney failure, and depression. A review of the comprehensive Minimum Data Set (MDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 3/13/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the immunization record for Resident #6 revealed the last documented COVID-19 vaccine was administered on 10/5/23, with no documented evidence that the vaccine was offered, accepted, refused, or that education was provided after that date. On 4/17/26 at 8:30 AM, S #1 interviewed the Infection Preventionist Nurse (IPN), who stated that COVID-19 vaccines were offered through a system called Care Feed and that notifications were sent to the resident or Resident Representative (RR) monthly. The IPN further stated that if the resident or RR wanted the vaccine, they would respond to the notification. On 4/17/26 at 10:40 AM, S #1 interviewed the Director of Nursing (DON), who stated that the facility considered the Care Feed notifications as documentation that the vaccine was offered. On 4/21/26 at 12:00 PM, the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, stated that the COVID-19 vaccine was offered through the Care Feed system and that general education was provided through postings in the facility; however, documentation of the resident's response and education was not maintained in the medical record. A review of the facility's Resident Vaccination for COVID-19 Protocol, reviewed 10/2025, which indicated, The resident's medical record includes documentation that indicates, at a minimum. consent for each COVID-19 vaccine and/or booster, and date of each dose of COVID-19 vaccine and/or booster administered. The policy goes on to say the facility shall, Ensure that the resident or RR is provided with education regarding the benefits, risks and potential side effects associated with the vaccine or booster. 2.On 4/16/26 at 9:46 AM, Surveyor #2 (S #2) observed Resident #7 in the activity room sitting in the wheelchair. Resident #7 was unable to participate in an interview. A review of Resident #7's electronic medical record (eMR) revealed that the resident was admitted with diagnoses including dementia (decline in memory, thinking and daily function severe enough to affect everyday life), psychosis (difficulty distinguishing what's real from what isn't), depression and anxiety disorder. A review of the quarterly MDS, with an ARD of 3/1/26, indicated a BIMS score of 0 out of 15, reflecting that the resident was severely cognitively impaired. A review of the immunizations records in the eMR, revealed COVID-19 booster history of administration on 10/21/21. There was no recent documentation for offered, administered or refusal of COVID-19 immunizations. There was no documented evidence that the RR was educated regarding the benefits and potential side effects of COVID-19 immunizations. On 4/17/26 at 11:47 AM, S #2 interviewed the IPN who stated they did not have a tracking system in place for tracking immunizations status for the residents. She further stated that the information for the immunizations for the residents was in the eMR. The IPN stated that when the residents were admitted to the facility, she documented their immunizations in her notebook. The IPN could not provide any other information including documented evidence that the RR was educated regarding the benefits and potential side effects of COVID-19 immunizations. On 4/17/26 at 1:07 PM, S #2 requested immunization information for Resident #7. The IPN and surveyor reviewed the eMR together and the IPN confirmed that the information regarding immunizations was not available. The IPN stated she would look at the nursing notes. There was no further information provided. On 4/21/26 at 11:59 AM, The survey team met with the LNHA, DON, Regional DON #1 (RDON1), and Regional DON #2 (RDON2), there was no further information provided regarding the immunization information for Resident #7. A review of the facility's Resident Vaccination for COVID-19 Protocol Policy, updated 4/2026, Purpose: The facility will offer vaccination for COVID-19 for residents according to CMS QSO-21-19-NH, including education of resident or RR regarding the benefits and potential side effects associated with the COVID-19 vaccine. The facility will offer vaccination and as currently associated with the COVID-19 vaccine. The facility will offer vaccination and as currently recommended by the Centers for Disease Control and Prevention (CDC) and by the New Jersey Department of Health (NJ DOH). Procedure: All newly admitted , readmitted and current residents are to be offered a pneumococcal vaccine unless the immunization is medically contraindicated or the resident has already been immunized. Screening residents prior to offering the vaccination for prior immunization, medical precautions and contraindications is necessary for determining whether they are appropriate candidates for vaccination at any given time. If the resident has already been immunized, ensure that all vaccination information, are documented in the resident's medical record. Ensure that the resident or RR is provided education regarding the benefits, risks and potential side effects associated with the vaccine or booster. The resident or RR has the opportunity to accept or refuse the pneumococcal vaccine, and change their decision. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or RR was provided education regarding the benefits and potential risks associated with COVID-19 vaccine. Consent for each COVID-19 vaccine. Date of each dose of the COVID-19 vaccine and/or booster administered to the resident. If the resident did not receive COVID-19 vaccine due to medical contraindications (e.g. allergy) or refusal. NJAC 8:39-5.1(a)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] at 9:28 AM, the surveyor, in the presence of the Food Service Director (FSD) and Regional FSD (RFSD), observed the following during the kitchen tour: 1. In the juice dispenser area, there were three 5-gallon beverage boxes that were past their best used by date. A thickened water (nectar consistency) 5-gallon box had a best if used by date of [DATE]. A thickened water (honey consistency) 5-gallon box had a best if used by date of [DATE]. A diet lemonade 5-gallon box had a best if used by date of [DATE]. The FSD stated that the beverage boxes were good for 6 months after their best if used by date. The FSD acknowledged the diet lemonade was expired. The surveyor requested documentation from the RFSD and FSD which indicated the beverage boxes were still good to be used 6 months after the best if used by date. 2. On a food preparation (prep) table there was a food processor machine. The surveyor observed a single fiber- like strand, more than 3 inches long with the top compartment cover of the machine. The surveyor pointed out the observation to the RFSD who took off the top of the machine off and took the hair strand. On the food prep table next to the machine there were food items covered with clear plastic wrap. The surveyor asked the RFSD and FSD if there was any concern with the fiber strand being found on the food processor machine and the area being a food prep area. The RFSD stated the strand was part of a hairnet, it was outside of the machine, and there was no food in the machine. The RFSD and FSD confirmed the items on the table were being prepared for the next meal and the table was a food prep area. 3. In the drying rack storage area, 1 of 3 small veggie steam pans checked was observed to be soiled with a dry, hard food-like debris on the side wall of the pan. The FSD confirmed the pan was soiled that it was expected to have been clean and would put the pan to be re-washed. On [DATE] at 10:48 AM, the surveyor, in the presence of the FSD and RFSD, observed the following during a kitchen tour: 4. The surveyor observed Dietary staff (DS) #1 exit the dishwashing area and walking through the food prep area to exit the kitchen. DS #1 had facial hair including a mustache and facial hair on their chin. DS #1 was not wearing a beard restraint (used to contain facial hair, such as, beards, mustaches, and goatees to prevent it from falling into food and contaminating it). The surveyor asked the RFSD about the observation of DS #1 with facial hair and not wearing a beard restraint. The RFSD stated DS #1 did not have facial hair. The surveyor interviewed DS #1 in the presence of the RFSD. The DS #1 acknowledged he had a mustache, facial hair on his chin, and that it should have been covered with a beard restraint. The surveyor asked DS #1 if there were any available beard restraints for him. DS #1 was not able to provide a verbal response. The surveyor asked the RFSD about beard restraints available for staff. The FSD went to look for the beard restraint supplies for the staff. 5. In the dishwashing area, the three-compartment sink had 1 of the 3-compartment filled with sanitizing solution water, and soaking dishes. No staff were in the dishwashing area. The RFSD stated the dishes were still in progress of being washed by staff. On a metal table in which clean dishware would come out from the dishwasher there was white solid, food-like debris on the table. 6. In the dishwashing area on a shelf above the 3-compartment sink, there were three serving trays filled with dessert bowls which were faced down on it. The RFSD stated it was to dry the dish ware and the shelf area was considered a clean area. The surveyor asked about the soiled dishes still being washed in the 3-compartment sink below the shelf and if there was a risk of contamination of the dishes. The RFSD replied that the clean dishes were not kept on that shelf when dirty dishes were being washed. The surveyor informed the RFSD of the dishwashing area being in use prior to the surveyor entering area. There was no additional verbal response by the RFSD about the clean bowls on the trays. Next to the trays on the shelf were four 5-gallon food bins on the shelf right side up and uncovered. The surveyor asked the RFSD what the bins were used for. The RFSD stated that the bins were considered clean and were used to store the dessert bowls when they dried. The RFSD further stated the bins would be covered once the bowls were stored inside. The surveyor asked to check the inside of all 4 of the uncovered bins. The first bin had an accumulation of clear liquid on the bottom of the bin. The RFSD stated that the bin was drying. The second bin had 1 dessert cup inside of it. The third bin had several loose dessert cups stored in it, and the last bin was empty. The outside of the bins had discolored stains/spots. The surveyor asked the RFSD if it was considered clean. The RFSD replied that the dishware was stored inside and covered for storage. 7. In the dishwashing area on the shelf above the 3-compartment sink there was a crumpled washcloth against the wall and next to one of the trays of the dessert bowls. The RFSD took the washcloth, confirmed it was wet and acknowledged it should not have been up there. The FSD stated she did not find any beard restraints and told DS #1 to wear a face mask to cover their facial hair. The FSD acknowledged DS #1 had facial hair and stated that he should have been wearing a beard restraint. The surveyor asked the FSD about the clean and soiled areas of the dishwashing area. The FSD stated the metal table in which the clean dishware comes out of dishwashing machine was considered a clean area. The surveyor asked about the white colored food-like debris observed on the table. The FSD acknowledged that the area was not clean and that it should have been clean. The surveyor asked the FSD about the concern of clean dessert bowls being stored on the shelf above the 3-compartment sink and the use of the 5-gallon bins being used to store dishware. The FSD replied that the clean dishware would be removed from the dishwashing area placed on a cart which was kept between the dishwashing and food prep areas. There was no additional verbal response by the FSD. 8. The surveyor accompanied by the FSD in the drying rack storage area, observed 1 of 2 long vegetable pans was soiled with dry, solid, food-like debris on the side wall of the pan. The FSD confirmed the pan was soiled and that it needed to be washed again. The surveyor requested from the RFSD and FSD for policies on kitchen cleanliness, storage, and hair restraints. On [DATE] at 12:46 PM, the surveyor interviewed the LNHA about if it was expected for beard restraint supply to be available in the kitchen for staff. The LNHA, replied Yes. The surveyor informed the LNHA of the concern that there was none available as per the FSD. The LNHA stated he would follow up. On [DATE] at 10:47 AM, the surveyor with the Registered Nurse/Unit Manager (RN/UM) inspected the nutrition refrigerator on the unit. The RN/UM stated the refrigerator was used to store snacks from the kitchen and resident food items, including food from outside the facility. The RN/UM further explained items were stored for up to 3 days in the refrigerator, housekeeping (HK) would clean the refrigerator, throw away outdated food every 3 days. The surveyor in the presence of the RN/UM observed the following: 9. In the refrigerator, there was a white bag with packaged food items that was labeled with a resident's name and room number. There was no date on the bag to indicate when it was placed in the refrigerator. There was also a fast-food brand bag which had the resident's name and room number written on it. There was no date on the bag to indicate when it was placed in the refrigerator. 10. In the freezer of the refrigerator, there were 3 wrapped foiled food items in a plastic storage bag which had the resident's name and room number written on it. The items were not dated to indicate when it was placed in the refrigerator. Additionally, there was an unopened bag of edadame beans which was dated [DATE]. The packaging did not have a resident's name or a room number on it. The RN/UM stated that the items should have the appropriate labeling which would include the resident's name, room number and the date the item was placed in the refrigerator. The RN/UM stated she would follow up with the residents about the items. She would discard outdated and food items that could not be verified. On [DATE] at 10:57 AM, the surveyor interviewed the Housekeeping Director (HKD) who stated HK would clean the refrigerator every Friday. The HKD further explained the refrigerator was cleaned thoroughly inside, anything not labeled with a name or date would be thrown away. The HKD added that items more than 3 days after their written date would be thrown away. The surveyor asked if the refrigerator was checked by HK on other days besides Friday. The HKD stated that during the week the refrigerator would be checked periodically by HK staff. The HKD further explained there was no set schedule besides the Friday and it would not be documented if the refrigerator was checked on other days of the week. The HKD stated there was a log for when the refrigerator was cleaned and checked on every Friday. The HKD added besides the log, he had additional documentation in his office. The surveyor accompanied the HKD to check the log posted on the refrigerator which read that the refrigerator was to be cleaned every Friday. A review of the log which included the date and the signature of the staff cleaning the refrigerator revealed there was no documentation for [DATE] and no signature indicating that the refrigerator was cleaned. The HKD stated he was the one who cleaned the refrigerator and that he must have forgotten to sign the form. The surveyor accompanied the HKD to his office to check for any additional documentation of the refrigerator being cleaned on [DATE]. The HKD was unable to provide any additional documentation for the date in question. On [DATE] at 11:03 AM, the RN/UM informed the surveyor for the foiled food item in the freezer (Resident #61) it was brought in on Friday and was discarded. The fast-food bag was brought in last night. The RN/UM stated she still had to find out who the edamame package belonged to and when the white bag of food items was brought in. The RN/UM added if unable to determine the food items would be disposed. The surveyor asked the RN/UM about the protocol for the food storage in the nutrition refrigerator. The RN/UM stated it was expected for the food items to be labeled with the resident's name, room number, and date the item was brought in. The RN/UM stated HK cleaned out the refrigerator every Friday. The RN/UM further explained the staff that placed food items for residents in the refrigerator were responsible for ensuring the food items were labeled appropriately and she was not aware if anyone else was responsible for checking food items in the refrigerator. On [DATE] at 11:14 AM the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concerns during the kitchen tours and inspection of the nutrition refrigerator on the unit. The LNHA was also informed that the FSD and RFSD stated they were going to provide supportive documentation that the beverage boxes were good for use 6 months after their best if used by date and no documentation had been provided. On [DATE] at 12:05 PM, during observation of tray line in the kitchen, the surveyor observed DS #2 enter the kitchen from the dining area. DS #2 was observed with hair bangs uncovered with the rest of their hair contained with a hair net. DS #2 walked through the food prep area and went to back area of the kitchen. DS #2 returned the same way, her hair bangs remained uncovered and exited the kitchen to the dining area. The surveyor asked the RFSD about hair restraint protocol. The RFSD stated all hair should be covered with a hairnet. The surveyor informed the RFSD of the observation. The RFSD acknowledged all of DS #2's hair should be contained with the hairnet. The RFSD stated she would go to speak with DS #2 and exited the kitchen. On [DATE] at 12:41 PM, the surveyor informed the LNHA and DON of the observed concern of DS #2's hair bangs remaining uncovered while passing through the food prep area during tray line. On [DATE] at 11:38 AM, the LNHA, the DON, the Assistant Director of Nursing (ADON), Regional DON #1, Regional DON #2, and the Co-President met with the survey team. The LNHA stated for the nutrition refrigerator that the HKD forgot to sign off the log and that he cleaned all refrigerators including the break room refrigerator in which he had signed the log. The surveyor asked the LNHA if it was expected for the HKD to have signed the cleaning log for the nutrition refrigerator after cleaning. The LNHA acknowledged that it should have been signed by the HKD. The LNHA stated for the fiber strand found on the food processor machine, stated that it was outside of the machine not inside and that there was no food in the machine. The surveyor asked if there would be a concern for something like that being found in a food prep area. The LNHA replied that staff wore hairnets in the kitchen. There was no additional response provided by the facility. The LNHA stated for the pans found soiled in the clean drying rack storage areas, the items were cleaned by the FSD after the observations. LNHA acknowledged it would be expected that the items were cleaned. The LNHA stated DS #2 was in-serviced on use of hairnet and that a restraint did not have to be used unless it was longer than ,d+[DATE] inch. The surveyor asked the LNHA about the guidance followed for kitchen policies. The LNHA replied that the references for their hair restraint policy was provided. The surveyor asked if the references and facility policies were based on regulations and from nationally recognized organizations and based on regulations. Regional DON #2 stated that the regulations did not specify the length and only indicated facial hair should be covered. The surveyor asked if the regulations did not specify the length of facial hair that should be restrained, was it ok for less than ,d+[DATE] inch to be without a beard restraint. There was no additional response by the facility. The LNHA stated the clean dishware were removed from the dishwashing area and would be stored in another area for drying storage. The LNHA stated for the nutrition refrigerator that items from the kitchen to the refrigerator were labeled every day prior to delivering. The LNHA stated that resident visitors sometimes brought food and forgot to date the food items. The LNHA added the staff regularly checked food items for dates and discarded when not dated. There was no additional information provided by the facility. There was no documentation provided by the facility to indicate that the beverage boxes were okay to be used up to six months after their best if used by date. A review of the facility's Hair Restraints Policy, with a last reviewed date of [DATE] revealed: Under Policy: All Dietary Staff shall wear hair restraints such as hats, hairnets and beard restraints if you have any facial hair growth, to keep their hair from contacting exposed food, clean equipment's, utensils and linens. Under Procedure: 1. Always cover all head hair with hair restraint .2. Always cover all facial hair with beard net .3. Never leave bangs or other part of your hair hanging outside of hair restraint. A review of the facility's Cleaning and Sanitation Equipment Policy, with a date of [DATE] revealed: Under Policy: Cleaning and sanitation of equipment is to remove food debris that bacteria need to grow and to kill those bacteria that are present. It is important that the clean and sanitized equipment are stored dry so as to prevent bacteria growth. A review of the facility's Food Storage Policy, with a last reviewed date of [DATE] revealed: Under Policy: Food storage areas shall be maintained in a clean, safe, and sanitary manner. The policy did not further address use of food items by manufacturer best if used by dates. A review of the facility's Food Brought in for Patients and Residents Policy, with an effective date of [DATE] revealed: Under Purpose: To ensure the safe consumption of food brought in to patients/residents. Under Procedure: for food brought in that required refrigeration: .1.2 Food items that require refrigeration must be labeled with the patient/resident's name and the date the food was brought in .1.5 Food will be held in the refrigerator for 3 days following the date on the label and will be discarded by staff upon notification to patient/resident. NJAC 8:,d+[DATE].2(g)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to adhere to professional standards of clinical practice by failing to: a.) follow the residents' meal tickets for 2 of 2 meal observations for Residents #41, #43, and #44; b.) clarify the physician's order with regard to supplement for 1 of 24 residents, Resident #41; and c.) ensure medication was administered in accordance with the manufacturer's specifications, and d.) ensure proper disposal of excess medication in a safe and approved manner for 2 of 6 residents, Residents #45 and #339, reviewed during the medication pass observation. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 12/15/2024 at 11:46 AM, the surveyor observed in the recreation room during lunch 6 residents and 3 staff. The surveyor observed Resident #41 received their tray and the meal ticket revealed that the resident should receive a magic cup. Resident #41 did not receive a magic cup. The surveyor asked Recreation Aide #1 (RA#1) about the magic cup in the resident's meal ticket, and RA#1 could not state where the magic cup was. The surveyor asked the Registered Nurse Supervisor (RNS) about Resident #41's magic cup and the RNS asked RA#1 to get it from the kitchen. The RNS acknowledged that the resident should receive what was on the meal ticket, including the magic cup. On 12/15/24 at 12:01 PM, the surveyor observed RA#1 offered the with magic cup that was taken from the kitchen and Resident #41 refused the magic cup. A review of the provided Minimum Data Set (MDS) by the Director of Nursing (DON) revealed: -Resident # 41's most recent quarterly MDS (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/7/24, Section C Cognitive Patterns revealed a brief interview for mental status (BIMS) score of 1 out of 15 reflected that the resident's cognitive status was severely impaired. A review of the Order Listing Report revealed an active physician's order (PO) dated 9/2/24 for Magic cup two times a day for supplement provide with lunch and dinner for Resident #41. The above order for the magic cup was transcribed to the December 2024 electronic Medication Administration Record (eMAR) and signed by nurses as administered (provided). On 12/15/24 at noon eMAR, the Registered Nurse (RN) electronically signed the eMAR as administered. The eMAR did not include information of resident's amount of intake and refusal. On 12/19/24 at 8:42 AM, the surveyor interviewed the RN who signed the eMAR on 12/15/24 at noon for Resident #41's magic cup. The RN confirmed that she was the nurse who signed the 12/15/24 at noon eMAR of Resident #41 for the magic cup. The RN acknowledged that she was not in the recreation dining room on 12/15/24 to observe the resident's intake of the magic cup and did not receive a report about the resident's refusal to take the magic cup. The surveyor asked the RN why she signed the magic cup on 12/15/24 if the resident did not take the magic cup at lunchtime, and the RN did not respond. On that same date and time, the RN informed the surveyor that the PO for the magic cup for Resident #41 should have been clarified with the physician to include the amount or percentage of intake of the magic cup as what was ordered in the health shake as best practice. 2. On 12/17/24 at 8:31 AM, the surveyor observed the recreation room for breakfast and there was a total of 4 residents and 2 staff. The surveyor observed Resident#43's meal ticket and revealed that the resident should receive a nectar-thickened orange juice (oj). The surveyor observed there was no nectar-thickened oj in the resident's tray. The surveyor asked RA#2 and RA#3 why the resident did not have nectar-thickened oj, and RA#2 responded that there was no nectar-thickened oj in the kitchen that was why the nectar-thickened cranberry juice was provided instead. On that same date and time, the surveyor observed Resident #44's meal ticket for 2 cups of coffee and the resident did not receive two cups of coffee. The surveyor asked RA#2 and RA#3 why the resident did not receive 2 cups of coffee according to what was in the meal ticket and RA#3 responded that it was the Certified Nursing Aide (CNA) who brought the breakfast tray and there was only one cup of coffee in the tray. On 12/17/24 at 8:44 AM, the surveyor went to the kitchen and interviewed the Food Service Director (FSD). The FSD showed what the facility fluids could offer to the residents during mealtime. The surveyor observed the kitchen stocks for the pre-thickened honey and nectar water, pre-thickened honey and nectar cranberry juice, cranberry juice, apple juice, oj, and strawberry juice. The surveyor did not see a supply of pre-thickened nectar oj and the FSD confirmed. Later, the Regional FSD (RFSD) joined the FSD during the interview. The FSD stated that the facility had thickened powder that could be mixed with water and juice. The FSD further stated that she was responsible for mixing the thickened powder and ensuring that the meal ticket corresponded with what should be on the tray. The surveyor notified the RFSD and the FSD of the above findings and concerns regarding meal tickets of Residents #41, #43, and #44. The surveyor also asked both FSDs, if the facility had a supply of thickened powder and oj, and why Resident #43 did not receive nectar oj, and both FSDs did not respond. On 12/17/24 at 11:09 AM, the surveyor interviewed the DON regarding dining services. The surveyor asked the DON what the facility's process for dining services was and who verified the meal tickets. The DON responded that it was the recreation people responsibility to check the meal ticket and what was in the tray. She further stated that it was an expectation if there was a discrepancy with the meal ticket, it should be checked with the nurse or dietary. The surveyor notified the DON of the above findings and concerns. The surveyor asked the DON why Resident #43 did not receive nectar oj when there was a thickened powder and oj, and the DON did not respond. At that same time, the surveyor also notified the DON of the concern with Resident # 44 that the resident did not have two cups of coffee in their tray and the meal ticket revealed that the resident should have two cups of coffee. the DON had no response when asked by the surveyor what should be the expectation when verifying the meal ticket and the tray, and the DON had no response. On 12/18/24 at 10:20 AM, the surveyor interviewed the Clinical Dietitian (CD). The CD informed the surveyor that everybody should have meal tickets in their trays. The surveyor asked what the importance of the preferences was in the meal ticket, and the CD responded that everybody was unique and for safety. The surveyor asked who should be checking the meal ticket and what was in the tray, and the CD responded that the aide serving should check. The surveyor notified the CD of the concern regarding Resident#43, and the CD responded that the RAs should follow the meal ticket for oj. At that same time, the surveyor notified the CD of the concern regarding Resident#44's coffee, the CD stated the meal ticket should have been followed for 2 cups of coffee. Furthermore, the surveyor notified the CD of the concerns regarding Resident #41. The CD stated that Resident #41 was on the magic cup and multiple supplements. She further stated that her notes on 12/5/24 reflected that the resident had a stable weight for the past 3 months and a one-month history of fluctuating weight due to advancing dementia. The CD also stated that the FSD was responsible for the tray line and following the diet according to the meal ticket. On 12/18/24 at 11:14 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the LNHA and the DON of the above findings and concerns. On 12/18/24 at 3:01 PM, the RFSD acknowledged that the meal ticket should be followed. The RFSD stated that Resident#43's preference was cranberry juice which was why the resident received the nectar cranberry juice. The surveyor then asked the RFSD and the CD, if the resident's preference was cranberry juice and why the meal ticket did not specify that. The surveyor asked the RFSD and the CD if was there documented evidence of the resident's preference for nectar cranberry juice and not nectar oj, and the CD responded that she would get back to the surveyor. A review of the provided documents by the DON revealed: -Resident # 43's most recent qMDS with an ARD of 10/11/24, Section C Cognitive Patterns revealed a BIMS of 5 out of 15 reflected that the resident's cognitive status was severely impaired. -Resident # 44's most recent significant change in status MDS with an ARD of 10/21/24 revealed a BIMS score of 5 out of 15 which reflected that the resident's cognitive status was severely impaired. On 12/19/24 at 11:38 AM, the survey team met with the LNHA, DON, Regional DON #1 (RDON#1), RDON#2, Assistant DON (ADON), and the CO-President. The surveyor notified the facility management of the above concerns and findings regarding Resident #41. A review of the facility's Food, Dining Service and HS (bedtime) Snacks Policy with a reviewed date of 6/2024 that was provided by the LNHA revealed: Policy Explanation and Procedures: -Food service staff members will serve the food choices made with consideration given to dietary restrictions/texture modifications. Plates will be verified for accuracy of service . Eating Environment: -Staff will develop appropriate measures to try to maximize appropriate seating, positioning, and interactions among residents and to assure that each resident receives his or her prescribed diet On 12/19/24 at 01:48 PM, the survey team met with the LNHA, DON, RDON#1, RDON#2, Co-President, and the ADON for an exit conference. The facility did not provide additional information. 49078 3. On 12/17/24 at 8:23 AM, the surveyor began the Medication (med) Pass Observation task. At 9:02 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) prepare and administer medications (meds) to Resident #45. The resident had a total of 4 meds to be administered. The meds included 10 milliliters (ml) of guaifenesin DM (Dextromethorphan belongs to a group of medications called antitussives (cough suppressants) liquid. The surveyor observed LPN#1 poured the guaifenesin DM more than the order indicated. Then LPN#1 poured the excess liquid into a second dose cup to get the proper amount. The surveyor observed LPN#1 dispose of the second dose cup with the excess liquid in the trash receptacle located on the side of the med cart (medcart). The surveyor observed the cup remain upright and not spill into the trash. Resident #45 refused the guaifenesin DM liquid. The surveyor observed LPN#1 dispose of the refused med into an approved med disposal system located in the bottom of the medcart. The surveyor asked LPN#1 what the policy or procedure on disposal of unused, refused, or extra meds was, and LPN#1 responded that they should be put in the med disposal system. At 9:15 AM, the surveyor observed LPN#2 prepare and administer meds to Resident #339. The resident had a total of 2 meds to be administered. The meds included 1 tablet (tab) of Sucralfate 1 gram (a drug used to treat ulcers and protect the stomach), ordered for 10:00 AM. During the administration of the meds to Resident #339, the surveyor observed the resident's breakfast tray present on a bedside table next to the resident. The surveyor observed that at least 50% of the meal was consumed. The surveyor asked Resident #339 when and if they had finished with the breakfast meal. The resident stated that they eat quickly and was finished eating approximately 8:15 AM to 8:20 AM. The surveyor reviewed the electronic medical records (eMR) for Resident #45 and Resident #339. Resident #45's eMR revealed a PO and eMAR for guaifenesin DM 10 ml TID (3 times a day) for cough for 7 days scheduled at 9:00 AM, 1:00 PM, and 5:00 PM. Resident #339's eMR revealed a PO and eMAR for Sucralfate Oral Tab 1 gram, 1 tab by mouth TID a day for gastric ulcer scheduled at 10:00 AM, 2:00 PM, and 8:00 PM. Resident #339's eMR also reflected a nurse's progress note that revealed an assessment that the resident was alert and oriented. A review of the manufacturer's informational package insert (PI) for Sucralfate which reflected, the recommended adult oral dosage for duodenal ulcer was 1 gram four times per day on an empty stomach. On 12/18/24 at 11:15 AM, the survey team met with the LNHA and DON, and the surveyor notified the above findings and concerns. The surveyor asked the DON when meds were administered, what would be considered an empty stomach. The DON stated that it was usually 1 hour before a meal or 2 hours after a meal. The surveyor asked the DON what the policy or procedure was for properly disposing of excess meds. The DON stated that meds should be disposed of in the drug disposal system in the medcart. On 12/18/24 at 12:19 PM, the surveyor interviewed the facility Consultant Pharmacist (CP) by telephone. The surveyor discussed the concerns with the med pass observation. The surveyor asked the CP when meds were administered, what would be considered an empty stomach. The CP stated the standard would be 1 hour before meals or 2 hours after meals. The surveyor asked the CP if excess meds should be disposed of in the trash receptacle on the side of the medcart. The CP stated, no, meds should be disposed of in the approved med disposal system in the cart. On 12/19/24 at 11:39 AM, the survey team met with the LNHA and DON, and the facility had no further pertinent information to provide. A review of the facility's Administering Medications Using Electronic System Policy dated 6/2024. The policy reflected under 3. Meds must be administered in accordance with doctor's orders, including any required time frame and following med cautionary. The policy did not reflect any information regarding disposal of unused or excess meds during the med pass. NJAC 8:39-11.2(b); 29.2 (d); 29.4(g)

REPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 5 of 11 staff (1 Housekeeper,1 Recreation Aide, 2 Dietary Staff, and 1 Physician), b.) disinfect the examination area after use, and follow appropriate infection control practices during meal observation, environment tour, and kitchen tour, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. On 12/15/24 at 11:58 AM, the surveyor observed the Recreation Aide (RA) with a surgical mask in use while distributing lunch trays in the recreation room. The RA's nose was not fully covered by the surgical mask and it was pulled below his mouth. The surveyor interviewed the RA regarding the surgical mask. The RA stated that the surgical mask kept going down his nose and the RA acknowledged that the surgical mask should be properly worn and cover his nose. The RA further stated that he received education on proper hand hygiene and the use of PPE. On that same date at 12:05 PM, the surveyor observed the RA took the tray of the resident from the table. Afterward, the RA used hand wipes to clean his hands. The RA did not discard the used hand wipes, went to the next dining room, left the dining room, and re-entered the recreation room with the same hand wipes in his hands. The surveyor asked the RA what was on his hands, and he responded that was the hand wipes he used for cleaning both hands. The surveyor asked the RA why he did not dispose of the used hand wipes and whether should he dispose of them immediately after use, and the RA responded, I guess not. A review of the Handwashing/Hand Hygiene Policy with a revised date of April 2010 that was provided by the Licensed Nursing Home Administrator (LNHA) on 12/16/24 at 9:37 AM revealed: Policy Interpretation and Implementation: 5. Employees must wash their hands for at least 20 seconds using antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals . 2. On 12/17/24 at 8:58 AM, Surveyor #1 (S#1) observed the provider (a Physician) and the Infection Preventionist Nurse (IPN) inside room [ROOM NUMBER]. The IPN talked to the Physician and left the room. The surveyor observed the Physician with a luggage bag inside the room and attended to Resident #241, the Physician performed handwashing inside the room, and the she donned (put on) gloves. The Physician took an alcohol individual pack, disinfected the lenses of two equipment, and placed them on top of the resident's table without disinfecting the table. During an eye examination, S#1 observed the Physician interchange the two pieces of equipment on top of the table without disinfecting the entire equipment. There was a personal belonging on top of the resident's table near the equipment. After the examination, the Physician discarded the used gloves in the garbage receptacle near the sink, put back the equipment inside the luggage bag, exited the resident's room without disinfecting the table, and did not perform hand hygiene. Outside the resident's room, S#1 interviewed the Physician. The surveyor asked the physician what she did inside the room and the physician stated that she examined the resident's eye with the use of a custom refractor (white equipment) which was used for measuring refraction of glasses and black equipment was the fundus camera. The surveyor asked the Physician why she did not perform hand hygiene after she doffed off her gloves and when she left the room. The Physician stated that when she grabbed all her stuff, it did not make any sense for her to perform hand hygiene even when she exited the room. She acknowledged that after she removed gloves inside the room, she did not perform hand hygiene. In the nursing station, S#1 asked the Physician if she was aware of the posted sign for EBP (enhanced barrier precautions; an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission MDROs [multidrug-resistant organism]) in room [ROOM NUMBER] and what was the EBP for, and the Physician responded that she did not know. Immediately, S#1 notified the IPN of the concerns that the Physician did not perform hand hygiene and did not disinfect the table used for putting the equipment. The IPN stated that staff, visitors, and vendors should perform hand hygiene before and after gloves use and follow the posted sign and she stated that she would talk to the Physician about it. On 12/17/24 at 9:50 AM, S#1 and Surveyor #2 (S#2) interviewed the IPN. S#1 asked the IPN about Standard Precaution or Universal Precaution, and the IPN responded that it applied to everyone (all staff, visitors, and vendors) and that gloves, after use, should be discarded and perform hand hygiene and that was basic. S#2 asked the IPN if the facility provided disinfecting wipes or PPE to the Physicians and vendors when they come to provide services. The IPN stated that she had to check first and would get back to the surveyors. S#1 asked if the facility provided education or information to the Physician about the facility's practice and policy about EBP or other infection control guidance that the facility followed, and the IPN responded that she was unsure. S#2 asked the IPN if that was something she should know as part of infection control. The IPN stated that she started in April this year and unsure if that was provided to the Physician before her starting in the facility as IPN. On 12/17/24 at 12:22 PM, S#1 and S#2 met with the Regional Director of Nursing #1 (RDON#1) and LNHA. The surveyor notified the LNHA and RDON#1 of the above concerns with the Physician. S#1 asked what the facility's practice was about disseminating information to providers and vendors with regard to the facility's policy and practice with EBP and other infection control practices. RDON#1 stated that she knew that the Physicians of the facility especially the Medical Director and the Infectious Disease Doctor were aware of the facility's practice and protocol with regard to infection control and was unsure about the other providers and vendors. RDON#1 acknowledged that the facility had the responsibility to notify the vendors and providers about it. RDON#1 further stated that hand hygiene should be done before gloves and after gloves use, disinfect the area to be used and used for treatment and examination. On 12/17/24 at 2:00 PM, the survey team met with the Co-President and the owner of the company (vendor) where the Physician who provided an eye examination to Resident #241. The vendor informed S#1 that it was not part of their protocol and policy to disinfect the table where the Physician placed our equipment. The vendor further stated that the Physician certainly for this day, removed her gloves and did not wash her hands. On 12/18/24 at 11:14 AM, the survey team met with the LNHA and the Director or Nursing (DON). S#1 notified the LNHA and the DON of the above findings and concerns regarding the RA and the Physician. On 12/19/24 at 01:48 PM, the survey team met with the LNHA, DON, RDON#1 and RDON#2, Co-President, and Assistant DON (ADON) for an exit conference. The facility did not provide additional information. 46049 3. On 12/15/24 at 10:40 AM, the surveyor observed Housekeeper #1 (HK #1) exit a resident room (Resident #5 and Resident #84), remove their gloves while standing in front of their cart outside the room door. HK #1 disposed their gloves in a garbage bin on the cart and retrieved cleaning supplies from the cart. The HK returned inside the room without performing hand hygiene. The surveyor observed HK #1 inside the resident room apply gloves and cleaned inside the room. On 12/15/24 at 10:43 AM, the surveyor observed HK #1 exit the resident's room, removed their gloves while going to their cart located at the door. HK #1 disposed of their gloves in the garbage bin on the cart, went into their cart for more cleaning supplies, and returned inside the room. The surveyor observed the HK did not perform hand hygiene. On 12/15/24 at 10:45 AM, the surveyor interviewed HK #1 about hand hygiene upon their exit from the resident's room. HK #1 stated that hand hygiene should be performed when entering a resident room, when finished cleaning up, and when putting on gloves, when removing gloves, and in between changing gloves. The surveyor informed HK #1 of the above observations. The HK acknowledged she did not wash her hands between changing gloves and stated it was supposed to be done. On 12/15/24 at 1:46 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM) about hand hygiene. The RN/UM stated hand hygiene should be performed between changing gloves and when exiting rooms. The surveyor informed the RN/UM of the above observations of HK #1. The RN/UM acknowledged she should have washed her hands in between changing gloves and when exiting the room. The RN/UM stated she would follow up with the HK to provide re-education. On 12/18/24 at 11:14 AM, the surveyor informed the LNHA and the DON of the observed concern of HK #1 not performing hand hygiene during changing of gloves. On 12/19/24 at 11:38 AM, the LNHA, DON, Co-President, ADON, RDON#1 and RDON#2 met with the survey team. The LNHA stated in-service education was provided to HK #1. 4. On 12/18/24 at 11:32 AM, the surveyor observed Dietary Staff (DS) #1 (DS#1) with gloves on for the start of tray line service of the lunch meal. DS#2 moved a wet floor sign to the hallway area between the food prep and dishwashing area. DS #2 removed their gloves, disposed of gloves, and put on a new pair of gloves. The surveyor observed DS #2 did not perform hand hygiene. The surveyor asked the Regional Food Service Director (RFSD) present in the kitchen about hand hygiene. The RFSD stated hands should be washed when changing gloves. The surveyor informed the RFSD of the above observation of DS #2 and stated states hands should be washed when changing gloves. The RFSD instructed the staff to remove their gloves and perform hand hygiene, and re-educated DS #2 that hand hygiene should be performed when gloves were changed. On 12/18/24 at 11:45 AM, during tray line the surveyor observed DS #3 while serving the food, removed their gloves and placed new gloves without washing their hands. The surveyor informed the RFSD of the observation. The RFSD and FSD instructed DS #3 to remove their gloves and wash their hands. On 12/18/24 at 12:41 PM, the surveyor informed the DON and LNHA of the hand hygiene concerns observed during tray line in the kitchen. There was no additional information provided by the facility. A review of the facility's Handwashing/Hand Hygiene Policy, last reviewed in May 2024 revealed: Under Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Under Policy Interpretation and Implementation: 5. Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions .u. after removing gloves . 6. If hands are not visibly soiled, use an alcohol-based hand rub containing at least 70% ethanol or isopropanol for all of the following situations .j. After removing gloves . 7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene. N.J.A.C. 8:39-19.4(a)(1,2),(l,n)

Based on observation, interview, and review of facility-provided documents, it was determined that the facility failed to ensure that a) meals were consistently provided in a dignified and homelike manner and b) resident meal assistance was provided in a dignified manner. The deficient practice was observed in the recreation dining room for 2 of 6 residents (Residents #15 & #44). The deficient practice was evidenced by the following: On 12/15/24 at 11:46 AM, the surveyor observed the Kitchen Staff (KS) deliver the food truck to the recreation room, there were 6 residents, 4 residents at one table, 1 resident at one table, and another resident at one table, there were 2 Recreation Aides (RA) inside the dining area and later Registered Nurse Supervisor (RNS) came and assisted in distributing lunch trays. The surveyor observed RA #1, RA#2, and RNS assisted 5 of 6 residents with hand hygiene using individually wrapped hand wipes on each resident's lunch trays. The facility staff did not offer Resident #44 hand hygiene and the staff then proceeded to set up the resident's meal. At that same time, the surveyor observed 5 out of 6 residents eating lunch except for Resident #15, who was seated at the same table with the other 3 residents. The surveyor then asked RA#2 why Resident #15 had no tray, and RA#2 responded that she would get back to the surveyor. Later, the surveyor asked the RNS why Resident #15 had no tray while the rest of the residents at the same table were eating, and the RNS responded that she would ask someone to get the resident's tray. On 12/15/24 at 11:56 AM, the surveyor observed the KS delivered a tray to Resident #15, the RNS provided the tray, set up the tray, and the RNS left the recreation room. The surveyor observed there was no diet slip in the tray and the piece of paper with black marker written 19W. On 12/15/24 at 12:01 PM, the surveyor interviewed RA#2 regarding Resident#44's hand wipes not use, and RA#2 responded that the resident should have been provided an opportunity to perform hand hygiene and the hand wipes should have been used. RA#2 further stated that she was not the one who provided Resident #44's tray. The surveyor also asked RA#2 why Resident #15 had no diet slip and what 19W in the paper meant. RA#2 stated that 19W was the room number and resident should receive a meal ticket (diet slip; that included the resident's name and diet). She further stated that the resident was in room [ROOM NUMBER]W and not 19W. The surveyor then asked RA#2 what the diet of 15W was and 19W, and why Resident #15 received the wrong tray. RA#2 then went to the next table and took the paper, and RA#2 stated that according to the paper, Resident #15 who was in room [ROOM NUMBER]W diet was regular and room [ROOM NUMBER]W was also regular diet. RA#2 stated that Resident#15 should have a diet slip and should receive the right diet. The surveyor asked RA#2 why Resident #15 had to wait for 10 minutes while the 3 other residents were eating lunch at the same table, and RA#2 did not respond. A review of the medical records revealed: Resident#15's most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 12/5/24, section C Cognitive Patterns included the brief interview for mental status (BIMS) score of 5 out of 15 which reflected that the resident's cognitive status was severely impaired. Resident#44's most recent significant change in status MDS with an ARD of 10/21/24, section C Cognitive Patterns included the BIMS score of 5 out of 15 which reflected that the resident's cognitive status was severely impaired. On 12/17/24 at 11:09 AM, the surveyor interviewed the Director of Nursing (DON) regarding dining services. The surveyor asked the DON what the facility's process for dining services was. The DON stated that the food truck comes in from the kitchen, the dietary staff brings the food truck trays, and then the recreation staff distributes the trays, always one assigned nurse for lunch and dinner, and breakfast residents eat in their room. The surveyor asked the DON who verified the meal ticket, and the DON responded that it was the recreation people who must check the meal ticket versus what was in the tray. The surveyor asked when and who offered assistance with hand hygiene during mealtime, the DON stated that the recreation staff or whoever bringing the tray to the resident should offer and assist residents in performing hand hygiene by using individual packets of hand wipes in the resident's tray be done before and after eating. On that same date and time, the surveyor notified the DON of the concerns with Resident # 15. The DON stated that the staff should have brought the resident inside their room or asked for the tray because residents should be eating all at the same time. The surveyor also notified the DON of the concerns with Resident # 44 with hand hygiene during lunch observation, and the DON stated that the staff should have checked and if not opened should been offered for hand hygiene. On 12/18/24 at 11:14 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON. The surveyor notified the LNHA and the DON of the above findings and concerns. A review of the facility's Food, Dining Service and HS (bedtime) Snacks Policy with a reviewed date of 6/2024 that was provided by the LNHA revealed: Policy Explanation and Procedures: -Nursing staff will remind all residents/patients of the meal. Nursing is responsible for assisting those needed help. Individuals are assisted to prepare for the meal (glasses on, hearing aids in, hands washed, etc) . -Food service staff members will serve the food choices made with consideration given to dietary restrictions/texture modifications. Plates will be verified for accuracy of service . -Individuals are offered (or assisted to use) a hand wipe or cloth to wipe their hands prior to leaving the dining room . Eating Environment: -Staff will develop appropriate measures to try to maximize appropriate seating, positioning, and interactions among residents and to assure that each resident receives his or her prescribed diet A review of the Handwashing/Hand Hygiene Policy with a revised date of April 2010 that was provided by the LNHA revealed: Policy Interpretation and Implementation: 5. Employees must wash their hands for at least 20 seconds using antimicrobial soap and water under the following conditions: g. Before and after assisting a resident with meals . On 12/19/24 at 01:48 PM, the survey team met with the LNHA, DON, Regional DON #1 (RDON#1), RDON#2, Assistant Director of Nursing, and Co-President for an exit conference, and there was no additional information provided by the facility. NJAC 8:39-4.1(a),12,28;27.1(a);27.3(a)

Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation of a resident's advance directives for 1 of 7 residents (Resident #10) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #10 which revealed: The Admission Record (a summary of important information about the resident) revealed that the resident was admitted with diagnoses that included but were not limited to, chronic respiratory failure (a chronic condition when the airways in the lungs become damaged and narrow), anxiety disorder, and type 2 diabetes mellitus. A Significant Change Minimum Data Set (MDS) assessment tool used to facilitate the management of care, dated 11/30/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #10 scored a 14 out of 15, which indicated the resident had no cognitive impairment. The New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form, which was undated and not filled out indicating what advance directives (AD) (directions for the type of life sustaining care to be given or not given) nor was it signed by the resident, attending or facility staff. There was no documentation that indicated what AD status the resident desired to have. A review of the physician's orders did not reveal any orders reflecting any AD status. A review of the resident's electronic medical record (eMR) did not reveal any information that reflected any AD status in the resident information area. On 12/16/24 at 11:51 AM the surveyor interviewed the Director of Social Services (DSS) and the Licensed Social Worker (LSW). The surveyor confirmed with the DSS that the Social Workers were part of the process for obtaining and documenting the AD and POLST status for residents. The surveyor asked how the DSS and LSW obtain and document AD and POLST status for residents. The DSS stated that the POLST was addressed in the resident assessment, and, depending on the resident's cognitive status, the forms are brought to the resident, everything was explained to the resident and forms were signed. The form was then signed by the physician, the form uploaded to the resident's eMR and the form was filed. The DSS further stated that the family can be contacted to confirm the resident's AD/POLST status if needed. The status should also be included in the resident's Care Plan (CP). The DSS also stated that as of September 2024, the Social Work department had an ongoing project to ensure all resident's have completed AD/POSLT and the results were reported to the facility's Quality Assurance Performance Improvement (QAPI) committee. The surveyor reviewed Resident #10's eMR and paper chart with the DSS. At this time the surveyor showed the DSS the blank POLST form and asked the DSS if there was any information in the medical record that indicates the AD or POLST status. The DSS stated they did not know why the blank form was in the chart and why there was no form uploaded, no note or order for an Advanced Directive. The DSS removed the blank form from the paper chart. The DSS stated they would get back to the surveyor with any additional information. On 12/16/24 at 1:29 PM the surveyor interviewed the LSW. The LSW stated that all residents that were full code prior to September did not have a POLST in the chart. In September, when the need was seen verify that there were AD/POLST in the medical records, the QAPI project was started. The LSW stated there was some difficulty getting the physicians sign POLSTs for residents who were full code. The LSW stated that Resident #10 had an admitted in August. The surveyor asked the LSW what would happen if a resident with no AD/POLST listed in the medical record needed to be checked for code status during an emergency, especially if the nurse on duty was unfamiliar with the resident. The LSW stated that the family would be called. The surveyor asked what if the family could not be reached. The LSW stated that the hospital records would be checked. The surveyor asked if these options could take extra time and possibly delay care. The LSW stated yes, they could. The surveyor asked the LSW if the missing documentation for Resident #10 could have been inadvertently missed or fell through the cracks. The LSW stated yes, it could have. At that time, the LSW stated that a progress note (PN) was placed in chart addressing the missing code status. A review of the resident's eMR revealed a new note by nursing recorded after surveyor inquiry. A review of the PN revealed: 12/16/2024 13:30 Note Text: PMD (primary medical doctor) notified of (redacted name) code status as full code, code status updated. On 12/18/24 at 10:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) and made them aware of the concern with the missing documentation for Resident #10's code status. A review of the facility's Advance Directive Policy, revised 11/2021, provided by the LSW revealed: 4.executed advance directive be displayed prominently in med record. The policy does not reflect anything specific about full codes and POLST/AD. The facility did not provide any further pertinent information. N.J.A.C. 8:39-9.6(b)

COMPLAINT NJ#169518 Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Representative (RR) of a change in condition for 1 of 24 sampled residents (Resident # 239). This deficient practice was evidenced by the following: The surveyor reviewed Resident #239's closed hybrid (paper and electronic) medical record. Resident #239's Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dysphagia (difficulty swallowing foods or liquids), dementia (group of brain disorders that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and judgment) and protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident #239's Universal Transfer Form (UTF) from the return to the facility after the first rehospitalization , indicated that the resident did not have any wounds. A review of Resident #239's progress notes (PN) included a wound note written by a Physician Assistant (PA) dated 9/5/23 which included the following: being seen today for a follow up wound evaluation .patient with multiple wounds. I was asked to evaluate and manage wound care for this patient Further review of the wound notes written by the PA indicated that the next visit was 10/3/23. There were three weeks of wound notes that were not in the resident's medical record. The next wound note written by the PA was dated 10/03/23. There was no documented evidence of wound measurements or appearance during those 3 weeks in Resident #239's medical record. There was no documentation in the PA's note that the RR was notified. Further review of Resident #239's PN did not include a documented notification of the RR regarding the DTI (deep tissue injury; a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers, while the skin surface might remain intact) identified on 9/5/23. On 12/18/24 at 9:37 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) regarding Resident #239's wound. The ADON stated that the resident did not have any wounds on readmission from the hospitalization but that on 9/5/23 there was a reoccurrence of a DTI on the resident's buttock and bilateral heels. The surveyor asked the ADON if there was documented notification of the family of the DTI's. The ADON stated that she would have to check the medical record. On 12/18/24 at 3:00 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) the concern that there was no documented evidence that the RR was notified of the change in condition, specifically the DTIs that were investigated on 9/5/23 in the resident's medical record. On 12/19/24 at 9:59 AM, in the presence of the survey team, the ADON stated that the notification of the DTIs to the RR was documented in the Facility Acquired Pressure Injury Investigation Form. The surveyor asked if the investigation form was part of the medical record. The ADON stated that she would have to ask because she was not sure. The ADON then confirmed that there was no documentation in the electronic medical record that the RR was notified of the DTI on 9/5/23. On 12/19/24 at 10:18 AM, in the presence of the survey team, the ADON confirmed that the investigation form was not part of the medical record. On 12/19/24 at 12:31 PM, in the presence of the survey team, LNHA, DON, ADON, Regional DON #1, Regional DON #2 and the Co-President, the surveyor asked if the notification of the RR should be documented in the resident's medical record and the ADON stated yes. A review of the facility provided policy titled, Acute Condition Changes-Clinical Protocol with a revised date of 6/2024, included the following under Cause Identification: .2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization . The facility did not provide any additional information. N.J.A.C. 8:39-13.1(a)(d)