Every finding on record at Dwellside Care and Rehab

COMPLAINT #259311 Based on interview, review of medical records and other pertinent facility documentation on 1/6/26, it was determined that the facility failed to maintain an accurate and complete medical record in accordance with acceptable professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed (Resident #1) and was evidenced by the following:During an interview on 1/6/26, at 12:24 PM, Resident #1 stated that there was a time in August when they ran out of morphine and that the facility did not refill the medication timely. The resident further stated that they received Oxycodone and Percocet as substitute during the period when the morphine was not available. A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: osteoarthritis of the knee, spinal stenosis, abnormalities of gait, major depressive disorder, and anxiety. The comprehensive Minimum Data Set (MDS), an assessment tool, dated 12/15/25, revealed a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicated that the resident was cognitively intact. Further review of the MDS indicated that Resident #1 had frequent pain. A review of Resident #1's Order Summary Report indicated that the resident had an active order for Morphine Sulfate Tablet Extended Release.A review of Resident #1's Medication Administration Record (MAR) for August 2025 indicated that the resident was prescribed: Morphine Sulfate Oral Tablet Extended Release 15 mg - Give 1 tablet by mouth every 12 hours for moderate pain. The following was also noted on the specified dates/times:-8/18/25 at 9 AM: #9-8/18/25 at 9 PM: #9-8/19/25 at 9 AM: #9-8/19/25 at 9 PM: #9-8/20/25 at 9 AM: #9-8/20/25 at 9 PM: #5-8/21/25 at 9 AM: #9-8/21/25 at 9 PM: #9-8/22/25 at 9 AM: #9-8/22/25 at 9 PM: #5-8/23/25 at 9 AM: #9 Further review of MAR revealed a Chart Codes section which indicated the following:#5 = Hold/See Nurse Notes#9 = Other/See Nurse Notes A review of Resident #1's Progress Notes (PN) for the corresponding dates revealed the following:-8/18/25 Physician Note (3:30 PM) Resident was seen after a report of pain in the left knee that was slightly better. A Lidocaine patch was ordered.-8/18/25 EMAR Note (11:54 PM) Awaiting pharmacy delivery-8/20/25 APN Note (2:41 PM) Resident was seen for a medication refill. The resident was noted as yelling and cursing and stated that the prescribed morphine had not been received. Nurse reported that they were waiting for the pharmacy delivery. APN provided a script for the morphine sulfate to the nurse.-8/20/25 EMAR Note (9:35 PM) Awaiting pharmacy delivery.-8/22/25 EMAR Note (9:49 PM) Waiting on pharmacy delivery.-8/22/25 EMAR Note (8:00 PM) Med [Out of stock] awaiting order A review of the medical record did not reveal documented evidence that the facility made an attempt to contact Resident #1's medical provider to request a refill for the Morphine Sulfate Oral Tablet Extended Release 15 mg from 8/18/25 until 8/20/25. A review of a grievance dated 8/21/25, revealed that the DON interviewed the resident regarding this concern and that it was resolved as of 8/22/25. On 1/6/26 at 3:35 PM the surveyor attempted to contact Licensed Practical Nurse (LPN #1) via telephone, without success. During an interview with the facility's contracted pharmacy on 1/6/26, at 2:20 PM, the pharmacist provided the following timeline regarding the Morphine Sulfate prescribed to Resident #1:8/20/25: -Electronic request from facility received by pharm to refill Morphine Sulfate -Pharm sent fax to MD, stating a script was needed -Pharm received script w/missing info8/21/25: -Pharm spoke w/[staff] at facility advised of clarification needed8/22/25: -Pharm received correct script8/23/25: -Pharm delivered medication During an interview with the Registered Nurse (RN #1) on 1/6/26 at 3:39 PM, RN #1 stated that nurses were to monitor medication counts to ensure that there was no gap in between deliveries. RN #1 further stated that narcotics cannot be re-ordered electronically, a script is needed. RN #1 stated that this made monitoring the counts even more important because the doctor needs to be contacted and that, All of this takes time. RN #1 further stated that all of this should be documented. In the presence of the surveyor RN #1 reviewed Resident #1's August 2025 MAR and confirmed that she entered #9 in the 8/19/25 box at 9 PM. RN #1 also confirmed that there was no corresponding PN for that date explaining any further details. RN #1 stated that she could not recall calling the doctor but that she should have and that she also should have documented it so that everyone was aware that it was done. During an interview with the Director of Nursing (DON) on 1/6/26 at 4:20 PM, the DON stated that as part of the investigation into grievance, the DON interviewed Licensed Practical Nurse (LPN #1) who was assigned to Resident #1 on 8/18/25. The DON stated that LPN #1 informed the DON that an attempt to reach the physician was made during the 8/18/25 day shift and multiple times after that. The DON stated that he was unsure why nurses were not documenting their efforts to obtain a script but that they should have. The DON further stated documentation in the medical record was important to ensure that the record accurately reflects the care being provided to each resident. A review of the facility's undated Charting and Documentation policy revealed that all services provided to residents should be documented and that documentation would be complete and accurate.A review of the facility's Medication Procurement Policy dated January 2025, revealed that all communication with physicians and supervisory staff must be documented in a resident's medical record. N.J.A.C. 8:39-27.1(a)

COMPLAINT #: 2599447Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 9/10/2025, 9/11/2025, 9/18/2025, and 9/23/2025, it was determined that the facility failed to provide adequate supervision of a severely cognitively impaired resident (Resident #2) with a known history of exit seeking behaviors and documented history of previous attempts to elope from their unit; who eloped form the facility on 8/23/2025. The deficient practice was identified for 1 of 3 residents reviewed (Resident #2).A review of facility record revealed that on 8/23/2025 at approximately 8:15 AM, Resident #2 eloped from the facility while wearing a Wander Guard (WG; alarmed security bracelet) through an alarmed second floor elevator, down to the first floor, and exited the building through the employee entrance door on the first floor. A review of facility document revealed that the Certified Nursing Aide (CNA #3) observed the resident as they exited the building through an employee entrance door as CNA #3 was entering the facility through the same employee door. CNA #3 confirmed during interview on 9/11/2025, that he observed the resident exit the building, but he did not stop the resident because he thought the resident was a visitor because they were well dressed and the exit alarm which was supposed to sound to alert staff that a resident with a WG exited the building, did not sound when Resident #2 exited the building. CNA #3 further stated that he did not recognize Resident #2 because the resident resided on the second floor and I work on B-wing on the first floor. Resident #2 was located in the community five hours later on 8/23/2025 at 1:46 PM, by the local police department and transferred the resident to the hospital for evaluation. The facility's failure to provide adequate supervision to a severely cognitively impaired resident who was at risk for elopement and eloped, posed a likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/23/2025 at 8:15 AM, after Resident #2 eloped from the facility. The facility Administration was notified of the IJ on 9/11/2025 at 6:00 PM. The facility submitted an acceptable Removal Plan (RP) on 9/19/2025 at 10:46 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 9/23/2025. The evidence was as follows: A review of the facility provided Elopements and Wandering Residents policy dated July 2024, included the facility ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Policy Explanation and Compliance Guidelines 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk.4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering.d. Adequate supervision will be provided to prevent accidents or elopements.A review of the Facility Reportable Event (FRE) dated 8/22/2025, that the facility submitted to the New Jersey Department of Health (NJDOH), revealed that on 8/23/2025, at around 9:34 AM, the Nursing Supervisor, a License Practical Nurse (LPN #3), called the Director of Nursing (DON) and informed him that she could not find Resident #2 in the facility. The DON then called the local police and reported the resident missing, and that the police went to the facility and initiated a search for the resident. The police later found Resident #2 in the community and transferred them to the hospital for evaluation.According to the police report dated 8/25/2025, facility staff notified the police of the missing resident on 8/23/2025, at approximately 9:49 AM. The report included that the police arrived at facility and conducted interviews with facility staff, and the staff informed the police that Resident #2 was a known wander and that Resident #2 wore ankle monitors which were supposed to disable the use of elevators and sound alarms to detect if a resident left the building. The report further indicated that their review of the facility's camera footage showed Resident #2 leaving the building at 8:15 AM, heading westbound on [name of street]. The report indicated that police then searched the building several times with negative results. The family member responded back to the facility about the elopement of Resident #2 and mentioned that the resident may return to old addresses. The family member provided the police with two addresses and emphasized that the police check one of the addresses because Resident #2 had previously repeatedly mentioned that address. The police report included that at approximately 1:46 PM, the family member informed the police that Resident #2 showed up to the house (old address). The resident was then taken to the hospital for an evaluation.According to an undated Investigation Summary document provided by the facility, Resident #2 returned back to the facility from the hospital at approximately 6:30 PM on 8/23/25, and that the facility assessed the resident for pain and injury, and none was noted and placed Resident #2 on one-to-one (1:1) supervision to monitor behavior and prevent further elopement.A review of CNA #3's statement revealed that he observed Resident #2 as they exited the building through an employee entrance door at the same time he was entering the building. CNA #3 indicated that he did not stop the resident because he thought the resident was a visitor because they were well dressed; was dressed in a thin long sleeve buttoned up dress shirt, black pants, socks, and loafers.During interview with the Licensed Nursing Home Administrator (LNHA) on 9/10/2025 at 9:50 AM, he stated that the employee entrance was a locked door and that a code needed to be entered on the pin pad for an employee to exit the building through that door. The LNHA also stated that when a resident who was wearing a WG approached the door, the door was supposed to sound an alarm and remain locked.The surveyor reviewed the medical record for Resident #2.According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: dementia, Alzheimer's Disease, hallucinations, and cognitive communication deficit.According to the quarterly Minimum Data Set (MDS), an assessment tool dated 8/06/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired.The surveyor reviewed Resident #2's Admit/Readmit Screener (admission assessment) with an effective date of 7/31/2025 at 4:55 PM, which revealed that Resident #2 needed supervision for locomotion off the unit.A review of Resident #2's Care Plan (CP) with an initiated date of 8/08/2025, revealed that Resident #2 was an elopement risk/wanderer as evidenced by disoriented to place. The CP also indicated that Resident #2 had a WG placed on their right ankle and that the resident should be distracted from wandering.A review of the Progress Note (PN) dated 8/03/2025 at 12:03 AM, written by LPN #4, included that Resident #2 was redirected for attempting to transfer on to the elevator.A review of the PN dated 8/06/2025 at 11:45 AM, written by LPN #5, included that the resident was redirected back to the floor from the first floor, Management made aware that the resident had a functioning wander guard that has been checked multiple times, however, the elevator isn't working properly to contain the resident.A review of the PN dated late entry 8/23/2025 at 6:00 PM, written by the Director of Nursing (DON), included that the Nursing Supervisor alerted the DON of potential elopement that morning as resident could not be found in the bedroom or on unit. The DON arrived at facility with the local police, they reviewed the camera, and the resident was confirmed to have eloped from the facility at 8:15 AM. The police then went into active search and rescue and were able to locate the resident and transported them to the hospital for evaluation.A review of the PN dated 8/23/2025 at 6:00 PM, written by LPN #5, included that the resident returned from the Emergency Department (ED) on a stretcher with no noticeable injuries and a functioning wander guard to right ankle. The resident was placed on 1:1 supervision as well as fifteen minute checks.On 9/10/2025 at 11:25 AM, the surveyor conducted an interview with Resident #2's assigned CNA (CNA #2), who stated that she last saw the resident on 8/23/2025, at around 7:20 AM, in the dining room. CNA #2 was later alerted by CNA #1 that she could not locate the resident after she went to give resident their breakfast. CNA #2 further stated that Resident #2 had gone down on the elevator two to three days after admission and had also gone and stood by employee door hanging around and that they went and got the resident by the employee door on that day and reported it to the nurse. CNA #2 stated that she could not remember the nurse's name because the nurse was from an agency. CNA #2 stated that usually if a resident who had a WG went on the elevator, the elevator door would probably close, but would not move up or down, it would beep and if it kept beeping long enough, the elevator would go down. When asked about staff responsibility and how staff supervised residents that wandered, she stated: the mentality is if they are not their Aide, they are not responsible . they are not going to chase or fight with resident to get off the elevator.On 9/10/2025 at 12:43 PM, the surveyor conducted a telephone interview with Resident #2's assigned nurse (LPN #1), who stated that for a resident at risk for wandering and elopement, the resident should be redirected to the dining room for activities; they should monitor the resident; make sure WG was working; and monitor them 1:1 to ensure the resident did not leave the unit. LPN #1 stated that on 8/23/2025, Resident #2 stopped at her medication cart, and that she told the resident that breakfast would be there shortly and encouraged the resident to go to the dining room, which the resident did. LPN #1 stated that 10 minutes later, around 8:15 AM, CNA #1 told her that she could not find Resident #2, and that she then informed Resident #2's CNA, and they all started to search for the resident. LPN #1 further stated that she informed the overnight Nursing Supervisor (LPN #3), who was supervising the 7:00 AM-3:00 PM shift. LPN #1 stated that LPN #3 and herself went up to the second floor, and checked the unit. LPN #3 stated that she called 911, contacted the DON, and initiated a Code Grey around 8:50 AM, because that was when they did a complete sweep (look around) including outside.On 9/10/2025 at 2:08 PM, the surveyor conducted an interview with CNA #1, who stated that Resident #2 had been going on the elevator since day one of admission to the facility. CNA#1 stated that on 8/23/2025, she saw Resident #2 with another resident on the unit, and when the breakfast tray cart arrived on the floor, (she did not remember the time), she took Resident #2's tray to the dining room but the resident was not there. CNA #1 stated she then went to Resident #2's room, but they were not in the room either, and she went immediately to LPN #1and informed her, and they all started searching for Resident #2. CNA #1 stated that she had previously witnessed Resident #2 walking onto the elevator at least two to three other times prior to the elopement on 8/23/2025. CNA #1 stated that the elevator has been a problem and that no one with a WG should get into the elevator because if they did, the elevator closed and would go down to another floor. CNA #1 stated she reported the elevator issue to the Agency nurse, and that she remembered reporting it to the nurse because she was agitated on that day. CNA #1 stated that two other people were at the nurse's station waiting for her to finish care with another resident and they then sent her downstairs to get Resident #2 instead of going downstairs to get the resident themselves.CNA #1 further stated that the other aides and herself had previously informed the Unit Manager that they were tired of chasing Resident #2 in and out of the elevator, and the Unit Manager usually replied that she would report to the higher ups. CNA #1 stated that when the DON would come to the second floor to check on the unit, the aides had previously reported to him about the elevator issues with multiple residents including Resident #2, and that Resident #2 succeeded in exiting the building. CNA #2 further stated that a day or two before Resident #2's elopement, she informed the DON about the elevator issue and that he asked her to inform the manager.On 9/10/2025 at 2:59 PM, the surveyor conducted an interview with LPN #2, who stated that the pin pad outside of the elevator door was newly placed that morning and required a code to be entered for the elevator to open. LPN #2 stated that the pin pad inside the elevator was previously in place and required a code for the elevator to operate when a resident with a WG entered the elevator because it was a locked unit. LPN #2 stated that the elevator alarm had been an issue and not effective in sensing WG, and that after a few minutes of opening the elevator, the elevator would close even without the code being entered, and that Resident #2 on more than one occasion went down the elevator to another floor. LPN #2 stated that it was not the first time that Resident #2 eloped to another unit, and that Management was aware and had even brought Resident #2 up to the second floor unit on more than one occasion. LPN #2 stated that she had witnessed Resident #2 being brought back to the unit by Management who stated, we need to do a better job watching the resident. LPN #2 further stated that they previously explained to Management that staff do watch the resident, but the elevator system is not effective. LPN #2 did not provide the name of the person she informed of the elevator alarm issues.On 9/10/2025 at 4:20 PM, the surveyor conducted an interview with the LNHA, who stated that Resident #2 should not be able to get off the unit because they had a sensor in the elevator that would shut off the elevator if someone with WG enter the elevator. The LNHA stated that he was not sure that Resident #2 ever came off the unit with the WG. The LNHA stated that staff were trained and supposed to recognize residents with WGs because they had binders on the nursing units with list of residents wearing WGs including pictures of those residents. The LNHA did not offer an explanation for why staff did not recognize and prevent Resident #2 from eloping out of the facility on 8/23/2025.At that time, the surveyor asked about the PN from 8/6/2025, that indicated Resident #2 went off the unit and was brought back to second floor from the first floor, and the LNHA stated that he could not remember now. When asked if the facility completed an investigation for the incident, he stated that the facility administration team was not made aware of the incident. The LNHA also stated that he was not aware of any reports regarding the elevator alarm issues, and that the Maintenance Director (MD) usually checked the WG alarm system weekly for function.On 9/10/2025 at 4:56 PM, the surveyor attempted to reach LPN #5 who wrote the PN 8/6/2025, via telephone and got no response.On 9/10/2025 at 5:19 PM, the surveyor reviewed the camera footage with the LNHA. The security camera revealed that on 8/23/2025, the Receptionist responded to the sound of the door at the employee entrance to allow CNA #3 into the facility. At that same time, Resident #2 was leaving out that same entrance at 7:21:46 AM. The LNHA explained that the camera had a time lag on the clock timer, so the actual time was 8:15 AM, and not 7:21 AM.On 9/11/2025 at 10:52 AM, the surveyor interviewed the Regional Director of Nursing (RDON), who stated that there was a glitch in the system and the WG system was not connecting to the sensor in the ceiling. The RDON stated that she was not aware of the PN from 8/6/2025, about Resident #2 leaving their unit and being returned to the second floor from the first floor. The RDON stated that after Resident #2 eloped on 8/23/2025, the facility recognized gaps in the system and they started addressing them.On 9/11/2025 at 12:14 PM, the surveyor interviewed CNA #2 who stated; if a staff member was at the end of the hallway, they would not be able to see the resident get onto the elevator or hear an alarm sound from the WG. CNA #2 stated that she did not recall hearing an alarm sound when Resident #2 went onto the elevator on 8/23/2025, and eloped.According to the Assistant Director of Nursing (ADON), during interview on 9/11/2025 at 12:46 PM, Resident #2 was found at their childhood home which was approximately a sixteen minute drive or a two hour walk from the facility.On 9/11/2025 at 12:55 PM, the surveyor conducted an interview with the Maintenance Director (MD), who stated that he was familiar with the WG system and did weekly checks by taking the WG sensor to the elevator and to employee entrance door to see if the alarm sounded up to three to five feet away from the exit. The MD stated that the setup was to not allow the resident with the WG to go down on the elevator unaccompanied and that when he checked the door alarms, they worked. The MD stated maybe the signal on the ankle did not connect. The MD also stated that the technicians moved the antenna box from the top when they were called to check the elevator alarms after elopement incident.On 9/11/2025 at 1:27 PM, the surveyor interviewed second floor Unit Manager (UM), who stated that she was aware that Resident #2 had exit seeking behavior and that the entire staff was aware that resident had exit seeking behavior and the WG and resident's behavior is on the resident's care plan.On 9/11/2025 at 1:40 PM, the survey conducted an interview with CNA #3, who stated that on 8/23/2025, he was already at work and had to get something from the car. When he opened the door to re-enter the building, the resident came out and that CNA #3 was a bit frightened because of the way the resident came out. CNA #3 further stated that Resident #2 looked like a doctor and that he did not hear an alarm or else it would have triggered him to check. CNA #3 also stated that he did not recognize the resident because the resident resided on the second floor and he worked on the first floor.On 9/11/2025 at 2:15 PM, the surveyor re-interviewed the LNHA in the presence of the ADON and RDON, who stated that it was expected of all facility staff to know who the residents were at risk for elopement and who had WGs for the alarm system to work consistently.During interview with the DON on 9/18/2025 at 10:05 AM, the surveyor asked about the facility's protocol for how staff communicated and reported any system issues including WG alarm related issues. The DON stated that staff were supposed to verbally inform the supervisor, DON, LNHA or any other administrative member. The DON also stated that he was not made aware of any issues with the elevator alarming system.On 9/18/25 at 12:45 PM, during the survey team's verification of the Removal Plan (RP), the surveyor went to the employee entrance door with the MD to test the alarm system. As part of the test, the surveyor asked CNA #4 to bring a resident with a WG to the employee entrance door, and when the resident approached the door, the alarm did not sound. At that time, the MD opened the employee entrance door and asked the staff to walk with the resident through the door. The resident, who was wearing a WG, walked out of the building and the door alarm did not sound. Both CNA #4 and the MD stated that the alarm was supposed to sound to alert staff that a resident with a WG exited the building.On 9/18/2025 at 1:00 PM, the surveyor went to the second floor and requested CNA #5 to walk a resident with a WG through the elevator to test the functioning of the alarm system. CNA #5 then accompanied Resident #2 to Elevator #1, and when Resident #2 entered Elevator #1, the alarm did not sound. The surveyor entered the same elevator and joined CNA #5 and the resident. Without entering the alarm code, CNA #5 pushed the elevator down button; the elevator door closed and went down to the first floor without the code being entered and the alarm did not sound. CNA #5 stated that the elevator alarm was supposed to sound; the door was not supposed to close; and the elevator was not supposed to go down if a resident was in the elevator with a WG and the code was not entered. CNA #5 then checked the resident's ankle to make sure the resident was wearing their WG and confirmed the presence of the WG on the resident's ankle. The surveyor then requested that the WG alarm be tested on Elevator #2, and CNA #5 accompanied the resident into Elevator #2, and the alarm did not sound.During interview with the LNHA, in the presence of the DON on 9/18/2025 at 1:55 PM, he stated that he expected the alarm systems to work consistently whenever a resident with a WG tried to enter the elevator or to exit through the employee door.The implementation of the Removal Plan was not verified, and the immediacy continued.An acceptable Removal Plan (RP) was received on 9/19/2025 at 10:56 AM, indicating the action the facility will take to prevent serious harm from occurring or recurring.The facility implemented a corrective action plan to remediate the deficient practice to include Resident #2 was located on 8/23/2025, sent to the hospital for evaluation, returned to the facility the same day, and immediately placed on 1:1 supervision that was maintained until 8/24/2025. Resident #2 had a skin and pain assessment with no injury; the physician and family were notified; and the resident's WG was checked every shift for placement and function. On 8/25/2025, the facility's vendor serviced the WG system, and staff were stationed at employee entrance/exit until 9/18/2025, when the system was repaired when the WG vendor increased the system's sensitivity. All residents with WG were checked; updated resident photos for residents with WGs were posted in both elevators and employee entrance. All receptionists were educated on the process of buzzing employees in and out of the facility, and all staff were educated on the facility's elopement policy, wandering binders and identification process, and elopement drills were conducted.The surveyor verified the implementation of the RP on-site during the continuation of the survey on 9/23/2025.NJAC 8:39-27.1(a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the physician of a resident's elevated blood pressure for 1 of 28 sampled residents (Resident #13). This deficient practice was evidenced by the following: The surveyor reviewed the medical record for Resident #13. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, essential hypertension (high blood pressure), and unspecified dementia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/25, included 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. A review of the individual comprehensive care plan (ICCP) included a focus, dated 5/15/25, that the resident had hypertension related to lifestyle, poor diet, and stroke. Interventions included: Give anti-hypertensive medications (medications that lower blood pressure) as ordered. A review of the Weights and Vitals Summary, as of 5/15/25, revealed the following blood pressures (BP): On 5/7/25 at 10:16 AM, a BP of 188/92 (machine), with an alert that the diastolic (bottom number) exceeded 89 and the systolic (top number) exceeded 139. On 5/7/25 at 10:15 PM, a BP of 164/80 (manual), with an alert that the systolic exceeded 139. On 5/8/25 at 9:58 AM, a BP of 191/83 (machine), with an alert that the systolic exceeded 139. On 5/9/25 at 9:48 AM, a BP of 224/110 (machine), with an alert that the diastolic exceeded 89 and the systolic exceeded 139. On 5/13/25 at 10:13 AM, a BP of 214/95 (machine), with an alert that the diastolic exceeded 89 and the systolic exceeded 139. On 5/14/25 at 10:07 AM, a BP of 233/98 (machine), with an alert that the diastolic exceeded 89 and the systolic exceeded 139. On 5/14/25 at 10:22 PM, a BP of 158/80 (manual), with an alert that the systolic exceeded 139. A review of the Progress Notes, dated 5/7/25 through 5/14/25, did not indicate the physician was notified of the elevated BPs listed above. Further review of the Progress Notes included a General Note, dated 5/12/25 at 10:41 PM and written by the Attending Physician (AP), which revealed the resident had no complaints, but had an elevated BP. Further review of the note revealed the resident's neck was supple without Jugular Vein Distention (JVD - an indicator of increased blood pressure) and the resident's heart rate and rhythm were normal. The note also included that the AP increased the resident's Metoprolol Succinate ER (an anti-hypertensive medication) to 50 mg by mouth every 12 hours. On 5/15/25 at 1:42 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #4 who stated that if the resident had an elevated BP, the nurse should notify the physician and document the notification in the resident's progress notes. On 5/15/25 at 1:54 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that if the resident had an elevated BP, the nurse should notify the physician and document the physician's recommendations in the resident's progress notes. When asked about Resident #13, the LPN/UM stated she was not notified of the resident's high BP on the above dates, but that the nurse should have rechecked the BP, notified the physician if the BP was still high, and documented the physician's response in the resident's progress notes. On 5/15/25 at 2:29 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the nurse should notify the physician if the resident's BP was abnormal, or the resident was experiencing distress. The DON further stated that the nurse should document the physician notification in the resident's progress notes. When asked about Resident #13, the DON stated he was not notified about the resident's elevated BP on the above dates, but that whoever took the resident's BP should have notified the nurse so the nurse could assess the resident and contact the physician. Further review of the Progress Notes included a NN, dated 5/15/25 at 2:33 PM (after surveyor inquiry) and written by LPN/UM #2, which revealed the physician was notified of the resident's elevated BP of 157/92 and the physician provided new orders for anti-hypertensive medication. Further review of the NN revealed the resident was assessed and denied blurry vision, headache, or nausea. On 5/16/25 at 9:41 AM, the surveyor interviewed LPN/UM #1 who stated there was a contracted company that sent a Medical Assistant (MA) to obtain vital signs at the facility. The LPN/UM explained it was never the same MA who came to the facility and that the MA was required to get 100 sets of vital signs prior to leaving the facility. The LPN/UM then stated that if the vital signs were abnormal, the MA should report that to the nurse so that the nurse could assess the resident and recheck the vitals to ensure accuracy. LPN/UM #1 further stated that if a resident's BP was high, the nurse should notify the physician and document the physician's response in the resident's progress notes because an uncontrolled BP could cause issues for the resident. On 5/16/25 at 10:00 AM, the surveyor interviewed the MA that was in the facility that day who stated she was responsible for getting 100 sets of vital signs in the facility prior to leaving. The MA further stated that she started on the first floor and worked her way up to the second floor until she got 100 vitals. The MA explained that when she obtained vital signs, the vital signs were automatically uploaded into the resident's electronic medical record through the vital signs machine. When asked about abnormal vital signs, the MA stated that she reported any abnormal vital signs to the nurse just in case something is wrong with the resident, or they need their medications. On 5/16/25 at 10:18 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated if a resident had a high BP, it was important to notify the physician so the physician could order anti-hypertensive medications. On 5/16/25 at 10:25 AM, the surveyor interviewed the Attending Physician (AP) who stated if a resident had a high BP, the nurse should notify the physician to obtain further orders. When asked about Resident #13, the AP stated he was not notified of the resident's high BP, but reviewed the resident's BP himself during his routine monthly visit on 5/12/25 and increased the resident's anti-hypertensive medication. A review of the facility's Vital Signs policy, undated, included the following: Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. Acceptable ranges for adults: .d. Blood pressure: average <120/<80 A review of the facility's Notification of Changes policy, undated, included the following: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Significant change in the resident's physical, mental or psychosocial condition . Circumstances that require a need to alter treatment. A review of the facility's Conducting an Accurate Resident Assessment or Reassessment policy, undated, included the following: Reassessments will be performed to determine the efficiency of treatment or to identify additional needs when the residents' condition or diagnosis changes. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) maintain one resident bathroom in good condition, b.) ensure that bath towels and wash cloths were readily available in sufficient quantities for resident care needs, and c.) maintain the resident's environment, equipment and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 unsampled resident's bathroom (Resident room [ROOM NUMBER]), 1 of 1 resident (Resident #47) observed for pressure ulcer/injury, and 2 of 3 residents (Residents #26 and #78) observed for tube feeding, and was evidenced by the following: 1.) On 5/14/25 at approximately 9:26 AM, Surveyor #1 observed inside Resident room [ROOM NUMBER]'s bathroom that the wallpaper was loose and lifting apart form the wallboard. Further inspection identified an approximately 18 inch by 22 inch section of wallboard (where the wallpaper was lifted) with a black substance adhered to the wallboard. The Administrator and the Maintenance Director (MD) were informed of the deficient practice during the Life Safety Code survey exit on 05/16/2025 at approximately 12:15 PM. 2.) Refer to F880 On 5/14/25 at 9:44 AM, Surveyor #2 observed Resident #47 lying in bed awake. The resident stated that there were frequently no linens, towels, or wash cloths available and staff resorted to using toilet paper or sheets to dry the resident after care. The resident agreed to allow the surveyor to observe his/her next scheduled wound treatment. On 5/14/25 at 10:23 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who stated that there were plenty of linens today, but not usually. CNA #1 stated that the linen closet was stocked and then the aides pulled from the closet and stocked the linen carts. On 5/14/25 at 10:44 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that she planned to complete Resident #47's wound treatment at that time. LPN #1 stated that she first needed to obtain a towel to change the resident's brief post-wound treatment. LPN #1 then proceeded to look in the linen closet and three linen carts before she stated there were no towels left in that hallway. LPN #1 then proceeded to search the two linens carts on the opposite hallway and stated that there were no towels left. On 5/14/25 at 10:49 AM, LPN #1 observed CNA #2 inside of Resident room [ROOM NUMBER] and then proceeded to ask her if she had any towels. CNA #2 then provided LPN #1 with bath towels from inside of the Resident room [ROOM NUMBER]. On 5/14/25 at 10:51 AM, LPN #1 entered Resident #47's room and stated that she needed to change the resident's brief. LPN #1 then proceeded to place a towel on the resident's bed as drape for the resident's wound treatment supplies, a second towel was placed on the floor beside the resident's bed, and a third towel was used for incontinence care post-wound treatment to both clean and dry the resident. On 5/14/25 at 11:21 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the facility has had the issue of not being stocked with enough linens. LPN/UM #1 stated that the issue was brought to the Director of Environmental Services (DEVS) attention and additional linens were received. On 5/14/25 at 12:17 PM, the surveyor interviewed the Certified Volunteer Advocate (CVA) via telephone. The CVA stated that she started volunteering at the facility in July of 2024 and the residents had expressed that there were ongoing laundry and linen issues that had occurred for a long time. The CVA stated that most of her visits were on a Saturday or Sunday during dinner hours and most of the residents were still in bed. The CVA stated that they had enough staff it seemed, but there were not enough linens on the units. The CVA stated that the Housekeeping Director left and a new Housekeeping Director started four or five weeks ago. The CVA stated that she had a conference and expressed her concerns with the Licensed Nursing Home Administrator (LNHA) who stated that there was a Quality Assurance Performance Improvement (QAPI) in place and it was determined that the linens were not being returned to be laundered. The LNHA stated that they implemented an intervention of checking in with the night housekeeper for follow-up. On 5/15/25 at 9:33 AM, the surveyor interviewed CNA #2 who stated that she had worked at the facility for 25 years. CNA #2 stated that sometimes there were enough linens, and sometimes not. CNA #2 stated that they called the laundry department when they needed additional linens, but it could take awhile to get more. CNA #2 further stated, I had extra in a bag yesterday, so I gave it to LPN #1. On 5/15/25 at 10:07 AM, the surveyor interviewed LPN #2 who stated that the aides complained there were no linens and she told them to go downstairs to get more. LPN #2 further stated that the residents also complained about a lack of linens and that the aides held onto the linens for their residents. LPN #2 also stated that was really the only issue, that there was not enough linens. On 5/15/25 at 10:17 AM, LPN #2 and CNA #2 showed the surveyor the linen closet and there were nine wash cloths and five bath towels that remained at that time. On 5/15/25 at 10:59 AM, the surveyor interviewed the DEVS who stated that he had worked at the facility for two months. The DES stated that he had his first encounter with the resident council recently and a resident brought up that there was never enough linens. The DES stated that a couple of times he saw that the linen closet was empty, so he started a PAR (Periodic Automatic Replenishment) level to keep an eye on it a little better. On 5/16/25 at 12:37 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the facility had no linen shortage, but that the issue had been brought up at resident council. The DON further stated that it was not uncommon for there to be no linens left around 11:00 AM, and it just showed how hard the aides were working. On 5/16/25 at 1:39 PM, the surveyor shared the concerns regarding insufficient quantities of towels and wash cloths that were noted during the provision of resident care. A review of the facility's Handling Clean Linen policy, updated and reviewed May 2024, included: Clean washcloths and towels shall be readily available to all residents at all times to support personal hygiene and comfort. If clean washcloths or towels are not available, staff must promptly notify the supervisor and housekeeping to ensure timely replenishment and provide suitable alternatives (such as; but not limited to; disposable wash cloths, wipes .) to maintain resident care and hygiene standards. 3.) On 5/15/25 at 8:50 AM, Surveyor #3 observed Resident #78's enteral feeding [a method of providing nutrition directly into the gastrointestinal tract (GI tract) through a feeding tube] running. At that time, the surveyor observed dried formula drippings on the intravenous pole (IV pole) and harden spillage on the wheels and floor. On 5/15/25 at 8:53 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #5 who stated that housekeeping was responsible for cleaning the IV poles and the floor, but that the nurses were also responsible for cleaning the area if dirty. On 5/15/25 at 9:32 AM, the surveyor interviewed the Housekeeper (HK) who stated that she was responsible for cleaning everything in the resident's room. She stated that she cleaned the IV poles and mopped the floors. The HK stated that she cleaned the rooms daily and the equipment as needed. When asked if she followed a checklist for cleaning the rooms, the HK stated the cleaning checklist was in her head. On 5/15/25 at 9:38 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated the housekeeping department was responsible for cleaning the rooms and equipment and the nurses were responsible for spot checking and cleaning as needed. On 5/15/25 at 9:42 AM, the surveyor and LPN/UM #3 entered Resident #78's room and she confirmed the IV pole and the bottom of the IV pole needed to be cleaned and that there was dried formula on the floor that needed to be removed. 4.) On 5/14/25 at 10:26 AM, the surveyor observed Resident #26 lying in bed watching tv, with the enteral feeding running. At that time, the surveyor observed dried formula on the floor. On 5/15/25 at 9:44 AM, the surveyor and LPN/UM #3 entered Resident #26's room. The LPN/UM confirmed there was dried formula on the floor. She then stated she would call the HK. On 5/15/25 at 9:49 AM, the surveyor interviewed the Director of Environmental Services (DEVS), who stated housekeeping was responsible for cleaning the resident's rooms daily. The DEVS stated the HKs were expected to clean dried formula off the floor and clean equipment as needed. On 5/15/25 at 9:55 AM, the surveyor showed the DEVS the pictures from tour with LPN/UM #3 and he confirmed the IV poles and floors were dirty and needed to be clean. The DEVS stated his expectation was that staff was cleaning those areas when observed dirty. On 5/16/25 at 11:44 AM, in the presence of the survey team, the Director of Nursing (DON) stated the HKs were responsible for cleaning the IV poles and floors. He stated that the resident's rooms and equipment should be inspected daily and cleaned as needed. At that time, the surveyor showed the DON the pictures of the rooms. The DON stated he did not feel it was that disastrous but his expectation was for the equipment and floor to be clean. On 5/16/25 at 12:05 PM, in the presence of the DON, Regional Nurse #1, and the survey team, the Licensed Nursing Home Administrator (LNHA) stated the floors should be cleaned daily, the equipment should be clean as needed, and if the nurses noticed it needed to be cleaned, they could clean it as well as notify the HK. A review of the facility's undated WeeklyMinders: Stretchers, IV Poles and Wheelchair form included, Process: wipe all surfaces with germicidal solution including wheels. Use all purpose cleaner and white hand pad on stubborn stains. A review of the facility's Environmental Cleaning policy dated July 2021, included, equipment is cleaned and disinfected according to manufacturers' instructions .Objects and environmental surfaces that are touched frequently and in close proximity to the resident are cleaned and disinfected at least daily and when visibly soiled . All floors shall be mopped/cleaned/vacuumed daily. NJAC 8:39-31.4(a); 27.2(h)(j);4.1 (a)11; 31.2(e)

2.) On 5/14/25 at 1:33 PM, the surveyor observed Resident #2 awake and alert in his/her room. The resident was not displaying any behaviors. The surveyor reviewed the medical record for Resident #2. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: dementia, major depressive disorder, and post-traumatic stress disorder (PTSD). A review of the resident's quarterly MDS, an assessment tool used to facilitate the management of care, dated 4/22/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received an antidepressant and antianxiety medication within the last seven days of the assessment. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 10/14/24, that the resident had experienced a past trauma. Interventions included: monitor and report any changes to mood, behavior, sleep appetite and/or cognition. Further review of the ICCP included a focus area, dated 1/13/25, that the resident used psychotropic medications related to depression. Interventions included: monitor/record occurrence for target behavior symptoms and document per facility protocol. A review of the Order Summary Report (OSR), dated as of 5/15/25, included the following physician orders (PO): A PO, dated 1/13/25, for Lexapro 10 milligrams (mg) give one tablet by mouth one time a day for depression. A PO, dated 10/15/24, for Temazepam 30 mg give one capsule by mouth at bedtime for insomnia. A review of the PMQS evaluations in the resident's medical record revealed no documentation that monthly/quarterly PMQS were completed. A review of the Psychiatry Notes in the resident's medical record revealed the resident was last seen by the psychiatrist on 5/14/25. 3.) On 5/14/25 at 12:47 PM, the surveyor observed Resident #20 eating lunch in the day room. The resident was not displaying any behaviors and was in a pleasant mood. The surveyor reviewed the medical record for Resident #20. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: encephalopathy (a broad category of brain disorders that affect brain function, resulting in altered mental status and neurological symptoms), and major depressive disorder. A review of the resident's comprehensive MDS, an assessment tool used to facilitate the management of care, dated 3/27/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident received an antipsychotic and antidepressant medication within the last seven days of the assessment. A review of the individual ICCP included a focus, dated 4/10/23, that the resident used drugs having an altering effect on the mind characterized by problems with cardiac, neuromuscular, gastrointestinal systems, decline in mood/behavior, hallucinations/delusions, involuntary movements. Interventions included: monitor residents mood/state behavior. A review of the Order Summary Report (OSR), as of 5/15/25, included the following physician orders (PO): A PO, dated 5/14/25, for Remeron 15 mg give one tablet by mouth at bedtime for depression. A PO, dated 3/20/25, for Seroquel 25 mg give 0.5 mg tablet by mouth at bedtime for mood. A review of the Psychotropic Monthly/Quarterly Summary (PMQS) evaluations in the resident's medical record revealed the last PMQS was completed on 12/11/24. A review of the Psychiatry Notes in the resident's medical record revealed the resident was last seen by the psychiatrist on 5/14/25. 4.) On 5/14/25 at 8:48 AM, the surveyor observed Resident #49 lying in bed with their eyes closed. The surveyor reviewed the medical record for Resident #49. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: metabolic encephalopathy (is a change in how your brain works due to an underlying condition), epilepsy (seizure disorder), depression, unspecified dementia, and anxiety A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/6/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident received an antipsychotic, an antianxiety, and an anticonvulsant medication within the last seven days of the assessment. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 12/18/24, that the resident used drugs that had mind altering effects on the mind characterized by problems with cardiac, neuromuscular, gastrointestinal systems, involuntary movement, motor agitation and tremors. Interventions included: monitor mood state/behavior and evaluate the effectiveness and side effects of medciations for possible decrease/elimination of psychotropic drugs. A review of the Order Summary Report (OSR), dated as of 5/15/25, included the following physician orders (PO): A PO, dated 4/3/25, for Depakote delayed release125 mg give one tablet by mouth two times a day for mood. A PO, dated 12/4/24, for Olanzapine 5 mg give one tablet by mouth in the evening for mood disorder. A PO, dated 3/6/25, for Zoloft 25 mg give one tablet by mouth one time a day for depression/anxiety. A review of the PMQS evaluations in the resident's medical record revealed the last PMQS was completed on 2/15/25. A review of the Psychiatry Notes in the resident's medical record revealed the resident was last seen by the psychiatrist on 5/14/25. 5.) On 5/13/25 at 10:27 AM, during the initial tour of the B Unit, the surveyor observed Resident # 79 awake and alert, lying in bed. The resident was not displaying any behaviors and was in a pleasant mood. The surveyor reviewed the medical record for Resident #79. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: metabolic encephalopathy (is a change in how your brain works due to an underlying condition), depression, Type 2 Diabetes, Non -Hodgkin's Lymphoma (a type of blood cancer), anxiety, and chronic pain. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/21/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received an antianxiety, and an antidepressant in the last seven days of the assessment. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/16/24, that the resident was on antianxiety medications, antidepressant medication, diuretic medication, and pain management medications. Interventions included: monitor and record occurrence of target behaviors symptoms. A review of the Order Summary Report (OSR), dated as of 5/15/25, included the following physician orders (PO): A PO, dated 2/12/25, for Sertraline HCL (hydrochloride) 50 mg give one tablet one time a day for depression. A PO, dated 2/17/25, for Xanax (Alprazolam) 0.5mg give one tablet by mouth three times a day for anxiety. Give with 1 mg for a total of 1.5 mg. A PO, dated 2/18/25, for Alprazolam (Xanax) 1 mg give one tablet by mouth three times a day for anxiety. Give with 0.5 mg tab for a total of 1.5 mg. A review of the PMQS evaluations in the resident's medical record revealed the last PMQS was completed on 1/6/25. A review of the Psychiatry Notes in the resident's medical record revealed the resident was last seen by the psychiatrist on 5/7/25. 6.) On 5/14/25 at 8:44 AM, the surveyor observed Resident #115 awake and alert sitting in the activity lounge. The resident was not displaying any behaviors. The surveyor reviewed the medical record for Resident #115. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: anxiety disorder, bipolar, and PTSD. A review of the resident's quarterly MDS, an assessment tool used to facilitate the management of care, dated 2/21/25, included the resident had a BIMS score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received antipsychotic, an antianxiety, and an antidepressant in the last seven days of the assessment. A review of the resident's ICCP included a focus area, dated 1/20/25, that the resident was on antianxiety, antidepressant, and antipsychotic medications. Interventions included: monitor and record occurrence of target behaviors symptoms and ongoing signs and symptoms of anxiety and depression. A review of the Order Summary Report (OSR), dated as of 5/1/25, included the following physician orders (PO): A PO, dated 1/15/25, for Klonopin 1 mg give one tablet by mouth two time a day for anxiety. A PO, dated 1/15/25, for Seroquel 100 mg give two tablets by mouth two times a day for bipolar disorder. A PO, dated 1/20/25, for Trazadone 50 mg give one tablet by mouth at bedtime for depression. A review of the PMQS evaluations in the resident's medical record revealed no documentation that monthly/quarterly PMQS were completed. A review of the Psychiatry Notes in the resident's medical record revealed the resident was last seen by the psychiatrist on 3/19/25. On 5/15/25 at 10:35 AM, the surveyor interviewed LPN #3 who stated that the PMQS was in the electronic medical record but I haven't done one yet. On 5/15/25 at 10:51 AM, the surveyor interviewed the LPN/UM #2 who stated that the PMQS was completed monthly and should be completed by the 6th of each month. On 5/16/25 at 11:36 AM, during an interview with the DON, the DON verified that Residents #2, #20, #79, #49, and #115 should have had a PMQS completed monthly. A review of the facility's Psychotropic Medication - Monthly and Quarterly Monitoring Summaries policy, undated, included the following: Psychotropic medications shall be reviewed monthly and quarterly to evaluate effectiveness, side effects, ongoing indication, and opportunities for gradual dose reduction (GDR). These reviews are essential to reduce unnecessary use and protect resident rights. Monthly Summary: A nursing progress notes or summary that evaluates a resident's response to prescribed psychotropic medications each month. Documentation: Must be entered into the resident's medical record . Use standardized facility form or HER [electronic health record] template if available. NJAC 8:39-27.1(a) Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to complete monthly psychotropic medication summaries for 1 of 4 residents (Resident #63) reviewed for mood/behavior and 5 of 5 residents (Resident #2, #20, #48, #79, and #115) reviewed for unnecessary medications. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.) On 5/14/25 at 12:47 PM, the surveyor observed Resident #63 eating lunch in the day room. The resident was not displaying any behaviors and was in a pleasant mood. The surveyor reviewed the medical record for Resident #63. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, major depressive disorder and insomnia. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/29/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed the resident received an antidepressant medication within the last seven days of the assessment. A review of the individual comprehensive care plan (ICCP) included a focus, revised 3/21/25, that the resident had the potential for altered psychosocial well-being related to ongoing adjustment to placement, health status, and/or age/condition related losses. The focus further included the resident was on antidepressant medications. A review of the Order Summary Report (OSR), as of 5/15/25, included the following physician orders (PO): A PO, dated 3/5/25, for Escitalopram Oxalate 10 milligrams (mg) give one tablet by mouth one time a day for depression. A PO, dated 3/20/25, for Mirtazapine 7.5 mg give one table by mouth at bedtime for depression/sleep. A PO, dated 5/3/25, for Trazodone 100 mg give one tablet by mouth at bedtime for depression/sleep, give with half tablet to equal 125 mg. A PO, dated 5/3/25, for Trazodone 50 mg give half tablet by mouth at bedtime for depression/sleep, give with 100 mg to equal 125 mg. A review of the Psychotropic Monthly/Quarterly Summary (PMQS) evaluations in the resident's medical record revealed the last PMQS was completed on 1/12/25. A review of the Psychiatry Notes in the resident's medical record revealed the resident was last seen by the psychiatrist on 3/19/25. On 5/16/25 at 9:33 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 who stated the PMQS evaluations were completed by the Unit Managers to ensure the residents' psychotropic medications were working effectively. On 5/16/25 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the PMQS evaluations were completed by the nurses by the 15th of each month. The LPN/UM further stated the importance of the PMQS was to keep staff updated on the psychotropic medications prescribed, to know how many behaviors the resident had each month, and to know if the psychotropic medications were working. On 5/16/25 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated the PMQS evaluations were completed collaboratively by the nursing team by the 15th of each month in order to capture the events of the previous month including any gradual dose reductions, psychiatry visits, and the resident's behaviors. At that time, the surveyor informed the DON that Resident #63's last PMQS was in January 2025, and the DON verified the resident should have had a PMQS completed in February, March, and April 2025.

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to notify the physician of a physician's order that was pending a physician's signature which resulted in five missed doses of an anti-hypertensive medication for 1 of 4 residents (Resident #13) observed during the medication administration pass. This deficient practice was evidenced by the following: On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13. As the LPN was reviewing the physician's orders (PO) to dispense the resident's medications, the surveyor observed a PO for Metoprolol Succinate (an anti-hypertensive medication which is used to lower blood pressure) which had an alert of Pending Order Signature and the PO would not allow the LPN to administer the medication. When the LPN administered the resident's scheduled medications, the surveyor observed the resident was sitting on the side of the bed, had no complaints, and was not in distress. The surveyor reviewed the medical record for Resident #13. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, essential hypertension (high blood pressure), and unspecified dementia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/25, included 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. A review of the individual comprehensive care plan (ICCP) included a focus, dated 5/15/25, that the resident had hypertension related to lifestyle, poor diet, and stroke. Interventions included: Give anti-hypertensive medications as ordered. A review of the Progress Notes included a General Note, dated 5/12/25 at 10:41 PM and written by the Attending Physician (AP), that the resident had no complaints, but had an elevated blood pressure. Further review of the note revealed the resident's neck was supple without Jugular Vein Distention (JVD - an indicator of increased blood pressure) and the resident's heart rate and rhythm were normal. The note also included that the AP increased the resident's Metoprolol Succinate ER to 50 mg by mouth every 12 hours. A review of the Order Summary Report (OSR), as of 5/15/25, included the following physician orders (PO): A PO, dated 3/1/25, for Apixaban Oral Tablet 2.5 milligrams (mg) Give one tablet by mouth every 12 hours for A-Fib (a condition that causes an irregular and rapid heartbeat). A PO, dated 12/13/23, for Losartan Potassium Oral Tablet 100 mg Give one tablet by mouth one time a day for hypertension (HTN). A PO, with a start date of 5/13/25, for Metoprolol Succinate Oral Capsule Extended Release (ER) 24 Hour Sprinkle 50 mg Give one capsule by mouth every 12 hours for HTN, with an order status of Pending Order Signature. A review of the May 2025 Medication Administration Record (MAR) included the following: PENDING ORDER SIGNATURE Metoprolol Succinate Oral Capsule ER 24 Hour Sprinkle 50 MG Give 1 capsule by mouth every 12 hours for HTN - Order Date- 05/12/2025. Further review of the May 2025 MAR revealed the above order was scheduled to start on 5/13/25, but was not signed out as administered on the following dates/times: On 5/13/25 at 9:00 AM On 5/13/25 at 9:00 PM On 5/14/25 at 9:00 AM On 5/14/25 at 9:00 PM On 5/15/25 at 9:00 AM A review of the Weights and Vitals Summary, as of 5/15/25, revealed the following blood pressures (BP): On 5/13/25 at 10:13 AM, a BP of 214/95 (machine), with an alert that the diastolic (bottom number) exceeded 89 and the systolic (top number) exceeded 139. On 5/14/25 at 10:07 AM, a BP of 233/98 (machine), with an alert that the diastolic exceeded 89 and the systolic exceeded 139. On 5/14/25 at 10:22 PM, a BP of 158/80 (manual), with an alert that the systolic exceeded 139. Further review of the Progress Notes revealed Nurses' Notes (NN) on the following dates: On 5/13/25 at 2:52 PM, there was a NN which did not indicate the resident was experiencing any symptoms related to high blood pressures. On 5/14/25 at 3:40 AM, there was a NN which indicated the resident was stable and without signs of distress. On 5/15/25 at 1:42 PM, the surveyor interviewed LPN #4 who stated if a PO had an alert of Pending Order Signature, the nurse should notify the physician to verify whether the medication should be given. LPN #4 further stated that if a resident did not receive their anti-hypertensive medication, depending on the resident's blood pressure, the resident could experience a stroke. On 5/15/25 at 1:54 PM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated if a PO had an alert of Pending Order Signature, the nurse should report it to the UM who would then report it to the Director of Nursing (DON). LPN/UM #2 further stated that it was important to have the order signed by the AP because even though the pharmacy would still deliver the medication, the nurse would not be able to administer the medication until the order was signed. The LPN/UM explained that if a resident missed multiple doses of an anti-hypertensive medication, the resident could have issues with their blood pressure. When asked about Resident #13, the LPN/UM stated she was not notified by the nurse that the resident's PO for Metoprolol Succinate was pending the physician's signature and that the nurse should have notified the physician to sign the order. On 5/15/25 at 2:29 PM, the surveyor interviewed the DON who stated if a PO had an alert of Pending Order Signature, the nurse would not be able to administer the medication. The DON further explained that the nurses would not have any responsibility to clarify the PO or notify the physician to sign the order, as it was the responsibility of the physician to sign the order. The DON stated that the physicians saw residents for their monthly visits, but had access to the residents' electronic medical record at all times. When asked about Resident #13, the DON stated he was not notified by the nurse or UM that the resident's PO for Metoprolol Succinate was pending the physician's signature. Further review of the Progress Notes included a NN, dated 5/15/25 at 2:33 PM (after surveyor inquiry) and written by LPN/UM #2, revealed the physician was notified of the resident's elevated BP of 157/92. Further review of the NN revealed the resident was assessed and denied blurry vision, headache, or nausea. On 5/16/25 at 10:18 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated if a PO for an anti-hypertensive medication had an alert of Pending Order Signature, the nurse should notify the physician to sign the PO because multiple missed doses of an anti-hypertensive medication could cause the resident to experience the consequences of high blood pressure. On 5/16/25 at 10:25 AM, the surveyor interviewed the AP who stated if a PO had an alert of Pending Order Signature, the nurse should notify the physician to sign the order so that the medication could be administered to the resident. The AP further stated it was important to notify the physician as soon as possible that a PO was Pending Order Signature because the nurse should not wait for something to happen to the resident before addressing it. When asked about Resident #13, the AP stated he was not notified of the PO which required a physician's signature until the day prior (5/15/25, after surveyor inquiry). A review of the facility's Medication Orders and Treatment policy, undated, included the following: All orders for the treatment of the resident's medical problems must be in writing and signed and dated by the physician. Medication orders and treatment will be administered by nursing service personnel as soon as the order has been received. A review of the facility's Medication and Treatment Orders policy, undated, included the following: All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders shall be by signature or a personal computer key. NJAC 8:39-11.2(b), 27.1(a), 29.2(d)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to properly secure medication within the medication cart for 1 of 2 nurses observed during the medication administration pass. This deficient practice was evidenced by the following: On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13, which included two medicated eye drops: Cosopt and Brimonidine Tartrate. The LPN then locked the medication cart and took the PO (by mouth) medications into the resident's room, but left the medicated eye drops on top of the medication cart while the cart was left unattended. At 8:29 AM, after administering the PO medications, the LPN unlocked the medication cart, used alcohol-based hand rub, put on gloves, and retrieved the Cosopt eye drops from the top of the medication cart. The LPN left the Brimonidine Tartrate eye drops on top of the medication cart and the medication cart unlocked when she re-entered the resident's room. At 8:32 AM, after administering the Cosopt eye drops, the LPN returned to the medication cart, used alcohol-based hand rub, put on gloves, and retrieved the Brimonidine Tartrate eye drops. The LPN then re-entered the resident's room and left the medication cart unlocked while unattended. At 8:33 AM, after administering the Brimonidine Tartrate eye drops, the LPN used alcohol-based hand rub, received a box of Lidocaine pain patches from another nurse, and prepared one Lidocaine patch for Resident #13. The LPN then locked the medication cart and entered the resident's room, but left the box of Lidocaine patches on top of the medication cart while unattended. At 8:49 AM, the surveyor interviewed LPN #4 who stated she should not have left medications on top of the medication cart unattended and should have locked the medication cart prior to leaving the cart unattended to protect residents from taking medications from the cart. On 5/16/25 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the nurse should ensure there were no medications left on top of the medication cart and should lock the cart prior to leaving the cart unattended to prevent residents from taking medications from the medication cart. On 5/16/25 at 10:18 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated nurses should not leave medications on top of the medication cart and should lock the medication cart when unattended to prevent anyone from taking medications from the cart. On 5/16/25 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated LPN #4 should not have left medications on top of the medication cart and should have locked the medication cart when it was left unattended for the safety of the residents. A review of the facility's Storage of Medications policy, undated, included, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, cart, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. NJAC 8:39-29.4(h)

Based on observation, interview, and review of facility documents, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 5/13/25 from 9:41 AM until 10:52 AM, the surveyor observed the following in the presence of the Food Service Director (FSD): 1.) In the walk-in refrigerator, on the second shelf from the top of a four-tiered wired rack, there was an opened and undated container of cranberry juice. The FSD stated that it should not have been in there and discarded the cranberry juice 2.) In the galley of the kitchen, the bottom aspect of the oven was heavily soiled with a thick, black substance. The FSD stated that it was cleaned recently and regularly. On 5/14/25 between 12:19 PM and 12:35 PM, the surveyor observed the following in the B-Wing Nursing Unit Pantry in the presence of Licensed Practical Nurse (LPN) #6 and Licensed Practical Nurse/Unit Manager (LPN/UM) #2: 3.) In the freezer, there was a clear plastic cup with a convenience store logo that contained ice and was not labeled or dated. LPN #6 stated the cups should not be in there without being labeled or dated. LPN #6 further stated that they thought that it could have belonged to a resident, as family members sometimes brought in ice or beverages. 4.) In the refrigerator, two 64-ounce containers of prune juice were found to be opened, unlabeled, and undated, with a best by date of 11/4/24. LPN #6 stated that the juices should have been labeled and dated, and should have been discarded after one month. LPN/UM #2 stated the refrigerator should be checked daily for outdated items to discard. LPN/UM #2 further stated that residents could get stomach problems if they were served expired juice. On 5/15/25 from 12:22 PM until 12:39 PM, the surveyor observed the following in the A-Wing Nursing Unit Pantry in the presence of LPN #7: 5.) The microwave was found to be soiled with a dark, brown colored substance on the upper aspect of the interior and along the interior corners. LPN #7 stated that per the cleaning log, the microwave should have been cleaned by housekeeping and that the substance should not have been present. A review of the facility's Daily Pantry and Fridge cleaning log revealed the log was signed off as cleaned at 9 AM that day. 6.) In the freezer, there were three clear plastic cups with a convenience store logo that contained ice and were not labeled or dated. LPN #7 stated they were unsure who the cups belonged to, and that the cups should have been labeled and dated. LPN #7 discarded the cups at that time. On 5/15/25 from 12:30 PM to 12:38 PM, the surveyor observed the following in the [NAME] Unit pantry in the presence of LPN #2: 7.) In the freezer, there was a clear plastic cup with a convenience store logo that contained ice that was not labeled or dated. LPN #2 stated that they believed an agency nurse brought the ice in and might have been unaware that the break room had a freezer for personal storage. LPN #2 discarded the cup and stated that they should not have been kept in the pantry freezer. 8.) In the cabinet below the sink, there was an opened case of individual eight-ounce cartons of a thickened milk product. LPN #2 stated they were not aware that there was a case of thickened milk under the sink, and they did not know that it could not be stored there. On 5/16/25 at 9:45 AM, the surveyor interviewed the Housekeeper (HK) #2 regarding the cleaning of the unit pantries. HK #2 stated that they believed that cleaning the microwave was their responsibility. HK #2 stated that it was not done properly if it was still dirty after someone signed the cleaning log. On 5/16/25 at 1:30 PM, in the presence of the survey team, DON, and Regional Director of Nursing, the surveyor informed the Licensed Nursing Home Administrator (LNHA) of the concerns with both the kitchen and pantries. The LNHA stated that cartons of beverages should not have been stored under the sink and the preferred option would be for it to have been stored on a shelf on top of the sink. A review of a facility Unit Refrigerators policy, undated, included the following: Housekeeping staff should clean the refrigerator daily and as needed. Nursing staff should discard any foods that are out of compliance and clean up spills as needed, or refer to housekeeping staff. Foods with use-by dates shall be discarded accordingly. No staff food, personal food to be in refrigerator. A review of a facility Foods Brought by Family/Visitors policy, updated and reviewed March 2024, included the following: Food brought by family/visitors that is left to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. The nursing staff will discard perishable foods on or before the use by date. A review of a facility Storage Areas policy, undated, included the following: To prevent the risk of water damage, mold growth, and potential pest issues, storing items under the sink is not permitted. A review of a facility Dietary Department Cleaning Schedule policy, updated April 2024, included the following: Weekly Cleaning Tasks: Deep clean and sanitize all kitchen equipment (ovens, refrigerators, freezers, and dishwashers). A review of a facility Food Receiving and Storage policy, updated January 2023, included: 'Food items and snacks kept on nursing units' that all food items to be kept below 41 degrees must be placed in the refrigerator and labeled with a use by date and beverages must be dated when opened and discarded after twenty-four (24) hours. A review of a facility Dating and Labeling policy, undated, included the following: Always use manufacturers expiration dates when available; all food must have a receive date as well as a use by dated; and discard all foods that expire immediately. NJAC 8:39-17.2 (g); 19.4

Based on interview and review of facility documentation, it was determined that the facility failed to employ a full time Social Worker (SW) from 3/24/25 to 5/19/25. This deficient practice was evidenced by the following: On 5/14/25 at 12:41 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the full time Social Worker (SW) was on a leave of absence. When asked who was filling in for the full time SW, he stated they had a part time SW. On 5/16/25 at 9:33 AM, the surveyor interviewed the Receptionist who stated the full time SW was out on leave, and they had a part time SW who handled all of the social service related concerns. On 5/16/25 at 12:07 PM, the surveyor interviewed the part time SW who stated her role was very limited and she was just the assistant. She stated that for certain issues she redirected the resident and/or the resident's representative to the Director of Social Services (DSS), the LNHA, or the Director of Admissions. When asked who was filling in for the DSS in her absence, the SW stated she was trying to do the things that were needed, but it was very limited. A review of the facility provided time clock punches for the SW revealed the SW worked as follows: 3/23/25 to 3/29/25 a total of 28.75 hours 3/30/25 to 4/5/25 a total of 30.0 hours 4/6/25 to 4/12/25 a total of 29.50 hours 4/13/25 to 4/19/25 a total of 28.50 hours 4/20/25 to 5/3/25 a total of 33.25 hours 5/4/25 to 5/10/25 a total of 8.75 hours 5/11/25 to 5/17/25 a total of 25.50 hours On 5/16/25 at 1:54 PM, in the presence of the Director of Nursing (DON), Regional Nurse #1, and the survey team, the LNHA stated the DSS was full time, but was on a leave of absence for six to eight weeks. The LNHA confirmed did not currently have a full time SW but that they tried to have the part time SW in as much as possible. The LNHA stated they did not have a Regional SW, and the part time SW had taken the role as the main SW. On 5/19/25 at 9:29 AM, in the presence of the DON and the survey team, the LNHA provided the resume and job description of the SW. He stated that the part time SW worked 48 hours in a pay period (8 hours a day, 3 days a week to equal 24 hours in a week). He stated he attempted to hire a temporary full time SW, but was unsuccessful. The LNHA verified the full time SW had been out since 3/24/25 and that they only had the part time SW. He then stated the full time SW was scheduled to return to work 5/20/25. The facility was on record as being licensed for 162 beds. The Centers for Medicare & Medicaid Services (CMS) guidelines implemented 11/28/17, included, but were not limited to, a qualified SW full-time for a facility with over 120 beds. A review of the facility's Social Worker job description included, The primary purpose of your job position is to plan organize, develop, and direct overall operations of the Social Services Department in accordance with the current federal, state, and local standards, guidelines and regulation, our established policies and procedures, and as may be directed by the Administrator, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. N.J.A.C. 8:39-9.3(a); 39.2; 39.4(i)

Based on interviews and review of other pertinent facility documentation, it was determined that the facility failed to implement the antibiotic stewardship program, including ongoing monitoring and use of surveillance criteria when antibiotics were being prescribed. This deficient practice was identified for 10 of the 10 months reviewed and evidenced by the following: On 5/16/25 at 10:47 AM, the surveyor interviewed the Infection Preventionist (IP) and reviewed the the facility's Antibiotic Stewardship Program (efforts to ensure that antibiotics are used only when necessary and appropriate). The IP stated that she completed the facility's Infection Tracking Worksheet (clinical and laboratory findings used to define and track infections) for each resident when an antibiotic was prescribed to ensure that the resident met the criteria for antibiotic usage. At that time, the surveyor reviewed the Infection Control Binder which included the following: A review of the Order Listing Report (OLR - which includes a list of residents receiving antibiotics) with the order date range from 3/1/2024 through 9/30/2024, revealed that 40 residents were prescribed antibiotics. A review of the OLR with the order date range from 1/1/2025 through 5/31/2025, revealed that 43 residents were prescribed antibiotics. At that time, the IP further stated that the Monthly Antibiotic Tracking Log was completed to determine if there was an influx of infections and to monitor antibiotic usage. The surveyor then asked the IP to show how she tracked the infections. The surveyor and the IP continued to review the Infection Control Binder together which revealed the following: For the months of April 2024 through September 2024, January 2025, March 2025, April 2025, and May 2025, there was no documented evidence or tracking log for the prescribed antibiotics. The surveyor continued to interview the IP who confirmed that she did not have the tracking logs for the months mentioned above. She further stated that she did not know what happened to them. The IP then stated that the tracking log should have been updated when an antibiotic was initiated and kept in the binder. On 5/16/2025 at 1:14 PM, the surveyor interviewed the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, who stated that the Monthly Antibiotic Tracking Log and the Infection Tracking Worksheet should have been updated and completed when a new antibiotic was initiated to monitor infections in the facility and ensure that the resident met the criteria for antibiotic usage. On 5/19/2025 at 9:20 AM, during a follow up interview, the DON, in the presence of the LNHA and the survey team, stated that the tracking logs and infection worksheets should have been readily available for the surveyors. He further stated that they were found and were back in the infection control binder. The facility was unable to provide the surveyor with evidence that the Infection Tracking Worksheet was completed for the residents who were prescribed antibiotics for the months mentioned above. A review of the facility's Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy, reviewed February 2025, included, Antibiotic usage and outcome data will be documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist (IP), or designee.all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. NJAC 8:39-19.4(c) (d)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to develop an individual comprehensive care plan to include a resident's fall risk for 1 of 4 residents (Resident # 12) reviewed for accidents. This deficient practice was evidenced by the following: On 5/14/25 at 12:46 PM, the surveyor observed Resident #12 being fed by staff in the day room. The surveyor reviewed the medical record for Resident #12. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia, muscle weakness, and difficulty in walking. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/1/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had one fall with injury since the prior assessment. A review of the individual comprehensive care plan (ICCP), which included resolved and cancelled items, revealed a focus, initiated 2/16/25, that the resident was at risk for falls related to an increased need for assistance with activities of daily living and transfers, poor safety awareness, and unsteady gait. The interventions for the risk for falls focus were all initiated between 2/16/25 and 2/17/25. A review of the Fall Risk Evaluation, dated 3/17/24 and signed by the Director of Nursing (DON) on 3/25/24, revealed the resident scored a 19 which indicated the resident was a high risk for falls at that time. A review of the Progress Notes included a General Nurses Note, dated 2/16/25 at 8:48 PM, which revealed the resident fell and sustained a laceration to the right side of his/her forehead. On 5/16/25 at 9:33 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 who stated the nursing supervisors initiated the ICCP within 24 hours. The LPN further stated the purpose of the ICCP was for staff to know the goals for the residents and improve the residents' condition. On 5/16/25 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated the Unit Managers initiated the ICCP about a week after the resident's initial care conference meeting. The LPN/UM further stated the purpose of the ICCP was to keep staff updated with any changes to the residents' care and to be used as a reference for new staff to know what was going on with the residents. On 5/16/25 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated the ICCP was initiated by the interdisciplinary team within 21 days of the resident's admission. The DON further stated the purpose of the ICCP was to ensure the facility was meeting the residents' needs. At that time, the surveyor informed the DON that Resident #12 was identified as a high risk for falls on 3/17/24, but that a fall risk care plan was not initiated until 2/16/25 after the resident sustained a fall. The DON then verified the fall risk care plan should have been initiated on 3/17/24 at the time of the fall risk identification. On 5/19/25 at 9:23 AM, the surveyor conducted a follow-up interview with the DON, in the presence of the survey team and the Licensed Nursing Home Administrator (LNHA). The DON verified the fall risk care plan was not initiated until the resident experienced a fall on 2/16/25 and further stated he did not feel as though Resident #12 was at risk for falls despite receiving the high score on the Fall Risk Evaluation on 3/17/24. A review of the facility's Care Planning - Interdisciplinary Team policy, undated, included the following: Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). A review of the facility's Care Plan Revisions policy, updated 2/2025, included the following: The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. NJAC 8:39-27.1(a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to obtain a physician's order for a resident's code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 1 of 1 resident reviewed (Resident #142) for death. This deficient practice was evidenced by the following: On [DATE] at 12:49 PM, the surveyor reviewed the medical record for Resident #142. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but was not limited to, dementia, chronic kidney disease, and adult failure to thrive. A review of the Order Summary Report (OSR) as of [DATE], did not include a physician's order (PO) for the resident's code status. A review of the Baseline Care Plan, dated [DATE], revealed the Code Status section was left blank. A review of the Universal Transfer Form (UTF), dated [DATE], included a Code Status of Do Not Resuscitate (DNR). A review of the Social Service Assessment, dated [DATE], included a Code Status of DNR. A review of the electronic medical record (EMR) did not include a completed New Jersey Practitioner Orders for Life-Sustaining Treatment (POLST) form or Advance Directive (legal document that outlines your wishes for medical care). A review of the Progress Notes dated [DATE] at 6:36 PM, reflected the resident was found unresponsive, Cardiopulmonary Resuscitation (CPR) was initiated, and the resident was pronounced deceased at 6:24 PM. On [DATE] at 10:06 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #5 who stated she would ask the nurses the resident's code status, and she could also check the resident's plan of care (POC) in the EMR. On [DATE] at 10:15 AM, the survey interviewed the Director of Nursing (DON), in the presence of the survey team, who stated the code status was included in the Social Services assessments. The DON stated the Social Worker (SW) would gather the information from the UTF. He then stated that the nurses would notify the physician to obtain the PO, but until then they treated the resident as a full code. When asked if there would be a PO if the resident was a full code, the DON stated if the resident was a full code there would be a PO because it had to be verified. The DON stated the code status should be obtained on admission and confirmed by the physician during the history and physical (HP) within 48 hours. The DON stated that Resident #142 was on a respite stay (allows for a short-term break for the primary caregiver) and did not have a PO for DNR. On [DATE] at 10:33 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #5 who stated the code status was in the medical record and if the resident did not have one, they would call the physician and talk to the resident/representative to obtain the code status. The LPN stated if there was no PO they would treat the resident as a full code. She stated they would call to get report within 24 hours of the resident's admission, but that the Interdisciplinary Team was responsible for reviewing the code status. LPN #5 stated that the physicians were very good at coming in to visit the residents and putting in the orders. When asked if the process was the same for a resident on respite, the LPN stated it was the same process. She further stated if the nurse was unsure of the resident's code status they should call the physician to clarify if the resident was a full code or DNR. On [DATE] at 12:41 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the resident's codes status was reviewed during their morning meetings when they discussed all admissions. On [DATE] at 9:03 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated there should be a PO for the code status which was also on the checklist for the nurses to ask. She stated they should always ask the resident's code status and obtain a PO. LPN/UM #3 stated that Medical Doctor (MD) and his team were at the facility six days a week and if they were not in the facility, they had a 24 hours on-call service. She explained if the resident was admitted late Saturday night or on a Sunday, there may not be a physician to sign orders, but on Monday morning there was a physician in the facility to sign and review the orders. She stated they have another physician that generally came during off hours so they caught every shift. On [DATE] at 9:14 AM, the surveyor and LPN/UM #3 reviewed the EMR. LPN/UM #3 confirmed there was no PO for the resident's code status or POLST form. She acknowledged the code status should be reflected in the EMR. On [DATE] at 11:34 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who stated there should be a PO for the code status and the nurse should verify the code status with the resident and physician. He further stated that the code status should be obtained on admission. On [DATE] at 12:12 PM, the surveyor interviewed the Social Worker (SW) who stated during the social services assessment they asked the resident or the resident's representative their code status and they also reviewed the medical records. She stated the nurses obtained the code status on admission and the SW would assist with completing the POLST form. The SW stated that every resident should have a code status. She stated knowing the resident's code status was important, so everyone was aware of the resident wishes such as DNR or full code. She stated the physician should also review the code status and if there was no order, then the resident was considered a full code. On [DATE] at 9:51 AM, in the presence of the LNHA and the survey team, the DON stated they did not have a PO for the code status. The DON acknowledged there should have been a physician's order for the code status. A review of the facility's undated Cardiopulmonary Resuscitation (CPR) policy, included It is the policy of this facility to adhere to the residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR. A review of the facility's Advance Directives policy dated [DATE], included, The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. A review of the facility's Practitioner Orders for Life-Sustaining Treatment (POLST) policy dated [DATE], included, At the time of admission the facility will determine whether the individual has completed a POLST form. If the individual does not have a POLST form at the time of admission, the facility will introduce POLST. NJAC 8:39-27.1(a)

Based on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain, record, and monitor weights on admission, readmission, and weekly in accordance with professional standards of practice. This deficient practice was identified for 2 of 3 residents (Resident #20 and Resident #48) reviewed for nutrition and was evidenced by the following: 1.) On 5/13/25 at 10:01 AM, the surveyor observed Resident #20 awake and alert sitting in a wheelchair in the lounge. On 5/14/25 at 9:18 AM, the surveyor observed Resident #20 during breakfast, but the resident refused to eat. The resident had a split plate, built-up angled utensils, nectar thickened liquids, and a fortified frozen supplemental dessert on his/her tray. On 5/14/25 at 1:15 PM, the surveyor observed Resident #20 during lunch. Resident #20 was seated in a wheelchair with a clothing protector eating lunch with built-up utensils and drinking thickened liquids out of a cup. The surveyor reviewed the medical record for Resident #20. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: encephalopathy (a broad category of brain disorders that affect brain function), major depressive disorder, unspecified protein-calorie malnutrition, muscle wasting and atrophy (to waste away), and muscle weakness. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/27/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the MDS revealed the resident weighed 142 pounds (lbs) and had experienced a weight loss of five percent (5%) or more in the last month or a loss of 10% or more in the last six months while not on a physician-prescribed weight-loss regimen. A review of the individual comprehensive care plan (ICCP) included a focus area, revised 4/25/25, that the resident had a potential nutritional problem. Interventions included: Monitor weights per protocol/as ordered and monitor/record/report to Medical Doctor as needed for signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. A review of the Weights and Vitals Summary, as of 5/15/25, included the following weights: 12/6/24 176.4 lbs (Wheelchair) 1/7/25 171.8 lbs. (Wheelchair) 2/5/25 162 lbs. (Wheelchair) 2/27/25 156 lbs. (Wheelchair) 3/4/25 142.4 lbs. (Wheelchair) 3/7/25 142 lbs. (Sitting) 4/2/25 148.4 lbs. (Wheelchair) 5/12/25 147.6 lbs. (Wheelchair) A review of the Dietician Progress Note (DPN), dated 2/11/25, included that the resident had a significant weight loss in one month and recommendations to obtain a re-weight to confirm significant loss and to increase the frozen nutritional supplement to twice daily. Further review of the DPN, dated 2/28/25, included an addendum that the resident was added to weekly weights for four weeks upon readmission for strict weight monitoring of any further weight loss. A review of the February 2025 Treatment Administration Record (TAR) revealed the following: -A physician's order (PO), dated 2/14/25, for weekly weights every Wednesday for four weeks for weight monitoring. There was no documented evidence a reweight on 2/11/25 and a weekly weight on 2/19/25 were obtained. -A PO, dated 2/27/25, for weights on admit/readmit, day after admit/readmit, then weekly every Friday for four weeks. There was no documented evidence a weekly weights on 2/28/25 was obtained. A review of the March 2025 TAR revealed there were no documented evidence weekly weights on 3/14/25, 3/21/25, and 3/28/25 were obtained. A review of the April 2025 TAR revealed there were no documented evidence weekly weights were obtained on 4/8/25, 4/15/25, 4/22/25, 4/29/25, and 5/6/25. A review of the Order Summary Report (OSR) included the following active PO: A PO, with an ordered date of 3/25/25 and a start date of 4/1/25, for weekly weights every Tuesday morning. 2.) On 5/13/25 at 10:15 AM, the surveyor observed Resident #48 awake, alert, and sitting in bed. Resident #48 stated they may have lost some weight and sometimes I eat sometimes I don't, depends on what they serve. On 5/14/25 at 9:30 AM, the surveyor observed Resident #48 sitting on the side of the bed eating breakfast. On 5/14/25 1:25 PM, the surveyor observed Resident #48 sitting on the side of the bed eating lunch. The resident stated the food was good. The surveyor reviewed the medical record for Resident #48. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: encephalopathy (a broad category of brain disorders that affect brain function), altered mental status, Alzheimer's disease with early onset, unspecified protein-calorie malnutrition, muscle wasting and atrophy (to waste away), and dysphagia (difficulty swallowing). A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/20/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident's cognition was intact. Review of the MDS revealed the resident weighed 231 pounds (lbs) and no known history of weight loss. A review of the individual comprehensive care plan (ICCP) included a focus area, revised 3/7/25, that the resident had a nutritional problem. Interventions included: Monitor/record/report to Medical Doctor as needed for signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. A review of the Dietician Progress Note (DPN), dated 2/28/25, included a recommendation to add Resident #48 to weekly weights for four weeks for strict weight monitoring upon readmission. A review of the DPN, dated 3/7/25, included: Re-weight obtained and resident continues to trigger for a significant weight change Weight History: Weight with significant loss x 1mo [month] and non-significant loss x 3mo. 6mo weight measurement not available to review. Current wt hx [weight history] as follows: 2/10/25 - 236.2 lb. (-17.8 lb., -7.5%) 12/13/24 - 229 lb.(-10.6 lb., -4.6%) Further review of the note included: Resident [#48] added to weekly weights x 4 weeks upon 3/4/25 readmission, will closely monitor weight trends via weekly weights for any additional undesirable weight changes. Current diet is liberalized diabetic, regular texture/consistency, and PO [oral] intakes noted to be good (70-100% at meals) since readmission and w/o [without] noted chewing/swallowing difficulties. A review of the Physician's Orders (PO) for March 2025 included: A PO, dated 3/4/25, for weights on admit/readmit, day after admit/readmit then weekly for four weeks every Tuesday. A review of the Treatment Administration Record (TAR) for March and April 2025 for Resident #48 revealed the following: Weekly Weight (Tuesday) 3/18/25 - Blank in TAR, No Weight Recorded Weekly Weight (Tuesday) 3/25/25 - No Weight, Marked as refused, No nursing note clarifying refusal/follow-up Weekly Weight (Tuesday) 4/1/25 - Blank in TAR, No Weight Recorded On 5/15/25 at 10:16 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #6 who stated that the nurses would let them know in the morning who needed to be weighed; that all residents were weighed at the beginning of each month, and that on admission the residents were weighed right away. The CNA further stated that the nurses recorded the weights in the electronic medical record (eMAR) and if a resident refused or missed a weight for another reason, that they would report it to the nurse, would try to weigh the resident again later, or pass it to the next shift to complete. On 5/15/25 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #3 who stated that weekly and monthly weights populated in the computer system for the nurse to sign as completed, whereas a re-weigh request would usually come from the dietician or the Unit Manager. LPN #3 further stated that if a resident refused a weight, they would try again later and if refusal continued, the nurse would inform the Unit Manager and document the refusal in the eMAR. LPN #3 further stated that if there was a significant change or discrepency in the weight, they would reweigh the resident to confirm the weight, and if accurate would inform the provider, dietician and unit manager. LPN #3 stated that the importance of maintaining an accurate weight log for a resident with a PO for weekly weights was to see if there was a weight gain or loss, implement timely interventions, and to update the plan of care for the resident. On 5/15/25 at 10:51 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that when a resident was first admitted to the facility or readmitted from a hospital stay, the resident would be put on weekly weights for four weeks, and that any reweight requests would come from dietary. LPN/UM #2 then stated that weekly weights were entered into the Weights and Vitals section of the eMAR by the nurses and signed as completed in the TAR. LPN/UM #2 stated that if a resident's weight was missed or refused, the nurse would weigh the resident as soon as possible and document the refusal or reason in the eMAR. LPN/UM #2 stated that the importance of maintaining an accurate weight log for residents with ordered weekly weights was so the doctors could adjust medications based on weight, monitor for any significant changes, and address any issues the resident may have. On 5/15/25 at 3:22 PM, the surveyor interviewed the Registered Dietician (RD) and Regional Registered Dietician (RRD). The RRD stated that weights were completed on admission and readmission to the facility, and then weekly for four weeks. RRD then stated that nursing had been entering weights and vitals into the electronic medical record. The RRD also stated that if there was a descrepency or significant change in a weight they would want the resident to be reweighed and follow up with the nursing team. The RRD confirmed that Resident #20 and Resident #48's ordered weights were not documented in the eMAR. On 5/19/25 at 9:20 AM, the Director of Nursing (DON), in the precense of the Licenced Nursing Home Administrator and Survey Team, stated that weekly weights should be documented in the electronic medical record. A review of the facility policy Weight Monitoring, undated, revealed that a weight monitoring schedule will be developed upon admission for all residents: weights should be recorded at the time obtained, new admitted residents - monitor weight weekly for 4 weeks, residents with weight loss - monitor weight weekly per indications of orders or recommendations, if clinically indicated - monitor weight daily. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. NJAC 8:39 - 27.2 (a)

3.) On 5/13/25 at 10:27 AM, during the initial tour of the B Unit, the surveyor observed Resident #79 awake, alert, and lying in bed. Resident #79 stated that his/her medications were always late, usually about an hour and a half late. Resident #79 further stated I did not get my morning medications yet. On 5/13/25 at 1:06 PM, the surveyor reviewed the medical record for Resident #79. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: metabolic encephalopathy (a change in how your brain works due to an underlying condition), depression, Type 2 Diabetes, Non -Hodgkin's Lymphoma (a type of blood cancer), anxiety, and chronic pain. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/21/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident took the following high-risk medications: insulin injections, antianxiety, antidepressant, diuretic, opioid, hypoglycemic, and anticonvulsant. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/16/24, that the resident is on antianxiety medications, antidepressant medication, diuretic medication and pain management medications. Interventions included: antianxiety, antidepressant, methadone and pain medications as ordered. A review of the Order Summary Report (OSR), dated as of 5/15/25, included the following physician orders (PO): A PO, dated 2/13/25, for Pantoprazole Sodium delayed release 40 milligram (mg), give one tablet by mouth one time a day for reflux. A PO, dated 2/13/25, for MiraLAX Oral packet 17 Gram (gm), give 17 gm by mouth one time a day for constipation. mix well in at least 4 oz (ounces) of water, juice, coffee, or tea prior to administration. A PO, dated 2/10/25, for Lisinopril 20 mg give one tablet by mouth one time a day for hypertension. A PO, dated 2/10/25, for Furosemide 20 mg give one tablet by mouth one time a day for hypertension. A PO, dated 2/12/25, for Sertraline HCL (hydrochloride) 50 mg give one tablet one time a day for depression. A PO, dated 4/25/25, for Gabapentin 300 mg give one capsule by mouth three times a day for neuropathy. A PO, dated 4/29/25, for Colace 100 mg give two capsules by mouth one time a day for constipation. A PO, dated 3/28/25, for Nifedipine ER (extended release) 24-hour 60 mg give 60 mg by mouth one time a day for high blood pressure. A PO, dated 4/17/25, for Ozempic (0.25 or 0.5 mg/dose) Subcutaneous Solution Pen- Injector 2mg/3ml(milliliters) inject 0.5mg subcutaneously one time a day every Monday. A PO, dated 2/17/25, for Xanax (Alprazolam) 0.5mg give one tablet by mouth three times a day for anxiety. Give with 1 mg total 1/5 mg. A PO dated 2/17/25 for Alprazolam (Xanax)1 mg give one tablet by mouth three times a day for anxiety. Give with 0.5mg tablet total 1.5 mg. A review of the Medication Administration Audit Report, dated 5/1/25 through 5/14/25, revealed the following: On 5/4/25: 1.Pantaprazole 40 mg tablet, scheduled for 9:00 AM was administered at 10:43 AM. 2.Lisinopril 20 mg tablet, scheduled for 9:00AM was administered at 10:43 AM. 3. Sertraline 50 mg, scheduled for 9:00AM was administered at 10:43 AM. 4.Furosimide 20 mg tablet, scheduled for 9:00AM was administered at 10:43 AM. 5.Gabapentin 300 mg capsule, scheduled for 9:00AM was administered at 10:43 AM. 6. Nifedipine ER 60mg tablet, scheduled for 9:00AM was administered at 11:29 AM. 7. Colace 100 mg capsule, scheduled for 9:00AM was administered at 11:29 AM. 8. MiraLAX 17 gm, scheduled for 9:00 AM was administered at 11:29AM. On 5/5/25: 1.Ozempic Injection, scheduled for 9:00 AM was administered at 10:52 AM. On 5/6/25: 1.Gabapentin 300 mg capsule, scheduled for 5:00 PM was administered at 8:06 PM. 2.Xanax 0.5 mg tablet, scheduled for 6:00 PM was administered at 8:06 PM. 3.Tamsulosin 0.4mg capsule, scheduled for 6:00 PM was administered at 8:06 PM. 4.Alprazolam (Xanax)1 mg tablet scheduled for 6:00 PM was administered at 8:06 PM. On 5/7/25: 1.Pantaprazole 40 mg tablet, scheduled for 9:00 AM was administered at 1:48 PM. 2.Lisinopril 20 mg tablet, scheduled for 9:00AM was administered at 1:48 PM. 3. Sertraline 50 mg, scheduled for 9:00AM was administered at 1:48 PM. 4.Furosimide 20 mg tablet, scheduled for 9:00AM was administered at 12:52 PM. 5. Gabapentin 300 mg capsule, scheduled for 9:00AM was administered at 10:43 AM. 6. Nifedipine ER 60mg tablet, scheduled for 9:00AM was administered at 11:29 AM. 7. Colace 100 mg capsule, scheduled for 9:00AM was administered at 12:52 PM. 8. MiraLAX 17 gm, scheduled for 9:00 AM was administered at 1:48 PM. 9. Alprazolam 1mg tablet, scheduled for 12:00 PM was administered at 1:52 PM. 10.Xanax 0.5mg tablet, scheduled for 12:00 PM was administered at 1:52 PM. On 5/8/25: 1.Pantaprazole 40 mg tablet, scheduled for 9:00 AM was administered at 10:20 AM. 2.Lisinopril 20 mg tablet, scheduled for 9:00AM was administered at 10:20 AM. 3. Sertraline 50 mg, scheduled for 9:00AM was administered at 10:20 AM. 4.Furosimide 20 mg tablet, scheduled for 9:00AM was administered at 10:20 AM. 5. Gabapentin 300 mg capsule, scheduled for 9:00AM was administered at 10:20 AM. 6. Nifedipine ER 60mg tablet, scheduled for 9:00AM was administered at 10:20 AM. 7. Colace 100 mg capsule, scheduled for 9:00AM was administered at 10:20 AM. On 5/9/25: 1. Gabapentin 300 mg capsule, scheduled for 5:00 PM was administered at 6:51 PM. On 5/11/24: 1.Pantaprazole 40 mg tablet, scheduled for 9:00 AM was administered at 10:37 AM. 2. MiraLAX 17 gm, scheduled for 9:00 AM was administered at 10:37 AM. 2.Lisinopril 20 mg tablet, scheduled for 9:00AM was administered at 10:37 AM. 3. Sertraline 50 mg, scheduled for 9:00AM was administered at 10:37 AM. 4.Furosimide 20 mg tablet, scheduled for 9:00AM was administered at 10:37AM. 5. Gabapentin 300 mg capsule, scheduled for 9:00AM was administered at 10:37 AM. 6. Nifedipine ER 60mg tablet, scheduled for 9:00AM was administered at 10:37 AM 7. Colace 100 mg capsule, scheduled for 9:00AM was administered at 10:37AM. On 5/12/25: 1.Ozempic Injection, scheduled for 9:00 AM was administered at 12:47 PM. On 5/13/25: 1.Pantaprazole 40 mg tablet, scheduled for 9:00 AM was administered at 11:26 AM. 2.Lisinopril 20 mg tablet, scheduled for 9:00AM was administered at 11:26 AM. 3. Sertraline 50 mg, scheduled for 9:00AM was administered at 11:26 AM. 4.Furosimide 20 mg tablet, scheduled for 9:00AM was administered at 11:26 AM. 5. Gabapentin 300 mg capsule, scheduled for 9:00AM was administered at 11:26 AM. 6. Nifedipine ER 60mg tablet, scheduled for 9:00AM was administered at 11:26 AM. 7. Colace 100 mg capsule, scheduled for 9:00AM was administered at 11:26 AM. 8. MiraLAX 17 gm, scheduled at 9:00AM was administered at 11:26 AM. A review of the Progress Notes, dated 5/1/25 to 5/16/25, revealed no documentation for the reasons the medications were administered late. On 5/15/25 at 10:35 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #3 who stated that medications were to be administered one hour before or one hour after the scheduled administration time. The LPN #3 further stated that it was important to administer medications within the scheduled time frame to prevent any risks or complications that may be associated with the reason they are getting the medications. On 5/15/25 at 10:51 AM, the surveyor interviewed LPN/Unit Manager (LPN/UM) #2 who stated that scheduled medication should be administered one hour before and one hour after the scheduled time. The LPN/UM further stated that it was important that the medications were administered within the timeframe because of the effectiveness of the medications. On 05/16/25 11:49 AM, the surveyor interviewed the Director of Nursing (DON) who stated the timeframe for administering scheduled medications was one hour before and one hour after the scheduled administration time. The DON further stated it was important to administer the medications within the timeframe to ensure the medications were given consistently at the same time daily. A review of the facility's Medication Administration policy, undated, included the following: Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. NJAC 8:39-27.1(a) Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to a.) administer medicated eye drops according to manufacturers' instructions for 1 of 4 residents (Resident #13) observed during the medication administration pass and b.) ensure medications were administered in the allotted timeframe for 2 of 2 residents (Resident #79 and #110) reviewed for medication administration times. This deficient practice was evidenced by the following: 1.) On 5/15/25 at 8:12 AM, the surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications for Resident #13, which included two medicated eye drops: Cosopt 2-0.5% and Brimonidine Tartrate 0.2%. At 8:29 AM, the LPN administered one drop of the Cosopt eye drops to each of Resident #13's eyes. At 8:32 AM, only three minutes later, the LPN administered one drop of the Brimonidine Tartrate eye drops to each of Resident #13's eyes. At 8:49 AM, the surveyor interviewed LPN #4 who stated she had to wait three to five minutes between administering two different eye drops in the same eye to give the eye drops a chance to be effective. The surveyor reviewed the medical record for Resident #13. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, unspecified dementia. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/23/25, included 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. A review of the individual comprehensive care plan (ICCP), dated 4/2/21, included a focus that the resident had impaired cognitive function and dementia. Interventions included: Administer medications as ordered. A review of the Order Summary Report (OSR), as of 5/15/25, included the following physician orders (PO): A PO, dated 1/10/24, for Cosopt Ophthalmic Solution 2-0.5% instill one drop in both eyes two times a day for Glaucoma. A PO, dated 3/5/25, for Brimonidine Tartrate Ophthalmic Solution 0.2% instill one drop in both eyes two times a day for Glaucoma. A review of the May 2025 Medication Administration Record (MAR) included the above PO with administration times as follows: Cosopt 2-0.5% was scheduled to be administered at 9:00 AM and 5:00 PM Brimonidine Tartrate 0.2% was scheduled to be administered at 9:10 AM and 5:10 PM. A review of the Cosopt 2-0.5% manufacturer instructions, provided by the facility, included the following instructions: If more than one topical ophthalmic drug is being used, the drugs should be administered at least five minutes apart. A review of the Brimonidine Tartrate 0.2% manufacturer instructions, provided by the facility, included the following instructions: If more than one topical ophthalmic product is to be used, the different products should be instilled at least 5 minutes apart. On 5/16/25 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated nurses had to wait three to five minutes between administering two different eye drops in the same eye to prevent mixing the two different eye drops together. On 5/16/25 at 10:18 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated nurses had to wait five minutes between administering two different eye drops in the same eye so the first eye drop could be absorbed in time before the second eye drop. On 5/16/25 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated the nurse should follow the manufacturer's instructions to determine how long to wait between administering two different eye drops to the same eye. The DON further stated that LPN #4 should have administered the two medicated eye drops according to the manufacturer's instructions. A review of the facility's Administration of Eye Drops or Ointments policy, undated, included the following: If a second medication is required in the same eye, wait appropriate amount of time per manufacturer's specifications (usually five minutes). 2.) On 5/13/25 at 10:39 AM, the surveyor observed Resident #110 lying in bed. The resident stated he/she had pain in his/her back, legs, and hands, but did not always receive pain medications on time. The surveyor reviewed the medical record for Resident #110. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, osteoarthritis of the knee, spinal stenosis in the lumbar region (lower back), and other low back pain. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/14/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident had frequent pain and rated his/her pain as moderate intensity. A review of the individual comprehensive care plan (ICCP), dated 3/7/24, included a focus that the resident had chronic pain related to spinal stenosis and lower back pain. Interventions included: Administer analgesia per physician's orders. A review of the Order Summary Report (OSR), as of 5/15/25, included the following physician orders (PO): A PO, dated 3/8/24, for Morphine Sulfate (MS) Contin Extended Release 15 milligrams (mg) give one tablet by mouth every 12 hours for moderate pain. A review of the May 2025 Medication Administration Record (MAR) included the above PO with administration times as follows: MS Contin was scheduled to be administered at 9:00 AM and 9:00 PM. A review of the Medication Administration Audit report for 5/1/25 through 5/14/25, revealed the following: On 5/5/25, the 9:00 PM dose of MS Contin was administered at 10:39 PM. On 5/10/25, the 9:00 AM dose of MS Contin was administered at 10:32 AM. On 5/12/25, the 9:00 AM dose of MS Contin was administered at 11:19 AM. On 5/14/25, the 9:00 AM dose of MS Contin was administered at 10:28 AM. On 5/16/25 at 9:33 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #2 who stated medications should be administered within one hour before and one hour after the scheduled administration time because if the medication was scheduled for multiple times per day, the medications would need appropriate spacing in between to prevent over dosage. The LPN further stated that if the medication had to be given late, the nurse should contact the physician to get approval. On 5/16/25 at 9:41 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated medications should be administered within one hour before and one hour after the scheduled administration time to ensure the resident received the proper dosages and the proper effect. On 5/16/25 at 10:18 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated medications should be administered within one hour before and one hour after the scheduled administration time because some medications work better at the times they are scheduled. On 5/16/25 at 11:36 AM, the surveyor interviewed the Director of Nursing (DON) who stated medications should be administered within one hour before and one hour after the scheduled administration time to ensure the medications were given consistently at the same time daily. The DON further stated that Resident #110's MS Contin should have been administered within the allotted timeframe and if the medications had to be administered late, the nurse should have notified the physician as appropriate.

Complaint #: NJ184692 Based on observation, interview, record review, and other facility documents, it was determined that the facility failed to ensure that resident's preferences were accurately identified and implemented for 2 of 5 residents (Resident #111 and Resident #128) reviewed for food and dining services. This deficient practice was evidenced by the following: 1.) On 5/14/25 at 9:12 AM, the surveyor observed Resident #128 lying in bed with their meal tray in front of them. The resident's meal ticket indicated that the resident was on a liberalized diabetic diet with no pork, beef, or fish, and included that the resident received regular skim milk six (6) ounces (oz). The surveyor observed the meal tray and noted that the resident had received whole milk instead of skim milk. On 5/15/25 at 12:44 PM, the surveyor observed Resident #128 seated in the wheelchair in the dining room with their meal tray in front of them. The resident stated that he/she received everything that was requested except for skim milk. The resident stated that he/she received whole milk again, and not skim milk. The surveyor reviewed the medical record for Resident #128. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Morbid (severe) obesity due to excess calories, cerebral infarction (stroke), unspecified, and Type 2 diabetes mellitus (adult onset diabetes) without complications. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 2/26/25, 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. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 2/21/25, that the resident had a nutritional problem or potential nutritional problem. Interventions included: Provide, serve diet as ordered: Offer replacement foods as necessary. A review of the Order Summary Report (OSR), included the following physician's order (PO): A PO, dated 5/16/25, for Liberalized Diabetic, NAS (No Added Salt) diet, Regular texture, Thin consistency, increased protein options at breakfast and small carb portions at all meals. On 5/15/25 at 3:22 PM, the surveyor interviewed the Regional Registered Dietician (RRD) who stated that while the resident's liberalized diabetic diet just restricted sugar packets and a smaller portion of dessert or sugar free dessert if available, the facility could always modify the resident's preferences further. The RRD stated that skim milk and salads were a preference that the resident previously identified and that whole milk should not be given to the resident, as it was not his/her preference. The RRD stated that she would have expected that the tray were inspected for accuracy prior to the meal service. A review of a Dietician Progress Note, dated 5/16/25 at 7:57 AM, revealed a nutritional follow-up: Recorded additional food preferences from resident, and Kitchen notified of all additional changes. On 5/16/25 at 9:29 AM, the surveyor observed the resident lying in bed awake with their breakfast tray in front of them. The resident had whole milk on their tray, but the meal ticket indicated skim milk. The resident stated that the Registered Dietician was there yesterday, but the resident still received whole milk with their cereal. The resident stated that he/she really preferred skim milk to be served with their cereal. On 5/16/25 at 10:28 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that dietary delivered the meal carts to the unit and the aides delivered the trays. LPN/UM #1 stated that the aides were supposed to look at the meal ticket to make sure that the right things are on the tray, and the right food consistency was served. LPN/UM #1 stated that if the correct type of milk were not served, they could call downstairs to get skim milk. On 5/16/25 at 10:48 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #4 who stated that he did not pass the resident's meal tray that morning. CNA #4 stated that he did not know if the meal ticket indicated skim milk, but he could always swap it out if it were not received. 2.) On 5/14/25 at 10:35 AM, the surveyor conducted a resident council meeting with six awake, alert, and oriented residents (Resident #44, #55, #62, #85, #109 and #111). During the meeting, 6 out of 6 residents stated that their meal trays were not accurate. Resident #111 stated that he/she preferred no margarine, and he/she had received margarine on his/her meal trays. On 5/16/25 at 9:28 AM, the surveyor observed Resident #111 awake, alert, and lying in bed with his/her breakfast tray on the overbed table. The surveyor observed the resident's meal ticket which included whole milk and jelly, but the breakfast meal tray did not include the whole milk or jelly. Resident #111 stated that sometimes condiments had been missing from the meal trays. The surveyor reviewed the medical record for Resident #111. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: Type 2 Diabetes Mellitus (DM), Hypertension (HTN), and Cerebral Infarction (a type of stroke). A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/20/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was a set-up for eating, had no significant weight loss, and was on a therapeutic diet A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 7/24/23, that the resident has a nutrition problem or potential nutrition problem related to the need for a therapeutic diet, obesity, altered skin integrity and diagnosis of DM and HTN. Interventions included: provide food preferences as able. A review of the Order Summary Report (OSR), dated as of 5/16/25, included the following physician orders (PO): A PO, dated 8/28/24, for No Added Salt (NAS) diet, regular/level 7 texture (easy to chew). Thin liquids, level 0 consistency (unthicken liquids). No Pork. A review of the progress notes included a Dietician Note, dated 1/27/25 at 6:10 PM, which included the current diet order was NAS, regular consistency, thin liquids, no new food allergies, no new food preferences. On 5/15/25 at 3:22 PM, the surveyor interviewed the Registered Dietician (RD) and the Regional Registered Dietician (RRD). The RRD stated that the RD usually assessed for food preferences on admission and then quarterly. The RRD stated that she would expect meal tray tickets to be checked for accuracy prior to the delivery to the resident. On 5/16/25 at 11:15 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #3 who stated it was the CNAs or nurses' responsibility to check that the meal ticket matched what was on the meal tray, and if something was missing, they would call the kitchen and get the missing item. The CNA further stated it was important to make sure the meal ticket matched the meal tray because the resident could have allergies or could be on a special diet. On 5/16/25 at 11:17 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that the nurse or the CNA who delivered the meal tray should check that it was the right resident and the right diet. The LPN further stated that it was important that the resident received everything that was on the meal ticket because it was their preference. On 5/16/25 at 12:08 PM, the surveyor interviewed the Director of Nursing (DON) who stated that both aides and nurses delivered the meal trays and they should check the meal trays for accuracy. The DON stated that it was important that the meal ticket matched the items received to ensure that resident requests and nutritional needs were met in order to provide a homelike environment. On 5/16/25 at 1:41 PM, the Licensed Nursing Home Administrator (LNHA) was made aware of concerns with tray accuracy. A review of the facility's Nutritional Management policy, dated November 2017, included: Interviewing the resident and/or resident representative to determine if their personal goals and preferences are being met. Directly observing the resident and observing for tray accuracy. NJAC 8:39-17.4(a)(1

Based on observation, interview, and review of facility documents, it was determined that the facility failed to properly dispose of waste in and around the trash compactor in order to maintain a safe, and sanitary environment. This deficient practice was evidenced by the following: On 5/13/25 at 10:46 AM, in the presence of the Food Service Director (FSD) the surveyor observed that there were three cigar tips and an empty pack of cigars outside of the trash compactor on the loading dock. The FSD stated that staff cleaned the area around the trash compactor three times daily. When the surveyor asked if staff were permitted to smoke on the loading dock, the FSD stated that smoking was not permitted. The FSD stated the cigar packaging and cigar tips may have blown from trash onto the ground. The surveyor also observed that there was a surgical mask, two pair of disposable gloves, and a coffee cup on the ground. The FSD stated that those items were usually placed in the trash can after use. The surveyor also observed that there were two No Smoking signs in the immediate vicinity. On 5/16/25 at 12:44 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if cigars were thrown on the ground, it was uncleanly and should not have been done. On 5/16/25 at 1:30 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), in the presence of the survey team, who stated that there were designated smoking areas with receptacles that were to be used and that it may create an unsafe environment if smoking materials were not disposed of properly. A review of the facility's undated Disposal of Garbage and Refuse policy, included: Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpster shall be kept covered when not being loaded. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized . A review of the facility's Resident Smoking policy, accessed July 2022, included: Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. NJAC 8:39-31.5(a)1

Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to develop and implement a baseline care plan within 48 hours of admission to include a resident's code status for 1 of 1 resident (Resident #142) reviewed for death. This deficient practice was evidenced by the following: On 5/13/25 at 12:49 PM, the surveyor reviewed the medical record for Resident #142. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, dementia, chronic kidney disease, and adult failure to thrive. A review of the Baseline Care Plan, dated 2/28/25, revealed the Code Status was left blank. A review of the Universal Transfer Form, dated 2/28/25, include a Code Status of Do Not Resuscitate (DNR). A review of the Social Service Assessment, dated 3/3/25, included a Code Status of DNR. On 5/16/25 at 9:03 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated the facility had 48 hours to complete the baseline care plan. When asked if the code status would be included in the baseline care plan, LPN/UM #3 stated the code status should included. She further stated the facility should always ask the residents their code status and get a physician's order. On 5/15/25 at 9:09 AM, LPN/UM #3 reviewed the EMR with the surveyor and confirmed the code status was left blank on the baseline care plan. On 5/16/25 at 11:34 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who stated the process for the baseline care plan should be initiated upon admission and completed within 48 hours. He also stated that a baseline care plan covered the resident's history, the resident's needs, and the resident's goals. The DON further stated the code status should be obtained on admission and included on the baseline care plan. On 5/19/25 at 9:51 AM, in the presence of the LNHA and the survey team, the DON stated once they have a physician's order (PO) then it would be entered into the baseline care plan so that it will be completed in a timely manner. The DON acknowledged the code status should have been included on the baseline care plan. A review of the facility's Baseline Care Plan policy dated revised October 2022, included, 1. The baseline care plan will b. include the minimum healthcare information necessary to properly care for a resident. NJAC 8:39-11.2(d)(g)

Based on interview and review of facility documents, it was determined that the facility failed to ensure that residents who maintained a Personal Needs Account (PNA) received a written notification that their account approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI). This deficient practice was identified for 2 of 94 residents (Resident #28 and #51) who maintained a Personal Needs Accounts at the facility and was evidenced by: On 5/13/25 at 1:10 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the PNA balances. A review of the Funds Balance Report, dated 5/6/25, included a list of 94 active resident names with a total balance of $45,057.40. There were two (2) residents (Residents #28 and #51) listed with PNA funds that ranged from $1,835.38 to $1,868.83. On 5/14/25 at 12:39 PM, the surveyor interviewed the LNHA who stated that the Business Office informed him of the PNA balances and if the account needed to be spent down to prevent reaching the limit that could jeopardize a resident's eligibility for Medicaid or SSI. He stated that if the residents were close to the maximum allowed, then the facility spoke with the resident. When asked if a written notification was provided to the resident, the LNHA stated the residents were notified, but not by a written notification. On 5/14/25 at 2:34 PM, during a follow up interview, the LNHA stated that the Business Office provided a verbal notification to the residents who reached $1,800.00. The LNHA confirmed a written notification was not provided. On 5/16/25 at 9:33 AM, the surveyor interviewed the Receptionist who stated that herself and the evening receptionist handled the PNA money, distributed the statements, and reviewed the statements with the residents. She then stated that an outside company notified the resident and/or the resident's representative that they were reaching the maximum amount. When asked if she was aware of a written notification, the Receptionist stated she was not aware that she needed to provide a written notification to the residents that reached $1,800.00. She further stated she was not sure if Social Services provided a written notification since the Director of Social Services typically asked for the monthly statements. On 5/16/25 at 11:47 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who stated he was not aware of the PNA process. On 5/16/25 at 12:07 PM, the surveyor interviewed the Social Worker (SW) who stated she worked part time, and that the Director of Social Services (DSS) provided the residents their statements. The SW stated that she did not distribute the statements, and she did not provide a written notification of their balances as that was not in her role. She further stated she was unaware of any written notification as she was just the assistant and her role was very limited. The SW stated that she would redirect the resident and/or the resident's representative to the DSS, the LNHA, or the Director of Admissions as they were in contact with the business office which was an outside company. On 5/19/25 at 9:24 AM, in the presence of the DON and the survey team, the LNHA stated he spoke with Resident #28 and Resident #51 regarding their PNA balances and provided a check request for the money to be spent down. The LNHA stated that the check request was considered a written notification for the accounts that were over $1,800.00. The LNHA acknowledged it was after surveyor inquiry when he spoke with the residents to complete the check request. He further stated that any time during the month that the resident reached $1,800.00, the resident should be notified that they were over the maximum threshold. A review of the facility's undated Resident Personal Funds policy included, Notice of Certain Balances: 1. The facility must notify each resident that receives Medicaid Benefits: a. when the amount in the resident's account reaches $200 less than the SSI resource limit for one person and; b. If the amount if the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. NJAC 8:39-9.5(c)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to report an allegation of staff-to-resident verbal abuse to the New Jersey Department of Health (NJDOH) within two hours of the allegation being made for 1 of 2 residents (Resident #4) reviewed for abuse. This deficient practice was evidenced by the following: On 5/14/25 at 9:01 AM, the surveyor observed Resident #4 seated in the wheelchair at the nurse's station. The resident stated that he/she wanted to leave the facility. The resident further stated that a nurse called him/her a bitch yesterday. When the surveyor asked the resident who said that, the resident pointed to a nurse who walked past the nursing station in blue scrubs. The resident was unable to state the nurse's name or to give any further details. The resident then pointed to the accused nurse a second time and stated, That's her. The surveyor reviewed the medical record for Resident #4. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: End stage renal (kidney) disease, muscle weakness, and difficulty in walking. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/7/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated that the resident's cognition was moderately impaired. Further review of the the MDS revealed the resident had no documented behaviors. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 3/29/25, that the resident had Behavior: Passive-aggressive behavior: Argumentative and directs frustrations toward others and staff including negative attitudes, resistance to cooperate with care even when the situation is non-threatening. Resident is undergoing the early stages of grief due to the disease process, placement, and loss of independence. Interventions included: Appropriate limit setting: do not engage in negative conversation, attempt to move conversation with a positive goal, listen and offer support as needed, agree only when resident's statement or behavior is appropriate or positive. A review of the progress notes (PN) failed to contain documented evidence of the accusation of staff-to-resident verbal abuse as previously described by the resident. On 5/14/25 at 10:07 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #2 who stated that the resident was not on her assignment. CNA #2 stated the resident had a foul mouth, cussed at staff and residents, and was very inappropriate. CNA #2 further stated that the resident hates me, so I just kept quiet and walked away. CNA #2 also stated that she reported her concerns with the resident's behavior to the Licensed Nursing Home Administrator (LNHA) and they spoke with the resident. On 5/14/25 at 10:17 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #8 who stated that she was an agency nurse and today was her first day back after not being at the facility for awhile. LPN #8 stated that she was never assigned to the resident, and while she did know the resident, she never had any verbal exchanges with the resident. LPN #8 described the resident as a very particular person. On 5/14/25 at 10:26 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the resident had behaviors which included agitation, hitting and pushing the medication carts, and name calling. LPN/UM #1 stated that the resident had not come to her with any accusations against staff. LPN/UM #1 further stated that if an allegation was made, she usually did an investigation, obtained statements, and changed the staffing assignments. LPN/UM #1 stated that this was the first time that she heard about the above allegation. On 5/14/25 at 11:41 AM, LPN #8 came into LPN/UM #1's office to speak with the surveyor who was present at that time. LPN #8 stated that she spoke with the resident, who was then present outside of the office door in his/her wheelchair. At that time, LPN #8 stated the resident denied that it was LPN #8 who called him/her a bitch. LPN/UM #1 asked the resident to confirm LPN #8's statement and the resident nodded their head in agreement, and confirmed that LPN #8 was mistakenly identified as having called the resident a bitch. The resident stated that he/she would find the employee and let LPN/UM #1 who said it. On 5/15/25 at 11:11 AM, the surveyor interviewed the Director of Nursing (DON) who stated that there were no investigations or reportable events reported to the NJDOH on behalf of Resident #4. The DON stated that the resident made allegations against staff and it may have been documented in a PN, but there have been no investigations or reportable events made to the NJDOH for Resident #4. The DON stated that he was not aware of the allegation that the resident made the day prior until after surveyor inquiry today. On 5/15/25 at 11:40 AM, the DON stated that LPN #8 was sent home pending an investigation. On 5/15/25 at 11:52 AM, during a follow-up interview, the DON stated that he was not made aware of the allegation the day prior. The DON stated that LPN #8 was not assigned to the resident, but to be safe, he did not want the presence of LPN #8 to trigger another situation, so she was sent home today. The DON stated that psychiatry was consulted and the resident was educated on respecting staff. The DON further stated that the resident was a difficult resident. On 5/16/25 at 9:19 AM, the surveyor observed the resident seated in the wheelchair in the dining room eating breakfast. The resident stated that the accused employee had not returned back to work today. On 5/16/25 at 10:05 AM, the surveyor interviewed LPN/UM #1 who stated that she told the DON that the allegation was made and that the resident informed the surveyor that no one up here heard LPN #8 call the resident a bitch. LPN/UM #1 stated that the resident was later heard saying that he/she made that up. LPN/UM #1 explained that employees should be sent home immediately until the investigation was over with, and added, I guess the DON makes that determination. LPN/UM #1 further stated that she was unsure why the DON waited until yesterday to send LPN #8 home because she wrote a statement and obtained statements from everyone who was present at the desk at the time the allegation was made and handed them right over to the DON. On 5/16/25 at 12:18 PM, the surveyor interviewed the DON who stated that when an allegation of verbal abuse was made, an investigation should be started. The DON stated that statements were obtained and the allegation was reported to the NJDOH as necessary. The DON maintained that the report was not made within two hours of the allegation since he was not alerted of the allegation against LPN #8 until the following day. The DON stated that LPN/UM #1 informed him on the same day (5/14/25) and then later told the him the resident recanted the allegation. The DON stated the resident said quote, I made the whole thing up, and he/she laughed about it to LPN/UM #1. The DON stated that when LPN/UM #1 gave him the details, the only thing that she mentioned was that the resident pointed to LPN #8 initially. Once he learned of that, then he reported it. When the surveyor asked the DON when the allegation of verbal abuse was made, the DON stated that he was notified the following day, and he had received conflicting stories. The DON stated, I think that I handled it the best way possible. The DON further stated, LPN/UM #1 never told him that LPN #8 was initially, positively identified by the resident. On 5/16/25 at 1:42 PM, the surveyor interviewed the LNHA regarding the allegation of verbal abuse. The LNHA stated that the employee's superior should be alerted immediately upon the identification of an allegation of verbal abuse to ensure that proper action was taken. The LNHA stated that if it were something of that caliber, then the DON or the LNHA should have been notified. The LNHA stated that the NJDOH would be notified as soon as the DON or LNHA were made aware. The DON provided the surveyor with an Investigation Summary which included a LTC (long-term care) Reportable Event Survey, Form AAS-45, Reportable Event Record/Report which indicated that on 5/15/25 at 10:00 AM, the NJDOH was notified in writing of the allegation of Staff-to-Resident abuse, and the allegation was then phoned into the NJDOH on 5/15/25 at 10:30 AM, for the event that occurred on 5/14/25 at 10:00 AM. A review of the facility's Abuse, Neglect and Exploitation policy, included: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 (two) hours after the allegation is made, if the events that caused the allegation involve and/or result in serious bodily injury, or b. No later than 24 hours if the events that cause the allegation do not result in serious bodily injury. NJAC 8:39-9.4(f)

Based on interview, record review, and review of pertinent facility documents it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care for all residents, accurately. This deficient practice was identified for 1 of 28 residents reviewed for MDS (Resident #69), and was evidenced by the following: On 5/13/25 at 9:52 AM, during entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor requested a list of residents who smoke. On 5/13/25 at 10:33 AM, during the initial tour, Licensed Practical Nurse/Unit Manager (LPN/UM) #3 identified Resident #69 as a smoker. On 5/13/25 at 10:51 AM, during the initial tour, the surveyor observed Resident #69 sitting in a wheelchair in their room resting with their eyes closed. On 5/13/25 at 2:05 PM, the surveyor reviewed the medical record for Resident #69. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, high blood pressure and chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/29/25, included 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 MDS revealed the resident as coded as 0. No for tobacco use, which indicated Resident #69 was assessed as a non-smoker. A review of the resident's Safe Smoking assessment dated [DATE], revealed the resident was safe to smoke with supervision. A review of the resident's Independent Smoking Contract and Lighter Contract revealed the resident signed both forms dated 4/23/25. A review of the individual comprehensive care plan (ICCP), included a focus, initiated 5/13/25, that the resident used tobacco. The interventions included conduct smoking safety evaluation on admission and as needed (PRN). On 5/15/25 at 9:17 AM, the surveyor conducted a telephone interview with the MDS Coordinator who stated she worked at the facility part time and came to the facility on Mondays and Tuesdays. When asked if she was the only MDS Coordinator for the facility, she stated no, there was another MDS Coordinator that was also part time but that they worked remote only. The MDS Coordinator stated she collected her data from the resident's medical record, and she reviewed the diagnoses, the physician orders, and progress notes. When asked where she collected her data if the resident was a smoker, the MDS Coordinator stated the data for the smokers was generally collected by the activities staff or she would get the information from the smoking contract or the hospital records. At that time, she reviewed the electronic medical record (EMR) for Resident #69 and stated the smoking contract was completed 4/23/25 but it was not uploaded until 5/13/25, so it would not be reflected on the admission MDS dated [DATE]. She further stated she also reviewed the History and Physical (H&P) and if it was in those records she must have missed it. On 5/16/25 at 9:20 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #3 who stated the MDS Coordinator completed the MDS, but the interdisciplinary team could also complete the MDS. LPN/UM #3 stated that if a resident was a smoker the MDS Coordinator would be able to determine the resident was a smoker by the smoking contract and the smoking assessment which was uploaded into the electronic medical record (EMR). She then stated they were slow moving with uploading as they only had one Unit Secretary Monday through Friday for the entire building. At 9:25 AM, the surveyor and LPN/UM #3 reviewed the EMR, and the LPN/UM confirmed the MDS was coded inaccurate as the resident was a smoker. On 5/16/25 at 11:41 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the survey team who stated the MDS Coordinator was responsible for coding the MDS and collecting data from the EMR, hospital records, interviews, and assessments. When asked did he review the MDS for accuracy, the DON stated he did not conduct any audits of the MDS or look behind the MDS Coordinator's work. On 5/19/25 at 9:47 AM, in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, the DON stated the MDS coordinator did not code the resident as a smoker because there was no documentation that the resident smoked within the last 7 days of the MDS. When asked if it would trigger the resident as a smoker if the resident had a signed smoking contract and received a smoking assessment, the DON stated since it was not documented in the progress notes that the resident went out to smoke, it would not trigger for the MDS Coordinator to code the resident as a smoker. A review of the facility's undated Resident Smoking policy, included: 5. All resident will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. NJAC 8:39-27.1(a);33.2 (d)

NJ00176090, NJ00175919, NJ00171909, NJ00169026, NJ00165303, NJ00181236, NJ00179553, NJ00179421, NJ00175629, NJ00177976, NJ00183043, NJ00167029, NJ00165390, NJ00165211, NJ00164234, NJ00181173, NJ00183473, N00183733. Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure three residents (Resident (R)21, R22, and R24) were free from physical abuse by R20 out of a total sample of 32 residents. Due to the vulnerable nature of the nursing home population, the potential for serious injury or serious physical or psychosocial impairment from being physically abused by R20 existed, and the likeliness of R20 hitting another resident in the facility was high and required immediate action to prevent further events of physical abuse by R20. In addition, R20 physically assaulted three staff members Certified Nursing Assistant (CNA)4, Licensed Practical Nurse (LPN)16, and LPN1). The facility's Administrator and Regional Director of Nursing (DON) were informed on 02/26/25 at 3:33 PM of the Immediate Jeopardy related to the failure to ensure R21, R22, and R24 were free from abuse from R20. The Immediate Jeopardy began on 01/04/25 at 6:30 AM, which was the second resident-to-resident physical assault. On 02/27/25 at 2:32 PM, the facility provided an acceptable Immediate Jeopardy Removal Plan. The survey team verified the implementation of the facility's IJ Removal Plan on 02/27/25 at 6:40 PM, which included the following: The Director of Nursing (DON) immediately implemented 1:1 Monitoring for Resident #20 on all shifts. The in-service included the staff member assigned for 1:1 monitoring and will not be assigned other duties. Resident # 20 will remain on 1:1 monitoring per the physician's order indefinitely. The 1:1 monitoring will be for 24 hours, including the 7-3PM, 3-11 PM, and 11PM-7AM shifts. On 2/26/25, the DON initiated verbal education for all working nursing staff, including agency staff. The in-service included is as follows: a Staff member will be assigned for 1:1 monitoring and will not be assigned to any other duties. 2, The Unit manager and supervisors will ensure 1:1 is implemented and maintained at all times. Nursing staff reporting to duty will be educated by the supervisor/ designee prior to working unit 100% of the nursing staff education is completed. A staff member will be assigned to 1:1 monitoring and will not be assigned to any other duties. All newly hired nursing staff will be educated during orientation by Human resources on 1:1 monitoring per the facility's policy. The staff who received the education will verbalize understanding by signing the in-service as an acknowledgment of the education provided. After the Immediate Jeopardy was removed, the deficiency remained at a G scope and severity for actual harm due to R24 voicing that he/she was afraid and kept his/her door closed. Findings include: Review of the facility's Abuse, Neglect, and Exploitation policy dated 10/21/24 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include . certain resident to resident altercations . Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking . Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R20 was admitted to the facility on [DATE]; diagnoses included Alzheimer's disease, dementia, major depressive disorder, mood (affective) disorder, and hallucinations. Review of the annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/14/25 located in the EMR under the MDS tab revealed R20 was moderately impaired in cognition with a BIMS score of eight out of 15. R20 was independent in mobility and walked 150 feet independently. R20 did not exhibit behavior during the assessment period. The progression of R20's aggressive behavior was as follows: a. Review of the Reportable Event Record/Report form dated 06/17/24 and provided by the facility revealed the type of incident was resident-to-resident abuse, and it occurred on 06/15/24 at 6:10 PM. The incident was called into the State Survey Agency on 06/16/24 at 11:33 AM. The description of the event read, On 06/15/24 at about 6:10 PM, C.N.A [CNA4] in his/her w/c [wheelchair] between the A and B bed. The CNA [CNA4] called for help, resident [R20] was taken out of the room to calm his/her down . Review of the undated Investigation Summary provided by the facility verified the incident occurred as described on the Reportable Event Record/Report form dated 06/17/24, in which R20 became agitated, flailed his/her arms which came in contact with R21's head and arms. The Investigation Summary indicated both residents were assessed for injury, and no injuries were noted. The Investigation read, In conclusion, the incident was unintentional. [R20] accidentally hit [R21] when flailing his/her arms . On 06/17/24 both residents were interviewed by this writer, they had no recollection of the incident. [R21] was moved to a different room, however, on Wednesday, 06/19/24, he/she verbalized that he/she missed his/her roommate and requested to go back to his/her room . Review of R20's Care Plan revised on 06/15/24 was included in the Event Reporting file dated 06/15/24 and revealed a problem of [R20] is/has potential to be physically aggressive, refusing care, and strong desire to be independent r/t [related to] dementia, poor impulse control . 06/15/24 [R20 unintentionally hit another resident [R21]. The goal was for R20 to not harm himself/herself or others. Intervention in pertinent part[s] included psych consult, medication review, giving choices, and documenting behavior and interventions. CNA4 was an agency staff member. The facility did not have a phone number for CNA4, who witnessed the incident, and an interview was not conducted with CNA4. b. Review of a Nurse's Note dated 11/17/24 at 10:56 PM revealed, Resident [R20] was received (sic) in the hallway ambulating. Later he/she walked into room [ROOM NUMBER] and was scattering things in the room . In an attempt to redirect him/her to his/her room he/she punched me [LPN16] on my face. During an interview on 02/26/25 at 4:24 PM, LPN16 stated he was the nurse for the resident who resided in room [ROOM NUMBER] on 11/17/24 when the incident with R20 occurred. LPN16 stated another nurse called him to go to room [ROOM NUMBER] to remove R20 from the room, adding that the nurse told him R20 was combative. LPN16 stated that R20 was in the bathroom in room [ROOM NUMBER] and went to use the resident's (who resided in room [ROOM NUMBER]) toothbrush. LPN16 said there were two other staff (a nurse and a CNA) in the room [ROOM NUMBER]. LPN16 stated he tried to prevent R20 from using the toothbrush, and he/she punched him/her in the face. LPN16 stated he quit trying to get him/her to come with him/her out of the bathroom. LPN16 stated it was painful, and he sustained a cut to his nose from being punched. During an interview on 02/26/25 at 2:12 PM, the DON stated that he was not aware of this incident. c. Review of a Nurses Note dated 12/11/24 at 10:25 PM in the EMR under the Progress Notes tab revealed, This nurse [LPN]1 was called by one of the aides reporting that patient [R20] had entered another patient's room and was barricading himself/herself in room # . This nurse [LPN1] went to room # . and attempted to redirect the patient [R20] out of the room. Patient then proceeded to grab this nurse's left ear and punch his/her closed fist in the face twice. This nurse stepped away and asked patient [resident] to leave the room at which point the patient [R20] placed this nurse in a choke hold and continued to physically assault this nurse. This nurse called the unit manager to deescalate situation. During an interview on 02/25/25 at 2:45 PM, LPN1 stated R20 was strong and was aggressive to staff and residents. LPN1 stated R20 punched her in the face twice and put her in a chokehold on 12/11/24 when she tried to redirect R20 out of another resident's room. LPN1 stated she did not think it was safe for residents with R20 continuing to reside in the facility. LPN1 stated she reported the incident to the supervisor on duty. During an interview on 02/26/25 at 2:12 PM, the DON stated that he was not aware of this incident. d. Review of the Reportable Event Record/Report form dated 01/05/25, provided by the facility revealed the event occurred on 01/04/25 at 6:30 AM and was classified as resident-to-resident abuse. The description of the event read, Nurse reported to supervisor that during 6 AM med [medication] pass on 01/04/24, CNA observed a physical altercation between the two residents [R20 and R22]. [R20] had no visible injuries and [R22] had visible bruising to left eye area and left side of the face and mouth. [R22] was transported to [the] hospital for evaluation and returned with no new orders. [R20] was escorted to crisis with police and returned with no new orders. Physician and family members were contacted and made aware. 1:1 supervision applied to [R20] as primary intervention for incident . Review of the undated CNA Statement provided by the facility revealed CNA5 documented, I was doing my rounds and I asked [R21] where was his/her roommate [R20] and he/she (sic) was just here. Walked out of the room, heard talking so I went in the room and [R20] was on top off (sic) [R22] with his/her hands on [R22's] neck. Review of the undated Investigation Summary revealed . Upon further investigation, the CNA stated that both residents were both seen in their individual bedrooms at 0430 [4:30 AM] and upon another round @ 0500 [5:00 PM], residents were seen in a physical altercation in [R22] s room. Following [the] return from crisis, staff attempted to transfer [R20] to another room however he/she refused and became combative with staff. Room change was then offered to [R22], and his/her family agreed to room change temporarily for safety. [R22] was moved to another unit, [R20] was placed on q [every] 15 [15 minutes] checks and was then evaluated via telehealth by psych who gave [an] order to remove q 15 checks and recommended med [medication] increase pending lab results . [R21 and [R20] have no previous issues, and this incident is isolated. It is concluded that [R20] may have entered [R22]'s room in a moment of confusion, which then caused [R22] to get out of bed and approach him/her to remove him/her from his/her bedroom. This may have led to the altercation . Both residents also did not recall the incident when interviewed the following day . Interventions were separating the residents immediately, skin evaluations, police notification, physician notification, families notified, [R22] transported to the emergency department and R20 transported to crisis. Increased supervision was removed on 01/06/25. Review of R22's Weekly Skin Evaluation dated 01/04/25 revealed R22 had a scratch on his/her right arm, sore on his/her right lower arm, two bruises on his/her left front thigh, a swollen area under his/her eye, eyeball that was red, swollen right side of his/her face, scratches on the front of his/her face, scratches on the side of his/her face, a scratch on the neck on the left side, and a swollen left lip. The narrative read, Resident was attacked by another resident [R20]. He/She has injuries to his/her face and left eye. Scratches on his/her face, left neck, right arm, and a bruise on his/her left thigh . Review of R20's Weekly Skin Evaluation dated 01/05/25 revealed R20 had an abrasion to the front of his/her right knee. The narrative read, The abrasion is a result of physical altercation with peer. First aid Triple Antibiotic applied. No pain verbalized or observed. Review of the Order Summary Report current through 02/25/25 in the EMR under the Order tab revealed the physician ordered a psych consult for R20 for aggression and violent behavior on 01/08/25. Review of the investigation file revealed Statewide Clinical Outreach Program for the Elderly (S-COPE) was conducted on 01/13/25 Review of the S-COPE clinical consultation form dated 01/13/25 revealed R20 jumped on another resident and had his/her hands around the resident's neck. No injuries were sustained. S-Cope support was requested. The form read, Risk factors: No risk at [the] time of assessment for harming others. Recommendations included monitoring interactions with residents, monitoring for unmet needs, and follow up with psychiatry with ongoing concerns of behavior. Training recommended included staff training on Resident Aggression in LTC. CNA5, an agency staff, was called on the phone on 02/26/25, and a message was left by the surveyor. CNA5 did not return the call, and CNA5, who was a witness to the incident, was not interviewed. LPN14, an agency staff assigned to R20 on 01/04/25, was called on 02/26/25; there was no answer, and voice mail was not activated to leave a message. LPN14 was not interviewed. There was no written statement by LPN14 regarding the incident. During an interview on 02/26/25 at 2:04 PM, the DON stated he completed the investigation and stated R20 was sent to the psych portion of the ER [emergency room] following this incident. The DON stated it was common, as in this case, that the hospital reported the resident had dementia, and they sent R20 back to the facility. The DON stated R20 was initially on 1:1 observation, then 15-minute checks, and then the Psychiatrist recommended the discontinuation of 15-minute checks. The DON stated R20's Depakote [seizure medication with off label use for behaviors] was increased after this incident. The DON verified there were no additional staff statements and no staff training after the incident (as recommended in the S-COPE evaluation). The DON stated both residents had histories of behaviors. During an interview on 02/27/25 at 7:03 PM, the DON was asked if the abuse was substantiated as this was not documented on the Investigation Summary. The DON stated he was not sure if it was substantiated. e. Review of the Reportable Event Record/Report form dated 02/20/25 provided by the facility revealed the incident was classified as resident-to-resident abuse that occurred on 02/19/25 at 5:45 PM and was reported to the state on 02/19/25 at 7:40 PM by the DON. The Reportable Event Record/Report revealed that the incident occurred in R24's bedroom, and it was reported to the DON that R20 had wandered into R24's bedroom. Staff intervened and attempted to redirect R20 out of the room. R20 became combative and a physical altercation started between the residents. Both residents were separated, and Emergency Medical Services (EMS) was called. R24 was transported to the hospital for evaluation and returned on 02/20/25 with no new orders or injuries. EMS was requested to send R20 to crisis, but they refused. R20 was placed on 1:1 supervision immediately. Skin evaluations were completed, and new skin issues were noted; however, what the skin issues were was not documented. Interventions included separating the residents, skin evaluations, pain evaluations, police notification, emergency contacts and physician notified, 1:1 supervision implemented, emergency psych telehealth consult ordered, psychosocial evaluation and S-COPE consult, as well as emotional support being provided. Review of LPN15's Employee Statement revealed the incident occurred at 5:30 PM as follows, Resident was last seen in [the] hallway going to dayroom for dinner. Was notified by aide that resident [R20] was in R24's room following a physical altercation and refusing to leave the room. Resident became physically aggressive with staff upon entry. Physical altercation resulted in another resident [R24] being injured and sent to the hospital with hematoma to the back of his/her head. Review of R20's Weekly Skin Evaluation dated 02/19/25 and provided to the surveyor revealed R20 was not documented with any skin issues/abnormalities. Review of R24's Weekly Skin Evaluation dated 02/19/25 and provided to the surveyor revealed R24 was observed with a medium sized knot to the back of his/her head that hurts even more per the facial pain scale. R24 was noted with swelling on the back of his/her head and the narrative read, Resident hit back of head when he/she fell. Sent to ER for evaluation and treatment. Review of the Emergency Department report dated 02/19/25 and provided by the facility revealed R24's diagnoses of, closed head injury, initial encounter, disorder of spinal cord in neck, hematoma of occipital region of scalp . Review of the Order Summary Report dated 02/20/25 in the EMR under the Orders tab revealed a physician's order on this date for, 1:1 observation every shift for observation and monitor and document. During observation on 02/26/25 at 6:09 AM, R20 was in his/her room. R20's roommate was in bed with his/her eyes closed. There was no CNA providing 1:1 in the room, and no CNA was observed in the hallway outside R20's room. A second observation on the same day, 8:15 AM through 8:30 PM, revealed that R20 was under continuous 1:1 observation. During an interview on 02/26/25 at 2:12 PM, the DON stated that there should be 1:1 on all shifts. The DON stated usually R20 was a lovely lady/man, but when anyone tried to redirect him/her, there was no stopping him/her. The DON stated that it was his/her personality. During an interview on 02/26/25 at approximately 5:15 PM, R24 recalled the incident on 02/19/25. R24 stated he/she was eating dinner in his/her room, and R20 came into his/her room and told him/her that it was his/her bed. R24 stated he/she told R20 no; it was not his/her room and asked him/her to leave. R24 stated that R20 tried to grab a small bag at the head of the bed with his/her cell phone in it. R24 stated that two staff members came into the room and tried to get R20 to go out, but R20 said No and would not leave. R24 stated he/she got up and walked to the door and R20 followed him/her, the staff having already left the room. R24 stated he/she was standing by the door, and R20 pushed him/her, and he/she fell in the hallway, hitting the back of his/her head on the floor, which caused him/her pain to the back of his/her head. R24 stated the police came, and he/she was asked by the nurse if they wanted to go to the hospital, which he/she stated he/she did. R24 stated the incident on 02/19/25 was not the first time R20 came into his/her room uninvited. R24 stated, a few days before that, R20 came into his/her room, went into his/her bathroom, and stayed there for about 30 minutes. R24 reported it to the CNA and asked if she could see what R20 was doing. R20 eventually left the room. R24 stated after the incident on 02/19/25, he/she was in the dining area, and she saw R20 walking around and did not see any staff with him/her. R24 stated he/she was nervous about that. R24 stated he/she was traumatized by the incident on 02/19/25. R24 stated he/she was keeping the door to his/her room closed so people wouldn't come in. R24 stated none of the staff came and asked him/her to give them a statement of what occurred on 02/19/24 or came to discuss how he/she was doing. Review of R20's Psychiatric Progress Note dated 02/20/25 and provided by the facility, revealed recommendations were made regarding R20 to consider supportive and non-pharmacological approaches, redirect, provide support, provide comfort, reduce stimulation, treat medical issues, encourage participation in activities, and social engagement. The recommended medication changes were to add Depakote 125 q day at 2:00 PM and increase the bedtime dose to 250 mg, with the morning dose remaining unchanged. Review of the Order Summary Report current through 02/25/25 in the EMR under the Orders tab revealed the recommended changes to Depakote were ordered. LPN15 was called on 02/26/25, and a message was left. LPN15 did not return the surveyor's call, and she was not interviewed. CNA6 was called on 02/26/25 at 3:57 PM, and a message was left. CNA6 did not return the surveyor's call and was not interviewed. During an interview on 02/26/25 at 6:19 AM, CNA7 stated she had an assignment of residents, including R20. CNA7 stated there was no permanent CNA completing 1:1 on the night shift; 1:1 for R20 was completed on the day shift and evening shift only. CNA7 was in the hallway after coming out of a different resident's room and stated she had a chair she sat in outside of R20's room for extra supervision when she was not providing care or doing rounds. During an observation on 02/26/25 at 7:00 AM, R20 was observed in his/her room. There were no staff in the room providing 1:1 observation. At this time, the day shift CNA came on duty and went to R20's room. During an interview on 02/26/25 at 10:55 AM, the Medical Director stated wandering and aggressive residents were a big concern, and they looked at each case and patient individually. The Medical Director stated he was not aware of any residents that were currently having a problem with wandering or of resident-to-resident abuse incidents. The Medical Director stated he would like to be involved in the plan to address these incidents. The Medical Director reviewed R20's Physician's Orders and stated the 1:1 should be on all shifts per the orders. The Medical Director stated he was not the attending physician of R20. During an interview on 02/26/25 at 5:10 PM, the Administrator stated 1:1 required staff to be in the resident's line of sight. During an interview on 02/27/25 at 11:57 AM, CNA8 stated that R20 tended to be aggressive towards staff and could also be aggressive towards residents. CNA8 stated that R20 said, Don't you dare at times when trying to provide care or redirect, and he/she was very quick and aggressive. CNA8 stated that the main approach was to redirect R20 when he/she became aggressive and to keep him/her busy to prevent behaviors. During an interview on 02/27/25 at 3:01 PM, LPN9 stated R24 was traumatized by the incident with R20. During an interview on 02/27/25 at 6:39 PM, the DON stated he had spoken with R24 on the phone after the incident occurring on 02/19/25. The DON stated R24 reported to him that R20 wandered into his/her room and the staff tried to get R20 out. The DON stated R24 told him R20 pushed him/her down. The DON stated R24 had not reported R20 coming into his/her room previously and trying to get his/her cell phone. The DON stated he was aware that there were wanderers on the [NAME] unit. The staff had talked with families, offered stop signs to residents to place on their doors, put photos on the doors so residents knew which room was theirs. The DON stated the wandering occurred mostly in the evenings, and they could not restrain residents. The DON stated they had consulted psych and did tele-visits for R20. The DON stated the facility was seeking placement elsewhere for R20, although his/her family was not open to it. The DON stated R20 would be more appropriate in a behavioral facility so her behaviors could be better managed. Additionally, the DON stated that their regular night shift nurse was sick on 02/26/25, and the night 1:1 supervision was not provided. The DON stated that LPN17 should have assigned a CNA for 1:1 supervision for R20 and should not have given that CNA any other assignment. The DON verified that there was a charge nurse working the night shift who also could have caught the error of R20 not having a staff member assigned for 1:1 supervision. N.J.A.C. 8:39-4.1(5)

Based on record review and interview, the facility failed to monitor and assess a resident's skin around a cast and notify the physician timely when necrotic skin was found around the cast for one of one (Resident (R)14) reviewed for timely monitoring and assessments of 32 sampled residents. This failure resulted in harm when R14 was sent to the hospital, surgery was required, and a maggot infestation was found under the cast. Findings include: Review of R14's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed that R14 had been admitted to the facility initially on 10/14/22 with the diagnosis of dementia and diabetes mellitus. The resident passed away at the facility on 01/25/25. Review of R14's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 04/17/23 revealed that he/she had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated he/she was severely cognitively impaired. Review of R14's Progress Notes dated 04/23/23 at 4:25 AM, located under the Progress Note tab in the EMR, revealed that the resident had an unwitnessed fall. The resident was assessed; his/her right wrist was noted with swelling, and he/she was unable to flex it. Emergency Medical Services (EMS) was notified, and the resident was transferred to the emergency room (ER). The Progress Note further revealed at 10:31 AM, and the resident returned to the facility with a diagnosis of right wrist fracture with a wrap to immobilize his/her right arm. At 11:56 AM, the resident was sent to the hospital to have a cast placed on his/her right arm due to him/her taking the wrap off continuously. At 8:16 PM, the resident was admitted to the hospital for surgery of his/her right wrist. The resident returned to the facility on [DATE] with a right hand cast in place. There was no further documentation of any assessments or monitoring of the resident's arm, wrist, or skin around the cast until 06/18/23. Review of R14's Progress Note dated 06/18/23 revealed that the resident complained of pain in his/her arm. After the cast was assessed, necrotic skin and an opening under the cast were noted around the resident's wrist. The supervisor was notified. There was no further documentation or assessment of the resident's skin until 06/20/23. Review of R14's Progress Note dated 06/20/23 at 12:55 PM revealed, a foul odor was noted from the resident's right arm cast. The physician was notified and an order was received for Keflex (antibiotic) for 10 days. There was no documentation showing that the physician had been notified of the necrotic tissue found two days prior. Review of R14's Progress Note dated 06/22/23 at 8:19 AM revealed the resident was noted with a persistent foul odor on his/her right arm. The physician was made aware, and the resident was sent to the ER and admitted with a right wrist infection. Review of R14's admission Worksheet located under the MISC tab in the EMR dated 06/29/23 revealed the resident returned to the facility with the diagnosis of right wrist infection, status post hardware removal and maggot infestation. An attempt was made to contact Licensed Practical Nurse (LPN)18, who was identified by the Director of Nursing (DON) as the Nursing Supervisor on 06/18/23 when the necrotic skin was identified. A voice message and no return call was received prior to the survey's on exit 02/27/25. An attempt was made to contact LPN19 on 02/26/25 at 2:57 PM, who had been assigned to the care of R14 from 04/23/23 to 06/23/23. A voice message was left, but no return call was received prior to the survey's exit on 02/27/25. An attempt was made to contact LPN20 on 02/26/25 at 4:10 PM, who had previously been the B wing Unit Manager where R14 had resided. A voice message was left, but no return call was received prior to the survey's exit on 02/27/25. During an interview on 02/26/25 at 5:50 PM, LPN8 stated, I know that he/she [R14] broke his/her arm, and we sent him/her [R14] out to the hospital. He/She [R14] came back and kept picking at the ace wrap, and then we had to send him/her [R14] back out to the hospital, at which time he/she had a cast on his/her arm. I remember that he/she [R14] had to go to the hospital to have it debrided, and then he/she came back to us. An attempt was made to contact the Medical Doctor for R14 on 02/27/25 at 4:00 PM. A voice message was left, but no return call was received prior to the survey's exit on 02/27/25. During an interview on 02/27/25 at 7:00 PM, the DON was asked his expectations of the nurses caring for a resident, such as R14 with a cast, and he stated, 'I would rather not speak to this as I was not the DON at that time. N.J.A.C. 8:39-3.2 (a)(b)

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to administer a physician ordered scheduled pain medication to a resident who was verbalizing pain at a level of ten (10) out of ten. This deficient practice was identified for one (1) of one residents, (Resident #35) reviewed for pain management and was evidenced by the following: Refer to F684E On 04/06/23 at 12:35 PM, Surveyor #1 observed Surveyor #2 talking to Resident #35 at the end of the hallway on the [NAME] unit. Surveyor #1 overheard the resident tell Surveyor #2 that he/she had not received any of his/her medications that day and their shoulders were in pain. At that time, Surveyor #1 observed Surveyor #2 walk toward the Licensed Practical Nurse/Acting Unit Managers (LPN/AUM) office to notify the facility staff member that Resident #35 was requesting his/her medications. On 04/06/23 at 12:36 PM, Surveyor #1 walked down the end of the hallway toward Resident #35 and observed the resident seated in his/her wheelchair. The resident stopped the surveyor and stated that he/she had not received their medications that day and was in pain. The resident stated his/her pain was constant and in his/her shoulders. The resident further stated, I don't know why they haven't given me my medications. On 04/06/23 at 12:40 PM, Surveyor #1 interviewed the LPN/AUM at the medication cart in front of the nurse's station. The surveyor asked the LPN/AUM if Resident #35 had received his/her pain medications. The LPN/AUM stated that she had just taken the resident's blood pressure because the resident was on a blood pressure medication, and she was going to administer the resident's medications now. On 04/06/23 from 12:40 PM to 12:46 PM, Surveyor #1 stood at the nurse's station, next to the medication cart and observed the LPN/AUM gather the resident's medications, walk down the hallway, and administer medications to Resident #35. On 04/06/23 at 12:48 PM, the surveyor reviewed Resident #35's April 2023 Medication Administration Record (MAR) on the computer attached to the medication cart in the presence of the LPN/AUM. At that time, Surveyor #1 identified that the resident had not received his/her routine scheduled Tramadol 50 milligrams (mg) by mouth three times a day at 8:00 AM and had not received the application of his/her Lidocaine 4% patch to the left shoulder which was scheduled to be administered at 9:00 AM. Surveyor #1 asked the LPN/AUM what medications she had administered to the resident and the LPN/AUM stated that she had just administered all the resident's 8:00 AM and 9:00 AM physician prescribed medications and normally would not have administered them this late. Surveyor #1 asked the LPN/AUM why the medications were administered outside of the physician prescribed time frame, and the LPN/AUM stated that she was caring for other residents, it was an oversite, and there were other nurses available that could have helped her. The surveyor asked the LPN/AUM if she had evaluated Resident #35's pain prior to administering the pain medication, Tramadol. The LPN/AUM stated that she had not evaluated the resident's pain prior to the administration of the Tramadol because it was a routine schedule pain medication, and the resident had a diagnosis of chronic pain. The LPN/AUM further stated that if a resident had chronic pain, the pain medication should have been administered according to Physician Orders (PO)'s to prevent the resident from being in pain. The LPN/AUM told Surveyor #1 that she had one hour before and one hour after to administer the resident his/her medications. The LPN/AUM explained that when she had administered the resident his/her medications the resident had complained of pain because the resident did not sleep with his/her usual pillow the night before. On 04/06/23 at 01:01 PM, Surveyor #1 interviewed Resident #35 in his/her room. The surveyor asked the resident what his/her pain level was on a scale of zero (0) to 10. The resident stated his/her pain was a 10 because he/she had, locked arms. At that time, the resident showed the surveyor that he/she was unable to lift his/her arms and was only able to slowly bend them from the elbow without pain. The resident stated, I feel bad that nobody realizes what constant pain is. I'll be so truthful to you. Sometimes the pain is so bad, I can't take it anymore. I've had locked arms for two years, and the pain never goes away. Sometimes it's tolerable because I'm used to it, but it's intolerable when I don't receive my medications. The resident further told the surveyor that he/she, didn't want to cause problems for nobody and just wanted to be treated right. On 04/06/23 at 01:26 PM, Surveyor #1 interviewed the resident's Certified Nursing Aide (CNA) who stated that he had been working at the facility for a month or two and Resident #35 was on his care assignment that day. The CNA stated that he had provided care to the resident about four (4) to five (5) times before. Surveyor #1 asked the CNA if the resident ever complained to him about pain? The CNA stated that, yes, the first time anyone provided care to the resident, he/she would tell the staff that took care of him/her that he/she had pain in his/her arms and to be careful with the arms. The CNA told Surveyor #1 that he had helped the resident get dressed earlier in the day around 9:45 AM - 10:00 AM and at that time the resident did not complain of pain, but the resident told him to be mindful of his/her arms. The CNA further stated that when he had dressed the resident that morning, he dressed the resident very slowly, helped the resident get out of bed, and sat the resident in his/her wheelchair. The CNA told the surveyor that the resident did not tell him that he/she had not been administered his/her medications when he provided care to the resident that morning. On 04/06/23 at 01:46 PM, in the presence of the Licensed Nursing Home Administrator (LNHA), Surveyor #1 interviewed the Director of Nursing (DON) who stated that the resident's medications should have been administered as ordered by the physician, one hour before and one hour after the scheduled medication time, unless otherwise indicated in the PO. The DON stated that he was a little familiar with the residents and the resident had a past medical history of respiratory illness, history of a hip fracture, and arthritis. Surveyor #1 asked the DON, what was the importance of administering pain medication as ordered by the physician for a resident with chronic pain? The DON stated that it was important that pain medications were administered as ordered by the physician to alleviate or minimize the discomfort of pain as much as possible. On 04/11/23 at 11:29 AM, Surveyor #1 interviewed the facility's Consultant Pharmacist (CP) who stated that medication was to be administered one hour before and one hour after the scheduled medication times. The CP further stated that if a resident was prescribed routine medications to treat chronic pain, the expectation would have been for the nurses to administer the medications as scheduled to hopefully keep the resident from having pain. On 04/11/23 at 12:56 PM, Surveyor #1 conducted a follow up interview with the resident in his/her room who stated that his/her pain had been better, and he/she was now receiving his/her medications on time. On 04/12/23 at 11:09 AM, Surveyor #1 conducted a follow up interview with the DON who stated that he had reviewed Resident #35's March 2023 and April 2023 Medication Administration Audit Report (MAAR) and had identified that the nurses had not been administering Resident #35's medications on time as prescribed by the physician. On 04/18/23 at 09:47 AM, Surveyor #1 interviewed the resident's Primary Care Physician (PCP) who stated that when a resident had a PO for a medication, the medication should be administered one hour before and one hour after the scheduled administration time. Surveyor #1 asked the PCP why administering scheduled pain medication was important if a resident had diagnoses that supported chronic pain. The PCP stated that it was important to administer the pain medication on time and appropriately to manage the resident's pain level and keep the resident's pain at a level that was tolerable. The surveyor reviewed the electronic medical record for Resident #35. A review of the resident's Admission Record (an Admission Summary) reflected that the resident was a long term care resident at the facility and had diagnoses which included but were not limited to polyarthritis (a term used where at least five joints are affected with arthritis), muscle weakness, unspecified fracture of sacrum, subsequent fracture with routine healing, difficulty walking, need for assistance with personal aftercare, other specified arthritis, unspecified site (inflammation of one or more joints, causing pain and stiffness that can worsen with age), unspecified osteoarthritis, unspecified site (a type of arthritis that occurs when flexible tissue at the ends of bones wears down; the wearing down of the protective tissue at the ends of bones which occurs gradually and worsens over time), and repeated falls. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 03/14/23, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated the resident's cognition was moderately impaired. A further review of the resident's MDS, Section J - Health Conditions - Pain Assessment Interview indicated that the resident's pain was almost constant, pain made it hard for the resident to sleep at night, and the resident verbally described their pain as severe. A review of the resident's March 2023 Order Summary Report (OSR) reflected a PO dated 02/20/21 for the medication, Tramadol 50 mg by mouth three times a day for arthritis pain, please give at 8:00 AM, 2:00 PM, and 8:00 PM. A further review of the resident's March 2023 OSR revealed a PO dated 02/20/23 for Lidocaine Patch 4%, apply to left shoulder one time a day for chronic shoulder pain. Remove patch at bedtime and apply per schedule. A review of the resident's March 2023 MAR revealed that the nurses had signed that the medication Tramadol 50 mg by mouth three times a day for arthritis pain was administered at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) throughout the month of March. A further review of the March 2023 MAR revealed that the nurses had signed that the Lidocaine Patch 4% was applied topically to the resident's left shoulder one time a day for chronic shoulder pain at 0900 (9:00 AM) and removed at 2100 (9:00 PM) throughout the month of March. A review of the resident's April 2023 OSR reflected a PO 02/20/21 for the medication, Tramadol 50 mg by mouth three times a day for arthritis pain, please give at 8:00 AM, 2:00 PM, and 8:00 PM. A further review of the resident's April 2023 OSR revealed a PO dated 02/20/23 for Lidocaine Patch 4%, apply to left shoulder one time a day for chronic shoulder pain. Remove the patch at bedtime and remove per schedule. A review of the resident's April 2023 MAR revealed that the nurses were signing that the medication Tramadol 50 mg by mouth was administered three times a day for arthritis pain at 0800 (8:00 AM), 1400 (2:00 PM), and 2000 (8:00 PM) from 04/01/23 through 04/06/23. A further review of the April 2023 MAR revealed that the nurses had signed that they had applied the Lidocaine Patch 4% topically to the resident's left shoulder one time a day for chronic shoulder pain at 0900 (9:00 AM) and removed at 2100 (9:00 PM) from 04/01/23 through 04/06/23 at 0900. A review of the March 2023 MAAR revealed the following: -On 03/01/23, Tramadol 50 mg was administered at 9:48 AM. Forty-eight (48) minutes late. -On 03/03/23, Tramadol 50 mg was administered at 10:31 AM. One (1) hour and thirty-one (31) minutes late. -On 03/03/23, Lidocaine Patch 4% was administered at 10:31 AM. Thirty-one (31) minutes late. -On 03/05/23, Tramadol 50 mg was administered at 10:36 AM. One (1) hour and thirty-six (36) minutes late. -On 03/05/23, Lidocaine Patch 4% was administered at 10:38 AM. Thirty-eight (38) minutes late. -On 03/06/23, Tramadol 50 mg was administered at 9:51 AM. Fifty-one (51) minutes late. -On 03/07/23, Tramadol 50 mg was administered at 10:34 AM. One (1) hour and thirty-four (34) minutes late. -On 03/07/23, Lidocaine Patch 4% was administered at 10:34 AM. Thirty-four (34) minutes late. -On 03/09/23, Tramadol 50 mg was administered ay 9:40 AM. Forty (40) minutes late. -On 03/10/23, Tramadol 50 mg was administered a 10:06 AM. One (1) hour and six (6) minutes late. -On 03/11/23, Tramadol 50 mg was administered at 12:29 PM. Three (3) hours and twenty-nine (29) minutes late. -On 03/11/23, Lidocaine Patch 4% was administered at 12:29 PM. Two (2) hours and twenty-nine (29) minutes late. -On 03/12/23, Lidocaine Patch 4% was administered at 10:31 AM. Thirty-one (31) minutes late. -On 03/13/23, Tramadol 50 mg was administered at 10:40 AM. One (1) hour and forty (40) minutes late. -On 03/13/23, Lidocaine Patch 4% was administered at 10:40 AM. Forty (40) minutes late. -On 03/16/23, Tramadol 50 mg was administered at 9:46 AM. Forty-six (46) minutes late. -On 03/17/23, Tramadol 50 mg was administered at 11:25 AM. Two (2) hours and twenty-five (25) minutes late. -On 03/17/23, Lidocaine Patch 4% was administered at 11:25 AM. One (1) hour and twenty-five (25) minutes late. -On 03/18/23, Tramadol 50 mg was administered at 10:09 AM. One (1) hour and nine (9) minutes late. -On 03/19/23, Tramadol 50 mg was administered at 9:47 AM. Forty-seven (47) minutes late. -On 03/20/23, Tramadol 50 mg was administered at 10:46 AM. One (1) hour and forty-six (46) minutes late. -On 03/20/23, Lidocaine Patch 4% was administered at 10:54 AM. Fifty-four (54) minutes late. -On 03/21/23, Tramadol 50 mg was administered at 9:57 AM. Fifty-seven (57) minutes late. -On 03/22/23, Tramadol 50 mg was administered at 9:36 AM. Thirty-six (36) minutes late. -On 03/22/23, Lidocaine Patch 4 % was administered at 10:31 AM. Thirty-one (31) minutes late. -On 03/24/23, Tramadol 50 mg was administered at 9:40 AM. Forty (40) minutes late. -On 03/25/23, Tramadol 50 mg was administered at 10:51 AM. One (1) hour and fifty-one (51) minutes late. -On 03/25/23, Lidocaine Patch 4% was administered at 10:52 AM. Fifty-two (52) minutes late. -On 03/27/23, Tramadol 50 mg was administered at 9:58 AM. Fifty-eight (58) minutes late. -On 03/28/23, Tramadol 50 mg was administered at 10:48 AM. One (1) hour and forty-eight (48) minutes late. -On 03/28/23, Lidocaine Patch 4% was administered at 11:07 AM. One (1) hour and seven (7) minutes late. -On 03/29/23, Tramadol 50 mg was administered at 10:14 AM. One (1) hour and fourteen (14) minutes late. -On 03/30/23, Tramadol was administered at 10:01 AM. One (1) hour and one minute late. -On 03/31/23, Lidocaine Patch 4% was administered at 11:05 AM. One (1) hour and five (5) minutes late. -On 03/31/21, Tramadol 50 mg was administered at 6:01 PM. Three (3) hours and one (1) minute late. A review of the April 2023 MAAR revealed the following: -On 04/01/23, Tramadol 50 mg was administered at 9:45 AM. Forty-five (45) minutes late. -On 04/02/23, Tramadol 50 mg was administered at 12:33 PM. Three (3) hours and thirty-three (33) minutes late. -On 04/03/23, Lidocaine Patch 4% was administered at 10:55 AM. Fifty-five (55) minutes late. -On 04/04/23, Lidocaine Patch 4% was administered at 14:09 (2:09 PM). Four (4) hours and nine (9) minutes late. -On 04/05/23, Tramadol 50 mg was administered at 10:07 AM. One (1) hour and seven (7) minutes late. -On 04/06/23, Tramadol 50 mg was administered at 12:41 PM. Three (3) hours and forty-one (41) minutes late. -On 04/06/23, Lidocaine patch 4% was administered at 12:43 PM. Two (2) hours and forty-three (43) minutes late. A review of the resident's physician progress note dated 03/21/23 at 2100 (9:00 PM) indicated that the resident had a past medical history of bilateral shoulder pain and was on the medication Tramadol three times a day as a pain management regimen. A review of the resident's Care Plan (CP) dated 12/14/21, reflected a focus area that the resident had chronic pain related to arthritis, repeated falls, and a sacral fracture. The goal of the resident's CP was that the resident would not have an interruption in normal activities due to pain through the review date. Interventions in the resident's CP included to anticipate the resident's need for pain relief and respond immediately to any complaints of pain. The resident's CP did not speak to administering pain medication as ordered by the physician for the treatment of chronic pain. A review of the facility's undated policy, Pain Assessment and Documentation Policy and Procedure, indicated, It is the policy of [the facility] to provide an effective and appropriate method of assessment and documentation of our resident's verbal and non-verbal complaints of pain and attempt to identify the source and effectively manage resident's chronic and/or acute pain. The effective treatment, reduction or elimination of pain and the associated discomfort will enable the resident/patient to participate or increase participation in therapy or activities of daily living. A review of the facility's policy, Medication - Administration Policy and Procedure, revised 08/01/17, indicated that medications could be administered one hour before and one hour after the scheduled medication time. NJAC 8:39-27.1(a)

Complaint Intake #NJ155732 Based on interviews, record review, and facility policy review, the facility failed to ensure two-person assistance was provided with transfers in accordance with a resident's care planned needs, to prevent accidents/injuries for 1 (Resident #7) of 3 sampled residents reviewed for accidents. Specifically, Resident #7, who was care planned for two-person assistance with transfers, was transferred with the assistance of only one staff member on 06/15/2022 and sustained a skin tear to the left leg. Later the same day, Resident #7 was again transferred with only one staff member assisting, which resulted in Resident #7 sustaining a laceration to the anterior aspect of the right lower leg with exposure of subcutaneous tissue which required care in the hospital emergency room (ER). Findings included: Review of an Admission Record revealed the facility originally admitted Resident #7 on 11/24/2021 and readmitted the resident on 06/08/2022 with diagnoses which included displaced fracture of lateral condyle of right femur (large bone in the leg extending from the hip to the knee), muscle weakness, and Alzheimer's disease. The Admission Record indicated the facility discharged the resident on 06/15/2022. Review of the resident's medical record revealed an admission Minimum Data Set (MDS) assessment had not yet been completed as of the date the resident was discharged . Review of a care plan, dated as initiated 11/25/2021, revealed Resident #7 was at high risk for falls related to confusion, gait/balance problems, incontinence, and being unaware of safety needs. The goal, which was dated as revised 06/09/2022, was for the resident to be free of falls through the next review date (09/09/2022). A planned intervention dated as initiated 11/25/2021 indicated the resident was transferred with the assistance of two people and use of a sliding board. Further review of Resident #7's care plan revealed a focus statement dated as initiated 11/25/2021, which indicated the resident had the potential for impairment to skin integrity related to decreased mobility, fragile skin, and incontinence of bowel and bladder. A planned intervention dated as initiated 11/25/2021 was to use caution during transfers and bed mobility to prevent striking the arms, legs, and hands against any sharp or hard surface. Review of an incident report, dated 06/15/2022 at 10:09 AM, revealed Nurse Manager (NM) #1 was called in to Resident #7's room by Certified Nursing Assistant (CNA) #6. NM #1 documented that he noticed Resident #7 was bleeding from the left leg and had sustained a skin tear that was 4 centimeters (cm) by 2 cm while being transferred to a wheelchair. The report indicated that CNA #6 stated the resident's leg hit the chair during the transfer. The nurse cleaned the skin tear with normal saline, applied steri-strips (thin adhesive bandages used to hold a wound closed) and a dry dressing, and notified the physician and the resident's family member. Review of an incident report, dated 06/15/2022 at 8:50 PM, revealed Licensed Practical Nurse (LPN) #5 was informed by CNA #6 that Resident #7's leg hit the side of the bed during a transfer. LPN #5 evaluated Resident #7 and found that the resident had two skin tears and a laceration to the right leg. According to the incident report, Resident #7 was unable to give a description of the incident. The incident report indicated the immediate action taken was that LPN #5 informed Unit Manager (UM) #1, and UM #1 instructed LPN #5 to clean the wounds with normal saline, do a wet-to-dry dressing, and wrap with Kling (a conforming stretch gauze). The report further indicated the physician and family member were notified, and the physician instructed LPN #5 to send Resident #7 to the hospital emergency department (ED) for evaluation. Review of a Progress Note, dated 06/15/2022 at 8:50 PM, revealed a nursing note that included a description of the injuries sustained by the resident during the transfer. The note indicated that the nursing supervisor observed the resident lying on the bed with an abrasion/skin tear and lacerations to the right lower leg that scraped the skin off. The note revealed that bleeding and bruising were noted to the surrounding tissue. The CNA reported that while transferring the resident to bed, the resident's right leg may have hit the lower part of the bed and resulted in the abrasion and laceration. Review of a hospital ED Provider Note, dated 06/15/2022, revealed Resident #7 had a small subacute skin tear to the anterior (front) left lower leg that had multiple steri-strips applied. Additionally, a significant skin tear injury was noted to the anterior aspect of the lower leg that was approximately 8 cm by 10 cm. The note indicated there were multiple skin tears with some complete loss of the skin and subcutaneous (the deepest layer of skin which lies closest to the muscle) tissue was visible. Review of an Accident/Incident Report revealed that on 06/16/2022 CNA #6 demonstrated how she transferred Resident #7 from the chair to the bed. The report indicated LPN #4 and the Physical Therapist (PT) were present during the demonstration. The report indicated the CNA demonstrated proper technique and that historically, the resident had been able to participate with transfers. In the area of the report titled, Recommended steps to prevent recurrence the report stated there was no deviation in care and it appeared the resident was suddenly unable to bear weight and the staff was unable to prevent the resident's leg from hitting the lowered side rail. Review of a Progress Note, dated 06/16/2022 at 9:30 AM, revealed the Interdisciplinary Team (IDT) met to discuss Resident #7's recent skin alterations. The note indicated the resident sustained a skin tear to the left shin during morning care on 06/15/2022 while being transferred from the bed to the wheelchair with an aide assisting and that the aide reported the resident's leg hit the wheelchair. The note indicated the team discussed leg sleeves; however, the resident weighed 75 pounds and the sleeves were not effective because they rolled down. The note indicated that later in the day, the resident was being transferred from the wheelchair to the bed but was being resistant at the time, and the resident's leg hit the bed during the transfer, which was reported by the aide. The note indicated the resident sustained an injury to the right leg that the physician thought should be evaluated at the ED. The note indicated the resident had a history of dementia and was known to be resistant to care at times. Review of a care plan focus statement dated as initiated 06/15/2022 revealed Resident #7's care plan was revised to indicate the resident was resistive to care at times related to dementia. During an interview on 10/21/2022 at 3:41 PM, NM #1 indicated Resident #7 was being transferred by CNA #6 from the bed to the wheelchair and sustained a bruise on their leg. He stated that later in the day, the resident sustained a skin tear and laceration during a transfer from the wheelchair to the bed. NM #1 reported that, according to CNA #6, Resident #7 was resisting the transfer when the resident hit their leg on the side of the bed. He indicated CNA #6 was not assisted by another staff member during the transfer of Resident #7 from the wheelchair to the bed. NM #1 revealed he was not aware that Resident #7 required two people for transfers. He stated on 06/16/2022, he re-educated CNA #6 on proper transfer technique for Resident #7. NM #1 stated leg sleeves were tried on Resident #7's legs, but they were rolling down the resident's legs. He indicated Resident #7 was sent out to the ER for evaluation of the bruises and laceration. During an interview on 10/21/2022 at 3:56 PM, LPN #5 indicated it was reported to her by CNA #6 that the resident had a laceration on their leg and was bleeding. She stated she observed the skin on the resident's leg had been scraped off on the side, and that the laceration was deep. She indicated she cleaned the resident's laceration using normal saline solution (NSS), then the resident was sent out to the hospital. CNA #6 was not available for an interview during the complaint investigation. He was no longer employed at the facility. During an interview on 10/21/2022 at 4:10 PM, the Director of Nursing (DON) stated the resident had incidents that resulted in skin tears on two separate occasions during transfers conducted by CNA #6. He indicated CNA #6 was educated on proper transfer techniques after Resident #7's skin tear and laceration incident. He reported that his expectation was for the residents at the facility to be transferred safely from their wheelchairs to bed. During an interview on 10/21/2022 at 4:05 PM, the Administrator reported that Resident #7 sustained skin tears during transfers, and she expected the staff to follow the plan of care when transferring a resident. She confirmed that Resident #7 required two persons for transfer. Review of a facility policy titled, Incident and Accident Report/Falls, dated 02/2021, revealed, Procedure 1. Incidents or accidents include but are not limited to falls, injuries, medication errors, drug reaction, or any event which may result in trauma or inflicted bodily injury to a resident, guest, or employee. 2. Information recorded should include the resident's or individual's name, room number, date, and time of incident, extent of injury, treatment given- if any, and medical advice obtained, description of how the incident occurred, and names of any witnesses. New Jersey Administrative Code: 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to implement interventions to keep a resident safe from falls. Resident #19 had multiple falls with fall #8 resulting in 11 sutures to the ear. Also, the facility failed to provide supervision for a resident who had a history of [REDACTED].#12 had a fall when not being supervised and sustained a head injury that required hospitalization for approximately one week. This deficient practice was identified for Residents #12 and #19, two of 13 residents reviewed for falls. Additionally the facility failed to maintain a safe resident environment by ensuring that medical equipment was plugged directly into an electrical wall outlet. This deficient practice was evidenced by the following: 1. Resident #19 was admitted to the facility on [DATE] after a fall at home that resulted in a fracture. The resident's [DIAGNOSES REDACTED]. During the initial tour on 5/12/15 at approximately 10 a.m. the surveyor observed Resident #19 seated in a wheelchair (w/c) near the nurses station wearing bilateral protective arm sleeves and bilateral hearing aides. At that time, the surveyor was told by the Unit Manager (UM), "This is my resident who likes being on the floor. He/she falls a lot." The UM also stated that Resident #19 self-propelled the w/c with his/her feet. On 5/15/15 at 11 a.m. the surveyor asked the UM why the resident fell a lot. The surveyor was told "it's a pride issue, (Resident #19) won't let the (opposite gender) help in the bathroom. (The resident) believes he/she is very independent." The surveyor asked if a safety belt was attempted. The UM stated, "we have never presented that to him/her as we can only use a belt on people who can release it themselves." On 5/18/15 at 10:30 a.m. the UM told the surveyor that Resident #19 fell from the wheelchair in the room on Sunday morning 5/17/15 at 7:45 a.m. She stated further that the resident was bleeding from the ear and was sent to the hospital for evaluation. On 5/18/15 at 11:15 a.m. the surveyor reviewed the Care Plan (CP) for Resident #19. The CP indicated Resident #19 had experienced 8 falls since admission less than 5 months ago. Also, the Physical Therapy Evaluation dated 4/27/15 indicated Resident #19 needed extensive assistance with transfers due to impulsive behavior, forward leaning of the trunk and knee wobble. On 5/18/15 at 1 p.m., the surveyor reviewed all fall investigations for Resident #19. The following information was obtained from that review: Unwitnessed fall #1 from the w/c occurred on 1/14/15 at 7:45 a.m. in Resident #19's room. The resident sustained [REDACTED]. Unwitnessed fall #2 from the bed occurred on 2/1/15 at 8:30 a.m. in the room. The resident stated he/she was getting out of bed to get dressed, sustained a skin tear to the left hand. Unwitnessed fall #3 from the w/c occurred on 3/4/15 at 9:45 a.m. in the room. Resident #19 suffered lacerations on the top of the head that matched the grill pattern on the heater in the room. There was also a skin tear on the resident's right thumb and the back of the right leg. Unwitnessed fall #4 from the w/c occurred the next day on 3/5/15 at 7 p.m. in another resident's room. Resident #19 was unable to tell staff what had caused the fall. Fall #5 was witnessed. It occurred on 4/23/15 at 8:30 a.m. while Resident #19 was seated in the dining room for breakfast. The resident reached for food on another resident's plate and while staff attempted to deter him/her, the resident stood up and fell . Resident #19 sustained a skin tear on the right forearm. Fall #6 was witnessed. It occurred on 4/27/15 at noon near the elevator. The investigation into the fall indicated that Resident #19 threw him/herself out of the w/c when an activity aide left the unit. Unwitnessed fall #7 from the w/c occurred on 4/29/15 at 6:45 a.m. in Resident 19's room. Unwitnessed fall #8 from the w/c occurred on 5/17/15 at 8:30 a.m. in Resident #19's room. The resident was transferred to the hospital that day and returned on 5/19/15. Resident #19 sustained a laceration to the right ear and received 11 stitches. On 5/20/15 at 11:30 a.m. the surveyor observed Resident #19 seated in the wheelchair at an activity. The resident had their head down and appeared to be asleep. The sutures were visible and the right ear was swollen and purple. 2. During the initial tour of the facility on 5/12/15 at approximately 10 a.m. the Unit Manager (UM) told the surveyor that Resident #12 was confused and had a history of [REDACTED]. The 1/27/15 Resident Assessment Instrument, an assessment tool, indicated Resident #12 was severely cognitively impaired, unable to walk and depended on staff for transferring from bed to chair. On 5/15/15 at 10:45 a.m. the surveyor observed the resident in the activity room seated in the wheelchair and leaning to the right side. Upon review of the resident's Fall Investigation Worksheet, the surveyor noted that Resident #12 had a fall on 9/23/14 when he/she got up from the bed. The surveyor reviewed another fall document, dated 11/11/14 at 6:15 p.m., which revealed that while the resident was seated in the wheelchair in the lounge, he/she stood up to walk and fell . The resident sustained [REDACTED]." The resident also complained of right hip pain and right arm pain and was sent to the hospital. According to the fall investigation documentation, a Certified Nursing Assistant (CNA) had been assigned to the lounge to monitor the residents. The CNA who had been assigned to the lounge was providing resident care on the unit. The investigation also included a written statement from a unit nurse which stated she became aware that there was no staff member in the lounge at 6:15 p.m. and that she had called out to the CNA assigned to the lounge to remind the CNA it was time for lounge duty. The nurse stated that after she had reminded the CNA, she went to talk with the UM in the UM's office and then heard the resident fall. At the time of the resident's fall, there was no staff member present in the lounge; neither the assigned CNA nor the nurse who had observed there was no CNA present. The investigation also included a 11/11/14 statement by the UM which noted the CNA did not go into the lounge when the unit nurse told her to go there and that both she and the unit nurse were standing at the doorway to her office when they heard a "thud." The UM wrote that they ran to the lounge and observed the resident lying on the floor crying. When interviewed on 5/19/15 at 9:30 a.m., the UM said it was their practice for staff to be present in the lounge whenever residents were there and that a CNA was always assigned to lounge duty. The UM confirmed that the CNA had not been in the lounge as assigned. According to the hospital records of 11/12/14, the resident sustained "frontal scalp hematoma with small volumes of underlying acute subarachnoid hemorrhage" (bruise and bleeding in the brain). When interviewed on 5/20/15 at 9:35 a.m., the Director of Nursing told the surveyor that staff should have been in the lounge. 3. On 5/12/15 at 12:10 p.m. the surveyor observed a nebulizer (a breathing machine) plugged into a power strip in resident room 136. NJAC 8:39 - 27.1 (a) 31.2(e)

Based on observation, interview and record review, it was determined that the facility failed to readdress nutritional interventions for a resident who continued to lose weight. Resident #9, who was dependent on a tube feeding for all nutrition, experienced a significant, unintentional weight loss of 30 pounds, or 19.7 % of body weight, over a period of 11 months. In addition, the facility failed to consistently provide nutritional interventions to a resident, Resident #8, with documented unintentional weight loss. The deficient practice was identified for Residents #9 and #8, 2 of 5 residents reviewed for nutritional concerns and was evidenced by the following: 1. During an initial tour of the facility on 3/5/13 at 11:45 a.m., the Unit Manager (UM) said Resident #9 had a feeding tube, was NPO (nothing by mouth), had a stable weight and had an unstageable heel pressure sore. According to the medical record, Resident #9 had [DIAGNOSES REDACTED]. The record confirmed that the resident was not able to eat by mouth and was dependent on gastrostomy tube feedings for adequate nourishment. The resident's height was 5 feet tall. The surveyor reviewed Resident #9's weight records which revealed a stable body weight of 152 lbs between 2/12 and 4/12. A 5/12 weight was not documented. The surveyor reviewed the 2/12/12 nutritional progress note that indicated the resident received an 800 ml total volume daily of a tube feeding formula, Glucerna 1.5. This provided the resident with 1200 calories per day. In addition, the resident received an additional 750 ml of water via the feeding tube. On 3/1/12 the dietitian documented the resident had been readmitted from the hospital. The order for Glucerna 1.5 was decreased to a total volume of 600 ml daily which provided 900 calories a day. The resident continued to receive an additional 750 ml of water via the feeding tube. The dietitian documented that hospice requested the decrease in tube feeding secondary to respiratory distress. Hospice services were discontinued in May, 2012. The resident's 6/12 monthly weight was documented as 136 lbs. This was a 16 lb weight loss over 3 months. A nurse's note on 6/6/12 at 3:25 p.m. indicated the dietitian had been notified of the resident's weight loss. The dietitian recommended the tube feeding total volume be increased to 1000 ml daily to provide 1500 calories. The nurse documented that the dietitian had spoken with the resident's family member about the need for increased tube feeding. The nurse documented the family member was initially agreeable to the increase in tube feeding but asked that the resident's physician call the family before a change. The nurse contacted the physician who was made aware of the weight loss and reminded of the heel pressure sore. According to documentation, the physician agreed with the dietitian but was unable to speak with the resident's family. The physician asked the nurse to tell the resident's family member that he/she would call the resident's family member when in the facility. The nurse called the resident's family member and gave the family member the information. The resident's family member then said that no change in the tube feeding formula could be made because of fear that the resident would develop [MEDICAL CONDITION] and become unable to breathe due to an increase in fluid. The dietitian was present while the nurse spoke with the resident's family member. There was no documented evidence that the facility addressed the risk/benefit of increased tube feeding to prevent weight loss vs respiratory distress concerns when the resident was on Hospice. On 6/6/12 the dietitian documented the resident's weight was 131.2 lbs, indicative of a 20 lb weight loss in 2 months. The dietitian also documented she had been notified that the resident had an unstageable pressure sore, 5 cm by 3.5 cm, on the heel which would put further demands on the resident's nutritional stores. The dietitian noted that she had spoken with Resident #9's daughter regarding whether the tube feeding formula could be increased. The dietitian documented no recommended changes in the total volume of tube feeding until the physician made a request to change the tube feeding. On 6/6/12 in a second nutrition progress note, the dietitian documented the physician wanted to increase the volume of Glucerna 1.5 to 1000 ml daily but when the Unit Manager called the resident's family member back, the family member, who had not spoken to the physician, no longer agreed to an increase in the tube feeding total volume. (An increase in the total volume of tube feeding would have provided additional calories and nourishment needed by the resident.) There was no documentation indicating that the family understood the relationship of the increase in the tube feeding volume to Resident #9's weight status and increased nutritional needs for wound healing. A dietitian's 6/20/12 nutritional progress note indicated the physician had ordered Prosource Plus, a supplement, 1 oz twice a day which would provide an additional 200 calories and 30 grams of protein. On 7/23/12 a dietitian's nutritional progress note indicated the resident was receiving a total of 1100 calories and 79.5 grams of protein from the tube feeding (19 calories and 1.4 grams of protein per kg of body weight). In addition, the resident continued to receive an additional 750 ml water via the feeding tube. The dietitian documented the resident had lost an additional 4 lbs during the past month and continued to receive treatments to the heel pressure sore. The dietitian documented if further weight loss occurred, she would contact the resident's family to see if they (the facility) could increase the tube feeding. An untimed 6/25/12 nurse's note indicated the resident's family member had called and they discussed the heel pressure sore which the nurse described as stable. The nurse documented that she had also discussed the resident's tube feeding. The resident's family member was under the impression that the resident's tube feeding had been increased by 100 ml. The nurse documented she reminded the family member that an increase in tube feeding had been declined on 6/6/12 so the tube feeding was not increased by the physician. There was no evidence that the physician was made aware of this conversation with Resident #8's family and the tube feeding volume was not increased. On 7/23/12 a dietitian's nutritional progress note indicated Resident #9 was receiving a total of 1100 calories and 79.5 grams of protein from the tube feeding (the resident's minimum nutritional requirements were 1560 calories per day). In addition, the resident continued to receive an additional 750 ml water via the feeding tube. The dietitian documented the resident had lost an additional 4 lbs during the past month and continued to receive treatments to the heel pressure sore. The dietitian documented if further weight loss occurred, she would contact the resident's family to see if they could increase the tube feeding. A weight assessment reflected a 25.2 lbs weight loss/16.5 % severe loss of body weight in 6 months. Nutritional progress notes dated from 8/15/12 through 1/22/13 indicated the resident continued to receive a total volume of 600 ml Glucerna 1.5 daily and Prosource Plus 1 oz twice daily. No change in the tube feeding had been made except a physician's orders [REDACTED]. A 1/22/13 quarterly nutrition progress note, documented the resident's weight had decreased to 122 lbs, indicative of an unintentional weight loss of 30 lbs. The dietitian documented the heel pressure sore had not improved. On 3/11/13 at 10:10 a.m. the surveyor observed a Certified Nursing Assistant weigh the resident. The resident weighed 122.2 lbs. The surveyor reviewed the resident's 6/6/12 nutrition care plan that identified a significant weight loss of 23 lbs during the previous 6 months, an unstageable pressure sore on the heel and a tube feeding rate below the caloric needs of the resident. The surveyor found no documentation in the medical record review that addressed the resident's fluid needs or the need for a fluid restriction, if any. There was no documentation of any attempt to decrease the additional water given through the feeding tube to allow additional tube feeding formula to be given or a formula change to meet the resident's nutritional needs as Resident #9 continued to lose weight. 2. During the initial tour on 3/5/13 at 11:15 a.m., the UM stated Resident #8, who had [DIAGNOSES REDACTED]. On 3/8/13 at 12:05 p.m. the surveyor observed the resident in the dining room being fed lunch by the speech therapist. The resident drank 8 oz of juice, 1/4 piece of chocolate layer cake and 3 spoons of rice. When interviewed on 3/8/13 at 12:15 p.m., the nurse in the dining room stated the resident had not been eating well but liked the nutritional supplement. On 3/11/13 at 12:10 p.m. the surveyor observed the resident in the dining room during the lunch meal. The resident consumed 12 oz of juice, 2 bites of cake and 2/3 of the chopped chicken. The resident left the rice, soup and vegetable. According to the resident's weight records, the resident's weight was 206 lbs in 8/12. A 9/16/12 dietitian's progress note indicated the resident now weighed 189 lbs and the dietitian changed the nutritional supplement. In 1/13 the resident's weight had decreased to 175.6 lbs. A 1/13/13 Weight Change Alert Sheet indicated the resident had weight loss during the past 6 months. On 1/13/13 the resident was evaluated by the dietitian who recommended the high calorie nutritional supplement, which the resident liked, be increased from 3 times per day to 4 times per day. According to documentation on the 1/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to documentation, the resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The 2/19/13 readmission physician orders, however, did not include an order to restart the high calorie nutritional supplement. When interviewed on 3/7/13 at 1:30 p.m., the UM stated the administration of nutritional supplements and the amount consumed was documented on the resident's MAR. When reviewed, the high calorie nutritional supplement had not been reordered on the 2/19/13 readmission Physician order [REDACTED]. There was no documented evidence the resident had received the high calorie supplement after readmission to the facility. NJAC 8:39 - 27.2(a)(e)