Every finding on record at Excel Care at Wayne

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to: a) complete pre and/or post dialysis assessments for 2 of 2 residents (Resident #11 and #96); and b) ensure timing of a resident's medication was adjusted to accommodate their dialysis schedule, for 1 of 2 residents (Resident #96) reviewed for dialysis services.This deficient practice was evidenced by the following: 1. On 5/17/26 at 10:50 AM, the surveyor observed Resident #96 resting in bed, with their eyes closed. There were no observed concerns. On 5/18/26 at 9:48 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #96. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to end stage renal [kidney] disease, dependence on renal dialysis, hypertension (high blood pressure) and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, dated 5/2/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #96 scored 11 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order dated 4/26/26 indicated Resident #96 was scheduled for dialysis on Monday, Wednesday, and Friday with a pickup time of 2 PM. A physician's order dated 4/25/26 indicated to give sennosides-docusate sodium (Senna-Docusate) 8.6-50 milligram (mg) one tablet by mouth one time a day for constipation. The medication was scheduled to be given at 5 PM. A physician's order dated 5/6/26 indicated midodrine 5 mg, one tablet by mouth three times a day for hypotension (low blood pressure); and hold for systolic blood pressure (SBP; the top number in a blood pressure reading which measures the maximum pressure in your arteries when the heart beats) greater than 130. The medication was scheduled to be given at 9:30 AM, 1:30 PM, and 5:30 PM. On 5/18/26 at 10:47 AM, the surveyor interviewed a Licensed Practical Nurse (LPN) assigned to care for Resident #96 about dialysis care. The LPN stated that prior to sending a resident to dialysis, the nurse would check: the dialysis access site; the resident's vital signs (VS; blood pressure, heart rate, temperature, and respiratory rate); check the resident's overall status; and administer medications as ordered by the physician. The LPN further explained that a binder was sent with a dialysis communication form for each session. The top portion of the form was completed by the sending nurse at the facility, and the bottom portion was completed by the dialysis center. The surveyor asked the LPN about post-dialysis documentation upon the resident's return to the facility. The LPN replied that a progress note should be documented in the EMR about their overall status and VS checked. The LPN stated a resident's medication should be timed around their dialysis session. On 5/18/26 at 10:55 AM, the surveyor observed Resident #96 in their room, alert and verbally responsive. Resident #96 confirmed they go to dialysis every Monday, Wednesday, and Friday. Resident #96 had no concerns with their care. Resident #96 stated they returned from the dialysis center to the facility around 6 to 7 PM. On 5/18/26 at 11:05 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) about dialysis care. The RN/UM stated a resident's medication should be timed around their dialysis session. The surveyor asked the RN/UM when Resident #96 usually returned from dialysis. The RN/UM replied around 7 PM. The surveyor informed the RN/UM of concerns for medications timed around 5 PM as the resident would be in dialysis during the medication administration timeframe. The RN/UM provided the surveyor with Resident #96's dialysis communication binder. The binder included dialysis communication forms which had two sections. The first section was to be completed by the nurse prior to sending the resident to dialysis. The second section was completed by the dialysis center nurse. The RN/UM stated that upon a resident's return from the dialysis, the nurses were to assess the resident, check their VS, and write a note in the EMR. The RN/UM and the surveyor reviewed the progress notes in the EMR. There were two progress notes dated 5/8/26 and 5/15/26 which documented the resident's post-dialysis assessment and return from dialysis. Additionally, the 5/15/26 progress note indicated the resident returned from dialysis around 8 PM. The RN/UM stated the nurses should be documenting post-dialysis assessments and the timing of medications would be reviewed. On 5/19/26 at 1:12 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) about the concerns of no post dialysis assessments documentation for Resident #96 and medication scheduled when the resident would be at dialysis session. On 5/20/26 at 11:02 AM, the DON and the LNHA met with the survey team. The DON stated education was being provided to staff about dialysis assessment completion and timing of medication administration. The DON added, all dialysis residents' EMR were being audited. There was no additional information provided by the facility. The surveyor reviewed the undated facility provided policy titled Administering Medications which revealed under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation of the policy revealed: 4. Medications are administered in accordance with prescriber orders, including any required timeframe. 7. Medications are administered within one hour of their prescribed time, unless otherwise specified. The surveyor reviewed the facility provided policy titled Dialysis/ESRD Care dated 5/1/25 which revealed under Policy Statement: Dialysis services will be provided in accordance with physician orders and industry best practices to ensure the safety, comfort, and well-being of residents. The policy did not further address documentation of dialysis resident assessments; and the timing of medication administration for dialysis residents. A review of the electronic medical record revealed the following information. The admission Record indicated the resident was admitted dependent on renal dialysis for end stage renal disease. The Order Summary Report contained a physician's order for hemodialysis three times a week at 6 AM. The dialysis access site was noted to be a left arm arteriovenous (AV) fistula, a surgical procedure connecting an artery to a vein. On 5/18/26 at 10:25 AM, the surveyor interviewed the Registered Nurse Unit Manager (RNUM) who stated the dialysis access site and vital signs should be assessed when the resident leaves for dialysis and when they return. The assessment should be documented in the electronic nursing progress notes. This was confirmed by the Director of Nursing (DON) on 5/18/26 at 12:25 PM. Nursing documentation in electronic Skilled Nursing Progress Notes during April and May failed to reveal consistent assessment pre and post dialysis. The Dialysis Communication report, a one-page form accompanying the resident to the dialysis clinic, was also inconsistently filled out – often containing only a blood pressure. The dialysis care plan initiated 12/16/24 and revised 7/24/25 contained interventions to monitor vital signs and the access site, however, it did not address pre and post dialysis assessments. The Dialysis/End Stage Renal Disease Policy and Procedure, dated 5/1/25, indicated residents receiving dialysis will be closely monitored, although, it did not address pre and post dialysis assessment of vital signs and dialysis access site integrity. On 5/20/26 at 11:00 AM, the RNUM stated all nurses were reeducated to perform pre and post dialysis assessments. NJAC 8:39-2.9, 27.1 (a)

Based on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for: a) personal protective equipment (PPE) use while performing high contact care in an enhanced barrier precaution (EBP) room for 1 of 1 Certified Nurse Aide (CNA) observed on 1 of 2 units; b) handling of personal care items for a resident for 1 of 1 CNA observed on 1 of 2 units; and c) storage of medical equipment and linens to decrease the possibility of spreading infection during a tour of the laundry area. 2. On 5/20/26 at 10:37 AM, the surveyor toured the laundry area with the Housekeeping Director (HKD), who stated that the facility collected the soiled laundry every 2 hours from units and they used two containers in soiled utility rooms. One container was for soiled linens and another for garbage. The surveyor observed that the isolation linens and clothing for resident's was kept outside in the docking area. There were multiple items being stored there, including full laundry detergent items, wheelchairs and other resident equipment. There was an awning covering the outside area, yet a large portion of the awning was missing and the items below it were wet with rainwater. Additionally, the surveyor observed plastic curtains leading up to the dock ramp, which were soiled with a brown coloration and was observed to be wet as well. The HKD stated that the area needed to be washed and the facility would use a power washer to clean the area except that the power washer was not working at the moment. The HKD stated that the docking area is not the best place to store items and the awning needed to be repaired. In the laundry room, the surveyor observed storage of equipment, and some of the equipment was open to the air, including bedside commode chairs, mattress, wedge pillows next to boxes of cleaning products. The HKD picked up an item form the shelf and dust like particles came off of the item. The HKD stated that there is limited storage space and the items should be clean and acknowledged that some items stored there need to be cleaned. In the laundry room, near the dryers and the folding area, the surveyor observed shelves with extra equipment stored on the shelves. Several items were also not stored in plastic bags, including white cleaned linens and a wheelchair cushion, which was open to the air. The wheelchair cushion was observed to be covered with dust-like particles. There were two fans in use, which had black colored debris on them and the fans both had broken pieces hanging off of them. The HKD stated that these items are all cleaned and should be stored in bags. On 5/21/26 at 1:24 PM, the surveyor discussed the above concerns with the Administrator. No further information was provided. N.J.A.C. 8:39-19.4 2. On 5/20/26 at 10:37 AM, the surveyor toured the laundry area with the Housekeeping Director (HKD), who stated that the facility collected the soiled laundry every 2 hours from units and they used two containers in soiled utility rooms. One container was for soiled linens and another for garbage. The surveyor observed that the isolation linens and clothing for resident's was kept outside in the docking area. There were multiple items being stored there, including full laundry detergent items, wheelchairs and other resident equipment. There was an awning covering the outside area, yet a large portion of the awning was missing and the items below it were wet with rainwater. Additionally, the surveyor observed plastic curtains leading up to the dock ramp, which were soiled with a brown coloration and was observed to be wet as well. The HKD stated that the area needed to be washed and the facility would use a power washer to clean the area except that the power washer was not working at the moment. The HKD stated that the docking area is not the best place to store items and the awning needed to be repaired. In the laundry room, the surveyor observed storage of equipment, and some of the equipment was open to the air, including bedside commode chairs, mattress, wedge pillows next to boxes of cleaning products. The HKD picked up an item form the shelf and dust like particles came off of the item. The HKD stated that there is limited storage space and the items should be clean and acknowledged that some items stored there need to be cleaned. In the laundry room, near the dryers and the folding area, the surveyor observed shelves with extra equipment stored on the shelves. Several items were also not stored in plastic bags, including white cleaned linens and a wheelchair cushion, which was open to the air. The wheelchair cushion was observed to be covered with dust-like particles. There were two fans in use, which had black colored debris on them and the fans both had broken pieces hanging off of them. The HKD stated that these items are all cleaned and should be stored in bags. On 5/21/26 at 1:24 PM, the surveyor discussed the above concerns with the Administrator. No further information was provided.

Based on observation, interview, and record review, it was determined that the facility failed to ensure the facility remained free of accident hazards. The deficient practice was identified for 1 of the 22 sampled residents and 1 unsampled resident reviewed for safe and homelike environment.The deficient practice was evidenced by the following:On 5/17/26 10:30 AM, the surveyor observed in room [ROOM NUMBER] the surveyor noted the grab bar in the bathroom of room was loose at both ends and pulling away from the wall. The surveyor observed an unopened plastic vial of nebulizer solution on the bedside table next to the window bed.On 5/17/26 at 10:58, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the second floor nursing care unit in room [ROOM NUMBER]. The LPN was asked about the vial of medication on the bedside table of the window bed. The LPN acknowledged medication is not supposed to be left unattended in the room. The LPN Acknowledged the medication was an unopened budesonide .25mg in2ml ampule. She removed medication from the room and stated she would report the medication found to supervisor.On 5/18/26 at10:00 AM, the survey interviewed the Unit Manager (UM) for the second floor nursing care unit. The surveyor asked about the unopened Budesonide vial at the bedside table. The UM acknowledged this was a medication for Resident #28 and acknowledged medications should not be left unattended at any time.On 5/18/2026 at 11:05 AM The surveyor interviewed the Director of Nursing (DON). The DON was made aware of the medication found in room [ROOM NUMBER] on 5/17/26 and acknowledged that medications including nebulizer vials should never be left unattended in resident rooms. On 5/19/2026 at 12:30 PM, the surveyor interviewed the Maintenance Director (MD). The surveyor asked about loose grab bar next to resident's toilet in room [ROOM NUMBER]. The MD acknowledged the rail is in place to assist residents with transfers to and from toilet and presented a safety hazard to the resident's if it was not fastened to the wall securely. The MD stated he would repair the loose grab bar immediately.On 5/19/2026 at 1:10PM, the surveyor and the survey team met with the Licensed Nursing Home administrator (LNHA) and the DON. Both acknowledged that the loose bathroom grab bar in room [ROOM NUMBER] and the observation of an unattended medication in the same room both presented a potential hazard to resident safety.On 05/20/2026 11:50 AM, the surveyor Interviewed Resident #10. The resident acknowledged he used grab bar during transfers to and from the toilet.A review of electronic health record (EHR) for resident #10 reflected the resident was admitted to the facility with diagnoses that included Mucle wasting and atrophy, a history of falling and dementia. A review of Resident #10's annual Minimum Data Set (MDS), an assessment tool, reflected that the resident is severely cognitively impaired and the resident requires assistance with transfers.On 5/20/26 at 12:05 PM, the surveyor interviewed Resident #28. The resident acknowledged he received nebulizer medications previously and stated he refused to take any more but could not recall when they stopped giving them to him.A review of Resident #28's EHR reflected the resident was admitted to the facility with diagnoses that included but were not limited to muscle weakness and a need for assistance with personal care.A review of Resident #28's annual Minimum Data Set (MDS), an assessment tool, reflected that the resident has minimal cognitive impairmentA review of Resident #28's physician orders reflected the resident was ordered Budesonide suspension, 0.25MG/2ml, 2ml inhale orally through nebulizer every 12 hours. The order was dated to start on 4/20/26 and discontinued on 5/5/26.

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain a homelike environment. Specifically, the facility failed to: a) keep the facility's environment in an adequate state of repair on 1 of 2 nursing care units surveyed, and b) failed to clean and maintain the equipment for 1 of 22 residents (Resident #5) reviewed for homelike environment.The deficient practice was evidenced by the following:On 5/17/26 at 10:17 AM, during an initial tour of 2nd floor nursing care unit the surveyor observed a two foot wide by two foot long area of damaged sheet rock and a large torn flap of wallpaper next to the door bed in room [ROOM NUMBER]. The utility pole and the attached enteral feeding pump attached, for Resident #5, was observed to be soiled with spatters of light brown dried substance and large areas of dark brown to black areas of crusted dried substance and missing paint.On 5/17/26 at 10:35 AM, during an initial tour of 2nd floor nursing care unit the surveyor observed the following in room [ROOM NUMBER]: A three foot long area of damaged baseboard cove base with a twelve inch long 2 inch high hole in the sheetrock, Torn wallpaper with a loose flap in the bathroom over the sink, 2 feet of missing cove base molding and damaged sheetrock in the bathroom to the right of the toilet and a six inch by twelve inch torn flap of wallpaper on the wall behind the window bed.On 5/18/26 at 10:10 AM the surveyor interviewed the Unit Manager (UM), a Registered Nurse (RN), the surveyor asked the UM about the observed utility pole and soiled equipment in room [ROOM NUMBER] pole and pump, soiled with dried brown substance splatters and crusty brown to black substance and missing paint on base. RN acknowledged the equipment should be kept clean and in good repair and the observed condition detracted from the facility's homelike environment. On 5/19/2026 at 12:30 PM, the surveyor interviewed the Maintenance Director (MD). The surveyor reviewed the findings of the damage to walls in room [ROOM NUMBER] and room [ROOM NUMBER]. The MD acknowledged the areas are a detraction of from the facility's homelike environmentOn 5/19/26 at 1:10 PM, the surveyor and the survey team met with Licensed Nursing home administrator and the Director of Nursing LNHA and DON to discuss concernsDON and LNHA acknowledged torn wallpaper, broken sheetrock, soiled pole and equipment observed in rooms [ROOM NUMBERS] detracted from facility's homelike environment. A review of the facility provided policy titled Homelike Environment reflected . Residents are provided with a safe, clean, comfortable and homelike environment. NJAC 8:39-31.2(e)

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 25 residents reviewed (Resident # 122).The deficient practice was evidenced by the following:The surveyor reviewed Resident # 122's records. The resident was discharged from the facility to the emergency room (ER) and according to the Discharge Return Not Anticipated MDS, an assessment tool used to facilitate the management of care, dated 2/19/26, the resident was assessed as having an unplanned discharge to home/community.A review of Resident # 122's progress notes dated 2/19/26 revealed the resident was discharged to the ER.During an interview on 5/19/26 at 1:13 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator.NJAC 8:39-11.2(e)1

Repeat Deficiency Based on observation, interview, and review of the pertinent medical record, it was determined that the facility failed to ensure that necessary care was provided to a dependent resident who required staff assistance for personal hygiene for 1 (one) of 4 sampled residents (Resident #13) reviewed for Activities of Daily Living (ADL). This deficient practice was evidenced by the following: On 5/17/26 at 10:01 AM, the surveyor observed Resident #13 lying in bed awake, able to answer the surveyor's inquiry. The surveyor observed that both residents' fingernails are long, and there is blackish debris underneath the fingernails. On 5/19/26 at 10:30 AM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) went to the resident's room to observe that Resident #13's fingernails were long, and there was blackish debris underneath the fingernails. The resident stated they want the fingernails to be trimmed by the staff. The RN/UM stated that the nurses usually trim the fingernails, and he will get the nurse's attention regarding the concern above. On 5/19/25 at 9:31 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #13, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #13 was admitted with diagnoses that included but were not limited to vascular dementia (caused by blocked blood flow to the brain, leading to memory problems), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) of 4/23/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated that the resident had severely impaired cognition. Further review of Q/MDS, as reflected in Section GG - Mobility, revealed that Resident #13 was dependent on staff assistance with the ADL. A review of the Care Plan (CP) report initiated on 5/16/23 that focuses on Resident #13 has an ADL self-care performance deficit related to balance problems, decreased mobility, and multiple medical conditions. Interventions included, but were not limited to, checking nail length and trimming and cleaning on bath day and as necessary. On 5/19/26 at 1:40 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing regarding the concern above, but did not provide further information. A review of the facility's policy title Activities of Daily Living (ADLs), Supporting, with a revised date on April 2025, revealed under Policy Statement: Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal hygiene. A review of the facility policy title Quality of Life - Dignity stated under Policy Interpretation and Implementation 3. a. Personal grooming - residents are groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). NJAC 8:39-27.2(g)

Repeat Deficiency Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 5 of the 22 residents (Resident #2, 15, 33, 67, and #92) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 5/17/26 at 9:54 AM, the surveyor observed Resident #2 in bed asleep. The surveyor observed that the resident's call device was wrapped around the resident's right side rail, almost touching the floor. On 5/18/26 at 8:58 AM, the surveyor observed that Resident #2 was awake, and the call device was wrapped around the resident's side rail, almost touching the floor. Resident #2 stated that they don't know where the call device is. The surveyor asked the resident if they were able to reach the call device. Resident #2 stated that they cannot reach it. On 5/18/26 9:04 AM, the surveyor, together with the Registered Nurse (RN), went to Resident #2, and the RN observed that the resident's call device was wrapped around the side rails and almost touching the floor. The RN stated that it should be within the resident's reach. On 5/18/26 at 10:25 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #2, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #2 was admitted with diagnoses that included but were not limited to Parkinson's disease with dyskinesia (involuntary, uncontrollable movement). A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) of 4/9/26, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had intact cognition. Further review of Q/MDS, as reflected in Section GG - Mobility, revealed that Resident #2 was dependent on staff assistance with the activities of daily living (ADL). A review of the Care Plan (CP) report initiated on 5/9/23 that focused on Resident #2 is at risk for falls related to balance problems, use of antipsychotic medication, and multiple medical conditions. Interventions included, but were not limited to, ensuring the resident's call light is within reach and encouraging the resident to use it for assistance as needed. 2. On 5/17/26 at 9:52 AM, the surveyor observed Resident #15 asleep in bed with O2 (oxygen) at 2 lpm (liters per minute) via nasal cannula (NC - a plastic prong attached to a tube, inserted into the nostrils through which oxygen flows) attached to the concentrator (a device that supplies oxygen). It was observed that the water in the plastic bottle attached to the oxygen concentrator was almost empty. The surveyor observed that the resident's call device was wrapped around the left side rail and almost touching the floor. On 5/18/26 at 10:25 AM, the surveyor reviewed the eMR of Resident #15, which revealed the following: A review of the AR reflected that Resident #15 was admitted with diagnoses that included but were not limited to hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke) affecting the left non-dominant side. A review of the recent Q/MDS of 4/29/26 indicated that the facility assessed the residents' cognitive status using a BIMS score of 0 out of 15, which indicated that the resident had severely impaired cognition. Further review of Q/MDS, as reflected in Section GG - Mobility, revealed that Resident #15 was dependent on staff assistance with the ADL. A review of the CP report initiated on 5/8/24 focused on Resident #15, who is at risk for falls related to gait/balance problems and wandering, and at risk of an ADL self-care performance deficit related to Dementia. Interventions included, but were not limited to, ensuring the resident's call light is within reach and encouraging the resident to use it for assistance as needed. 3. 05/18/2026 at 9:09 AM, the surveyor observed Resident #33 asleep in bed. The surveyor observed that the resident's call device was lying on the floor, located to the left side of the resident. On 5/18/26 9:10 AM, the surveyor, together with the RN/Unit Manager (RN/UM), went to the residents' room to observe the call device. The RN/UM picks up the call device from the floor and puts it within the residents' reach. On 5/18/26 at 10:40 AM, the surveyor reviewed the eMR of Resident #33, which revealed the following: A review of the AR reflected that Resident #33 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the annual Minimum Data Set (A/MDS) of 4/17/26 indicated that the facility assessed the residents' cognitive status using a BIMS score of 6 out of 15, which indicated that the resident had severely impaired cognition. Further review of A/MDS, as reflected in Section GG - Mobility, revealed that Resident #33 was dependent on staff assistance with the ADL. A review of the CP report initiated on 4/24/23 focused on Resident #33, who is at risk of falls related to balance problems. Interventions included, but were not limited to, ensuring the resident's call light is within reach and encouraging the resident to use it for assistance as needed. 4. On 5/17/26 at 9:52 AM, the surveyor observed Resident #67 in bed, awake, unable to answer the surveyor's inquiry. The surveyor observed that the resident's call device was wrapped around the side rails, almost touching the floor. On 5/18/26 at 8:54 AM, the surveyor reviewed the eMR of Resident #67, which revealed the following: A review of the AR reflected that Resident #67 was admitted with diagnoses that included but were not limited to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the significant change Minimum Data Set (SC/MDS) of 4/10/26 indicated that the facility assessed the residents' cognitive status using a BIMS score of 99 out of 15, which indicated that the resident had severely impaired cognition. Further review of SC/MDS, as reflected in Section GG - Mobility, revealed that Resident #67 was dependent on staff assistance with the ADL. A review of the CP report initiated on 4/24/23 focused on Resident #67, who is at risk for falls related to balance problems. Interventions included, but were not limited to, ensuring the resident's call light is within reach and encouraging the resident to use it for assistance as needed. 5. On 5/18/26 at 9:09 AM, the surveyor observed Resident #92 awake, sitting at the edge of the bed on the left side. The surveyor observed that Resident #92's call device was wrapped around the right-side rails, almost touching the floor. On 5/18/26 at 9:10 AM, the surveyor, together with the RN/UM, went to the resident's room. The RN/UM unwrapped the call device from the side rails and put it within the resident's reach. On 5/18/26 at 11:22 AM, the surveyor reviewed the eMR of Resident #92, which revealed the following: A review of the AR reflected that Resident #92 was admitted with diagnoses that included but were not limited to unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the A/MDS of 5/1/26 indicated that the facility assessed the residents' cognitive status using a BIMS score of 2 out of 15, which indicated that the resident had severely impaired cognition. Further review of A/MDS, as reflected in Section GG - Mobility, revealed that Resident #92 was dependent on staff assistance with the ADL. A review of the CP report initiated on 5/9/23 that focused on Resident #92 is at risk for falls related to gait/balance problems and wandering, and at risk of an ADL self-care performance deficit related to Dementia initiated on 4/6/23. Interventions included, but were not limited to, ensuring the resident's call light is within reach and encouraging the resident to use it for assistance as needed. On 5/18/26 at 9:00 AM, the surveyor interviewed a Certified Nursing Assistant (CNA), who stated that the call device should be within the resident's reach in case they need help from the staff. On 5/18/26 9:04 AM, the surveyor interviewed the RN, who stated that the call device should be placed within the resident's reach. On 5/18/26 at 9:06 AM, the surveyor, together with the RN/UM, went to all the residents' rooms (Resident #2, 15, 33, 67, & 92). The RN/UM stated that the call device should always be within the resident's reach. Reinforce the residents to use the call device if they need any assistance from the staff. On 5/19/26 at 1:40 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing regarding the concern above, but did not provide further information. A review of the facility's policy titled Answering the Call Light, with the revision date of September 2022, stated under General Guidelines 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. NJAC 8:39-31.8(c)9

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident with an indwelling catheter (inserted into the urethra (tube) and draining urine to the bag) had a privacy bag for dignity. This deficient practice was identified in 1 (one) of 3 residents (Resident #13) who were reviewed for urinary catheter use. This deficient practice was evidenced by the following: On 5/17/26 at 10:01 AM, the surveyor observed Resident #13 lying in bed awake, able to answer the surveyor's inquiry. The surveyor observed that the resident's indwelling catheter is on the right side of the bed, not in the privacy bag facing the door and the roommate. On the same day, the surveyor interviewed the Licensed Practical Nurse (LPN), who stated that the resident should have a privacy bag. On 5/19/26 at 8:57 AM, the surveyor observed that Resident #13's indwelling catheter has a privacy bag, but the privacy bag covers half of the drainage bag; the remaining half of the drainage is visible and exposing the urine. On 5/19/26 at 9:00 AM, the surveyor, together with the Registered Nurse/Unit Manager, went to the resident's room. The RN/UM stated that the indwelling catheter should cover the whole drainage bag, and the urine should not be exposed since the resident had a roommate. On 5/19/25 at 9:31 AM, the surveyor reviewed the hybrid (paper and electronic) medical record of Resident #13, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #13 was admitted with diagnoses that included but were not limited to other mechanical complications of the urinary catheter, subsequent encounter, and benign prostatic hyperplasia (BPH -prostate grows larger than normal) without lower urinary tract symptoms. A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) of 4/23/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated that the resident had severely impaired cognition. Further review of Q/MDS, as reflected in Section H - Appliances, revealed that Resident #13 had an indwelling catheter. A review of the Order Summary Report (OSR) revealed an active order for suprapubic catheter (a medical device used to drain urine from the bladder) care every shift as of 4/24/26. A review of the Care Plan (CP) report initiated on 5/16/23 that focuses on Resident #13 has a suprapubic catheter related to obstructive uropathy (urine cannot flow freely), and BPH. Interventions included, but were not limited to, a privacy bag at all times. On 5/19/26 at 1:40 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing regarding the concern above, but did not provide further information. A review of the facility policy title Quality of Life - Dignity stated under Policy Interpretation and Implementation 11. a. Helping the resident to keep urinary catheter bags covered. NJAC 8:39-33.2(c)5

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that residents received the necessary respiratory care and services, according to the standard of clinical practice, specifically documenting PRN (as needed) of oxygen (O2) use and provide enough water in the humidifying bottle according to the facility's policy and procedure for 1 (one) of 1 resident (Resident #15) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/17/2026 at 10:35 AM, the surveyor observed a nebulizer machine on the bedside table of the window bed in room [ROOM NUMBER].The tubing of the nebulizer machine tubing lying on floor behind the bedside table, the surveyor was unable to visualize the date on the tubing. On 5/17/2026 at 10:54 AM, the surveyor asked the Certified Nursing Assistant (CNA) to observe nebulizer tubing, the Unacknowledged in was trailing on the floor behind the bedside table. The CNA picked up tubing, and there was no nebulizer unit attached to the end of the tubing, The tubing was marked with a tape flap, which was dated 4/17/26. On 5/17/2026 10:58 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the care for Resident #28. The LPN acknowledged the tubing was dated 4/17/26. The LPN could not state what the facility policy was for changing nebulizer tubing. On 5/18/2026 at 11:05 AM, the surveyor interviewed the Director of Nursing (DON). The DON acknowledged tubing and nebulizers are changed on a once a week schedule and this tubing was three weeks overdo for change. A review of the facility provided policy titled Administering Medications through a Small Volume Handheld Nebulizer reflects . change equipment and tubing every seven days according to protocol. 2. On 5/17/26 at 9:52 AM, the surveyor observed Resident #15 asleep in bed with O2 at 2 lpm (liters per minute) via nasal cannula (NC, a plastic prong attached to a tube, inserted into the nostrils through which oxygen flows) attached to the concentrator (a device that supplies oxygen). It was observed that the humidifying bottle attached to the O2 concentrator had less than 10 ml (milliliter) of water. On 5/18/26 at 8:58 AM, the surveyor observed that Resident #15 was asleep with O2 at 2 lpm via NC, and the water from the humidifying bottles attached to the concentrator was almost empty. On the same day at 9:04 AM, the surveyor interviewed the Certified Nurse Assistant (CNA), who was inside the resident's room at that time. CNA stated that Resident #15 was using O2 daily. The CNA added that the nurses are the ones changing the humidifying bottle. On 5/18/26 at 9:08 AM, the surveyor, together with the Registered Nurse/Unit Manager (RN/UM), showed the RN/UM that the water humidifier attached to the resident's concentrator had less than 5 ml of water. On the same day at 12:20 PM, the surveyor observed that the O2 humidifier water was almost empty. The RN/UM stated that the nurse will change the humidifying bottle right away. On 5/18/26 at 10:25 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #15, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #15 was admitted with diagnoses that included but were not limited to hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke) affecting the left non-dominant side. A review of the recent quarterly Minimum Data Set (Q/MDS), (an assessment tool used to facilitate the management of care) with an assessment reference date (ARD) (the last day of the observation period) of 4/29/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated that the resident had an severely impaired cognition. A review of the Order Summary Record (OSR), the physician ordered 2 lpm oxygen via NC for SOB (shortness of breath) PRN (as needed) with the start date of 3/4/25. A review of the electronic Medication Administration Record (eMAR) schedule for May 2026 revealed that there is no documentation of May 17 and 18, 2026, that Resident #15 received an O2. A review of the Care Plan (CP) report initiated on 10/27/25, focused on Resident #15, who is on [Name Redacted] hospice care. Interventions included, but were not limited to, providing O2 as needed. On 5/18/26 at 9:10 AM, the surveyor interviewed the RN who is assigned to the resident. The RN stated that she should document that the resident received the PRN O2 used and assess the resident to determine if the treatment was effective. There is no added information provided on where the documentation was located. On 5/19/26 at 1:13 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing to discuss the above concern; no additional information was provided. A review of the facility policy titled Oxygen Administration revealed under Steps in the Procedure 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. NJ 8:39-25.2(c)3

Based on observation, interview, and record review, it was determined that the facility failed to: a) consistently ensure an as needed (PRN) pain medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing for (one) 1 of four (4) residents (Resident #18), administered by one (1) of four (4) nurses, observed during medication administration; and b) provide pharmaceutical services in accordance with professional standards to ensure appropriate transcription and administration of a medication for 1 of 22 residents (Resident #125) reviewed.This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/18/26 at 9:18 AM, the surveyor observed Licensed Practical Nurse (LPN) assigned to the middle cart of the first-floor, prepared medications for Resident #18. The physician's orders (PO) included Acetaminophen (APAP) tablets 325 milligrams, give 2 tablets by mouth every 4 hours PRN for mild pain (scale of 1 to 3), not to exceed 3 grams from all sources within 24 hours. The order started on 4/10/26. At 9:36 AM, the surveyor observed the LPN complete a third check of the medications against the electronic Medication Administration Record (eMAR). The LPN confirmed she had 8 pills in the medication cup, was ready to administer, and did not include the APAP. The LPN stated that she would take Resident #18's blood pressure prior to the administration of their blood pressure medication Losartan and their inhalers. At 9:40 AM, the surveyor observed the LPN administer 8 pills to Resident # 18 who stated they experienced pain and requested for their APAP. The surveyor observed the LPN acknowledged Resident #18's request and took Resident 18's blood pressure on the left arm then exited the resident's room. At 9:49 AM, the surveyor observed the LPN prepare Resident #18's Losartan, and the inhalers. At 9:57 AM, the LPN confirmed with the surveyor that she was ready to administer Resident #18's Losartan, and inhalers. The prepared medications did not include the APAP. At 9:58 AM, the surveyor observed the LPN enter Resident #18's room. At 9:59 AM, the surveyor observed the LPN administered Resident #18's Losartan and their oral inhaler. At that time, the Resident refused their nasal inhaler and requested for their APAP again. The surveyor observed the LPN exit the resident's room. At 10:03 AM, the surveyor observed the LPN signed the eMAR for the administered medications that did not include the APAP. At 10:05, the surveyor observed the LPN opened the eMAR for Resident #18's roommate. At 10:06 AM, the surveyor observed the LPN enter the room, addressed Resident 18's roommate and asked if they were ready for the administration of their medication. At 10:08 AM, the surveyor and LPN reviewed Resident #18's eMAR together. At that time, the surveyor asked the LPN why she did not administer Resident #18's PRN APAP when the resident had requested for their pain medication. At that time, the LPN confirmed and acknowledged that she had forgotten to administer the medication. The LPN stated she would inform the prescriber and supervisors of the concern. The surveyor reviewed the medical record for Resident #18. According to the admission Record, (face sheet) an admission summary, Resident #18 was admitted to the facility with diagnoses which included but were not limited to; wedge compression fracture of third lumbar vertebra (a type of spinal injury) and sciatica (nerve pain from an injury or irritation of the sciatic nerve). A review of the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 2/27/26, reflected a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident #18 was cognitively intact. Further review of the MDS reflected that a pain assessment interview should be conducted. A review of the Care Plan (CP) included a focus on the potential and/or alteration on pain discomfort. The interventions included, to notify physician of interventions were unsuccessful or if current complaint is a significant change from resident's past experience of pain. The focus and interventions were initiated on 9/14/25. On 5/19/26 at 1:13 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern that occurred during the medication pass observation wherein the LPN had omitted the PRN APAP medication that Resident #18 had requested. On 5/20/26 at 11:03 AM, during a meeting with the survey team, and the LNHA, the DON confirmed and acknowledged that the PRN pain medication should have been offered when the resident had requested the medication. No further information was provided. A review of the facility provided policy, titled Administering Medications, dated/revised 4/2019 included that medications are administered in accordance with prescriber orders, including any required time frame. 2. On 5/20/26 at 12:30 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #125. The resident no longer resided at the facility. The admission Record revealed Resident #125 had diagnoses that included but were not limited to polyosteoarthritis (chronic degenerative joint disease in which the tissues in the joint wears down in five or more joints at the same time). A physician's order dated 12/1/25 indicated to give Acetaminophen 325 milligram(mg) tablet, 2 tablets by mouth three times a day for pain management. In addition, the order entry indicated 3 tabs =975 mg. A review of Medication Administration Record (MAR) and progress notes revealed no documentation regarding clarification of the order dosage. On 5/20/26 at 1:49 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the concern regarding Resident #125's Tylenol order 2 tablets versus 3 tablets was not identified and clarified. On 5/21/26 at 10 AM, the LNHA and the DON met with the survey team. The DON stated in-service education was provided to the staff regarding medication orders including transcription and medication administration. There was no additional information provided by the facility's management. A review of the undated, facility provided policy titled, Administering Medications, under Policy revealed: Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation of the policy revealed: 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. NJAC 8:39-29.2(d), 2

Based on observation, interview, and record review it was determined the facility failed to: a) administer medications with parameters in accordance with a physician's order and standards of practice for 1 of 2 residents (Resident #96) reviewed for dialysis services.The deficient practice is evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.2. On 5/18/26 at 9:48 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #96.The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to end stage renal [kidney] disease, dependence on renal dialysis, hypertension (high blood pressure) and atrial fibrillation (an irregular, often rapid heart rate).A comprehensive Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, dated 5/2/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #96 scored 11 out of 15, which indicated the resident had moderate cognitive impairment.A physician's order dated 5/6/26 indicated to give midodrine (a medication to help treat low blood pressure) 5 mg one tablet by mouth three times a day; and to hold for SBP greater than 130. The medication was scheduled to be given to Resident #96 at 9:30 AM, 1:30 PM, and 5:30 PM.A physician's order dated 5/8/26 indicated to give metoprolol tartrate 25 milligram (mg) one tablet by mouth two times a day for atrial fibrillation; and to hold for systolic blood pressure (SBP; the top number in a blood pressure reading which measures the maximum pressure in your arteries when the heart beats) less than 90 and heart rate (HR) less than 50. The medication was scheduled to be given to Resident #96 at 12 PM and 6 PM.A review of the May 2026 Medication Administration Record (MAR) revealed:-There was no documentation of the BP results at the time of the midodrine medication's administration to the resident.-There was no documentation of the blood pressure (BP) and HR results at the time of the metoprolol tartrate medication's administration to the resident.A review of the Weights and Vitals section of the EMR revealed no consistent documentation of Resident #96's BP and HR for each metoprolol tartrate and midodrine administration to reflect that the medications were administered as per the physician's orders.A review of progress notes revealed no additional documentation of Resident #96's BP and HR result for each medication's administration.On 5/7/26 at 1:39 PM, the surveyor interviewed a Licensed Practical Nurse (LPN) about medications with parameters. The LPN stated at the time of the medication's administration the resident's BP and HR were checked; the results were documented in the MAR; and the medication was administered according to the physician's order.The LPN with the surveyor reviewed the midodrine and metoprolol tartrate orders for Resident #96. The LPN confirmed the medication orders included parameters. Upon further review the LPN explained the orders did not include the supplementary documentation section for the nurses to document the BP and/or HR results. The LPN stated the nurses could document under the Vital Signs (VS; measurement of BP, HR, temperature and respiratory rate) section of the EMR if there was no supplementary documentation to note a resident's BP and HR at the time of a medication's administration. On 5/18/26 at 11:05 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated the nurses documented the BP and HR results in the supplementary documentation section of the medication order in the MAR. The RN/UM with the surveyor reviewed Resident #96's metoprolol tartrate and midodrine order MAR entries. The RN/UM confirmed there was supplementary documentation section in the MAR and proceeded to check the VS section of the EMR. The RN/UM acknowledged there was no consistent documentation of the BP and HR results at the time of each medication administration. The RN/UM stated it would be expected for the nurse to document the results in the EMR and to inform the RN/UM if an order needed to be clarified. On 5/19/26 at 1:12 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concerns. On 5/20/26 at 11:02 AM, the LNHA and the DON met with survey team. The DON stated that supplementary documentation sections for the identified orders were added, and education was provided to the staff. There was no additional information provided by the facility. The surveyor reviewed the undated facility provided policy titled, Administering Medications which revealed under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation of the policy revealed:4. Medications are administered in accordance with prescriber orders, including any time frame.11. The following information is checked/verified for each resident prior to administering medications: VS, if necessary.The policy did not further address medication with parameters and documentation of VS at medication administration.NJAC 8:39-11.2 (b); 29.2(d)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a prescription medication was labeled, sterile treatment supply and IV treatment were stored and discarded in accordance with currently accepted professional principles and facility's policy. This deficient practice was identified for 1 of 3 medication carts inspected and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.On 5/19/25 at 10:02 AM, the surveyor inspected the First-floor South treatment cart, in the presence of the Licensed Practical Nurse (LPN). During the inspection the surveyor and the LPN observed the following:-unlabeled, opened, dated 5/18/26, Silver Sulfadiazine cream (SSD (Silvadene; a prescription topical antibacterial cream used for the prevention and treatment of wound sepsis for those with second- and third-degree burn).-opened sterile [brand redacted] gauze sponge (used for protective coverage, absorbent for drainage from wounds, packed into deeper wound, for wound cleansing or to wipe away debris.-intravenous (IV) supply for Unsampled Resident #102 (central line and midline kit, are all the necessary, sterile, and single-use supplies used to maintain or insert a peripherally inserted central catheter; essential items to ensure cleanliness and prevention of infections).At 10:13 AM, the surveyor and the LPN reviewed the items found in the treatment cart. At that time, the LPN confirmed and acknowledged that the SSD should have had a pharmacy label with the resident's name to reflect who the medication belonged to and applied to the correct resident. The LPN also stated that it should have been stored in a plastic bag to prevent cross contamination of house stocked creams.At that time, the LPN stated that the sterile gauze once opened were no longer sterile, was for one time use, should have been discarded and not stocked in the treatment cart for further use.At that time, the LPN confirmed that the IV supply should have been stored with the IV cart. The surveyor and the LPN reviewed the electronic Medical Record (eMR) together which reflected that the midline was discontinued on 5/3/26. At that time, the LPN stated it should have been removed from active inventory. The LPN informed the surveyor that she would remove all the items, discard the items and inform her supervisors.On 5/19/26 at 1:13 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concern with the unlabeled prescription antimicrobial SSD cream, commingled with over-the-counter treatment, the opened sterile gauze, the IV supply in the treatment cart that was for Unsampled Resident #102 and was discontinued on 5/3/26.On 5/20/26 at 11:03 AM, during a meeting with the survey team, and the LNHA, the DON acknowledged and confirmed that the SSD cream should have been labeled, the gauze and the IV supply should have been discarded. The DON also stated that education regarding proper storage was provided to staff.No further information was provided.A review of the facility provided policy, titled Storage of Medication, dated/revised 11/2020 included that the facility stored all drugs and biologicals in a safe, secure, and orderly manner. Drug containers that had missing, incomplete, improper, or incorrect labels were returned to the pharmacy for proper labeling before storing. Discontinued outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. NJAC 19.8(c)(g),29.4(a)(h), 29.7(b)

Complaint #2713977Based on observation, interview, and record review, it was determined that the facility failed to maintain accurately documented, complete and readily accessible medical records. This deficient practice was identified for 1 of 22 residents (Resident #125) reviewed.On 5/18/26 at 9:09AM, the surveyor reviewed the electronic medical record (EMR) of Resident #125. The resident no longer resided at the facility.The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to urinary tract infection, acute on chronic congestive heart failure (a condition where the heart muscle is too weak or stiff to pump blood efficiently), and polyosteoarthritis (chronic degenerative joint disease in which the tissues in the joint wears down in five or more joints at the same time).A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 12/1/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #125 scored 15 out of 15, which indicated the resident was cognitively intact. Resident #125 was coded as dependent on assistance for toileting hygiene; required substantial/maximum assistance with personal hygiene and transferring; and was frequently incontinent of bladder. A review of a physician progress note, by the primary medical doctor (PMD) dated 1/9/26 at 4:06 PM documented Resident #125 had a right shin hematoma and was unaware if they hit it on something; the area was tender but now it was better. In addition, the note documented the resident was last seen by the PMD two days ago, marked, now looks less bluish, smaller, instructed for leg elevation, ice pack, avoid physical contact to the site. The PMD documented they discussed with Resident #125's [relation to the resident] at the bedside. A review of progress notes for January 2026 revealed no nursing documentation regarding the resident sustaining a right shin hematoma or notification to the PMD or emergency contact (EC).On 5/18/26 at 1:00 PM, the surveyor requested from the Director of Nursing (DON), any investigations for Resident #125 for January 2026. The DON stated they were not the DON in January 2026 and would review facility records to provide the requested information. On 5/19/26 at 9:24 AM, the surveyor reviewed the facility provided investigation dated 1/6/26, which indicated during rounds the (former) DON was notified the resident was found with a right shin hematoma. The documents included a summary of the investigation including written staff statements; an assessment of the resident's status; a review of potential causes and risk factors; and a conclusion. The investigation under notification revealed notified resident representative written as [relation to the resident]. There was no documented name of the EC, date or time of notification.There was no documentation found in the resident's medical record to indicate notification to the resident's EC regarding their right shin hematoma in January 2026.On 5/19/26 at 10:48 AM, the surveyor interviewed a Registered Nurse (RN) who cared for Resident #125. The RN stated they recalled the resident had a discoloration, like a blood filled blister but could not recall more details of what had occurred during that time. The RN acknowledged that if there was a change in a resident's status, their EC/resident representative should be notified, and it should be documented by the nurse.On 5/19/26 at 1:12 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the concern there was no documentation of notification to Resident #125's EC regarding the right shin hematoma and there was no nursing documentation related to the right shin hematoma.The surveyor additionally requested for review a copy of December 2025 and January 2026 Resident #125's Tasks documentation report, a record where the CNA's document and sign for care provided to the residents.On 5/20/26 at 11:02 AM, the LNHA and the DON met with the survey team. The DON stated on the investigation provided documented notification to Resident #125's EC. The DON with the surveyor reviewed the investigation document which indicated the [relation to the resident] was notified. The DON confirmed there was no name of the person notified, no date, and no time of the notification.The surveyor asked the DON if the investigation was considered part of Resident #125's medical record. The DON replied that it was not part of the resident's medical record. The surveyor informed the DON that there was no documentation in the EMR by the nurses about the hematoma being identified or notification to an emergency contact. There was no verbal response at this time.On 5/20/26 at 12:20 PM, the surveyor interviewed over the phone an RN supervisor who worked at the facility in January 2026. The RN supervisor stated that if an injury of unknown origin, such as a discoloration or hematoma identified, part of the reporting and investigating process would be to notify the resident's EC/resident representative. The RN supervisor acknowledged that notification to the EC should be documented in a progress note in the EMR. The RN supervisor stated that even if a resident was cognitively intact, the EC would be made aware of a resident's status change or condition.On 5/21/26 at 9:13 AM, the surveyor reviewed the facility provided December 2025 (CNA tasks) Documentation Survey Report which revealed unsigned and blank entries. The entries included but were not limited to:-The entry for bladder elimination had 37 of 93 shift entries which were blank and unsigned.-The entry for bowel elimination had 37 of 93 shift entries which were blank and unsigned. -The entry for toileting hygiene had 37 of 93 shift entries which were blank and unsigned. The surveyor reviewed the facility provided January 2026 (CNA tasks) Documentation Survey Report which revealed unsigned and blank entries. The entries included but were not limited to:-The entry for bladder elimination had 15 of 29 shift entries which were left blank and unsigned.- The entry for bowel elimination had 15 of 29 shift entries which were left blank and unsigned.-The entry for toileting hygiene had 15 of 29 shift entries which were left blank and unsigned.On 5/21/26 at 1:24 PM, the surveyor informed the LNHA of the concerns of unsigned and blank entries for Resident #125's December 2025 and January 2026 documentation survey report. There was no additional information provided by the facility. The surveyor reviewed the undated facility provided policy titled Change in a Resident's Condition or Status which revealed under Policy Interpretation and Implementation:4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident, including injuries of an unknown source.The policy did not further address documentation of the notification about a resident's change in condition or status.The surveyor reviewed the facility provided policy titled Activities of Daily Living, Supporting dated April 2025 which did not address documentation of ADL or incontinence care.NJAC 8:39-27.1 (a) ;35.2

Complaint #: 2650138 Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 10/27/2025 and 10/29/2025, it was determined that the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering and wore a wander guard, who eloped from the facility on 10/19/2025. The deficient practice was identified for 1 of 4 residents reviewed for elopement (Resident #2). On 10/19/2025 at approximately 2:30 PM, the Licensed Practical Nurse (LPN #1) noticed Resident #2 was not in their room, and she could not find the resident. LPN #1 initiated a search, and a visiting family (VF #1) of another resident stated that they observed a [gender redacted] outside wearing [sleepwear], and LPN #1 and other staff immediately went outside to search for Resident #2. While outside the facility, VF #2, who was at the facility's gazebo next to a winding downhill paved foot path, directed the staff to search down towards the highway to the right. LPN #1 stated during an interview with the surveyor on 10/27/2025, that the resident was found on the sidewalk approximately one block away in the company of two women who stated the resident looked out of place wearing [sleepwear]. The resident was returned to the facility immediately at approximately 2:45 PM, assessed with no injury, and placed on one-to-one (1:1) supervision. The facility's failure to provide adequate supervision to a severely cognitively impaired resident who was at risk for elopement and eloped, placed Resident #2 as well as all residents, at risk for elopement. This posed a likelihood of serious harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/19/2025 at approximately 2:30 PM, after Resident #2 was last seen by staff in the facility. The facility Administration was notified of the IJ on 10/27/2025 at 5:15 PM. The facility submitted an acceptable Removal Plan (RP) on 10/28/2025 at 12:30 PM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 10/29/2025. The facility further failed to b.) ensure all staff were able to identify a resident (Resident #4) who was a wanderer to provide adequate supervision to prevent elopement. This deficient practice was identified for 1 of 4 residents reviewed for elopement (Resident #4). The evidence was as follows:Part A A review of the facility provided Elopement Policy and Procedure dated 6/1/2025, included It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practicable . Procedure .9 d. In the event that there is any doorway equipment malfunction, supervision of that area will be provided unless there is only one resident at risk in which case the assigned staff member will provide 1:1 or other frequency or observation to the resident as determined by the physician or supervisor . A review of the facility provided Wanderguard Use Policy dated 5/1/2025, included the facility will provide safe, resident-centered, and regulatory-compliant guidance for the electronic wander management systems (e.g. Wanderguard) to prevent elopement. Maintenance, Testing, and Security 1. Maintenance staff or vendor shall perform proof scheduled preventative maintenance and immediate repairs . 2. Test system functionality per facility schedule and after any power outage, building work, or reported malfunction. A review of the Facility Reportable Event (FRE) dated 10/19/2025, that the facility submitted to the New Jersey Department of Health (NJDOH), revealed that on 10/19/2025, at approximately 2:40 PM, Resident #2 was noted not to be in their room after the resident was last seen at the nurse's station at approximately 2:30 PM. An elopement protocol was initiated, and the search was initiated inside the facility. While the search was happening, a visiting family member (VF #1) [of another resident] stated that she saw a [gender redacted] walking outside the facility. The facility staff prompted a prioritized search outside of the facility and found Resident #2 in the company of a person who noticed the resident outside the facility. At approximately 2:45 PM, the resident was brought back to the facility, and their wanderguard was noted to be fully functional. A skin assessment was completed, and no visible injuries were noted. At 3:00 PM, Resident #2's doctor and family were notified, and the resident was placed on one-to-one (1:1) supervision. A review of LPN #1's statement included that she saw Resident #2 at approximately 2:30 PM, ambulating by the nurse's station, and at approximately 2:40 PM, she checked, and Resident #2 was not in their room. LPN #1 stated that she paged all staff to the First-Floor and all staff arrived. LPN #1 further stated that she was informed there was a [gender redacted] walking outside. LPN #1 stated that she and the staff ran outside and found the resident outside of the facility and brought the resident back into the facility. LPN #1 noted the resident's wanderguard alarmed when the resident re-entered the building. During an interview with the Licensed Nursing Home Administrator (LNHA) on 10/27/25 at 10:36 AM, he stated that there were no cameras, and that he was not sure of the exact route the resident took, but he surmised that Resident #2 went down the hallway on the First-Floor nursing unit, through the unzipped plastic construction dust barrier, then through the unlocked double doors into the dining and therapy area that were closed for renovations, and out an unsecured back door. The LNHA stated that he surmised that was the route of exit since all other exit doors' wanderguard systems were functioning and the receptionist at the main entrance denied seeing Resident #2 exit or hearing the wanderguard system alarm. The LNHA stated the wanderguard pin pad at the back door was not operational at that time, and the lights on the wanderguard pin pad were off when Resident #2 exited. At that time, the LNHA guided the surveyors through the now zipped plastic dust barrier, through the double doors, into the construction area and out the back door. While outside, the LNHA took the surveyors to the right on a path that led to a courtyard with a gate that accessed the facility's front driveway. The LNHA stated that he thought Resident #2 traveled that path, and the facility had now secured that gate with a chain lock. When the LNHA was bringing the surveyors back into the building from the back exit door, the surveyor observed an opening approximately two-feet wide from the building to [NAME]. The LNHA stated that since the ground beneath the opening was uneven rocks, he did not assume the resident went that way. At that time, the surveyors and the LNHA went through the opening, which led to the back of the building and around the dumpster/loading area, to the front parking lot area. In that area, the surveyor observed a gazebo on top of a hill with a winding paved foot path to the right, that led the surveyors down a wooded hill area that had a fallen tree trunk blocking the path approximately half-way down to the sidewalk at the roadside. The LNHA stated the tree trunk had fallen that past weekend and was not yet cleared. Towards the end of the path was a pond, and the path ended on a sidewalk adjacent to a four-lane highway. The surveyor asked the LNHA how far the facility was to the sidewalk, and the LNHA stated approximately the length of a football field. During an interview with LPN #2, who identified himself as the unit manager, on 10/27/2025 at 11:02 AM, he stated that on 10/15/2025, he observed Resident #2 for a while wandering in and out of the residents' rooms, and up and down the hallways aimlessly. LPN #2 stated that he assessed Resident #2 as an elopement risk and placed a wanderguard on the resident. During an interview with LPN #1 on 10/27/2025 at 11:19 AM, she stated that at approximately 2:30 PM, the resident was walking around back and forth by the nurse's station. LPN #1 stated that the assigned nurse (LPN #3) gave her the keys to LPN #3's medication cart because LPN #3 was going on break. LPN #1 stated that Resident #2 complained they had a headache, and she was going to give the resident a Tylenol. LPN #1 stated when she went to Resident #2's room, the resident was not there. LPN #1 stated that she checked the hallway and did not find the resident, so she paged all staff to come to the First-Floor nursing unit. LPN #1 stated that as staff came, VF #1 of a different resident told her that they just saw a [gender redacted] outside wearing [sleepwear]. LPN #1 stated that she, along with the other staff members, ran outside and ran for about 1-2 minutes, and there was VF #2 sitting by the gazebo on the facility's property that told them that the resident went that way (pointing to the right). LPN #1 stated that they found the resident a block down on the right standing on the sidewalk with two women who stated that the resident looked out of place standing there wearing [sleepwear]. LPN #1 stated that resident was brought back inside the building and the assigned nurse (LPN #3) assessed the resident and there were no injuries. During an interview with the Director of Maintenance (DM) on 10/27/2025 at 11:54 AM, he stated that there was a malfunction on the wanderguard pin pad by the exit door in the therapy room construction area. The DM stated that the wanderguard pin pad usually had a red and green light on, and when he got there, no lights were lit, and the power for the magnet lock was disconnected. The DM stated that he extended the wire and tightened the screws to fix the pin pad connection. The DM further stated that when Resident #2 pushed on the door, the alarm should have alarmed to notify the nurses at the nurse's station that someone with a wanderguard exited. The DM stated that he checked all the exit doors and elevators daily on Monday through Friday, and the Manager on Duty (MOD) checked them on Saturdays and Sundays. The DM stated on the day of the elopement, the MOD had not yet checked the alarms, so he had checked the alarms that day when the DM arrived after the elopement. During interview with the Housekeeping Director (HD) on 10/27/2025 at 2:11 PM, he confirmed he was the MOD on 10/19/2025. The HD stated that on 10/19/2025, he was busy that day and did not get to check the door prior to Resident #2 eloping. The surveyor reviewed the medical record for Resident #2. According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnosis which included but were not limited to; dementia, epilepsy, and history of falling. According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/15/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #2's Elopement Evaluation dated 10/15/2025 at 2:01 PM, included that Resident #2 wandered, wandered aimlessly or non-goal directed, and wandering behavior likely to effect the safety or well-being of self/others. Resident #2 scored 5, and a score of 1 or higher indicated a risk of elopement on the assessment. A review of Resident #2's Care Plan (CP) with an initiated date of 10/15/2025, included that Resident #2 had the potential risk for elopement related to (r/t) wandering and potential for injury. The CP also indicated that Resident #2 had a wanderguard placed on the resident's left wrist and that the resident should be engaged in purposeful activity. A review of the Progress Note (PN) dated 10/20/2025 at 12:00 PM, with an effective date of 10/19/2025 at 4:00 PM, written by LPN #3, included, Skin warm and dry, skin color within normal limit (WNL) and turgor is normal. The resident does not have an external device. 1. Foot evaluation completed. There was no documentation of Resident #2's elopement. A review of the PN dated late entry on 10/21/2025 at 12:21 PM, with an effective date of 10/15/2025 at 3:13 PM, written by LPN #2, included, Resident was noted to be wandering in other residents' rooms disturbing them, going behind and pulled curtain. Resident redirected out of the room. Resident then proceeded to go to another resident's room and try to open the bathroom door. Resident noted to have increased wandering. Elopement risk reassessed and wanderguard applied. On 10/29/2025 at 12:56 PM, the surveyor attempted to conduct a telephone interview with LPN #3, who did not answer. LPN #3 did not return the surveyor's telephone call, and she was not present during the survey for an interview. An acceptable Removal Plan (RP) was received on 12/28/2025 at 12:29 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: on 10/19/2025, Resident #2 was located and brought back in building, wanderguard was functional, the resident was assessed with no injuries and placed on 1:1 supervision. On 10/19/2025, the DM checked doors, elevators, and wanderguard systems to confirm functional, and identified a possible exit in a non-residential area and secured with alarm. On 10/19/2025, the facility began an investigation, and wanderguard devices were tested. On 10/27/2025, the Neighborhood Watch list with residents' photos was updated, an elopement drill was conducted, Certified Nursing Aide (CNA) assignments were updated to include identification of residents at risk for elopement, and all staff were educated on elopement process. The surveyor verified the implementation of the Removal Plan on-site on 10/29/2025, and determined the immediacy was removed as of 10/29/2025 at 2:00 PM. Part B On 10/27/2025 at 9:57 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who identified herself as the unit manager for the Second-Floor nursing unit. The ADON stated that the facility used a Neighborhood Watch list that identified who was at risk for elopement that was hung at the nurse's station. At that time, the ADON provided a list from the nurse's station that included three residents (Resident #1, Resident #2, and Resident #3), who were identified as at risk for elopement. On 10/27/2025 at 10:30 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #2), who identified himself as the unit manager. LPN #2 stated that there were no residents residing on the First-Floor nursing unit who were an elopement risk. At that time, the surveyor observed a Neighborhood Watch list hanging at the nurse's station that included four residents (Resident #1, Resident #2, Resident #3, and Resident #4) with their room numbers. On 10/27/2025 at 10:55 AM, the surveyor observed Resident #4's name was still listed on the name plate outside their assigned room. On 10/27/2025 at 11:07 AM, the surveyor requested from the Director of Nursing (DON) to test the three residents' wanderguard bracelets for function. At that time, the surveyor observed the DON select Resident #1, Resident #2, and Resident #3, and he tested their wanderguard, and they all functioned. The DON did not ask which three residents and did not mention any additional residents who may have wandergaurds including Resident #4. The surveyor reviewed the medical record for Resident #4. A review of the admission Record face sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; syncope and collapse (falling due to fainting), unspecified fall, contusion (bruise) to scalp, and hypertension (high blood pressure). A review of the Progress Notes included a Social Services note dated 10/23/2025 at 11:43 AM, that the resident was admitted to the facility on [DATE redacted] from home for subacute rehabilitation. The resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, [which indicated a severely impaired cognition]. The resident was verbal and able to express some of their needs to staff. An additional review of the Progress Notes included a Nurses Progress Note dated 10/23/2025 at 10:29 PM, that the resident was noted with increased wandering and attempting to open doors. A wanderguard was applied and the family was notified who was aware of wandering behaviors and agreed to a room change. A review of the Order Listing Report included a physician's order dated 10/23/2025, for a wanderguard to left ankle, check placement every shift. A review of the Care Plan (CP) included a focus area dated 10/23/2025, that the resident was an elopement risk with regards to wandering. Interventions included to engage resident in purposeful activity; identify wandering/elopement de-escalation behaviors; provide care in a calm and reassuring manner; provide reorientation to surroundings, environment; and resident to have wanderguard to left ankle. On 10/27/2025 at 12:36 PM, the surveyor observed the Neighborhood Watch sign at the Second-Floor nursing unit now included four residents (Resident #1, Resident #2, Resident #3, and Resident #4). On 10/27/2025 at 12:37 PM, the surveyor interviewed Resident #4's Certified Nursing Aide (CNA #1), who stated that Resident #4 was new to the unit and had no behavioral issues. CNA #1 stated that the resident self-propelled in a wheelchair, and that he checked on the resident when he checked on Resident #4's roommate who was a wanderer. CNA #1 stated that Resident #4 was not a wanderer and did not wear a wanderguard. CNA #1 stated that the facility had three residents who wandered and named (Resident #1, Resident #2, and Resident #3). When asked how he was informed who was a wanderer, CNA #1 stated that staff informed him. On 10/27/2025 at 12:52 PM, the surveyor interviewed LPN #4, who cared for Resident #4. LPN #4 confirmed Resident #4 self-propelled in their wheelchair and wore a wanderguard bracelet on their left ankle that she checked every shift for placement. At that time, the surveyor observed Resident #4 lying bed. LPN #4 showed the surveyor the resident's wanderguard bracelet that was on their left ankle. On 10/27/2025 at 1:00 PM, the surveyor re-interviewed the ADON, who stated that the resident was moved up to the unit during the evening shift on Friday (10/24/2025, medical record indicated the resident was moved on 10/23/2025). The ADON confirmed it would be important that both the staff and she were aware of all the residents who were wanderers. The ADON stated that during morning huddle, staff were made aware of who the residents that wandered were. The ADON further stated that there was a new Neighborhood Watch sign that included all four residents at the nurse's station, but it was not hung earlier. At that time, the surveyor requested the ADON inform the DON that they wanted to test the function of Resident #4's wanderguard bracelet. On 10/27/2025 at 1:19 PM, the DON tested Resident #4's wanderguard bracelet for function. At that time, the surveyor asked the DON why he did not test Resident #4's wanderguard earlier, and the DON stated because the surveyor only requested three residents' wanderguard bracelets tested. The surveyor stated that they did not specify which three residents so how did the DON determine which residents the surveyor wanted tested. The DON stated that it slipped my mind when asked for three, and I forgot there was a fourth. When the surveyor questioned the DON that he forgot, the DON sated he did not forget, I misremembered. The DON stated that there were originally three residents who wandered, and Resident #4 was recently added. On 10/27/2025 at 5:04 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, and the [NAME] President of Clinical (VPC), and the DON stated that the nurses identified someone at risk for elopement and placed a wanderguard bracelet on them. The DON continued that the Receptionist updated the facility's Neighborhood Watch list, and during morning meeting with the department heads, they were made aware of any changes. At that time, the surveyor informed the facility about their observation of the Neighborhood Watch list with three residents only and that staff were unaware Resident #4 was at risk for elopement. NJAC 8:39-27.1 (a)

Complaint # 265013 Based on interviews and review of other pertinent facility documents on 10/27/2025 and 10/29/2025, it was determined that the facility failed to ensure the nursing staff documented a resident's (Resident #2) elopement from the facility in the resident's medical record in accordance with professional standards of practice. This deficient practice was identified for 1 of 4 residents reviewed for elopement (Resident #2). 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 response 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 restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized Physician or dentist. Reference: 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 otherwise legally authorized Physician or Dentist. The evidence was as follows: A review of the Facility Reportable Event (FRE) dated 10/19/2025, that the facility submitted to the New Jersey Department of Health (NJDOH), revealed that on 10/19/2025, at approximately 2:40 PM, Resident #2 was noted not to be in their room after the resident was last seen at the nurse's station at approximately 2:30 PM. An elopement protocol was initiated, and the search was initiated inside the facility. While the search was happening, a visiting family member (VF #1) [of another resident] stated that she saw a [gender redacted] walking outside the facility. The facility staff prompted a prioritized search outside of the facility and found Resident #2 in the company of a person who noticed the resident outside the facility. At approximately 2:45 PM, the resident was brought back to the facility, and their wander guard was noted to be fully functional. A skin assessment was completed, and no visible injuries were noted. At 3:00 PM, Resident #2's doctor and family were notified, and the resident was placed on one-to-one (1:1) supervision. According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to; dementia, epilepsy, and history of falling. According to the comprehensive Minimum Data Set (MDS), an assessment tool dated 10/15/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident's cognition was severely impaired. A review of Resident #2's Care Plan (CP) with an initiated date of 10/15/2025, revealed that the resident had a potential risk for elopement related to (r/t) wandering and potential for injury. The CP also indicated that Resident #2 had a wander guard placed on their left wrist and that the resident should be engaged in purposeful activity. A review of Resident #2's Progress Notes included a Nurse's Progress Note dated 10/20/2025 at 12:00 PM, with an effective date of 10/19/2025 at 4:00 PM, written by the Licensed Practical Nurse (LPN #3) included that the resident's Skin warm and dry, skin color within normal limit (WNL) and turgor is normal. Resident does not have an external device. 1. Foot evaluation completed. The Progress Notes did not include any documentation that the resident eloped from the facility on 10/19/2025. During an interview with LPN #1 on 10/27/2025 at 11:19 AM, she stated that at approximately 2:30 PM, the resident was walking around back and forth by the nurse's station. LPN #1 stated that the assigned nurse (LPN #3) gave her the keys to LPN #3's medication cart because LPN #3 was going on break. LPN #1 stated that Resident #2 complained they had a headache and she was going to give the resident a Tylenol. LPN #1 stated when she went to Resident #2's room, the resident was not there. LPN #1 stated that she checked the hallway and did not find the resident, so she paged all staff to come to the First-Floor nursing unit. LPN #1 stated that as staff came, VF #1 of a different resident told her that they just saw a [gender retracted] outside wearing [sleepwear]. LPN #1 stated that she, along with the other staff members, ran outside and ran for about 1-2 minutes, and there was VF #2 sitting by the gazebo on the facility's property that told them that the resident went that way (pointing to the right). LPN #1 stated that they found the resident a block down on the right standing on the sidewalk with two women who stated that the resident looked out of place with [sleepwear] on. LPN #1 stated that the resident was brought back inside the building and the assigned nurse (LPN #3) assessed the resident and there were no injuries. During an interview on 10/27/2025 at 5:04 PM, with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the [NAME] President of Clinical (VPC), the surveyor asked what should be documented in the resident's medical record in accordance with professional standards of practice. The DON stated falls, wounds, changes in status, medication changes, appointments, and behaviors. The surveyor asked if an elopement was considered a behavior, the VPC confirmed it would be and technically should have been documented in the resident's medical record. During a follow-up interview on 10/29/2025 at 12:06 PM, LPN #1 stated that the assigned nurse (LPN #3) had stepped away for five minutes and it was her responsibility to document Resident #2's elopement incident. LPN #1 confirmed that there should have been a Progress Note that included the resident's elopement on 10/19/2025, so other staff were aware the resident had eloped. LPN #1 stated that charting was usually done on post incidents, and that this was an incident that should have been documented. On 10/29/2025 at 12:56 PM, the surveyor attempted to conduct a telephone interview with LPN #3, who did not answer. LPN #3 did not return the surveyor's telephone call, and she was not present during the survey for an interview. A review of the facility's policy titled Nursing Documentation dated 5/01/2025, included Purpose: This policy is to establish guidelines and procedures for nursing documentation . to ensure accurate, timely and legally compliant documentation practices. Proper documentation provides a clear, consistent record of care, facilitates communication among care team members, and ensures continuity of care for residents. Policy Statement General Guidelines included: 1. Accuracy: All nursing documentation must be factual, accurate, and free from abbreviations that could cause confusion. 2. Timeliness: Documentation should occur promptly after . Or receiving new information. Consistency: Documentation should be consistent across all records, ensuring that data is cohesive and easily understood by the entire team. The same policy under Documentation Requirements included: 3. Documentation: Document all nursing interventions and observations, including but not limited to: . changes in condition or behavior. 4. Nursing Notes: Write concise, chronological notes on the resident status, interventions, and outcomes. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of residents. This deficient practice was identified for 2 of 21 residents reviewed for the accommodation of needs (Resident #8 and #11), and was evidenced by the following: On 12/2/24 at 11:00 AM, the surveyor observed the door to room [ROOM NUMBER] was closed. The surveyor heard someone from 232 calling out for assistance. The surveyor knocked and with permission entered the room. The surveyor observed Resident #8 in their room seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell (used to summon staff for assistance) was affixed to the right enabler, not within his/her reach. On 12/3/24 at 9:30 AM, the surveyor observed Resident #8 seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell was affixed to the right enabler, not within his/her reach. On 12/4/24 at 8:40 AM, the surveyor observed Resident #8 seated in a wheelchair to the left of the bed. The surveyor observed that the resident's call bell was affixed to the right enabler, not within his/her reach. The surveyor reviewed the medical record for Resident #8. A review of Resident #8's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure, diabetes mellitus, and hypertension. A review of Resident #8's quarterly Minimum Data Set, (MDS), an assessment tool dated 9/8/24 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated a moderately impaired cognition. The MDS further assessed that the resident required maximum assistance from staff for Activities of Daily Living (ADL) care. A review of Resident 8's Individualized Care Plan (CP) included a focus that indicated the resident had an ADL self-care performance deficit with an intervention that included but was not limited to Encouraging the resident to use the bell to call for assistance. On 12/2/24 at 11:19 AM, the surveyor and Certified Nursing Assistant (CNA #1) assigned to Resident #8's care that day, entered the resident's room and observed the resident seated in a wheelchair to the left of the bed and the call bell affixed to the right enabler, not within the resident's reach. CNA #1 acknowledged that she should have placed the call bell within the resident's reach. On 12/4/24 at 9:25 AM, the surveyor and CNA #2 assigned to Resident #8's care on 12/3/24 and 12/4/24 (7am-3:00 pm shift) entered the resident's room and observed the resident seated in a wheelchair to the left side of the bed with the call bell was affixed to the right enabler, not within the resident's reach. CNA #2 stated that he should have ensured the resident's call bell was within the resident's reach when he made his rounds each morning. On 12/2/24 at 11:38 AM, the surveyor observed Resident #11 in bed on a specialty mattress with the call bell on the floor under the resident's bed. The resident did not respond to the surveyor's greeting. The surveyor reviewed the medical record for Resident #11. A review of the Admission Record reflected Resident #11 was admitted to the facility with diagnoses that included but were not limited to hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body) and dementia. A review of Resident #11's quarterly MDS dated [DATE] reflected Resident #11 had a BIMS score of 5 out of 15 which indicated a severe cognitive impairment. The MDS further assessed that Resident #11 was dependent on staff for ADL care. A review of Resident #11's CP revealed a focus area that indicated the resident has an ADL self-care performance deficit related to a cerebral vascular accident (CVA) with interventions that included encourage the resident to use the call bell for assistance. On 12/2/24 at 12:00 PM, the surveyor and CNA #3 entered resident #11's room. CNA #3 confirmed that the call bell should not be on the floor and acknowledged that all call bells should be placed within the resident's reach. A review of the facility's Call System policy and procedure indicated .residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . On 12/4/24 at 1:33 PM, the surveyor discussed the above observations and concerns with the Administration. The Licensed Nursing Home Administrator confirmed that the call bells should be placed within the residents' reach. NJAC 8:39- 31.8 (c)(9)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) blood pressure apparatus was utilized in accordance with the manufacturer's specifications, b.) an antibiotic treatment was administered as ordered by the physician, and in accordance with professional standards of practice. This deficient practice was observed during the medication pass observation of 1 of 5 nurses who administered to 1 of 6 residents (Resident #20) and identified for 1 of 1 resident investigated for abuse (Resident # 16). The evidence was as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: According to the manufacturer's specifications of the (brand name redacted) a blood pressure monitor machine, under measurement and procedure included the following: Wrap the cuff around upper left arm. Rubber tube should be on the inside of the extending arm. Ensure the cuff lies 1/2 to 3/4 inches above the elbow. 2 fingers should fit between the arm and the cuff . Refer F759 1.) On 12/4/24 at 9:52 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who asked Resident #20, if she can take their blood pressure (BP). Resident #20 was agreeable and informed the surveyor and LPN #1 that they felt shaky. At 9:53 AM, the surveyor observed LPN #1 place the BP cuff on the resident's left forearm (part of the arm extending from the elbow to the wrist or the fingertips), the rubber tube was on the outside of the extending arm. An error reading resulted. At that time, LPN #1 informed the surveyor that she used the same machine around 8 something, that morning for the same resident and received a reading. At 9:56 AM, the surveyor observed LPN #1 retake the BP on the same location, without an adjustment made to the BP cuff, and the rubber tube. LPN #1 received an error reading. At 9:57 AM, the surveyor observed LPN #1 place the BP cuff onto Resident #20's right forearm, the rubber tube was on the outside of the extended arm. LPN #1 received an error reading. At 9:58 AM, the surveyor observed LPN #1 place the BP cuff on the resident's left wrist. LPN #1 received an error reading. At 10:00 AM the Registered Nurse/Unit Manager (RN/UM) entered the room and observed LPN #1 take Resident #20's BP reading. At 10:01 AM, the surveyor and the RN/UM observed LPN #1 place the BP cuff onto Resident #20's left forearm, the rubber tube was on the outside of the extended arm. LPN #1 received an error reading. The surveyor asked LPN #1 if she had another machine in her cart. At that time, LPN #1 stated that she had only one machine which is the one she used with Resident #20. The RN/UM left the room to obtain another BP machine. At 10:04 AM, the surveyor observed RN/UM walking with another BP machine toward Resident #20's room. At that time, during an interview with the surveyor, the RN/UM stated that LPN #1 placed the cuff too loose, the ciff was at the wrong location, and that the rubber cord should have been on the inside of the extended arm. The RN/UM stated that she would provide education to LPN #1, on how to properly use the BP monitor device. On 12/4/24 at 10:49 AM, during an interview with the Director of Nursing, the surveyor discussed the concern with LPN #1's incorrect technique while using the BP device. On 12/4/24 at 1:33 PM, in the presence of the survey team, [NAME] President of Clinical Services, the Licensed Nursing Home Administrator, the Director of Nursing, the surveyor discussed the concerns regarding the incorrect technique used by LPN #1 while using the device for Resident #20 who had a physician ordered medication that had a BP parameter, prior to administration. No further information was provided. 2.) On 12/5/34 at 9:48 AM, the surveyor observed Resident #16 laying on their left side towards the side rail. Resident #16 stated that sometime in November a physician ordered Gentamycin (antibiotic used to treat bacterial infections) for their wound and there was a day or two, it was not administered. On 12/5/24 at 10:29 AM during an interview with the surveyor, LPN #2 stated that the pharmacy delivered the medications sometime between the 7:00 AM to 3:00 PM shift and sometime between the 3:00 PM to 11:00 PM shift; if an item was missing from the orders, the nursing staff called the pharmacy, and requested for the item to be delivered. The facility also had a stat (immediate) order available which arrived withing 4 hours. LPN #2 also stated that the nursing staff communicated with the pharmacy through a tablet and the estimated time of arrival of the medication would be communicated back to the nurses from the pharmacy, through the same tablet. The surveyor reviewed the medical record for Resident #16. According to the Admission Record face sheet, an admission summary, reflected that Resident #16 was admitted to the facility with diagnoses that included: morbid obesity, and type 2 diabetes mellitus. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 9/13/24, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS reflected that the resident had a stage 4 pressure ulcer/injury that was present upon admission with treatments that included applications of ointment medication. A review of the individualized comprehensive care plan included a focus of Resident #16's stage 4 pressure ulcer on the right trochanteric area (outside part of the hip) which was present during admission. The interventions included administer treatment as ordered and monitor for effectiveness. On 12/5/24 at 10:47 AM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) reviewed the Order Audit Report together which reflected an order for Gentamicin Cream, to be applied to the right trochanter wound topically once a day for infected right trochanter wound for 10 days that was ordered by the physician on 10/31/24. The order was confirmed to be started on 11/1/24. The order supply summary reflected that the medication was on hand (in stock) on 11/1/24. The surveyor and the RN/UM reviewed the electronic Medication Administration Record (eMAR) for November 2024, which reflected that the doses on 11/1/24 and 11/10/24 were not administered. A review of the nurses' progress notes did not reflect that the physician, the wound physician, or the infectious disease consultant were notified of the missed doses and a request for a later administration time was also not found. A review of the packing slip reflected the pharmacy delivered the medication on 11/ 1/ 24, a replenishment was sent on 11/5/24 and another replenishment was sent on 11/10/24. A review of the 11/21/24 surgical note documented by the physician on 11/21/24 reflected that the resident's wound was stable and required continued topical wound dressing therapy. On 12/5/24 at 12:06 PM, the surveyor discussed with the DON the concern regarding the two doses of Gentamicin that was not administered to Resident # 16, and the failure of the nursing staff to ensure the resident's physicians were informed of the two missed doses. On 12/9/24 at 10:53 AM, in the presence of the survey team, the Director of Nursing stated that the facility policy did not require for the physician to be contacted unless two consecutive doses were missed which included antibiotics. The DON acknowledged that the physician order was for the administration of Gentamicin for 10 days and only 8 doses were administered. The DON could not provide evidence that the physicians were aware of the missed doses. At that time, the DON agreed that it was not the standard of practice for a physician not to be informed when the course of therapy ordered was not followed. A review of the provided facility policy, Medication Administration, dated 5/1/24, included the following under documentation: if a dose of regularly scheduled medication is withheld refused or given at other than the scheduled time . The administering person will document in the MAR an explanatory note is entered in the progress note. If two consecutive doses of a vital medication are withheld or refused the physician is notified. NJAC 8:39-11.2(b), 27.1(a)(b)

Complaint NJ#175927 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence care was provided to a dependent resident for 1 of 4 residents reviewed for incontinence care (Resident #71) on 1 of 2 nursing units, 2nd-floor unit. This deficient practice was evidenced by the following: On 12/2/24 at 11:00 AM, the surveyor observed Resident #71 in the bathroom seated in a wheelchair. The surveyor observed the resident exposed their incontinence brief. The surveyor observed two incontinence briefs were in place, both saturated with urine. At that time, the Hospitality Aide who was in Resident #71's room, stated that she was not assigned to provide direct care and left to summon the Certified Nursing Assistant (CNA) assigned to Resident #71's care. On 12/2/24 at 11:13 AM, the CNA entered Resident 71's room. The CNA observed the resident's two incontinence briefs were saturated with urine. The CNA stated that she had 12 Residents on her assignment and therefore had not provided any care for Resident 71 that morning. The CNA confirmed that double diapers were unacceptable. The surveyor reviewed the medical record for Resident #71. A review of the Admission Record reflected the resident was admitted to the facility with diagnoses that included chronic kidney disease, fracture of the right femur (break in the thigh bone), and hypertension. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 9/26/24 reflected Resident #71 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated a severe cognitive impairment. Further review indicated Resident #71 required supervision with toileting and was frequently incontinent of urine. A review of the resident's Individual Care Plan (CP) revealed no care plans that addressed Resident #71's incontinence care. A review of the facility's Incontinent Care policy dated 5/1/24 included .the purpose is to provide consistent, compassionate, and effective care for residents with incontinence, ensuring dignity, comfort, and prevention of complications such as skin breakdown or infections .develop and document a care plan tailored to each resident's needs .staff must check and change incontinence products as needed, following the resident's care plan and at least every 2-4 hours or when soiled . On 12/4/24 at 1:33 PM, the survey team met with the Administration to discuss the above observations and concerns. The Director of Nursing (DON) acknowledged that two incontinence briefs should not be used unless requested by the resident due to the risk of skin breakdown. The DON confirmed that the CP for incontinence care and the resident preference for the use of two incontinence briefs had not been initiated until 12/2/24 after the surveyor's inquiry. NJAC 8:39-27.1(a), 27.2(h)

Based on observation, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication pass on 12/4/24, the surveyor observed five (5) nurses administer medications to six (6) residents. There were 26 opportunities and two (2) errors observed which calculated to a medication administration error rate of 7.6 %. The deficient practice was identified for 2 of 5 nurses for 2 of 6 residents, (Resident #97 and #20) as evidenced by the following: 1. On 12/4/24 at 08:46AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #97. The medications included a physician's order for Sennosides - Docusate sodium 8.6 milligram (mg) - 50 mg (Senna Plus), 1 tablet by mouth every 12 hours for constipation with an order date of 10/28/24. At 8:51 AM, the surveyor observed LPN #1 pour one (1) tablet of Sennoside (Senna) 8.6 mg into a medication cup for administration to Resident #97. LPN #1 informed the surveyor that the container of Sennoside 8.6 mg was a house stock (facility supply) bottle. At 8:54 AM, the LPN #1 confirmed with the surveyor that she was ready to administer the resident's medication and walked toward the resident's room threshold. At 8:55 AM, the surveyor stopped the medication pass observation at the resident's room threshold and asked LPN #1 to walk back to the med cart parked at the hallway. At 8:56 AM, the surveyor and the LPN #1 reviewed the electronic Medication Administration Record (eMAR) against the house stock bottle from which the Sennoside 8.6 mg was poured from. At 8:58 AM, LPN #1 confirmed and acknowledged that she had poured the wrong drug and recognized the physician order was for Sennoside -Docusate sodium 8.6 - 50mg as opposed to the poured medication of Sennoside 8.6 mg. 2. On 12/4/24 at 9:37 AM, the surveyor observed LPN #2 prepare medications for Resident #20. The medications included a physician's order for Amlodipine 10 mg, 1 tablet by mouth one time a day for hypertension; hold for systolic blood pressure less than 110. At 9:40 AM, LPN #2 took out a small notebook that reflected the resident's room number and blood pressure (BP). LPN #2 entered the BP values from the notebook into the eMAR. At 9:48 AM, LPN #2 confirmed with the surveyor that she was ready to administer the resident's medication and walked toward the resident's room threshold. At that time, the surveyor stopped the medication pass observation at the resident's room threshold and asked LPN #1 to walk back to the med cart parked at the hallway. At 9:50 AM, during an interview with the surveyor, LPN #2 stated that she had taken Resident #20's blood pressure around 8 something that morning. At that time, LPN #2 acknowledged that the blood pressure should have been taken immediately before the administration of the Losartan in accordance with the physician's order. On 12/4/24 at 10:49 AM, during an interview with the Director of Nursing, the surveyor discussed the concerns regarding the medication pass observation. On 12/4/24 at 1:33 PM, in the presence of the survey team, [NAME] President of Clinical Services, the Licensed Nursing Home Administrator, the Director of Nursing, the surveyor discussed the concerns regarding the incorrect medication poured for administration for Resident #97 and the concern regarding the blood pressure that was not taken prior to administration in accordance with the physicians' order for Resident #20. A review of the provided facility policy, Medication Administration, dated 5/1/24, included: Medications are administered as prescribed in accordance with good nursing principles and practice. NJAC 8:39-11.2(b), 29.2(d)

Based on the interview and record review, it was determined that the facility failed electronically transmit the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment for 5 of 25 residents, (Resident #103, #92, #31, #76, and #107) reviewed for resident assessment. The deficient practice was evidenced by the following: 1. Resident #103 was observed to have a Death MDS of 4/02/23 and was due to be transmitted no later than 4/16/23. The Death MDS was not transmitted until 4/28/23. 2. Resident #92 was observed to have an Entry MDS of 4/05/23 and was due to be transmitted no later than 4/20/23. The Death MDS was not transmitted until 4/28/23. 3. Resident #31 was observed to have an Admission MDS of 3/31/23 and was due to be transmitted no later than 4/14/23. The Death MDS was not transmitted until 4/15/23. 4. Resident #76 was observed to have an Admission MDS of 4/05/23 and was due to be transmitted no later than 4/20/23. The Death MDS was not transmitted until 4/28/23. 09/14/23 09:47 AM, the surveyor interviewed the facility's Registered Nurse (RN) MDS Coordinator who was responsible for completing and transmitting the MDS assessments who agreed that the above MDS assessments were transmitted late due to transition of the system in April this year. 34033 5. The surveyor reviewed the closed medical records for Resident #107. On 9/21/23 at 9:38 AM, the surveyor reviewed the Progress Notes which revealed that the resident was discharged to the hospital on 8/18/23. The surveyor then reviewed the MDS assessment submissions which revealed that there was no MDS submission of a discharge assessment completed. In addition, the electronic records indicated that the MDS discharge assesssment was 19 days overdue. On 9/20/23 at 1:04 PM, the survey team met with the LNHA and DON to review the MDS records for Resident #107. The DON stated that she would check with the MDS Coordinator. On 9/21/23 at 9:30 AM, the surveyor interviewed the DON who stated that the MDS discharge was completed for Resident #107. The DON provided the surveyor with a CMS Submission Report MDS 3.0 NH Final Validation Report which reflected that Resident #107's discharge MDS had a Target Date of 8/18/23 and the Record Submitted Late: Submission date is more than 14 days after. NJAC 8:39-11.1