Every finding on record at Family of Caring at Park Ridge LLC

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 1 of 33 residents (Resident #125) and 3 of 3 nursing units (1st, 2nd, and 3rd floors), and was evidenced by the following: 1. On 6/10/26 at 10:02 AM, the Surveyor observed in Resident #125's room the paint was peeling off the wall behind the bed and the call bell apparatus was coming out of the wall. On 6/11/26 at 9:50 AM, the Surveyor observed in Resident #125's room, the paint was peeling off the wall behind the bed and the call bell apparatus was coming out of the wall. Resident #125 stated that a Maintenance Worker was in the room earlier and put up a piece of molding in the corner of the room. On 6/11/26 at 10:06 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN), who stated that if there was an issue with the room like peeling paint, then they would tell the Unit Manager (UM), and there was a computer system for maintenance to fix. The LPN confirmed that the paint was peeling and call bell was falling out of the wall. She stated that it should have been addressed by maintenance and that they were in the room earlier. On 6/11/26 at 10:12 AM, the Surveyor interviewed LPN/UM #1 (LPN/UM #1) of 3 East, who stated that there was a book that they put items that needed to be fixed in and that maintenance looked at it every day, and they would initial it when fixed. LPN/UM #1 stated that if something had to be fixed right away that they would call. The Surveyor reviewed the book and there was no entry for the issues in Resident #125's room and the last entry was dated 6/2/26. LPN/UM #1 confirmed that the last entry was 6/2/26. On 6/16/26 at 11:31 AM, the Surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Director of Quality Assurance (DQA) the concern that Resident #125's room had peeling paint and call bell coming out of the wall. On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that the concerns had been corrected after surveyor's inquiry. The LNHA did not provide any additional information. 2. During an initial tour of the 1st (first) floor nursing unit on 6/10/26 at 10:31 AM, the Surveyor observed the following concerns: The windows at the end of the hallway near room [ROOM NUMBER] (R115), with accumulation of cob web and grayish substances. The Registered Nurse/UM (RN/UM) stated that she did not know what those were identified concerns in the windows, and she had to ask her Supervisor because she was a new UM. The ceiling light near R115 hallway with accumulation cob web and grayish substances. Outside of activity room, in front of R115, there was one sprinkler head with a gap in the ceiling tile. There were three busted lights in the hallway (two busted lights near R114 and one near R112). The RN/UM stated she did not know what happened to those busted lights and had to ask her Supervisor. The ceiling vent in restroom [ROOM NUMBER] (R1) with accumulation of grayish substances. The ceiling tiles in R2, near R109, with brownish stains. On 6/10/26 at 10:43 AM, the Surveyor interviewed the Maintenance Assistant (MA), who stated, it should not be like that. The MA further stated that there should be no gaps in the sprinkler head and no busted lights. He also added that the windows were not his responsibility, it was the responsibility of the Housekeeper to maintain cleanliness. On 6/11/26 at 11:55 AM, the Surveyor with the DQA both observed the ceiling light that was seen yesterday (6/10/26) with accumulation of cob web and grayish substances. The Surveyor notified the DQA of the above findings and concerns with busted lights, windows, gaps in the ceiling, and R1 and R2. On 6/16/26 at 8:09 AM, both the Surveyor and the Registered Nurse (RN) observed the 1st floor medication (med) room ceiling vent with heavy accumulation of blackish substances and the sink with heavy accumulation of brownish, reddish substances. The RN stated that she would notify the housekeeping. The RN stated she did not know what those were and should have been cleaned. On 6/16/26 at 11:31 AM, the survey team met with the LNHA, DON, DQA, and the Surveyor notified them of the above findings and concerns with the environment. On 6/18/26 at 8:31 AM, the Surveyor observed in the 3rd (third) floor, 3 [NAME] unit hallway, a linen cart parked near R406, was not fully covered, and the top portion of the cover was ripped. There were linen supplies inside the three tier linen cart. The Housekeeper (HK) did not respond as to why the linen cover was ripped and not fully covered. On 6/18/26 at 8:34 AM, LPN/UM #2 of 3 [NAME] nursing unit stated that the linen supplies were considered clean and he would notify someone about the ripped linen cover that was observed with the HK. On that same date and time, both the Surveyor and LPN/UM #2 went to another wing of 3 [NAME] unit and observed a linen cart near R427 that was uncovered. LPN/UM #2 stated that they should be covered because the cart had clean linen supplies. On 6/18/26 8:45 AM, both the Surveyor and LPN/UM #2 observed a linen cart between R204 and R202 uncovered. LPN/UM #2 stated that they should be covered to maintain cleanliness because the cart had clean linen supplies. On 6/18/26 at 11:16 AM, survey team met with the LNHA, DON, DQA, and the Surveyor notified them of concerns with linen carts that were left uncovered and with ripped cover that had a clean linen supplies. On 6/18/26 at 11:45 AM, the survey team met with the DON, DQA, and the LNHA stated that the vent was cleaned right away, the linen carts, we will do audit, and ordered a new cover. The DQA stated that 1st floor busted lights, ceiling light, and med room were corrected after Surveyor's inquiry. A review of the facility's Quality of Life-Homelike Environment Policy, that was provided by the DQA, date reviewed 10/2025, revealed that residents are provided a safe, clean, comfortable and homelike environment. These characteristics include cleanliness and order. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment. The use of contrasting paint to aid visually impaired residents. NJAC 8:39-31.2(e), 31.4(a)(f)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer residents a COVID-19 Immunization. This deficient practice was identified for 5 of 5 residents reviewed (Residents #1, #2, #3, #4, and #172). The deficient practice was evidenced by the following: 1. The Surveyor reviewed Resident's #1's medical record which revealed the following information: A review of the admission Record (AR) or face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; unspecified severe protein-calorie malnutrition, unspecified dementia, unspecified severity, with other behavioral disturbance, and basal cell carcinoma of skin (the most common form of skin cancer), unspecified. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 5/9/26, revealed in Section C (cognitive patterns), the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which reflected that the resident's cognition was moderately impaired. Further review of the MDS revealed that the resident's COVID vaccine was not up to date. A review of the electronic medical records (eMR) revealed that there was no documented evidence that COVID vaccination was offered and provided an opportunity for resident or resident representative (RR) to decline and receive education about the vaccine. A review of Resident #1's hybrid medical record did not include any information regarding COVID-19 vaccination. On 6/11/26 at 12:30 PM, the Surveyor in the presence of the Registered Nurse (RN) reviewed the paper chart of Resident #1, and the RN confirmed that there was a blank form consent for pneumococcal vaccine and none for COVID vaccine in the chart. The RN further stated that it was the Infection Preventionist Nurse (IPN) responsibility to obtain consents for immunizations. On 6/11/26 at 12:35 PM, the Medical Records Staff informed the surveyor that she was responsible for thinning the chart of the residents, and the immunization records were the records in the chart that were not being removed. She further stated that the immunization consents should be in the resident's chart. On 6/11/26 at 12:43 PM, the surveyor interviewed the IPN, who stated the process of obtaining consents for immunizations were, the nurse admitting the resident would be responsible for obtaining immunization consents, and then on the second day, the IPN would call the RR to obtain a verbal consent for resident who were cognitively impaired. She further stated that if the resident was cognitively intact, the consent would be obtained from the resident, and it would be documented in the eMR. At the same time, the IPN stated that for LTC (long term care) residents, I keep up to date with all immunizations that included COVID. She further stated that she had a binder for files and also documented in eMR. On 6/11/26 at 12:51 PM, during the follow up interview of the surveyor with the IPN, who stated that COVID-19 records of immunization should be in the eMR, and if it was not documented in the eMR, then it was not done. The IPN also confirmed that the binder she had, and copies of consent were for RSV (Respiratory Syncytial Virus is a very common, contagious virus that infects the nose, throat, and lungs) and influenza, and the rest of immunization consents should be in eMR. S #1 notified the IPN of the above findings and concerns with Resident #1's COVID-19 immunization, and she acknowledged that if it was not documented in the eMR, it was not done. On 6/16/26 at 11:31 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Director of Quality Assurance (DQA), and the surveyor notified them of the above findings and concerns with regard to COVID-19 immunization of Resident #1. 2. On 6/15/26 at 9:00 AM, the Surveyor reviewed the eMR of Resident #2. A review of the resident's Significant Change MDS, with an ARD of 4/15/26, revealed that the resident's COVID-19 vaccination was not up to date. A review of Resident #2's immunization section of the eMR did not include any information regarding COVID-19 vaccination. A review of Resident #2's hybrid medical record did not include any information regarding COVID-19 vaccination. 3. On 6/15/26 at 9:10 AM, the Surveyor reviewed Resident #4's eMR. A review of the resident's quarterly MDS, with an ARD of 3/16/26, revealed that the resident's COVID-19 vaccination was not up to date. A review of Resident #4's immunization section of the eMR did not include any information regarding COVID-19 vaccination. A review of Resident #4's hybrid medical record did not include any information regarding COVID-19 vaccination. On 6/16/26 at 11:32 AM, in the presence of the survey team, the surveyor discussed the above concerns with the LNHA, DON, and DQA. On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated they were going to enhance the process to really look at every resident who was here and speak to residents and RR regarding vaccinations. 4. On 6/10/26 at 10:26 AM, the Surveyor observed Resident #3 seated up in bed. A review of Resident #3's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to bipolar disease with psychotic features (mental illness that causes a temporary disconnect from reality in the form of hallucinations, delusions, or disorganized thinking) and dementia with agitation (clinical condition where a person diagnosed with a cognitive impairment syndrome exhibits observable signs of emotional distress through excessive motor activity, verbal aggression, or physical aggression). A review of Resident #3's quarterly MDS with an ARD of 5/22/26, reflected that the resident had a BIMS score of 12 out of 15, which indicated that the resident's cognition was mildly impaired. Further review of the MDS reflected that the resident's COVID-19 vaccination was not up to date. A review of Resident #3's immunization section of the eMR did not include any information regarding COVID-19 vaccination. A review of Resident #3's hybrid medical record did not include any information regarding COVID-19 vaccination. 5. On 6/15/26 at 11:00AM, the surveyor observed Resident #172 seated in a wheelchair near the nursing station. A review of Resident #172's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia with agitation and hypertension (high blood pressure). A review of Resident #172's comprehensive MDS dated [DATE], reflected that the resident had a BIMS score of 3 out of 15, which indicated that the resident's cognition was severely impaired. Further review of the MDS reflected that the resident's COVID-19 vaccination was not up to date. A review of Resident #172's immunization section of the eMR did not include any information regarding COVID-19 vaccination. A review of Resident #172's hybrid medical record did not include any information regarding COVID-19 vaccination. On 6/16/26 at 11:31 AM, the surveyor notified the LNHA, DON, and DQA the above concerns with Resident #3 and Resident #172's COVID-19 vaccination. On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that she did not have a response for the covid vaccination concern. The LNHA did not provide any additional information. A review of the facility's Resident Vaccination for COVID-19 Protocol, with a reviewed/revised date of 10/2025, included the following: 1. All newly admitted , readmitted and current residents are to be offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. a. Screening residents prior to offering the vaccination for prior immunization, medical precautions and contraindications is necessary for determining whether they are appropriate candidates for vaccination at any given time. b. If the resident has already been immunized, ensure that all vaccination information, are documented in the resident's medical record. 2. Ensure that the resident or resident representative is provided with education regarding the benefits, risks and potential side effects associated with the vaccine or booster. 4. The resident or RR has the opportunity to accept or refuse a COVID-19 vaccine and change their decision. 5. The resident's medical record includes documentation that indicates, at a minimum, the following: a. That the resident or RR was provided education regarding the benefits and potential risks associated with COVID-19 vaccine. b. Consent for each COVID-19 vaccine. c. Date of each dose of COVID-19 vaccine and/or booster administered to the resident. d. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. NJAC 8:39-19.4 (a); 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to a.) follow the physicians orders with regard to side effect monitoring for 4 of 7 residents (Residents #1, 110, #67, and #172), b.) document as medications were administered for 1 of 38 residents (Resident #67), and c.) clarify, separate, and discontinue orders with regard to preventative treatments for 1 of 1 resident (Resident #16) reviewed, according to the standard of clinical practice and facility's policies. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 6/10/26 at 10:45 AM, the Surveyor observed Resident #1's room was closed and was told to come back at later time because the resident was being changed. On 6/10/26 at 1:27 PM, the Surveyor reviewed the medical records of Resident #1. A review of the admission record (AR) or face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to, unspecified severe protein-calorie malnutrition; unspecified dementia, unspecified severity, with other behavioral disturbance; and basal cell carcinoma of skin (the most common form of skin cancer), unspecified. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 5/9/26, revealed in Section C (cognitive patterns), the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which reflected that the resident's cognition was moderately impaired. Section N (medications) revealed that the resident was taking antipsychotic (AP), antianxiety (AA), antidepressant (AD), and anticoagulant (AC) medications (meds) during the last seven days of the look-back period (specific timeframe during which a nursing home resident's clinical status, treatments, and behaviors are evaluated). A review of the Order Summary Report (OSR) revealed the following active physician orders (PO): AA medication (med)-observe for side effects (s/e): drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the progress notes (PN) every shift for routine monitoring. The order date was 5/2/26. AC med: observe for s/e: discolored urine, black tarry stools, sudden severe headache, nausea & vomiting (N&V), diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath (SOB), and nosebleeds. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the PN every shift for routine monitoring. The order date was 5/2/26. AD med: observe for s/e: gastrointestinal (GI) upset, insomnia, fatigue, dizziness, dry mouth, and headache. Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the PN every shift for routine monitoring. The order date was 5/2/26. AP med: observe for s/e: dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N&V, lethargy, drooling, extrapyramidal symptoms (EPS, tremors, gait issues, agitation, restlessness, and involuntary movement of mouth/tongue). Document Y if s/e are present; document N if s/e are absent. If Y is documented also document in the PN every shift for routine monitoring. The order date was 5/2/26. The above s/e PO were transcribed to 5/2026 and 6/2026 electronic Medication Administration Record (eMAR) for monitoring, and revealed: For AA med, the nurse in night shift (11:00 PM-7:00 AM) coded NA (not applicable) for 13 days in 5/2026 and 10 days in 6/2026. For AC med, the nurses in evening shift (3:00 PM-11:00 PM) coded NA for one day and the night shift coded NA for 14 days in 5/2026 and 10 days in 6/2026. For AP med, the nurse in the night shift coded NA for 14 days in 5/2026 and 10 days in 6/2026. For AP med, the nurse in evening shift on 5/6/26 did not follow the PO and left it blank. The nurse in the night shift coded NA for 14 days in 5/2026 and 9 days in 6/2026. On 6/15/26 at 9:51 AM, the Surveyor interviewed the Director of Nursing (DON) with regard to the PO for monitoring s/e to use codes Y and N, and the nurses were coding NA. The DON responded that the nurses should follow the PO. A review of the facility's Psychotropic Drug Use Policy, that was provided by the LNHA, with a reviewed date of 2/2026, revealed, the assessment of s/e for residents receiving AP includes the adverse effects (a/e): tardive dyskinesia, postural or orthostatic hypotension, cognitive and/or behavior impairment.The physician weighs the risk versus the benefits and documents them in the medical record. If the gradual dose reduction (GDR) is causing an a/e on the resident or deemed a failure, the GDR is discontinued. Documentation of this decision and reasons for it are included in the clinical record. 2. On 6/10/26 at 10:28 AM, the Surveyor observed Resident #16 lying on bed with eyes closed. On 6/10/26 at 12:36 PM, the Surveyor reviewed the medical records of Resident #16. A review of the AR revealed the resident was admitted to the facility with diagnoses that included but were not limited to; hypertensive heart disease without heart failure, unspecified severe protein-calorie malnutrition, Alzheimer's disease with late onset, and combined forms of age-related cataract, bilateral. A review of the most recent comprehensive MDS (cMDS), with an ARD of 4/3/26, revealed in Section C a BIMS score of 0 out of 15, which reflected that the resident's cognition was severely impaired. A review of the OSR revealed the following PO: Apply protective barrier cream to buttocks and perineal area every shift and as needed (PRN) every shift for moisture barrier. Start date 8/12/21. Zinc oxide external ointment 20 %, apply to bilateral buttocks topically every day shift for skin protection cleanse with normal saline solution (nss), pat dry, apply zinc oxide, hydrophilic foam pad, secure with dry dressing. Start date 12/30/25. The above order for Zinc oxide was transcribed in 5/2026 and 6/2026 eMAR and signed by nurses as administered in day shift (7:00 AM-3:00 PM). The above order for protective barrier cream to buttocks and perineal area was transcribed in 5/2026 and 6/2026 electronic Treatment Administration Record (eTAR) and signed by nurses as administered in day, evening, and night shifts. The order was not separated for buttocks and perineal area, and there was no separation between routine and PRN orders. Furthermore, the duplicate treatment orders for buttocks were not clarified. On 6/15/26 at 10:04 AM, the Surveyor interviewed the DON with regard to the above PO for buttocks and perineal area. The DON stated that the order for protective barrier cream for buttocks and perineal area should have been clarified and separated, and the order should have been discontinued when the new order for buttocks on 12/30/25 was ordered. On 6/16/26 at 11:31 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Director of Quality Assurance (DQA), and the Surveyor notified them of the above findings and concerns with Resident #1 and Resident # 16. On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated that Resident #16's protective barrier had been clarified and there was only one order now. The DQA further stated that nurses were educated to follow the PO for s/e monitoring. A review of the facility's Physician Medication Orders Policy, that was provided by the LNHA, with a revised date of 4/2010, revealed, meds shall be administered only upon the written order of a person duty licensed and authorized to prescribe such meds in this state. 3. On 6/15/26 at 10:30 AM, the Surveyor observed Resident #67 seated in a wheelchair (w/c) in their room. On 6/15/26 at 10:49 AM, the Surveyor reviewed the medical record for Resident #67. A review of the AR revealed the resident had diagnoses which included, but were not limited to; Parkinson's disease, type 2 diabetes mellitus, hypertension (HTN), depression, psychotic disorder with delusions, dysphagia, and long-term insulin use. A review of the resident's quarterly MDS (qMDS), with an ARD of 5/5/26, revealed the resident had a BIMS score of 12 out of 15, which indicated moderately impaired cognition. Further review of the qMDS revealed the resident received AP and AD meds. A review of the resident's individual comprehensive care plan (CP) included focus areas related to depression, psychosis, and the use of AD and AP meds. Interventions included administering meds as ordered and monitoring for effectiveness and a/e each shift. A review of the OSR included the following PO: Escitalopram oxalate 20 milligrams (mg), one tablet (tab) by mouth at bedtime (HS) for depression. Mirtazapine 7.5 mg, one tab by mouth at HS for depression. Quetiapine fumarate 100 mg, one tab by mouth at HS for psychosis. Atorvastatin calcium 10 mg at HS for cholesterol. Losartan potassium 100 mg every evening for HTN. The above PO were transcribed to the June 2026 eMAR and were electronically signed as administered by the nurses from 6/1 through 6/14/26, except on 6/5/26 at 9:00 PM. Further review revealed there was no documented evidence that the above meds were administered, refused, held, unavailable, or otherwise omitted. A review of the facility's Administering Medications Policy, dated 4/2026, included that meds were to be administered as ordered by the physician and documented appropriately in the medication (med) administration record. The policy further included that med administration records must accurately reflect meds administered to residents and that omissions in documentation must be accounted for according to facility procedures. 4. On 6/15/26 at 9:03 AM, the Surveyor observed Resident #110 inside their room, lying on their bed. On 6/16/26 at 9:04 AM, the Surveyor reviewed the medical record for Resident #110. A review of the AR revealed the resident had diagnoses which included, but were not limited to; nondisplaced intertrochanteric fracture of the left femur with routine healing, osteoarthritis, dementia, and recurrent depressive disorder. A review of the resident's qMDS, with an ARD of 4/9/26, revealed the resident had a BIMS score of 8 out of 15, which indicated moderately impaired cognition. A review of the resident's individual comprehensive CP, revised 4/26/26, included a focus area for pain related to a nondisplaced intertrochanteric fracture of the left femur and osteoarthritis. Interventions included administering analgesic meds as ordered, monitoring for pain, and observing for non-verbal signs and symptoms of pain. A review of the OSR, dated as of 6/16/26, included the following PO: Tramadol hydrochloride 50 mg, one tab by mouth every eight hours PRN for moderate to severe pain (4-10), with instructions to monitor for respiratory depression, sedation, and constipation while administering tramadol. Staff to observe for opioid s/e every shift, including tolerance, physical dependence, increased sensitivity to pain, constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, depression, itching, and sweating. Staff to observe for AD med s/e every shift, including GI upset, insomnia, fatigue, dizziness, dry mouth, and headache. The order further instructed staff to document Y if side effects were present and N if side effects were absent and to document findings in the PM when s/e were identified. The above PO were transcribed to the June 2026 eMAR and the orders for s/e monitoring for opioid and AD meds use were not followed. On 6/16/26 at 9:12 AM, the Surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who confirmed that the nurses did not follow the PO for monitoring the s/e for the use of opioid and AD meds, instead, the nurses were placing a check mark instead of a Y or an N. On 6/16/26 at 9:15 AM, the Surveyor interviewed the DON, who stated the orders should have included supplemental coding options to allow nursing staff to document s/e monitoring in accordance with the PO. The DON further stated that nursing staff should have documented their observations in a PN when supplemental coding options were unavailable. The DON stated the facility would revise the orders within the eMAR to allow nurses to document s/e monitoring as ordered. A review of the facility's Pain Data Management Policy dated 10/2025, included that residents receiving pain meds were to be monitored for effectiveness and a/e, that s/e and adverse reactions were to be identified, assessed, documented, and communicated to the physician as appropriate, and that staff were responsible for monitoring residents for med-related complications and changes in condition. 5. On 6/15/26 at 11:00AM, the Surveyor observed Resident #172 seated in a w/c near the nursing station. A review of Resident #172's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to dementia with agitation (clinical condition where a person diagnosed with a cognitive impairment syndrome exhibits observable signs of emotional distress through excessive motor activity, verbal aggression, or physical aggression) and HTN. A review of Resident #172's cMDS with an ARD of 4/7/26, reflected that the resident had a BIMS score of 3 out of 15, which indicated that the resident's cognition was severely impaired. A review of Resident #172's June 2026 eMAR included the following: AD Med - Observe for s/e: GI upset, insomnia, fatigue, dizziness, dry mouth, headache. Document Y if side effects are present; document N if side effects are absent. If Y is documented also document in the PN. every shift for routine monitoring with a start date of 4/1/26. The nurses wrote a checkmark as administered and not the Y or N. The nurses did not follow the PO. AP Med: Observe for s/e: dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N&V, lethargy, and drooling. Document Y if s/e present; document N if side effects absent. If Y also document s/e in PN. every shift for routine monitoring with a start date of 4/1/26. The nurses wrote a checkmark as administered and not the Y or N. The nurses did not follow the PO. On 6/15/26 at 9:54 AM, the Surveyor interviewed the DON who stated that the PO should be followed. The DON further stated that for Resident #172's orders that the nurses should have had the Y or N and not a checkmark. On 6/16/26 at 11:31 AM, the Surveyor notified the LNHA, DON, and DQA the concern that Resident #172's PO were not followed. On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that the nurses were educated. The LNHA did not provide any additional information. N.J.A.C. 8:39-11.2 (b); 27.1(a)

Based on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a resident with severe cognitive impairment, who was at risk for elopement was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building for 1 of 2 residents reviewed for elopement (Resident #3). This deficient practice was evidenced by the following:On [DATE] at 10:26 AM, the Surveyor observed Resident #3 seated up in bed. The surveyor observed Resident #3 had a wanderguard (wearable device that triggers alarms or locks doors to prevent unsupervised exits) on their right wrist.On [DATE] at 12:08 PM, the Surveyor reviewed Resident #3's medical record.A review of Resident #3's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; bipolar disease with psychotic features (mental illness that causes the individual experiences a temporary disconnect from reality in the form of hallucinations, delusions, or disorganized thinking) and dementia with agitation (clinical condition where a person diagnosed with a cognitive impairment syndrome exhibits observable signs of emotional distress through excessive motor activity, verbal aggression, or physical aggression).A review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of [DATE], reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was mildly impaired.A review of Resident #3's individualized comprehensive care plan included that the resident was an elopement risk/wanderer with an initiated date of [DATE].A review of Resident #3's [DATE] electronic Treatment Administration Record (eTAR) included the following:Device: Wander Guard to right wrist; Check for placement and function every shift for safety monitoring secondary to elopement risk every shift for facility protocol with a start date of [DATE].The order indicated a Y/N (yes/no) to be written by the nurse each shift. There was a N on all three shifts for [DATE], and two shifts (evening and night) shift for [DATE]. The order did not include to check the expiration date of the wanderguard.Further review of the eTAR did not reveal any additional order to check the expiration date of the wander guard.On [DATE] at 10:58 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN), who stated that there was a small machine that they used to check the function and placement of the wander guard every shift.On [DATE] at 10:14 AM, the Surveyor interviewed the Registered Nurse (RN), who stated that they checked the wander guard for placement and function with a machine that blinked green to make sure it was working every shift and was marked on the eTAR. The RN stated that the wander guard did have an expiration date. The surveyor asked if the expiration date was documented anywhere and if it was checked. The RN stated that the order just had placement and function. She added that if the wander guard expired, they would notify the Unit Manager (UM) and change it.At that same time, the RN stated that the Y meant it was there and functioning and the N meant that it was not there and the UM would be notified and an investigation done. The RN stated that she was unsure as to why the N was written on the eTAR for five shifts.On [DATE] at 10:24 AM, the Surveyor interviewed the LPN/UM (LPN/UM) of 3 East, who stated that if there was a N then there should be a progress note (PN) to indicate why. The LPN/UM further stated that she knew that the wander guard was there and that she would notify the Director of Nursing (DON).On [DATE] at 10:45 AM, the LPN/UM stated that the nurses that marked N were called to find out why they marked N. The LPN/UM stated that the nurses had clicked N incorrectly.On [DATE] at 11:52 AM, the Surveyor interviewed the DON who stated that the nurses check placement and function of the wander guard and put Y/N in the eTAR. The DON stated that they had a log with all the wander guards and their expiration dates. The surveyor asked the DON if the log was part of the medical record. The DON stated no. The surveyor asked the DON if the expiration date should be checked by the nurses. The DON stated that they had not been doing that and that they had their own log and know when they expire. The DON stated that the Assistant DON (ADON) was responsible for the log. On [DATE] at 11:31 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA) the concern that Resident #3's wander guard order did not have the expiration date checked and that the nurses were indicating N for the placement and function for five shifts.On [DATE] at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that the nurses were called and that they made a mistake when they wrote N. She added that the wander guard was always there. The DQA stated that the expiration date of the wander guard was not added in the resident's medical record because if a resident rip it off, they would get a new one and would have to be changed in the medical record each time. She stated that they had an internal tracking system for the expiration date and that they reviewed it every month.The LNHA did not provide any additional information.A review of the facility's Wander guard Use for Wandering, Unsafe Resident Policy, with a reviewed date of 10/2025, included the following:Policy: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.6. Wander guard placed to resident legs, wrist, arms, wheelchair as indicated.The policy did not include any information on checking the wander guard bracelet, expiration date or documentation.N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were easily accessible. This deficient practice was identified for 1 of 5 residents (Resident #6) reviewed for hospice services and was evidenced by the following: On 6/10/26 at 9:30 AM, the surveyor observed Resident #6 lying in bed with oxygen in use.During an interview on 6/12/26 at 9:12 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated hospice records were maintained in a hospice section of the resident's binder, and that facility staff did not have access to hospice Registered Nurse visit notes through the electronic medical record (eMR). The LPN/UM further stated hospice records would need to be requested from the hospice agency and acknowledged the records were not available in the eMR.On 6/12/26 at 9:33 AM, the surveyor reviewed the medical record for Resident #6.A review of the admission Record or face sheet (an admission summary) revealed Resident #6 had diagnoses which included but were not limited to; end stage cerebrovascular accident (CVA); pressure ulcers; and shortness of breath.A review of the resident's Significant Change status Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/26/26, revealed the resident received hospice services and had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment.A review of the resident's individual comprehensive care plan (CP) included a focus area for hospice services, and the resident was admitted to hospice services on 10/17/25, with a diagnosis of end stage CVA. The interventions included but were not limited to monitoring and reporting changes in condition to the physician and hospice provider and communicating signs and symptoms affecting the resident's comfort and quality of life.A review of the medical record revealed, there were no hospice nursing visit notes that were available within the facility's eMR system.On 6/15/26 at 10:00 AM, the surveyor conducted a follow-up interview with the LPN/UM, who stated she contacted the hospice agency and requested copies of recent hospice nursing notes. The requested hospice visit notes were provided by the hospice agency to the LPN/UM for dates 5/26/26, 6/1/26, and 6/4/26. The LPN/UM further stated hospice nurses communicated recommendations to facility staff through a paper communication form. The LPN/UM acknowledged that the hospice visit notes as part of resident's medical records should have been available for review by the IDT (interdisciplinary team) and filed in the resident's medical records.On 6/15/26 at 11:41 AM, the surveyor interviewed the Director of Nursing (DON), who stated that each hospice agency communicated differently and that her expectation was that hospice nurses document a note regarding their visit either in the resident's individual binder or in the hospice binder on the date of the visit. The DON further acknowledged there was a gap in communication between hospice nurse visits and the facility nursing department.A review of the facility's Family of Caring Hospice Program Policy, dated 10/2025, included that hospice services were to be coordinated between the facility and hospice provider and that communication between the hospice agency and facility staff was necessary to ensure residents received appropriate care and services.NJAC 8:39-35.2 (d)(5, 6, 7, 10)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to: a.) ensure the recommendations for supplement diet was followed for resident identified as at risk for nutritional problem and b.) update the care plan for 1 of 1 resident (Resident#16), reviewed for nutrition.This deficient practice was evidenced by the following:On 6/10/26 at 10:28 AM, the Surveyor observed Resident #16 lying on bed with eyes closed and with water container at the bedside.On 6/10/26 at 12:36 PM, the Surveyor reviewed the medical records of Resident #16. A review of the admission Record or face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; hypertensive heart disease without heart failure, unspecified severe protein-calorie malnutrition, Alzheimer's disease with late onset, and combined forms of age-related cataract, bilateral.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/3/26, revealed in Section C (cognitive status) a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which reflected that the resident's cognition was severely impaired. Section K (swallowing/nutritional status) reflected that resident's weight was 132 pounds (lbs) and was coded with weight loss and not on physician prescribed weight loss regimen.A review of the annual nutrition assessment dated [DATE], revealed that the current diet was regular/mechanical soft ground/thin liquids with health shake 4 oz (ounces) BID (twice a day), super cereal at breakfast, and super mash at dinner. The current documented weight (wt) was 132 lbs on 3/24/26, and the resident had a significant wt loss over the past three and six months, losing roughly 10% and 14% total BW (body weight). The new recommendation were to continue with current diet regimen and fortified foods and would add double protein portions and would double super cereal at breakfast as resident had good acceptance of these.A review of the weight records revealed the following recorded weight summary in the electronic records:3/24/26 at 2:42 PM, 131.4 lbs.4/7/26 at 2:52 PM, 133 lbs.4/14/26 at 4:30 PM, 134.5 lbs4/21/26 at 7:49 AM, 134.8 lbs.5/8/26 at 9:32 AM, 135 lbs.6/8/26 at 9:47 AM, 137.2 lbs.A review of the care plan (CP) report revealed a focus on nutrition that the resident met the criteria for severe malnutrition r/t (related to) moderate muscle and fat wasting wt loss, that was initiated on 8/12/21, revised on 2/16/26. The CP interventions included but were not limited to, provide assistance with meals as needed (PRN) that was revised on 2/13/23; provide fortified foods as ordered: super cereal at breakfast and super mash at dinner that was initiated on 2/2/26 and revised on 6/10/26.Further review of the CP revealed that the recommendations on annual nutrition assessment dated [DATE], to add double protein portions and double super cereal at breakfast were not followed and to reflect an update in the resident's CP.On 6/16/26 at 8:20 AM, the Surveyor observed the 1st (first) floor dining room with staff assisting residents in preparation for breakfast that included Resident #16. The Director of Nursing (DON) provided the surveyor with a copy of the resident's diet slip. The DON assisted the resident for breakfast. The surveyor observed the resident's tray with the same amount of scrambled eggs as the rest of residents inside the dining room and no super cereal.At that same time, the DON confirmed that Resident #16 had the same amount of scrambled eggs as the other residents. The DON also confirmed what the resident received in their breakfast tray, which included, two container of apple juices, one cup of coffee, 236 ml (milliliters) of milk, the plate with ground waffles, and the scrambled eggs. There was no double portion of super cereal. A review of the diet slip that was provided by the DON revealed, resident's name, Tuesday breakfast, 6/16/26, 2x apple juice, plain scrambled eggs, waffles, dices peaches, coffee, milk, alternate: cold cereal with milk, and assist with meals PRN. The super cereal was written twice and had a straight mark of black marker.Further review of the above diet slip revealed that there was no information about double portion for protein as reflected on 3/31/26 annual nutrition assessment recommendation of the dietician.On 6/16/26 at 8:33 AM, the Surveyor asked the Director of Quality Assurance (DQA), who at that time was at the 1st floor nursing station, in front of the dining area about resident's diet order. The Surveyor also notified the DQA of the above concerns that the resident did not receive a double portions of protein and super cereal as recommended on the annual nutrition assessment on 3/31/26, and the Surveyor showed the diet slip. The DQA immediately called the Dietician and told the Dietician to talk to the Surveyor about Surveyor's concernsOn 6/16/26 at 8:44 AM, the Surveyor interviewed the Registered Dietician (RD), who informed the Surveyor that Resident #16 was cognitively impaired, needed help with eating, had a good appetite, and with history of weight loss. The Surveyor notified the RD of the above findings and concerns that the resident's CP was not updated or revised to include the recommendation on 3/31/26, and the observation that the resident did not receive double portions of protein and super cereal during breakfast.At that same time, the RD stated, maybe super farina (an excellent, low-fat source of carbohydrates, iron, and B-vitamins) would be provided instead of the super oatmeal that was why the super cereal was erased in the diet slip. On 6/16/26 9:47 AM, the RD stated he did not know as to why there were no double portion of super cereal, and it was erased in the diet slip. On 6/16/26 at 9:55 AM, the DON stated that there were no super cereal in the resident's tray during breakfast when she fed the resident. She further stated that after Surveyor's inquiry, the kitchen brought applesauce, and she thinks the super farina too was sent afterward. On 6/16/26 at 10:40 AM, the Surveyor interviewed the Food Service Director (FSD), who informed the Surveyor that it was the dietician's responsibility to add the information in the resident's diet slip, the supplements and other double portions like super cereal and protein. He further stated, I think we sent the super farina after Surveyor's inquiry, and that was why it was erased because the resident would be provided with other supplemental food.At that same time, the FSD stated that there was another list that they had for residents that included double portion. He further stated that it was the Dietary Aide (DA) who was responsible for providing the double portions in resident's tray. On 6/16/26 at 10:50 AM, the Surveyor and the FSD went to the kitchen to check the list of residents that included double portions. In the kitchen, the FSD provided the printed census list that provided the resident names, that included their diets, and diet notes. Further review of the list revealed it was dated 6/16/26 at 10:53 AM, with Resident #16's information and diet note included double protein. There was no information about double super cereal at breakfast. The Surveyor asked for the printed list that the DA was followed during breakfast tray preparation, and the FSD was unable to provide documentation.Afterward, outside the kitchen, the Surveyor interviewed the DA, who stated that he was responsible for plating double portions, and that he knew who the residents were who should receive double portions according to residents' diet slip. He further stated that there was no other list that he followed for plating double portions except for the diet slip that goes to resident's meal trays. The Surveyor showed the provided printed list dated 6/16/26 at 10:53 AM to the DA, and the DA stated that he was unaware of the list.Furthermore, the DA confirmed that Resident #16 was not on the list to receive double portions. On 6/16/26 at 11:31 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, DQA, and the Surveyor notified them of the above findings and concerns with Resident #16's breakfast tray and CP.On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated that there was a glitch in the system that was why the double protein recommendation was not reflected in the diet ticket of Resident #16, and it was corrected after Surveyor's inquiry.On 6/18/26 at 12:53 PM, the survey team met with the LNHA, DON, DQA, two Regional DONs, Assistant DON, and the Co-President for an exit conference, and there was no additional information provided by the LNHA. There was no policies provided with regard to diet slip and following recommendations of the Dietician. NJAC 8:39-17.1(c); 17.4(c); 27.1(a)

Based on observation, interview, and record review of other pertinent facility documentation, it was determined that the facility failed to: a.) follow the physician order with regard to tube feeding and b.) obtain a physician order with regard to tube feeding site treatment and care. This deficient practice was identified for 1 of 1 resident (Resident #146) reviewed for enteral tube feeding, in accordance with facility's policies and protocol. This deficient practice was evidenced by the following:On 6/10/26 at 10:17 AM, the Surveyor observed from the hallway, Resident #146 in their room seated on a wheelchair and observed an enteral feeding pole and pump in the room. On 6/10/26 at 1:16 PM, the Surveyor reviewed the admission Record or face sheet (an admission summary) which revealed diagnoses that included but not limited to; pneumonia (a lung infection), dysphagia (difficulty swallowing), malignant neoplasm of tongue, and gastrostomy status. A review of the comprehensive Minimum Data Set (MDS), an assessment tool to facilitate the care plan, with an assessment reference date (ARD) of 6/5/26, revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15 indicating moderate impaired cognition. The MDS also reflected that the resident had a tube feeding (TF). A review of the Care Plan revealed that the resident required TF related to dysphagia, date initiated: 5/29/26. A review of the Physician Orders (PO) revealed:An order dated 6/2/26, in the afternoon Provide Jevity 1.5 at 80ml/hr (milliliters/hour) via PEG continuous feed up at 4:00 PM and down once TV [total volume] infused: 1440 ml, 2160 kcals (kilocalories), 92 g (gram) protein, and 1094 ml H2O (water) and every day shift record TV Infused.An order dated 5/29/26, every evening shift continue TF until prescribed amount was delivered, allowing for interruption. Hung at 4:00 PM and down when dose complete.An order dated 5/29/26, every shift record the reading on pump at end of each shift.An order dated 5/29/26, one time a day cleanse tube site with NS [normal saline] daily.A review of the electronic Medication Administration Record (eMAR) for the month of June 2026, revealed the order dated 5/29/26, for enteral feed order every shift record the reading on pump at end of each shift: On the evening shifts of 6/2/26 and 6/10/26, there were no documented values on the pump and were blanks. The night shifts [combined total amount of TF from evening and night shifts=15 hours at 80 ml/hr=approximately 1200 ml total] reflected on 6/1/26=400 ml; 6/2/26=958 ml; 6/3/26=1133 ml; 6/4/26=900 ml; 6/5/26=500 ml; 6/6/26=688 ml; 6/7/26=1081 ml; 6/8/26=290 ml; 6/9/26=400 ml; 6/10/26=397 ml. On 6/11/26 at 11:28 AM, the Surveyor, from the hallway observed Resident #146 in their room, seated on a wheelchair. Both the Surveyor and the Registered Nurse (RN) entered the resident's room, and the RN stated that the TF was finished. The RN showed the Surveyor the pump which reflected the TV administered was 1440 ml. The RN stated on his shift he would enter the TV of 1440 ml as registered in the machine. He further stated that the other shifts, evenings, and nights, would also put what was the TV registered on the machine on their shift. On that same date and time, the Surveyor asked the RN what his process for TF site care and he stated that the doctor gave a verbal order to the Nurse Practitioner to apply Silvadene cream and split gauze to the site, about five days ago because the resident was complaining of discomfort, burning, and itching on the site. The RN also stated that the resident stated the treatment had stopped the discomfort, burning, and itching. The RN proceeded to show the surveyor the TF site with the resident's permission and observed a split gauze on the TF site, and the tube was secured against the abdomen. The RN confirmed that he applied the Silvadene this morning. On 6/11/26 at 11:40 PM, at the nursing station, the Surveyor, the RN, and the Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed the orders and the eMAR. The RN and LPN/UM confirmed that the eMAR did not make sense and would fix the order. The LPN/UM confirmed that the PO for TF were not followed on what to document on TV.At that same time, the Surveyor, the RN, and the LPN/UM reviewed the electronic Treatment Administration Record (eTAR) for the month of June 2026. Both the LPN/UM and the RN confirmed that there was no order for TF care site that included Silvadene treatment. On 6/16/26 at 11:45 AM, the survey team met with the License Nursing Home Administrator (LNHA), Director of Nursing (DON), and the Director of Quality Assurance (DQA), and the surveyor notified them of the concerns regarding PO for TV was not followed and the treatment for Sivadene was administered with no PO. On 6/18/26 at 11:45 AM, the survey team met with the LNHA, the DON, and the DQA stated that nurses were confused with the documentation, moving forward they (nurses) would document at the end of their shift. The DQA further stated that they corrected the PO after surveyor's inquiry. The DQA added that nurses were educated to obtain an order and transcribed the PO prior to administering a treatment. A review of the facility's Enteral Nutrition Policy, with a reviewed date of 6/2026, revealed under policy explanation and procedure: #5. Enteral feeding orders will be written to ensure consistent volume infusion .to ensure that the full volume will be infused, regardless of any interruption of feeding .A review of the facility's Administering Medications (meds) Using Electronic System Policy, with a reviewed date of 11/2025, revealed under policy interpretation and implementation #3. Meds must be administered in accordance with doctor's orders, including any required time frame Under #9.4. Topical meds used in treatments must be recorded on the resident's eTAR.NJAC 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, 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, a.) that nebulizer treatment equipment and incentive spirometer were dated and stored in accordance with infection control measures and b.) had a physician's order for the respiratory care for 1 of 3 residents (Resident #174) reviewed for respiratory care. This deficient practice was evidenced by the following:On 6/10/26 at 9:54 AM, the Surveyor observed Resident #174 seated in a wheelchair (wc) in their room. The Surveyor observed a nebulizer (neb) treatment mask attached to a machine on a three drawer cart. The tubing was not dated and the mask was not stored in a bag. The Surveyor observed an incentive spirometer sitting on the dresser. The incentive spirometer was not stored in a bag. Resident #174 stated that they were in the hospital for pneumonia and had been using the puffer and received treatments.On 6/11/26 at 9:27 AM, the Surveyor reviewed Resident #174's medical record. A review of Resident #174's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to pneumonia (an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus) and hypertension (high blood pressure).A review of Resident #174's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/29/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact.A review of Resident #174's June 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) did not include any order for neb treatment or incentive spirometer.A review of Resident #174 May 2026 eTAR included the following physician order (PO): a neb treatment order that was discontinued (d/c) on 5/28/26.On 6/11/26 at 9:54 AM, the Surveyor observed Resident #174 seated in a wc in their room. The Surveyor observed an incentive spirometer sitting on the dresser and it was not stored in a bag. Resident #174 stated that the last time they had used the neb treatment was about a week ago. Resident #174 stated that they used the incentive spirometer once or twice a week and it helps with breathing. On 6/11/26 at 9:59 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN), who stated that neb treatment tubing and incentive spirometer was dated and stored in a plastic bag. The Surveyor showed the LPN the picture of Resident #174's neb treatment and incentive spirometer observation. The LPN stated that it was not acceptable and that it should not have been left out. The Surveyor asked about the d/c neb order and the LPN stated that she did not know why it was left there after it was d/c.On 6/11/26 at 10:14 AM, the Surveyor interviewed the LPN/Unit Manager (LPN/UM) of 3 East, who stated that neb treatment equipment was changed weekly on Sunday 11-7 shift and should be dated. She added that they should be stored in a plastic bag with label. The LPN/UM stated that the incentive spirometer was stored in a bag and that it needed a PO. The Surveyor notified the LPN/UM of Resident #174's respiratory equipment observations and that there were no current PO for the neb treatment or incentive spirometer. The LPN/UM stated that she believed that the resident had an order when they came back from the hospital and was probably d/c because it was for a certain amount of time.On 6/15/26 at 11:49 AM, the Surveyor interviewed the Director of Nursing (DON), who stated that the neb treatment equipment and incentive spirometer should be in a bag and labeled with the date. The DON further stated that for the incentive spirometer there was an order usually for two weeks. The Surveyor showed the DON the pictures of Resident #174's respiratory equipment observations and that there was no current PO for them. The DON stated that the equipment should not have been that way. The DON checked the resident's PO and stated that the incentive spirometer had been ordered for two weeks in April.On 6/16/26 at 11:31 AM, the Surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA) the concern that Resident #174's neb treatment mask/tubing and incentive spirometer was not dated and stored in a plastic bag and there was not a current PO for the neb treatment and incentive spirometer.On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that Resident #174's respiratory equipment had been removed. The LNHA did not provide any additional information.A review of the facility's Oxygen/Neb Care Policy, with a reviewed date of 10/2025, included the following:1.j. cannulas, masks, and incentive spirometers should be changed weekly or as necessary.2.d. Change neb tubing weekly and PRN (as needed), label with date and initials.2.e. Change incentive spirometer weekly and label with date and initials.2.f. All tubing and masks shall be placed in a plastic bag for storage when not in use.A review of the facility's Incentive Spirometry Policy, with a reviewed date of 10/2025, included the following:2. Verify Medical order. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to: a.) ensure accuracy of shift to shift counting of residents controlled medications (meds) in medication (med) carts and b.) routinely follow the shift to shift count of controlled meds in the backup machine. This deficient practice was identified in 1 of 5 med carts (2nd floor med cart 1) and 1 of 4 med rooms (controlled backup med room). This deficient practice was evidenced by the following:1. On 6/15/26 at 11:46 AM, the Surveyor in the presence of the Registered Nurse (RN) inspected the 2nd (second) floor nursing unit med cart 1. A review of the narcotics located in the secured and locked narcotic box and reconciled to the controlled drug administration record, a declining inventory sheet, revealed Unsampled Resident #1's tramadol 50 milligram (mg) half tablet (tab) (half tab=25 mg), a med used to relieve pain, did not match. The blister packs contained 54 tablets (tabs) and the declining inventory sheet indicated there should be 55 tabs remaining. There was a bingo card slot that was intact and did not have a med tab inside.On that same date and time, the RN stated when she did the shift to shift count with the outgoing 11-7 (11:00 PM-7:00 AM) Licensed Practical Nurse (LPN) this morning she did not notice the 30 counts bingo card tramadol med one slot was empty. She confirmed that there should only be 54 half tabs of tramadol, and there was a discrepancy of one half tab. The RN also stated that the 1/29/26 date in the two of 30 counts bingo cards (bingo card #1 contained 25 tabs and bingo card #2 contained 29 [number 16 was not inside the blister pack) of tramadol was the filled up date from the pharmacy and could be the delivery date as well.On 6/15/26 at 1:17 PM, the Surveyor interviewed the Director of Nursing (DON), who stated that she was unaware of the concern that the tramadol had discrepancy during med storage inspections of the Surveyor. The DON further stated that when the tramadol was delivered in January 2026, the discrepancy should have been identified, and not until Surveyor's inquiry. She added that she would investigate the incident and asked the nurses as it was part of the shift to shift endorsement the accuracy of controlled meds count. On 6/16/26 at 11:31 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Director of Quality Assurance (DQA), and the Surveyor notified them of the above findings and concerns with regard to med cart 1 in 2nd floor nursing unit discrepancy with tramadol.2. On 6/18/26 at 8:41 AM, the Surveyor with the 2 East Licensed Practical/Unit Manager (LPN/UM) went to the 2 East med room where the backup machine for controlled meds were located. The LPN/UM informed the Surveyor the process for cycle count, that as per facility practice, it was being done between the LPN/UM and the Assistant DON (ADON) or the ADON and the nursing Supervisor at least once a day. The LPN/UM stated there was a log where the two nurses would sign to confirm that they did the cycle count. She also stated that there was no printed reports when the cycle count was done, it would be in machine.At that same time, the LPN/UM showed the Surveyor the log, which she confirmed in the first page of the binder was for June 2026. The form had no month and year, with signatures from 1st to 17th. The Surveyor asked why there was no signatures for the 18th, and the LPN/UM responded that they still have time to do it this shift (7:00 AM-3:00 PM). The Surveyor asked for copy of the backup narcotics (controlled meds) shift count sign in sheets for cycle count for the last three months and the cycle reports, and she responded that she would get back to the Surveyor.A review of the provided backup narcotics shift count sign in sheets for the last three months revealed:April 2026, the sign in sheet was signed by off going nurses and witness nurse on dates 4/1, 4/3, 4/6, 4/7, 4/8, 4/10, 4/13, 4/14, 4/15, 4/16, 4/17, 4/20, 4/22, and 4/28/26. It was 16 out of 30 days that the cycle counts were not done.May 2026, the sign in sheet was signed by off going nurses and witness nurses on dates 5/1, 5/4, 5/6, 5/8, 5/11, 5/20, 5/22, 5/25, 5/26, 5/27, 5/28, and 5/29/26. It was 19 out of 31 days that the cycle counts were not done.June 2026, the sign in sheet was signed by off going nurses and witness nurses on dates 5/1 through 5/17/26.On 6/18/26 at 10:16 AM, the Surveyor observed the LPN/UM and the Licensed Practical Nurse Supervisor (LPNS) did the cycle count of backup controlled meds in the backup machine inside the 2 East med room, and there were no discrepancies noted.Afterward, the Surveyor interviewed both the LPN/UM and the LPNS stated that per facility practice, the cycle count should be done at least once a day to ensure there were no discrepancies and in order to determine which controlled meds needed to be reordered and to be taken out from the machine due to expiration date. The LPNS further stated, I do not know, as to why there were days in April and May 2026 that cycle counts were not done, and no one signed and those dates. The LPN/UM acknowledged that the cycle count should be done daily. On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated that the cycle count not being done, they were missed, and moving forward it would be done. A review of the facility's Dispensing Machine Policy, that was provided by the Infection Preventionist Nurse, with a reviewed/revised date of 10/25, revealed under procedure, controlled substances in the dispensing machine is counted by two licensed nurses once a day.NJAC 8:39-29.7(c)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more. During the medication (med) administration observation on 6/12/26, the surveyor observed two nurses administering meds to four residents. There were 31 opportunities, and five errors were observed which resulted in a med error rate of 16.13%. This deficient practice was identified for 3 of 4 residents (Residents #61, #79, and #174), that was administered by one nurse. This deficient practice was evidenced by the following:1. On 6/12/26 at 9:45 AM, the Surveyor observed the Licensed Practical Nurse (LPN) preparing meds for Resident #79. The meds included, but were not limited to, the following Physician's Order (PO):Sevelamer Carbonate oral tablet (tab) 800 milligrams (mg), give 2 tablets (tabs) by mouth two times a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for chronic kidney disease (CKD; a condition in which the kidneys are damaged and cannot filter blood as well as they should), 2 Tabs = 1600 mg may give with vanilla pudding one at a time, and give 2 tabs by mouth with meals every Mon (Monday), Wed (Wednesday), Fri (Friday), Sun (Sunday) for CKD, 2 Tabs = 1600 mg, may give with vanilla pudding one at a time. The PO started on 12/2/25.At this time, the Surveyor observed the PO above was due at 8:00 AM and was highlighted in red on the electronic med administration record (eMAR), indicating the med was overdue.Error #1. On 6/12/26 at 10:09 AM, the Surveyor observed the LPN administered the med to Resident #79 without a meal. The Surveyor observed there was no breakfast tray in the resident's room.On 6/12/26 at 10:13 AM, the Surveyor interviewed the LPN who stated the expectation was to give the med within an hour before or an hour after its scheduled time. The LPN acknowledged that they administered the PO listed above late to Resident #79. The LPN stated the resident's meal tray arrived at 8:30 AM today. The LPN confirmed breakfast time had passed and that they did not follow the instructions to give sevelamer carbonate with a meal. The LPN further stated they would prioritize in the future.A review of the Medication Administration Audit Report (MAAR) of 6/12/26, for Resident #79, revealed that Sevelamer Carbonate oral tab 800 mg was scheduled for 6/12/26 at 8:00 AM, was administered on 6/12/26 at 9:45 AM, and documented on 6/12/26 at 10:14 AM.2. On 6/12/26 at 10:18 AM, the Surveyor observed the LPN preparing meds for Resident #61. The meds included, but were not limited to, the following PO:Toprol XL oral tab Extended Release (ER) 24 Hour 25 mg, give 0.5 tab (12.5 mg) by mouth one time a day for hypertension (HTN; high blood pressure), hold for systolic blood pressure (SBP)<100 or heart rate (HR) <60, administer with meal. The PO started on 5/23/26.On 6/12/26 at 10:30 AM, the Surveyor observed Resident #61's bingo card (a multi-dose card containing individually packaged meds) labeled Metoprol Succinate tab 25 mg ER. Brand: Toprol XL, containing a whole tab in 28 of 30 individual compartments. At this time, the LPN popped out one whole tab of Toprol XL 25 mg ER from Resident #61's bingo card.On 6/12/26 at 10:35 AM, the LPN informed the Surveyor that they were ready to administer the meds to Resident #61.On 6/12/26 at 10:37 AM, the Surveyor observed the LPN entered Resident #61's threshold for administration. The Surveyor stopped the med pass and requested to speak with the LPN outside the resident's room to review the eMAR and the PO.Error #2. At this time, the LPN admitted they were about to administer the wrong dose of the Toprol XL to Resident #61, as they had prepared one whole tab of 25 mg, but the PO was for 0.5 tab (12.5 mg). The LPN stated they would clarify the order with the doctor.On 6/12/26 at 10:41 AM, the LPN split the Toprol XL tab along the score line with their fingers wearing gloves and placed one half of the tab in a med cup.At 10:42 AM, the LPN wasted the other half of the tab in the drug buster. Then, the LPN administered Resident #61's meds, including 0.5 tab (12.5 mg) of Toprol XL.A review of the MAAR of 6/12/26 for Resident #61, revealed that Toprol XL 0.5 tab (12.5 mg) was scheduled for 6/12/26 at 8:00 AM, was administered on 6/12/26 at 10:24 AM, and documented on 6/12/26 at 10:46 AM.On 6/15/26 at 9:30 AM, the surveyor interviewed the Director of Nursing (DON), who stated their investigation revealed that on 5/22/26, the Nurse Practitioner (NP) updated the resident's order of Toprol XL from one tab (25 mg) to one half tab (12.5 mg). When the NP updated the order, the NP clicked yes under existing active supplies. The pharmacy did not send the new med dosage because the order was sent as profile only under the exiting active supplies. The DON stated they explained to the NP that whenever the NP changes a dose of a med, they must not click yes under existing active supplies. Rather, the NP should return the med to the pharmacy, and the pharmacy could send a new med. The DON further stated the NP was unaware of this.In addition, the DON stated they spoke with three nurses who verbalized that they had been cutting the Toprol XL 25 mg tab in half to administer one half tab, and they had been disposing of the other half in the drug buster. The DON further stated the nurses did not notify anyone.Furthermore, the DON stated that the nurses were expected to call the pharmacy to obtain the actual med they were supposed to give, and ensure they administered the actual dose as ordered to the resident. The DON further stated the nurses were expected to tell the doctor that they received whole tabs from the pharmacy, and the doctor would have had to provide approval for the nurses to give a half tab. The DON confirmed the nurses did not call the pharmacy or the doctor. The DON added that the facility started an in-service with their nurses. The DON confirmed it was a med error regarding the residents' Toprol-XL.3. On 6/12/26 at 10:51 AM, the Surveyor observed the LPN preparing meds for Resident #174. The meds included, but were not limited to, the following POs:Carvedilol oral tab 25 mg, give 1 tab by mouth every 12 hours for HTN hold for systolic blood pressure (sbp; the top number in a blood pressure (bp) reading) <110 or heart rate (hr) <60. The PO started on 6/5/26.Metformin Hydrochloride (HCl) tab 1000 mg, give 1 tab by mouth two times a day for diabetes mellitus (DM), give with meals. The PO started on 4/10/26.Pregabalin oral capsule (cap) 100 mg, give 1 caps by mouth two times a day for pain. The PO started on 4/10/26.Error #3. At this time, the Surveyor observed that carvedilol was due at 9:00 AM and was highlighted in red on the electronic Medication Administration Record (eMAR), indicating the med was overdue.On 6/12/26 at 11:22 AM, the Surveyor observed the LPN administered carvedilol to Resident #174. In addition, the surveyor observed that the order for carvedilol did not have instructions to give with food.A review of the prescribing information for carvedilol revealed under dosage and administration, Coreg (carvedilol) should be taken with food to slow the rate of absorption and reduce the incidence of orthostatic effects (a drop in bp that occurs upon standing).Error #4. At this time, the Surveyor observed that metformin HCl was due at 9:00 AM and was highlighted in red on the eMAR, indicating the med was overdue.On 6/12/26 at 11:22 AM, the Surveyor observed the LPN administered metformin to Resident #174 without a meal. The Surveyor observed there was no breakfast tray in the resident's room.Error #5. At this time, the Surveyor observed that pregabalin was due at 9:00 AM and was highlighted in red on the eMAR, indicating the med was overdue.On 6/12/26 at 11:22 AM, the Surveyor observed the LPN administered pregabalin to Resident #174.On 6/12/26 at 11:27 AM, the Surveyor interviewed the LPN who stated the expectation was to give the med within an hour before or an hour after its scheduled time. The LPN stated that Resident #174's meal tray arrived at 8:30 AM today. The LPN acknowledged that they administered the POs listed above late to Resident #174. The LPN confirmed breakfast time had passed and that they did not follow the instructions to give metformin with a meal. When the surveyor asked the LPN if they planned to notify the doctor that the LPN administered the meds late and did not give metformin with a meal, the LPN stated they were not going to notify the doctor.A review of the MAAR of 6/12/26 for Resident #174 revealed the following:Carvedilol oral tab 25 mg was scheduled for 6/12/26 at 9:00 AM, was administered on 6/12/26 at 10:56 AM, and documented on 6/12/26 at 11:27 AM.Metformin HCl tab 1000 mg was scheduled for 6/12/26 at 9:00 AM, was administered on 6/12/26 at 11:00 AM, and documented on 6/12/26 at 11:27 AM.Pregabalin oral cap 100 mg was scheduled for 6/12/26 at 9:00 AM, was administered on 6/12/26 at 11:12 AM, and documented on 6/12/26 at 11:27 AM.On 6/15/26 at 9:30 AM, in the presence of the survey team, the Director of Nursing (DON) confirmed that when the nurse administered residents' meds late and did not follow the PO, these were med errors.On 6/16/26 at 11:32 AM, in the presence of the survey team, the Surveyor discussed the concerns with the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA).On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated the nurses should be passing their meds in a timely manner, and their performance did not meet the criteria. The DQA further stated they updated resident #174's carvedilol order to administer with food, and in-serviced staff regarding med orders as well as timely med administration documentation and order compliance.A review of the facility's Administering Medications Using Electronic System Policy, reviewed 6/2026, revealed, meds shall be administered in a safe and timely manner, and as prescribed. Meds must be administered in accordance with doctor's orders, including any required time frame and following med cautionary. The individual administering the med must check the label three times to verify the right med, right dosage, right time and right method (route) of administration before giving the med. Meds may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified.NJAC 8:39-29.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain a medication (med) refrigerator temperature log and b.) ensure med refrigerator freezer free from ice accumulation to ensure safe med storage. This deficient practice was observed in 2 of 3 med storage rooms (1st and 2nd floor med rooms), and was evidenced by the following:On 6/15/26 at 11:30 AM, the Surveyor in the presence of the Licensed Practical Nurse (LPN) and the LPN/Unit Manager (LPN/UM) inspected the 2nd floor nursing unit's med room and observed the uncovered med freezer inside the med refrigerator (ref) with accumulation of ice with medications (meds) that included TB (tuberculin) vial, a med used for TB testing, and locked controlled meds.At that same time, the LPN/UM provided the ref temperature (temp) log for June 2026, with a handwritten time, temp, and nurses initials for AM (morning) and PM (afternoon). There were no documented logs on PM of 6/14/26 and AM of 6/15/26. The log on PM of 6/11/26 was crossed out and there was no identifiable information on the ref temp.Furthermore, the LPN/UM stated that the med ref freezer should not be like that, and she would call the maintenance about it. She further stated that the temp log was probably missed.On 6/16/26 at 8:09 AM, the Surveyor in the presence of the Registered Nurse (RN) inspected the 1st floor med room. Inside the med room, both the Surveyor and the RN observed the med ref freezer with heavy accumulation of ice and there was a mounjaro box, a prescription injectable med used to improve blood sugar with type 2 diabetes. The RN stated that she would ask for maintenance to check the med ref for accumulation of ice. She acknowledged that the med ref should have been maintained and there should be no heavy ice accumulation to protect the meds.On 6/16/26 at 11:31 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Director of Quality Assurance (DQA), and the Surveyor notified them of the above findings and concerns with regard to med rooms refrigerators and temp log.On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated that 1st and 2nd floor med rooms ref freezers accumulation of ice were addressed and corrected after surveyor's inquiry.A review of the facility's Refrigerator and Freezer Policy, that was provided by the DQA, with a revised date of 10/25, revealed, that all refrigerator units should be kept clean and in good working condition at all times. Thermometers should be checked at least two times each day. Refrigerators/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures.NJAC 8:39-29.4(h), 29.7(c)

Based on observation, interviews, record review, and review of other pertinent documentation, it was determined that the facility failed to provide necessary dental care services in a timely manner for 1 of 1 resident (Resident #159) reviewed for dental care services.This deficient practice was evidenced by the following:On 6/10/26 at 10:11 AM, the Surveyor observed Resident #159 seated in a wheelchair in their room. Resident #159 stated that they needed to see a dentist and needed a cleaning. Resident #159 stated that they told the staff but that they had been moved a couple times to different units.On 6/11/26 at 10:45 AM, the Surveyor reviewed Resident #159 hybrid (electronic and paper) medical record.A review of Resident #159's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to congestive heart failure (a chronic condition where the heart muscle is too weak or stiff to pump blood effectively) and hypertension (high blood pressure).A review of Resident #159's most recent Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/12/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated that the resident's cognition was moderately impaired.A review of Resident #159's Order Summary Report included the following order: Consult: May be seen and treated by a Dentist as needed with an order date of 12/24/24.A review of Resident #159's hybrid medical record did not include any dental consultation information.On 6/11/26 at 10:53 AM, the Surveyor interviewed the Licensed Practical Nurse (LPN), who stated that if a resident or resident representative (RR) requested a dental visit then the nurse would notify the Unit Manager (UM).On 6/11/26 at 11:31 AM, the surveyor interviewed the LPN/UM of 3 East, who stated that she emailed a list of residents to the Dental Consultant (DC) and that the DC visit forms were kept in the medical record. The Surveyor asked if someone that was at the facility for more than a year should have a DC visit form in their medical record, and the LPN/UM stated yes. The LPN/Um further stated that the resident was fairly new to their unit and that she would have to look in the medical record. The LPN/UM reviewed the medical record and confirmed that there was no DC visit form.On 6/15/26 at 10:44 AM, the LPN/UM stated that Resident #159 had not been seen yet by a DC and that she just sent a referral for the resident to be seen on their next visit to the facility. The LPN/UM confirmed that Resident #159 did not have a DC visit prior to surveyor's inquiry. On 6/15/26 at 11:59 AM, the Surveyor interviewed the Director of Nursing (DON), who stated that for residents on Medicaid that they see a DC when they send a referral. The Surveyor notified the DON that there was no documented evidence that Resident #159 was seen by the DC and asked if the resident should have been seen. The DON stated that everyone should have a visit if long term care.On 6/16/26 at 11:31 AM, the Surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA) the concern that Resident #159 was not seen by the DC.On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that the LPN/UM was educated that residents would have a dental consult one time a year and that a referral for a DC was made for Resident #159 after surveyor's inquiry.A review of the facility's Dental Examination/Assessment Policy, with a revised/reviewed date of 6/2026, included the following:1. Prior to, or within ninety days after admission, the resident will have a dental consult if needed and will undergo a dental examination.2. Dental examinations will be made by the resident's personal dentist or by the facility's Consultant Dentist.3. Records of dental care provided shall be made a part of the resident's medical record.4. Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist.N.J.A.C. 8:39-15.1

Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to: a.) clarify the duplicate instructions for ambulation, b.) ensure the functional maintenance program (FMP) was provided, and c.) update or revise care plan to reflect the FMP. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for the residents with limited mobility and receives appropriate services to maintain or improve and prevent further decline. This deficient practice was evidenced by the following:On 6/10/26 at 10:47 AM, the surveyor did not observed Resident #11 in their room.On 6/11/26 at 10:58 AM, the surveyor reviewed the medical records of Resident #11.A review of the admission Record or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and essential hypertension (elevated blood pressure).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 4/14/26, revealed in Section C (cognitive patterns), the resident had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, which reflected that the resident's cognition was severely impaired. Section GG (functional abilities) revealed that the resident had an impairment on one side of upper extremity limitation that interfered with daily functions.A review of the tasks tab in the electronic medical records (eMR) revealed:FMP: active range of motion for BLE's (bilateral lower extremities) in all planes of motion 3 x 10 reps (repetitions) each as tolerated), revised by the Director of Nursing (DON) on 6/4/24. A review of the above FMP for BLEs revealed that for 30 days, it was signed as done for 7 of 30 days. The FMP was not provided routinely and the above instructions for FMP was not clear as to how often it should be done.FMP: ambulation for 50 feet with assist of CGA (contact guard assist, a level of physical assistance where a caregiver or therapist keeps one or two hands directly on the resident (usually on a gait belt) to provide balance and prevent falls, but provides zero physical effort to move the patient forward) with RW (rolling walker)/gait belt as tolerated, revised by the Infection Preventionist Nurse on 3/20/26. A review of the above FMP ambulation from 6/1/26 to 6/11/26, revealed, 1 of 11 days FMP was done.Walk 50 feet with two turns, with revision date of 7/10/25, that was a system generated.A review of the above system generated ambulation for 50 feet, revealed, it was coded with substantial/maximal (helper does more than half the effort) assistance on 6/1/26, and dependent (helper does all of the effort) on 6/2, 6/4, 6/5, 6/8, 6/9, and 6/10/26. The instructions did not include complete information on how often the system generated ambulation should be done.A review of the care plan (CP) report revealed there was no documented evidence that the resident's FMP for BLEs range of motion and ambulation were reflected in the CP.On 6/11/26 at 12:40 PM, the surveyor observed Resident #11 in the 1st (first) floor dining area and was able to feed self-post set up.On 6/12/26 at 8:20 AM, the surveyor interviewed the assigned Certified Nursing Assistant (CNA) of Resident #11, who informed the surveyor that the resident was pleasantly confused and required extensive assistance with adls (activities of daily living), able to feed self-post set up, and non-ambulatory. The CNA was unaware of any FMP or exercise done to the resident. On 6/12/26 at 8:29 AM, the surveyor interviewed the Director of Rehabilitation/PT (Physical Therapist) (DoR/PT) who informed the surveyor that there were two staff assigned to FMP and they document in the task section of the eMR. The surveyor asked for list of residents on FMP, printed task of Resident #11 for the last three months, and facility's policy with regards to FMP.At the same time, the surveyor notified the DoR/PT of the above concerns. The DoR/PT stated that FMP was not daily, it should be done at least two to three times a week (2-3x/week). He did not respond when asked by the surveyor if the frequency of the FMP was in order or instructions. From 6/12/26 at 9:20 AM, both the surveyor and the DoR/PT reviewed the provided MDS [NAME] Priority List by floor/unit, and on 1st floor, Resident #11 was included on the list. A review of the resident's log on the list revealed the following weekly information:From 3/15 to 3/21/26, the form was blank, and the DoR/PT confirmed that neither FMPs were done.From 3/22 to 3/28/26, the form was signed on 3/27/26, for 1 of 7 days FMP was done. From 3/29 to 4/4/26, the form was blank, and 0 of 7 days FMP was done.From 4/5 to 4/11/26, the form was blank, and the DoR/PT confirmed that neither FMPs were done.From 4/12 to 4/18/26, the form was blank, and the DoR/PT confirmed that neither FMPs were done.From 4/19 to 4/25/26, the form was signed by the Restorative Aide (RA) for dates 4/21 and 4/22/26, and 2 of 7 days FMP was done.From 4/26 to 5/2/26, the form was signed by the RA for dates 4/28 and 4/29/26, and 2 of 7 days the FMP was done.From 5/3 to 5/9/26, the form was signed by the RA for dates 5/3, 5/4, 5/5, and 5/6/26, and 4 of 7 days FMP was done. From 5/10 to 5/16/26, the form was signed by the RA for dates 5/11 and 5/13/26, and 2 of 7 days FMP was done. From 5/17 to 5/23/26, the form was signed by the RA for dates 5/17 and 5/20/26, 2 of 7 days FMP was done. From 5/24 to 5/30/26, the form was signed by the RA for date 5/26, and 1 of 7 days FMP was done. From 5/31 to 6/6/26, the form was signed by the RA for dates 6/2 and 6/3/26, and 2 of 7 days FMP was done. From 6/7 to 6/13/26, the form was signed by the RA for date 6/8, and 1 of 7 days of FMP was done. Furthermore, the DoR/PT stated that there was no comments written in the list provided, and confirmed there was no documented evidence as to why the FMPs were not done routinely. The DoR/PT further stated that coding the resident dependent and substantial/maximal assistance with FMP ambulation was not accurately coded. He also stated that dependent meant the two staff were performing the task of ambulation for the resident. The DoR/PT added that there should only one ambulation order and it should have been clarified.On 6/12/26 at 10:27 AM, the DoR/PT stated that per the RA, the resident had no decline and still a CGA for ambulation. The DoR/PT further stated that it was wrong coding for ambulation.On 6/12/26 at 10:53 AM, the surveyor interviewed the RA who stated that once the resident was discharged from Skilled PT, he followed the order for FMP and the direction on how to assist the resident for FMP, and it would be documented in the eMR. He further stated that he provided FMP to residents at least 2-3x/week, no specific days, and at times the residents who were alert and oriented asked for more days depending on their needs. He also stated that he was unsure if that was in their policy, he was aware that FMP was done 2-3x/week.On that same date and time, the RA informed the surveyor that there was no decline with Resident #11's ambulation. He stated that he was unable to provide 2-3x/week of FMP to Resident #11, and did not respond as to why he did not follow the 2-3x/week. He further stated that he was aware that there were duplicate orders for ambulation, and he could only speak about the FMP and not the system generated ambulation which the CNAs signed off, and why it was coded dependent and substantial/maximal assistance.On 6/16/26 at 11:31 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON, Director of Quality Assurance (DQA), and the surveyor notified them of the above findings and concerns with Resident #11's FMP. On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated, we added on the FMP task that Resident #11 should be ambulated 2-3x/week. The DQA further stated that the CP was updated to reflect the FMP, and the RA was educated about frequency of ambulation and if they were on vacation, the other RA should pick up. The DQA also stated that the resident was screened the other day and there was no decline, I believe it was not the CNA's responsibility to ambulate the resident.A review of the facility's Functional Maintenance Program Policy, that was provided by the DoR/PT, with a reviewed date of 5/2026, revealed that there was no information on how often FMP should be provided to the residents.NJAC 8:39-27.1(a); 27.2(m)

COMPLAINT #2720685 Based on interviews, review of medical records, and pertinent facility documentation, it was determined that the facility failed to notify the Resident's Representative of a change in condition for 1 of 1 sampled residents reviewed (Resident #183). This deficient practice was evidenced by the following:On 6/10/26 at 1:08 PM, the surveyor reviewed Resident #183's closed hybrid (paper and electronic) medical record.A review of Resident #183's admission record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (an umbrella term for a decline in mental ability that is severe enough to interfere with everyday life) and hypertension (high blood pressure).A review of Resident #183's most recent discharge return anticipated Minimum Data Set (MDS) reflected that the resident's cognitive skills for daily decision making was severely impaired. Further review reflected that the resident had an unstageable pressure ulcer/injury which was not present on admission (facility acquired).A review of Resident #183's individualized care plan included that the resident had an actual skin impairment of MASD (moisture associated skin damage) to sacral region noted on 12/18/25, and evolved to unstageable on 12/26/25.A review of Resident #183's progress notes (PN) did not include any notification of the Resident Representative (RR) to the new skin impairment on 12/18/25. Further review did not include any notification of the RR of the change to unstageable on 12/26/25.A review of the facility provided timeline of Resident #183's facility acquired wound (pressure ulcer/injury) included that the new skin impairment was noted on 12/18/25. Further review reflected that the RR was given an update on condition on 12/29/25.On 6/12/26 at 10:52 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that when a resident had a MASD that she thought that the RR was notified.On 6/15/26 at 9:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated that if a resident had a new impairment that the RR would be notified. The surveyor asked about Resident #183 and RR notification. The DON stated that she had to check on that.On 6/15/26 at 12:05 PM, the DON stated that she did not see any note about notification [for Resident #183]. On 6/16/26 at 11:31 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA) the concern that the RR was not notified when the resident had a new skin impairment and when it changed to an unstageable.On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that she had no additional information. She added that it was a closed record and whatever was in the record was in the record.The LNHA did not provide any additional information.A review of the facility's Acute Condition Changes-Clinical Protocol Policy, with a revised/reviewed date of 3/2026, included the following:8. RR will be notified for any changed in condition with the resident's permission.A review of the facility's Wound Assessment and Treatment Protocol Policy, with a reviewed date of 10/2025, included the following:New Pressure Ulcer2. Notify Physician, Resident/RR, Interdisciplinary Team.N.J.A.C. 8:39-13.1

Based on observation, interview and record review, it was determined that the facility failed to incorporate the recommendations from a Pre-admission Screening and Resident Review (PASRR) level II determination into a resident's plan of care for 1 of 2 residents reviewed for PASRR (Resident #3). This deficient practice was evidenced by the following:On 6/10/26 at 10:26 AM, the Surveyor observed Resident #3 seated up in bed.On 6/11/26 at 12:08 PM, the Surveyor reviewed Resident #3's medical record.A review of Resident #3's admission record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; bipolar disease with psychotic features (mental illness that causes the individual experiences a temporary disconnect from reality in the form of hallucinations, delusions, or disorganized thinking) and dementia with agitation (clinical condition where a person diagnosed with a cognitive impairment syndrome exhibits).A review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/22/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was mildly impaired.A review of Resident #3's June 2026 electronic Medication Administration Record (eMAR) included the following:Behavior monitoring orders for antipsychotic medication (med) with target behaviors of cursing, hallucinations, impulsiveness, paranoia and physical aggressiveness.Behavior monitoring order for antidepressant med with target behavior of irritability/anger.A review of Resident #3's PASRR Level I Screen revealed a positive screen for MI (mental illness) only which indicated refer to DMHAS (Division of Mental Health and Addiction Services) for a Level II screen.A review of Resident #3's PASRR Level II Determination Notification included that the resident has mental health treatment needs that can be met in a Nursing Facility and that the following recommendations were being made which included but was not limited to, Develop a Crisis Intervention/Safety Plan with the client.A review of Resident #3's individualized comprehensive care plan (CP) included the following:Focus: Resident #3 has a PASRR Level II. Resident #3 has a dx (diagnosis) of serious mental illness with an initiated date of 4/20/26.Goal: Resident #3's care needs will be met. Resident #3's Level II recommendations will be followed with an initiated date of 4/20/26, revision on 6/3/26 and target date of 8/14/26.Interventions: Resident #3's will be followed by psychiatry and psychology. Resident #3 will received rehabilitation. Resident #3 will participate in the plan of care. Initiated: 4/20/26.The CP did not include all of the PASRR Level II recommendations and did not specifically include a Crisis Intervention/Safety Plan.On 6/12/26 at 10:26 AM, the surveyor interviewed the Registered Nurse (RN) who stated that she was unaware of a Level II PASRR.On 6/12/26 at 10:29 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) of 3 east who stated that the Social Worker (SW) did the PASRR. The surveyor asked the LPN/UM if there was anything that Resident #3 needed or any special instructions beside what was in the CP. The LPN/UM stated only in the CP.On 6/12/26 at 11:14 AM, the surveyor interviewed the Director of Social Services (DoSS) who stated that the hospital submitted the Level I and if applicable the Level II PASRR. The DoSS stated that Admissions and the SW would read the Level II recommendations. The surveyor asked the DoSS if a recommendation was for a crisis plan, where would it be. The DoSS stated that she would need to get back to the surveyor. She added that she did not recall any resident having a crisis plan. The DoSS stated that if a resident needed a crisis plan then it would be documented and put it in the CP. The surveyor notified the DoSS that Resident #3 had a Level II determination that recommended a crisis intervention/safety plan and that it was not in the resident's CP. The DoSS stated that she would need to check with the resident's SW. On 6/12/26 at 11:33 AM, in the presence of the SW, the DoSS stated that she confirmed with the nursing team and that the Level 2 recommendations were reviewed by the psychologist and psychiatrist and that anything implemented was done by the psychiatry team. The DoSS stated the purpose of crisis plan was, that their role was to make sure the resident was safe. The DoSS stated that SW saw it [Level II recommendation of Crisis Intervention/Safety Plan]. The SW stated that she did not think that she saw it at that time the recommendations itemized in Level 2 PASRR. The SW further stated that it was an expectation that she would inform the doctor and psychiatrist (psych) to make them aware of the recommendations and see if they had any further recommendation. The surveyor asked if that happened with Resident #3. SW stated that she did not review Resident #3's Level II recommendation. She added that it was reviewed by the admission team.On 6/12/26 at 12:02 PM, the DoSS stated that she read the last psych note of Resident #3 and that it stated that the resident had been stable. She added that she spoke with the nursing team and that they knew that if something was going on that was acute that they would call 262, the crisis intervention hotline and that they would guide them what to do.On 6/15/26 at 11:10 AM, the surveyor reviewed Resident #3's paper medical record and observed that a Crisis Response paper which was dated 6/12/26 11:59 AM was there. The surveyor interviewed the LPN/UM who stated that she believed that the SW placed it there.On 6/15/26 at 11:58 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the SW did the PASSR Level II and that they communicated the information to nursing. The DON stated yes, it was an expectation that the SW would let nursing know of the recommendations in the PASSR. The surveyor asked the DON if the recommendation would be followed. The DON stated that she knew psych would see, psychotherapy, and needed med monitoring. The DON stated that she was unsure if the recommendations would be in CP.At that same time, the surveyor asked the DON if the resident had a crisis plan, and the DON stated that if the resident had a behavior then we would have to make sure to keep safe, keep eyes [on the resident] and call 262 for help. The DON added that if 262 could not help then they would call 911. The surveyor asked the DON if that would be in the resident's CP. The DON stated that they established a crisis plan [in the CP] for Resident #3, after surveyor's inquiry.On 6/16/26 at 11:31 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA) the concern that Resident #3's Level II recommendations, specifically the Crisis Intervention/Safety Plan, was not implemented and included in the resident's CP.On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that the crisis plan was added to Resident #3's CP after surveyor's inquiry.The LNHA did not provide any additional information.A review of the facility's PASRR (Preadmission Screening and Resident Review) Policy, with a reviewed/revised date of 10/25, included the following:admission or designee will review admission prior to entry to have a Level I PASRR.Social Services or designee will initiate PASRR when residents admitted from home, out of state or etc.PASRR recommendations will be reviewed by Social Services and will be referred to the psychiatrist.PASSR level II recommendations and plan will be included in the resident plan of care as discussed by the psychiatrist.When Behavior symptoms worsen, care team will consult with the medical/psychiatric team for recommendations and resident will be transported to Psychiatric hospital of choice.In the event of an immediate crisis, facility will call 262 or 911.N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic medications for 1 of 5 residents (Resident #3) reviewed for unnecessary medications. This deficient practice was evidenced by the following:On 6/10/26 at 10:26 AM, the surveyor observed Resident #3 seated up in bed and had a wander guard on their right wrist.On 6/11/26 at 12:08 PM. the surveyor reviewed Resident #3's medical record.A review of Resident #3's admission record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; bipolar disease with psychotic features (mental illness that causes the individual experiences a temporary disconnect from reality in the form of hallucinations, delusions, or disorganized thinking) and dementia with agitation (clinical condition where a person diagnosed with a cognitive impairment syndrome).A review of Resident #3's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 5/22/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that the resident's cognition was mildly impaired.A review of Resident #3's June 2026 electronic Medication Administration Record (eMAR) included the following:Lorazepam oral tablet (tab) 0.5 mg (milligram) give 1 tab by mouth at bedtime (HS) for anxiety. Start date 5/15/26.Trazodone HCl (hydrocholoride) oral tab 50 mg give 1 tab by mouth at HS for depression. Start date 5/17/26, Venlafaxine HCl ER (extended release) oral tab 150 mg give 1 tab by mouth one time a day for depression. Start date 5/16/26.Depakote oral tab delayed release 125 mg give 3 tablets (tabs) by mouth three times a day for bipolar 3 tabs = 375 mg. Start date 5/15/26.Olanzapine oral tab 5 mg give 1 tab by mouth three times a day for bipolar. Start date 5/19/26.A review of Resident #3's hybrid (electronic and paper) medical record revealed a signed consent dated 5/15/26, with the medication (med) lorazepam listed. The consent did not have the other medications (meds) the resident was receiving listed. Under the assessment tab was additional consent forms that indicated some of the meds but those consent forms were not signed. There was no other signed consent for meds in the hybrid medical record.On 6/12/26 at 10:14 AM, the surveyor interviewed the Registered Nurse (RN) who stated for psychotropic meds they would obtain an informed consent which listed the meds from the Resident Representative (RR).On 6/12/26 at 10:26 AM, the surveyor asked the RN to check the hybrid medical record for the informed consent for all the meds. The RN confirmed that the only informed consent listed lorazepam and that there was no consent obtained from the RR for the antipsychotic and antidepressant meds. The RN stated that there should have been. The Licensed Practical Nurse/Unit Manager (LPN/UM) stated that she would obtain the consent from the RR and in-service the staff.On 6/15/26 at 11:56 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the consent was populated in the assessment tab of the electronic medical record (eMR), printed out and then signed by the resident or resident representative (RR). She added that the expectation was to have a consent or consents which included all the meds the resident received.On 6/16/26 at 11:31 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, and Director of Quality Assurance (DQA) the concern that Resident #3 did not have a signed consent for all the psychotropic meds the resident received.On 6/18/26 at 11:51 AM, in the presence of the LNHA, and DON, the DQA stated that the consent was signed by the RR for olanzapine after surveyor's inquiry. The LNHA did not provide any additional information.A review of the facility's Psychotropic Drug Use Policy, with a reviewed date of 2/2/26, included the following:A. Each resident receiving an antipsychotic med for organic mental disorders (now referred to as dementia, Alzheimer's disease, or other cognitive disorders) is observed for:.6. Signed consent is posted in resident clinical records in eMR.N.J.A.C. 8:39-4.1(a)2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 2 of 6 days during the annual re-certification survey.This deficient practice was evidenced by the following:On 6/10/26 at 8:58 AM, the Surveyor observed that the staffing report for 6/10/26, 7:00 AM to 3:00 PM shift, had a current resident census (total number of residents) of 169. On 6/10/26 at 9:24 AM, the Licensed Nursing Home Administrator (LNHA) stated that the census was 167. The LNHA also provided documentation to the survey team, titled Annual Survey Census, dated 6/10/26, with a total census of 167. On 6/18/26 at 8:14 AM, the Surveyor observed that the staffing report for 6/18/26, 7:00 AM to 3:00 PM shift, had no Certified Nursing Assistants (CNAs) included or written on the report.On 6/18/26 at 10:55 AM, the Surveyor interviewed the Nursing Payroll Coordinator (NPC), who stated that they selected Licensed Practical Nurses (LPNs) twice on the computer screen and did not select CNAs when making the staffing report. The NPC confirmed the printed the staffing report that was posted it at the reception desk did not include information about total number of CNAs and the ratio of CNA to Residents. The NPC further stated they were in a rush and made a mistake. On 6/16/26 at 11:32 AM, in the presence of the survey team, the Surveyor discussed the above concerns with the LNHA, Director of Nursing (DON), and Director of Quality Assurance (DQA).On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and the DQA stated they had corrected the staffing report for 6/18/26 after Surveyor's inquiry.A review of the facility's Staffing Policy, revised 6/2026, revealed, the facility provides adequate staffing to meet needed care and services for our resident population. The CNAs are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. The facility staffing is posted in the receptionist desk or in the area visible to residents, staff and visitors.NJAC 8:39-41.2

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 3 of 5 Certified Nurse Aides (CNAs) reviewed for mandatory education (CNA #1, CNA #2, and CNA #3). This deficient practice was evidenced by the following:On 6/12/26 at 12:57 PM, the Surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh).A review of the facility-provided annual education transcripts, in-service sign in sheets, individual in-service logs, employee training reports, and training hours for courses revealed the following:CNA #1 with a doh of 3/1/16, did not have QAPI training.CNA #2 with a doh of 4/2/01, did not have QAPI training completed during the required annual time frame of 4/2/25 through 4/2/26 based on their doh.CNA #3 with a doh of 6/1/23, did not have QAPI training.On 6/16/26 at 9:21 AM, in the presence of the survey team, the surveyor interviewed the Assistant Director of Nursing (ADON), who was also the educator, regarding CNA education and mandatory topics. The ADON confirmed that the documents they gave the Surveyor for the five CNAs were complete, containing all the education that the CNAs completed.On 6/16/26 at 11:32 AM, in the presence of the survey team, the Surveyor discussed the concern with the LNHA, DON, and Director of Quality Assurance (DQA).On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and DQA for responses. The LNHA did not provide additional information.NJAC 8:39-33.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that Certified Nursing Aid (CNA) education included compliance and ethics for 5 of 5 CNAs reviewed (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). This deficient practice was evidenced by the following:On 6/12/26 at 12:57 PM, the Surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was done for five randomly selected CNAs based on their date of hire (doh).A review of the facility-provided annual education transcripts, in-service sign in sheets, individual in-service logs, employee training reports, and training hours for courses revealed the following:CNA #1 did not have compliance and ethics training.CNA #2 did not have compliance and ethics training.CNA #3 did not have compliance and ethics training.CNA #4 did not have compliance and ethics training.CNA #5 did not have compliance and ethics training.On 6/16/26 at 9:21 AM, in the presence of the survey team, the surveyor interviewed the Assistant Director of Nursing (ADON), who was also the educator, regarding CNA education and mandatory topics. The ADON confirmed that the documents they gave the surveyor for the five CNAs were complete, containing all the education that the CNAs completed.On 6/16/26 at 11:32 AM, in the presence of the survey team, the Surveyor discussed the concern with the LNHA, DON, and Director of Quality Assurance (DQA).On 6/18/26 at 9:11 AM, the ADON provided the surveyor with a document which listed the names of the employees who completed Corporate Compliance & Ethical Standards with completion dates and participant hours. A review of the document revealed that CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 were not any of the employees listed on the document. On 6/18/26 at 10:54 AM, the Surveyor interviewed the ADON, who confirmed the document they provided included all of the employees who completed the compliance and ethics training. The ADON further stated that compliance and ethics training would be part of the August 2026 training.On 6/18/26 at 11:45 AM, the survey team met with the LNHA, DON, and DQA for responses. The LNHA did not provide additional information.

Complaint #2611374Based on interview, record review, and review of other pertinent facility provided documentation, the facility failed to follow appropriate tuberculosis (TB) testing and documentation for 3 of 3 residents, Residents #1, #2, and #3 according to the standard of clinical practice and facility's policies. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 10/23/25 at 10:49 AM, Surveyor #1 (S #1) reviewed the paper and electronic medical record (eMR) of Resident #2. A review of the admission Record or face sheet (AR; an admission summary) documented that the resident had diagnoses that included but were not limited to, lesion of the lumbar spinal cord, secondary malignant neoplasm (cancer) of the bone, cord compression, morbid obesity, chronic kidney disease, and type 2 diabetes. A review of the comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 7/31/25, revealed a brief interview for mental status (BIMS) score of 14 out of 15, which indicated Resident #2's cognition was intact. A review of the physician's order (PO) dated 8/27/25, tuberculin PPD (Purified Protein Derivative, which is a key component used in the TB skin test to determine if a person has been infected with TB bacteria) Solution 5 UNIT/0.1milliliter (ml), inject 0.1 ml intradermally (ID) one time only for house protocol (HP) until 8/27/25, PPD Step (1) administration. Repeat in 14 days if results of 1st PPD is negative. A review of the August 2025 eMAR (electronic Medication Administration Record) of the above PPD order entry dated 8/27/25, revealed the entry was not signed by a nurse to indicate if the PPD solution was administered to Resident #2. The entry was left blank. A review of August 2025 progress notes (PN) revealed there was no documentation to indicate if the PPD solution was administered or not administered to Resident #2 on 8/27/25. On 10/23/25 at 1:39 PM, S #1 interviewed the Director of Nursing (DON), regarding PPD solution administration. The DON stated there was a HP for PPD administration upon a resident's admission, according to a PO. The DON further explained the PPD administration would be documented in the eMAR, and the order entry would be signed to indicate that the PPD was administered or not administered. The DON stated it was expected that eMAR order entries were signed and not left blank. On 10/23/25 at 4:09 PM, S #1 notified the Licensed Nursing Home Administrator (LNHA), the DON, the Assistant DON (ADON), and the Regional DON (RDON) of the above concern that Resident #2's order entry for the PPD testing which was scheduled to be administered 8/27/25 was unsigned and left blank. There was no verbal response from the facility management at this time. On 10/23/25 at 4:59 PM, the LNHA, DON, ADON and the RDON met with the survey team. There was no additional information provided by the LNHA. A review of the facility's Tuberculosis, Screening Residents for Policy, last reviewed date of January 2025, under the Policy statement revealed, this facility shall screen all residents for tuberculosis infection and disease (TB). Further review of the above policy did not address documentation for PPD administration. 2. On 10/23/25 at 10:00 AM, Surveyor #2 (S #2) reviewed the paper and eMR of Resident #1. A review of the AR revealed Resident #1 with diagnoses that included but not limited of urinary tract infection, sepsis, cerebral infarction, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, aphasia, and chronic combined systolic and diastolic congested heart failure. A review of the cMDS, with an ARD of 9/11/25, revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. A review of the PO dated 9/4/25, tuberculin PPD Solution 5 Unit/0.1 ml, inject 0.1 ml ID one time only for HP until 9/4/25, PPD Step (1) administration. Repeat in 14 days if results of 1st PPD is negative. A review of the September 2025 eMAR of the above PPD order entry dated 9/4/25, revealed the entry was signed and administered by Registered Nurse #1 (RN #1) (3-11 shift). An additional entry on the September eMAR of the above PPD order entry dated 9/5/25, revealed RN #1 signed with a chart code of (9) indicating Other/See PN Ineffective. A review of the nursing PN at 11:00 AM, revealed PPD Double Entry. At 2:20 PM, S #2 interviewed the LNHA who stated, that when the ADON was completing an audit for immunizations, the next day after admission, she saw the immunization tab in the Resident #1's eMR was blank, so she asked the nurse to give the PPD, not knowing that it was already given the previous day. The LNHA stated that this was a self-identified medication (med) error, investigation, report, statements, and education were completed. At 3:22PM, S #2 interviewed RN #2, who stated that he admitted the Resident#1, he forgot to put an order for PPD and to administer it. He further stated that the ADON asked him the next day if a PPD was given because according to the admission checklist, the PPD was not checked off that it was given. He was then asked to administer the PPD, and he confirmed he administered the PPD the next day. At that same time, RN #2 stated that the Personal Aide (PA) was in the room when he administered the PPD. The PA called the Resident's Representative (RR), and the RR called the facility to say that Resident#1 received the PPD the previous day. RN #2 stated he was not aware that the Supervisor from the day before (3-11 shift) put an order in for the PPD and administered it. RN #2 further stated that there was no negative reaction to the resident, the Physician was made aware, and he received education. At 4:15 PM, the survey team met with the LNHA, DON, RDON, and the ADON, and S #2 notified them of the concern with the two PPD administrations. The LNHA provided a copy of the med error report and in-services. The LNHA stated they self-identified the PPD med error and included it in their Quality Assurance and Performance Improvement program. 3. On 10/23/25 at 9:46 AM, Surveyor #3 (S #3) reviewed the closed medical record of Resident #3, and revealed: A review of AR reflected that Resident #3 was admitted to the facility with medical diagnoses which included but not limited to; malignant neoplasm of colon (commonly known as colon cancer, is a type of cancer that begins in the large intestine and can develop from precancerous growths called polyps) unspecified, muscle weakness (generalized), and difficulty walking, not elsewhere classified. A review of the most recent (cMDS), with an ARD of 7/25/25, revealed a BIMS score of 15 out of 15, reflected that the resident's cognition was intact. A review of the July and August 2025 eMAR revealed the following PO: A PO with a start date (SD) of 7/18/25, tuberculin PPD 5 unit/0.1 ml, inject 0.1 ml ID one time only for HP for 1 day ppd step (1) administration. Repeat in 14 days if results of 1st ppd is negative. The order was administered and signed on 7/19/25 at 1257 (12:57 PM) by Licensed Practical Nurse #1 (LPN #1). A PO with a SD of 7/21/25, read ppd: 2 step one time only for HP for 1 day read 72 hours after step (1) administration and document in mm (millimeters). The order was coded 6 (six) in the eMAR on 7/21/25 by LPN #2 at 2:58 PM. The code six meant the resident was hospitalized (result was not read). A PO with a SD of 8/1/25, tuberculin ppd solution 5 unit/0.1 ml inject 0.1 ml ID one time only for HP for 1 day ppd step (2) administration 14 days after step 1 if results of 1st ppd is negative. The step 2 ppd was signed as administered by LPN #3 at 11:06 AM. A PO with a SD of 8/1/25, read PPD: 2 step one time only for HP for 1 day read 72 hours after step (2) administration and document in mm. The order was coded with a check mark in the eMAR, the mm was coded n on 8/1/25 by LPN #3 at 11:06 AM. The code check mark meant the step 2 ppd was read and the measurement (result) was n, which did not have a corresponding information in the custom prompt legend and chart codes. Further review of the medical record revealed that there was no documented evidence that the step 1 ppd was read and result was negative. On 10/23/25 at 12:25 PM, S #3 interviewed LPN #2, who informed S #3 that step 1 ppd should be administered on the day of admission, read within 48-72 hours, and step 2 ppd should be administered on the 14 day if step 1 ppd was negative. LPN #2 stated that the orders for ppd and the reading should be in the eMAR, other documentation should be in the PN and the electronic record immunization tab. On that same date and time, S #3 asked LPN #2 what the expectation for the nurse would be to do when the resident was hospitalized and returned the same day and the ppd was due to read. LPN #2 stated that he did not know the answer. LPN #2 was unable to remember Resident #3. On 10/23/25 at 12:55 PM, S #3 attempted to call LPN #3 twice for an interview. On 10/23/25 at 4:10 PM, the survey team met with the LNHA, DON, ADON, and the RDON, and S #3 notified them of the above findings and concerns with Resident #3's ppd. On 10/23/25 at 4:44 PM, the survey team met with the LNHA, DON, ADON, and RDON, and the DON acknowledged that ppd step 2 should be administered after step 1 ppd was negative, and step 1 and 2 ppd should be read within 48-72 hours of administration. On 10/23/25 at 5:00 PM, the survey team met with the LNHA, DON, ADON, and RDON for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-11.2(b)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) identify, assess, and implement interventions for a resident (Resident #35) with an unplanned significant weight loss of 7 pounds (lbs) or 5.1% in one month and 25.2 lbs or 25.71% significant weight loss in six months from 4/12/24 through 10/7/24, b.) identify, assess, and implement interventions for a resident (Resident #92) with a significant weight loss of 14 lbs. or 10.03% in one month for 48 days; c.) identify, assess, and implement interventions for a resident (Resident #3) with a significant weight loss of 18 lbs. or 13.4% in one month; d.) obtain, record, and monitor weights in accordance with physician's orders; e.) obtain re-weights to verify a significant weight change; and f.) monitor the effectiveness of interventions for a resident with a significant weight loss. The deficient practice was identified in 3 of 7 residents (Residents #3, #35, and #92) reviewed for nutrition. This deficient practice was evidenced by the following: 1. On 1/6/25 at 12:06 PM, the surveyor observed Resident #35 lying in bed, who was alert and verbally responsive to the surveyor's greeting. The resident stated, I'm hungry. The surveyor observed the lunch meal trays had just arrived on the unit, and Resident #35 received their lunch tray which was set up by the nursing staff. On 1/7/25 at 11:13 AM, the surveyor observed Resident #35 lying in bed with an opened health shake (a nutrition supplemental drink) that was within the resident's reach. Resident #35 stated to the surveyor I'm hungry. At that time, the Hospitality Aide entered the room, spoke with the resident, and went to get assistance for the resident. On 1/8/25 at 9:30 AM, the surveyor reviewed the electronic medical records (EMR) of Resident #35. A review of the Admission Record (AR; an admission summary) reflected the resident was admitted to the facility with diagnoses that included but were not limited to; osteoporosis (a condition in which bones become weak and brittle), hypertension (high blood pressure), hyperlipidemia (high levels of fat particles in the blood), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), unspecified psychosis (group of symptoms that affect a person's mind and cause them to lose touch with reality), fracture of the humerus (long bone of the upper arm) and compression fracture of the thoracic vertebrae (a bone in the spine breaks and collapses). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 10/4/24, reflected a Brief Interview Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severe cognitive impairment. A review of Section K (Swallowing/Nutritional Status) revealed the resident was 73 lbs. and was coded for having a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician prescribed weight loss regimen. A review of Resident #35's weights revealed: 4/12/24: 98.0 lbs. 5/3/24: 93.0 lbs. (7 lbs loss or a 5.1% significant weight loss in one month) 6/25/24: 96.0 lbs. 10/7/24: 72.8 lbs. (25.2 lbs loss or a 25.71% significant weight loss six months) 10/15/24: 73.0 lbs. 10/29/24: 73.0 lbs. 12/9/24: 66.2 Lbs. 12/19/24: 73.2 lbs. 12/23/24: 71.2 lbs. 12/30/24: 71.2 lbs. There were no documented weights for Resident #35 for July 2024, August 2024, September 2024, and November 2024, and there were no corresponding notes or orders in the medical record as to why the resident's weights were not obtained. The resident had a significant weight loss of 23.2 lbs or 24.7% in three months (6/25/24 to 10/7/24) with no documentation of the resident's weight loss until it reached 23.2 lbs. A review of Progress Notes (PN) revealed: A Nutrition/Dietary Note dated 5/24/24, written by the Registered Dietician (RD #1), documented the resident was noted with weight loss and had edema (swelling caused by fluid buildup in the body's tissues) upon admission. RD #1 indicated that the resident was on a diuretic medication (helps increase urine production, helping the body get rid of excess fluid and salt) and weight loss may be expected. An Interdisciplinary Care Plan (IDCP) Note dated 7/9/24, written by RD #1, documented a quarterly nutrition assessment that cultural foods were provided. The resident's weight was stable since admission, and the resident's intake was 75-100%. The RD indicated to continue the current diet for the resident and to monitor nutritional intake. An IDCP Note dated effective 10/4/24, written by RD #1, included the resident's weight on 4/12/24, was 98 lbs. and the resident's current weight on 10/7/24, was 72.8 lbs. RD #1 documented that she spoke with the Resident's Representative (RR #1) about the weight loss, who indicated the resident had a history of variable intake at meals, very small portion sizes with meals, and that weight loss was noted with legs look smaller. RD #1 indicated that Resident #35 had edema upon admission, a diuretic medication (med) was in use, and the team was made aware of the weight loss. RD #1 recommended a three-day calorie count, weekly weights for four weeks, a magic cup (a calorically dense frozen supplement) at lunch, and a health shake twice a day at 10:00 AM and 2:00 PM. A Nurse Practitioner (NP) PN dated 10/10/24, documented the resident had severe weight loss. The note indicated a calorie count for three days, weekly weights for four weeks, and laboratory tests were ordered for the next day. A Nutrition/Dietary Note dated 10/15/24, documented the results of the three-day calorie count that the resident was eating between 25-75% of meals and referred to a NP note regarding the resident's weight loss. The note included the RD recommended to continue fortified foods, monitor weekly weights and the resident's nutritional status. A review of Physician's Orders (PO) for Resident #35 included: A PO dated 4/11/24, for a no-added salt (NAS) diet, regular consistency texture, and thin liquids. A PO dated 4/13/24, for hydrochlorothiazide (a diuretic) oral tablet (tab) 25 milligram (mg); give one tab by mouth one time a day for hypertension. The order was discontinued (d/c) on 11/14/24. A PO dated 10/8/24, to give a four ounce (4 oz) health shake two times a day for supplement and record the percentage consumed. A PO dated 10/8/24, to give magic cup one time a day for supplement and record the percentage consumed. A PO dated 10/8/24, for a three-day calorie count every shift for three days and to ensure calorie count paper was completed after each meal or snack, including supplements. A PO dated 10/8/24, with a start date of 10/15/24, and an end date of 11/12/24, to document the resident's weights weekly for four weeks every day shift every Tuesday. These interventions were implemented after the resident lost 25.2 lbs. since admission to the facility. A review of the October and November 2024 electronic Medication Administration Record (eMAR) for the weekly weights for four weeks order entries revealed the following: The 10/22/24, entry was left blank. A review of the corresponding PN did not include the resident's weight or any documentation as to why the resident's weight was not obtained. The 11/5/24, entry was signed 9 by the nurse which indicated to Other/See PN. A review of the corresponding PN did not include a note regarding the resident's weight. The surveyor continued to review the PN which revealed the next documented note the RD wrote regarding the resident's significant weight loss was a Nutrition/Dietary Note dated 12/18/24. The note indicated it was for a follow-up for a 9% weight loss; that the resident weighed 72.8 lbs. on 10/7/24, and 66.2 lbs. on 12/9/24. RD #1 documented that weight loss persisted despite nutrition interventions and that weight loss may also be attributed to diuretic use. RD #1 indicated a re-weigh would be completed to confirm the weight. The RD did not include the missing weights from October and November, and did not assess the effectiveness of the interventions added on 10/8/24, which were implemented after the resident had a 25.71% significant weight loss since admission to the facility. There was no evidence that the RD continued to monitor the resident's nutritional status as documented in the 10/4/24, Nutrition/Dietary Note. A review of the Nutrition/Dietary Note dated 12/19/24, documented the weight committee met to review unplanned weight loss for Resident #35. The RD included the resident's weight on 12/19/24 was 73.2 lbs. The RD recommended to continue the current nutrition interventions which included super cereal ( a calorically dense cereal) at breakfast, a 4 oz health shake supplement twice a day, and a magic cup at lunch. The resident's nutritional status will continue to be monitored. A review of an IDCP Note dated 12/31/24, written by RD #2, indicated that cultural foods were provided and the resident's meal intake was between 25-75%. Weekly weights were ordered on 12/23/24. RD #2's recommendations included to continue current nutrition interventions and monitor nutritional status. An additional review of the Physician's Orders included a PO dated 12/18/24, with a start date of 12/23/24, for weekly weight every Monday. A review of the corresponding December 2024 and January 2025 electronic Treatment Administration Record (eTAR) revealed the following weights: 12/23/24: 71.2 lbs. 12/30/24: 71.2 lbs. 1/6/25: 71.2 lbs. A review of the individualized comprehensive care plan (ICCP) included a focus area dated 4/11/24, that the resident was at risk for malnutrition and was revised on 10/8/24, to include actual weight loss and variable intake. Interventions included to monitor nutritional status initiated on 4/11/24; communicate with the [RR #1] initiated on 10/8/24; and to provide health shake and magic cup initiated on 10/8/24. On 1/8/25 at 10:37 AM, the surveyor interviewed the Registered Nurse (RN) assigned to care for Resident #35, who stated that the facility's protocol was for residents to be weighed once a month, and the weight was documented in the weights section of the EMR. The RN stated that if the resident had a PO for weights obtained more frequently, the weights were documented on the eMAR or eTAR and may also be included in the weights section. The RN further stated Resident #35 sometimes did not like to eat at mealtime; that they consumed approximately 45-50% of meals; and in between meals, they informed staff that they were hungry. On 1/8/25 at 10:56 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding weights, who stated that the resident's weights were obtained at least monthly and more frequently if there was a PO. The RN/UM stated the nursing staff obtained monthly weights in the first seven days of the month. The RN/UM further explained that she or the assigned nurses informed the Certified Nurse Aides (CNA) which residents needed to be weighed that day, and the CNA informed the nurse or RN/UM of the residents' obtained weights that they documented in the weights section of the EMR. The RN/UM stated the list was given to the RD to review. The RN/UM stated if there was a significant weight discrepancy from the previous weight, the resident was reweighed to confirm accuracy. The RN/UM stated if the resident lost a significant amount of weight, the RD and Physician were notified for recommendations. The RN/UM stated if a weight could not be obtained for a resident, the nurses documented the reason why it was not completed. At that time, the surveyor and the RN/UM reviewed the weights for Resident #35, and the RN/UM confirmed there were no weights in July 2024, August 2024, September 2024, and November 2024. The RN/UM could not speak to why there were no weights for those months, and the RN/UM acknowledged there should have been documentation for why the resident's weights were not obtained. The RN/UM confirmed the resident had a significant weight loss that was attributed to a poor appetite and was a selective eater. On 1/8/25 at 11:18 AM, the surveyor interviewed RD #1 about the facility's weight protocol, who stated the weights for all residents were taken once a month unless otherwise indicated in a PO. RD #1 stated all weights were documented in the weights section of the EMR, and she ran a report daily to review the weights. RD #1 stated if there was a discrepancy in the weight or a significant weight loss, a new weight was obtained immediately. At that same time, the surveyor notified RD #1 of the concern for Resident #35's significant weight loss and the missing weekly weights on 10/22/24 and 11/5/24. RD #1 stated she would review the EMR and provide additional information. On 1/8/25 at 1:01 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Assistant Administrator (AA), and the Director of Nursing (DON) of the concern for Resident #35's significant weight loss and missing weights identified for the resident. The LNHA stated they would review and provide further responses the next day. On 1/9/25 at 10:37 AM, the LNHA, the DON, RD #1, and the Medical Director (MD) met with the survey team. The MD stated that he examined the resident yesterday (1/8/25) as per facility request and the MD stated that the resident had dementia, non-compliance at home with care regimen, a history of hypothyroidism, and edema which the resident received a course of diuretics. The MD added that the resident was a picky eater, finicky with eating, and was observed eating that morning their super cereal at breakfast and two-thirds of eggs. The MD stated their current weight was probably their baseline and would recommend to lower blood pressure (BP) meds and thyroid meds. The surveyor asked why the BP and thyroid meds were not lowered prior to surveyor inquiry, and there was no response. At that time, the surveyor asked about the missing weights from July to September 2024, and the concern for the significant weight loss that was identified in October 2024 based on the weights. RD #1 acknowledged the resident's significant weight loss and the missed monthly weights. RD #1 stated that her assessments were not only based on the resident's weights, that she did rounds on the units to observe the resident and the nursing staff informed her if there were concerns with the resident's intake. The surveyor asked RD #1 if she had reviewed the four weekly weights requested in October 2024 for Resident #35 after the significant weight loss was identified, and RD #1 stated she reviewed the weights on 10/7, 10/15, and 10/28. The RD stated the resident's weights were stable and acknowledged there were some missing weights. Additionally, RD #1 stated a calorie count was completed, and the team discussed the resident being on a diuretic. There was no additional information provided by the facility. 2. On 1/6/25 at 12:30 PM, the surveyor observed Resident #92 lying on their bed with their eyes closed. The resident had a meal tray unopened on their bedside table. On 1/7/25 at 11:25 AM, the surveyor observed Resident #92 sitting up at the side of their bed with their breakfast tray on the bedside table in front of them. The resident was alert and did not respond to the surveyor's greeting. Resident #92 was eating eggs that were on their breakfast meal tray. On 1/9/25 at 9:20 AM, the surveyor reviewed the EMR of Resident #92. A review of the AR reflected Resident #92 was admitted to the facility with diagnoses that included but were not limited to; dementia, anxiety disorder, sleep disorder, gastroesophageal reflux disease (GERD), orthostatic hypotension (low BP while standing up from sitting or lying position), depression, and muscle weakness. A review of the most recent quarterly MDS dated [DATE], indicated a BIMS score of 9 out of 15, which indicated the resident had moderate cognitive impairment. A review of Section K revealed the resident was coded for having a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a physician-prescribed weight loss regimen. The resident's weight was coded 126 lbs in the MDS. A review of Resident #92's weights revealed: 8/16/24: 139.6 lbs. 9/16/24: 139.6 lbs. 10/11/24: 125.6 lbs. (14 lbs loss or a 10.03% significant weight loss in one month) 11/18/24: 122 lbs. 12/4/24: 119 lbs. 12/8/24: 118.6 lbs. 12/12/24: 117.8 lbs. 12/18/24: 123 lbs. 12/25/24: 121 lbs. 1/6/25: 120 lbs. A review of PN revealed the following: A Nutritional assessment dated [DATE], written by RD #1, documented that RR #2 was present, the resident's food preferences were reviewed and per the resident's history, their weight had been stable. The resident's current weight was 139.6 lbs and their body mass index (BMI; calculation based on weight to height) was within normal limits. The note included recommendations to continue to monitor the resident's nutritional status and for the resident to continue a therapeutic diet of fat-controlled, regular texture, and thin liquid diet. A Nutrition/Dietary Note dated 11/5/24, written by RD #1, documented that the resident had a 10% weight loss with a weight of 139.6 lbs on 9/16/24, and a weight of 125.6 lbs on 10/11/24. RD #1 indicated recommendations were to follow up weight, liberalize therapeutic diet, super cereal at breakfast, and super mash (calorically dense mashed potatoes) at dinner. A review of the Physician's Orders did not include a PO for super cereal or super mash. A review of an IDCP Note dated 11/15/24, written by RD #1, indicated a weight follow-up was pending, weight loss notes, provided liberalized diet, and to continue to monitor. A review of a Nutrition/Dietary Note dated 11/28/24, written by RD #1, indicated a reweigh was pending and weight loss was reviewed with the IDCP team. The RD indicated recommendations for a 4 oz health shake to be given twice a day, a three-day calorie count, weekly weights for four weeks, liberalize therapeutic diet, super cereal at breakfast, and super mash at dinner. A review of the corresponding Physician's Orders included the following POs: A PO dated 4/11/24, for a regular diet, regular consistency texture, and thin liquids. A PO dated 11/5/24, to obtain weight one time only for one day. A PO dated 11/28/24, to give a 4 oz health shake two times a day for supplement mouth and record the percentage consumed. A PO dated 11/28/24, for three-day calorie count every shift for three days and to ensure calorie count paper was completed after each meal or snack, including supplements. A PO dated 11/28/24, for weekly weights for four weeks every day shift on Wednesday. The interventions that were implemented on 11/28/24, which to give a health shake twice a day, a three-day calorie count, and weekly weights for four weeks were added 48 days after the resident had a significant weight loss of 14 lbs. on 10/11/24. The resident also had continued weight loss with an additional 3.2 lbs. from 10/11/24 to 11/18/24. There was no PO for super cereal at breakfast or super mash at dinner. A review of a Nutrition/Dietary Note dated 12/2/24, written by RD #1, documented the results of a three-day calorie count indicated that the resident was meeting estimated nutritional needs. The RD recommended to continue current nutrition interventions, superfoods (cereal and mash), health shake supplements twice a day, and to continue to monitor weight trends. A review of a Nutrition/Dietary Note dated 12/18/24, written by RD #1, documented the resident had a weight gain with an improved weight status. The RD recommended to continue current nutrition interventions. A review of a Nutrition/Dietary Note dated 12/19/24, written by RD #1, documented a weight committee meeting took place to review the resident's unplanned weight loss. The resident had a weight gain with an improved weight status. The note indicated a message was left for RR #2. The RD recommended to continue the current nutrition interventions and to continue to monitor. A review of the November 2024 eMAR which revealed that on 11/5/24, the resident was documented with a weight of 125.6 lbs. A review of the December 2024 eMAR which revealed the following weights: 119 lbs on 12/4/24 117.8 lbs on 12/11/24 123 lbs on 12/18/24 121 lbs on 12/25/24 A review of the ICCP included a focus area dated 8/16/24, for the resident being at risk for malnutrition and revised on 11/5/24, to reflect an unplanned weight loss. Interventions included to: monitor nutritional status initiated on 8/16/24; regular diet initiated on 11/5/24, and health shake twice a day initiated on 11/28/24. The ICCP did not include super cereal at breakfast and super mash at dinner. On 1/9/25 at 11:39 AM, the surveyor interviewed RD #1 about Resident #92's 10% weight loss from September to October 2024 that was not documented as assessed until 11/5/24. RD #1 stated she would review her notes to provide a response to the surveyor's questions. The surveyor requested any documentation for any weight committee meetings for the resident. On 1/9/25 at 2:10 PM, RD #1 provided weight committee meeting sign-in sheets for 9/27/24 and 12/19/24. The sheet for 9/27/24, did not include Resident #92. A review of the untitled form dated 12/19/24, included the name, title, and signature of staff who attended the meeting and the name of the residents discussed in the meeting which included Resident #92. The meeting was attended by RD #1, a MDS staff, Director of Rehab, Assistant DON, LNHA, AA, Social Services, unit manager of 2 E unit, and the DON. RD #1 did not provide any weight committee meetings for October or November 2024, and provided no additional information regarding Resident #92's weight loss. On 1/9/25 at 12:50 PM, the surveyor informed the LNHA, DON, and the AA of the above concerns for Resident #92's significant weight loss between September to October 2024, and requested additional information. On 1/10/25 at 11:15 AM, the LNHA, DON, and AA met with the survey team. The LNHA stated there was no additional response or information regarding the concern for Resident #92. 37791 3. On 1/7/25 at 9:08 AM, the surveyor observed Resident #3 in bed and watching television. The surveyor attempted an interview but the resident declined. A review of Resident #3's medical records revealed: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but not limited to; metabolic encephalopathy (a brain dysfunction that occurs when there's an imbalance of chemicals in the blood, usually due to an underlying medical condition), congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and unspecified intestinal obstruction (blockage in the small or large intestine that prevents food and liquid from passing through). A review of the most recent quarterly MDS dated [DATE], reflected a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of the weights revealed: 9/23/24: 138.0 lbs. 10/23/24: 120.0 lbs. (18 lbs or 13.4% significant weight loss in a month) 11/19/24: 122.6 lbs. 12/9/24: 118.6 lbs. 1/2/25: 117.8 lbs. A review of the resident's Admission Nutritional assessment dated [DATE], included that RD #1 identified that the resident was 138 lbs. and the resident's ideal body weight was 80-98 lbs and the BMI was 32 (obese). The resident was on a NAS, fat-controlled diet. The RD identified the resident reported having a poor appetite. A review of the Nutritional assessment dated [DATE] at 1:24 PM, revealed that the resident's current weight was 119 pounds, and that weight loss was expected with the resident was on a diuretic (Lasix). The resident's BMI was 27.6 and was overweight. The RD recommended a therapeutic diet and to continue monitoring the resident's nutritional status. There was no Nutrition/Dietary Note to address the 18 lbs weight loss on 10/23/24, or a reweigh. On 1/9/24 at 1:00 PM, the surveyor interviewed RD #1, who stated Resident #3 had multiple hospitalization s and comorbidities including congestive heart failure that contributed to their weight loss. RD #1 stated that she saw the resident after their re-admission on 10/21/24, and she was waiting for the resident to be weighed; that the weight loss could have happened during the resident's hospitalization . RD #1 acknowledged that the resident had a significant weight loss on 10/23/24, and that the resident should have been re-weighed, and that she should have written a Nutrition Note to address the 18 lbs or 13.4% weight loss. The RD stated that the resident's weight was now stable, and that she was monitoring the resident's weight. On 1/9/24 at 1:30 PM, the surveyor discussed the above concerns with the LNHA, DON, and the RDON. No further information was provided. A review of the facility's Weight Assessment and Intervention Policy with a last revised date of October 2024, include: Policy Statement: The multidisciplinary team [MDT] will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation: Weight Assessment 1. The nursing staff will measure the resident's weight on admission, the next day, and weekly for four weeks thereafter. If no weight concerns are noted, weights will be measure monthly thereafter. 2. Weights will be recorded in the Weights and Vitals tab in the EMR. 3. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will immediately notify the RD. 4. The RD will respond within 24 hours of receipt of notification. 5. The RD will review the unit's weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant; greater than 5% is severe. b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months-10% weight loss is significant; greater than 10% is severe. Analysis: 1. Assessment information shall be analyzed by the MDT and conclusions made regarding the: a. The resident's target weight range including rationale if different from ideal body weight. b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake. c. Relationship of current medical condition or clinical situation and recent fluctuations in weight. d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The physician and the MDT will identify conditions and medication that may be causing anorexia, weight loss or increasing the risk of weight loss. Care Planning 1. Care planning for weight loss or impaired nutrition will be an MDT effort. 2. Individualized CP should address to the extent possible: a. The identified causes of weight loss. b. Goals and benchmarks for improvement. c. Time frames and parameters for monitoring and reassessment. NJAC 8:39 - 11.2(e)(1)(f), 17.1(c), 17.2(c)(d), 27.1(a)

C#NJ 520 Based on interview and record review, it was determined that the facility failed to a.) promptly notify the physician of a change in condition and provide timely service; b.) monitor and document the change of condition; c.) document the assessment of a Registered Nurse; and d.) ensure that staff were aware of the physician's written transfer order. This deficient practice was identified for 1 of 2 residents (Resident #223) reviewed for hospitalization , according to the standards of clinical practice. Resident #223 was hospitalized on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 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. According to the Centers for Disease Control and Prevention (CDC), Stroke guidelines Page last reviewed: August 28, 2020, included Stroke Signs and Symptoms: During a stroke, every minute counts! Fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of stroke, you can take quick action and perhaps save a life-maybe even your own. Signs of Stroke in Men and Women sudden numbness or weakness in the face, arm, or leg, especially on one side of the body. Sudden confusion, trouble speaking, or difficulty understanding speech. Also, sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, loss of balance, or lack of coordination, sudden severe headache with no known cause. Call 9-1-1 right away if you or someone else has any of these symptoms. Acting F.A.S.T. Is Key for Stroke. Acting F.A.S.T. can help stroke patients get the treatments they desperately need. The stroke treatments that work best are available only if the stroke is recognized and diagnosed within 3 hours of the first symptoms. A review of the CDC Stroke Treatment Page last reviewed: May 25, 2021, included, If someone you know shows signs of stroke, call 9-1-1 right away. The key to stroke treatment and recovery is getting to the hospital quickly. Yet 1 in 3 stroke patients never calls 9-1-1. The emergency workers may take you to a specialized stroke center to ensure that you receive the quickest possible diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Brain scans will show what type of stroke you had. If you get to the hospital within 3 hours of the first symptoms of an ischemic stroke, you may get a type of medicine called a thrombolytic (a clot-busting drug) to break up blood clots. Tissue [MEDICATION(S)] activator (TPA) is thrombolytic. TPA improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive TPA are more likely to recover fully or have less disability than patients who do not receive the drug. Patients treated with TPA are also less likely to need long-term care in a nursing home. Unfortunately, many stroke victims don't get to the hospital in time for TPA treatment. This is why it's so important to recognize the signs and symptoms of stroke right away and call 9-1-1. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic late entry Nursing Note (NN) dated 5/10/21 and timed at 19:24 documented by a Licensed Practical Nurse #1 (LPN#1) indicated, 1 PM-During rounds, was informed that resident is with [family member/RP] downstairs. 2 PM-Resident transferred to unit after [family member] visited. The [family member] left and [LPN #1] was informed by PT [physical therapy] that [family member] placed concern [about] the resident: VS taken: BP [blood pressure] 129/80 P [pulse] 77 RR [respiratory rate] 17 O2 [oxygen saturation] 96%, RA [room air] T [temperature] 97.9. Assessment done. RN [Registered Nurse] supervisor was called . [family member] was made aware that if any changes he would be informed .Will continue to monitor. A review of the medical records for Resident # 223 revealed that there was no assessment documented by the Registered Nurse/Supervisor #1 (RN/S #1) on 5/9/21. There was no documented evidence that the physician or the nurse practitioner was notified of the RP's concern with the resident's change in condition. A review of the 24-Hour Daily Report (24 HDR) provided by the Director of Nursing (DON) did not reveal a report or documentation on 5/9/21 regarding the RP's concern of a change in condition or that Resident # 223 would be monitored. A review of the Nursing schedule (Ns) provided by the Licensed Nursing Home Administrator (LNHA) dated 5/9/21 revealed that both LPN #1 and RN/S #1 worked the 7-3 and 3-11 shifts. The 5/9/21, Ns indicated that LPN #1 was scheduled to start the shift at 1:00 PM for the 7-3 shift. A review of the 5/10/21, Ns revealed that the Registered Nurse/Unit Manager (RN/UM) and LPN #2 worked the 7-3 shift, and LPN #1 and RN/S#2 worked the 3-11 shift. A review of the NN dated 5/10/21 timed at 17:38 and documented by the RN/UM indicated, 11-12 PM .NP [nurse practitioner] also examined resident as requested by resident's [family member]. 3:30 PM complete head-to-toe body assessment done by [name redacted] nurse NP, this writer, and shift supervisor . A review of the NN dated 5/10/21, timed at 19:29 and documented by LPN #1 indicated Received report regarding resident's [family member's] request. [name redacted] NP .ordered to send resident to [name redacted] ER [emergency room ] for further evaluation. Altered mental status. [name redacted] NP discussed with [name redacted] NP .Resident left facility at 5:19 PM via [name redacted] transportation. A review of the 5/10/21 Discharge Minimum Data Set (DMDS), an assessment tool used to facilitate care management, indicated that Resident # 223 had an unplanned discharge to an acute hospital. The 5/10/21 DMDS also indicated that the cognitive skills for decision-making were moderately impaired. A review of the NP #1's handwritten physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . discussed with Np #2. A review of the 5/10/21, timed at 19:37 Individual Psychotherapy Progress Note (IPPN) by [name redacted]-LSW (Licensed Social Worker) indicated that the resident was seen for a face-to-face encounter. A review of the NP's #1 Acute/Reassessment (A/R) notes dated 5/10/21 included the History of Present Illness (HPI), which reflected that the [family member] called NP and reported that while visiting [Resident # 223] on 5/9 [Resident # 223] 'looked different,' he/she was 'drooling' and could not 'pin point what was going on with him/her.' Pt [patient] was elevated at bedside .Pt noted to be slower in responses and noted to have weaker grip on left side. [Family member] denied any previous hx [history] of stroke. Facetime with pt and [family member]-pt [patient] noted to be more slower while talking on facetime with [family member] .Pt [patient] to be evaluated further in ED [emergency department] per family request. On 6/28/21 at 8:27 AM, the surveyor interviewed NP #1, who stated that the RP called her on 5/10/21 and notified her about a change in the condition of Resident #223 during a visit with the resident on 5/9/21. NP #1 further stated that according to the RP, the resident showed signs and symptoms of facial drooping and was unable to open the right eye. NP #1 said that she did not receive a call from the facility on 5/9/21 regarding the RP's concerns. On that same date and time, NP #1 informed the surveyor that the resident was transferred to the hospital on 5/10/21, and the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At that same time, NP #1 confirmed that she handwrote the 5/10/21 order timed at 3:45 PM to transfer the resident to the hospital for further evaluation due to slurred speech and discussed it with NP #2. NP #1 stated, it will not make any difference now because the hospital will ask when the symptoms of stroke started, and according to the RP, it began on 5/9/21. The surveyor asked NP #1 why the resident wasn't transferred to the hospital via 911 on 5/10/21 at 5:19 PM? The NP #1 stated, because the window period for stroke is within 3 hours. On 6/28/21 at 10:12 AM, the RN/UM informed the surveyors that as a standard of practice, if a staff member or responsible party reported a change in condition of the resident, then the LPN should have called the RN/S or the RN/UM to assess the resident because the assessment should be done by an RN. The RN/UM stated that the RN/S #1 should have assessed the resident on 5/9/21, called the physician, and documented her assessment and findings in the electronic medical records. On 6/28/21 at 10:48 AM, the surveyor, in the presence of the survey team, conducted a telephone interview with LPN #1 who stated she was the nurse assigned to Resident # 223 on 5/9/21, from 1:00 PM and the 3-11 shift, and on 5/10/21 during the 3-11 shift. LPN #1 stated that as a standard of practice, an LPN should call the RN/S or RN/UM if there is a report of change in condition because the RN was responsible for assessing the resident. She further stated that the RN would initiate a Situation-Background-Assessment-Recommendation (SBAR ), notify the physician, and document; [The SBAR allows for an easy and focused way to set expectations for what will be communicated and how between a member of the team, which is essential for developing teamwork and fostering a culture of patient safety in the electronic medical record as part of the RN's assessment]. LPN #1 further indicated that the nurse should have documented in the 24 HDR for another shift to continue monitoring the resident. She further acknowledged that she should have documented in the 24 HDR to communicate with the oncoming shift. On that same date and time, LPN #1 informed the surveyors that she remembered that the RP visited on 5/9/21 at 1:00 PM and had a concern regarding a change in the resident's condition. The RP asked the Restorative Certified Nursing Aide (RCNA) to have the nurse call the RP. LPN #1 stated that she informed RN/S#1 of the RP concerns. LPN #1 could not speak to why there was no report in the HDR on 5/9/21. When asked why there was no documented evidence of the change in condition reported by the RP until 5/10/21, timed at 7:24 PM. LPN #1 stated, I have no answer. LPN #1 further said, looking back now, I should have called the doctor on 5/9/21 to notify the physician that the RP had a concern with the resident's condition. LPN #1 informed the surveyors that the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/21 at 11:08 AM, the [name redacted]-LSW (SCT/LSW) informed the surveyors that she's been coming to the facility as a Psychotherapist and writes her consultation reports electronically. The SCT/LSW stated that before she saw the resident on 5/10/21 at 1:30 PM, the facility Director of Social Services (DSS) asked her to check on the resident to see if there were any changes in condition because the RP called him and expressed concerns that the resident had a change in condition regarding the resident's speech and handgrip. On that same date and time, the SCT/LSW stated, since I've been seeing the resident for a while now, and I know the resident well. I can't remember what side of the arm was weak. The SCT/LSW stated, as per her observations, that the resident's speech was different, slower, and delayed, which was different for the resident. She further said that she informed NP #1 and RN/UM at that time, and that staff was aware of the RP's concerns since 5/9/21. The staff just wanted me to confirm the resident's changes since I knew the resident well. She stated, unless you take time to talk to the resident, you wouldn't be able to see the changes. The surveyor asked the SCT/LSW if she documented the resident's change of condition in her consult notes on 5/10/21? She stated, it should have been documented. On 6/28/21 at 11:20 AM, the RCNA informed the surveyors that on 5/9/21, he transported the resident to the visiting area and back to the unit. The RCNA stated that the resident was ok when he transported the resident to see the RP, and later, the RP called him because the RP observed changes in the resident. He further stated that he observed the resident was slow to respond and looked sleepy and was leaning to one side of the body, but he couldn't remember which side of the body. The RCNA stated that he brought the resident back to the unit, informed LPN #1 of the RP's concerns and that the RP wanted a call back regarding the resident's condition. On 6/28/21 at 11:32 AM, the surveyor, in the presence of the surveyor team, interviewed the DSS, who stated that he was unable to remember what the concerns of the RP were on 5/9/21 and could not speak of an incident or the RP's concerns. He further stated that there was no documented report regarding the 5/9/21 incident. On 6/28/21 at 1:08 PM, the surveyor conducted a telephone interview with the Registered Nurse (RN) in the presence of two other surveyors. The RN confirmed that he worked the 11-7 shift on 5/9/21. The RN stated that he remembered Resident # 223, and there were no reports or a shift to shift report to monitor the resident's condition. He said he was unaware that the resident's RP had concerns regarding the resident's condition on 5/9/21. On 6/28/21 at 2:18 PM, the survey team met with the LNHA, DON, Assistant Director of Nursing (ADON), Quality Assurance Performance Improvement Certified Specialist (QAPI/CS), Regional Nurse and discussed the above concerns. On 6/28/21 at 9:00 AM, 9:15 AM, and 10:00 AM, the surveyor, in the presence of the survey team, attempted to conduct a telephone interview with RN/S #1 but was unable to. On that same date, at 9:30 AM and 9:36 AM, the surveyor, in the presence of the survey team, attempted to conduct a telephone interview with NP#2 and the resident's primary care physician but was unable to. On 6/29/21 at 9:29 AM, the surveyor, in the presence of the survey team, interviewed LPN #2, who stated that Resident #223 was alert with some forgetfulness and confusion, able to make needs known to staff, and able to verbalize needs. LPN #2 confirmed that she worked the 7-3 shift on 5/10/21 and that there was an incident over the weekend that happened. I don't know what happened. She further stated, I know that was the priority at that time because the RN/UM and NP #1 were the ones taking care of the resident. The surveyor asked LPN #1 what the priority was at that time? LPN #1 stated, I don't know. On 6/29/21 at 9:37 AM, the surveyor, in the presence of another surveyor, interviewed the RN/UM, who confirmed that she worked the 7-3 shift on 5/10/21. She stated there were no reports about the resident from the medical record and no reports from the Staff about monitoring the resident's condition. The RN/UM noted that she was unaware that the RP had concerns on 5/9/21, not until NP #1 came into the facility on [DATE]. The NP #1 informed her that the RP called the NP #1 with concerns of the resident, that the resident had a change in the condition of drooping and unable to speak. The RN/UM further stated that NP #1 and the RN/UM were able to assess the resident when the resident came back from an Orthopedic appointment in the afternoon. She further stated that the assessment was done with the RP via facetime. The RN/UM noted that the resident was fine at that time, except the resident was slow to respond than normal, and NP #1 ordered to transfer the resident to the hospital for further evaluation. On that same date and time, the RN/UM stated that she was not aware of NP #1's handwritten order dated 5/10/21 timed at 3:45 PM to transfer the resident to the hospital for slurred speech. She further stated that the resident should have been transferred to the hospital via 911 if the reason for the transfer was signs and symptoms of stroke, which was slurred speech, and stated, yes, I should have called 911. On 6/29/21 at 10:58 AM, the DON, in the presence of the ADON, informed the surveyors that the eInteract is the same as an SBAR. On that same date and time, the surveyor, in the presence of the DON, reviewed the electronic medical records for Resident # 223. There was no documented eInteract dated 5/9/21. A review of the staff statements provided by the DON on 6/29/21 at 1:38 PM reflected that the DSS had a typewritten statement which reflected that he received a call from the RP on 5/10/21, indicating that the RP visited on 5/9/21 and felt there were some changes with the resident. On 6/30/21 at 12:58 PM, the survey team met with the LNHA, Corporate [NAME] President of Nursing, DON, ADON, QAPI/CS. The DON informed the surveyors that she provided the staff statements to the surveyor. On 7/2/21 at 9:22 AM, during a post-survey telephone interview with RN/S#2, who confirmed that she worked the 3-11 shift on 5/10/21 but arrived at work around 3:30-4:00 PM. The RN/UM asked her to go with RN/UM and NP #1 to assess the resident. RN/S#2 stated that she could not remember the RN/UM and NP's names and why the resident was being assessed. RN/S#2 was unable to remember the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that there was a concern on Sunday. I didn't work that day. She noted that the resident's family member was concerned that the resident had a stroke, and there were different stories about that day. She further stated that as a standard of practice, the RN/S should immediately assess the resident, call the doctor about the assessment and concern of the RP about signs and symptoms of stroke as reported, follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Change in a Resident's Condition or Status Policy that the DON provided with the last update of March 2021 included Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident . NJ 8:39-11.2 (b)

Complaint #NJ Cross Reference: F226, F281 and F309 Based on interviews and review of policies, electronic health records (EHRs) and other facility documentation, it was determined that the Administrator (Licensed Nursing Home Administrator/LNHA) failed to: ensure the development of EHRs policies and procedures to follow when residents with the same or similar names were residing in the facility. Two residents with the same first and last name, Residents #3 and #4 resided in the facility from [DATE] to 12/8/2014. Resident #3 received a medication ordered for Resident #4 and Resident #3's EHR indicated a Do Not Resuscitate (DNR) status which was ordered for Resident #4. Additionally, separate facility staff members, identified errors in the EHRs in medication transcription, assessment notes and DNR status. Although errors were removed from the incorrect EHR, no investigation was completed as to the cause, therefore Resident #4 didn't receive medications as ordered by the physician and her EHR indicated she had no DNR status for a period of time. The failure of some facility staff's awareness that two residents with the same first and last name and the possibility to have future residents with the same and/or similar names combined with the lack of preventative and corrective measures after discovery of Residents #3 and #4's medication errors placed Residents #3 and #4 in Immediate Jeopardy (IJ) and had the potential to place future residents in an IJ situation. The IJ to the residents' health and safety began on 12/5/14, was identified by the surveyor and reported to the Administrator and Director of Nursing (DON) on 2/12/15, the third day of survey and was corrected that day when an acceptable plan of correction was implemented. This deficient practice is evidenced by; 1. F 226 - See Example #1 2. F 309 - See Examples #1 and #2 3. F 514 - See Examples #1 and #2 The immediate jeopardy which began on 12/5/14 was identified on 2/12/15, the third day of survey and corrected that day when an acceptable plan of correction was implemented by the facility. 1. Immediate revisions have been made to our same name or similar name policy and charting and documentation policy to insure this deficient practice doesn't reoccur. Additionally, the policy new encompasses the use of EMR. 2. In-servicing will be conducted on all nursing personnel on our new policy. 3. Audits will be conducted by the Director of Nursing/Assistant Director of Nursing and/or designee on a weekly basis reviewing same name or similar name chart accuracy. Nurse will contact physician on admission to obtain an order q shift for; "Be on Duplicate Name Alert-Resident with Same Name as Another Resident in Facility". Nurse will also enter "Duplicate Name Alert" on "EMAR" under "Special Needs"or "allergies [REDACTED]. 4. Audits will be conducted to ensure policy compliance weekly by the Administrator. Audits will be submitted to the quarterly CQI committee for compliance. Completion Date: 2/12/15 NJAC 8:39-9.2 (a)

Complaint # NJ Cross Reference F309 Based on interviews and review of Electronic Health Records (EHRs) and other facility documentation, it was determined the facility did not conduct a timely and thorough investigation for the failure to enter physician's orders [REDACTED].#3 and #4) with the same first and last name. Resident #4 was admitted to the facility on [DATE] at 5:30pm and the Nursing Admission Assessment and the physician's orders [REDACTED].#4's EHR. Resident #4 did not receive ten medications and did not have a Do Not Resuscitate (DNR) status from 5:30pm on 12/5/14 until sometime on 12/6/14. A physician's orders [REDACTED].#4's Electronic Medication Administration Record [REDACTED]#4. Resident #3 was not administered one medication and a nutritional liquid supplement at 8am and 9am on 12/6/14 which was ordered for Resident #3. In addition, RN #2, identified that the Nursing Admission Assessment in Resident #3's EHR was a "wrong entry," but didn't inform anyone, nor did she enter/transfer the Nursing Admission Assessment onto Resident #4's EHR and was not aware of the 12/5-6/14 incident, until the surveyor interviewed her on 2/9/15. The failure to conduct a timely and thorough investigation for two residents with the same first and last name and the possibility to admit future residents with the same or similar names combined with the lack of preventative and corrective measures after discovery of Residents #3 and #4's medication errors placed Residents #3 and #4 in Immediate Jeopardy (IJ) and had the potential to place future residents in an IJ situation. The IJ to the residents' health and safety began on 12/5/14, was identified by the surveyor and reported to the Administrator and Director of Nursing (DON) on 2/12/15, the third day of survey and was corrected that day when an acceptable plan of correction was implemented. This deficient practice is evidenced by the following; 1. See Examples #1 and #2 The immediate jeopardy which began on 12/5/14 was identified on 2/12/15, the third day of survey and corrected that day when an acceptable plan of correction was implemented by the facility. 1. An investigation with Resident #3 and Resident #4 medical record that occurred 12/5/14 has been completed on 2/12/15. 2. An investigation of all residents with similar or like names was completed to ensure that medication orders and documentation are accurate. 3. In-servicing will be provided to all nursing staff about revised Charting and Documentation Policy and Incidents and Accidents procedure. In-servicing will be conducted to all nursing staff on the aforementioned policies. All staff will be in-serviced on the employee concern/grievance process to ensure employee concerns are documented and investigated appropriately. 4. On a weekly basis the DON or designee will review MEDICATION ORDERS FOR [REDACTED]. On a weekly basis the Administrator or designee will review all employee concern forms to ensure employee concerns have been investigated and resolved as appropriate. The results of these audits will be reported to the Quality Assurance committee on a quarterly basis and they will decide on the need for continued audits. Completion Date: 2/12/15 NJAC: 8:39-29.3(a) 6

Complaint # NJ Based on interviews and review of electronic health records (EHRs) and other facility documentation, it was determined that the facility did not provide the necessary care and services, including entering the physician's orders [REDACTED].(Residents #3 and #4). Resident #4 was admitted to the facility on [DATE] at 5:30pm and the Nursing Admission Assessment and the physician's orders [REDACTED].#4's EHR. Resident #4 did not receive 10 medications, [MEDICATION NAME] Insulin [MEDICATION NAME], Vitamin C, [MEDICATION NAME], Isorbide [MEDICATION NAME] and Aspirin (ASA) Chewable and did not have a Do Not Resuscitate (DNR) status from 5:30pm on [DATE] until sometime during [DATE]. A physician's orders [REDACTED].#4's Electronic Medication Administration Record [REDACTED]#4. Resident #3 was not administered an ordered medication, [MEDICATION NAME], and a liquid nutritional supplement, Pro Stat which was ordered for Resident #3. In addition, a Departmental Note by RN #2 identified that the Nursing Admission Assessment in Resident #3's EHR was a "wrong entry" but didn't inform anyone, nor did RN #2 enter the assessment onto Resident #4's EHR. The lack of some staff's awareness that two residents with the same first and last name resided in the facility and the possibility to admit future residents with the same or similar names combined with the lack of preventative and corrective measures after discovery of Residents #3 and #4's medication errors placed Residents #3 and #4 in Immediate Jeopardy (IJ) and had the potential to place future residents in an IJ situation. The IJ to the residents' health and safety began on [DATE], was identified by the surveyor and reported to the Administrator and Director of Nursing (DON) on [DATE], the third day of survey and was corrected that day when an acceptable plan of correction was implemented. This deficient practiced 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 or 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: "The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist." 1. According to a Face Sheet, dated [DATE], Resident #4 was admitted on [DATE] at 6:30pm with [DIAGNOSES REDACTED]. A careplan, initiated [DATE] indicated the resident had a potential/actual alteration in elimination related to constipation with interventions that included but not limited to; administer stool softener and/or laxative per physician's orders [REDACTED]. The careplan also indicated the resident had altered thought process with interventions that included but not limited to; observe for changes of cognitive status and give medications as ordered. In addition the careplan indicated the resident was on anticoagulant therapy, including ASA and [MEDICATION NAME] with interventions that included but not limited to administer medication as ordered. According to Physician order [REDACTED].#4 was admitted with the following DNR status and ten medications dated [DATE] that included but not limited to; -Resident is a Do Not Resuscitate (DNR) -[MEDICATION NAME] 75 milligram (mg) tablet one by mouth (PO) daily at 9am - an antiplatelet agent -[MEDICATION NAME] 100 mg liquid 50 mg/5 milliliters (ml) give 10 cubic centimeters (cc) PO daily - a stool softener -Vitamin C 250 mg tablet one tablet PO daily - a supplement - Isorbide [MEDICATION NAME] (MN) 20 mg tablet one tablet PO daily - an [MEDICAL CONDITION] agent - [MEDICATION NAME] 100 mg tablet one tablet PO daily - an antigout drug - Aspirin 81 mg Chewable tablet one tablet daily - an antiplatelet drug - [MEDICATION NAME] 2 mg tablet one tablet PO at 9am and 5pm - a diuretic - [MEDICATION NAME] Syringe, with sliding scale as follows: ,[DATE] = 2 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units, notify physician if less than 70 are (or) greater than 400 - insulin for [MEDICAL CONDITION] -[MEDICATION NAME] 137 micrograms (mcg) tablet one tablet PO daily - [MEDICAL CONDITION] hormone - [MEDICATION NAME] 800 mg tablet one tablet PO with meals at 8am, 12pm and 5:30pm - a calcium-[MEDICATION NAME] binder A [DATE] EMAR confirmed the orders. Review of the [DATE] EMAR indicated the first time [MEDICATION NAME], Vitamin C, Isorbide MN, [MEDICATION NAME] and Aspirin Chewable were initialed as administered was [DATE] at 9am. The first time [MEDICATION NAME] was initialed as administered was [DATE] at 8am. The first time [MEDICATION NAME] was initialed as administered was [DATE] at 5pm. The first time [MEDICATION NAME] was initialed as administered was [DATE] at 6am. The first time blood sugars with [MEDICATION NAME] sliding scale coverage were documented on the EMAR was on [DATE] at 4:30pm. There was no indication why the frequency of blood sugars was on the EMAR without a physician's orders [REDACTED]. Review of Resident #4's Departmental Notes (DNs) did not reveal a Nursing Admission Assessment note. Resident #4's Nursing Admission Assessment note by RN #6 dated [DATE] at 1:58am was located in the DNs of Resident #3. A Nursing Admission Assessment note in Resident #3's EHR revealed, "Resident arrived on the unit via stretcher at 5:30pm (on [DATE])...admitting [DIAGNOSES REDACTED]." There was no indication in Resident #3 or #4's EHR or EMAR that 4 units of [MEDICATION NAME]coverage was administered as ordered for the elevated blood sugar fingerstick of 222 on [DATE]. During a telephone interview with RN #6 on [DATE] at 3:15pm, she disclosed that she wrote Resident #4's Nursing Admission Assessment. She revealed she did not know that she entered Resident #4's Nursing Admission Assessment into Resident #3's EHR. She stated, "This is the first time I was told about it. I did not know I wrote in the wrong chart" and "I knew there were two residents with the same name". Review of Resident #3's DNs revealed a Miscellaneous note entered on [DATE] at 6:59pm by RN #2, "Wrong entry on [DATE] assessment entry at 5:50pm." During an interview with RN #2 on [DATE] at 2:30pm, she clarified the Miscellaneous note in Resident #3's EHR dated [DATE] and stated, "I should have written wrong entry on [DATE] assessment entry. I wrote the wrong date ([DATE]). It should say [DATE]." She stated, "I realized the admission note was entered in the wrong chart. I didn't tell anyone. I just wanted to make the resident's (Resident #3's) record right." RN #2 did not appear to be aware of the EHR policy that the incorrect entry in Resident #3's EHR should also have been deleted with lines through the entry by RN# 6, who entered the Nursing Admission Assessment. Review of Resident #4's DN did not reveal any nurse's notes for [DATE] on 3pm-11pm or 11pm-7am shift and [DATE] on 7am-3pm shift which would have indicated if any assessment and/or monitoring was done. The first nurse's note entered in Resident #4's EHR was dated [DATE] at 12:09am by RN #4 who worked the 3pm-11pm shift on [DATE] according to the daily schedule. "resident asleep mostly (most) of time. O2 continue via n/c (nasal cannula). SPO2 98%. ADLs care continue. Refused meds. Very poor appetite, encourage fluids. Safety maintained, will monitor." Review of a DN entered in the EHR on [DATE] at 7:04am by LPN #5, the nurse who worked from 11pm on [DATE] to 7am on [DATE] according to the daily schedule, indicated, "Received in bed sleeping. Breathing even and unlabored. Cont (continuous) O2 (oxygen) in progress 2 LPM (liters per minute) via n/c (nasal cannula). No SOB (shortness of breath) observed. All needs met by staff. Safety measures in place. Call bell at reach." Review of a DN entered in the EHR on [DATE] at 2:54am by LPN #5, the nurse who worked from 11pm on [DATE] to 7am on [DATE] according to the daily schedule, revealed, "Resting comfortably in bed. Breathing even and unlabored. Cont (continuous) O2 (oxygen) in progress, no SOB (shortness of breath) observed. All needs met. Will monitor." Review of DN entered in the EHR on [DATE] at 4:40pm by RN #5, the nurse who worked from 7am on [DATE] to 3pm on [DATE] according to the daily schedule, indicated, "Was called @ (at) 9:10am re (regarding) resident is observed unresponsive with no vital signs appreciated on DNR, (physician) service was called no response and (hospital receptionist) made aware to page Dr (physician) to aware awaiting to call back Pronounced expired @ (at) 9:10 am. Daughter is @ (at) bedside and is aware death certificate is done and body is piked (picked) up by funeral homes arranged by the (family member)." Review of a DN entered in the EHR on [DATE] at 2:25am (the day after Resident #4 expired) by LPN #6, the nurse who worked from 7am on [DATE] to 11pm on [DATE] according to the daily schedule, revealed, "[DATE] at 7:30am Received resident in bed sleeping. O2 (oxygen) via n/c (nasal cannula) no distress noted. 8:30am Went to resident room to do her blood sugar, noted resident to be unresponsive, unit manager made aware, resident is DNR (do not resuscitate). Review of the 24 hour daily reports for 3 East dated [DATE]-[DATE] included multiple resident information on each page which was handwritten. The information on the 24 hour reports was not entered into Resident #4's EHR. Review of a 24 hour daily report, dated [DATE] indicated Resident #4 was admitted on the 3pm-11:30pm shift with, "Dx (diagnoses):Rapid [MEDICAL CONDITION] Fib, DM, HTN, Dementia Behavioral Dist (disturbances); Total care, fall precautions, aspiration precautions, has to be fed, T & P (turn and position) q (every) 2 hours, incontinent of B & B (bowel and bladder) O2 cont (continuous) @ (at) 2 LPM (liters per minute), PPD given to left fore arm and MD (physician) to come in tom (tomorrow)" Review of the 24 hour daily report dated [DATE] 11pm-7:30am revealed, "N/A (new admission Resident #4) day #,[DATE] (day #2 of 7) stable, slept throughout the shift O2 @ (at) 2 LPM (liters per minute) continuous HOB (head of bed) up, T&P (turn and position) q 2 hrs" A 24 hour daily report dated, [DATE] on the 7am-3:30pm shift for Resident #4 revealed, "O2 (oxygen) at 2LPM (liters per minute) cont (continuous), aspiration precautions, T&P q 2 hrs, ate 50% meal, thick liquids given, VS (vital signs) ,[DATE], P (pulse)=99, T(temperature)=97.5, R (respirations) =18, O2 98%, BS (blood sugar) at lunch 314." The ,[DATE]:30pm shift revealed, "O2 continuous via n/c (nasal cannula), poor appetite, refused meds, very sleepy, total care. The ,[DATE]:30am shift report for Resident #4 revealed, "all needs met" A 24 hour daily report, dated [DATE] on the 7am-3:30pm shift revealed, "VS ,[DATE] P=99, BS 365 @ BF (breakfast), 321 @ lunch, O2 @ 97%." The 3pm-11:30pm shift revealed cont (continuous) O2 in progress, asp (aspiration) precautions." The 11pm-7:30am shift revealed N/A #3, all needs met, T&P (turn and position) q 2 hrs" A 24 hour report, dated [DATE] (wrong date written) on the 7am-3:30pm shift revealed, "(Resident #4) Expired @ (at) 9:10am" Review of a New Jersey Electronic Death Registration confirmed Resident #4's date of death was [DATE]. During a post survey telephone interview with the DON on [DATE] at 3:41pm, she indicated that the 24 hour reports are kept in a book in "archives". She revealed she has 24 hour reports that go back at least 7 years. There are two copies; a yellow and a white copy. She stated, "As long as I am here, I will keep them forever." She stated that the 24 hour reports are mostly for the nurses to refer to and that she was not aware that physicians have read them, but if they wanted to they are available to them. 2. According to a Minimum Data Set (MDS) an assessment tool dated [DATE], Resident #3 had severe cognitive impairment and needed assistance with activities of daily living (ADLs). The resident resided in the facility since [DATE]. According to a Hospital Admission Assessment Report Resident #3 was discharged to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A careplan, initiated [DATE] indicated the resident had Alzheimers Dementia, Hypertension (HTN), [MEDICAL CONDITION] and therapeutic diet with interventions that included but not limited to; ProStat SH 30 milliliters (ml) twice a day (bid). Review of [DATE] POS revealed physician's orders [REDACTED].#3's EHR on [DATE] and discontinued on [DATE]; - DNR -[MEDICATION NAME] 75 milligram (mg) tablet one by mouth (PO) daily at 9am -[MEDICATION NAME] 100 mg capsule one tablet PO at 9am -Vitamin C 250 mg tablet one tablet PO daily at 9am - Isorbide [MEDICATION NAME] (MN) 20 mg tablet one tablet PO daily at 9am - [MEDICATION NAME] 100 mg tablet one tablet PO daily at 9am - [MEDICATION NAME] 2 mg tablet one tablet PO bid at 9am and 5pm - [MEDICATION NAME] Syringe, with sliding scale coverage as ordered: ,[DATE] = 2 units, ,[DATE] = 4 units, ,[DATE] = 6 units, ,[DATE] = 8 units, ,[DATE] = 10 units, notify physician if less than 70 or greater than 400 -[MEDICATION NAME] 137 micrograms (mcg) tablet one tablet PO daily - [MEDICATION NAME] 800 mg tablet one tablet PO three times a day (tid) with meals -[MEDICATION NAME] 325 mg tablet one tablet PO daily - an iron supplement The above physician's orders [REDACTED]. Review of the Resident #3's [DATE] EMAR confirmed the above orders. The [DATE] EMAR revealed that [MEDICATION NAME] was initialed as administered by LPN #4 on [DATE] at 6am. The EMAR indicated that 9 medications ([MEDICATION NAME] capsule, Vitamin C, Isorbide, [MEDICATION NAME] coverage, [MEDICATION NAME], and [MEDICATION NAME]) were not administered. During a telephone interview on [DATE] at 10:10am with LPN #4 she stated, "I know I didn't give [MEDICATION NAME] to (Resident #3). She was not on any meds at 6am and I wasn't working on 3 West on that night. I did not make a med (medication) error." Review of the daily schedule confirmed that LPN #4 was scheduled on 3 East on [DATE] at 11pm until [DATE] at 7am. During an interview with the Unit Manager on 3 West on [DATE] at 1:10pm she stated, "I did not know there was another resident with the same name in the building, but I knew these meds (medications) were not my resident's (Resident #3's) meds. I found out Monday morning ([DATE]) there were two residents with the same name." Review of a pharmacy shipping manifest, dated [DATE] and a printed time 4:14:43am, indicated a medication delivery time 6:29am and was signed as accepted by LPN #4, the nurse assigned to Resident #4 on 11pm-7am shift. Listed on the pharmacy manifest were the following medications for Resident #4; -[MEDICATION NAME] 75 mg tablets - generic for [MEDICATION NAME] -[MEDICATION NAME] tablets 137 mcg -Isorbide Din 20 mg tablets -[MEDICATION NAME] 2 mg tablets [MEDICATION NAME] 800 mg tablets -[MEDICATION NAME] 100 mg tablets [MEDICATION NAME] capsules, Vitamin C tablets, [MEDICATION NAME] Syringe, [MEDICATION NAME] tablets and [MEDICATION NAME] tablets were not included on the shipping manifest. Review of a pharmacy shipping manifest, dated [DATE] at 6:56:41 pm was signed as accepted by RN #4, the nurse assigned to Resident #4 on the 3pm-11pm shift. It did not indicate a delivery time. Listed on the pharmacy manifest were the following medications for Resident #4; -[MEDICATION NAME] 75 mg tablet (gen (generic) for [MEDICATION NAME]) -[MEDICATION NAME] 100 mg tablets -Isorbide "Monon" 20 mg tablets -[MEDICATION NAME] 2 mg tablets -[MEDICATION NAME] tablet 137 mcg -[MEDICATION NAME] 800 mg tablets [MEDICATION NAME] capsules, Vitamin C tablets, [MEDICATION NAME] Syringe and [MEDICATION NAME] tablets were not included on the shipping manifest. Further review of Resident #3's [DATE] POS indicated additional physician's orders [REDACTED]. - Pro Stat 64 Liquid 30 ml PO bid order initiated on [DATE] - [MEDICATION NAME] 10 mg tablet one tablet PO bid order initiated on [DATE] Review of the [DATE] EMAR revealed [MEDICATION NAME] was not initialed as administered at 9am on [DATE] and Pro Stat were not initialed as administered at 8am on [DATE]. During an interview with the Unit Manager of 3 West on [DATE] at 1:10pm, she stated, " I don't have an explanation why [MEDICATION NAME] and Pro Stat were not given." During an interview with the DON on [DATE] at 10am she revealed that after Resident #4's medications were discovered on Resident #3's POS and EMAR on [DATE] the errors were corrected on [DATE]. She revealed she did not have a written investigation about the incident. In addition, she disclosed that she was not aware that [MEDICATION NAME] was initialed as administered to Resident #3 and that [MEDICATION NAME] and Pro Stat were not initialed as administered to Resident #3. A statement provided by the DON to the surveyor on [DATE], revealed RN #3 "stated that there was a problem with 2 charts that appeared to be intertwined" and "the charts were reviewed and the problems were rectified" and "The following Monday ([DATE]), I started an investigated (investigation) as to what was the cause of the 2 chart issues. The IT (Information Technology) employee also was notified and the issues were discussed. Verbally the IT reported to me that there was an error when the second patient was entered into the system" and "My discovery concludes that there was an error due to the lack of similar name alert, alerting the staff that a new patient with the same name was being admitted ". Review of a statement submitted by LPN #2 on [DATE] revealed, " On [DATE] resident (Resident #4) was admitted to the facility. I entered the date and time in to (into) the system as always. I then called the MD (physician) to get the okay to carry out the medications and then entered them into the system. On [DATE] I also received a call from the weekend supervisor (RN #3) informing me that the medications had gone into another resident's (Resident #3) records who's (whose) name also is (the same)." Review of a statement provided by RN #3 on [DATE] revealed, "(Resident #3) didn't have her regular meds 'firing' on the computer for her"...and..."upon assessment and further analysis I noted that meds were different" and "no meds on ,[DATE] were given to each of the (residents; Resident #3 and Resident #4) until something/corrections have been made". During a telephone interview with LPN #2 on [DATE] at 12:45pm she revealed that she entered the physician's orders [REDACTED]. She stated, "It had to be a computer glitch. I entered the physician's orders [REDACTED]. They somehow didn't fire onto (Resident #4's) MAR." LPN #2 explained that "fire" meant the physician's orders [REDACTED]. "Both resident names were in the computer when I entered the physician's orders [REDACTED]. The new resident's name (Resident #4's) was already in the computer ready for me to enter admission orders [REDACTED] Review of Resident #3's DN dated,[DATE] at 11:38pm revealed, "Noted with small amt (amount) of undigested food particles after dinner. No distress noted. B/p (blood pressure) ,[DATE] temp (temperature) 98.2 resp (respirations) 20, No facial grimacing noted needs met condition remain (remains) stable. Will continue to monitor." Review of a DN dated [DATE] at the following times indicated; 5am- "Resident is sleeping" 5:40am- "CNA (Certified Nursing Assistant) done with her morning care and after 5 mins (minutes) of care, the resident noted to past (pass) bowel in large amount" 6:05am- "CNA noticed to that there is something different to the patient, informed the nurse" 6:15am- "Came to the room, the resident noted to have tachypnea, cold clammy skin, and unresponsive; Vital signs taken as follows: BP=,[DATE] mmHg (millimiters of mercury), P=75 bpm (beats per minute), SPO2=74%, RR (respiratory rate)=45 bpm (respirations per minute), BS (blood sugar)=256mg/dl (milligrams per deciliter); informed the supervisor, place on O2 @ (at)10 Lpm (liters per minute) via non-rebreather; keep monitoring the patient's condition; called 911; the SPO2 ranges ,[DATE]%, still unresponsive" 7:00am- "Informed (physician) and family; 911 came, assess the resident" 7:20am- "Sent to (hospital) per stretcher, with O2" Review of a 24 hour daily report for 3 West dated, [DATE] indicated, "(Resident #3) sent out to (hospital) by 911 @ (at) 7:20am". Review of a 24 hour daily report dated, [DATE] on the 7am-3:30pm shift revealed, "admitted to (hospital) DX (diagnosis)-respiratory distress". Review of a 24 hour daily report dated, [DATE] on the 3pm-11:30pm shift revealed "(Resident #3) Expired at (hospital)" During an interview with the Administrator on [DATE] at 3pm he stated there were no medication errors in [DATE]. Review of a facility quality assurance report provided on [DATE] at 3:15pm by the Administrator revealed there were no medication errors between [DATE] and [DATE]. Review of a policy, dated ,[DATE] "Identifying and Managing Medication Errors and Adverse Consequences" revealed "The staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur" and Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form" and "The Medical Director, Director of Nursing Services and Consultant Pharmacist shall review medication errors and adverse medication consequences as part of the facility's Quality Assurance process." Review of a blank Medication Administration Error/Medication Documentation Error/Wasted Control Drug Report form dated ,[DATE] and faxed to the New Jersey Department of Health (DOH) revealed a section for "Cause of Incident" and "Specific Corrective Action Taken or Recommended". Review of a policy written prior to EHRs, dated [DATE] "Charting and Documentation" revealed "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record"...and..."All observations, medications administered, services performed, etc., must be documented in the resident's clinical records"...and..."All incidents, accidents, or changes in the residents condition must be recorded"...and..."Resident with the same name or last name an: "alert" sticker sign will be posted in the alert condition tab and besides resident's name at the door. Resident date of birth, social security, and room number must be check before any procedures or when making and (an) entry into resident's clinical record." Review of a policy, dated [DATE] "Addendums, Amendments, Corrections and Deletions in the EHR" revealed "If the original author determines a correction must be made to the EHR, only the same author may access the note in question and click on the corrections bar. This will alert the system to render incorrect information appearing with a single black line drawn through the center of it in the original record with the corrected information appearing as well. The corrected information will also be accompanied by the current date and time that the information was corrected as well as an electronic signature added as a consequence of user log-in." The immediate jeopardy which began on [DATE] was identified on [DATE], the third day of survey and corrected that day when an acceptable plan of correction was implemented by the facility. 1. All residents with the same name or similar named records have been reviewed immediately to insure physician order [REDACTED].#3 and resident #4 medical records including MAR's and POS's were reviewed [DATE] for accuracy. 2.All residents with the same name or similar names will be reviewed upon admission to ensure chart and documentation accuracy. In-servicing will be conducted on all nursing personnel on Charting and Documentation Policy. All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation indicated that: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g.., RN, LPN, physicians, therapists, etc.) in accordance with state state law and facility policy. 3. All incidents, accidents or changes in the resident's condition must be recorded. 4. Every effort will be made to locate patients or residents with the same full or last names on separate floors/units. 5. Admissions Director will document "Duplicate Name Alert" on the Face Sheet at admission and place an alert (red) sticker identifying "Duplicate Name Alert" on the "Admission Approval Notification" form that is provided to the DON/Nurse Supervisor prior to admission. On admission, the assigned Medical Record number will be checked by the Admissions Director to ensure it is not a duplicate number. 6. For Patients or Residents with the same full or last name: Nurse will place alert (red) sticker identifying "Duplicate Name Alert" in the "Condition Alert" tab of the manual medical record. A blank alert (red) sticker will be posted beside the resident's name located at the room entry. Resident's name, date of birth and medical record number must be checked before any procedures including assessments, medication and treatment transcription and administration, and when making an entry in the resident's clinical record. Nurse will place "Duplicate Name Alert" (red) sticker and resident's medical record number on resident's "Dietary Communication" form at admission and upon any change in diet. The Food Service Director/Designee will created a "Duplicate Name Alert" list with each resident's name, medical record number, room number, and diet order. Food Service Staff will refer to the "Duplicate Name Alert" list during each meal preparation and apply a "Duplicate Name Alert" (red) sticker with the resident's medical record on the appropriate resident's tray ticket based on matching the information on "Duplicate Name Alert" list. 7. Nurse will contact physician on admission to obtain an order q shift for ; "Be on Duplicate Name Alert-Resident with Same Name as Another Resident in the Facility". Nurse will also enter "Duplicate Name Alert" in "EMAR" under "Special Needs" or "allergies [REDACTED]. 8. Information documented in the resident's clinical record is confidential and may only be released in accordance with state law and facility policy. Refer all requests for information to the Director of Nursing Services, Nurse Supervisor/Charge Nurse or to the business office. 9. To ensure consistency in charting and documentation of the resident's clinical record' only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records. 10. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; g. The signature and title of the individual documenting. 3. All admissions with the same name or similar name will be reviewed by the nursing supervisor and again reviewed by the Director of Nursing and/or Assistant Director of Nursing the following day. the Charting and Documentation Policy was revised and all staff will be in-serviced regarding the policy. 4. Weekly audits will be conducted by the Director of Nursing/Assistant Director of Nursing and/or designee. Audits will be submitted to the quarterly CQI committee for compliance. Completion Date: [DATE] NJAC 8:,[DATE].1 (a)

Based on observation, interviews and record review it was determined that the facility failed to implement interventions intended to prevent falls for residents who had fallen or were at high risk for falling. This deficient practice was noted in 2 of 7 residents reviewed for falls, Residents #4 and #14. Resident #14 sustained 3 falls in the facility since 10/31/13. The most recent fall on 8/15/14 caused the resident to be transferred to a hospital Emergency Department and required sutures to close two head lacerations. This deficient practice was evidenced by the following: 1. During the tour of Unit 2 East on 8/12/14 at 10:00 a.m. the Unit Manager informed the surveyor that Resident #4 was alert but aphasic and had family that visited daily. The surveyor reviewed the medical record at 10:22 a.m. and noted that Resident #4 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/13/14 at 12:35 p.m. the surveyor reviewed the Electronic Medical Record (EMR) and the Annual Minimum Data Set (MDS), an assessment tool, dated 3/1/14 and the Quarterly MDS dated [DATE] which documented that Resident #4 was nonverbal/unable to speak related to the resident's Tracheostomy. The resident was totally dependent upon staff for activities of daily living (ADL's). Resident #4 was also noted to be at risk for falls due to decreased mobility, limited range of motion (ROM) and history of seizures. On 8/13/14 at 12:35 p.m. the surveyor reviewed Resident #4's EMR Care Plan for "Communication Difficulty Related to Tracheostomy" due to the resident's inability to speak. According to this Care Plan the resident used gestures in an attempt to communicate and was able to "nod and make facial expressions when asked simple questions." Fall #1: On 10/31/13 Resident #4 had a fall from the bed. On 8/13/14 at 2:15 p.m. the surveyor reviewed the facility's "Incident/Accident Report" dated 10/31/13 concerning this fall. The report indicated the resident "slid off bed and sustained a bump with a laceration on the left side of the forehead." An ice pack, pressure, and a dressing was applied. A call was placed to 911 at 10:25 a.m., and the resident was transferred to the hospital for evaluation and the resident's spouse was notified. Review of the facility's "Investigative Report for Known/Unknown Falls dated 10/30/13 stated the the resident's cognitive status prior to the fall was "confused & disorientated." The resident was unable to relay any information about the fall as the resident was non-verbal. Review of the Certified Nursing Assistant's (CNA) statement dated 10/31/13 noted the following: "after morning care I went back to the room at 10:00 a.m. to see the resident and found the resident out of bed on the floor on the resident's side position and called the nurse in charge." Review of the "Fall Risk Assessment" form for Resident #4 dated 9/11/13 indicated a score of 9 and the assessment dated [DATE] indicated a score of 10. According to the form a total score of 10 or above represents that a resident is at high risk for falls. New interventions initiated after the 10/31/13 fall included the bed should be placed in the lowest position, bilateral floor pads and padded side rails were to be used. Fall #2: On 8/13/14 at 2:40 p.m. the surveyor reviewed the facility's "Incident/Accident Report" concerning Resident #4's second fall, which occurred on 6/30/14. According to this report the resident fell "while the CNA performed a.m. care standing at the right side of the bed with the resident in the center of the bed." The CNA turned her back away from the resident and picked up soap from the side table. According to the description of the incident when the CNA turned back to face the resident, the CNA noticed a jerk and "the resident rolled to the left side and off the bed." New interventions initiated after the June fall included the "Review of the Interdisciplinary Team's Care Plans" (IDCP) initiated after the fall on 6/30/14 and the addition of "bed bolsters to be ordered" and "staff inserviced that the resident would require 2 person assist during care." Continued review of the facility's "Investigation of Incident" report dated 6/30/14 noted that "CNA's/Nurses were" inserviced on how to prevent Resident #4 from sliding off the bed especially during care. The IDCP team noted that the resident would now be taken care of with two person assistance. On 8/13/14 at 2:45 p.m. the surveyor reviewed the facility's "IDC Team 3-Day Post Fall Review" report dated 7/2/14 which noted that the facility would "install bed bolsters and inservice staff to have 2 person assistance during care to prevent incident to re-occur." On 8/13/14 at 2:55 p.m. the surveyor reviewed the facility's "Employee In-Service Record" dated 6/30/14. The subject of the inservice was titled "Safe repositioning/care of 2 assistance" for Resident #4 and included, the "resident will be taken care of with 2 person assistance to protect from falling out of bed." Review of the record contained the signature of only one employee, reflecting that only this one employee received the inservice. On 8/18/14 at 10:30 a.m. the Administrator provided a hand written piece of plain paper to the surveyor relating to the inservice provided to the Unit 2 East staff. It was dated 6/30/14. The inservice was given by an RN and provided to one CNA. A request for the copy of the lesson plan used for the in-service was requested and not provided. Fall #3: On 8/18/14 at 11:55 a.m. the surveyor observed Resident #4 in the resident's room in bed and the resident's family member was seated in a chair on the left side of the resident. The resident had two bandages above the left eye and visible signs of a hematoma. The surveyor interviewed the family member and learned that the family member received a phone call from the facility on 8/15/14 at about 10:00 a.m. and was informed that the resident had fallen during morning care and sustained two lacerations above the left eye and was sent out to the hospital for evaluation and treatment. The resident received four sutures in one of the lacerations and eight sutures in the other laceration. The resident also received a chipped tooth and one tooth was pushed up into the gum area that required a dental consultation to be done in the near future. On 8/19/14 at 10:10 a.m. the surveyor interviewed both the CNA and the LPN that were in the room at the time of the fall. They both told the surveyor that the resident's night stand was across from the resident's bed against the wall. The left bolster was on the bed and the right bolster was off. The LPN left the room to get a towel and the CNA turned sideways "so she could move the floor mat away." "The right siderail was up, but the resident jerked from a spasm and rolled off the bed, onto the CNA's leg and onto the floor." The CNA was not facing the resident at the time of the fall. During a review of the facility's "Incident/Accident Report" on 8/19/14 which was dated 8/15/14 it was documented that the writer, the Licensed Practical Nurse (LPN), and the CNA began to prepare the resident for morning care. The resident was in the center of the bed in a semi-fowler position with a pillow under the head. The other pillows were removed from the head of the bed and the bilateral bed bolsters had been removed from the bed. Before a.m. care was started the LPN left the room to retrieve a towel. Upon returning to the room the LPN observed the CNA turned sideways, away from the resident, to move the right floor pad aside. The CNA felt the resident jerk and the resident rolled off the bed, hit the CNA's back right leg, the corner of the night stand and landed on the floor. The resident sustained [REDACTED]. Both the LPN and the CNA that were in the room with Resident #4 on 8/15/14 had not been inserviced as indicated after the fall on 6/30/14 or any time after and prior to the fall on 8/15/14. 2. On 8/12/14 at 10:10 a.m. during the initial tour of the unit, the Unit Manager told the surveyor that Resident #14 had a [DIAGNOSES REDACTED]. The surveyor observed a hoyer lift pad under the resident who was asleep in the bed. On 8/13/14 at 9:00 a.m. the surveyor reviewed Resident #14 ' s medical record. According to The Minimum Data Set (MDS), an assessment tool, dated 12/10/13 and 5/30/14 the resident was assessed to be a total assist of two for all transfers. On 8/18/14 at 10:00 a.m. the surveyor reviewed an "Incident/Accident Report" dated 2/25/14 at 12:00 p.m. which indicated that following a two person transfer from the bed to the wheelchair (WC) via hoyer lift, Resident #14's WC tipped forward and the resident slid off the seat onto the lifted leg rests and calf pad. The section of the "Incident/Accident Report" titled "Steps Taken to Prevent Recurrence" indicated a rehabilitation screen would be done. The "Rehabilitation Communication Form" attached to the incident report indicated that a screen was done for Resident #14 on 2/27/14. The report included instructions for the staff to make sure that "when transferring the resident to the WC, the leg rests should be in the lowest position and the calf pad removed, or the weight of the WC becomes shifted forward (due to the weight of the leg rests in front when elevated)." On 8/20/14 at 11:00 a.m. the surveyor observed two CNA's preparing to transfer Resident #14 from the bed to the WC. The leg rests on the WC were elevated and a calf pad and pillow were on top of the leg rests. On 8/20/14 at 11:02 a.m. the surveyor interviewed Resident #14's primary Certified Nursing Assistant (CNA) who stated that the resident's WC was "prepared for transfer." When the surveyor questioned the CNA if she had been given in-service education regarding the proper transfer of Resident #14 from the bed to the chair and the CNA replied "no." The surveyor then requested the CNA to stop the transfer. At 11:10 a.m. the surveyor interviewed the primary staff nurse and the UM. Both stated they were unaware of the Rehabilitation Department recommendations. On 8/20/14 at 11:30 a.m. the surveyor interviewed the Director of Rehabilitation who stated "when a screening has been completed after a fall, a copy of the results are given to the Director of Nursing (DON). The DON should then notify the rehab department if an in-service was conducted." The Director checked the department's in-service book and there was no documentation that an in-service for Resident #14 had been conducted. On 8/20/14 at 2:00 p.m. the surveyor interviewed the Administrator and DON who agreed that an in-service should have been conducted concerning the rehab department's recommendations on 2/27/14 for proper transfer of Resident #14 to prevent future falls. NJAC 8:39-27.1(a)