Every finding on record at Green Hill

COMPLAINT # 423030Refer to F0689Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to notify the physician and the resident representative (RR) about an alleged fall reported by the resident. This deficient practice was identified for 1 of 2 residents, Resident #1, reviewed for incidents and accidents. This deficient practice was evidenced by the following:On 10/28/25 at 9:30 AM, the surveyor requested from the License Nursing Home Administration (LNHA) and the Director of Nursing (DON) all Facility Reported Event (FRE) investigations and a list of residents with falls and injuries in the last six months. On 10/28/25 at 11:20 AM, the DON provided the FRE investigations for the last six months. Resident #1 had one FRE investigation dated 5/2/25. The surveyor reviewed a facility provided investigation dated 5/2/25 which indicated Resident #1 had an injury of unknown origin for Resident #1 which occurred on 4/30/25. The investigation conclusion and incident note revealed the following:On 4/30/25 at 7:15 AM, Resident #1 was seen by a nurse practitioner (NP) at the bedside. At 7:50 AM, the primary nurse saw the resident and morning care was rendered by the Certified Nursing Assistant (CNA) with nothing unusual observed. At 9:30 AM, the Certified Occupational Therapist Assistant (COTA) visited the resident for a therapy session in their room and the resident reported to the COTA that he/she had a fall and complained of left arm pain. The COTA reported this to the resident's assigned Licensed Practical Nurse (LPN). The LPN went to check the resident. There was no bruising, or any previous fall reported. The LPN applied the resident's routine lidocaine topical cream to their left arm dialysis site which was due to be given prior to their outpatient dialysis treatments. The resident was sent out to their scheduled dialysis session. At approximately 3:00 PM, the facility received a call from the dialysis center stating that the resident was observed with bruising to their face and was transferred to the emergency room (ER) for further evaluation.A review of the facility's investigation revealed that the LPN did not initiate an investigation as per the facility's fall protocol at the time of the resident's reported fall. Additionally, there was no documentation that the physician or the RR was informed at the time that the resident reported falling. A review of the Electronic Health Record (EHR) revealed Resident #1 was not in the facility. The Resident #1's EHR revealed diagnoses which included but were not limited to metabolic encephalopathy (the brain does not function properly due to metabolic disturbance), end stage renal disease, and dependence on renal dialysis. A review of the April 2025 order summary revealed:A physician's order for hemodialysis (a treatment to remove waste products and excess fluids from the blood when the kidneys are not able to) on Monday, Wednesday, and Friday with a pickup time of 12:30 PM and their session was scheduled for 1:15 PM at the dialysis center. A physician's order for Lidocaine cream 2.5% that indicated to apply to the left arm dialysis site topically in the morning every Monday, Wednesday, and Friday for pain. A physician's order for skilled Occupational Therapy five times per week for four weeks.A review of the comprehensive Minimum Data Set (MDS), a facility assessment tool to facilitate the plan of care, dated 4/27/25 revealed the resident's cognition using a Brief Interview of Mental Status (BIMS) test. Resident #1 scored a 6 out of 15 which indicated the resident had severe cognitive impairment. On 10/28/25 at 2:40 PM, the surveyor interviewed the Registered Nurse (RN) Supervisor who stated if a resident had a new injury or a fall was reported, a skin assessment and vital signs were completed. The RN Supervisor explained the supervisor, the DON, the physician, and the RR were to be notified of the incident; and the resident's care plan would be updated; and an incident report started.On 10/29/25 at 12:09 PM, the surveyor interviewed the LPN, who was assigned to care for the resident on 4/30/25 for the 7AM to 3PM shift. The LPN stated she recalled the COTA informed her that Resident #1 stated that they fell, and she went to check on the resident. The LPN stated that there was no change or injury with the resident. The LPN further explained that she applied lidocaine topical cream to the resident's left arm dialysis access site as ordered and the resident was sent to dialysis in good condition. The LPN stated that the dialysis center called the facility and reported that the resident had a bruise on their face and was going to the ER for evaluation. The LPN confirmed that she did not report to the supervisor, the resident's physician and the RR that Resident #1 reported having a fall incident to a staff member. The LPN also confirmed that she did not initiate the facility's fall incident protocol. On 10/29/25 at 2:00 PM, the surveyor interviewed the COTA who confirmed that he treated Resident #1 in their room for a therapy session that day and the resident reported they had a fall. The COTA further explained Resident #1 couldn't say when the fall occurred or what happened. The COTA stated that the resident complained of left arm pain by the dialysis access site and observed no visible injury. On 10/29/25 at 3:10 PM, the surveyor informed the LNHA and the current DON regarding the concern that the physician and the RR were not informed at the time that the resident reported having a fall to the staff. The current DON acknowledged that the LPN did not follow the facility's fall protocol. On 10/29/25 at 3:59 PM, the DON and the LNHA met with the surveyor. There was no additional information provided to the surveyor. A review of the undated facility policy titled, Assessing Falls and Their Causes which revealed under Steps in the Procedure After a Fall: #5 Notify the resident's attending physician and family in an appropriate time frame.NJAC 8:39-13.1(c)(d)

Complaint #2622045Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 1 of 9 residents reviewed, (Resident #3). The deficient practice was evidenced by the following:On 10/28/25 at 12:25 PM, the surveyor conducted the initial tour in the presence of the License Nursing Home Administrator (LNHA) and observed the following:1. In the family room, used by residents, near the first-floor unit, the surveyor observed one broken window blind on the window. The LNHA stated, I don't know how long it's been like that, but I will have maintenance look at it. The LNHA further stated that he made rounds every day. The surveyor requested from the LNHA for the Homelike Environment policy.2. At 12:32 PM, on the second floor, in the main resident dining room entrance, the door's frame had areas with broken wood on both of its sides. The LNHA confirmed observation of the damaged door frame and stated he would put in a maintenance work order. 3. In room [ROOM NUMBER], by the bathroom entrance, the carpet was observed torn and frayed; and a sharp plastic piece was broken off the frame of the bathroom entrance. The surveyor and the LNHA were joined by the Assistant Director of Nursing (ADON) who stated, she did not notice the environmental concerns. The ADON explained that the process for work orders was to let the receptionist know and they would contact maintenance staff. The LNHA added that they previously submitted work orders through an electronic system and were currently transitioning to a new system. The LNHA was not able to provide the surveyor documentation of any work orders entered for the issues observed in the main dining room and room [ROOM NUMBER].On 10/28/25 at 3:42 PM, the LNHA stated that they do not have a facility policy for Homelike Environment.4. On 10/29/25 at 11:00 AM, the surveyor observed room [ROOM NUMBER] on the first floor. The surveyor observed two ceiling tiles near the window loose and out of alignment. The surveyor observed Resident #3 lying in the bed and the resident stated that the tiles on the ceiling were loose and have been like that since February 2025. The resident stated that they're afraid it may fall down. On 10/29/25 at 11:15 AM, the License Practical Nurse (LPN) assigned to Resident #3 accompanied the surveyor to the room to observe the ceiling tiles. The LPN confirmed the observation of the broken ceiling tiles and stated, I've never noticed that. I will let maintenance know.The surveyor reviewed the Resident #3's medical records which revealed diagnoses which included but were not limited to bilateral osteoarthritis of knee, morbid obesity, anxiety and depression. A review of a Quarterly Minimum Data Set (MDS), a facility assessment tool that facilitates the plan of care, dated 9/30/25, revealed the resident's cognition was assessed using a Brief Interview Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. At 3:10 PM, the surveyor informed the LNHA and the DON of the observed concerns regarding homelike environment. There was no additional information provided to the surveyor. NJAC 8:39-31.4(a)

Repeat DeficiencyBased on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to ensure a resident's dietary preferences were honored for 1 of 4 residents (Resident #4) reviewed for food concerns. This deficient practice was evidenced by the following:On 10/28/25 at 10:40 AM, the surveyor accompanied by the Assistant Director of Nursing (ADON) were conducting incontinence rounds. Resident #4 was observed lying in their bed with the head of the bed elevated. The resident was alert, and verbally responsive. Resident #4 had a meal tray on their overbed table positioned in front of them. Resident #4 stated they only received cereal and biscuit on their tray and nothing else. The resident further explained that they were also supposed to receive pancakes on their tray and another staff already went to follow up with the kitchen. Resident #4 stated that this was not the first time that they did not receive food items ordered on their meal tray. The ADON informed the resident she would follow up with the staff regarding their pancakes. On 10/28/25 at 12:56 PM, the surveyor reviewed the electronic medical record (EMR) of Resident #4.The admission Record (a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to hypertension and generalized muscle weakness. A quarterly Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 9/23/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #4 scored a 15 out of 15, which indicated the resident was cognitively intact. A physician's order dated 9/11/25 revealed the resident was on a regular texture, and regular (thin) liquid diet. On 10/29/25 at 10:19 AM, the surveyor interviewed the ADON to follow up on the resident's breakfast yesterday. The ADON stated after following up with the kitchen, the resident did not receive pancakes. The ADON further explained that the kitchen did not have it, and the resident was given a sandwich as a substitute. The ADON acknowledged the resident should have received what was listed on the meal ticket for their meal.On 10/29/25 at 2:18 PM, the surveyor informed the Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON) of the above concern for Resident #4 not receiving the food ordered and what was listed on their meal ticket for their breakfast meal. The LNHA stated the resident's food was substituted. The surveyor asked if prior to receiving their breakfast tray, was the resident informed that their pancakes were not available and provided substitution options as the resident had received their meal tray without pancakes or its substitute. There was no further verbal response from the facility at this time.On 10/29/25 at 3:59 PM, the LNHA and the DON met with the survey team. There was no additional information provided to the surveyor. The surveyor reviewed the facility provided policy titled, Dining and Food Preferences with a last review date of October 2022. Under Policy Statement revealed: Individual dining, food, and beverage preferences are identified for all residents/patients. Under Procedures revealed: .The alternate meal and/or beverage selection will be provided in a timely manner.NJAC 8:39-17.4 (e); 27.1 (a)

COMPLAINT # 423030Based on interview, review of medical records and other facility documentation, it was determined that the facility failed to comprehensively investigate a resident reported fall to ensure resident safety according to the facility's policy. This deficient practice was identified for 1 of 1 resident (Resident #1) reviewed for falls and accidents. This deficient practice was evidenced by the following:On 10/28/25 at 9:30 AM, the surveyor requested from the License Nursing Home Administration (LNHA) and the Director of Nursing (DON) all Facility Reported Event (FRE) investigations and a list of residents with falls and injuries in the last six months. On 10/28/25 at 11:20 AM, the DON provided the FRE investigations for the last six months. Resident #1 had one FRE investigation dated 5/2/25 for an injury of unknown origin which occurred on 4/30/25.The surveyor reviewed a facility provided investigation dated 5/2/25 which indicated Resident #1 had an injury of unknown origin for Resident #1 which occurred on 4/30/25. The investigation conclusion and incident note revealed the following:On 4/30/25 at 7:15 AM, Resident #1 was seen by a nurse practitioner (NP) at the bedside. At 7:50 AM, the primary nurse saw the resident and morning care was rendered by the Certified Nursing Assistant (CNA) with nothing unusual observed. At 9:30 AM, the Certified Occupational Therapist Assistant (COTA) visited the resident for a therapy session in their room and the resident reported to the COTA that he/she had a fall and complained of left arm pain. The COTA reported this to the resident's assigned Licensed Practical Nurse (LPN). The LPN went to check the resident. There was no bruising, or any previous fall reported. The LPN applied the resident's routine lidocaine topical cream to their left arm dialysis site which was due to be given prior to their outpatient dialysis treatments. The resident was sent out to their scheduled dialysis session. At approximately 3:00 PM, the facility received a call from the dialysis center stating that the resident was observed with bruising to their face and was transferred to the emergency room (ER) for further evaluation. The family was in the dialysis center when the resident was transferred to the hospital, and then the physician was made aware by the facility of the resident's ER transfer.A review of the facility's investigation revealed that the LPN did not initiate an investigation as per the facility's fall protocol at the time of the resident's reported fall. Additionally, there was no documentation that the physician or RR was informed at the time that the resident reported falling. A review of the Electronic Health Record (EHR) revealed the Resident #1 was not in the facility. Resident #1's EHR revealed diagnoses which included but were not limited to metabolic encephalopathy (the brain does not function properly due to metabolic disturbance), end stage renal disease, and dependence on renal dialysis. A review of the comprehensive Minimum Data Set (MDS), a facility assessment tool to facilitate the plan of care, dated 4/27/25 revealed the resident's cognition using a Brief Interview of Mental Status (BIMS) test. Resident #1 scored a 6 out of 15 which indicated the resident had severe cognitive impairment. A review of the April 2025 order summary revealed:A physician's order for hemodialysis (a treatment to remove waste products and excess fluids from the blood when the kidneys are not able to) on Monday, Wednesday, and Friday with a pickup time of 12:30 PM and their session was scheduled for 1:15 PM at the dialysis center. A physician's order for Lidocaine cream 2.5% that indicated to apply to the left arm dialysis site topically in the morning every Monday, Wednesday, and Friday for pain. A physician's order for skilled Occupational Therapy five times per week for four weeks.On 10/28/25 at 2:40 PM, the surveyor interviewed the Registered Nurse (RN) Supervisor who stated if a resident had a new injury or a fall was reported, a skin assessment and vital signs were completed. The RN Supervisor explained the supervisor, the DON, the physician, and the RR were to be notified of the incident; and the resident's care plan would be updated; and an incident report started.On 10/29/25 at 11:52 AM, the surveyor interviewed the CNA, who was assigned to Resident #1 on 4/30/25, 7AM to 3PM shift. The CNA confirmed that she was assigned to care for the resident and stated that the resident had no bruising before they left for their appointment.On 10/29/25 at 12:09 PM, the surveyor interviewed the LPN, who was assigned to care for the resident on 4/30/25 for the 7AM to 3PM shift. The LPN stated she recalled the COTA informed her that Resident #1 stated that they fell, and she went to check on the resident. The LPN stated that there was no change or injury with the resident. The LPN further explained that she applied lidocaine topical cream to the resident's left arm dialysis access site as ordered and the resident was sent to dialysis in good condition. The LPN stated that the dialysis center called the facility and reported that the resident had a bruise on their face and was going to the ER for evaluation. The LPN confirmed that she did not report to the supervisor, the resident's physician and the RR that Resident #1 reported having a fall incident to a staff member. The LPN also confirmed that she did not initiate the facility's fall incident protocol. On 10/29/25 at 2:00 PM, the surveyor interviewed the COTA who confirmed that he treated Resident #1 in their room for therapy session that day and the resident reported they had a fall. The COTA further explained Resident #1 couldn't say when the fall occurred or what happened. The COTA stated that the resident complained of left arm pain by the dialysis access site and observed no visible injury. On 10/29/25 at 3:10 PM, the surveyor informed the LNHA and the current DON regarding the concern that the LPN did not initiate an investigation as per facility fall protocol when the COTA informed her that the resident said they fell. The current DON acknowledged that the LPN did not follow the facility's fall investigation protocol.On 10/29/25 at 3:59 PM, the DON and the LNHA met with the surveyor. There was no additional information provided to the surveyor. A review of the undated facility policy titled, Assessing Falls and Their Causes revealed under Purpose, The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.NJAC 8:39-27.1(a)

Complaint #423030, and #2622045Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that proper incontinence care was provided to 1 of 3 residents (Resident #5) reviewed for incontinence care.This deficient practice was evidenced by the following:On 10/28/25 at 10:46 AM, the surveyor conducted incontinence (loss of bladder/bowel control) rounds with the Assistant Director of Nursing (ADON) on randomly selected residents who were incontinent. Resident #5 was observed resting in their bed covered with blankets. The resident was alert, verbally responsive, and agreeable to speak with the surveyor. Resident #5 stated that they were waiting for their assigned Certified Nursing Aide (CNA) to return to provide hygiene care. Resident confirmed they were incontinent, wore incontinent briefs, and required staff assistance for hygiene care. The surveyor asked Resident #5 when they last received hygiene care and had their incontinent brief changed. The resident replied, last night and could not recall the exact time. The surveyor asked the resident if they were changed this morning. The resident replied not yet, and that the CNA was returning to provide care. Resident #5 was agreeable for the ADON with the surveyor present to check their incontinent brief. Upon the ADON removing the blanket off the resident, the surveyor and ADON observed the resident had on two incontinent briefs. The outer brief was green in color and the inner brief was yellow in color. The yellow incontinent brief was saturated with dark yellow in color urine. The ADON asked the resident if they requested to have two diapers. The resident stated that the CNAs used the two incontinent briefs, and the resident was ok with it because they don't get changed frequently at times and was worried of soiling outside of their brief. The surveyor asked Resident #5 if the resident initially requested to have the two incontinent briefs applied. The resident replied that they did not initially request to have two incontinent briefs, that the CNA would apply the two briefs, and they thought it was ok. After exiting the room, the ADON stated that some residents may request to use two incontinent briefs at a time and would have to check if it was documented in the resident's care plan. The ADON provided the CNA assignment for the shift which included important information about the residents such as, their assistant needs, incontinent brief size, and other pertinent information. There was no documentation that indicated Resident #5 preferred or requested the use of two incontinent briefs. On 10/28/25 at 11:03 AM, the surveyor interviewed Resident #5's assigned CNA, who stated that at the start of the shift, after receiving her assignment, she would round to check on assigned residents to make sure they were ok and if they were soiled, she would come back to clean them. The surveyor asked the CNA how often she rounded on assigned residents to check if residents needed incontinence care. The CNA replied two to three times on the shift. The surveyor asked the CNA about Resident #5. The CNA confirmed she was the resident's assigned CNA and that on morning rounds the resident was checked and didn't need any assistance. The CNA further explained she answered the resident's call light at approximately 10:38 AM. The CNA stated that Resident #5 thought they had the urge to move their bowels, but it went away, and the CNA told the resident that she would return to provide hygiene care as she was taking care of another resident. The surveyor asked the CNA if she checked the resident's incontinent brief at that time. The CNA replied that she did. The surveyor asked the CNA how she checked the resident's brief. The CNA replied that she felt the outside of the two incontinent briefs. The CNA further explained that she knew the resident was dry from the outside of the two incontinent briefs because if they were soiled it would feel heavy. The surveyor asked the CNA about the use of two incontinent briefs. The CNA replied that staff were supposed to use one incontinent brief, but the residents could request two. The CNA further explained some residents have special requests and Resident #5 liked to wear a liner and an incontinent brief. On 10/28/25 at 11:45 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #5. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, right lower leg laceration, right lower leg contusion (bruise), generalized muscle weakness, type 2 diabetes, urinary tract infection, congestive heart failure, and chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems).A quarterly Minimum Data Set (MDS) assessment, an assessment tool to facilitate the management of care, with an Assessment Reference Date of 7/24/25, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #5 scored a 15 out of 15, which indicated the resident was cognitively intact. A BIMS assessment dated [DATE] revealed Resident #5 scored a 15 out of 15, indicating the resident was cognitively intact. A care plan with a focus area on bladder incontinence, last revised on 10/20/25, included the intervention Check the resident as per protocol and as required for incontinence. There was no intervention documented that the resident preferred or requested two incontinent briefs. A care plan with a focus area on bowel incontinence, last revised on 8/18/25, included interventions: Check resident every two hours and assist with toileting as needed; and Observe pattern of incontinence, and initiate toileting schedule if indicated. There was no intervention documented that the resident preferred or requested two incontinent briefs.A care plan with a focus area on Activities of Daily Living (ADL) self-care performance deficit, last revised on 10/20/25, included interventions: The resident is totally dependent on 1 staff to provide bathing/showering; The resident is totally dependent on 1 staff for dressing; The resident requires extensive assistance by 1 staff with personal hygiene and oral care; and The resident is totally dependent on staff for toilet use.Additional review of the resident's medical record including the care plan revealed no documentation that the resident preferred or requested the use of two incontinent briefs. On 10/28/25 at 12:25 PM, the surveyor interviewed the Director of Nursing (DON) regarding incontinence care. The DON stated staff were expected to round on residents at least every two hours and check if incontinence care or toileting was needed. The DON stated more than one incontinent brief should not be applied to the resident unless the resident requested it. The DON continued to explain that if the resident requested or preferred two incontinent briefs the resident should be educated on the risks for increased infection and skin impairment. The DON stated if the resident still wished to use two incontinent briefs it should be documented in their care plan regarding their preference. The surveyor informed the DON of the above concerns for Resident #5's incontinence care during rounds with the ADON, the interview with the CNA, and that no documentation was found to indicate that the resident requested to use two incontinent briefs. The DON acknowledged the incontinence care concerns. On 10/29/25 at 4:59 PM, the surveyor informed the Licensed Nursing Home Administrator and the DON about the concern related with Resident #5's incontinence care. There was no additional information provided by the facility's administration. A review of an undated policy titled Incontinent Care revealed, It is the policy of [facility name] that incontinent residents will be maintained clean and dry.A review of the facility's policy titled Care planning with an effective date of 11/1/19 revealed under Policy: A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient.Under Procedure of the policy revealed: .5. Care plans will be updated on an ongoing basis as changes in the patient occur.A review of an undated facility provided policy and procedure titled Incontinence Care revealed: Take all incontinent residents to the bathroom or put on the bedpan before and after meals and at least every two hours between meals. The policy did not address use of incontinent brief. NJAC 8:39- 27.2 (h)

COMPLAINT #423030 and #2620240Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a) conduct a thorough investigation to address an allegation of abuse; and b) maintain documentation that a thorough investigation was conducted for an allegation of abuse. This deficient practice was identified for 2 of 2 residents (Resident #1 and Resident #2), reviewed for abuse.This deficient practice was evidenced by the following: 1. On 10/28/25 at 9:30 AM, the surveyor requested from the License Nursing Home Administration (LNHA) and the Director of Nursing (DON) all Facility Reported Event (FRE) investigations and a list of residents with falls and injuries in the last six months. On 10/28/25 at 11:20 AM, the surveyor reviewed the resident's electronic medical record (EMR) which revealed the following: Resident #1 had diagnoses which included but were not limited to metabolic encephalopathy (the brain does not function properly due to metabolic disturbance), end stage renal disease, and dependence on renal dialysis. Resident #1 was no longer residing in the facility. A review of the May 2025 physician's order revealed an order for hemodialysis (a treatment to remove waste products and excess fluids from the blood when the kidneys are not able to) on Monday, Wednesday, and Friday with a pickup time of 12:30 PM and their session was scheduled for 1:15 PM at the dialysis center. A review of a comprehensive Minimum Data Set (MDS), a facility assessment tool to facilitate the plan of care, dated 5/13/25 revealed the resident's cognition was assessed using a Brief Interview of Mental Status (BIMS) test. Resident #1 scored a 6 out of 15 which indicated the resident had severe cognitive impairment. A progress note dated 5/23/25 at 3:07 PM, written by Registered Nurse (RN) #1, indicated Resident #1's RR called and reported that the resident was noted at dialysis with a bruise to their left foot and complained of pain to the site. The note further revealed that the resident had been seen prior to dialysis by the physician and a body assessment was done by RN #1 with no bruise noted resident with no complaint of pain to lower extremities. On 10/28/25 at 2:40 PM, the surveyor interviewed the Registered Nurse (RN) Supervisor on the process for new skin changes or bruising. The RN Supervisor stated that if a resident was reported to have bruising or any new skin changes, the resident would be assessed; the supervisor, the DON, the physician, and the RR would be notified; and the resident's care plan would be updated. On 10/28/25 at 4:30 PM, the surveyor requested from the DON any investigation for Resident #1 regarding the left foot bruise reported by the RR on 5/23/25. On 10/28/25 at 5:03 PM, the DON informed the surveyor that she could not find any investigation for the report of Resident #1's left foot with a bruise. The DON stated the nursing staff should have called the dialysis center to follow up and completed a full investigation which was the facility's protocol for any injury found or reported. On 10/29/25 at 9:00 AM, the DON provided a body check assessment form for Resident #1 dated 5/23/25, which was completed by RN#2. The assessment revealed the body check was completed on 3PM to 11PM shift and documented no swelling or bruising noted, patient denies pain. On 10/29/25 at 12:25 PM, the surveyor interviewed the primary License Practical Nurse (LPN) #1, who the DON confirmed was assigned to Resident #1 on 5/23/25 during the 7AM to 3PM shift. She stated that she did a skin assessment before the resident left for dialysis and when they returned from dialysis. LPN #1 stated the resident did not complain of left foot pain or have any bruising before leaving and when they arrived back from dialysis. On 10/29/25 at 12:35 PM, the surveyor interviewed Certified Nursing Assistant (CNA) #1 who was assigned to Resident #1 on 5/23/25 for the 7AM to 3PM shift. CNA #1 stated the facility's protocol was to report immediately any bruising, or skin tears. She further stated that the RR called from the dialysis center to say that Resident #1 had bruising on their foot. On 10/29/25 at 12:50 PM, the DON informed the surveyor that there were no fall or incident investigations found for Resident #1 for 5/23/25. On 10/29/25 at 3:10 PM, the surveyor informed the LNHA and the DON of the concern that there was no investigation completed regarding the RR's report that Resident #1 had bruising to their left foot. The DON acknowledged that a thorough investigation should have been completed. 2. On 10/28/25 at 12:56 PM, the surveyor reviewed the EMR of Resident #2. The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, Alzheimer's disease, hypertension (high blood pressure), depression, and bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels, and behavior). A quarterly MDS assessment, an assessment tool to facilitate the management of care, with an Assessment Reference Date of 7/15/25, indicated the facility assessed the resident's cognition using a BIMS test. Resident #2 scored an 8 out of 15, which indicated the resident had moderate cognitive impairment. A progress note dated 9/17/25, written by LPN #2 indicated approximately 2:10 PM, one of Resident #2's representative reported to the nurse that the resident was hit by a black male last night. The resident was assessed and had a scratch mark on their forehead with no redness, bleeding or pain. The LPN documented .Area around the forehead appears lightly discolor. and the Director of Nursing (DON), the physician, and the Licensed Nursing Home Administrator (LNHA) were notified. The resident was transferred to the hospital for further evaluation and treatment. A follow up progress note dated 9/18/25 indicated the resident was admitted to the hospital with a diagnosis of bruising of unknown origin. The surveyor reviewed the facility provided investigation for the 9/17/25 incident which included the following: -A summary of the investigation which included interventions and a conclusion. The summary indicated the RR stated Resident #2 told them a black mail [male] aid [aide] hit them. The summary documented a 72 hour look back was initiated all staff were interviewed. Additionally, two CNAs (CNA #2 and CNA #3) who fit the description of the alleged perpetrator and were assigned to care for resident during the 72-hour lookback were suspended pending the investigation on 9/17/25. -A completed AAS-45, a Reportable Event Record/Report, dated 9/18/25 to the New Jersey Department of Health (NJDOH) which indicated the incident was called in to the NJDOH by the facility on 9/17/25 at 4 PM. - The facility's investigation included statements from LPN #2, Registered Nurse/Nurse Supervisor (RN/NS), CNA #2, and interviews with seven residents on the unit regarding care by CNAs. There was no statement by CNA #3 and there were missing statements with the investigation for the 72-hour lookback of the incident as follows: The surveyor did not see a statement from the nurse who cared for the resident on 9/14/25, 7-3 shift.The surveyor did not see a statement from the nurse who cared for the resident on 9/14/25, 3-11 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/14/25, 7-3 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/14/25, 3-11 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/14/25, 11-7 shift.The surveyor did not see a statement from the nurse who cared for the resident on 9/15/25, 3-11 shift.The surveyor did not see a statement from the nurse who cared for the resident on 9/15/25, 11-7 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/15/25, 7-3 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/15/25, 3-11 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/15/25, 11-7 shift.The surveyor did not see a statement from the nurse who cared for the resident on 9/16/25, 3-11 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/16/25, 7-3 shift.The surveyor did not see a statement from the CNA who cared for the resident on 9/17/25, 7-3 shift. On 10/28/25 at 12:53 PM, the surveyor interviewed the LNHA who stated the facility went back 72 hours prior to the incident to interview and obtain statements from the staff who were assigned to the resident. The surveyor informed the LNHA of the concern that the statement for CNA #3 and additional staff statements was not found with the investigation. The LNHA stated that they did obtain CNA #3's statement, all staff were interviewed and that there should be written statements. The LNHA stated he would provide additional information. On 10/29/25 at 9:40 AM, the LNHA provided a statement by CNA #3. There were no additional statements provided by the LNHA. On 10/29/25 at 1:50 PM, the LNHA and DON met with the surveyors. The LNHA and the DON confirmed for a 72-hour lookback, statements from all staff interviewed should be obtained. The LNHA stated that he did interview all staff but did not obtain written statements from them. There was no additional information provided by the facility's management. The surveyor reviewed the facility's policy titled Freedom from Abuse Neglect and Exploitation with a last revised date of October 2022 revealed, The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment: Thoroughly investigate the alleged violation. Under Policy Interpretation and Implementation revealed: .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.and providing complete and thorough documentation of the investigation. NJAC 8:39-4.1(a)(5)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences were consistently implemented and followed for 4 of 4 residents (Resident #104, #105, #1 and #3) reviewed for dietary preferences during meal observations. This deficient practice was evidenced as follows: 1. On 2/18/25 at 11:55 AM, the surveyor was observing the lunch meal on first floor unit. The surveyor observed Resident #104's tray, per the tray ticket, Resident #104 was supposed to receive 4 ounce (oz) assorted ice cream and a 6oz Coffee, both items were missing from the tray. On 2/20/25 at 10:00 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #104. A review of Resident #104's Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to muscle weakness, hypothyroidism and unspecified dementia. A review of the admission MDS, (an assessment tool used to facilitate care management) dated 2/12/25, reflected a Brief Interview for Mental Status (BIMS) score was unable to be calculated as Resident #104 was unable to complete a BIMS interview due to cognition. A review of the Physician Order (PO summary dated 2/20/25, identified an order with an original date of 2/13/25, Regular diet, pureed texture and thin liquid consistency. A review of Resident #104's care plan (CP) revealed a nutrition CP with an initiation date of 2/10/24, the intervention portion of the CP revealed two nutrition interventions, Provide, serve diet as ordered with an initiation date of 2/10/25 and Provide fortified foods, super cereal, super mashed potato BID, super soup at dinner, and ice cream twice per day (BID), juice, soft fruit, with an initiation date of 2/13/25. 2. On 2/18/25 at 11:58 AM, the surveyor was observing the lunch meal on first floor unit. The surveyor observed Resident #105's tray, per the tray ticket Resident #105 was given 1/2 cup of mandarin oranges instead of 1/2 cup of sliced pears and was missing a 6 oz Hot coffee. On 2/20/25 at 10:10 AM, the surveyor reviewed the E-mar for Resident #105. A review of Resident #105's FS was admitted to the facility with diagnoses that included but were not limited to predominant Hodgkin's lymphoma, muscle weakness and hyperlipidemia. A review of the admission MDS, dated [DATE], reflected a BIMS score of 13 out of 15, indicating Resident #105 cognition is intact. A review of the PO summary dated 2/20/25, identified an order with an original date of 2/7/25, No added salt (NAS), Renal diet Regular texture, and Thin liquid consistency. A review of Resident #105's CP revealed a nutrition CP with an initiation date of 2/10/24, the intervention portion of the CP revealed two nutrition interventions both with 2/10/25 initiation dates, Provide, serve diet as ordered and Provide and serve NAS, renal diet, regular texture, thin liquid as ordered. 3. On 2/20/25 at 9:16 AM, the surveyor was observing the breakfast meal on the second-floor unit. The surveyor observed Resident #1's tray, per the tray ticket Resident #1 was supposed to receive one container of rice crunchy cereal and a 1/2 cup fruit cocktail, both items were missing from the tray. On 2/20/25 at 10:15 AM, the surveyor reviewed the E-mar for Resident #1. A review of Resident #1's FS was admitted to the facility with diagnoses that included but were not limited to depression, acute kidney failure, and essential hypertension. A review of the quarterly MDS, dated [DATE], reflected BIMS score was unable to be calculated as Resident #1 was unable to complete a BIMS interview due to cognition. A review of the PO summary dated 2/20/24, identified an order with an original date of 2/1/24, NAS (No Added Salt) diet Chopped/Soft &Bite Sized texture, Thin liquids consistency A review of Resident #1's CP revealed a nutrition CP with an initiation date of 1/22/24, the intervention portion of the CP revealed nutrition interventions, Staff/nursing to check tray. 4. On 2/20/25 at 9:20 AM, the surveyor was observing the breakfast meal on the second-floor unit. The surveyor observed Resident #3's tray, per the Resident #3's tray ticket, they were supposed to receive an assorted yogurt cup and 2 oz brown gravy, both items were missing from the tray. On 2/20/25 at 10:25 AM, the surveyor reviewed the E-mar for Resident #3. A review of Resident #3's FS was admitted to the facility with diagnoses that included but were not limited to hyperlipidemia, anxiety disorder and depressive episodes. A review of the re-admission MDS, dated [DATE]reflected BIMS score of 11 out of 15 indicating, moderately impaired cognition. A review of the PO summary dated 2/20/24, identified an order with an original date of 12/6/24, NAS (No Added Salt) diet Regular texture, Thin liquid consistency A review of Resident #3's CP revealed a nutrition CP with an initiation date of 9/4/24, the intervention portion of the CP revealed two nutrition interventions, Provide diet as ordered: NAS, regular, thins. And Support the patients right to make decisions regarding their diet. Make a reasonable effort to provide food and fluids according to preferences. On 2/20/25 at 09:28 AM, the surveyor interviewed FSD who stated tray accuracy audits are conducted but was unable to explain why residents had incorrect and missing items observed on 2/18/25 and 2/20/25. On 2/20/25 at 12:30 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review survey concerns and surveyor findings. On 2/20/25 at 1:30PM, the Regional FSD (RFSD) provided the surveyor with a facility policy titled, Dining and Food Preferences with a revised date of 10/2022. Under the policy section of the chart it states, 3. The food preference interview will be entered into the medical chart. 4. Food allergies, food intolerances, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu software system .7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences. On 2/24/25 at 11:50 AM, the surveyor met with the LNHA and DON for the exit conference. No further information provided by the facility staff NJAC - 17.4(a)1, (e)

Based on interview, and review of pertinent facility documents, it was determined that the facility failed to serve and document residents received a nourishing snack in the evening when there was more than a 14-hour span between dinner and breakfast mealtimes. This deficient practice was identified for 6 of 6 (Resident's #9, #34, #41, #53, #60, and #78) residents during the resident council meeting and was evidenced by the following: On 02/18/25 at 11:08 AM, the surveyor conducted a group meeting with six residents who were alert and oriented and selected by the facility to participate. Six out of six residents stated they were not offered nor receive snacks in the evening. On 2/20/25 at 9:50 AM, the surveyor interviewed the Food Service Director (FSD) who stated that if there was more than 14 hours between dinner and breakfast, the facility was required to provide the residents with a nourishing evening snack. She acknowledged there was more than 14 hours between dinner and breakfast. The FSD stated the kitchen provided snacks to all units but were unable to state if the evening snacks were passed out by the nursing staff. On 2/20/25 at 10:30 AM, the surveyor made multiple attempts to contact the Registered Dietitian (RD) via telephone, but was unable to contact the RD. On 2/20/25 at 10:45 AM, the surveyor conducted a phone interview with the 3-11 PM nursing supervisor (RNS), who stated, they think the evening snacks were passed out but there is no record or accountability of the residents receiving evening snacks. 2/20/25 11:25 AM, the surveyor interviewed the Director of Nursing (DON), who stated there is no record book of evening snacks being passed out and acknowledged the facility needs to have a better system to ensure snacks were offered and provided to all residents. On 2/20/25 at 12:35 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and DON to review facility concerns and surveyor findings. On 2/20/25 at 1:30 PM, the Regional FSD (RFSD) provided the surveyor with a facility policy titled, Snacks with a revised date of 10/2022. Under the policy statements section of the policy it states, Bedtime (HS snacks) snacks will be provided for all residents. Under the procedures section of the policy it states, 4. The dining services department will assemble and deliver to each unit the individually planned snack items and bilk snack items to be offered at bedtime. 6. Nursing services is responsible of delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. On 2/24/25 at 11:50 AM, the surveyor met with the LNHA and DON for the exit conference. No further information provided by the facility staff. NJAC 8:39-17.2 (f))(1) (i) (ii)

REPEAT DEFICIENCY Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 2/14/25 at 10:23 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. Upon entering the kitchen, the surveyor observed the Regional FSD (RFSD) and three dietary aides (DA) all wearing large earrings. FSD alerted staff and earrings were removed. 2. In the cooking area of the kitchen the surveyor observed on top of the 2-door standing oven, burnt-on debris and a large build up of a greyish dust like substance. The FSD stated all kitchen equipment would be cleaned immediately. 3. In the preparatory area the surveyor observed a 1-gallon bottle of white vinegar no lid. The FSD was unable to state why the vinegar was missing the lid and was discarded immediately. 4. In the walk-in refrigerator, the surveyor observed 2 fans with blackish dust-like debris. The FSD stated the fans would be cleaned immediately. 5. In the dry storage area, the surveyor observed a 7 pound (lb.) can vanilla pudding observed dented in regular rotation. The FSD stated all dented cans should be removed from the regular rotation and put in the dented can area. On 2/20/25 at 12:35 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to review facility concerns. The LNHA stated the facility just hired a new company to run the food service department and all concerns would be addressed immediately. On 2/20/25 at 1:30 PM, the RFSD provided the surveyor with copies of four facility policies. The facility policy titled, Staff Attire with a revised date of 10/2023, stated under the procedures section, 5. Hand jewelry will be limited to a plain band. Arm jewelry and dangling jewelry is not permitted. The facility policy titled, Equipment with a revised date on 9/2017, stated under the procedures section, 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's direction and training material. 6. All non-food contact equipment with be cleaned and free of debris. The facility policy titled, Food Storage with a revised date of 2/2023, stated under the procedures section, All packaged and canned food items will be kept clean, dry, and properly sealed. The facility policy titled, Receiving with a revised date of 2/2023, stated under the procedure section, 4. All canned goods with be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal. On 2/24/25 at 11:50 AM, the surveyor met with the LNHA and DON for the exit conference. No further information provided by the facility staff. NJAC 8:39-17.2(g)

REPEAT DEFCIENCY Complaint # NJ181689 Based on observation, interview, record review and policy review it was determined the facility failed to a. record urinary catheter (UC) output every shift in accordance with the physician's order (PO) and b. the primary physician (MD) failed to accurately document the resident's wound assessment. This deficient practice was observed for 2 of 7 residents, (resident #160 and resident #153) was evidenced by the following: 1. On 2/14/25 11:52 AM, the surveyor reviewed closed electronic medical record (E-mar) with Resident #160. A review of Resident #160's E-mar revealed the following: A review of Resident #160's Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to chronic osteomyelitis, Covid-19, tinea, and muscle weakness. A review of the quarterly MDS, (an assessment tool used to facilitate care management) dated 12/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates intact cognition. A review of the December 2024 Physician Order Sheet (POS) revealed an ordered dated 8/30/24, Urinary catheter output every shift for Monitoring. A review of the Resident #160's treatment administration record (TAR) from September 2024 to December 2024 revealed multiple occasions of the urinary catheter output was not recorded. In September 2024 the UC output was not record in 1 of 7 opportunities, in October 2024 the UC output was not recorded in 6 of 90 opportunities, in November 2024 the FC output was not recorded in 4 of 90 opportunities, and in December the FC output was not recorded in 7 of 88 opportunities. On 2/20/25 at 11:55 AM, the surveyor conducted an interview with the Director of Nursing (DON) who stated all physician orders should be followed by every shift and missing UC outputs in the TAR is unacceptable. DON unable to state why the UC output was not recorded in the TAR. On 2/20/25 at 12:30 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Care of the resident with a foley catheter, with a revised date 1/2025. Under the assessment portion of the policy it states, 11. Licensed Nurses will monitor residents'' urine output. Under the documentation portion of the policy it states, Chart every shift on the electronic accountability record. On 2/20/25 at 12:35 PM, the surveyor met with the LNHA and DON to review facility concerns. On 2/24/25 at 11:50 AM, the surveyor met with the LNHA and DON for the exit conference. No further information provided by the facility staff. 46889 2. On 2/18/25 at 10:11 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #153, which revealed the following: A review of the Admission Record (an admission summary) (AR) reflected that Resident #153 was admitted with diagnoses that included but were not limited to pressure ulcer (PU) (open wounds that developed when skin was damaged by constant friction) of sacral region stage 3 and unspecified kidney failure (kidney stopped working). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) with an assessment reference date (ARD) (the last day of the observation period) of 1/19/23 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had an intact cognition. Further review of the A/MDS in Section M - Skin Conditions C. Stage 3 1. Number of Stage 3 pressure ulcers Enter Number 1. A review of the universal transfer form from the hospital on 1/19/23 stated under 15. Skin condition: [NAME] it with YES pressure. A review of the pressure ulcer timeline given by the Licensed Nursing Home Administrator (LNHA) on 2/18/25 revealed that Resident #153 was admitted to the facility with Stage 3 PU to the sacrum on 1/19/23. A review of the Order Summary Report (OSR) revealed an order dated 1/20/23, to cleanse the sacral with NS (normal saline), pat dry, and apply foam dressing every shift. A review of the individualized person-centered care plan (CP) revealed under Focus that Resident #153 had an actual skin breakdown related to pressure ulcer - Location: Stage 3 (sacral wound). and under Goal that Resident #153 wound will decrease in size by 5% date initiated on 1/26/23. A review of the Physician Progress Notes (PPN) with a created date of 3/5/23 and an effective date of 1/27/23 and 1/29/23 under integumentary revealed Stage 2 sacral decubitus. The PPN with an effective on 1/20/23 and 1/23/23 stated Stage 2 to sacral. On 2/20/25 at 11:49 AM, the surveyor interviewed MD regarding the above concern. The MD stated that he thought the pressure ulcer was Stage 2 at that time, but it suddenly became Stage 3. He added that it was somewhere between Stage 2 and Stage 3 wounds. On 2/20/25 at 1:01 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) who did not provide any further information. A review of the facility's policy titled Physician Visits with a reviewed date of 1/2025 is stated under Policy Interpretation and Implementation 5. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation, and 9. The resident's attending physician must write, sign, and date the physician progress notes after each visit. NJAC 8:39-29.3(a), 23.2(a)

Complaint #: NJ00180085 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to failed to develop and implement a comprehensive person-centered care plan (CP) that include the use continuous Oxygen (O2). The deficient practice was identified for 1 of 22 residents (Resident #158) reviewed for Care Plans. This deficient practice was evidenced by the following: 1. On 2/18/25 at 9:27 AM, the surveyor reviewed closed electronic medical record (E-mar) with Resident #158. A review of Resident #158's E-mar revealed the following: A review of Resident #158's Face sheet (FS) (an admission summary) was admitted to the facility with diagnoses that included but were not limited to pneumonia, Covid-19 and type 2 diabetes mellitus. A review of the admission MDS, (an assessment tool used to facilitate care management) dated 10/31/24, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicates the residents had moderately impaired cognition. The MDS also revealed the resident was on continuous oxygen. A review of the November 2024 Physician Order Sheet (POS) revealed an ordered dated 10/25/24, Oxygen therapy at 2 liters per minute (l/min) via Nasal Cannula (NC) continuously. A review Resident #158's care plan (CP) with a start date of 10/25/24 and a last reviewed date of 1/23/25, revealed that no care plan for the use of continuous oxygen had been initiated. On 2/20/25 at 11:55 AM, the surveyor conducted an interview with Director of Nursing (DON) who stated any residents receiving oxygen should have a care plan indicating oxygen use. The DON also confirmed Resident #158 did not have an oxygen care plan in place, and did not provide any further information as to why the care plan was not in place. On 2/20/25 at 12:30 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a facility policy titled, Care Plan - Comprehensive with a revised date of 1/2025. Under the policy interpretation and implementation section of the policy it states, 2. The comprehensive care plan is based on a through assessment that includes: but is not limited to, the MDS. 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem area. On 2/20/25 at 12:35 PM, the surveyor met with the LNHA and DON to review facility concerns. On 2/24/25 at 11:50 AM, the surveyor met with the LNHA and DON for the exit conference. No further information provided by the facility staff. NJAC 8:39-11.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to initiate a baseline care plan (CP) for a resident who had a fall and was a fall risk. This deficient practice was identified for 2 of 22 residents (Resident #155 and #153) and was evidenced by the following: 1. On 2/19/25 at 9:03 AM, the surveyor reviewed Resident #155's medical records, which revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to cerebral infarction (blood flow to the brain is blocked), thrombocytopenia(low platelet levels) and dysphagia(difficulty swallowing). Resident #155 was discharged to the hospital on 1/26/24. A review of the 12/29/23 Morse Fall Scale revealed a score of 10 indicating that the resident was a fall risk. A review of Resident #155 interdisciplinary person-center comprehensive care plan (CP) did not identify that the resident was high risk for fall. On 2/21/25 at 10:34 AM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that the CP did not address the resident was a fall risk. A review of the facility's policy titled Care Plan-Comprehensive with a review date of 1/25 revealed a resident baseline care plan will be developed with 48 hours of admission. A compressive care plan will be developed with 7 days of admission. 46889 2. On 2/18/25 at 10:11 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #153, which revealed the following: A review of the Admission Record (an admission summary) (AR) reflected that Resident #153 was admitted with diagnoses that included but were not limited to pressure ulcer (PU) (open wounds that developed when skin was damaged by constant friction) of sacral region stage 3 and unspecified kidney failure (kidney stopped working). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) with an assessment reference date (ARD) (the last day of the observation period) of 1/26/23 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had an intact cognition. Further review of the A/MDS in Section M - Skin Conditions C. Stage 3 1. Number of Stage 3 pressure ulcers Enter Number 1. A review of the universal transfer form from the hospital on 1/19/23 stated under 15. Skin condition: [NAME] it with YES pressure. A review of the timeline given by the Licensed Nursing Home Administrator (LNHA) on 2/18/25 revealed that Resident #153 was admitted to the facility with Stage 3 PU to the sacrum on 1/19/23. A review of the individualized person-centered care plan (CP) revealed under Focus that Resident #153 has an actual skin breakdown related to pressure ulcer - Location: Stage 3 (sacral wound). and under Goal that Resident #153 wound will decrease in size by 5% date initiated on 1/26/23. Further review of the CP showed that the facility did not initiate Resident #153's refusal of care from the day the resident was admitted . A review of the Progress Notes on 1/19/23 under Admission Summary revealed that Resident #153 refused body assessment. A review of the timeline given by the LNHA on 2/18/25 revealed that Resident #153 was admitted to the facility with Stage 3 PU to the sacrum, and the admitting nurse was unable to measure the wound at the time due to the resident's refusal. Furthermore, Resident #153's Progress Notes (PN) revealed that on 2/14/23, the resident refused medication; on 2/18/23, the resident refused to be changed, wound care to the sacral, and weights on 2/15/23; 2/23/23, and 2/24/23. On 2/20/25 at 10:10 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN), who stated that baseline CP is in the assessment pocket and goes automatically to the CP tab. The baseline CP should be initiated within 24-48 hours upon admission. The UM/LPN added that the PU should be captured in the CP for at least 0-3 days because the resident has wounds from the hospital. The Registered Nurse (RN) Supervisor (RN/S) will assess the skin. If the resident refuses to be assessed on the 1st day, the staff will try it the following day. If the PU is more than Stage 2, the Director of Nursing (DON) or Wound Nurse will assess the resident. If there is a wound and refusal of care, the nurse should put it in the CP within 3 days of admission. On 2/20/25 at 11:20 AM, the surveyor interviewed the RN/S, who stated that the CP should be initiated at least during admission. If there is a wound and refusal of care, it should be in the CP. On 2/20/25 at 1:01 PM, the surveyor met with the LNHA and Director of Nursing (DON) and no further information was provided A review of the facility's policy title, Care Plans-Comprehensive, with the reviewed date 1/2025, revealed under Policy Interpretation and Implementation 11. Residents' baseline care plan will be developed within 48 hours of admission, and a comprehensive care plan will be developed within 7 days of admission. Further care plan updates will be ongoing and in correlation with the MDS assessment schedule. NJAC 8:39-11.2(d)

REPEAT DEFICIENCY Based on interviews and record reviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 18 residents (Residents #39, and #157) reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 2/14/25 at 11:10 AM, the surveyor observed Resident #39 in bed watching television, unable to answer the surveyor's inquiry. On 2/18/25 at 11:51 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #39, which revealed the following: A review of the Admission Record (an admission summary) (AR) reflected that Resident #39 was admitted with diagnoses that included but were not limited to depression (feeling of sadness) and Parkinson's (movement disorder) disease. A review of the recent Annual Minimum Data Set (An/MDS), with an ARD of 11/27/24, indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had severe impairment in cognition. Further review of the An/MDS in Section N-Medications revealed that C. Antidepressant 1. Is taking - not checked. A review of the Order Summary Report (OSR) with an active order as of 2/19/25 revealed an order of trazodone HCl (hydrochloride) 50 mg (milligram) by mouth at bedtime related to depression with an order date of 11/7/24. A review of the November 2024 electronic Medication Administration Record (eMAR) revealed that the above order was signed as given by the nurses from 11/7/24 to 11/30/24 at 9:00 PM. 2. On 2/18/25 at 12:01 PM, the surveyor reviewed the eMR of Resident #157, which revealed the following: A review of the AR reflected that Resident #157 was admitted with diagnoses that included but were not limited to nondisplaced fracture (bone that is cracked and not completely broken) of the right tibial tuberosity, initial encounter for closed fracture (skin remains intact). A review of the recent quarterly Minimum Data Set (Q/MDS), with an ARD of 8/9/24, indicated that the facility assessed the residents' cognitive status using a BIMS score of 2 out of 15, which indicated that the resident had severe impairment in cognition. Furthermore, the Q/MDS in Section J - Fall revealed, Has the resident had any falls since admission/entry or reentry or the prior assessment .Enter code 0. No. A review of the Progress notes (PN) dated 7/17/24 revealed that Resident #157 had a fall incident inside the room, sustaining redness to the left cheek. A review of the individualized person-centered care plan (CP) under focus revealed that, on 7/17/24, Resident #157 had a fall incident inside their room with face facing in a prone position and noted left cheek redness. On 2/20/25 at 9:32 AM, the surveyor interviewed the MDS Coordinator (MDSC), who stated that she missed coding the antidepressant and the fall. The MDSC added that they follow the RAI (Resident Assessment Instrument-a tool that helps gather information about a resident's strengths and needs, which is used to create an individualized care plan) Manual. On 2/20/25 at 1:01 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) but did not provide further information. NJAC 8:39-33.2 (c)

Based on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 9 of 18 system-selected residents, Resident #3, #10, #16, #21, #35, #39, #153, #157, and #162 ) and was evidenced by the following: On 2/14/25 at 1:11 PM, the surveyor reviewed the facility assessment task, including the Resident's MDS assessment. The MDS is a comprehensive tool federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. On 2/17/25 at 10:21 AM, the surveyor provided the MDS Coordinator (MDS/C) with the list of nine (9) system-selected residents who had not completed an MDS in over 120 days. The surveyor also requested a copy of the resident's final validation report (a report that is generated after every MDS transmission) from the Centers for Medicare and Medicaid Services (CMS). On 2/18/25 at 10:35 AM, the surveyor interviewed the MDS/C, who started working in November 2024. The MDS/C added that she tried to submit it at least twice every week. The MDS/C further stated that they followed the RAI (Resident Assessment Instrument, a tool that helps gather information about a resident's strengths and needs, which is used to create an individualized care plan) Manual. The MDS/C stated that she could not speak about what had happened previously in the late MDS submission. The surveyor and the MDS/C reviewed the 9 residents' MDS assessments that were not submitted within fourteen days of completion as follows: 1. Resident #3 had a Q/MDS assessment with an ARD of 8/20/24 that was signed as completed on 9/3/24 and was not transmitted until 9/28/24. 2. Resident #10 had the following assessment and was completed late: a. The annual MDS (An/MDS) assessment has an assessment reference date (ARD) of 4/14/23. It was signed as completed on 4/28/23 and was not transmitted until 5/19/23. b. The quarterly MDS (Q/MDS) assessment with an ARD of 7/13/23 was signed as completed on 7/27/23 and was not transmitted until 8/18/23. c. The Q/MDS assessment with an ARD of 10/12/23 was signed as completed on 10/26/23 and was not transmitted until 11/29/23. d. The Q/MDS assessment with an ARD of 1/12/24 was signed as completed on 1/26/24 and was not transmitted until 2/25/24. 3. Resident #16 had the following assessment and was completed late: a. The Q/MDS assessment with an ARD of 2/2/23 was signed as completed on 2/16/23 and was not transmitted until 3/6/23. b. The significant change MDS (Sc/MDS) assessment with an ARD of 6/8/23 was signed as completed on 6/22/23 and was not transmitted until 8/28/23. c. The Q/MDS assessment with an ARD of 9/7/23 was signed as completed on 9/21/23 and was not transmitted until 10/23/23. d. The Q/MDS assessment with an ARD of 12/7/23 was signed as completed on 12/21/23 and was not transmitted until 1/23/24. 4. Resident #21 had a Q/MDS assessment with an ARD of 12/1/23, that was signed as completed on 12/15/23 and was not transmitted until 1/7/24. 5. Resident #35 had the following assessment and was completed late: a. The An/MDS assessment with an ARD of 4/10/23 was signed as completed on 4/24/23 and was not transmitted until 5/19/23. b. The Q/MDS assessment with an ARD of 10/5/23 was signed as completed on 10/19/23 and was not transmitted until 11/6/23. c. The Q/MDS assessment with an ARD of 1/5/24 was signed as completed on 1/19/24 and was not transmitted until 2/25/24. 6. Resident #39 had the following assessment and was completed late: a. The Q/MDS assessment with an ARD of 3/16/23 was signed as completed on 3/30/23 and not transmitted until 4/26/23. b. The Q/MDS assessment with an ARD of 9/14/23 was signed as completed on 9/28/23 and transmitted on 10/23/23. c. The An/MDS assessment with an ARD of 12/8/23 was signed as completed on 12/22/23 and not transmitted until 1/23/24. d. The Q/MDS assessment with an ARD of 5/14/24 was signed as completed on 5/28/24 and not transmitted until 7/13/24. e. The An/MDS assessment with an ARD of 11/27/24 was signed as completed on 12/11/24 and not transmitted until 12/20/24. 7. Resident #153 had an admission MDS (Ad/MDS) assessment with an ARD of 1/26/23. It was signed as completed on 2/1/23 and was not transmitted until 2/22/23. 8. Resident #157 had the following assessment and was completed late: a. The Q/MDS assessment with an ARD of 8/10/23 that was signed as completed on 8/24/23 and was not transmitted until 9/22/23. b. The Q/MDS assessment with an ARD of 11/9/23 that was signed as completed on 11/23/23 and was not transmitted until 12/26/23. c. The Q/MDS assessment with an ARD of 8/9/24 that was signed as completed on 8/23/24 and was not transmitted until 9/15/24. 9. Resident #162 had the following assessment and was completed late: a. The Q/MDS assessment with an ARD of 8/27/23 was signed as completed on 9/10/23 and was not transmitted until 9/29/23. b. The Q/MDS assessment with an ARD of 11/23/23 was signed as completed on 12/7/23 and was not transmitted until 1/3/24. On 2/20/25 at 1:01 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) regarding the above concern and no further information was provided. NJAC 8:39-11.1

Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to follow a Physician Orders (PO) for the administration of blood pressure medication for 1 of 1 resident's (Resident #22) reviewed for blood pressure management. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/18/25 at 10:15 AM, the surveyor observed Resident #22 in the 2nd floor dining/activity room. The resident was observed in a recliner chair, the resident was observed with their eyes closed. The surveyor reviewed Resident #22's medical record A review of the Admission Record (an admission summary) (AR) reflected that the resident was admitted to the facility with diagnoses that included but not limited to congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (a condition in which the force of the blood against the artery walls is too high) and coronary artery disease (damage or disease in the heart's major blood vessels). A review of the significant change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 02/07/25, reflected that the resident's cognitive skills for daily decision-making score was 11, which indicated that the resident had moderate impairment. A review of the Medication Review Report(MRR) revealed a PO dated 12/21/24, for Nifedipine capsule 10 mg (milligrams), give 2 capsules by mouth every 8 hours for hypertension. Hold for SBP (systolic blood pressure-top number of blood pressure) below 120 and HR (heart rate) less than 60. A review of the January 2025 electronic Medication Administration Record (eMAR) revealed a PO dated 12/21/24, for Nifedipine 10 mg capsule, give 2 capsules by mouth every 8 hours. Hold for SBP below 120 and HR below 60 with a plotted time of 0600 (6:00 AM), 1400 (2:00 PM) and 2200 (10:00 PM). A Further review of eMAR revealed that the Nifedipine was signed as administered (7) seven times when the resident's SBP was below 120 and HR below 60 the following dates: 1/19/25 at 2:00 PM (Blood Pressure (BP) 100/54, HR 83), 01/22/25 at 10:00 PM (BP 112/67, HR 79), 01/24/25 at 10:00 PM (BP 107/48, HR 81), 01/28/25 at 10:00 PM (BP 105/66, HR 71), 01/29/25 at 10:00 PM (BP 101/80, HR 84), 01/30/25 at 10:00 PM (BP 108/55, HR 86) and 01/31/25 at 10:00 PM (BP 110/72, HR 70). A review of the February 2025 electronic Medication Administration Record (eMAR) revealed a PO dated 12/21/24, for Nifedipine 10 mg capsule, give 2 capsules by mouth every 8 hours. Hold for SBP below 120 and HR below 60 with a plotted time of 0600 (6:00 AM), 1400 (2:00 PM) and 2200 (10:00 PM). A Further review of eMAR revealed that the Nifedipine was signed as administered (7) seven times when the resident's SBP was below 120 and HR below 60 the following dates: 02/02/25 at 10:00 PM (BP 118/63, HR 81), 02/06/25 at 2:00 PM (BP 116/78, HR 82), 02/06/25 at 10:00 PM (BP 101/59, HR 54), 02/11/25 at 10:00 PM (BP 115/70, HR 71), 02/14/25 at 10:00 PM (BP 108/67, HR 65), 02/15/25 at 10:00 PM (BP 110/68, HR 78) and 02/17/24 at 10:00 PM (BP 114/69, HR 74). On 2/18/25 at 1:40 PM, the surveyor interviewed the resident's medication nurse, Licensed Practical Nurse (LPN#1) who in the presence of the surveyor reviewed Resident #22's physician's orders. LPN #1 stated that the resident's Nifedipine had perimeters to hold the medication when the SBP was below 120 or when the HR was below 60. In the presence of the surveyor, LPN#1 reviewed the resident's eMAR and acknowledge that Resident #22's Nifedipine was administered on multiple occasions when the resident's SBP was less than 120 and the HR was less than 60. LPN#1 further stated that whenever administering a medication that a nurse should read the full order including the perimeters and when a medication had an order to hold the nurse must hold that order. On 02/20/25 at 1:00 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing. There was no additional information provided. A review of facility's policy for Medication Administration that was undated and was provided by the LNHA included the following: 3. Medications must be administered in accordance with the orders, including any required time frame. 8. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's primary physician (MD) accurately dated their physician progress notes (PPN) during their visit to ensure the resident's current medical regimen was up to date. This deficient practice was observed for 3 of 18 residents (Resident #39, #153, and # 157,). This deficient practice was evidenced by the following: 1. On 2/18/25 at 10:11 AM, the surveyor reviewed the electronic Medical Record (eMR)/ hybrid medical record (paper and electronic) of Resident #153, which revealed the following: A review of the Admission Record (an admission summary) (AR) reflected that Resident #153 was admitted with diagnoses that included but were not limited to pressure ulcer (open wounds that developed when skin was damaged by constant friction) of sacral region stage 3 and unspecified kidney failure (kidney stopped working). A review of the admission Minimum Data Set (A/MDS), (an assessment tool used to facilitate the management of care) with an assessment reference date (ARD) (the last day of the observation period) of 1/19/23 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that the resident had an intact cognition. A review of the PPNs in the eMR reflected the following Effective Date, Created Date, and/or Late Entry (any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a late entry.) designation which indicated the PPN was not documented on the effective date (Date of service): 1. PPN with an effective date of 1/27/2023 and a created date of 3/5/2023. 2. PPN with an effective date of 1/29/2023 and a created date of 3/5/2023. 3. PPN with an effective date of 2/1/2023 and a created date of 3/5/2023. 4. PPN with an effective date of 2/3/2023 and a created date of 3/5/2023. 5. PPN with an effective date of 2/6/2023 and a created date of 3/5/2023. 6. PPN with an effective date of 2/10/2023 and a created date of 3/5/2023. 7. PPN with an effective date of 2/13/2023 and a created date of 3/5/2023. 8. PPN with an effective date of 2/15/2023 and a created date of 3/5/2023. 9. PPN with an effective date of 2/17/2023 and a created date of 3/5/2023. 10. PPN with an effective date of 2/20/2023 and a created date of 3/13/2023. 11. PPN with an effective date of 2/22/2023 and a created date of 3/12/2023. 12. PPN with an effective date of 3/1/2023 and a created date of 3/12/2023. 2. On 2/18/24 at 12:01 PM, the surveyor reviewed the eMR of Resident #157, which revealed the following: A review of the AR reflected that Resident #157 was admitted with diagnoses that included but were not limited to nondisplaced fracture (bone does not break completely, but there is a crack on the bone) of the right tibial tuberosity, initial encounter for closed fracture (skin remains intact). A review of the recent quarterly Minimum Data Set (Q/MDS), with an ARD of 8/9/24, indicated that the facility assessed the residents' cognitive status using a BIMS score of 2 out of 15, which indicated that the resident had severe impairment in cognition. A review of the PPNs in the eMR reflected the following Effective Date, Created Date, and/or Late Entry designation, which indicated the PPN was not documented on the effective date are the following: 1. PPN with an effective date of 10/2/2024 and a created date of 10/6/2024. 2. PPN with an effective date of 10/4/2024 and a created date of 10/10/2024. 3. PPN with an effective date of 10/7/2024 and a created date of 10/20/2024. 3. On 2/14/24 at 11:10 AM, the surveyor observed Resident #39 in bed watching television, unable to answer the surveyor's inquiry. On 2/18/24 at 11:51 AM, the surveyor reviewed the eMR of Resident #39, which revealed the following: A review of the AR reflected that Resident #39 was admitted with diagnoses that included but were not limited to depression (feeling of sadness) and Parkinson's (movement disorder) disease. A review of the recent Annual Minimum Data Set (An/MDS), with an ARD of 11/27/24, indicated that the facility assessed the residents' cognitive status using a BIMS score of 3 out of 15, which indicated that the resident had severe impairment in cognition. A review of the PPNs in the eMR reflected the following Effective Date, Created Date, and/or Late Entry designation, which indicated the PPN was not documented on the effective date are the following: 1. PPN with an effective date of 12/26/2024 and a created date of 1/3/2025. 2. PPN with an effective date of 12/23/2024 and a created date of 1/11/2025. 3. PPN with an effective date of 12/9/2024 and a created date of 12/18/2024. 4. PPN with an effective date of 11/13/2024 and a created date of 1/18/2024. 5. PPN with an effective date of 11/11/2024 and a created date of 12/1/2024. 6. PPN with an effective date of 11/6/2024 and a created date of 12/2/2024. 7. PPN with an effective date of 11/4/2024 and a created date of 11/12/2024. 8. PPN with an effective date of 10/9/2024 and a created date of 10/13/2024. 9. PPN with an effective date of 9/27/2024 and a created date of 10/1/2024. 10. PPN with an effective date of 8/19/2024 and a created date of 8/24/2024. 11. PPN with an effective date of 8/5/2024 and a created date of 8/14/2024. 12. PPN with an effective date of 7/29/2024 and a created date of 8/3/2024. 13. PPN with an effective date of 7/12/2024 and a created date of 7/17/2024. 14. PPN with an effective date of 6/28/2024 and a created date of 7/7/2024. 15. PPN with an effective date of 6/10/2024 and a created date of 7/2/2024. 16. PPN with an effective date of 6/5/2024 and a created date of 6/16/2024. 17. PPN with an effective date of 6/4/2024 and a created date of 6/16/2024. On 2/20/25 at 11:47 AM, the surveyor interviewed MD over the phone. MD stated that he is aware that he is behind with all the documentation because he is always busy. He added that there was a problem with the computer during that time, and he was catching up on the documentation. That's why he will do the documentation in one day. On 2/20/25 at 1:01 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) regarding the concern and no furtherr information was provided. A review of the facility's Physician Visits policy revealed a review date of 1/2025 under Policy Interpretation and Implementation. 5. The attending physician must perform relevant tasks at the time of each visit, including reviewing the resident's total program of care and appropriate documentation. 9. The resident's attending physician must write, sign, and date the physician's progress notes after each visit. NJAC 8:39-23.2(b)

Based on observation, interview, and record review it was determined that the facility failed to a. provide effective preventative treatment to a known high risk resident who was admitted to the facility with a Stage 1 (redness) pressure ulcer that progressed and developed into an open pressure ulcer (Stage 2) and, b. accurately monitor and document weekly skin assessments resulting in the development of an open pressure ulcer that had a delay in being identified and treated, for a resident who was found in pain. This deficient practice resulted in the development, progression delaying the identification and treatment of an open pressure ulcer. This deficient practice was identified for 1 of 5 resident, Resident #3 reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 1/20/23 at 10:25 AM, during the initial tour of the facility, the surveyor observed Resident #3 lying in bed on a regular mattress (not pressure releasing mattress). Resident #3 spoke to the surveyor complaining of significant pain on their sacral area for the past three days. Resident #3 could not articulate their pain level from 1 to 10. Resident #3 was able to reveal that the pain was at a level to prevent them from sleeping comfortably throughout the night. Resident #3 informed the surveyor that they had informed the nurse staff of the pain, but it was not being addressed. The surveyor alerted the Ripple 1 Unit Manager (UM) of the issue. Review of Resident #3's electronic Admission Face Sheet (summary of resident's information) indicated that Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Acute Respiratory Failure with Hypoxia, Hyperlipidemia, Muscle Weakness (Generalized), and Cardiac Arrhythmia. The surveyor reviewed the Progress Note (PN) dated 1/20/23 and timed at 12:27 PM, written by RN#1 after she performed a skin assessment on Resident #3. The PN skin/wound note established, Resident c/o pain on her sacrum, Tylenol given with relief. Wound noted on her sacrum upon assessment, measurement done as follows: pressure ulcer stage 1, no drainage, one part (1 cm X 0.75 cm); other (0.50 cm x 1 cm). Barrier cream applied cover with DBP (Disinfectants and Disinfection Byproducts) for protection until wound doctor come to assess it. Family member made aware, wound consult ordered. Review of PN and Assessments previous to this assessment on 1/20/23 by RN#1 did not provide any proof that an open pressure ulcer existed with measurements. Review of RN#1 Assessment note dated 1/20/23 and timed at 12:42 PM, titled Skin check-weekly or other supported with a diagram of the body documenting the affected sights and identified as Coccyx. Further description of the wound included Right Buttocks, Pressure Ulcer, redness. Pressure Ulcer, Stage 1, redness. Review of the PN documented by RN #2 written on 1/20/23 at 12:54 PM, Resident verbal c/o (complains of) pain to sacrum. Tylenol 325 mg 2 tab was given for comfort. Wound noted on her sacrum. Measurement taken and was staged as pressure ulcer stage 1, no drainage. It was cleaned with NSS and pat dry with dry dressing applied to it. Nurse supervisor informed. A review of the Admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, dated 12/16/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact for daily decision making. The surveyor reviewed Section M (Skin Conditions), subsection M0100 of the AMDS, (Determination of Pressure Ulcer/Injury Risk). The documentation indicated that Resident #3 has a. Resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. A review of Resident #3's Admission Summary dated 12/11/22 and written by the admission Registered Nurse, indicated Skin intact noted left chest pacemaker, redness to sacrum. A review of the resident's electronic Medical Record (eMR) under the assessment section, revealed an assessment titled, Skilled Documentation-V2 dated 12/14/22, indicated under Section VII Skin, that the resident's skin is intact, but is at risk for developing pressure ulcers. Further review of the resident's eMR revealed an assessment titled, Braden scale for predicting pressure sore risk located under the assessment section. Review of the Braden Score (The Braden scale assesses a patient's risk of developing a pressure ulcer) performed during admission on 12/11/22, reflected 17 out of 23, which indicated that Resident #3 was at risk for developing a pressure sore. Review of Resident #3's December 2022 Electronic Treatment Administration Record (eTAR) revealed a PO started on 12/18/22 for, Braden Scale every evening shift every Sunday for assessment for 4 weeks. Review of the December 2022 and January 2023 eTAR indicated that the Braden Scale was calculated and signed for by the nursing staff on 12/18/22, 12/25/22, 1/1/23, and 1/8/23. Review of the eMR Assessment section presented only one Braden Scale for Predicting Pressure Sore Risk calculated on 12/25/22 by a staff RN, with a score of 16 At Risk. No further documentation was initiated or completed for the PO. A review of Resident #3's Care Plan (CP) with an initiation date of 12/11/22 and target completion date of 12/27/22 did not reveal upon admission or at any time after that a CP was developed that addressed the resident's sacral redness, protective and preventative treatments for a Stage 1 pressure ulcer or the need for continued skin assessments. A review of the Physician Order (PO) Summary dated 1/24/23, identified an order with an original date of 12/11/22, for Weekly Skin Assessment every evening shift every Sunday for assessment. Review of the December 2022 eTAR presented the PO that began on 12/18/22 documented as, Weekly Skin Assessment, every evening shift every Sunday for assessment. Documentation on the December 2022 and January 2023 eTAR recorded that the facility nurses signed performing skin checks on Resident #3 for 12/18/22, 12/25/22, 1/1/23, 1/8/23, 1/15/23 and 1/20/23. Continued review of the two months of documentation in the Assessment and Progress Note (PN) sections of the EMR, revealed that there was no further information related to the facility nursing staff performing skin checks for 12/18/22, 1/1/23, 1/8/23 and 1/15/23. Review of the eMR Assessment section written by a staff RN on 12/25/22 revealed, Skin intact, no pen area noted, oral cavity intact, denies pain. No further information or documentation was noted. Review of the December 2022 and January 2023 electronic Medication Administration Record (eMAR) revealed that pain levels for Resident #3 were monitored every 6 hours. Pain levels were documented as 0 (no pain) on all days for the month of December 2022 and January 2023 except for 4 days with level 1-3 (mild pain) documented in December and 5 days in January 2023. Continued review of the January 2023 eMAR revealed a documented pain level of 4 (moderate pain) on 1/24/23 at 12:00 PM. The surveyor reviewed the PO for Acetaminophen 325 mg (2) tablets every 6 hours as needed for mild pain scale 1-3 with a start date of 12/11/22, documented on the December 2022 and January 2023 eMAR. Resident #3 was documented as receiving the Acetaminophen 325 mg (2) tablets on 12/19/22 at 5:46 PM with a 3 pain level (mild), on 1/18/23 with a 3 pain level at 6:30 PM, 1/20/23 with a 6 pain level (moderate) at 11:39 AM, and 1/23/23 with a 6 pain level at 9:07 AM. On 1/25/23 at 9:46 AM, another surveyor interviewed RN #2 who stated that she has been working in the facility for a year. The surveyor also interviewed the CNA who stated that she had been working in the facility for 7 months. The surveyor viewed the wound with the permission of the Resident, and the aid of RN#2 and the CNA in the privacy of the Resident's room. The surveyor observed RN #2 remove a white bordered dressing on Resident #3's sacrum area. The surveyor observed the sacrum area having a small opening (yellow in appearance) and redness to the surrounding area. RN #2 informed the surveyor, there's a small opening in the sacrum. RN #2 explained that RN#1 was the nurse who assessed and staged the wound. RN #2 acknowledged, Stage 1 is when there's an opening in the area. Review of pressure ulcer staging practice defines Stage 1 Pressure Ulcer as, Intact skin with discoloration of the skin that does not turn white when pressed, redness of a localized area, usually over a bony prominence. Review of pressure ulcer staging practice defines Stage 2 Pressure Ulcer as, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. On 1/25/23 at 11:15AM, surveyor interviewed the Certified Nursing Assistant (CNA), who routinely takes care of Resident #3 on the day shift (7:00 AM to 3:00 PM). The CNA stated she has not been assigned to Resident #3, in a few weeks. The CNA informed the surveyor that when assisting residents during changing their clothes, bathing and/or use of the bathroom, she would report any skin conditions found to the resident's nurse and/or the Unit Manager. On 1/25/23 at 11:22 AM, the surveyor interviewed the Ripple 1 Registered Nurse (RN #1). RN #1 stated that she was the nurse that performed the skin assessment for Resident #3 on 1/20/23, when the Stage 1 pressure ulcer was discovered. RN#1 explained that she documents information related to the pressure ulcer in the Assessment and PN section of the EMR. The surveyor discussed the four missing weekly PN and assessments as well as the three missing Braden Scale evaluations with RN#1. RN#1 could not explain why the nurses on duty did not enter information evaluating the residents skin assessment in the eMR as well as calculate the Braden Scale related to the resident's risk of developing pressure sores. RN#1 stated that if the nursing staff signs the eMAR and eTAR documenting that the task was completed, there should be documented proof of the task. On 1/25/23 at 11:27 AM, the surveyor interviewed Ripple 1 RN#2, who also assessed Resident #3's pressure ulcer on 1/20/23. RN#2 informed the surveyor that when performing a skin assessment the facility protocol includes: writing the skin assessment note in the eMR PN and Assessment section, documenting the appearance of the skin, information related to informing the physician, and identifying the physician's recommendations. The surveyor discussed the four missing weekly PN and assessments as well as the three missing Braden Scales, which should have been documented in the eMR, with RN#2. RN#2 could not explain why the nurses on duty did not enter information evaluating the residents skin assessment in the eMR as well as calculate the Braden Scale related to the resident's risk of developing pressure sores. RN#2 acknowledged that all nursing staff documenting in the eMAR and eTAR that the task was completed, should be documented proof of the task. On 1/26/23 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON). The DON explained that when a resident is admitted to the facility with sacral redness (Stage 1 pressure ulcer), the protocols include: Alerting the physician, possibly providing an air mattress, turning and repositioning are added to the resident's plan of care. We also do skin assessments, which are automatically started for new and readmitted residents. We may also add a foam dressing with padding and Periguard (barrier cream) if needed. The DON stated that Resident #3 should have had an individualized Care Plan (CP) upon admission that addressed the sacral redness noted during admission. The CP should have included preventative measures to avoid the development of an open pressure ulcer. The DON acknowledged that Resident #3 was admitted with a Stage 1 pressure ulcer that had progressed to a Stage 2 pressure ulcer. The DON verified that after review of RN#1 and RN#2's PN and Assessment Notes, once the pressure ulcer was open, it was staged wrong by RN#1 and was no longer a Stage 1 pressure ulcer, but rather a Stage 2. The DON verified that Resident #3 should have had those protocols in place on admission when the sacral redness was discovered. The DON established that the weekly skin assessments should be completed on the eMR under the Assessment area. The DON could not explain why four weekly skin PN and assessments as well as the three Braden Scale Scores for Resident #3 were missing and not performed. On 1/23/23 at 2:40 PM, the DON provided the surveyor with a facility policy titled, Pressure Injury Risk Assessment, last reviewed on 11/11/2022. Under the Purpose section of the policy it states, The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injures (PIs). Continued review of the policy under General Guidelines identifies; 1. The purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take [NAME] to modify. 3. The risk assessment should be completed as soon as possible after admission, but no later than eight hours after the admission. 4. Use only a facility-approved risk assessment tool to obtain risk assessment data. 5. Supplement the risk assessment tool with assessment of additional risk factors. 6. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. 7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Documented under Steps in the Procedure, it explains; 1. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. 4. Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of the skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Explained under the Documentation it states, The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment(s) conducted. 2. The date and time and type of skin care provided, if appropriate. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. On 1/26/23 at 1:37 PM, the DON provided an additional facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, which was last updated on 11/11/22. Under the Assessment and Recognition section, it states, 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall assess and reassess, describe and document/report on PCC (computer program used by the facility) / Paper and upload weekly assessments On 1/26/23 at 1:35 PM, the surveyor met with the DON to further discuss the issue. No further information was provided. NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to accurately complete the Minimum Data Set, (an assessment of all residents for Medicare and Medicaid) (MDS) for 2 of 18 residents reviewed for accurate MDS completion, Resident #43 and Resident #21. The MDS is a federally mandated process for the clinical assessment of all residents to facilitate the management of care. This deficient practice was evidenced by the following: 1. On 1/20/23 at 10:56 AM, the surveyor in the presence of the Director of Nursing (DON), observed Resident #43 in their room, awake and alert, seated in their wheelchair. The surveyor introduced self to the resident who responded in Spanish. The DON stated that the resident speaks and understands only Spanish. The surveyor reviewed Resident #43's hybrid medical record: The Admission Record (an admission summary) revealed that Resident #43 was admitted to the facility with diagnoses that included but were not limited to Dehiscence of Amputation Stump and Iron Deficiency Anemia, Unspecified. It further indicated that the resident's primary language was English. The quarterly MDS (QMDS), with an Assessment Reference Date (ARD) of 12/8/22, reflected that the resident had a Brief Interview of Mental Status (BIMS) score of 9 out of 15, indicating that the resident had a moderately impaired cognition. The QMDS assessment further reflected under Section A1100, Language did not need or wanted an interpreter to communicate with a doctor or healthcare staff. In fact, it did not indicate the resident's preferred language. A review of Resident #43's Care Plan (CP) revealed the following: Resident is ESL (English as a Second Language)- Spanish Speaking. The resident has a communication problem r/t Language barrier-speaks primarily Spanish. On 1/23/23 at 1:35 PM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN stated that Resident #43 spoke and understood Spanish and that a translator was needed for the resident 'to address and communicate their needs. 2. On 1/20/23 at 11:04 AM, the surveyor observed Resident #21 in a left side-lying position in bed with their eyes closed in their room. The surveyor reviewed Resident #21's hybrid medical record: The Admission Record revealed that Resident #21 was admitted to the facility with diagnoses that included but were not limited to Pressure Ulcer of Sacral Region, Stage 3 and Rheumatoid Myopathy with Rheumatoid Arthritis of Multiple Sites. The QMDS with an ARD of 11/7/22, reflected that Resident #21's BIMS was not completed due to cognitive impairment. It further indicated under Section N, (the section used to indicate the number of days the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days) that the resident did not receive any Opioids. Review of the November 2022 electronic Medication Administration Record (eMAR) revealed the following medication order, Tramadol HCl Tablet 50 mg Give 1 tablet by mouth three times a day for pain management with a start date of 10/13/22 and a discontinued date of 12/14/22. The November 2022 eMAR further revealed that the resident received the Tramadol on November 1, 2, 3, 4, 5, 6, and 7 for a total of 7 days. On 1/26/22 at 1:50 PM the surveyor interviewed the MDS Coordinator in the presence of 3 surveyors. The MDS Coordinator explained how she completes Section A1100 and Section N in the MDS by stating that Section A1100, It's auto-populated and it is filled by admissions. She continued to explain that she reviews the residents' eMAR for the 7-day look-back period and records the number of days a resident received medications such as injections, insulin, Opioids, antidepressants, anticoagulants, antipsychotics, antianxieties, and diuretics in Section N. She indicated that Tramadol is classified as an Opioid. The surveyor and the MDS Coordinator reviewed Resident #43's CP and their QMDS with an ARD of 12/8/22. She acknowledged that Section A1100, Language was coded incorrectly. She stated that Resident #43's preferred language was Spanish. The MDS Coordinator established that Resident #43 needed and wanted to communicate with a doctor or health care staff member in Spanish. The surveyor and the MDS Coordinator reviewed Resident #21's November 2022 eMAR and QMDS with an ARD date of 11/7/22. The MDS Coordinator acknowledged that the resident received Tramadol (an Opioid) for 7 days and that she did not code the Tramadol as being administered to Resident #43 for the time periods reviewed. The MDS Coordinator acknowledged that it was her responsibility to make sure that all residents' MDSs are completed correctly. On 1/27/22 at 1:16 PM, the team met with the Licensed Nursing Home Administrator, DON, Regional Board of Director, and Executive Director. The surveyor discussed the above concern. No further information was provided. NJAC 8:39-11.1

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired, unidentified bottle and discontinued medications were removed from the medication cart in a timely manner. This deficient practice was identified in 2 of 4 medication carts inspected. The deficient practice was evidenced by the following: 1. On [DATE] at 1:12 PM, the surveyor inspected [NAME] first floor unit medication cart 1 in the presence of the Licensed Practical Nurse (LPN). The inspection of [NAME] first floor unit medication cart 1, presented an unopened bottle of One Daily Multivitamin (MVI) with minerals 100 tablets which expired ,d+[DATE] and an unlabeled bottle of liquid that was found on the top drawer. The LPN could not identify the liquid found in the bottle and could not explain why the bottle was there without a label. On [DATE] at 2:00 PM, the surveyor discussed the above observations with the Director of Nursing (DON) who stated that the unidentified bottle was the solution used for COVID 19 testing. The DON could not explain why the liquid was unlabeled and stored in the medication cart. There was no further information provided for any of the other items found in the [NAME] first floor medication cart. 2. On the same day at 1:39 PM, the surveyor inspected [NAME] unit second floor medication cart 1 in the presence of LPN 2. The surveyor found a blister pack of Ativan 0.5 mg tablet for Resident #14 locked inside a narcotic box inside the medication cart. The documented delivery from the Provider Pharmacy date was [DATE]. A review of Resident #14's active [DATE] Physician's orders (PO) did not include a current PO for Ativan 0.5 mg tablet. A review of the PO history revealed that the order for Ativan 0.5 mg tablet was discontinued as per the physician on [DATE]. A review of the facility's policy titled; Controlled Substances indicated under #5. Should a controlled substance order be discontinued the Nurse must return the medication to the Director of Nursing and/or designee. a. Director of Nursing and/or designee will conduct at least bi-weekly rounds for discontinued medications. On [DATE] at 10:30 AM, the Director of Nursing (DON) stated that she has not been able to perform her rounds recently. The DON explained the facility policy indicated that bi-weekly rounds should be established to make sure that the discontinued narcotics are removed from the medication cart narcotic box. On [DATE] at 1:30 PM, the surveyor discussed the above observations with the facility's Licensed Nursing Home Administrator and DON who did not provide any further information. NJAC 8:,d+[DATE].4(h)

Based on observation, interview, and record review, it was determined that the facility failed to accurately follow physician's orders (POs), obtain a PO for a device utilized daily by a resident and obtain daily weights in accordance with the PO. This deficient practice was identified for 2 of 18 residents reviewed for POs, Resident #48 and Resident #8. 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 1/27/23 at 9:49 AM, the surveyor observed medication administration (medpass) preparation for Resident #48 by the 2nd floor Licensed Practical Nurse (LPN2). LPN2 informed the surveyor that she had evaluated Resident #48's vital signs in the morning at 8:15 AM. LPN2 recorded Resident #48's Blood Pressure (BP) as 132/79 and Heart Rate (HR) as 99. LPN2 indicated that Resident #48 had a PO for Carvedilol (Coreg) 3.125 mg (medication that lowers BP and slows HR) 1 tablet two times daily for Hypertension hold for Systolic Blood Pressure (SBP) less than 100 and HR less than 60. LPN2 verified that since the vitals taken at 8:15 AM were SBP 132 and HR 99, that she would administer the Coreg 3.125 mg. On 1/27/23 at 9:57 AM prior to LPN2 administering medication to Resident #48, the surveyor asked if she could recheck the residents BP and HR. LPN2 rechecked Resident #48's BP/HR with a new value of 104/70 BP and 87 HR. LPN2 proceeded to administer the Coreg 3.125 mg to Resident #48. When the medpass for Resident #48 was completed, the surveyor interviewed LPN2. LPN2 was not aware that when there is a PO that includes a BP and HR parameter, it is considered part of the PO. When the parameter order is associated with a medication that controls BP and HR, the BP and HR should be taken immediately prior to administering the medication. LPN2 stated, That makes sense. Review of Resident #48's Facility Information Sheet indicated that they were admitted to the facility on [DATE] with diagnoses included but not limited to Essential Hypertension, Paroxysmal Atrial Fibrillation, Heart Failure Unspecified, and Presence of Prosthetic Heart Valve. A review of Resident #48's Admission Minimum Data Set (MDS) an assessment tool used to facilitate the management of care, dated 11/10/2022, identified that Resident #48 had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that the resident was cognitively intact. Review of the January 2023 Electronic Medical Administration Record (eMAR) indicated that Corvedilol (Coreg) 3.125 mg with directions of 1 tablet two times a day for hypertension was initially ordered on 11/10/22. The PO included and was documented on the eMAR, Hold for SBP less than 100 and HR less than 60. On 1/24/23 at 2:00 PM, the surveyor discussed the issue regarding parameter monitoring when part of a PO with the Director of Nursing (DON) and the Licensed Nursing Home Administrator. The DON acknowledged that when there is a PO for parameters associated with an antihypertensive medication, the BP and HR should be taken immediately prior to administration of the medication. The DON could not explain why LPN2 did not do this. No further information was provided. 39399 2. On 1/23/23 at 1:07 PM, Resident #8 was observed seated in a wheelchair. The surveyor interviewed the resident. The surveyor also observed that the resident was wearing a specialized heel boot to the right foot. The surveyor reviewed Resident #8's electronic medical record (eMR). Resident #8 was admitted to the facility on [DATE] with diagnoses which included but were not limited to Multiple Myeloma, Osteoporosis, Congestive Heart Failure (CHF) and Alzheimer's Disease. A review of the Quarterly MDS, an assessment tool used to facilitate the management of care, dated 11/10/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating that the resident had a moderately impaired cognition. Further review of the Resident #8's medical records did not include any Care Plan or physician's order (PO) for the specialized right heel boot. On 1/27/23 at 9:27 AM, the surveyor interviewed the Certified Nurse's Assistant (CNA), who cared for Resident #8. The CNA explained that she puts on the right heel boot after rendering morning care and that the boot is scheduled to be removed before bedtime. The CNA indicated that facility nurses give the instructions for devices used by residents before the start of their shift. The CNA identified that she performs skin checks for all the residents that she cares for in the morning during her shift. The CNA was not able to provide any documented evidence of the resident's skin checks. On 1/27/23 at 10:00 AM, the surveyor interviewed the DON who stated that Resident #8 needed the specialized boot to prevent further contracture of the resident's right foot. The DON established that for any specialized device, there must be a PO. The DON verified that there was no PO for Resident #8's specialized boot. The DON could not provide any further information as to why there was no PO, care plan or Physical therapy recommendation for Resident #8's specialized right heel boot. Further review of Resident #8's eMR revealed an active PO dated 11/18/22 for Daily Weight one time a day for CHF protocol. Daily health monitoring is extremely effective in managing CHF. Through daily monitoring of weights, people can be alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period. On 1/27/23 at 9:27 AM, the surveyor interviewed the CNA taking care of Resident #8 who stated that the facility staff nurses instruct the CNAs as to which residents needed daily weights (DW). The CNA further stated that Resident #8 was one of the residents that needed DW. The CNA explained that after weighing the resident, they inform the nurse who then documents in the eMR. On 1/27/23 at 9:30 AM, the surveyor interviewed the LPN assigned to the resident who stated that DW were being documented in the eMR. On 1/27/23 at 9:33 AM, in the presence of the RN Unit Manager, the surveyor reviewed the daily weight log for Resident #8. The surveyor noted that no weights had been entered daily. The surveyor further observed that the eMAR did not include any documentation for daily weights. A review of the facility's policy titled, Weighing and Measuring the Resident did not specifically address obtaining daily weights. On 1/27/23 at 1:30 PM, the surveyor discussed the above concerns with the facility's LNHA and the DON who could not explain why there were no weights documented for Resident #8. The facility did not provide any further information. NJAC 8:39-11.2 (b); 29.2 (d)

NJ# 023 Based on observation, interview and record review it was determined that the facility failed to provide care and services in a timely manner for Resident #1. The resident was noted with bruising, swelling and pain to the left arm and was subsequently hospitalized for [REDACTED]. This deficient practice was identified for Resident #1, 1 of 15 residents reviewed as evidenced by: During the initial tour on 10/27/14 at 11:15 a.m. the surveyor observed Resident #1 in bed receiving morning care. The Assistant Director of Nurses (ADON) told the surveyor that the resident was recently hospitalized for [REDACTED]. The ADON further stated that the resident was confused, totally dependent on staff for care and the origin of the injury was unknown. The ADON stated that while at the hospital the resident had two unsuccessful attempts at a closed reduction of the shoulder and returned to the facility with a sling in place. The surveyor observed a sling at the resident's bedside which the ADON stated would be applied by therapy after morning care was completed. The surveyor reviewed Resident #1's medical record on 10/28/14. According to the nursing progress notes, the resident was transferred to the hospital on [DATE] and was admitted with a dislocation and Hill-Sachs [MEDICAL CONDITION] shoulder. The resident was readmitted to the facility on [DATE]. Upon readmission the resident had a physician order [REDACTED]." The resident also had a PO for Tylenol Arthritis 650 mg. three times daily and [MEDICATION NAME] 5 mg.-325 mg. every four hours as needed for acute pain due to trauma. On 10/29/14 the surveyor reviewed the facility's investigation which was conducted to determine the possible cause of the injury. According to statements which were written by staff who provided care to the resident, a Certified Nurse Aide (CNA) notified the nurse of "a big bruise on the left arm" while providing evening care to the resident on 10/9/14. A nurse wrote a corresponding statement that after the CNA reported the bruising the nurse assessed the resident and noted "minimal redness throughout left upper arm and a reddened bruise to the left elbow." The CNA who provided care to the resident on 10/10/14 wrote a statement that while providing morning care "the resident was crying for pain to the left arm. The nurse was present." The surveyor reviewed a statement documented on 10/11/14 by the nurse who provided care to the resident on the 7 a.m. to 3 p.m. shift. The statement revealed that on the afternoon in question, the CNA called her to the resident's room and she noted a bruise on the left elbow and swelling to the left arm. The statement also included "when the arm was touched the resident pulled it away and appeared to be in pain. Pain medication was given and the MD (physician) was paged for an X-ray." The statement further included that it was endorsed to the next shift to follow up with the physician. The same nurse wrote a statement that when she arrived back to work the next morning at 7 a.m. it was reported that the physician had not called back. The resident's "arm was still the same with bruise to left elbow and swelling. The resident continued to pull arm away and grimaced when touched." The nurse again paged the physician. According to a nursing progress note, entered electronically on 10/12/14 at 9:04 p.m. the resident "moans when touched on shoulder with some swelling noted to left shoulder" and the physician ordered x-rays of both shoulders. A nursing note, entered on 10/13/14 at 6:13 a.m. included that the X-ray result showed an "anterior dislocation of the left shoulder with a Hill-Sachs fracture." The physician was notified and the resident was transferred to the hospital and admitted . On 10/30/14 at 10 a.m. the surveyor reviewed the hospital record for Resident #1. According to the hospital Admission H & P, while in the emergency room there were "numerous attempts made to reduce the fracture without success." At that time the resident was administered [MEDICATION NAME] intravenously for pain. The resident was admitted for orthopedic evaluation. On 10/14/14 the resident was taken to the operating room and under general anesthesia again had an unsuccessful attempt to do a closed reduction of the left shoulder fracture. On 10/15/14 the resident was returned to the facility with pain medication and a left arm sling to immobilize the shoulder. Although the staff statements in the facility investigation included that the first observation of the bruises to the left arm were noted in the evening of 10/9/14 and the resident had pain and discomfort on 10/10/14 and 10/11/14, there was no evidence that the physician was notified until 10/11/14. At that time the physician was "paged" and there was no evidence that the facility followed up with notification of the physician until the afternoon of 10/12/14. At that time an x-ray was ordered which was positive for a dislocated and fractured left shoulder and the resident was sent to the hospital for treatment after midnight on 10/13/14, approximately four days after documented resident status. NJAC - 8:39-27.1(a)