Every finding on record at Health Center at Galloway, The

Based on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to a.) prevent the potential for cross contamination by not initiating and implementing Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for a resident with a wound in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. b.) follow appropriate infection control practices in a manner to prevent the potential spread of infection and/or cross-contamination during the provision of a wound care treatment and c.) transport linen in a manner that prevents the spread of infection for 1 (one) of 1 resident (Resident #11) reviewed for pressure ulcers d.) maintain the feeding tube pump pole, overbed table, and wall in a sanitary manner, for 1 of 2 residents (Resident #2) reviewed for tube feeding e.) implement Enhanced Barrier Precautions (EBP) in accordance with the facility policy, physician orders, and the resident's care plan to prevent the potential spread of infection for 1 of 1 resident reviewed for tracheostomy/laryngectomy (a surgically created hole in the throat) care (Resident #14) f.) follow appropriate infection control practices for 1 of 3 nurses observed during the medication pass observation for 1 of 3 residents (Resident #92). This deficient practice was evidenced by the following: 1.On 2/12/2026 at 12:57 PM during a tour of the facility, the surveyor entered the resident's room and observed that the responsible party (RP) was visiting with the resident. The surveyor interviewed the RP at that time who explained that Resident #11 had fallen and was sent to an acute care facility a month and a half ago. Subsequently, the resident was admitted to this facility for rehabilitation. The RP explained that the resident had a diagnosis of dementia and would remain in the facility for long-term care. The RP added that the resident enjoyed sitting in the reclining chair and had an open area on the buttocks that he had developed while at home. The RP stated that she had no concerns related to the resident's care. The surveyor observed that there was no signage posted on the resident's door that indicated Resident #11 was on Enhanced Barrier Precautions (EBP) for a previously identified wound. The surveyor also did not observe any personal protective equipment (PPE) readily available outside of the resident's room. On 2/13/2026 at 1:20 PM, the resident's RP was observed visiting Resident #11. The resident was sitting in a recliner chair with the call light within reach. The resident was well-groomed, wore clean clothes and no complaints were offered from the resident or the RP. The surveyor again did not observe any signage that the resident was on EBP and there was also no PPE readily available outside of the resident's room. The surveyor reviewed the electronic medical records (EMR) which revealed the following: A review of the admission Record (AR) an admission summary revealed the resident had diagnoses which included, but were not limited to unspecified dementia (a brain sickness that makes it hard for a person to remember things, think clearly, or control their feelings; Muscle weakness (generalized); type 2 Diabetes Mellitus (a chronic condition where the body cannot properly manage blood sugar (glucose) for energy, leading to high sugar levels in the blood.); Essential (Primary) Hypertension (Long-term high blood pressure that does not have one specific, identifiable cause); Cognitive communication deficit (difficulty with speaking, listening, reading, or writing caused by brain-based thinking problems); Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances in and on the artery walls); heart failure (the heart is not pumping blood as well as it should, making it harder to supply oxygen to the body); history of falling. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/14/2025, included the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident was occasionally incontinent of urine and frequently incontinent of bowel. A review of the physician Order Summary Report (OSR) revealed an order dated 2/6/26, to cleanse the left buttocks with normal saline solution (NSS) and apply Santyl (an enzyme (protein) that breaks down collagen in damaged or dead skin) cover with a clean dry dressing (CDD) one time a day on the day shift. A review of the wound care Nurse Practitioner (NP) Note dated, 2/11/26 at 1:24 PM, indicated that Resident #11 had a wound on the left buttocks since December 2025. A review of the Individual Comprehensive Care Plan (ICCP) dated 12/16/2025, indicated that Resident #11 had actual skin breakdown and a history of previous pressure ulcer. There was no documented evidence that indicated EBP was implemented at the time the wound was discovered. On 2/17/2026 at 10:20 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) perform a treatment to Resident #11's left buttocks. LPN #1 was observed performing hand-hygiene using alcohol-based hand sanitizer and then donned (put on) clean gloves. She then cleaned the bedside table with a disinfectant and retrieved one package of 4 x 4 gauze dressings, a four-ounce bottle of normal saline solution (NSS), a tube of Santyl ointment in the original box, and a bordered gauze in a pre-wrapped plastic packaging from the treatment cart and placed them directly on the bedside table. LPN #1 did not place a clean barrier on the table before she placed the treatment supplies on the table. LPN #1 then assisted the resident to a standing position to perform a wound treatment and instructed the resident to hold onto the bedside table, where all the treatment supplies had been placed. Upon observation, the resident was noted to be incontinent of urine. The nurse then proceeded to provide incontinence care. During this time, the nurse placed the soiled washcloth and the resident's soiled garment on the bedside table, which interminged with the clean treatment supplies. Following incontinence care, the nurse seated the resident on the bedside and exited the room with the soiled garments in her gloved hand and walked down the hallway. The nurse did not remove her gloves or perform hand hygiene after completing incontinence care and then proceeded to continue the wound treatment wearing the same soiled gloves. The nurse reached into the package of clean gauze with contaminated gloves and removed some gauze pads, and then applied the NSS to the gauze pads, and cleansed the wound without changing the gloves or performing hand hygiene. LPN #1 then applied the Santyl ointment to the dressing using her gloved finger to spread the ointment and then applied the dressing on the resident's wound. Without changing her gloves or washing her hands, the nurse attempted to return the opened package of 4 x 4s and bottle of NSS to the treatment cart. The surveyor intervened and informed the nurse that contaminated treatment supplies could not be returned to the cart. LPN #1 stated she intended to place the items on top of the cart and further stated, Oh yeah, I was not supposed to bring the treatment supplies into the resident's room. LPN #1 then discarded the contaminated supplies into the trash receptacle. On 2/17/2026 at 10:40 AM in a later interview with LPN #1, LPN #1 acknowledged that she should have placed a clean barrier on the table prior to setting up the treatment supplies. LPN #1 further acknowledged that she should have removed her gloves and performed hand hygiene after providing incontinence care, before initiating a wound treatment, and after the wound treatment. LPN #1 confirmed that soiled washcloths and garments should not be placed in the treatment area. LPN #1 stated that she could not recall if she received education in the facility regarding hand hygiene or infection control practices specific for wound care. LPN #1 also confirmed that EBP should have been implemented; however, she reported she was unaware that the resident had a wound until the surveyor requested to observe the wound treatment. On 2/17/2026 at 11:01 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM #1) who explained that EBP was utilized to protect the residents from infections. LPN/UM #1 explained that EBP was to be implemented for any resident with an identified wound. LPN/UM #1 stated staff were responsible for donning appropriate PPE, including gloves and gown for any direct physical contact with the residents. LPN/UM #1 stated that a physician's order was required for EBP and that once Resident #11 was identified with a wound, EBP should have been ordered. LPN/UM #1 confirmed that LPN#1 should have disinfected the resident's bedside table and placed a clean barrier on the table prior to setting up the treatment supplies. LPN/UM #1 further stated that LPN #1 should have doffed (removed) her gloves, performed hand hygiene, and donned clean gloves after completing incontinence care and before resuming the wound treatment. LPN/UM #1 also confirmed that hand hygiene should have been performed after cleaning the wound with NSS and prior to applying a clean dressing. LPN/UM #1 stated that Santyl ointment should not have been applied directly to the dressing using a gloved finger and that a sterile applicator should have been utilized. Additionally, LPN/UM #1 confirmed that walking in the hallway while carrying unbagged soiled linen and garments posed an infection control risk and increased the potential for cross contamination. On 2/17/2026 at 11:55 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated that for any resident with a wound the staff was required to obtain a treatment order, an order for EBP to include signage outside the resident's door and PPE in an isolation cart readily available, and a designated trash receptacle, initiate a ICCP, and weekly skin checks. The surveyor explained the wound care observation that provided to Resident #11 by LPN #1. The ADON/IP confirmed that LPN #1 breached infection control during the treatment. The ADON/IP also confirmed that LPN #1 should not have walked through the hallways with gloves on, with unbagged soiled linen and soiled resident garments as it was also a breach in infection control. A review of facility's policy dated October 2023 and titled, Handwashing/Hand Hygiene indicated that hand hygiene was the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of health-associated infections. 2.) All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection to other personnel, residents, and visitors. The policy specified that hand hygiene was indicated after contact with blood, bodily fluids, or contaminated surfaces, after touching a resident, after touching the resident's environment, before moving work on a soiled body site to a clean body site on the same resident, immediately after glove removal, use an alcohol-based hand rub containing 60% alcohol for most clinical situations, wash hands with soap and water, when hands are visibly soiled ., single-use disposable gloves should be used, before aseptic procedures, when anticipating contact with blood or body fluids .The use of gloves does not replace hand washing. A review of facility's policy dated December 2024 and titled Enhanced Barrier Precautions indicated 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EPBs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied to performing high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. C. Face protection may be used if there is also a risk of splashes. 3. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and /or indwelling medical devices regardless of MDRO colonization. 7. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. A review of the facility policy dated January 2014 and titled, Department (Environmental Services)- Laundry and Linen indicated that the facility was to provide a process for safe and aseptic handling, washing and storage of linen. The policy indicated that staff were to consider all soiled linen to be potentially infectious and handle with standard precautions. 2. On 2/12/26 at 11:34 AM, the surveyor observed Resident #14 in bed awake. The dressing that surrounded the resident's tracheostomy tube (a surgically created hole in the front of the neck into the windpipe, or trachea) was soiled. On 2/13/26 at 12:35 PM, the surveyor reviewed the Electronic Medical Record (EMR) of Resident #14 which revealed the following: A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: malignant neoplasm of the esophagus (a disease where the tissues of the tube-like structure that connects the throat to the stomach (esophagus) becomes malignant (cancer), tracheostomy status, and gastrostomy status (a surgical procedure that creates an opening (stoma) into the stomach through the abdomen, allowing for the direct insertion of a feeding tube, known as a PEG-Tube (percutaneous endoscopic gastrostomy) or G-Tube for long-term nutritional support, hydration, and medication delivery for individuals who cannot eat by mouth). A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/30/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident was occasionally incontinent of both bowel and bladder. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 11/11/2025, for Enhanced Barrier Precautions (an infection control intervention designed to reduce the transmission of multi-drug resistant organisms (MDROs) and involves the use of gowns and gloves during high-contact resident care activities for resident's with indwelling devices such as a breathing tube regardless of MDRO colonization status) r/t (related to) Peg tube, and laryngostomy tube (a short, soft, flexible tube inserted into the stoma (neck opening) after total laryngectomy (surgery to remove the larynx (voice box) )to keep the airway open and prevent the stoma from shrinking). Interventions included: Hand hygiene before and after care, and Maintain precautions as ordered. A review of the Order Summary Report (OSR), included the following physician's orders (PO): A PO, dated 11/11/2025, for Enhanced Barrier Precautions due to Peg/laryngostomy every day and night shift for Infection Prevention. On 2/17/26 at 11:17 AM, the surveyor observed Resident #14 lying in bed awake. The resident did not speak when spoken to and instead nodded their head yes or no to communicate. The dressing that surrounded the resident's laryngectomy tube was clean, dry and intact. At that time, the surveyor noted that there was no signage outside of the resident's room to instruct those who entered to perform hand hygiene prior to entry, and to donn (put on) Personal Protective Equipment (PPE) (equipment such as gloves, gowns, goggles, or face shield worn to protect one from injury or infection) prior to resident care. On 2/17/26 at 11:59 AM, the surveyor observed Licensed Practical Nurse (LPN #6) as she knocked on Resident #14's door and then proceeded to enter the resident's room without first performing hand hygiene. LPN #6 then proceeded to look in the residents' drawers and closets reportedly to find an Ambu bag (a device used to provide respiratory support to patients in emergency and non-emergency situations). LPN #6 then proceeded to leave the resident's room without first performing hand hygiene and she then proceeded to access the emergency cart at the nurse's station to reveal that there was an Ambu bag available if it were required. When interviewed, LPN #6 stated that she had worked at the facility for six years and she was scheduled to work again tomorrow. On 2/18/26 at 9:44 AM, the surveyor observed that there was no signage outside of Resident #14's room to indicate that the resident was ordered EBP and there was no PPE cart outside of the resident's room for PPE equipment storage. On 2/18/26 at 9:49 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #2 who stated that Resident #14 had a trach, and since she had not provided any trach care, she just used standard precautions to care for the resident. CNA #2 identified as an agency aide and further stated that LPN #6 informed her that she only needed to donn a gown if she had gotten close to the resident's trach. CNA #2 stated that while the resident was on hospice care, she had not seen anyone from the hospice agency provide care to the resident yet today. CNA #2 further stated that the resident was able to stand and fed themselves. On 2/18/26 at 9:49 AM, the surveyor interviewed LPN #6 outside of Resident #14's room. When the surveyor asked LPN #6 what type of precautions were required to enter the resident's room she stated that she thought the resident was on EBP, and there was supposed to be a sign posted outside of the resident's door. LPN #6 then proceeded to explain that the signage described how you must garb up (what type of PPE to donn prior to entry) to go into the resident's room. LPN #6 further explained that the resident was on EBP due to their laryngectomy. When the surveyor asked LPN #6 who was responsible to ensure that EBP precaution signage, and equipment were readily available outside of the resident's door she stated that the Infection Preventionist (IP) was responsible, but she was not here anymore. LPN #6 stated that it was important to ensure that EBP precautions were adhered to because the resident was very vulnerable and if the proper PPE were not worn by staff and visitors during care they could bring contaminants into the room. At that time, LPN #6 stated that the hospice nurse had already rendered all care to the resident today including the resident's laryngectomy care. LPN #6 stated that if she had to suction the resident thereafter, she would first wash her hands, donn a mask, and gown, and gloves before she suctioned the resident. LPN #6 further stated, she would then have to doff (remove) her PPE and place it in the trash before she washed her hands for 20 seconds and left the resident's room. At that time, the surveyor asked LPN #6 where she obtained the PPE to provide Resident #14's care as described and she stated, I was used to snatching PPE from across the hall, so I should have noticed the PPE cart was not outside of the resident's room. LPN #6 stated she thought there was a sign outside of the resident's room, but she did not know what happened to it. On 2/18/26 at 10:16 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2) who stated Resident #14 should have been on EBP because the resident had a laryngectomy that was opened, and the resident had a previous infection too. LPN/UM #2 stated she expected to see a sign outside of the resident's room to indicate EBP was required and a cart with gowns, goggles, face shields, and gloves. LPN/UM #2 stated that you must also clean your hands before entering the resident's room and after resident care. LPN/UM #2 stated there was a concern for the spread of infection to the resident if the EBP protocol were not followed. LPN/UM #2 stated that the facility educator was responsible for ensuring the sign for EBP and cart were placed outside of the resident's room. LPN/UM #2 further stated but since the educator did not do it, both she and all the nurses were responsible for the omission of the EBP signage and PPE cart. On 2/18/26 at 11:38 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated that EBP were needed for someone with a laryngectomy tube and a gown, gloves, and mask were needed for direct care to prevent the spread of infection. The ADON/IP further stated that there should have been signage outside of the resident's room with instructions to enter and the PPE bin should have been in close proximity to the resident's door with all necessary supplies. The ADON/IP further stated that EBP should have been included in both the residents' physician's orders and care plan. The ADON/IP further stated that both the resident and the staff could get sick if they were exposed if they had not adhered to EBP. On 2/18/26 at 12:53 PM, the surveyor interviewed the Director of Nursing (DON) who stated that Resident #14 should have been on EBP as we did not want to transmit infection to the resident or the staff. The DON stated that she would have expected to have seen a sign outside of the resident's room and the supplies should have been available in a cart near the entrance to the room. The DON further stated that if there were a physician's order for EBP and the Care Plan illustrated the resident was on EBP the IP should have ensured that there was both a sign and a cart that contained PPE at the entrance to the resident's room. The DON further stated that the nurse and the unit manager also should have made rounds and made sure the sign and the cart were there for communication purposes and to prevent contamination as the resident was on hospice and was compromised. The DON further stated that it was for both the safety of the patient and the staff to adhere to EBP precautions. On 2/18/26 at 2:42 PM the surveyor, in the presence of the survey team, informed the Licensed Nursing Home Administrator (LNHA) of the concerns related to EBP. A review of the facility's Enhanced Barrier Precautions policy, (dated December 2024), included: Enhanced barrier precautions (EBPs) are recommended by the Centers for Disease Control (CDC) to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. .EBPs employ targeted gown and glove use during high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. EBPs are indicated (when contact precautions do not otherwise apply ) for residents with wounds and/or indwelling medical devices regardless of MDROs colonization. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs included: Dressing, bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; .device care or use of the following are some examples: .feeding tube, tracheostomy. .EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk. .Staff are trained on EBPs. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is accessible in the resident care area and bins are not required to be in front of each door of an EBP room. A review of a facility provided Enhanced Barrier Precaution signage revealed: Everyone must: Clean their hands including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: .Device care or use: .feeding tube, tracheostomy tube. 3. On 2/12/26 at 11:19 AM, the surveyor observed Resident #2 resting in bed and a feeding pump pole was observed next to the resident's bed. The resident was receiving nutritional formula via (by way of) a tube feeding pump (Pump designed to deliver formula through a tube placed in a stomach). The pumps electronic display showed the formula was being delivered at 65 milliliters per hour (ml/hr.). On 2/13/26 at 10:01 AM, the surveyor reviewed Resident #2's electronic medical record which revealed the following: A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to gastrostomy (the surgical creation of an opening into the stomach to insert a feeding tube for direct nutrition), gastritis (inflammation of the stomach lining), and anemia. A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/19/25, included a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the MDS revealed the resident was receiving nutritional formula via a feeding tube. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 9/10/25, that Resident #2's nutrition/hydration was at risk related to the feeding tube dependency. Interventions included but were not limited to: Glucerna 1.5 at 65 ML/hr. A review of the Order Summary Report (OSR), included the following physician orders (PO): A PO, dated 12/8/25, for nothing by mouth (NPO). A PO, dated 12/7/25, for Glucerna 1.5 via a peg tube (a tube inserted through the skin directly into the stomach to provide long-term nutrients) at 65 ML/hr. On 2/13/26 at 11:27 AM, the surveyor conducted a follow-up visit to Resident #2's room and Resident #2 was observed lying in bed with the head of the bed elevated and nutritional formula infusing at 65 ml/hr. The surveyor observed several small black insects crawling on the nutritional formula bottle, pump, and tubing. The surveyor also noted dried tan colored substance on the lower part of the tube feeding pole and on Resident #2's wall. On the same day at 11:34 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM #2) walked into Resident #2's room. When asked to look at the tube feeding, she stated, I see ants. LPN/UM #2 pointed at the ants crawling on the tube feeding pole, floor, and overbed table. She further stated that the tan colored stain on the wall looked like the resident's tube feeding. On 2/13/26 at 11:45 AM, the surveyor interviewed Housekeeper #1, who stated, that she had already cleaned the Resident #2's room. On 2/13/26 at 11:48 AM, the surveyor interviewed the Director of Housekeeping (DOH) who stated that any surfaces that were not cluttered, including high-touched areas, bed rails, phones, call bells, TV remotes, overbed tables, and light switches and bathroom were cleaned daily. She also stated that the tables should be cleaned from the top down on a daily basis and as needed. The DOH further added that the walls were spot cleaned during general cleaning, and as needed and that the tube feeding poles were wiped down daily. On 2/13/26 at 11:58 AM, the surveyor, accompanied by the DOH, went to Resident #2's room and confirmed the findings. On 2/13/26 at 12:16 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated that the resident's room should be kept clean, and it was a team effort to maintain a clean and sanitary environment. She stated that any spillage should be cleaned right away and that anyone could report a resident's area that was not cleaned. On 2/17/26 at 11:35 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated that the walls, overbed tables, and tube feeding poles should be cleaned daily and as needed. On 2/18/26 at 10:34 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the resident's environment should be maintained in a clean a sanitary manner. A review of the facility's Infection Prevention and Control Program, revised June 2023 included, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility's Resident/Patient Room Cleaning, last reviewed 2/1/25, included, Rooms will be regularly cleaned and disinfected with a particular focus on disinfecting high-touch surfaces.Walls are generally considered low-touch surfaces. Wall washing frequency will vary depending on the location (common areas, resident/patient care areas, isolation rooms). Between scheduled cleanings, walls will be spot cleaned when they are visibly soiled. 4. On 2/13/26 from 9:15 AM through 9:49 AM, during the Medication Pass observation of Licensed Practical Nurse #7 (LPN #7) the surveyor made the following observations: LPN #7 was observed as she exited a resident's room and pushed a vital signs monitor (used to obtain blood pressure, heart rate, etc.) mounted on a rolling stand. LPN #7 proceeded straight to her medication cart, donned (put on) gloves, and wiped the blood pressure cuff with a sanitizing wipe. LPN #7 then immediately began to prepare medications for administration for the next resident on her assignment list. The surveyor then stopped LPN #7 from continuing. When the surveyor asked LPN #7 when she should use hand sanitizer, she stated she should use hand sanitizer between caring for each resident and before and after donning gloves. LPN #7 acknowledged she had not followed that practice. LPN #7 then began to prepare medications for an unsampled resident by pouring the medications into a medicine cup she had placed on top of her nursing binder, both pills and oral solutions. LPN #7 then used the binder as a tray and began walking toward the room to administer the resident medications. The surveyor stopped LPN #7 before she entered the room and asked her if she should use the binder as a tray to carry the medications to the room and LPN #7 stated she thought it was ok because she wiped the bottom of the binder with a sanitizing wipe when she was finished. LPN #7 then acknowledged using a nurse's binder as a tray to help administer medications could be an infection control issue, and that she could be spreading germs from one resident to another. On 2/18/26 at 11:40 AM, the surveyor interviewed the third floor Licensed Practical Nurse Unit Manager #1 (LPN/UM #1) who confirmed that LPN #7 should have either washed her hands or used hand sanitizer between caring for residents and before and after applying and removing gloves. LPN/UM #1 stated a clip board should never be used as a tray to aid in administering medications and would be an infection control concern because you could cross contaminate surfaces and possibly spread infection. On 2/18/26 at 2:56

NJ#2643473Based on observation, interview, and record review, it was determined that the facility failed to a.) Re-implement a comprehensive care plan (CCP) for a resident (Resident #72) who had a previously identified history of inappropriate sexual behaviors b.) implement a CCP for a resident (Resident #11) who was on psychotropic medications with behaviors, c.) develop a person-centered care plan for a resident who changed the setting on the oxygen concentrator (Resident #129) d.) develop a person-centered care plan for 1 of 5 residents (Resident #130) reviewed for unnecessary medications who was prescribed an anticoagulant (a medication used to prevent blood clots). This deficient practice occurred for 4 of 29 residents surveyed (Resident #11, #72, #129, and #130) and was evidenced by the following: 1. On 2/12/2026 at approximately 10:00 AM, the surveyor attempted to conduct an interview with Resident #72 during the initial tour of the facility. It was determined from interview with staff and review of the electronic medical record that Resident #72 no longer was a resident of the facility and had been discharged to an acute care facility. A review of the facility provided REPORTABLE EVENT RECORD/REPORT, revealed that on 10/14/2025 Resident #72 was observed by a physical therapist (PT) staff on the 2nd floor dining/day room. At approximately 2:50 PM, the PT observed Resident #72 with his/her hand inside the shirt/blouse of Resident #61 massaging the left breast. Resident #72 was observed to have their pants situated in a way that allowed for Resident #72 to have their genitalia (penis/vagina) exposed. The PT immediately removed Resident #61 from the dining room/day room and had them assessed by nursing. Resident #72 was moved to the third floor of the facility. No injuries were reported. The parties responsible were notified. Resident #72 was evaluated by psychiatry and care plans were updated. A review of the reportable event revealed that Resident #72 had a care plan with the following Focus: Inappropriate Sexual Behavior (Verbal and Physical) related to: resident exposes self, resident makes inappropriate remarks. Date Initiated: 06/03/2024 and Cancelled Date: 05/29/2025. The following Interventions/tasks were observed as CANCELLED: Avoid type of conversation that could encourage or initiate inappropriate behavior, Cancelled date: 05/29/2025. Encourage attendance at recreational/activation [sic] programs. Cancelled Date: 05/29/2025. Provide privacy. Cancelled Date: 05/29/2025. Remain calm and avoid angry reactions towards resident. Cancelled Date: 05/29/2025. On 2/13/2026 at 12:32 PM, the surveyor reviewed the closed medical record for Resident #72. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: infection and inflammatory reaction, muscle weakness, difficulty in walking, limitation of activities due to disability, and unspecified dementia. A review of the resident's significant change/comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/20/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident's cognition was severely impaired. According to section E of the MDS, Resident #72 had no behaviors. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 10/15/2025, that the resident had Inappropriate Sexual Behavior (Verbal or Physical) related to the resident exposing self, the resident had one episode of touching another resident inappropriately. Interventions included: Avoid type of conversation that could encourage or initiate inappropriate behavior. Distract resident if possible. Monitor [resident name] frequently when out of bed. Remove resident from public areas when behavior is disruptive/unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. A further review of the ICCP included an intervention dated 10/22/2025, for Provide privacy. Resident #72's care plan that addressed inappropriate sexual behavior was Cancelled on 5/29/2025. Upon return to the facility the facility failed to reimplement Resident #72's care plan addressing inappropriate sexual behavior, which was a known behavior prior to hospitalization dating back to 06/03/2024. On 2/18/2026 at 9:43 AM, the surveyor conducted an interview with Licensed Practical Nurse/Unit Manager (LPN/UM#2). The surveyor asked LPN/UM #2 if Resident #72 should have had their care plan that addressed inappropriate sexual behavior reimplemented upon readmission to the facility on 5/31/2025 after an acute care stay. LPN/UM #2 stated, I'm not going to lie; we should have put the care plan (inappropriate sexual behavior) back in place because it was a known behavior. LPN/UM #2 further stated that it just got dropped. On 2/28/2026 at 10:21 AM, the surveyor conducted an interview with the facility Assistant Director of Nursing/Infection Preventionist (ADON/IP) who had participated in the development of Resident #72's care plan on 10/15/2025. The surveyor asked the ADON/IP if she had been involved in Resident #72's care plan development and she stated, Yes. The ADON/IP told the surveyor that Resident #72 had a care plan when they were admitted to the facility that addressed inappropriate sexual behavior. The ADON/IP further stated that the inappropriate behavior mostly involved masturbation that would occur in the room or sometimes in the hallway. The ADON/IP also confirmed that the care plan for inappropriate sexual behavior had been discontinued during Resident #72's hospitalization.The surveyor asked the ADON/IP if the care plan for inappropriate sexual behavior should have been reimplemented upon their return to the facility. The ADON/IP stated Yes, It should have been reimplemented upon readmission to the facility. The ADON/IP then stated that the care plan was re-implemented and updated on 10/15/2025, after the incident with Resident #61 occurred. On 2/18/2026 at 2:11 PM, the surveyor conducted an interview with the facility administration, which included the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and the ADON/IP. The surveyor asked if Resident #72 had a history of inappropriate sexual behavior and both the DON and the ADON/IP confirmed that Resident #72 did have a history of inappropriate sexual behavior. The surveyor pointed out that Resident #72's care plan for inappropriate sexual behavior was discontinued on 5/29/2025, during their acute care hospitalization. The facility DON and the ADON/IP confirmed that Resident #72 should have had the inappropriate sexual behavior care plan implemented upon return to the facility. They stated that Resident #72 should have been reassessed upon readmission, and the care plan should be updated as indicated. The surveyor asked how the facility ensured the safety of other residents from this type of inappropriate behavior. The acting DON stated that staff was familiar with the residents, and they would continue to oversee the resident's behavior. The surveyor then asked what if staff were not familiar with Resident #72, such as agency nursing staff. The LNHA told the surveyor that it would be definitely helpful to unfamiliar staff if there was a care plan in place that addressed the resident's inappropriate sexual behavior. A review of the facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, included: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The following were revealed under Policy Interpretation and Implementation: .The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. .Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the quarterly MDS assessment. 2. A review of Resident #11's admission Record, an admission summary, indicated the resident was admitted to the facility with diagnoses which included, but were not limited to: dementia and diabetes mellitus (DM). A review of the resident's comprehensive Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 12/14/2025, included the resident had a Basic Interview for Mental Status (BIMS) score of 3 (three) out of 5 (five), which indicated the resident's cognition was severely impaired. The MDS also indicated that Resident #11 did not exhibit behaviors and required supervision and assistance with activities of daily living (ADLs). Further review of the MDS reflected that Resident #11 was on psychotropic (psychiatric) medications. On 2/12/2026 at 12:57 PM, the surveyor entered the resident's room, and the resident's responsible party (RP) was visiting with the resident. The surveyor interviewed the RP who explained that Resident #11 had fallen and was sent to an acute care facility a month and a half ago. Subsequently, the resident was admitted to this facility for rehabilitation. The RP explained that the resident had a diagnosis of dementia and would remain in the facility for long-term care. The RP further stated that she had no concerns related to the resident's care. On 2/13/2026 at 1:20 PM, the resident's RP was observed visiting Resident #11. The resident was sitting in a recliner chair with call light within reach. The resident was well-groomed, wore clean clothes and no complaints were offered from the resident or the RP. No behaviors were observed. The surveyor reviewed the resident's electronic medical record (EMR) which revealed the following: A review of the Order Summary Report (OSR), dated as of 1/28/26, included the following physician's orders (PO): A PO, dated 1/28/26, for Haldol 1 mg (antipsychotic) one tablet by mouth three times a day for psychotic mood disorder. A PO dated 12/8/25, for Seroquel 100 mg (antipsychotic) one tablet by mouth at bedtime for psychosis. A PO dated 12/8/25, for Citalopram Hydrobromide 20 mg (antidepressant) give two tablets by mouth in the evening for depression. A review of the psychiatry progress note dated 1/29/26 at 1:27 PM, indicated that the resident had diagnoses of depression, anxiety, mood disorder, psychosis and dementia. The psychiatrist recommended continuation of all current psychoactive medications and for the staff to document any changes in mood or behavior. The psychiatrist also indicated that a gradual dose reduction (gdr) was contraindicated and that treatment was medically necessary at this time. On 2/18/2026 at 9:46 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #11 exhibited behaviors such as agitation, exit seeking and repeatedly expressed a desire to go home. CNA #1 reported using distraction and redirection interventions, including taking the resident for wheelchair rides throughout the building and engaging in one-to-one conversations. He stated that these interventions were generally effective in calming the residents. CNA #1 reported that the resident did not display verbal or physical aggression. CNA #1 further stated that the resident experienced sundowning, characterized by increased confusion, agitation and behavior changes during the evening hours beginning around 7:00 PM. CNA #1 indicated that offering peanut butter and jelly sandwiches and ice water had been effective in decreasing the residents' anxiety. CNA #1 also reported that the resident remained calm when the RP was present. A review of the resident's Individual Comprehensive Care Plan (ICCP) revealed that the resident was at risk of elopement related to dementia and interventions included encourage independence while in the building but ensure supervision while outside and utilize a security bracelet. There were no further interventions documented on the ICCP to manage the resident's behaviors associated with the resident's diagnoses of dementia. A review of Resident #11's progress notes revealed that there was no documentation to reflect that the resident was exhibiting sundowning at night, searching for the RP or threatening to call the police. There was also no documentation in the progress notes regarding redirection interventions that were provided when Resident #11 exhibited these behaviors. On 2/18/2026 at 10:02 AM, the surveyor interviewed the Licensed practical Nurse (LPN #2) who stated that behavior monitoring was ordered by the physician and conducted every shift. LPN #2 reported uncertainty regarding whether behaviors were required to be documented in the progress notes. He stated the resident had been adjusting since admission but continued to exhibit sundowning in the evening, including agitation, searching for the RP and threatening to call the police. LPN #2 reviewed the ICCP in the presence of the surveyor and confirmed that it was not resident specific and did not include individualized interventions to address agitation or sundowning behaviors during the evening shift. He further confirmed that an ICCP was not implemented for the use of psychotropic medications or interventions associated with the use of psychotropic medication use. On 2/18/2026 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM#1) who also reviewed Resident #11's ICCP in the presence of the surveyor and confirmed that individualized interventions to address agitation or sundowning behaviors during the evening shift were not implemented for Resident 11's use of psychotropic medications. She further added that she was now aware of the discrepancy, since it was brought to her attention by the surveyor, but she stated that she would address the issue. A review of the facility's Behavior Assess, Intervention and Monitoring policy, dated March 2019, included: The Interdisciplinary Team (IDT) will evaluate behavior symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. The care plan will incorporate findings from the comprehensive assessment. The family or representative will be involved in the development and implementation of the care plan. A review of the facility's Care Plans, Comprehensive Person Centered policy, dated March 2022, included: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. On 2/12/26 at 10:58 AM, the surveyor observed Resident #129 sitting upright in bed. Resident #129 had a nasal cannula (clear plastic tubing used to deliver supplemental oxygen or air to a patient through the nostrils) delivering humidified oxygen via an oxygen concentrator (a medical device that provides purified oxygen) set at eight (8) liters. The humidification bottle connected to the oxygen concentrator contained only a small amount of liquid. On 2/13/26 at 8:46 AM, the surveyor reviewed Resident #129's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed that the resident had diagnoses that included, but were not limited to: chronic obstructive pulmonary disease (COPD) [a progressive, incurable, yet treatable lung disease that causes chronic airflow restriction, often resulting from smoking, leading to severe breathing difficulties], anemia (a condition where low red blood cell or hemoglobin levels reduce oxygen delivery to tissues, causing fatigue, pale skin, dizziness, and shortness of breath), emphysema (a chronic, progressive lung disease and a form of COPD (chronic obstructive pulmonary disease) that destroys the alveoli (air sacs) in the lungs, making it difficult to breathe), morbid obesity, and atrial fibrillation (heart arrhythmia, characterized by a chaotic, an irregular heartbeat). A review of the admission Evaluation included that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP), which included a focus area initiated on 2/20/26, showed that the resident used oxygen therapy. The interventions included encouraging or assisting with ambulation as indicated. There were no other interventions. A review of the Order Summary Report (OSR) included a physician order (PO) dated 2/10/26 for oxygen running at 5 (five) liters per minute via nasal cannula for 18-24 hours daily. A review of the Treatment Administration Record (TAR) did not include the oxygen setting. On 2/13/26 at 10:31 AM, the surveyor made a follow-up visit with Resident #129, who was observed sitting upright in their room. Resident #129 was receiving oxygen via the nasal cannula. The oxygen concentrator was set at nine (9) liters. The humidification bottle was empty. At that time, the surveyor interviewed the resident. When asked how long the humidification bottle had been empty, they replied, Since yesterday. On 2/13/26 at 10:50 AM, the surveyor interviewed Licensed Practical Nurse (LPN #3), who stated that she had administered Resident #129's medication that morning and the resident did not voice any concerns. When asked if she had checked to see what the oxygen concentrator was set on, she replied, No. She added that the oxygen concentrator setting should be checked every shift and maintained on the setting in accordance with the physician's order. On 2/13/26 at 11:00 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM #2), went to Resident #129's room. LPN/UM #2 confirmed that the oxygen concentrator was set at 9 (nine) liters per minute and the humidification bottle was empty. At that time, Resident #129 stated that they had turned up the oxygen setting to 9 (nine) liters. LPN/UM #2 then proceeded to adjust the setting on the oxygen concentrator and replaced the humidification bottle. At that time, The surveyor and LPN/UM #2 exited the resident's room to conduct an interview. LPN/UM #2 stated that prior to Resident #129 being admitted to the facility, the sending facility reported to her that when Resident #129 got out of bed, they would get anxious and increased the oxygen setting themselves. LPN/UM #2 further stated that both she or the admitting nurse was responsible for developing the care plan and updating it quarterly and as needed. LPN/UM #2 added that the care plan should have included that the resident increased their oxygen setting without the nurse's knowledge, so that the nurses would know what to watch for. LPN/UM #2 added that when the nurse comes in, they were supposed to do walking rounds to make sure that all oxygen was on the right settings, ensured that humidification was present, check the dates on the oxygen tubing, and make sure the resident was not in any respiratory distress. LPN/UM #2 further added that it was important for the setting to be correct because Resident #129 has COPD. LPN/UM #2 also stated that for a resident who has COPD, if the oxygen was set at 9 (nine) liters per minute, they could retain carbon dioxide and go into respiratory distress due to their inability to blow off the carbon dioxide. On 2/13/26 at 12:08 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP), who stated that if the resident increased the oxygen setting themselves, they should have a care plan that addressed that they were changing the settings. The ADON/IP stated that she would probably check on the resident more often to make sure that the oxygen was on the correct setting. The ADON/IP added that when the nurses first came in and during all interactions with the resident, they should check the physician's order versus the setting on the oxygen concentrator to ensure that it was on the correct setting. On 2/18/2026 at 10:16 AM, the surveyor interviewed the Director of Nursing (DON), who stated that the admitting nurse or the unit manager developed the care plan and updated it as needed. The DON added that when the resident has a history of changing the oxygen setting, it should be included on the care plan. The DON further stated that everyone involved in the resident's care should know the plan of care for the resident and what to look for just in case. On 2/18/2026 at 11:43 AM, the surveyor made a follow-up visit to see Resident #129. They were observed sitting in their wheelchair, receiving humidified oxygen at 5 liters via nasal cannula. Resident #129 stated that their nose was awfully dry and felt much better now that the oxygen was humidified. A review of the facility's Care Plans, Comprehensive Person-Centered dated, revised March 2022, included A comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. 4. On 2/17/26 at 11:54 AM, the surveyor observed Resident #130 in their room seated in a wheelchair beside their bed. The surveyor asked if the resident was taking a blood thinner and the resident responded they were and would occasionally have bruising, but no bleeding or other real problems. The surveyor reviewed the medical record for Resident #130. A review of the admission Record, an admission summary, reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; proximal atrial fibrillation (an irregular rapid heart rhythm) (afib), anxiety, cellulitis (skin infection) of left lower limb and pleural effusion (an abnormal accumulation of excess fluid in the pleural space, the thin cavity between the layers of the membrane lining the lungs and the chest wall. A review of the Admission/readmission Evaluation V6-V2, an assessment tool, dated 2/4/26, section G; Neurological, resident's level of consciousness was indicated as alert and that they were oriented to person and place and were verbally appropriate. A review of the physician orders showed an active order dated 2/7/26, for an anticoagulant; Eliquis oral tablet 5 mg (milligram) (apixaban); give one tablet by mouth two times a day for afib. A review of individualized comprehensive care plan (ICCP) initiated on 2/5/26 revealed no documented evidence to address the use of an anticoagulant medication. It was not until after surveyor inquiry that a Focus indicating [Resident's name] (redacted) was at risk for easy bleeding and bruising due to use of anticoagulant (Eliquis) was initiated on 2/18/26 by the Director of Nursing (DON). On 2/18/26 at approximately 12:00 PM, the surveyor interviewed LPN/UM #1 who stated a care plan should include any risks associated with caring for the resident including pain, medications, etc. LPN/UM #1 acknowledged if the resident were prescribed an anticoagulant, then there should be a care plan to monitor the resident for bruising or bleeding, dark stool and lethargy. LPN/UM #1 could not explain why the resident did not have a care plan to address the use of anticoagulants. A review of the facility's Care Plan, Comprehensive Person-Centered'' policy, revised March 2022, included: A comprehensive, person-centered plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.7.) The comprehensive person-centered care plan.b.) describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.e.) reflects currently recognized standards of practice for problem areas and conditions. NJAC 8:39-11.2(e)(f)(g), 27.1 (a)

Complaint# NJ2699824 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that critical laboratory results obtained on 12/15/25 were immediately conveyed to the physician, which resulted in a three (3) day delay in notification on 12/18/25 and immediate transfer to the hospital for evaluation and treatment. This deficient practice was identified for 1 of 1 resident (Resident #123), reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and well-being, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. The surveyor reviewed the electronic medical records for Resident #123. A review of Resident #123's admission Record, an admission Summary, reflected that the resident was admitted to the facility with diagnoses which included acute respiratory failure (a rapid-onset, life threatening condition where the lungs cannot properly move oxygen into the blood or remove carbon dioxide), heart failure (a chronic condition where the heart does not pump blood as well as it should), presence of an implanted cardiac defibrillator (a device implanted under the skin that constantly monitors the heart rate to detect irregular heartbeats and delivers electric shocks to restore normal heartbeat), chronic obstructive pulmonary disease (COPD) [progressive irreversible lung disease that restricts airflow, making it hard to breath], and type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). A review of the progress notes included a physician's progress note (PPN) dated 12/7/25 at 10:17 AM, which included a history and physical for Resident #123. The note indicated that the resident had been admitted to the facility after being hospitalized for respiratory failure and was treated for pneumonia and was currently completing antibiotics. The physician evaluated the resident and identified prior medical history which included generalized weakness, and chronic back pain, with a treatment plan to provide physical, occupational therapy and physiatry per protocol, complete antibiotics, and trend labs. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/18/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 11/12/25, that the resident was at risk for bleeding and bruising due to use of Plavix (a medication that prevents platelets from sticking together to form a blood clot). Interventions included labs as ordered and report abnormal results to physician asap (as soon as possible). A review of the Order Summary Report (OSR), included the following physician's orders (PO): A PO dated 12/8/25, for CBC (complete blood count; a blood test that measures the number and type of cells in the blood) and BMP (basic metabolic panel; a blood test that assesses overall health, kidney function and electrolyte levels) weekly, one time a day on Mon (Monday). A PO dated 12/18/25, reflected and order to send to ER (emergency room) for low platelet count. A review of the resident's laboratory report dated reported 12/8/25 2:45 PM, and collected 12/8/25 at 8:20 AM, included CBC, auto differential/basic metabolic panel, included, but was not limited to the following: CBC:Hemoglobin: 8.6 g/dl (gram per deciliter) with a reference range of 10.7-15.1Hematocrit: 27% with a reference range of 32-46%Platelets: 59 K/CU.MM with a reference range of 126-400 Basic Metabolic Panel: Creatinine: 0.82 mg/dl with a reference range of 0.60-1.50Glucose: 104 mg/dl with a reference range of 65-99Sodium: 131 mmol/L (micromoles per liter) with reference range of 135-145eGFR (estimated glomerular filtration rate): 79 with a reference range of >59 A further review of the progress notes included a PPN dated 12/9/25 at 5:14 PM, which indicated that the physician had seen the resident at their bedside, and a call was made to the resident's responsible party, and their concerns were addressed, there were no new complaints, and medications were discussed. The residents' vital signs were reviewed, the resident was awake, alert, and in no acute distress. The note also included trend labs as needed, noted 12/8. A further review of the progress notes included a PPN dated 12/14/25 at 11:56 AM, the resident was seen at their bedside, there were no complaints, at baseline. No CP (chest pain), SOB (shortness of breath) or abd (abdominal) pain. Trend labs as needed, noted 12/8. A review of the resident's laboratory results reported 12/15/25 at 8:01 PM, and collected on 12/15/25 at 11:39 AM, included CBC, auto differential/basic metabolic panel, included, but was not limited to the following: CBC:Hemoglobin: 8.7 g/dl with a reference range of 10.7-15.1Hematocrit: 28% with a reference range of 32-46%Platelets: 20 K/CU.MM with a reference range of 126-400 Basic Metabolic Panel: Creatinine: 1.99 mg/dl with a reference range of 0.60-1.50Glucose: 67 mg/dl with a reference range of 65-99Sodium: 130 mmol/L with reference range of 135-145eGFR: 27 with a reference range of >59 A further review of the progress notes included a Nursing Progress Note (NPN) dated 12/16/25 at 6:28 PM, indicating lab (name redacted) called for critically low platelets (20). MD (medical doctor) was notified. No new orders. A continued review of the progress notes included a late entry IDT (Interdisciplinary team) note entered by the social worker and created on 12/21/25 at 4:28 PM (after the resident had been sent to the hospital), with an effective date of 12/18/25 at 1:00 PM, regarding a care plan meeting which indicated the conference was held via telephone with the resident's responsible party to review resident's current status and discharge plan. The resident did not wish to attend the meeting. The therapy note included that the resident was self-limiting in their goals due to lack of participation. Nursing included labs were reviewed with noted low platelets, that MD was aware of labs and advised team to continue monitoring. A NPN dated 12/18/25 at 2:17 PM, revealed there was a care plan meeting held via telephone with resident's responsible party who questioned the resident's lab work and not having received a phone call from the resident's physician. The Licensed Practical Nurse Unit Manager #3 (LPN/UM #3) informed the resident's responsible party she would call the MD regarding their concerns and would call the responsible party back. A follow-up NPN dated 12/18/25 at 2:19 PM, indicated LPN/UM #3 had spoken with MD and discussed the resident's responsible party's concern regarding lab results. LPN/UM #3 noted labs from the last 2 (two) draws were compared and MD stated to send the resident to the ER (emergency room) due to the drop in platelet count. The responsible party was informed and was agreeable, resident care was rendered, they were awaiting transport to the hospital, and resident was in no distress at the time. A PPN dated 12/18/25 at 2:51 PM, revealed Called by [LPN/UM #3] regarding labs, I was not called prior about labs, rather results for another patient. I instructed her to send the patient to the ER. I then called the [resident's responsible party] and discussed the case. A NPN dated 12/18/25 at 3:30 PM, included Transport arrived and report was given. MD aware of pick up. A NPN dated 12/19/25 at 12:56 AM, indicated the resident was admitted to the hospital with an admitting diagnosis of septic shock and PNA (pneumonia), and that the MD was notified. On 2/17/26 at 11:36 AM, the surveyor attempted to interview Licensed Practical Nurse #4 (LPN #4) via telephone. A voicemail message was left; however, the surveyor did not receive a return call. On 2/18/26 at 9:10 AM, the surveyor again attempted to interview Licensed Practical Nurse #4 (LPN #4) via telephone. A voicemail message was left; however, no return call was received. On 2/18/26 at 9:30 AM, the surveyor interviewed Resident #123's responsible party, who stated they had attended a meeting with facility staff, including social work, the facility director, and another individual believed to be the Director of Nursing (DON). During the meeting, the resident's responsible party asked whether any recent lab work had been collected, and staff reported that the results had been received three days prior. The resident's responsible party was upset and stated that the facility was expected to provide daily updates and questioned whether the physician had been notified of the results. At that time, the resident's responsible party requested to speak with the physician and asked that the resident be sent to the hospital. The responsible party stated that the physician contacted them and reported that they had not been notified of the lab results. On 2/18/26 at 10:01 AM, the surveyor interviewed the resident's physician (Ph #1) who stated that Resident #123 had multiple comorbidities but had been stable with no new complaints.Ph #1 stated, unfortunately, the resident decompensated quickly, with no clear signs or symptoms of infection identified prior to the decline and the resident succumbed to sepsis or respiratory failure at the hospital with no clear indication of infection, only abnormal blood counts. The physician further stated that the resident had recently completed a course of antibiotics for an infection and had a history of low platelet counts prior to admission to his service. The physician noted that a miscommunication had occurred with the facility nurse. The resident had critical labs that were not called into him. Once the critical labs were communicated, he sent the resident to the hospital. At that time, ph #1 stated the nurse texted the physician the critical lab results regarding the platelets, however, that text was not seen. Ph #1 stated that critical lab results must be directly communicated by speaking with the physician and should not be relayed by text message or voicemail. Ph #1 stated he only became aware of the critical labs when LPN/UM #3 called him on 12/18/25, three days after the lab results were available. The physician stated he never saw the initial text message regarding Resident #123 that was sent around 1:30 AM on 12/16/25 so he did not respond. The nurse then sent another text message regarding a different resident at 5:30 AM, to which he responded at 6:20 AM, but the physician again stated he never saw the 1:30 AM text, as it had gotten buried. The physician further stated on 12/18/25, when Resident #123 was sent to the hospital, there had been no change in the resident's clinical status, the resident was only sent because of the critical labs. Ph #1 further stated that he then called the resident's responsible party and had Resident #123 sent to the hospital. On 2/18/26 at 11:26 AM, the surveyor interviewed Licensed Practical Nurse #5 (LPN #5), who stated that when critical laboratory results are received, staff were not to leave a text message; rather, the nurse must speak with the physician to communicate the results. LPN #5 emphasized that this process was important because critical laboratory values may be life-threatening. Additionally, LPN #5 stated that the nurse was expected to notify the unit manager or nursing supervisor of the critical results. On 2/18/25 at 11:21 AM, the surveyor interviewed the current third floor LPN/Unit Manager #1 (LPN/UM #1) who stated that upon receipt of critical laboratory results, the nurse was required to telephone the physician directly so the physician could determine whether the resident required transfer to the hospital or required new orders. The nurse should also notify the nursing supervisor and assess the resident. On 2/18/26 at 11:57 AM, the surveyor interviewed the Assistant Director of Nursing /Infection Preventionist (ADON/IP) who stated that critical laboratory results must be communicated regardless of the time of day. The ADON/IP reported that staff had informed her that Resident #123's physician (Ph #1) preferred to receive lab results via text message. When asked how she ensured that Ph #1 received the text messages, the ADON/IP stated that if she had not received a response within 20 minutes, she would send a second text message. If there was still no response, she would telephone the Medical Director, who was available at any hour and was responsible for overseeing all physicians. The IP confirmed that a platelet count of 20 was serious and should have been communicated immediately to Ph #1. On 2/18/26 at 12:24 PM in a later interview with the ADON/IP, she stated that LPN #4 worked overnights. The ADON/IP reported that attempts were made to contact LPN #4 by telephone; however, she was unable to reach her. On 2/18/26 at 12:40 PM, the surveyor interviewed the Director of Nursing (DON), who stated for a critical lab result, the expectation was for the nurse to call or text the physician, because some physicians preferred to be texted. The DON stated if the nurse texted twice without response, then they should call the Medical Director (MD). The DON stated, in addition, the nurse should contact the nursing supervisor, who was to ensure that if a follow up was needed, it was completed. The DON stated the nurse was also be expected to write a progress note which included the critical lab, and the call to the physician with their response. When asked when a critical lab should be communicated to the physician, the DON stated as soon as the nurse received the critical lab results. The DON further added depending on the scenario, there could be a negative outcome for the resident if the physician was not contacted immediately. The DON then confirmed that a platelet count of 20 was critical and the physician should have been contacted immediately. On 2/18/26 at 12:56 PM, LPN #4 called the surveyor via telephone. When asked how critical labs were communicated to a physician, LPN #4 stated that staff either called the physician or sent a text message. LPN #4 explained that the method depended on the time of day, as some physicians did not answer their phones late at night, so texts were sometimes used. At that time, when asked how she ensured that a physician received a text message, LPN #4 stated that if she did not receive a response, she would call the physician before the end of her shift. LPN #4 further stated that it was important to ensure the physician was aware of critical lab results and that she would also notify a supervisor.At that time, LPN #4 stated she recalled Resident #123 and that she had sent the resident's critical lab results via text to Ph #1. LPN #4 stated that later in the night, she sent a second text regarding a different resident. LPN #4 reported receiving two text message responses and assumed that the first response noted referred to Resident #123, while the second response referred to the other resident. LPN #4 stated that she had also notified her supervisor about the critical lab results. When asked if she followed up with Ph #1, she responded no, that in her experience, Ph #1 did not respond immediately. LPN #4 further stated that she had endorsed to the day shift that Resident #123 had critical lab values and that she had contacted Ph #1, who responded noted with no new orders and believed that Ph #1 would be in to see Resident #123 that day. On 2/18/26 at 3:13 PM the DON provided the surveyor a screenshot of the text conversation between LPN #4 and Ph #1 dated Tuesday, 11/25/26 at 1:28 AM, which included Hi Doc. This is (name redacted, LPN #4) from facility name (redacted). Just received a critical lab result for Resident #123 (name redacted) . platelet count is critically low (20). Any orders? There was no response. At 5:26 AM, LPN #4 sent another message, this time for another unsampled resident which indicated FYI. (name redacted) has dark red urine output. There were two text messages sent at 6:23 AM from Ph #1 which indicated Noted and a second text which indicated Hold Eliquis (a blood thinner). On 2/19/26 at 9:42 AM, the surveyor reviewed Resident #123's New Jersey Universal Transfer Form (NJUTF), [a mandatory document designed to standardize the transfer of clinical information between healthcare facilities, such as hospitals and long-term care facilities, to reduce errors]. The form was dated 12/18/25 at 3:55 PM. The documented reason for transfer to the hospital was, drop in platelet count. On 2/19/26 at 10:19 AM, the surveyor re-interviewed Ph #1 via telephone in the presence of the survey team. When asked if he would have done anything differently had he been made aware of the laboratory results immediately, Ph #1 stated that, at the very least, additional actions would have been considered, including ongoing laboratory surveillance, escalation of care to a higher level, or evaluation in an acute care hospital. When asked about a possible emergency room evaluation, Ph #1 stated that it would depend on the circumstances, as a patient could be very stable or very ill. He noted that Resident #123's condition had been stable, but would have warranted further consideration if he had been aware of the critical lab results.Ph #1 repeated that no nurse had called him with any concerns. He stated that the labs were a concern and would have warranted further action. During his last visit with the resident, there were no new concerns. He further stated that he would have needed to speak directly with the nurse at the time to obtain a complete understanding of the resident's condition. He confirmed that he received a phone call two days later from the nurse reporting that the resident's representative was concerned, and he believed it was reasonable to send the resident to the hospital for evaluation. Ph #1 stated that critical laboratory results must be called in to the physician emergently. If the nurse was unable to reach the physician, the nurse should contact the Medical Director. On 2/19/26 at 10:34 AM, Ph #1 called the surveyor in the presence of the survey team. He stated that during the earlier interview, he did not have Resident #123's chart open or accessible. After speaking with the surveyor, he reviewed the resident's medical chart and noted a substantial decline in renal function (kidney functions) as well, which had not been included in the initial text message and would have prompted emergency medical intervention. Ph #1 stated that when the nurse called on 12/18/25, he opened the resident's chart and personally reviewed the laboratory results. He emphasized that he was highly accessible and had received multiple phone calls regarding other residents. He further stated that Resident #123 had been seeing a nephrologist (kidney specialist), though he did not currently have access to the nephrology note. Ph #1 stated that once he was made aware of the critical laboratory results, he took immediate action and sent the resident to the hospital for evaluation. He then discussed the situation with the resident's responsible party, who agreed with the decision to transfer the resident to the hospital. On 2/19/26 at 10:52 AM, the surveyor attempted to interview the former Unit Manager Licensed Practical Nurse #3 (LPN/UM #3) via telephone in the presence of the survey team. However, LPN/UM #3 did not answer her phone. On 2/19/26 at 11:08 AM, the surveyor interviewed the Medical Director (MD) in the presence of the survey team. The MD stated that he expected all nurses, including night shift nurses, to communicate critical lab results by calling him directly. He emphasized that nurses may call him at any time, nights, weekends, or holidays. He further stated he informed the previous administration the nurses needed education, that critical labs required a phone call, not a text message. The MD cited a prior incident at the facility involving another physician which created a lot of mess, in the sense the physician texted the nurse back, the nurse thought the issue was addressed, and the resident did not do well. There was a delay in treatment. The MD further stated he held a meeting with the facility staff within the last few months and communicated that any critical results, including labs, radiology, or ultrasounds, must be communicated by phone rather than text message. As a result of this incident, we needed to change the policy to state that critical results required a phone call and not a text message. A text was just a short message and can create confusion. however, a phone call would allow for discussions, questions, and review of previous labs. When asked whether sending the resident to the hospital immediately would have made a difference, the MD stated he could not determine the outcome. However, he noted that investigation of the labs at the hospital was the appropriate course of action. He further stated that the resident's condition could have continued to decline, so transferring the resident to the hospital was the right decision. On 2/19/26 at 12:36 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The LNHA stated that he was unable to locate an investigation regarding Resident #123's critical laboratory results. The ADON/IP stated that when Resident #123 was sent to the hospital, it was considered an acute discharge, and the facility reviewed all acute discharges. The ADON/IP further stated that she had reviewed all of the resident's medical records and had looked into the incident, which was how she was able to provide the surveyor with a copy of the text messages between LPN #4 and Ph #1. The ADON/IP acknowledged that there had been a delay in care. The DON also acknowledged that there was a delay in treatment. The LNHA stated that the ADON/IP's work represented a follow-up on the acute transfer and was not necessarily a formal, required investigation. A review of the facility Lab and Diagnostic Test results- Clinical Protocol policy, revised November 2018, included:. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results.whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. A physician should respond within one hour regarding a lab result requiring immediate notification. If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. Physician decisions. When responding to notification of test results, the physician and staff will discuss the implications of the test results for the resident, as well as subsequent actions; for example, obtaining additional tests, new or modified medication orders, additional monitoring, etc. A review of the Acute Condition Changes- Clinical Protocol policy, revised March 2018, included: . The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications. the nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less).The attending physician (or practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The nurse and the physician will discuss and evaluate the situation. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. NJAC 8:39-27.1(a)

Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to secure a treatment cart during a wound treatment observation that was conducted on 2/17/2026. This deficient practice occurred with 1 of 1 nurse observed for the provision of a wound treatment and was evidenced by the following:On 2/17/2026 at 10:20 AM, the surveyor conducted a wound treatment observation on the third floor nursing unit with the Licensed Practical Nurse (LPN #1). LPN#1 was observed gathering treatment supplies from the treatment cart. LPN #1 then proceeded to put the treatment supplies on top of the treatment cart. She then entered a resident's room, and left the treatment cart with the treatment supplies on top of the cart unlocked, unattended and out of her line of sight. LPN#1 returned to the cart to obtain additional supplies, then re-entered the resident's room, again leaving the cart unlocked, unsecured, and unattended.The treatment supplies left on top of the treatment cart consisted of one bottle of normal saline solution (NSS), one tube of Santyl ointment (a topical medicine used to help clean and remove dead tissue from long-lasting skin wounds).During the observation, LPN#1 exited the resident's room carrying soiled garments and walked past the unlocked and unattended treatment cart without securing it. LPN #1 placed trash bags on top of the cart, re-entered the resident's room to obtain a trash bag, and again left the treatment cart unlocked, unsecured and out of her view. There were no residents in the hallway at the time; however, the treatment cart remained accessible and unsecured.On 2/17/2026 at 10:40 AM, the surveyor interviewed LPN #1 who stated that she should have locked and secured the cart when not in sight and she should not have left the cart unattended as a resident could have gained access to the treatment supplies.On 2/17/2026 at 11:01 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1) who confirmed that the treatment cart should be kept secured and locked when not in sight as a resident could gain access to the treatment supplies. LPN/UM #1 also indicated that the ointments and creams in the treatment cart were considered medications.The facility policy dated November 2020 and titled, Storage of Medications indicated that the facility stored all drugs and biologicals in a safe, secure and orderly manner.NJAC 8:39-29.2(d)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman's Office of a resident transfer to an acute care hospital in a timely manner.This deficient practice was identified for 1 of 2 residents (Resident #123) reviewed for hospitalization and was evidenced by the following: On 2/17/26 at 10:20 AM, the surveyor reviewed the closed medical record of Resident #123.A review of the admission Record, an admission summary, revealed the resident was admitted to the facility with diagnoses which included but were not limited to: acute respiratory failure, chronic obstructive pulmonary disease (COPD) (a condition which makes it difficult to breathe), heart failure, unspecified, and Type 2 (two) diabetes mellitus (a condition in which the body does not produce enough insulin or use it effectively).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/18/25, included the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident's cognition was moderately impaired.A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 11/12/25, which indicated that the resident was at risk for easy bleeding and bruising due to the use of Plavix (a medication that prevents platelets in your blood from sticking together). Interventions included: .Labs as ordered. Report abnormal result to physician asap (as soon as possible), and monitor for active bleeding, i.e. hematuria (blood in the urine), bruising, nose bleeds, rectal bleeding, blood in stool, bleeding gums.A review of the Order Summary Report (OSR), dated as of 12/18/2025, included the following physician orders (PO):A PO, dated 12/18/2025, for Send to ER (emergency room) for low platelet (cell fragments that compose the smallest component of blood and are responsible for stopping bleeding) count.A review of a Progress Notes (PN) dated 12/18/25 at 2:19 PM, revealed, Spoke with MD (Medical Doctor). Discussed [name redacted] concern and questioning lab work. Compared labs over last 2 (two) draws. MD stated send to ER due to drop in Platelet Count (measures the platelet count in a person's blood and if high or low platelet counts, can increase the risk of clotting or excessive bleeding). Call placed to [name redacted] and informed of order to send to ER. [name redacted] is agreeable. Resident care rendered. [Name redacted] called for transport. Awaiting pickup. No distress at this time.A further review of a Progress Note (PN) dated 12/19/25 at 12:56 AM, revealed that the resident was admitted to the hospital [name redacted] with an admitting diagnosis of septic shock (a condition in which the blood pressure fails, and the organs of the body fail to receive sufficient oxygen) and PNA (pneumonia). MD notified. Will endorse the incoming nurse and staff.On 2/17/26 at 12:24 PM, the surveyor requested and received a copy of Resident #123's Notice of Emergency Transfer from the Licensed Nursing Home Administrator (LNHA) that was dated 12/18/25. When the surveyor requested confirmation of notification to the Office of the State Long-Term Care Ombudsman's Office the LNHA stated that when he spoke with the Director of Social Services (DSS) and questioned the process, he learned that the current DSS did not realize that he was required to notify Ombudsman. The LNHA stated the DSS then proceeded to send the notifications for both November and December 2025 to the Ombudsman's Office on 2/13/26. The LNHA confirmed that the resident's responsible party was notified of the Notice of Bed Hold on 12/18/25, however, the Office of the State Long-Term Care Ombudsman's Office was not notified of the resident's acute hospitalization at that time as required.On 2/18/26 at 9:28 AM, the surveyor interviewed the DSS who stated that he just received notification of the need to notify both the family member and the Ombudsman of hospital transfer. The DSS stated that he notified the Ombudsman via fax either at the very end of the month, or the very beginning of the following month. The DSS stated that he received education on the process late last month related to the notification and he did not know that the notices needed to be faxed. The DSS further stated that the previous DSS was doing it prior, but it was a miscommunication on my end.A review of the Transfer or Discharge Notice policy, (Revised March 2021), included:Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge.Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: .An immediate transfer or discharge is required by the resident's urgent medical needs;.A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to offer snacks to residents between meals and at bedtime. This deficient practice was identified for 2 of 4 residents (Resident #80, Resident #83,) who attended a resident's group meeting and for an additional two residents interviewed for the provision of snacks, (Resident #5, Resident #130).This deficient practice was identified on 2 of 2 nursing units (Second and Third Floor) and was evidenced by the following:On 2/13/2026 at 10:31 AM, the surveyor conducted a meeting with four alert and oriented residents. When asked about bedtime snacks, two residents stated that snacks were not passed out at night. Resident #83 stated that they did not receive snacks and worried about their blood sugars as a diabetic. Resident #83 further stated that they had spoken to the Dining Director (DD) previously about it and they had agreed to look into it.On 2/17/2026 at 11:47 AM, the surveyor observed Resident #5 seated in a wheelchair in their room eating lunch. When the surveyor asked if they received a snack at night the resident stated no, but they wished they would.On 2/17/2026 at 12:31 PM, the surveyor interviewed Resident #130 at their bedside who stated that they had not received a snack last night but would have liked to.On 2/17/2026 at 12:35 PM, the surveyor interviewed Certified Nurse Aide (CNA #3) who stated that snacks came up from the kitchen at every meal and some were assigned to specific residents with their name attached and some additional snacks were provided for the general census. CNA #3 stated that the aides must go around and offer snacks, but they were not required to sign the snacks out to demonstrate resident receipt. CNA #3 further stated that he knew his residents and offered them snacks even if they were not on the list.On 2/17/2026 at 12:39 PM, the surveyor interviewed Licensed Practical Nurse (LPN #5) who stated that snacks were offered at 10 AM, 2 PM and between 5 and 6 PM from the kitchen. LPN #5 stated that the snacks were labeled with the residents' names, and we passed them out and we had extras for residents who may want snacks. LPN #5 stated if the resident had a physician's order and were ordered a sandwich, health shake, or bedtime snack, the order was reflected on the Medication Administration Record (MAR) and nursing was required to sign the snack out on the MAR. LPN #5 stated that diabetics should have that process in place. LPN #5 stated that if there were extra snacks that came up from the kitchen, then they were passed out. LPN #5 further stated we let the kitchen know to put the resident on the list for snacks if they had requested.On 2/18/26 at 9:37 AM, the surveyor interviewed the Dining Director (DD), who stated that bulk snacks were delivered to the nursing units at 7:00 PM with assigned snacks for residents with orders with their name, consistency, and room number. The DD stated that snacks were also delivered at breakfast, lunch, dinner, and at 7:00 PM. The DD stated that we send unlabeled crackers, cookies, chips and sugar free items. At that time, the surveyor requested a list of residents who had snack orders and any documented evidence that the staff had signed for receipt of the snacks as described.On 2/18/26 at 9:46 AM, the DD provided the surveyor with a blank Food and Nutrition Services Meal Service Delivery Log that failed to have illustrated the delivery confirmation of snacks to the nursing units.On 2/18/2026 at 9:49 AM, the surveyor interviewed CNA #2 who stated the residents had two meals served during the day shift and if residents asked for snacks during that time, then she could call the kitchen for it. CNA #2 further stated that snacks were then offered before bedtime thereafter.On 2/18/2026 at 10:00 AM, the surveyor interviewed LPN #6 who stated that she only had to sign out the provision of a health shake on the MAR. LPN #6 stated diabetics did not have to ask for a snack, because they were provided with snacks on their meal trays. LPN #6 further stated the snacker's families brought snacks into the facility from home. On 2/18/2026 at 10:31 AM, the surveyor interviewed Licensed/ Practical Nurse/Unit Manager (LPN/UM #2) who stated that snacks were delivered to the nurse's station around 5:30 PM or 6:00 PM and the nurse had to sign receipt. LPN/UM #2 stated the aides then passed the snacks out and the nurses had snacks on their carts that they passed out when they gave their medications. LPN/UM #3 further stated that staff did not have to sign the snacks out as administered, and she would have to ask the resident if they received them to verify receipt.At that time, LPN/UM #3 reviewed the electronic medical record (EMR) and stated that none of the residents (Resident #80, Resident #83, and Resident #130) the surveyor inquired about had orders for snacks. At that time, the surveyor heard an unsampled resident call out at the nurse's station, I want my sandwich. LPN/UM #3 confirmed that the resident was requesting to have their snack provided to them.On 2/18/2026 at 11:56 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated some patients were ordered scheduled snacks if they were diabetic and other residents were offered snacks at HS (hours of sleep). The ADON/IP stated that the nurses and aides handed them out and signed for them if the snacks were dietician assigned and there was a physician's order.On 2/18/2026 at 12:30 PM, the surveyor interviewed the Lead Dietician (LD) who stated not every resident required an HS snack. The LD explained that if the doctor felt it necessary due to low blood sugar in the morning or a hefty dose of insulin at night, then we will add something. The LD stated that snacks came up to the nursing units on a snack tray and nursing handed them out. The LD further stated that only supplements and fortified foods were required to be signed out as administered by nursing.On 2/18/2026 at 1:04 PM, the surveyor interviewed the Director of Nursing (DON) who stated the facility did bring snacks for everybody. The DON stated that the snacks should be offered in the afternoon and at night. The DON further stated, except for residents with orders, then the nurses passed them out and signed them out on the MAR.On 2/18/2026 at 2:05 PM, the surveyor in the presence of the survey team, informed the Licensed Nursing Home Administrator (LNHA) of the resident's allegation that they had not been offered snacks in between meals and at bedtime.A review of the Snacks (Between Meal and Bedtime) , Serving policy, (Revised September 2010), included: The purpose of this procedure is to provide the resident with adequate nutrition.The person performing this procedure should record the following in the resident' s medical record:The date and time the snack was served, The name and title of the individual (s) who served the snack. The amount of snack eaten by the resident (i.e., 50%, 75%, etc.).The signature and title of the person recording the data.NJAC 8:39-17.2(f) 1 (ii)

Based on observation, interview and record review, it was determined that the facility failed to administer medication with an error rate of less than 5%. The surveyor observed 3 nurses administer medications for 3 residents with 26 opportunities for error. There were 2 errors resulting in an error rate of 7.6% as evidenced by the following: During the medication pass observation on 2/13/2026 from 8:27 AM until 8:35 AM, the surveyor observed the following: At 8:27 AM, the surveyor observed Licensed Practical Nurse #8 (LPN #8) prepare five medications for Resident #100 including Coreg tablet 25 mg (milligram) (carvedilol); give one tablet by mouth two times a day for HTN (hypertension) take with food, and Metformin HCL tablet 1000 mg; give one tablet by mouth two times a day for DM (diabetes mellitus) with a pharmacy cautionary label indicating to take this medication with food. At the time of the medication administration, the facility breakfast trays had not been delivered, and LPN #8 had not provided, offered, or instructed the resident to take the medication with food. At that time. the surveyor stopped LPN #8 and reviewed the electronic medical record (EMR) with LPN #8 who acknowledged the two medications should have been given with food. LPN #8 stated that usually breakfast had been served by then, she should have offered food with the medications such as applesauce, a sandwich or crackers. LPN #8 then proceeded to provide Resident #100 with a cup of applesauce. On 2/18/26 at 12:12 AM, the surveyor interviewed the Assistant Director of Nursing/ Infection preventionist (ADON/IP) who stated if medication should be taken with food, then a cup of pudding, a cup of applesauce or a half sandwich should have been given. If breakfast had not been served, then the nurse should have provided food to the resident before administering the medication. The ADON/IP stated it was important to follow the instructions to take with food because some medications could have side effects if not taken with food. On 2/18/26 at 11:40 AM, the surveyor interviewed the third floor Licensed Practical Nurse/ Unit Manager #1 (LPN/UM #1) who stated take with food meant a meal, or some type of snack, a sandwich, a pudding or applesauce cup, or a banana usually to prevent stomach upset. LPN/UM #1 acknowledged LPN #8 should have administered medications to Resident #100 with food or waited until they had been served their breakfast. On 2/18/26 at 1:40 PM, the pharmacist attempted to interview the facility's Consultant Pharmacist (CP) via telephone, but the call went directly to voicemail. On 2/18/26 at 2:56 PM, the surveyor interviewed the Director of Nursing (DON) who stated LPN #8 should have followed the pharmacy cautionaries and given the medications with food. The DON further stated food would be considered sandwiches, applesauce, or pudding. A review of the Administering Medications policy, revised October 2023, included Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescribers orders. The policy did not address cautionaries or the definition of food during medication pass. NJAC 8:39-29.2(d)

Based on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to a.) develop an individualized Comprehensive Care Plan (ICCP) with specific interventions to address dementia care, and b.) follow the facility policy for dementia care. This deficient practice was identified for 1 of 2 residents (Resident #11) reviewed for dementia care and was evidenced by the following: A review of the admission Record (admission summary) indicated that Resident #11 was admitted to the facility with diagnoses that included but were not limited to dementia and diabetes mellitus.A review of the comprehensive Minimum Data Set (MDS), an assessment tool that facilitates a resident's care, dated 12/14/2025, indicated that the resident scored 3 (three) out of 15 (fifteen) on the Basic Interview for Mental Status (BIMS) assessment which indicated that the resident had severe cognitive impairment. The MDS also indicated that Resident #11 did not exhibit behaviors and required supervision and assistance with activities of daily living (ADLs). The MDS further reflected that Resident #11 was on psychotropic medications.On 2/12/2026 at 12:57 PM, the surveyor entered the resident's room, and the responsible party (RP) was visiting with the resident. The surveyor interviewed the RP who explained that Resident #11 had fallen and was sent to an acute care facility a month and a half ago. Subsequently, the resident was admitted to this facility for rehabilitation. The RP explained that the resident had a diagnosis of dementia and would remain in the facility for long-term care. The RP stated that she had no concerns related to the resident's care.On 2/13/2026 at 1:20 PM, the resident's RP was observed visiting Resident #11. The resident was sitting in a recliner chair with call light within reach. The resident was well-groomed, wore clean clothes and no complaints offered from the resident or the RP. No behaviors observed.The surveyor reviewed the resident's electronic medical record (EMR) which revealed the following information:A review of the psychiatry notes dated 1/29/26 at 1:27 PM, indicated that Resident #11 had diagnoses of dementia and had clinical signs such as forgetfulness, memory loss, confusion, anxiety, depression, delusions and mood swings.A review of the Order Summary Sheet ([NAME]) contained an order for Namenda 10 mg one tablet by mouth two times a day for dementia.On 2/18/2026 at 9:46 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated that Resident #11 exhibited behaviors such as agitation, exit seeking and repeatedly expressed a desire to go home. The CNA #1 reported using distraction and redirection interventions, including taking the resident for wheelchair rides throughout the building and engaging in one-to-one conversations. He stated that these interventions were generally effective in calming the resident. The CNA #1 reported that the resident did not display verbal or physical aggression. The CNA #1 further stated that the resident experiences sundowning, characterized by increased confusion, agitation and behavior changes during the evening hours beginning around 7:00 PM. He indicated that offering peanut butter and jelly sandwiches and ice water had been effective in decreasing the residents' anxiety. The CNA #1 also reported that the resident remained calm when the RP was present.A review of the Individual Comprehensive Care Plan (ICCP) revealed that the resident was at risk of elopement related to dementia and interventions included encourage independence while in the building but ensure supervision while outside and utilize a security bracelet. There were no further interventions documented on the ICCP to manage the residents' behaviors associated with the residents' diagnosis of dementia.A review of Resident #11's progress notes revealed that there was no documentation that the resident was exhibiting sundowning at night, searching for the RP or threatening to call the police. There was also no documentation in the progress notes regarding redirection interventions that were provided when the resident exhibited these behaviors.On 2/18/2026 at 10:02 AM, the surveyor interviewed the Licensed practical Nurse (LPN #2) who stated that behavior monitoring was ordered by the physician and conducted every shift. LPN #2 reported uncertainty regarding whether behaviors were required to be documented in the progress notes. He stated the resident had been adjusting since admission but continued to exhibit sundowning in the evening, including agitation, searching for the RP and threatening to call the police. LPN #2 reviewed the ICCP in the presence of the surveyor and confirmed that it was not resident specific and did not include individualized interventions to address agitation or sundowning behaviors during the evening shift. He further confirmed that the ICCP did not include a resident specific dementia-focused care area with related goals and interventions to address the resident's dementia care needs.On 2/18/2026 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM#1) who also reviewed Resident #11's ICCP in the presence of the surveyor and confirmed that individualized interventions to address agitation or sundowning behaviors during the evening shift. She further confirmed that the ICCP did not include a resident specific dementia-focused ICCP. She further added that she was now aware of the discrepancy, since brought to her attention by the surveyor, and would address the issue.A review of the facility policy dated 11/2018 and titled, Dementia-Clinical Protocol indicated individuals with dementia can have personality disorders, mental illness, psychosis, delirium, depression, adverse drug reactions or conditions contributing to impaired cognition and problematic behaviors. The policy further indicated that for individuals with confirmed dementia, the Interdisciplinary Team (IDT) would identify a resident-centered care plan to maximize remaining function and quality of life. The IDT would identify and document the residents' condition and level of support needed during care planning and review changing needs as they arise. Resident needs would be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses notes and documentation tools). The IDT will adjust interventions and overall plan depending on the individuals' responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.N.J.A.C 8:39-45.1 (a)

Based on record review and interview, it was determined that the facility failed to ensure physician supervision and oversite of medical care for 1 of 2 residents (Resident #11) reviewed for pressure ulcer management and was evidenced by the following:The surveyor reviewed Resident #11's Electronic Medical Records (EMRs) which revealed the following information:A review of the admission Record, an admission summary, indicated that Resident #11 was admitted to the facility with diagnoses that included but were not limited to dementia: (a loss of mental functioning that affects thinking, memory, mood, and behavior) and diabetes mellitus (a condition in which the body is unable to properly regulate blood sugar due to problems with insulin production or use).A review of the admission Minimum Data Set (MDS), an assessment that facilitates a resident's care, dated 12/14/2025, indicated that the resident scored 3 (three) out of 5 (five) on the Basic Interview for Mental Status (BIMS), which indicated that the resident had severe cognitive impairment. Further review of the MDS also indicated that Resident #11 did not exhibit behaviors and required supervision and assistance with activities of daily living (ADLs). The MDS further reflected that Resident #11 was on psychotropic medications.A review of the Wound Care Practitioner (WCP) notes dated 2/11/2026 at 1:24 PM, indicated that Resident #11 had a wound on the left buttocks that had been present since December 2025. According to the Resident Representative (RP), the resident had a history of multiple wound sites while residing in the community. The wound on the left buttocks was identified as unstageable and measured 2.5 cm x 4.5 cm x 0.3 cm. The documentation further indicated the presence of moisture-associated skin damage (MASD) to the scrotal area.A review of the Medication Administration Record (MAR) reflected ongoing treatment orders beginning in December 2025 for the left buttock wound. The MAR further indicated treatment orders initiated in February 2026 for MASD to the scrotal area.A review of the Comprehensive Care Plan (CCP) dated 12/16/25, indicated that the resident had actual skin breakdown on the buttocks with a previous history of pressure ulcers. Preventative protective skin care interventions were in place.A review of the primary care physician (PCP) documentation dated 12/17/25, 12/29/25, 1/5/26, 1/8/26, 1/13/26, 1/20/26, 1/27/26, 2/26, 2/6/26, and 2/10/26 revealed no evidence that the physician addressed the residents' medical condition related to the wounds, awareness of the wounds, or demonstrated medical supervision of the resident's wound.On 2/19/2026 at 9:18 AM, the surveyor telephone interviewed Resident #11's PCP who stated that she was aware that the resident had a wound on the buttocks, however, did not document an assessment of the wound because the wound care Nurse Practitioner (NP) in the facility performed the assessments. The provider stated, I'm sorry, I should have mentioned assessing wound care in my note, moving forward, I will mention the wound care in my notes.The facility policy dated February 2021 and titled Physician Services indicated that the medical care of each resident was supervised by the licensed physician. The policy specified that the supervision of the medical care of the residents included participating in the resident's assessment and care planning, monitoring changes in the resident's medical status, providing consultation or treatment when called by the facility, prescribing medications and therapy, ordering transfers to the hospital, conducting routine required visits, delegating and supervising follow-up visits by non-physician practitioners (NPs, PA, CNS); and overseeing a relevant plan of care for the resident. NJAC 8:39-11.2 (a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to: a.) properly store a bi-level positive airway pressure (BiPAP), machine [helps breathing by delivering air through a face mask), in a bag when not in use, b.) ensure that oxygen was being administered as per physician's orders, and c.) ensure that oxygen was humidified in accordance with professional standards of practice. This deficient practice was identified for 2 of 2 residents (Resident #116 and Resident # 129) reviewed for respiratory care and was evidenced by the following:1.On 2/12/26 at 10:58 AM, the surveyor observed Resident #129 sitting upright in bed. Resident #129 had a nasal cannula (clear plastic tubing used to deliver supplemental oxygen to a patient through the nostrils) that delivered humidified oxygen via an oxygen concentrator set at eight (8) liters. The humidification bottle connected to the oxygen concentrator contained a small amount of liquid. On 2/13/26 at 8:46 AM, the surveyor reviewed Resident #129's electronic medical record (EMR). A review of the admission Record, an admission summary, revealed that the resident had diagnoses that included, but were not limited to, chronic obstructive pulmonary disease (COPD) [a progressive, incurable, yet treatable lung disease that causes chronic airflow restriction, often resulting from smoking, leading to severe breathing difficulties], anemia (a condition where low red blood cell or hemoglobin levels reduce oxygen delivery to tissues, causing fatigue, pale skin, dizziness, and shortness of breath), emphysema (a chronic, progressive lung disease and a form of COPD (chronic obstructive pulmonary disease) that destroys the alveoli (air sacs) in the lungs, making it difficult to breathe), morbid obesity, and atrial fibrillation (heart arrhythmia, characterized by a rapid, chaotic, and irregular heartbeat). A review of the admission Evaluation included that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating that the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP), which included a focus area initiated on 2/20/26, showed that the resident used oxygen therapy. The interventions included encouraging or assisting with ambulation as indicated. No additional interventions related to oxygen therapy were identified in the care plan. A review of the Order Summary Report (OSR) included a physician order (PO) dated 2/10/26 for oxygen running at 5 liters per minute via nasal cannula for 18-24 hours daily. A review of the Treatment Administration Record did not include the oxygen setting. On 2/13/26 at 10:31 AM, the surveyor made a follow-up visit with Resident #129, who was observed sitting upright in their room. Resident #129 was receiving oxygen via the nasal cannula. The oxygen concentrator was set at nine (9) liters. The humidification bottle was empty. At that time, the surveyor interviewed the resident. When asked how long the humidification bottle had been empty, the resident replied, Since yesterday. On 2/13/26 at 10:50 AM, the surveyor interviewed Licensed Practical Nurse (LPN #3), who stated that she had administered Resident #129's medication that morning and that the resident did not voice any concerns. When asked if she had checked the oxygen concentrator setting, she replied, No. LPN #3 confirmed that the oxygen concentrator setting should be checked every shift and maintained according to the physician's order. On 2/13/26 at 11:00 AM, the surveyor, accompanied by the Licensed Practical Nurse/Unit Manager (LPN/UM #2) and proceeded to Resident #129's room. LPN/UM #2 confirmed that the oxygen concentrator was set at 9 liters per minute and the humidification bottle was empty. At that time, Resident #129 stated that they had turned up the oxygen setting to 9 liters. LPN/UM #2 adjusted the setting on the oxygen concentrator and replaced the humidification bottle. The surveyor and LPN/UM #2 exited the resident's room to conduct an interview. LPN/UM #2 stated that when the nurse comes in, they are expected to complete walking rounds to ensure that all oxygen equipment is set to the correct flow rate, confirm that humidification is present, check the dates on the oxygen tubing, and assess that the resident is not experiencing any respiratory distress. She further stated that maintaining the correct oxygen setting was important because Resident #129 had COPD. She explained that if the oxygen liters were set at nine (9) liters per minute for a resident with COPD, the resident could retain carbon dioxide and potentially go into respiratory distress due to an inability to adequately expel the carbon dioxide. LPN/UM #2 further stated that she or the admitting nurse was responsible for developing the care plan and updating it quarterly and as needed. She confirmed that the care plan should have included documentation indicating that the resident independently increased the oxygen setting, so nursing staff would be aware of this behavior and monitor accordingly. On 2/13/26 at 12:08 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP), who stated that the nurses should verify the physician's order against the oxygen concentrator setting to ensure it was set correctly. The ADON/IP explained that this should be done at the beginning of each shift and during any subsequent interactions with the resident. The ADON/IP further stated that nurses should check the humidification bottle to ensure it contained water and confirmed during rounds that humidification was in place, as non-humidified oxygen can dry the mucous membranes. The ADON/IP further stated that for a resident with COPD, higher oxygen levels could place the resident at risk for respiratory distress and potentially cause them to stop breathing. Th ADON/IP also noted that if a resident independently increased the oxygen setting, the care plan should have addressed this behavior. The ADON/IP stated that in such a situation, she would likely monitor the resident more frequently to ensure the oxygen remained at the prescribed setting. On 2/18/2026 at 10:16 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated that the nurse should check each shift to ensure the oxygen was set at the correct flow rate and that humidification was in place. The DON further stated that the nurse should contact the physician to obtain an order for humidified oxygen, as high-flow oxygen without humidification can cause dryness and irritation for the resident. The DON further stated that the admitting nurse or unit manager was responsible for developing the care plan and updating it as needed. The DON added that if the resident had a history of independently changing the oxygen setting, this information should have been included in the care plan. The DON further stated that all staff involved in the resident's care should be aware of the plan of care and understand what to monitor for in order to ensure the resident's safety. On 2/18/2026 at 11:43 AM, the surveyor made a follow-up visit to see Resident #129. They were observed sitting in their wheelchair, receiving humidified oxygen at 5 (five) liters via nasal cannula. Resident #129 stated that their nose was awfully dry and felt much better now that the oxygen was humidified. A review of the facility's Oxygen Administration policy, revised 10/23, included Review the physician's orders or facility protocol for oxygen administration . Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. 2. On 2/12/26 at 11:33 AM, during the initial facility tour, the surveyor observed Resident #116 lying in bed receiving three liters per minute (3LPM) of humidified oxygen (O ) via an oxygen concentrator (a medical device that filters and delivers oxygen from the air). The surveyor also observed that the Resident's BiPAP (a type of noninvasive ventilation that helps you breathe) machine was not in use and was not stored in a protective, labeled plastic bag. A review of the admission Record, an admission summary, indicated that Resident #116 was admitted to the facility with diagnoses that included, but were not limited to: acute and chronic respiratory failure with hypoxia (lung disease with low oxygen levels in the blood) and obstructive sleep apnea (OSA), [a condition where airway obstruction causes repeated pauses in breathing during sleep]. A review of the quarterly Minimum Data Set (MDS), an assessment that guides a resident's care, dated 12/13/25, indicated that Resident #116 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the Resident's cognition was intact. Further review of Section O: Special Treatments, Procedures, and Programs of the MDS, revealed the Resident was receiving O . On 2/13/26 at 11:08 AM, the surveyor observed the BiPAP machine placed in an open area on the Resident's bedside table, exposed and not maintained in a protected, labeled bag. On 2/13/26 at 11:08 AM, the surveyor observed the BiPAP machine placed in an open area on the resident's bedside table. The machine was exposed and not maintained in a protected, labeled bag when not in use. On 2/13/26 at 11:18 AM, the surveyor reviewed the medical record for Resident #116. A review of the Resident's Individual Comprehensive Care Plan (ICCP) included a focus area, dated 10/20/25, indicating that Resident #116 was receiving O therapy related to (r/t) ineffective gas exchange and using BiPAP. Interventions included ensuring that the BiPAP was placed as ordered. However, the ICCP did not specify how the BiPAP machine should be stored when it was removed from the Resident. A review of the Order Summary Report (OSR) dated as of 2/12/26, included the following physician orders (POs) for Resident #116: A PO, dated 11/18/25, to place the BiPAP at night and remove after sleep. A PO, dated 11/18/25, for O at 3 LPM via nasal cannula to maintain O of 92% or greater every day and night shift for hypercapnic respiratory failure (inability of the lungs to remove carbon dioxide from the blood, causing high levels in the body). A PO, dated 1/20/26, for overnight sleep study evaluation for OSA. On 2/13/26 at 11:25 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who confirmed that the Resident's BiPAP machine should not be placed on the bedside table but should be cleaned and stored in a labeled bag upon removal in the morning. On 1/21/26 at 11:36 AM, the surveyor interviewed the (Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated that all devices with masks, including the BiPAP machine, should be cleaned, placed in a protective bag, and labeled when not in use. The LPN/UM #1 further stated that proper storage of respiratory equipment was important for infection control. On 2/18/26 at 2:16 PM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP), who stated that staff were expected to clean, bag, and label respiratory equipment, including BiPAP machines, when not in use. The ADON/IP confirmed that proper storage was important for infection control purposes. A review of the facility's CPAP/BiPAP Support policy, revised March 2015, included that the purpose 3). was . to promote resident comfort and safety. Additionally, review of the facility's Departmental (Respiratory Therapy) - Prevention of Infection policy, revised November 2011, indicated that the purpose of this procedure was to guide prevention of infection associated with respiratory therapy tasks and equipment.among residents and staff. NJAC 8:39-27.1(a)

Based on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the pharmacy consultant conducted a monthly review of each resident's medication regimen b.) to clarify a physician's order, c.) address a pharmacy consultant recommendation for one (1) of five (5) residents reviewed for unnecessary medications (Resident #113). This deficient practice was evidenced by the following:On 2/12/26 at 11:20 AM, the surveyor observed Resident #113 lying in bed.On 2/13/26 at 1:40 PM, the surveyor reviewed the electronic medical record for Resident #113.A review of the admission Record, an admission summary, revealed that the resident had diagnoses which included, but were not limited to: type 2 diabetes mellitus (a chronic metabolic condition where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond to insulin properly) and rheumatoid arthritis (a chronic autoimmune disorder where the immune system attacks joint linings (synovium), causing painful, stiff, and swollen joints, primarily in the hands and feet).A review of the resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 1/12/26, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident's cognition was severely impaired.On 2/13/26 at 9:45 AM, the surveyor requested the pharmacy consultant recommendations for August 2025 through January 2026.A review of Resident #113's pharmacy consultant recommendations did not include the month of August 2025.A review of the pharmacy consultant recommendation for the month of September 2025 revealed 9/29/25. Patient is receiving Prednisone (a fast-acting corticosteroid used for inflammatory, allergic, and autoimmune conditions) 15 mg QD (every day) for CHF (7/6/25 order). Instructions read: 'MD will taper med (medication) Is taper appropriate at this time?There was no evidence that the 9/29/25 pharmacy consultant recommendation was addressed.A review of the Order Summary Report (OSR) included the following physician orders (PO):A PO, dated 7/5/25, for prednisone 5 milligrams (mg), one time a day for congestive heart failure (CHF). Give 3 tablets by mouth and MD (provider) will taper med (medication). The physician's order did not include a stop date.A PO, dated 11/17/26, for Prednisone 5 mg, give 2 tablets, one time a day for CHF.A PO, dated 11/19/26, for Prednisone 5 mg tablet, give one tablet by mouth for CHF.A review of the Medication Administration Record (MAR) revealed that Prednisone 15 mg was administered daily during the entire month of July (as of July 6, 2025), August, September, and October 2025.A review of the MAR for the month of November revealed that Resident #113 was administered Prednisone 15 mg from 11/1/25 through 11/16/25, Prednisone 10 mg from 11/17/25 through 11/19/25, and prednisone 5 mg from 11/20/25 through 11/22/25.On 2/18/26 at 12:57 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #2), who stated that the pharmacy consultant recommendations were sent to the facility monthly. She also stated that she was unaware of what happened to the August 2025 pharmacy consultant recommendation for Resident #113. She further stated that when a PO indicated that a medication would be tapered, the nurse should have called the physician to clarify the order to ensure that the resident received the correct dose. LPN/UM #2 stated that she was not working at the facility on 9/25, so she was not sure why the pharmacy consultant recommendation was not addressed. She also noted that when the provider was made aware of the pharmacy recommendations, the provider would sign the recommendation, and it would be placed in the resident's paper chart. At that time, LPN/UM #2 looked in the resident's hard chart and did not see a signed pharmacy consultant report for 9/29/25, regarding the prednisone.On 2/18/26 at 10:27 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the pharmacy consultant conducted monthly reviews of each resident's medication regimen. She added that the pharmacy recommendations were given to the DON and followed up and addressed as soon as they were received. The DON stated that the facility received the recommendations as early as 24 hours after the medication regimen review had been conducted. The DON stated that the ADON would give the recommendations to the unit manager and the unit manager would address the pharmacy consultant recommendations. Each unit manager was responsible to address their units' recommendations. She added that if the provider wrote an order to taper a medication, it should be clarified right away or as soon as it was noted because prednisone was not to be given for an extended period of time. On 2/18/2026 at 1:25 PM, the surveyor interviewed Nurse Practitioner #1, who stated that the facility had a communication binder in which the pharmacy consultant recommendations were placed in for the provider to review. She further stated that there was a box on the pharmacy consultant recommendation that was to be circled to indicate if she had accepted or declined the recommendations and the rationale; then the form was placed back in the communication binder, and the nurse would be notified to review the response.A review of the Pharmacy Services - Role of the Consultant Pharmacist dated revised April 2019 included, The Consultant Pharmacist will provide specific activities related to medication regimen review including a. A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services .e. Providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.N.J.A.C. 8:39-27.1 (a)

Based on interview, review of medical records and other pertinent facility documents on 9/26/25, it was determined that the facility failed to maintain an accurately documented and complete an investigation in accordance with acceptable standards and practice. This deficient practice was identified for 1 of 3 residents (Resident #3) reviewed and was evidenced by the following: The surveyor reviewed a Facility Reported Event (FRE) that was submitted to the New Jersey Department of Health (NJDOH) on 9/16/25. The FRE was submitted by the Licensed Nursing Home Administrator (LNHA) and revealed that Resident #3 alleged that, someone raped me. The resident then went on to describe the person as, a short black male wearing tan, that was standing outside of the window. The FRE also included that the allegation was not substantiated as the resident's visitor's log was reviewed and a review of the staff schedule was conducted, and both did not reveal anyone that matched the description. Additionally, Resident #3's room was located on the second floor and the window did not allow for a body to fit through. The FRE further indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 5, meaning that the resident's cognition was severely impaired. A review of the admission Record revealed that Resident #3 was admitted to the facility with diagnoses that included but were not limited to: cerebral infarction (the death of brain tissue due to a lack of blood flow, typically caused by a blood clot), hemiplegia (the paralysis of one side of the body), and hemiparesis (muscle weakness on one side of the body). During an interview with the Director of Nursing (DON) on 9/26/25 at 12:10 PM, she stated that she was onsite at the facility when she received a call from a nurse reporting that the resident was making statements of wanting to harm/kill themselves, and then immediately said that they took it back and requested for staff to not call a family member. The DON then stated that as she was on her way to the unit, accompanied by the LNHA, she received another call from the nurse who stated that the resident was now saying that someone had climbed on top of them. The DON said that she told her they were on their way and ended the conversation. The DON stated that a body check was performed, 911 was contacted for further assessment, and an investigation was initiated by the LNHA. The surveyor then requested for all documentation related to the event. After reviewing the documentation, the surveyor noted that no witness statements were included as a part of the investigation. During an interview with the DON, the Assistant DON (ADON), and the Assistant LNHA (ALNHA) on 9/26/25 at 3:56 PM, the ALNHA stated that if abuse was alleged the floor staff were expected to immediately ensure the resident's safety and report the allegation to a supervisor. The ALNHA further stated that upon notification, an investigation was to be initiated which included obtaining witness statements. The surveyor asked what the importance of obtaining witness statements was, and the ALNHA stated that they were firsthand accounts that contained the most accurate information, and that they were an important part of the investigation. The surveyor then explained that all documentation related to the FRE was requested and no statements were received. The ALNHA stated that it was possible that they had them and that they would keep searching as the statements were a part of the investigation. No additional documentation was received by the surveyor prior to exiting the facility. After surveyor exit, on 9/26/25, the surveyor received two witness statements electronically that were submitted by the ALNHA at 5:23 PM. A review of a facility training titled Abuse and Neglect, dated 6/29/23, included a page on Abuse & Reporting Topics, that indicated that witness statements were to be completed. N.J.A.C. 8:39-27.1(a)

Complaint # 360598Based on observations, interviews, and record reviews on [DATE], it was determined that the facility failed to ensure infection control guidelines were followed for a resident who had a sick cat visiting the facility to prevent infection. This deficient practice was identified for 1 of 14 residents reviewed for infection control (Resident #6). This deficient practice was evidence by the following:A review of the Electronic Medical Record (EMR) was as follows:According to the admission Record (AR) face sheet, Resident #6 was admitted to the facility with diagnoses which included but were not limited to Spondylosis (degenerative changes in the spine), expressive language disorder, dysphagia (difficulty swallowing), sepsis, and muscle weakness.A review of the Minimum Data Set (MDS), an assessment tool, dated [DATE], Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact.A review of Resident #6's Order Summary Report (OSR), did not include an order for Resident #6 to have a pet at bedside in the facility.A review of Resident #6's care plan (CP) initiated on [DATE] did not include a focus including a pet as therapy for Resident #6.A review of Resident #6's Progress Note (PN) dated [DATE] at 05:31 A.M, written by a Licensed Practical Nurse (LPN#1) revealed Resident #6 had a cat on the bed and lying on Resident #6. LPN #1 noted there were feces and urine stains on the bed and documented that the Power of Attorney (POA) for Resident #6 stated that the stains were from the cat. A second PN from [DATE] at 11:31 A.M., by LPN #2, revealed that the family pet had expired.During an interview on [DATE] at 11:06 A.M., the surveyor interviewed a Certified Nursing Assistant (CNA) who worked at the facility for over 30 years. The CNA stated that the facility did allow pets but that the pets paperwork and temperament must be reviewed and the paperwork for the pet needs to be brought to the front desk. During an interview on [DATE] at 11:06 A.M the surveyor interviewed LPN #3 who stated that she had never experienced personal pets on her unit which was considered the rehabilitation unit.During an interview on [DATE] at 11:50 A.M., the surveyor interviewed the Licensed Nursing Home Administrator (LNHA), who stated, We do have a policy on pets for the facility. The receptionist keeps a file of the pets' vaccinations. She handles all that. Residents are admitted and pets visit but that is usually managed by the Receptionist and activities has pet therapy. We did have a complaint regarding a cat. Resident was here short term and resident had a cat who had chemotherapy. The agreement was that the cat could stay with the resident in the room. We had to make sure the cat was staying in the cage. There was noncompliance. A staff member did complain. Staff wanted me to tell her (the staff member) the issues with a cat on chemotherapy being near the staff and what kind of issues they may have dealing with the cat. I sent an email to all staff after Googling.The surveyor requested a copy of this email along with immunizations for this pet. No immunizations were able to be retrieved. The Surveyor received an electronic medical record system communication dated [DATE], that stated, The family of Resident #6 is aware that the cat must be transported by crate and no litter box in the room. The patient can have the cat on the bed with him while the cat is in the harness. Cat is not to come out of the room during visits. A secondary electronic medical record system communication was also received dated [DATE], that stated, No pregnant or nursing mothers can have contact with Resident #6's cat.During an interview on [DATE] at 02:37 P.M., the surveyor interviewed the LNHA and ADON together. The LNHA stated that Resident #6's friend was responsible for bringing the cat back and forth in the crate into the facility since September of 2024. The LNHA stated that she was not aware of the cat defecating or urinating in the room and stated that once a litter box was brought but Resident #6 and the friend were instructed that this was not allowed. A review of the facility's policy Pets, Animals, and Plants revised 05/17 under Policy Statement revealed: Animals allowed in the facility will be monitored and managed in order to prevent the spread of microorganisms/infections resulting from contact with animals. Under the same policy, under Personal Pet Visits stated: 2c. The resident's physician and primary care nurse must approve the visit.A review of the facility's policy Infection Prevention and Control Program revised 06/23 under 6. Policies and Procedures revealed, a. Policies and procedures are utilized as the standards of the infection prevention and control program. b. Policies and procedures reflect the current infection prevention and control standards of practice. N.[NAME].C.: 8:39-19.4

Complaint 2579597Based on interviews, medical record review, and other pertinent facility documentation on 08/07/25, it was determined that the facility failed to obtain a physician's order (POs) for the resident's (Resident #7) oxygen in accordance to professional standards of practice. This deficient practice was identified for 1 of 14 residents and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.A review of Resident #7's closed Electronic Medical Record (EMR) was as follows:According to the admission Record (AR) face sheet, Resident #7 was admitted to the facility with diagnoses which included but were not limited to fibromyalgia (widespread musculoskeletal pain), difficulty walking, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (lung and airway diseases that restrict your breathing), and Dysphagia (difficulty swallowing).A review of the Minimum Data Set (MDS), an assessment tool dated 07/30/25, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #7 was admitted with intermittent oxygen use on admission and while a resident at the facility.A review of Resident #7's Order Summary Report (OSR), included POs dated 07/25/25, such as, change oxygen tubing weekly on Sundays, 6 Min rest/walk test on room air and an order to monitor pulse oximetry Q Shift. The OSR did not include PO for the administration of oxygen.A review of Resident #7's care plan (CP) initiated on 07/25/25, did not include the resident received oxygen.A review of Resident #7's Progress Note (PN) dated 08/04/25 at 09:45 A.M, revealed Resident was walking all over the facility and going out to smoke and never observed with oxygen as well as when visited in her room, she did not have oxygen on.During an interview on 08/07/25 at 11:30 A.M the surveyor interviewed the Social Worker (SW), who had discharged Resident #7, and she stated that she did remember Resident #7 and stated that the resident was awake, alert, oriented and up walking. The SW also stated that Resident #7 used oxygen one day and then no longer utilized it.During an interview on 08/07/25 at 12:53 P.M, the surveyor interviewed a Licensed Practical Nurse (LPN) at the facility who stated, If a resident has an order for oxygen I would make sure the resident was receiving it and receiving the correct amount. The LPN further stated that he remembered Resident #7, that Resident #7 did not wear oxygen, and that the oxygen order for Resident #7 was an as needed order.During an interview on 08/07/25 at 01:04 P.M, the surveyor interviewed the Unit Manager (UM) of the third floor, who stated that the expectation for her nursing staff regarding a resident with oxygen, would to make sure that the resident had an order for oxygen and to notify the doctor if there wasn't and to ensure that oxygen tubing was dated and changed weekly.During an interview on 08/07/25 at 01:22 P.M., the surveyor interviewed Director of Nursing (DON) and Assistant Director of Nursing (ADON) together. The DON stated that residents who were on oxygen should have an oxygen order and when they were no longer on oxygen, that order should be changed. The ADON stated that Resident #7 was admitted on 2 liters of oxygen and that Resident #7 was not on oxygen upon discharge. The ADON stated that Resident #7 should have had the oxygen concentrator removed from their room if there was no order for oxygen.During an interview on 08/07/25 at 01:46 P.M., the surveyor interviewed the ADON, DON, and Licensed Nursing Home Administrator (LNHA) together regarding Resident #7's oxygen needs. The ADON confirmed that there was no oxygen order for Resident #7, but that there should have been one while Resident #7 was using oxygen. The DON confirmed there was no oxygen CP for Resident #7 and that there should have been one.A review of the facility's policy Oxygen Administration dated revised 10/23, under Preparation revealed: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the residentN.[NAME].C.: 8:39-27.1(a)

Based on interview and review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 days of 10 weeks reviewed. This deficient practice was evidenced by the following: A review of the Nurse Staffing Reports completed by the facility for the weeks of 11/05/2023, 12/31/2023 thru 01/06/2024 revealed the facility had no RN coverage for 8 consecutive hours for all shifts on 11/05/2023, 11/08/2023, 11/11/2023, 12/31/2023, 01/01/2024, and 01/06/2024. On 09/12/2024 at 03:15 PM, the surveyors conducted an interview with the facility Director of Nursing (DON) and the surveyor said she reviewed the facility staffing sheets which indicated that the facility had days without a Registered Nurse (RN) for at least 8 consecutive hours. When asked should there be an RN on duty for at least 8 consecutive hours daily the DON replied, Yes, we should have 8 hours minimum for RN on duty per day. A review of the facility provided policy titled Staffing, revised October 2017, revealed the following under Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. The following was revealed under the heading Policy Interpretation and Implementation: 5. Efforts are made to fill open shifts as well as call-outs utilizing incentive programs and agency. Staffing is monitored daily. NJAC 8:39-25.2(h)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 09/09/2024 from 7:39 to 8:23 AM, the surveyors, accompanied by the cook and the Food Service Director (FSD), observed the following in the kitchen: 1. Prior to entering the walk-in refrigerator and freezer the surveyors reviewed the temperature logs. Review of the September 2024 Refrigerator Temperature log revealed that no AM or PM temperatures were recorded on 9/7, 9/8, and 9/9/2024. On interview the FSD stated that the aide was responsible for recording the refrigeration temperatures and that the aide had not worked on those days. 2. On a lower shelf in the walk-in freezer, a sheet pan contained frozen hamburger patties. The hamburger patties were covered with plastic wrap. There were no dates labeled on the pan or plastic wrap. 3. On a middle shelf in the walk-in refrigerator, a plastic milk crate contained [NAME] Ready Care supplements (A frozen nutritional supplement for people with unintended weight loss). Approximately 20 vanilla shakes were in the crate. No dates were observed on the crate or supplements. The FSD told the surveyor that the shakes are good for 14 days once pulled from frozen storage. 4. On a lower shelf in the kitchen prep area (under toaster) a clear plastic container contained cleaned and sanitized dessert plates. The plates were uncovered and were not in the inverted position leaving the eating surface exposed to contamination. 5. Four (4) pans and a colander on a middle shelf of the pot and pan drying/storage rack were not in the inverted position and were not covered. The food contact surface of the pans and colander were exposed, and the pan contained a clear liquid substance on the interior of the pan. FSD removed to be rewashed and sanitized. On 09/11/2024 from 08:58 to 09:12 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #2), observed the following on the 3rd Floor resident pantry: 1. Observation of the temperature log revealed that the facility was only monitoring refrigerator temperatures and there was no monitoring of the freezer temperatures. 2. The lower glass shelf and lower storage drawers of the refrigerator were covered with an off white unidentified substance. All foods are labeled and dated, however sign on outside of refrigerator stated that all foods were to only be held for 24 hours after the labeled date and then would be discarded. A gray plastic bag on the lower shelf contained unidentified resident food. The bag was labeled Rec 9/9/24 Discard 9/15/24. In addition, on the same shelf a plastic Tupperware style container contained unidentified resident food. The container was labeled with resident name and room number. The container had no dates. On 09/11/2024 from 09:47 to 09:53 AM, the surveyor, accompanied by LPN #3, observed the following on the 2nd Floor resident pantry: 1. Observation of the temperature log revealed that temperatures were being recorded in the AM and PM for the refrigerator. No monitoring of freezer temperatures was conducted. On 09/11/2024 at 09:57 AM, the surveyor conducted an interview with the food service District Manager (DM). The surveyor asked the DM who was responsible for maintaining the facility resident pantries. The DM explained that It' a concerted effort between food service and nursing (no housekeeping). We (food service) are responsible for cleaning the refrigerator and freezer. The surveyor then questioned what the use by date should be when a food from out of the facility is stored in the pantry refrigerator. The DM told the surveyor the use by date should be 72 hours. 24 hours is too short. The DM further told the surveyor I will get with the DON (Director of Nursing) and get on the same page with dates today. The surveyor then asked the DM why there was no monitoring of freezer temperatures on the facility pantry's The DM stated, I might have to ask the FSD about freezer temps. The freezer temperatures on the pantry's should be monitored, yes. The DM agreed that the facility policy for food brought from family/visitors was inconsistent with the posted signage on the 3rd floor refrigerator door indicating that food was to be discarded after 24 hours and the dietary policy of 3 days. The DM assured the surveyor that they would meet with facility administration to establish a consistent policy for use by dating related to food brought by visitors/family. On 09/12/2024 from 10:33 to 10:57 AM, the surveyors, accompanied by the FSD and the DM, observed the following in the kitchen: 1. The surveyors requested to see the tray line temperature monitoring logs from the FSD. Observation of the TService Line Checklist (Food temp log) revealed that Item names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below. Review of the Service Line Checklists provided to the surveyor by the facility FSD revealed the following: On 8/17/2024 the cook failed to record hot and cold food temperatures at the breakfast and lunch meal, on 8/18/2024 the cook failed to record food temperatures for the breakfast, lunch, and dinner meals, on 8/22/2024 the cook failed to record hot and cold food temperatures for the lunch and dinner meals, on 8/25/2024 the cook failed to record hot and cold food temperatures for the dinner meal, on 8/26/2024 the cook failed to record hot and cold food temperatures at the dinner meal, On 9/2/2024 the cook failed to record hot and cold food temperatures at the lunch and dinner meal, on 9/3/2024 the cook failed to record hot and cold food temperatures at the dinner meal, on 9/4/2024 the cook failed to record hot and cold food temperatures at the dinner meal, on 9/5/2024 the cook failed to record hot and cold food temperatures at the dinner meal, and on 9/7/2024 the cook failed to record hot and cold food temperatures at the dinner meal. When interviewed the FSD and DM told the surveyor, It's our responsibility to make sure that the food temperatures are being done correctly. It's important to monitor to ensure that food is not in the danger zone (41-134 degrees Fahrenheit (F)). The surveyor asked why it was important to monitor food temperatures for hot and cold foods. The FSD and DM explained, People (residents) could potentially get food poisoning if food is in the danger zone. The surveyor asked who was responsible for taking food temperatures of hot and cold foods prior to meal service. The FSD stated, The cooks are in charge/responsible for checking temperatures prior to tray line. The surveyor reviewed the facility policy titled Food: Preparation, [company name] Policy 016, revised 2/2023. The following was revealed under the heading Procedures: 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, or per state regulation. 13. All foods will be held at appropriate temperatures, greater than 135 F (or as state regulation requires) for hot holding, and less than 41 F for cold holding. 14. Temperature for TCS (time/temperature control for safety) will be recorded at time of service and monitored periodically during meal service periods. The surveyor reviewed the facility policy titled Receiving, [company name] Policy 017, revised 2/2023. The following was revealed under the heading Procedures: 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. The surveyor reviewed the facility policy titled Food Storage: Cold Foods, [company name] Policy 019, revised 2/2023. The following was revealed under the heading Procedures: 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. The surveyor reviewed the facility policy titled Warewashing, [company name] 022, revised 2/2023. The following was revealed under the heading Procedures: 4. All dishware will be air dried and properly stored. The surveyor reviewed the facility policy titled Foods Brought by Family/Visitors, revised March 2022. The following was revealed under Policy Interpretation and Implementation: 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. b. Perishable foods are stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. NJAC 18:39-17.2(g)

C/O #NJ 174603 Based on observation, interview, review of the Electronic Medical Record (EMR) it was determined that the facility nursing staff failed to document in the progress notes (PN) unusual incidents, specifically regarding a.) a fracture found on x-ray, b.) staff to resident abuse allegation and c.) a resident-to-resident altercation. This deficient practice was identified for 4 of 26 sampled residents (Resident #13, Resident #5, Resident #48 and Resident #257) and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical 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 stated, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. During the initial tour of the unit, Resident #13 told Surveyor #1 that he/she had pain due to a fracture of the hip. Resident #13 denied having fallen and said he/she will be following up with the orthopedic physician on Thursday. A review of the EMR was conducted on 09/09/2024 at 01:05 PM and included the following: According to the Admission Record Resident #13 was admitted to the facility with diagnoses including but not limited to: HIV (Human immunodeficiency virus), chronic pain syndrome and disorder of bone density and structure (osteoporosis). A review of the most recent comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate care dated 9/02/2024, revealed Resident #13 had a Brief Interview for Mental Status score of 15/15 indicating intact cognition. A review of the Clinical Orders revealed a physician order (PO) dated 8/28/2024 for B/L (bilateral) hip x-ray to r/o (rule/out) fracture/dislocation. D/C (discontinue) when completed. A further review of the Order Summary Report revealed a physician order dated 8/30/2024 for Orthopedic eval (evaluation) and treat. On 09/10/2024 at 10:45 AM, a review of the EMR progress notes for 8/28/2024 through 8/31/2024 did not include documentation of what had occurred that the physician would have ordered the B/L hip x-ray on 8/28/2024 and the Orthopedic eval and treat on 8/30/2024. On 09/11/2024 at 09:19 AM, a review of x-ray dated 8/28/24 revealed a fracture of right distal femur relationship of the femoral head appears within acetabulum. Displaced femur noted superior lateral to the acetabulum. Degenerative changes hip joint noted. Under the impression section Fracture displacement involving the femoral neck and distal femur relationship of the femoral head. During an interview with Surveyor #1 on 09/11/2024 at 10:17 AM, the Director of Nursing (DON) was asked what had occurred with Resident #13 having sustained a fractured right femur. The DON replied I don't know how the fracture happened. The resident has a history of osteopenia and bone density disorder. The DON went on to say, I would say this is an injury of unknown origin and should have been reported to NJDOH. The DON said, I know there's no documentation in EMR regarding his/her c/o pain and follow up x-ray ordered and the fracture. Surveyor #1 requested any information including reporting of this to the NJDOH from DON. On 09/12/2024 at 02:58 PM, a review of a facility policy titled Charting and documentation with a revised date of July 2017 revealed under the Policy Statement section All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Under the Policy Interpretation and Implementation section 2. d. any changes in the resident's condition; e. events, incidents or accidents involving the resident. 39460 2. On 9/10/2024 at 10:00 AM, the surveyor reviewed the facility provided Facility Reported Event (FRE) dated 2/22/24 which was an alleged verbal altercation involving two residents over the volume of the television, Resident #5 and Resident #48. On 9/11/2024 at 1:45 PM, the surveyor interviewed Resident #5's and Resident #48's nurse, LPN #3, who stated she was unaware of any verbal altercations between the two residents. LPN #3 stated that Resident #5 could be argumentative at times but was easily redirected. On 9/11/2024 at 1:51 PM, the surveyor interviewed LPN #3 regarding Resident #48, who stated the resident got along with both the staff and residents but would become easily agitated if he/she felt their needs weren't satisfied in a timely manner. When asked the facility process for reporting an altercation between two residents LPN #3 stated the residents would be separated, then she would let management either the unit manager or the Assistant Director of Nursing (ADON) or the DON know about the incident. Then there would be a risk management report entered into the resident's medical record including a Situation, Background, Assessment and Recommendation (SBAR) a tool used in nursing for communication with other healthcare professionals regarding patient information, notification to resident's physician, and family the incident would be discussed at a morning meeting of department heads On 9/12/2024 at 12:24 PM, the surveyor reviewed the medical record for Resident #48. A review of the Admission Record reflected the resident was admitted to the facility with diagnoses which included hemiplegia and hemiparesis (paralysis on one side of the body), unspecified mood disorder, major depressive disorder and aphasia following cerebral infarction (a language disorder that can occur after a stroke that impairs the expression and understanding of language as well as reading and writing). A review of the most recent quarterly Minimum Data Set (MDS) an assessment tool dated 3/8/24, reflected the resident had a brief interview for mental status score of 14 out of 15, which indicated a fully intact cognition. A review of the individualized person-centered care plan reflected a focus area initiated 10/24/22, for a behavioral problem related to verbally abusing staff. Interventions included caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Educate [Resident #48] .on successful coping and interaction strategies . A review of the resident Progress Notes (PN) for February 2024 did not reveal any notes or references to the FRE incident reported to the New Jersey Department of Health (NJDOH) regarding the alleged event on 2/22/24. On 9/12/2024 at 2:28 PM, the surveyor reviewed the medical record for Resident #5. A review of the Admission Record face sheet reflected the resident was admitted to the facility with diagnoses which included dementia, major depressive disorder, anxiety and unspecified intellectual disabilities. A review of the most recent quarterly Minimum Data Set (MDS), and assessment tool dated 2/01/2024, reflected a brief interview for mental status (BIMS) score of 15 out 15, which indicated a fully intact cognition. A review of the individualized person-centered care plan reflected a focus area initiated 9/15/21, for mood distress related to his/her diagnosis of impulse control disorder and history of depression, and anxiety evident by occasional verbal outbursts (not directed at others), frustration, anger, tearfulness, perseveration on issues and expressions of sadness over past life events. Interventions included to allow time for verbalization of feelings/needs and attempt to resolve area of upset. Attempt to re-focus [Resident #5's] behavior to something positive when upset . A review of the resident Progress Notes (PN) for February 2024 did not reveal any notes or references to the FRE incident reported to the New Jersey Department of Health (NJDOH) regarding the alleged event on 2/22/24. 40039 3. A review of a Facility Reported Event, dated 01/02/2024, revealed that Resident #257 alleged that Certified Nursing Aide (CNA #1) verbally abused him/her on the 11 PM - 7 AM shift on 01/01/2024. Resident #257 alleged that CNA #1 was talking loudly in the hallway. Resident #257 stated that he/she went to the threshold of their door and yelled at CNA #1 for talking loudly and then slammed the door shut. Resident #257 then stated that CNA #1 opened the door to the room and spoke to him/her in an aggressive manner. Resident #257 stated that CNA #1 told him/her that they could not have their door closed and that they could pull the privacy curtain if they wanted privacy. According to Resident #257's Admission Record they were admitted to the facility with the following but not limited to diagnoses: Muscle weakness, cirrhosis of liver, morbid obesity, insomnia, and cognitive communication deficit. According to a review of the Minimum Data Set (MDS) an assessment tool, Resident #257 had a Brief Interview for Mental Status score of 12/15, indicating mild cognitive impairment. According to Section D of the MDS, Resident #257 had trouble falling or staying asleep, or sleeping too much for several days in the observation period. Review of the comprehensive care plan for Resident #257 revealed a care plan Focus: Adjustment to new environment & involvement in activity interests limited due to recent hospitalization . New admission. Date Initiated: 12/11/2023. The following was observed under Interventions/Tasks: My usual bed time is 12 AM. Date Initiated: 12/11/2023. On 09/11/2024 at 02:34 PM, a review of the PN from 01/01/2024 through 01/03/2024 did not include documentation of the alleged incident between Resident #257 and CNA #1. On 09/12/2024 at 02:40 PM the surveyor conducted an interview with the Certified Social Worker (CSW). The surveyor asked the CSW to briefly describe what she would do concerning a report of alleged abuse in the facility. The CSW stated, I would find out from the resident what the actual event was from their perspective and would meet in private with the resident. The surveyor then asked the CSW if she would document the interview/meeting in the EMR. The CSW responded, Of course, I would document the encounter with alleged victim in the social service progress notes in PCC (Point Click Care, an electronic medical record). The surveyor told the CSW that he was unable to find any documentation of the CSW's interview with Resident #257 concerning the alleged abuse. The surveyor asked if the encounter should have been documented in the EMR. The CSW responded, Yes, I would have documented and should have documented the event in the progress notes for the alleged event that occurred on 1/1/2024 with Resident #257. On 09/12/2024 at 02:58 PM, a review of a facility policy titled Charting and documentation with a revised date of July 2017 revealed under the Policy Statement section All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Under the Policy Interpretation and Implementation section 2. d. any changes in the resident's condition; e. events, incidents or accidents involving the resident. On 9/13/2024 at 9:23 AM the survey team met with facility Administration. The DON told the surveyor's that a summary of the alleged incident would be expected to be documented in the resident's progress notes. The DON further acknowledged that an FRE should have been documented in the resident's progress notes. NJAC 8:39-11.2(b); 27.1(a)

Based on observation, interview review of the Electronic Medical Record (EMR) and review of other facility documentation, it was determined that the facility failed to report an injury of unknown origin, specifically a fracture of the right distal femur, as well as an allegation of staff to resident abuse to the New Jersey Department of Health (NJDOH) in a timely manner for 2 of 26 sampled residents, (Resident #13 and Resident #257). This deficient practice was evidenced by the following: 1. During the initial tour of the unit, Resident #13 told Surveyor #1 that he/she had pain due to a fracture of the hip. Resident #13 denied having fallen and said he/she will be following up with the orthopedic physician on Thursday. A review of the EMR was conducted on 09/09/2024 at 01:05 PM and included the following: According to the Admission Record Resident #13 was admitted to the facility with diagnoses including but not limited to: HIV (Human immunodeficiency virus) chronic pain syndrome and disorder of bone density and structure (osteoporosis). A review of a the most recent comprehensive Minimum Data Set (MDS) an assessment tool used to facilitate care dated 09/02/2024, revealed Resident #13 had a Brief Interview for Mental Status score of 15/15 indicating intact cognition. A review of the Clinical Orders revealed a physician order dated 8/28/2024 for B/L (bilateral) hip x-ray to r/o (rule/out) fracture/dislocation. D/C (discontinue) when completed. A further review of the Order Summary Report revealed a physician order dated 8/30/2024 for Orthopedic eval (evaluation) and treat. On 09/10/2024 at 10:45 AM, a review of the EMR progress notes for 8/28/2024 through 8/31/2024 did not include documentation of what had occurred that the physician would have ordered the B/L hip x-ray on 8/28/2024 and the Orthopedic eval and treat on 8/30/2024. On 09/11/2024 at 09:19 AM, a review of x-ray dated 8/28/24 revealed a fracture of right distal femur relationship of the femoral head appears within acetabulum. Displaced femur noted superior lateral to the acetabulum. Degenerative changes hip joint noted. Under the impression section Fracture displacement involving the femoral neck and distal femur relationship of the femoral head. During an interview with Surveyor #1 on 09/11/2024 at 10:17 AM, the Director of Nursing (DON) was asked what had occurred with Resident #13 having sustained a fractured right femur. The DON replied I don't know how the fracture happened. The resident has a history of osteopenia and bone density disorder. The DON went on to say, I would say this is an injury of unknown origin and should have been reported to NJDOH. The DON said, I know there's no documentation in EMR regarding his/her c/o pain and follow up x-ray ordered and the fracture. Surveyor #1 requested any information including reporting of this to the NJDOH from DON. On 09/11/2024 at 01:00 PM, Surveyor #1 reviewed a type written document from the Licensed Nursing Home Administrator (LNHA) indicating the following; Resident name admitted A&O x3 8/28/24 Resident complained to family about hip pain. Family contacted Social Worker (SW) and informed of pain. SW communicated family concern to clinical team. 8/28/24 x-ray ordered. x-ray completed. x-ray results received. 8/29/24x-ray reviewed by NP documented on x-ray results 8/30/24 order received for ortho eval and treat. 9/11/23 Resident interviewed by Assistant director of Nursing (ADON). Resident noted sitting in wheelchair in his room. He is awake, alert and orientedx3 He shows no signs or symptoms of pain or discomfort at the time of the interview. Resident stated that he has had bilateral hip pain for years. He denies any falls while here in the facility. He denies anyone causing any injuries to him. He stated that he does not think he has ever had any studies or imaging previously on his hips. 9/11/24 Reportable called into the NJDOH. Notified Office of Ombudsman. The LNHA confirmed this was called into the NJDOH after surveyor inquiry. During an interview with Surveyor #1 on 09/11/2024 at 1:26 PM, the LNHA said the facility became aware of resident's fracture when the surveyor inquired about the investigation. The LNHA said the staff should have informed administration at the time they knew resident had a fracture. It was a communication problem. During an interview with Surveyor #1 on 09/12/2024 at 09:24 AM, the Registered Nurse/Unit Manager (RN/UM) was asked what her expectations were regarding being notified of allegations of abuse, resident altercations or injuries of unknown origin. She replied my expectations are when I come in, I ask what is going on and what is new from both nurses and aides. I call in on weekends and staff knows I am available by phone. RN/UM said staff knows to call me with resident-to-resident allegations, abuse or fractures. If I become aware of abuse allegation, resident to resident altercation, misappropriation of property or fracture it is instant call to DON (Director of Nursing), ADON (Assistant Director of Nursing) and Administrator. During an interview with Surveyor #1 on 09/12/2024 at 09:35 AM, Licensed Practical Nurse (LPN #1) was asked what the facility policy was when there was a resident-to-resident altercation, resident allegation of abuse, or a resident was found to have a fracture with no identified cause. LPN #1 replied we report to DON, MD (medical doctor), Family. We ask the resident what happened, risk management form on computer (incident report) we would make a note in medical record of the incident or allegation. We would call DON on her cell phone if she were not here. We would also notify supervisor on duty. We do have supervisors on and would tell them as well. We would write and get statements from assigned aides that day and nurse who had them as well as prior nurse and cnas. LPN #1 went on to say Yes, one of the first things we would do was assess the resident for pain, injury, and vitals. We would get statements from residents involved as well. We would do this immediately. On 09/12/2024 at 08:34 AM, a review of a facility policy titled Facility Responsibilities for Reporting Allegations with a revised date of September 2022 revealed the following addresses facility responsibilities for reporting allegations/occurrences involving staff to resident abuse; resident to resident altercations; injuries of unknown source; and misappropriation of resident property/exploitation. Under the Injuries of Unknown Source Required to report incudes but not limited to: Unobserved/unexplained fractures, sprains or dislocations The policy did not include timeframes for reporting or steps for facility to take once the allegation/injury. On 09/12/2024 at 09:48 AM, a review of the above facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of April 2021, revealed under the Policy Statement, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under the Policy Interpretation and Implementation section Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; .3. Immediately is defined as: within 2 hours of the allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 40039 2. A review of a facility reported event involving an alleged incident of staff to resident abuse revealed that Resident #257 alleged that Certified Nursing Assistant (CNA #1) was talking to a co-worker on the 11 PM - 7 AM shift on 01/01/2024. Resident #257 alleged that CNA #1 was talking too loudly, and Resident #257 went to their door threshold and yelled at CNA #1 for being too loud. Resident #257 then slammed their door shut. According to Resident #257, who no longer resides at the facility, CNA #1 opened Resident #257's door and spoke to him/her in an aggressive manner telling Resident #257 that he/she could not keep their door closed and they could pull their privacy curtain for privacy before exiting the room. This event was noted to have occurred late on the 11 Pm - 7 AM shift, however the Reportable Event Record/Report indicated that the event occurred on 01/01/2024 at a11:45 PM. Review of the facility investigation summary dated 1/3/2024 revealed that the facility Director of Nursing (DON) was not made aware of the alleged verbal abuse until 9:30 AM on 01/02/2024. The DON documented on the investigation summary that it was a presumed delay in reporting the matter to the appropriate management. The incident occurred on the evening of 1/1/24 but was not reported until the morning of 1/2/24. The reporting nurse will receive a 1:1 refresher education on reporting events in a timely manner. On 09/12/2024 at 02:54 PM the surveyor conducted an interview with the 2nd Floor Registered Nurse/Unit Manager (RN/UM #1). The surveyor asked RN/UM #1 what the facility practice was when al alleged event of staff to resident abuse was alleged. RN/UM #1 told the surveyor, I would immediately report it to the Administrator, DON, and the ADON (Assistant Director of Nursing). I would then assist in getting any information that those people would require of me. I would also notify the physician and I would notify the family afterwards. I also assess the involved resident. On 09/12/2024 at 03:22 PM the surveyor conducted an interview with the facility DON and Licensed Nursing Home Administrator (LNHA) concerning the alleged verbal abuse investigation of Resident #257. The surveyor asked the DON and LNHA what the facility practice was for alleged incidents of abuse. The DON told the surveyor, Nursing should report to the facility DON and LNHA any alleged incident of abuse. The surveyor asked what the time frame was for reporting an alleged incident of abuse to the New Jersey Department of Health. The DON stated, An alleged event of abuse should be reported to the NJDOH within 2 hours and for residents over the age of 60 it should also be reported to the ombudsman. On 09/12/2024 at 09:48 AM, a review of the above facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with revised date of April 2021.revealed under the Policy Statement, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under the Policy Interpretation and Implementation section Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; . 3. Immediately is defined as: within 2 hours of the allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. NJAC 8:39-9.4(f)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives, timelines, and interventions to meet resident's medical and nursing needs specifically by failing to implement a care plan for an antibiotic that was infused through a Peripherally Inserted Central Catheter (PICC) used to deliver the antibiotic, and 2.) a resident diagnosed with PTSD (Post Traumatic Stress Disorder) on admission. The deficient practice was identified for 2 of 26 sampled residents, (Resident #86 and Resident #99). The deficient practice was evidenced by the following: 1.) On 09/09/2024 at 08:28 AM, during the initial tour, Resident #86 was identified by the nurse preparing an Intravenous Antibiotic (IV Antibiotic), as being ordered an IV antibiotic for an infection. A review of Resident #86's Admission Record revealed that he/she had a diagnosis that included but not limited to: Cutaneous Abscess of Buttock, and Local Infection of the Skin and Subcutaneous tissue. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 08/15/2024, under Section N-Medications: High-Risk Drug Classes: Use and Indication: indicated that Resident #86 is taking an Antibiotic; Under Section O-Special Treatments, Procedures, and Programs: IV Medications: Yes. A review of the Physician Orders revealed the following: Change PICC dressing on RUE (Right Upper Extremity) weekly every night shift every Tuesday; Eravacycline Dihydrochloride Intravenous Solution Reconstituted 50 MG, use 100 mg Intravenously two times a day for Acinetobacter infuse via pump. A review of Resident #86's Care Plan did not include a care plan that addressed that Resident #86 had a PICC line and was receiving IV Antibiotics. During an interview with the surveyor on 09/12/2024 at 3:15 PM, the Director of Nursing (DON) was asked what the expectations for a comprehensive person-centered Care Plan to include that a PICC line and Antibiotic should be included in the residents Care Plan. The DON said yes it should be included. 40039 2. On 09/09/2024 at 08:43 AM, the surveyor conducted an interview with Resident #99 on the initial tour of the facility. Resident #99 told the surveyor the he/she was a veteran and stated to the surveyor that he/she had PTSD (post traumatic stress disorder). Resident #99 was observed to be anxious on interview and told the surveyor that they were medicated for PTSD. On 09/09/2024 at 12:16 PM, the surveyor conducted a record review for Resident #99. According to the Admission Record, Resident #99 was admitted to the facility with the following but not limited to diagnoses: Post-traumatic stress disorder, depression, anxiety disorder, unspecified mood (affective) disorder. A review of the comprehensive Minimum Data Set (MDS) an assessment tool, dated 8/13/2024, revealed Resident #99 had a Brief Interview for Mental Status score of 15/15, indicating intact cognition. According to Section D of the MDS, Resident #99 had feelings of little interest or pleasure in doing things and feeling down, depressed, or hopeless on a frequency of 2-6 days. A review of Section I of the MDS revealed Resident #99 had active diagnoses of anxiety disorder, depression, and post traumatic stress disorder. Section N of the MDS revealed Resident #99 received daily antidepressant medication. A review of the Order Summary Report revealed Resident #99 had the following physician order: FLUoxetine HCl (hydrogen chloride) Oral Tablet 20 MG (milligram) (Fluoxetine HCl) Give 2 tablet by mouth one time a day for depression/anxiety/PTSD.: Order Date: 08/13/2024. A review of Resident #99's comprehensive care plan did not include a care plan for PTSD. On 09/12/2024 02:38 PM, the survey team conducted an interview with the facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). On interview both the facility LNHA and DON agreed that, PTSD is a diagnosis that should be care planned. On 09/13/2024 at 10:40 AM, the surveyor conducted an interview with the Licensed Practical Nurse/Unit manager (LPN/UM) of the 3rd floor. The LPN/UM was responsible for developing care plans for Residents on the third floor of the facility where Resident #99 resided. The surveyor then asked the LPN/UM if Resident #99 should have been care planned for a diagnosis of PTSD. LPN/UM told the surveyor, I'm really not sure if it should have been care planned, but yes, I should've care planned Resident #99 for PTSD. I have to be honest I never had anybody with a diagnosis of PTSD before. I'm glad that I know now. A review of a facility policy on 09/12/2024 at 12:10 PM, titled Care Plans, Comprehensive Person-Centered, with a revised date of March 2022, Policy Statement as follows: A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Under #7, The Comprehensive, Person-Centered Care Plan: reflects currently recognized standards of practice for problem areas and conditions. a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; e. reflects currently recognized standards of practice for problem areas and conditions. NJAC 8:39-11.2(f)

Based on observation and interview, it was determined that the facility failed to maintain resident dignity when staff were observed standing while feeding residents their meals on 1 of 2 Nursing units, 2nd floor, for 1 of 1 resident reviewed for dignity (Residents #20). This deficient practice was evidenced by the following: On 09/10/2024 at 12:13 PM, the surveyor observed a facility staff on the 2nd floor dining room at the lunch meal assisting Resident #20 to eat. The staff was standing next to the table to assist the Resident #20 to eat from a standing position. Resident #20 was seated in a wheelchair at a table in the center of the dining room facing the television. The staff did not attempt to get a chair while assisting Resident #20 to eat. The staff continued to feed Resident #20 from the standing position throughout the meal. On interview, the staff who identified herself as a Licensed Practical Nurse (LPN #1). The surveyor asked LPN #1 what the facility procedure is when assisting residents at meal time. LPN #1 stated to the surveyor, Should I be seated? According to the Admission Record, Resident #20 was admitted to the facility with the following but not limited to diagnoses: Dementia, and moderate calorie-protein malnutrition. According to section GG of the Minimum Data Set, an assessment tool, dated 6/12/2024, Resident #20 required partial/moderate assistance with eating. On 09/13/2024 at 09:53 AM, during an interview with the facility administration, which included the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the surveyor asked what the facility practice was for assisting residents who are unable to independently eat at mealtimes. The LNHA told the surveyors, Staff who assist residents who require assist with eating at meals should be seated at eye level. Thy surveyor then asked the LNHA why staff should assist residents seated at eye level. The LNHA responded, We do it that way because it is a dignity issue. A review of the facility provided policy titled Assistance with Meals, revised March 2022, revealed the following under Policy Interpretation and Implementation: Dining Room Residents: 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. NJAC 8:39 - 4.1(a)12

Based on observation, interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to A.) administer physician prescribed insulin to diabetic residents as ordered for 8 of 24 residents (Residents #22, #24, #33, #73, #74, #81, #260, and #261) residing on 2 of 2 floors and B.) failed to follow a physician order for weekly weights on 1 of 3 residents reviewed for nutrition, (Resident # 35). Failure to administer the prescribed insulin and/or blood sugars (BS) put diabetic residents at risk for hyperglycemic reactions (high blood sugar that affects people with diabetes. Skipping doses or not taking enough insulin to lower blood sugar can lead to hyperglycemia, hospitalization , and possible death). This deficient practice resulted in an Immediate Jeopardy (IJ) situation which was identified on 10/30/2023, when the facility staff failed to administer physician prescribed insulin. The facility Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified of the IJ on 10/30/2023 at 2:04 PM. A removal plan was received and was verified by the survey team on 10/31/2023 at 9:59 AM. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 10/24/2023 at 10:25 AM during the initial tour of the facility, the surveyor observed Resident #22 lying in bed. Resident #22 did not respond to the surveyor's voice. The resident had eyes open and exhibited slightly labored breathing. The resident was neat in appearance with no aberrant behaviors or aggressive behavior observed during this observation. On 10/30/2023 at approximately 10:15 AM the survey team asked the facility DON to provide a list of all residents in the facility who were prescribed insulin for diabetes mellitus (DM). After receiving the list, the survey team reviewed the Medication Administration Record (MAR) dated 10/01/2023-10/31/2023 for each of the 24 identified residents that were prescribed insulin. After reviewing the facility provided list, the survey team identified an additional (7) residents prescribed insulin that did not receive insulin and/or blood sugar checks as physician prescribed. A.) 1. On 10/27/2023 the surveyor requested the past six months of the facility consultant pharmacist (CP) monthly medication regimen reviews (MRR) for an unnecessary medications survey task for Resident #22. According to the Admission Record (AR), Resident #22 (3rd floor) had been admitted to the facility with the following diagnoses but not limited to Type 2 diabetes mellitus. On 10/30/2023 the surveyor reviewed the 10/19/2023 CP MRR for Resident #22. The following recommendation was made to the facility nursing staff: Medication not charted on MAR (medication administration record) see 10/7 Please review & confirm documentation on paper/back up is available. On 10/30/2023 at 09:30 AM the surveyor reviewed the 10/1/2023-10/31/2023 MAR for Resident #22. The review revealed that on 10/7/2023 Resident #22 did not receive the following medications in the AM, as indicated by a blank on the MAR. Resident #22 did not receive Lantus SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ML (milliliter) (Insulin Glargine) Inject 10 unit subcutaneously (the insertion of medications beneath the skin either by injection or infusion) two times a day for DM, as ordered by physician on 03/02/2023 at 0900 on 10/07/2023. Further review of the MAR for Resident #22 revealed that Resident #22 did not receive BS checks at 0730, 1100, and 1600 on 10/07/2023, as per the following physician order, dated 09/26/2023: Novolog FlexPen Subcutaneous Pen-Injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0-150 = 0; 151-200 = 2 (nits); 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10 BS OVER 400 GIVE 12 UNITS RE-CHECK bs WITHIN 1 HOUR CALL MD 9 medical doctor) IF GREATER THAN 400., subcutaneously before meals and at bedtime for DM. The surveyor reviewed the progress notes (PN) in the electronic medical record (EMR) for Resident #22. Review of the PN's revealed that no progress notes were documented for Resident #22 between 10/06/2023 and 10/08/2023. The last PN was written on 10/5/2023 at 18:30 and the next entry in the PN was 10/09/2023, which revealed that Resident #22 refused his/her lunch meal and 2 PM medication. There was no documentation on 10/7/2023 to indicate why Resident #22 did not receive their physician prescribed medications for DM, as indicated by blanks on the MAR. A review of the Care Plan for Resident #22 did not include a care plan for diagnosis of Type 2 Diabetes Mellitus. 2. According to the AR, Resident #24 was admitted to the facility with the following diagnoses but not limited to Type 2 diabetes mellitus. A review of the Order Summary Report (OSR), with Active orders As Of: 10/30/2023, revealed the following physician orders: HumaLog KwikPen Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) (1 Unit Dial) Inject as per sliding scale: If 60 -150 = 0U (zero units) Below 70 Monitor for s/s (signs/symptoms) of hypoglycemia (low blood sugar) and notify MD; 151-200 = 2U; 201-250 = 4U; 251-300 = 6U; 301-350 = 8U; 351-400 = 10U; 401-550 = 12U Above 400 notify MD, subcutaneously before meals and at bedtime for DM. The resident will self-check his/her blood sugar level in the presence of the nurse by way of the Freestyle Libre (a type of glucose monitor) twice daily. HumaLog KwikPen Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Lispro) Inject 2 unit subcutaneously three times a day for Diabetes Mellitus. Levemir Subcutaneous Solution 100 UNIT/ML (Insulin Detmir) Inject 27 unit subcutaneously every morning and at bedtime for Diabetes. A review of the 10/01/2023-10/31/2023 MAR indicated the medications for Resident #24 and that Resident #24 was to receive 27 units of Levemir at 0900 and 2100. A further review of the MAR showed a blank on 10/02/2023 at 2100, indicating that the physician prescribed insulin was not administered as ordered. A review of the Care Plan for Resident #24 revealed a Focus area of [Resident's Name] has a diagnosis of diabetes. Insulin dependent. Under the Goal section, [Resident name] will be from further complications secondary to diabetes. Interventions included but were not limited to: Monitor blood sugars as ordered. 3. According to the AR, Resident #33 was admitted to the facility with the following diagnosis of but not limited to Type 2 diabetes mellitus. A review of the OSR with Active Orders as Of: 10/30/2023, revealed the following physician order(s): Humalog KwikPen Subcutaneous Solution Injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: If 70 -150 = 0U; 151-200 = 2 units; 210-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Lantus SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Glargine) Inject 15 unit subcutaneously every 12 hours related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. A review of the 10/1/2023-10/31/2023 MAR revealed that Resident #33 did not receive physician prescribed Lantus SoloStar on 10/5/2023 at 2100 and 10/9/2023 at 2100, as indicated by blanks on the MAR. A review of the Care Plan for Resident #33 revealed a Focus area of I have Diabetes Mellitus. Under the Goal section, I will have no complications related to diabetes through the review date. Interventions included but were not limited to: Diabetes medication as ordered by physician. 4. According to the AR, Resident #73 was admitted to the facility with the following diagnosis of but not limited to Type 2 diabetes mellitus. A review of the 10/1/2023-10/31/2023 OSR revealed Resident #73 had the following physician order(s): HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject 12 unit subcutaneously three times a day for DM. HumaLOG Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: If 60-150 0U; Below 70 monitor for s/s of hypoglycemia; 151-200 = 4U; 201-250 = 6U; 251-300 = 8U; 301-350 = 10U; 351-400 = 12U; 401-500 = 19U give 19 units of regular insulin subcutaneously before meals and at bedtime for Diabetes Mellitus. Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously at bedtime for Diabetes Mellitus. Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine) Inject 16 unit subcutaneously in the morning for Diabetes Mellitus. A review of the 10/01/2023-10/31/2023 MAR revealed that Resident #73 did not receive Humalog (Insulin Lispro) 12 units subcutaneously on 10/06/2023 at 0630, as indicated by a blank on the MAR, 10/17/2023 at 0630 as indicated by a blank on the MAR, 10/24/2023 at 0630 as indicated by a blank on the MAR, and 10/26/2023 as indicated by a blank on the MAR. A further review of the MAR revealed that Resident #73 did not receive blood sugar checks as ordered and possible insulin coverage on the following dates, as indicated by blanks on the MAR: 10/06/2023 at 0630, 10/17/2023 at 0630, 10/24/2023 at 0630, and 10/26/2023 at 0630. A review of the Care Plan for Resident #73 revealed a Focus area of [Residents name] has a diagnosis of diabetes. Under the Goal section, I will be free of all signs/symptoms of hypo/hyperglycemia such as excessive perspiration, trembling, thirst, fatigue, weakness, blurred vision, slurred speech X 90 days. Interventions section did not include documentation of monitoring of blood sugars or insulin use. 5. According to the AR, Resident #74 was admitted to the facility with the following diagnosis of but not limited to Type 2 diabetes mellitus. A review of the 10/01/2023-10/31/2023 OSR revealed the following physician orders for Resident #74: Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: 0-150 = 0 CALL MD FOR BS BELOW 60; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10 CALL MD FOR BS ABOVE 400, subcutaneously three times a day every Tue, Thu, Sat for DM. Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: 0-150 = 0 CALL MD FOR BS BELOW 60; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units above 400, give 12 units and call MD, subcutaneously before meals and at bedtime every Mon, Wed, Fri, Sun for DM. A review of the 10/01/2023-10/31/2023 MAR for Resident #74 revealed that Resident #74 did not receive BS monitoring on the following dates and times and possible insulin administration: 10/7/2023 at 1100, and 10/7/2023 at 1700. A review of the Care Plan for Resident #74 revealed a Focus area of [Resident's name] has Diabetes Mellitus. Under the Goal section, I will have no complications related to diabetes through the review date. Interventions included Diabetes Medication as ordered by doctor. Monitor/document for side effects and effectiveness. 6. According to the AR, Resident #81 was admitted to the facility with the following diagnosis of but not limited to Type 2 diabetes mellitus. A review of the OSR with active orders as of: 10/30/2023, revealed that Resident #81 had the following physician orders: NovoLog FlexPen Subcutaneous Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 70-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10 give 12 unit for BS greater than 400. Notify MD if no improvement, subcutaneously before meals and at bedtime for DM. Toujeo SoloStar Solution Pen-Injector 300 UNIT/ML (insulin Glargine) Inject 15 unit subcutaneously every 12 hours for DM prime with each needle change with 3 units of medication, discard then draw up correct amount as ordered for administration. A review of the 10/1/2023-10/31/2023 MAR for Resident #81 revealed that Resident #81 did not receive BS checks and possible administration of insulin on the following dates and times: 10/7/2023 at 1100 and 1600. A review of the care plan for Resident #81 revealed a Focus are of I have Diabetes. Under the Goal section, I will be free of all signs and symptoms of hypo/hyperglycemia such as excessive perspiration, trembling, thirst, fatigue, weakness, blurred vision, slurred speech X 90 days. Interventions included but were not limited to: Access and record blood glucose levels as ordered. 7. According to the AR, Resident #260 was admitted to the facility with the following diagnosis of but not limited to Type 2 diabetes mellitus. A review of the OSR with active orders as of: 10/30/2023, revealed the following physician order(s) for Resident #260: Humalog KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0-150 = 0 CALL MD IF BS IS BELOW 70; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10 CALL MD IF BS IS ABOVE 400, subcutaneously three times a day every Mon, Wed, Fri for DM Before meals and at bedtime. Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: If 70-150 = 0; 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10 Give 12 units of insulin for BS greater than 400 recheck BS within 30 minutes notify MD if <400, subcutaneously before meals and at bedtime every Tue, Thu, Sat, Sun for DM. Lantus SoloStar Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Glargine) Inject 5 unit subcutaneously at bedtime for DM. A review of the 10/1/2023-10/31/2023 MAR for Resident #260 revealed that Resident #261 had blanks for the following medication date and times: Insulin Glargine 5 units at bedtime (2100) on 10/13, 10/14, 10/15, 10/16, and 10/17/2023. The MAR also revealed that Resident #260 did not receive BS checks and possible insulin Lispro coverage, as indicated by blanks on the MAR on 10/7/2023 at 1100 and 1600. A review of the care plan for Resident #260 revealed a Focus area of [Resident's name] has Diabetes Mellitus. Under the Goal section, I will have no complications related to diabetes through the review date. Intervention did not include monitoring of blood sugars or use of Insulin. 8. According to the AR, Resident #261 was admitted to the facility with the following diagnosis of but not limited to Type 2 diabetes mellitus. A review of the OSR with active orders as of: 10/30/2023, revealed the following physician orders for Resident #261: Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargine) Inject 26 unit subcutaneously in the afternoon for DM. Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject 5 unit subcutaneously before meals for DM. Insulin Lispro (1 unit dial) Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151-200 = 2; 201-250 = 4; 251-300 = 6; 301-350 = 8; 351-400 = 10; 401-450 = 12 Call MD if above 450, subcutaneously before meals for DM. Review of the 10/1/2023-10/31/2023 MAR for Resident #261 revealed that Resident #261 did not receive Insulin Glargine sliding scale insulin as ordered, indicated by a blank on the MAR on 10/06/2023 at 0900. On 10/06/2023 Resident #261 failed to have physician ordered BS checks performed at 1100 and 1600, which also potentially contributed to missed administration of insulin based on the physician order for sliding scale insulin. A review of the Care Plan for Resident #261 revealed a Focus area of I have a diagnosis of diabetes. Insulin Dependent. Under the Goal section, I will be free of all signs/symptoms of hypo/hyperglycemia such as excessive perspiration, trembling, thirst, fatigue, weakness, blurred vision, slurred speech X 90 days. Interventions included Access {sic} (assess) and record blood sugar levels as ordered. On 10/30/2023 at 09:48 AM the surveyor conducted an interview with the Licensed Practical Nurse (LPN #2) who was assigned to the third-floor unit of the facility. The surveyor asked LPN #2 what was the facility process for residents who refuse medication. LPN #2 told the surveyor that a resident who refuses medication(s) will be documented on the MAR. Specifically, the nurse documents their initials and codes the medication as refused. The surveyor then asked LPN #2 what a blank would indicate on the MAR for a medication. LPN #2 responded, A blank would indicate that the medication was not given. If it's not documented, it's not done. The surveyor further asked LPN #2 what she would do if she came on shift and discovered that the previous shift nurse left blanks on the MAR for the 7 AM - 7 PM shift medications. LPN #2 responded, Well, hopefully I am able to speak with them before change of shift. I would contact the nurse and ask them if the resident refused medications or discuss it with my unit manager. On 10/30/2023 at 10:10 AM the surveyor conducted an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM) assigned to the 3rd floor of the facility where Resident #22 resided. The surveyor asked the LPN/UM what is the facility process when a resident refuses medication during medication pass? The LPN/UM responded, So, when a resident refuse (medication) we make several attempts to encourage the resident to be compliant with the medication administration. If the resident continues to refuse, then we notify the family and MD. In the MAR we should document the meds as refused using the appropriate number for refused and initialize. A progress note should briefly describe what happened during the refusal. The surveyor asked the LPN/UM if the MAR should be left blank for a physician prescribed medication. The LPN/UM responded, No. If it is left blank, we don't know what's going on. A blank indicates that the drug was not given. If it ain't documented, they didn't get it. The surveyor asked the LPN/UM what she would do if she observed a blank on a resident MAR. The LPN/UM told the surveyor, I would reach out to the nurse on the previous shift and ask them what happened. Did you give the med, did you forget. What's going on? The surveyor then asked the LPN/UM who is responsible for monitoring the MARs of facility residents. The LPN/UM responded, We do a 24-hour chart check, it is the responsibility of the 11-7 nursing staff. We check the physical binder for new orders, and we also go into the EMAR to check for new orders. We do not look at the MAR we just check for new orders. On 10/30/2023 at 2:04 PM, the surveyor interviewed the LNHA and DON. When interviewed the LNHA and DON agreed that a blank on a resident MAR would indicate that a drug was not administered. On 10/31/2023 at 08:24 AM the facility LNHA while being interviewed told the survey team that they (nurses involved), should have realized on the Electronic Medication Administration Record (EMAR) that the dashboard will turn green when all medications are administered. If all medications have not been administered, the dashboard will be red. So, if it is red, you are not done and if it is green, you have given all your medications. They [the nurses] should have known. The surveyor reviewed the facility policy titled Insulin Administration, Revised September 2014. The policy revealed the following under the heading Documentation: 1. The resident's blood glucose result, as ordered; 2. The dose and concentration of the insulin injection; 3. Size and gauge of the needle used for injection; 4. Injection site (presence or absence of any bruising, pain, redness, swelling or unusual marks in or near the injection site); 5. How well the resident tolerated the procedure. The following was revealed under the heading Reporting: 1. Notify your supervisor if the resident refuses the insulin injection. The surveyor reviewed the facility provided policy titled Administering Medications, Revised April 2019. The following was revealed under Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. The following was further revealed under the heading Policy Interpretation and Implementation: 2. The Director of Nursing Services supervises and directs all personnel who administer without unnecessary interruptions. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 20. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR and/or utilize the code that corresponds in the space provided for that drug and dose or utilize the appropriate code on the EMAR. 22. The individual administering the medication initials (written or electronic) the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those were observed; and g. The signature and title of the person administering the drug. 34423 B.) According to the Admission Record, Resident #35 was admitted to the facility with diagnoses including but not limited to: Dementia, Morbid Obesity. A review of the current Order Summary Report (OSR) with Active Orders as of 10/27/2023, revealed a physician order with a start date of 07/18/2023, for Weekly Weights-dayshift in the morning every Monday for weight monitoring. A review of the Medication Administration Records for the months of August 2023, September 2023 and October 2023, revealed the physician order for weekly weights. The dates for every Monday were open blocks for the weights to be documented and all the blocks for the aforementioned timeframes were blank. There was no documentation to indicate that the weights had been completed as ordered. A review of Resident #35's Weights on 10/25/2023 indicated weights were obtained on 08/03/2023, 09/08/2023, 09/19/2023. There was no documentation that weights were completed for 08/14/2023, 08/21/2023, 08/28/2023, 09/04/2023, 09/11/2023, 09/25/2023, 10/02/2023, 10/16/2023, and 10/23/2023. During an interview with the surveyor on 10/27/2023 at 9:44 AM, Certified Nursing Assistant (CNA #1) revealed that weights are done monthly in the beginning of month. If the nurse needs weekly weights, we get them too. CNA #1 went on to say, we write them (weights) down on a piece of paper and give to the nurse to document. During an interview with the surveyor on 10/27/2023 at 09:52 AM, Registered Nurse /Unit Manager said the facility weights policy is done by 10th of the month. If there are any discrepancies, dietary reviews the weight. When asked who is responsible to do the weights, RN/UM replied, usually aides or nurses do weights. The nurse documents the weights in the Electronic Medical Record (EMR). If resident is on weekly weights, usually the order is put in EMR, and nurse can see the order when they do medication pass. When asked if the nurse is to document the weights on the MAR, RN/UM said, Not necessarily do they have to chart weights in the MAR, they document the weight but there is a section in EMR where you document the weight. The surveyor asked UM where the weight dated 10/10/23 come from when the last weight the surveyor had is from 9/19/23. The RN/UM said she just put the weight in the EMR today. The surveyor asked the RN/UM to read the dates of the weights in vitals/weights tab in the EMR. RN/UM read 10/10, 9/19, 9/8, 8/3. RN/UM said might have dropped off (the order for weekly weights) the MAR, it depends on duration. When asked by the surveyor if the weights were required weekly, RN/UM reviewed the OSR and said they were ordered in July and confirmed there is still an active order for weekly weights. Yes, the weights should have been done weekly. During an interview with the surveyor on 10/27/2023 at 10:23 AM, the Director of Nursing (DON) said the facility policy for weights is for admissions weight then weekly x 4 then monthly. The weights are documented in the EMR under the weight/vitals tab. When asked should the weights be documented on the MAR as well, the DON responded Yes, they are to be documenting the weight on the MAR for weekly weights. They are to enter weight into EMR when they get it. When asked would weights be documented any in any other place, the DON said they may be written elsewhere on unit, and she will check and get back to the surveyor. On 10/31/2023 at 09:20 AM, the Don confirmed there were no further weights for Resident #35. During an interview with the surveyor on 10/31/2023 at 10:21 AM, the Dietitian said weights are supposed to be taken on admission then follow up in 24 hours then weekly weights for 4 weeks for subacute then monthly weights. The Dietitian went on to say that Nursing is responsible to obtain the weights and they should be documented under weights. A review of a facility policy titled Weight Assessment and Intervention with a revised date of March 2022, revealed under the Policy Interpretation and Implementation section 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. A further review revealed 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. NJAC 8:39-27.1(a)