Every finding on record at Holly Manor Center

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable temperature on 1 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 6/9/26 at 11:41 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Regional Food Service Director (RFSD).At 12:08 PM, the surveyor and RFSD observed the food truck arrive on the North 1st floor unit. The surveyor observed the first lunch tray being served at 12:08 PM. At that time a test tray of a regular diet and pureed consistency was identified by the surveyor and FSD, this tray was left in the food truck. After the last meal tray was delivered to a resident at 12:15 PM, the RFSD removed the test tray and the surveyor took the temperatures of the following items in the presence of RFSD with the calibrated thermometer and the temperatures were as follows: Cream of broccoli: 159,7 FSloppy [NAME]: 123.6 F Mashed potatoes: 126.2 FStrawberry yogurt: 45.1 FCranberry juice: 50.7 F At 12:18 PM, following the food temperature recording, the RFSD agreed and acknowledged the sloppy joe, mashed potatoes, strawberry yogurt and cranberry juice were not in range for serving temperature. The RFSD further stated corrective action would be taken immediately. At 12:30 PM, the Licensed Nursing Home Administrator provided the surveyor with a facility policy titled, Food: Preparation with a revised date of 2/2026. The procedures section of the policy revealed, 14. All foods will be held at appropriate temperatures greater than 135 degrees Fahrenheit (F) for hot holding, and less than 41F for cold food holding.On 6/9/26 at 12:30 PM, the surveyor met with the LNHA and Regional Registered Nurse (RRN) to review facility concerns. The LNHA stated the food temperature concerns would be addressed immediately. On 6/10/26 at 12:43 PM, the surveyor met with the LNHA and RRN for the exit conference. No further pertinent information was provided. NJAC 8:39-17.2(a) 2, (e)

Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms and common areas. The deficient practice was observed on 2of 2 units during the facility tour. The deficient practice was evidenced by the following: On 6/3/26 at 10:45 AM, while on initial tour of the facility, the surveyor observed the following: Stained ceiling tiles in 56-west Scuff marks on the wall in room [ROOM NUMBER]-West On 6/8/26 at 11:17 AM, while interviewing a resident, the surveyor observed stained ceiling tiles in room [ROOM NUMBER]-South At 11:22 AM, while in the dining room the surveyor observed a multiple ceiling tiles the were curving upward at their edges. At 11:24 AM, while in the kitchen, the surveyor observed a ceiling tile that did not fit and was hanging down. On 6/9/26 at 10:32 AM, the surveyor observed the following: A stained ceiling tiles outside room [ROOM NUMBER]-West An ill-fitted vent outside rooms [ROOM NUMBERS]-North Multiple broken ceiling tiles outside of room [ROOM NUMBER]-West A gap in the adjoining wall in room and broken crown molding 64-West Broken ceiling tile in room [ROOM NUMBER]-West Broken ceiling next to the exit sign in the [NAME] hallway. Multiple stained and broken ceiling tiles outside the [NAME] unit pantry. Broken ceiling tile and brackets in the north unit hallway outside room [ROOM NUMBER]. Multiple broken ceiling tiles above the double doors in the North unit hallway On 6/3/26 at 10:39 AM, while on initial tour of the facility, the surveyor observed scuffed and scratched furniture in room [ROOM NUMBER]. On the same day, the surveyor observed peeling wallpaper and a scuffed, scratched windowsill with an accumulation of a black substance in room [ROOM NUMBER]. On the same day, in the presence of another surveyor, the surveyor observed the South shower room. The observation included broken corner tiles near the floor molding, floor molding separating from the wall with a black substance behind it and an accumulation of a black substance in the corner and the bottom of the entry door frame, both sides were separating from the frame and sticking out. The surveyor showed the Director of Maintenance (DOM) the concerns in the shower room. The DOM stated that he was not aware of these concerns but confirmed it was a safety concern. The surveyor also observed in the South hallway poorly fitted ceiling tiles, with gaps visible, and a sprinkler head below the ceiling tile with a visible gap. On 6/4/26 at 12:14 PM, the surveyor observed, on the North Unit, poorly fitted ceiling tiles near the nurses' station, with visible gaps and a white substance. A gray rectangular box hanging from the ceiling by 1 wire or string. Gray ceiling vents behind the nurses' station with gray paint on the adjoining tiles, one vent was separated from the ceiling with a visible gap. A door with an entry keypad with a white substance applied above the keypad. On 6/9/26 at 12:27 PM, the survey team met with the LNHA and RRN for concerns. The surveyor notified the LNHA of the concerns with a safe clean environment and showed them the related evidentiary photographs. On 6/10/26 at 11:20 AM, the survey team met with the LNHA and RRN for responses to concerns. The LNHA stated that the previously mentioned concerns were fixed immediately. The facility did not provide any further pertinent information. On 6/03/2026 at 11:25 AM, during environmental rounds, the surveyor observed multiple ceiling tiles on the South Nursing Unit that were visibly buckled, sagging, and partially displaced from the ceiling grid, posing a risk of the tiles falling. The condition of the tiles failed to maintain a safe, clean, and well-maintained environment. On 6/3/26 at 11:40 AM, the surveyor presented the above concerns to the Director of Maintenance. The Director of Maintenance stated that he was not aware of the above findings but confirmed that it was a safety concern. On 6/10/26 at 11:00 AM, the surveyor reviewed the facility's, Safe and Homelike Environment policy dated 11/14/25 which reflected .The resident/patient has the right to a safe, clean, comfortable and homelike environment . NJAC 8:39-31.2(e), 31.4(a)(f)

Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident's dietary preferences and menus were consistently provided for 2 of 4 residents (Resident #38 and #100) reviewed for dietary preferences. This deficient practice was evidenced as follows: 1. On 6/3/26 at 10:45 AM, the surveyor observed Resident #100 in their room sitting in a wheelchair (w/c). Resident #100 indicated they do not speak English and called a family member for a phone interview. The family member revealed Resident #100 had been in the facility about 8 days and the resident did not like the food. The family member further revealed that Resident #100 did not receive a menu as well as no staff members had asked about their food preferences.On 6/3/26 at 11:50 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #100.The admission Record ((AR) a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to perforated gallbladder (when the gallbladder wall tears leading to leakage of bile and digestive fluids into the abdominal cavity), peritoneal abscess (a localized collection of pus within the abdominal cavity, formed when infection in the peritoneal space becomes encapsulated by surrounding tissues) and malignant neoplasm of the stomach (a cancerous growth that begins in the cells lining the stomach).A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/3/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #100 scored 14 out of 15, which indicated the resident had normal cognitive function.A review of the Physician Order Summary Report (OSR) included a Physician Order (PO) dated 5/28/26 for, Regular/Liberalized diet, Regular texture, thin liquids consistency.A review of Resident #100 care plan (CP) revealed a nutrition CP with a focus, resident is at potential nutritional risk due to chronic medical issues, needs moister foods, admitted with fluid retention, screens at malnutrition risk and interventions that included, honor food preferences within meal plan.2. On 6/3/26 at 10:43 AM, the surveyor interviewed Resident #38 in their room. Resident #38 revealed they have been in the facility for 6 weeks, have received the same breakfast (oatmeal, scrambled eggs but no breakfast meat, i.e. bacon or sausage) everyday, did not receive a menu, and nobody has asked about their food preferences. Resident #38 further revealed they had been on a low salt diet, but the diet has been changed to regular.On 6/3/26 at 12:23 PM, the surveyor reviewed the EMR for Resident #38The AR documented resident had diagnoses that included but were not limited to, essential primary hypertension (high blood pressure) and type 2 diabetes mellitus (a chronic condition characterized by insulin resistance and high blood sugar levels).A review of the admission (MDS), dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #38 scored 14 out of 15, which indicated the resident had normal cognitive function.A review of the Physician OSR included a PO dated 5/20/26 for, Regular/Liberalized diet, Regular texture, thin liquids consistency.A review of Resident #38 CP revealed a nutrition CP with a focus, resident is at potential nutritional risk due advanced age, multiple chronic medical issues and interventions that included, honor food preferences within meal plan.On 6/4/26 at 10:14 AM, the surveyor interviewed the Regional Food Service Director (RFSD), who revealed they have covering for facility Food Service Director (FSD) for the past 6 weeks. The RFSD further revealed the subacute residents should be receiving weekly menus but cannot confirm if the residents have been receiving their menus. On 6/9/26 at 9:01 AM, the surveyor interviewed the Registered Dietitian (RD#1), who revealed they have been working in the facility for five months and there is another dietitian who works at the facility as well. RD#1 revealed part of their responsibilities include asking resident for their food preferences, dislikes, and only provides menus to residents if they request one. RD#1 further revealed that the low salt diet is redundant and does not include breakfast meats.On 6/9/26 at 9:28 AM, the surveyor interviewed the dietary cook who revealed, the facility does not have low sodium breakfast meats. On 6/9/26 at 12:20 PM the Licensed Nursing Home Administrator provided the surveyor with a facility policy, Dining and Food Preferences with a revised date of 9/2025. The procedure section of the policy revealed, 2. The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 72 hours of admission. The purpose of this interview is to identify preferences for food and beverages preferences. On 6/9/26 at 12:30 PM, the surveyor met with the LNHA and Regional Registered Nurse (RRN) to review facility concerns. The LNHA stated concerns about food preferences and providing menus would be addressed immediately. On 6/10/26 at 12:43 PM, the surveyor met with the LNHA and RRN for the exit conference. No further pertinent information was provided.NJAC - 17.4(a)1, (e)

Repeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/3/26 at 9:28 AM, the presence of the Food Service Director (FSD), the surveyor observed the following: 1. On top of the ice machine, the surveyor observed a dust-like build up. The FSD stated they were covering for the regular FSD and were not sure of the cleaning schedule.2. In the 2-door standing refrigerator, the surveyor observed a container of sliced apples with a use by date of 6/2/26. The FSD stated the evening staff should have discarded the apples last night. The container of apples was discarded.3. In the 6-door standing freezers, the surveyor observed a bag of carrots with use by date of 5/14/26 and an open bag of breakfast sausages without an open or use by label. The FSD stated the evening staff should have discarded the carrots and the breakfast sausages should have been labeled after they were opened. Both items were discarded4. In the walk-in refrigerator, the surveyor observed the fans with a blackish substance. The FSD stated the maintenance department would be contacted immediately for cleaning and sanitizing. 5. In the chef preparation area, the surveyor observed an opened 16-ounce (oz) container of parsley, a 24oz container of chicken seasoning, and a 20oz container of onion powder all without use by labels. The FSD stated all seasoning should be labeled upon opening; all seasoning containers were discarded.6. The surveyor observed the can opener holder with a blackish substance. The FSD stated they were not aware of when the can opener holder was lasted cleaned but would be cleaned immediately. On 6/4/26 at 9:30 AM, the Licensed Nursing Home Administrator provided the surveyor with multiple facility polices. The Equipment policy with a revised date of 9/2017 revealed under the procedures section, 1. All equipment will be routinely cleaned and maintained.3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-foods contact equipment will be cleaned and free of debris. The Receiving policy with a revised date of 2/2023 revealed under the procedures section, 5. All food items will be appropriately labeled and dated. On 6/9/26 at 12:30 PM, the surveyor met with the LNHA and Regional Registered Nurse (RRN) to review facility concerns. The LNHA stated all kitchen concerns would be addressed immediately. On 6/10/26 at 12:43 PM, the surveyor met with the LNHA and RRN for the exit conference. No further pertinent information was provided. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to implement a comprehensive person-centered care plans (CP) that included: a. oxygen (O2) and b. non-English speaking residents. The deficient practice was identified for 3 of 4 residents (Resident #4, Resident #59 and #100) reviewed for care plans. 1. On 6/3/26 at 10:32 AM, the surveyor observed Resident #59 in their room receiving O2 via nasal cannula ((NC) a medical device to provide supplemental oxygen therapy to people who have lower O2 levels) running at 2 liters per minute (L/min). Resident #59 stated using O2 since being admitted to the facility. On 6/3/26 at 11:20 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #59. The admission Record ((AR) a summary of important information about the resident) documented the resident had diagnoses that included but were not limited to; Hodgkin's lymphoma (a type of cancer of the lymphatic system) and acute respiratory failure with hypoxia (inability of the lungs to maintain adequate oxygen levels in the blood). A review of the 5-Day Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/22/26, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #59 scored 8 out of 15, which indicated the resident had moderate cognitive impairment. The MDS further revealed Resident #59 was receiving O2. A review of the Physician Order Summary Report (OSR) included a Physician Order (PO) dated 5/27/26, Oxygen at 2L/min via Nasal Cannula. A review of Resident #59 CP did not reveal a care plan for the residents' use of O2. 2. On 6/3/26 at 10:45 AM, the surveyor observed Resident #100 in their room sitting in a wheelchair (w/c). Resident #100 indicated they did not speak English and called a family member for a phone interview. The family member revealed Resident #100 had been in the facility about 8 days, the language interpreter was not being used regularly, and the facility had not provided a communication board. On 6/3/26 at 11:50 AM, the surveyor reviewed the EMR for Resident #100. The AR documented the resident had diagnoses that included but were not limited to; perforated gallbladder (when the gallbladder wall tears leading to leakage of bile and digestive fluids into the abdominal cavity), peritoneal abscess (a localized collection of pus within the abdominal cavity, formed when infection in the peritoneal space becomes encapsulated by surrounding tissues) and malignant neoplasm of the stomach (a cancerous growth that begins in the cells lining the stomach). A review of the admission MDS, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #100 scored 14 out of 15, which indicated the resident had normal cognitive function. The MDS further revealed Resident #100's preferred language is Spanish and needs an interpreter. A review of Resident #100 CP did not reveal a care plan for the resident's preferred language or the need for an interpreter. 3. On 6/3/26 at 10:56 AM, the surveyor observed Resident #4 in their room in bed. Resident #4 was able to answer basic questions and converse with the surveyor. The surveyor observed an oxygen concentrator (a machine that extracts and purifies oxygen from the surrounding air) with tubing attach and lying on the floor. The resident was not using O2 at the time of observation. On 6/3/26 at 11:45 AM, the surveyor reviewed the EMR for Resident #4. The AR documented the resident had diagnoses that included but were not limited to; traumatic brain injury (brain damage caused by a violent blow or jolt), oropharyngeal dysphagia (difficulty moving food from the mouth into the throat and esophagus) and need for assistance with personal care). A review of the comprehensive MDS, dated [DATE], indicated the facility assessed the resident's cognition using a BIMS test. Resident #4 scored 4 out of 15, which indicated the resident had severe cognitive impairment. A review of the OSR included a PO dated 5/2/26, check O2 and apply oxygen 2LPM/NC if less than 92% every shift for SOB. A review of Resident #4 CP did not reveal a care plan for the resident's use of oxygen. On 6/8/26 at 9:21 AM, the surveyor interviewed the Social Worker (SW) who stated initial care plans are completed within 72 hours of the resident's admission and should cover resident's medical status, medications, rehabilitation, and general preferences. SW revealed they were aware Resident #100 was non-English and but was unaware Resident #100 did not have CP addressing their preferred language. On 6/8/26 at 10:17 AM, the Regional Registered Nurse (RRN) provided the surveyor with facility policy, Person-Centered Care Plan with a revision date of 9/15/25. The policy revealed, care plan includes measurable objectives and timetables to meet patient's medical, nursing, nutrition and mental and psychosocial needs that are identified in the comprehensive assessments. On 6/9/26 at 12:30 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and RRN to review facility concerns. The LNHA stated concerns about resident care plans would be addressed immediately. NJAC 8:39-11.2 (e)

Refer to; F686, F880, and F947Based on facility staff interviews and review of pertinent facility documentation, it was determined that the facility failed to provide a designated Infection Prevention and Control Nurse effective 1/1/26 through and including 4/14/26 (totaling 104 days). This deficient practice was evidenced by the following: Reference:(Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) S483.80(b) Infection preventionist the facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must: S483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; S483.80(b)(2) Be qualified by education, training, experience or certification; S483.80(b)(3) Work at least part-time at the facility; and S483.80(b)(4) Have completed specialized training in infection prevention and control.A review of the Infection Preventionist (IP) employment file revealed a hire date of 3/30/26. Further review revealed a Centers for Disease Control and Prevention (CDC) certificate indicated a completion date of 4/14/26 for 19 contact hours in the Nursing Home Infection Preventionist Training Course (WB4973).On 6/8/26 at 10:22 AM, the Licensed Nursing Home Administrator (LNHA) stated the facility did not have a designated IP for the dates of 1/1/26 through and including 4/14/26. She further stated that the facility was trying to hire a permanent IP, and during that time, until 4/14/2026, the Director of Nursing (DON) was helping the facility.On 6/10/26 at 11:48 AM, the survey team met with the LNHA and the Regional Registered Nurse (RRN). The RRN acknowledged that the IP should be a designated part-time (pt) or full-time (ft) position within the facility, and the DON could not be assigned to both positions as per federal regulations and guidelines. A review of the facility's policy, Infection Prevention and Control Program Incidents (IPCP) revised on 7/15/25, revealed .facilitate compliance with state and federal regulations relating to infection prevention and control.the IP develops, implements, monitors and maintains the IPCP and fulfills the basic requirements for the role.the IP has the following responsibilities. facilitate the implementation of IPCP .facilitate annual review and updating of IPCP for effectiveness and currency with standards of practice.educate new personnel . Provide ongoing infection prevention and control updates.facilitate an annual in-service on infection prevention and control.provide staff with necessary education relating to outbreaks and other infection control related issues.initiate specific precautions, monitor procedures for proper infection prevention and control technique, as indicated and appropriate.participate in the screening of employees for physical, health history, and immunization status upon hiring and annually. A review of the facility's policy, Infection Control Outcome and Process Surveillance and Reporting, with a revision date of 3/20/26, revealed the following: the IP will conduct regular Outcome surveillance (collecting and documenting) and Process Surveillance to review practices directly related to patient care.based on recognized standards. NJAC 8:39-19.1 (b), 19.4(d) (e)

Based on observation, interview and record review it was determined that the facility failed to maintain infection control standards and procedures during a wound care treatment for 1 of 3 residents (Resident #8) reviewed for care and services for pressure ulcers. The deficient practice was evidenced by the following: Refer to F882 Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or patient's surroundings; after contact with blood, body fluids, or contaminated surfaces.CDC recommendations for Hand Hygiene: Updated February 27, 2024:https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. On 06/03/2026 at 10:25 AM, the surveyor observed Resident #8 in bed with a urinary catheter in place, and the drainage bag affixed to the lower aspect of the bed. The surveyor observed signage on the door indicating that the resident was on Enhanced Barrier Precautions. (infection control measures used to prevent the silent spread of multidrug-resistant organisms (MDROs). The surveyor reviewed the medical record for Resident # 8. A review of the admission Record reflected the resident was admitted to the facility with diagnoses that included but were not limited to; Parkinson's Disease (neurological disorder that damages dopamine producing brain cells) and a Stage 4 pressure ulcer of the sacral region (Involves full thickness tissue loss over the tailbone, exposing muscle, tendon, or bone). A review of the Annual Minimum Data Set(MDS), an assessment tool dated 12/4/25, reflected that Resident #8 had a brief interview for mental status (BIMS) score of 14 out of 15, indicating intact cognition. A further review indicated Resident #8 was admitted to the facility with a stage 4 pressure ulcer. A review of the current Order Summary Report (OSR) included physician orders (PO) for the following: soak the stage 4 sacral wound for 3-5 minutes with wound cleanser, apply silver alginate dressing (highly absorbent wound dressing), cover with a silicone bordered superabsorbent dressing two times a day, and as needed (prn).PO: Apply Calmoseptine external ointment (moisture barrier ointment) to the sacrum periwound (area of skin surrounding the wound) every day and evening shift. On 6/9/26 at 10:50 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform the treatment to Resident #8's sacral wound and observed the following:The surveyor observed the LPN perform hand hygiene. The LPN applied soap to her hands and immediately placed them under running water without first lathering.The LPN gathered the supplies, which included a tube of Calmoseptine External Ointment, Vashe wound cleanser, Nystatin topical powder, 4x4 gauze pads, Foam border dressing, Calcium silver alginate, and applicators. The LPN donned (put on) a disposable gown and gloves, entered the resident's room, placed a clean barrier on the resident's overbed table, and then placed the supplies on top of the overbed table. The LPN removed and discarded the soiled dressing, which she described as having copious purulent and serosanguineous drainage.The LPN removed and discarded the glove from her right hand and, with no observed hand hygiene, donned another glove. The LPN cleansed the wound with the [NAME] wound cleaner and then packed and soaked it for 5 minutes. The LPN discarded the glove from her right hand and, with no observed hand hygiene, donned another glove. The LPN applied the Calmoseptine external ointment to the periwound, applied the silver alginate to the wound bed, and covered it with a border dressing, which was dated prior to its application. The LPN disinfected the tube of Calmoseptine ointment and nystatin powder, doffed her gloves, and, without any observed hand hygiene and without removing her disposable gown, entered the hallway and returned the supplies to the treatment cart.The surveyor discussed the Infection Control breaches with the LPN. The LPN acknowledged that she should have performed hand hygiene, removed her soiled gown before exiting the resident's room and should have sanitized her hands between glove changes. The LPN further stated that she should have brought only the supplies that would be used for the treatment into the resident's room and should not have placed the supplies back into the treatment cart. The LPN stated that her hands should be washed and lathered for 20 seconds outside the stream of water.On 6/9/26 at 12:20 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN). The LNHA confirmed that the LPN should have performed hand hygiene between glove changes, brought only the supplies to be used for the single treatment into the resident's room, and removed her gown before exiting the resident's room. A review of the facility's Skin Integrity and Wound Management policy dated 9/15/25 reflected.Purpose: to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing. A review of the facility's Hand Hygiene policy dated 3/20/26 reflected.The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene before donning gloves and immediately after removing gloves.Hand hygiene technique.Wet hands with warm (not hot) water, apply soap, and rub them vigorously outside the stream of water for 20 seconds, covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use clean, disposable towels to turn off the faucet.NJAC 8:39-19.4(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 4 of 5 residents (Resident #1, #41,#51 and #56) on 2 of 2 units South and North Nursing units. This deficient practice was evidenced by the following: Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. Direct care staff member means any registered professional nurse, licensed practical nurse, or certified nurse aide who is acting in accordance with that individual's authorized scope of practice and pursuant to documented employee time schedules. The following ratio(s) were effective on 02/01/2021: 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) One certified nurse aide to every eight residents for the day shift. (2) One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties, and (3) One direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties 1.A review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks of staffing from 5/17/26 through 5/30/26, prior to the Standard survey of 6/12/26, revealed the facility was deficient in staffing hours as evidenced by the following: For the 2 weeks of AAS-11 staffing, the facility was deficient in Certified Nursing Assistant (CNA) staffing for residents on 6 of 14 day shifts as follows:-05/17/26 had 10 CNAs for 92 residents on the day shift, required at least 11 CNAs.-05/18/26 had 9 CNAs for 92 residents on the day shift, required at least 11 CNAs.-05/19/26 had 10 CNAs for 92 residents on the day shift, required at least 11 CNAs.-05/24/26 had 9 CNAs for 90 residents on the day shift, required at least 11 CNAs.-05/26/26 had 10 CNAs for 92 residents on the day shift, required at least 11 CNAs.-05/29/26 had 10 CNAs for 93 residents on the day shift, required at least 12 CNAsOn 6/9/26 at 8:20 AM, the surveyor interviewed the staffing coordinator (SC), who stated they were aware of the CNA staffing ratios. The SC also stated that if they were unable to meet the minimum staffing requirements, she would inform the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON).2. On 6/8/26 at 7:45 AM, the surveyor conducted an incontinence care tour on the South and North Nursing Units and observed the following:a. On 6/8/26 at 7:45 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #1), observed Resident #56 in bed. LPN #1 exposed Resident #56's incontinence brief and observed that the brief was saturated with urine and feces. The resident pulled at their saturated brief and stated, Get this off of me. LPN #1 confirmed that the brief was saturated. b. On 6/8/26 at 7:55 AM, the surveyor accompanied by LPN #1 observed Resident #1 in bed. The surveyor detected a strong odor of urine. LPN #1 exposed the incontinence brief and observed a second brief in place. The surveyor observed that both briefs were saturated with urine. The surveyor asked LPN #1 if it was appropriate to use two briefs. LPN #1 confirmed that using double briefs was against the facility's policy.c. On 6/8/26 at 8:10 AM, the surveyor conducted an incontinence care tour on the North Nursing Unit. The surveyor, accompanied by LPN #2, observed Resident #41 in bed. LPN #2 exposed Resident #41's incontinence brief. The surveyor observed that the brief was saturated with urine. LPN #2 confirmed the brief was wet. d. On 6/8/26 at 8:15 AM, the surveyor, accompanied by LPN #2, observed Resident #51 in bed. LPN #2 exposed Resident #51's incontinence brief. The surveyor observed that the brief was saturated with urine. LPN #2 confirmed that the brief was saturated. Review of the 11-7:00 AM CNA assignment sheet revealed that the South nursing unit had a census of 47 Residents with 2 assigned aides. CNA #1 had an assignment of 23 residents on that 11-7 AM shift. On 6/9/26 at 10:00 AM, the surveyor conducted a telephone interview with the 11:00 PM-7:00 AM CNA (CNA #1) assigned to Resident #56 and Resident #1. CNA #1 stated that she was responsible for 23 residents during that shift and was unable to provide incontinence care every two hours as required. CNA #1 stated that Resident #1 was a heavy wetter and, due to uncertainty about when she could provide timely incontinence care, she applied double incontinence briefs. CNA #1 acknowledged that the use of double briefs was a violation of facility policy. On 6/9/26 at 10:21 AM, during an interview with the surveyor, the acting DON confirmed the census on the South Nursing Unit was 47 and that CNA #1 was responsible for 23 residents on that shift. On 6/ 9/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) to discuss the above observations and concerns. The LNHA confirmed that nurses should provide incontinence care every 2 hours on all shifts and that the facility does not use double incontinence briefs for residents.A review of the Facility's Staffing/Center Plan policy reflected.The Center maintains appropriate staffing levels, with qualified personnel, 24 hours/day, seven days per week on each shift, to ensure that patients are safe and their needs are met. Inquiries concerning nursing staffing should be referred to the Director of Nursing. A review of the facility's Continence Management policy reflected.Patients who are incontinent of bladder or bowel will receive appropriate treatment for the prevention of incontinence associated dermatitis (IAD).Cleanse routinely in accordance with the plan of care, and promptly as needed upon soiling.On 6/10/26 at 11:48 AM, no further information was provided. NJAC 8:39-27.1 (a), (e), 27.2 (h)

Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 5 residents (Residents #1, #41, #51, and #56) observed for incontinence care on 2 of 2 Nursing units (South and North).This deficient practice was evidenced by the following: On 6/8/26 at 7:45 AM, the surveyor conducted an incontinence care tour on the South Nursing Unit and observed the following:1. On 6/8/26 at 7:45 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #1), observed Resident #56 in bed. LPN #1 exposed Resident #56's incontinence brief and observed that the brief was saturated with urine and feces. The resident pulled at their saturated brief and stated, Get this off of me. LPN #1 confirmed that the brief was saturated. The surveyor reviewed the medical record for Resident #56.A review of the admission Record (AR) reflected that Resident #56 was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD), (a progressive lung disease that restricts air flow and makes breathing difficult), and diabetes mellitus (high blood sugar).A review of the annual minimum data set (MDS), an assessment tool dated 1/8/26, reflected that the resident had a brief interview for mental status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. The MDS further assessed that Resident #56 was frequently incontinent of bowel and bladder and required staff assistance for toileting.A review of Resident #56's Care Plan (CP) indicated the resident was at risk for skin breakdown related to incontinence with interventions that included but were not limited to; assist with perineal care as needed .2. On 6/8/26 at 7:55 AM, the surveyor accompanied by LPN #1 observed Resident #1 in bed. The surveyor detected a strong odor of urine. LPN #1 exposed the incontinence brief and observed a second brief in place. The surveyor observed that both briefs were saturated. The surveyor asked LPN #1 if it was appropriate to use two briefs. LPN #1 confirmed that it was against the facility's policy.The surveyor reviewed the medical record for Resident #1.A review of the AR reflected Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to; hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke); COPD and diabetes mellitus.A review of the annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 15 out of 15, which indicated their cognition was intact. A further review of the MDS indicated the resident was always incontinent of bowel and bladder and was dependent on staff for toileting.A review of Resident #1's CP indicated that the resident required assistance for ADL care with interventions that included but were not limited to; provide resident with dependent assistance for toileting. On 6/8/26 at 8:10 AM, the surveyor conducted an incontinence care tour on the North Nursing Unit. The surveyor, accompanied by LPN #2, observed Resident #41 in bed. LPN #2 exposed Resident #41's incontinence brief. The surveyor observed that the brief was saturated with urine. LPN #2 confirmed the brief was wet.The surveyor reviewed the medical record for Resident #41.A review of the AR reflected the resident was admitted to the facility with diagnoses that included, but were not limited to; end stage renal disease (the kidneys can no longer remove waste and extra fluid from the body well enough to support life), dementia (decline in mental abilities), and an overactive bladder (a group of urinary symptoms occurring when bladder muscles contract crating a strong urge to urinate even when the bladder is not full).A review of the annual MDS dated [DATE] reflected that the resident had a BIMS score of 3 out of 15, indicating severe cognitive impairment. The MDS further assessed that Resident #41 was always incontinent of bowel and bladder and required staff assistance for ADL care.A review of Resident #41's CP reflected that the resident was incontinent of bowel and bladder, with interventions that included but were not limited to: changing the resident with each episode of incontinence and providing peri care.4. On 6/8/26 at 8:15 AM, the surveyor, accompanied by LPN #2, observed Resident #51 in bed. LPN #2 exposed Resident #51's incontinence brief. The surveyor observed that the brief was saturated with urine. LPN #2 confirmed that the brief was saturated.The surveyor reviewed the medical record for Resident #51.A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; chronic kidney disease and dementia.A review of the Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 6 out of 15, indicating severe cognitive impairment. A further review of the MDS assessed that Resident #51 was always incontinent of Bowel and Bladder and required staff assistance for ADL care.A review of Resident #51's CP reflected the resident was incontinent of bowel and bladder with interventions that included but were not limited to; provide skin care after each incontinence episode and apply a moisture barrier.On 6/9/26 at 10:00 AM, the surveyor conducted a telephone interview with the 11:00 PM-7:00 AM certified nursing assistant (CNA #1) assigned to Resident #56 and Resident #1. CNA #1 stated that she was responsible for 23 residents during that shift and was unable to provide incontinence care every two hours as required. CNA #1 stated that Resident #1 was a heavy wetter and, due to uncertainty about when she could provide timely incontinence care, she applied double incontinence briefs. CNA #1 acknowledged that the use of double briefs was a violation of facility policy.On 6/9/26 at 10:21 AM, during an interview with the surveyor, the acting Director of Nursing confirmed that incontinence care should be provided every two hours and that it was against facility policy to use double incontinence briefs. On 6/9/26 at 10:32 AM, the surveyor conducted a telephone interview with the 11:00 PM-7:00 AM CNA (CNA #2) assigned to Resident #41 and Resident #51. CNA #2 stated that she provided incontinence care to Residents #41 and #51 twice during the 11:00 PM-7:00 AM shift and confirmed that the facility policy was to provide incontinence care every 2 hours.On 6/ 9/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) to discuss the above observations and concerns. The LNHA confirmed that nurses should provide incontinence care every 2 hours on all shifts and that the facility does not use double incontinence briefs for residents.A review of the facility's Continence Management policy dated 7/15/25 reflected .Patients who are incontinent of bladder or bowel will receive appropriate treatment for the prevention of incontinence-associated dermatitis (IAD). IAD refers to skin damage caused by prolonged or recurrent contact with stool and or urine .A review of the facility's Activities of Daily Living (ADLs) policy dated 3/20/26 reflected.Purpose: To ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and the patient's choices and preferences.A patient who is unable to carry out ADLs will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene.On 6/10/26 at 11:48 AM, the surveyor team met with the LNHA and RRN for exit conference, no further information was provided. NJAC 8:39-27.1 (a), (e), 27.2 (h)

Complaint #3031109 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to protect residents from misappropriation of resident specific controlled substance medication by the Director of Nursing. The deficient practice was identified for 5 of 5 unsampled residents, and was evidenced by the following:On 6/8/26 at 11:10 AM, the survey team was made aware by the Licensed Nursing Home Administrator (LNHA) of a Facility Reportable Event (FRE) dated 5/28/26, involving diversion of residents' controlled substance (CDS) medications (meds). The LNHA provided the survey team with the FRE. The surveyor reviewed the FRE dated 5/28/26, provided by the LNHA, which revealed the following: The summary indicated on 5/27/26, at approximately 6:00 PM, the Regional Nurse received a call from an employee [Licensed Practical Nurse (LPN #1)] relating to concerns with the CDS process at the facility. LPN #1 alleged that certain CDS meds were being ordered earlier than expected and then discontinued shortly after being dispensed. LPN #1 also alleged the Director of Nursing (DON) would take CDS meds out of the med cart on numerous occasions with no explanation as to why the meds were being removed since the residents still had active orders for that med. LPN #1 also alleged that the DON would come to the facility in the early morning hours and remove the CDS meds from the med cart shortly after being delivered. LPN #1 stated that declining inventory sheets were also missing, and when she had asked the DON about it, the DON stated the declining inventory sheets were in her possession.The investigation indicated that the DON was placed on leave pending an investigation. The investigation indicated that CDS meds and empty blister packages for CDS meds were in the DON's office without their dedicated declining inventory sheets. The most recent empty blister package was delivered on 5/26/26, and the empty blister packages were ordered by the DON. The residents who the empty blister packages belonged to still resided in the facility with active orders for the CDS meds. Interviews and investigation into the medication revealed that no residents went without their CDS meds. There was no evidence that the CDS meds were destroyed.The conclusion indicated that based on evidence found, the facility determined that the DON was not following processes for ordering, storage, security and destruction of CDS meds. The local police, dispensary pharmacy, Board of Nursing, and Drug Enforcement Agency (DEA) were notified, and all nurses were in-serviced on the narcotic shift-to-shift report and the Management of Controlled Substances. On 6/8/26 at 11:10 AM, the surveyor re-interviewed the LNHA, who stated that the DON was reordering as needed (PRN) CDS meds for residents who were not routinely using the as needed med. The LNHA continued that the DON reordered the med as if the resident was taking it at the frequency of the maximum allowed per directions, which could have been as soon as seven days after the facility received it for thirty doses. The DON reordered the CDS meds every five days, and then she took the CDS med upon delivery. The LNHA stated that the DON would come to the facility early in the morning and take the CDS med that she had ordered out of the med cart, and she would tell the nurses that she was locking them up. The LNHA stated they found six empty bingo cards in the DON's office for five residents with no associated declining inventory sheets. The LNHA stated that the DON appeared to only be ordering Oxycontin (a narcotic pain medication), and she had been doing that for six weeks. On 6/8/26 at 11:55 AM the surveyor interviewed the Interim DON (IDON), who was a Unit Manager at the time of the investigation. The IDON stated that the DON usually came into the facility before 7:00 AM, which was before he arrived, and sometimes the DON came as early as 4:000 AM. The IDON stated that the DON often stayed late and kept track of what CDS meds needed to be ordered. The DON also called the doctors herself for the residents' refills for their CDS meds. On 6/8/26 at 12:01 PM, the surveyor interviewed LPN #1, who stated that she called the Regional Nurse because of how the DON was removing CDS meds and the associated declining inventory sheets from the med carts felt strange to her since usually the nurse assigned to the med cart reordered the meds and not the DON. LPN #1 stated she questioned the DON about why a count was done and meds were removed without any documentation of where it was going, and the DON had told her that she was removing excess meds to give the staff less to count and she was checking the inventory of the CDS meds to see what needed to reorder. LPN #1 stated she was unaware how long it had been occurring for, but the residents always had their meds they needed and never went without. On 6/8/26 at 12:28 PM, the surveyor interviewed the Regional Registered Nurse (RRN) for the Provider Pharmacy. The RRN stated there were no concerns with how the CDS meds were being ordered because the CDS meds that were ordered had a legitimate orders and were not being ordered early. A review of the facility's Abuse Prohibition policy, dated revised 11/24/25, included that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all patients.Federals Definitions.Misappropriation of Patient Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of patient's belongings or money without patient's consent. NJAC 8:39-4.1(a)15

Based on interview, and review of facility documentation, it was determined that the facility failed to ensure that a Certified Nurse Aide (CNA) received at least 12 hours of mandatory in-service training education for 2 of 5 CNAs reviewed (CNA #1 and CNA#2). The deficient practice was evidenced by the following:On 6/9/26 at 9:00 AM, the surveyor reviewed the facility provided in-service education for five randomly selected CNAs for the year 2025, which revealed the following: CNA #1 with a date of hire (DOH) 4/11/23 had 7 hours of in-service training. CNA # 2, with a DOH 8/1/23, had 3 hours of in-service training. On 6/9/26 at 12:20 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Regional RN (RRN). On 6/10/26 at 8:05 AM, during an interview with the surveyor, the LNHA stated that the former Director of Nursing (DON) was responsible for CNA education and performance evaluations. The LNHA further stated that she generates quarterly reports to monitor staff completion of required online education. The LNHA explained that she follows up with department heads regarding any staff members who are not in compliance with the facility's education requirements. On 6/10/26 at 8:15 AM, the surveyor requested the CNA/staff education policy and procedure. On 6/10/26 at 11:47 AM, no further information was provided. N.J.A.C. 8:39-43.17(b)

Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify and report an irregularity for 1 of 6 residents, (Resident #12), reviewed for unnecessary medications.This deficient practice was evidenced by the following: On 6/4/26 at 1:00 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #12.A review of Resident #12's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; essential hypertension (high blood pressure) and bilateral osteoarthritis of the knee (a painful degenerative joint disease).A review of Resident #12's Comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 5/28/26, reflected that the resident had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated Resident #12 had severe cognitive impairment.A review of the resident's Order Summary Report (OSR, a listing of the resident's active meds and other orders) revealed the following:An order for Lidoderm Patch: Apply to the right knee in the morning for pain management; remove at bedtime per schedule, with a start date of 8/6/25.A review of the resident's electronic medication administration record (eMAR) for May and June 2025 revealed that the Lidoderm order was scheduled for application at 8:00 AM and removal at 7:59 AM the next day.A review of the care plan report revealed that the care plan documented that the resident's chart had been reviewed, but it did not reflect any irregularities in the timing of Lidoderm application and removal. On 6/9/26 at 10:50 AM, the surveyor interviewed the CP by telephone. The CP stated that they reviewed the eMAR and that the Lidoderm should be applied for 12 hours, then removed, leaving 12 hours without the patch before the next one is applied. The surveyor asked the CP if they would consider it an irregularity if the patch was scheduled at 8:00 AM and removed at 7:59 AM. The CP stated that they would comment on the timing. The surveyor stated that they could not locate any CP comment regarding the timing. The CP stated that they would investigate it.The CP did not provide any further information. The surveyor reviewed the manufacturer's package insert for Lidoderm patch, which reflected, under Dosage and Administration, . Apply the prescribed number of patches. only once for up to 12 hours within a 24-hour period. On 6/09/26 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) to discuss the above observations and concerns. On 6/10/26 at 11:20 AM, the survey team met with LNHA and RRN for responses. The LNHA stated that the Lidoderm patch time was adjusted.The facility did not provide any further information. The surveyor reviewed the facility's Consultant Pharmacist Provider Requirement, undated. The policy reflected . Reviewing medication/drug regimen.incorporating standards of care, professional standards, and documenting in the medical record; Timely communication to the facility of problems/issues detected, recommendations for changes. NJAC 8:39-29.3(a)(1)

Based on observations, interview, and review of facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration and documentation of medications and appropriately observe a resident while administering medications for 1 of 15 residents observed during initial tour.The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/3/26 at 10:28 AM, the surveyor observed Resident #5 seated in a wheelchair in their room. The surveyor observed the resident with a small cup containing various tablets and capsules. The resident stated that they normally take them right away, but today they didn't, and the nurse left them. The surveyor observed the resident finish taking the remaining meds. On 6/3/26 at 1:00 PM, the surveyor reviewed the electronic medical record (EMR) for Resident #5. A review of the admission Record (AR) (a document that includes pertinent resident information such as admission dates and diagnoses), which reflected that the resident had diagnoses that included but were not limited to; hypertension (high blood pressure), chronic diastolic congestive heart failure (when the heart can't fill properly after emptying), and a history of falling. A comprehensive Minimum Data Set (cMDS) (an assessment tool to facilitate the management of care), dated 2/28/26, included a brief interview for mental status (BIMS) score of 15 out of 15, indicating intact cognition.A review of the electronic medication administration record (eMAR), revealed 15 meds scheduled for 6:00AM, 8:00 AM, 9:00 AM and 1:00 PM.A review of the Order Summary Report (OSR), (a listing of the resident's current active physician orders), did not include an order for the resident to self-administer meds.A review of the comprehensive care plan (CCP), (relevant information about a patient's needs and goals of treatment), did not reflect the resident self-administering medications. On 6/4/26 at 12:05 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) on the South Nursing unit. The RN/UM confirmed that no residents on the unit had physician orders to administer their own medications. On 6/9/2026 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) to discuss the above observations and concerns. The LNHA confirmed that the staff should not leave medications at the bedside for a resident who has not been approved for self-administering medications. The facility did not provide any further pertinent information. The surveyor reviewed the policy titled Medication Preparation for Administering with a revised date of 2/16/22, which was provided by the LNHA. The policy did not mention resident self-administration of medications. NJAC 8:39-29.2(c)1-6

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a specialty low air loss mattress was accurately set and monitored according to the resident's weight for 1 of 6 residents (Resident #51). This deficient practice was evidenced by the following: On 6/8/26 at 8:15 AM, the surveyor observed Resident #51 in bed and a specialty mattress in place. The resident's air mattress pump was set at 250 pounds (lbs).On 6/8/26 at 10:30 AM, the surveyor reviewed the medical record for Resident #51.A review of the admission Record reflected Resident #51 was admitted to the facility with diagnoses that included but were not limited to; chronic kidney disease (the kidneys can no longer remove waste and extra fluid from the body) and dementia (decline in mental abilities).A review of the quarterly minimum data sheet (MDS), an assessment tool dated 5/28/26, reflected that Resident #51 had a brief interview for mental status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. The MDS further assessed that Resident #51 had a pressure-reducing device for their bed.A review of the current Order Summary Report included a Physician order (PO) for a pressure-redistribution mattress to bed, dated 7/9/24. A review of the current treatment administration record (TAR) included an air mattress was in place and to monitor every shift; check for placement and function with a start date of 11/18/24 and signed by nurses which indicated it was being monitored.A review of the resident's vital signs revealed the resident's last known weight was 123 lbs on 5/12/26.A review of Resident #51's care plan included a focus statement, the resident was at risk for skin breakdown related to advanced age, fragile skin, incontinence, limited mobility, and a history of pressure ulcer with interventions that included but were not limited to; pressure redistribution surface to bed (air mattress).On 6/8/26 at 8:20 AM, the surveyor showed the Licensed Practical Nurse (LPN) assigned to Resident #51, the gauge setting on the specialty mattress. The LPN acknowledged that the setting was 250 lbs. and stated that it should have been set to the resident's weight of 123 lbs. The LPN confirmed that the specialty mattress had been ordered to prevent and assist in the prevention of pressure ulcers and stated that maintaining the correct weight setting was important to ensure the effectiveness of the deviceOn 6/9/26 at 12:20 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) to discuss the surveyor's observations and concerns. The LNHA confirmed that the nurses should monitor the air mattresses for function, placement, and ensure the pump is set to the resident's weight.On 6/10/26 at 11:48 AM, the surveyor met with the LNHA and RRN for exti conference, no further information was provided.NJAC 8:39-27.1 (a)

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration of a medication according to the physicians' order for 1 of 3 residents observed during the facility's medication pass observation.The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/8/26 at 8:42 AM, while observing the medication pass (med-pass), the surveyor observed the licensed practical nurse (LPN) prepare and administer medications for Resident #102. The surveyor observed the LPN prepare to give the medication, ascorbic acid tablet 500 milligram (mg) (Vitamin C) Give 2 tablet by mouth one time a day for supplement. The surveyor observed the LPN select and prepare a bottle of ascorbic acid tablet 250mg and pour out 4 (four) tablets. The surveyor asked the LPN if that was the only ascorbic acid available in the medication cart (med cart). The LPN stated that they did not have 500mg tablets and it has been that way for several weeks.The surveyor concluded the observation.The surveyor reviewed the electronic medical record (EMR) for Resident #102 which revealed the following:An admission Record (AR) (a document that includes pertinent resident information such as admission dates and diagnoses) which reflected that the resident had diagnoses that included but were not limited to; essential hypertension (high blood pressure), and paroxysmal atrial fibrillation (periodic irregular heartbeat).A review of Resident #102's electronic medication administration record (eMAR) revealed an order for Ascorbic Acid Tablet 500mg Give 2 tablet by mouth one time a day for supplement that was administered 6/3/26 through 6/9/26. The eMAR also reflected that the order for Aspirin Enteric Coated (ASA EC 81) was discontinued, with an order for Aspirin oral tablet chewable 81mg (ASA Chew 81) being initiated after the surveyor observation.A Physician Order Summary (POS) (a document detailing medication or other orders), reflected an order dated 6/3/26, Ascorbic Acid tablet 500mg Give 2 tablet by mouth one time a day for supplement. On 6/9/26 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) to discuss concerns. The surveyor discussed the results of the med-pass observation with the LNHA and RRN and asked if there is an expectation that the staff follow physicians' orders. The LNHA stated yes, they should and that if a medication was not available the MD should be contacted for an alternate.On 6/9/26 at 12:45 PM, the LHNA provide the surveyor with a facility policy titled, Medication Preparation for Administering with a revised date of 2/16/22. The policy reflected, under Procedure: D. 1. Confirm that medication name and dose are correct. The policy did not reflect anything regarding substituting medications if one is not available.On 6/10/25 at 10:17 AM, the survey team met with the DON for any responses to concerns. The LNHA stated that the Vitamin C order was updated. The facility did not provide any further pertinent information. NJAC 8:39-29.2(d)

Complaint Intake ID 2980927 Based on observation, interview and record review, it was determined that the facility failed to thoroughly investigate an unwitnessed fall for Resident #99, 1 of 5 residents reviewed for accidents. This deficient practice was evidenced by the following: A review of Resident's #99 admission Record, reflected the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; metabolic encephalopathy (caused by chemical imbalances in the blood, organ failure, or systemic illness), anoxic brain injury (occurs when the brain is completely deprived of oxygen), paraplegia (paralysis that affects your legs) It further revealed a discharge date of 4/26/26.A review of the Quarterly Minimum Data Set (MDS), an assessment tool revealed Resident #99 had a Brief Interview for Mental Status (BIMS) score of 00 (which indicated severely impaired cognition) and that the resident required extensive assistance of two staff members for bed mobility, transfers and toileting.A review of the incident / accident report, dated 4/12/26, provided by the facility revealed an unwitnessed fall without injury around 7:30 am on 4/12/26. Resident #99 was found on the floor mat beside the bed. The resident was put back to bed by 2 nurses and 2 certified nursing assistants. The primary physician and the resident's wife were notified. Neurological evaluations were ordered and started.The facility was unable to provide statements from staff about the fall, and the neurological checks status post the fall on 4/12/26.On 06/10/26 at 12:45 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and Regional Registered Nurse (RRN) agreed and acknowledged the surveyor concerns for the facility's incomplete investigation and lack of supporting documents. the LNHA stated that they could not find the supporting documents which should have been kept with the investigation. A review of the facility policy, Falls Management Policy, with a revised date of 1/15/26, which revealed.5.3- any patient who has an unwitnessed fall will be observed for neurological abnormalities by performing neurological checks. 5.6- document circumstances of the fall, post fall assessment, and patient outcome.A review of the facility policy, Accidents /Incidents, with a revision date of 3/1/24, revealed. Policy: center staff will report, review, and investigate all accidents and incidents which occurred.purpose: to determine root cause and contributing factors, identify measures to reduce further occurrences and adverse outcomes.to meet regulatory requirements.4.1-the administrator or designee will coordinate all investigations.NJAC 8:39-4.1(a)5

Based on observation, interviews, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the dumpster and surrounding area free of garbage and debris. On 2/4/25 at 9:47 AM, the surveyor toured in the presence of the Food Service Director (FSD) toured the kitchen and the designated garbage area and observed the following: There was garbage debris that included food wrapper, cups, gloves, paper products, and medication cups, surrounding the dumpster and surrounding areas. The FSD stated that the area should have been clean by the maintenance and dietary departments. On 2/10/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Clinical Lead (RCL) who were informed of the surveyor's findings. The LNHA stated the garbage area should be kept free of debris. On 2/10/25 at 12:50 PM, the DON provided the surveyor with a copy of the facility policy titled, trash Removal, with a revised date of 3/1/24. Under the process section of the policy it states, 7. The trash container is scheduled to be cleaned on regular cleaning cycle or when visibly soiled. On 2/11/25 at 11:14 AM, the surveyor met with the LHNA, DON, RCL and Marketing Clinical Advisor (MCA) for the exit conference. No further information provided by the facility staff. NJAC 8:39-19.7

Repeat Deficiency Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 2/4/25 at 9:47 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour: 1. In the dry storage area, the surveyor observed a 16 ounce (oz) opened bottle of maple syrup labeled with a use by date of 1/1/24 and an opened 1 gallon opened container of cooking oil labeled with a use by date 1/5/24. The FSD stated both of those items should have been discarded per the use by date. 2. In the walk-in refrigerator, the surveyor observed a 1-gallon opened fat free Italian dressing without a label displaying the open and use by dates. The surveyor also observed a blackish dust like substance on the fan grate of the refrigerator. observed with a black colored substance. The FSD stated the Italian dressing should have been discarded and the fan grate would be cleaned by the maintenance department immediately. 3. On the chef preparation table, the surveyor observed a 1 gallon opened container of Red Wine Vinegar labeled with a use by date of 1/5/25. The FSD stated the vinegar should have been discarded per the use by date. On 2/10/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON) and Regional Clinical Lead (RCL) to review facility concerns. The LNHA stated all items in the kitchen should be discarded by their use by dates. On 2/10/25 at 12:50 PM, the DON provided the surveyor with copies of three facility policies. The facility policy titled, Food Storage Dry Goods with a revised dated of 2/2023, stated under the procedures section, 6. Storage areas will be meat, arranged for easy identification, and date marked at appropriate. The facility policy titled, Food Storage: Cold Foods with a revised date of 2/2023, stated under the procedures, 5. All foods will be stored wrapped or in covered containers, labeled and dated. The facility policy titled, Equipment with a revised date of 9/2017, stated under the procedures sections, 1. All equipment will be routinely cleaned and maintained .4. All non-food contact equipment will be cleaned and free of debris. On 2/11/25 at 11:14 AM, the surveyor met with the LNHA, DON, RCL and Marketing Clinical Advisor (MCA) for the exit conference. No further information provided by the facility staff. NJAC 8:39-17.2(g)

Based on interviews, and review of pertinent facility documents, it was determined that the facility failed to (a). provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of the receipt of a controlled substance for 6 of 6 Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on three Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed and (b) to follow a physician orders (PO) for the administration of blood pressure medications for 1 or 1 resident's (Resident#60) reviewed for blood pressure management. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 2/05/25 at 11:15 AM, the surveyor reviewed a binder provided by the Director of Nursing (DON), containing, but not limited to; facility DEA 222 Forms, copies of medical director state and federal controlled substance registration certificates, and packing slips associated with the DEA 222 Forms for controlled substance deliveries. A review of the facility DEA 222 Forms that were filled out and used to order controlled substances (CDS) revealed the following: DEA 222 Form with order form # 231868319 dated 01/09/24, for one box of five (5) Fentanyl 25 microgram (mcg) patches, one box of five (5) fentanyl 50 mcg patches, thirty (30) tablets of oxycodone 15 milligram (mg) tablets, fifty (50) tablets of oxycodone 5 mg tablets, and thirty (30) tablets of oxycodone/acetaminophen 5/325 mg tablets (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was present. DEA 222 Form with order form # 231868317 dated 02/26/24, for one box of five (5) Fentanyl 25 mcg patches, one box of five (5) fentanyl 50 mcg patches, one box of five (5) fentanyl 12 mcg patches, twenty (20) tablets of Morphine Sulfate SA (extended release) tablets, thirty(30) tablets of oxycodone 5 mg tablets, and twenty (20) tablets of oxycodone 15 mg tablets (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was present. DEA 222 Form with order form # 231868325 dated 04/02/24, for two boxes of five (5) Fentanyl 25 mcg patches, two boxes of five (5) fentanyl 50 mcg patches, one box of five (5) fentanyl 12 mcg patches, fifty (50) tablets of oxycodone 5 mg tablets, and 5 cups of five (5) ml of morphine sulfate 10 mg/5ml liquid (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was present. DEA 222 Form with order form # 231868321 dated 05/22/24, thirty (30) tablets of hydromorphone 2 mg tablets, and thirty (30) tablets of morphine sulfate immediate release 15 mg tablets (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was present. DEA 222 Form with order form # 240840168 dated 10/03/24, thirty (30) tablets of hydromorphone 2 mg tablets, and thirty (30) tablets of morphine sulfate immediate release 15 mg tablets (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was present. DEA 222 Form with order form # 240840167 dated 12/02/24, thirty (30) tablets of oxycodone 5 mg tablets (a schedule II-CDS used for pain) with the section Part 5: to be filled in by purchaser, number received, date received, not filled in. A supplier packing slip for the items was present. On 02/05/25 at 11:10 AM, the surveyor in the presence of the Director of Nursing (DON) reviewed all the above DEA 222 forms. After reviewing all the above DEA 222 forms the DON acknowledge that none of the above DEA 222 forms were filled out under part 5 which was the section that was supposed to be filled out by the purchaser (the facility) which will include documenting the quantity received and the date received. b). On 02/05/25 at 10:19 AM, the surveyor observed Resident #60 in their room, the resident was observed seated in a chair and was watching television. The resident was alert and oriented and was wearing a knee brace on their left knee. The surveyor reviewed Resident #60's medical record. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/03/24, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15 which indicated that the resident was cognitively intact. A review of the Order Summary Report (OSR) revealed a PO dated 09/19/24, Cozaar Tablet 25 MG (milligrams) (Losartan), give 1 tablet by mouth one time a day for hypertension. Hold for SBP (systolic blood pressure-top number of blood pressure) below 110. A review of the December 2024 electronic Medication Administration Record (eMAR) revealed a PO dated 09/19/24, for Cozaar tablet 25 mg tablet, give 1 tablet by mouth one time a day. Hold for SBP less than 110. Further review of eMAR revealed that the Cozaar 25 mg tablet was signed as administered ten (10) times without the resident's blood pressure (BP) being documented on the eMAR on the following days: 12/01/24, 12/07/24, 12/8/24, 12/09/24, 12/13/24, 12/19/24, 12/21/24, 12/22/24, 12/25/24 and 12/30/24. A review of the January 2025 eMAR revealed a PO dated 09/19/24, for Cozaar tablet 25 mg tablet, give 1 tablet by mouth one time a day. Hold for SBP less than 110. Further review of eMAR revealed that the Cozaar 25 mg tablet was signed as administered fourteen (14) times without the resident's BP being documented on the eMAR on the following days: 01/04/25, 01/05/25, 01/06/25, 01/10/25, 01/13/25, 01/14/25, 01/16/25, 01/18/25, 01/19/25, 01/21/25, 01/24/25, 01/26/25, 01/27/25, and 01/30/25. A review of the February 2025 eMAR revealed a PO dated 09/19/24, for Cozaar tablet 25 mg tablet, give 1 tablet by mouth one time a day. Hold for SBP less than 110. Further review of eMAR revealed that the Cozaar 25 mg tablet was signed as administered two (2) times without the resident's BP being documented on the eMAR on the following days: 02/01/25 and 02/02/25. On 02/05/25 at 11:00 AM, the surveyor reviewed Resident #60's eMAR in the presence of a South unit Licensed Practical Nurse (LPN#1). The LPN acknowledge that Cozaar had a perimeter to hold for BP less than 110 and that on multiple occasions from December 2024 through February 2025 a nurse omitted documenting the resident's blood pressure when administering the resident's Cozaar. She further stated that since they had no blood pressure documented on the eMAR that there was no way to tell what the resident's systolic BP was when the medication was administered. She further stated that when a resident had perimeters to hold a medication that the blood pressure needs to be documented on the eMAR. On 02/10/25 at 12:05 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing (DON) and the Regional Nurse to discuss the above concerns. There was no additional information provided. A review of the facility's policy titled Controlled Drugs: Management that had a revision date of 01/31/25 revealed the following: Receipt: Controlled substances are received in separate containers with separate invoices. Licensed nursing staff must accept delivery and take responsibility for receipt of controlled substances. A review of the facility's policy titles Medication Administration that had a revision date of 01/2025 revealed the following: Under Medication Administration: 2. Obtain and record any vital signs as necessary prior to medication administration. NJAC 8:39-11.2 (b), 29.2 (d)

Based on interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities in the resident's medical record, to the facility staff, and attending physician. This deficient practice was identified for one (1) of twenty (24) residents reviewed, (Resident #60) for medication management and was evidenced by the following: On 2/5/25 at 10:19 AM, the surveyor observed Resident #60 in their room, the resident was observed seated in a chair and was watching television. The resident was alert and oriented and was wearing a knee brace on their left knee. The surveyor reviewed Resident #60's medical record. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood). A review of the annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 12/03/24, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15 which indicated that the resident was cognitively intact. A review of the Order Summary Report (OSR) revealed a physician's order (PO) dated 9/19/24, Cozaar Tablet 25 MG (milligrams) (Losartan), give 1 tablet by mouth one time a day for hypertension. Hold for SBP (systolic blood pressure-top number of blood pressure) below 110. A review of the December 2024 electronic Medication Administration Record (eMAR) revealed a PO dated 9/19/24, for Cozaar tablet 25 mg tablet, give 1 tablet by mouth one time a day. Hold for SBP less than 110. A Further review of eMAR revealed that the Cozaar 25 mg tablet was signed as being administered ten (10) times without the resident's blood pressure (BP) being documented on the eMAR on the following days: 12/1/24, 12/7/24, 12/8/24, 12/9/24, 12/13/24, 12/19/24, 12/21/24, 12/22/24, 12/25/24 and 12/30/24. A review of the January 2025 eMAR revealed a PO dated 9/19/24, for Cozaar tablet 25 mg tablet, give 1 tablet by mouth one time a day. Hold for SBP less than 110. A Further review of eMAR revealed that the Cozaar 25 mg tablet was signed as administered fourteen (14) times without the resident's BP being documented on the eMAR on the following days: 1/4/25, 1/5/25, 1/6/25, 1/10/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/19/25, 1/21/25, 1/24/25, 1/26/25, 1/27/25, and 1/30/25. A review of the February 2025 eMAR revealed a PO dated 9/19/24, for Cozaar tablet 25 mg tablet, give 1 tablet by mouth one time a day. Hold for SBP less than 110. Further review of eMAR revealed that the Cozaar 25 mg tablet was signed as administered two (2) times without the resident's bp being documented on the Emar on the following days: 2/1/25 and 2/2/25. On 2/5/25 at 11:00 AM, the surveyor reviewed Resident #60's eMAR in the presence of a South unit Licensed Practical Nurse (LPN#1). The LPN acknowledge that Cozaar had a perimeter to hold for BP less than 110 and that on multiple occasions from December 2024 through February 2025 a nurse omitted documenting the resident's blood pressure when administering the resident's Cozaar. She further stated that since they had no blood pressure documented on the eMAR that it was no way to tell what the resident's systolic BP was when the medication was administered. She further stated that when a resident had perimeters to hold a medication that the blood pressure needs to be documented on the eMAR. The LPN further stated that this was something that the Consultant Pharmacist (CP) would identify during their monthly medication reviews. The surveyor reviewed the Consultant Pharmacist's Medication Regimen Review from December 2024 through February 2025 which revealed that the CP failed to identify that the facility nurse was not documenting the resident's BP for a medication that had a perimeter to hold a blood pressure medication. On 2/10/25 at 10:15 AM, the surveyor called the CP who told the surveyor that she was unable to answer any questions because she was on medical leave. She gave the phone number of her supervisor. The surveyor left a message with the supervisor and never received a follow-up phone call. On 2/10/25 at 11:00 AM, the surveyor interviewed the Director of Nursing (DON) who told the surveyor that it was the CP's responsibility to identified and then notified the facility when a nurse are not documenting the BP for a resident who has a perimeter to hold a blood pressure medication. On 2/10/25 at 12:05 PM, the surveyor presented the above concerns to the facility administrative staff which included the Licensed Nursing Home Administrator (LNHA). The DON and the Regional nurse. No further information was provided. On 2/10/25 at 12:05 PM, the surveyor met with the Licensed Nursing Home Administrator, Director of Nursing (DON) and the Regional Nurse to discuss the above concerns. There was no additional information provided. A review of the facility's policy for Consultant Pharmacist Services Provider Requirements dated 1/31/23 included the following: Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected, and other findings related to medication therapy orders at least monthly. Communicate recommendations for changes in medication therapy and the monitoring of medication therapy. NJAC 8:39-29.3

Based on observation, interview, and record review, the facility failed to provide care and services to maintain nutrition status and prevent weight loss for one of three residents reviewed for nutrition (Resident (R) 56). Due in part to the failure to communicate R56's ongoing, significant weight loss to the interdisciplinary team, implement nutritional interventions that were recommended and closely monitor the resident's weight, R56 experienced a significant unintentional weight loss which resulted in his inability to maintain a healthy weight. Findings include: Review of R56's Admission Record, located in R56's electronic medical record (EMR) under the Profile tab indicated he was admitted on [DATE] with diagnoses which included pneumonia, respiratory failure, hematuria, and dementia. Review of R56's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/22 revealed that R56 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed R56 was independent with eating and weighed 160.9 pounds (lbs.) on 07/07/22. Review of R56's weights under the Weights/Vitals tab in the EMR documented the following weights. On 7/7/22 160.9 lbs. On 8/3/22 146.6 lbs. On 8/30/22145.3 lbs. On 9/6/22 145.6 lbs. On 10/1/22 149.9 lbs. On 10/26/22 133.8 lbs. On 11/10/22 136.8 lbs. On 12/1/22 132.6 lbs. On 1/18/23 131.6 lbs. Review of the Nutrition assessment dated [DATE], found in the EMR under the Assessments tab revealed R56's height was 72 inches tall, and his body mass index (BMI) was 18.0 (underweight.) The resident's current body weight was 132.6 pounds. He was noted to be losing weight despite meeting his needs on most days. R56 remained on a Regular/Pureed diet with a good appetite. By mouth (PO) intake was reported at greater then [>]75 percent (%) for most meals. He had lost 28.3lbs /17.6% BW times (x) 180days/Sig; and 13.0lbs /8.9% x 90 days/Sig. He received the house supplement every day. Problem/Etiology/Statement (PES) revealed a nutrition diagnosis of underweight as related to Decreased ability to consume sufficient energy and protein as evidenced by BMI of 18/underweight RD's [Registered Dietician] nutrition plan documented that she would discuss w/[with] care team as the resident is exceeding needs on most days and should not be losing weight. RD will monitor. Review of R56's Physician's Orders located in R56's EMR under the Orders tab indicated an order for a Regular diet, Dysphagia Advanced texture, Thin Liquids; Feeding assistance- alternate bite/sip and slow pace activated on 11/15/2022. Another order indicated a House Supplement one time a day, 118 milliliters (ml) q[per] daily, for additional energy and protein activated on 01/23/22. Review of the R56's Care Plan located in the EMR under the Care Plan tab, initiated on 07/08/22 and revised on 12/30/22 listed a Focus: a nutrition problem r/t [related to] unintended weight loss, Goals initiated on 07/08/22 were to maintain a BW 133+/- [plus or minus] 5 lbs. (revised on 01/03/23) and R56 will tolerate dysphagia advance diet as ordered (revised on 11/05/22) and R56 will complete 75% of 3 meals per day (revised on 11/05/22) and R56 will complete 75% of house supplement q daily (revised on 11/15/22.) R56 interventions included: Honor food preferences as able; Pudding at 2:00PM (Snack 2 (S2)) (initiated on 07/08/22), provide and serve Dysphagia Advance Diet as ordered (initiated on 07/08/22, revised on 09/30/22) provide and serve house supplement as ordered (initiated 08/19/22, no revision date) and the resident will be weighed 1x/month or more if necessary to monitor weight (initiated on 07/08/22, revised on 01/03/23.). There were no revisions to the care plan following R56's 14.3lb weight loss on 08/03/22, a significant weight loss of 8.8% in one month; and his 16.1lb weight loss on 10/26/22, a significant weight loss of 10.74% in one month from 10/01/22. Review of R56's Nutrition/Dietary Note, dated 08/16/22 located in R56's EMR under the Progress Notes tab indicated that the Registered Dietitian (RD) would implement a three day meal monitor to assess energy intake. A house supplement was also started at S2. There was no documentation of the three day meal monitor in the EMR and no intervention added to the care plan. Review of R56's Nutrition/Dietary Note, dated 12/13/22 located in R56's EMR under the Progress Notes tab indicated that the RD would implement magic cup frozen supplement one time a day. This intervention was not added to the care plan and there was no documentation in the EMR that it was added to the resident's orders. Review of a R56's Nutrition/Dietary Note dated 11/11/22 located in R56's EMR under the Progress Notes tab indicated that the RD would implement pudding twice a day and double portions. These interventions were not added to the care plan. Review of R56's Nutrition/Dietary Note dated 01/18/23 located in R56's EMR under the Progress Notes tab indicated that the RD would address weight loss with the care teams. No further follow up is documented in the progress notes. Review of R56's Nursing Progress Notes dated 07/07/22 through 01/25/23 made no mention of any significant weight losses noted during that time period. Review of R56's Physician Progress Notes dated 07/07/22 through 01/25/23 made no mention of any significant weight losses noted during that time period. During an interview on 01/24/23 at 3:17 PM, Certified Nursing Assistant (CNA) 1 stated R56 required total care assistance, he knew everything that was going on. CNA1 stated that the resident has been here over the past six months and that with direction he can turn himself. He can tell you if he needs assistance. He has a good appetite, but he can't stop losing weight, he eats everything sometimes he even asks for snack. He can feed himself, gets a shake regularly. He got a shake at 2pm, he asks for other items like food etc. CNA1 stated that they document his intake in the computer, sometimes he complains about a stomachache and she tells the nurse. During an interview on 01/24/23 at 3:48 PM, the director of Physical Therapy stated that they had just picked R56 back up for therapy. She stated that he was not the same functional status that he was when he was discharged from therapy. She stated that he was moving around well, then started to decline from 10/14/22-11/16/22 so they were able to pick him up from their quarterly screen. During an interview on 01/26/23 at 11:14 AM, the RD stated that R56 eats everything, the weight loss is confounding, he gets a supplement. The RD stated that she was bringing it up as a medical issue now and she did not know why there has not been any follow up. The RD also stated she did not remember if she told the Nurse Practitioner (NP) or the Physician's Assistant (PA) about the weight loss. She indicated that she speaks to the physician on the days that he was at the facility. She had not called the physician about the weight loss but asked the surveyor if she should. The RD stated that there was a NP and a PA that she would tell normally but they had not had a morning meeting. The RD stated she thought she brought it up on the 18th or the 20th of January 2023, and thought they said, okay we will look at it. During a lunch observation of R56 on 01/26/23 at 12:31 PM, he was independently eating his lunch, One half a tuna salad sandwich had already been eaten. R56 stated that he never gets double portions of food and he didn't get any today. Review of the facility's policy titled, Nutrition/Hydration Management revised 06/01/21 revealed To provide safe and effective care to manage patients' nutrition and hydration needs .Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration .Revise patient's care plan as needed. NJAC 8:39-17.1(c) NJAC 8:39-17.2(d) NJAC 8:39-27.2(e)