Every finding on record at King Manor Care and Rehabilitation Center

Based on observation, interview and record review, it was determined that the facility failed to ensure staff provided care in a manner for residents to attain their highest practicable physical and psychosocial well-being by ensuring processes were put in place a.) to identify a change in condition in a timely manner, b.) to assess any decline in the functional status of a resident (Resident #58) who required assistance with bathing and was not provided a shower for over three months, and c.) to ensure a recommended physician follow-up appointment was scheduled. On 3/25/26, Resident #58 asked the surveyor to assist them in obtaining a shower, who was then showered, and the resident had a skin assessment completed by the physician who identified bilateral lower extremity cellulitis (infection) that required antibiotic treatment. This deficient practice was identified for 1 of 3 residents (Resident #58) reviewed for quality of care. The facility further failed to ensure processes were in place d.) to ensure for twelve days a resident (Resident #7) was provided their wheelchair after a room to change to get out of bed and e.) ensure a physician's order for the application of bilateral ace wraps to a resident's (Resident #8) lower extremities was followed. This deficient practice was identified for 3 of 3 residents reviewed for quality of care and physician's orders (Resident #7, #8 and #58), and was evidenced by the following: A review of the facility's policy titled Change in a Resident's Condition or Status, last updated December 2025, included that the facility will promptly notify the resident, his or her representative or his or her physician of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, reside rights, etc.) .1.The nurse will notify the resident's attending physician on call when there has been a (an): Accident or incident involving the resident; Discovery of an injury of unknow origin; Adverse reaction to medications; Needs to alter the resident's medical treatment significantly; Significant change in the resident's physical, emotional/mental condition; Need to transfer the resident to a hospital/treatment center; Discharge without proper medical authority; and or; Specific instructions to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in a resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting); Impacts more than one area of the resident's health status; Requires interdisciplinary review/or revision to the care plan; and ultimately is based on judgement of the clinical staff and the guidelines in the Resident Assessment Instrument. 3.Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.6. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or status.8. The nurse will record information in the resident's medical record relative to changes in the resident's medical/ mental condition or status. 1.On 3/22/26 at 8:40 AM, the surveyor observed Resident #58 sitting in their room, in a wheelchair, eating breakfast. Resident #58 had no slippers/socks on their feet that were placed directly on the floor. Both feet appeared discolored, reddened, swollen, and covered with dry scaly skin. The top of the resident's left foot had clear fluid weeping that was running onto their left foot through their toes. Their third toe on their right foot had a bluish color and appeared swollen and tight. The resident asked the surveyor to return after breakfast, and the surveyor exited their room to continue their tour. On 3/22/26 at 10:08 AM, the surveyor returned to Resident #58's room and the resident was sitting in the same position as observed at 8:40 AM, still dressed in their pajamas. On 3/23/26 at 9:15 AM, the surveyor returned to Resident #58's room and observed the resident sitting in their wheelchair by the bed. Their feet again were bare and appeared swollen, covered with dry scaly skin, and had some discoloration. Resident #58 had both feet resting on the floor. The resident had the same pair of pajamas as observed on 3/22/26 at 8:40 AM. Resident #58 informed the surveyor that they wanted to talk with them at another time. The surveyor exited the room and interviewed a Certified Nursing Aide (CNA) regarding where the documentation was located for a shower log. The CNA escorted the surveyor to the nursing station and provided the shower logbook for review. According to the log provided, Resident #58 was scheduled to have a shower every Sunday during the 7:00 AM-3:00 PM (7-3) shift, and on Thursday during the 3:00 PM-11:00 PM (3-11) shift. The surveyor reviewed the assignment sheets and observed that Resident #58 was scheduled for a shower on 3/22/26. A skin assessment was also supposed to be completed on shower days. According to the Treatment Administration Record (TAR), the nurses had signed the TAR indicating that a skin assessment was completed on Resident #58 and there were no skin issues on 3/22/26. On 3/24/25 at 8:45 AM, the surveyor observed Resident #58 in their room still eating breakfast and the resident had asked the surveyor to return in thirty minutes. The surveyor returned to the room at 9:50 AM, and observed Resident #58 sitting in their wheelchair still wearing the same pair of pajamas observed on 3/22/26 at 8:40 AM. The resident's feet were swollen and appeared to have more discoloration. The surveyor interviewed the resident and inquired if they received assistance with care. The resident replied, I used to ride my bike for two hours every day to go to work, and then I was involved in an accident, was in a coma for some time, and then ended up here. The resident continued that, I used to do things on my own but now you must ask, and ask, I have been asking for assistance with a shower for quite some time and I could not get a shower. The resident stated to the surveyor Do you think you can help me to get a shower? The surveyor then asked the resident when the last time they were showered and the resident replied, The last time I had a shower was in January. The surveyor then conducted a follow-up review of the TAR, which verified that staff had signed that Resident #58 received a shower on Sunday, 3/22/26. At that time, the surveyor reviewed Resident #58's TAR with the Unit Manager (UM), who stated that staff did not report any refusal of care for the resident. The UM then stated that Resident #58 was independent with care and required only minimum assistance with care. According to the TAR, Resident #58 received a shower twice a week on their assigned days, Sunday and Thursday. The surveyor reviewed the electronic medical record for Resident #58. A review of the admission Face Sheet, an admission summary, reflected that Resident #58 was admitted to the facility with diagnoses which included but were not limited to; anemia, unspecified type 2 diabetes, with unspecified complications, peripheral vascular disease (a condition characterized by narrow arteries that reduce blood flow to the limbs), and unspecified osteoarthritis. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 2/27/26, reflected that Resident #58 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated an intact cognition. A further review of the MDS, revealed for Section GG Functional Abilities, that the resident had no upper or lower extremity impairments and required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for showering/bathing. A review of the resident's 12-page Care Plan (CP), provided by the facility on 3/25/26 at 11:42 AM, revealed that resident had an activities of daily living (ADLs) self-care performance deficient related to lack of motivation and forgetfulness, initiated on 12/2/19. The goal was to maintain current level of function in ADL function and in ADL tasks through the review date, initiated on 12/2/19. The interventions all initiated on 12/2/29, included for bathing/showering: resident can bathe and dress upper body and needs staff encouragement to do so, shower days are Sunday 7-3 and Thursday 3-11, physical and occupational therapy as ordered, and dressing: [Resident #58] is able to: dress [themselves] with staff reminders to change clothing. All the interventions were initiated on 12/2/19, and the CP had not been revised to make it current. A review of a Consultation Note from the Vascular Doctor indicated that Resident #58 was last seen on 7/21/25. Resident #58 had diagnoses of peripheral vascular disease and chronic venous insufficiency (not enough blood flow to the legs). Resident #58 was seen at that appointment for a three-month follow-up post bilateral leg revascularization (a procedure that aims to restore blood flow to the legs) and was scheduled to follow-up with Vascular Health in six months. A review of the medical record revealed Resident #58 missed their scheduled appointment for their Vascular Health follow-up on 1/26/26. On 3/25/26, the surveyor reviewed the consultation with the UM and inquired about the follow-up. The UM reviewed the calendar at the nursing station and informed the surveyor that they could not locate the appointment for the Vascular Doctor. During surveyor observations between 3/22/26 to 3/25/26, the surveyor observed Resident #58 with their lower extremities discolored, appeared swollen, and their lower extremities were covered with dry scaly skin. The left foot dorsal area was weeping clear fluid. The third digit of their right foot appeared tight with some discoloration. Resident #58 had a skin check documented as completed on 3/22/26, which indicated that their skin was intact. On 3/25/26, the surveyor accompanied by the UM went to Resident #58's room, and the UM confirmed the observation of Resident #58's lower extremities that were swollen with discoloration, dry and scaly. On 3/25/26 at 10:47 AM, during a telephone interview with the Medical Director, who was Resident #58's physician, the surveyor asked if the facility had informed her of the condition of Resident's 58's lower extremities and she stated that she had not been contacted by the facility regarding Resident #58's lower extremities. On 3/25/26 at 10:53 AM, after surveyor inquiry, the UM documented in the Progress Notes that Resident #58 was noted to have bilateral lower extremity edema (fluid retention) that was more on their left side, with weeping area on their left ankle. The UM documented that the Medical Director was notified and ordered for bilateral venous doppler and to re-consult the Vascular Doctor. On 3/26/26 at 9:00 AM, the surveyor further reviewed the medical record which included a Physician Note dated 3/25/26 at 5:04 PM, that revealed the resident had complaints of bilateral pain and left lower extremity swelling. The left lower extremity was swollen erythematous (abnormal redness of the skin) and painful to touch. No fever. Skin dry, bilateral legs painful left leg worse, lower leg swelling. Physical examination: Chief Complaint weak pulse palpable. Left lower extremity erythematous from the knee down and painful to touch.Assessment: Bilateral leg cellulitis (potentially serious bacterial skin infection and underlying tissue) with the left side worse. The plan was to start Bactrim (a broad-spectrum antibiotic), monitor for changes, and a vascular consult and venous doppler were ordered. On 3/26/26 at 11:30 AM, the UM provided a note dated 3/26/26, that the appointment was canceled on 1/21/26 and 2/16/26, due to a scheduling conflict. The UM did not provide any additional information as to why the information was not documented in the medical record and further stated that Resident #58 had an appointment scheduled for 3/26/26, as ordered by the Medical Director. 2. During the initial tour of the facility on 3/22/26 at 10:15 AM, the surveyor observed Resident #7 in bed. Resident #7 was alert and able to participate in the interview. On 3/23/26 at 8:35 AM, the surveyor observed Resident #7 in bed. The breakfast tray was on the bedside table. The resident asked the surveyor to raise the head of the bed to assist with the meal. The surveyor informed the resident that they would notify the staff. The surveyor left the room and informed a staff member in the hallway. The staff entered the room and assisted the resident. On 3/24/26 at 9:15 AM, the surveyor observed Resident #7 in bed. The surveyor then asked Resident #7 if they ever got out of bed. Resident #7 replied, I would love to get out of the bed, but I do not have a wheelchair. On 3/24/26 at 10:30 AM, the surveyor conducted a brief review of Resident #7's medical record. The record revealed that Resident #7 had a history of pressure ulcer and was bedridden. On 3/24/26 at 10:45 AM, the surveyor interviewed the Unit Manager (UM) and inquired about Resident #7's status. The UM stated that Resident #7 was transferred to this unit on 3/12/26. The surveyor accompanied the UM to the room, and the resident was able to restate in the presence of the UM, that they would like to get out of bed, but they do not have a wheelchair. At that time, the UM stated that the resident was transferred from another unit, and the resident's wheelchair was not transferred with the resident (twelve days prior). The UM stated she would inquire about their wheelchair. On 3/24/26 at 11:30 AM, the surveyor interviewed the Certified Nurse Aide (CNA #1) who cared for Resident #7 regarding their pressure sore. CNA #1 informed the surveyor that the pressure sores were healed. The surveyor followed CNA #1 to the room and verified during an incontinence check that the skin was intact. The surveyor reviewed Resident #7's medical record. A review of the admission Face Sheet reflected that Resident #7 was admitted to the facility with diagnoses which included but were not limited to; wedge compression fracture of second lumbar vertebra, adult failure to thrive, and unspecified atrial fibrillation (heart rhythm disorder). A review of the most recent quarterly MDS dated [DATE], revealed that Resident #7 had a BIMS score of 08 out of 15, which indicated a moderate cognitive impairment. A review of Resident #7's CP provided by the facility on 3/25/26, included a focus area for ADL self-care performance deficit related to activity intolerance and fatigue. The goal was for Resident #7 to maintain current level of function through the review date with a target date of 6/10/26. The interventions included: Out of bed daily to tilt in space via Hoyer lift, initiated on 11/27/24. Transfer: The resident required a mechanical lift transfer with (2) staff assistance for transfers, initiated on 1/2/25. Monitor/document /report as needed any potential for improvement, reasons for self-care deficit, expected course, declines in function, initiated on 1/2/25. On 3/24/26 at 11:15 AM, the surveyor interviewed CNA #1, who stated that usually Resident #7 refused to get out of bed, but she did not ask Resident #7 that morning if they would like to get out of bed. On 3/25/26 at 9:15 AM, the surveyor observed the resident out of bed in a wheelchair. The resident was smiling. On 3/25/26 at 9:45 AM, the surveyor interviewed CNA #2, and inquired if the resident was resistive with care or refused to get out of bed, CNA #2 stated no. CNA #2 stated that she worked for hospice, and she was informed and now provided with a wheelchair for Resident #7 to get out of bed. The surveyor reviewed the resident's Progress Notes from 3/12/26 through present, which did not include any documentation that Resident #7 refused to get out of bed. On 3/26/26 at 9:30 AM, the surveyor observed Resident #7 in activities. Resident #7 was alert and actively participating. 3. On 3/22/26 at 9:36 AM, the surveyor observed Resident #8 sitting up in a wheelchair wearing an ace wrap on their right leg and wearing black shoes. The surveyor observed bilateral edema to their lower extremities. The resident stated the ace wrap was only on their right leg because they did not have one for the left, and I think they lost it. Resident #8 also stated that they previously wore ace wraps on both legs. On 3/23/26 at 8:55 AM, the surveyor observed Resident #8 out of bed sitting in a wheelchair with one ace wrap on their right lower leg. The resident was wearing black shoes and edema was observed to both lower extremities. The surveyor then reviewed the medical record for Resident #8 which revealed the following: A review of the admission Record face sheet reflected that the resident was admitted with diagnoses which included but were not limited to; muscle wasting and atrophy (when muscles get smaller), COPD (chronic obstructive pulmonary disease; a lung condition), chronic kidney disease (kidneys lose their ability to filter waste from the blood), gout (type of arthritis), atrial fibrillation (heart rhythm disorder), acute embolism and thrombosis (a clot that travels through the bloodstream) and hypertension (high blood pressure). A review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 11 out of 15, indicating that the resident was moderately cognitively impaired. A review of the physician's orders (PO) revealed an order dated 1/20/26, for ace wraps to bilateral lower extremities one time a day for edema; apply before getting out of bed. The surveyor reviewed the Treatment Administration Record (TAR) and noted that Resident #8 was scheduled to have their ace bandages applied to their bilateral lower extremities one time a day before getting out of bed for edema. A review of the March 2026 TAR revealed that there was no documentation Resident #8 had ace wraps applied on 3/2/26, 3/7/26, 3/12/26, 3/15/26, 3/16/26, 3/21/26 and 3/23/26. The TAR was left blank. On 3/23/26 at 12:48 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) regarding the physician's order for bilateral ace wraps on Resident #8's lower extremities. LPN #1 stated that the resident wore ace wraps on bilateral lower legs because their legs were edematous. LPN #1 stated she would usually put them on the resident in the morning but today the assigned CNA had the resident up in the chair early, so I told the CNA I would put the ace wraps on after lunch. In the presence of the surveyor, LPN #1 then observed that Resident #8 was wearing an ace wrap on the right leg and there was no ace wrap on the left leg. LPN #1 then acknowledged that the ace wrap was only applied to the right leg. LPN #1 stated, the left one was not on because it was dirty and needed to be washed. When the surveyor asked LPN #1 if it was facility protocol to wash ace wraps, LPN #1 stated the resident had pain in their left leg, and they refused to have it put on. The surveyor asked LPN #1 if the refusals and pain was documented in the Electronic Health Record (EHR), and LPN #1 stated it was not documented, but it should have been documented, and the doctor should have been notified. On 3/25/2026 at 8:30 AM, Resident #8 was observed with ace wraps on both lower extremities. Resident #8 stated their legs were feeling much better and the swelling had gone down. The resident further stated, they were only putting the wrap on the right leg for a while I guess they lost the other one, but now they are putting it on both legs. On 3/26/26 at 10:13 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the UM, the Regional DON (RDON), the Quality Assurance Nurse (QA Nurse), the [NAME] President of Clinical Operations (VPCO), and the [NAME] President of Operations (VPO) to discuss concerns. The UM stated that the order for bilateral ace wraps had been discontinued because the resident reported pain and the order was updated on 3/23/26, to apply ace wrap to right leg. The UM was unable to explain why Resident #8 was observed on 3/25/26 at 8:30 AM, with ace wraps on their bilateral lower extremities if the order was changed to apply the ace wrap to their right leg on 3/23/26 (after surveyor inquiry). The UM also acknowledged that there were blanks in the March TAR which indicated that the treatment was not administered. A review of the facility's policy Charting and Documentation, updated 11/2025, included: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation.2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition.7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was performed; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. NJAC 8:39-11.2 (b), 27.1(a)

Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to a.) provide adequate supervision and implement targeted interventions to prevent falls for a resident (Resident #58) who sustained six falls between 12/5/25 and 2/26/26, including multiple unwitnessed falls and three falls that required hospitalization. On 2/8/26, Resident #58 sustained a right periorbital hematoma (bruising and swelling of the tissue around the eye) with a 2-centimeter laceration to the right eyebrow from an unwitnessed fall. This deficient practice was identified for 1of 2 residents reviewed for falls (Resident #58). The facility further failed to b.) have a system in place to identify potential vulnerabilities of residents to reduce and mitigate potentially avoidable accidents for residents with a history of substance use disorder who signed themselves out of the facility on pass. On 8/7/26, Resident #5 signed themself out of the facility on pass at 1:30 PM, did not return, and the facility was notified that the resident was in the hospital after an electric scooter/bike accident, when they crashed into a parked car and was diagnosed with a right hip fracture. On 3/22/26 at 8:10 AM, Resident #115, who required supervised smoking and was at high risk for falls, was observed exiting the facility alone smoking a cigarette. This deficient practice was identified for 2 of 2 residents reviewed for accidents (Resident #5 and Resident #115). The facility also failed to c.) implement a system to ensure residents safely smoked by utilizing appropriate smoking receptacles and ensure cigarettes were appropriately disposed of on facility grounds. This deficient practice had the potential to affect all residents and was evidenced by the following: A review of the facility's policy titled Falls- Clinical Protocol, last reviewed and updated 9/2025, included the physician will help identify individuals with a history of falls and risk factors for falling. Cause Identification: For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke, or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. The staff and the physician will continue to collect and evaluate information until either the cause of the fall is identified, or it is determined that the cause cannot be found or is not correctable. Treatment/ Management: Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address the risks of clinically significant consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to get up and walk without waiting for assistance.) Monitoring and follow-up: The staff, with the physician's guidance, will follow up on any fall associated injury until the resident is stable and delayed complications, such as late fracture or subdural hematomas or either intracranial bleeding could occur up to several weeks after a fall. The staff and physicians will monitor and document the individual's response to interventions intended to reduce fall or the consequences of falling. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed. If the individual continues to fall, the staff and physicians will re-evaluate the situation and reconsider possible causes for the residents' falling (instead of, or in addition to those that have already been identified) and reconsider the current interventions. 1.On 3/22/26 at 10:00 AM, the surveyor observed Resident #58 seated in a wheelchair in their room. The resident was eating dry cereal and observed with their bare feet directly on the floor. There were no slippers or non-skid socks on their feet. A pair of black heavily soiled sneakers were observed on the floor in the corner of the room. Resident #58 answered the surveyor's greetings and stated that they did not want to discuss any concerns at present time. On 3/24/26 at 10:42 AM, the surveyor observed the resident sitting at the bedside not wearing shoes or non-skid socks. Their feet were visibly swollen with discoloration and covered with flaky dead skin. During the visit, the resident stated that they used to ride a bike for two hours every day to go to work, they were involved in an accident and were in a coma for long period of time, and now they could not do much for themself. The surveyor then reviewed the medical record for Resident #58 which revealed: A review of the admission Face Sheet (an admission summary), reflected that Resident #58 was admitted to the facility with diagnoses which included but were not limited to; peripheral vascular disease (a condition characterized by narrow arteries that reduce blood flow to limbs), unspecified malignant neoplasm of skin, left upper limb including shoulder, unspecified osteoarthritis, obesity due to excess calories. A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 2/27/26, reflected that Resident #58 had a Brief Interview for Mental Status (BIMS) score of 13 out 15, which indicated an intact cognition. A review of the comprehensive Care Plan (CP), provided by the facility on 3/24/26 at 10:05 AM, included a focus area for falls related to poor balance, initiated on 12/8/25. The goal was that Resident #58 will resume usual activities without further incidents through the review date, initiated on 12/11/25, with a target date of 4/15/26. The interventions included: Provide and reinforce use of non-skid socks as tolerated, initiated on 12/10/25. Place assist rails to left side of bed for mobility, initiated on 12/27/25. Offer assistance with morning care, initiated on 12/18/25, [Fall] strip on floor window side, initiated on 12/8/25. Educate and reinforce to call for assistance with toileting and transfers, initiated on 2/9/26. Staff will encourage Resident #58 to wear appropriate footwear/shoes with rubber soles, initiated on 3/2/25. On 3/25/26 at 10:30 AM, the surveyor requested from the Director of Nursing (DON) any and all investigations for Resident #58, along with any fall risk assessments and a timeline of Resident #58's falls. The surveyor reviewed the Fall Risk Evaluations that were provided by the DON which revealed the following: -A Fall Risk Evaluation dated 12/08/25, reflected Resident #58 scored a 7, which indicated not a high fall risk. A total score of 10 or above represented a high risk. -A Fall Risk Evaluation dated 12/11/25, reflected that the facility identified Resident #58 as a low risk for fall. Resident #5 received a score of 6. -A Fall Risk Evaluation dated 12/17/25, reflected that the facility did not identify Resident #58 as a high fall risk. Resident #58 received a score of 3. -A Fall Risk Evaluation dated 12/19/25, reflected that the facility did not identify Resident #58 as a high fall risk. Resident #58 received a score of 9. -A Fall Risk Evaluation dated 2/9/26, reflected that the facility identified Resident #58 as a high fall risk. Resident #58 received a score of 12. -A Fall Risk Evaluation dated 2/27/26, reflected that the facility identified Resident #58 as a high fall risk. Resident #58 received a score of 12. The following incidents were documented in the Electronic Medical Record, and/or provided by the Regional DON which revealed the following: Unwitnessed Fall #1: On 12/5/25 at 6:28 AM, a Nursing Progress Note (PN) revealed Resident #58 was found sitting upright on the floor beside the bed. The PN revealed that the resident was found on the floor during medication administration. A pool of blood was observed under the resident's right leg, and a laceration was noted to the right eyebrow. Predisposing factors: poor lighting, crowding, furniture. The resident was transferred to the Emergency Department (ED) for evaluation and diagnosed with head trauma. The resident returned to the facility on [DATE]. The Interdisciplinary Care (IDC) team met on 12/8/25, and documented that the resident had no recollection of the fall and exhibited altered mental status. The team was in agreement to place a fall strip to the left side of the bed upon return, and for Rehabilitation (Rehab) to screen. Unwitnessed Fall #2: On 12/10/25 at 5:00 AM, a Nursing PN revealed that the writer was making rounds and observed the resident lying on the floor on their right side with their head toward the foot of the bed. The resident had injuries over their right eye, right arm, and right knee. The resident was noted not wearing any socks. Resident #58 was transferred to the ED. Contributing factors: Recent change in condition, confusion, gait imbalance, and impaired memory. The IDC team met on 12/10/25, and documented that the resident did not recall how the fall happened, the resident was not wearing non-skid socks, and the team agreed to apply non-skid socks. A PN from the Physician dated 12/11/25, revealed the following: plan discussed with nursing. Unwitnessed fall with head injury (acute, improving). Continue fall precautions, supervised transfers, environmental safety measures, low bed, proper footwear, avoid slippers, ongoing therapy for strengthening and balance training. Reinforce call bell use and safe transfer techniques. Monitor for delayed neurologic symptoms given anticoagulation. Recurrent falls gait instability /deconditioning. Unwitnessed Fall #3: On 12/17/25 at 12:05 AM, a Nursing PN revealed that a Certified Nursing Aid (CNA) found the resident on the floor. The resident stated that they rolled out of bed. The IDC team met on 12/17/25, and interviewed the resident and staff. As per the resident, they rolled out of bed. Assist rails were provided to bed to assist the resident with bed mobility. Unwitnessed Fall #4: On 12/17/25 at 8:00 AM, a PN revealed that Resident #58 was found on the floor beside the bed. The resident stated they were trying to transfer from the bed to the wheelchair, lost their balance, and fell on the floor. The resident was noted with a reopened wound on their toes upon assessment. The IDC team met on 12/18/25, to discuss fall of 12/17/25, (second fall on same day), and the intervention to offer assistance with morning care was added. Unwitnessed Fall #5: On 2/8/26 at 11:10 PM, a PN revealed that the nurse observed the resident sitting on the floor between the bed and the radiator. There was dried blood and abrasions noted on the resident's left forehead, and pressure dressing was applied. The resident's clothing was wet with urine, and they reported a slight headache. Resident #58 was transferred to the ED for evaluation and treatment. Predisposing factors: wet floor. Contributing factors: incontinent, gait imbalance. A CT scan of the head (computed tomography- procedure using X-rays to help diagnose injuries, infection and tumors or guides treatment) performed and compared with the 12/30/25, CT scan which revealed a right periorbital hematoma and soft tissue changes. The IDC team met on 2/9/26, to review the fall that occurred on 2/8/26, and documented the following: Resident is able to make needs known and able to call for assistance as needed. Staff will educate the resident upon return to use call bell to ask for assistance with toileting and transfers. On 2/27/26 at 7:45 AM, a Nursing PN revealed the nurse entered the room to administer medications and observed the resident sliding onto the floor. The resident was trying to transfer from the bed to the wheelchair. Predisposing factors: gait imbalance. The IDC team met on 3/2/26, to review the fall. Staff will encourage the resident to wear appropriate footwear/shoes with rubber soles. A review of a handwritten Screen/Referral Form dated 3/25/26, revealed the following: [Resident #58] returned to rehab due to lower extremities edema, resident has history of chronic edema. Resident was recently discharged from rehab 3/6/26. Resident is not a candidate for rehab due to having no decline. Discussed leg rests with nursing but was not a candidate at this time as resident stands in room and self-propelled. No additional therapy notes were provided by the facility for review. The facility could not provide any documentation that the resident received therapy for strengthening and balance training, as well as reinforcement for safe transfer techniques were implemented as recommended by the Physician on 12/11/25. A review of the Physiatrist (rehabilitation physician) note dated 2/2/26, included the following recommendations: functional decline, gait impairment, generalized weakness, communication deficit, with recommendations for ongoing therapy services and reinforced fall-prevention measures. There was no documented evidence that these recommendations were implemented and there were no specific interventions implemented in the Care Plan to prevent recurrent falls. On 3/26/26 at 8:58 AM, the surveyor interviewed the DON regarding Resident #58's multiple falls at the facility including the falls with injuries. The DON stated that the resident tended to be independent and stated, I must look what I have on file. The DON stated, what is missing, is more observations. I relied on the staff to be my eyes and ears on the units, but the oversight is lacking. The DON further stated that the IDC team met and discussed the falls and implemented interventions after each fall. When asked if the causal factor was identified after each fall and a specific intervention was implemented to prevent further falls, the DON stated that she would have to review the documentation. 2.On 3/22/26 at 9:16 AM, the surveyor observed Resident #5 ambulating in their room independently. On 3/23/26 at 8:38 AM, the surveyor reviewed the electronic medical record (EMR). A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; lung cancer spread to the brain and other psychoactive substance dependance in remission. A review of the comprehensive MDS dated [DATE], reflected that the resident had a BIMS score of 15 out of 15, which indicated a fully intact cognition. The MDS also revealed that the resident was independent with all activities of daily living (ADLs) and mobility. A review of the History and Physical (H&P) dated 8/12/25, indicated the resident was hospitalized from [DATE] to 8/11/25, after a fall with right hip fracture while out on pass and had an ORIF (open reduction, internal fixation) done. A Progress Note (PN) dated 8/7/25, indicated that the resident signed themself out of facility at approximately 1:30 PM. A PN dated 8/7/25 at 7:47 PM, indicated the resident did not return from out on pass and went to the [local] ED. A PN dated 8/7/25 at 10:51 PM, indicated the resident was admitted to [local] hospital with a right hip fracture. A review of the physician's order dated 7/31/24, indicated May go out on pass with family or friends. A review of the Release of Responsibility for Leave of Absence, from Resident #5's paper medical chart revealed the resident frequently signed themself out of the facility on pass from July 2025 through the present. The forms were signed on multiple occasions by the resident as the responsible party and the return date/time and staff signatures were blank on multiple occasions. A review of the resident's leave of absences from the facility for March 2026 were as follows: On 3/1/26 at 9:35 AM, the destination of store was written with a projected return at 3:30 PM. There was no resident or responsible (Rep) party signature, and the return time/date and staff signature upon return were blank. On 3/2/26 at 3:00 PM, the destination of store was written with a projected return time of 3:00 PM. There was no resident or Rep party signature, and the resident returned to the facility at 4:00 PM. On 3/3/26 at 10:15 AM, the destination of store was written with a projected return time of 4:00 PM. There was no resident or Rep party signature, and the return time/date and staff signature upon return were blank. On 3/4/36 at 4:38 PM, the destination of store was written. The was no projected time of return or resident or Rep party signature, and the return time/date and staff signature upon return were blank. On 3/5/26 at 12:10 PM, the destination of store was written with a projected return time of 7:00 PM. There was no resident or Rep party signature, and the return time/date and staff signature upon return were blank. On 3/6/26 at 12:55 PM, the destination of store was written with a projected return time of 7:00 PM. There was no resident or Rep party signature, and the resident signed in as returned at 10:00 PM. On 3/7/26 at 10:55 AM, the destination of store was written with a projected return time of 7:00 PM. There was no resident or Rep party signature, and the return time/date and staff signature upon return were blank. On 3/8/26 at 11:20 AM, the destination of store was written with a projected return time of 7:00 PM. There was no resident or Rep party signature, and the return time/date and staff signature upon return were blank. On 3/9/26 at 9:25 AM, the resident signed out to the store with a projected time to return at 7:00 PM. The return date/time and staff signature upon return were blank. On an illegible departure date at 9:15 AM, the resident signed themself out with a projected return time of 7:00 PM. The resident returned on 3/18/26 at 12:30 PM. On 3/20/26 at 9:15 AM, the resident signed themself out to the store with a projected return time of 7:00 PM. The return date/time and staff signature upon return were blank. On 3/21/26 at 9:38 AM, the resident signed themself out to the store with a projected return time of 7:00 PM. The return date/time and staff signature upon return were blank. On 3/22/26 at 3:30 PM, an illegible signature signed that the resident was at the store with a projected return time of 7:00 PM. The return date/time and staff signature upon return were blank. On 3/23/26 at 1:44 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) about the process for residents signing out on pass, and he stated if a resident was signing themself out, they needed a specific order that indicated they may sign themself out. The LNHA stated an order for may go out on pass with friends or family did not allow the resident to sign themself out. On 3/24/26 at 8:20 AM, the surveyor observed Resident #5 ambulating in their room, getting breakfast ready. The surveyor inquired about their fractured hip, and Resident #5 stated it was from an accident on an e- bike (electric scooter or bike). The resident stated they were living here at the time. The resident also stated the bike was not here, I signed out of here, went to where I kept the bike, got the bike, and had an accident. When asked where the bike was, the resident stated, why would I tell you? I'm not telling you, that's none of your business. On 3/24/26 at 8:38 AM, the surveyor interviewed the Rehabilitation (Rehab) Director who stated Resident #5 came to the facility not needing therapy, but was placed on therapy after a hip fracture. The Rehab Director further stated the facility knew there was a scooter involved, but they did not have any additional information about the scooter. On 3/24/26 at 1:21 PM, the surveyor reviewed the facility provided investigation dated 8/7/25. The investigation summary revealed the resident had signed out on pass and was involved in an accident involving a scooter and a parked car. The resident stated they wore a helmet, and they were with a family member. Notes on what appears to be an incident report indicated the resident was riding a scooter with a [family member] when they were hit by a car, which prompted them to go to the ED. A review of the hospital records indicated the resident presented to the ED after colliding into a parked car on their e-scooter. The resident stated they were not wearing a helmet, and they did not hit their head. An oncology consultation indicated that the resident presented with polysubstance and tobacco abuse after colliding their e-scooter into a friend's bike that were both moving at about 10 miles per hour. On 3/24/26 at 1:37 PM, the surveyor interviewed the LNHA and the DON, who stated the resident called the facility to let them know they were in the ED. The DON stated they were still under the facility's care, but they did not think to call the police to report it. They stated they took the resident's statement as to what happened when the resident returned to the facility. On 3/25/26 at 8:25 AM, the Unit Manager (UM #1) was asked how the Release of Responsibility for Leave of Absence form worked, and she stated the residents signed out, and then nurses signed them back in upon their return. The surveyor showed UM #1 pages of Resident #5's Release of Responsibility for Leave of Absence from July 2025 to present. UM #1 confirmed there were multiple blanks on the documents and that the nurse was supposed to sign them in when they returned. When asked how it worked with residents signing themselves out, she stated it depended on their BIMS and if the resident had a BIMS of 15, they were responsible for themself and could sign themself out. UM #1 stated they do need orders to go out on pass. When asked if their history, for example substance abuse, had any bearing on someone's ability go out on pass without a family or friend, and UM #1 stated that it came from the front and pointed to the administration area of the facility. On 3/25/26 at 9:43 AM, the surveyor observed Resident #5 ambulating in the front lobby on the way out of facility. On 3/25/26 at 10:05 AM, the surveyor interviewed the Medical Director (MD), who was also responsible for Resident #5. The MD was aware of Resident #5's substance abuse history. The surveyor asked about Resident #5's fracture that occurred when Resident #5 left the facility and rode an e-scooter and had the accident. The MD stated, I wasn't aware of that part, I should have been made aware. When asked if the MD reviewed incidents and accidents at the Quality Assurance meetings and asked if the accident that occurred when Resident #5 left the facility, rode an e-scooter and wound up in the hospital, the MD stated, no and that should have been investigated as she did not know how the fracture occurred. On 3/25/26 at 10:32 AM, the surveyor interviewed the DON, who stated that Resident #5 was not in the building when they fractured their hip. The DON again stated the facility was not aware of the e-scooter until the incident happened. As far as substance abuse history, the DON stated that the residents were monitored when they came back from being out on pass. The DON further stated she was not aware of any blanks for the return dates and times and that the form should be signed when the resident returned to the facility so that the staff knew and could observe for any changes. The DON then stated maybe they should have called the police department and should have investigated further. The DON stated she does review hospital records and remembered briefly going through Resident #5's hospital records upon readmission. The DON also remembered discussing what happened with the resident. On 3/25/26 at 11:29 AM, the surveyor interviewed the LNHA, who stated that ultimately the facility was responsible for the residents. When asked about nursing not documenting the resident's returns on the release form, the LNHA stated it was documented in the medical record in Progress Notes and was checked every morning for compliance. The LNHA stated there was a team discussion after Resident #5's incident and it was not discussed in the Quality Assurance meeting. The LNHA further stated the incident with the resident's hip fracture was a significant event and they should be reviewing significant events to ensure they had a process to prevent future incidents. On 3/26/26 at 10:13 AM, the LNHA and DON stated Resident #5's incident happened while they were out on pass, and it was their right to go out on pass. They stated, they were not under our care because they were out on pass. On 3/26/26 at 12:53 PM, the LNHA stated he has no further information to provide. 3. On 3/22/26 at 8:00 AM, the survey team entered the facility to conduct a survey and at 8:10 AM, while in the lobby, the survey team observed a person [Resident #115] ambulating with a walker. The person [Resident #115] then exited the facility, placed a cigarette in their mouth, and proceeded to ambulate down a hill while smoking the cigarette. When asked, the Receptionist confirmed that it was Resident #115. When asked if the resident was supposed to be smoking in that area and lighting a cigarette on their own, the Receptionist stated no, and that Resident #115 leaves the facility and that was their routine. On 3/22/26 at approximately 8:20 AM, the surveyor exited the facility to look for Resident #115 in the area the resident was observed and the surveyor could not locate the resident. The Smoking Policy was provided by the LNHA during the entrance conference held on 3/22/26 at 8:55 AM, and revealed that the facility established and maintains safe resident smoking practices and 2. Smoking is only permitted in designated resident smoking area which are located outside of the building . 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times when smoking. The Smokers Break Times and Location List was provided, and the smoking area was located on the patio near room [ROOM NUMBER]. The first smoke break was at 9:30 AM, second smoke break was at 1:00 PM, third smoke break was at 4:00 PM, and the fourth smoke break was at 6:00 PM. Resident #115 was observed smoking by the survey team prior to the first scheduled smoking break. On 3/22/26 at 12:18 PM, a review of the electronic medical record (EMR) for Resident #115 revealed the following: A review of the admission Record, revealed the resident was admitted to the facility with diagnoses which included but were not limited to; schizoaffective disorder and depressive type. A review of the comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 13 out of 15, which indicated a fully intact cognition. A review of Section GG revealed the resident required supervision/touching assistance to walk 50 feet with turns. A review of the current 15-page Care Plan revealed a focus area for: I have chosen to continue to smoke and need you to observe me for safety, dated initiated 12/19/25, and the resident has substance use evidenced by a history of substance and/or polysubstance use and/or illicit drug use including: (marijuana) and/or alcohol abuse. Exhibits ineffective individual coping, use of manipulation to avoid responsibility and delay in seeking, or refusal of healthcare attention to the detriment of health/life/safety, dated initiated 2/5/26. The resident was also at high risk for falls due to gait/balance problems, psychoactive drug use dated initiated 12/19/25. A review of the Active Physician's Orders for Resident #115 dated 3/1/26, revealed there was no physician's order for Resident #115 to go out on pass. The March 2026 Medication and Treatment Administration Records for Resident #115 were also reviewed and did not include an order to go out on pass. Th Behavior Monitoring section did not indicate any monitoring related to history of substance use disorder or alcohol use. A review of the Progress Notes (PN), beginning 12/9/25 through 3/21/26, revealed the following: A Health Status Note dated 2/24/26 at 9:24 AM, revealed the resident approached the desk and requested to sign out on pass, and they were made aware that the weather outside was extremely cold and the street was icy and not fully plowed and it was dangerous for them to go out. The resident was advised to defer going out in extreme frigid weather, verbalized understanding, but still wanted to go out. they signed the release of responsibility form and returned as promised with no complaints. A PN documented by the Activity Director (AD) on 3/17/26, revealed Resident #115 left the faciity on pass daily. At that time, a review of the document titled Release of Responsibility for Leave of Absence, revealed the following and was also the same document that was kept in a book located at the front desk: I, the undersigned resident and/or my assigned responsible party, herby request a Leave of Absence (LOA) from the facility. I understand and agree to the following conditions: .1. I am voluntarily leaving the facility on the date and time listed below and understand that this LOA is temporary and expected to last no more than 24 hours; 2. I acknowledge that if I do not return to the facility within 24 hours of my expected return time, and if I or my responsible party fail to notify the facility of any delay, my absence will be considered as leaving the facility Against Medical Advice (AMA); 3. I understand that failure to return within the specified time frame without notice will result in my being voluntarily discharged from the facility; 4. By signing below, I acknowledge that I have been informed of the risks and consequences of leaving the facility, including the possibility of adverse health effects, loss of bed hold, interruption of care and medical management; 5. I release the facility, its staff, administrators, and affiliates from any liability or responsibility for outcomes resulting from my decision to leave the facility under these terms; 6. I confirm that this signed form will serve as both an AMA acknowledgement and a voluntary discharge notice if I fail to return within the specified timeframe. On 3/23/26 at 10:03 AM, the surveyor interviewed the assigned Certified Nurse Aide (CNA #1) for Resident #115 in the resident's room. The resident was out of the facility at that time. The surveyor informed CNA #1 of their observations of the resident ambulating and smoking independently outside of the facility and also asked what care the resident required from her. CNA #1 stated the resident leaves all day. CNA #1 stated the resident smokes and goes to the liquor store. The surveyor observed two locked cabinets at that time on the resident's nightstand and asked if the residen

Based on observation, interview and document review it was determined that the facility failed to have a system in place to ensure quarterly financial statements were provided to residents who maintained Personal Needs Account (PNA) funds with the facility. This deficient practice was identified for 7 of 7 residents who attended a resident council meeting, and affected all 84 residents identified as maintaining a facility PNA account.The evidence was as follows: On 3/23/26 at 8:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of all Personal Need Account balances as of 3/19/26. The Trial Balance listed 84 total PNA accounts with a $33,770.89 balance held by the facility. On 03/23/26 at 10:28 AM, the surveyor conducted a resident council meeting with 7 residents. When asked if the residents were provided quarterly statements for their PNA accounts, the residents stated no and they would have to request a PNA statement from the facility.On 03/24/26 at 10:39 AM, the surveyor met with Resident #56 and the regular Certified Nurse Aide (CNA) was present. When asked if the resident needed anything, the CNA showed the surveyor the closet with less than 5 pairs of pants and blouses and the CNA stated the resident needed clothing. When asked the resident if they knew that they had PNA funds to spend on items that they needed, they stated, no they were not aware (Resident #56's PNA balance was $2036.12). The resident showed the surveyor earrings and stated they would like bracelets also.On 03/24/26 at 9:47 AM, the surveyor interviewed the Business Office Manager (BOM) who stated he worked for the management company that managed the facility. The surveyor asked about the PNA funds and the BOM stated that the residents would take out money through the receptionist as needed and that he provided the receptionist with a daily report of PNA funds. On 03/24/26 at 10:08 AM, the surveyor conducted a follow-up interview with the BOM regarding the PNA process and asked if there was a process in place to send quarterly PNA statements to the residents. The BOM stated he did not distribute any statements and also confirmed that he was the person who maintained the access to the PNA management program for the facility. The BOM stated he was aware that residents were supposed to be provided with PNA statements and he stated that one family asked for a statement a few months ago. When asked if the process was for residents to request statements, he stated, no, shouldn't be, they are supposed to get them quarterly. The BOM confirmed he had been aware that the facility was not providing residents with quarterly PNA statements. A review of the Resident Funds Management System (PNA) policy last revised 10-2025 revealed a Policy Statement: The facility shall maintain a PNA account for any resident who chooses to deposit funds with the facility. These funds are managed solely for the resident's personal use. The facility will ensure secure handling, accurate accounting, and timely access to funds upon resident request. The policy did not indicate a process for providing quarterly statements. NJAC 8:39-9.5(a)

Based on observation interview and document review it was determined that the facility failed to ensure a process was in place to ensure that all residents that maintained a Personal Needs Account (PNA) that approached the limit that could jeopardize a resident's eligibility for Medicaid or Supplemental Security Income (SSI) were notified. This deficient practice was identified for a resident who had PNA funds in excess of $2000.00 (Resident #56) and affected all 84 residents who maintained a facility PNA. The evidence was as follows: On 3/23/26 at 8:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of all Personal Need Account balances as of 3/19/26. Resident #56 had a current balance of $2036.12, and the Trial Balance listed 84 total accounts with a $33,770.89 balance held by the facility. On 03/23/26 at 12:45 PM, the surveyor interviewed both Social Workers (SW #1 and SW #2) regarding the PNA process to assist residents to use their funds. SW #1 stated that the Activity Director talked to the residents to determine what they needed from the store and the business office would keep an eye on the PNA funds to identify who needed to spend down PNA funds. On 03/24/26 at 9:47 AM, the surveyor interviewed the Business Office Manager (BOM) who worked for the management company that managed the facility. The surveyor asked about the PNA funds process. The BOM stated that the residents would take out money through the receptionist as needed and that he provided the receptionist with a daily report of PNA funds. When asked what he did if resident had a large amount of funds, he stated he would reach out to SW and tell them that the resident needed to spend down the funds. He then stated, he hasn't noticed anyone with the need to spend down. The BOM stated that if a resident was over $2000.00 in their PNA they could be shut down and become ineligible for Medicaid. Then he stated he would not get involved as it was the SW's responsibility to ensure the residents spent their money. When asked about the policy, he stated he was unsure of the official policy. On 03/24/26 at 10:39 AM, the surveyor met with Resident #56 and the regular Certified Nurse Aide (CNA) was present. When asked if the resident needed anything, the CNA showed the surveyor the closet with less than 5 pairs of pants and blouses and the CNA stated the resident needed clothing. When asked the resident if they knew that they had funds to spend on items that they needed, they stated, no they were not aware. The resident showed the surveyor earrings and stated they would also like bracelets. The surveyor then reviewed the medical record for Resident #56 which revealed an admission Record that revealed diagnoses which included, but were not limited to, poly-osteoarthritis, unspecified dementia and anxiety. A review of the quarterly Interdisciplinary Team Meeting (IDT) Note dated 3/11/26 did not reveal any documentation regarding any resident needs, or the available PNA. A review of a Psychotherapy note dated 11/26/25 and signed by a Licensed Clinical Social Worker which revealed .the resident was thinking about what to wear and their jewelry. On 03/24/26 11:27 AM, the surveyor interviewed Resident #56's SW regarding her role in assisting residents with their PNA and asked if Resident #56 needed anything. The SW stated that typically the residents would go to the Activity Department when they needed something from the store. When asked about the $2036.12 PNA balance and had that been discussed with the resident, since there was a recent IDT meeting held on 3/11/26. The SW stated the PNA should have probably been discussed in the quarterly meeting. The SW stated that she may have purchased $ 1000.00 of clothing for Resident #56 one year ago and the surveyor asked for documentation of those purchases. A subsequent review of Resident #56's PNA statement provided by the BOM, from 3/3/25 through 3/3/26 revealed there were no personal needs items or cash withdrawals. After surveyor inquiry regarding Resident #56's PNA, the surveyor reviewed a SW's progress note dated 3/24/26 at 3:45 PM which revealed SW and Activities met with Resident #56 to discuss spending down some of their PNA. The third time we asked they said they would like some bracelets. asked SW to pick out some gold bracelets . stated they would like some 2-piece pant sets, undergarments, snacks/chocolates and some earring and necklaces.On 3/25/26 at 1:57 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the facility management company Regional DON, Quality Assurance Nurse (QA Nurse), [NAME] President of Clinical Operations (VPCO) and the [NAME] President of Operations (VPO), and the surveyor discussed the above concerns.On 03/26/26 at 10:13 AM, during the exit conference held between the survey team, the facility administration and management company there was no additional information provided. NJAC 8:39-4.1(3)(8)(10)(12)

Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that there was sufficient competent staff to ensure a) all residents were provided with appropriate and timely incontinence care, nail care and were consistently available to provide appropriate care to maintain residents highest practicable physical, mental, and psychosocial wellbeing and b) the minimum staffing requirements per the New Jersey Department of Health based on acuity of the residents was maintained. The deficient practice was identified for 5 of 5 residents reviewed (Resident #10, #31, # 58, #68 and #122) and had the potential to affect all residents who resided in the facility.The evidence was as follows: Refer to F677a)1. On 3/22/26 at 8:30 AM, the surveyor observed Resident #122 in bed, the resident informed the surveyor that they just finished their breakfast meal. The resident had the lid tray in their hand and informed the surveyor that they could not see, they were blind. The surveyor inquired regarding care, and Resident #122 stated they were not changed last night. The resident stated a staff checked them this morning and informed them that the whole bed had to be changed, the staff left the room and did not return.On 3/22/26 at 9:00 AM, the surveyor reviewed the assignment sheet and located the Certified Nursing Aide (CNA) who confirmed she was the resident's aide for the day and stated that she was informed that the resident had not been changed during the 11:00 PM-7:00 AM shift. The surveyor accompanied by CNA and entered Resident #122's room the CNA informed the resident of the procedure and then pulled back the resident's blanket which revealed the resident was saturated with urine through their gown and bed sheets, and the surveyor observed a strong urine odor. The CNA informed the surveyor that she had not yet provided care to that resident. The CNA further stated that she was assisting other residents with the breakfast meal. A review of the 11:00 PM-7:00 AM staffing reflected that the Census was 59 and the facility had 3 CNAs working for the shift.Review of the CNA assignment sheet revealed the unit had a census of 58 Residents with five assigned aides. The CNA had an assignment of 12 residents on that shift.On 3/22/25 at 9:15 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) she stated that incontinent care should be completed every two hours during the day shift and every 4 hours on the 11:00 PM-7:00 AM shift.On 3/24/26 at 10:17 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who confirmed that incontinent care should be provided every two hours and as needed during the day shift. The UM stated that the CNAs were to inform the nurses if any resident refused care. 2. 03/22/26 at 9:30 AM, Resident #68 for incontinence care. Resident #68 was in bed, and their incontinence brief was saturated with urine. Resident #68 stated that they were provided with incontinence care around 4:00 in the morning. The CNA who assisted the surveyor with the incontinence care stated that the resident should have been checked and changed before breakfast was served.3. On 3/22/26 at 9:31 AM, the surveyor observed Resident #31 in bed, when asked about how their stay had been at the facility Resident #31 stated 1 would like my fingernails to be cut I can't do it myself. Resident #31 stated that I asked the staff a couple times, but they still haven't cut my nails. The surveyor observed all 10 fingernails extended over the fingertips with a black substance underneath the nails. Resident stated that I asked the staff again this morning and they stated they would cut my nails.On 3/23/26 11:18 AM, the surveyor interviewed the CNA regarding grooming and nail care. The CNA stated that Resident #31 required total care. She stated today was their shower day, but they never took a shower, they received a full bed bath, and they were dressed and assisted out of bed. The CNA stated that nail care should have been included on their shower day. The CNA stated if the nails were too long, she would cut them because the resident could scratch someone. The CNA stated that Resident #31 never asked to have their nails cut. The surveyor and CNA went to Resident #31's room together to observe their fingernails. The CNA stated they could be cut but if they had diabetes, I would not cut their nails, the nurse would cut their nails if they were a diabetic. When the surveyor asked the CNA if Resident #31 had diabetes, the CNA was unable to answer.On 3/23/26 at 11:27 AM, the surveyor interview Licensed Practical Nurs (LPN) regarding grooming and nail care. The LPN stated that only if they asked, we would cut their nails, and their spouse usually cut their nails. The LPN further stated that she didn't notice Resident #31's nails and they had not requested to have their nails cut. LPN #1 stated the nurses would cut the resident's nails if the resident had diabetes and the CNA should not cut nails. The LPN stated Resident #31 was not diabetic. The LPN then stated, we should offer to cut the residents' nails when we provided care on their shower days, they should not have to ask. 4. On 3/22/ 26 at 9:43 AM, the surveyor observed Resident #10 sitting in a wheelchair in the room and was eating the breakfast meal. The surveyor observed Resident #10's nails were long, jagged and soiled. The surveyor asked the resident if they would like their nails to be trimmed and cleaned, the resident stated that they would like to.On 3/23/24 at 9:30 AM, the surveyor observed the resident eating breakfast in the room and the resident's nails were in the same condition as observed during the initial tour on 3/22/26. The surveyor asked the resident again if they would like their nails to be trimmed and cleaned, the resident stated, yes.On 3/25/26 at 11:30 AM, the surveyor asked the nurse educator when staff were to provide nails care to the residents. The Nurse educator stated that nails care was to be provided on shower days. The surveyor accompanied the nurse educator to the room, and we both observed that nail care was not provided on 3/23/26 as scheduled. Resident #10 received nail care after the surveyor inquiry on 3/25/26. Review of the CNA assignment sheet for 3/23/26 during the day shift revealed the unit had a census of 58 Residents with five assigned aides. The CNA had an assignment of 12 residents on that shift.On 3/25/26 at 10:14 AM Resident #58 informed the surveyor that they had not had a shower since January. The surveyor reviewed the shower log and observed that Resident #58 was to receive their shower on Sunday 3/22/26. Resident #58 stated that they had been asking for a shower and did not receive a shower on Sunday. The surveyor observed Resident #58 with the same set of pajamas on for 3 days. Resident #58 lower extremities were covered with dry flaky skin. The Physician prescribed a medicated ointment to be applied to the legs daily. Resident #58 had a container of the medicated cream delivered to the facility on [DATE]. The container was still half full, and another container delivered from the pharmacy on 1/29/26 was unopened. On 3/25/26 at 10:17 AM, the surveyor interviewed the Unit Manager who confirmed that nail care was to be provided on shower days and was listed on the daily assignment sheet. The Unit Manager confirmed also that incontinence care should be provided every two hours on the day shift and twice on the night shift. The first incontinence rounds should be completed between 12:00 AM and 2:00 AM, and then again between 5:00 AM and 7:00 AM.b) 1. The following ratio(s) were effective on 02/01/2021:One Certified Nurse Aide (CNA) to every eight residents for the day shift.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 CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: andOne 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 CNA and perform CNA duties.Staffing had been calculated for the following time frames and revealed the following: For the 2 weeks of AAS-11 and 2 weeks of AAS-12 staffing from 03/08/2026 to 03/21/2026 the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 1 of 14 evening shifts and deficient in total staff for residents on 4 of 14 overnight shifts as follows: -03/08/26 had 12 CNAs for 116 residents on the day shift, required at least 14 CNAs.-03/09/26 had 13 CNAs for 115 residents on the day shift, required at least 14 CNAs.-03/10/26 had 13 CNAs for 115 residents on the day shift, required at least 14 CNAs.-03/10/26 had 7 total staff for 115 residents on the overnight shift, required at least 8 total staff.-03/11/26 had 13 CNAs for 115 residents on the day shift, required at least 14 CNAs.-03/12/26 had 13 CNAs for 115 residents on the day shift, required at least 14 CNAs.-03/13/26 had 12 CNAs for 115 residents on the day shift, required at least 14 CNAs.-03/14/26 had 12 CNAs for 115 residents on the day shift, required at least 14 CNAs.-03/14/26 had 7 total staff for 115 residents on the overnight shift, required at least 8 total staff.-03/15/26 had 12 CNAs for 119 residents on the day shift, required at least 15 CNAs.-03/15/26 had 7 total staff for 119 residents on the overnight shift, required at least 8 total staff.-03/16/26 had 11 CNAs for 119 residents on the day shift, required at least 15 CNAs.-03/16/26 had 11 total staff for 119 residents on the evening shift, required at least 12 total staff.-03/17/26 had 11 CNAs for 119 residents on the day shift, required at least 15 CNAs.-03/18/26 had 13 CNAs for 119 residents on the day shift, required at least 15 CNAs.-03/19/26 had 10 CNAs for 119 residents on the day shift, required at least 15 CNAs.-03/19/26 had 7 total staff for 119 residents on the overnight shift, required at least 8 total staff.-03/20/26 had 13 CNAs for 119 residents on the day shift, required at least 15 CNAs.-03/21/26 had 12 CNAs for 119 residents on the day shift, required at least 15 CNAs. For the 2 weeks of AAS-12 staffing from 03/08/2026 to 03/21/2026, the facility was deficient in staffing for required resident services on 2 of 14 days as follows: For the week of 03/15/26Required Staffing Hours: 306.75 2.-03/16/26 had 304 actual staffing hours, for a difference of -2.75 hours.-03/19/26 had 296 actual staffing hours, for a difference of -10.75 hours. A review of the facility's Staffing policy updated December 2025, included the following: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care and facility assessment, staffing numbers and skills requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care A review of the facility's Activities of Daily Living (ADLs) Supporting policy dated revised included resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living . NJAC 8:39-5.1(a); 27.1(a)

Based on interviews and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of all Certified Nursing Aides (CNA) to provide specific education aligned with the facility assessment and based on staff observed needs for improvement. This deficient practice was identified for 5 of 5 CNAs whose personnel records were reviewed, and was evidenced by the following:On 3/24/26 at 10:30 PM, the surveyor requested the Licensed Home Administrator (LNHA) to provide the list of all new hires since the last survey, including employees who were no longer employed by the facility and contracting facility's employees. On 3/24/26 at 10:00 AM, the surveyor interviewed the Nurse educator and required the orientation package, the facility assessment and the Performance Evaluation for 5 selected CNAs. The nurse educator informed the surveyor that the Director of Nursing and the LNHA were responsible for the employees' Performance evaluation. On 3/24/26 at 10:30 AM, the surveyor requested from the LNHA the performance evaluation for five randomly selected CNAs and one Licensed Practical Nurse for review. On 03/24/26 at 10:22 AM, during an interview with the surveyor, the LNHA stated that they have not done performance reviews for any the CNAs and nurses recently. The LNHA further stated, The facility should have done it. It is important to ensure the job performance was based on an employees job description. Another surveyor asked the LNHA why it is important for the facility to evaluate their staff. The LNHA stated it is important to facilitate communication and make sure that their performance aligned with their standard of practice. The LNHA stated they slacked off regarding the performance reviews and he confirmed that the facility doesn't have them to provide to the survey team. The facility could not provide any employee files for review of performance evaluations. A review of the facility's policy titled, Staffing last updated December 2025 revealed the following: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and ImplementationLicensed nurses and certified nursing assistants are available 24 hours a day to provide direct care services.Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. NJAC 8:39-43.17(b)

Based on observation, interview, record review and review of pertinent documents it was determined that the facility failed to ensure that it maintained responsibility for the care and services provided to residents at all times, and ensure a process was in place to integrate care and services for residents who regularly attended an outside Program of All -Inclusive Care of the Elderly (PACE). This deficient practice was identified for 1 of 3 residents reviewed for accidents (Resident #115) and attended a PACE program, and had the potential to affect all residents who resided in the facility and for 6 of 6 residents who attended a PACE program.The evidence was as follows: On 3/22/26 at 8:00 AM, the survey team entered the facility to conduct a survey and at 8:10 AM, while in the lobby, the survey team observed a person ambulating with a walker, then exited the facility, placed a cigarette in their mouth, and proceeded to ambulate down a hill while smoking the cigarette. When asked, the receptionist confirmed that it was Resident #115. When asked if the resident was supposed to be smoking in that area, light up cigarettes on own, she stated no, and that Resident #115 leaves the facility and that was their routine.On 3/22/26 at approximately 8:20 AM, the surveyor exited the facility to look for Resident #115 in the area the resident was observed and the surveyor could not locate the resident. On 3/22/26 at 12:18 PM, a review of the electronic medical record (EMR) for Resident #115 revealed the following: The admission Record revealed diagnoses which included but were not limited to; Schizoaffective Disorder, Depressive Type. The admission Minimum Data Set, an assessment tool, dated 12/15/25 revealed the resident was admitted from Home/Community (e.g., private home/apartment, board/care, assisted living, group home .), The Brief Interview for Mental Status score was 13 out of 15 which indicated the cognition was intact. The Discharge Plan was coded Yes, to indicate active discharge planning already occurring for the resident to return to the community.The current 15 page Care Plan was reviewed and revealed a Focus for: I have chosen to continue to smoke and need you to observe me for safety, Date Initiated: 12/19/25 and Resident has substance use evidenced by a history of substance and/or polysubstance use and/or illicit drug use Including: (marijuana) and/or alcohol abuse. Exhibits ineffective individual coping, use of manipulation to avoid responsibility and delay in seeking, or refusal of healthcare attention to the detriment of health/life/safety. Date Initiated: 02/05/2026 High risk for falls r/t Gait/balance problems, Psychoactive drug use Date Initiated: 12/19/2025. The Care Plan did not include information regarding attendance at a PACE program, or goals and interventions regarding a discharge plan. A review of the Progress Notes beginning 12/9/25 through 3/21/26 revealed the resident was admitted from the PACE at 2:55 PM and ambulated with rolling walker without difficulty. A review of the admission documents from the PACE program revealed the participant was coming from home .with a potential discharge date no discharge date at this time. A Health Status Note effective 1/14/26 at 2:52 PM, and documented by the Director of Nursing revealed: Team met with the PACE via zoom. Clinical and discharge plans updated and the discharge plan is long term care, and will continue visits with the [Pace program] every Monday, Wednesday and Friday with transportation.A review of a Release of Responsibility for Leave of Absence document that was in a book at the front desk, and also located in Resident #115's medical record revealed: I, the undersigned resident and/or my assigned responsible party, herby request a Leave of Absence (LOA) from the facility. I understand and agree to the following conditions: .1. I am voluntarily leaving the facility on the date and time listed below and understand that this LOA is temporary and expected to last no more than 24 hours; 2. I acknowledge that I do not return to the facility within 24 hours of my expected return time, and if I or my responsible party fail to notify the facility of any delay, my absence will be considered as leaving the facility Against Medical Advice; 3. I understand that failure to return within the specified time frame without notice will result in my being voluntarily discharged from the facility; 4. By signing below, I acknowledge that I have been informed of the risks and consequences of leaving the facility, including the possibility of adverse health effects, loss of bed hold, interruption of care and medical management; 5. I release the facility, its staff, administrators, and affiliates from any liability or responsibility for outcomes resulting from my decision to leave the facility under these terms; 6. I confirm that this signed form will serve as both an AMA acknowledgement and a voluntary discharge notice if I fail to return within the specified timeframe. On 03/23/2026 at 12:45 PM, the surveyor interviewed both facility Social Workers (SW) #1 and SW #2 regarding their involvement with the residents who attended the PACE program. Both SWs stated the PACE program had their own SWs. When asked SW #2, who was assigned to Resident #115 what the discharge plan was for Resident #115, SW #2 stated she was not involved in the discharge planning process and that was the responsibility of the PACE program. When asked if the resident was allowed to hold their own cigarettes/lighter the SWs confirmed no. On 03/23/26 at 10:03 AM, interviewed the assigned Certified Nurse Aide (CNA) for Resident #115 in the resident's room. The resident was out of the facility at that time. The surveyor informed the CNA of their observations of the resident ambulating and smoking independently outside of the facility, and asked what care the resident required. The CNA stated the resident leaves all day. The CNA stated the resident smokes and goes to the liquor store. The surveyor observed two locked cabinets at that time, on the resident's nightstand and asked if the resident kept liquor and cigarettes in the cabinet and the CNA did not know as the cabinets were locked by the resident. When asked what help or care the resident required from the CNA stated, they didn't need any help. The CNA stated they didn't eat at the facility, but wanted the meal tray left at the bedside. On 03/23/26 at 10:28 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to Resident #115. When asked does she provide care for Resident #115, she stated when [he/she] is here, they go out and goes to the PACE program Monday, Wednesday and Friday and returned back at 2:30 PM. On 3/23/26 at 1:55 PM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of the PACE contract which revealed a different named PACE and the contract was signed by a former LNHA on 2/6/20. The LNHA confirmed the contract was the current contract. A further review revealed the Program of all-inclusive Care for the Elderly (PACE) which is designed to provide community-based, comprehensive, integrated acute and long-term care healthcare for qualified members of the frail elderly population. 3.1.7 Participate in IDT (Interdisciplinary Team) Meeting. The Provider agrees to participate in the IDT as required by the PACE team. 3.7.7 Provider shall designate an employee with sufficient authority who shall act as liaison between Provider and PACE. Name: (left blank); contact information: (left blank) shall act as Provider's liaison with PACE . On 03/24/26 at 12:57 PM, the surveyor interviewed the LNHA regarding how many current residents were enrolled in the PACE program and the LNHA stated he did not know, but he would find out. The LNHA then provided the surveyor with a list of 6 residents, that included Resident #115. On 03/25/26 at 11:32 AM, two surveyors interviewed the LNHA and asked about the facility Quality Assurance Process and asked about PACE program process. The LNHA stated the PACE referred to and also placed residents at the facility and the residents would then attend the PACE day program. When asked about the contract, and the blank areas for the Liaison and the facility integration with the PACE. The LNHA stated, I was not aware it was blank and stated there was a biweekly phone call held with the PACE, and that the discharge plan was the sole responsibility of the PACE program and it was collaborated with the SW. When informed that the SWs were not involved in the discharge planning, the LNHA was unaware. When asked who was responsible to ensure care and services were provided for the residents who attended the PACE program. The LNHA stated it was his responsibility and stated there should be oversight between the PACE program and the facility. When asked if there was a process in place, the LNHA stated, no, and stated the collaboration should be documented in the medical record. On 03/25/26 at 1:56 PM, the survey team conduced a pre-exit conference with the facility LNHA and Director of Nursing (DON), and the Regional DON, [NAME] President of Clinical Operation, [NAME] President of Operations and the Quality Assurance Nurse from the Management Company for the facility. The surveyor reiterated the above concerns. On 03/26/26 at 10:13 AM, the survey team met with the above individuals with the addition of the Infection Preventionist and the Unit Manager for the [NAME] Unit. The facility informed the survey team that the out on pass process form was revised to remove the waiver language and confirmed there was a breakdown between the PACE program and the facility and they realized the need for integration between both the facility and the PACE program. NJAC 8:36-5.1(a); 27.1(a)

Based on interview and record review it was determined that the facility failed to have a process in place to ensure that prior to signing a binding arbitration agreement, that was included within the admission Packet, the agreement was clearly communicated to the resident or representative in a manner they understood, and they acknowledged they understood the agreement. The deficient practice was identified for 7 of 7 residents (Resident #15, #37, #38, #86, #102, #106, and #114) who attended a resident council meeting and a resident with a severely impaired cognition (Resident #105).The evidence was as follows: On 3/22/26 at 10:19 AM, during the facility entrance conference held with the Licensed Nursing Home Administrator (LNHA), the surveyor asked the LNHA if the facility used Arbitration Agreements and asked if any residents had signed the agreements. The LNHA stated the admission department would handle the Arbitration Agreements and that he would inform the surveyor if anyone had signed the agreement.On 3/22/26 at 11:07 AM, the surveyor interviewed Resident #105 who was unable to elaborate on the care provided and appeared somewhat confused.On 3/22/26 at 11:13 AM, a surveyor reviewed Resident #105's admission Agreement which revealed the AA was accepted with a signature of the resident that was one line, no signature of a legal representative and a signature of the LNHA as the Facility Representative as being signed by both on 09/09/25, however, the LNHA signed the admission Agreement 10/20/25. The admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 5 out of 15 on the Brief Interview for Mental Status which indicated the resident had severely impaired cognition. The Care Area Assessment section indicated the resident triggered for Cognitive Loss and Dementia. On 3/23/26 at 9:03 AM, the LNHA stated he was unable to provide a list of residents who signed an arbitration document, and he had somebody working on it. On 03/23/26 at 10:28 AM, a resident council meeting was held with seven residents. The surveyor explained an arbitration agreement and inquired the residents that had recalled signing an arbitration agreement. All seven residents stated they did not recall, because the admission process was completed orally. One resident stated they were unable to see the agreement on the small tablet and the facility would provide them with a copy and the facility never did. On 3/23/26 at 1:11 PM, the LNHA provided the surveyor with a list of Arbitration Agreements (AA) which indicated what residents signed the agreements. Residents #38 and #106 were on the list, and Resident #105 was not listed. On 03/23/26 at 1:20 PM, the surveyor interviewed the admission and Marketing Staff (ADM). The surveyor asked what her responsibilities were regarding admissions. The ADM stated she would get admissions from the hospital and handle referrals and worked on getting the insurance coverage for the residents prior to being admitted into the facility. When asked about the admission Agreement, the ADM stated that it was completed after the resident was admitted and it was completed using a tablet and was signed electronically. When asked what the review of the AA entailed with the residents, she stated it was something outside of a courtroom. When asked how she would know if the residents were able to understand the AA, and did she document that information anywhere. She stated that usually the Social Worker would let her know if there were concerns about a resident being able to understand and sign the paperwork themselves. The ADM stated she did not document anything related AA being explained with the residents and when asked if the ADM provided the residents with a copy of the agreement that was signed electronically, she stated the residents don't get a physical copy of the admission Agreement. The ADM stated that the LNHA would sign the admission Agreement. On 03/23/26 at 1:38 PM, the surveyor interviewed the LNHA about his role with the admission Agreement process and if her documented in the medical record regarding any questions the residents may have or anything that was reviewed with the residents including the AA. The LNHA confirmed he did not document in the medical record and he confirmed that the ADM also did not document in the medical record. The LNHA stated that if a resident had a BIMS of 12 and up that they would be able to sign the admission Agreement on their own, and if they had a BIMS lest than 12 that a Responsible Party would have to sign the agreement. The LNHA stated that the ADM could look up the BIMS and that any admission Agreement with his signature meant that the BIMS was 12 or higher. When asked if he signed the admission Agreement in the presence of the resident, he said he signed it, but not in the presence of the resident. On 03/25/26 at 1:56 PM, the survey team met with the LNHA, Director of Nursing, and the Management Company: Regional Director of Nursing, [NAME] President of Clinical Operations and the [NAME] President of Operations and the Quality Assurance Nurse and reviewed the concerns with the AA. On 3/26/26 at 11:37 AM, during the exit conference held with the facility and Management Company representatives, there was no information provided regarding the process of the AA. NJAC 8:39-4.1(a)8; 33 (b)

Based on observation, interview and document review it was determined that the facility Quality Assurance and Performance Improvement (QAPI) committee failed to self-identify systems and processes that may negatively affect resident quality of care, quality of life and review significant events and implement data driven QAPI program. The deficient practice affected all residents who resided at the facility and was evidenced by the following: Refer to F568, F569, F584, F677, F679, F684, F689, F730, F925Refer to F568, F569, F584E, F677E, F679E, F684H, F689H, F730F, F925E a. On 3/23/26 at 8:13 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of all Personal Need Account balances as of 3/19/26. Resident #56 had a current balance of $2036.12, and the Trial Balance listed 84 total accounts with a $33,770.89 balance held by the facility. On 03/24/26 at 9:47 AM, the surveyor interviewed the Business Office Manager (BOM) who worked for the management company and went to multiple facilities. The surveyor asked about the PNA funds and the BOM stated that the residents would take out money through the receptionist as needed and that he provided the receptionist with a daily report of PNA funds. When asked what he did if resident had a large amount of funds, he stated he would reach out to SW and tell them that the resident needed to spend down the funds. He then stated, he hasn't noticed anyone with the need to spend down. The BOM stated that if a resident was over $2000.00 in their PNA they could be shut down for Medicaid and become ineligible. Then he stated he would not get involved as it was the SW's responsibility. When asked about the policy, he was unsure of the official policy. b. On 3/22/26 at 8:57 AM, Resident #54 showed the surveyor a plastic bag with 4 dead cockroach- like insects inside. The resident then stated that when they used the bathroom during the night, and then turned on the light, they would see the cockroaches scatter. On 3/24/2026 at 11:27 AM, the surveyor reviewed the pest control reports provided by the facility which revealed the following:1/14/26, Rosewood wing; roach (cockroach) cleanout complete. Treated all cracks and crevices. Activity found coming out of the drop ceiling and molding around the ceiling. On 3/24/2026 at 12:33 PM, the surveyor interviewed the Director of Housekeeping who explained the procedure for insect sightings to log the sightings in the book. There was a book in each nurse's station, and then he called the pest control company. He confirmed that Resident #54 had reported to him earlier that month regarding the cockroaches and the pest company came, assessed the room and didn't find anything. He further stated that Resident #54 provided him with a bag with dead insects in it, and he held on to it and showed it to the pest control company. He also stated that lately (this month) the facility has had a little roach problem. On 3/22/2026 at 10:03 AM, the surveyor entered Resident #13's room, the surveyor observed a large portion of the floor molding between the dresser and the heating/air conditioning unit was in disrepair, the blinds were broken, the hardware on the large dresser were broken and hanging off the furniture, the molding area under the sink was not affixed to the wall and falling off the wall and there was no calking around the sink area/vanity.On 3/22/26 at 10:40 AM, during the initial tour, the surveyor entered Residents #15's bathroom, observed broken tiles behind the toilet, 4 of the 9 ceiling tiles had gaps which also surrounded the sprinkler head and were deteriorated on the corners of the tiles. A piece of plywood on top of the bathtub which was not fastened and was covered with half a mat that positioned lengthwise. On 3/22/26 at 10:45 AM, the surveyor and the CNA entered Resident #19's bathroom and observed blackish-brownish sediment on the tiles toward the left-hand side of the toilet bowl and brownish, rust colored sediment on the bathtub. c.On 3/22/26 at 8:30 AM, surveyor #1 entered Resident #122's room and observed Resident #122 in bed. Upon inquiry, Resident #122 informed the surveyor that they were not provided with incontinent care on the 11:00 PM-7:00 AM shift. The surveyor left the room and asked a Certified Nurse Aide in the hallway to assist with an incontinence check. The CNA informed the resident of the procedure, the resident agreed to get checked. The resident was covered with a clean blanket. The CNA pulled the cover, and we observed the bedding including the resident's gown, the blanket was saturated with urine and yellow stained. The surveyor left the room and accompanied the Licensed Practical Nurse (LPN) in the room. The LPN observed that the resident was saturated with urine. The LPN stated that the CNA reported that the resident refused care. The Licensed Practical Nurse confirmed that Resident #122, needed to be changed. The surveyor then asked the LPN if she spoke with the resident regarding incontinence care, she stated, No. On 3/22/26 at 9:30 AM, surveyor #1 observed Resident #10 seated at the bedside eating breakfast. Resident #10's fingernails were long, jagged with black coated substances underneath the fingernails. Upon inquiry, Resident #10 informed the surveyor that they would like their nails to be trimmed and cleaned. Resident #10 was to have their nails trimmed and cleaned on their scheduled shower days. Resident #10 received a shower on 3/23/26 and were observed with fingernails in the same condition as observed on 3/22/26 until 3/25/26. d. On 03/25/26 at 10:47 AM, the surveyors conducted a telephone interview with the Medical Director (MD) regarding her role at the facility. The surveyor asked if there were residents with a history of substance abuse disorder at the facility, and the MD stated yes. When asked if that posed any risks, the MD stated, of course, if they leave the facility and when asked if the MD was involved in any policies regarding substance abuse history with residents, she stated, I wasn't asked about that by the facility. When asked if the MD could residents with history of using illicit substances have the potential to continue to use illicit substances, currently uses illicit substances. The MD stated, yes for sure, and they could bring drugs into the facility. When asked the MD regarding knowing that Resident #5 left the facility and rode a [NAME], was involved in an accident and fractured their hip. The MD stated, I wasn't aware of that part, I should have been made aware (Re: scooter.) When asked if the MD was involved with the residents who attended the PACE program, the MD stated she did not follow up with the PACE program. When asked about developing policies with the facility regarding the PACE program, she stated she did not. When asked if she reviewed the scooter accident with the facility at QAPI, she stated she did not. On 03/24/26 at 12:57 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) regarding how many current residents were enrolled in the PACE program and the LNHA stated he did not know, but he would find out. The LNHA then provided the surveyor with a list of 6 residents, that included Resident #115. On 03/25/26 at 11:29 AM, two surveyors interviewed the LNHA, and asked how often he communicated with the MD. The LNHA stated, primarily at the QAPI meeting. On 03/25/26 at 11:32 AM, two surveyors interviewed the LNHA and asked about the facility Quality Assurance Process and asked about PACE program process. The LNHA stated the PACE referred to and also placed residents at the facility and the residents would then attend the PACE day program. When asked about the contract, and the blank areas for the Liaison and the facility integration with the PACE. The LNHA stated, I was not aware it was blank and stated there was a biweekly phone call held with the PACE, and that the discharge plan was the sole responsibility of the PACE program and it was collaborated with the SW. When informed that the SWs were not involved in the discharge planning, the LNHA was unaware. When asked who was responsible to ensure care and services were provided for the residents who attended the PACE program. The LNHA stated it was his responsibility and stated there should be oversight between the PACE program and the facility. When asked if there was a process in place, the LNHA stated, no, and stated the collaboration should be documented in the medical record. Both surveyors asked the LNHA how the facility determined what was reviewed by the QAPI team and how QAPI plans were developed. The LNHA stated every quarter the department heads would present (Performance improvement Plans- PIP) and assessed their departments and determined where they could improve. The surveyor asked what all the current facility QAPI initiatives were. The LNHA stated the facility currently had the following QAPI plans which included:-Activities regarding attendance rates and residents' satisfaction with activities. (Not specific to room visits) -CNA staffing was short at times. -Minimum Data Set (MDS)- improve assessment accuracy, improve communication with team members, reduce number of modifications. -Kitchen ensured food preferences were adhered to. -Call bell audit grievances 3:00 PM-11:00 PM, 11:00 AM-7:00 PM residents and related to a complaint survey. The LNHA confirmed that the facility did not have any QAPIs for the concerns identified during the survey which included, but were not limited to; the lack of staff performance reviews, environmental concerns, pests, activity room visits, smoking and the waiver process, PNA, and falls with injuries. In addition, the LNHA stated the facility did not currently review any significant events in QAPI. On 03/25/2026 at 1:56 PM the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional DON (RDON), the Quality Assurance Nurse (QA Nurse), the [NAME] President of Clinical Operations (VPCO) and the [NAME] President of Operations (VPO) to discuss concerns. No further information was provided. The surveyor reviewed the facility QAPI-Quality Control and Monitoring Plan, revised 7/20/25. How Potential Topics for PIP's will be identifiedThe QAA committee will review data and input monthly to look for potential topics for PIPs. We will monitor and analyze data, and review feedback and input from residents, staff, families. We will look at issues, concerns, and areas that need improvement as well as areas that will improve the quality of life and quality of care and services for the residents living and staying in our community. Factors we will consider high-risk, high-volume, or problem prone areas that affect health outcomes, quality of care and services, and areas that affect staff. NJAC 8:39-33.1(a)(c); 33.2(a)

Based on interview and document review, it was determined that the facility Quality Assessment and Performance Improvement (QAPI) committee failed to utilize the facility Performance Improvement Plan (PIP) to follow the facility process to measure and utilize data acquired and develop quantitative and measurable goals, this deficient practice was evidenced by the following:On 3/24/2026 at 11:00 AM, the surveyor reviewed facility provided Performance Improvement Plans (PIPs) for activities regarding resident participation, missed reimbursement related to failure to capture respiratory treatments, CNA staffing, MDS modifications, and baseline care plans. All PIPs reviewed did not include quantitative and measurable goals. In addition, there were no goals and thresholds listed for performance measurements. On 3/26/2026 at 8:42 AM, two surveyors interviewed the Licensed Nursing Home Administrator (LNHA) regarding how the facility determined what was reviewed by the QAPI team and how QAPI plans were developed. The LNHA stated every quarter the department heads would present their (PIPs) and assessed their departments and determined where they could improve. The surveyor asked what all the current facility QAPI initiatives were. The LNHA stated the facility currently had the following QAPI plans which included:Activities regarding attendance rates and resident satisfaction with activities. (Not specific to room visits) Staffing due to CNA staffing was short at times.Minimum Data Set (MDS)- improve assessment accuracy, improve communication with team members, reduce number of modifications. Kitchen ensured food preferences were adhered to. Call bell audit grievances 3pm-11pm, 11am-7pm residents and due to a complaint survey. The surveyor asked the LNHA if he could provide any data from the PIPs that was analyzed to assess whether the PIP was effective or not. The LNHA stated that he confirmed that he did not have any specific quantitative and measurable goals, outcomes and/or audits written down, but he knows there has been an improvement.The surveyor reviewed the facility QAPI-Quality Control and Monitoring Plan, revised 7/20/25. How Our QAPI Plan Address Key Issues: Identify and use data to monitor our performance; Establish goals and thresholds for our performance measurements; Systematically analyze underlying causes of systematic problems and adverse events; Ensure Planned Changes/Interventions Are Implemented and Effective; To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, our organization chooses indicators/measures that tie directly to the new action and conducts ongoing periodic measurement and review to ensure that the new action has been adopted and is performed consistently. N.J.A.C. 8:39--33.1(a), 33.2(b), 33.2(d)

Complaint # NJ 2577317 Based on observation, interview and document review, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable and homelike manner for 4 of 4 resident rooms (#1, #13, #15 and #19) observed on 1 of 2 resident units (Rosewood), and for 1 of 2 shower rooms ([NAME]). The evidence was as follows: a. On 3/22/26 at 10:40 AM, during the initial tour, the surveyor entered Residents room [ROOM NUMBER]'s bathroom, observed broken tiles behind the toilet, four (4) of the 9 ceiling tiles had gaps which also surrounded the sprinkler head ,were deteriorated on the corners of the tiles, a plywood on top of the bathtub which was not fastened, and was covered with half a mat, positioned lengthwise. At that time, the surveyor invited the Certified Nurse Aide (CNA) to enter room [ROOM NUMBER]'s bathroom. The CNA confirmed she observed the same and stated she would inform the nurse of the concerns. On 3/22/26 at 10:45 AM, the surveyor and the CNA entered Residents room [ROOM NUMBER]'s bathroom and observed blackish-brownish sediment on the tiles toward the left-hand side of the toilet bowl and brownish, rust colored sediment on the bathtub. At that time, the CNA confirmed she observed the same and stated that she would inform the nurse of the concerns. On 3/23/26 at 12:45 PM, during an interview with the surveyor, the Director of Maintenance (DM) stated each nursing station had a book wherein any staff could report a problem (such as broken tiles, malfunctioning equipment.) and he fixed the problems that were logged. The DM stated he conducted rounds and conducted audits but could not provide the surveyor evidence that rounds and audits were conducted. The DM stated he did not audit for mold, and he did not receive any reports of mold like substances. On 3/24/26 at 11:13 AM, during an interview with the surveyor, the VP of Environmental Services (VPES) stated he oversaw the building and visited twice per month, audited the rooms in no specific order. The surveyor requested any documentation of the audits, and the VPES stated he could not provide any documented evidence of any previous audits that were conducted. On 3/24/26 at 11:18 AM, the surveyor, the DM and the VPES entered Residents' room [ROOM NUMBER]'s bathroom and observed brownish colored sediment on the bathtub. At that time, the DM stated that he was not sure if the bathtub could be painted. The DM and the VPES stated that the brownish color on bathtub was rust. At that time, the VPES confirmed the observation did not reflect a homelike environment. On 3/24/26 at 11:32 AM, the surveyor, the DM and the VPES entered Resident #15's room bathroom and observed the plywood over the bathtub that was not fastened. At that time, the VPES could not state if the placement of the unfastened plywood was safe and added that he would discuss the concern with the nursing department. At that time, the VPES and the DM confirmed observing 4 of the 9 ceiling tiles that surrounded the sprinkler head were deteriorated and had gaps. The VPES acknowledged that the condition of the ceiling tiles was not safe and could be a fire hazard. On 3/24/26 at 11:35 AM, the surveyor, the DM and the VPES entered Residents' room [ROOM NUMBER] and observed the brownish-blackish colored tile behind the toilet and confirmed the discoloration on the tub was rust. At that time both acknowledged that the bathroom did not have the appearance of home-like environment. On 3/25/26 at 8:59 AM, in the presence of a surveyor, the DM and the VPES, the surveyor observed the shower room. At that time, the DM confirmed that the shower stall observed was where the residents who lived in the [NAME] unit took a shower. The shower stall had blackish-brownish colored sediments underneath the tiles, located underneath the shower head, across the shower head and to the corners, a whiteish, pinkish residue was also found on the floor tiles. The DM stated that it did not look like mold. At 9:12 AM, the Housekeeping Director entered the shower room and informed the surveyors, the DM and the VPES that all the tiles could be cleaned with bleach to remove the brownish-blacking and whitish-pinkish substance on the tiles. The HK stated that the cleaning schedule for the shower rooms was twice a week and that shower was last cleaned 6 days ago. b. On 3/22/26 at 10:03 AM, during the initial tour, the surveyor entered Resident #13's room, the surveyor observed a large portion of the floor molding between the dresser and the heating/air conditioning unit was in disrepair, the blinds were broken, the hardware on the large dresser were broken and hanging off the furniture, the molding area under the sink was not affixed to the wall and falling off the wall and there was missing calking around the sink area/vanity. On 3/24/26 at 8:42 AM, the surveyor and the Certified Nurse Aide (CNA) entered Resident #13's room, the CNA acknowledged that the blinds should not have been broken, the molding on the floor should have been repaired and around the sink area/vanity should have been repaired. The CNA further stated that if she had noticed something needed to be repaired, she would have called maintenance or gone to the maintenance department to report the issues. The CNA stated that she was unsure if the issues had been reported. On 3/24/26 at 11:55 AM, the surveyor interviewed the DM in the presence of the VPES. The DM stated each nursing station had a Maintenance logbook available for staff to log maintenance issues. The DM stated that he checked the maintenance logs every day and he fixed the problems that were logged. The DM stated that he fixed things every day. The DM stated he conducted rounds and conducted audits, but he did not keep documentation. The VPES and DM went to Resident #13's room to view the items in disrepair. The VPES and DM agreed that all the above mentioned items should be repaired. On 3/24/26 at 12:15 PM, the surveyor reviewed Maintenance log located at the nurse's station reviewed, there were no reports written for Resident #13's room. The last entry that was recorded in the log was 1/20/26. On 3/25/26 at 1:57 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional DON, the Quality Assurance Nurse (QA Nurse), the [NAME] President of Clinical Operations (VPCO) and the [NAME] President of Operations (VPO), the survey team discussed the above concerns. On 3/26/26 at 10:15 AM, during a meeting with the survey team, the Regional DON, the DON, the VPOC, the VPO, the Unit Manager for [NAME], and the Infection Preventionist, the LNHA stated the root cause was the age of the building, recognized that they should have a program in place, and had a transition that contributed to the absence of preventative maintenance. Additionally, the LNHA stated that the repairs were completed in Resident #13's room. A review of the provided facility policy titled, Homelike Environment, reviewed/updated 9/2025 included that the Residents are provided with safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. NJAC 8:36-4.1(a)11; 31.8(e)

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that residents who were dependent on staff for activities of daily living was provided with a) routine and appropriate incontinence care, b) a shower that was consistent with their needs and preferences, c) assistance to get out of bed, d) routine and appropriate nail care in a timely manner This deficient practice was identified for 4 of 4 residents reviewed for activities of daily living (Resident #10, Resident #31, Resident # 58 and Resident #122).The evidence was as follows:1) On 3/22/26 at 8:30 AM, the surveyor #1 entered Resident #122's room and observed Resident #122 in bed. Upon inquiry, Resident #122 informed the surveyor that they were not provided with incontinence care on the 11:00 PM-7:00 AM shift. The surveyor asked a Certified Nurse Aide (CNA) in the hallway to assist with an incontinence check. The CNA informed the resident of the procedure, and the resident agreed to get checked. The resident was covered with a clean blanket, and when the CNA removed the blanket, we both observed the bedding, underneath blanket and the resident's gown were all saturated with urine and were yellow stained. The surveyor left the room and accompanied the Licensed Practical Nurse (LPN) into the room. The LPN observed also observed that the resident was saturated with urine. The LPN stated that the CNA reported that the resident had refused care. The LPN confirmed that Resident #122 needed to be changed. The surveyor then asked the LPN if she spoke with the resident after the CNA stated the resident refused incontinence care and to follow up on the resident's condition. The LPN she stated, No, she had not followed up with the resident. On 3/22/26 at 9:00 AM, during an interview with Resident #122, Resident #122 stated that a CNA had checked them this morning and observed they were saturated with urine. The CNA informed them the whole bedding had to be changed. The staff then left the room and did not return. Resident #122 was also served breakfast while being saturated with urine. The Resident stated to the surveyor, What you observed was not over six hours only. The surveyor asked Resident 122, if they refused to be changed, Resident #122 stated, I do not recall that I refused to be changed. On 3/23/26 at 10:00 AM, the surveyor reviewed Resident #122's medical record which revealed the following: According to the admission Minimum Data Set (MDS) dated [DATE], Resident #122 had a BIMS score of 12 out of15 which was indicative of moderate cognitive impairment. After the surveyor's observation on 3/22/26, Resident 122's Care Pan revealed a Care Plan implemented on 3/24/26, for refusal of care. The Care Plan also a focus for ADL Self Care Performance Deficit. The interventions were for staff to encourage participation with ADLs care. Initiated 3/24/26. 2) On 3/22/26 at 9:30 AM, the surveyor observed Resident #10 seated at the bedside eating breakfast. Resident #10's fingernails were long, jagged with black coated substances underneath the fingernails. Upon inquiry, Resident #10 informed the surveyor that they would like their nails to be trimmed and cleaned. Resident #10 was supposed to have their nails trimmed and cleaned on their scheduled shower days. Resident #10 received a shower on 3/23/26 and was observed with fingernails in the same condition as observed on 3/22/26 through 3/25/26. Resident #10 had their nails trimmed and cleaned after the surveyor inquiry on 3/25/26. 3) On 3/22/26 at 10:00 AM, the surveyor entered Resident #58's room. The surveyor observed Resident #58 seated in a wheelchair at the bedside. Resident #58's lower extremities were dry, scaly and covered with flaky skin. The surveyor observed Resident #58 with the same pajamas on 3/22/26, 3/23/26, 3/24/26 and 3/25/26, seated in the room. On 3/25/26 at 9:45 AM, Resident #58 stated that they had been trying to have a shower for so long, and it did not happen. The resident asked the surveyor if they could facilitate a shower for them. The surveyor asked the resident when they last had a shower. The resident stated, the last shower was in January. The surveyor then reviewed the medical record for Resident #58 which revealed: A review of the admission Face Sheet (an admission summary) reflected that Resident #58 was admitted to the facility with diagnoses which included but were not limited to; peripheral vascular disease, unspecified malignant neoplasm of skin left upper limb including shoulder, unspecified osteoarthritis, obesity due to excess calories. According to the quarterly Minimum Data Set (MDS) dated [DATE], Resident #58 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #58 had a care plan for ADL Self Care performance deficit related to lack of motivation and forgetfulness Initiated 12/02/19. The goal was to maintain current level of functioning. Initiated 12/02/19. The interventions included to assist Resident #58 as needed. 4. On 3/22/26 at 9:31 AM the surveyor observed Resident #31 in bed, when asked about how their stay had been at the facility Resident #31 stated 1 would like my fingernails to be cut, and I can't do it myself. Resident #31 stated that I asked the staff a couple of times, but they still haven't cut my nails. The surveyor observed all 10 fingernails extended over the fingertips with a black substance underneath all of the nails. Resident #31 stated that I asked the staff again this morning and they stated they would cut my nails. On 3/22/26 at 11:10 AM The surveyor reviewed the medical record for Resident #31. According to the admission Record (an admission summary) Resident #31 was admitted to the facility with diagnoses that included but were not limited to; cerebral infarction (stroke), hemiplegia (one sided paralysis)and hemiparesis (one sided weakness) affecting right dominant side and peripheral vascular disease (problems with blood vessels outside the heart and brain), benign prostate hyperplasia (enlargement of the prostate), atrial fibrillation (heart rhythm disorder) and hypertension (high blood pressure), A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 3/04/26, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Section GG revealed that Resident #31 was coded as Shower/bathe self 01 dependent (Helper does all the effort) and personal hygiene 04 Supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity). A review of the resident's comprehensive Care Plan effective 9/12/19, identified a problem area of ADL self-care performance deficit related to weakness diagnosis CVA, the goals were maintain current level of function in turning side to side with assistance, self-propelling in wheelchair through the review date and the interventions included Resident #31 was a total care for showering on Thursday 7:00 AM-3:00 PM and Monday 3:00 PM-11:00 AM date initiated 10/12/23. A review of the resident's March 2026, Physician Order Sheet reflected a physician's order dated 2/23/26, for Bi-weekly Shower days, Shower Day every day shift every Thursday, and physician order dated 2/23/26, Bi-weekly Shower days, Shower Day every evening shift every Monday. On 3/23/26 at 11:18 AM, the surveyor interviewed the CNA regarding grooming and nail care. The CNA stated that Resident #31 required total care. She stated today was their shower day, but they never took a shower, they received a full bed bath, and they were dressed and assisted out of bed. The CNA stated that nail care should have been completed on their shower day. The CNA then stated if the nails were too long, she would cut them because the resident could scratch someone. The CNA stated that Resident #31 did not ask to have their nails cut. The surveyor and CNA went to Resident #31's room together to observe their fingernails. The CNA then stated they could be cut but if they had diabetes, I would not cut their nails, the nurse would have to cut their nails. When the surveyor asked the CNA if Resident #31 was diabetic and the CNA was unable to answer. On 3/23/26 at 11:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding grooming and nail care. LPN #1 stated that only if they asked, we would cut their nails. Their spouse usually cut their nails. The LPN further stated that she didn't notice Resident #31's nails, and they had not requested to have their nails cut. The LPN stated the nurses would cut the resident's nails if the resident was diabetic, and the CNA should not cut nails if the resident was diabetic. The LPN stated Resident #31 did not have diabetes. The LPN stated, we should offer to cut the resident nails, when we provided care on their shower days, they should not have to ask. On 03/25/26 at 1:56 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), the Regional DON (RDON), the Quality Assurance Nurse (QA Nurse), the [NAME] President of Clinical Operations (VPCO) and the [NAME] President of Operations (VPO) to discuss concerns. No further information was provided. A review of the facilities policy updated 10/25 titled Activities of Daily Living (ADL), Supporting revealed Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene Policy Interpretation and Implementation 2. Appropriate care and services will be provided for residents who are unable to carry our ADLs independently . a. hygiene (bathing, dressing, grooming, and oral care). NJAC 8:39-27.1 (a)2(g)(h)

Based on observation, interview and document review it was determined that the facility failed to ensure a process was in place to provide an ongoing program to support a resident's individual activity preferences to support the psychosocial needs of the residents. The deficient practice was identified for 1 of 1 resident (Resident # 56) reviewed for activities and was evidenced by the following: On 03/24/26 at 10:39 AM, the surveyor interviewed Resident #56 and asked Resident #56 regarding what they liked to do for activities, and Resident #56's regular certified nurse aide was also present. The resident stated they loved jewelry and showed the surveyor their earrings. When asked if the resident attended the trips, the resident stated they were never asked about the trips and would go on trips. When asked if the resident walked, the resident stated they could dance and the Certified Nurse Aide (CNA) stated the resident liked to dance. On 03/24/26 at 11:00 AM, the surveyor reviewed the medical record for Resident #56 which revealed the following:A Quarterly Minimum Data Sheet (assessment tool) dated 3/14/26 which revealed a Brief Interview for Mental Status score of 11 out of 15 which indicated the resident had moderately impaired cognition. The Resident Mood Interview revealed the resident had experienced episodes of feeling down, depressed, or hopeless on 3 occasions during the two weeks prior to the assessment. The resident was coded as having no impairment in upper or lower extremity mobility. The Care Plan revealed a Focus area for Resident #56 was dependent on staff for meeting emotional, intellectual, physical and social needs. At risk for social isolation. Initiated 1/14/19. The Goal was to maintain insolvent in cognitive stimulation, social activities as desired through review date and reduce the risk of social isolation, with a Target date of 6/14/26. Interventions included: All staff to converse while providing care, Initiated 1/14/19; Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary, Initiated 1/14/19; Invite/ encourage to scheduled activities, Initiated 1/14/19; Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility Initiated 1/14/19; Provide with activities calendar. Notify of any changes to the calendar of activities. Initiated 12/09/24; Enjoys watching games shows. Initiated 1/14/19; Loves listening to rock n roll and Elvis [NAME], Initiated 1/14/19; Resident needs 1:1 bedside/in-room visits and activities. Initiated 2/24/25; Preferred activities are: music, watching game shows and loves to shop, Initiated 1/14/19.An Activity assessment dated [DATE] revealed the resident was coded as Yes for on occasion Connect 4; Yes for Trips/Shopping (the If yes, specific dated and the activity section was blank); Yes for Movies/Television/Radio (the If yes, specific dated and the activity section was blank).On 03/24/26 at 11:07 AM, the surveyor interviewed the Activity Director (AD) regarding the activities and how often trips were scheduled. The AD stated trips were scheduled once per month, and that she asked residents if they wanted to attend. When asked if Resident #56 went on trips, the AD stated Resident #56 wanted the bus all to themselves and when they went on shopping trips, there would be other residents and Resident #56 refused to go. The surveyor asked were the trip refusals documented? The AD it was a long time ago and confirmed that she did not document refusals and when asked what activities were provided for Resident #56 and the AD stated, room visits were provided to Resident #56 three times per week and the surveyor asked if that was documented. On 03/24/26 at 11:49 AM, the AD provided the surveyor with one-page handwritten document with Resident #56's name on the top, with Date of Room Visit, and a section for brief description of visit with resident. The document did not indicate the time spent with the resident, or staff signature that identified the staff. When asked how long the visits were supposed to be. The AD stated they should be 15-30 minutes long. When asked if the information was documented anywhere else, the AD stated no. When asked how she could confirm how long the visits were, or what happened when a refusal was documented? The AD could not confirm the staff who documented the visits, or the time spent with the resident and no additional information was provided. The document revealed: 1/7/26 offered [checker game name redacted] and refused, 1/11/26 talked about family, 1/19/26- offered trips-refused, 1/21/26 offered to take a walk- refused, 1/24/26 refused visit, 1/31/24 offered games (no specific). Three visits per week were not documented for January 2026.On 03/25/26 at 1:56 PM, the survey team met with the LNHA, Director of Nursing (DON), and the facility management company staff: Regional DON, [NAME] President (VP) of Clinical Operations, Quality Assurance Nurse, and the VP of Operations and informed them of the above concerns. No additional information was provided. NJAC 8:39-7.3(a)(g)

Refer to 759. Based on observation, interview, and record review, it was determined that the facility failed to ensure the recommendation made by the Consultant Pharmacist (CP) was acted upon in a timely manner for one (1) of two (2) residents (Resident #95) with a physician ordered diet of nectar thickened liquid and was evidenced by the following: On 3/23/26 at 9:45 AM, the surveyor began the Medication Observation Pass for Resident #95. The Licensed Practical Nurse (LPN) began to prepare the medication that included a physician order (PO) of Levetiracetam (Keppra) oral solution 500 milligram (mg)/5 milliliter (ml); give 10 ml by mouth every 12 hours for seizures. The order started on 12/27/25 and scheduled for administration at 9:00 AM. No additional instruction was reflected on the PO. At that time, the surveyor observed an order on the electronic Medication Administration Record (eMAR) that indicated the resident had a nectar thickened diet. On 3/23/26 at 9:52 AM, the LPN requested assistance from another staff to retrieve a pre thickened nectar liquid for Resident #95 since she did not have one in her medication cart. At 9:53 AM, the other staff member brought the LPN a cranberry cocktail that was pre-thickened with nectar thick consistency. At that time, the LPN randomly poured an unmeasured amount of liquid into the medication cup that contained the Keppra solution and stated that she did not have a thickening powder in her cart. On 3/23/26 at 9:55 AM, the LPN confirmed with the surveyor that she was ready to administer the medications to Resident #95, turned and walked toward the Resident's door threshold. At that time, the surveyor asked to speak with the LPN to review the electronic Medical Record (eMR). On 3/23/26 at 9:59 AM, the surveyor and the LPN reviewed the eMR together. The LPN informed the surveyor that the thickening powder was not something she had in her cart. The LPN stated that administering a thin liquid to a resident with a diet order of nectar thickened liquid could cause the resident to aspirate (accidental inhalation of fluid, food or vomit into the airway and lungs which can cause pneumonia). At that time, after reviewing the resident's eMR, LPN stated that the administration of the Keppra solution was not appropriate for Resident #95 who had a nectar thickened diet, and she would call the physician for an alternative. On 3/23/26 at 10:24 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that residents with diet changes were reviewed by the CP, and the nurses, who also notified the physician. The surveyor reviewed the medical record for Resident #95. According to the admission Record, face sheet, an admission summary reflected that Resident #95 was admitted to the facility with diagnoses which included but were not limited to; Lennox-Gastaut syndrome (LGS; a severe form of epilepsy, seizures that began in early childhood), not intractable (may respond to treatment) with status epilepticus (a seizure lasting longer that 5 minutes or multiple seizures occurring closely together without returning to a normal level of consciousness in between). A review of the quarterly Minimum Data Set (qMDS) dated [DATE], reflected Resident #95 had a Brief Interview for Mental Status (BIMS) score of one (1) out of 15 which indicated Resident #95's cognition was severely impaired. Further review of the MDS section N under High-Risk Drug Classes revealed that the resident was administered an anticonvulsant (medication used to treat, prevent or reduce the frequency if seizure and convulsions associated with epilepsy and other neurological disorders). On 3/23/26 at 11:55 AM, during an interview with the surveyor, the Speech-Language Pathologist (SLP) informed the surveyor that the resident was admitted with dysphagia of the oropharyngeal phase (difficulty moving food/liquid from the mouth to the esophagus). The SLP stated the resident had been admitted with honey thickened diet and was upgraded to nectar thickened liquid on 3/18/26 which allowed Resident #95 more time to safely swallow and avoid aspiration. The SLP also stated that diet consistency change was shared with the dietician, the dietary staff and the nursing staff. On 3/23/26 at 1:29 PM, during a follow-up interview with the surveyor, the LPN/UM stated that the expectation was that the CP would notify us of medication irregularities. The LPN/UM could not recall if the CP made recommendations. At that time, the surveyor requested for all of the CP recommendations report for Resident #95. On 3/24/26 at 10:27 AM, during an interview with the surveyor, the Regional Director of Nursing (Regional DON) provided the surveyor with the previously requested CP recommendations report for Resident #95. The surveyor and the Regional DON reviewed the CP recommendations together which included a recommendation to notify the prescriber of the Keppra solution and to ask the prescriber if the current consistency was safe for administration. A facility staff signed the CP recommendations report. At that time, the Regional DON acknowledged and confirmed that the CP recommendation was signed and was not acted upon. The Regional DON informed the surveyor that the resident was assessed after the medication pass observation, the physician was notified, and the medication orders were updated. On 3/25/26 at 1:57 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional DON, the Quality Assurance Nurse (QA Nurse), the [NAME] President of Clinical Operations (VPCO) and the [NAME] President of Operations (VPO), the surveyor discussed the concern with the CP recommendation was signed and not acted upon. On 3/26/26 at 10:15 AM, during a meeting with the survey team, the LNHA, the DON, the VPOC, the VPO, the Unit Manager for [NAME], and the Infection Preventionist, the Regional DON stated that a Quality Assurance Performance for Improvement (QAPI) was started after surveyor inquiry, the interdisciplinary team which included the dietician and the pharmacist would review the diet change and medications to ensure safe administration. A review of the facility provided document titled, Pharmacist Recommendations Review, Nursing Protocol dated 12/2025, included the following under Notify the Attending Physician/APN [Advanced Practical Nurse]: Pharmacist-identified irregularities must be acted upon. The attending physician must review, decide on action, and document justification if no change is made. Nursing staff contact the provider within 24 hours for urgent issues (e.g. high-risk drug interactions, missing monitoring.) NJAC 8:39-29.3

Refer to 756. Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 3/23/26 and 3/24/26, the surveyor observed six (6) nurses administer medications to six (6) residents. There were 26 opportunities, and three errors were observed which resulted in a medication error rate of 7.69%. This deficient practice was identified for two (2) of six (6) residents (Resident #84 and #95), that was administered by two (2) of six (6) nurses. This deficient practice was evidenced by the following:a. On 3/23/26 at 8:46 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #84. The medications included a physician's order (PO) of Aspercreme with Lidocaine Cream 4% (Lidocaine); apply to the right shoulder topically one time a day for chronic pain and was to be removed per schedule. The PO started on 3/13/26. At 8:52 AM, LPN #1 confirmed she was ready to administer 8 oral [tablets and capsules] medications to Resident #84. At that time, the surveyor observed Resident #84 self-propelling in their wheelchair in their room toward the doorway and stated that they were scheduled for rehabilitation that morning. LPN #1 administered 8 oral medications to Resident #84 and LPN #1 returned to their medication cart. On 3/23/26 at 8:55 AM, LPN#1 informed the surveyor and Resident #84 that the Lidocaine Cream was not in her medication cart and was going to retrieve it from her treatment cart. At 9:02 PM, LPN #1 returned and stated to Resident #84 and the surveyor, that she could not find the Lidocaine Cream in the treatment cart, was not aware if it was stocked in the facility as house stock and the Unit Manager was going to call the physician for an alternative. At 9:07 AM, LPN #1 saw the new PO of Diclofenac Gel 1%; apply to the right shoulder topically every day shift for pain. The PO started that morning 3/23/26. At 9:09 AM, LPN #2 squeezed the tube, measured 2 grams of the cream onto a ruler, wiped the cream off the ruler with their gloved hand, and turned to administer the cream to Resident #84. At that time, the surveyor stopped the medication pass observation to review the PO with LPN #1. On 3/23/26 at 9:12 AM, during an interview with LPN #1, the surveyor asked how she knew how much to administer when it was not specified on the PO. At that time, LPN #1 acknowledged and confirmed that the PO for Diclofenac did not have a dosage and that she should have clarified the order prior to administration. b. On 3/23/26 at 9:45 AM, the surveyor began the Medication Observation Pass for Resident #95. LPN #2 began to prepare the medication that included a physician order of Lamotrigine (Lamictal) 200 milligram (mg); give 1 table by mouth one time a day for Lennox-Gastaut syndrome (LGS; a severe form of epilepsy, seizures that began in early childhood) DO NOT CRUSH, disintegrate in applesauce if needed. The order started on 2/6/26 and scheduled for administration at 9:00 AM. At that time, the surveyor observed an order on the electronic Medication Administration Record (eMAR) that indicated the resident had a nectar thickened diet. On 3/23/26 at 9:50 AM, the surveyor observed LPN #2 remove one (1) tablet of Lamictal from the bingo card (a multidose card containing individually packaged medications) that included a cautionary Swallow tablet whole. Do Not Chew, Break or Crush. At that time, LPN #2 crushed the Lamictal and mixed the crushed Lamictal into chocolate pudding. On 3/23/26 at 9:55 AM, the LPN confirmed with the surveyor that she was ready to administer the medications to Resident #95, turned and walked toward the Resident's door threshold. At that time, the surveyor asked to speak with the LPN to review the electronic Medical Record (eMR). On 3/23/26 at 10:00 AM, during an interview with the surveyor, LPN #2 stated she missed the cautionary of on the bingo card of Swallow tablet whole. Do Not Chew, Break or Crush and the special instructions on the eMAR of DO NOT CRUSH, disintegrate in applesauce if needed. At 10:04, LPN #2 stated she would inform the LPN/Unit Manager (LPN/UM) and the Director of Nursing of the concern. On 3/23/26 at 10:24 AM, during an interview with LPN/UM, the surveyor discussed the concerns that occurred during the medication pass observation. The LPN/UM stated she would contact the physician and place a request for the Consultant Pharmacist to review Resident #95's medications. On 3/25/26 at 1:57 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Regional DON, the Quality Assurance Nurse (QA Nurse), the [NAME] President of Clinical Operations (VPCO) and the [NAME] President of Operations (VPO), the surveyor discussed the concern with the administration of Resident #84's pain medication cream without dosing to ensure that the resident's pain would be adequately managed and the concern with the administration of Resident #95's seizure medication against the pharmacy cautionary label and specified physician's order for administration. On 3/26/26 at 10:15 AM, during a meeting with the survey team, the LNHA, the DON, the VPOC, the VPO, the Unit Manager for [NAME], and the Infection Preventionist, the Regional DON stated that a Quality Assurance Performance for Improvement (QAPI) was started after surveyor inquiry, the interdisciplinary team which included the dietician and the pharmacist would review the diet change and medications to ensure safe administration. A review of the facility provided policy titled, Administering Medications, reviewed and updated on 7/2025, included Medications are administered in accordance with prescriber orders. Further review reflected that the individual administering the medication checks the label three (3) times to verify the right resident, the right dosage, right time, and right method (route) of administration before giving the medication. NJAC 8:39-11.2(b), 29.2(d)

Complaint NJ #2743500Based on observation, interview and document review, it was determined that the facility failed to maintain an effective pest control program to ensure the facility was free of cockroaches. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following:On 3/22/26 at 8:57 AM, Resident #54 approached surveyor and stated that they had been in the facility approximately two months and they resided in the third room since they had been admitted . The resident then proceeded to show the surveyor a plastic bag with 4 dead cockroach- like insects inside. Resident #54 then informed the surveyor the dead bugs were cockroaches. The resident then stated that when they used the bathroom during the night, and then turned on the light, they would see the cockroaches scatter. The resident also stated that they reported this to the facility, and when they sprayed for the cockroaches the last time, the Administrator was also present with the exterminator. The resident further stated this was the second bag they had with examples of dead cockroaches and stated the first bag was given to the facility. On 3/24/26 at 8:26 AM, the surveyor interviewed Resident #54, who stated when awake around 3:00 AM to use the bathroom, they saw them (cockroaches) and showed the surveyor a gap between the door molding and the floor. Resident #54 stated that the cockroaches would come in and out of that gap.On 3/24/2026 at 11:27 AM, the surveyor reviewed the pest control reports provided by the facility which revealed the following:-1/14/26, Rosewood wing; roach (cockroach) cleanout complete. Treated all cracks and crevices. Activity found coming out of the drop ceiling and molding around the ceiling;-1/12/26, room [ROOM NUMBER] treated the bathroom and heater for general pests. Treated entire kitchen, replaced glue traps due to roach activity on them;-1/7/26, Inspected and treated for initial roach clean out. Unit wasn't fully prepared, there were cabinets that had items inside of them; -1/5/26, Follow- up in room # 25 for roaches;-12/15/25, Treated rooms #27 and #5 due to roach sightings throughout any accessible floorboards and bathrooms . Replaced any visible glue boards and monitors throughout the kitchen area due to wet traps or roach activity on them;-11/10/25, Replaced any glue traps in the kitchen due to roach activity on them or wet traps;-10/13/25, Replaced most glue boards and monitors throughout each area due to roach activity on them or wet traps. Kitchen and dishwasher areas roach activity seen on glue traps;-9/22/25, Kitchen prep station, dishwasher areas, changed insect monitor by dishwasher area due to minor roach activity.-9/15/25, Replaced the glue boards and monitors throughout the kitchen and basement due to minor roach activity or ineffective glue traps. On 3/24/26 at 12:01 PM, the surveyor toured with the Maintenance Director (MD) and showed him the gap between the molding and floor in Resident #54's room. He stated he was not aware of roaches in that room. He further stated that he completed environmental rounds, however didn't document the rounds. The MD stated if he observed something, he would fix it, and stated the pest company came in every Monday. He stated the procedure to report a pest sighting would be that after an insect would be reported to staff, the staff was supposed to put it in a the pest log. The MD stated there was one at each nursing station and one was also located in the kitchen. The pest company was responsible to checks the books and treat accordingly. On 3/24/26 at 12:33 PM, the surveyor interviewed the Director of Housekeeping who explained the procedure for insect sightings was to log the sightings in the book. There was a book at each nursing station, and then he would call the pest control company. He confirmed that Resident #54 reported to him, sometime earlier that month regarding the cockroaches, and the pest company came, assessed the room and didn't find anything. He further stated that Resident #54 provided him with a bag with dead insects in it, and he held onto it and showed it to the pest control company. He also stated that lately (this month) the facility has had a little roach problem. The pest control company came, sprayed and also fumigated the section that had a problem. On 3/25/26 at 9:03 AM, the surveyor reviewed Resident #54's electronic medical record (EMR) which revealed the resident had a Brief Interview for Mental Status score of 15 out of 15, dated 2/2/26, which indicated a fully intact cognition. On 3/25/26 at 12:32 PM, the surveyor reviewed the Commercial Pest Control Service Agreement between [name redacted] Services and the facility which was dated 2/3/25, and which indicated treatment would be on a weekly basis. On 3/25/26 at 12:47 PM, the surveyor reviewed the facility provided policy, Pest Control Program, with a revised date of November 2025, which included: Policy: Facility will maintain an effective pest control program that eradicates and contains common household pests.Policy Explanation and Compliance Guidelines:3. Facility will maintain a report system of issues that may arise i between scheduled visits with the outside pest service and treat as indicated. On 3/25/26 at 1:56 PM, the surveyor notified the facility leadership of above concerns. On 3/26/26 at 10:13 AM, the Licensed Nursing Home Administrator (LNHSA) stated that every resident or employee who sees a bug called it a roach, and he did not believe it was a widespread concern. No further information was provided NJAC 8:36-4.1(a)11; 31.5(a)(1)

Based on observation, interview and review of facility's documentation, the facility failed to ensure that medications were administered according to standards of practice. This deficient practice was identified for 1 of 1 resident observed with medication left unattended at the bedside (Resident #58). The evidence was as follows: On 3/22/26 at 10:00 AM the surveyor entered Resident #58's room and observed a medication cup with 6 tablets inside the cup and a cup of water on the bedside table. The surveyor observed the resident seated in the room by the bed. Upon inquiry, the resident informed the surveyor that the nurse left the medications at the bedside for them to take. The surveyor exited the room at 10:28 AM, and the medications were still at the bedside. The surveyor did not observe any other residents wandering in the hallway.On 3/22/26 at 10:30 AM, the surveyor observed the Licensed Practical Nurse (LPN) on the medication cart in the hallway and inquired regarding Resident #58's medications. The LPN stated that Resident #58 received their medications at 9:00 AM, and the surveyor asked the LPN to elaborate on the facility's policy regarding medication administration.The LPN stated the process was as follows: Check the identification bracelet to ensure this is the right patient, ensured the resident swallowed the medication prior to exiting the room, then signed the medication administration record after the medications were administered. The surveyor then asked the LPN if she observed Resident #58 swallowing their medications this morning. The LPN then stated she observed Resident #58 took their medications, drank the water prior to leaving the room. The surveyor showed the nurse the tablets in the cup and the cup of water still at the bedside 90 minutes later, the nurse stated I am going to lose my job. The nurse then ran to the room and had a conversation with Resident #58 regarding the medications left at the bedside.On 3/24/26 at 11:00 AM, the surveyor reviewed Resident #58' medical record.A review of the admission Face Sheet (an admission summary) reflected that Resident #58 was admitted to the facility with diagnoses which included but was not limited to; peripheral vascular disease, unspecified malignant neoplasm of skin left upper limb including shoulder, unspecified osteoarthritis, obesity due to excess calories.The Quarterly Minimum Data Set (MDS), an assessment tool, of 12/27/26, indicated that the resident's BIMS (Brief Interview for Mental Status) was13 out of 15 which indicated that the resident had intact cognition.On 3/22/26 at 11:30 AM, the surveyor interviewed the UM regarding Resident #58 and requested a printed copy of the Medication Administration Record (TAR) The surveyor then inquired if staff should leave medications unattended at the bedside. The UM stated that the nurses were to ensure that residents took their medications prior to leaving the room.The following medications were scheduled to be administered at 9:00 AM and were observed by the surveyor as left at the bedside:Metformin 850 milligrams (mg) medication to control blood glucose, Cyanocobalamin 1000 mg for supplement, Lisinopril 10 mg medication to control high blood pressure, Clopidogrel 75 mg medication to prevent blot clotting, Apixaban 5 mg medication to treat irregular heartbeat. The LPN signed the MAR that the above medications were administered at 9:00 AM.On 03/24/2026 at 12:35 PM, during an interview with the Regional Director of Nursing, she stated, nurses were not to leave medications at the bedside for safety. This is standard of practice. On 3/25/26 at 2:00 PM, during a pre-exit meeting held with the survey team and the administrative staff (DON, Regional Director of Nursing and the Licensed Nursing Home Administrator) the surveyor reviewed the concerns regarding Resident #58's medications left at the beside unattended and requested any additional information. The Regional Director of Nursing stated that the staff had been educated.On 3/26/26 at 1:30 PM, the facility provided in-service education regarding the above concerns, and no other information was provided.A review of the facility's policy titled, Administering Medications provided by the DON last updated 7/2025, reflected the following:Policy:Medications are administered in a safe and timely manner, and as prescribed. The facility will maintain appropriate system to ensure medications are available and that residents receive their medications in a timely manner. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.NJAC: 8:39-29.2(d)

Complaint #: 407581Based on interviews, review of medical records, and pertinent facility documents, it was determined that the facility failed to notify the resident's physician and responsible party of a change in condition for 1 of 3 residents (Resident #1) reviewed. This deficient practice was evidenced by the following:On 10/27/2025 at 8:30 AM, the surveyor reviewed the closed medical record for Resident #1.A review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/7/2025, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition.A review of the corresponding Medication Administration Record (MAR) revealed that the resident's temperature on 2/24/2025, during an unspecified time on the 11-7 shift was 100.2'F.A review of the progress notes did not reveal any nursing notes related to the temperature recorded in the MAR on 2/24/2025 during the 11-7 shift. There were no follow up temperatures recorded in the MAR during the said shift. There was no documentation that the resident's physician and responsible party were notified of the resident's fever.On 10/27/2025 at 12:47 PM, during an interview with the surveyor, Registered Nurse (RN) #1 stated that if a resident has fever, Tylenol would be administered and that temperatures should be taken every 4 hours to see if the staff need to give Tylenol. RN #1 further stated that the staff documents for any change in condition and call the physician and family.On 10/27/2025 at 12:49 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that if a resident has fever, the staff should be documenting all they do so they would know what to follow through. The DON further stated that staff should continue monitoring, offer fluid, call the physician if they want laboratory work done. The family should be notified. They need to give Tylenol. They need to document everything. A review of the facility-provided policy dated January 2025, titled Change in a Resident's Condition or Status included under Policy Interpretation and Implementation, 1.) The nurse will notify the resident's attending physician or physician on call when there has been a: d.) significant change in the resident's physical/ emotional/ mental condition. 4.) Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b.) there is a significant change in the resident's physical, mental, or psychosocial status.A review of the facility-provided policy dated December 2024, titled Charting and Documentation under Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. N.J.A.C. 8:39 - 13.1 (c) (d)

Complaint #: 407581Based on interviews, record review, and review of other pertinent facility documents, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, by failing to ensure that medication was administered and documented according to a physician order. This deficient practice was identified for 1 out of 3 residents reviewed for quality of care (Resident #1). This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 10/27/2025 at 8:30 AM, the surveyor reviewed the closed medical record for Resident #1.A review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; urinary tract infection, congestive heart failure, and chronic respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues).A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 1/7/2025, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition.A review of the Order Summary Report dated 2/25/2025, included a physician's order (PO) started on 2/9/2025, for acetaminophen tablet 325 milligrams, give 2 tablets by mouth every 4 hours as needed for temperature 100'F and above. Two tablets = 650mg *Do not exceed 3 gram/day.A review of the corresponding Medication Administration Record (MAR) revealed that the resident's temperature on 2/24/2025, during an unspecified time on the 11-7 shift was 100.2'F. The MAR reflected that the resident did not receive a dose of acetaminophen on 2/24/2025 and 2/25/2025 during the 11-7 shift. The nursing administration signatures for those dates and shift were blank. A review of the resident's progress notes did not reveal any nursing notes related to the temperature recorded in the MAR on 2/24/2025 during the 11-7 shift. There were no follow up temperatures, assessments, or monitoring documented in the resident's medical record after the fever was noted.On 10/27/2025 at 12:47 PM, during an interview with the surveyor, Registered Nurse (RN) #1 stated that if a resident has fever, Tylenol would be administered and that temperatures should be taken every 4 hours to see if the staff need to give Tylenol. RN #1 further stated that the staff documents for any change in condition and call the physician and family.On 10/27/2025 at 12:49 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that if a resident has fever, the staff should be documenting all they do so they would know what to follow through. The DON further stated that staff should continue monitoring, offer fluid, call the physician if they want laboratory work done. The family should be notified. They need to give Tylenol. They need to document everything. A review of the facility-provided policy dated July 2025, titled Administering Medications included under Policy Interpretation and Implementation, 22.) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 23.) The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. A review of the facility-provided policy dated December 2024, titled Charting and Documentation under Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. N.J.A.C. 8:39 - 27.1 (a); 29.2 (d)

Complaint # NJ 168449 Based on observation, interview, record review, and review of facility provided documents it was determined that the facility failed to consistently provide appropriate and timely incontinence care for residents who were dependent on staff for Activities of Daily Living (ADLs) care. This deficient practice was identified for 2 of 3 residents (Resident #3 and #184) reviewed for ADL care and was evidenced by the following: 1. On 10/21/24 at 8:20 AM, the surveyor conduced an initial tour of the [NAME] Unit and observed a strong urine odor in the hallway. On 10/21/24 at 8:21 AM, the surveyor observed Resident #3 in bed in their room. The surveyor inquired regarding the care received at the facility, and Resident #3 stated that they were soiled and needed to be changed. The resident, then activated the call light, and stated that staff took a long time to answer the call light. Resident #3 stated sometimes it could take one hour for staff to answer the call light and incontinence care was not provided timely. The surveyor exited the room and informed the certified Nursing Assistant (CNA #1) in the next hallway of Resident #3's request. The CNA informed the surveyor that she was on light duty but she would get another CNA to assist. On 10/21/24 at 8:45 AM [24 minutes later], CNA #2 entered the room to provide incontinence care to Resident #3. The surveyor observed that the incontinence brief was bulging from the front to the back, and Resident #3 was wearing two incontinent briefs which were both saturated with urine and feces. The surveyor observed that the bed pad was yellow stained. CNA #2 then informed the surveyor that she had not yet provided care to the resident. On 10/21/24 at 11:30 AM, the surveyor interviewed CNA #1 who confirmed she delivered the breakfast tray to the resident around 7:50 AM. CNA #1 stated she did not ask the resident if they were soiled and did not check to see if they needed incontinence care prior to providing the resident with the breakfast meal. On 10/23/24 at 9:04 AM, the surveyor entered the room and observed Resident #3 was in bed. A CNA was also in the room and Resident #3 stated in the presence of the CNA the they were last changed yesterday, referring to the 3:00 PM to 11:00 AM shift. The incontinence brief was again observed bulging to the front and Resident #3 was soiled with feces and urine. The bed pad to protect the bed was again observed yellow stained. On 10/24/24 at 8:32 AM, the surveyor observed Resident #3 in bed. Resident #3 stated that they already ate breakfast. When inquired if they received incontinence care, Resident #3 stated in the presence of the Licensed Practical Nurse (LPN), I was last changed yesterday. The LPN checked the resident with the surveyor present and observed that the brief was soiled with urine and feces. On 10/24/24 9:40 AM, a telephone interview was conducted with CNA #2 who provided care to Resident #3 on 10/21/24 who stated that she provided incontinence care to the resident at 5:00 AM. CNA #2 stated that she placed two incontinent briefs on Resident #3 because the resident requested two briefs. She then stated that did not inform the nurse that she had been placing two briefs on the resident. When inquired about what could happen with two briefs that were saturated with urine and feces, she stated the skin could break down. On 10/24/24 at 10:30 AM, the surveyor reviewed Resident #3's medical record which revealed the following: -Admission Record (AR) revealed, Resident #3 was admitted to the facility with diagnoses which included but were not limited to: Anemia, difficulty walking, acute respiratory failure with hypoxia, metabolic encephalopathy. -The quarterly Minimum Data Set (MDS) assessment tool dated 09/16/24, revealed that Resident #3 had intact cognition. Resident #3 received a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). Section G of the MDS which referred to Activities of Daily Living (ADLs) revealed that Resident #3 was totally dependent on staff for care. -Review of the Care Plan for Resident #3 initiated on 06/08/22, included a Focus for ADL Self Care Performance Deficit related to: Activity intolerance, fatigue and impaired balance. The goal was for Resident # 3 to improve current level of function in bathing, dressing, toileting, transfers and walking through the review date. Revised 03/07/2024. The interventions were to provide all necessary supplies for each ADL task and assist as needed. The care plan did not indicate the frequency for staff to provide incontinence care to the resident. On 10/24/24 at 9:39 AM, the surveyor interview the Registered Nurse/ Unit Manager (RN/UM) regarding Resident #3's incontinence care. The RN/UM revealed that she was not aware that direct care staff were placing two incontinent briefs on the resident. The RN/UM stated she was made aware on 10/21/24 of the double incontinent briefs being used on residents. The RN/UM added that double briefs should not be used on residents as they could cause skin irritation. When inquired regarding the frequency of incontinence care should be provided, the UM stated that incontinence should be provide every two hours. The 7:00 AM- 3:00 PM shift were supposed to check residents for incontinence care as soon as they received their assignment. The surveyor asked about Resident #3 wearing two incontinent briefs and she stated that staff should only apply only one incontinent brief and Resident #3 did not request double briefs. 2. On 10/21/24 at 9:30 AM, the surveyor entered a room and observed Resident #184 in bed. Resident #184 stated that incontinence care was not being provided in a timely manner. Resident #184 stated that they wore a Condom Catheter (a gender specific external catheter to facilitate urinary flow) and all the staff did not know how to properly apply the Condom Catheter (CC). The resident stated that most of the time the CC would be dislodged and they would be wet and staff did not check for incontinence care in a timely manner. Resident #184 added sometimes staff would not be available for 4 to 5 hours. The CC would be leaking and they would be soaked with urine. The surveyor then asked Resident #184 to activate the call light, and a CNA entered the room within 5 minutes and inquired regarding the call light. The CNA assisted with the incontinence care and the surveyor observed Resident #184's hospital gown and incontinence brief was soaked with urine. Resident #184 informed the surveyor that they were not checked during the night, or before breakfast. The CNA confirmed that she did not check Resident #184 prior to serve the breakfast meal. On 10/23/24 at 8:00 AM, the surveyor reviewed Resident #184's medical record which revealed the following: - The admission Face Sheet, an admission summary revealed that Resident #184 had diagnoses which included but were not limited to; quadriplegia (severe medical condition characterized by the partial or total loss of function in all limbs and the torso). -The Admission Minimum Data Set (MDS), dated [DATE], an assessment tool used by the facility to prioritize care reflected that Resident #184 was alert and able to make their needs known. Resident #184 received a score of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. -Resident #184 care plan had a Focus for ADLs self-care performance deficit related to quadriplegia, initiated 08/05/24. The goal was for Resident #184 to improve current level of functioning. Interventions included: Provide all necessary supplies for each ADL task and assist as needed. Resident #184 is totally dependent on staff for toilet use. On 10/23/24 at 11:30 AM, the surveyor reviewed the TASK (electronic record where the CNA documented the care provided to each resident). The ADL task page which included toileting was left blank for 10/21 and 10/22. On 10/24/24 at 12:30 PM, during the pre-exit conference with the Assistant Administrator (AA) and Director of Nursing (DON), the above findings were presented. A review of the facility policy titled, Activities of Daily Living (ADL) Supporting, last revised 2018, indicated the following: Policy Statement revealed: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and persona and oral hygiene. NJAC 8:39-27.1 (a)

Based on observation, staff interview and review of the medical record, it was determined that the facility failed to develop appropriate interventions to keep a resident free from injury during staff transport in a wheelchair which caused Resident #7 to have 2 subsequent incidents resulting in fractures to the resident's ankle and knee and placement on a pain management regimen. The facility also failed to revise and to consistently implement fall prevention interventions for Resident #8. This deficient practice was observed for 2 of 9 residents reviewed for fall/accidents and was evidenced by the following: 1. During the initial tour on 12/6/11, the Unit Nurse Manager (UNM) told the surveyor that Resident #7 sustained fractures while being wheeled in a wheelchair by a staff member. On 12/7/11 at 9:10 a.m., the surveyor observed Resident #7 who was in her room and in a geri recliner eating breakfast. The surveyor requested to review the facility investigations of the injuries on 12/7/11. During review of these investigations, the surveyor observed a nurses' note dated 6/28/11 which stated that while a Certified Nursing Assistant (CNA) was about to assist Resident #7 out of bed, she observed that the resident's left ankle and foot had edema and blue discoloration. The note continued that upon this discovery, the doctor was notified and an x-ray was ordered. The x-ray showed that Resident #7 had a fractured Fibula (ankle area). The facility's investigative report revealed that on 6/24/11, while the CNA transported the resident to an activity in a wheelchair (w/c), the resident's left foot bent backwards. The accident investigation concluded that the fracture might have resulted from the foot - bending backward incident of 6/24/11. Resident #7 had a follow- up assessment by the orthopedic doctor who then placed the resident on non-weight bearing status and the resident was placed in a geri-recliner chair with the foot elevated. The resident was also started on Dilaudid for pain. The left leg was placed in a cast and later changed to a Cam boot. On 8/10/11, the resident was upgraded to full weight -bearing of the left leg with the Cam boot and was then able to use a regular wheel chair. Upon further review of the medical record on 12/8/11, the surveyor noted another incident report, dated 9/7/11, which stated that Resident #7 screamed of pain to the left leg while being transported in a w/c by a CNA. The report stated that the resident had the Cam boot on during this incident but there was no leg support on the wheelchair to support the resident's left leg during the transport. An X-ray was ordered by the doctor and it showed an acute fracture to the resident's left knee. A nurse's note dated 9/7/11 at 5:30 p.m. stated that the resident was in great pain. The resident was then sent out to the hospital where she was hospitalized for [REDACTED]. The surveyor reviewed the September 2011 Medication Administration Record which indicated the resident used the pain medication frequently. The surveyor reviewed the care plan interventions for Resident #7 which did not include any interventions regarding wheelchair positioning during transport after the 6/27/11 fracture. The surveyor reviewed the physical therapy notes and did not see any evaluations or recommendation from the rehab services regarding the wheelchair usage after the resident had stopped using the geri-recliner chair. There was no notation regarding the previous incident of injury while being transported in the wheelchair in the therapy notes. On 12/8/11 at 11:30 a.m. the surveyor interviewed the UNM and asked how they ensured that the resident was protected from future injury during wheelchair transportation. The UNM told the surveyor that the 6/24 incident was viewed as an isolated incident and as such, they did not see the need to evaluate the wheelchair positioning and that it was after the second fracture that they felt they "should have, could have." During a follow -up interview with the facility administration on 12/12/11 at 10 a.m., the UNM told the surveyor that wheelchair leg rests were not tried and no other positioning devices were on the wheelchair to protect the resident from injury when being transported by staff. 2. During the initial tour on 12/6/11, the RN unit manager told the surveyor that Resident #8 had a history of [REDACTED]. The surveyor reviewed the medical record and observed that the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 12/7 at 11:15 a.m., the surveyor observed the resident as he sat in a Broda chair (a speciality wheelchair) and was self-propelling in the hallway. On 12/8/11, the surveyor reviewed the fall investigation reports provided by the facility. The surveyor observed the following fall reports: On 8/25/11, the resident lost his balance and fell in his room while walking with the CNA following behind him. On 9/7/11, the resident lost his balance and fell while walking in the bathroom with the CNA with him. The resident sustained [REDACTED]. The surveyor then reviewed the resident's fall prevention interventions included on the fall investigation reports which included to have a walker at the bedside for walking to the bathroom. The fall report indicated that the walker was not in use by the resident during these 2 falls. There was no explanation as to why the walker was not offered to the resident who had a previous fall from loosing his balance while walking without the walker. The resident had additional fall investigation reports which included an unwitnessed fall out of his merrywalker on 10/9/ 11. The resident had another unwitnessed fall out of the merrywalker on 11/11/11 and sustained skin tears to the left elbow, left shoulder and left inner arm. The surveyor observed a rehab service note which indicated that the resident was tried on the use of a smaller merry walker on 10/21/11-10/22/11, but it was unsuccessful and unsafe for the resident. After the one day trial, the resident was placed back on the original merrywalker, the same one from which the resident had the previous 2 falls. The surveyor reviewed 2 additional fall investigation reports which indicated that on 12/2/11 and 12/3/11, the resident fell out of the merrywalker while walking in the hallway. The resident sustained [REDACTED]. The surveyor interviewed the UNM on 12/8/11 at 1:30 p.m. The UNM told the surveyor that the facility discussed the falls with the resident's family and weighed the risk vs benefit of the resident's continued use of the merry walker. The UNM stated that the resident's family did not want to limit the resident's movement even if the resident had falls and they all agreed to continue the use of the merry walker. The UNM also stated that they felt the resident might have a negative reaction to being restricted in the wheelchair but admitted that they did not try any other type of chair or device until after the 12/3/11 fall. During a meeting with the facility administration on 12/12/11 at 10 a.m., the UNM told the surveyor that the resident was now in a Broda chair which allowed him to propel throughout the unit without falling, and that the resident did not have any objection to the chair and had adjusted well to it. NJAC 8:39-27.1 (a)