Every finding on record at Lawrence Rehab & Hcc/The Meadows at Lawrence

Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 07/23/2026, it was determined that the facility failed to maintain a safe environment for a resident (Resident #2), with severe cognitive impairment. The facility staff failed to follow their Resident Leaves of Absence policy requiring authorization by Resident #2's Power of Attorney (POA), before the resident left the facility with a caregiver. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for incidents and was evidenced by the following: On 7/19/2026 at approximately 9:30 AM, an outside Home Health Aide (HHA #1) informed facility staff that they were at the facility to take Resident #2 out on a Leave of Absence (LOA) pass. The facility staff did not verify that HHA #1 had authorization, before they signed the resident out and took them out of the facility. Resident #2's POA came to the facility at 1:00 PM to visit the resident and was told by the facility staff that the resident left the facility with HHA #1. The POA stated they had not authorized or provided permission for the resident to leave the facility with HHA#1. The facility staff member stated that there was another resident living in the Assistant Living Facility (ALF) building with the same name as Resident #2. The ALF was contacted and confirmed that the resident with the same last name was expecting HHA #1. The facility contacted HHA #1 and Resident #2 was brought back to the facility at approximately 2:30 PM. The facility's failure to maintain a safe environment and ensure a resident did not leave the facility without the POA's knowledge or permission, placed Resident #2 and all other residents at risk with the likelihood of serious harm, injury, impairment, or death. This resulted in an Immediate Jeopardy (IJ) situation.The IJ began on 07/19/2026 at approximately 9:30 A.M. when Resident #2 was signed out of the facility without permission from their POA. The Executive [NAME] President (EVP), in the presence of the Director of Nursing (DON), were notified of the IJ and provided with the IJ template on 07/23/2026 at 5:36 P.M.An acceptable Removal Plan (RP) was received on 07/28/2026 at 10:41 A.M. indicating the action the facility would take to prevent serious harm from occurring or reoccurring. The surveyor verified the implementation of the RP onsite and determined the immediacy was removed as of 07/29/2026 at 1:00 P.M. A review of the facility's policy titled: Resident Leaves of Absence with an implementation date of March 2022, under Policy Interpretation and Implementation revealed: The resident, or resident representative as applicable, may provide permission for the resident to leave the facility premises for a therapeutic leave of absence (LOA).A review of Resident #2's admission Record (AR), revealed that the resident was admitted to the facility with the following diagnosis which included but are not limited to: Cerebral Vascular Accident (CVA) (when blood flow to part of the brain stops or gets cut off), dementia, difficulty walking, cognitive communication deficit, Crohn's disease (a lifelong inflammatory bowel disease) and hemiplegia (a medical condition that causes total paralysis on one side of the body).A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 04/21/2026, revealed Resident #2 had a BIMs score of 3 out of 15, which indicated the resident's cognition was severely impaired. The MDS also revealed Resident #2 had the following active diagnosis: atrial fibrillation (irregular and chaotic heart rhythm), coronary artery disease (a common heart condition where waxy plaque builds up inside the arteries that supply blood to your heart), diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels resulting from defects in insulin production), dysphagia (difficulty or discomfort when swallowing), and asthma (a long-term lung disease where your airways swell, tighten, and make extra mucus).A review of the facility document titled Grievance Report (GR) with an incident date of 07/19/2026, under Grievance Details revealed: On 07/19/2026, HHA #1 came to the facility and signed out Resident #2 from the facility. The facility staff did not communicate with the family, and they had no idea who HHA #1 was. The GR further revealed: Upon further investigation we realized that HHA #1 took the wrong resident out of the facility.On 07/23/2026 at 11:35 A.M., the surveyor attempted to conduct a phone interview with HHA #1, however; HHA#1 was not able to be reached for the interview.On 07/23/2026 at 11:43 A.M., the surveyor interviewed the Licensed Practical Nurse (LPN #1) assigned to Resident #2 on 07/19/2026, during the 7:00 A.M. to 3:00 P.M. shift. LPN #1 acknowledged the facility policy was not followed when Resident #2 went out on LOA with HHA #1. LPN #1 stated, I should have asked HHA #1 for her name, where she was from, looked on Resident #2's face sheet and obtained a consent from the resident's POA prior to allowing HHA #1 to sign Resident #2 out of the facility. LPN #1 further stated, if the proper steps are not followed to sign out a resident, there is a likelihood the resident could be in danger, harmed or injured.On 07/23/2026 at 12:05 P.M., the surveyor conducted an interview with the Supervisor/Registered Nurse (SRN #1), who worked on 07/19/2026 during the 7:00 A.M. to 3:00 P.M. shift. The SRN #1 stated, if a resident is going out on LOA with a family member, it should be documented on the twenty-four-hour (24hr) report. She stated, To verify that the resident is going out with an authorized person, we must check the resident's face sheet in the electronic medical record (EMR). If the person is not listed on the face sheet, I would have to call the listed POA to get their permission for resident to go out on a LOA. The SRN #1 further stated, If a resident went out with an unauthorized person, that would be a safety concern. The resident could be in possible danger or harm.On 07/23/2026 at 12:55 P.M., the surveyor interviewed the DON, in the presence of the EVP. The DON stated HHA #1 was not identified as an authorized person prior to signing Resident #2 out of the facility. The DON further stated that the nursing staff should have identified HHA #1, verified them on Resident's #2's face sheet, and obtained consent from the POA, prior to Resident #2 leaving the facility. The DON and EVP acknowledged the facility's LOA policy was not followed. The surveyor did not find any documented evidence that any pertinent medical information for Resident #2 was provided to HHA#1, prior to them taking the resident out of the facility.On 07/23/2026 at 2:19 P.M., the surveyor conducted a telephone interview with Resident #2's POA. The POA stated on 07/19/2026, they attempted to reach Resident #2 via their personal cell phone between 10:00 A.M. to 11:00 A.M. The POA was unable to reach the resident at that time. The POA then called the facility and spoke with the facility staff, who informed them that Resident #2 was out of the facility on a LOA, with HHA#1. The POA informed the facility staff that they were unaware of a scheduled LOA for Resident #2 and they did not give permission for the resident to leave the facility. The POA further stated that they arrived at the facility around 1:00 P.M. and Resident #2 was not in their room or at the facility. The POA expressed their concerns to the nurse. The nurse looked through the resident sign out book and realized that the caregiver (HHA #1) came to pick up a different resident from the ALF, with the same last name as Resident #2. HHA #1 was allowed to sign out Resident #2 from the facility in error. Resident #2 was returned to the facility at approximately 2:00 P.M.An acceptable Removal Plan (RP) was received on 07/28/2026 at 10:41 A.M. indicating the action the facility would take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice, including: On 07/19/2026, a head count was completed immediately by the Licensed Nurses/ Manager on Duty (MOD) and no variances were identified.On 07/19/2026, the private duty aide was contacted by the ALF Administrator upon the family's arrival and Resident #2 was returned to the center without incident.On 07/19/2026, the Licensed Nurse completed a skin evaluation and pain evaluation on Resident #2, no variances identified.On 07/20/2026, the DON informed Resident #2's physician and medical director were updated of the event, resident's status, and facility Quality Assurance & Performance Improvement (QAPI) plan. No additional orders were received.On 07/20/2026, the DON/designee completed an audit to ensure that all residents had a photo, door tag, and photo in the Electronic Medical Record (EMR) for identification purposes, no variances identified.On 07/20/2026, the Licensed Nurse completed a trauma informed care evaluation for Resident #2 with no variances identified.On 07/20/2026, the DON/designee reviewed all residents in-house to determine if they had supportive services such as HHA services private duty. No residents were affected.On 07/202/2026, the DON/Designee reviewed all residents in-house to determine if they had a scheduled out on pass (OOP) or leave of absence (LOA) scheduled event in the next 72 hours. No residents were affected.All residents leaving the facility, regardless of whether they are accompanied by family or a private duty aide, transportation services, or another outside provider, will follow the same sign-out process. Staff will verify the resident, confirm the individual picking up the resident is an authorized escort or scheduled provider, complete all required LOA documentation, and notify the responsible party when applicable.All residents who are leaving the facility with an outside provider will be verified by their responsible party prior to leaving the facility.All staff were educated by the EVP and DON at greater than 98% which included: Leave of Absence protocol, documentation, signing out a resident, identification of a resident, and customer service. Employees on leave of absence from the center will have education prior to taking their assignment. Education was initiated on 07/19/2026 and completed 07/22/2026.All residents and residents on LOA will be reviewed weekly for a period of four weeks, then twice monthly for a period of two months by the DON/Designee to ensure the LOA process is followed per facility protocol. Monitoring is ongoing.All grievances will be reviewed weekly by the Administrator/Designee to audit customer service trends and resolution for a period of four weeks, then twice monthly for a period of two months. Ongoing.On 07/29/2026 at 12:50 P.M., an interview was conducted with the EVP who stated that the facility was at a 100% completion for re-educating all staff on the following topics: Leave of Absence protocol, documentation, signing out a resident, identification of a resident, and customer service.The surveyor verified the implementation of the RP on-site on and determined the immediacy was removed as of 07/29/2026 at 1:00 P.M. NJAC: 8:39-27.1 (a)

Complaint #: 2988988, 3074567Based on observation, interviews, review of medical records and review of pertinent facility documents on 07/14/2026 and 07/15/2026, it was determined that the facility failed to ensure that a cognitively impaired resident (Resident #2) who was dependent on staff for care, was protected from physical and verbal abuse by a Certified Nursing Assistant (CNA #1).Resident #2 was physically and verbally abused by CNA #1 on 04/13/2026. This deficient practice was identified for 1 of 7 residents (Resident #2) reviewed for abuse and was evidenced by the following: A review of the facility's policy on Abuse, Neglect, and Exploitation and Misappropriation Prevention Program, revised date of April 2021, included under Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical or chemical restraint not required to treat the resident's symptoms. Under Policy Interpretation and Implementation include: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not limited to: a. facility staff. A review of the Facility Reportable Event (FRE), indicated the abuse incident occurred on 04/13/2026 at 12:37 PM.The FRE indicated that on 04/13/2026, Resident #2's representative reported to the facility that they saw CNA#1 on video camera verbally and physically abuse Resident #2.A review of the facility's Summary and Conclusion (SC) of the incident, revealed that when the facility interviewed CNA #1, she denied any wrongdoing; but when the facility showed her the video footage of her actions, CNA #1 acknowledged that her actions towards Resident #2 could have been gentler.The surveyor reviewed the footage of the personal camera located in the resident's room on 07/15/2026, which revealed the following:On 04/13/2026, between the hours of 12:00 AM and 1:00 AM, CNA #1 was noted walking behind the Resident #2 with her hands under the resident's armpits. As CNA #1 walked up to the resident's bed, she pushed the resident onto the bed and then picked up the resident's legs and placed them on the bed.After CNA #1 left the room, the resident got up from the bed and was seen standing near the bed. At this point, CNA #1 walked back into the resident's room and using both her hands, she pushed Resident #2 back to the bed and told the resident to lay down and go to sleep. CNA #1 then lifted the resident's legs and placed them under the blanket. When the resident attempted to show CNA #1 something by saying, look at this, CNA #1 replied no, and told the resident to go to sleep.Further review of the video footage revealed that when Resident #2 started to sit up again, CNA #1 told the resident to lay down. Resident #2 stated to CNA#1 that they could not lay down, CNA #1 walked to the resident, and using both hands, she grabbed the resident by the upper arms and placed the resident down onto the bed. The resident told the CNA #1 that they needed to go to the bathroom. CNA #1 repeatedly said no to the resident. CNA #1 then sat on the resident's bed close to the resident. When Resident #2 attempted to sit up again, CNA #1 used her right hand to push on the resident's left chest area and pushed the resident back down onto the bed. Resident #2 tried to sit up again, CNA #1 placed her right hand and placed on the resident's right upper chest area and pushed the resident back down onto the bed. Resident #2 stated: you don't understand, I can't, to which CNA #1 responded by telling the resident to lay down and go to sleep. Resident #2 stated to CNA #1, listen to me and CNA #1 replied no.Resident #2 tried to sit up and roll to the opposite side of the bed, CNA #1 used her right hand and pushed on the resident's right upper chest area again and pushed the resident back down. A review of Resident #2's admission Record (AR), an admission record summary, revealed that the resident was admitted to the facility with the following diagnoses which included but are not limited to: gastro-esophageal reflux disease (chronic digestive condition where the stomach acid or bile repeatedly flows back into the esophagus), muscle weakness (a perceived lack of physical strength where extra effort is required to move), unspecified psychosis (a temporary medical classification for individuals showing significant psychotic symptoms), and repeated falls.A review of the Minimum Data Set (MDS), an assessment tool dated 06/12/2026, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident's cognition was severely impaired. The MDS further revealed the resident required total assistance from staff in the completion of their care. A review of Resident #2's Care Plan (CP) with an initiated date of 07/08/2024, under Focus, revealed that Resident #2 has ADL self-care performance deficit related to decline in mobility, has dementia and needs assistance with all ADLs. Under Interventions, the care plan indicated that the resident requires supervision/set-up with toilet use.The surveyor called the assigned Licensed Practical Nurse (LPN #1) that worked on the night of the incident, but was unable to reach her. On 07/14/2026 at 12:53 PM, the surveyor interviewed the Licensed Nursing Home Administrator, Director of Nursing and Executive [NAME] President (EVP). They acknowledged that the CNA #1's action would be considered abuse. The EVP stated that staff knew that there was a video camera in Resident #2's room. EVP stated there was signage on the door to Resident #2's room regarding the presence of video camera being in use in the resident's room.The surveyor reviewed CNA #1's employee file which showed that CNA #1 received abuse training a year before the abuse incident occurred. CNA #1's employee file revealed a non-abused related incident against CNA #1 which occurred prior to CNA #1's employment at the facility. The surveyor attempted to call CNA #1 for an interview, but CNA #1 did not respond.The Immediate Jeopardy (IJ) began on 04/13/2026, at approximately 12:30 P.M., when the facility became aware of the video footage that showed CNA #1 abuse of Resident #2.The IJ is past noncompliance. The surveyor verified the implementation of the Removal Plan (RP) on-site on 07/15/2026 and determined that there is sufficient evidence that the facility self-corrected the noncompliance on 04/14/2026.The facility's RP dated 07/14/2026, showed how the facility removed the immediacy and prevented serious harm from occurring or reoccurring by implementing the following:On 04/13/2026, immediately upon notification of a concern identified by the family from the resident's personal camera footage, the involved CNA was identified and placed on immediate suspension pending investigation. The resident was immediately assessed by the Registered Nurse, with no physical injury or signs of distress identified.On 04/13/2026, Social Services met with the resident involved to address immediate psychosocial needs.On 04/13/2026, the Administrator notified the party responsible, attending physician, law enforcement and the Long -Term Care Ombudsman were notified of the allegation.On 04/13/2026, the Social Services completed Trauma-informed evaluation with no negative outcome.On 04/13/2026, oriented residents on the same assignment sheet were interviewed by the Social Services and or designee using the do you feel safe here? script to identify any unreported concerns of abuse, neglect, or mistreatment. No variances were identified.On 04/13/2026, residents on the same assignment unable to verbally communicate immediately received a full-body skin assessment by a licensed nursing staff to rule out bruising or injury of unknown origin. No variances were identified.On 04/13/2026, a 30-day look-back (03/13/2026-04/13/2026) of all incident reports, grievances, and self-reports has been initiated by the DON to ensure no prior allegations met abuse criteria and were appropriately reported. Mo variances were identified.On 04/13/2026, a mandatory in-service for all staff (clinical and non-clinical) on Abuse Prohibition, Recognition, Reporting, and Preservation of Evidence was initiated by the Executive [NAME] President, Nurse Educator, Administrator and DON-completed on 04/14/2026. All new hires will receive this training prior to first shift.On 04/13/2026, re-education of supervisory staff (Department Heads, Supervisors, ADON, DON) on immediate investigation and 2-hour/24-hour reporting requirements completed by the Administrator and Executive [NAME] President.On 04/13/2026, installation of additional signage throughout the facility reminding residents and families of the 24/7 abuse reporting hotline and ombudsman contact information.The Social Service Director/designee will conduct a minimum of 15 random residents interviews weekly for the next 90 days (or until QAPI committee deems substantial compliance) using the standardized abuse screening tool. A random 5 non-interviewable residents will have a skin check completed by a Licensed Nurse weekly for the next 90 days (or until QAPI deems substantial compliance).Results of interviews, skin checks, and allegations will be reported at the weekly IDT risk meeting and monthly QAPI meeting.The DON/designee will audit 10 random employee records weekly for documentation of abuse training completion.Audit results will be tracked on the QAPI Abuse Prohibition Monitoring Tool and reviewed monthly by the QAPI committee, Medical Director, and Administrator.Monitoring will continue until three consecutive months of substantial compliance are achieved, at which time QAPI committee may recommend reduction in frequency. N.J.A.C. 8:39- 4.1(a)5

Complaint #: 2674711 Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 11/25/2025, it was determined that the facility failed to provide adequate supervision to a cognitively impaired resident who wore a wander guard and had a known history of wandering (Resident #2), who eloped from the facility on 11/17/2025. The deficient practice was identified for 1 of 3 residents reviewed for elopement (Resident #2).During the survey a finding that constituted Immediate Jeopardy (IJ) was identified under CFR 483.12(a)(1) F689. The facility failed to: a) provide adequate supervision to prevent a cognitively impaired resident (Resident #2) who was a known elopement risk and wore a wander guard bracelet (a wearable device that triggers alarms and/or locks) from exiting their secure second floor unit when LPN #1 saw Resident #2 on the facility's first floor, b) LPN #1 recognized that Resident #2 belonged on the second floor and took the resident back to the second floor via the facility elevator and returned Resident #2 to the second-floor common sitting area without notifying second floor staff, and c) staff failed to respond appropriately to alarms to prevent the resident from leaving their secure unit, and the facility unsupervised. On the afternoon on 11/17/2025, Resident #2, who resided on the facility's second floor secure unit and wore a wander guard, was found by a Licensed Practical Nurse (LPN #1) on the facility's first-floor asking another resident for directions to a different address. LPN #1 returned Resident #2 to the second floor and left them in the common area. The nurse assigned to Resident #2 was not made aware that the resident has left the facility's second floor secure unit. On 11/17/2025 at approximately 2:30 PM, Resident #2 pushed open a stairwell door on the facility's second-floor secured unit. The resident then pushed open the exit door at the bottom of the stairwell and left the facility. The second-floor Unit Secretary (US #1) silenced the stairwell door alarm without completely checking the area for the resident who caused the alarm to sound. On 11/17/2025 at approximately 3:30 PM or 4:00 PM, LPN #2 could not find Resident #2 while doing his rounds. LPN #2 searched hallways, resident rooms, and bathrooms on the second floor. The search performed by LPN #2 alone lasted approximately 30 minutes. LPN #2 then expanded his search to the facility's first floor, Assisted Living, and Hospital, assisted by LPN #3 and a Certified Nursing Assistant (CNA #1). At approximately 6:00 PM, LPN #2 informed the Director of Nursing (DON) that Resident #2 was missing. It was on 11/17/2025 at approximately 6:00 PM, when Resident #2 had been missing for approximately two and a half hours, that the facility's elopement protocol was enacted. On 11/17/2025 at approximately 10:30 PM, Resident #2 was found by facility staff laying on the ground in a wooded area at the back of facility grounds. The resident was dressed in a shirt and sweater, long pants and socks. The resident called out to facility staff for help and complained of hip pain. The resident was transported to the hospital by ambulance and remained in the hospital until 11/22/2025. Resident #2 returned to the facility with diagnoses including but not limited to compression deformity of the vertebra; urinary retention; and possible pneumonia. The resident was placed on one-to-one (1:1) supervision when they returned to the facility. The facility's failure to a.) provide adequate supervision to prevent a cognitively impaired resident who was at risk for elopement from exiting a secure unit, b.) respond appropriately to wandering and door alarms, and c) enact their elopement protocol timely, placed Resident #2 as well as all residents at risk for elopement and posed a likelihood of serious harm, injury, impairment, or death and resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 11/17/2025 at an unknown time when Resident #2 exited the secure second floor unit and was found on the facility first floor unit. The facility Administration was notified of the IJ on 11/25/2025 at 7:47 PM. The facility submitted an acceptable Removal Plan (RP) on 11/25/2025 at 8:00 PM. The surveyor verified the implementation of the RP during the continuation of the on-site survey on 12/01/2025.The evidence was as follows: A review of the facility policy Wandering and Elopements, with a revision date of March 2019, revealed under Policy Statement, that, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Under Policy Interpretation and Implementation, the facility policy revealed, .3. If a resident is missing, initiate the elopement/missing resident emergency procedure. This section of the facility policy further revealed that staff should determine if the resident is out on pass; initiate a search of the buildings and premises; if the resident is not located, notify facility administration, the resident representative, attending physician, and law enforcement. A review of the facility policy Safety and Supervision of Residents, with a revision date of July 2017, revealed under Systems Approach to Safety, that, Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. This section of the facility policy further revealed that the type and frequency of resident supervision may vary over time for the same resident and may need to be increased when there is a change in the resident's condition. A review of the Facility Reportable Event (FRE) dated 11/17/2025, that the facility submitted to the New Jersey Department of Health (NJDOH), revealed that on 11/17/2025, at 6:00 PM, facility administration was notified that Resident #2 was missing. A search of the building and campus were conducted, Resident #2's family was notified, and police were notified. The FRE further revealed that Resident #2 was located on facility grounds at 10:33 PM and was sent to the Emergency Department for evaluation. An undated facility document with Resident #2's name and November 17, 2025, at the top was reviewed. The Investigation Details: section of the facility document revealed the following:The facility video footage showed that Resident #2 exited the second-floor unit from a stairwell door by activating the egress release on that door. Resident #2 then proceeded down the stairwell and exited the facility through the stairwell's exterior door. This section of the facility document further revealed that the Unit Manager (UM #1) and a Unit Secretary (US #1) reset the second-floor stairwell door alarm without thoroughly investigating the reason for the alarm. A review of a statement from CNA #2, dated 11/20/2025, revealed that during morning care, Resident #2 requested that the CNA dress them in a shirt and sweater. When asked by CNA #2 why they needed a sweater Resident #2 replied that they were going for a walk. A handwritten statement by LPN #1 dated 11/18/2025, revealed that she saw Resident #2 on the facility's first floor and heard them asking for directions to a different address. LPN #1 recognized that Resident #2 belonged on the second floor and took the resident back to the second floor via the facility elevator. LPN #1 returned Resident #2 to the second-floor common sitting area and went back to the first floor. A statement by US #1 dated 11/18/2025 at 6:20 PM, was reviewed. US #1's statement revealed that between 2:30 and 3:00 PM, she silenced an alarm at the second-floor stairwell door. The statement revealed that US #1 asked UM #1 about the alarm and the code prior to using the keypad near the stairwell door to silence the alarm. US #1's statement further revealed that another resident who wore a wander guard was close to the door, so it was believed that it was that resident who caused the door alarm to sound. A statement by CNA #1 dated 11/19/2025, revealed that she realized that Resident #2 was missing at 4:50 PM. CNA #1 reported the missing resident to LPN #2 at that time. A statement by LPN #3 dated 11/18/2025, revealed that at 5:15 or 5:30 PM, LPN #2 notified him that Resident #2 was missing. The statement revealed that LPN #2 and LPN #3 searched all rooms at the facility. LPN #3's statement further revealed that at 5:45 or 6:00 PM, LPN #2 reported that Resident #2 was missing to the facility's DON. An undated statement by the facility's DON was reviewed. The DON's statement revealed that at 6:00 PM, LPN #2 and LPN #3 notified her that Resident #2 could not be located. It was at that time that a systematic search of the facility and campus were conducted, and the local police department was notified at 8:45 PM. The DON's statement revealed that Resident #2 was found outside near the Assisted Living at 10:38 PM and was transported to the hospital. The DON's statement further revealed that the facility's security cameras were reviewed and showed Resident #2 exit the facility at 2:32 PM. An undated statement by a staff member (Staff #1) revealed that Resident #2 was found laying on their side on a path in a wooded area on the facility campus. The statement revealed that the resident asked for help and replied, yes, when asked if they were in pain. Screen captures from the facility's security cameras were provided to the Surveyor on 11/25/2025 at 11:39 AM, by the facility's DON. Security camera images dated 11/17/2025 at 2:28 PM, revealed that Resident #2 approached the area of the second-floor stairwell door. Security camera images dated 11/17/2025 at 2:33 PM, revealed that US #1 approached the second-floor stairwell door. A security camera image dated 11/17/2025 at 2:31 PM, revealed that Resident #2 opened and passed through an exterior door near the facility entrance. On 11/25/2025 at 12:25 PM, the [NAME] President of Clinical Services (VPCS) and Executive [NAME] President (EVP) guided the surveyor along a route that Resident #2 may have taken during their time away from the facility. The VPCS led the surveyor through the second-floor stairwell door, down a flight of stairs, and out of a door at the bottom of the stairwell which opened to sidewalks and a parking lot near the facility entrance. The VPCS stated that the resident's exact route to the place they were found was not known. The Surveyor was guided over a paved walkway for approximately 2 minutes, then onto a gravel path which led behind and between other buildings and a graveyard on the facility campus. The VPCS indicated that Resident #2 was discovered in a partially wooded area between the Assisted Living facility and the interstate highway near a low cement structure that contained a large metal access panel. An interview was conducted with LPN #1 on 11/25/2025 at 1:40 PM. LPN #1 stated that on 11/17/2025 in the afternoon, she observed Resident #2 on the first floor talking with another resident. LPN #1 stated that she was not sure how Resident #2 got to the first floor. LPN #1 stated that she returned the resident to the second-floor common area, and she was not sure if she reported to any second-floor staff that Resident #2 had been found on the first floor. An interview was conducted with LPN #2 on 11/25/2025 at 3:22 PM. LPN #2 stated that Resident #2 had a Care Plan (CP) in place for wandering and elopement because the resident tried to go to other areas of the facility. LPN #2 stated that he was not told that Resident #2 was found on the facility's first floor earlier that day. LPN #2 stated that when he became aware that Resident #2 was missing at 3:30 or 4:00 PM on 11/17/2025 he conducted a search of resident rooms and bathrooms on the second floor. LPN #2 stated that he searched independently for approximately 30 minutes. LPN #2 stated that he then got help from LPN #3 and CNA #1 to search the facility's first floor for approximately one hour. During the same interview LPN #2 stated that the proper process when a resident was missing was to notify a supervisor within 10 minutes. LPN #2 further stated that supervisor notification and activating a Code Yellow (facility procedure for responding to a missing resident) would have made all staff aware of the elopement and that they needed to search for the missing resident. An interview was conducted with CNA #1 on 11/25/2025 at 4:14 PM. CNA #1 stated that on 11/17/2025, she was not able to round at the beginning of her shift to see her assigned residents. CNA #1 stated at 4:30 or 5:00 PM, she reported to LPN #2 that Resident #2 was not in their expected location and LPN #2 searched for the resident. A telephone interview was conducted with UM #1 on 11/25/2025 at 5:34 PM. UM #1 stated that on 11/17/2025 she was not informed that Resident #2 was found on the first floor and returned to the second floor by LPN #1. UM stated that if she had been aware that Resident #2 made attempts to leave the facility that day she would have done something more for the resident like assigning them a 1:1 monitor or providing extra attention to the resident. During the same interview UM #1 stated that she did not recall the stairwell door alarm sounding on 11/17/2025. UM #1 stated that when US #1 asked her for the alarm code, she asked US #1 if anyone had gone down the stairs. UM #1 stated that she did not see anyone go down the stairs, did not check the stairs, and did not see US #1 check the stairs. UM #1 stated that when she asked US #1 if anyone went down the stairs US #1 replied that she did not see anyone. An interview was conducted with the DON on 11/25/2025 at 6:07 PM. The DON stated that it was not customary for Resident #2 to go to the first floor without staff's knowledge. The DON stated that LPN #1 did not communicate with Resident #2's nurse after the resident was found on the facility's first floor and returned to the second floor on the afternoon of 11/17/2025. The DON stated that it was her expectation that when a stairwell alarm sounded, staff would investigate the reason for the alarm. The DON stated that her expectation was for staff to check down the stairs, open the outside door and check the area, and conduct a resident head count before the alarm was turned off. The DON stated that her expectations were not met in the case of Resident #2's elopement because when the door alarm sounded there was a delayed response. The stairwell alarm sounded at 2:28 PM, and US #1 disengaged the alarm at 2:33 PM without checking the stairwell. The DON further stated that staff's failure to check the stairwell and outside of the exit door prevented Resident #2 from being located and allowed the resident to get further away from the facility. During the same interview the DON stated that LPN #2 and LPN #3 informed her that Resident #2 was missing on 11/17/2025 at approximately 6:00 PM and it was at that time that the facility's elopement protocol was activated. The DON stated that she was absolutely not notified timely that the Resident #2 was missing. The DON stated that when she was notified that Resident #2 was missing she was under the impression that the resident had just gone missing. The DON stated that the true timing of Resident #2's elopement was discovered during her investigation and review of security camera footage. The DON stated that the facility's Wandering and Elopements, policy should have been implemented at 3:40 PM on 11/17/2025, when facility staff became aware that Resident #2 was missing. The DON stated that it was better to call a Code Yellow as soon as possible because delaying could allow the resident to get further from the facility, make it difficult to locate the resident, and could result in the resident being hurt. An interview was conducted with the Licensed Nursing Home Administrator (LNHA) on 11/25/2025 at 6:56 PM. The LNHA stated that the facility campus is separated from an interstate highway by a 5-foot fence and bordered by Route 206 (a 40 mile per hour road) on the other side where there was no fence. During the same interview the LNHA stated that facility administration should have been notified within a reasonable amount of time if a resident could not be located. The LNHA stated that staff could not locate Resident #2 at 3:40 or 3:45 PM on 11/17/2025 and Administration was not notified until 6:00 PM. The LNHA stated that when he was notified, he was led to believe that the resident had just gone missing. The LNHA stated that when administration learned the true timing of the incident, the parameters of the search were shifted from inside to outside of the building. The LNHA further stated that he wished he had known that the resident was missing sooner because it would have helped to expedite the process. The surveyor reviewed the medical record for Resident #2. According to the admission Record face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: difficulty walking; anxiety disorder (mental health condition that causes fear, dread and symptoms that are out of proportion to the situation); muscle weakness; and traumatic subdural hemorrhage (bleeding near the brain that can happen after a head injury). According to the quarterly Minimum Data Set (MDS), an assessment tool dated 08/19/2025, Resident #2 had a Brief Interview for Mental Status score of 12 out of 15, which indicated the resident's cognition was moderately impaired. A review of Resident #2's Elopement/Wandering Risk Evaluation dated 08/19/2025 at 5:18 PM, indicated that Resident #2 was a moderate risk for elopement. The evaluation included that Resident #2 was cognitively impaired and had poor decision-making skills; wandered aimlessly or non-goal-directed; and verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. A review of Resident #2's Care Plan (CP) revealed a focus initiated on 06/22/2023, that Resident #2 was at risk for falls and chose to walk with their wheelchair in front of them. Interventions included advising the resident to keep their shoelaces tied to avoid stepping on them while walking; advise the resident to sit and relax when they became tired while walking so that their legs could rest; create a safe environment with clutter free floors and adequate lighting; and to educate the resident to take a nap when they were tired to allow their legs to be elevated to prevent swelling. Resident #2's CP revealed a focus initiated on 07/03/2023, that Resident #2 had the potential risk for elopement related to wandering and needed to be redirected when they approached doors. The CP also indicated that Resident #2 had a wander guard placed on their ankle and that the resident's behaviors should have been monitored. Further review of Resident #2's CP revealed a focus initiated on 04/15/2025 that Resident #2 was at risk for elopement because they were disoriented to place, had a history of attempts to leave the facility unattended, and had impaired safety awareness. Interventions included provision of structured activities including toileting and walking inside and outside. A review of a Progress Note (PN) dated 11/17/2025 at 10:38 PM, written by the DON revealed, . resident located on the ground side lying able to make some needs known [.] Resident Oriented x2 responding to simple questions. Resident denied pain or discomfort. Resident noted to be wearing long pants, a gray sweater and red socks. [.] Resident was then advised he would be transferred to the hospital for assessment . An acceptable Removal Plan (RP) was received on 11/25/2025 at 8:00 PM, indicating the action the facility will take to prevent serious harm from occurring or reoccurring. The facility implemented a corrective action plan to remediate the deficient practice including: On 11/17/2025 a headcount was performed to confirm that all residents were accounted for.On 11/17/2025, Resident #2 was located and sent to the hospital for evaluation.On 11/17/2025 Regional Plant Operations reviewed all doors and locking mechanisms and addressed variances.On 11/18/2025 Nursing administration reviewed residents on wanderguard for appropriate orders and care plans.On 11/18/2025 elopement binders were reviewed to ensure that all residents at elopement risk were included.On 11/21/2025 all staff were educated on procedures for elopement drill and announcement of Code Yellow.On 11/21/2025 all staff were educated on the facility policies on wandering and elopement, and safety checks and supervision.On 11/21/2025 nursing staff were educated on rounding at the start of their shift and every 2 hours.On 11/18/2025 and 11/22/2025 elopement drills were conducted. The surveyor verified the implementation of the Removal Plan on-site on 12/01/2025, and determined the immediacy was removed as of 11/22/2025. There is sufficent evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirements for F689. NJAC 8:39-27.1 (a)

Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA), the facility failed to prevent the potential for cross-contamination by allowing the drain from the ice machine to extend down into the floor drain. This had the potential to affect 156 of 165 residents receiving meals from the kitchen.Findings include: Review of the facility's policy titled, Ice Machines and Ice Storage Chests, dated January 2012 (sic) revealed, Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a sage and sanitary supply of ice. Policy Interpretation and Implementation: 1. Ice-making machines, ice storage chests/containers, and ice can all become contaminated by: .d. improper storage or handling of ice.3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. Further review of the facility policy reveals it fails to address the need for maintaining an air gap for the machines drain line to prevent the possibility of a backflow into the ice machine. The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: 5-402.11 Backflow Prevention. (A) .a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During an observation and interview on 09/01/25 at 12:10 PM, the Dietary Manager (DM), the ice machine drain line was observed to be stuck down into the floor drain. The DM confirmed the drain line to be extended down into the floor drain. Removal of the drain line from the floor drain found the line to be coated with a black substance. When asked, should the drain line be placed inside the floor drain the DM stated, No, it should not be directly in the drain, it should have an 'air gap' to prevent the possibility of backflow entering the ice machine. NJAC 8:39-17.2(g)

Based on record review, interview, and policy review, the facility failed to provide a written notice of transfer and information regarding the bed hold process to the responsible party, and a transfer notice to the receiving hospital for seven residents (Resident (R) 3, R4, R6, R7, R12, R20, and R84) out of the eight residents sampled for hospitalization. This failure had the possibility to negatively impact all residents residing at the facility due to important medical information not being provided to receiving hospital and the resident's responsible party not being aware of the reason for the Resident's transfer or bed hold information.Findings include: 1. Review of R7's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE]. Review of R7's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/27/25, located under the MDS tab indicated R7 was assessed to have a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating R7 was moderately impaired. Review of R7's form titled, New Jersey Universal Transfer Form dated 08/13/25 and provided by the facility revealed the facility provided medical information to the receiving hospital regarding R7 in preparation of R7's transfer. Review of R7's EMR indicated there was not a notice of transfer or bed hold notice that was provided to R7's responsible party. Also, the information regarding the appeals process could not be located and was not provided to the responsible party. 2. Review of R20's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R20 was admitted to the facility on [DATE]. Review of R20's five-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/24/25, located under the MDS tab indicated R20 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating R20 was moderately cognitively impaired. Review of R20's EMR indicated there was not a notice of transfer or bed hold notice provided to R20's responsible party. Also, the information regarding the appeals process could not be located and was not provided to the responsible party. During the EMR review a copy of the transfer form that was sent to the hospital with R7 was not located. 3. Review of R3's ''admission Record in the Electronic Medical Record (EMR) under the ''Resident tab indicated he was initially admitted to the facility on [DATE] with a diagnosis of acute respiratory failure. Review of R3's quarterly ''Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/25 and located in the resident's EMR under the MDS tab indicated that the resident had been re-admitted on [DATE] and did not include most recent hospitalization of 07/28/25 from a short-term hospital. Review of R3's ''Progress Note dated 07/28/25 located in under the ''Progress Notes tab stated, ''Received patient in bed, patient was in distress.patient was transferred to Capital Health. Review of R3's ''SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form dated 07/28/25 and provided by the facility indicated that R3 was sent to the hospital for shortness of breath. Review of R3's ''Notice of Intent to Transfer/Discharge Resident with less than 30-day notice (New Jersey) - V 5 dated 07/28/25 and provided by the facility indicated that R3 was transferred to an acute care hospital ''.The discharge or transfer is necessary for the resident's welfare, and the facility cannot meet the resident's needs. During an interview on 09/03/25 at 8:52 AM, Responsible Party (RP) 3 stated she was aware that R3 was sent to the hospital on [DATE] due to chest congestion, but she did not receive any documents or any information on bed holds or transfers. 4. Review of R12's ''admission Record in the EMR under the ''Resident tab indicated he was initially admitted to the facility on [DATE] with a diagnosis of bloodstream infection. Review of R12's Entry ''MDS with an ARD of 08/25/25 was re-admitted from a short-term general hospital. Review of R12's medical records located in the EMR revealed no ''SNF/NF to Hospital Transfer Form or ''Notice of Intent to Transfer/Discharge Resident with less than 30 day notice (New Jersey) - V 5. Review of R12's Census tab in the EMR revealed he was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Review of R12's ''Progress Notes located in the EMR under the ''Progress Notes tab and dated 08/20/25 stated ''.Resident will be transfer to [NAME] Medicine of Plainsboro ER [Emergency Room] for Purulent drainage from Abdominal Surgical Wound. 5. Review of R4's admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R4's discharge MDS with an ARD 06/28/25 located in the resident EMR under the MDS tab revealed the resident was an unplanned discharged to an acute care setting with return anticipated. Review of R4's Nurses Note, dated 06/28/25 and located in the resident's EMR under the Progress Notes tab revealed the resident was admitted to the hospital with diagnosis of acute kidney injury, heart failure, and elevated potassium level. Review of R4's Hospital Transfer Form, dated 06/27/25 and located in the resident's EMR under the Evaluations tab revealed information from the resident's transfer from the hospital to the nursing facility and not the 'resident's transfer from the facility to the hospital. There was no documentation on the transfer form or in the nurses' notes discussion of the bed hold policy. During an interview on 09/03/25 at 5:15 PM, the Social Services Director (SSD) stated that she fills out the Intent to Transfer in the EMR and she does not send it to anyone. She was under the impression that the facility provided the bed hold policy upon admission, and she was not sure if anyone sends anything to the Responsible Party upon transfer to the hospital. 6. Review of R6's admission Record located in the resident's EMR tab titled Profile revealed the resident was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. with diagnoses that included cerebral infarct and above the knee amputation. Review of R6's discharge MDS with an ARD 06/24/25 and located in the resident's EMR under the MDS tab revealed the resident was discharged to an acute care facility with return to the facility anticipated. Review R6's Nursing Note dated 06/24/25 and located in the resident's EMR under the Progress Notes tab documented the resident with blackish discoloration of the left foot with foul smelling wounds on the great and second toes. The physician and R13's spouse were notified of the findings. The spouse agreed to transfer to acute care facility for evaluations and treatment. Also, the progress notes did not indicate if a bed hold was discussed with the spouse. Review of R6's Hospital Transfer Form, dated 06/24/25 and located in the resident's EMR under the Evaluations tab failed to reveal if the required documents were sent with the resident when transferred to the hospital. Interview on 09/03/25 at 12:45PM with Family Member (F) 1 revealed she was present when the facility made her aware that R6 needed to be transferred to the acute care facility for evaluation and treatment. F1 also stated the facility did not provide her with copies of the documents sent with the resident to the acute care facility. F1 further stated the nursing staff did not discuss the facility bed hold policy with her prior to the resident's transfer. 7. Review of R84's admission Record located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R84's entry MDS with and ARD 06/04/25 and located in the resident's EMR under the MDS tab revealed the resident was readmitted to the facility from acute care hospital. Review of R84's Nurses Note dated 05/24/25 and located in the resident's EMR under the Progress Notes tab revealed the resident was found unresponsive on the floor. The resident was noted to have bump to left side of the forehead, skin tear to left facial check, and left elbow. The nurse's note documented the facility physician and family were notified. However, there was no documentation of the bed policy being discussed with the resident and/or the resident's family. Review of R84's Hospital Transfer Form dated 05/24/25 and located in the resident's EMR under the Evaluation tab revealed the resident's responsible party was notified of the resident's transfer but did not receive anything in writing about the transfer. Also, there was no documentation of the Bed Hold Policy that was discussed with the responsible party. Interview with Registered Nurse (RN) 2 on 09/03/25 at 10:03 AM revealed once it was identified a resident needed to be transferred to an acute care facility for evaluation, the family was notified. RN2 stated the paperwork sent with the resident included face sheet, physician orders, the resident's medication administration record, lab and x-ray report, and their progress notes. RN2 stated the nurses were more focused on the clinical aspect of transferring the resident to acute care setting. RN2 also stated the bed hold policy was signed upon admission to the facility but the nurses do not review the bed hold policy with the residents or the residents' responsible party prior to transfer to an acute care setting. RN2 also stated a copy of the documents sent with the resident during transfer was not given to the residents' responsible party. RN2 further stated she was not aware if this had ever been done or who was responsible for getting this information to the resident's responsible party. During an interview on 09/04/25 at 12:15 PM with the Administrator, stated she was not aware that transfer information (medical information) needed to be provided to the receiving hospital upon transfer. Also, the Administrator was not aware of the reason for the residents' transfer and bed hold information was not being provided to responsible party. The Administrator stated a phone call was always made by nursing to the Responsible Party/family member regarding the resident's transfer. During an interview on 09/04/25 at 4:10 PM, Registered Nurse (RN) 1 and RN3 stated when they sent a resident out to the hospital they filled out a Universal Transfer Form that goes with the resident's packet which would include the face sheet/admission record, labs, orders, and advance directive information. Both nurses confirmed that when a resident was being sent out to the hospital, a phone call would be placed to the responsible party (RP), but they did not provide any transfer/discharge or bed hold notifications to the RP. Review of the facility's policy titled, Transfer, Emergency Acute Care dated 03/2025 indicated, Policy Statement Residents transferred to an acute care setting for emergency treatment are provided with a notice of transfer and are permitted to return to the facility. Policy Interpretation and Implementation.2. When a resident is temporarily transferred to an acute care facility, a notice of transfer is provided to the resident and resident representative as soon as practicable before the transfer.7. The facility bed-hold and return policy ensures residents may return to their previous room within the bed hold period following a hospitalization.regardless of payment choice. 8. Residents who seek to return to the facility after the expiration of the bed-hold period.are allowed to return to their previous room if available or immediately to the first available bed. Review of the facility's undated document titled Hospital Transfer Documentation Checklist directed staff as follows: Please send the following to the hospital at the time of transfer. Transfer form/face sheet with demographics.Current medication list (with last administered doses) to Recent physician orders. Advance directives/DNR status/Code status/POLST. Bed Hold Policy notice. Latest vital signs. Current care plan Summary.Nursing progress notes. MAR (Medication Administration Record) / TAR (Treatment Administration Record) .Allergies list.Any recent (within the last 30 days) labs or diagnostic studies. NJAC 8:39-4.1(a)32,33NJAC 8:39-5.3(b)

Based on observations, record review, and interviews, the facility failed to ensure three of five residents (Resident (R) 11, R33, and R141) were offered the COVID-19 vaccine boosters. This failure increased the risk of contracting COVID-19. Findings include: Review of the facility's policy titled, COVID-19 Vaccination, revised 09/14/23 stated, Staff members and residents who meet COVID-19 vaccine eligibility criteria will be offered vaccination in accordance with recommendations from the Center for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP). Review of CDC recommendations for 2024-2025 COVID-19 vaccinations located at cdc.gov/covid/vaccines/stay-up-to-date.html as of May 29, 2025, the schedule incorporates the HHS [Health and Human Services] directive regarding COVID-19 vaccine recommendations.for adults19-26, 27-29, and 50-64 was to receive one or more doses of 2024-2025 vaccine and for adults older than [AGE] years of age should receive two or more doses of 2024-2025 vaccine. 1. Review of R11's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab indicated that he was originally admitted to the facility on [DATE] with a primary diagnosis of pleural effusion. R11 was an [AGE] year-old male. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/25 and located in the resident's EMR under the MDS tab indicated that a Brief Interview for Mental Status (BIMS) was unable to be completed due to severe cognitive deficits. Additionally, the assessment indicated that the COVID-19 immunization was not up to date. Review of R11's Physician Orders, located in the EMR under the Orders tab did not include any immunization orders. Review of R11's Care Plan located in the EMR under the Care Plan tab did not include any immunization status. Review of R11's Immunizations located in the EMR under the Immunizations tab revealed that R11 had not received any COVID-19 immunizations since 04/13/21. No declination or education was available to indicate he had been offered the vaccine in 2024 or 2025. During an interview on 09/04/25 at 5:41 PM, the IP confirmed R11's medical records did not include any indication that he had been offered the COVID-19 immunization in 2024 or 2025 but should have been. 2. Review of R33's admission Record located in the EMR under the Profile tab indicated that she was originally admitted to the facility on [DATE] with a primary diagnosis of diabetes mellitus. R33 was an [AGE] year-old female. Review of R33's annual MDS with an ARD of 08/18/25 and located in the resident's EMR under the MDS tab indicated that she had a BIMS score of 12 out of 15 indicating that she was moderately cognitively impaired. Additionally, the assessment indicated that the COVID-19 immunization was not up to date. During an interview on 09/01/25 at 11:50 AM, R33 stated her only concern was that she would receive the COVID-19 vaccine this year. R33 stated the facility refused to administer her the COVID-19 vaccine last year with no reason given. Review of R33's Physician Orders located in the EMR under the Orders tab included an order dated 12/13/23 for COVID-19 vaccine as indicated by CDC Guidelines. Review of R33's Care Plan located in the EMR under the Care Plan tab did not include any immunization status. Review of R33's Immunizations located in the EMR under the Immunizations tab revealed that R33 had received COVID-19 immunizations on 03/03/21, 09/27/22, 12/13/23, and 05/07/25. No declination or education was available to indicate he had been offered the vaccine in 2024. Review of R33's COVID-19 Immunization Informed Consent- Resident form dated 05/07/25, located in the EMR under the Misc [miscellaneous] tab indicated that she was educated on COVID-19 immunizations and accepted to receive the immunization. During an interview on 09/03/25 at 2:35 PM, the Infection Preventionist (IP) stated based on CDC guidelines, R33 could have received a dose in 2024, and she was not sure why this was not offered and given by the previous IP. 3. Review of R141's admission Record located in the EMR under the Profile tab indicated that she was originally admitted to the facility on [DATE] with a primary diagnosis of dementia. R141 was a [AGE] year-old female. Review of R141's quarterly MDS with an ARD of 08/24/25 and located in the resident's EMR under the MDS tab indicated that a BIMS was unable to be completed due to severe cognitive deficits. Additionally, the assessment indicated that the COVID-19 immunization was up to date. Review of R141's Physician Orders located in the EMR under the Orders tab included an order dated 11/09/23 for COVID-19 vaccine as indicated by CDC Guidelines. Review of R141's Care Plan located in the EMR under the Care Plan tab indicated that she had COVID-19 on 08/26/25. Review of R141's Immunizations located in the EMR under the Immunizations tab revealed that R141's most recent COVID-19 immunization was on 11/09/23. Review of R141's COVID-19 Immunization Informed Consent- Resident form dated 09/24/24, located in the EMR under the Misc [miscellaneous] tab indicated that she was educated on COVID-19 immunizations and accepted to receive the immunization but did not receive it. Review of R141's Progress Notes located in the EMR under the Progress Notes tab dated 01/22/25 stated, per MD [medical doctor] - hold covid vaccine administration until patient is recovered from flu. During an interview on 09/04/25 at 1:58 PM, the IP confirmed R141 was not offered the COVID-19 immunization after recovering from influenza on 1/22/25. The IP also confirmed R141 should have received the COVID-19 immunization in 2024 and was not sure why this did not occur. NJAC 8:39-5.1(a)

Based on observation, record review, and interview, the facility failed to ensure one of five residents (Resident (R) 11) reviewed for immunizations was offered the influenza immunization. Specifically, the facility failed to offer R11 the influenza immunization in 2024. This failure increased the risk of R11 contracting the influenza virus.Findings include: Review of the facility's policy titled, Influenza Vaccine, revised 03/2022 stated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza.Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. Review of R11's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab indicated that he was originally admitted to the facility on [DATE] with a primary diagnosis of pleural effusion. Review of R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/25 indicated that a Brief Interview for Mental Status (BIMS) was unable to be completed due to severe cognitive deficits. Review of R11's Physician Orders, located in the EMR under the Orders tab did not include any immunization orders. Review of R11's Care Plan located in the EMR under the Care Plan tab did not include any immunization status. Review of R11's Immunizations, located in the EMR under the Immunizations tab revealed that R11 had not received the influenza immunization since 10/02/23. No declination or education was available to indicate he had been offered the vaccine in 2024. During an interview on 09/04/25 at 5:41 PM, the Infection Preventionist (IP) confirmed R11's medical records did not include any indication that he had been offered the influenza immunization in 2024 but should have been. NJAC 8:39-19.4(h)

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure medications were properly stored for one of 37 sampled residents (Resident (R) 162) when Flonase (an over the counter nasal spray medication used to treat allergies) was observed at the resident's bedside. Additionally, the facility failed to ensure one of two treatment carts was locked. These failures had the potential to result in residents being subject to unsafe or ineffective treatment or adverse effects leading to more serious illnesses and could permit unauthorized access to residents' medications and treatment supplies.Findings include:Review of facility's undated policy titled Administering Medications, directs staff as follows .Residents may self -administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision -making capacity to do so safely. Review of the facility's undated policy titled Medication Labeling and Storage directs staff .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. Review of R162's admission Record, located in the EMR under the Profile tab revealed R162 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction. Review of R162's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/25 included a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating that the resident was cognitively intact. Review of R162's Care Plan located in the EMR under the Care Plan tab did not indicate that he was a candidate for self-administration of medications.Review of R162's Assessments, located in the EMR under the Assessments tab did not include a Self-Administration of Medications assessment.Review of R162's Order Summary Report, located in the EMR under the Orders tab included an order dated 06/28/25 of fluticasone propionate (Flonase) nasal suspension 50 micrograms (mcg), administer two sprays in both nostrils once daily for allergy. During an observation and interview on 09/04/25 at 3:20 PM, R162 was sitting up in his high back wheelchair and Registered Nurse (RN) 5 was administering the resident medications. Continued observation revealed R162 had a container of Flonase nasal spray on his dresser in his room. RN5 stated the medication should be in the locked medication cabinet on the wall, not on the dresser. RN5 then took the medication and locked it away. RN5 confirmed that the resident was not a candidate for self-administration of medication due to physical disability.During an interview on 09/04/25 at 7:04 PM, the Director of Nurses (DON) confirmed that no medications should have been left at the bedside unless the resident had been approved for self-administration of medications. The DON confirmed that R162 was not a candidate for self-administration of medications.2. Observation on 09/03/25 at 9:10 AM revealed the treatment cart on the [NAME] Unit was left unlocked while the Licensed Practical Nurse (LPN) 3 and the Wound Care Consultant were in a resident's room. The treatment cart was out of line of sight of LPN3. The treatment care supplies contained wound cleanser, several types of wound care supplies, hydrogen peroxide, alcohol wipes, zinc oxide, etc. Interview on 09/03/25 at 9:30 AM with LPN3 revealed she could not lock the treatment cart because only the medication nurse had the keys to the treatment cart. The LPN started since the treatment cart contained the supplies above, the cart should have been locked when she was away from the cart. Interview on 09/04/25 at 4:27 PM with the Director of Nursing (DON) revealed she was aware of the incident with LPN3 and the treatment cart. The DON stated she had the keys to all medication and treatment carts and there was no reason why LPN3 could not have come to her to sign out the keys for the treatment cart. NJAC 8:39-29.4(h)

Based on observations, record review, and interviews, the facility failed to ensure that quality of care/treatment was provided to one resident (Resident (R) 75) of eight residents reviewed for weights. Specifically, the facility failed to follow physician orders related to daily weights for fluid retention monitoring/congestive heart failure. This failure increased the risk of worsening heart failure which could lead to fluid retention, increased swelling/edema, and shortness of breath. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, revised 03/2022 and .Residents are weighed upon admission and at intervals established by the interdisciplinary team. Review of R75's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with a primary diagnosis of multiple sclerosis and comorbidities including congestive heart failure (CHF) (per physician orders). Review of R75's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/25 included a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that the resident was cognitively intact. Additionally, the assessment included daily diuretic usage with no weight gain/loss noted. Review of R75's Care Plan Report, located in the EMR under the Care Plan tab included R75 being on diuretic therapy related to heart failure (05/31/24) with the need for obtaining weights at ordered intervals (05/31/24). Review of R75's Order Summary Report, located in the EMR under the Orders tab included an order for daily weight in the morning for CHF as of 01/29/25. During an interview on 09/01/25 at 11:45 AM, R75 stated that she had persistent left leg swelling and was on a diuretic for heart failure. R75 stated she had not been weighed in 2 weeks and was supposed to be weighed daily. Staff told her they could not find the part to weigh her on the mechanical lift scale. During an interview on 09/03/25 at 10:45 AM, Licensed Practical Nurse (LPN) 4 stated that the Certified Nursing Assistants (CNAs) weighed the residents and then recorded the weights on the weight log, and then the nurses then enter the weights in the EMR. During an interview on 09/03/25 at 11:45 AM, CNA3 stated the CNAs weighed the residents throughout the day and either write it on the paper and if not there, then the nurses enter the information into the EMR. If the weight was not documented, then it was not done. During an interview on 09/03/25 at 11:55 AM, R75 stated she was weighed today, they told her they found the mechanical weight device, but for August they did not do daily weights. During an interview on 09/03/25 at 3:45 PM, LPN5 stated the CNAs obtained the weights and then write them in the weight binder. LPN5 demonstrated that the mechanical lifts were attached to the ceiling and if the aides did not know how to use it or if it got stuck and they are unable to use it, then the resident would not be weighed that day. Also, if the 11:00 PM to 7:00 AM shift was unable to weigh the resident, which did happen on occasion, then the resident would not be weighed because they want to weigh the resident before they ate or drank anything. LPN5 confirmed R75's weights on file and confirmed that if the weights were not in the paper binder or in EMR then the weight was not obtained. If no one was available that knew how to use the machine, then no one weighed the resident. During an interview on 09/03/25 at 3:53 PM, CNA1 stated if a new aide came and did not know how to use it (mechanical lift scale) then they may not weigh R75; however, they should have asked someone that was familiar with the machine but that did not always happen. During an interview on 09/04/25 at 6:09 PM, the Director of Nurses (DON) stated weights were done on the 11:00 AM-7:00 PM shift and that she would check with the unit manager to see if she had any additional weights for R75. The DON confirmed R75 was supposed to be weighed daily before 7:00 AM and her expectation was that the resident would have been weighed daily per the resident's physician orders. NJAC 8:39-27.1

Based on record review, interview, and review of facility's policy, the facility failed to ensure care plans were developed to include hospice services for one resident reviewed for hospice services (Resident (R) 13) out of 37 sampled residents. This failure had the potential for R13 not to receive adequate hospice nursing services.Findings include:Review of the facility's policy titled Comprehensive Care Plan Development, revised March 2022 reads in part The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition.Review of the facility's policy titled Hospice Program, revised July 2017 read in part .It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice re presentative, and ensure that the level of care provided is appropriately based on the individual resident's needs.Review of R13's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included dementia, senile degeneration of the brain, diabetes mellitus type II, and gastroesophageal reflux.Review of R13's Physicians Order dated 06/17/25 and located in the resident's EMR under the Orders tab revealed Hospice to evaluate and treat.Review of R13's Hospice Care Business Office Notification Form, dated 06/18/25 and located in the resident's EMR under the Miscellaneous tab revealed R13 was accepted for hospice services.Review of R13's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date of 06/23/25 and located in the resident's EMR under the MDS tab revealed the resident was placed on hospice services.Review of 13's Care Plan revised 06/19/25 and located in the resident's EMR under the Care Plan tab revealed the resident was receiving hospice services due to terminal diagnosis; however, the care plan interventions only included services provided by social services but did not reflect the services provided by nursing services.An interview on 09/03/25 at 3:10 PM with Registered Nurse (RN) 2 revealed the resident received weekly visits from the hospice and daily visits from the hospice certified nursing assistant. RN2 acknowledged the resident's care only addressed the services provided by the hospice social services and nothing from the hospice nursing services. RN2 stated the resident's care plan should have included the hospice nursing services. NJAC 8:39-11.2(e) thru (i)NJAC 8:39-27.1(a)

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the presence of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident (R) 169) out of 37 sampled residents. This failure placed the resident at risk for unmet care needs.Findings include:Review of the RAI Manual dated 10/01/19 indicated, . information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment.Review of R169's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarct with hemiplegia and hemiparesis, and cutaneous abscess.Review of R169's five-day Medicare MDS with an Assessment Reference Date (ARD) of 10/08/24 and located in the resident's EMR under the MDS tab revealed the resident was admitted to the facility with one stage III pressure ulcer.Review of R169's Wound Assessment Report, dated 10/25/24 and located in the resident's EMR under the Miscellaneous tab revealed the resident had a stage III pressure ulcer to the sacrum measuring four centimeters by three centimeters.Review of R169's quarterly MDS with and ARD of 10/30/24 and located in the resident's EMR under the MDS tab revealed the resident was not coded as having any pressure ulcers.During an interview on 09/04/25 at 3:48 PM, the MDS Coordinator (MDSC) reviewed R169's wound assessment reports and the quarterly MDS with an ARD of 10/30/24. The MDSC acknowledged the quarterly MDS did not reflect the resident's stage III pressure ulcer. NJAC 8:39-33.2(d)

Complaint #: NJ185063 Based on interviews, closed medical record review, and review of pertinent facility documentation on 4/3/25, it was determined that the facility failed to follow standards of clinical practice by not obtaining a physician's order for oxygen for a resident (Resident #2) that utilized continuous oxygen therapy. The facility also failed to follow its policy titled Oxygen Administration. This deficient practice was identified in 1 of 3 residents (Resident #2) reviewed for oxygen therapy and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. According to the Admission Record (AR), Resident #2 was admitted to the facility in March of 2025 with diagnoses which included but were not limited to: Acute Respiratory Failure (occurs when the lungs cannot adequately exchange oxygen and carbon dioxide), Obstructive Sleep Apnea, and Acute Kidney Failure. According to the Admission Minimum Data Set (MDS), an assessment tool dated 3/27/25, revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. The MDS further revealed that the resident was on oxygen therapy on admission and while a resident at the facility. According to Resident #2's March 2025 Progress Notes (PN) revealed that the resident was admitted to the facility and continuous oxygen via nasal cannula (medical device used to deliver supplemental oxygen to individuals with low oxygen levels) was initiated. The PNs further revealed that the resident wore oxygen therapy via nasal cannula throughout his/her stay at the facility. According to Resident #2's Order Summary Report (OSR) dated 3/30/25, there were no physician's orders for as needed or standing oxygen therapy. On 4/3/25 at 11:36 AM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who confirmed that Resident #2 had worn continuous oxygen while at the facility. LPN #1 stated that if a resident required continuous oxygen, they would have a physician's order for it and it would be on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). On 4/3/25 at 12:44 PM, the surveyor interviewed the Meadows Unit Manager (UM) who confirmed that Resident #2 was supposed to wear oxygen all the time. The UM stated Yes, a resident has to have an order for oxygen if they use it. The UM stated that the nurse was responsible for putting in oxygen orders and it was important to have an order because it was considered a drug. The UM stated No, I do not see an order for oxygen for Resident #2, there should have been an order since admission. On 4/3/25 at 3:44 PM, the surveyor interviewed the Regional Director of Nursing (RDON) in the presence of the Licensed Nursing Home Administrator (LNHA) who confirmed that Resident #2 did not have an order for oxygen but required it. The RDON stated, Yes, there should be an order to know administration route and amount of liters. The RDON stated that the admitting nurse should have put in Resident #2's oxygen orders. Review of the facility's policy titled Oxygen Administration with an adopted date of August 2021 revealed under Preparation, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility's job description titled LPN Nurse revealed under Duties and Responsibilities, Charting and Documentation: Complete the admission process for all newly admitted residents including completion of checklists, evaluations, treatments, physician orders and all other nursing responsibilities as required by Center policy, procedure, or practice. NJAC 8:39-11.2 (a)

Complaint # NJ175300 Based on interviews, medical record review, and review of other pertinent facility documents on 08/05/2024, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status, follow the Certified Nursing Assistant (CNA) job description and follow its policy titled Charting and Documentation for 3 of 3 residents (Resident #2, Resident #12, and Resident #15) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility with diagnoses that included but were not limited to Hemiplegia and Hemiparesis (loss of the ability to move and sometimes to feel anything on one side of the body), Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and Weakness. The Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 06/27/2024 revealed that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe impairment. The MDS also indicated that Resident #2 required substantial/maximal assistance to roll left to right. Review of Resident #2's Care Plan (CP) revealed a Focus, initiated on 01/24/2024, that Resident #2 had skin impairment on the sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis), right buttocks, left buttocks, left heel, right and left breast, bilateral groin. The CP indicated that the resident required reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. Resident #2's DSR for July 2024 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Bed Mobility- Turn and Positioning for a total of 18 days: On 07/01/2024, 07/02/2024, 07/04/2024 through 07/07/2024, 07/09/2024, 07/11/2024, 07/12/2024, 07/14/2024 through 07/18/2024, and 07/23/2024 through 07/26/2024. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning. for a total of 22 days: On 07/01/2024 through 07/10/2024, 07/12/2024, 07/14/2024 through 07/17/2024, 07/19/2024, 07/20/2024, 07/26/2024, 07/27/2024, and 07/29/2024. On the 11:00 P.M. to 7:00 A.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 21 days: On 07/01/2024, 07/04/2024, 07/10/2024, 07/11/2024, 07/13/2024 through 07/16/2024, 07/18/2024, and 07/20/2024 through 07/31/2024. Review of Resident #2's Progress Notes (PNs) for July 2024 revealed no documentation that Resident #2 was turned and repositioned during the aforementioned shifts. There was no documentation in the PNs for the month of July 2024 for any worsening in skin condition. 2. According to the AR, Resident #12 was admitted to the facility with diagnoses that included but were not limited to Muscle Weakness (generalized), Unspecified Dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and Lack of Coordination. The MDS dated [DATE] revealed that Resident #12 had a BIMS score of 0 out of 15, which indicated severe impairment. The MDS also indicated that Resident #12 required substantial/maximal assistance to roll left to right. Review of Resident #12's CP revealed a Focus, initiated on 08/03/2023, that Resident #12 had an ADL self-care performance deficit related to deconditioning after hospitalization and requires assistance with ADLs. The CP indicated that the resident required 1 staff assist with turning and repositioning. Resident #12's DSR for July 2024 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Bed Mobility- Turn and Positioning for a total of 5 days: On 07/06/2024, 07/07/2024, 07/20/2024, 07/28/2024, and 07/29/2024. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 11 days: On 07/02/2024, 07/07/2024, 07/13/2024, 07/15/2024, 07/18/2024, 07/22/2024, 07/25/2024, 07/26/2024, and 07/31/2024. On the 11:00 P.M. to 7:00 A.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 7 days: On 07/02/2024, 07/07/2024, 07/13/2024, 07/15/2024, 07/18/2024, 07/22/2024, 07/25/2024, 07/26/2024, and 07/31/2024. Review of Resident #12's Progress Notes for July 2024 revealed no documentation that Resident #12 was turned and repositioned during the aforementioned shifts. 3. According to the AR, Resident #15 was admitted to the facility with diagnoses that included but were not limited to Muscle Weakness (generalized), and Spinal Stenosis, Lumbosacral Region (Narrowing of the spinal canal, compressing the nerves traveling through the lower back possibly causing pain, tingling, numbness, and muscle weakness). The MDS dated [DATE] revealed that Resident #15 had a BIMS score of 11 out of 15, which indicated moderate impairment in cognition. The MDS also indicated that Resident #15 required partial/moderate assistance to roll left to right. Review of Resident #15's CP revealed a Focus, initiated on 05/25/2024, that Resident #15 had ADL self-care performance deficit related to unsteady gait and impaired balance. The CP indicated that Resident #15 requires the assist of 1 staff and a sheet for turning and repositioning. Resident #15's DSR for July 2024 showed the following: On the 7:00 A.M. to 3:00 P.M. shift, there was no documentation for Bed Mobility- Turn and Positioning for a total of 5 days: On 07/06/2024, 07/18/2024, 07/20/2024, 07/24/2024, and 07/31/2024. On the 3:00 P.M. to 11:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 2 days: On 07/01/2024 and 07/06/2024. On the 11:00 A.M. to 7:00 P.M. shift, there was no documentation noted for Bed Mobility- Turn and Positioning for a total of 18 days: On 07/02/2024, 07/04/2024 through 07/07/2024, 07/08/2024, 07/09/2024, 07/11/2024, 07/13/2024 through 07/16/2024, 07/18/2024, 07/21/2024, 07/23/2024, 07/27/2024, 07/28/2024, 07/30/2024, and 07/31/2024. Review of Resident #15's PNs for July revealed no documentation that Resident #15 was turned and repositioned during the aforementioned shifts. During an interview on 08/02/2024 at 2:40 P.M., Certified Nursing Assistant (CNA#1) stated that CNAs were responsible for ADL care and that documentation was done in the electronic system. She further stated that changes of position were provided every two hours, or more frequently if the resident requested or appeared uncomfortable. CNA #1 stated that blank spaces in DSR may be due to staff forgetting to document the care that was provided, or staff having issues with access to the electronic record. On 08/05/2024 at 10:49 A.M., the Unit Manager/Registered Nurse (UM/RN) stated that it was expected that all documentation was completed by staff by the end of their shift. The UM/RN stated that there should be no missing documentation on the DSR. The UM/RN stated that if residents refused treatment, this should be documented in the progress notes. On 08/05/2024 at 2:11 P.M., during an interview with the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA), stated that CNAs were responsible for completing ADL care and for documenting care provided before the end of their shift. The LNHA stated the expectation is that documentation is 100% complete. The LNHA stated that blank spaces on the ADLs sheet may not mean the task was not completed because the blank could be due to a documentation error. The DON revealed that the facility changed the format of documentation in August of 2023. The DON reported that she has previously recognized that CNAs required additional education related to the format change for documentation. DON reported that auditing of CNA documentation was done routinely, and CNAs were reminded frequently to document care provided to residents. Review of the facility's job description document for the position Certified Nurse Assistant/Geriatric Nursing Assistant revealed under Duties and Responsibilities: Record all entries on flow sheets, notes, charts, computers etc., in an informative and descriptive manner. Duties and Responsibilities also include: assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts, etc. Review of the facility's policy last revised July 2012, titled Charting and Documentation, under Policy Statement revealed: All services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Under Policy Interpretation and Implementation #3 the policy stated Documentation in the medical record will be objective .complete, and accurate. NJAC 8:39-35.2(f)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to complete performance review of Certified Nurse Aides (CNA) at least every twelve months and provide regular in-service education based on the outcome of these reviews. The deficient practice was identified for 5 of 5 CNAs (CNA #1; #2; #3; #4; and #5) reviewed for performance evaluations and was evidenced by the following: On 4/3/24 at 10:01 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with five randomly selected CNA employees' education for 2023. The LNHA stated that she could not locate the CNAs' employee performance reviews for 2023. The LNHA stated that the facility took ownership of the building in February of 2023 and were starting to complete performance reviews now. A review of the education revealed: CNA#1: date of hire 8/16/21; no performance review for 2022 or 2023; most recent performance review 4/1/24 CNA #2: date of hire 10/11/15; no performance review 2022 or 2023; last performance review 2/17/24 CNA #3: date of hire 6/10/22; no performance review 2023; last performance review 2/7/24 CNA #4: date of hire 8/12/19; no performance review 2022 or 2023; last performance review 3/30/24 CNA #5: date of hire 9/20/21; no performance review 2022 or 2023; last performance review 2/6/24 On 4/4/24 at 9:43 AM, the LNHA informed the surveyor that the facility had no performance reviews for 2023 and acknowledged that CNAs should have an annual review that was stored in their employee file. The LNHA stated that the facility started this year reviewing the CNAs, and all the CNAs have not been reviewed. On 4/5/24 at 9:19 AM, the surveyor interviewed the Human Recourses Director who confirmed CNAs should have performance evaluations completed yearly. On 4/8/24 at 10:17 AM, the LNHA in the presence of the Director of Nursing (DON), Regional LNHA, and survey team who acknowledged CNAs needed annual performance reviews to determine any additional inservices and education they needed for improvement. A review of an undated facility provided policy titled Performance Evaluations included the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review . NJAC 8:39-43.17(b)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident's food preference of no gravy on meals was honored. This deficient practice was identified for 1 of 5 residents reviewed for nutrition (Resident #27), and was evidenced by the following: On 3/27/24 at 12:41 PM, the surveyor interviewed Resident #27 who stated they disliked gravy on his/her food because it upset their stomach. The resident stated they informed the Registered Dietitian (RD) their concern, but they still received gravy on his/her dinner meal every night. The surveyor then reviewed the medical record of Resident #27. A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses that included unspecified escherichia coli (E. coli; bacteria found in the lower intestine) and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the individualized comprehensive care plan (ICCP) dated effective 3/2/24, included a focus area that the resident had a nutritional problem. Interventions included my food preferences will be recorded and updated as needed. A review of the Admission Nutrition assessment dated effective 3/8/24, included the resident received a therapeutic diet (such as low salt, diabetic, low cholesterol), and had no dietary preferences. A review of the Progress Notes did not include any Dietary/Nutrition Notes with the resident's dietary preferences. On 4/1/24 at 12:30 PM, the surveyor observed Resident #27 in their room eating lunch which consisted of soup, apple pie and iced tea. The surveyor reviewed the resident's lunch Selection Sheet (meal ticket) which indicated no preferences or dislikes. On 4/2/24 at 11:47 AM, the surveyor interviewed the RD in the presence of the Regional RD who stated she spoke to Resident #27 on 3/11/24, and the resident stated he/she disliked gravy on their food, but she failed to document it. The RD also acknowledged that she should have communicated the dislike to the kitchen. The RD stated the resident attended the Food Committee Meeting on 3/21/24, and the resident informed her that he/she did not want gravy on their food. A review of the Food Committee Meeting dated 3/21/24, included Resident #27 asked for the facility to not put gravy on all his/her food because it upset their stomach. On 4/3/24 at 11:31 AM, the surveyor interviewed Resident #27 who informed them that last night he/she received meat and noodles on their dinner tray that had gravy on it. On 4/3/2024 at 12:00 PM, the surveyor interviewed the RD who stated she had spoken with the resident this morning who informed her they received gravy on their dinner meal last night. The RD stated she did inform the kitchen yesterday that the resident did not prefer gravy, so their should have been no gravy on the resident's dinner last night. On 4/8/24 at 10:17 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Regional LNHA, Director of Nursing (DON), and survey team acknowledged the facility should honor resident's food preferences. A review of the facility's Resident Food Preferences Orders policy dated revised July 2017, included upon the resident's admission the dietician and /or nursing staff will identify a resident's food preferences . NJAC 8:39-17.4(a)1

Complaint#: NJ167771; NJ168132 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure activities of daily living (ADLs) including incontinence care and assistance with meals were performed for a resident. This deficient practice was identified on 1 of 30 residents reviewed for sufficient staffing (Resident #57), and was evidenced by the following: On 4/1/24 at 11:58 AM, the surveyor observed Resident #57 awake in bed with their untouched breakfast tray on their overbed table. At this time, the surveyor requested from the Unit Clerk a copy of the Certified Nursing Aide (CNA) assignment sheet for that day. A review of the assignment sheet revealed the Registered Nurse (RN) was scheduled and assigned as Resident #57's CNA for the 7:00 AM to 3:00 PM (7-3) shift. On 4/1/24 at 12:00 PM, the surveyor interviewed the RN who confirmed that they were scheduled as a CNA for the care of Resident #57. The surveyor asked if the resident ate breakfast that morning or received their morning care. The RN responded that they had not yet assisted the resident with their breakfast or performed incontinence care for that shift. The RN stated they had fifteen assigned residents for the day and still needed to provide care for Resident #57. The RN confirmed that the resident received nutrition through an enteral feeding tube (tube inserted in the stomach to provide nutrition) but also received regular meals that the resident needed assistance with. On 4/1/24 at 12:01 PM, the surveyor in the presence of the RN requested the Unit Manager/Licensed Practical Nurse (UM/LPN) to accompany them to Resident #57's room. The surveyor asked the UM/LPN to check if the resident's incontinent brief was soiled, and the UM/LPN confirmed the brief was saturated with urine and needed to be changed. At this time, the surveyor asked the UM/LPN if the the resident had been assisted with breakfast that morning. The UM/LPN confirmed the breakfast tray was untouched and the resident still needed to eat. The UM/LPN stated the breakfast tray was delivered around 8:30 AM. The surveyor reviewed the CNA assignment sheet for the 7-3 shift on 4/1/24, which revealed the census for the nursing unit was 59, and there were four assigned CNAs for the residents. The RN who was assigned as a CNA had fifteen residents on her assignment for the day. The surveyor then reviewed the medical record of Resident #57. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included dysphagia, (swallowing problems occurring in the mouth and or the throat), gastrostomy status (enteral feeding tube), and gastro-esophageal reflux disease. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, reflected the resident had long and short-term memory problems with a severely impaired cognition. A further review revealed the resident received more than 51% of their total calories via a feeding tube, and the resident was dependent on staff for eating and toileting. A review of the individualized comprehensive care plan (ICCP) dated effective 1/8/24, included a focus area that the resident was at risk for alteration in nutrition in regards to his/her varying by mouth intake. Interventions included to provide me with a diet as ordered regular pureed consistency; monitor intake and tolerance; monitor for changes in chewing or swallowing. An additional focus area included Activities of Daily Living (ADL) self-care performance with interventions that included to provide hands-on-assistance for eating, drinking, and toileting. A review of a Nutrition Note dated 2/2/24 at 11:50 AM, the resident received a pureed diet with nectar thick liquids and no concerns with weight were identified. A review of the CNA tasks included eating and nutrition required hand-on assistance for eating and drinking with total assistance with eating and drinking. The tasks also included for toileting to check resident approximately every two hours and provide incontinence care as needed. On 4/3/24 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON) who stated the CNAs began morning care around 7:30 AM, and morning care should be completed by 11:00/11:30 AM. The DON stated the CNAs also conducted rounds to ensure residents incontinence brief were changed every two hours. The DON stated there should be one CNA assigned to eight residents for the 7-3 shift. On 4/8/24 at 10:17 AM, the DON in the presence Licensed Nursing Home Administrator (LNHA), Regional LNHA, and survey team acknowledged it was not acceptable that the resident was not seen by the CNA that morning; the resident should have been fed breakfast and received morning care before 12:00 PM. A review of the facility's Activities of Daily Living (ADLs), supporting policy dated revised March 2018, 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 . A review of the facility's Urinary Continence and Incontinence-Assessment and Management policy dated August 2022, included the physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible . NJAC 8:39-5.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure an electronic pharmacy drug interaction alert was communicated to a physician in accordance with professional standards of practice. This deficient practice was identified for 1 of 30 residents reviewed for professional standards of practice (Resident #450). Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. This deficient practice was evidenced by the following: On 3/27/24 at 12:12 PM, the surveyor observed Resident #450 lying in bed with a wound vacuum (enclosed wound suction device) on the left lower leg. The resident stated that he/she had a blood clot (a mass of blood that forms when blood platelets, proteins, and cells stick together) in their left leg and they were leaving for doctors appointment. The surveyor reviewed the medical record for Resident #450. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included generalized muscle weakness, complete traumatic amputation, and acute embolism (a clot that moves to another part of the body) and thrombosis (stationary blood clot). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, indicating a fully intact cognition. A review of the Progress included a Physician's Order Note dated 4/2/24 at 11:11 PM, included the order you have entered Keflex oral capsule 500 milligram (mg), an antibiotic, give one capsule by mouth every twelve hours for wound healing for ten days; has triggered a drug to drug interaction. The system has identified a possible drug interaction with the multivitamin with minerals oral tablet order. A review of the corresponding April 2024 Medication Administration Record, revealed Keflex and the multivitamin were scheduled to be administered at 9:00 AM. A further review of the Progress Notes did not include the physician was made aware of the possible drug interaction. On 4/4/24 at 11:28 AM, the surveyor interviewed the Consultant Pharmacist (CP) who stated that when a physician order was inputted into the electronic medical record, the Pharmacy will automatically generate a drug interaction alert that the facility was responsible to address. The CP stated Keflex interacted with the iron in the multivitamin which affected the absorption of the antibiotic (Keflex). On 4/4/24 at 1:05 PM, the surveyor interviewed the Registered Nurse (RN) who stated when a drug interaction was identified, the nurses called the physician to inform them, and the physician determined how to proceed. The nurse then documented in the Progress Notes that they spoke to the physician, and how the physician wanted to proceed. At this time the surveyor and the RN observed the facility's house stock multivitamin with minerals bulk bottle which contained iron as one of the minerals. On 4/4/24 at 1:10 PM, the surveyor interviewed the Unit Manger/Licensed Practical Nurse (UM/LPN) who confirmed the nurse notified the physician of any drug interactions, and documented the notification with any new orders. The UM/LPN acknowledged Keflex should not be administered at the same time as the multivitamin with minerals, and that the physician was never notified. On 4/8/24 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Director of Nursing (DON), Regional LNHA, and survey team confirmed the nurses should be contacting the physician at the time a pharmacy drug interaction alert was generated, and document the notification in the Progress Notes. The LNHA acknowledged the physician was not notified of the interaction between the Keflex and multivitamin with minerals until surveyor inquiry. A review of the facility's Medication and Treatment Orders policy dated revised July 2016, did not include a procedure for pharmacy drug interaction alerts. NJAC 8:39-27.1(a)

Complaint #NJ 169996; NJ172438 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to complete a thorough investigation for an alleged theft (wedding ring) for 1 of 4 residents reviewed for abuse (Resident #35). This deficient practice was evidenced by the following: According to Resident #35's Admission Record face sheet (an admission summary), the resident was admitted to the facility with diagnoses which included unspecified dementia and atherosclerotic heart disease. According to the most recent quarterly Minimum Data Set (MDS), an assessment tool, Resident #35 had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. The MDS documentation also identified that Resident #35 is dependent on staff for Activities of Daily Living (ADL). A review of the facility provided Grievance Summaries included an incident date of 9/26/2023, reported date of 1/4/2024, and a resolved date of 12/15/2023 which was completed by the Director of Nursing (DON) included a missing ring reported to facility 10/26/23 and the police report filed in December. Summary of Investigation included resident's [representative] had no explanation when asked why [he/she] did not report missing item immediately. Summary of Findings included difficult to investigate due to time lapse in reporting. Summary of Actions Taken included resident's [representative] decided to report to the local police. On 4/2/24 at 11:30 AM, the surveyor interviewed the Director of Nursing (DON) who stated they were unaware if the previous Administrator had completed an investigation or if there were any statements from staff written. The surveyor asked if incident should have been investigated, the DON replied, it was hard to investigate, due to being reported a month later. On 4/8/24 at 10:17 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Regional LNHA, and survey team stated they were aware that the resident lost a wedding ring but the previous Administrator was at the facility at the time. The LNHA acknowledged the incident should have been investigated. A review of the undated facility provided policy titled Investigating Incident of theft and/or Misappropriation of Resident Property included .when an incident of theft and/or misappropriation of resident property is reported, the administrator appoints a staff member to investigate the incident . A review of facility provided policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating with a revised date of September 2022, included all allegations are thoroughly investigated. The administrator initiates investigations . NJAC 8:39-5.1(a)

Complaint # NJ169996; NJ172438 Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to report an alleged theft (wedding ring) to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident # 35), and was evidenced by the followning: According to Resident #35's Admission Record face sheet (an admission summary), the resident was admitted to the facility with diagnoses which included unspecified dementia and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls). According to the most recent quarterly Minimum Data Set (MDS), an assessment tool, Resident #35 had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. The MDS further indicated the resident was dependent on staff for Activities of Daily Living (ADL). A review of the facility provided Grievance Summaries included an incident date of 9/26/2023, reported date of 1/4/2024, and a resolved date of 12/15/2023 which was completed by the Director of Nursing (DON), included a missing ring reported to facility 10/26/23 and the police report filed in December. This was reported to the facility at least a month after the occurrence at which point the family was explained it would difficult to follow-up on; family upset. Summary of Actions Taken included, resident's [representative] decided to report to the local police. The grievance did not include documentation that the NJDOH was notified of the alleged theft. On 4/3/24 at 9:36 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated the previous Administrator was in charge of this grievance and they were aware of the missing wedding ring. The LNHA stated the incident was not reported to the NJDOH and acknowledged that it should have been. A review of facility provided policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022, included if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility . A review of an undated facility provided policy titled Investigating Incident of theft and/or Misappropriation of Resident Property included .if an alleged or suspected case of the theft, exploitation or misappropriation of resident property is reported, the facility administrator, or his/her designee, notifies the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: a. State licensing and certification agency . NJAC 8:39-4.1(a)15

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within reach of the resident. This deficient practice was identified for 1 of 32 residents reviewed for accommodation of needs (Resident #89), and was evidenced by the following: On 3/27/24 at 12:09 PM, the surveyor observed Resident #89 in their room, seated in a wheelchair with their eyes closed. The surveyor observed the resident's call bell (a bell used to summon staff for assistance) was on the floor, not within his/her reach. On 3/27/24 at 12:17 PM, the surveyor observed Resident #89 in his/her room seated in a wheelchair with their call bell located on the floor, not within his/her reach. On 4/4/24 at 1:18 PM, the surveyor observed Resident #89 in his/her room seated in a wheelchair eating their lunch meal. The surveyor observed the call bell was positioned in the middle of the resident's bed; not within their reach. The surveyor asked the resident how he/she called the staff when they needed assistance, and the resident pointed to the call bell and stated that he/she would hit the buzzer. The resident then reached out his/her arms and stated, I have long arms, but not that long. On 4/4/24 at 1:25 PM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated the resident used their call bell to alert staff they needed assistance. At that time, the surveyor accompanied by the CNA and the Licensed Practical Nurse (LPN) entered Resident #89's room, and they observed the call bell in the middle of the resident's bed, not within the resident's reach. The CNA and LPN acknowledged the call bell should have been left within the resident's reach and proceeded to place it within reach. The surveyor reviewed the medical record for Resident #89. A review of the Admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included a history of falling, fracture of the right pubis, and urinary retention. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, reflected the resident had a brief interview for mental status score of 12 out of 15, which indicated a mild cognitive impairment. A further review indicated they required moderate assistance from staff for transfers and toileting. A review of the individual comprehensive care plan included a focus area dated 12/4/23, I am at risk for falls. Interventions included keeping the call [bell] within reach and providing reminders to use it to call for assistance. On 4/8/24 at 10:18 AM, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), Regional LNHA, and survey team acknowledged that all residents should have their call bells within reach, and confirmed that the staff member who set the resident up with their lunch tray should have ensured the call bell was within reach. A review of the facility's Certified Nursing Assistant job description included .the primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services .which included keeping the nurses' call system within easy reach of the resident. NJAC 8:39- 31.8 (c)(9)