Every finding on record at Mountainside Skilled Nursing and Rehab

COMPLAINT #: 2723201, 2790272 , 2977831 Based on observations, interviews, record reviews, and review of pertinent facility documents it was determined that the facility failed to a.) obtain, record, and monitor weights monthly per their protocol, b.) implement weekly weights timely after a significant weight loss, and c.) reliably document meal intake for a resident with a known history of adult failure to thrive (syndrome characterized by unintentional weight loss, decreased appetite, poor nutrition, and increasing inactivity) who required intravenous (IV) fluids for dehydration (Resident #4). This deficient practice was identified for 1 of 3 residents (Resident #4) reviewed for nutrition and hydration. This deficient practice was evidenced by the following:On 07/06/2026 at 11:05 AM, the surveyor observed Resident #4 seated in bed, awake and not interviewable due to the resident's severely impaired cognition. A handwritten sign hanging on Resident #4's side of the room revealed please give me water. The surveyor reviewed the medical record for Resident #4. According to the admission Record Resident #4 was admitted to the facility with diagnoses including but not limited to metabolic encephalopathy (disruption to the brain's normal function due to chemical or metabolic imbalances which results in confusion and/or memory problems); other Alzheimer's disease (degenerative brain disease); malignant neoplasm of the colon (medical term for colon cancer); type two diabetes mellitus (DM) without complications (body's inability to effectively use insulin, leading to high blood sugar levels but with no associated health issues or complications); and adult failure to thrive (syndrome of general decline in well-being including unintentional weight loss, decreased appetite, poor nutrition, and decreased activity). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 04/10/2026, revealed that Resident #4 had severely impaired cognitive skills for daily decision making. Further review of the MDS revealed that resident #4 required substantial or maximal assistance (a helper does more than half of the effort) with eating. A review of Resident #4's Care Plan (CP) initiated on 08/14/2025 revealed a focus that Resident #4 met the criteria for moderate protein calorie malnutrition (PCM) (severe deficiency of protein and calories in the diet) due to a body mass index (BMI) of 22, age, and that loss of muscle mass was noted to the resident's clavicles, and limbs. Goals related to this focus included but were not limited to the resident having a meal intake of greater than 75%, and stable weight from 125 to 135 pounds. Interventions related to this focus included but were not limited to Monitor my weights and labs as available. A review of the Order Summary Report (OSR) for Resident #4 which contained active, completed, and discontinued orders revealed no orders specifying that Resident #4 should have been weighed, or the frequency for resident weights from 10/12/2025 to 03/27/2026. A review of a document titled Mountain Nutrition assessment (MNA) for Resident #4 dated 08/14/2025, revealed that the resident had a usual body weight of 175 pounds and an ideal body weight of 142 pounds. The MNA revealed that Resident #4's weight was 142 pounds on 08/14/2025. The MNA further revealed under Monitor to monitor the resident's intake, weights, and labs as available. A review of the Weight Summary for Resident #4 revealed the following:The resident's weight on 12/01/2025 was 144.1 pounds. The scale used was listed as Wheelchair (WC).The resident's weight on 01/14/2026 was 130.0 pounds. The scale used was listed as WC.The resident's weight on 01/15/2026 was 127.6 pounds. The scale used was listed as WC.The resident's weight on 01/28/2026 was 131.5 pounds. The scale used was listed as WC.There were no documented weights between 12/01/2026 and 01/14/2026, and between 01/15/2026 and 01/28/2026. A review of the Documentation Survey Report v2 (DSRv2) (a report that cross-references tasks against completed entries in the electronic medical record (EMR)) for Resident #4 was reviewed. The January DSRv2 had no documentation of the Amount Eaten for the 9:00 AM and 1:00 PM day shift meals on 01/09/2026. Further review of the DSRv2 revealed no documentation in the PRN (as needed) Amount Eaten section for the day shift on 01/09/2026. A review of the progress notes (PNs) revealed no documentation of Resident #4's oral intake for the day shift on 01/09/2026. In an interview with Certified Nursing Assistant (CNA #1) on 07/07/2026 at 11:39 AM, CNA #1 stated that she had been assigned to Resident #4 regularly for approximately 1 year. CNA #1 stated that Resident #4 could not feed their self and had to be fed by staff. CNA #1 further stated that most residents at the facility were weighed monthly, but if residents required weekly or more frequent weights the nurse would inform the CNA. CNA #1 further stated that after she weighed a resident, she would write the resident's weight, name, and room number down and give the written information to the nurse for documentation in the EMR. In an interview with the Unit Manager (UM #1) on 07/07/2026 at 12:02 PM, UM #1 stated that residents should be weighed monthly between the first and the sixth of the month. UM #1 stated that CNAs weigh the residents and then provide the weights to the UM who writes the weights down on a census list. UM #1 stated that the census list with weights is then provided to the facility's Registered Dietician (RD). UM #1 stated that Resident #4 may have been in the hospital in January and that is why the resident was not weighed until 01/14/2026, but if the resident was not in the hospital then the weight was late. UM#1 stated that weights are important to monitor how a resident is doing. UM #1 further stated that UMs and the RD are responsible for making sure residents were weighed. A review of the PNs for Resident #4 revealed no documentation that Resident #4 was hospitalized between 01/01/2026 and 01/14/2026. In an interview with the RD on 07/07/2026 at 12:55 PM, the RD stated that the facility practice is to weigh long-term care residents monthly, if a significant weight change occurs then the resident's weights should be done weekly until the weight has stabilized. The RD stated that all weights should be completed by the tenth of the month, but he preferred to have them done by the fifth of the month. The RD stated that Resident #4 had weight loss in January. The RD stated that weight for Resident #4 on 01/14/2026 was late because the resident's last weight was documented on 12/01/2026. The RD stated that there was a significant weight loss of 14 pounds between those dates. The RD stated that if done [weight check] on time interventions related to weight loss would have been put into place earlier. In an interview with the Regional Director of Nursing (RDON) on 07/07/2026 at 3:25 PM, the RDON stated that Resident #4 should have been weighed by 01/10/2026. The RDON further stated that weighing the resident on 01/14/2026 delayed the RD's interventions by two or three days. The RDON further stated that the facility did not have documentation of the amount that Resident #4 ate on the day shift on 01/09/2026. In a follow up interview with the RD on 07/07/2026 at 4:47PM, the RD stated that after Resident #4 lost weight in January (January 14th), their weights should have been done weekly. The RD stated that there was a weight missing from the documentation because Resident #4 was not weighed the next week. In a second follow up interview with The RD on 07/07/2026 at 5:25 PM, in the presence of the RDON and the Licensed Nursing Home Administrator, the RD stated that Resident #4 was receiving IV fluids during the time that their first weekly weight was due and that may have been why the resident was not weighed. The RD further stated that it was not the facility's usual practice to not weigh residents who were receiving IV fluids and his notes did not reveal a reason that the resident's weekly weight was not done. The facility policy Weight Assessment and Intervention with a revised date of September 2025 was reviewed. Under Policy Statement the policy revealed Resident weights are monitored for undesirable or unintended weight loss or gain. Under Weight Assessment the policy revealed 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. The facility policy Charting and Documentation with a revision date of September 2025 was reviewed. Under Policy Statement the policy revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Under Policy Interpretation and Implementation the policy revealed 3. Documentation in the medical record will be objective [.], complete, and accurate. N.J.A.C 8:39-27.1(a);27.2(a)

Complaint # 2587610 Based on interviews and review of pertinent facility documents on 08/19/25, it was determined that the facility failed to implement their abuse prevention policy to protect a cognitively impaired resident (Resident #1) from physical abuse when Resident #1's Representative (RR #1) reported to the facility's Social Worker (SW) an allegation of abuse. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1). On 8/4/25, RR #1 reported to the SW that they were on the phone with Resident #1 while the Certified Nursing Aide (CNA #1) was providing care, and the resident was screaming. RR #1 stated that they spoke to CNA #1 through the phone who was not receptive or admitting any wrongdoing. On 8/5/25, RR #1 escalated the concern alleging that CNA #1 bent the resident's fingers/hand back and poured liquid on the resident. The SW immediately reported the allegation to the Registered Nurse Unit Manager (RNUM #1) who went to Resident #1's room to complete a body assessment. CNA #1 continued to work and was not suspended until 8/8/25, three days after the allegation of physical abuse was made, and they worked six shifts on multiple resident care assignments. An interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 8/19/25, revealed that the facility initiated an investigation into the allegation on 8/5/25, but confirmed that CNA #1 was not suspended until 8/8/25. The facility's failure to implement their abuse policy including protecting all residents from abuse during an investigation, placed all residents at risk for abuse. This posed the likelihood of serious physical and emotional harm, or impairment which resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 8/5/25, after RR #1 alleged CNA #1 physically abused Resident #1. The facility's Administration was notified of the IJ on 8/19/25 at 6:00 PM. The facility submitted an acceptable Removal Plan on 8/20/25 at 2:00 PM. The surveyor verified the implementation of the Removal Plan during an on-site visit survey on 8/21/25. The deficient practice was evidenced as follows: A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy initialed by the LNHA with a handwritten date of 8/7/2025, included Policy Statement: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are [.] thoroughly investigated by facility management.Reporting Allegations to the Administrator and Authorities.6. Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for protection of residents.Investigating Allegations .6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 8/11/25, included the date and time of event: 8/4/25 at 10:00 AM. The FRE further included under Narrative that on 8/4/25, [RR #1] reported concern to facility's SW that [RR #1] was on the phone with [the] resident while care being rendered by [CNA #1]. [RR #1] stated resident was yelling through the phone. [RR #1] stated [they] spoke to [CNA #1] through the telephone and [CNA #1] was not admitting to wrongdoing. Nursing unit manager made aware and responded immediately to resident room for body assessment and interview. On 8/7/25, [RR #1's] concern escalated to accusations requesting investigation of [RR #1's] concern and on 8/8/25, [an Interdisciplinary Care Plan (IDCP)] team held over the phone with [RR #1] and updated [RR #1] with good result. Another escalated email followed. Doctor informed, police notified, and [CNA #1] suspended pending investigation. A review of the facility's Investigation Report (IR) with date of incident 8/4/25, and date of investigation 8/8/25, included the following: Summary of Alleged Incident: On 8/4/25, [RR #1] reported a concern to SW [that they were] on the phone with resident while care being rendered. [RR #1] stated that the resident was yelling through the phone, [RR #1] states [they] spoke to [CNA #1] on the phone and [CNA #1] was not receptive nor admitting to wrongdoing. Concern was concluded with [RR #1's] satisfaction. On 8/5/25, [RR #1] escalated the initial concern and alleged [CNA #1] bent fingers/hand back and poured liquid on [the] resident. SW made nursing unit manager aware and responded immediately to resident room for body assessment and interview following report. No redness, no swelling, no bruising noted, skin intact, resident declined pain. Resident did not recollect account of an incident in room or bed on this date but stated in [a house of worship] over the weekend they jumped on top of [the resident], bent [the resident's] hands back, pulled [the resident's] hair, and poured liquid on [the resident]. Interview with [CNA #1] stated she was washing resident body and was assisting [the resident] to turn to the other side by reaching for [the resident's] hands which were on the edge of bed, no intention to cause harm to resident. While assisting resident to the other side, resident began to yell out and [CNA #1] stopped. [CNA #1] was able to complete care and transferred resident into [wheelchair]. Call placed [to RR #1] for discussion of alleged incident by unit manager with good result and agreeable to take [CNA #1] from resident assignment due to [RR #1's] negative perception of [CNA #1's] response when on the phone. On 8/7/25, at approximately 2:45 PM, [RR #1] sent an email regarding care concern requesting updates. On 8/8/25 at 11:35 AM, [RR #1] sent another email awaiting another response. [RR #1] began to escalate [CNA #1] allegations. On 8/8/25 at 2:22 PM, another email escalating care concern was received with allegation of [CNA #1]. Allegation was reported. Police were called. [CNA #1] was suspended until investigation was completed. A review of CNA #1's statement dated 8/5/25 at 1:30 PM, for the incident dated 8/4/25, included that I went to provide care for [Resident #1], who was refusing, but [RR #1] was on the phone and encouraged to finish care. While providing care I asked [Resident #1] to roll to other side and [the resident] refused. I reached out my hands to assist to roll over since resident was grabbing edge of bed. While assisting to the other side, the resident began to yell out and I stopped. [RR #1] began to yell through the phone asking what I was doing to the patient. I responded that I was cleaning resident and did not do anything to [the resident]. I finished dressing resident and transferred to [wheelchair] and resident thanked me. I would not cause harm to any resident. The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to: metabolic encephalopathy (a condition where the brain's function is impaired due to underlying metabolic disturbance), cerebral infarction (stroke), hypotension (low blood pressure), insomnia (sleep disorder), obesity, muscle weakness, and type 2 diabetes mellitus without complications. A review of the Minimum Data Set (MDS), an assessment tool dated 6/2/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs). A review of the resident's individual comprehensive care plan (ICCP) included a focus area initiated 1/3/25, that the resident was resistive/noncompliant with treatment/care refusing ADL, nails, [laboratory work], and medications related to belief that treatment was not needed/working. Interventions included to allow flexibility in ADL routine to accommodate mood, preferences, and customary routine; and if resists care, leave (if safe to do so) and return later. According to CNA #1's statement, the resident was refusing care, and CNA #1 continued, which was not what the intervention instructed to do. On 8/19/25 at 11:38 AM, the surveyor interviewed RNUM #1, who stated that on 8/5/25, Tuesday morning, RR #1 called the SW and said, I know that I said that, but I slept on it and felt like something happened. The SW then told RNUM #1 and the DON about RR #1's phone call and their conversation with RR #1 from the previous day. RNUM #1 stated then she went upstairs with the DON and interviewed Resident #1, who stated, yes something happened in the [house of worship]. RNUM #1 stated they then did an immediate body assessment of the resident, assessed them for pain, removed CNA #1 from the resident's care assignment, and she did the incident report with the DON. RNUM #1 further stated that with the DON, they called and spoke to RR #1 and informed them that they did a body and pain assessment right away when they found out and started an investigation. RNUM #1 stated that RR #1 was satisfied that CNA #1 was taken off the resident's care. RNUM #1 stated on that same day, they took statements from other residents and Resident #1's roommate. RNUM #1 said that the roommate stated they did not hear anything, and the police came later in the week after the LNHA and DON received an email from RR #1 regarding the investigation. On 8/19/25 at 12:21 PM, the surveyor requested CNA #1's timecard and resident care assignments for the month of August 2025. A review of the timecard provided by the facility revealed that CNA #1 worked on the following days: -8/4/25 - CNA #1 punched in at 6:48 AM and out at 3:14 PM.-8/5/25 - CNA #1 punched in at 6:48 AM and out at 11:05 PM.-8/6/25 - CNA #1 punched in at 6:48 AM and out at 3:19 PM.-8/7/25 - CNA #1 punched in at 6:48 AM and out at 3:13 PM, and -8/8/25 - CNA #1 punched in at 6:48 AM and out at 5:37 PM. A review of the documents provided by the facility for CNA #1's resident care assignments according to Unit assignments were as follows: -8/4/25 - Unit 2, 7:00 AM to 3:00 PM (7-3) shift, CNA #1 was assigned to Post 4 with 9 room assignments. Resident #1 was in CNA #1's assignment. -8/5/25 - Unit 2, 7-3 shift, CNA #1 was assigned to Post 6 with 10 room assignments.-8/5/25 - Unit 2, 3:00 PM to 11:00 PM (3-11) shift, CNA #1 was assigned to Post 5 with 12 room assignments.-8/6/25 - Unit 1, 7-3 shift, CNA #1 was assigned to Post 3 with 11 room assignments.-8/7/25 - Unit 1, 7-3 shift, CNA #1 was assigned to Post 5 with 9 room assignments, and-8/8/25 - Unit 2, 7-3 and 3-11 shifts, CNA #1 was assigned to Post 5 with 10 room assignments. On 8/19/25 at 12:59 PM, the surveyor interviewed the SW, who stated that on 8/4/25, RR #1 called them around 10:00 AM during morning meeting. RR #1 asked the SW if they could run upstairs and check on [the resident] because they did not sound right when RR #1 was talking to the resident on the phone. The SW stated they went upstairs and saw the resident in their room in their wheelchair and eating their lunch. The SW stated that they asked the resident how they were, and the resident stated they could not remember the SW's name and said they were ok. The SW further stated the resident was pleasant and appeared to be in no distress, so the SW called RR #1 while they were in the resident's room and gave them updates on the resident. The SW said the RR #1 frequently called them and asked to check on [the resident]. The SW stated at that time, RR #1 reported they had a concern with CNA #1 splashing liquid on the resident. The SW stated they told RR #1 that the resident was sitting in their wheelchair and eating lunch and there was no liquid anywhere else in the room. The SW stated they then asked RR #1 if they were referring to when CNA #1 was washing or bathing the resident? The SW reported that at the end of the conversation, RR #1 was ok after the SW explained the splashing could have been during care. The SW stated they did not report that conversation with RR #1 to any of the nursing staff until 8/5/25, when RR #1 called again and said after sleeping on it, I felt like it was more than the splashing of liquid and [RR #1] further said that [CNA #1] was bending the resident's hand back, pulled [the resident's] hair, and hit [the resident] with a chair. The SW stated they then reported RR #1's concerns to RNUM #1 and the DON, who went upstairs and spoke to the resident and CNA #1. On 8/19/25 at 1:21 PM, the surveyor interviewed the LNHA and the DON. The LNHA and the DON stated that when they knew of RR #1's concerns on 8/5/25, they started the investigation; RNUM #1 did a body assessment on the resident, they interviewed and gathered witness statements, and conducted a customer service in-service. They further stated they removed CNA #1 from the resident's care and assigned a two-person assistance for [the resident's] care. They stated that they started the investigation, but did not suspend CNA #1 from other residents' care assignments because at the end of the day on 8/5/25, when they spoke to RR #1, RR #1 was agreeable with the result of their report. The LNHA and DON stated they suspended CNA #1 and called police on 8/8/25, when RR #1 emailed and escalated their concerns. An acceptable Removal Plan (RP) was received on 8/20/25 at 2:00 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 8/19/25, CNA #1 remained suspended; all residents who received care by CNA #1 were assessed for pain, skin, and social services with no concerns; past three months of grievances were reviewed with no concerns for abuse; Regional staff in-serviced the LNHA and DON on the facility's abuse and abuse reporting policies; the DON or designee began in-servicing all staff on abuse and abuse reporting; and the DON or designee will quiz all staff on abuse.The survey team verified the implementation of the RP on-site on 8/21/25. N.J.A.C. 8:39-4.1(a)5

Complaint # 2587610 Based on interviews and review of pertinent facility documents on 08/19/25, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of physical abuse that occurred on 8/4/25. This deficient practice was identified for 1 of 3 residents reviewed (Resident #1), and was evidenced by the following: A review of the Facility Reportable Event (FRE) submitted by the facility to the New Jersey Department of Health (NJDOH) on 8/11/25, included the date and time of event: 8/4/25 at 10:00 AM. The FRE further included under Narrative that on 8/4/25, [RR #1] reported concern to facility's SW that [RR #1] was on the phone with [the] resident while care being rendered by [CNA #1]. [RR #1] stated resident was yelling through the phone. [RR #1] stated [they] spoke to [CNA #1] through the telephone and [CNA #1] was not admitting to wrongdoing. Nursing unit manager made aware and responded immediately to resident room for body assessment and interview. On 8/7/25, [RR #1's] concern escalated to accusations requesting investigation of [RR #1's] concern and on 8/8/25, [an Interdisciplinary Care Plan (IDCP)] team held over the phone with [RR #1] and updated [RR #1] with good result. Another escalated email followed. Doctor informed, police notified, and [CNA #1] suspended pending investigation. The FRE further indicated that the event was called in on 8/8/25 at 6:30 PM. A review of the facility's Investigation Report (IR) with date of incident 8/4/25, and date of investigation 8/8/25, included the following:Summary of Alleged Incident:On 8/4/25, [RR #1] reported a concern to SW [that they were] on the phone with resident while care being rendered. [RR #1] stated that the resident was yelling through the phone, [RR #1] states [they] spoke to [CNA #1] on the phone and [CNA #1] was not receptive nor admitting to wrongdoing. Concern was concluded with [RR #1's] satisfaction.On 8/5/25, [RR #1] escalated the initial concern and alleged [CNA #1] bent fingers/hand back and poured liquid on [the] resident. SW made nursing unit manager aware and responded immediately to resident room for body assessment and interview following report. No redness, no swelling, no bruising noted, skin intact, resident declined pain. Resident did not recollect account of an incident in room or bed on this date but stated in a mosque over the weekend they jumped on top of [the resident], bent [the resident's] hands back, pulled [the resident's] hair, and poured liquid on [the resident]. Interview with [CNA #1] stated she was washing resident body and was assisting [the resident] to turn to the other side by reaching for [the resident's] hands which were on the edge of bed, no intention to cause harm to resident. While assisting resident to the other side, resident began to yell out and [CNA #1] stopped. [CNA #1] was able to complete care and transferred resident into [wheelchair]. Call placed [to RR #1] for discussion of alleged incident by unit manager with good result and agreeable to take [CNA #1] from resident assignment due to [RR #1's] negative perception of [CNA #1's] response when on the phone.On 8/7/25, at approximately 2:45 PM, [RR #1] sent an email regarding care concern requesting updates.On 8/8/25 at 11:35 AM, [RR #1] sent another email awaiting another response. [RR #1] began to escalate [CNA #1] allegations.On 8/8/25 at 2:22 PM, another email escalating care concern was received with allegation of [CNA #1]. Allegation was reported. Police were called. [CNA #1] was suspended until investigation was completed. A review of CNA #1's statement dated 8/5/25 at 1:30 PM, for the incident dated 8/4/25, included that I went to provide care for [Resident #1], who was refusing, but [RR #1] was on the phone and encouraged to finish care. While providing care I asked [Resident #1] to roll to other side and [the resident] refused. I reached out my hands to assist to roll over since resident was grabbing edge of bed. While assisting to the other side, the resident began to yell out and I stopped. [RR #1] began to yell through the phone asking what I was doing to the patient. I responded that I was cleaning resident and did not do anything to [the resident]. I finished dressing resident and transferred to [wheelchair] and resident thanked me. I would not cause harm to any resident.The surveyor reviewed the medical record for Resident #1. A review of the admission Record face sheet (an admission summary), revealed that Resident #1 was admitted to the facility with diagnoses which included but were not limited to: metabolic encephalopathy (a condition where the brain's function is impaired due to underlying metabolic disturbance), cerebral infarction (stroke), hypotension (low blood pressure), insomnia (sleep disorder), obesity, muscle weakness, and type 2 diabetes mellitus without complications. A review of the Minimum Data Set (MDS), an assessment tool dated 6/2/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated a severely impaired cognition. The MDS further revealed that the resident required assistance from staff in the completion of their activities of daily living (ADLs).On 8/19/25 at 12:59 PM, the surveyor interviewed the SW, who stated that on 8/4/25, RR #1 called them around 10:00 AM during morning meeting. RR #1 asked the SW if they could run upstairs and check on [the resident] because they did not sound right when RR #1 was talking to the resident on the phone. The SW stated they went upstairs and saw the resident in their room in their wheelchair and eating their lunch. The SW stated that they asked the resident how they were, and the resident stated they could not remember the SW's name and said they were ok. The SW further stated the resident was pleasant and appeared to be in no distress, so the SW called RR #1 while they were in the resident's room and gave them updates on the resident. The SW said the RR #1 frequently called them and asked to check on [the resident]. The SW stated at that time, RR #1 reported they had a concern with CNA #1 splashing liquid on the resident. The SW stated they told RR #1 that the resident was sitting in their wheelchair and eating lunch and there was no liquid anywhere else in the room. The SW stated they then asked RR #1 if they were referring to when CNA #1 was washing or bathing the resident? The SW reported that at the end of the conversation, RR #1 was ok after the SW explained the splashing could have been during care. The SW stated they did not report that conversation with RR #1 to any of the nursing staff until 8/5/25, when RR #1 called again and said after sleeping on it, I felt like it was more than the splashing of liquid and [RR #1] further said that [CNA #1] was bending the resident's hand back, pulled [the resident's] hair, and hit [the resident] with a chair. The SW stated they then reported RR #1's concerns to RNUM #1 and the DON, who went upstairs and spoke to the resident and CNA #1. On 8/19/25 at 1:21 PM, the surveyor interviewed the LNHA and the DON. The LNHA and the DON stated that when they knew of RR #1's concerns on 8/5/25, they started the investigation; RNUM #1 did a body assessment on the resident, they interviewed and gathered witness statements and conducted a customer service in-service. They further stated they removed CNA #1 from the resident's care and assigned a two-person assistance for [the resident's] care. They stated that they started the investigation, but did not suspend CNA #1 from other residents' care assignments because at the end of the day on 8/5/25, when they spoke to RR #1, RR #1 was agreeable with the result of their report. The LNHA and DON stated they suspended CNA #1 and called police on 8/8/25, when RR #1 emailed and escalated their concerns. They further stated they called in the event to NJDOH on that day 8/8/25 but submitted the FRE [AAS-45] to NJDOH on 8/11/25. The LNHA and DON stated that they were aware that incidents involving abuse and neglect have to be reported immediately to NJDOH. On 8/19/25 at 3:49 PM, the surveyor interviewed the LNHA regarding the facility's policy and procedure on Abuse allegations and reporting. The LNHA stated that on 8/5/25, RR #1 was agreeable with the facility's explanation of events and there were no signs of abuse and the resident was confused and inconsistent with their stories so we did not consider it as abuse. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy initialed by the LNHA with a handwritten date of 8/7/2025, included Policy Statement: All reports of abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation are [.] thoroughly investigated by facility management.Reporting Allegations to the Administrator and Authorities:1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .N.J.A.C 8:39-9.4(f)

Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner in multiple areas on 2 of 2 floors located throughout the facility. The deficient practice was evidenced by the following: 1. On 2/25/25 at 1:55 PM, in Resident # 236's room located on the 1st floor in room [ROOM NUMBER], the surveyor observed five different areas of peeling and scratched wall paper on the wall, across from the resident's bed, which was exposing the sheet rock underneath. The surveyor also observed an 8 inch area of torn wall paper and a white colored spackle on the wall around it. The surveyor observed that the top drawer on the dresser located near the resident's bed, was observed to be broken and unable to be pushed back into the dresser. The survyeor observed that the bottom left side of the top drawer had paint peeling off and the pressed wood was exposed. Lastly, the surveyor observed that the cove base in the residents room, between the bathroom and closet doors was discolored with a brown coloration and also separating from the wall as well. 19106 2. On 2/26/25 beginning at 9:24 AM, the surveyor observed the following environmental concerns on the 2nd floor nursing units: In room [ROOM NUMBER]A, a 12 inch area of a wallpaper seam had peeled away from the wall. The area was stapled and taped to the wall. The doorknob on the door to the entrance to room [ROOM NUMBER] had caused a circular hole in the wall behind it. The bathroom of room [ROOM NUMBER] contained a raised toilet seat with rusted screws and a cracked seat. In the hallway across from room [ROOM NUMBER], a full soiled linen cart emitted a strong odor of urine and stool. In room [ROOM NUMBER]B, a section of cove base was missing near the heating unit. A section of wallpaper was missing near the head of the bed. In room [ROOM NUMBER]A, a red wheelchair had multiple cracked vinyl areas on the seat and on the back. In room [ROOM NUMBER]B, there were several areas of peeling wallpaper. In room [ROOM NUMBER]A, there were several areas of peeling wallpaper across from the foot of the bed. In the hallway outside of room [ROOM NUMBER], a section of vinyl floor planking was broken. On 2/26/25 at 11:18 AM, the surveyor observed in the left elevator, 2 pieces of broken wood paneling screwed into the elevator wall. On 2/27/25 at 10:37 AM, 5 of 5 residents attending the resident group meeting told the surveyor that the facility needs sprucing up when asked about the condition of the environment. The facility provided their 11/2024 Homelike Environment policy and procedure to the surveyor on 3/4/25 at 12 PM. The policy indicated the residents are to be provided with a safe, clean, comfortable, and homelike environment. 36419 3. On 02/27/25, beginning at 9:50 AM, the surveyor observed the following environmental concerns on the 2nd-floor nursing units: In room [ROOM NUMBER], a section of the cove base was missing near the HVAC unit. A section of wallpaper on the wall next to the head of the bed was missing. The ceiling tiles in the bathroom were stained; the wallpaper behind the toilet was peeling; the cove base was soiled, and the floor was stained. In room [ROOM NUMBER]A, there was a hole in the wall to the left of the headboard; a section of wallpaper on the wall next to the head of the bed was missing. In room [ROOM NUMBER] B, there was a section of wallpaper on the wall next to the head of the bed missing, and the area was patched. On Unit 2 East, several ceiling tiles around the nurse's station were broken, missing, and scotch taped. In the Unit 2 Dining room, there were holes in the walls and peeling wallpaper. 45449 4. On 2/27/25 at 12:14 PM, the surveyor observed inside Resident #76's room, number 255, The wallpaper underneath the window was peeling off and had a blackish/grayish material in between the wall and the wallpaper. Adjacent to the wallpaper was the cooling/heating system. NJAC 8:39-4.1(a), 11, 31.4 (a), (b), (c), (f)

Complaint # NJ 00162506, NJ 177359, NJ 183441 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 4 of 6 residents (Resident #,76 #103, #105, and #113) observed for incontinence care on 1 of 2 units (2nd-floor Nursing Unit). This deficient practice was evidenced by the following: On 2/26/25 at 7:50 AM, the surveyor completed an incontinence tour on the 2nd floor Nursing Unit and observed the following: 1. On 2/26/25 at 8:00 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1) observed Resident #103 in bed. CNA #1 exposed Resident #103's incontinence brief, and the surveyor observed that it was saturated with urine. CNA #1 confirmed that the brief was saturated with urine. A review of Resident #103's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to; myasthenia gravis, dysphagia, quadriplegia, and history of traumatic brain injury. A review of Resident #103's Quarterly Minimum Data Set (MDS), an assessment tool dated 1/21/25, revealed Resident #103 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated Resident #103 had a moderate cognitive impairment. The MDS further revealed that the resident was dependent on staff for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident #103's Individualized Care Plan (CP) initiated on 8/12/24 and revised on 2/10/25 had a focus area that included Urinary incontinence related to impaired mobility with interventions that included but were not limited to; provide incontinent care as needed. 2. On 2/26/25 at 8:15 AM, the surveyor accompanied by CNA #2 observed Resident #113 in bed. CNA #2 exposed Resident #113's incontinence brief, which was saturated with urine. At that time, when CNA #2 exposed the incontinence brief, another incontinence brief was observed, which was also saturated with urine. CNA #2 acknowledged the two briefs were saturated with urine and confirmed that the facility policy was that residents should not have two incontinence briefs in place. A review of Resident #113's Admission Record revealed Resident #113 was admitted to the facility with diagnoses which included but were not limited to; diabetes mellitus, obstructive uropathy (a condition where urine flow is blocked within the urinary tract), and reflux uropathy (urine flows backward from the bladder into the ureters; the tubes leading to the kidneys.) A review of Resident #113's most recent MDS, dated [DATE], revealed Resident #113 had a BIMS score of 3 out of 15, which indicated a severe cognitive impairment. The MDS further revealed that the resident was dependent on staff for toileting and was always incontinent of bowel and bladder. A review of Resident #113's CP initiated on 9/1/24 and revised on 1/6/25 had a focus area that included the resident was at risk for alteration in skin integrity related to .diabetes and incontinence .with interventions that included an air mattress in place at all times, barrier cream to peri area/buttocks as needed, observe skin condition with ADL care daily . 3. On 2/26/25 at 8:20 AM, the surveyor, accompanied by CNA #2, observed Resident #76 in their room seated in a wheelchair with the mechanical lift pad positioned underneath them. Resident #76 stated that she/he was only provided incontinence care once per shift and was informed by staff that since she/he required the use of a mechanical lift during transfers, it was too difficult to get him/her back into bed before the evening shift arrived at 3:00 PM, therefore she/he had to stay in a saturated brief, which at times was saturated with urine and feces. The surveyor reviewed the medical record for Resident #76. A review of Resident #76's Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body) and urinary incontinence. A review of Resident #76's Quarterly MDS dated [DATE] revealed Resident #76 had a BIMS score of 15 out of 15 which indicated Resident #76's cognition was intact. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was always incontinent of bowel and bladder. A review of Resident #76's CP initiated on 3/14/24 had a focus area that included urinary incontinence related to impaired mobility with interventions that included to provide incontinence care as needed. 4. On 2/26/25 at 8:30 AM, the surveyor, accompanied by CNA #3, observed Resident #105 seated on the side of his/her bed. CNA #3 exposed Resident #105's incontinence brief, and the surveyor observed it was saturated with urine. CNA #3 acknowledged the brief was saturated with urine. CNA #3 confirmed that all residents should be provided incontinence care every 2 hours and should not be left saturated. A review of Resident #105's Admission Record reflected that the Resident was admitted to the facility with diagnoses which included but were not limited to; chronic kidney disease, dementia, and hypertension. A review of Resident #105's Admission MDS dated [DATE] revealed Resident #105 had a severe cognitive impairment. The MDS further revealed that the resident required staff assistance for personal hygiene, and he/she was occasionally incontinent of bladder and always incontinent of bowel. A review of Resident #105's CP initiated on 1/12/25 had a focus area that included occasional urinary and bowel incontinence with interventions that included to provide incontinence care as needed. During an interview with the surveyor on 2/27/25 at 12:48 PM, the Director of Nursing (DON) confirmed that incontinence rounds should be done every 2-3 hours on the night shift and that residents should not have two diapers in place. The surveyor attempted phone interviews with the 11:00 PM-7:00 AM CNAs assigned to the above residents on 2/25/25-2/26/25. The CNAs did not return the call. On 2/27/25 at 2:40 PM, the survey team discussed the above observations and concerns with the DON and Licensed Nursing Home Administrator (LNHA). A review of the facility's Activities of Daily Living (ADL), Supporting policy dated as revised July 2024 reflected that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, and record review it was determined that the facility failed to assess residents' vital signs and dialysis access site for complications upon return from the renal dialysis (RD) center. This deficient practice was identified for 2 of 2 residents (Resident #3 and #13) reviewed for dialysis and was evidenced by the following: 1. On 2/25/25 at 11:31 AM, during the initial tour of the facility the surveyor observed Resident #13 lying in bed. The head of the bed was elevated. The resident stated that the breakfast and care were satisfactory. The surveyor reviewed the medical record of Resident #13. According to the Admission Record face sheet, an admission summary, reflected that Resident #13 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of Resident #13's renal dialysis (RD) communication book revealed the resident went to the RD center on Monday, Wednesday, and Friday with a chair time of 9:30 AM. On 2/27/25 at 7:53 AM, during an interview with the surveyor, the Licensed Practical Nurse (LPN) stated Resident #13 left for dialysis at 8:30 AM, and her morning medications and her meals were given before the resident left for their RD appointment. A review of the February 2025, communication forms (CF) and the Nurses Progress Notes did not reflect the following: the resident's dialysis access site was assessed (eval; evaluation of the access site for the following: clean, dry, intact, in place, functional, signs of bleeding, signs of infections, warmth to the area, pain, bruising or redness) after returning to the facility from RD (post). The Nurse's Progress Notes (NPN ) included the following: On 2/24/25, no pre and post RD eval of access site were documented on the PN; the pre-RD vitals were documented on the CF. On 2/21/25, no pre and post RD eval of access site were documented on the PN; the pre-RD vitals were documented on the CF. On 2/17/25, no pre and post RD eval of access site were documented on the PN; the pre-RD vitals were documented on the CF. On 2/14/25, no pre and post RD eval of access site were documented on the PN; the pre-RD vitals were documented on the CF. On 2/12/25, no pre and post RD eval of access site was documented on the PN; the pre-RD vitals were documented on the CF. On 2/5/25 no post RD eval of access site were documented on the PN; the pre-RD vitals were documented on the CF. On 3/3/25 at 10:58 AM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) stated that the pre and post RD assessment were documented in the PN. The surveyor and the RN/UM reviewed the PN together which revealed the assessments were inconsistent and were not always documented. The concern was discussed with the RN/UM. On 3/3/25 at 11:49 AM, the surveyor discussed the concern the Licensed Nursing Home Administrator (LNHA). On 3/3/25 at 3:03 PM, during a meeting with the survey team, and the LNHA, the Director of Nursing acknowledged that the pre and post RD assessment should have been documented each time the resident went and returned from RD. A review of the provided facility policy, Hemodialysis Access Care reviewed 7/2024, included that the medical nurse should document in the resident's medical record, observations of post-dialysis. 36419 2. On 02/25/25 at 11:18 AM, during the initial tour on the 2nd floor, the surveyor observed Resident # 3 in their room seated in a geriatric chair. The resident stated that he/she goes out of the facility for dialysis. On 3/3/25 at 1:00 PM, the surveyor observed Resident #3 was not in their room. The Unit Manager stated that the resident was at the dialysis center. The surveyor reviewed the medical record for Resident #3. A review of the Admission Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included but were not limited to; dependence on renal dialysis. A review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #3 had a brief interview for mental status score of 12 out of 15 which, indicated a moderate cognitive impairment. Section O revealed Resident #3 received dialysis. A review of the Order Summary Report revealed an active physician order (PO) for: Dialysis Monday & Friday pick up time 12:15 PM, with a start date 9/24/24. A review of the Individual Comprehensive Care Plan (CP) included a Focus area for: Renal insufficiencies related to: chronic renal failure and, the presence of fistula; with interventions that included checking the access site for lack of thrill/bruit (vibration and sound caused by blood flowing through the fistula which indicates the fistula is working) the evidence of infection, swelling, or excessive bleeding, to coordinate dialysis care with the dialysis treatment center, Dialysis on Monday and Friday at 1:00 PM, meal to accompany patient, send Hemodialysis communication book to Dialysis center on HD days. A review of the February 2025, communication book, which contained the Hemodialysis Communication Forms (CF) and a review of Nurses' Progress Notes (NN) revealed the following: the resident's dialysis access site was not assessed for the following: clean, dry, intact, in place, functional, signs of bleeding, signs of infections, warmth to the area, pain, bruising or redness) after returning to the facility from (Renal Dialysis) RD (post). The NN revealed the following: On 2/28/25, no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/24/25, no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/21/25, no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/17/25, no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/14/25, no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/10/25 no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/7/25 no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 2/3/25 no pre or post RD evaluation of the access site was documented in the NN; the pre-RD vitals were documented on the CF. On 3/3/25 at 2:58 PM, the survey team discussed the above observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON confirmed that the pre and post RD assessment should have been documented in the NN each time the resident went and returned from RD. A review of the provided facility policy, Hemodialysis Access Care reviewed 7/2024, included that the medical nurse should document in the resident's medical record, observations of post-dialysis. NJAC 8:39 - 27.1 (a)

Complaint # NJ 00162506, NJ 177359, NJ 183441 Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 4 of 6 residents (Resident #76 #103, #105, and #113) on 2 of 3 units (2nd-floor Nursing Unit 1 and Unit 2). This deficient practice was evidenced by the following: Refer to F677 Reference: NJ State requirement, CHAPTER 112. An Act concerning staffing requirements for nursing homes and supplementing Title 30 of the Revised Statutes. Be It Enacted by the Senate and General Assembly of the State of New Jersey: C.30:13-18 Minimum staffing requirements for nursing homes effective 2/1/21. 1. a. Notwithstanding any other staffing requirements as may be established by law, every nursing home as defined in section 2 of P.L.1976, c.120 (C.30:13-2) or licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall maintain the following minimum direct care staff -to-resident ratios: (1) one certified nurse aide to every eight residents for the day shift. (2) one direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be certified nurse aides, and each staff member shall be signed in to work as a certified nurse aide and shall perform certified nurse aide duties, and (3) one direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a certified nurse aide and perform certified nurse aide duties b. Upon any expansion of resident census by the nursing home, the nursing home shall be exempt from any increase in direct care staffing ratios for a period of nine consecutive shifts from the date of the expansion of the resident census. c. (1) The computation of minimum direct care staffing ratios shall be carried to the hundredth place. (2) If the application of the ratios listed in subsection a. of this section results in other than a whole number of direct care staff, including certified nurse aides, for a shift, the number of required direct care staff members shall be rounded to the next higher whole number when the resulting ratio, carried to the hundredth place, is fifty-one hundredths or higher. (3) All computations shall be based on the midnight census for the day in which the shift begins. d. Nothing in this section shall be construed to affect any minimum staffing requirements for nursing homes as may be required by the Commissioner of Health for staff other than direct care staff, including certified nurse aides, or to restrict the ability of a nursing home to increase staffing levels, at any time, beyond the established minimum . A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report for the two weeks of staffing from 2/9/25 through 2/22/25 prior to the Standard survey of 3/4/25 revealed the facility was deficient in staffing hours as evidenced by the following: For the 2 weeks of staffing prior to survey from 02/09/2025 to 02/22/2025, the facility was deficient in CNA staffing for residents on 8 of 14 day shifts as follows: -02/14/25 had 17 CNAs for 145 residents on the day shift, required at least 18 CNAs. -02/15/25 had 17 CNAs for 145 residents on the day shift, required at least 18 CNAs. -02/16/25 had 17 CNAs for 143 residents on the day shift, required at least 18 CNAs. -02/17/25 had 17 CNAs for 143 residents on the day shift, required at least 18 CNAs. -02/19/25 had 17 CNAs for 142 residents on the day shift, required at least 18 CNAs. -02/20/25 had 16 CNAs for 142 residents on the day shift, required at least 18 CNAs. -02/21/25 had 16 CNAs for 141 residents on the day shift, required at least 18 CNAs. For the 2 weeks of Complaint staffing from 10/13/2024 to 10/26/2024, the facility was deficient in CNA staffing for residents on 2 of 14 day shifts as follows: -10/13/24 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs. -10/21/24 had 16 CNAs for 133 residents on the day shift, required at least 17 CNAs. The surveyor observed postings of daily nursing staffing reports on each day of the survey. On 3/4/25 at 10 am the survey team discussed the shortages of nursing staffing hours with the Licensed Nursing Home Administrator. 36419 On 2/26/25 at 7:50 AM, the surveyor completed an incontinence tour on the 2nd floor Nursing Unit and observed the following: 1 On 2/26/25 at 8:00 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1) observed Resident #103 in bed. CNA #1 exposed Resident #103's incontinence brief, and the surveyor observed that it was saturated with urine. CNA #1 confirmed that the brief was saturated with urine. Review of the 11-7:00 AM CNA assignment sheet revealed that unit 2 on the second floor nursing unit had a census of 58 Residents with 3 assigned aides.The CNA (CNA # 4 ) had an assignment of 19 residents on that 11-7AM shift. 2. On 2/26/25 at 8:15 AM, the surveyor accompanied by CNA #2 observed Resident #113 in bed. CNA #2 exposed Resident #113's incontinence brief, which was saturated with urine. At that time, when CNA #2 exposed the incontinence brief, another incontinence brief was observed, which was also saturated with urine. CNA #2 acknowledged the two briefs were saturated with urine and confirmed that the facility policy was that residents should not have two incontinence briefs in place. Review of the CNA assignment sheet revealed the unit 2 second floor had a census of 58 Residents with 3 assigned aides. The CNA (CNA #5) had an assignment of 19 residents on that 11-7AM shift. 3. On 2/26/25 at 8:20 AM, the surveyor, accompanied by CNA #2, observed Resident #76 in their room seated in a wheelchair with the mechanical lift pad positioned underneath them. Resident #76 stated that she/he was only provided incontinence care once per shift and was informed by staff that since she/he required the use of a mechanical lift during transfers, it was too difficult to get him/her back into bed before the evening shift arrived at 3:00 PM, therefore she/he had to stay in a saturated brief, which at times was saturated with urine and feces. Review of the CNA assignment sheet revealed the unit 2 second floor had a census of 58 Residents with 3 assigned aides. The CNA (CNA #5) had an assignment of 19 residents on that 11-7AM shift. 4. On 2/26/25 at 8:30 AM, the surveyor, accompanied by CNA #3, observed Resident #105 seated on the side of his/her bed. CNA #3 exposed Resident #105's incontinence brief, and the surveyor observed it was saturated with urine. CNA #3 acknowledged the brief was saturated with urine. CNA #3 confirmed that all residents should be provided incontinence care every 2 hours and should not be left saturated. Review of the CNA assignment sheet revealed that unit 1 second floor nursing unit had a census of 47 Residents with 3 assigned aides. The CNA (CNA# 6 ) had an assignment of 17 residents on that 11-7AM shift. During an interview with the surveyor on 2/27/25 at 12:48 PM, the Director of Nursing (DON) confirmed that incontinence rounds should be done every 2-3 hours on the night shift and that residents should not have two incontinence briefs in place. The DON confirmed that the ratio for the 11:00 PM-7:00 AM, shift was 1 CNA to 14 Residents. During an interview with the surveyor on 3/4/25 at 10:21 AM, the Staffing Coordinator confirmed that on 2/25/25 during the 11:00 PM-7:00 AM, shift the census on Unit 1 (second floor) was 47 and Unit 2 (second floor) was 58. The Staffing Coordinator stated that there were two CNA call outs for that shift and confirmed that the CNAs had 17 and 19 residents on each of their assignments. The Staffing coordinator stated that she was aware of the 1 CNA to 14 resident ratio for the night shift. The surveyor attempted phone interviews with the 11:00 PM-7:00 AM CNAs assigned to the above residents. The CNAs did not return the call. On 2/27/25 at 2:40 PM, the survey team discussed the above observations and concerns with the DON and Licensed Nursing Home Administrator (LNHA). A review of the facility's Activities of Daily Living (ADL), Supporting policy dated as revised July 2024 reflected that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. NJAC 8:39-5.1(a), 27.1 (a), 27.2 (h)

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards and ensure a.) expired biologicals were removed from active inventory, b.) consistently implement a system of records for all controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications, and c.) an intravenous bag was stored in a tamper proof and contaminant resistant packaging, The deficient practices were identified for two (2) of two (2) medication rooms and two (2) of three (3) medication carts inspected during the medication storage and labeling observation and was evidenced by the following. Reference: According to the manufacturer specification of Aplisol, under storage included that vials in use for more that 30 days should be discarded due to possible oxidation and degradation which may affect potency. According to the Centers for Disease Control and Prevention , for Prevention Unsafe Injection Practices, dated [DATE], included the following under key points for multi-dose vials: Once a multi-dose vial is opened (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date. https://www.cdc.gov/injection-safety/hcp/clinical-safety/ 1. On [DATE] at 9:47 AM, in the presence of the Registered Nurse/Unit Manager (RN/UM) began the medication room inspection located on the first floor. At that time, the surveyor observed an open vial of Aplisol (an injectable used to detect tuberculosis (TB)). The opened Aplisol vial had a handwritten date of [DATE]. At that time, the surveyor asked the RN/UM when did the Aplisol expire. The RN/UM looked at the box and stated that the Aplisol did not expire until ,d+[DATE]. 2. At that time, the surveyor continued the inspection of the refrigerator and found an opened, punctured Lorazepam Injectable 20 milligram /10 milliliter (a controlled substance used to treat symptoms of anxiety and is also used as an anticonvulsant) . The bottle had a handwritten date of [DATE] and a pharmacy label that reflected House Stock dated [DATE]. The RN/UM stated the Lorazepam Injectable expired after 60 days from the first date it was opened; She acknowledged the Lorazepam had been expired [for six (6) months]. At that time, the surveyor and the RN/UM reviewed the Controlled Substance Record for Lorazepam Injection (an accountability log, that denoted who administered the medication, the date and time of the administration, amount on-hand, amount received, amount given, and the amount remaining). The accountability log was blank, did not indicate who administered the medication to whom, when, the amount removed, the amount given and the remaining quantity. The RN/UM stated that a shift-to-shift count was conducted daily between two nurses and could not explain how in six (6) months, the discrepancy of who opened the controlled substance Lorazepam, and if it was administered to a resident or was diverted was not identified. The RN/UM stated she would inform the Director of Nursing and investigate. 3. On [DATE] at 10:56 AM, in the presence of the Licensed Practical Nurse (LPN #1) the surveyor began the narcotic medication inspection, which was stored in a mounted, double locked portion of the medication cart located in unit 1, on the second floor. The surveyor observed Resident #16's bingo card (blister packet which contains the medication) with a pharmacy label for Tramadol 50 mg, and contained 11 tablets. The Individual Patient Controlled Drug Record (IPCDR) for Resident #16's Tramadol reflected a remaining quantity of 12 tablets. At that time, LPN #1 stated she administered the medication that morning and acknowledged she should have signed the IPCDR immediately upon removal of the narcotic medication. At that time, the surveyor observed Resident #64's bingo card with a pharmacy label for Methylphenidate 5 mg, that was empty. The IPCDR reflected a remaining quantity of one (1) tablet. LPN #1 stated she administered the medication that morning and did not sign when she removed the Methylphenidate for administration. 4. On [DATE] at 11:27 AM, in the presence of LPN #1 began the medication room inspection and observed -one (1) bag of sodium chloride for injection 250 ml, without an outer packaging or seal. At that time, LPN #1 stated she would dispose of the sodium chloride ad inform her supervisor. 5. On [DATE] at 12:18 PM, On [DATE] at 10:56 AM, in the presence of LPN #2, the surveyor began the narcotic medication inspection, of the medication cart located in unit 2, on the second floor. LPN #2 stated that the previous nurse on the cart had to suddenly leave, and a narcotic count prior to taking over the cart did not occur. The surveyor observed the following: -Resident #38's bingo card had a pharmacy label for Tramadol 50 mg and contained 2 tablets. The corresponding IPCDR for reflected a remaining quantity of 3 tablets. -Resident #75's bingo card had a pharmacy label for Lorazepam 0.5 mg and contained 45 tablets. The corresponding IPCDR reflected a remaining quantity of 46 tablets. - Resident #63's bingo card had a pharmacy label for Oxycodone Immediate Release 10 mg and contained 19 tablets. The corresponding IPCDR reflected a remaining quantity of 20 tablets. On [DATE] at 2:36 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) , and the Director of Nursing (DON), the surveyor discussed the concerns regarding the expired TB diagnostic [24 days], the expired Lorazepam [6 months], an intravenous bag that was not stored in a tamper and contaminant resistant packaging, failure to consistently implement a system of records for controlled drugs in sufficient detail to enable an accurate reconciliation for the dispensing of controlled medications, the opened Lorazepam's accountability log was blank without evidence of whom it was administered to, or diverted and the multiple discrepancies between the Resident's medication inventory (Resident #16, #64, #38, #75 and #63) and the corresponding IPCDR. On [DATE] at 10:21 AM, during a follow-up meeting with the survey team, and the LNHA, the DON acknowledged that expired medication should be removed from active inventory. The DON could not account to whom the Lorazepam was administered to and presented a blank accountability log. The DON also stated that an in-service for intravenous packaging was provided and for the process of proper narcotic documentation. A review of the provided facility policy, Controlled Substances dated/revised [DATE], included: Upon Administration, the nurse administering he medication is responsible for recording name of the resident receiving the medication, name, strength and dose of the medication, time of administration, method of administration, remaining quantity of the medication, and signature of the nurse administering the medication. At the end of each shift, the nurse on duty and the nurse going off duty, determine the count together. A review of the provided facility policy, Storage of Medications, dated/reviewed ,d+[DATE], included that drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. No further information was provided. NJAC 8:,d+[DATE].1(a), 29.4 (g)(k), 29.7(c)

Refer 658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation on 2/26/25 and 2/27/25, the surveyor observed four (4) nurses administer medications to four (4) residents. There were 30 opportunities, and three errors were observed which resulted in a medication error rate of 10%. This deficient practice was identified for two (2) of four (4) residents (Resident #80 and #115), that was administered by two (2) of four (4) nurses. This deficient practice was evidenced by the following: Reference: A review of the manufacturer's specifications for Humalog under Dosage and Administration: Administer HUMALOG(R) U-100 or U-200 by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Under Warning and Precautions included Hypoglycemia: May be life-threatening. Monitor blood glucose and increase monitoring frequency with changes to insulin dosage, use of glucose lowering medications, meal pattern . 1. On 2/26/25 at 7:48 AM, the surveyors observed Resident #80 seated in a wheelchair, on the hallway speaking with the Licensed Practical Nurse (LPN #1) standing in front of the medication cart. Resident #80 requested for Tramadol (a narcotic pain medication) from LPN #1. LPN #1 asked the resident to rate their pain level from 1 (mild) to 10 (severe). Resident #80 stated their pain level at that time was 1 or 2 (mild). At that time, the surveyors observed LPN #1 prepare medications for Resident #80. The medications included the following physician's order: -Humalog 100 units/milliliter (Insulin Lispro; used to control high blood sugar) Inject per sliding scale: 151-200 = 2 units . subcutaneously before meals and at bedtime; was started on 2/12/25. -Ferrous Sulfate 325 milligram (mg) , give 1 tablet by mouth one time a day for supplement; was started on 8/10/22. -Tylenol 8 Hour Extended Release (Acetaminophen) give 325 mg (1 tablet) by mouth every 8 hours for pain management. Not to exceed three grams; was started on 9/2/22. At that time, LPN #1 informed the surveyor, that Resident #80 had an appointment that morning and was preparing to leave. LPN #1 took the resident's blood sugar level in the hallway. The blood sugar monitor reflected a reading of 158. LPN #1 injected, 2 units of the Humalog to Resident #80 in the hallway and failed to provide privacy. On 2/26/25 at 7:54 AM, LPN #1 confirmed she had three (3) tablets in the medication cup and that it contained one (1) tablet of Ferrous Sulfate, and two (2) tablets of Tylenol 325 mg. LPN #1 stated she reviewed the electronic Medication Administration Record (eMAR) and was ready to administer. At that time, the surveyor and LPN #1 reviewed the eMAR together. The eMAR reflected that the resident did not have an order for two ( 2) tablets of Tylenol for pain. LPN #1 acknowledged and confirmed that she had made an error in preparing two tablets of Tylenol. Further review of the eMAR reflected Tylenol was administered that morning by a different nurse from a prior shift. LPN #1 stated that she looked at the As needed order for Tylenol 325 mg , one (1) tablet every 4 hours for elevated temperature. Additionally, an order for Tramadol 50 milligram (mg) 1 tablet every 12 hours as needed for pain/severe pain; started on 5/21/24, was observed. LPN #1 stated that Tramadol was indicated for pain level of 0 to 10 and could have administered as needed Tramadol to the resident. At that time, LPN #1 also acknowledged that she should not have administered insulin to a resident in the hallway to protect patient's privacy rights. At that time, the LPN stated that the resident was given a breakfast bag that they took with them to the appointment. On 2/26/25 at 8:05 AM, the breakfast truck arrived. The surveyor asked the Certified Nursing Assistant (CNA) for the breakfast tray for Resident #80 . The CNA pulled and showed the surveyor Resident #80's breakfast tray which was untouched. On 2/26/25 at 11:34 AM, during an interview with the surveyor, the CNA stated that when a resident had an early morning appointment, the nurse on duty would inform her to have the resident ready for their appointment. The nurse on duty would also call dietary services to send the breakfast tray for the resident earlier so they can have breakfast before leaving. On 2/26/25 at 11:47 AM, during an interview with the surveyor the Registered Nurse (RN) assigned to unit 1 of the second floor, stated that they had a calendar in the electronic Medical Record (eMR). The RN stated that for resident with an early morning appointment were known to the nursing staff through the calendar. When a resident on her unit had an appointment, she would inform the CNA assigned to resident to provide morning care earlier. The RN also stated that she would call dietary to ensure the breakfast tray was provided earlier, this was important for those who were to receive a dose of insulin and/or medications that required to be administered with food. On 2/26/25 at 12:06 PM, during an interview with the surveyor, Resident #80 stated that prior to an appointment breakfast does not happen. The resident stated that they did not want to bother the nurses as they were busy and was satisfied that the CNA provided the morning care prior to the appointment. Resident #80 informed the surveyor that they did not receive a snack bag from the facility that morning. The resident stated that the nurse checked their blood sugar level when they returned, and it was about 100. The resident also stated that they bounced along while traveling to their appointment and would have normally received Tramadol for comfort. A review of the eMAR reflected the resident's blood sugar on 2/26/25 at 11:30 AM was 101. On 2/27/25 at 7:53 AM, during an interview with two surveyors, LPN #2 stated that for residents that required insulin the resident must eat before leaving for their appointment to avoid hypoglycemia (low blood sugar). 2. On 2/27/25 at 8:02 AM, the surveyor observed LPN #2 prepare medications for Resident #115. The medications included a physician's order of Carvedilol 3.125 mg, give 1 tablet twice a day for hypertension (high blood pressure). Hold for systolic blood pressure less than 105, heart rate less than 60. Give with food. The order was started on 2/24/25. At 8:14 AM, the LPN #2 finished preparing the medications, and confirmed she was ready to administer the medications to Resident #115. At 8:17 AM, the surveyor stopped the medication pass observation and asked to speak with LPN #2 outside the resident's room. The surveyor and LPN #2 reviewed the order for Carvedilol. LPN #2 stated she had taken all the vitals at 7:30 AM. LPN #2 acknowledged blood pressure should be taken prior to administration and stated that she would take the blood pressure prior to administration of the medication. On 2/27/25 at 2:36 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) , and the Director of Nursing (DON), the surveyor discussed the concerns regarding the failure provide privacy to Resident #80, failure to ensure medication that were required to be administered before meals, received a meal, failure to administer medications in accordance with the physician's order (Resident #80 and #115). On 3/3/25 at 10:21 AM, during a follow-up meeting with the survey team, and the LNHA, the DON acknowledged and provided education on privacy. The DON stated that breakfast should have been offered earlier. The DON acknowledged and confirmed that an order with parameters should be followed. A review of the provided facility policy, Administering Medications, dated/revised 9/2024, indicated that medications were to be administered in a safe, timely and as prescribed. Additionally, t under Policy Interpretation and Implementation: Medications were administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify the right resident, the right medication, the right dosage . NJAC 8:39-11.2(b), 29.2(d)

Based on observaton and interview it was determined that the facility failed to interact with residents in a dignified and respectful manner. The deficient practice was noted for 1 resident (Resident #45) during an individual interview, for 5 of 5 residents (#34, 84, 67, 108, 24) in attendance at the resident group meeting, and in 1 of 2 nursing unit dining rooms during lunch meal observations. The findings were as follows: 1. The surveyor interviewed Resident #45 in their room on 2/25/25 at 11:18 AM. The resident stated nursing staff spoke in a foreign language in front of the resident. Resident #45 stated that they did not understand the language and it made the resident feel uncomfortable. The surveyor conducted the resident group meeting on 2/27/25 at 10:30 AM. During the meeting, 5 of 5 residents in attendance stated staff frequently spoke in a foreign language in front of them. The surveyor discussed the concern with the Administrator and the Director of Nursing on 2/27/25 at 2 PM. The facility provided the 9/2024 Dignity policy and procedure on 3/4/25. The policy indicated residents were to be treated with dignity and respect at all times and spoken to respectfully at all times. 36419 2. On 2/25/25 at 12:30 PM, the surveyor observed the lunch meal on the second floor in the dining room. On each of the 3 tables, staff served the residents' meals on trays. Additionally, the dome lids from the plates were placed upside down in the center of the tables and used as trash receptacles. At one table where two residents were seated, one of the two residents was eating their meal while the other resident sat and waited eight additional minutes for their meal to be served. On 3/3/25 at 12:13 PM, the surveyor observed the lunch meal on the second floor in the dining room. The Registered Nurse/ Minimum Data Set (MDS) Coordinator served 4 of the 6 residents seated in the dining room. Two residents who were seated at two different tables, waited for more than 10 minutes for their meals to be served. On 3/3/25 at 12:50 PM, during an interview, the RN/MDS Coordinator acknowledged that the two residents should not have waited more than 10 minutes for their trays while all the other residents had been served. On 3/3/25 at 1:00 PM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated that she should have served the residents by tables and should not have used the dome lids as trash receptacles. On 3/3/25 at 2:58 PM, the surveyor discussed the above observations and concerns with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) who confirmed that residents should be served by tables and that the dome lids should not be used as trash receptacles. NJAC 8:39-4.1(a)12.

Based on observation and interview it was determined that the facility failed to provide residents access to the NJ Department of Health (NJDOH) survey results. This deficient practice was identified for 5 of 5 residents in attendance at the resident group meeting (Resident #34, 84, 67, 108, 24) and was evidenced by the following: On 2/25/25 at 9:00 AM, the surveyor observed a binder in the lobby area containing past NJDOH survey results. On 2/27/25 at 10:30 AM, the surveyor conducted the resident group meeting. All 5 of the 5 residents stated they were unaware of how they could access the NJDOH survey reports. The residents stated they do not go into the lobby. They stated they have not seen the survey reports on their nursing units. On 2/27/25 at 1:30 PM, the Administrator and the Director of Nursing stated the survey reports were only located in the lobby and were not available to the residents on the nursing units. The facility provided their 9/2024 Examination of Survey Results policy and procedure to the surveyor on 3/4/25 at 12:00 PM. The policy indicated the survey results were kept in areas frequented by most residents. NJAC 8:39-4.1(a)35

Complaint #NJ181450 Based on interview and record review it was determined that the facility failed to a.) respond to residents' requests for assistance in a timely manner for 5 of 5 residents in attendance at the resident group meeting (Resident #24, 34, 67, 84, and 108) and b.) ensure the call bell (bell used to summon staff for assistance) was placed within a resident's reach for 1 of 30 Residents (Resident # 74). This deficient practice was evidenced by the following: 1. The surveyor conducted the resident group meeting on 2/27/25 at 10:30 AM. All 5 of 5 residents stated that the call bell response was slow on the 11 PM -7 AM shift. One resident stated one time they had waited from 1:00 AM to 3:00 AM. The resident stated they needed drinking water and I have bilateral contractures and can't do it myself. A review of minutes from past resident council meetings included a 12/26/24 comment from a resident stating that staff needs to answer call bells in timely manner. 36419 2. On 2/25/25 at 11:15 AM, during an initial tour of the second-floor unit, the surveyor observed Resident #74 in his/her room seated in the wheelchair with anti-tippers. The surveyor observed the call bell on the floor under the bed, not within the resident's reach. The surveyor reviewed the medical record for Resident #74. A review of Resident #74's Admission Record reflected that the Resident was admitted to the facility with diagnoses that included but were not limited to; blindness in the right eye, anoxic brain damage (occurs when the brain is deprived of oxygen for an extended period of time), hemiplegia (mild or partial weakness or loss of strength on one side of the body) and hemiparesis (severe or complete loss of strength or paralysis on one side of the body), affecting the resident's right dominant side. A review of Resident #74's Quarterly Minimum Data Set (MDS), an assessment tool dated 1/8/25, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated a severe cognitive impairment. A review of Resident #74's individualized comprehensive care plan (ICCP) initiated on 4/18/24, reflected a focus area that included impaired vision related to a history of ocular injury to the left eye and cataract to both eyes initiated 4/18/24 with interventions that included keeping frequently used items within easy reach; encourage to wear glasses and provide activity of daily living assistance as needed. On 2/27/25 at 2:30 PM, the surveyor discussed the above observations and concerns with the Licensed Nursing Home Administrator and Director of Nursing who confirmed that all residents should have their call bells answered timely and kept within thier reach. NJAC 8:39- 31.8 (c)(9)

Complaint #: NJ162370; NJ1162293 Based on interview and record review, it was determined that the facility neglected to provide a resident who required extensive assistance of two or more caregivers for personal care the required amount of assistance who complained of rough care while being repositioned by one caregiver. The deficient practice was identified for 1 of 6 residents reviewed for those requiring assistance with activities of daily living (ADL) (Resident #333), and was evidenced by the following: The surveyor reviewed the closed electronic medical record of Resident #333 which revealed the following information: A review of the Minimum Data Set (MDS), an assessment tool dated 2/25/23, indicated the resident had mild cognitive impairment and required extensive assistance of two or more caregivers with bed mobility and incontinence care. A review of the individualized comprehensive care plan (ICCP) included a focus area for ADL self-care deficit as evidenced by the need for assistance related to physical limitations initiated 12/20/21 through 7/21/24. Interventions included to provide two caregiver assistance for care. A review of a General Progress Note dated 3/4/23, indicated that on 3/4/23 at 3:15 PM, the Resident's Representative (RR) complained that Resident #333 rough care when being repositioned during personal care on the 3/4/23 night shift. A physical assessment was performed by the Director of Nursing (DON) with the RR present at the bedside, and no injuries were found. The resident's physician was notified on the same day of the incident. A review of the Social Services Note dated 3/20/23, identified as a late note, indicated that the Social Worker met with the resident on 3/6/23, to provide counsel to the resident. The resident informed the Social Worker that they felt comfortable after the incident was addressed with the people in charge and the resident felt safe in the facility. The resident stated they understood the Certified Nursing Assistant (CNA) would no longer be caring for the resident. The Social Services Note included that the Social Worker documented that she had interviewed six other residents who required assistance with care who were also on the same CNA's assignment. There were no further complaints about the care received from that CNA. The facility's investigation dated 3/4/23 concluded the allegation of abuse was unsubstantiated. The facility documented that no injuries were noted on a head-to-toe nursing assessment. The facility documented no other residents reported rough handling by the CNA. However, the facility documented that the CNA failed to enlist the assistance of a second caregiver to care for the resident as was required. The facility provided one-to-one education to the CNA. The CNA was suspended during the investigation. A review of the Human Resource Department records indicated that the CNA was employed for 14 months at the time of the alleged incident. The CNA had a negative criminal background check, an active CNA certification, and received abuse prevention training as an orientee and annually. The CNA was suspended for two days during the completion of the investigation. The CNA's statement indicated that the resident was checked on three times during the 3/4/23 night shift. At 12:00 AM, the resident was dry and did not require care. At 5:00 AM, the resident needed to have incontinence care that was performed, and the CNA reported nothing unusual during that time. At 7:00 AM, the resident was brought water. The CNA stated she had this resident on her assignment many times and did not know the resident required a two person for assistance for care. During orientation, the CNA signed the Nurse Aide job description on 1/27/22, which included the following statements - observes the safety needs of patients as indicated in the resident's care plan and receives a nursing report upon reporting for duty. The CNA was unavailable for interview by the surveyor during the 3/4/25 survey. The concerns were discussed with the Licensed Nursing Home Administrator (LNHA) and the DON on 2/27/25 at 1:30 PM. A review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 9/2024, included in Section 7 .adequately prepare staff for caregiving responsibilities . NJAC 8:39-4.1(a)5

Based on observation, interview, and record review, it was determined that the facility failed to accurately assess a resident's status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 3 of 30 residents reviewed (Resident #59, #131, and #132) and was evidenced by the following: 1. The surveyor reviewed Resident # 132's records. The resident was discharged from the facility, and according to the Discharge Return Not Anticipated MDS, dated [DATE], the resident was discharged to the hospital. A review of Resident #132's progress notes dated 12/20/24, revealed the resident was discharged home. On 2/27/25 at 1:06 PM, the surveyor interviewed the Registered Nurse/MDS Coordinator (RN/MDS), who stated that the discharge MDS for Resident #132 should have indicated that the resident was discharged to their home. 34421 2. The surveyor reviewed Resident # 131's records. The resident was discharged from the facility and according to the Discharge Return Not Anticipated MDS, an assessment tool used to facilitate the management of care, dated 11/27/24, revealed that the resident was discharged to home/community. A review of Resident # 131's progress notes dated 11/27/24, revealed the resident had a discharge to the hospital. On 3/3/25 at 12:20 PM, the surveyor interviewed the MDS Coordinator, who stated that the discharge MDS for Resident # 131 should have indicated that the resident was discharged to the hospital. During an interview on 3/3/25 at 2:06 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and Administrator. 45449 3. On 2/25/25 at 11:15 AM, the surveyor observed Resident #59 lying in bed with both arms raised and hands tucked behind their head. The resident had a left leg brace, and the bed was at the lowest position. The resident informed the surveyor that they came from the hospital with a fractured kneecap and was able to move from their bed to their wheelchair independently to smoke outside. On 2/25/25 at 1:06 PM, the surveyor observed the resident outside smoking and propelled their wheelchair with their hands. The surveyor reviewed the medical record for Resident #59. Resident #59's Admission Record (AR; or face sheet; an admission summary) reflected that the resident was admitted to the facility with diagnoses which included fracture of the left patella (kneecap). A review of the admission Minimum Data Set (MDS), an assessment tool dated 1/29/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. A review of the resident's functional range in motion reflected the following: Resident #59 was assessed with an upper extremity (shoulder, elbow, wrist and hand). The assessment also reflected that the resident was assessed with no limitation of motion for the lower extremity (hip, knee, ankle and foot). Further review of the MDS reflected the MDS for the range of motion was signed accurate and completed by the Director of Rehabilitation (DoR). A review of the Occupational Therapy (OT) Evaluation/ Plan of Treatment, under assessment reflected the resident had impairments in balance, strength and mobility. The OT's goal for the resident included a process to achieve dynamic standing balance. On 2/26/25 at 11:06 AM, during an interview with the surveyor, the OT/DoR confirmed Resident #59 received services and that the assessment for the resident was completed by her. On 2/27/25 at 2:36 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA) , and the Director of Nursing (DON), the surveyor discussed the concern regarding the discrepancy for Resident #59's limited range of motion for the upper extremity and did not reflect limited range of motion for the lower extremity. On 3/3/25 at 10:21 AM, during a follow-up meeting with the survey team, and the LNHA, the DON acknowledged and confirmed that it was coding error by the rehabilitation department. The DON also stated that the coding of MDS was important for proper care, and appropriate services. A review of the facility provided policy; Resident assessment dated /revised March 2024 included that all persons who completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. N.J.A.C. 8:39-11.2(e)1

Based on observation, interview, and record review, it was determined that the facility failed to accurately develop and implement a person-centered comprehensive care plan for care and service needs. This deficient practice was observed for 1 of 30 residents reviewed, Resident # 236, was evidenced by the following: On 2/25/25 at 1:55 PM, the surveyor observed Resident # 236, in bed in their room and the resident was receiving oxygen therapy via nasal cannula (NC). The surveyor reviewed Resident #236's Electronic Medical Record. Resident #236's face sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic respiratory failure and pulmonary fibrosis. A review of the Physician's Order Sheet dated February 2025, revealed the resident had a physician's order for O2 via NC continuous at 3 LPM. The surveyor reviewed the resident's current care plans. There was no comprehensive care plan developed regarding the resident's order for the oxygen therapy. On 2/27/25 at 10:46 AM, the surveyor interviewed the Licensed Practical Nurse, who cared for Resident # 236, who stated that there should be a care plan in place for oxygen therapy and he was not sure why there was none in place. On 3/3/25 at 2:58 PM, the surveyor discussed the above concerns with the Administrator and the Director of Nursing, who stated that there should have been a care plan in place. NJAC 8:39- 11.2 (e)

Based on observation, interview, and record review, it was determined that the facility failed to ensure a.) proper administration of Fluticasone nasal spray in accordance with manufacturer's specifications, and b.) administration and availability of prescribed medication(s) in accordance with professional standards of practice. The deficient practice was identified for 1 of 4 nurses who administered medications to 1 of 4 residents (Resident #127) and 1 of 27 Residents reviewed for Medication Record Review. The evidence was as follows: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The nurse practice act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. A review of the manufacturer's specification for Fluticasone under instructions for use included the following: Step 1: Blow nose to clear the nostrils; Step 2: Close 1 nostril. Tilt head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the nostril; Step 3: Breathe in through nose, while breathing in press firmly and quickly 1 time on the applicator to release the spray . 1. On 2/26/25 at 9:04 AM, the surveyor observed the Licensed Practical Nurse (LPN #1) prepare medications for Resident #127. The medications included a physician's order for Fluticasone (Flonase; used to relieve allergies and nasal congestion) Allergy Relief nasal suspension 50 microgram /actuation, 1 spray in each nostril one time a day for allergies with an order start date of 1/18/25. At 9:06 AM, the LPN confirmed that he was ready to administer Resident #127's medications, knocked on the door and entered the resident's room. The surveyors observed the resident seated and was receiving oxygen via nasal cannula (ube inserted to the nose for oxygen delivery). At 9:08 AM, the LPN removed the nasal cannula and administered the flonase to each side of the resident's nostril then gave the resident a tissue. At 9:09 AM, the resident dabbed their nostrils and stated that their nose was always running. At 9:12 AM, outside the resident's room, in front of the medication cart, the surveyor and the LPN reviewed the manufacturer's specification for Fluticasone nasal spray that was stored in the LPN's medication cart. At that time, the LPN acknowledged that he should have performed step 1 which was to ask the resident to blow their nose to clear the nostrils and step 2, was to close one nostril while administering to the other nostril. The LPN acknowledged that these steps were important for proper dosing. 2. On 2/25/25 at 11:31 AM, during the initial tour of the facility the surveyor observed Resident #13 lying in bed. The head of the bed was elevated. The resident stated that the breakfast and care were satisfactory. According to the Admission Record face sheet, an admission summary, reflected that Resident #13 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of the electronic Medication Administration Record (eMAR) included the following physician's orders: -Sevelamer 800 mg. give 1 tablet by mouth three times a day for phosphorus, started on 1/30/25, and discontinued on 2/19/25. Further review of the eMAR reflected that the medication was not consistently signed as administered three times a day, every day, had documented code of 9 on non-Renal Dialysis days and reflected the following: 1/30/25 signed administered at 5pm 1/31/25 signed administered at 9am and 5pm 2/1/25 signed administered at 5pm 2/2/25 signed administered at 9am, 1pm and 5pm 2/3/25 signed administered at 9am and 5pm 2/4/25 signed administered at 9am, 1pm 2/5/25 signed administered at 9am and 5pm 2/6/25 signed administered at 9am, 1pm and 5pm 2/7/25 signed administered at 9am and 5pm 2/8/25 signed administered at 9am, 1pm and 5pm 2/9/25 signed administered at 9am, 1pm and 5pm 2/10/25 signed administered at 9am and 5pm 2/11/25 signed administered at 9am, 1pm and 5pm 2/12/25 signed administered at 9am and 5pm 2/13/25 signed administered at 9am, 1pm and 5pm 2/14/25 signed administered at 9am and 5pm 2/15/25 signed administered at 9am, 1pm and 5pm 2/16/25 signed administered at 9am, 1pm and 5pm 2/17/25 signed administered at 9am and 5pm 2/18/25 signed administered at 9am, 1pm and 5pm 2/19/25 signed administered at 9am -Velphoro 500 mg, give 1 tablet by mouth three times a day for phosphate binder with meals, started on 1/30/25, and discontinued on 2/19/25. Further review of the eMAR reflected that the medication was not consistently signed as administered three times a day, every day, had documented code of 9 on non-Renal Dialysis days and reflected the following: 1/30/25 signed administered at 5pm 1/31/25 signed administered at 9am and 5pm 2/1/25 signed administered at 5pm 2/2/25 signed administered at 9am, 1pm and 5pm 2/3/25 signed administered at 9am and 5pm 2/4/25 signed administered at 9am, 1pm and 5pm 2/5/25 signed administered at 9am and 5pm 2/6/25 signed administered at 9am, 1pm and 5pm 2/7/25 signed administered at 9am and 5pm 2/8/25 signed administered at 9am, 1pm and 5pm 2/9/25 signed administered at 9am, 1pm and 5pm 2/10/25 signed administered at 9am and 5pm 2/11/25 signed administered at 9am, 1pm and 5pm 2/12/25 signed administered at 9am and 5pm 2/13/25 signed administered at 5pm 2/14/25 signed administered at 9am and 5pm 2/15/25 signed administered at 9am, 1pm and 5pm 2/16/25 signed administered at 9am, and 1pm 2/17/25 signed administered at 5pm 2/18/25 signed administered at 5pm 2/19/25 was not administered. A review of the Renal Dialysis communication form (RDCF) for February 2024 did not reflect the RD center administration of Sevelamer and Velphoro to Resident #13 while at the RD center. On 2/27/25 at 7:53 AM, during an interview with the surveyor, LPN #2 stated that the supply of Sevelamer and Velphoro were provided by the RD center but could not definitively say if the medication was in the facility from 1/30/25 to 2/19/25. On 3/3/25 at 10:58 AM, the surveyor, and the Registered Nurse/Unit Manager (RN/UM) reviewed the eMAR together. The RN/UM stated that the codes 5 and 9 on the eMAR meant the medication was not given. The RN/UM could not explain the reason why the medication was not consistently administered, including on the non-dialysis days. The RN/UM stated she would inform her supervisor. On 3/3/25 at 10:21 AM, the surveyor discussed the concerns with the Licensed Nursing Home Administrator regarding Resident #13's duplicate therapy, the inconsistent administration of Sevelamer and Velphoro according to the eMAR. On 3/3/25 at 2:07 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator and the Director of Nursing (DON), the surveyor asked who was responsible for identifying a duplicate therapy. The DON stated that the CP conducted an MRR review upon admission and monthly thereafter. The DON provided a medication manifest from the pharmacy provider that reflected medications delivered for Resident #13. The Sevelamer and Velphoro medication were not listed in the manifest. At that time, the surveyor discussed the concern that the nurses inconsistently signed for administration of both Sevelamer and Velphoro and did not inform the physician when the medicaton was documented as not administered. The DON stated that she would conduct further investigation to see if the medications inconsistently signed as administered were available in the facility from 1/30/25 to 2/19/25. A review of the provided facility policy, Administering Medications, dated/revised 9/2024, included the following under Policy Interpretation and Implementation: The individual administering the medication, initials the resident MAR . No further information was provided. NJAC 8:39-11.2(b), 29.2(d)

Based on observation, interview, and record review it was determined that the facility failed to maintain medical equipment in good working condition to prevent injuries for 1 of 24 residents reviewed (Resident #108). This deficient practice was evidenced by the following: The surveyor interviewed Resident #108 on 2/25/25 at 1:13 PM. The resident stated several months ago they reported to staff that the raised toilet seat had rusted screws which affixed the seat to the metal frame. The raised toilet seat was replaced with another which had similiar rusted screws and also a crack in the seat. The resident stated they would put a paper towel over the crack and lean to the side in order not to get pinched. At that time, the surveyor observed the raised toilet seat which was in place in the resident's bathroom. The seat had 2 rusted screws and a thin crack running from the center of the seat to the upper edge near the screws. The quarterly 11/21/24 Minimum Data Set (MDS) assessment indicated the resident had no cognitive deficits and required assistance with toilet use. The surveyor interviewed the Administrator on 2/27/25 at 2:00 PM regarding the damaged raised toilet seat. The Administrator provided documentation to the surveyor on 3/3/25 that the resident received a new raised toilet seat. Additionally, documentation was given to the surveyor showing facility-wide medical equipment received safety checks in November 2024 and was scheduled to be rechecked in May 2025. The surveyor interviewed the Maintenance Director on 3/04/25 at 9:49 AM. He stated he goes into every resident room at least once a month to check room temperatures and observe for any equipment that needs to be fixed/replaced. Additionally, he stated there is an electronic system for staff to log in requests. He stated replacements are made with new equipment if in stock, if not available, a used replacement is given. He added, any rusted equipment would be replaced. NJAC 8:39-33.1(d)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) administer oxygen therapy according to the physician's order for 2 of 2 residents reviewed for oxygen therapy (Resident #66 and #236) and b.) ensure respiratory nasal cannula (NC) tubing was stored in accordance with infection control measures for 1 of 1 resident (Resident #52). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 2/25/25 at 1:00 PM, the surveyor observed Resident #66 in their room seated in a wheelchair and the resident was receiving oxygen (O2) therapy via a NC tubing. The surveyor observed that the O2 flow via the concentrator for the resident, was set to 1.5 Liters per minute (LPM). The NC tubing was dated 2/10/25. The resident stated that he/she needed O2 continuously for difficulty breathing. On 2/26/25 at 8:40 AM, the surveyor observed Resident #66 in their room, seated in a wheelchair, receiving O2 therapy via a NC tubing. The surveyor observed that the O2 flow via the O2 concentrator was again set to 1.5 LPM. The NC tubing was dated 2/26/25. The surveyor reviewed the medical record for Resident #66. A review of the Admission Record reflected the Resident was admitted to the facility with diagnoses which included but were not limited to; Chronic Obstructive Pulmonary Disease (COPD) (a lung disease that causes breathing difficulties). A review of the Admission Minimum Data Set (MDS), an assessment tool dated 1/14/25 reflected Resident #66 had a brief interview for mental status (BIMS) score of 3 out of 15, which indicated a severe cognitive impairment. Section O indicated Resident #66 received Respiratory Treatment which included O2 Therapy. A review of the current Physician Order Sheet (POS) revealed an active Physician's Order (PO) dated 1/9/25 for O2 therapy at 3 LPM via NC continuous; record O2 saturation every shift for Shortness of Breath (SOB) keep greater than 92% and a PO dated 1/29/25 to change O2 tubing, storage bag, and humidifier q Saturday 11-7 AM, shift and as needed, label and date. A review of Resident #66's Individual Comprehensive Care Plan (CP) had a focus area that included the Resident was at risk for respiratory impairment related to COPD and was dated as initiated on 1/9/25 with interventions that included to administer O2 as per PO at 3 LPM via NC. On 2/26/25 at 8:45 AM, the surveyor and the Licensed Practical Nurse (LPN) #1 entered Resident #66's room and together observed the O2 via the O2 concentrator was set at 1.5 LPM. The LPN #1 stated the O2 should be set at 3 LPM per the PO. The LPN #1 confirmed that she had not checked to ensure the O2 concentrator was set at 3 LPM when she conducted her rounds that morning. 34421 2. On 2/25/25 at 1:55 PM, the surveyor observed Resident # 236, in bed in their room and the resident was receiving oxygen therapy via nasal cannula (NC). The surveyor observed that the oxygen flow via the oxygen concentrator for the resident, was set to 3.5 LPM. On 2/26/25 at 7:50 AM, the surveyor observed Resident # 236, in bed in their room and the resident was receiving oxygen therapy via NC. The surveyor observed that the oxygen flow via the oxygen concentrator for the resident, was again set to 3.5 LPM. The surveyor reviewed Resident #236's Electronic Medical Record. Resident #236's face sheet revealed that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic respiratory failure and pulmonary fibrosis. A review of the Physician's Order Sheet revealed the resident had a physician's order for O2 via NC continuous at 3 LPM. On 2/26/25 at 8:28 AM, the surveyor interviewed the LPN #2, who cared for Resident # 236 and he stated that the oxygen should be set at 3 LPM and could not explain why the oxygen was set for 3.5 LPM. 3. On 2/25/25 at 11:22 AM, during the initial tour on the 2nd-floor unit, the surveyor observed Resident #52 was not in their room. The surveyor observed an O2 concentrator in the room with the NC tubing hung over the concentrator, with the part of the tubing that was supposed to be connected to the O2 concentrator, disconnected and on the floor. On 2/27/25 at 11:34 AM, the surveyor observed the resident was not in their room. The surveyor observed an O2 concentrator in the room with the NC tubing hung over the concentrator with the part of the tubing that was supposed to be connected to the O2 concentrator disconnected and on the floor. On 2/27/25 at 12:59 PM, the surveyor observed the Resident in the hallway in front of their room, seated in a wheelchair. The resident stated that he/she used O2 every night for difficulty breathing. The surveyor reviewed the medical record for Resident #52. A review of Resident #52's Admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to diabetes mellitus, obstructive sleep apnea, and COPD. A review of the Admission MDS, dated [DATE], reflected Resident #52 had a BIMS score of 14 out of 15, which indicated fully intact cognition. A review of the current POS included a PO dated 10/17/24 for O2 at 2 LPM for shortness of breath (SOB) if the O2 is below 90 %. A review of the CP revealed a focus area which included the resident has COPD with interventions that included but were not limited to; give O2 therapy as ordered by the physician. On 2/27/25 at 11:38 AM, the surveyor and the Certified Nursing Assistant (CNA) assigned to Resident #52's care entered Resident #52's room and together observed the NC tubing hung over the concentrator and on the floor. The CNA picked the tubing up off the floor and put it in the bag that was affixed to the concentrator. On 2/27/25 at 11:44 AM, the surveyor interviewed the Licensed Practical Nurse/ Unit Manager (LPN/UM), who stated that all O2 NC tubing was changed weekly and should be contained in a plastic bag when not in use. The LPN/UM further stated that the CNA should have discarded the NC tubing and that both the CNA and the nurse assigned to Resident #52 should have ensured the NC tubing was stored in the plastic bag for infection control prevention. On 2/27/25 at 2:30 PM, the surveyor discussed the above concerns with the Licensed Nursing HomeAdministrator (LHNA) and the Director of Nursing (DON). On 3/3/25 at 9:40 AM, the LNHA and the DON stated that the resident's O2 should have been administered according to the physician's order and that O2 NC tubing should be stored in a bag when not in use. NJAC 8:39-27.1 (a)

Refer F658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Consultant Pharmacist (CP) identified and reported a medication irregularity, to the attending physician, the facility's medical director, and the director of nursing (DON). This deficient practice was identified for 1 of 5 residents (Resident #13) reviewed for unnecessary medications and was evidenced by the following: On 2/25/25 at 11:31 AM, during the initial tour of the facility the surveyor observed Resident #13 lying in bed. The head of the bed was elevated. The resident stated that the breakfast and care were satisfactory. The surveyor reviewed the medical record of Resident #13. According to the Admission Record face sheet, an admission summary, reflected that Resident #13 was admitted to the facility with diagnoses that included, end stage renal disease, dependence on renal dialysis. A review of medication list from the hospital included the following: -Sevelamer carbonate (Renvela; a phosphate binder to control serum phosphorus levels for those with chronic kidney disease) 800 milligrams (mg). Take 1 tablet by mouth three times a day with meals. Sevelamer was last given to the resident 01/29/25 at 5:01 PM -Sucroferric Oxyhydroxide (Velphoro; a phosphare bnder for the control of serim phosphorus levels for those with chronic kidney disease on dialysis). Chew one tablet (500 mg) three times a day. The last administered time was not indicated. A review of the electronic Medication Administration record included the following physician's orders: -Sevelamer 800 mg. give 1 tablet by mouth three times a day for phosphorus, started on 1/30/25, and discontinued on 2/19/25. -Velphoro 500 mg, give 1 tablet by mouth three times a day for phosphate binder with meals, started on 1/30/25, and discontinued on 2/19/25. A review of the Renal Dialysis communication form (RDCF) for February 2024 did not reflect the RD center administered to Resident #13, the Sevelamer and the Velphoro while at the RD center. A review of the CP's Medication Regimen Review (MRR) for January 2025, revealed that the CP failed to identify, obtain a rationale, and report the duplicate therapy of two phosphate binders prescribed to Resident #13. On 3/3/25 at 12:06 PM, during an interview with the surveyor, the CP stated that he had seen both medications prescribed in the past for different residents and did not think to question the prescriber. The CP acknowledged that MRRs should be individualized. At that time, the CP also stated that he did not review the admission medication record for Resident #13. On 3/3/25 at 2:07 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator and the DON, the surveyor asked who was responsible for identifying duplicate therapy. The DON stated that the CP was responsible for the identification of duplicate therapy/irregularity. The CP conducted an MRR review upon admission and monthly thereafter. The concern regarding the failure to identify, obtain a rationale and report the irregularity of two phosphate binders for Resident #13 was discussed with the LNHA and the DON. A review of the provided facility policy, Medication Regimen Reviews (MRR), dated/revised 3/11/24, included that the MRR involved a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example . duplicative therapies . No further information was provided. NJAC 8:39-29.3

Based on interview and record review it was determined that the facility failed to provide a nourishing snack at bedtime when the time between dinner and breakfast exceeded 14 hours. The deficient practice was identified for 5 of 5 residents (Resident #34, 84, 67, 108, 24) in attendance at the resident group meeting and was evidenced by the following: The surveyor conducted the resident group meeting on 2/27/25 at 10:30 PM. All 5 of 5 residents stated they were not aware that evening snacks were available for residents. All of the residents resided on the second floor nursing units. All of the residents stated they would like to have an evening snack available to them. Resident #34 stated they eat dinner at 5 pm and eat breakfast at 9 AM. A review of the Meal Truck Delivery Schedule revealed the time between delivery of dinner and the delivery of breakfast ranged from 14.5 hours to 15.5 hours. The 7/2024 facility Frequency of Meals policy indicated a nourishing snack will be offered if the time span between evening meal and the next day's breakfast exceeds 14 hours. NJAC 8:39-17.2(f)1; 17.4(b)