Every finding on record at Peace Care St Joseph's

Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner for 3 of 4 kitchenettes (2nd, 3rd, 4th), and b) maintain kitchen equipment in a clean, safe and sanitary manner 4 of 4 pantries (1st, 2nd, 3rd, 4th), on the nursing floors as evidenced by the following. On 4/09/26 at 11:50 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following on the nursing units:The kitchenette microwaves had multicolored food debris on the interior ceiling of the units for 3 of 4 units, (2nd, 3rd, and 4th). The FSD acknowledged and agreed that they were not cleaned according to facility policy. The pantry microwaves had multicolored food debris on the interior ceiling of the units and food particles on the rotating tray for 3 of 4 units (2nd, 3rd, and 4th). The FSD acknowledged and agreed that they were not cleaned according to facility policy. The refrigerators on 2 of 4unit pantries, (1st and 3rd,) were observed to have copious amounts of standing water on the glass top shelving in the refrigerator. The FSD acknowledged it and cleaned the water with several paper towels. He stated that it has been on ongoing issue since he started at the facility and that it has been entered in the electronic maintenance system several times. On 4/09/26 at 11:50 AM, the surveyor interviewed the FSD, who stated the kitchenettes are to be cleaned daily. Everything should be wiped down and if there are any issues noted by the staff regarding pest or equipment issues, they are instructed to let him know. He further stated that the cleaning of equipment should be done on a schedule to prevent food borne illness and maintain safe and sanitary environment for the staff and residents. The FSD acknowledged the surveyors concerns and agreed they were not done according to facility policy.On 04/09/2026 at 12:29 PM, the surveyor met with Licensed Nursing Home Administrator (LNHA). The LNHA acknowledged the surveyor's concerns. She stated that the equipment should be cleaned and maintained to prevent food borne illness, contamination, or injury; to ensure the safety of the residents and staff. She further stated that she was aware of the pantry unit freezers having an issue with draining into the refrigerator and that it was fixed recently after being serviced. A review of the facility's policy, Sanitation Inspection, with a revise date of 1/25, revealed. a basic sanitation is conducted.to ensure that the established procedures are being followed and that sanitation standards are maintained. A review of the Manufacturer Tray Dispenser / Plate lowerator, provided by the facility revealed; cleaning should be done daily by removing the dishes.wipe down any visible soiled areas and wet another cloth with sanitizer solution and apply, allow to dry. NJAC 8:39-17.2(g)

Complaint NJ# 2593527Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to include a resident in the planning of care by informing them of the risks and benefits of proposed care. This was observed in 1 of 2 residents (Resident #109), reviewed for use of anticoagulant medications.The deficient practice was evidenced by the following: On 4/9/26 at 11:11 AM, the surveyor interviewed Resident # 109 The surveyor asked the resident about his concerns with a discontinued medication in August of 2025. The resident answered My Eliquis was stopped at the end of May and The doctor never talked to me about it, there was no notice, no discussion, I found out when the cariologist caught it in July. The resident added The doctor never discussed it with my sister either. The cardiologist restarted it the day I saw him in July, and he figured out it was stopped. The resident acknowledged his sister was his durable power of attorney for health care. A review of Resident # 109's admission record indicates he was admitted to the facility with diagnoses including but not limited to: left side hemiplegia and hemiparesis following a stroke (the left side of the resident's body is weak or paralyzed) and a chronic embolism of the left upper extremity (a clot in the blood vessels of the left arm)A review of Resident #109's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which reflected that the resident's cognition was not impaired.A review of the Resident #109's physician's orders reflects an order for an anticoagulant (a medication to treat and prevent blood clots), Eliquis 2.5mg tablet, give one tablet by mouth 2 times daily. This order was in effect beginning 6/22/24 and was discontinued on 5/31/2025. A review Resident #109's electronic health record (EHR) revealed a physician progress noted dated 6/1/2025. Eliquis did not appear in the medication list contained in that progress note, there was no notation of a discussion with the resident of risks or benefits of continuing versus discontinuing the anticoagulation therapy.A review of Resident#109's EHR did not reflect any physician or facility professionals documented a discussion with the resident or his sister regarding the discontinuation of Eliquis prior to 5/31/25. The EHR contained a report of consultation from the resident's cardiologist, a provider outside of the facility, from an appointment on 7/22/25 that recommended restarting Eliquis 2.5 mg tablet, give 1 tablet 2 x daily.On 4/16/25 at 11:05 AM, the surveyor met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) and both confirmed the residents EHR does not reflect documentation that a conversation occurred with Resident#109 or his sister about discontinuing the resident's Eliquis medication prior to the discontinuation on 5/31/25. On 4/16/26 at 11:55 AM, the surveyor conducted a phone interview with Resident #109's primary physician of record during May 2025. The surveyor asked the doctor about the discontinuation of residents Eliquis in May of 2025. The doctor could not confirm the exact date of 5/31/25 during the phone call but acknowledged he discontinued the medication at around that time. When asked if he discussed discontinuing this medication the Dr. stated I probably had a discussion with the resident, but I cannot recall for sure, there would be a note the surveyor informed the doctor that the surveyor, the DON and The LNHA reviewed the EHR and found no documentation of this discussion, the doctor stated, I should have, that is my mistake.On 4/15/26 at 12:05 PM, the surveyor interviewed Resident #109's sister. The interview occurred in the resident's room, with the resident present and participating. The resident's sister confirmed that no doctor or representative of the facility discussed the discontinuation of Eliquis before or after the medication was stopped on 5/31/25. The resident's sister stated I was shocked when the cardiologist asked why it was discontinued04/14/2026 12:45 PM, the surveyor met with LNHA and DON to discuss concerns with Resident#109's Eliquis medication. The LNHA and DON agreed the resident had the right to participate in the decision to discontinue the medication and that a risk and benefit discussion should have been held with the resident and/or his sister and documented accordingly. No further information provided by the facility.NJAC 8:39-4.1(a)2: 13.2: 13.3

Based on observation and interview it was determined the facility failed to maintain the residents' living environment in a safe and homelike manner for 1 of 25 residents (Resident #12) reviewed. The deficient practice was evidenced by the following:On 4/8/26 at 12:15 PM, the surveyor observed Resident # 12 in bed. The surveyor observed a bed controller with the cord attached to it, which was laying on the resident's bedside. The cord sheath attached to the bed controller was broken in several areas and the wires were exposed. The resident stated that the cord was like that for many months and the resident had told the facility about it a while ago but it was never fixed.At 12:41 PM, the surveyor asked the Licensed Practical nurse (LPN), who cared for Resident # 12, to come into the resident's room. The surveyor showed the LPN the broken cord sheath. The LPN stated that she did not notice that the cord sheath was broken and she had been in the resident's room around about 11:45 AM.At 12:49 PM, the surveyor interviewed the Director of Nursing (DON), who also stated that she did not notice that the cord sheath was broken and exposed the wires and she will look into having it fixed as soon as possible.On 4/9/26 at 1:30 PM, the surveyor discussed the above concerns with the Administrator and DON. NJAC 8:39-4.1(a)11. 31.4 (a), (b), (c), (f)

Complaint NJ-2803539 Based on observation, interview, and record review it was determined that the facility failed to ensure 1 of 2 residents (Resident #14) was free from neglect. The facility failed to provide personal care and assistance from the assigned Certified Nursing Assistant (CNA) for one 8-hour shift. The deficient practice is evidenced by the following.On 4/9/26 at 10:40 AM, the surveyor observed the resident awake in bed. The resident spoke to the surveyor in Arabic and did not understand the English language. At that time, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated a translator phone number is posted in the resident's room to communicate with the resident. He stated the resident's 2 daughters visit daily during the day shift.A review of the electronic medical record (EMR) revealed the following information.The 3/4/26 admission Minimum Data Set (MDS) assessment tool indicated that the resident had no cognitive deficits and exhibited no mood or behavioral concerns. The resident was noted to be independent eating meals after staff set-up the food tray.The resident's plan of care included a focus area of communication. An intervention indicated that staff were to use a translator phone to communicate with the resident when family was not present.On 4/9/26, the Director of Nursing (DON) provided the surveyor with a Facility Reporting Incident Data and Analysis Yield (FRIDAY) form, dated 3/13/26, regarding an allegation of neglect by a Certified Nursing Assistant (CNA) for failing to follow the resident's care plan.The form indicated the resident told the Assistant Director of Nursing (ADON) that the resident did not receive morning care from their assigned CNA (CNA #1) on the 8 AM to 4 PM day shift on 3/12/26. CNA #1 told the ADON she had distanced herself from the resident because the resident's family had been rude to her early in the shift. The CNA's documentation in the EMR reflected she did not provide care to the resident for the shift. Another CNA (CNA#2) was assigned to provide personal care to the resident during the 3/12/26 day shift.On 4/8/26 at 1:22 PM, the surveyor interviewed the DON. She stated on 3/12/26 the resident complained to the ADON that CNA #1 did not provide care. CNA#1 stated she distanced herself from the resident because the resident's family was rude to her early in the shift. She did not report this to her supervisor. The DON stated CNA #1 was suspended during the investigation. The CNA was terminated when the investigation was complete. The incident was reported on 3/13/26 to the Department of Health and the Long Term Care Office of the Ombudsman.On 4/9/26 at 10:40 AM, the surveyor interviewed the ADON. She stated CNA #2 reported to her that CNA #1 had not cared for the resident during the day shift. CNA #2 stated she performed personal care for the resident towards the end of the day shift. The ADON interviewed CNA #1 who stated she did not care for the resident because the family was rude to her. CNA #1 did not report this to her supervisor. The ADON stated if CNA #1 had come to her at the time of the alleged 'rudeness', the ADON would have immediately assigned another CNA to care for the resident.On 4/10/26 at 8:54 AM, the surveyor interviewed the resident's daughter by telephone. The resident's granddaughter acted as an interpreter. She confirmed the regular CNA did not come in to see the resident on the 3/12/26 day shift. She confirmed nurses were in for medication and treatment administration and the resident received their meals on the day shift.The surveyor reviewed the 3/12/26 Electronic Medication Administration Record (EMAR) and confirmed that nurses were in to see the resident 4 times during the day shift to administer medications.Additionally, the surveyor reviewed CNA #1's employee file and confirmed a criminal background check and 2 job references were obtained prior to the CNA's date of hire. The surveyor reviewed the facility's Abuse, Neglect and Exploitation policy, revised 5/2025. The document reflected that it is the facility's policy to protect residents from abuse, neglect, exploitation and misappropriation of resident property. Neglect was defined as the willful failure to provide services to the resident. On 4/15/26 at 1:00 PM, the surveyor discussed the concern of neglect with the Administrator and the DON.NJAC 8:39-4.1(5)

Based on interview and record review it was determined that the facility failed to ensure newly hired employees underwent criminal background checks before they began employment at the facility. The deficient practice was identified for 9 of 82 employee records reviewed (Employee #12, 13, 14, 17, 34, 38, 54, 55, 67). The deficient practice is evidenced by the following. On 4/13/26 and 4/14/26, the surveyor reviewed the Human Resources records including Criminal Background Investigations (CBI) for 82 employees who were hired since the previous Department of Health Recertification Inspection. The following concerns were revealed.Employee #12, a Certified Nursing Assistant (CNA), began employment on 10/20/25. The CBI was requested by the facility on 10/27/25.Employee #13, a nurse, began employment on 10/20/25. The CBI was requested on 2/10/26.Employee #14, a nurse, began employment on 12/15/25. The CBI was requested on 2/9/26.Employee #17, a nurse, began employment on 5/5/25. The CBI was requested on 10/3/25.Employee #34, a housekeeper, began employment on 6/2/25. The CBI was requested on 10/10/25.Employee #38, a CNA, began employment on 3/2/26. The CBI was requested on 3/18/26.Employee #54, a nurse, began employment on 12/22/25. The CBI was requested on 1/6/26.Employee #55, a nurse, began employment on 8/11/25. The CBI was requested on 2/11/26.Employee #67, a dietary aide, began employment on 10/6/25. The CBI was requested on 2/11/26.(None of the CBI results would have disqualified employment)On 4/14/26 at 1:00 PM, the surveyor discussed the concerns with the Administrator and the Director of Nursing. No further information or documentation was provided to the surveyor.The facility policy titled Abuse, Neglect and Exploitation, reviewed 5/20/25, indicated in the 'Screening' section, part A, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background checks .shall be conducted on potential employees .NJAC 8:39-4.1(a)5

Based on the interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for 1 (one) of 1 resident (Resident#104), system selected for resident assessment for MDS record over 120 days old. This deficient practice was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1) the Assessment Reference Date (ARD) of the Quarterly MDS (QMDS) was within 92 days after the ARD of the previous MDS, and 2) the completion date was no later than 14 days after the ARD. On 4/12/26 at 10:00 AM, the surveyor reviewed the electronic Medical Record (eMR) of Resident #104, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #104 was admitted with diagnoses that included but were not limited to unspecified dementia (loss of memory), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (feeling of worry). A review of the recent quarterly Minimum Data Set (Q/MDS) with an assessment reference date (ARD) (the last day of the of the observation period) of 12/5/25 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that the resident had a severe impairment cognition. Further review of the eMR Resident #104's next Q/MDS was due on 3/5/26; the quarterly assessment was not completed until 4/14/26, 40 days later, after the surveyor's inquiry. On 4/14/26 at 10:13 AM, the surveyor interviewed the MDS Coordinator/Registered Nurse, who stated that he missed the next MDS quarterly assessment on 3/5/26, and added that it was a mistake on their part. On 4/14/26 at 1:14 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The DON acknowledged the concern with the late completion and submission of the MDS. NJAC 8:39-11.1

Based on observations, interviews, record review, and review of other facility documents, it was determined that the facility failed to a) provide pharmaceutical services in accordance with professional standards to ensure signing from the reconciliation form Controlled Drug Administration Record Tablet (CDART; declining inventory log) form after the dispensed and administered a controlled dangerous substance with high potential for drug diversion medication for 1 (one) of 1 resident (Resident #107) and b) follow physician orders for 1 of 1 resident (Resident #5) reviewed for medication storage and labeling. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1.On 4/13/26 at 11:45 AM, the surveyor observed the medication cart on the 2nd floor with the Registered Nurse (RN). The surveyor observed that Resident#107's declining inventory log form for Lacosamide 200 mg (milligram) tablet had 15 tablets left, while the medication card had 14 tablets left. On 4/13/26 at 12:30 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #107, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #107 was admitted with diagnoses that included, but were not limited to, other seizures (when the normal flow of electrical signals in the brain is disrupted, causing sudden changes in movement). A review of the recent quarterly Minimum Data Set (Q/MDS) (an assessment tool used to facilitate the management of care) of 2/1/26 indicated that the facility assessed the residents' cognitive status using a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that the resident had intact cognition. Further review of Q/MDS reflected in Section N - High-Risk Drug Classes: Use and Indication that Resident #107 was taking an anti-convulsant medication. A review of the Order Summary Report (OSR) with an order date of 3/5/26, Lacosamide 200 mg oral tablet by mouth two times a day for seizure disorder A review of the April 2026 electronic Medication Administration Record (eMAR) Lacosamide 200 mg tablet was signed as given on 4/13/26 at 9:00 AM. On 4/13/26 at 11:45 AM, the surveyor reviewed the CDART (reconciliation sheet) with a handwritten date of 4/12/26 at 8:00 PM with a signature of 15 tablets left. In the medication (bingo) card, there are 14 tablets left available. On 4/13/26 at 11:50 AM, the surveyor interviewed the RN, who stated that she was caught up and she needed to sign it because she had given the medications already this morning at 9:00 AM, and acknowledged that she did not sign the declining log sheet. On 4/14/26 at 11:55 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that the nurse should sign the reconciliation sheet as soon as they removed the medication from the card. Then sign it in the eMAR as soon as the resident swallows the pills. On 4/13/26 at 1:40 PM, the team of surveyors met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The DON stated that it had already happened in August 2025, when the same nurse did not sign the controlled medications. A review of the facility policy titled Controlled Substance Administration & Accountability with a revised date on 1/19/26 revealed under Policy Explanation and Compliance Guidelines: h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. 2.On 4/14/26 at 12:11 PM, the surveyor reviewed the electronic medical record (EMR) of Resident #5. The AR revealed Resident #5 had diagnoses that included, but were not limited to, dementia, Congestive Heart Failure (CHF; a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), hypertension, and a cardiac pacemaker. A comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated the facility assessed the resident's cognition using a Brief Interview Mental Status test. Resident #5 scored 11 out of 15, which indicated the resident had moderate cognitive impairment. A physician's order dated 3/15/26 indicated furosemide 40 mg tablet, give 1 tablet by mouth two times a day for CHF; Hold for systolic blood pressure (the top number in a blood pressure reading which measures the maximum pressure in your arteries when the heart beats) less than 100. A review of the March 2026 and April 2026 Medication Administration Record (MAR) revealed that there was no documentation of the resident's blood pressure (BP) at the time of the furosemide medication's administration. A review of progress notes revealed there was no documentation of the resident's BP result at the time of the medication's administration. A review of the Weights and Vitals section of the EMR revealed BP entries for March 2026 and April 2026 as follows: 3/3/26 at 12:24 AM BP=137/82 3/3/26 at 12:26 AM BP=137/82 3/11/26 5:53 PM BP 132/80 4/1/26 at 10:13 PM BP= 132/80 There were no documented BP results at the time of the furosemide medication's administration. On 4/14/26 at 12:42 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to care for Resident #5 about medications with parameters. The LPN stated the medication order entry in the MAR would prompt the nurse to enter BP results for the resident at the time of a medication's administration. The LPN further explained the physician's order indicated when a medication should be held per parameter. The surveyor reviewed with the LPN, Resident #5's Furosemide entry on the MAR. The LPN confirmed the medication order included parameters and there were no documented BP results at the time of its administration. The LPN with the surveyor reviewed the weights and vitals section and the progress notes in the EMR. The LPN acknowledged there were no BP results found in the EMR to be documented at the time of the medication's administration. On 4/14/26 at 12:47 PM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) about medications with parameters. The RN/UM stated that the BP would be assessed, the results documented in the supplementary section of the MAR entry at the time of the medication's administration, and the medication would be held according to the physician's order if needed. The surveyor with the RN/UM reviewed the March 2026 and April 2026 MAR entries for the furosemide order. The surveyor informed the RN/UM of the concern that there were no BP results found documented in the EMR at the time of medication's administration. The RN/UM acknowledged there were no BP results documented in the MAR which was the expectation. The RN/UM stated she would review to provide any additional information. On 4/14/26 at 12:55 PM, the surveyor informed the LNHA and the DON about the above concerns. The DON stated the RN/UM just informed her of the concern and the RN/UM was clarifying the order with the physician. On 4/15/26 at 11:07 AM, the DON and the LNHA met with the survey team. The DON provided a physician progress note documented after surveyor inquiry, which detailed that Resident #5's BP had been stable and did not require BP monitoring with every medication administration. There was no documentation provided which indicated the order was previously clarified with the physician. The surveyor reviewed the facility provided policy titled, Medication Parameters, with a last revised date of 5/15/25 which revealed under Policy: To establish and maintain clear medication administration parameters to ensure medications are administered safely, consistently, and in accordance with physician orders, clinical standards, and applicable state and federal regulations. Medication parameters shall be followed for all residents receiving medications, withholding instructions, monitoring requirements, or clinical conditions that may affect administration. The surveyor reviewed the facility provided policy titled, Administration of Medication, with a last revised date of 1/5/25 which did not address medications with parameters. NJAC 8:39-27.1(a); 29.2

Complaint #2613352Based on interview, and review of facility documentation, it was determined that the facility failed to provide services in compliance with applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles for a resident who was denied admission to the facility to provide services. This deficient practice was identified for 1 of 3 residents' referrals reviewed, Resident #138.This deficient practice was evidenced by the following:Reference: According to the Centers for Disease Control (CDC) guidelines dated 4/24/24, the Transmission-Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) for Candida Auris (C. Auris; a multidrug- resistant fungus that can cause severe infections in very sick, vulnerable patients) are similar to those used for other multidrug-resistant organisms (MDROs). In most instances, facilities equipped to care for patients with other MDROs can also care for patients with C. Auris. In nursing homes and skilled nursing facilities, healthcare providers should use either Contact Precautions or EBP (an infection control intervention to wear gown and gloves during high contact care to prevent multidrug-resistant organism transmission), based on the situation and local or state jurisdiction recommendations.Reference: According to the local and state guidance from New Jersey Department of Health (NJDOH), dated 3/24/23 for C. Auris: Identification, Reporting and Infection Prevention Guidance Updates, under Key Points revealed .2) Most healthcare facilities can provide adequate care for C. Auris positive individuals and therefore should not deny admission to patients based upon their C. Auris diagnosis .On 4/8/26 at 10:00 AM, the survey team requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), all admission referrals, including declined admissions, from July 2025 to September 2025.On 4/8/26 at 1:09 PM, the LNHA provided the document, Provider Referral Rejection Report for July 2025 to September 2025.On 4/9/26 at 11 AM, the surveyor interviewed the Hospital Liaison (HL) of the facility, who was covering for Admissions Director who had recently resigned. The HL stated the facility received admission referrals through two electronic systems which the HL would complete a clinical and insurance review for referred residents. The HL further explained if the resident was clinically ok and their insurance approved, the resident would be accepted for admission to the facility. The HL stated if a resident's referral was declined or approved it would be documented in the electronic referral system, and the referring facility would be able to view the information.The HL explained reasons for denial of admission referrals included but were not limited to, insurance not covering the stay, the resident referral was outside of the service area (e.g. out of state), a resident needed a higher level of care, intravenous drug use, and residents on a ventilator. The surveyor reviewed with the HL the provided referral rejection report and asked if these were the only hospitals referrals were received from. The HL stated there was an additional list of referrals from the second electronic referral system. The surveyor requested a copy of the second list of referrals.On 4/9/26 at 12:10 PM, the LNHA provided the second admission referral list. The surveyor reviewed the list which included an entry for Resident #138 dated 8/9/25 with a declined reason of facility cannot provide for patient's need.On 4/9/26 at 12:35 PM, the surveyor requested from the DON additional information regarding the reason for the resident's denial for admission.On 4/9/26 at 2:01 PM, the LNHA provided a one-page document with the facility's letterhead which included Resident #138's denial of admission was due to candida auris.A review of the facility's Electronic Medical Record (EMR) system revealed that Resident #138 had a previous admission stay in the facility in 2024.On 4/13/26 at 11:00 AM, the LNHA provided the survey team with an additional document with the facility's letterhead which indicated the resident was denied admission due to limited availability of private rooms, increased vulnerability to the existing population, and need for strict infection prevention measures. In addition, the document detailed, .admission of residents with confirmed or suspected Candida auris may be declined when appropriate isolation, staffing, and infection control resources are not available to safely manage care and protect the current resident population. On 4/14/26 at 10:26 AM, the surveyor interviewed the Infection Preventionist/Registered Nurse (IP/RN) about care for a resident with C. auris. The IP stated expectation was prior to admission it would be known about the diagnosis to adequately prepare and take appropriate precautions. The IP/RN further explained ensuring a private room for isolation was available and if possible, adjustments could be made to cohort residents to accommodate a resident who required isolation. The surveyor asked the IP/RN what type of precautions were required for C. auris positive residents. The IP/RN replied contact isolation precaution (an infection control measure used to prevent spread of germs transmitted by direct or indirect contact with a patient or their environment; key requirements included placing the patient in a private room, wearing gloves and gowns for all interactions, dedicated equipment use, and strict hand hygiene). On 4/14/26 at 11:05 AM, the surveyor requested from the DON the resident census report for 8/9/25 and 8/10/25.On 4/14/26 at 11:12 AM, the LNHA provided the surveyor with the Midnight census report for 8/9/25 and 8/10/25. A review of the Census report for 8/9/25 revealed rooms 109-1 (a private room), 115-1 and 115-2 were empty on the sub-acute unit. A review of the census report for 8/10/25 revealed rooms 109-1, 115-1 and 115-2 were empty on the sub-acute unit. On 4/14/26 at 12:55 PM, the surveyor informed the LNHA and the DON of the concern about Resident #138's admission referral being declined due to their C. auris diagnosis and there was no additional documentation which evidenced the resident required higher level of care or the facility being unable to care for the resident.The DON explained that there was concern for their resident population and for a resident with C. auris a room on one end of a unit wing was preferred, not in the middle of a unit or between other residents' room. The surveyors discussed that contact isolation precautions as with other infectious microorganisms were implemented to prevent the spread and there was no supportive documentation provided that indicated the resident needed a higher level of care or care could not be provided by the facility. The DON and LNHA had no verbal response at this time and would look to provide any additional information.On 4/15/26 at 11:07 AM, the LNHA and the DON met with the survey team. The LNHA and the DON had no additional information or response regarding Resident #138's denial of admission. A review of the facility provided policy titled, Admissions Criteria with a last reviewed date of May 2025, revealed under Policy: It is the policy of [the facility's name] to admit residents whose needs can be safely and appropriately met within the scope of services offered by the facility, in compliance with applicable federal and state regulations, including those established by the Centers for Medicare & Medicaid Services and the New Jersey Department of Health.A review of the facility provided policy titled Infection Prevention and Control Program, with a reviewed date of 2/19/26, revealed under Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Under Policy Explanation and Compliance Guidelines, Isolation Protocol (Transmission-Based Precautions): .A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards.NJAC 8:39-5.1(a),5.2(b)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control measures to prevent the potential spread of infection for failing to ensure a midline intravenous (IV) connector cap was properly secured for 1 of 1 residents (Resident # 12) with a midline IV.The deficient practice was evidenced by the following: On 4/8/26 at 12:15 PM, the surveyor observed Resident # 12, in bed, with a midline IV on the resident's left arm with a date of 4/6/26 on the dressing which covered the IV site. The surveyor observed that the midline IV line was clamped but the connector was uncapped. The resident stated that the nurses gave the resident medicine in the IV yesterday.A review of the resident medical records revealed the following:Resident # 12 was admitted with diagnoses which included, but were not limited to sepsis and cellulitis of right lower limb.The Quarterly Minimum Data Set (MDS) (an assessment tool), dated 2/3/26, revealed that Resident # 12 had a Brief Interview for Mental Status (BIMS) score of 15/15, that indicated that Resident # 12 was cognitively intact.A review of the resident's Physicians Orders (PO) revealed a PO dated 3/16/26 for insert midline. A review of the electronic Medication Administration Record (eMAR) revealed an order for Ertapenem Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for right leg cellulitis until 04/07/2026.At 12:41 PM, the surveyor asked the Licensed Practical nurse (LPN), who cared for Resident # 12, to come into the resident's room. The surveyor showed the LPN the resident's midline IV connector site, and the LPN stated that the resident had IV antibiotics and the last dose of antibiotic was yesterday via the midline. The LPN stated that the midline IV line was clamped but the connector should be capped and acknowledged that it was not. The LPN stated that she was not sure what happened with the IV line connector cap and she stated that she was last in the resident's room this morning around 11:45 AM, and she did not see that the connector uncapped.At 12:49 PM, the surveyor interviewed the Director of Nursing (DON), who stated that the midline IV line was clamped but the connector should have been capped and the resident is now on hospice care services and the facility was waiting for the doctor to determine if the antibiotic and the IV line would continue to remain in place. The DON also stated that she would immediately contact the doctor and address this situation.On 4/13/26 at 9:45 AM, the DON told the surveyor that the midline IV was removed as the doctor determined that it will no longer be used. A review of the PO's revealed an order for remove midline on 4/8/26. On 4/13/26 at 12:52 PM, the surveyor interviewed that Infection Preventionist (IP), who stated that the midline IV connector cap should have been on to prevent the potential spread of infection to the resident.On 4/9/26 at 1:30 PM, the surveyor discussed the above concerns with the Administrator and DON. No further information was provided.NJAC 8:39-19.4 (a)

Based on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) consistent maintenance of the system of record keeping of the Drug Enforcement Agency (DEA) order Form-222 (a federal narcotic requisition form), that enabled accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention) that was ordered and received, b) the development and implementation of policy and procedure for DEA order Form-222, c) removal and disposition of a discharged Resident's medication from the active inventory, and d.) properly label an opened blood glucose test strip. The deficient practice was identified for five (5) of 12 DEA Form-222s reviewed, one (1) of two (2) medication storage rooms, one (1) of three (3) medication carts inspected during the medication storage and labeling observation. The evidence was as follows: Reference: 21 CFR 1305 Part 1. Purchaser Information 6.Purchaser must make a copy of the order form for its records before mailing the original to the supplier. Part 5 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item. 21 CFR 1305.16 6. Lost or stollen order forms must be documented and reported to your local DEA office. 21 CFR 1305.18 7. Unused order forms should be voided and returned to Drug Enforcement Administration . 1.) On 11/6/24 at 12:11 PM, the surveyor and the newly appointed Director of Nursing (DON) reviewed the DEA Form-222 together. The DON informed the surveyor that the Consultant Pharmacist was at the facility the day before to organize the facility's record keeping file for the DEA Form-222. A review of the DEA Form-222 from September 2023 revealed the following: -231381123 and 231381124 were missing. -240365257 had the incorrect address. -240365258 and 240365259 were at that time, missing, (which was later found), unexecuted (not used), not voided and had the incorrect address. Further review of the DEA Form-222 revealed the staff did not consistently complete Part 5, as instructed on the front of DEA Form-222 (for the accurate reconciliation and accountability of the ordered narcotic medication against the received narcotic medication from the supplier). The discrepancies were identified on the following forms: -231381125 the number received, and the date received were blank and had no packing slip (facility signed invoiced quantities received from the supplier). -240531774 the number received, and the date received were blank. Part 1 of the requirement for this form was to enumerate the total quantity ordered. This line item was also blank. -231381120 the number received, and the date received were blank and had no packing slip. -231381119 the number received, and the date received were blank and had no packing slip. On 11/6/24 at 3:06 PM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the surveyor discussed the concerns regarding the inconsistencies in reconciliation, accountability for the narcotic medications ordered and received utilizing the DEA Form-222. On 11/7/24 at 10:07 AM, in the presence of the survey team, the LNHA stated that when the previous DON had left (no longer employed in the facility) he took all the unused DEA Form-222 for safe keeping. The LNHA also stated that the DON was responsible for ensuring the tracking and accountability of the narcotic medication ordered and received. At that time, the LNHA provided the surveyor the unused/unexecuted DEA-Form 222 (240365258 and 240365259), acknowledged that those forms had the incorrect address and voided the forms. At that time, the new DON informed the LNHA that the same forms had to be returned to the DEA. On 11/7/24 at 10:10 AM, in the presence of the survey team, the DON confirmed and acknowledged that there were errors, and the evidence of the tracking and accountability was not present. The DON stated that moving forward she would track all the DEA-Form 222 and its associated requirements. 2.) At that time, the surveyor requested for the facility's policy and procedures for controlled dangerous substance/ narcotic medications for the discrepancies identified with the DEA Form-222 (the process the facility follows for resolving discrepancies, process for accurate ordering, receiving, administering of narcotic medications, and when drug diversion was found). On 11/7/24 at 12:01 PM, in the presence of the survey team, the DON stated that there were no other policies for the tracking, ordering, and receiving, identification of diversion of controlled dangerous substance/narcotic medications in relation to the DEA Form-222. 3.) On 11/6/24 at 9:43 AM, in the presence of the Registered Nurse/Nurse Supervisor (RN/NS) the surveyor began the medication room observation located on the First floor. At that time, the surveyor and the RN/NS observed 2 clear plastic bags, that had a pharmacy label for Resident #179 and reflected the following: Rx 84570805 contained 2 bottles of Retacrit (injectable medication for anemia with increased risks, that includes death and stroke, requiring monitoring of blood levels prior to administration) dated 9/21/24. Rx 85083139 contained 1 bottle of Retacrit dated 10/27/24. At that time, the RN/NS stated that Resident #179 was discharged last week, and the resident's medication should have been removed from the active inventory to prevent medication administration errors. All nurses on all shifts were responsible to ensure discontinued medications and discharged residents' medication were removed from active inventory, returned to the pharmacy, or disposed. The RN/NS stated that she would remove the medication, return to the pharmacy, and inform her supervisor. 4.) On 11/6/24 at 10:39 AM, in the presence of the RN, the surveyor began the medication cart observation located on the Third floor. At that time, the surveyor and the RN observed an opened bottle of the blood glucose test strip that was opened and not dated. The RN stated that the test strips should have been dated immediately after it was opened to know the use by date. The RN stated she would dispose of the undated, opened blood glucose test strop and replace it with a new one. According to the blood glucose test strip manufacturer's package insert, under storage and handling, reflected instructions that included, to use within 6 months of first opening or the expiration date on the label, whichever comes first. On 11/6/24 at 3:06 PM, in the presence of the survey team, the LNHA and the DON, the surveyor discussed the concern regarding the discharged resident's Retacrit and the opened and undated blood glucose test strips. At that time, the DON acknowledged the concerns and informed the surveyor that she was made aware of the observation by the nurses. The DON confirmed the Retacrit should have been removed and the test strip should have been dated. A review of the facility policy provided; Medication Storage dated/revised 1/1/24 included the following: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendations . Policy Explanation and Compliance Guidelines 2.Narcotics and Controlled Substances: c. Any discrepancies which cannot be resolved mist be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy. ii Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted . 8. Unused Medications: all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medication with worn, illegible, or missing labels. These medications are destroyed in accordance with our destruction of unused drug policy. No further information was provided. NJAC 8:39-29.4 (c)(g)(h)(k),29.7(c)

REPEAT DEFICIENCY Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 4 of 4 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 10/31/24 at 10:00 AM, upon entrance conference, the surveyor requested to review the QA meeting sign in sheets for the last few quarters of QA meetings held. On 11/4/24 at 10:30AM, the surveyor received QA meeting sign in sheets dated, 10/17/24, 7/18/24, 4/18/24 and 1/18/24, which revealed that the Infection Preventionist (IP) was not in attendance for any of those scheduled meetings. At 10:35 AM, the surveyor interviewed the Administrator who stated that if the IP is in the building during the QA meeting, then, she will attend and could not explain why she was not in attendance for those 4 QA meetings. The surveyor reviewed the Infection Preventionist policy and procedure, dated 2/2024, which revealed that the facility's IP must have time necessary to participate in required committees such as QAA. The surveyor reviewed the Quality Assurance and Performance Improvement policy and procedure, dated 3/2024, which revealed the QA committee shall consist of a minimum of . The Infection Preventionist. N.J.A.C. 8:39-33.1 (b)

Based on observation, interview, and record review it was determined that the facility failed to a) maintain infection control standards and procedures during wound care treatments for 2 of 5 residents (Resident #181, #6) reviewed for care and services for pressure ulcers, b) provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to both residents and staff by sharing personal care items between residents and a linen cart which contained linen for multipe residents was brought into a Resident room (room [ROOM NUMBER]) and then back out into the hallway, observed for 1 of 3 CNAs (CNA #1) on 1 of 4 nursing units, (4th-floor unit) and c) failed to practice acceptable hand hygiene as recommended by the CDC. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. The surveyor observed Resident #181 on 11/1/24 at 9:30 AM sitting up in bed eating breakfast. A review of the electronic medical record revealed the following. The resident's Admission Record noted the resident was admitted with Parkinson's disease. The 8/17/24 Admission Minimum Data Set assessment tool (MDS) indicated the resident was cognitively intact as referenced by a score of 15 on the Brief Interview for Mental Status (BIMS) in Section C. Section M indicated the resident was at risk for developing pressure ulcers. The 11/1/24 Wound Assessment Report included documentation regarding a sacral pressure ulcer. The ulcer was noted to have initially been identified as a full thickness wound which was currently improving without complications. The treatment recommendation (which was reflected in the November 2024 physician's order summary) was for the following treatment to be performed twice daily and as needed - cleanse with normal saline, pat dry, apply 0.5% Dakin's solution (a topical antiseptic) moistened fluffed gauze, and cover with a bordered gauze. The surveyor observed the pressure ulcer treatment on 11/6/24 at 11:24 AM. The treatment was performed by RN #1 who was assisted by RN #2. After reviewing the physician's treatment order, RN #1 proceeded to the resident's bathroom to perform hand washing. RN #1 wet her hands, applied soap, and lathered outside of running water for 10 seconds. RN #1 turned off the faucet handle with bare wet hands. RN #1 set up the clean field and wound treatment supplies on the sanitized over bed table and proceeded to Resident #181's bedside to begin the treatment. RN #1 removed the soiled dressing from the resident's sacral area, removed her gloves, and proceeded to the bathroom to perform hand washing. RN #1 lathered outside of running water for 5 seconds, rinsed and dried her hands, and closed the faucet with a wet paper towel. RN #1 applied clean gloves and cleansed the wound by wiping in a circular motion from inside the wound bed to the outside peri-wound area (the correct method to keep from re-introducing bacteria into the wound bed). The second cleansing was performed by wiping from inside the wound bed to the outside peri-wound area and back into the wound bed. RN #1 wearing the same gloves (now considered soiled) patted the wound with a dry gauze pad. RN #1 wearing the same soiled gloves poured Dakin's solution onto a clean gauze pad and pulled the gauze pad apart to fluff it. RN #1 placed the area of the gauze pad which had been touched by soiled gloves into the wound bed. The bordered gauze dressing was placed over the wound while RN #1 wore soiled gloves. RN#1 reached into her uniform pocket with soiled gloves to obtain a pen. She wrote the date and her initials on the bordered gauze which had already been applied to the resident's sacrum. RN #1 placed the pen which she had handled with soiled gloves back into the uniform pocket. The surveyor interviewed RN #1 after she had completed the treatment. RN #1 stated the facility policy for handwashing required to lather outside of running water for at least 20 seconds. She stated the wound should be cleansed from in to out only. She stated she knew she erroneously wiped back in again contaminating the wound . She acknowledged she should have dated the dressing prior to placing it on the resident's body. The surveyor discussed the treatment observation with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) on 11/06/24 at 3 PM . The DON stated the resident was an agency nurse and he would contact the nursing agency to see if there was education done for hand hygiene and pressure ulcer treatment. On 11/07/24 at 10:17 AM the LNHA stated he was unable to obtain nurse education for RN #1 from the nursing agency. At that same time the DON provided a photocopy of a remedial treatment observation and handwashing evaluation performed with RN #1 on 11/6/24. The documents indicated hands should be lathered outside of running water for 20 seconds before rinsing. A new paper towel should be used to turn off faucets. Gloves should be discarded when soiled. The method for cleaning the wound was not addressed, nor was the correct method for documenting on the bordered gauze cover dressing. 36419 2. The surveyor observed Resident #6 on 10/31/24 at 12:25 PM, in bed on a specialty mattress with their eyes closed, and the head of the bed elevated. The surveyor observed the tube feeding (TF) running via a machine and the Oxygen concentrator on with the gauge set on 4 LPM via a nasal cannula. A review of Resident #6's medical record revealed the following. The resident's Admission Record noted the resident was admitted with diagnoses that included but were not limited to Alzheimer's disease, pressure ulcer of sacral region, stage 3 (a wound that involves full thickness loss of skin), and gastrostomy status (a tube that is surgically inserted into the stomach to provide nutritional support). A review of the November 2024 Physician Order Summary (POS) included a physician's order dated 11/3/24 to cleanse the sacral opening with Normal Saline, pack the sacral wound with moistened soaked gauze of 1/4 strength Dakins solution, apply skin prep to the outer wound and periguard to the surrounding area every day and evening shift and when needed. A review of the quarterly Minimum Data Set (MDS) dated [DATE], an assessment tool, indicated that Resident #6 had aphasia (inability to speak), was unable to make him/herself understood and was unable to understand others. The MDS further assessed that Resident #6 was dependent on staff for Activities of Daily Living (ADLs), had a stage 3 pressure ulcer, and received oxygen therapy. A review of the Individual Care Plan with a focus area indicated the Resident had an impairment to their skin integrity r/t history of stage 4 pressure wound to sacrum upon admission with interventions which included but were not limited to wound consult weekly if needed, weekly skin assessment by nurse, air mattress, incontinence care every 2 hours and to keep skin clean and dry. The surveyor observed the pressure ulcer treatment on 11/4/24 at 11:10 AM. The treatment was performed by the Licensed Practical Nurse (LPN) who was assisted by the Certified Nursing Assistant (CNA #1). After reviewing the physician's treatment order, the LPN proceeded to the resident's bathroom and performed hand washing. The LPN set up the clean field and wound treatment supplies on the sanitized over-bed table and proceeded to Resident #6's bedside to begin the treatment. The supplies included a full package of 4x4 gauze pads, a bottle of Dakin's 1/4 Strength Solution, a bottle of Normal Saline (NSS), skin prep pads, a full tube of periguard, and 6 bordered dressings. All supplies were contained in a plastic bag. The LPN donned a disposable gown and gloves and removed the soiled dressing from the resident's sacral area. The LPN described the dressing as having a copious amount of serosanguinous exudate. The LPN removed her gloves and washed her hands. The LPN applied clean gloves, reached into the package of 4x4 gauze pads, wet the pad with NSS and in a circular motion cleansed the peri-wound area. The LPN discarded the gauze pad and using the same gloves, reached into the package of 4x4 gauze pads and removed another pad. The LPN wet the pad with NSS, cleansed the peri-wound, and then using the same contaminated gauze pad, cleansed the inside of the wound bed. The third cleansing was performed by wiping from the outside of the peri-wound area back into the wound bed. The LPN removed the gloves, sanitized her hands using Alcohol Based Hand Rub (ABHR), poured Dakin's solution onto a cleanse gauze pad placed it inside the wound bed, and placed the dated, initialed bordered gauze dressing over the wound onto the excoriated peri wound without first applying the Perigaurd. The LPN applied the Periguard to the portion of the peri-wound that was not covered and then covered the area with another bordered dressing. The LPN brought all of the supplies out of the room and put them back into the treatment cart. The surveyor discussed the breaks in technique with the LPN on 11/4/24 at 11:45 AM. The LPN stated that the wound should be cleansed from the center of the wound to the peri wound. The LPN acknowledged that she should have only brought the supplies needed for the treatment into the resident's room and should have discarded the bag of contaminated 4x4 gauze pads and the contaminated bottle of NSS. The LPN confirmed that she should have applied the Periguard to the peri-wound before she applied the first bordered dressing. The surveyor interviewed the Infection Control Nurse (ICN) on 11/4/24 at 12:55 PM, who confirmed the supplies brought into the resident's room should have been discarded, not put back into the treatment cart. On 11/4/24 at 1:34 PM, the surveyor discussed the observations and concerns with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). The DON confirmed only supplies needed for the wound treatment should be brought into the resident's room. A review of the Treatment Observation Protocol included .Treatment Procedure .understands steps of wound care procedure; follow treatment order as written .cleanse wound as per MD order and pat dry with sterile 4x4. Preparing Treatment .tubes of cream and ointments are kept out of resident rooms .place amount needed on sterile 4x4 .place used supplies in receptacles . 3. On 11/4/24 at 12:00 PM, the surveyor observed CNA #1 obtained a bag of personal care supplies from the resident in room [ROOM NUMBER] bed 1 and used the same personal care items for the resident in 417 bed 2 (Resident #22). At that same time, the surveyor observed the linen cart that contained linens for multiple residents on the 4th floor unit was inside room [ROOM NUMBER]. After the CNA had provided care for Resident #22, CNA #1 put the bag of personal care items she had used for both residents in room [ROOM NUMBER] onto the linen cart and pushed the cart out into the hallway. At that time, CNA #1 acknowledged she should not have shared the personal care items between residents and that the items should be kept in each resident's room. CNA #1 confirmed that only the linen needed for each resident should be brought into the room not the entire linen cart for infection control reasons. On 11/4/24 at 12:50 PM, the surveyor interviewed the Registered Nurse/ Unit Manager on the 4th-floor unit who stated that linen carts should remain outside of rooms, only linen needed for each resident should be brought into the room, and personal care items should be used for only one resident, not shared between residents. On 11/4/24 at 1:34 PM, the surveyor discussed the above observations and concerns with the LNHA and DON. 4. On 11/4/24 at 12:40 PM, the surveyor observed CNA #2 entered the bathroom in Resident room [ROOM NUMBER]. The surveyor observed CNA #2 applied soap to her hands and immediately placed her hands under the stream of running water without first lathering her hands outside of the running water. At that same time, the surveyor interviewed CNA #2 who acknowledged that she should have applied soap and then lathered her hands for 20 seconds outside the stream of water. On 11/4/24 at 1:34 PM, the surveyor discussed the above observations and concerns with the LNHA and DON. NJAC 8:39 19.4 (a) (n)

Based on observation, interview, and record review, it was determined that the facility failed to ensure pneumococcal vaccination was offered according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for Residents #23, #36 and #83. This deficient practice was identified for three (3) of five (5) residents reviewed for immunization status. The deficient practice was evidenced by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 9/12/24, included the following. The CDC recommends a single dose of PCV21 (pneumococcal 21-valent conjugate vaccine; Capvaxive), PCV20 (pneumococcal 20-valent conjugate vaccine), or PCV15 (pneumococcal 15-valent conjugate vaccine) greater than or equal to 1 year after the last PPSV23 (pneumococcal 23-valent polysaccharide vaccine; Pneumovax23) dose. Reference [previous guidelines] A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 3/15/23, included the following: The CDC recommends a single dose of PCV20 or PCV15 greater than or equal to 1 year after PPSV23. On 11/4/24 at 1:13 PM, during an interview with a surveyor, the Registered Nurse/Infection Preventionist stated that the pneumococcal vaccine offered at the facility was the PCV21 (Capvaxive) and that she was aware of the new guidelines for the pneumococcal vaccine. At that time, the RN/IP stated that the facility had not offered the newest pneumococcal vaccine to residents who had previously received the vaccine. 1.) On 10/31/24 at 11:13 AM, the surveyor observed Resident #23 seated in a wheelchair, mobile and conversant. The resident informed the surveyor of their diagnosis of heart failure and how they have worked hard during rehabilitation treatment to achieve the mobility they currently have. The surveyor reviewed the hybrid (combination of paper and electronic) medical record for Resident #23. According to the Admission Record (AR; an admission summary) reflected Resident #23 was admitted to the facility with diagnoses which included but were not limited to type 2 diabetes (high blood sugar) heart failure, and chronic obstructive pulmonary disease (a condition that causes airflow blockage and breathing-related problems). Resident # 23's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 8/6/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated the resident's cognition was intact. Further review of the qMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine to date? The response was marked 1, which reflected Yes. A review of the electronic Medical Record (eMR) reflected Resident #23 had received Pneumovax on 11/22/22. A review of the paper-based chart for Resident #23 did not reveal documentation that the pneumococcal vaccine was offered, or was declined, and that education was provided to the resident in 2023. 2. On 10/31/24 at 10:48 AM, the surveyor observed Resident #36 in bed with oxygen infusing at 3 liters per minute (lpm) via a nasal cannula (a device used to deliver supplemental oxygen), and the head of the bed was elevated approximately 40 degrees. According to the AR Resident #36 was admitted to the facility with diagnoses which included but were not limited malignant neoplasm of the colon (colon cancer) and chronic obstructive pulmonary disease (a condition that causes airflow blockage and breathing-related problems). Resident # 36's most recent Annual Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, dated 9/18/24, reflected that the resident had a BIMS score of 15 out 15 which indicated the resident's cognition was intact. Further review of the AMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine to date? The response was marked 1, which reflected Yes. A review of the eMR reflected Resident #36 had received Pneumovax on 8/4/21. A review of the paper-based chart did not reveal documentation that the pneumococcal vaccine was offered, or was declined, and that education was provided to the resident in 2023. 36419 3. On 10/31/24 at 11:45 AM, the surveyor observed Resident #83 ambulating on the 4th floor unit. According to the AR Resident #83 was admitted to the facility with diagnoses which included but were not limited to dementia, anxiety, and hypertension. Resident #83's most recent quarterly MDS dated [DATE] reflected the resident had a BIMs score of 6 out of 15 which indicated a severe cognitive impairment. Further review of the qMDS , under section O0300 A. Is the resident's Pneumococcal vaccine to date? The response was marked 1, which reflected No. Under section 0300 B. If Pneumococcal vaccine not received state the reason .the box was left blank. A review of the eMR reflected Resident #83 had received Pneumovax on 11/12/22. On 11/6/24 at 3:06 PM, the surveyor requested any documentation showing that the resident was offered and or had declined the Pneumococcal Vaccine. On 11/6/24 at 3:06 PM, in the presence of the survey team, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the surveyor discussed the concern regarding Resident #23, #36 and #83 who were not offered pneumococcal vaccination according to the current Centers for Disease and Control Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommendations. On 11/7/27 at 10:10 AM, in the presence of the survey team, and the LNHA, the DON confirmed that there was no further information that could be provided regarding the concerns for the pneumococcal vaccine. A review of the undated facility policy for Pneumococcal Vaccine included: It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations (policy references included CDC dated 10/26/24). No further information was provided. N.J.A.C. 8:39-19.4 (i)

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 3 of 6 residents (Resident #22, #109, and #87) observed for incontinence care on 1 of 3 units, the 4th floor Unit. This deficient practice was evidenced by the following: a. On 11/4/24 at 11:55 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) on the 4th floor unit. CNA #1 stated that she had 8 residents on her assignment and was also helping another aide with some of their residents. On 11/4/24 at 12:00 PM, the surveyor and CNA #1 entered Resident #22's room and observed the resident in bed. CNA #1 stated that she had not provided care to Resident #22 yet as she was very busy all morning. The CNA exposed Resident #22's incontinence brief which was saturated with urine. At that time when CNA #1 exposed the incontinence brief another incontinence brief was observed which was also saturated with urine. CNA #1 acknowledged the two briefs were saturated with urine and stated that no residents should be wearing two incontinence briefs. CNA #1 stated that it was the night CNA who double-diapered the resident. A review of Resident #22's Admission Record reflected the Resident was admitted to the facility with diagnoses which included but were not limited to anxiety, kidney failure, and legal blindness. A review of Resident #22's quarterly Minimum Data Set (MDS) an assessment tool dated 10/11/24 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated Resident #22 had a severe cognitive impairment. The MDS further assessed Resident #22 required extensive assistance from staff for personal hygiene and was always incontinent of bowel and bladder. The surveyor reviewed Resident #22's Individual Care Plans (ICPs) which revealed there were no care plans initiated that focused on the resident's Bowel and Bladder Incontinence. b. On 11/4/24 at 12:15 PM, the surveyor and CNA #1 observed Resident #109 in bed. CNA #1 stated that she had not provided care for Resident 109 until this time. The CNA exposed the resident's incontinence brief which was saturated with urine. CNA #1 acknowledged that she should have provided incontinence care for Resident #109 every two hours but stated that she had been too busy. A review of Resident #109's Admission Record reflected 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), hemiparesis (severe or complete loss of strength or paralysis on one side of the body) and dysphagia. A review of Resident #109's quarterly MDS dated [DATE] revealed Resident #109 had a BIMS score of 1 out of 15 which indicated Resident #109 had a severe cognitive impairment. The MDS further assessed that the resident required maximum assistance from staff for personal hygiene, and he/she was always incontinent of bowel and bladder. The surveyor reviewed Resident #109's ICPs which revealed there were no care plans initiated that focused on the resident's Bowel and Bladder Incontinence. c. On 11/4/24 at 12:30 PM, the surveyor observed Resident #87 in bed. The resident stated that she/he had not been changed or bathed all morning and further stated that she/he wanted to get washed up and changed. On 11/4/24 at 12:35 PM, the surveyor interviewed CNA #2 who stated that Resident #87 was on her assignment. CNA #2 confirmed she had 10 Residents on her assignment and had not yet provided care to Resident #87. At that time, CNA #2 and the surveyor entered Resident #87's room. CNA #2 exposed Resident #87's incontinence brief which was wet, and both the surveyor and CNA #2 observed the resident had a bladder pad inserted within the incontinence brief. CNA #2 stated that she doesn't use bladder pads, that it was the night CNA that put it there. A review of Resident #87's Admission Record reflected Resident #87 was admitted to the facility with diagnoses which included but were not limited to dementia, diabetes mellitus, and chronic kidney disease. A review of Resident #87's Admission MDS dated [DATE] revealed Resident #87 had a BIMS score of 12 out of 15 which indicated Resident #87 had a moderate cognitive impairment. The MDS further revealed that the resident required maximum assistance from staff for personal hygiene, and he/she was always incontinent of bowel and bladder. The surveyor reviewed Resident #87's ICPs which revealed there were no care plans initiated that focused on the resident's Bowel and Bladder Incontinence. On 11/4/24 at 1:34 PM, the survey team met with the Licensed Nursing Home Administrator and Director of Nursing (DON) to discuss the above observations and concerns. The DON confirmed that incontinence rounds should be done every two hours and that no resident should have two incontinence briefs. The DON further stated that bladder pads should be used only if the resident requests. On 11/6/24 at 2:15 PM, the surveyor interviewed the DON who stated that all residents who were incontinent of bowel and bladder should have a care plan in place since incontinence care was part of the resident's care. The surveyor attempted a phone interview with the 12:00 AM-8:00 AM, CNA who was assigned to Resident #22, #109 and #87. The surveyor left a voice message with no return call. NJAC 8:39-27.1 (a), 27.2 (h)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to administer oxygen therapy according to the physician's order for 1 of 1 resident, (Resident #6). 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. On 10/31/24 at 12:25 PM, the surveyor observed Resident #6 in bed on a specialty mattress with his/her eyes closed and the head of the bed elevated. The surveyor observed the tube feeding (TF) running via a machine. The surveyor observed Resident #6 wearing a nasal cannula (NC) with an oxygen concentrator on and the gauge was set at 4 liters per minute (LPM). A review of Resident #6's Admission record revealed Resident #6 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease, pressure ulcer of sacral region, stage 3 (a wound that involves full thickness loss of skin) and gastrostomy status (a tube that is surgically inserted into the stomach to provide nutritional support). A review of Resident #6's annual Minimum Data Set (MDS), an assessment tool, dated 8/6/24 revealed Resident #6 had aphasia (inability to speak), was unable to make him/her self-understood and was unable to understand others. The MDS further assessed that Resident #6 was dependent on staff for Activities of Daily Living (ADLs), had a stage 3 pressure ulcer, and received oxygen therapy. A review of the Individual Care Plan (ICP) initiated on 2/21/24 reflected a focus area: resident has shortness of breath with interventions that included but were not limited to Oxygen continuous at 2 LPM via NC. A Review of the November 2024 Order Summary Report (OSR) revealed an active physician order (PO) with an order date of 2/28/23 for Oxygen 2 LPM via NC every shift for shortness of breath (SOB). On 11/1/24 at 1:07 PM, the surveyor observed Resident #6 in bed with the head of the bed elevated, the TF running via a machine. The surveyor observed Resident #6 wearing a nasal cannula (NC) with an oxygen concentrator on and the gauge was set at 4 LPM. On 11/1/24 at 1:10 PM, the surveyor asked the Licensed Practical Nurse (LPN) to accompany her to Resident #6's room. The surveyor and the LPM entered Resident #6's room, and both observed the resident in the bed with the head of the bed elevated, and a TF running via a machine. The resident was wearing a NC and the oxygen concentrator was on with the gauge set at 4 LPM. The LPN confirmed the concentrator was on and the gauge was set at 4 LPM. On that same day at the same time, the surveyor and the LPN together reviewed the electronic medical record (EMR) for the resident's order for oxygen. The LPN stated that the resident's PO was for 2 LPM, not 4 LPM and acknowledged the PO should have been followed. On 11/1/24 at 1:29 PM, the surveyor discussed the above observations and concerns with the Director of Nursing (DON) who confirmed the PO should have been followed for the administration of Oxygen. A review of the facility's Oxygen Therapy policy and procedure dated 5/24 indicated .The purpose of oxygen therapy is to administer oxygen in cases where insufficient oxygen is carried to the tissues by the blood .oxygen therapy is administered only as ordered by a physician .the physician's order will specify the rate of oxygen flow. NJAC 8:39 27.1 (a)

Based on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: 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 (CNA) 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 Reports (AAS-11 and AAS-12) for the 11/07/2024 Standard survey at Peace Care St. Joseph's revealed the following. There were no deficient practices identified for Registered Nurse staffing as submitted for the 2 weeks of AAS-12 staffing from 10/13/2024 to 10/26/2024. The facility was deficient in CNA staffing for residents on 4 of 14 day shifts for the 2 weeks of AAS-11 staffing from 10/13/2024 to 10/26/2024, as follows: -10/13/24 had 14 CNAs for 123 residents on the day shift, required at least 15 CNAs. -10/18/24 had 15 CNAs for 128 residents on the day shift, required at least 16 CNAs. -10/19/24 had 15 CNAs for 128 residents on the day shift, required at least 16 CNAs. -10/20/24 had 15 CNAs for 128 residents on the day shift, required at least 16 CNAs. On 11/4/24 at 12:30 PM, the surveyor observed Resident #87 in bed. The resident stated that she/he had not been changed or bathed all morning and further stated that she/he wanted to get washed up and changed. On 11/4/24 at 12:35 PM, the surveyor interviewed the CNA who stated that Resident #87 was on her assignment. The CNA confirmed that she had 10 Residents on her assignment and had not yet provided care to Resident #87. At that time, the CNA and the surveyor entered Resident #87's room. The CNA exposed Resident #87's incontinence brief which was wet, and both the surveyor and the CNA observed the resident had a bladder pad inserted within the incontinence brief. The CNA stated that she doesn't use bladder pads on resident. She stated that it was the night CNA who put it there. On 11/4/24 at 1:34 PM, in the presence of the survey team, the Director of Nursing (DON) stated that incontinence care should be provided to the residents every 2 hours. The surveyor informed the DON and Licensed Nursing Home Administrator of the staffing ratio concerns on 11/7/24 at 1:00 PM. No further information was provided to the surveyor by the facility administration. Refer to F677D NJAC 8:39-5.1(a); 27.1(a); 27.2(d); 27.2(h)

Based on interviews, record review, and review of pertinent facility documentations, it was determined that the facility failed to ensure medication orders for a newly admitted resident from the hospital were completely and accurately relayed to the Attending Physician (AP). On the day Resident #1 was admitted to the facility, there were six discontinued medications not clarified with the AP for continuance. This deficient practice was observed in one of three newly admitted residents (Resident #1) reviewed for admission orders as evidenced by the following: According to Resident #1's Admission Record (AR), the Resident Information revealed that Resident #1 had diagnoses of which included but not limited to Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. According to the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities and helps the facility identify residents' health problems, dated 06/07/2024, showed that Resident #1 Brief Interview for Mental Status (BIMS) Summary Score is 15 which indicated Resident's cognition was intact. A review of Resident #1's Progress Notes (PN), dated 05/26/2024 at 23:04 [11:04 pm, evening] and documented by Registered Nurse (RN) #1, .All due meds given per MAR [medication administration record} but pt [Resident] refused some meds . A review of Resident #1's PN, dated 05/27/2024 at 09:16 [9:16 am, morning] and documented by RN #2, .res [Resident] alert and oriented but declined all medication and advised that [she/he] had left a voicemail for the social worker to discuss medication as [she/he] insisted was not ordered any of the medications contained on her MAR. res refused all AM [morning] medication . A review of Resident #1's After Visit Summary (AVS), a paper from the hospital with detailed summary of discharge instructions that explains patient's health and guide for recovery. The AVS may include information on vitals, allergies, medication lists, orders, diagnoses, and upcoming appointments. The AVS for Resident #1 dated and printed at 5/24/2024 1:14 pm [afternoon], revealed: (a) on page 1 of 7 with instructions Your medications have changed; START taking: acetaminophen (TYLENOL), Quetiapine (Seroquel), (b) on page 2 of 7 with instructions Change how you take: levothyroxine (Synthroid); STOP taking: hydralazine 10 mg tablet (Apresoline),hydrochlorothiazide 25 mg tablet (Hydrodiuril), losartan 100 mg tablet (Cozaar), metoprolol succinate 50 mg XL tablet (Toprol-XL), trazodone 50 mg tablet (Desyrel), and valproic acid 250 mg capsule (Depakene). The AVS further revealed on page 3 of 7 the Medication List: acetaminophen 500 mg tablet, Freestyle Libre 2 Sensor kit, Levothyroxine 88 mcg tablet, melatonin 3 mg tablet, One Touch Delica Plus Lancet, and Quetiapine 25 mg tablet. The AVS provided no pages of 4 of 7, 5 of 7, 6 of 7, and page 7 of 7. A review of Resident #1's Order Recap Report (ORR) with Order Date: 05/01/2024 - 06/30/2024, indicated the following: Hydralazine Oral Tablet 10 MG (Hydralazien HCl) Give 1 tablet by mouth two times a day for htn [hypertension] with Order Date: 05/24/2024 Start Date: 05/25/2024 End Date: 05/27/2024. Hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day for htn [hypertension] with Order Date: 05/24/2024 Start Date: 05/25/2024 End Date: 05/27/2024. Losartan Potassium Oral Tablet 100 MG (Losartan potassium) Give 1 tablet by mouth in the afternoon for htn [hypertension] with Order Date: 05/24/2024 Start Date: 05/25/2024 End Date: 05/27/2024. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for htn [hypertension] with Order Date: 05/24/2024 Start Date: 05/25/2024 End Date: 05/26/2024. Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 0.5 tablet by mouth at bedtime for depression 0.5 tab=25mg with Order Date: 05/24/2024 Start Date: 05/25/2024 End Date: 05/28/2024, and Valproic Acid Oral Capsule 250 MG (Valproic Acid) Give 2 capsule by mouth in the evening for seizure with Order Date: 05/24/2024 Start Date: 05/25/2024 End Date: 05/27/2024. A review of Resident #1 MAR dated 5/1/2024 - 5/31/2024 indicated the following: Hydrochlorothiazide Oral Tablet 25 MG (Hydrochlorothiazide) Give 1 tablet by mouth one time a day at 0900 [9 am] - checked and initialed [administered] by nurse on 5/25/24 and 5/26/24, initialed by nurse and recorded as 2 (drug refused) on 5/27/24. Losartan Potassium Oral Tablet 100 MG (Losartan Potassium) Give 1 tablet by mouth in the afternoon for htn [hypertension] at 1800 [6 pm] - checked and initialed [administered] by nurse on 5/25/24 and 5/26/24, recorded as 2 (drug refused) on 5/27/24 and initialed by nurse. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for htn [hypertension] at 0900 [9 am] - checked and initialed [administered] by nurse on 5/25/24 and 5/26/24. Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 0.5 tablet by mouth at bedtime for depression 0.5 tab=25mg at 2100 [9 pm] - checked and initialed [administered] by nurse on 5/25/24, 5/26/24, and 5/27/24. Valproic Acid Oral Capsule 250 MG (Valproic Acid) Give 2 capsule by mouth in the evening for seizure at 1800 [6 pm] - checked and initialed [administered] by nurse on 5/25/24, 5/26/24, and 5/27/24. Hydralazine HCl Oral Tablet 10 MG (Hydralazine HCl) Give 1 tablet by mouth two times a day for htn [hypertension] at 0900 [9 am and 2100 [9 pm] - checked and initialed [administered] by nurse on 5/25/24 and 5/26/24 at 0900, recorded as 2 [drug refused] on 5/26/24 at 2100, and recorded as 2 [drug refused] on 5/27/24 at 0900 and 2100 and initialed by the nurse. In an interview of the surveyor with RN #3 on 09/20/24 at 12:42 pm [afternoon], RN #3 stated newly admitted residents (NAs) would come with medical records from the hospital. RN #3 further stated with NAs she would follow up with the MD [physician]/ AP on the list of medications upon admission of the residents. In an interview of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the House Supervisor Registered Nurse (RN #4) on 09/20/24 at 3:41 pm, RN #4 stated with newly admitted residents from the hospital, they would follow the newly admitted residents' medication list from the hospital. RN #4 further stated the nurse doing the admission will call the AP and go over the list of medications with the physician. RN #4 was shown Resident #1's AVS by the surveyor revealing six medications were discontinued from the hospital and Resident #1 AVS with missing pages. RN #4 cannot provide an answer. The facility LNHA stated they will look further for the missing pages. In an interview with the AP [name] on 09/20/24 at 3:36 pm, AP stated the facility nurse would call him to confirm newly admitted residents' medications from the hospital. AP further stated he normally does not see the patient until 2 days after the admission. At this point, surveyor informed AP that there were six medications of Resident #1 discontinued from the hospital prior to coming to the facility. AP stated he was not aware of the six discontinued medications, and he cannot remember. In the facility policy on New Admissions Policy: The organization will maintain and communicate accurate resident medication information. Under Procedure: .2. The medications ordered for the resident on the hospital discharge medication list will be compared and any discrepancies (for example, omissions, duplications, contraindications, unclear information, potential interactions and changes) are resolved by bringing them to the attention of the resident's physician 4. The physician will be contacted to review and approve the medication list on day of admission. NJAC 8:39-29.2(d)

Based on interviews, record review, and review of pertinent facility documentations, it was determined that the facility failed to keep an accurate and complete list of Resident #1 discharged medical records from the hospital which entailed important medication discharge instructions for reference upon admission of the Resident to the facility. This deficient practice was evidenced in one out of three residents (Resident #1) reviewed for admission orders as follows: According to Resident #1's Admission Record (AR), the Resident Information revealed that Resident #1 had diagnoses of which included but not limited to Type 2 Diabetes Mellitus, Anemia, Hypothyroidism, Bipolar Disorder, Depression, and Acute Pancreatitis without Necrosis or Infection. According to the Minimum Data Set (MDS), an assessment tool that provides a comprehensive assessment of a resident's functional capabilities and helps the facility identify residents' health problems, dated 06/07/2024, showed that Resident #1 Brief Interview for Mental Status (BIMS) Summary Score is 15 which indicated Resident's cognition was intact. A review of Resident #1's After Visit Summary (AVS), a paper from the hospital with detailed summary of discharge instructions that explains patient's health and guide for recovery, and may include information on vitals, allergies, medication lists, orders, diagnoses, and upcoming appointments, dated and printed at 5/24/2024 1:14 pm [afternoon], revealed: (a) on page 1 of 7 with instructions Your medications have changed; START taking: acetaminophen (TYLENOL), Quetiapine (Seroquel), (b) on page 2 of 7 with instructions Change how you take: levothyroxine (Synthroid); STOP taking: hydralazine 10 mg tablet (Apresoline),hydrochlorothiazide 25 mg tablet (Hydrodiuril), losartan 100 mg tablet (Cozaar), metoprolol succinate 50 mg XL tablet (Toprol-XL), trazodone 50 mg tablet (Desyrel), and valproic acid 250 mg capsule (Depakene). The AVS further revealed on page 3 of 7 the Medication List: acetaminophen 500 mg tablet, Freestyle Libre 2 Sensor kit, Levothyroxine 88 mcg tablet, melatonin 3 mg tablet, One Touch Delica Plus Lancet, and Quetiapine 25 mg tablet. The AVS provided no pages of 4 of 7, 5 of 7, 6 of 7, and page 7 of 7. In an interview of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the House Supervisor Registered Nurse (RN #4) on 09/20/24 at 3:41 pm, RN #4 stated with newly admitted residents (NAs) from the hospital, they would follow the newly admitted residents' medication list from the hospital. RN #4 further stated the nurse doing the admission will call the AP and go over the list of medications with the physician. RN #4 was made aware by the surveyor of Resident #1 six medications were discontinued from the hospital. RN #4 cannot provide an answer and was shown the Resident's AVS with missing pages. In the facility policy on New Admissions Policy: The organization will maintain and communicate accurate resident medication information. Under Procedure: .3. If it is difficult to obtain complete information on current medications from a resident, a good faith effort to obtain this information from other sources will be attempted. NJAC 8:39- 35.2(d)12

Complaint # NJ00161813 Based on interview and record review it was determined that the facility failed to provide effective care and services to promote healing of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Resident #105's right heel wound was left untreated for more than a month. During this period the wound's length doubled in size. The deficient practice was evidenced by the following: The surveyor reviewed Resident #105's closed hybrid medical record which revealed the following information. The Admission Record indicated the resident was admitted to the facility from the hospital on 12/5/22. The nurse documented in a 12/5/22 Admission Summary Progress Note that the resident had a small skin opening on the coccyx and an Ace Wrap (an elastic bandage wrap) on the right lower extremity. The nurse documented in a 12/6/22 Nursing Admission Screening/History report that the resident was admitted with a fibula and tibia fracture (not indicating whether left or right leg) and a Stage II coccyx skin opening measuring a length of 0.1 centimeter (cm) x a width of 0.1 cm x by a depth of 0.1 cm (a Stage II is a partial thickness loss of dermis presenting as a shallow open ulcer; may also present as an intact or open blister). The resident's Pressure Ulcer Comprehensive Care Plan, initiated on 12/6/22 and revised on 1/30/23, listed a Focus area of [resident] has potential for pressure ulcer development due to decreased mobility and incontinency of bladder. An entry was added on 1/23/23 which read noted with a stage 2 pressure ulcer and right heel DTI [deep tissue injury]. One intervention was added on 1/23/23 to apply an air mattress. All other care plan interventions were initiated on 12/6/22 consisting of general measures to prevent pressure ulcers. The 12/12/22 Admission Minimum Data Set assessment tool coded the resident as having no long or short term memory impairment (Section C), having an other fracture (Section I) and one Stage II pressure ulcer (Section M) present on admission. A 12/15/22 Report of Consultation written by the orthopedic physician indicated a cast was applied to the right leg for a diagnosis of right tibia fibula fracture. A 1/12/23 Report of Consultation written by the same orthopedic physician indicated the right leg cast was removed and a right leg CAM walker boot was prescribed. (A CAM boot is an adjustable walking boot used for the treatment and stabilization of fractures.) The orthopedic physician's 1/12/23 physical examination indicated the skin to the right leg was dry and intact. The nurse documented in a 1/27/23 Wound-Weekly Observation Tool that a right heel wound was acquired on 12/29/22 and was improving. The wound was measured at a length of 15 millimeters (mm) x a width of 15 mm x a depth of 1 mm. The tool's section for the current treatment plan noted the use of Skin Prep (a protective barrier wipe). A review of physician and nursing progress notes from 12/29/22 through 1/26/23 failed to reveal evidence of the development of a right heel pressure ulcer on 12/29/22. A 1/27/23 Wound Consultation indicated the resident was observed with a full thickness wound of the right heel, 1.5 cm x 1.5 cm x 0.1 cm. (This is equivalent to 15 mm x 15 mm x 1 mm.) Wound base dry eschar [necrotic tissue], no drainage noted. The treatment plan was identified to cleanse affected area with NSS [normal saline solution]; apply skin prep twice daily; offload affected; continue/upgrade to alternating pressure mattress. A review of December 2022 and January 2023 Treatment Administration Records failed to reveal a physician's order for a wound treatment to the right heel. There was a 12/6/22 physician's order to maintain right leg splint and a 12/7/22 physician's order to monitor skin integrity to right leg while using splint. However, there was no physician's order for a treatment to the right heel in December 2022 or January 2023. A 2/3/23 Wound Consultation indicated the right heel was a full thickness wound measuring 2 cm x 2 cm (no depth measurement noted). It was noted by the practitioner that the size increased. Treatment plan was to continue Skin Prep. A 2/10/23 Wound Consultation indicated the right heel full thickness wound had increased in size to 3 cm x 2 cm. Skin Prep treatment was to continue. A 2/17/23 Wound Consultation noted the size of the right heel wound was stable at 3 cm x 2 cm. The practitioner's treatment plan was to discontinue Skin Prep and start Santyl-Collagenase ointment to the wound daily. A review of the February 2023 TAR included a 2/18/22 physician's order for a right heel wound treatment of Medihoney/Burn Dressing External Paste dressing; apply to right heel topically every day shift for wound treatment; cleanse with NS [normal saline], pat dry, apply Medihoney and cover with dressing. The right heel wound treatment was documented as completed by nursing on 2/19/23 and 2/20/23. A second physician's right heel wound treatment order was written on 2/20/23 for Santyl [an enzymatic debridement agent used to destroy necrotic tissue within a wound bed] External Ointment 250 units/gram (Collagenase); apply to right heel topically every day shift for wound care post wash with NSS; pat dry then cover with dry dressing. The wound treatment was documented as completed on 2/21/23. A 2/20/23 (17:41) Health Status Note documented Resident #105 was transferred to the hospital at 5:01 PM due to unresponsiveness. The surveyor interviewed a unit Licensed Practical Nurse (LPN) on 8/17/23 at 11:47 AM. The LPN stated she did not remember Resident #105. She further stated the Wound Consultant discusses the proposed wound treatment with the unit nurse and the Consultant writes the order. The surveyor interviewed a unit Registered Nurse (RN) on 8/17/23 at 12:04 PM. The RN did not remember Resident #105. The RN stated the Wound Consultant discusses the recommended treatment with the unit nurses and the Consultant calls the physician who then writes the treatment order. The surveyor interviewed the Director of Nursing (DON) and the Administrator on 8/17/23 at 12:30 PM. The DON stated the facility procedure is for the Wound Consultant to discuss the recommendations with the unit nurse. The unit nurse contacts the physician, who writes the order. The DON stated Resident #105 was first observed with a right heel wound on 1/23/23, not on 12/29/22. She stated a right heel treatment was initiated on 1/23/23. The DON was unable to provide evidence that a wound treatment was initiated on 1/23/23. The DON stated that the nurse who first observed the right heel wound on 1/23/23 did not follow facility protocol by calling the primary physician with the Wound Consultant's recommendation. The nurse was terminated. The surveyor interviewed the Wound Consultant on 8/18/23 at 11:47 AM. She stated that if the resident was receiving Skin Prep, she would have no way of knowing whether it was applied since the medication is clear and a dressing is not used to cover the wound. She further stated she discusses wound treatments with the unit nurse. The unit nurse contacts the primary physician to write the order. The Pressure Injury Prevention Guidelines, implemented 11/20/21 and reviewed/revised 2/20/23, was presented to the surveyor on 8/16/23 by the DON. Step 9 stated that the effectiveness of interventions will be monitored through ongoing assessment of the resident and/or the wound. Considerations for needed modifications included development of a new pressure ulcer and lack of progression of the wound. The Consulting Physician/Practitioner Orders policy, implemented 10/2021 and reviewed/revised 8/2023, was presented to the surveyor on 8/18/23 by the DON. Step 2 indicated the consulting physician/practitioner discusses the order recommendation with the nurse. The nurse contacts the primary physician to verify the order. NJAC 8:39-25.2(b)(c) NJAC 8:39-27.1(e)

Based on observation, interview, and record review, it was determined that the facility failed to a.) assess for complications upon their return from the renal dialysis center for 2 of 2 residents (Resident #61, and #49) and b.) consistently monitor fluid restriction instructions in accordance with the physician's order for 1 of 2 resident (Resident #49) reviewed for dialysis care. The deficient practice was evidenced by the following: 1. The surveyor observed Resident #61 awake in bed on 8/14/23 at 11:41 AM. At that time, the unit Licensed Practical Nurse (LPN #1) stated the resident went to the renal dialysis (RD) clinic on Tuesdays, Thursdays, and Saturdays. The LPN stated an assessment of vital signs and the RD access site prior to leaving for the RD clinic and upon return from the RD clinic were documented in electronic nurse progress notes. A review of the hybrid medical record revealed the following information: The 6/15/23 Quarterly Minimum Data Assessment (MDS) tool indicated the resident had end stage renal disease and was dependent on renal dialysis (Section I). The Medication Review Report included an 8/17/23 physician order for Dialysis Tues/Thurs/Sat at [hospital name] at 9am and Check left arm AV shunt q shift for bruit/thrill/bleeding. (The AV shunt is the RD venous access site which is assessed by sound and feel.) The RD Care Plan (initiated 3/14/22, revised 8/15/23 and 8/17/23) instructed nursing staff to check left arm AV shunt q shift for bruit/thrill/bleeding. The surveyor reviewed Nurse Progress Notes for 13 days in July and 6 days in August during which the resident went out for RD. Nursing documented a post-RD assessment of the AV shunt on 3 of 19 days. The surveyor interviewed the unit LPN #1 a second time on 8/15/23 at 9:35 AM. The LPN stated nursing should document vitals and access site assessments before and after the resident receives RD in the electronic progress notes. The surveyor discussed concerns with the Director of Nursing (DON) and the Administrator on 8/15/23 at 1:37 PM. During that discussion, no further information was provided by the DON or Administrator. On 8/16/23 at 1:38 PM the DON provided the surveyor with the facility policy and procedure for Hemodialysis, reviewed/revised 3/2023. Step 8 stated that The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. On 8/17/23 at 10:05 AM the DON stated to the survey team that the nurses were supposed to document the post-RD assessments in the electronic progress notes. She further stated that this had been done inconsistently. 46889 2. On 08/09/23 at 11:04 AM, the surveyor observed Resident #49 sitting in the chair with an eye patch to his right eye. The resident stated that he would go to dialysis today at 1:00 p.m. The surveyor reviewed the medical records of Resident #49, which revealed the following: The 7/07/2023 Quarterly MDS tool indicated the resident had end-stage renal disease and was dependent on renal dialysis (Section I). Physician Orders for Dialysis every MWF at 2 PM and Check for Bruit and Thrill on L arm q shift every shift for monitoring. The care plan in July and August does not reflect the order for left arm monitoring for bruit and thrill. The surveyor reviewed Progress Notes for 13 days in July and 4 days in August, during which the resident went out for RD. There's no nursing documentation post-RD assessment of the AV shunt on 3 of those days. Seventeen days RD days did not have post-RD nursing assessments of the AV shunt. On 08/15/23 at 11:04 AM, the surveyor interviewed the unit manager and stated there was no consistent documentation from the nurses/staff when the resident returned from dialysis. On 8/15/23 at 1:37 PM, The surveyor discussed concerns with the DON; no further information was provided. On 8/16/23 at 1:38 PM, the DON provided the surveyor with the facility policy and procedure for Hemodialysis, reviewed/revised on 3/2023. Step 8 states, The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. On 8/17/23 at 10:05 AM, the DON stated to the survey team that the nurses were supposed to document the post-RD assessments in the electronic progress notes. She further stated that this was done inconsistently. 3. The Order Summary Report (OSR) for Resident #49 was revealed in the Physician's Order (PO) dated 10/19/2022 for Fluid Restriction: 1000 ml/day. Nursing =176 ml (8-4 shift = 120 ml, 4-12 shift = 30 ml, 12-8 shift = 26 ml) Supplements = 344 ml, and Dietary = 480 ml. The Electronic Medication Administration Record (eMAR) in July 2023 reflected the above 10/19/22 order for 1000 ml Fluid Restriction per day. The order was also specified on the eMAR as 176 ml per day for nursing. The July 2023 eMAR reflected that nurses administered fluids 18 times outside the physician-ordered fluid restriction for Nursing of 176 ml per day on the following dates: 7/01/23: The nurse administered 290 ml per day. 7/02/23: The nurse administered 260 ml per day. 7/05/23: The nurse administered 210 ml per day. 7/06/23: The nurse administered 240 ml per day. 7/07/23: The nurse administered 266 ml per day. 7/08/23: The nurse administered 360 ml per day. 7/09/23: The nurse administered 266 ml per day. 7/10/23: The nurse administered 195 ml per day. 7/13/23: The nurse administered 266 ml per day. 7/14/23: The nurse administered 296 ml per day. 7/17/23: The nurse administered 232 ml per day. 7/22/23: The nurse administered 386 ml per day. 7/23/23: The nurse administered 266 ml per day. 7/24/23: The nurse administered 206 ml per day. 7/25/23: The nurse administered 266 ml per day. 7/27/23: The nurse administered 270 ml per day. 7/28/23: The nurse administered 200 ml per day. 7/29/23: The nurse administered 266 ml per day. On 8/14/23 at 11:36 AM, the surveyor interviewed the LPN/UM and stated that the resident goes out on pass with the son, who is both aware of the fluid restriction. The staff continued educating the resident and son on maintaining the fluid restriction. On 8/15/23 at 01:27 PM, the survey team met with the Licensed Nursing Home Director (LNHA) and Director of Nursing (DON) and did not comment further. The facility policy titled Fluid Restriction with the revised date of 08/14/2023 stated under Policy: It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. NJAC 8:39-27.1(a)