Every finding on record at Redbank Center for Rehabilitation and Healing

Complaint #2588341Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to maintain the resident's environment and living areas in a safe, sanitary, and homelike manner by ensuring that worn hallway carpeting and damaged shower flooring and equipment were identified and repaired in a timely manner. This deficient practice was identified for 2 of 3 nursing units (2nd floor and 4th floor units) and was evidenced by the following:On 7/14/2026 at 10:32 AM, the surveyor toured the second-floor nursing unit A-wing shower room and observed the following:1. A wet shower chair had a large tear on the blue mesh backing where the back of the occupant would lean back while being showered. The tear in the mesh backing was more than three quarters of the length.2. Tile grout and wall tiles inside the shower stall had blackish and yellowish substance. On 7/14/2026 at 10:46 AM, the surveyor toured the fourth-floor nursing unit and observed the following:1. Carpet flooring had multiple areas with thick build-up of grey to black substances. These were mostly on paths leading to the elevators. These areas were darker than the rest of the carpeting which had red and brown patterns.2. The carpeting at the bottom of a smoke barrier door in the hallway was taped with silver duct tape frayed on the edges.2. The surveyor tripped over a loose cream-colored tile when the surveyor entered the A-wing shower room. The surrounding tiles were either loose, cracked, or chipped.2. The shower room on A-wing side had tile grout with blackish and yellowish substances inside the shower stall.3. The shower room had an unlined trash bin beside the toilet bowl. The bin contained used gloves, tissue paper and other trash.4. The shower room had a wet shower chair without the mesh backing.5. A digital chair scale used for weighing residents had thick deposits of blackish dirt and other substances along the base. Inside the groove of the chair was a thick pile of dirt and debris to include bottle caps.6. A wet shower commode had a chipped adjustment dial on the right side with sharp edges.7. A wet shower chair had a seat with peeling masking tape around it. The rear right foot of the chair had pinkish to orange slimy substance. On 7/14/2026 10:46 AM, the surveyor showed the Unit Manager/ Licensed Practical Nurse (UM/ LPN #1) the loose, chipped and cracked tiles, the chair scale with heavy build-up of dirt and debris, and the shower chairs with peeling plaster, broken dial and absent backing. UM/ LPN #1 stated that they sent a message to the maintenance staff to take care of the shower flooring and shower chairs.On 7/15/2026 at 10:49 AM, the surveyor observed the door to the 4th floor shower room - A wing. The door had a signage posted outside with instructions not to use the room because the floor is being repaired. On 7/15/2026 at 12:07 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that the former Director of Maintenance (DOM) have retired without notice last 6/26/2026 and that they had a new DOM starting on 7/20/2026. The facility did have a maintenance staff (MS) and another one assisting from a sister facility. The LNHA stated that the plan was to replace the carpeting on the fourth floor. The LNHA provided the surveyor with a copy of a price quotation from a flooring vendor. No signed contract with the flooring vendor was provided to the surveyor. The LNHA also stated that shower chairs with torn mesh backing, with peeling plaster/ tape, the one with the chipped dial and sharp edge, and the one with missing mesh backing were taken out of service. The LNHA stated that the fourth-floor shower tiles were re-tiled and secured on 7/14/2026 after they were brought to their attention. The LNHA stated that the chair scale was cleaned immediately.On 7/16/2026 at 9:32 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the expectations regarding equipment in the facility, such as shower chairs used by the residents, were all in good working condition and clean. The DON also stated that shower rooms should not have loose tiles and be free from mold.On 7/16/2026 at 12:21 PM, during an interview with the surveyor, Maintenance Staff (MS) stated that the Maintenance department handles all the repairs in the facility and that housekeeping handles the cleanliness in the units, common areas, and the shower rooms. He/ she stated that they do daily rounds and check the maintenance book at each nurses' station or unit where staff write the work order requests. MS also stated that he/ she checks the shower rooms daily. MS denied that they previously received a work order for the flooring in the 4th floor shower room.A review of the facility policy reviewed in December 2025, titled Homelike Environment included under Policy the following: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Under the Policy Guidelines, the following are indicated: 3.) Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 11.) e. Report any items in disrepair to maintenance promptly using maintenance log. N.J.A.C 8:39 - 31.4 (a) (e) (f)

Complaint # 2588341; #2649970Based on interviews and review of pertinent documents provided by the facility, it was determined that the facility failed to implement their policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property by ensuring screening by reference checks were completed for newly hired employees. This deficient practice was identified for 19 out of 87 newly hired employee files reviewed. The deficient practice was evidenced by the following: On 7/16/2026 at 8:42 AM, Surveyor #1 reviewed 11 employee files, which revealed the following:1. Recreational Aide (RA #1), with a hire date of 7/10/2025, did not have a previous employment reference check on file.2. RA #2, with a hire date of 5/4/2026, did not have a previous employment reference check on file. On 7/16/2026 at 8:45 AM, Surveyor #2 reviewed 39 employee files, which revealed the following:1. Dietary Aide (DA #1), with a hire date of 6/5/2025, did not have a previous employment reference check on file.2. Certified Nursing Assistant (CNA #1), with a hire date of 10/1/2025, did not have a previous employment reference check on file.3. Director of Recreational Activities ([NAME]), with a hire date of 5/8/2026, did not have a previous employment reference check on file.4. Certified Occupational Therapist Aide (COTA), with a hire date of 12/8/2025, did not have a previous employment reference check on file.5. DA #2, with a hire date of 1/22/2026, did not have a previous employment reference check on file.6. CNA #2, with a hire date of 11/17/2025, did not have a previous employment reference check on file.7. Licensed Practical Nurse (LPN #1), with a hire date of 10/16/2025, did not have a previous employment reference check on file.8. CNA #3, with a hire date of 11/3/2025, did not have a previous employment reference check on file.9. CNA #4, with a hire date of 6/22/2026, did not have a previous employment reference check on file.10. LPN #2, with a hire date of 9/9/2025, did not have a previous employment reference check on file.11. CNA #5, with a hire date of 10/16/2025, did not have a previous employment reference check on file. On 7/16/2026 at 8:47 AM, Surveyor #3 reviewed 22 employee files, which revealed the following:1. CNA #6, with a hire date of 1/18/2026, did not have a previous employment reference check on file.2. Occupational Therapist (OT #1), with a hire date of 7/10/2025, did not have a previous employment reference check on file.3. Physical Therapist (PT #1), with a hire date of 10/13/2025, did not have a previous employment reference check on file.4. CNA #7, with a hire date of 7/10/2025, did not have a previous employment reference check on file.5. RA #3, with a hire date of 3/26/2025, did not have a previous employment reference check on file. On 7/16/2026 at 8:50 AM, Surveyor #4 reviewed 11 employee files, which revealed the following:1. CNA #8, with a hire date of 11/21/2025, did not have a previous employment reference check on file. On 7/17/2026 at 8:36 AM, during an interview with Surveyor #1, the Director of Human Resources (DHR) stated that their job description included recruitment, interviewing new hires, preparing the onboarding packet for new employees, collect credentialing, and payroll. The DHR stated that they are responsible for reference checks. The DHR further stated that they are responsible for making sure that employee files are completed.On 7/17/2026 at 8:38 AM, the DHR handed reference checks to Surveyor #1. The DHR stated that some reference checks are still missing.On 7/17/2026 at 8:52 AM, during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) stated that the head of human resources (DHR) is responsible for completing new employee files.A review of the undated document provided by the facility titled Position Description - Human Resources Director included under Essential Duties and Responsibilities the following: Onboarding and Employee File Maintenance - Perform reference checks.A review of the facility policy revised on 1/1/2026, titled Employment Process and Hiring Procedure included under Screening Procedure the following: 4.) For potential new hires, the hiring management is responsible for verifying applicant information and conducting reference checks. At least two professional reference checks are required. N.J.A.C. 8:39 - 9.3 (b)

Complaint #2649970Based on observation, interview, review of medical records and other pertinent facility documentation if was determined that the facility failed to a.) follow surgical consultation post-appointment recommendations to assure the continuity of care, and b.) follow wound care consultant recommendations for 2 of 33 residents reviewed (Resident #7 and Resident#174).This deficient practice was evidenced by the following: 1.) A review of the admission Record (AR) indicated that Resident #174 was admitted to the facility with the diagnoses which included but was not limited to removal of an external fixation device and acute embolism and thrombosis of deep vein of the right lower extremity. A review of the admission Minimum Data Set (MDS) an assessment that facilitates resident's care dated 7/19/2025, indicated that Resident #174 had moderate cognitive impairment and was dependent on activities of daily living (ADLs). The MDS also indicated that the resident had a surgical wound which required surgical wound care. A review of Resident #174's Treatment Administration Record (TAR) reflected a physician's order (PO) dated 7/12/25, to ensure that the resident wore a right lower extremity (RLE) immobilizer every shift. A review of the orthopedic surgical wound consult dated 7/25/26 indicated that Resident #174 was being seen for post two weeks out from a bicondylar tibial plateau and shaft open reduction and internal fixation (ORIF) with lateral meniscus repair and removal of fixator on 7/5/2025 after a motor vehicle accident. The surgical consult recommendations were as follows: -Hinged knee brace was provided, and the brace was unlocked with unlimited range of motion. The brace could be taken off when performing therapy and exercises as well as for hygiene and when the resident was at rest. -Elevation and icing for swelling. -May apply compression stockings. A review of the Medicare skilled daily note dated 7/25/2025 at 10:59 AM, indicated that Resident #174 returned from an orthopedic appointment. The RLE immobilizer was changed to a hinged brace, which could be removed during therapy and exercise, as well as for hygiene and while resting in bed. A review of the TAR reflected that the resident's RLE immobilizer was not discontinued until 7/30/25 and that a physician's order for the hinged brace was not obtained until 7/28/25. Documentation on the TAR, signed by nursing, indicated that from 7/28/25 through 7/30/25, the resident was wearing both the RLE immobilizer and the hinged brace simultaneously. A review of the TAR also reflected that application of ice daily for 20 minutes every evening shift was not ordered until 8/25/25 which was 31 days after the surgical consultation dated 7/25/25. A review of the TAR also indicated that the application of the compression stockings for swelling was not ordered until 8/11/25, which was 17 days after the surgeon recommended their application to the resident's legs. On 7/15/2026 at 10:36 AM, Surveyor #1 reviewed Resident #174's interdisciplinary care plan (ICP) dated 7/12/25, which indicated that the resident was dependent on staff daily in meeting ADL needs with admitting diagnosis of limited mobility, limited range of motion (ROM), and trauma. Interventions for compression stockings and hinged brace were not included on the ICP until 8/14/25. On 7/15/2026 at 9:41 AM, the surveyor interviewed the Director pf Rehabilitation (DOR) who stated that Resident #174 was admitted to the facility and received skilled physical therapy (PT) and occupational therapy (OT) from 7/14/25 until 9/21/25. The DOR stated that Resident #174 was admitted from the hospital with a right leg immobilizer. She confirmed that Resident #174 went to an orthopedic appointment on 7/25/25 and came back to the facility with a right leg hinged brace. She stated that the nursing department was responsible for obtaining physicians orders for the hinged brace as well as for any new treatment plans that the orthopedic surgeon recommended. On 7/15/2026 at 9:46 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #2) regarding Resident #174 orthopedic follow-up care. LPN/UM #2 stated that upon the resident's return from the orthopedic surgical consultation dated 7/25/25, staff should have immediately reviewed the documentation for new treatment recommendations. Following this review, nursing staff were responsible for contacting the primary care physician to secure matching orders. Upon reviewing the orthopedic surgeons' recommendations from 7/25/25, LPN/UM #2 confirmed that the nursing staff should have reviewed and obtained physician orders for: -Hinged knee brace was provided, and the brace was unlocked with unlimited range of motion. The brace could be taken off when performing therapy and exercises as well as for hygiene and when the resident was at rest. -Elevation and icing for swelling. -May apply compression stockings. During a subsequent review of the July 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR), the LPN/UM confirmed the following nursing and care delays: Documentation showed that nursing staff signed off on simultaneous use of both the RLE immobilizer and Right leg hinged brace from 7/28/25 until 7/30/25. The hinged brace recommended by the orthopedic surgeon on 7/25/25 was not ordered by a physician until 7/28/25. LPN/UM #2 could not explain why physician orders were never received or implemented for the resident's right leg elevation, ice application and compression stocking on 7/25/25 after the nurse reviewed the surgical consult recommendations. LPN/UM #2 concluded by confirming that all orthopedic surgical recommendations should have been processed and implemented on the same day they were recommended, emphasizing that no delay in care or treatment should have occurred. On 7/15/2026 at 11:32 AM, the surveyor interviewed Resident #174's nurse Practitioner (NP) who reviewed the orthopedic surgeon recommendation dated 7/25/25. The NP confirmed that physician orders should have been obtained immediately for all the treatments recommended by the orthopedic surgeon on 7/25/25. The NP noted that the not securing these orders in a timely manner could delay the resident's healing. On 7/16/2026 at 11:41 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the nursing department was responsible to ensure that the primary care physician was notified of the specialist recommendation and obtain orders at that time. The DON confirmed that the nurse did not notify the primary care physician of all the treatment recommendations from the orthopedic recommendations of 7/25/25 and obtain the orders immediately for the following recommendations: -Hinged knee brace was provided, and the brace was unlocked with unlimited range of motion. The brace could be taken off when performing therapy and exercises as well as for hygiene and when the resident was at rest. -Elevation and icing for swelling. -May apply compression stockings. A review of the facility policy with a review date of 12/2025 indicated that the facility would utilize outside consultation services as ordered by the physician and that the purpose was to evaluate and treat a resident's medical condition that may require the services of a specialist. The policy indicated that the consultant would document findings on the consultation form, and the nurse would notify the primary physician of consultants visit and recommendations and transcribe orders as directed by the physician. NJAC 8:39-27.1 2.) On 7/13/2026 at 10:47 AM, the Surveyor #2 observed Resident #7 in the day room sitting in a reclining chair. The resident was lying on their left side, and the Unit Manager/Licensed Practical Nurse (UM/LPN) said the resident always lays that way, they have an abrasion on the left hip. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; protein calorie malnutrition, elevation of liver enzymes, dysphagia (difficulty swallowing), and aphasia (impaired ability to speak, write, or understand language). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 6/30/2026, indicated that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which meant the resident had severe cognitive impairment. Section M, skin conditions indicated the resident was a high risk for pressure ulcer development. A review of Resident #7's Individual Comprehensive Care Plan (ICCP) initiated on 11/13/2024 and revised 2/16/2025, showed a focus area of high risk for skin impairment. Interventions included but were not limited to medications as ordered, and observe skin redness, swelling, or bruising with care. A review of the Wound-Weekly Observation Tool, completed on 7/9/2026 by nursing revealed the resident had a left buttock wound measuring 2.5 centimeters (cm) by 2.5 cm. The observation tool had the current treatment plan to cleanse with normal saline solution, apply bacitracin to wound and cover with a bordered gauze. A review of the Wound Consultant notes, dated 7/9/2026 revealed Resident #7 had a left buttock wound measuring 2.5 cm by 2.5 cm. Wound orders recommended were to clean the wound with normal saline solution, apply Bacitracin ointment, and cover with bordered gauze dressing daily and as needed. On 7/15/2026 at 9:52 AM, the surveyor reviewed the physician orders for wound care to the left buttock and could not locate any wound care orders. The surveyor then reviewed the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) and there was no documentation that Resident #7 was receiving any treatment to the left buttock wound. On 7/15/2026 at 11:16 AM, the surveyor observed Resident #7 in the dayroom in a reclining chair. The surveyor interviewed LPN #3 who was caring for the resident. The surveyor asked if the resident was receiving wound care to the left buttock abrasion and the nurse said, Yes, hydrogel and a dry dressing after cleaning with normal saline. The surveyor asked where it was documented, and she stated in the progress notes. The surveyor could not locate any documentation for the wound care in the progress notes. On 7/15/2026 at 11:40 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN#1) regarding wound care orders for Resident #7 and the wound care consultant process. She stated that the wound care consultants leave a paper with recommendations, But I don't know what happened to this resident. The surveyor asked the UM/LPN#1 to locate a wound care order for Resident #7, and she could not locate one, she told the surveyor that she did not know why the resident didn't have an order and she would call the physician. On 7/17/2026 at 9:53 AM, during a meeting with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the DON stated that the recommendation was missed, and the staff will be educated. The surveyor reviewed the policy titled Physician Orders, dated 12/2025. The policy included that medications shall be administered only upon the written order of a person fully licensed and authorized to prescribe such medications in this state. N.J.A.C. 8:39 - 27.1

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan that identified services to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. This deficient practice was identified for 1of 5 residents reviewed for unnecessary medications (Resident #6) and was evidenced by the following: On 7/13/2026 at 11:00 AM, during initial tour the surveyor observed Resident #6 in the day room sitting at a table by themselves. The resident was unable to be interviewed this time due to a language barrier. The resident spoke Arabic. A review of admission Record (AD) indicated that Resident #6 was admitted to the facility with the diagnoses which included but was not limited to metabolic encephalopathy [a general term describing brain dysfunction caused by chemical imbalances, systemic illness, or organ failure rather than direct physical damage to the brain], altered mental state and major depressive disorder.A review of the significant change Minimum Data Set (MDS) an assessment that facilitates the care of a resident dated 6/25/26 indicated that the resident scored a 6 out of 15 on the Basic Interview for Mental Status (BIMS) which indicated that the resident had severe cognitive impairment. The MDS indicated that Resident #6 did not exhibit any behaviors and requires partial to substantial assistance with activities of daily living. The MDS also indicated that Resident #10 was on antipsychotic medications.A review of the Medication Administration Record (MAR) which contained a physician order (PO) dated 4/8/26 for Lurasidone HCl (antipsychotic) Oral Tablet 120 MG (Lurasidone HCl) Give 1 tablet by mouth in the evening for psychosis.A review of the Black Box warning for the antipsychotic medication Lurasidone which indicated that Increased mortality in elderly patients with dementia-related psychosis. Latuda is not approved for dementia-related psychosis. Elderly patients with dementia who develop psychosis and are treated with antipsychotics (including Latuda) have an increased risk of death.A review of Resident's Interdisciplinary Care Plan (ICP) did not reflect an individualized resident specific ICP for the use of the antipsychotic medication Lurasidone. The ICP reflected a generalized ICP for the use of psychotropic medications such as antidepressant medications, however, did not reflect the use of antipsychotic medications.On 7/15/2026 t a10:00 AM, the surveyor attempted to telephone interview the resident's representative (RP) however there was no answer. The surveyor left a message.On 7/16/2026 at 9:32 AM, the surveyor interviewed the Director of Nursing (DON) who stated that ICPs were initiated on admission to the facility and focus care plans include pain, skin, mobility, falls, communication needs and psychotropic medications.On 7/17/2026 at 9:36 AM, the surveyor team met with the DON who confirmed that an ICP for the antipsychotic medication was not implemented for Resident #6 and stated that the facility added the care plan for the use of the antipsychotic medication after notification by the surveyor. A review of the facility policy dated 1/2026 and titled, Psychotropic Use indicated that resident had the right to be informed and participate in their treatment. Prior to initiating or increasing psychotropic medications resident, family or representative must be informed of the benefit, risk and alternative for the medication, including black box warnings for antipsychotic medications.A review of the facility policy dated 2/2026 and titled, Care Planning indicated that each resident's comprehensive care plan was designed to incorporate identified problem area, incorporate risk factors associated with identified problems, reflect treatment, timetables and objectives in measurable outcomes, aid in reducing declines in the resident's functional level and functional status.NJAC 8:39-11.2; 27.1

Based on observation, interview and record review, the facility failed to ensure services met professional standards of quality by implementing and maintaining a physician's order for heel protector boots for a resident at risk for skin breakdown. This deficient practice was identified for 1 of 1 resident (Resident #93) reviewed for pressure injury prevention and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 7/13/2026 at 11:24 AM, during the initial tour the surveyor observed Resident #93 lying awake in bed without heel protector boots on their feet. On 7/14/2026 at 12:38 PM, the surveyor observed Resident #93 was lying in their bed a second time, without heel protector boots on their feet. The surveyor observed the heel protector boots lying on top of resident's nightstand. On 7/14/2026 at 1:42 PM, the surveyor reviewed the Electronic Medical Records (EMR) for Resident #93 which revealed the following:A review of the admission Record, an admission summary, revealed Resident #93 had diagnoses which included, but were not limited to: alcohol dependence with withdrawal delirium, other seizures (a seizure is when the brain has a sudden burst of electrical activity that can change how a person moves, feels, or acts), displaced fracture of seventh cervical vertebra, initial encounter for closed fracture, (a displaced fracture means that one of these neck bones has broken and the pieces have moved out of place), wedge compression fracture of third thoracic vertebra, (a wedge compression fracture is a type of spinal fracture where the front of a vertebra collapses while the back stays intact, giving the bone a wedge or triangular shape), and fracture of manubrium (is a break in the upper part of the breastbone/sternum). A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/22/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident's skin condition was at risk for pressure ulcers/injuries. A review of the resident's Individual Comprehensive Care Plan (ICCP) dated 6/22/2026, included a focus area that Resident #93 was at risk for development of a pressure ulcer as evidenced by the resident's refusal to get out of bed and had decreased mobility and/or incontinence, and impaired mobility. Interventions included heel protector boots to feet. A review of the Order Summary Report (OSR) included the following physician orders (PO) dated 10/14/2025, for protective heel boots to feet every shift for prevention. A review of the Treatment Administration Record (TAR) for July 2026, revealed a nurse signed the order for heel protector boots to feet on both 7/13/2026 and 7/14/2026 day shift, which indicated the resident was wearing the heel protector boots to bilateral feet.On 7/15/2026 at 10:50 AM, the surveyor interviewed Licensed Practical Nurse #4 (LPN#4) who verified heel protector boots were not on resident's feet and were lying on the resident's nightstand. LPN#4 further stated the protective heel boots should have been applied to resident's feet and confirmed they were important to prevent skin breakdown. On 7/16/2026 at 11:39 AM, the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA) and the survey team, was made aware that Resident #93 was observed by surveyor not wearing physician ordered heel protector boots on their feet for two consecutive days. The DON further acknowledged nursing staff should not have initialed the TAR if the treatment had not been provided.On 7/16/2026 at 11:41 AM, the surveyor interviewed the LNHA who confirmed if there is a physician order for protective heel boots to resident's feet, they should have been applied. On 7/16/2026 at 11:52 AM, the surveyor interviewed the DON who confirmed that heel protector boots should be applied to prevent the development of pressure ulcers.On 7/16/2026 at 11:54 PM, during an interview with the LNHA, he stated it's important to have protective heel boots on the resident's feet to prevent skin breakdown. On 7/16/2026 at 12:10 PM, surveyor interviewed Certified Nursing Assistant #11 (CNA#11) who stated they noticed the resident without protective heel boots on their feet while in bed and the CNA reported it to the nurse. CNA#11 further stated the importance of the protective heel boots on resident's feet is to prevent skin breakdown. On 7/16/2026 at 12:15 PM, surveyor asked LPN#4 to review the resident's TAR with the surveyor. The TAR showed that nursing staff had initialed the form indicating that the protective heel boots were applied every shift on July 13 and July 14. LPN#4 agreed they should not have signed that the treatment was done on those dates in the TAR.On 7/16/2026 at 12:26 PM, surveyor interviewed Unit Manager/Licensed Practical Nurse #1(UM/LPN#1). Nurse acknowledged the nurse should have applied the protective heel boots as ordered by the physician. UM/LPN#1 confirmed the nurse should have applied the protective boots to prevent heel breakdown. A review of the facility provided policy titled Medication Administration revised 12/2025, included under General Information of Importance the following: I. It is a Standard of Practice that all medication and treatments be administered as ordered by the physician. NJAC 8:39 - 11.2(b); 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to implement pressure relief interventions to treat and prevent pressure ulcers/injury in a resident with wounds his/her right lower extremity. This deficient practice was identified for 1 of 4 residents (Resident #8) reviewed for pressure ulcers and was evidenced by the following:On 07/13/2026 at 10:25 AM Resident #8 was observed lying in bed on the initial tour of the facility. Resident #8's spouse stated that Resident #8 developed a sore on his/her leg. Surveyor observed pressure relief boots on top of a Geri-chair and not on Resident #8 while lying in bed.On 07/13/2026 at 12:33 PM the surveyor reviewed the electronic medical record (EMR) for Resident #8. A review of the admission Record revealed that Resident #8 had the following but not limited to diagnoses: acute osteomyelitis to the right ankle and foot, cellulitis, type 2 diabetes mellitus, and peripheral vascular disease. A review of the significant change in status Minimum Data Set (MDS), an assessment tool, dated 06/17/2026 revealed that Resident #8 had a Brief Interview for Mental Status score of 3/15, indicating that Resident #8 was severely cognitively impaired. According to Section GG of the MDS, Resident #8 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear and personal hygiene. Section M of the MDS revealed that Resident #8 had one or more unhealed pressure ulcers/injuries. Resident #8 had 2 unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar and three (3) unstageable pressure injuries presenting as deep tissue injury. Section O revealed that Resident #8 received hospice care while a resident.A review of the Order Summary Report with Active Orders as of 07/15/2026 indicated that Resident #8 had the following physician order: Waffle boots (inflatable medical devices designed to prevent and treat heel pressure ulcers) to BLE (bilateral lower extremities) at all times except during hygiene every shift with a start date of 05/09/2026.A review of the Individualized Comprehensive Care Plan (ICCP) revealed the following Focus: The resident has an arterial/ischemic ulcer of the bilateral lower extremities r/t (related to) peripheral arterial disease left lateral 3rd toe, left dorsal foot, left lateral lower leg, left 1st metatarsal, left lateral foot, right medial great toe, and right circumferential leg (on 7/23). Date Initiated: 07/28/2025 and revised on: 07/28/2025. Resident #8 had the following Intervention/task, Keep the feet clean and dry. Resident prefers to wear (SPECIFY: cotton socks, slippers, bunny boots).A review of the Treatment Administration Record (TAR) dated 7/1/2026 - 7/31/2026 reveled the following order: Waffle boots to BLE at all times except during hygiene every shift. Start Date - 05/09/2026 2300 (11 PM). Review of the TAR revealed that staff documented that Resident #8 had the waffle boots applied to BLE for all shifts from 7/1/2026 through 7/14/2026 night shift, as indicated by check marks and staff initials.On 07/14/2026 at 8:53 AM Resident #8 was observed lying in bed and awaiting the hospice aide to assist with the breakfast meal. There was no bilateral waffle boots in place as ordered. The surveyor observed two (2) green booties (waffle booties) on top of the Geri-chair, as previously observed on 7/13/2026.On 07/14/2026 at 12:04 PM the surveyor observed Resident #8 lying in bed and asleep. Waffle Booties were not observed to be on while in bed and the surveyor observed the booties placed on top of the dresser in front of the window.On 07/15/2026 at 10:35 AM Resident #8 was observed lying in bed with his/her eyes closed and asleep. Resident #8 did not respond to surveyor verbal stimuli. The surveyor observed Resident #8's Waffle boots on the dresser in front of the window and placed them on top of a plastic milk crate. This was the same location they were observed on 7/14/2026. The Waffle boots are ordered to be on at all times except for hygiene. There were no observations of hygiene being performed during surveyor observation.On 07/15/2026 at 10:44 AM [NAME] Woods/CNA (25 years): The surveyor conducted an interview with the Certified Nursing Assistant (CNA #12) The surveyor asked CNA #12 when the waffle booties were to be applied. CNA #12 told the surveyor that they started putting them on but due to his contractures they stopped putting them on because they would bother the resident. At this point Resident #8's spouse, who shares the same room, told the surveyor that Resident #8 would become agitated when staff tried to apply the waffle booties.On 07/15/2026 at 10:53 AM the surveyor interviewed the Licensed Practical Nurse (LPN #2) assigned to Resident #8 on that shift. LPN #2 told the surveyor that they would put the Waffle Booties on intermittently, but the resident becomes agitated. The surveyor then asked LPN #2 what she should do if a resident refuses treatment? LPN #2 stated, I know. I should have discontinued them. LPN further explained that they could get them on sometimes. The surveyor then told LPN #2 that he had observed the Waffle booties in the same place for three days and LPN #2 replied, I know.On 07/15/2026 at 11:25 AM the surveyor conducted an interview with Licensed Practical Nurse/Unit Manager (LPN/UM #3) The surveyor asked LPN/UM #3 why Resident #8 did not have the bilateral Waffle booties on as ordered by the physician. LPN/UM #3 stated the resident had them on earlier, but I guess hospice did not put them back on. The surveyor then pointed out that nursing staff had been documenting for the month of July that they have been in place every shift and the surveyor had not observed them in place over the past 72 hours. LPN/UM #3 replied, Ok. I'll notify the doctor.On 07/16/2026 at 11:48 AM during an interview with facility administration the surveyor alerted the facility Director of Nursing (DON) and Assistant Director of Nursing (ADON) that staff had documented that Resident #8's Waffle Booties were in place as ordered, however the surveyor had observed that the booties were not in place on 4 visual observations. The DON and ADON stated that they could do an intervention. The DON/ADON further stated, We should have documented that they were not tolerated and talked to the physician.A review of the facility provided policy titled Pressure Ulcers/Skin Breakdown Treatment - Clinical Protocol, reviewed: 12/2025. The following was revealed under Treatment/Management:The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.NJAC 18:39-27.1(a)

Based on observation, interview, and review of facility documentation it was determined that the facility failed to store respiratory equipment in a manner to prevent contamination and infection. This deficient practice was identified in 1 of 3 residents reviewed for respiratory (Resident #5) and was evidenced by the following: On 7/13/2026 at 10:36 AM, during the initial tour of the facility Resident #5 was in bed wearing nasal oxygen. The surveyor observed two nebulizer machines (machine that converts liquid medication into an inhalable mist) on the bedside table. There was also a mask used to deliver nebulizer treatments laying on the bedside table. The mask was not in a plastic bag, and the surveyor did not observe a plastic bag for storage. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to; hypertension, obesity, dyspnea (difficult or uncomfortable breathing), and depression.A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 4/11/2026, indicated that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which meant the resident was cognitively intact. Section O, special procedures/treatments indicated the resident wore oxygen at the facility. A review of Resident #5's Individual Comprehensive Care Plan (ICCP) initiated on 4/3/2025 and revised 6/13/2025, showed a focus area of COPD (Chronic Obstructive Pulmonary Disease). Interventions included but were not limited to giving aerosol treatments (medical technique to deliver medication directly into the airways and lungs as a fine, breathable mist) as ordered and monitor for any signs of respiratory infections such as fever, chills, increased difficulty in breathing On 7/15/2026 at 9:35 AM, the surveyor reviewed the physician orders which showed the following: oxygen via nasal cannula at 2 liters as needed for shortness of breath dated 6/1/2026 and Ipratropium-Albuterol Solution 0.5-2.5 (3) Milligrams/3 milliliters (aerosol treatment) 1 vial inhale orally every 4 hours for COPD ** ONLY GIVE TO RESIDENT WHILE AWAKE** DO NOT WAKE RESIDENT UP ordered 7/25/25. On 7/15/2026 at 11:36 AM, the surveyor observed Resident #5 in bed. The residents' nebulizer mask was lying on the bed, not in a bag. The surveyor asked the resident if they removed the mask themselves and the resident stated, Only if they don't come in time. The surveyor asked where it was stored when not in use and the resident opened the nightstand drawer pointed and said, in there. The surveyor asked if the facility provided a bag to store the mask in and the resident told surveyor they were never given a bag. On 7/15/2026 at 12:10 PM, the surveyor then interviewed the Licensed Practical Nurse (LPN#3) caring for the resident. The surveyor asked if the resident removed the nebulizer mask on their own and she said only if the staff doesn't get there fast enough. The surveyor asked how the mask should be stored, and she stated it should be stored in a bag for infection control reasons. The surveyor then interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN#1) regarding nebulizer mask storage. The UM/LPN#1 stated they were stored in plastic bags in the resident room. Review of the policy titled, Respiratory Equipment Management dated 12/2025. Number 8, storage of clean respiratory equipment should be protected from dust, stored in a clean dry area, and stored separately from contaminated equipment.NJAC 8:39-25.2 (c) 3

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that staff consistently monitored, assessed and documented the care of a hemodialysis (a treatment that replicates the kidney's function and cleans the waste from the blood of individuals with kidney disease or failure) access site. This deficient practice was identified for 3 of 3 residents reviewed (Resident #14, Resident #123, and Resident #153) for dialysis service. The deficient practice was evidenced by the following: 1.) On 7/13/2026 at 10:38 AM, Surveyor #1 observed Resident #14 enter his/ her room and said he/ she goes to dialysis on Tuesdays, Thursdays, and Saturdays w/ chair time at 12 PM. The resident had an arteriovenous fistula (AVF; a surgically created connection between an artery and vein used to access the blood for dialysis) to the right upper arm covered by their shirt sleeve. The surveyor reviewed the medical record for Resident #14. A review of the admission Record (an admission summary) revealed the resident had diagnoses which included but were not limited to the following: dependence on renal dialysis, anemia, and end-stage renal (kidney) disease. A review of the resident's most current quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 6/25/2026, reflected the resident had intact cognition. The MDS also revealed that the resident is on dialysis services. A review of the Clinical Physician Orders (CPO) with active orders as of 7/14/2026, revealed the following Physician Orders (PO): - A PO, dated 5/27/2026, for Dialysis on T(Tuesday), TH (Thursday), and S (Saturday) at [name of dialysis center redacted] with chair time at 1 PM. A review of discontinued CPO revealed a PO for checking the access site for bruit and/ or thrill discontinued on 2/19/2026. There was no PO to monitor the resident's dialysis access site (AVF) for bleeding or any sign and symptom of infection. There were no instructions on which arm to use for blood pressure monitoring. There was no PO to monitor and assess blood flow or patency of the access site by checking for bruit (an audible sound) and/or thrill (a vibration that indicates a good blood flow). The last scheduled order for checking the access site for bruit and/ or thrill was discontinued on 2/19/2026. A review of the corresponding Medication Administration Record (MAR) or Treatment Administration Record (TAR) did not reflect any documented evidence that staff was monitoring the resident's access site consistently on a scheduled basis. A review of the resident's individualized comprehensive care plan (ICCP) included a focus area, dated 11/6/2025, that the resident needed dialysis related to renal failure. Interventions included but not limited to: Do not draw blood or take BP (blood pressure) in arm with graft (AVF); Monitor thrill and bruit each shift; Monitor vital signs daily; and Monitor/ document/ report prn any sign and symptom of infection to access site such as redness, swelling, warmth, or drainage. On 7/16/2026 at 9:32 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the expectation was for the facility to give care to dialysis access sites by checking for bruit and/ or thrill pre (before) and post (after) dialysis. On 7/17/2026 at 9:36 AM, during an interview with the survey team, the DON stated that POs for checking bruit and or thrill on access sites were added in the orders for residents on hemodialysis. The DON also stated that nurses were educated to check the access sites every shift. A review of facility policy reviewed in December of 2025, titled Dialysis Policy indicated under Procedure Infection Control the following: The licensed nurse will evaluate, observe, and/or assess the shunt/ fistula site for signs/ symptoms of bleeding and infection every shift. This will be recorded on the resident's medical record. N.J.A.C. 8:39-27.1(a); 2.9 2.) On 7/13/2026 at 9:47 AM, during the initial tour of the facility Resident #123 was in the room in a wheelchair. The resident told Surveyor #2 they attend dialysis treatments three times per week. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, hypertension, dependence on renal dialysis, muscle weakness, and end stage renal disease. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate care, dated 4/28/2026, indicated that Resident #123 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which meant the resident was cognitively intact. Section O, special procedures/treatments indicated the resident was receiving hemodialysis treatments while at the facility. A review of Resident #123's Individual Comprehensive Care Plan (ICCP) initiated on 7/26/2024 and revised on 3/28/2025, showed a focus area of needing hemodialysis related to kidney failure. Interventions included but were not limited to AV fistula/graft (a connection between an artery and a vein to allow for efficient, long term hemodialysis) left arm, no blood pressures or lab work to left arm, and monitor for thrill (vibration felt with fingertips over an AV fistula and bruit (a sound heard with stethoscope over an AV fistula) every shift. A review of the physician order summary revealed Resident #123 had an order to check the left arm AV graft for thrill and bruit every shift. The order was dated 1/13/26. The surveyor reviewed the Medication Administration Record (MAR) and Treatment Administration Record and could not locate nursing documentation of checking for the thrill and bruit each shift. Review of the progress notes showed one nursing note dated 7/9/2026 which stated that the bruit/thrill were positive, meaning the AV graft was functioning. No other documentation was located.On 7/15/2026 at 11:30 AM, the surveyor observed Resident #123 in a wheelchair in the hallway, the resident told surveyor they received dialysis yesterday. On 7/15/2026 at 12:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN#3) for Resident #123 regarding assessing the residents' AV graft for bruit and thrill. She stated they are checked for function and documented in the progress notes. She said it is checked before the resident goes to dialysis. The surveyor then interviewed the Unit Manager/Licensed Practical Nurse UM/LPN#1 regarding documentation of the bruit and thrill. She looked at the order in the Electronic Medical Record (EMR) in the presence of the surveyor and said, Oh, it's not set up for documentation, but I will change it. The surveyor asked the UM/LPN#1 why it should be documented, and she said to show it was completed each shift as ordered and to be sure the AV graft is functioning. Review of the policy titled, Dialysis Policy dated 12/2025, section C indicated that the access site will be monitored per physician order, palpate for thrill and auscultate bruit every shift for the presence of blood flow. NJAC 8:39-2.9 3.) On 07/13/2026 11:14 AM, Resident #153 was observed lying in bed and asleep. Resident #153 did not respond to Surveyor #3's voice when spoken to on the initial facility tour. A review of Resident #153's admission Record revealed that Resident #153 had the following but not limited to diagnoses: Hemorrhage due to vascular prosthetic devices, implants and grafts; end stage renal disease, and dependence on renal dialysis. A review of the quarterly MDS dated [DATE] revealed that Resident #153 had a BIMS score of 15 indicating he/she was cognitively intact. Section O of the MDS revealed that Resident #153 received hemodialysis treatments while a resident at the facility. A review of the Order Summary Report with an order date range: 03/26/2026-07/31/2026, revealed that Resident #153 had the following physician order: Dialysis – Check thrill and bruit (left arm) every shift. Order date: 03/26/2026. A review of the ICCP with an initiated date of 08/03/2025 and revision date of 09/12/2025 revealed a care plan Focus the resident (Resident #153) needs dialysis (hemo) r/t (related to) renal failure. The following was included as an Intervention/Task, monitor/document/report any s/sx (signs/symptoms) of infection to access site: Redness, swelling, warmth or drainage. There was no specific focus for checking bruit and thrill. A review of the TAR on the following dates, 3/1/2026 - 3/31/2026, 4/1/2026 – 4/30/2026, 5/1/2026 – 5/31/2026 and 6/1/2026 – 6/30/2026 did not reveal an order to check bruit and thrill every shift. On 07/15/2026 at 11:54 AM the EMR revealed a progress note (PN) that Resident #153 was discharged to an acute care facility on 7/14/2026 for a blood transfusion and remained out of the facility at this time. On 07/15/2026 at 12:27 PM review of the MAR and TAR for 7/1-7/31/2026 revealed that Resident #153 did not have any documentation to check thrill and bruit (left arm) for the period of 7/1-7/15 2026. There was no order on the MAR to check thrill and bruit. In addition, there were no checks for thrill and bruit from 3/26/2026 thru 7/12/2026. On 07/15/2026 at 12:47 PM the surveyor conducted an interview with Interview with LPN #5: The surveyor asked LPN #5 where the checks for bruit and thrill every shift could be located for Resident #153. LPN #5 stated, I don't see it. We usually document it on the MAR or TAR. The surveyor asked LPN #5 what the purpose of checking for bruit and thrill was every shift and she explained that it should be there to ensure that it is working properly. She further explained that we usually check (bruit and thrill) prior to leaving for dialysis and upon return. On 07/15/2026 at 1:05 PM the surveyor conducted an interview with the Licensed Practical Nurse/Unit Manager (LPN/UM #3) assigned to the unit in which Resident #153 resided. When interviewed the LPN/UM #3 told the surveyor that Yes, it should be documented on the MAR and TAR to ensure the site is operating properly. On 07/16/2026 at 11:50 AM during an interview with facility administration the facility DON told the surveyor that we would document that on the TAR when asked where bruit and thrill should be documented for Resident #153. When made aware that Resident #153 had no documentation for bruit and thrill every shift, as ordered, the DON told the surveyors Yes. It should have been documented. We check that to make sure the access is functioning properly. Review of the policy titled, Dialysis Policy dated 12/2025, section C indicated that the access site will be monitored per physician order, palpate for thrill and auscultate bruit every shift for the presence of blood flow. NJAC 8:39-2.9

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate use of Personal Protective Equipment (PPE) during extensive contact with the environment of a resident on Enhanced Barrier Precautions (EBP) (an infection control strategy focused on reducing the spread of multidrug-resistant organisms [MDRO] in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. This deficient practice was identified for one resident (Resident #177) and was evidenced by the following: Reference: The research that was the basis for the current guidance evaluated high-contact resident care activities, not specifically the risk of transmission of MDROs to the hands or clothing of Environmental Services (EVS) or housekeeping personnel. However, changing linen is considered a high contact resident care activity; gowns and gloves should be worn by EVS personnel if they are changing the linen of residents on Enhanced Barrier Precautions and could be considered for additional environmental services or housekeeping responsibilities that involve extensive contact with the resident or the resident's environment. Gown and glove use by EVS should be based on facility policy and for anticipated exposures to body fluids, chemicals, or contaminated surfaces. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=As%20part%20of%20Standard%20Precautions,while%20using%20Enhanced%20Barrier%20PrecautionsOn 7/13/2026 at 10:36 AM, during the initial tour of the nursing unit, the surveyor observed an unsealed clear plastic bag on the floor outside the door of Resident #177's room. The room had a signage for EBP posted beside the door. The resident's name on A-bed had an orange-colored circle. There was no PPE immediately available near the room. The plastic bag contained soiled linens. Inside the room, the surveyor observed Certified Nursing Assistant (CNA #10) leaning on the mattress and fixing the bed sheets on the bed near the door. The CNA wore gloves but did not wear a gown. The surveyor pointed out the EBP sign and asked CNA #10 if they should have worn a gown when they changed the bed sheets. The CNA said no, they were not required to do so because they did not have physical contact with the residents. The CNA also stated that they received education about EBP.The surveyor reviewed the medical record of Resident #177.A review of the admission Record revealed Resident #177 was admitted to the facility with diagnoses laceration of the scalp, repeated falls, and rhabdomyolysis (rapid damage to the skeletal muscle).A review of Resident #177's most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 7/2/2026, revealed that the resident had an intact cognition. The MDS further revealed that the resident had medications/ ointments and non-surgical dressings applied to the body other than the feet.A review of the resident's Clinical Physician Order Report active as of 7/14/2026, revealed the following Physician's Orders (PO):A PO, dated 7/2/2026, for Enhanced Barrier Precautions to be maintained at all times, every shift for wound care.A PO, dated 7/9/2026, for Skin Prep to right hip for wound care. Cleanse with NS (normal saline solution) then skin prep, LOTA (leave open to air) daily and prn (as needed).A PO, dated 7/9/2026, for Skin Prep to right great toe every dayshift for wound care.A review of the comprehensive care plans revised on 7/2/2026, included a focus for the resident requiring EBP related to risk of infection due to wounds. The goal was to be free of signs and symptoms of infection. The interventions included the following: EBP must be followed when performing- dressing, bathing/showering, transferring, providing hygiene, changing linens, changing brief/ assisting with toileting, any device care, or wound care.On 7/14/2026 at 10:32 AM, during an interview with the surveyor, Unit Manager/ LPN (UM/LPN #2) stated that staff should absolutely wear gowns and gloves when changing bedsheets in rooms of residents on EBP. UM/ LPN #2 also stated that clean or soiled linen should not be placed on the floor even if wrapped in plastic bags because of cross contamination.On 7/15/2026 at 11:10 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated that even if the residents are not in the room, staff should still wear gloves and gown if they are changing bed linen. The IP further stated that the residents spend a lot of time in bed such that the greatest way of contamination would be through the bed linen. The IP stated that clean or soiled linen should absolutely not be placed on the floor.On 7/16/2026 at 9:32 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that changing of bed linens require staff to wear gloves and gown for residents on EBP. The DON also stated that linens should not be placed on the floor because it is an infection control issue.A review of the facility policy reviewed in January 2026, titled Enhanced Barrier Precautions included under Procedure the following: 4.) Prior to high contact care activity, staff must wear gloves and gowns. High-contact care activities include e.) Changing linens. N.J.A.C. 8:39 - 19.4 (a)

Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to provide documentation that the facility offered a resident a pneumococcal vaccine. This deficient practice was identified for Resident # 10, 1 of 4 residents reviewed for immunization status.The deficient practice was evidenced by the following:A review of the admission Record indicated that Resident #10 was admitted to the facility with the diagnosis which included but was not limited to hypertension and Parkinson's Disease.A review of the quarterly Minimum Data Set (MDS) an assessment that facilitates a resident's care dated 7/2/2026 which indicated that Resident #10 had moderate cognitive impairment and required supervision with activities of daily living (ADLs). The MDS also indicated that Resident #10 was not offered the pneumococcal vaccination.On 7/16/2026 at 9:29 AM, the surveyor reviewed Resident #10 immunizations with the Assistant Director of Nursing (ADON) who could not provide the consent or the declination that the resident was offered a Pneumovax since admission to the facility. On 7/16/2026 at 11:53 AM, the surveyor interviewed the Director of Nursing (DON) revealed that facility protocol required that staff were to offer immunizations to residents upon admission and reach out to the resident and resident representative (RP) to verify vaccine history. The DON confirmed that either a signed consent or declination form must be present in the medical record but acknowledged that Resident #10 lacked both documents. On 7/16/2026 at 12:55 PM, the surveyor interviewed the Infection Preventionist (IP) confirmed that residents must be offered influenza and pneumococcal vaccines upon admission, supported by written consent or declination. The IP noted the clinical significance of vaccinations to prevent the spread of infection among immunocompromised populations in a communal setting. The IP speculated that the resident's family might have declined due to the residents' cognitive status but confirmed that no physical declination form could be located.A review of the facility policy dated 12/2025 and titled, Pneumococcal Vaccinations for Residents the policy indicated that prior to admission the admissions department would try and obtain pneumococcal vaccination status. If the resident was appropriate to receive the pneumococcal vaccine and if the resident/representative decides to receive the vaccine, the resident/representative would be asked to sign the consent/declination form. This would be maintained in the medical record.NJAC 8:39-19.4(h), (i), (j)

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure activities were provided according to assessments and care plans for five of six residents (Resident (R) 5, R87, R92, R112, and R121) reviewed for activities out of the 32 sample residents This failure had the potential to affect the residents social and mental status. Findings include: 1. Review of R5's Admission Record face sheet located in the Admission Record tab of the electronic medical record (EMR) revealed R5 was readmitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis, dysphagia, congestive heart failure (CHF), peripheral vascular disease, diabetes, and hypertension. Review of R5's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 12/16/24 revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated severely impaired cognition. Review of the MDS further revealed it was very important to R5 to do her favorite activities. Review of R5's MDS revealed she was dependent on staff for dressing and transfers. Review of the MDS further revealed chair to bed and back to chair transfers did not occur during the look back period. Review of R5's comprehensive Care Plan located under the Care Plan tab in the EMR, with a target date of 12/15/24 revealed a problem for activities that included R5 being invited to scheduled activities and that were compatible with individual needs and abilities. During an interview on 02/23/25 at 9:30 AM, R5 revealed she did not go to activities in the dining room because she was not invited, and she wanted to go. Review of the January 2025 activity calendar revealed there were approximately 65 activities that were available in the dining room. Review of the February 2025 activity calendar revealed there were approximately 50 activities that were available in the dining room. Reviews of January 2025 and February 2025 log for R5 revealed she had not attended any of those activities. Review of the February 2025 activity calendar revealed on Sunday 02/23/25 at 2:00 PM bingo was being conducted in the dining area. On Monday 02/24/25 at 10:00 AM, the activity calendar revealed communion was being done, at 10:20 AM a blackjack activity was being done in the main dining room. On Tuesday 02/25/25 at 10:30 AM the activity calendar revealed sit, and stretch was going on in the main dining room. During an observation on 02/24/25 at 10:44 AM, R5 was in bed and awake and had not gone to the blackjack activity being done in the main dining room. During an observation on 02/25/25 at 10:44 AM, R5 was sitting up in her bed in her room while the sit and stretch activity was going on down in the dining room. During an interview on 02/25/25 at 10:44 AM R5 stated she had not been asked to go to the exercise program downstairs, and she would have gone if she had been asked. The interview further revealed she did not receive communion on Monday and was not asked to attend. R5 revealed she was Methodist and would receive communion if asked and she had never had communion since being at the facility. During an interview on 02/26/25 at 11:29 AM the Activity Director (AD) revealed R5 had not gone to the dining room for activities for the month of January or February because they had not had any music or dancing entertainment which R5 enjoyed. The Activity Director revealed the main activities done with R5 were conversation, coffee cart, chronicle news, and snack and beverage cart. The Activity Director further revealed R5 also liked entertainment and if she did not go to the baking activities downstairs, they brought the food up to her. During an interview on 02/26/25 at 12:58 PM, the Recreation Aid (RA) revealed R5 liked to go to anything that was going on and special events and he assisted her if she was up. The RA revealed he tried to get staff to get her up so R5 could go to the activities she enjoyed. 2. Review of R87's Admission Record face sheet located in the Admission Record tab of the EMR, revealed R87 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage, respiratory failure, failure to thrive, tracheostomy complications, gastrostomy status, and anxiety. Review of R87's annual MDS located under the MDS tab in the EMR, with an ARD of 01/06/25 revealed a BIMS was not conducted due to resident was rarely/never understood. Review of R87's comprehensive care plan located under the Care Plan tab in the EMR, with a revision date of 01/15/25, revealed a problem for activities was listed and the interventions included R87 needed one-on-one bedside/in-room activities if unable to attend out-of-room events. Review of the January 2025 activity calendar revealed there were approximately 65 activities that were available in the dining room. Review of the February 2025 activity calendar revealed there were approximately 50 activities that were available in the dining room. Review of the January 2025 and February 2025 log for R87 revealed he had not attended any of those activities. Reviews of the January 2025 and February 2025 log for R87 revealed he had room visits daily, but the log did not specify what activities were done. During an observation on 02/23/25 at 10:50 AM R87 was lying in his room with no television or radio playing. During an observation on 02/24/25 at 10:42 AM R87 was lying in bed in his room and was awake. Observation further revealed R87's brother was at bedside. Observation further revealed Enhanced Barrier Precautions (EBP) was posted on the door. During an interview on 02/24/25 at 10:42 AM Family Member (FM) 2 revealed R87 did not verbally respond. FM2 further revealed the staff did not get him up and he did not go to any activities. FM2 further revealed that R87 liked music. During an interview on 02/26/25 at 11:29 AM the AD revealed the RA was the activity person that provided activities to the residents on the third floor. During an interview on 02/26/25 at 11:55 AM the AD revealed R87's room visits consisted of hand massages, music channels, shut curtains for relaxation, and putting the television on. The AD revealed R87 did not speak English, so the music was in Spanish. During an interview on 02/26/25 at 1:06 PM the RA revealed R87 was on room visits but he had not done them, and another activity assistant might have done R87's activities. 3. Review of R92's Admission Record face sheet located in the Admission Record tab of the EMR, revealed R92 was admitted to the facility on [DATE] with diagnoses of nontraumatic acute subdural hemorrhage, anoxic brain damage, chronic obstructive pulmonary disease, atrial fibrillation, embolism and thrombosis of deep veins in extremities, convulsions, sepsis, quadriplegia, hypertension, and epilepsy. Review of R92's admission MDS under the MDS tab in the EMR with an ARD of 12/04/24 revealed a BIMS was not conducted because R92 was rarely/never understood and his decision-making ability was severely impaired. Review of the MDS further revealed R92 had a tracheostomy. Review of R92's comprehensive care plan located under the Care Plan tab in the EMR, with a target date of 12/17/24 revealed a problem for activities and one of the interventions was for one-on-one bedside/in-room visits if unable to attend out of room events. Review of the physician orders under the Orders tab in the EMR, dated 11/28/24 and revised on 02/13/25, revealed R92 was nothing by mouth (NPO). Review of the January 2025 activity calendar revealed there were approximately 65 activities that were available in the dining room. Review of the February 2025 activity calendar revealed there were approximately 50 activities that were available in the dining room. Review of the log for R92 revealed he had not attended any of those activities. Review of the January 2025 log revealed R92 received room visits every day, however it was not always noted what activity was done. Review of the January log further revealed on 01/12/25 through 01/16/25 and 01/20/25 through 01/22/25, R92 received conversation, snack, and beverage visits, and on 01/21/25, R92 had a food social activity. Review of the February 2025 activity log revealed room visits were done but there was no documentation of what the room visit consisted of. Review further revealed the room visits did not have a signature of who had completed the activity. During an observation on 02/23/25 at 4:02 PM, R92 was lying in bed, and his wife and son were visiting him. Observation further revealed EBP was posted on the door caddie of the resident's room. During an interview on 02/23/25 at 4:21 PM, Family Member (FM) 1 revealed staff never got R92 up and he did not go to any activities. FM1 revealed the Geri-chair that R92 used was broken and they had not yet replaced it. During observations on 02/24/25 at 9:47 AM, 10:40 AM, and 1:43 PM, R92 was lying in bed in his room and the television and radio were not on. During an observation on 02/25/25 at 8:48 AM and 9:15 AM, R92 was lying in bed in his room and the radio and television were both on at the same time. During an observation on 02/26/25 at 8:39 AM, R92 was lying in bed in his room and the radio and television were both on at the same time. During an interview on 02/26/25 at 8:54 AM, Therapy Director revealed the Geri-chair was broken, and they had ordered another one, but it had not arrived yet. The Therapy Director revealed therapy had established it was okay to get R92 up in a Geri-chair. During an interview on 02/26/25 at 11:40 AM, the AD revealed R92 preferred to stay in his room, so room visits that consisted of conversation and about life in general were done. The interview further revealed she was not sure if the Geri-chair was broken. The interview further revealed, after she reviewed the January 2025 log, if R92 had a trach then he would not get the snack and beverage activity as documented on the log. The Activity Director revealed she was not sure if he had a trach. During an interview on 02/26/25 at 12:51 PM, the RA revealed R92 did not go downstairs for any activity, and he had not done any activities with him. The RA revealed if they had an extra person, they would do more one on one activities. 4. Review of R112's Admission Record face sheet located in the Admission Record tab of the EMR, revealed R112 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage intraventricular, dysphagia, aphonia, and pneumonia. Review of R112's admission MDS located under the MDS tab in the EMR with an ARD of 11/23/24 revealed a BIMS was not conducted due to R112 being rarely/never understood and had severely impaired decision-making skills. Review of R112's comprehensive care plan located under the Care Plan tab in the EMR, with a target date of 12/26/24, revealed a problem for activities and the interventions included the resident needed one on one bedside/in room visits and activities if unable to attend out of room events. Review of the January 2025 activity calendar revealed there were approximately 65 activities that were available in the dining room. Review of the February 2025 activity calendar revealed there were approximately 50 activities that were available in the dining room. Review of the log for R112 revealed he had not attended any of those activities. Review of January 2025 and February 2025 log for R112 revealed he had room visits but there was no documentation of what those visits consisted of or what activity person had completed the activity. Review revealed the log that was kept in a book where the RA documented what activity was done. During an observation on 02/23/25 at 11:45 AM, R112 was lying in bed, and no activities were being done. During an observation on 02/24/25 at 12:44 PM, R112 was lying in bed and was awake with no activities being done. During an observation on 02/25/25 at 8:59 AM, R112 was lying in bed, and no activities were being done. During an interview on 02/26/25 at 11:57 AM, the AD revealed R112 received room visits daily which consisted of television, music on the television, hand massages, sensory things with lights and music. The AD further revealed R112 spoke and understood English. During an interview on 02/26/25 at 1:04 PM, the RA revealed he did not do any in-room visits with R112 but there were other activity assistants who might have. The RA further revealed R112 did not speak English and was nonverbal. 5. Review of R121's Admission Record face sheet located in the EMR under the Admission Record tab revealed R121 was admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury, traumatic subarachnoid hemorrhage, fracture of skull and facial bone, zygomatic fracture right side, stable burst facture of fourth thoracic vertebra, stable burst fracture of the first lumbar vertebra, wedge compression fracture of the second lumbar vertebra, epilepsy, depression, and anxiety. Review of R121's admission MDS located in the MDS tab of the EMR with an ARD of 01/13/25, R121 had a BIMS of 11 out of 15 which indicated moderately impaired cognition. Review further revealed R121 hand upper and lower impaired range of motion (ROM) to one side and dependent on staff for transfers. Review of the MDS further revealed it was somewhat important to him to participate in religious services, to do favorite activities, to listen to music, and participate in group activities. Review R121's comprehensive care plan located under the Care Plan tab of the EMR with an initiated date of 01/06/25 revealed a problem was listed for dependence on staff for meeting social needs and one intervention was to ensure R121 attended activities that were compatible with his interests, preferences, and physical condition. Review further revealed R121 should be invited to scheduled activities and one-on-one room visits if unable to attend out-of-room events. During an observation on 02/23/25 at 4:14 PM, R121 was lying in bed in his room and the television was on. During an observation on 02/24/25 at 8:38 AM, R121 was lying in bed in his room and no activities were being provided. During an observation on 02/24/25 at 10:38 AM, R121 was lying in bed in his room and no in-room activities were being done. During an observation on 02/24/25 at 1:04 PM, R121 was lying in bed in his room and no in-room activities were being done. During an interview on 02/25/25 at 10:04 AM, CNA4 revealed she had taken care of R121 on Monday 02/24/25 and was R121's aide today. CNA4 further revealed R121 had not been to any activities on those days. CNA4 revealed she was not even sure if he was supposed to go to any activity since he had just gotten to the unit Friday from another floor. During an interview on 02/26/25 at 9:43 AM, the AD revealed residents that were on EBP were not allowed to go to the dining room for activities such as entertainment, but the staff could do activities with them in their rooms. During an interview on 02/26/25 at 11:45 AM, the AD revealed RA did the activities for the third floor. The interview further revealed, after she reviewed the activity logbook twice, she could not find the January 2025 or February 2025 logs for R121. The AD revealed the pages may have fallen out and would look for the pages. During an interview on 02/26/25 at 12:26 PM, the Infection Preventionist (IP) revealed there was no reason why a resident that was on EBP could not go to any of the activity's downstairs. IP further revealed residents that had a trach did not have to stay in their rooms all the time. During an interview on 02/26/25 at 12:30 PM, the AD revealed she had overlooked the pages in the book and found his record of activities. The interview further revealed R121 had room visits for the months of January 2025 and February 2025 but there was no documentation of what activities had been done. During an interview on 02/26/25 at 1:23 PM, the Director of Nursing (DON) revealed residents that were on EBP could go to the dining room downstairs for any activity. The DON further revealed residents' activities should be established around their likes and dislikes, Review of the facility's policy titled, Activities, with a revised date of 02/19/25, revealed it was the policy of the facility to provide an ongoing activity program to support residents in their choices of activities. The policy further revealed activities referred to any endeavor, other than routine Activities of Daily Living (ADL) that enhance the resident's sense of well-being and emotional health. The Activity policy further revealed activities would be designed to reflect the residents' interests and religious preferences. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) with a revised date of 02/25, revealed residents that were on EBP were permitted to leave their room to participate in activities. The policy further revealed EBP should not prevent a resident from participating in a group activity or restrict a resident to their room. NJAC 8:39-7.3

Based on observation, interviews, and facility policy review, the facility failed to ensure staff changed gloves and washed hands after touching face and contaminated items while touching food and plates with the same contaminated gloves in one of one kitchen. This failure had the potential to result in the spread of infection and food borne illness for 132 of 141 residents consuming food in the facility. Findings include: On 02/25/25 at 11:25 AM, Cook1 was observed touching his face and nose with his gloved hands. At 11:35 AM, he began serving food off the steam table without first changing his gloves. While serving he was observed picking the fried fish filets up with his gloved hands not using utensils, removing sandwiches and chicken strips out of the oven with his gloved hands. At 11:47 AM, he picked up visibly soiled cooking mitts and placed one on each of his gloved hands, opened the oven door, removed a pan of fish, and placed it in the steam table. He took the oven mitts off and continued to serve the food touching the serving utensils, the top side of the plates and taking fish out of the pan with his gloved hands without first changing his gloves. At 11:54 AM, he again put the oven mitts over his gloved hands and removed a pan of fish out of the oven and again preceded to continue serving without first changing his gloves and washing his hands. He removed chicken strips out of the oven using his gloved hands. The Dietary Manger (DM) was alerted to the staff not changing his gloves and he also observed Cook1 put the contaminated gloves on and then remove them and continue touching the food without first changing his gloves. The DM confirmed the observation and obtained serving utensils for the fish and the chicken strips and handed them to Cook1 telling him the inside of the cooking mitts were soiled. Cook1 continued to use his hands with the same gloves on and was observed touching the side of his pants and his face again. Review of the facility's policy titled, Red Bank Center for Rehabilitation and Healing .Policy and Procedure .Title: Dietary - Handwashing with a created date of 03/24, revealed hands shall be washed in accordance with established procedures; before working, after eating, after touching any part of the body, after using the restroom, after working with any dirty equipment, and between working with foods. NJAC 8:39-17.2(g)

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure infection control Enhanced Barrier Precautions (EBP) were followed for two of four residents (Resident (R) 92 and R107) reviewed for EBP and failed to ensure medications were handled properly for one of four residents (R101) reviewed for medication administration of 32 sample residents. In addition, isolation supplies were not readily available on one out of four floors of the facility. These failures put all residents at risk of infection. Findings include: 1. During observations on [DATE] from 9:50 AM- 2:41 PM for rooms 316, 317, 319, 325, 326, and 328, EBP signage was located. Review of the signage for EBP located on the door caddie or wall of the rooms revealed everyone must clean their hands including before entering the room and when leaving the room. The signage further revealed providers, and staff must also put on gloves and a gown when doing high contact care which included changing a brief, device care for tracheostomy and wound care. During an observation on [DATE] at 12:56 PM, a lunch tray was passed to room [ROOM NUMBER] which had EBP posted on the door caddie by Certified Nurse Aide (CNA) 2 and CNA2 did not sanitize her hands before or after entering the room. CNA2 went down the hall and passed another tray to room [ROOM NUMBER] which had EBP signage on the door caddie and did not sanitize her hands going into the room or when leaving. CNA2 continued down the hall to the small dining room and helped residents without washing or sanitizing her hands. During an interview on [DATE] at 2:46 PM, CNA2 revealed she had been employed at the facility for eleven months and been in-serviced on EBP. CNA2 revealed if a resident was on EBP they had to gown up and put gloves on anytime they touched the resident. CNA2 revealed when they passed trays in a room with EBP they did not have to sanitize their hands when they entered or left the room. Review of the in-service training completed on [DATE] revealed CNA2 had education on infection control in healthcare setting and it contained information about EBP. During an observation on [DATE] at 8:55 AM, Licensed Practical Nurse (LPN) 5 went into R92's room, who had EBP posted on the door caddie, and did not sanitize her hands or apply a gown but she did put a mask on and gloves. LPN5 proceeded to clean the mucus from around the covering of the tracheostomy tube, did not remove her gloves, opened the drawer beside the bed, and reached down and unplugged the suction machine and plugged in the breathing treatment machine, fixed the blanket, removed her gloves, and sanitized her hands. LPN5 applied gloves but did not put on a gown and the nebulizer had a piece missing. LPN5 removed the gloves and did not sanitize or wash her hands. Observation of R92 revealed he was coughing and mucous sounding. Observation further revealed LPN5 did not have any gloves on and reached down beside the table and unplugged the nebulizer and plugged in the suction machine. LPN5 sanitized her hands and applied sterile gloves but no gown to suction R92. LPN5 suctioned R92 and after suctioning him she cleaned around the outer covering of the tube and wiped around the stoma area without changing gloves. LPN5 removed the gloves, sanitized her hands, and put a gauze around the tracheostomy with no gloves or gown on. LPN5 sanitized her hands and applied the nebulizer. During an observation on [DATE] at 12:53 PM, LPN5 applied gloves, mask, and no gown to clean mucus from the neck of R92. LPN5 removed her gloves and washed her hands. During an interview on [DATE] at 12:53 PM, LPN5 stated R92 was not on any precautions and when she suctioned him, she did not need to wear a gown. LPN5 revealed she had worn a gown previously that morning when she suctioned him but this time it was just a little suctioning, so she did not need a gown. LPN5 further revealed they did not have to sanitize their hands if they just went into the room and did not touch the resident even though the signage reflected you needed to sanitize your hands when going in and out of the room. LPN5 further revealed she had been in-service on EBP. During an observation on [DATE] at 9:15 AM, LPN6 went into R92's room and did not sanitize or wash her hands but had regular gloves on her hands. LPN6 did not have a gown or any type of face covering on her. Observation further revealed LPN6 removed the trach tie, neck gauze and cleaned the trach area with normal saline and gauze. Observation further revealed copious amount of light-yellow thick mucus was coughed out and LPN6 unplugged the nebulizer machine and plugged in the suction machine and did not remove her gloves to suction R92. Observation further revealed the cannula was changed but LPN6 did not use sterile gloves. LPN6 did not wash hands or sanitize her hands and did not change gloves to attach the nebulizer. Observation further revealed LPN6 had to unplug the suction machine and plug the nebulizer machine in. During an interview on [DATE] at 9:30 AM, LPN6 revealed she did not wash or sanitize her hands before doing R92's care because she had just come out of the room. LPN6 revealed she did not change gloves and was not aware that sterile gloves needed to be used for suctioning. LPN6 revealed she should have changed gloves when she had suctioned R92 and cleaned the area. LPN6 verified she had not worn a gown even though R92 had been coughing. LPN6 revealed she was not sure what type of precautions R92 was on and had not read the signage for EBP and was not even sure there had been a sign up there before. LPN6 revealed she thought she had an in-service on universal precautions but the agency she worked for did not offer in-services. LPN6 further revealed the room only had four electrical outlets and they were all being used and that was why she had to unplug the suction and nebulizer cords. During an interview on [DATE] at 10:30 AM, the Nurse Practitioner (NP) revealed sterile gloves should be worn to suction a resident and should be removed after suctioning. NP further revealed using dirty gloves that had touched a power cord should not be used to suction a resident and that was a no no. The NP further revealed sterile protocol was broken by not utilizing sterile gloves to suction. The NP revealed you do not know what you have on dirty gloves. During an interview on [DATE] at 1:47 PM, the Infection Preventionist (IP) revealed if a resident was on EBP staff should sanitize their hands before and after they went into a room and that included passing meal trays. The IP further revealed if staff were going to suction a resident that had a trach and was on EBP they should wear a gown, gloves, eye protection, and mask. The IP further revealed the eye shields or goggles should be on the door caddies for immediate use. The IP revealed suctioning was a port of entry for germs and if on EBP they must wear eye protection and a gown to keep from transmitting germs to the rest of the facility and staff. During an observation on [DATE] at 2:41 PM, there were no face shields or goggles on the isolation bins on Hall A, B, and C on the 300 unit. Observation further revealed the door caddies on Rooms 310, 318, 321, 325, and 329 did not have any goggles or face shields available for immediate use even though the residents were on EBP. During an interview on [DATE] at 2:41 PM, IP verified there were no goggles or face shields readily available on the third floor even though there were several trach residents on the unit. The IP stated face shields should be available for immediate use to help prevent the spread of germs, especially if a resident was on a tracheostomy and was coughing with sputum production. The interview with the IP further revealed the staff did not restock supplies as readily as they should. The IP revealed nursing staff, usually the night shift supervisor were the ones who were supposed to restock. During an observation and interview on [DATE] at 3:00 PM, the IP revealed there were supposed to be stock face shields in central supply but when he looked at the two boxes they expired on ,d+[DATE]. Observation further revealed there were no face shields available in the stockroom. Observations with the IP further revealed there were goggles available on the other floors but no face shields. During an interview on [DATE] at 1:23 PM, the Director of Nursing (DON) revealed she expected the staff to follow policy on EBP, transmission-based precautions, and isolation. The DON further revealed when a resident was on EBP staff should sanitize their hands before and after they go into the room and that included passing meal trays. The DON stated if staff provided hands on care, then they should sanitize their hands before going into the room, put a gown on, and gloves before doing care, and face shields if suctioning. The DON further revealed once the care was completed staff should remove PPE and hands should be sanitized or washed. The DON revealed if proper PPE was not utilized then it proposed a high risk of spreading an infection to other residents, families, and staff. During an interview on [DATE] at 1:23 PM, the DON further revealed agency staff had to have documented in-services on infection control before they could work at the facility. The interview with the DON further revealed central supply brought the supplies to the units and the nurse stocked the door caddies and hall bins. 2. Review of R107's Admission Record located in the resident's electronic medical record (EMR) Profile tab, revealed the resident was initially admitted to the facility on [DATE] and had diagnoses that included osteomyelitis and personal history of transient ischemic attack (TIA) and cerebral infarction. R107 returned from the hospital on [DATE]. Review of the R107's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the resident's EMR MDS tab, documented R107 had a feeding tube and received 50 percent or more of her total calories through tube feeding. The resident was rarely/never understood, and the Staff Assessment for Mental Status documented memory impairment. Review of R107's Orders tab of the EMR, revealed an order, dated [DATE], for Jevity 1.5 (liquid nutrition for tube feeding) at 50mL (milliliters) per hour. Hang each morning and give a four-hour break when finished. R107 also had orders for enhanced barrier precautions, dated [DATE]. Review of R107's Care Plan located in the Care Plan section of the EMR revealed a focus area dated [DATE], To prevent cross contamination utilize Enhanced Barrier Precautions r/t [related to] risk of infection: indwelling medical devices: foley cath [catheter]/trach/feeding tube. Another focus area, dated [DATE], revealed The resident requires tube feeding via Gtube [gastric feeding tube] r/t Dysphagia [impaired swallowing]. During an observation on [DATE] at 11:45 AM, an enhanced barrier precautions sign hung on R107's door with a door caddy holding gowns and gloves. During an observation on [DATE] at 2:45 PM, LPN5 flushed R107's feeding tube with water poured in a syringe attached to the tube. LPN5 then ran the tubing from the new feeding container she hung on a pole, through the pump, and attached the end of the tubing to R107's feeding tube. LPN5 pushed a button on the pump to start the flow of the feeding. During the observation, LPN5 wore gloves but no gown. During an interview on [DATE] at 3:10 PM, LPN5 stated EBP for R107 meant staff wore gowns and gloves when providing wound treatment or perineal care. LPN5 stated a gown was not needed for the tube feeding. During an interview on [DATE] at 1:47 PM, the IP stated staff should wear a gown if passing meds by a g-tube or feeding through a g-tube, as that was considered high contact. During an interview on [DATE] at 1:06 PM, the DON reported the expectation that nurses would use EBP and wore a gown and gloves when flushing a feeding tube and starting a feeding. 3. Review of R101's Admission Record located in Profile tab of the EMR revealed R101 was admitted on [DATE] and had diagnoses which included end stage renal disease. During an observation of a medication administration pass on [DATE] at 9:25 AM, LPN2 was tearing open medication packaging which held multiple pills when one pill landed on the medication cart instead of in a medication cup. LPN2 picked up the pill with an ungloved hand and placed it in the medication cup with the other pills. At 9:37 AM, LPN2 administered all the medications in the medication cup to R101. During an interview on [DATE] at 10:12 AM, LPN2 stated, My error. I would not normally do that, when asked about picking up the pill with an ungloved hand and placing it in the medication cup. During an interview on [DATE] at 1:47 PM, the IP stated when passing medication, staff should not touch pills. They should use touchless method, open the pack, and drop the medication into a cup. If staff needed to touch a pill, the IP recommended using gloves and perform hand hygiene before putting on the glove to pick up the pill. The IP stated by administering medication touched with bare hands, staff risked transmitting germs and putting the residents in jeopardy. During an interview on [DATE] at 1:06 PM, the DON stated nurses were expected to wear gloves if they were touching medications. Review of the facility's policy titled, Medication Administration, revised [DATE], revealed staff were to remove medications from med rolls and administer them using a no touch technique. Review of the facility's policy titled, Enhanced Barrier Precautions with a revised date of ,d+[DATE], revealed the policy was to reduce the risk of transmission of multidrug-resistant organisms in the facility while allowing those most likely to become colonized or those known to be colonized or infected to participate in group activities that night otherwise be limited if they were required to be maintained on contact precautions. The policy further revealed EBP was implemented based on an evaluation of the resident's risk of acquiring multidrug-resistant organisms. The policy revealed EBP would be implemented with residents who have risk factors that included wounds, indwelling medical devices, and colonization. NJAC 8:,d+[DATE].4 42440

15879 42440 Based on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three residents (Resident (R) 107, R129, and R92) out of 32 sampled residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the residents to have unmet care needs. Findings include: 1. Review of R107's Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed the resident was initially admitted to the facility on [DATE] and had diagnoses that included osteomyelitis, personal history of transient ischemic attack (TIA), and cerebral infarction. Review of R107's Medication Administration Record (MAR) for January 2025 revealed an order for oxygen at 4 LPM [liters per minute] via trach signed off each shift from 01/21/25 to 01/31/25. Another order for tracheostomy care every shift was signed off from 01/21/25 to 01/31/25. Review of R107's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/25 and located in the resident's EMR under the MDS tab, documented R107 received no oxygen therapy nor tracheostomy care. The resident was rarely/never understood, and the Staff Assessment for Mental Status documented memory impairment. Review of R107's Care Plan located in the Care Plan tab of the EMR revealed a focus area, dated 02/17/25, The resident has a tracheostomy r/t [related to] impaired breathing mechanics. During an observation on 02/23/25 at 11:45 AM, R107 had a tracheostomy tube in place with oxygen flowing at 4 LPM via a tracheostomy mask. During an interview on 02/25/25 at 2:23 PM, the Regional Nurse stated she expected the MDS to reflect tracheostomy cares and oxygen use for someone who received them in the facility in the seven days prior to the MDS ARD date. During an interview on 02/26/25 at 1:06 PM, the Director of Nursing (DON) expected that MDSs were coded accurately. 2. Review of R129's EMR revealed she had an Admission Record located in the Profile tab which revealed she was admitted to the facility on [DATE] with diagnosis of multiple fractures of pelvis with stable disruption of pelvic ring, fusion of spine, encounter screening of human immunodeficiency virus, mononeuropathy, retention of urine, pain, laceration of the liver, and laceration of right kidney. According to the Miscellaneous information section of the Admission Record, the resident was discharged on [DATE] at 12:42 AM to a private home/apartment with home health services. Review of R129's discharge MDS with an ARD date of 12/19/24 and located in the MDS tab of the EMR revealed it was coded under Discharge Status that she went to a short-term general hospital. During an interview on 02/25/25 at 12:55 PM, Licensed Practical Nurse (LPN) 4 was interviewed. She stated the resident was picked up by her grandmother and was discharged either to her mother's home or her grandmother's home. She stated the resident did not go to the hospital. During an interview on 02/25/25 at 2:22 PM, the Regional Nurse. stated the MDS was inaccurately coded because the resident was discharged to a private home and was not discharged to a short-term hospital. 3. Review of R92's Admission Record face sheet located in the EMR under the Admission Record tab revealed he was admitted to the facility on [DATE] after hospitalization with diagnoses which included quadriplegia, hypertension, and sepsis. Review of the admission assessment dated [DATE] and located under the Progress Notes tab of the EMR, revealed R92 had redness to the sacral area. Review of the skin assessment on 12/02/24 located under the Progress Notes tab of the EMR, revealed the sacral area had an area that was two-three centimeters but was not staged. Review of the Nurse Practitioner (NP) progress notes for 11/29/24 and located under the Progress Notes tab of the EMR, revealed R92 had impaired skin integrity with deep tissue injury and a wound consultation was ordered. Review of R92's admission MDS assessment located in the MDS tab of the EMR with an ARD of 12/04/24 revealed R92 did not have a BIMS score available. Review of the MDS further revealed R92 did not have any unhealed pressure ulcers and was not at risk for developing pressure ulcers. Review of the MDS revealed R92 did not have any other ulcers, wounds, or skin problems. Review of the MDS revealed R92 had nutrition or hydration interventions to manage skin problems, treatments of pressure ulcer/injury care, application of non-surgical dressings other than to feet, and applications of ointments and medications other than to the feet were checked as applicable for R92. Review of the physician orders dated 12/04/24 and located under the Orders tab of the EMR, revealed R92 had an order for wound care to the right buttock wound. Review of the Wound Consult progress notes dated 12/06/24 and located under the Evaluations tab of the EMR, revealed R92 had a stage two pressure injury to the right buttock. During an interview on 02/26/25 at 2:41 PM with the Regional Nurse verified the admission MDS was inaccurate. The Regional Nurse reviewed the admission MDS dated [DATE] and revealed R92 did not have any pressure concerns coded on the MDS. However, the Regional Nurse reviewed the admission skin assessment done on 11/27/24 which revealed there was redness to the sacrum and on the 12/02/24 skin assessment there was a two-to-three-centimeter pressure area to the sacrum but was not staged. The Regional Nurse reviewed the physician orders dated 12/04/24 and further revealed that R92 had orders for treatment to the right buttock and the sacral area was healed. The Regional Nurse revealed the admission MDS should have reflected the pressure area and the risk for further pressure areas. The Regional Nurse revealed the pressure ulcer area on the MDS which showed treatment was correct, but the pressure ulcer area was not coded correctly. The Regional Nurse revealed the MDS should have been coded as a pressure area existing on the sacral and buttock areas. Review of the facility's policy titled, MDS Guideline for Completion, reviewed October 2024, revealed It is the policy of [facility] to ensure accurate and timely completion of MDS . in accordance with Federal and State Operation Manual. Review of the RAI (Resident Assessment Instrument) Manual, dated 10/01/24 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed .It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment . NJAC 8:39-33.2(d)

42440 Based on record review, interview, and facility policy review, the facility failed to complete a new level one Preadmission Screening and Resident Review (PASARR) when a psychiatric diagnosis was identified for one of three residents (Resident (R) 20) and failed to ensure level II was conducted for one of three residents (R101) reviewed for PASARR out of 32 sample residents. This had the potential for a failure to identify what specialized or rehabilitative services the residents needed and whether placement in the facility was appropriate. Findings include: 1. Review of R20's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] without a psychiatric diagnosis. Review of R20's Pre-Admission Screening and Resident Review (PASARR) Level I Screen, located in the Misc tab of the EMR, revealed the hospital completed the form on 09/01/23 and documented no diagnosis or evidence of a major mental illness. Review of R20's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/11/23 revealed R20 had not been evaluated for a Level II PASARR and determined to have a serious mental illness and/or intellectual disabilities or a related condition. R20 had no schizophrenia diagnosis. Review of R20's diagnoses under the Med Diag tab of R20's EMR revealed the facility entered a diagnosis of schizoaffective disorder on 09/13/23, with an onset date of 09/12/23. Review of a Nursing Progress Note, dated 09/25/23 and located in the Prog Note tab of the EMR, revealed Call was placed to [daughter] in ref [reference] to her mother's psych history. [Daughter] stated that her mother was diagnosed with schizophrenia and bipolar disorder years ago. Review of R20's quarterly MDS assessment with an ARD of 12/02/24 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 indicating R20 was severely cognitively impaired. She had a diagnosis of schizophrenia (e.g., schizoaffective, and schizophreniform disorders). Review of R20's EMR revealed there was no evidence of a new PASARR level one screen after the facility added the schizoaffective diagnosis. During an interview on 02/25/25 at 11:16 AM, the Regional Nurse stated the MDS Coordinator (MDSC) who entered the schizoaffective diagnosis into the EMR was out of the country. The Regional Nurse stated she would check to see if a new PASARR level one screen had been completed with the addition of the schizoaffective diagnosis. The Regional Nurse stated the facility normally received the PASARR level one screen from the hospital. During an interview on 02/25/25 at 12:14 PM, the Regional Nurse reported she could not find a new PASARR level one screen when the diagnosis was added. The Regional Nurse stated the facility should have completed one at the time of the diagnosis. During an interview on 02/26/25 at 10:34 PM, the Social Services Director (SSD) stated if the social services department was made aware of a new psychiatric diagnosis, they should complete a new PASARR level one screening with the updated information. During an interview on 02/26/25 at 1:06 PM, the Director of Nursing (DON) stated she expected a new PASARR level one screening to be completed with the addition of a new psychiatric diagnosis. 2. Review of R101's Admission Record located under the Profile tab of the EMR revealed R101 was originally admitted to the facility on [DATE] with diagnoses that included depression, a history of mental and behavioral disorders, end stage renal disease, and general anxiety disorder. Review of the quarterly MDS with an ARD of 01/27/25 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated the resident had intact cognition. Review of R101's PASARR Level I Screening Tool, dated 02/15/24 and located under the Miscellaneous tab of the EMR, indicated a Positive Screen for MI (mental illness) based on responses to questions in Section II. Screening Outcomes, located in Section IV, revealed R101 was found to have a Positive screening under Section II and should have been referred for a level II. During an interview on 02/26/25 at 9:22 AM the SSD confirmed that the facility was aware of R101's positive Level I PASARR screening. She stated that the facility had been working with their psychological services department to get the resident scheduled for a Level II screening. In a subsequent interview, SSD stated that the facility was allowed to admit residents who had a positive screening but reiterated that she was working to get the resident a Level II screening. During an interview on 02/26/25 at 9:30 AM, the Assistance Director of Nursing (ADON) confirmed that the PASARR Level II Screening was requested yesterday, which would have been 02/25/25. Review of the facility's undated policy titled, Screen/ Pre-Admission Screen Resident Review (PASRR) Process, revealed If an issue is identified, it is reported to the Director of Social Services for further evaluation and consultation . Social Services is responsible receiving and confirming all PASSR Level I are completely correctly and if a Level II review is required. NJAC 8:39-40.3(d)

42440 Based on record review, interviews, and facility policy review, the facility failed to ensure a comprehensive care plan was developed for three of 32 sample residents (Resident (R) 13, R56, and R121) reviewed for care plans specific to vision, oxygen use, and boots for skin protection. The failures had the potential to affect resident care. Findings include: 1. Review of R13's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and heart failure. Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/25 and located in the resident's EMR MDS tab, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. The MDS documented R13 had impaired vision. Review of the Care Area Assessment (CAA) revealed, Triggers due to visual deficits. This puts resident at risk for falls and safety issues and decreased socialization and quality of life. Staff to provide support as needed to maximize his independence by informing him of item placement, who they are and providing adequate lighting. Review of the Orders tab of R13's EMR revealed an order, dated 01/25/25, for ophthalmology consult as needed blurry vision. Review of R13's Care Plan, located in the Care Plan tab of the EMR, revealed no documentation of vision impairment or associated interventions. During an interview on 02/23/25 at 10:19 AM, R13 reported he had cataracts which needed surgery. R13 reported he was unable to clearly see the TV in his room. During an interview on 02/26/25 at 12:44 PM, the Licensed Practical Nurse (LPN) Unit Manager (UM) 1 stated the unit managers initiated the care plans upon a resident's admission and updated them with changes. UM1 reported she was unfamiliar with CAAs. During an interview on 02/26/25 at 12:58 PM, the Regional Nurse reported if a CAA was triggered on the MDS, it was expected to be on the care plan. The MDS Coordinator (MDSC) was expected to review and sign off on the care plans. During an interview on 02/26/25 at 1:06 PM, the Director of Nursing (DON) reported a CAA area was expected to be on the care plan. 2. Review of R56's Profile tab of the EMR revealed she was initially admitted to the facility on [DATE] and had a hospital stay from 12/28/24 to 01/06/25. R56 had diagnoses of bronchiectasis, with onset date of 01/07/25, and acute respiratory failure with hypercapnia, dated 01/09/25. Review of R56's quarterly MDS with an ARD of 12/16/24 and located in the resident's EMR MDS tab, revealed R56 had a BIMS score of 13 out of 15 which indicated intact cognition. R56 did not utilize oxygen. Review of the Orders tab of R56's EMR revealed an order, dated 01/06/25, for oxygen at 2 LPM [liters per minute] via nasal cannula every shift. Review of R56's five-day MDS with an ARD of 01/13/25 and located in the resident's EMR section titled MDS revealed R56 had a BIMS score of 12 out of 15 which indicated moderately impaired cognition. R56 utilized oxygen. Review of R56's Care Plan located in the Care Plan tab of the EMR, revealed no documentation of the resident's need for supplemental oxygen. During a concurrent observation and interview on 02/23/25 at 11:59 AM, R56 was observed lying in bed with an oxygen concentrator administering oxygen at 5-LPM via a nasal cannula. R56 reported she had used oxygen since returning from the hospital. R56 did not know what her orders were for the oxygen setting. During an interview on 02/24/25 at 2:04 PM, LPN5 reported R56 had orders for oxygen to be delivered at 2-LPM and changed the oxygen concentrator setting from 3.5 LPM to 2-LPM. During an interview on 02/26/25 at 12:28 PM, LPN3 stated he was not involved in the care planning process and was unsure where to look in the EMR to find care plans. During an interview on 02/26/25 at 12:33 PM, Certified Nurse Aide (CNA) 6 stated if she wanted to know how to care for a resident, she referred to their hard chart or asked the nurse. CNA6 was unaware of anywhere she could look for a plan of care in the EMR. During an interview on 02/26/25 at 12:44 PM, UM1 stated the unit managers initiated the care plans upon a resident's admission and updated them with changes. UM1 reported oxygen should have been addressed on R56's Care Plan and verified it was not addressed. During an interview on 02/26/25 at 1:06 PM, the DON reported oxygen use was expected to be on the care plan. 3. Review of R121's admission MDS located in the MDS tab of the EMR with an ARD of 01/13/25, R121 had a BIMS score of 11 out of 15 which indicated moderately impaired cognition. Review further revealed R121 hand upper and lower impaired range of motion (ROM) to one side and was dependent on lower body dressing and putting on footwear. Review of the MDS revealed R121 was at risk for pressure sores. Review of the physician's order, dated 02/02/25, located under the Orders tab of the EMR revealed an order for heel protector boots to both feet while in bed to ensure skin and joint integrity and R121 needed assistance to apply and remove the boots. Review of the physician orders revealed an order, dated 02/02/25, for Multipodus boots to both feet while out of bed. Review R121's comprehensive care plan located under the Care Plan tab of the EMR with an initiated date of 01/06/25 revealed a problem was addressed for limited ROM but there was no intervention for green boots or black boots. Review of the care plan further revealed a problem was listed for dependence on staff for meeting Activities of Daily Living (ADL) and the interventions did not include the use of green boots or black boots. Review of the care plan further revealed a problem was listed for R121 for being at risk of skin impairment but no interventions for the boots were listed. During an interview on 02/25/25 at 10:12 AM, UM1 revealed it was CNA's responsibility to put the boots on R121. UM1 revealed the CNA point of care screen and verified there were no interventions for the boots to alert the CNA of the need for them. UM1 revealed it was the unit manager's responsibility to put the information into the computer for the CNA's and it had not been added. During an interview on 02/26/25 at 1:23 PM, the DON revealed all residents' care plan should be followed and the care plan was the basis of how staff should care for them. The DON revealed if the care plan was not followed or not accurate then a resident's care may not be what the resident needed. The DON revealed the care plan was like a recipe for how to take care of a resident. During an interview on 02/26/25 at 3:14 PM, the Regional Nurse revealed care plans should be followed. The Regional Nurse revealed the purpose of the care plan was to establish guidelines on how to care for a resident. The Regional Nurse revealed the nurse who admitted the resident would initiate the care plan then each discipline would follow up. The Regional Nurse revealed the MDS coordinator was responsible for verifying the care plan was in place and that it was accurate. Review of the facility's policy titled Care Planning with a revised date of 09/24, revealed an individualized comprehensive care plan would be developed for each resident. The policy revealed the comprehensive care plan was based on a thorough assessment that identified the highest level of functioning the resident may be expected to attain. The policy further revealed it reflected the residents' wishes regarding their care. The policy revealed identified problems would have interventions that were targeted and meaningful Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan .The Care Planning/ Interdisciplinary Team is responsible for the review and updating of care plans . when the resident has been readmitted to the facility from a hospital stay. Review of the facility's policy titled, MDS Guideline for Completion, revised October 2024, revealed that MDS director or MDS assessors will be responsible to ensure that all CAAs are completed and addressed in residents care plan before signing section V0100B. It also stated, The IDT [interdisciplinary team] is responsible for reviewing all resident strengths, problems, needs and plan of care to insure the delivery of appropriate and quality care. NJAC 8:39-11.2(e)thru(i) NJAC 8:39-27.1(a)

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure proper incontinence care assistance to avoid double briefing for one of two residents (Resident (R) 92) reviewed for incontinence care of 32 sample residents. This failure put R92 at risk of pressure sore formation and skin breakdown. Findings include: Review of R92's Admission Record face sheet located in the electronic medical record (EMR) under the Admission Record tab revealed he was admitted to the facility on [DATE] after hospitalization with diagnoses of non-traumatic acute subdural hemorrhage, anoxic brain damage, chronic obstructive pulmonary disease (COPD), atrial fibrillation, convulsions, acute embolism and thrombosis of deep veins, quadriplegia, hypertension, and sepsis. Review of R92's admission Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/04/24 revealed R92 did not have a Brief Interview for Mental Status (BIMS) available. Review of the MDS further revealed R92 was dependent on staff with all Activities of Daily Living (ADL). R92 was totally dependent on staff for toileting hygiene. Review of the MDS further revealed R92 was always incontinent of bowel and bladder and was not a candidate for a bowel and bladder program. Review of R92's comprehensive care plan located in the Care Plan tab of the EMR with an initiated date of 11/27/24 and revised on 12/04/24 revealed a problem for dependence on staff for meeting all R92's daily living needs which included toileting, dressing, personal hygiene, bathing, repositioning, bowel, and bladder elimination. Review of R92's comprehensive care plan located in the Care Plan tab of the EMR and initiated on 12/04/24 further revealed a problem for bowel and bladder incontinence with an intervention for pericare after every incontinent episode. Review of R92's comprehensive care plan located in the Care Plan tab of the EMR and initiated on 12/04/24 further revealed a problem for incontinent of bladder and was at risk for urinary tract infections. The care plan revealed the peri area was to be cleaned after each incontinent episode and the peri area was to be monitored for skin integrity. Review of the physician orders, dated 12/31/24, located under the Orders tab of the EMR, revealed an order for zinc oxide to the bilateral buttocks to be done every shift for protection. During an interview on 02/23/25 at 4:21 PM Family Member (FM) 1 revealed she had a concern with R92 being double briefed and showed this surveyor that he was indeed double briefed. During an observation and interview on 02/23/25 at 4:39 PM, Licensed Practical Nurse (LPN) 7 was going to get a Certified Nurse Aide (CNA) to change R92 but came back into the room without the CNA, who was on their lunch break. Observation further revealed LPN7 applied personal protective equipment (PPE) and checked R92's brief and verified he was double briefed, and the blue inner brief was soaked with urine and the yellow brief was slightly wet. During an interview on 02/23/25 at 4:45 PM, LPN7 revealed to her knowledge residents should not be double briefed and it was so wrong because it could cause skin breakdown. During an interview on 02/23/25 at 4:45 PM, CNA3 revealed a resident should not be double briefed and he did not have R92 that day. CNA3 further revealed if a resident was double briefed and not changed when wet, the resident was more at risk for a bedsore to worsen or develop a new pressure sore. During an observation on 02/24/25 at 1:43 PM, CNA4 was giving a bed bath to R92, and he was double briefed again. Observation further revealed the blue inner brief was wet, but the yellow outer brief was dry. During an interview on 02/25/25 at 1:23 PM, the Director of Nursing (DON) revealed no residents should be double briefed unless they have requested to be. The DON revealed there was only one resident in the facility who had requested to be double briefed, and it was not R92. The DON further revealed if a resident was double briefed it could cause skin breakdown and if a resident had a history of pressure sores, then it would put them more at risk of recurrent pressure sores. Review of the facility's undated policy titled, Incontinence Care Plan revealed it was the policy of the facility to provide care to residents who were incontinent of bowel and bladder. The policy further revealed CNA' s would follow a residents incontinence program as instructed in the CNA task. The policy further revealed residents should be checked for incontinence at least every two hours and the residents should be toileted as needed. The policy revealed brief, and pads should be used appropriately with one pad on the residents' bed and one diaper on the residents. The policy further revealed that briefs and pads were to be changed immediately when wet or soiled and pericare was to be completed. NJAC 8:39-4.1(a) NJAC 8:39-21.1(a)

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure physician orders were followed for two of 32 sample residents (Resident (R) 121 and R89) reviewed for orders regarding boots to prevent skin breakdown for R121 and dressing change for R89. This failure put residents at risk for skin breakdown, infection, and worsening contractures. Findings include: 1. Review of R121's Admission Record face sheet located in the electronic medical record (EMR) under the Admission Record tab, revealed R121 was admitted to the facility on [DATE] with diagnoses of zygomatic fracture right side, stable burst facture of fourth thoracic vertebra, stable burst fracture of the first lumbar vertebra, and wedge compression fracture of the second lumbar vertebra. Review of R121's admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/13/25 revealed R121 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderately impaired cognition. Review further revealed R121 had hand upper and lower impaired range of motion (ROM) to one side and was dependent on lower body dressing and putting on footwear. Review of the MDS revealed R121 was at risk for pressure sores. Review of R121's comprehensive care plan located under the Care Plan tab of the EMR with an initiated date of 01/06/25 revealed a problem was addressed for limited ROM but there was no intervention for green boots or black boots. Review of the care plan further revealed a problem was listed for dependence on staff for meeting Activities of Daily Living (ADL) and the interventions did not include the use of green boots or black boots. Review of the care plan further revealed a problem was listed for R121 for being at risk of skin impairment but no interventions for the boots were listed. Review of the physician's order, dated 02/02/25, located under the Orders tab of the EMR revealed an order for heel protector boots to both feet while in bed to ensure skin and joint integrity and R121 needed assistance to apply and remove the boots. Review of the physician orders, dated 02/02/25, revealed an order for Multipodus boots to both feet while out of bed. During an observation on 02/23/25 at 4:14 PM, R121 was lying in bed and did not have any boots on his feet. During an observation on 02/24/25 at 8:38 AM, R121 was lying in bed and did not have any boots on his feet. During an observation on 02/24/25 at 10:38 AM, R121 was lying in bed and did not have any boots on his feet. Observation further revealed there were green boots lying on the chair in the room. During an observation on 02/24/25 at 1:04 PM, R121 was lying in bed and did not have any boots on his feet. Observation further revealed there were green boots lying in the chair. During an observation on 02/25/25 at 10:05 AM, R121 was lying in bed and did not have any boots on his feet. Observation further revealed green and black boots were on the chair in the room. During an interview on 02/25/25 at 10:06 AM Certified Nursing Assistant (CNA) 4 revealed that the green boots were to be used when a resident was in bed and the black boots were to be used when the resident was up in a wheelchair. CNA4 revealed R121 had come to the unit on Friday, and she had not taken care of him before. CNA4 revealed she had seen the boots lying on the chair but did not know his schedule. CNA4 revealed she did not get any report from the nurses yesterday or today about his care. CNA4 revealed, after she reviewed the tablet that had the care needs of R121, there was not any indication that R121 needed to have the boots on his feet. CNA4 tried to look at the care plan on the tablet but she did not know how to get to the care plan to advance to the next page. The CNA4 confirmed the boots were not on the resident. During an interview on 02/25/25 at 10:12 AM with the Licensed Practical Nurse (LPN) Unit Manager (UM) 1 revealed it was CNA's responsibility to put the boots on R121. UM1 revealed the nurse told the CNA what the care needs were for R121, and it should be on the tablet. UM1 revealed R121 received green boots to his feet when in bed to prevent skin breakdown. UM1 further revealed R121 was to wear the black [NAME] boots on his feet when he was up in the wheelchair. UM1 reviewed the CNA point of care screen and verified there were no interventions for the boots to alert the CNA of the need for them. UM1 revealed it was the unit manager's responsibility to put the information into the computer for the CNA's and it had not been added. During an interview on 02/26/25 at 9:29 AM, the Therapy Director revealed R121 had been admitted to the facility from the hospital and the boots were already established from there and the therapy department did not have to address them. The Therapy Director further revealed the heel protectors should have been worn in bed for offloading to prevent skin breakdown. The Therapy director further revealed R121 was at risk of skin breakdown if boots were not being utilized. During an interview on 02/26/25 at 1:23 PM, the Director of Nursing (DON) revealed after an order was obtained it should be documented in the task section so the CNA's can see what the residents' needs were. The DON revealed if the order was not transferred over to the task, then the CNA might not be able to see the care needs. During an interview on 02/26/25 at 3:14 PM, the Regional Nurse revealed R121 had an order for the green boots to be worn when he was in bed. The Regional Nurse further revealed the green boots, and the black boots were not on the comprehensive care plan and should be an intervention for the resident. The Regional Nurse revealed R121 was at risk for skin breakdown and the boots should be utilized on the feet. 2. Review of R89's Admission Record located under the Profile tab of the electronic medical record revealed R89 was originally admitted to the facility on [DATE] with diagnoses that included diabetes mellitus due to underlying condition with diabetic chronic kidney disease, end stage renal disease, sepsis due to methicillin resistant staphylococcus Aurea (MRSA), and MRSA infection as the cause of diseases. During an observation on 02/23/25 at 11:20 AM, R89 was ambulating, unassisted, throughout the 4th floor. The resident was not wearing a top and a large bandage could be seen on the resident's left pectoral. Hanging from the bandage was a peripherally inserted central catheter (PICC) line along with a clamp. Upon closer assessment at 11:27 AM, the bandage revealed a date of 02/14/25. Review of the admission MDS with an ARD of 01/31/25 located under the MDS tab of the EMR revealed a BIMS score of 15 out of 15 which indicated R89 was cognitively intact. During an interview on 02/23/25 at 3:03 PM, R89 stated he did not recall the last time his bandage was changed but advised that he has had no complications related to his PICC line. Review of R89's orders located under the Orders tab of the EMR revealed the following dressing change orders: 1) Change PICC/Midline dressing once weekly, every night shift every Fri with a start date of 01/31/25; 2) R [right] chest PICC dressing change weekly on Wed 7-3 shift, every day shift every Wed starting on 01/12/24. Review of the Medication Administration Record (MAR) for the month of February 2025 revealed that the dressing change was performed on 02/07/25, 02/12/25, 02/14/25, 02/19/25, 02/21/25, 02/26/25. During an observation and interview on 02/24/25 at 3:45 PM, UM2 was shown the bandage dated 02/14/25 and confirmed that bandages are typically changed weekly. UM2 confirmed that per the order and administration record, the bandage had not been changed. During an interview on 02/25/24 at 10:26 AM, LPN9 stated that she entered the order for the bandage to be conducted weekly on Fridays. She was asked about the duplicate order to change bandages on Wednesdays, and she stated she was not aware of another order. LPN9 was also asked why the MAR had been documented as if the wound change occurred and she confirmed that she did not know. Review of the facility's policy titled, Dressings, Dry/Clean, dated June 2024, revealed its purpose was to provide guidelines for the application of dry, clean dressings. Per the policy, to prepare for a dressing change staff must verify there's a physician's order; review care, orders, and diagnoses to determine if there are special resident needs; check the treatment record; and lastly assemble the equipment and supplies as needed. 1. Adjust bedside stand to waist level. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 3. Tape a biohazard or plastic bag on the bedside stand or open on the bed. 4. Pull strips of tape adequate for securing dressing at the end of the procedure and add date, time, and initials. Place on edge of bedside table to enable easy access when needed. Review of the facility's policy titled, Adaptive Devices with a revised date of 10/24 revealed adaptive devices were utilized to maximize positioning comfort and function. Review further revealed the LPN would document adaptive device on the CNA accountability record and on the interdisciplinary care plan. NJAC 8:39-27.1(a) 37590

Based on observation, interview, record review, and policy review, the facility failed to administer oxygen at the physician prescribed dose for one of six residents (Residents (R) 56) reviewed for respiratory care out of 32 sample residents. This had the potential to cause residents' respiratory distress. Findings include: Review of R56's Profile tab of the electronic medical record (EMR) revealed she was initially admitted to the facility on [DATE] and had a hospital stay from 12/28/24 to 01/06/25. R56 had diagnoses of bronchiectasis, with onset date of 01/07/25, and acute respiratory failure with hypercapnia, dated 01/09/25. Review of the Orders tab of R56's EMR revealed an order, dated 01/06/25, for oxygen at 2 LPM [liters per minute] via nasal cannula every shift. Review of R56's five-day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/13/25 and located in the MDS tab of the EMR, revealed a BIMS score of 12 out of 15 which indicated R56 had moderately impaired cognition. R56 utilized oxygen. Review of R56's Medication Administration Record (MAR), dated February 2025 and located in the EMR under the Orders tab, revealed nurses signed off the order for oxygen at 2 LPM every shift and documented an oxygen saturation level. During a concurrent observation and interview on 02/23/25 at 11:59 AM, R56 was observed lying in bed with an oxygen concentrator administering oxygen at five LPM via a nasal cannula. R56 reported she had used oxygen since returning from the hospital. R56 did not know what her orders were for the oxygen setting. During an observation on 02/24/25 at 12:51 PM, R56 was in bed with her oxygen concentrator set at 3.5 LPM delivering oxygen via nasal cannula. During an observation and interview on 02/24/25 at 2:04 PM, Licensed Practical Nurse (LPN) 5 reported R56 had orders for oxygen to be delivered at two LPM, verified the concentrator was set incorrectly, and changed the oxygen concentrator setting from 3.5 LPM to two LPM. During an interview on 02/26/25 at 1:06 PM, the Director of Nursing (DON) stated she expected oxygen orders to be followed. The DON stated high settings of oxygen delivery could be problematic for residents with chronic obstructive pulmonary disease (COPD) or when trying to wean a resident off of oxygen. Review of the facility's policy titled, Oxygen Administration, reviewed October 2024, revealed staff were to, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. NJAC 8:39-27.1(a)

Based on record review, interview, and facility policy review, the facility failed to ensure a meal or snack was provided and that there was ongoing pre- and post-dialysis communication for a resident receiving dialysis three times a week for one of one resident (Resident (R) 13) reviewed for dialysis out of 32 sample residents. This had the potential to affect the nutritional status and health of residents receiving dialysis. Findings include: Review of R13's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed he was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and heart failure. Review of R13's Care Plan section of the EMR revealed a focus area, dated 07/20/23, [Resident] needs hemodialysis three times a week with interventions including: Vital signs are taken before and after dialysis. The Care Plan also included a focus for R13 being at risk for altered weight status [related to] edema . [hemodialysis]/fluid fluctuations. Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/25 and located in the resident's EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. R13 received dialysis. Review of the Orders tab of R13's EMR, revealed an order, dated 02/20/25, dialysis pick up - 5:30 am one time a day every Tue, Thu, Sat. Review of a Dialysis binder, located at the nurse's station for R13, revealed it contained Dialysis and Nursing Home Hand-Off Communication Tool papers in it for each dialysis day. The papers were pre-filled with R13's name, code status, allergies, diet, current type of precautions, contact person, and nursing home name and number. There were areas above the prefilled line containing the facility's name and number to fill in vital signs, what the last meal or snack was, and the time it was consumed. The middle section, below the nursing facility's name and number, and above To be completed by dialysis facility addressed dialysis access concerns, medications taken, and changes since last dialysis treatment. The areas had yes/no boxes to check. Further review of the Dialysis binder for R13 revealed that, of the 19 papers filled out for dialysis days between 01/11/25 and 02/25/25, fifteen contained no documentation of vital signs taken before dialysis. None of the papers documented any meal or snack. Seventeen of the papers had no boxes checked regarding whether the resident had taken any medications or had any changes since the last dialysis treatment. During an interview on 02/23/25 at 10:26 AM, R13 reported receiving dialysis for eleven years. R13 stated he went out to dialysis at 5:30 AM on Tuesdays, Thursdays, and Saturdays without receiving a snack. I'm very hungry when I return around 11:00 AM. During an interview on 02/25/25 at 4:15 PM, Licensed Practical Nurse (LPN) 4 stated dialysis communication forms were in a binder, which went with the resident to dialysis. LPN4 was unsure who filled out the top portion of the forms, above the to be completed by dialysis facility area since she did not send residents to dialysis. She stated when R13 returned from dialysis, LPN4 reviewed the bottom part of the communication form, which dialysis filled out, wrote a progress note, and checked his vital signs. During an interview on 02/25/25 at 4:20 PM, LPN3 stated the facility should fill out the top of the form above the to be completed by dialysis facility. LPN3 stated when LPN3 worked the evening shift, dietary staff did not send food in the evening for the residents to eat the morning of dialysis. During an interview on 02/25/25 at 4:24 PM, Unit Manager (UM) 1 stated that dialysis filled out the communication form under the nursing home name but above to be completed by dialysis facility. UM1 stated this section included medications taken, new medical problems or falls, hospitalization s or emergency department visits, labs drawn since last dialysis, and new medications or vaccinations. During an interview on 02/25/25 at 4:43 PM, the Director of Nursing (DON) stated the nurse sending the resident to dialysis was expected to fill out the top of the dialysis communication form all the way to the area to be completed by dialysis for ongoing communication with dialysis. During an interview on 02/26/25 at 9:39 AM, LPN8 reported the nursing staff made R13 tea each morning before dialysis. LPN8 stated that sometimes R13 took crackers in the morning before dialysis, but sometimes he refused. LPN8 stated dietary staff did not send up an early breakfast tray or snack. She stated the dialysis binder, with the communication forms, went with R13 to dialysis. She stated the top of the communication forms had prefilled information. LPN8 stated nursing documented vital signs prior to dialysis. She stated the rest of the form was only filled out with changes, and there were no recent changes. During an interview on 02/26/25 at 11:00 AM, the Dietary Manager (DM) stated if a resident went out to dialysis before 6:00 AM, dietary sent a bagged breakfast up to the unit the evening before, which nursing kept in the refrigerator until the next morning. DM stated if a resident went out at 6:00 AM or later, dietary was onsite and sent up an early breakfast tray. Review of the facility's policy titled, Meals for Dialysis Residents, created 03/24, revealed Nursing Services will notify the Food Services Department when a resident will be at dialysis during meal times. Such information will include, but is not necessarily limited to: need for an early meal tray; which meal(s) the resident will miss; how long the resident will be absent; and which meal the resident will be served upon returning to the facility. Review of the facility's Dialysis Procedure, reviewed 01/25, revealed Communication with the Dialysis Center will be maintained through the use of a communication book. The book is located at the nurse's station and is clearly labeled with the resident's name. The communication book is sent with the resident each time they are transported to dialysis. The nursing staff and the Dialysis Center will communicate any pertinent resident information through the communication book. In addition, the Dietician will be made aware to provide snacks/meals as needed. NJAC 8:39-2.9 NJAC 8:39-27.1(a)