Every finding on record at Ridgewood Center

Based on observation and interview on 5/20/26 and 5/21/26 in the presence of the Maintenance Director (MD) and Regional Plant Operations Director (RPOD), it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in safe operating condition. This deficient practice was evidenced for 28 of 28 PTAC units observed and could affect all residents in the facility by the following: Observations while touring the facility from 9:00 AM to 12:00 PM, revealed that PTAC filters were clogged and dirty throughout the facility.In an interview the MD and the RPOD both confirmed the findings.A policy and procedure for PTAC maintenance was requested but not provided at the time of the LSC exit conference.The Regional Plant Operations Director was notified of the deficient practice at the Life Safety Code exit conference on 5/21/26 at 12:45 PM.NJAC 8:39 - 31.2(e)

Based on interview and review of pertinent facility documentation, it was determined that the facility failed to ensure: a.) the Antibiotic Stewardship Program (ASP) Policy and Procedure, part of the facility Infection Prevention Control Program (IPCP) included a procedure for the reporting in Quality Assurance and Performance Improvement (QAPI), b.) the standardized infection assessment tool or management algorithm (IST) was consistently utilized for prescribed antibiotics, and c.) the facility maintained evidence of an ongoing analysis of surveillance data for organisms with a documented follow-up in response to the collected data. This deficient practice was evidenced and could affect all residents in the facility by the following: On 5/17/26 at 12:20 PM, during the entrance conference with Surveyor #1 (S #1) and S #2, with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the LNHA confirmed that the facility census (total number of residents) was 74. The DON stated that the facility followed the CMS (Centers for Medicare and Medicaid Services), NJDOH (New Jersey Department of Health), CDC (Centers for Disease and Control Prevention), and McGeer criteria (are standardized, evidence-based definitions used to identify and track infections in long-term care facilities (LTCFs), such as nursing homes and assisted living communities) for infection control.On 5/19/26 at 9:53 AM, S #1 interviewed the Infection Preventionist Nurse (IPN) via a phone conference. The IPN informed S #1 that she transitioned to per diem on January 2026, her responsibility included CDC weekly reporting, rounding the floor to ensure that infection control was followed, providing education to all staff, and all other infection control tasks that included ASP. She further stated that if she was not at the facility, it was the DON and the Unit Manager who was responsible for her tasks.On 5/19/26 at 2:01 PM, S #1 interviewed the DON in the presence of S #3, LNHA, Regional Nurse, and Regional Clinical Lead (RCL) regarding the facility's ASP. The DON stated that the audits were run monthly, and the antibiotic prescribed supposed to follow McGeer criteria. S #1 asked the DON where the ASP monitoring were and McGeer criteria since last recertification survey, the DON flipped over the white binder for ASP, and he stated the printed documents in the back of the binder was the ASP. S #1 notified the DON that it was the same copy provided to S #1, and it was the monthly reports from the pharmacy of list of residents with antibiotic with start date and did not include information in accordance with the facility's protocol and McGeer standards to follow. The DON stated that he probably have it in the office in another binder.On 5/19/26 at 2:11 PM, S #1 and the DON went to the other room where the Regional IP (Infection Preventionist) was inside the room. The DON checked binders, unable to find the ASP and McGeer criteria since last recertification survey. The DON stated he did not know as to why there was no ASP. On 5/19/26 at 2:15 PM, S #1 in the presence of S #3, and the LNHA reviewed the QAPI binder reports and revealed the following QAPI meeting dates:2/26/26=The IPN reported about EBP (enhanced barrier precautions) cart stocking and PPE (personal protective equipment) use reports. There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.3/27/26=There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.4/17/25=There was a list of infection. There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.7/17/25=There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.9/30/25=There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.10/31/25=There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.11/14/25=There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.12/18/25=There was no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.At that same time, the LNHA confirmed the dates of QAPI meetings with no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data.On 5/19/26 at 2:40 PM, S #1 notified the LNHA and the RCL of the above findings and concern that there were no ASP, IST, McGeer criteria reports, and ongoing analysis to the collected data documentation since last recertification in the Antibiotic Stewardship and QAPI binders that were provided by the facility. S #1 also notified the concern that the ASP Policy and Procedure, part of the facility's IPCP did not include a procedure for the reporting in QAPI, a standardized infection assessment tool or management algorithm was not consistently utilized for prescribed antibiotics, and the facility did not maintain evidence of an ongoing analysis of surveillance data for organisms with a documented follow-up in response to the collected data. On 5/19/26 at 2:45 PM, S #1 called and attempted again to interview the IPN, and there was no response from the IPN.On 5/21/26 at 11:34 AM, the survey team met with the LNHA, RCL, Regional Nurse, and the DON confirmed no surveillance for ASP and had only printed for order listing.A review of the facility's Antibiotic Stewardship Policy that was provided by the DON, with a review/revised date of 11/14/25, revealed under policy, centers will implement an ASP as part of the facility's overall IPCP. The IP is responsible for the IPCP including ASP. The Administrator is ultimately responsible for overall compliance with the ASP. The DON and Medical Director are responsible for executing the ASP standards. Process.1.2 The DON: 1.2.1 Establishes standards for nursing staff to assess, monitor, and communicate changes in a patient's condition that could impact the need for antibiotics.2. The ASP leaders use existing resources to support antibiotic stewards' efforts by working with the following partners:2.1. The IP:2.1.1 Uses expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring to adherence to evidence based, published criteria during the evaluation and management of treated infections; and2.1.2 Reviews antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms.4. The program includes antibiotic use protocols and a system to monitor antibiotic use.4.1.3 The center uses the CDC.updated McGeer's criteria, or other surveillance tool to define infections.4.2 Monitoring Patients' Antibiotic Use:4.2.1 Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made.4.2.4 Monitor during each monthly medication regimen review when the patient has been prescribed or is taking an antibiotic or any antibiotic regimen review as requested by the QAA (Quality Assessment and Assurance) committee.4.2.8 A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices.7. At least annually, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, patient and family council and the QAA Committee.11. Documentation related to the program is maintained by the IP, including, but not limited to:11.1 [NAME] plans and/or work plans associated with the program;11.2 Assessment forms;11.3 Antibiotic use protocols/algorithms;11.4 Data collection forms for antibiotic use, process, and outcome measures;11.5 Antibiotic stewardship meeting minutes;11.6 Feedback reports;11.7 Records related to education of practitioners, staff, patients, and families;11.8 Annual reports.12. Data obtained from antibiotic stewardship monitoring activities is discussed in the facility's QAPI meetings.On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA.NJAC 19.4(d)

Refer to F881Based on interview and review of pertinent facility provided documentation, it was determined that the facility failed to ensure that the employed designated Infection Preventionist (IP) a.) worked at least part-time at the facility and b.) completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role. This deficient practice was identified for 3 of 4 employees reviewed for IP requirements. This deficient practice was evidenced by the following:On 5/17/26 at 12:20 PM, during the entrance conference with Surveyor #1 (S #1) and Surveyor #2 (S #2) with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA informed the surveyors that Infection Preventionist Nurse #1 (IPN #1) was a part time employee, 20 hours per week, and had been with the facility as an IP since last recertification survey (4/10/25).On that same date and time, the DON informed the surveyors that the facility followed the CMS, NJDOH (New Jersey Department of Health), CDC (Centers for Disease Control and Prevention), and McGeer criteria (are standardized definitions used to identify and track infections in long-term care facilities, like nursing homes) for infection control. S #1 then asked for copy the IPN's signed job description, resume, and certificate.On 5/18/26 at 9:20 AM, S #1 reviewed the provided IPN #1's CDC completion for Nursing Home Infection Preventionist Training Course certificate and revealed she completed it on 5/25/25, with 19.7 contact hours.On 5/19/26 at 8:40 AM, S #1 asked DON if IPN #1 was at the facility for an interview. The DON informed S #1 that IPN #1 was not at the facility and would probably be here tomorrow. He further stated that there was no specific dates when IPN #1 was at the facility, it depended on IPN's full time job. The DON confirmed that this week IPN #1 did not work at the facility yet. The DON further stated that he would get back to S #1 for IPN #1's schedule. On 5/19/26 at 9:20 AM, S #1 asked the Regional Nurse and the Regional Human Resource Director (RHRD) information about IPN's time sheets, signed job description, and other Infection Preventionists (IPs) who worked at the facility since last recertification. S #1 also asked for the timeline of IPs since last recertification.On 5/19/26 at 9:53 AM, IPN #1 informed S #1 via phone conference that she began to assume the responsibility of the IP mid (middle) of May 2025 to November 2025, then she transitioned to per diem position as an IP afterward. IPN #1 stated that she did not sign a job description, the facility did not provide one.On that same date and time, IPN #1 stated, when she started mid-May 2025, she did not have a completed IP certification. She further stated that she left in November 2025, and was back in January 2026 to mid-February as per diem IP. She also stated that when she left in November, it was the previous DON who was covering at that time as an IP. She added that for this week, she supposed to work on Wednesday, but I do not think I am able to work, because she was needed in her full time job. She confirmed that she was just helping the facility until the facility able to find an IP, and if she was not at the facility, it was the DON and the Unit Manager who were covering for her.On 5/19/26 at 12:04 PM, S #1 in the presence of the HR Director (HRD) confirmed that the employee files did not include the signed job description of IPN #1.On that same date and time, the Regional Clinical Lead (RCL), in the presence of the HRD, LNHA, and the DON confirmed that there was no signed job description of IPN #1.On 5/19/26 at 12:13 PM, S #1 reviewed IPN #1's employee files and revealed that IPN #1 accepted and signed the position of Infection Preventionist Nurse/Nurse Educator on 5/9/25.Further review of the medical records revealed that IPN #1 assumed the position of an IP on 5/9/25, prior to completing the certification for an IP, which was completed on 5/25/25.On 5/19/26 1:10 PM, the survey team met with LNHA, DON, RCL, Regional Nurse, and S #1 notified them of the above findings and concern. The Regional Nurse stated that she thought the requirement for an IP could have up to six months to complete the certification as an IP. The RCL also stated that depended on how many hours the required part time, for their facility the part time was at least 16 hours per week. S #1 notified them that per IPN's interview, IPN #1 transitioned to per diem IP since after she came back on January and February 2026, and that she confirmed that she worked at least once a week and another week, two times a week.At that same time, S #1 also followed up the previously requested documents for IPs timeline, time sheets, and signed job description since last recertification, and the RCL stated that she would get back to S #1.On 5/21/26 at 9:09 AM, the RCL confirmed while providing a copy of the timeline and timesheets that IPN #1, IPN #3, and IPN #4 assumed their responsibilities of the IP without completing the certificate for an IP, and no signed job descriptions for them. She further stated that there were times that there were no IP at the facility.A review of the provided IPs timeline and corresponding time sheets revealed: -IPN #2 was at the IP from 2/7/25 through 5/6/25. The time sheets included for the following dates: 2/17/25, 2/18, 2/19, 2/20, 2/21, 2/24, 2/25, 2/26, 2/27, and 2/28/25 were all eight hours per day; no hours for March 2025 and April 2025; and on 5/1/25, 5/2, 5/5, 5/6, 5/7, 5/8, and 5/9/25 were all eight hours per day for non-paid sick. Further review of the above timeline and time sheets of IPN #2 revealed that for two months there was no IP at the facility.-IPN #1 was at the IP from 5/11/25 through 1/1/26. The time sheets included for the following dates: 5/1/25, 5/3, 5/4, 5/5, 5/7, and 5/8/25 were all direct care west wing RN (Registered Nurse) hours 7-3 shift; 5/12/25, 5/13, and 5/14/25 were all direct care/west wing RN eight hours per day; 5/15/25, 5/16, 5/19, 5/20, 5/21, 5/22, 5/23, 5/26, 5/27, 5/28, 5/29, and 5/30/25 were all eight hours per day as Admin (administrative) hours 96 hours, Direct Care/East Wing hours 8.12 hours, and Direct Care [NAME] wing hours 56.03 hours. 12/25/25 Christmas eight hours holiday salary.Further review of the above IPN #1's timeline and time sheets revealed that IPN #1 assumed responsibility for an IP prior to completing the certificate as an IP. The provided documents also showed that even after IPN #1 was the designated IP she also worked in the unit as a direct care nurse from 5/1/25 through 5/14/25.-IPN #3 was at the IP from 1/5/26 through 2/7/26. The time sheets included for the following dates: 2/2/26 worked for five hours, 2/3 worked for seven hours, and 2/4/26 worked for seven hours.Further review of the above information for IPN #3, revealed, that even though she was the IP from 1/5/26 through 2/7/26, there was no documented evidence from the time sheets provided that IPN #3 was at the facility in January 2026.-IPN #4 was the IP from 4/20/26 through 5/15/26. The time sheets included for the following dates: 4/22/26 worked for five hours, 4/23 worked for 10 hours, 4/24 worked for five hours, 4/28 worked for eight hours, 4/29 worked for eight hours, 4/30 worked for eight hours, 5/1 worked for eight hours, and 5/4/26 worked for eight hours.Further review of the above information for IPN #4, revealed, that there were no work hours for the week of 5/10 to 5/15/26. In addition, during the entrance conference meeting with S #1 and S #2 with the LNHA and DON, the surveyors were notified that IPN #1 was present since last recertification survey and that IPN #1 was a part time employee. The above provided timeline and time sheets of IPs since last recertification survey also revealed that there was no designated IP in April 2025, June 2025, July 2025, August 2025, October 2025, November 2025, December 2025, January 2026, and March 2026.On 5/21/26 at 11:34 AM, the survey team met with the RCL, Regional Nurse, DON, and the LNHA did not provide additional information. A review of the facility's Infection Prevention and Control Program Description Policy that was provided by the RCL, with a revision date of 7/1/24, revealed that the IPCP is a set of comprehensive processes that addresses preventing, identifying, reporting, investigating and controlling of infections and communicable diseases for patients/residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement.Design and Role Responsibilities, the IPCP is facilitated through a coordinated effort between the designated IP; center Administrator, DON, and the entire health care team. The IP develops, implements, monitors and maintains the IPCP and fulfills the basic requirements for the role.The IP must work at least part-time. To carry out the major activities of the program, the IP has the following responsibilities.Complete Monthly Infection Control Report and provide to the DON. As a member of the Center's QAPI committee, review information: obtained from the infection prevention, surveillance, and control activities to improve patient care, employee work practices, and the environment of care; as well as incidents identified under the center's IPCP. Report findings to the QAPI (Quality Assurance and Performance Improvement) Committee regularly.On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA.N.J.A.C. 8:39-19.1(b)

REPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified as 2 of 2 units (East and West), 2 of 2 shower rooms, and 1 of 3 dining rooms, and was evidenced by the following:The deficient practice was evidenced by the following: 1. On 5/18/26 at 10:02 AM, Surveyor #1 (S #1) observed Resident #5 lying in bed during the initial interview, with no call bell was observed within the resident's reach. On 5/18/26 at 10:41 AM, S #1 conducted a second observation of Resident #5 and again observed that no call bell was present at the bedside or within reach of the resident. At that time, S #1 interviewed the assigned Registered Nurse (RN), who identified that Resident #5's call bell was located with the roommate. The RN further observed that the roommate's call bell cord had been cut off from the wall jack and was broken. The RN stated that each resident was expected to have a functioning call bell accessible within reach. The RN then obtained a replacement call bell cord for the roommate and placed Resident #5's call bell within reach of the resident. On 5/19/26 at 11:09 AM, S #1 reviewed the medical record for Resident #5. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses that included, but were not limited to; Alzheimer's disease, unspecified dementia, heart failure, atrial fibrillation, muscle weakness, abnormalities of gait and mobility, and major depressive disorder. A review of the resident's Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 5/13/26, included a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated severely impaired cognition. A review of the resident's comprehensive care plan (CP) included that Resident #5 required extensive assistance with bed mobility, transfers, toileting, dressing, and personal hygiene. The CP further included interventions to arrange the resident's environment to facilitate activities of daily living performance and provide cueing for safety. On 5/21/26 at 11:30 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that call bell re-education was being conducted for all staff members and that ongoing call bell audits were being completed. A review of the facility's Call System Policy dated 7/15/25, included, residents were to have access to a functioning call system device to summon staff assistance and that staff were responsible for ensuring call devices remained accessible and operational . 2. On 5/17/26 at 10:03 AM, Surveyor #2 (S #2) observed Resident #11's room, entrance way with peeled molding, the paint was removed and the wood exposed. On 5/18/26 at 9:19 AM, S#2 observed the [NAME] Unit nursing station, on the right side with the molding broken. S #2 observed in the Main Activity room two residents in the room. The Main Activity room observed with bookshelves on the left wall with scuffed wood and some areas chipped wood; left wall molding chipped wood; ceiling air vent paint peeling; window on the right side with ripped screen and observed with dust/residues/cobwebs. At that same time, S #2 observed the hallway in front of the nursing station with ceiling cracked; on the left side of the hallway, two ceiling tiles out of alignment and one tile with heavy, brownish stains; and the ceiling return air vent with dust accumulation. Observed the [NAME] Unit double fire doors with chipped wood. On 5/18/26 at 9:36 AM, S#2 showed the Licensed Practical Nurse/Unit Manager (LPN/UM), Director of Maintenance (DM), and the Senior DM (SDM) regarding the concerns found. S#2 asked them if they were aware how long the issues have been like that and there was no reply. S#2 inquired about the heavy brownish substance on one ceiling tile and two tiles out of alignment and the DM stated it could be condensation from the HVAC (Heating, Ventilation, and Air Conditioning. It refers to the interconnected systems used to regulate temperature, control humidity, and improve overall indoor air quality in residential, commercial, and industrial buildings) unit. The DM confirmed the air vent was dusty and stated they should be cleaned. The DM also confirmed the ceiling in front of the nursing unit was cracked and stated it happened due to winter stress, they had put screws in there and needed to be spackled. The DM stated he made rounds every day and did not see those other issues in the Main Activity Room. On 5/20/26 at 11:33 AM, the survey team met with the administration LNHA, Director of Nursing (DON), Regional Nurse, and the Regional Clinical Lead (RCL), and S #2 notified them of the above concerns. On 5/21/26 at 11:26 AM, S#2 showed the Regional of Environmental, LPN/UM, and the SDM, Resident #11's room entrance doorway with broken molding. The Regional of Environmental confirmed the molding was broken and the wood was chipped. The LPN/UM was unable to state how long the molding was broken. On 5/21/26 at 11:36 AM, the survey team met with the LNHA, DON, RCL, and the Regional Nurse stated that the Regional of Environmental staff was at the facility to address all the issues. No additional information was provided by the LNHA. 3. During an initial tour of the facility on 5/17/26 at 10:15 AM, in East shower room, Surveyor #3 (S #3) observed the ceiling vent was uncovered, the floor tiles with greenish and brownish substances. On 5/17/26 at 10:20 AM, S #3 asked the Director of Recreation (DR) to accompany S #3 during the environmental tour. Both S #3 and the DR went to the main dining room, the DR informed S #3 that the room was being used by residents as main dining and main activity room. S #3 asked the DR what were in the ceiling tiles vent grayish substances and she claimed they were accumulation of dust and confirmed that the brownish substances around the ceiling tiles should not be like that. The DR further stated that it should not be like that too, about the wallpaper that were peeling off. Both S #3 and the DR observed the two tables near the glass door with chipped wood and the DR stated that it should have been fixed for the safety of the residents. She also stated that the television mantel were old and with tear should have been disposed of and replaced. Afterward, the DR accompanied S #3 inside the East Central Bath (also known as the shower room). The DR stated that the ceiling vent should not be like that with opening and she did not know why there were greenish and brownish substances on the floor tiles of the shower room. On 5/18/26 at 8:41 AM, both S #3 and the DM entered the [NAME] Central Bath and observed upon entrance the ceiling vent with accumulation of grayish to blackish substances which he claimed accumulation of dust and should have been cleaned; the cubicle to the left side upon entry with open ceiling vent and the vent cover was on the tile wall next to the dispenser, which the DM stated that should be covered and confirmed that was the cover for the open ceiling vent that should not left uncovered; and the cubicle next to the right upon entry to the door, the lower pipe was greenish and bluish in color, and the LNHA and DM both stated that should not be like that and understood. On 5/19/26 at 1:10 PM, survey team met with LNHA, DON, RCL, and Regional Nurse, and S #3 notified them of the above findings and concerns with regard to the environmental tour. On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA. A review of facility's Safe and Homelike Environment Policy, revision date 11/14/25, revealed under purpose, to provide a safe, clean, comfortable, and homelike environment . Under Process 1.2 revealed, Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 1.2.1 Ensure that furniture and fixtures in common areas frequented by patients are accommodating of physical limitations of patients . NJAC 8:39-31.2(e), 31.4(a)(b)(f)

Based on observations, interviews, record review, and review of pertinent facility documents, the facility failed to, a.) place an indwelling catheter collection bag in a privacy bag and post signage for enhanced barrier precautions (EBP) for 2 of 3 residents (Resident #3 and #42) and b) place an indwelling catheter collection bag below the level of the bladder and develop a care plan (CP) or included interventions for EBP based on current professional standards of practice for 1 or 3 residents (Resident #3) reviewed for urinary catheter care or urinary tract infection (UTI).The deficient practice was evidenced by the following:Reference: The Healthcare Infection Control Practices Advisory Committee guidance titled GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 with an updated date of June 6, 2019, includes the following:III. Proper Techniques for Urinary Catheter MaintenanceA. Following aseptic insertion of the urinary catheter, maintain a closed drainage system.B. Maintain unobstructed urine flow.1. Keep the catheter and collecting tube free from kinking.2. Keep the collecting bag below the level of the bladder at all times.1. On 5/17/26 at 10:14 AM, the surveyor observed Resident #3 seated up in bed, had an indwelling catheter collection bag that was hung on the rail of the head of the bed, and that the head of the bed was elevated and the bag was above the level of the resident's bladder. The collection bag was not in a privacy bag. The surveyor observed that Resident #3 did not have any signage for EBP on their door. Resident #3 stated that the Certified Nursing Assistant (CNA) had placed the bag there.On 5/17/26 at 10:29 AM, the surveyor asked the Registered Nurse (RN) to observe the placement of Resident #3's indwelling catheter collection bag. The RN confirmed that the bag was placed above the level of the bladder and stated that it should be lower. The RN then moved the bag to a lower rail.A review of Resident #3's admission Record (AR) of face sheet (resident information) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to malignant neoplasm of right kidney (a cancerous tumor originating in the renal tissue) and benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland which can restrict urine flow, leading to urinary frequency, urgency, a weak stream, and incomplete emptying).A review of Resident #3's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/26/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated that Resident #3's cognition was intact. Further review reflected that the resident had an indwelling catheter.A review of Resident #3's May 2026 electronic Treatment Administration Record (eTAR) included the following physician order (PO):Perform Indwelling Catheter Care every day and evening shift for care.A review of Resident #3's comprehensive care plan (CP) did not include a focus area or an intervention related to the resident being placed on EBP.2. On 5/17/26 at 10:12 AM, the surveyor observed Resident #42 laying in bed and had an indwelling catheter collection bag hung from the frame of the bed. The collection bag was not in a privacy bag and the collection bag was visible from the hallway. The surveyor observed that Resident #42 did not have any signage for EBP on their door.A review of Resident #42's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to multiple sclerosis (disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve) and atelectasis (the partial or complete collapse of a lung or a section of a lung).A review of Resident #42's most recent comprehensive MDS, with an ARD of 2/28/26, reflected that the resident had a BIMS score of 15 out of 15, which indicated that Resident #42's cognition was intact. Further review reflected that the resident had an indwelling catheter.A review of Resident #42's May 2026 eTAR included the following PO:Perform Indwelling Catheter Care every shift for care.On 5/19/26 at 9:58 AM, the surveyor, via telephone, interviewed the Infection Preventionist Nurse (IPN) who stated that a resident that had an indwelling catheter should be on EBP and have signage on door.On 5/19/26 at 10:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the indwelling catheter collection bag should have a privacy bag and be below the bladder. The LPN further stated that a resident with an indwelling catheter were on EBP and there would be a sign on the door and a bin for PPE (personal protective equipment). The LPN confirmed that there was not a EBP sign on Resident #3 and #42's door.On 5/20/26 at 9:56 AM, the surveyor interviewed the CNA who stated that the indwelling catheter collection bag should have a privacy bag and be below the bladder. She stated that the resident would be on EBP and that she would wear gown and gloves when taking care of the resident.On 5/20/26 at 10:12 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated that indwelling catheter collection bag should have a privacy bag and not be above the bladder. She added that there should be an EBP sign.On 5/20/26 at 10:22 AM, the surveyor interviewed the Director of Nursing (DON) and asked what the expectation was for an indwelling catheter collection bag if it should be in a privacy bag and below the level of the bladder. The DON stated that he would look at the policy. The DON stated that for an indwelling catheter, the resident would be on EBP and a sign would be placed.On 5/20/26 at 11:39 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Lead (RCL) and Regional Nurse the concern that Resident #3's indwelling catheter bag was not in a privacy bag and was above the level of the bladder and there was no signage to indicate the resident was on EBP and EBP was not in the CP.On 5/20/26 at 11:40 PM, the surveyor notified the LNHA, DON, RCL and Regional Nurse the concern that Resident #42's indwelling catheter bag was not in a privacy bag and there was no signage to indicate the resident was on EBP.On 5/21/26 at 11:38 AM, in the presence of the LNHA, DON, and RCL, the Regional Nurse stated that staff were educated on the privacy bag and below the level of the bladder.The LNHA did not provide any additional information.A review of the facility's Catheter: Urinary-Justification for Use Policy with a revised date of 8/7/23, did not include information regarding use of privacy bag or EBP use.A review of the facility's Enhanced Barrier Precautions Policy with a revised date of 11/14/25, included the following: Policy, EBP expands on the use of gown and gloves beyond anticipated blood and body fluids exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in transfer of MDROs ((Multi-drug Resistant Organisms, bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs) to hands and clothing of healthcare personnel.Because EBP do not impose the same restrictions as Contact Precautions, they are intended to be in place for the duration of the patient's stay in the Center or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.Purpose, to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.4. Implement Contact Precautions versus EBP per following table.Use EBP-Has a wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and not known to be infected or colonized with any MDRO.The policy did not contain any information regarding signage for EBP.N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that residents that received oxygen (O2) and nebulizer (neb) treatments received the necessary respiratory care and services, according to the standard of clinical practice, specifically a) that neb treatment equipment was dated and stored in accordance with infection control measures for 2 of 2 residents reviewed for respiratory care (Resident #6 and #42) and b) that O2 equipment were stored in accordance with infection control measures and that cautionary and safety signs indicating the use of O2 were posted for 1 of 2 residents reviewed for respiratory care (Resident #42). The deficient practice had the potential to affect all residents receiving respiratory care and was evidenced by the following: Reference: National Institutes of Health defines O2 as a colorless, odorless and tasteless gas. It will support life. It is noncombustible, but will actively support the burning of combustible materials. Some materials that will not burn in air will burn in O2. Materials that burn in air will burn more vigorously in O2. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/18/26 at 10:13 AM, Surveyor #1 (S #1) observed Resident #6 in their room lying in bed in an upright position with the call bell within reach, O2 via nasal cannula (n/c) was observed in placed at 2 liters per minute (2LPM). On 5/18/26 at 10:15 AM, S #1 interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM), who stated that Resident #6 was stable, had a history of hospitalizations, would call the ambulance independently, and frequently refused the BiPAP (Bilevel Positive Airway Pressure. It is a type of noninvasive breathing support that uses a mask to deliver pressurized air into the airways). On 5/18/26 at 10:17 AM, S #1 conducted a second observation of Resident #6, and was observed lying in bed with O2 administered via n/c at 2LPM. S #1 observed no date or label present on the O2 tubing. The Regional Nurse present during the observation stated, I would expect there to be a date/label present on the O2 tubing. At that same time, S #1 observed the neb tubing, a neb mask lying loose on the bedside table without a date or label present on the tubing, and was not properly stored in a bag. In addition, the BiPAP mask was observed lying loose on the bedside table and was not stored in a bag. Furthermore, S #1 interviewed the Registered Nurse (RN) and stated that the expectation was for the neb mask and BiPAP mask to be stored in a plastic bag with a date label present for infection control purposes. The RN further acknowledged that no label was present on the neb tubing. On 5/18/26 at 11:37 AM, S #1 reviewed the medical record for Resident #6. A review of the admission Record (AR) or face sheet (an admission summary), revealed Resident #6 was admitted with diagnoses that included, but were not limited to; chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, interstitial pulmonary disease, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, and chronic diastolic congestive heart failure. A review of physician orders (PO) included: O2 at 2LPM via n/c continuously; O2 tubing change weekly with instructions to label each component with the date and initials; BiPAP use at night while asleep if the resident agreed to use it; BiPAP mask style full face, size large; BiPAP change or clean intake filter and disposable supplies per manufacturer's instructions. A review of the resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/26/26, revealed a brief interview for mental status (BIMS) score of 15 out of 15, with reflected that the resident was cognitively intact. The MDS also included that the resident received O2 therapy and BiPAP therapy. A review of the resident's comprehensive care plan (CP) included that Resident #6 was at risk for respiratory complications related to (r/t) interstitial pulmonary disease, chronic obstructive pulmonary disease, and respiratory failure. Interventions included administration of aerosol treatments as ordered, maintenance of BiPAP settings, and monitoring for respiratory distress. On 5/20/26 at 10:10 AM, S #1 interviewed the Director of Nursing (DON), who stated that O2 tubing should have a label indicating when it was changed. The DON further stated that neb and BiPAP masks should generally be stored in a plastic bag. On 5/21/26 at 11:30 AM, in the presence of the survey team, the Licensed Nursing Home Administrator (LNHA) stated that audits were being conducted r/t respiratory equipment storage and that staff education was being provided regarding proper storage and infection control practices for respiratory tubing and masks. A review of the facility's Respiratory Equipment/Supply Cleaning/Disinfecting Policy, date 7/15/21, included that O2 delivery devices, neb/aerosols, O2 humidifiers, drain bags/water reservoirs, suction catheters, and O2 connecting tubing were to be changed every 7 days or as needed for soiling. The policy further included that O2 tubing was to be labeled with the date changed and that respiratory equipment was to be stored appropriately to prevent contamination. A review of the facility's BiPAP/Continuous Positive Airway Pressure (CPAP) Policy, dated 10/15/24, included that disposable supplies, including tubing, were to be changed per manufacturer guidelines or as needed if soiled and that respiratory equipment was to be cleaned and maintained according to infection control practices. 2. On 5/17/26 at 10:12 AM, Surveyor #2 (S #2) observed Resident #42 laying in bed. S #2 observed a O2 concentrator up against the wall between the bed and dresser and a n/c tubing was connected to the concentrator and the laying on the floor. The n/c was not dated and not stored in a plastic bag. Resident #42 stated that they stopped using O2 two weeks ago. S #2 observed that Resident #42's neb treatment mask was laid on top of the dresser on top of the plastic bag. The neb mask was not stored in a bag. S #2 observed that there was not a cautionary sign that O2 was in use on the resident's door. A review of Resident #42's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to multiple sclerosis (disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve) and atelectasis (the partial or complete collapse of a lung or a section of a lung). A review of Resident #42's most recent comprehensive MDS, with an ARD of 2/28/26, reflected that the resident had a BIMS score of 15 out of 15. A review of Resident #42's May 2026 electronic Medication Administration Record (eMAR) included the following PO: O2 at 2LPM via n/c for SOB (shortness of breath) or O2 saturation lower than 92%. The last documented administration was on 5/6/26. Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml (milligrams/milliliters) inhale orally two times a day for wheezing/sob for 7 days with a start date of 5/5/26 and was discontinued 5/13/26. On 5/20/26 at 10:13 AM, S #2 interviewed the Licensed Practical Nurse (LPN) who stated that n/c tubing and neb treatment mask should be dated and in a plastic bag and an O2 sign should be on the door. S #2 showed the LPN pictures of the observations and stated that they should have been in a bag. The LPN confirmed that there was not an O2 sign on the door. On 5/20/26 at 10:24 AM, S #2 interviewed the DON who stated that for O2 dating and placed in a plastic bag depended on the policy and would get back to S #2. The DON stated that he was not sure about the O2 sign. He stated that the neb mask should be in a bag well contained. On 5/20/26 at 12:02 PM, S #2 notified the LNHA, DON, Regional Clinical Lead (RCL) and Regional Nurse the concern that Resident #42's neb mask was laid on top of the plastic bag, n/c connected to the 02 concentrator was not dated and laying on floor not dated and no 02 cautionary sign on door. On 5/21/26 at 11:36 AM, in the presence of the LNHA, DON, and RCL, the Regional Nurse stated that staff were educated on labeling tubing and placement. The RCL stated that Resident #42's PRN order was discontinued. The LNHA did not provide any additional information. A review of the facility's Nebulizer: Small Volume Policy, with a revised date of 11/1/23, included the following: 21.1 Place in treatment bag labeled with patient name and date. A review of the facility's O2: Concentrator Policy with a revised date of 8/7/23, included the following: NOTE: An O2 concentrator extracts O2 molecules from room air. It can be used for low O2 flow rates (e.g., 1-4LPM). 11. Attach prescribed O2 delivery device. The policy did not include any information on dating or storing delivery device. The policy did not include any information on signage. A review of the facility's O2: High Pressure Cylinders Policy with a revised date of 12/26/24, included the following: Practice Standards 1.1 Fire hazard is increased in the presence of O2. No smoking or open flame within five feet of O2. 1.3 .A No Smoking-O2 in Use sign must be posted in any area where high pressure cylinders are stored. 2. Inform patients of O2 safety precautions and prohibitions (e.g., O2 is not permitted where smoking is allowed). N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure a.) timely meal delivery and provide warm food for 8 of 18 residents (Residents #4, #48, #70, Unsampled Resident (UR) #1, #2, #3, #4, and #5), b.) staff responded to call bell timely for 2 of 2 nursing units (East and [NAME] Units), and c.) staff signed off medication record and no blanks for 1 out of 18 residents ( Resident #1). This deficient practice was evidenced by the following: 1.On 5/17/26 at 10:00 AM, Surveyor #1 interviewed Certified Nursing Aide #1 (CNA #1) in the [NAME] nursing station who informed S #1 that there total of 41 residents in the unit, two nurses, and two CNAs. She further stated that she had total of 20 residents in her assignment. At that same time, S #1 observed that room [ROOM NUMBER]'s (R43's) call bell was ringing. On 5/17/26 at 10:06 AM, S #1 observed R43's call bell was still ringing. Registered Nurse #1 (RN #1) was in the hallway, did not respond to R43's call bell, instead went to Resident #29's room nearby because the resident asked for their breakfast tray and the resident stated they were hungry. RN #1 stated to the resident that it would be provided. Outside Resident #29's room, RN #1 informed S #1 that the breakfast truck came late around 8:45 AM, there were only two CNAs in the unit, and the nurses needed to help, and had to stop medication (med) pass. RN #1 stated that Resident #70 was a feeder. Furthermore, S #1 observed the breakfast food truck was distributed after Resident #29 had asked for their tray. On 5/17/26 at 10:10 AM, S #1 observed the CNA #2 entered R43 and turned off the light (total of 10 minutes). At that time, S #1 observed CNA #1 in the dining room in front of the nursing station seated in a chair next to Resident #74 and CNA #1 stated that she was doing 1:1 (one on one) with the resident. She also confirmed that her and CNA #2 take turns in 1:1 and CNA #2 was the only CNA in the unit at this time. On 5/17/26 at 10:38 AM, S #1 observed Resident #29 seated on their bed with breakfast tray, which the resident claimed they were done with breakfast, and confirmed that they received the breakfast late today. The resident further stated, usually the breakfast was delivered to them between 8:00 to 9:00 AM but today was passed 10 AM, they heard that the staffing was short today, and they felt it because it took time to respond to their need. On 5/18/26 at 8:17 AM, S #1 observed the call bell light was on in room [ROOM NUMBER] (R47), CNA #1 was inside the dining room in front of the [NAME] nursing unit with Resident #74 on 1:1 observation. CNA #3 was also in the [NAME] unit nursing station and informed S #1 that there were four CNAs today in the unit. RN #2 was also in front of the nursing station in his med cart while the call bell was ringing. There was a posted sign for staffing at the desk on top of the nursing station that included information for census of 74, seven CNAs with ratio of 1 CNA:10.6 Residents, with 1 LPN (licensed practical nurse) ratio of 1:74 Residents, and 3 RNs ratio of 1:24.7 residents. On 5/18/26 at 8:19 AM, S #1 observed the first (1st) breakfast tray truck was delivered in front of the [NAME] Unit nursing station. RN #2 was still in front of their med cart, the food truck was not distributed, and call bell of R47 was still ringing. On 5/18/26 at 8:21 AM, S #1 observed RN #3 informed S #1 that she was the other nurse in the [NAME] nursing unit, while the call bell in R47 was still ringing and no one attended to the resident. CNA #3 was at the nursing station at that time. On 5/18/26 at 8:28 AM, S #1 observed the second (2nd) breakfast food truck came, the 1st food truck was still not being distributed to residents, and the call bell in R47 was still ringing. On 5/18/26 at 8:31 AM, S #1 observed the 1st food truck was started to be distributed in [NAME] unit low side (total of 12 minutes), while the 2nd food truck was still not being distributed, and the call bell in R47 was still ringing. On 5/18/26 at 8:33 AM, S #1 asked RN #3 to accompany S #1 to R47. The call bell was still ringing on the R47 (total of 16 minutes). Inside R47, Unsampled Resident #1 (UR #1) was lying on bed and room was cold. UR #1 informed S #1 that they were cold and had been ringing because they were freezing, and that they needed someone to have their cellphone charger. RN #3 also confirmed that the room was cold. On 5/18/26 at 8:40 AM, S #1 observed the 2nd food truck (total of 9 minutes) was started to distribute by staff. On 5/19/26 at 1:10 PM, the survey team met with Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Clinical Lead (RCL), Regional Nurse, and S #1 notified them of the above concerns. On 5/21/26 at 11:34 AM, the survey team met with the LNHA, RCL, DON, and the Regional Nurse stated, we will be having another resident council meeting for cold food and call bell audits. She further stated that with regard to homelike environment we have our Senior Maintenance Director and Regional Director started cleaning the ceiling vents and other concerns. She also stated that education was provided with regard to delivery of food should be timely. 2. On 5/17/26 at 10:15 AM, during the initial tour, Surveyor #2 (S #2) observed Resident #48 seated in bed inside their room. S #2 asked if there were any concerns regarding the resident's stay at the facility, and the resident stated, I still did not get my breakfast this morning. At 10:20 AM, S #2 observed that Resident #48 had not yet received a breakfast tray. S #2 asked the Recreation Assistant (RA) outside the resident's room about resident's breakfast and the RA stated she would get back to the surveyor and would check with the kitchen. At 10:30 AM, S #2 observed the RA returned to Resident #48's room with the resident's breakfast tray. On 5/19/26 at 8:35 AM, S #2 interviewed the Food Service Director (FSD) and Regional Food Service Director (RFSD) regarding the late breakfast tray for Resident #48. The FSD and RFSD both stated that residents should not receive breakfast at 10:30 AM, and that the expectation was for residents to receive meals within the posted meal service time frames. The FSD stated that the expected breakfast meal service time was between 7:30 AM and 8:30 AM. On 5/20/26 at 10:13 AM, S #2 interviewed the DON, who stated that 10:30 AM was not the regular breakfast service time and that breakfast was usually served earlier. A review of the facility's Meal Distribution Policy, dated 2/2023, included that meals are transported to dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. The policy further included that nursing staff would be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 3. On 5/17/26 at 10:16 AM, Surveyor #3 (S #3) observed Resident #1 lying in bed receiving a tube feeding (TF) of Jevity at 70 ml/hr (milliliters/hour). A review of Resident #1's admission Record (AR) or face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic respiratory failure (a long-term condition where the respiratory system fails to properly oxygenate the blood or remove excess carbon dioxide) and pressure ulcer of right hip stage 4 (a severe, full-thickness wound where soft tissue damage reaches deep underlying structures). A review of Resident #1's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 5/8/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that Resident #1's cognition was severely impaired. A review of Resident #1's May 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) included the following: Five medication (med) orders and five other than med orders were blank on 5/9/26. The nurse did not document that the orders were administered. An additional 10 other than med orders were blank on both 5/9/26 and 5/14/26. The nurse did not document that the orders were administered. On 5/20/26 at 9:59 AM, S #3 asked the Licensed Practical Nurse (LPN) if the eMAR and eTAR should have blanks on it. The LPN stated that it was probably her on 5/9/26 because she was the only nurse and had 36 residents. She stated that she did not get to sign all the orders. She added that it might have been her on 5/14/26 also. S #3 asked how many nurses were usually on the unit, and the LPN stated that the majority of time there was only one nurse. On 5/20/26 at 10:15 AM, S #3 interviewed the LPN/Unit Manager (LPN/UM) who stated that the eMAR and TeAR should be signed or a reason why the order was not administered. She added that it should not be blank. On 5/20/26 at 10:41 AM, S #3 interviewed the DON who stated that there should not be blanks. On 5/20/26 at 11:43 AM, S #3 notified the LNHA, DON, RCL, and Regional Nurse the concern that Resident #1's April and May eMAR and eTAR had blanks on multiple orders for a total of one shift for 4 days. On 5/21/26 at 11:36 AM, the survey team met with the LNHA, DON, RCL and Regional Nurse for responses to the concerns provided. The LNHA did not provide any information. A review of the undated facility's Medication Preparation for Administering Policy included the following: K. After Med Administration: 1. Document necessary med administration/treatment information (e.g., when medications (meds) are administered, med injection site, refused meds and reason, prn meds, etc.) on appropriate forms. 4. On 5/17/26 at 12:20 PM, Surveyor #4 (S#4) interviewed the LNHA and the DON during the entrance conference. The LNHA stated the Resident Council President was Resident #48. S #4 requested for the last three months of Resident Council minutes. On 5/18/26 at 9:06 AM, S#4 interviewed the Activity Director (AD) who stated she was responsible for the monthly Resident Council meetings. The AD provided the residents who wanted to participate in the meeting: Resident #48, Unsampled Resident #2 (UR #2), Unsampled Resident #3 (UR #3), and Unsampled Resident #4 (UR #4). On 5/18/26 at 10:20 AM, the LNHA provided the three months of Resident Council minutes which revealed, on 3/4/26, at 2:15 PM, two unsampled residents complained that meals were late; on May 2026, an unsampled resident complained they occasionally get cold food. The minutes included grievances that were filed and addressed by the LNHA. On 5/18/26 at 10:30 AM, S#4 conducted Resident Council Meeting at the Main Dining Room and met with the four residents. Unsampled Resident #5 (UR #5) joined the meeting while S #4 was giving introductions. Four residents stated that the call bells were not responded to timely because of lack of staff; UR #5 did not use the call bell because they stated they take care of themselves. Resident #48 stated that the staff would come into the room and shut off the call bell and did not come back timely. UR #5 stated, food comes out on time from kitchen, but no one will deliver it, sometimes only one staff member gives out the trays, so the food was cold. UR #4 stated the nurses have been handing out trays to help feed because it was not enough nurses' aides. All five residents confirmed trays were late and food was cold because of short staffing. 5. On 5/17/26 at 10:30 AM, during the initial tour, S#4 observed Resident #4 in their room sitting up with their breakfast tray in front of them. Resident #4 stated, the tray was delivered late, the coffee was cold, eggs were average. The resident stated, from time to time, the food was cold like the eggs because of short staffing. The resident stated that when they come back from dialysis, the food was cold for dinner. A review of Resident #4's AR revealed diagnoses which included but not limited to' end stage renal disease, dependence on renal dialysis; chronic systolic (congestive) heart failure, and type 2 diabetes mellitus with diabetic chronic kidney disease. A review of the comprehensive MDS with an ARD of 4/22/26, revealed a BIMS score of 15 out 15 indicating intact cognition. 6. On 5/17/26 at 10:27 AM, S#4 observed Resident #70 in their room, asleep in bed, and the breakfast tray still in the room, untouched, on the over bed table against the far wall below the television. The resident has not had their breakfast. On 5/18/26 at 9:16 AM, S#4 observed Resident #70's breakfast tray on over bed table against the wall, untouched, the resident has not been fed breakfast. On 5/18/26 at 10:04 AM, S #4 observed the breakfast tray remained untouched, oatmeal and scrambled eggs on the tray. S #4 asked RN #1 who was in the hallway, and RN #1 stated CNA #4 who was scheduled for that side did not arrive, and that she had to rearrange the schedule. S #4 asked what time the breakfast cart and trays come in the morning, and she stated around 8:00 AM. S #4 asked the RN if she had asked the resident or if anyone had attempted to offer the breakfast meal and she confirmed she did not ask the resident if she wanted breakfast, she also stated Resident #70 needed assistance with feeding. A review of Resident #70's AR revealed diagnoses which included but not limited to rhabdomyolysis (damaged skeletal muscle tissue) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the comprehensive MDS with an ARD of 4/4/26, revealed a BIMS score of 2 out of 15 indicating severely impaired cognition. On 5/20/26 at 11:33 AM, the survey team met with the LNHA, DON, Regional Nurse, and the RCL, and S #4 notified them of the concerns verbalized by the five residents who participated in the Resident Council meeting. S #4 also notified the of Resident #4 and Resident #70's concerns regarding late trays, cold food, and late call bell response due to short staffing. On 5/21/26 at 11:36 AM, the survey team met with the LNHA, DON, RCL, and the Regional Nurse stated that staff education and audits were started for call-bell responses, a meeting will be held with the residents from the Resident Council regarding cold food, late trays, and short staffing. The LNHA did not provide additional information. A review of the facility's Staffing/Center Plan Policy, with a review date of 5/15/26, revealed under policy .Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week . A review of the facility's Call Lights Policy, with a review date of 7/15/25, revealed under policy, Staff will respond to call lights and communication devices promptly . A review of the facility's Meal Service Policy, with a review date of 3/20/26, revealed under policy, Meals are served accurately, timely, and at the appropriate temperature . Under Process #12. Room trays are served by nursing or other designated staff. #13. Residents are assisted with meals by staff, as agreed upon between Food and Nutrition Services and Nursing . On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-25.2(a)(b); 27.1(a)

REPEAT DEFICIENCYBased on interview, record review, and review of facility documents, it was determined that the facility failed to ensure Certified Nurse Aides (CNAs) had an annual performance evaluations for 5 of 5 CNAs reviewed. This deficient practice was evidenced by the following:On 5/19/26 and 5/20/26, the surveyor made multiple requested numerous times to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Human Resources Staff (HRS), and Regional Nurse for five CNA employee files containing documentation of their annual performance evaluations.On 5/21/26 at 10:00 AM, the surveyor interviewed the LNHA regarding the employee file review concerns. The LNHA acknowledged the facility concerns related to missing employee file documentation and stated, The files that have missing records, we can use this as an official way moving forward to make sure everything is correct in the future.On 5/21/26 at 10:56 AM, the surveyor interviewed the Regional Nurse again regarding the requested records who stated, I do not think they have them, but we will try to get what we have and provide that to you.The surveyor did not receive documentation of the five CNAs annual performance evaluations requested for review.On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, Regional Clinical Lead, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA.NJAC 8:39-43.16(e)

REPEAT DEFICIENCY Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer residents the influenza and pneumonia vaccinations. This deficient practice was identified for 3 out of 5 residents, (Resident #8, #9, and #10), reviewed for vaccination under unnecessary medications. The deficient practice was evidenced by the following: 1. On 5/18/26 at 11:30 AM, Surveyor #1 (S #1) reviewed Resident #8's electronic Medical Records (eMR), under the Immunization Tab, revealed there was no documentation that the influenza (Flu) vaccine was offered to Resident #8 for the 2025-2026 influenza season. On 5/18/26 at 11:47 AM, S #1 reviewed Resident #8's paper medical records on the unit revealed there was no documentation that the flu vaccine was offered to Resident #8 for the 2025-2026 flu season. 2. On 5/18/26 at 12:10 PM, S #1 reviewed Resident #9's eMR, under the Immunization Tab, revealed there was no documentation that the flu vaccine was offered to Resident #9 for the 2025-2026 flu season. On 5/18/26 at 12:28 PM, S #1 reviewed Resident #9's paper medical records on the unit revealed there was no documentation that the flu vaccine was offered to Resident #9 for the 2025-2026 flu season. On 5/21/26 at 10:03 AM, S #1 interviewed the Licensed Practical/Unit Manager (LPN/UM), who stated they checked everywhere in the eMR and paper medical records, and they confirmed there was no record that Resident #8 and Resident #9 were offered the flu vaccine for the 2025-2026 flu season. The LPN/UM stated the residents should have been offered the flu vaccine. On 5/21/26 at 10:15 AM, S #1 discussed the above concernswith the Director of Nursing (DON). On 5/21/26 at 11:37 AM, the survey team met with the License Nursing Home Administrator (LNHA), DON, Regional Clinical Lead (RCL), and Regional Nurse stated that a process will be in place to ensure consents and refusals were signed for flu vaccines. A review of the facility's Universal Influenza Vaccination Program Policy, with a review date of 11/14/25, revealed under purpose, Protect the health and safety of patients, employees, patient and employee family members, and the community as a whole from flu infection . 2. On 5/17/26 at 10:23 AM, Surveyor #2 (S #2) observed Resident #10 sitting on their bed, eating breakfast, the resident could not answer any questions. A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included but not limited to; Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified symptoms and signs involving cognitive functions and awareness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the modified comprehensive Minimum Data Set (MDS), an assessment tool which facilitates the plan of care, with an Assessment Reference Date (ARD) of 3/18/26, revealed that the resident was rarely understood. The MDS revealed flu was not offered and Pneumonia (PNA) vaccine not up to date. A review of the eMR under the Immunization Tab, revealed Pneumovax (pneumonia vaccine) 1st dose was historical 11/4/20. On 5/19/26 at 9:53 AM, S #2 interviewed the Infection Preventionist Nurse (IPN) via a phone interview regarding vaccination process for residents. The IPN stated that she helped with vaccinations, the DON, and Unit Manager (UM) were responsible when she was not in the facility. She stated that on admission, she goes over what the residents have received and obtain signed forms if they need a vaccine. She further stated the information for the flu vaccines for residents should be in their hard chart or eMR. On 5/19/26 at 10:43 AM, S #2 interviewed the LPN/UM, who stated, Normally the IPN administers the flu vaccine yearly, PNA vaccine was every five years. On 5/19/26 at 2:14 PM, S #2 and the LPN/UM reviewed the eMR including nursing progress notes, the documents tab and the hard chart. The LPN/UM confirmed that she did not find anything to indicate that the vaccines were up to date, and PNA and Flu vaccines were not offered last year, and it should have been offered. On 5/20/26 at 11:33 AM, the survey team met with the LNHA, DON, RCL, and Regional, and S #2 notified them of the above concern regarding Flu and PNA vaccines were not offered. On 5/21/26 at 12:58 PM, the survey team met with the LNHA, DON, RCL, and the Regional Nurse confirmed the concerns regarding vaccinations and that audits for residents will be completed for those in need of PNA and Flu vaccines. A review of the facility's Pneumococcal Vaccination Policy, with a review date of 9/15/25, revealed under Process #2, Based on the patient's pneumococcal vaccination history, offer .following the recommended schedule 2.3 For all adults, refer to CDC's for clinical guidance . NJAC 8:39-19.4(h)(i)

REPEAT DEFICIENCYBased on interview, record review, and review of facility documents, it was determined that the facility failed to maintain and provide documentation of required staff in-service education and competency records for 5 of 5 Certified Nurse Aide (CNA) employee files reviewed for staff training requirements. This deficient practice was evidenced by the following:On 5/19/26 and 5/20/26, the surveyor made multiple requests to the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Human Resources Staff (HRS), and Regional Nurse for five CNA employee files containing documentation of staff in-service education and annual competency/performance records.On 5/21/26 at 10:00 AM, the surveyor interviewed the LNHA regarding the employee file review concerns. The LNHA acknowledged the facility concerns related to missing employee files documentation and stated, The files that have missing records, we can use this as an official way moving forward to make sure everything is correct in the future.On 5/21/26 at 10:56 AM, the surveyor interviewed the Regional Nurse again regarding the requested records who stated, I do not think they have them, but we will try to get what we have and provide that to you.The surveyor did not receive documentation demonstrating completed staff in-service education records or annual competency/performance documentation for the five CNA employee files requested for review.On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, Regional Clinical Lead, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA.NJAC 8:39-43.17(c)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity. This deficient practice was identified for 1 of 18 residents (Resident #9) reviewed.On 5/17/26 at 10:14 AM, the surveyor observed Resident #9 in bed and stated their bathroom toilet was flooded, and was not able to use. Resident #9 further stated they had to go by themself in their wheelchair to another bathroom. Resident #9 stated they told the caregiver who said they would call somebody.On that same date and time, the surveyor observed that Resident #9's bathroom toilet was flooded with discolored water, filled with feces, and tissues. In addition, the surveyor observed that there were towels over the wet floor outside the bathroom.On 5/18/26 at 8:45 AM, the surveyor made a second observation of Resident #9's bathroom toilet which was clogged and dirty, filled with feces and tissues.On 5/18/26 at 12:17 PM, the surveyor made a third observation of Resident #9's bathroom toilet which was flooded with discolored water, filled with feces and tissues.A review of Resident #9's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference (ARD) date of 4/22/26, revealed that Resident #9 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderately impaired cognition.On 5/20/26 at 11:33 AM, the surveyor, in the presence of the survey team, discussed the concern with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Nurse, and Regional Clinical Lead (RCL).A review of the facility's Resident Right Under Federal Law Policy, revised 2/1/23, revealed the following:-Patients/Residents have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values.-Purpose - to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their self-esteem and self-worth; to protect and promote the rights of the resident.On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA.NJAC 8:39-4.1(a)12

Based on observation, interview, and record review, it was determined that the facility failed to inform the resident's representative (RR) in advance of treatment risks and benefits, options, and alternatives to a resident receiving psychoactive medications (meds). This deficient practice was identified for 1 of 5 residents (Resident #10), reviewed for unnecessary meds.This deficient practice was evidenced by the following:On 5/17/26 at 10:23 AM, the surveyor observed Resident #10 sitting on their bed, eating breakfast, the resident could not answer any questions.On 5/17/26 at 3:45 PM, the surveyor reviewed the medical records of Resident #10, and revealed: A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included but not limited to; Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified symptoms and signs involving cognitive functions and awareness, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, major depressive disorder, single episode, unspecified, unspecified psychosis not due to a substance or known physiological condition, and sleep disorder, unspecified.A review of the modified comprehensive Minimum Data Set (MDS), an assessment tool which facilitates the plan of care, with and Assessment Reference Date (ARD) of 3/18/26, revealed that the resident was rarely understood, memory problem, and decision making was severely impaired. The MDS also included anxiety, depression, psychotic disorder, Parkinsons, and dementia; and receiving antipsychotic, antianxiety, antidepressant medications (meds). The antipsychotic medication (med) was received on a daily basis.A review of the Care Plans (CP) revealed a focus that the resident with impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: Parkinson's disease, date initiated 8/24/21; and at risk for complications related to the use of psychotropic drugs, date initiated 9/3/21.A review of the order summary revealed a physician order (PO) on 2/19/26, for Quetiapine Fumarate (Seroquel) tablet (tab) 25 mg (milligram) give 1 tab by mouth at bedtime (HS) for anxiety disorder, target behavior: agitation, pacing, combativeness, yelling related to major depressive disorder, recurrent, unspecified; anxiety disorder, unspecified and psychosis.A review of the psychiatry consult dated 4/30/26, revealed under diagnosis and plan: psychosis and dementia; continue Seroquel for psychosis; target symptoms: hallucinations, and behavioral dysregulation. Indication/risks/benefits, treatment alternatives discussed with RR, who agreed to plan of care. There was no psychiatry consultation in February 2026 indicating the RR was informed of the med order for an antipsychotic med Seroquel.On 5/19/26 at 10:37 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the [NAME] Unit regarding the process for residents on antipsychotic meds. The LPN/UM stated that orders for antipsychotic meds should have diagnosis indicated as well as target behaviors that psychiatrist would document, and consent from patient or RR. The LPN/UM further stated at that time that the Seroquel ordered on 2/19/26, she did not see any Psychiatry note or a RR informed consent.On 5/19/26 at 12:45 PM, the LPN/UM provided the consent for the Seroquel order dated 9/5/21, which ended on 5/4/23. The Seroquel had a new order dated 2/19/26 and no documentation if RR was informed. On 5/19/26 at 2:14 PM, the surveyor and the LPN/UM reviewed the electronic Medical Records (eMR) including nursing progress notes (PN), documents and the hard chart. The LPN/UM confirmed that she did not find anything to indicate that RR was informed in February of 2026 when Seroquel was started again.On 5/20/26 at 11:33 AM, the survey team met with the License Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Clinical Lead (RCL), and Regional Nurse, and the surveyor notified them of the concern regarding antipsychotic med.On 5/21/26 at 12:58 PM, the survey team met with the LNHA, DON, Regional Nurse, and RCL confirmed that the antipsychotic med Seroquel was discontinued in 2023, and there was a new order on 2/19/26. She further stated that there was no informed consent to the RR. The LNHA did not provide additional information.A review of the facility's Behavioral Health Services Partnership Standards Policy, dated 9/15/25, revealed under Providers Duties-Center Level, to speak with family members when necessary and participate in patient and family conferences .Under Facility Obligation-Center Level, Obtain patient and/or representative's consent NJAC 8:39-4.1(a)2

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the residents' telephone and call devices were readily accessible. The deficient practice was identified for 3 of the 18 residents (Resident #7, Resident #57, and Resident #73) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 5/18/26 at 11:10 AM, Surveyor #1 (S #1) interviewed Resident #7 inside their room. During the interview, Resident #7 stated that the resident had recently been moved to the current room within the past week. The resident further stated that there had been a telephone in the previous room, but no telephone was present in the current room. Resident #7 stated that a request had been made for a telephone in the new room; however, none had been provided. S #1 observed that neither Resident #7 nor the roommate had a telephone available in the room. At that time, S #1 interviewed the assigned Registered Nurse (RN), who stated, Every room should have a phone for the residents to use. On 5/19/26 at 10:13 AM, S #1 interviewed the Licensed Nursing Home Administrator (LNHA) who stated that residents were expected to have access to telephones in their rooms. During the interview, the LNHA contacted the Director of Maintenance and requested that a telephone immediately be placed in Resident #7's room. The LNHA then removed a telephone from a bookshelf in the office and stated, We have plenty of phones, I will make sure the resident gets one. The LNHA further acknowledged that the roommate also did not have access to a telephone and stated that a telephone would immediately be provided for the roommate as well. On 5/19/26 at 10:35 AM, S#1 reviewed the medical record for Resident #7. A review of the admission Record (AR) or face sheet (an admission summary) revealed diagnoses that included, but were not limited to; wedge compression fracture of T11-T12 vertebra (are the last two bones of the thoracic spine (middle/upper back) located just before the lower back begins), post-traumatic stress disorder, anxiety disorder, depression, osteoporosis, and abnormalities of gait and mobility. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 3/16/26, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. A review of the resident's comprehensive care plan (CP) included a focus area related to post-traumatic stress disorder and interventions that included maintaining communication that was consistent, open, respectful, and compassionate, involving the resident in decision making, and respecting resident concerns and questions. On 5/20/26 at 10:04 AM, S #1 interviewed the Director of Nursing (DON), who stated that all resident rooms should have telephones available for resident use. On 5/21/26 at 11:30 AM, in the presence of the survey team, the LNHA stated, The rooms were all checked and all rooms now have phones and phones have to be available upon request. 2. On 5/17/26 at 11:11 AM, Surveyor #2 (S #2) observed Resident #57 lying in bed. The resident's call device was underneath the resident's bed, out of reach of the resident. On 5/17/26 at 11:15 AM, S #2 interviewed the Certified Nursing Assistant (CNA). The CNA stated that the call bell should be where the resident could reach it and confirmed that it was not within reach of the resident. Then, the CNA leaned the resident's bed forward in order to access and pull out the call bell from underneath the bed. A review of the AR), revealed Resident #57 was admitted to the facility with diagnoses that included, but were not limited to; muscle weakness (generalized), other abnormalities of gait and mobility, and history of falling. 3. On 5/17/26 at 11:00 AM, S #2 observed Resident #73 in bed. The resident's call device was out of reach of the resident, it was on the floor, and on the other side of the curtain by their roommate. Moreover, S #2 observed the wires on the call device were frayed and exposed, and pieces were broken off of the call device. On 5/17/26 at 11:01 AM, S #2 interviewed Resident #73 who stated that their call device had been in that location for a while with it was frayed wires and broken pieces, and they told the facility about it. Resident #73 also stated they did not feel comfortable using their call device because it was unsafe. A review of the AR revealed Resident #73 was admitted to the facility with diagnoses that included, but were not limited to; other lack of coordination, history of falling, and other abnormalities of gait and mobility. A review of the comprehensive MDS, with an ARD of 2/19/26, revealed that Resident #73 had a BIMS score of 13 out of 15, which indicated intact cognition. On 5/20/26 at 11:33 AM, S #2, in the presence of the survey team, discussed the concern with the LNHA, DON, Regional Clinical Lead (RCL), and Regional Nurse. On 5/21/26 at 11:34 AM, the survey team met with the LNHA, RCL, Regional Nurse, and the DON stated that Resident #73's call device was since replaced, rounding and audits were being done now about call bells being within reach, and education was being given now on call bell policy. A review of the facility's Call Lights Policy, revised 7/15/25, revealed, Staff will ensure the call light is within reach of the patient and secured as needed .The call system will be accessible to patients while in their beds or other sleeping accommodations within the patient's room . NJAC 8:39-4.1(a)13; 31.8 (c) 9

Based on interview and review of other facility documentation, it was determined that the facility failed to notify the resident in writing of the items and services that included the cost of those items and services that was required in the beneficiary notice for 1 of 1 resident reviewed for Beneficiary Protection Notification, (Resident #80). This deficient practice was evidenced by the following: On 5/21/26 at 10:15 AM, the surveyor reviewed the Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (SNF ABN) that was completed by the facility for Resident #80, and revealed: -The SNF ABN indicated Resident #80 last covered Medicare A day was 2/8/26, and Resident #80 remained in the facility. The SNF ABN further revealed that beginning 2/9/26, the resident had to pay out of pocket for this care if the resident's other insurance may not cover the costs for physical therapy, daily skilled nursing care, and occupational therapy. The form also included that we estimate that these services will cost the resident $ per day/item or service. There was no written amount per service indicated at SNF ABN. During an interview of the surveyor on 5/21/26 at 10:34 AM, the Clinical Reimbursement Coordinator (CRC) informed the surveyor that she was responsible for generating beneficiary notice forms and the Business Office Manager (BOM) was responsible for delivering the beneficiary notices to the resident or Resident Representative (RR). On that same date and time, both the surveyor and the CRC went to the BOM's office. The BOM in the presence of the Regional Clinical Lead (RCL) confirmed that there was no amount included in the SNF ABN form that the RR signed for Resident #80 because she notified them verbally. The surveyor then asked the BOM if she was aware of the regulation, and she responded that she was unsure. The surveyor reviewed the medical records of Resident #80, and revealed: A review of the end of part A stay Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 2/8/26, revealed that the resident was discharged from Medicare part a services. A review of the Progress Notes, that was electronically signed by the Social Worker, with an effective date of 2/11/26, reflected that the resident was transferred to another facility for hospice care. On 5/21/26 at 11:34 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), RCL, and the Regional Nurse stated that there was no response with regard to surveyor's concern with Resident #80's SNF ABN. She further stated, we will talk to the Regional CRC and SW, and education would be provided. On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an Exit Conference, and there was no additional information provided by the LNHA. NJAC 8:39-4.1(a)(8); 5.1

Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure reference checks were completed for newly hired employees in accordance with facility policy for 12 of 33 employee files reviewed for pre-employment screening. The deficient practice was evidenced by the following:On 5/19/26 at 9:20 AM, the surveyor reviewed 33 newly hired employee personnel files provided to the survey team by the Director of Human Resources and the Regional Market Director. During the review, the surveyor identified that 13 employee files lacked completed reference checks.The following employee files were identified as missing reference checks:Employee #4Employee #5Employee #6Employee #8Employee #10Employee #21Employee #23Employee #24Employee #26Employee #28Employee #29Employee #31On 5/21/26 at 10:00 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and the Regional Market Director regarding the employee file review concerns. The LNHA stated, Staffing and HR (Human Resources) does the paperwork and submits to Administrator for approval. The LNHA further stated, The files that have missing records, we can use this as an official way moving forward to make sure everything is correct in the future, and Audit active employees for missing references and discuss with Corporate HR on a plan to address the issue.On that same date and time, the Regional Market Director stated, The plan we are putting in place is for the regional HR to be onsite to reeducate the DON (Director of Nursing), UM (Unit Manager), Staff/Payroll, HR on the process and implement a checklist for hiring and make sure the administrator and DON sign off on the checklist before hiring and uploading into the system for the employee to have hire approved.A review of the facility's Hiring Policy, revised 7/1/22, included under External candidates that the facility Check at least two professional references. The policy further included that post-offer requirements included verifying credentials, licenses, certificates, and other required documents for the position.NJAC 9.3(b)

REPEAT DEFICIENCYBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to, a.) provide the Resident or Resident Representative (RR) with a written notification of the facility's bed hold policy that included the reserve payment information and b.) send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for 1 of 2 residents (Resident #77) reviewed for hospitalizations.This deficient practice was evidenced by the following:On 5/21/26 at 8:27 AM, the surveyor reviewed the medical records of Resident #77, and revealed:A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed in Section A-Identification Information that the resident had an unplanned discharge to the hospital.A review of the Progress Notes, a late entry type, with an effective date of 2/25/26, created date was on 2/26/26 at 2:05 AM, was electronically signed by the Licensed Practical Nurse (LPN), reflected that Resident #77 was observed during rounds while in bed with respiration labored with oxygen via non-rebreather mask, and was noted getting worse. The Nurse Practitioner was notified and ordered to transfer the resident to the hospital for further evaluation due to difficulty of breathing and the RR was also notified. The resident was transferred to the hospital at 12:40 AM via 911. Further review of the medical records revealed that there was no documented evidence that the bed hold policy and notification to the LTCO were provided when the resident had an acute transfer on 2/26/26.On 5/21/26 at 8:55 AM, the surveyor asked Regional Nurse about the acute transfer notifications to LTCO for 2026, and she responded, we do not have it. The surveyor also asked for the bed hold policy notices, and she responded that she would get back to the surveyor.On 5/21/26 at 8:57 AM, the surveyor reviewed the binder provided by the Regional Nurse for bed hold policy notices, and the Regional Nurse confirmed the resident did not have bed hold policy for 2/26/26. On 5/21/26 at 11:34 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Regional Clinical Lead (RCL), Regional Nurse, Director of Nursing (DON), and the surveyor notified them of the above findings and concerns with regard to bed hold policy and LTCO notifications of acute transfer of Resident #77.A review of the facility's Discharge and Transfer Policy that was provided by the RCL, with a review/revision date of 6/11/25, revealed that for unplanned, acute transfers, the patient must be permitted to return to the facility. Prior to the transfer, the resident and the RR will be notified verbally followed by written notification using the Notice of Hospital Transfer or state specific transfer form .5.1.1. Copies of notices of emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements.A review of the facility's Bed Holds Policy that was provided by the RCL, with a review/revision date of 9/15/25, revealed under policy, bed hold notification is required per Federal Regulation Title 42.The resident/representative may choose to pay to hold the bed privately if the bed hold is not covered by Medicaid, Medicare, insurance, etc. When a resident is transferred out of the facility to a hospital or on therapeutic leave, the designee will provide the resident/representative with the written Bed Hold Policy Notice & Authorization form regardless of payer.On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA.N.J.A.C. 8:39-4.1(a)(31);5.1 (a)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to; a.) ensure that as needed and routine orders were not duplicative or clinically appropriate and were clarified for 1 of 21 residents (Resident #78), b.) ensure tube feeding was labeled or dated, and c.) include Candida auris (C. Auris, an emerging, multidrug-resistant fungus (a type of yeast) that causes severe, potentially fatal infections) in the resident's medical diagnosis section of the medical record for 1 of 21 residents reviewed (Resident #1), in accordance with facility's policy and standards of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case-finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: Centers for Disease Control and Prevention Infection Control Guidance: Candida Auris dated April 24, 2024, included the following: Summary: C. auris spreads easily in healthcare settings and can cause outbreaks. Facilities that care for patients with other multidrug-resistant organisms (MDROs) can care for patients with C. auris. Environmental disinfection, staff training, and hand hygiene help prevent outbreaks. C. auris can colonize patients and persist on surfaces for many months and is not killed by some common disinfectants. C. auris status should be communicated during patient transfer and discharge. 1. On 5/17/26 at 10:16 AM, Surveyor #1 (S #1) observed Resident #1 lying in bed receiving a TF of Jevity at 70 ml/hr (milliiters/hour). S #1 observed that the water flush bag that was connected to the TF (tube feeding) was not dated. A review of Resident #1's admission Record (AR) or face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic respiratory failure (a long-term condition where the respiratory system fails to properly oxygenate the blood or remove excess carbon dioxide) and pressure ulcer of right hip stage 4 (a severe, full-thickness wound where soft tissue damage reaches deep underlying structures). A review of Resident #1's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 5/8/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that Resident #1's cognition was severely impaired. Further review reflected that the resident had a TF. A review of Resident #1's hospital records included the following: Transport Request Form from hospital to facility dated 1/30/26, which reflected the resident had a sacral wound and was on Contact precautions for C. auris. Target and Novel Multidrug-resistant Organism Case Transfer Information Sheet which reflected case status was confirmed to have a novel or targeted MDRO which was colonized and the diagnosed organism was candida auris. A review of Resident #1's electronic medical record (eMR) under the medical diagnosis section did not include the diagnosis of C. auris. A review of Resident #1's admission MDS, with an ARD of 2/5/26, under Section I Active Diagnoses did not indicate the resident had a Multidrug-Resistant Organism (MDRO) infection. Further review did not indicate under additional active diagnoses the resident had the diagnosis of C. auris. On 5/19/26 at 10:40 AM, S #1 interviewed the Director of Nursing (DON) who stated that Resident #1 had C. auris but that it was not an active infection. He stated that the resident was placed on contact precautions when they were transferred from the hospital but that now the resident was on EBP. On 5/20/26 at 9:59 AM, S #1 observed Resident #1 lying in bed receiving a TF of Jevity at 70 ml/hr. S #1 observed that the water flush bag that was connected to the TF was not dated. On 5/20/26 at 9:59 AM, S #1 interviewed the Licensed Practical Nurse (LPN) who stated that all the equipment should be dated. She added that there was a sticker that came with the water flush bag. The LPN confirmed that Resident #1's water flush bag was not dated. She stated that sometimes it fell off and stated that as far as she knew, it should be dated. On 5/20/26 at 10:14 AM, S #1 interviewed the LPN/Unit Manager (LPN/UM) who stated that the TF and the water flush bag should be dated. The LPN/UM stated that the expectation was for a resident's diagnoses to be listed in the medical record. On 5/20/26 at 10:25 AM, S #1 interviewed the DON who stated that the TF and water flush bag should both be dated. The DON stated that there was a window of time as to when a medical diagnosis was placed in the medical record. S #1 asked if that window was two months. The DON stated that it should not be up to two months but that he would look at the policy. On 5/20/26 at 11:43 PM, S #1 notified the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Lead (RCL), and Regional Nurse the concern that Resident #1's water flush bag for TF was not labeled or dated and the medical diagnosis of c. auris was not listed in the diagnosis section of the eMR or MDS. On 5/21/26 at 11:39 AM, in the presence of the LNHA, DON, Regional Nurse, and the RCL stated that staff were educated on TF and Resident #1's medical diagnosis was updated in the MDS. The LNHA did not provide any additional information. A review of the facility's Enteral Management Policy with a revised date of 7/22/25, included the following: 8. Enteral feeding tube care will consist of the following, but is not limited to: 8.6 Use of infection control Precautions and related techniques to minimize the risk of contamination; 8.7 Frequency of and volume used for flushing. The policy did not contain information about dating the water flush bag. A review of the facility's Diagnosis Coding Policy with a revised date of 1/15/26, included the following: Purpose, to ensure accurate ICD/CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is the standardized system used by healthcare providers and insurance companies to classify and code all diagnoses, symptoms, and procedures in the U.S.) codes for diagnosis on patients. Process. 1. Upon admission/re-admission of a patient, diagnoses will be recorded in the electronic medical record within 24 hours or no later than the next business day. 1.1 In addition, diagnosis coding will be recorded on the MDS, and for billing purposes on the claim form. 2. On 5/18/26 at 1:25 PM, Surveyor #2 (S #2) reviewed the medical records of Resident #78, and revealed: A review of the most recent comprehensive MDS) with an ARD of 1/12/26, reflected that the resident was coded for severely impaired cognition. Section I included but were not limited to; traumatic brain dysfunction (a disruption in normal brain function caused by a sudden bump, blow, or jolt to the head, or a penetrating object), anemia (low blood count), heart failure, diabetes mellitus, and history of falling. A review of the active Order Summary Report as of 5/5/26, revealed the following physician orders (PO) that were included but were not limited to: Acetaminophen oral tablet (tab) 325 mg (milligram), give 2 tablets (tabs) by mouth every 6 hours as needed (PRN) for pain (2 tabs=650 mg), ordered date 1/8/26. Acetaminophen suppository 650 mg, insert 1 suppository rectally every 6 hours PRN for mild pain or fever over 101, ordered date 3/31/26. Morphine sulfate oral solution 20 mg/5 ml (milliliters), give 0.25 ml by mouth every 2 hours PRN for pain. Ordered date 3/31/26. Further review of the above orders for PRN pain medications (meds) revealed that the Acetaminophen tabs and suppository had conflicting orders, one with order for PRN pain and the suppository was for mild pain. Furthermore, the Acetaminophen suppository had two orders that were not separated and there was no indication of when the PRN Morphine and Acetaminophen should be administered (no sequencing). Zinc oxide external ointment 20 % apply to sacral area topically every shift for skin protection, ordered date 1/8/26. Medihoney wound/burn dressing external gel apply to sacrum topically every day shift for wound care cleanse wound with NSS (normal saline solution). Pat dry. Apply medihoney gel. Cover wound with silicone dressing. Ordered date 3/10/26. Further review of the above treatment orders revealed duplicate orders for sacral area. A review of the provided Medication Regimen Review (MRR) binder revealed that there was no documented evidence that the irregularities for PRN pain medications and duplicate orders were identified. On 5/19/26 at 12:13 PM, S #2 interviewed the Consultant Pharmacist (CP) who informed S #1 that she was responsible for the MRR of all residents in the facility. S #1 asked why there was no MRR for March 2026, and she responded that there should be March 2026 in the report. At that same time, S #2 notified the CP of the above concerns that Resident #78's orders for PRN pain meds and duplicate orders for sacral area. The CP stated that the PRN pain meds should have sequenced and separated between PRN pain and PRN temperature which should have been checked by her as a CP. On 5/19/26 at 1:07 PM, the DON confirmed that she received MRR and the Unit Managers (UMs). S #1 notified the above concerns that there were no MMR for March 2026, and the reports for other months were incomplete. S #2 also notified the DON of the above concerns with PRN pain meds and duplicate orders for sacral area. On 5/19/26 at 2:45 PM, the CP informed S # 2, I do MRR beginning of the month, the order for pain PRN meds were from 3/31/26, that was why I did not capture them in March 2026 MRR. The CP further stated she was unsure as to why the March 2026 and April 2026 were not in the binder, maybe it was in filing of the facility but that should be identified in the MRR. On 5/19/26 at 1:10 PM, the survey team met with LNHA, DON, RCL, Regional Nurse, and S #2 notified them of the above concerns. On 5/21/26 at 11:34 AM, the survey team met with the RCL, DON, and the Regional Nurse, and there were no additional information provided by the LNHA with regard to the above concerns. A review of the undated facility's Consultant Pharmacist Provider Requirements Policy that was provided by the Regional Nurse, revealed under procedure.E. Reviewing the medication/drug regimen (e.g. (example) all drugs ordered for the customer, including PRN and routine drugs) of each customer at least monthly, incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and findings in the customer's medical record. This includes the evaluation and reporting of adverse drug reactions. On 5/21/26 at 1:32 PM, the survey team met with the LNHA, DON, RCL, and Regional Nurse for an exit conference, and there was no additional information provided by the LNHA. NJAC 8:39-11.2(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow the recommendations of the Wound Care Consultant Physician (WCCP) for 1 of 1 resident reviewed for PU (Pressure Ulcer), (Resident #1), consistent with professional standards of practice and facility's policy. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 5/17/26 at 10:16 AM, the surveyor observed Resident #1 lying in bed.A review of Resident #1's admission Record or face sheet (resident information) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to chronic respiratory failure (a long-term condition where the respiratory system fails to properly oxygenate the blood or remove excess carbon dioxide) and pressure ulcer of right hip stage 4 (a severe, full-thickness wound where soft tissue damage reaches deep underlying structures).A review of Resident #1's most recent quarterly Minimum Data Set (MDS), an assessment tool, with an Assessment Reference Date (ARD) of 5/8/26, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated that Resident #1's cognition was severely impaired. Further review reflected that the resident had 1 stage 4 PU present on admission.A review of Resident #1's May 2026 electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) included the following order:A review of the WCCP 2/17/26, visit included the following order: Wound #1 right Iliac crest clean wound with Vashe pack wound with calcium alginate apply collagen powder to wound base cover with silicone bordered dressing change daily and PRN (as needed). Plan of care discussed with facility staff.A review of the WCCP weekly visits from 3/3/26 to 5/12/26, included the following order: Wound #1 right iliac crest clean wound with Vashe pack wound with calcium alginate apply collagen powder to wound base cover with silicone bordered dressing change dressing three times a week and PRN. Plan of Care discussed with facility staff.The facility did not follow the WCCP's order.There was no documented evidence that the primary physician did not agree with the WCCP order.On 5/20/26 at 10:05 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that the WCCP recommendations went to the managers.On 5/20/2026 at 10:20 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) who stated that the WCCP came weekly and made recommendations and that they followed the WCCP orders. She added that if the primary physician did not agree with the WCCP order then they would not follow the order/recommendation. She added that if the primary physician did not agree then it should be documented in the medical record. On 5/20/26 at 10:27 AM, the surveyor interviewed the Director of Nursing (DON) who stated that for wounds the WCCP gave recommendations and they followed them. The DON stated that if the primary physician did not want the recommendation followed then there would be documentation.On 5/20/26 at 12:02 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Lead (RCL) and Regional Nurse the concern that Resident #1's WCCP recommendations were not followed.On 5/21/26 at 11:39 AM, in the presence of the LNHA, DON, and RCL, the Regional Nurse stated that Resident #1's wound order was changed.The LNHA did not provide any additional information.A review of the facility's Skin Integrity and Wound Management Policy with a revised date of 9/15/25, included the following:6.7 Notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments, as indicated.6.11 Implement Skin/Wound Care Guidelines as applicable.6.13 Implement special wound care treatments/techniques, as indicated and ordered.7. Collaborate with the wound provider to review co-morbid conditions that may affect healing.9. Notify physician/APP (advanced practice physician) to obtain orders.N.J.A.C. 8:39-27.1 (a)

REPEAT DEFICIENCYBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure the Nursing Home Resident Care Staffing Report was posted and maintained with accurate and current staffing/census information for each shift. The deficient practice, identified in the facility's staffing report posting process, for 2 of 5 days of observation, as evidenced by the following: On 5/17/26 at 9:00 AM, the survey team entered the facility and observed the Nursing Home Resident Care Staffing Report (NHRCSR) located at the receptionist desk. The posted staffing report was dated 5/15/26 (Friday) for the day shift. The surveyor observed that no staffing report was available at the receptionist desk for any day or shift over the weekend.On 5/18/26 at 11:00 AM, the surveyor interviewed the Human Resources Staff (HRS) member, who stated that she was responsible for posting the staffing report and did not realize the staffing report needed to be updated on the weekends.On 5/18/26 at 11:45 AM, the surveyor interviewed the Licensed Nursing Home Administrator, who stated that he thought the HRS member was posting the staffing report as required.On 5/19/26 at 8:10 AM, the surveyor obtained a copy of the staffing report from the receptionist desk upon entrance into the facility. The NHRCSR was dated 5/19/26 for the day shift and listed the facility census as 74 residents.On that same date at 8:23 AM, the HRS member provided the surveyor with a corrected staffing report for the day shift, which listed the current resident census as 73 residents. The HRS member stated that the original staffing report had an incorrect census.On 5/21/26 at 11:30 AM, in the presence of the survey team, the facility responded to the surveyor's concern related to the Nursing Home Resident Care Staffing Report postings. The Licensed Nursing Home Administrator (LNHA) stated that the staffing coordinator had been re-educated regarding the staffing report posting requirements and that the receptionist had been educated that the staffing reports must be posted each shift.A review of the facility's Posting Staffing Policy, revised 8/7/23, included that the posting should include the center name, current date, patient census at the beginning of each shift, center-specific shifts, and the number and actual hours worked per shift by category of licensed and unlicensed nursing staff directly responsible for the care of patients. The policy further included that the posting should be in readable format, prominently displayed and accessible for patient, visitor, and staff viewing, completed on a daily basis at the beginning of each shift, and adjusted either upward or downward if staffing changed.NJAC 8:39-43.2

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to properly store and label medications in 1 of 2 medication rooms and 1 of 3 med carts inspected. The deficient practice was evidenced by the following:On 5/20/26 at 10:19 AM, the surveyor inspected the medication (med) cart on the [NAME] Low Unit in the presence of the Registered Nurse (RN). Upon opening a drawer of the cart, the surveyor observed Unsampled Resident #1's (UR #1) Ipratropium Bromide 0.5 milligrams (mg) and Albuterol Sulfate 3 mg Inhalation Solution box with an opened foil pouch inside that contained unit-dose vials. The opened foil pouch had no date of opening written on it. As per the storage information on the foil pouch, Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week. UR #1 was not in the facility's electronic medical record. On 5/21/26 at 10:30 AM, the Director of Nursing (DON) stated the resident was never admitted to the facility.On 5/20/26 at 10:22 AM, the surveyor interviewed the RN. The RN stated that the foil pouch should have been labeled with the date of opening when it was opened.On 5/20/26 at 11:06 AM, the surveyor inspected the med room on the [NAME] Low Unit in the presence of the RN. During the inspection, the surveyor found the following:-Insulin Lispro KwikPen Injection 100 units per mL (milliliters) (U-100) 3 mL prefilled insulin delivery device that was expired and used, had a date of 3/28 written on it, and had no resident label.-Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg in 3 ml Inhalation Solution vial that had no resident label or date on it.-Glucose Control Solutions box with two bottles inside that were opened and expired. The date of opening written on the box was 2/16/26.-Resident #60's Insulin Lispro Injection 100 units per mL (U-100) 10 mL multiple-dose vial that expired with an expiration date of 5/19 written on it.On 5/20/26 at 11:18 AM, the surveyor interviewed the RN. The RN stated that the expired medications (meds) should have been discarded.On 5/20/26 at 11:33 AM, the surveyor, in the presence of the survey team, discussed the concerns with the Licensed Nursing Home Administrator (LNHA), DON, Regional Clinical Lead (RCL), and Regional Nurse.On 5/21/26 at 11:34 AM, the survey team met with the LNHA, DON, Regional Nurse, and the RCL stated that the Glucose Control Solution was good for 90 days and should have been thrown out, as it was expired.A review of the facility's Medication Storage Policy, revised 9/6/19, revealed, Expired, discontinued and/or contaminated meds will be removed from the med storage areas and disposed of in accordance with facility policy .NJAC 8:39-29.4

C# NJ & NJ Based on observation, interviews and a review of medical records and other facility documentation, it was determined that the facility failed to consistently implement identified safety interventions for 1 of 3 sampled residents, Resident #1, who was identified as at risk for falls due to impaired mobility, cognitive loss and lack of safety awareness. On [DATE], Resident #1 was transferred by one Certified Nursing Assistant using a Sit to Stand lift (SSL) which was not indicated on her plan of care. The CNA was in the process of getting the resident transferred from her shower chair to her Geri chair with the SSL after getting her dressed when, according to the CNA, the battery for the Sit to Stand lift died . The resident was lowered to a squatting position while the CNA waited for assistance from nursing staff who found the resident crying in pain with her feet and/or foot in a compromised position. Subsequently, Resident #1 was sent to the emergency room (ER), required surgery for [REDACTED]. This deficient practice is evidenced by the following: A review of Resident #1's medical record by the surveyor on [DATE] revealed the following: 1. According to her face sheet, Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), an assessment tool, dated [DATE], reflected that the resident had poor short and long term memory with impaired decision making skills and required total assistance with at least a two person assist with transfers. She was on a scheduled pain regimen and was assessed with [REDACTED]. A Nursing Care Plan (NCP), dated as reviewed last on [DATE] and which was dated as created/revised on [DATE] with a target date of [DATE], states, "Resident requires assistance/is dependent for ADL care in bathing, grooming, dressing, bed mobility, transfer, locomotion, toileting due to other generalized weakness." Interventions included, "Resident requires max assistance with transfers with hoyer lift." Additionally, Resident #1 was identified on [DATE] as a fall risk due to "impaired mobility, cognitive loss, lack of safety awareness." Interventions included, "Assist resident getting in and out of bed with the assist of 2 using the hoyer lift." A Lift-Transfer Repositioning Evaluation, dated [DATE] which was completed by a Licensed Practical Nurse, assessed the resident as non-ambulatory, unable to bear weight with her legs and required Total Lift 450 (type of lift). A review of the Invacare Sit to Stand Lift assessment criteria, which was the lift used by CNA who transferred Resident #1, reflected that a resident must bear weight on at least one leg. A Progress Notes (PN), dated [DATE] at 12:10pm, documented that the resident had a change in her medical condition. Further review of the PN revealed that, according to the CNA, after Resident #1 was showered and while she was "being transferred (sit to stand) to recliner chair . . . battery went dead, another CNA assisted." The PN documented that the resident experienced ". . . pain, a change from previous state. Severe left hip, left groin, right leg with less pain." The physician was notified at 11:00am and ordered the resident be sent to the hospital for evaluation. An Incident Report, dated [DATE] at 10:35am, corroborated what was documented in the aforementioned PN. Description of injuries included left hip pain, left groin pain and right leg rotation. A Reportable Event Record/Report (RERR), sent by the facility to the Department of Health and Senior Services (DHSS) on [DATE], documented in the Summary/Conclusion (S/C) that, on [DATE] at 10:30am, while being transferred via an Invacare Lift from the shower chair to her Geri chair, the lift became fixed in an upright position. The CNA used the emergency pull pin to lower the resident to the floor prior to getting assistance, as she did not want to leave the resident alone. Furthermore, the S/C documented that the resident was care planned for falls from admission and was assessed for her transfer needs and was designated as requiring a lift for transfers. It was concluded that the resident was eased to the floor utilizing the fail safe method of descent. Both her legs were noted to be in a winged position and she was guided to the floor by the CNA. However, the S/C did not specify what kind of lift should have been used for the resident and how many staff were required to assist with the transfer. There was no indication in the S/C that the facility had concerns regarding how the resident was transferred by the CNA. In an undated statement which was obtained by the facility from the ,[DATE] CNA who transferred the resident by herself, the CNA corroborated what was documented on the incident report. She further documented that she did not want to leave the resident alone to get help so she used the emergency ring and began to lower her to the floor. Once the resident was on the floor, the CNA received assistance from other aides and the nurse came. During an interview by the surveyor on [DATE] at 1:23pm with the ,[DATE] CNA in question, she corroborated her written statement that she was by herself when she decided to transfer the resident from the shower chair to the Geri chair using the Sit to Stand lift. When the Sit to Stand lift became stuck halfway down, she had to use the emergency pin to lower the resident on the floor. When questioned by the surveyor how the chairs were positioned with the lift, she stated that the shower chair was inside the shower curtain behind the resident, while the Geri chair was outside of the shower room/curtain behind the lift that was facing the resident and she had to turn the lift around in order for her to sit the resident down to the Geri chair. The CNA continued to say that she now knows that the next time she transfers a resident using a lift, the chairs should be next to each other. When questioned by the surveyor how many staff are required when transferring a resident with a lift, the CNA responded, "Two with any lift transfers." Additionally, when questioned by the surveyor why she transferred the resident by herself, the CNA stated that she has always done it the same way in the past and had no problems. She further stated that after the bathroom incident, another aide and a nurse assisted her with putting the resident back to her bed with a Hoyer lift. At that time, the resident was saying, "My leg, my leg." She also stated that she was later counseled regarding proper transfer and the required assistance. During an interview by the surveyor on [DATE] at 12:35 pm with the CNA who first responded to the call light, she stated that she has worked in the facility for [AGE] years and it was their practice to always have two staff members to assist with any lift transfers. She further stated that she was passing by the bathroom when she saw the light on. When she entered the bathroom, she saw the resident hanging on the Sit to Stand lift with her arms dangling and half squatting with one foot bent outwards saying, "My leg, my leg." She verified that the resident was alone with the CNA in question in the shower/dressing area behind the shower curtain and corroborated the CNA's statement regarding how the chairs and the lift were positioned. She left the bathroom, called for a nurse to come and denied assisting. She further stated that there should be another person before any lift procedure is started. During an interview by the surveyor on [DATE] at 1:00pm with the Registered Nurse (RN) who was called to the bathroom, she stated that she worked in the facility for 3 years. She stated that a CNA told her that she was needed in the bathroom. As she entered the door, she found Resident #1 on the shower mat by the left side of the door in a supine position with a Hoyer sheet tucked halfway on her back. She further stated that the resident's buttocks and legs were on the floor, her right leg was rotated inwards and her left leg was rotated outwards. When she asked the resident if she had any pain, the RN said that she pointed to her groin. Further interview with the RN revealed that there was no lift around the resident when she came in the bathroom and that the CNA in question was kneeling holding the resident's head up and another CNA was on the other side of the room. The RN stated that when she asked the CNA in question what happened, the CNA stated that the Sit to Stand lift battery died , the lift went down and the resident slowly ended up on the floor. The other CNA in the room assisted with the Hoyer transfer and helped with putting the resident back to her room. When questioned by the surveyor regarding how Resident #1 should be transferred, the RN stated that the staff are supposed to use a Hoyer lift for the resident and not the Sit to Stand lift. She further stated that the Assistant Director of Nursing was also there that day and showed the CNA the sign on the resident's door indicating the resident was total assist and required the assistance of two staff members at all times. During an interview by the surveyor on [DATE] at 9:50am with the CNA who assisted with the Hoyer lift transfer, she stated that she has worked in the facility for [AGE] years and is familiar with Resident #1. According to the CNA, the resident was not supposed to use the Sit to Stand lift and required a Hoyer lift for transfers. Further, the CNA stated that she came to the bathroom after she was called by the other CNA who first responded to the scene. When she arrived, she found Resident #1 hanging on the Sit to Stand lift. The resident's feet "were crooked, twisted underneath on the floor" with the resident saying, "My leg, my leg." Contrary to the RN's statement who initially responded to the bathroom call, the CNA stated that the resident was still hanging on the Sit to Stand lift when the RN came and the RN assisted with lowering her to the floor. During an interview by the surveyor on [DATE] at 2:20pm with the Physical Therapist (PT), she stated that she had Resident #1 in the past and the resident could not sit to stand. She was not sure if Resident #1 is capable or if it is safe to use a Sit to Stand lift since a resident has to hold on to use it and, being the resident was cognitively impaired, she did not think that the resident could do it consistently. A Corrective Action Notice, dated [DATE] and signed by the CNA in question, documented that the CNA failed to use the appropriate lift device as per lift transfer assessment and door sticker and failed to use a second staff member to assist with the transfer. Counseling was given by the DON. Resident #1 was returned to the facility during the surveyor's visit. At 2:50pm, she was observed by the surveyor with an RN staff member. The resident was unable to remember about the incident. She had swelling on both knees, bruising on the left side of the knee with approximately 10 staples and approximately 15 staples on her right hip. Her entire right leg had red ecchymosis from her knee to above her ankle. Her right thigh was noted with 3 staples. She responded to the nurse that she was in pain. The hospital History and Physical, dated [DATE] and which was signed by a physician, documented that the resident, who has advanced Dementia, had a fall while being transferred in the facility and was noted to have bilateral hip fractures. She was assessed with [REDACTED]. Pain management was with IV Dilaudid. The hospital Discharge Summary, dated [DATE], documented that Resident #1 was admitted on [DATE] and came in with bilateral hip fractures. A diagnostic test showed Bilateral Hip Fractures and the resident had bilateral hip pinnings. It was further documented that she was being raised on a Sit to Stand lift when the mechanism failed and she was slightly lowered down resulting in fracture of both hips. NJAC 8:,[DATE].1 (a) 8:,[DATE].1 (b)