Every finding on record at Rose Garden Nursing and Rehabilitation Center

Complaint # 2561976Based on observation, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure residents were protected from neglect after an aphasic, cognitively impaired resident (Resident #1), was left unattended on the outside patio in the heat and sun from approximately 12:50 PM until approximately 3:30 PM on 7/3/25 (two hours and forty minutes). Resident #1 was sent to the hospital, was diagnosed with heatstroke and sustained second degree burns. This deficient practice was identified for 1 of 2 residents, (Resident #1) reviewed for neglect.On 7/3/25 at approximately 12:50 PM, a Certified Nursing Assistant (CNA #1) transported Resident #1 (who was cognitively impaired and required maximal staff assistance with mobility), in a wheelchair to the outside patio on the second floor. CNA #1 did not communicate to other facility staff that Resident #1 was outside on the patio. Resident #1's assigned CNA (CNA #2) nor did any other staff did not check on the resident from 12:20 PM through the end of her shift which was 3:00 PM. At approximately 3:20 PM, Resident #2 and a visitor were on the patio and observed Resident #1 slumped over in their wheelchair. The visitor went back inside the facility and informed a staff member. Resident #1's skin was hot to touch and dry; vital signs were: temperature 103.1 degrees Fahrenheit; heart rate 93 beats per minute; blood pressure 102/64; and respiratory rate of 14. Resident #1 was transferred to the emergency room and presented as lethargic and with a temperature of 104.1 degrees. The resident was diagnosed with dehydration and an elevated troponin (a protein released into the bloodstream when the heart muscle is damaged) and was admitted to the hospital from [DATE] to 7/9/25. The facility's failure to ensure Resident #1 was free from neglect by failing to monitor Resident #1 when they were in an environment of exposure to heat and sun for an extended period posed serious physical harm and impairment to Resident #1 which resulted in an Immediate Jeopardy (IJ) situation. The IJ was determined to be Past Non-Compliance. The IJ began on 7/3/25 at approximately 12:50 PM, after Resident #1 was left unattended in the heat and sun. The facility corrected the immediacy on 7/11/2025, by implementing the following: patio keypad changed from operation from 8 AM to 8 PM to locked; camera installed on the patio; facility wide re-education on Outdoor Resident Policy and Resident Safety/Updated Log Sheets; re-education to CNA #1 and CNA #2; and 30-minute observation checks.The facility's Licensed Nursing Home Administrator (LNHA) was notified of the IJ on 10/31/25 at 5:16 PM. The facility submitted an acceptable Removal Plan (RP) and the survey team verified the implementation of the RP on-site on 10/31/25 during the continuation of the survey.The evidence was as follows:A review of the facility's Abuse Prohibition Policy, dated 3/26/2024, provided by the Assistant Licensed Nursing Home Administrator (AA), included a policy statement that the facility would provide a safe resident environment where residents are free from abuse, neglect, misappropriation of property and exploitation. Abuse was defined by the Code of Federal Regulations (CFR) 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being. Neglect, was defined by CFR 483.5 as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Willful was defined by CFR 483.5, and used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 10/31/25 at 9:50 AM, the surveyor observed Resident #1 in bed with their eyes closed. The surveyor was unable to interview Resident #1.A review of the facility initiated Reportable Event Record/Report dated 7/3/25, and completed by the AA revealed: Resident was noted on the patio leaning in [their] wheelchair, resident was brought indoors, and MD (medical doctor) was notified of condition; medics called. Resident was admitted to the hospital for dehydration at 6:55 P. [PM].A review of the investigation provided by the AA revealed statements from CNA #1 explaining that she was in the dining room and brought Resident #1 in a wheelchair to the patio after lunch at approximately 12:50 PM. CNA #1 had not communicated to anyone that Resident #1 was outside. A statement from Resident #2 explained that they were outside on the patio with a guest and saw Resident #1's hand come off the arm rest and the resident slumped forward, and the guest informed the staff. In addition, the investigation revealed CNA #2 was assigned to Resident #1 but there was no written statement from CNA #2. The AA documented CNA #2 was not aware of the resident's whereabouts when the resident finished lunch until the end of CNA #2's shift at 3:00 PM. CNA #2 reported that after lunch until the end of her shift she was providing care/rounding on the other residents assigned to her during the shift. CNA #2 also reported she was unable to recall the last time she saw Resident #1.A review of an Employee Discipline Notice dated 7/8/25, revealed CNA #2 had poor performance and Employee's assigned resident was not monitored for toileting, changing, food/snack or drink, location for extended period of time.A review of a Job Description for Certified Nursing Assistant with CNA #2's name on it included but was not limited to; responsibilities to Conduct resident rounds as assigned, and Be responsible for the safety of residents under his/her supervision.On 10/31/25, surveyor reviewed the electronic medical record for Resident #1.A review of the Resident Face Sheet (an admission summary), reflected that Resident #1 was admitted to the facility with diagnoses that included but were not limited to; secondary malignant neoplasm of the brain (cancer of the brain), malignant neoplasm of the colon (cancer of the colon), traumatic subdural hemorrhage with loss of consciousness of unspecified duration (collection of blood between the brain and inner layer of skull as a result of head trauma), aphasia (impairment in ability to comprehend or formulate language), and Alzheimer's disease (a buildup of plaque in the brain causing brain cells to die).A review of the comprehensive quarterly Minimum Data Set (MDS), an assessment tool dated 5/28/25, revealed that a Brief Interview for Mental Status (BIMS) score was not able to be obtained because the resident was rarely/never understood. In addition, the MDS indicated the resident had short and long-term memory problems and had moderately impaired cognitive skills for decision making. A further review of the MDS, revealed the resident required substantial/maximal assistance with mobility and activities of daily living for toileting, bathing and dressing.A review of the individual comprehensive Care Plan Activity Report (CPAR) included a focus area dated 2/17/25, for cognitive loss: memory impairment. Interventions included but were not limited to; monitor for any changes in cognitive status, reorient resident to person, place and time as needed. There was no focus area in relation to going to the outside patio.A review of a Nursing Progress Note (NPN) dated 7/3/25 at 9:27 PM by the Director of Nursing (DON), revealed Resident observed in WC (wheelchair) with lethargy. Skin hot to touch, dry. T(temperature):103.1, HR (heart rate): 93, BP (blood pressure): 102/64, RR (respiration rate): 14. Ice packs applied for cooling measures. Call placed to MD (medical doctor) with immediate response for orders to send to ER (emergency room). 911 called. Family advised. Nursing staff present with resident until transferred to [hospital name redacted] further eval (evaluation). In addition, another PN on 7/4/25 at 7:52 AM revealed The resident was admitted to the hospital with diagnosis of dehydration and high troponin level at 6 PM.A review of the hospital records, provided by the AA, revealed a Progress Note with an admission date 7/3/25 at 4:30 PM, and chief complaint of Heat Exposure. The History of Present Illness: included: [Resident #1] presents to the Emergency Department today altered. Patient was brought in from [inaccurate facility name redacted] via EMS (emergency medical services) who report [they] had a fever of 104.1. Per EMS, patient was found outside after unknown amount of time around lunchtime. Patient is non-verbally (sic) at baseline Otherwise: Per EMS, patient denies chills, nausea, vomiting, abdominal pain, and other acute complaints at this time. Poor historian due to acuity of condition. ER work-up was noted, patient was admitted for further management. The physical exam indicated General: pt (patient) is in acute distress. Also, the hospital records revealed a Pulmonology Consult dated 7/5/25 at 9:54 AM, indicated History of Present Illness: included: [Resident #1] presents to the Emergency Department today altered. Patient was brought in from [inaccurate facility name] via EMS who report [they] had a fever of 104.1. Per EMS, patient was found outside after unknown amount of time around lunchtime, slumped in [their] wheelchair. Patient is non-verbally (sic) at baseline and patient required and received my immediate attention. Otherwise: Per EMS, patient denies chills, nausea, vomiting, abdominal pain, and other acute complaints at this time. Poor historian due to acuity of condition. Principal Problem: Dehydration. The assessment was dehydration and elevated troponin, principal problem: dehydration.Further review of hospital records revealed a Neurology Consult dated 7/6/25 at 7:41 AM, indicated that the resident was brought to the hospital due to a high-grade fever and change in mental status. In emergency room patient was hypotensive, hypoxic and febrile. CT [cat scan] scan of head was negative for any acute event. In the emergency room patient was nonverbal and fixed deviation on the left side. Unclear if [Resident #1] had eye deviation. No report of any involuntary movement of upper or lower extremities. Currently patient is more awake but aphasic. The assessment indicated [Resident #1] with encephalopathy. Likely multifactorial due to heatstroke with associated multiple metabolic derangement, acute kidney injury. Cannot rule out provoked seizure episode with post ictal state.Additionally, the hospital records revealed a Cardiology Consult dated 7/6/25 at 10:43 AM, revealed an assessment which included [Resident #1] who came in with change in mental status, fevers, found to have increased troponins, most likely due to supply demand issues, dehydration, possible CVA [stroke], leukocytosis and we are called for cardiac evaluation.Further review of the resident's medical records provided by the hospital revealed the following:A review of the hospital emergency room plan of care 7/3/25, revealed Patient is admitted . Upon ED [ER] evaluation, it has been determined that 63 y.o. (year old) [gender redacted] with heatstroke with a high risk and concern for worsening symptoms. I expect the patient to require hospital care that crosses two midnights. My experience is based on complex medical factors including the patient's need for ongoing treatment to manage the acute nature of the patient's presentation, complicated by the patient's medical conditions. The Final diagnoses included Dehydration, AKI (acute kidney injury), Elevated troponin.A review of the Infectious Disease Consult Note dated 7/4/25, revealed an assessment that included but not limited to, Skin: Warm, dry, no rashes, no open wounds, sun burned skin on the face and trunk with some blisters on the trunk. In addition, the Assessment and Recommendations included Impression: Fever with leukocytosis and lactic acidosis may be secondary to dehydration and acute kidney injury r/o (rule out) sepsis A review of the Discharge summary dated [DATE], revealed Discharge Diagnoses: .Lactic acidosis due to dehydration, Metabolic encephalopathy due to Acute renal failure from dehydration .Further review of the NPN revealed on 7/9/25 at 7:36 PM, the resident returned to the facility at 2:45 PM. The NPN on 7/9/25 at 7:38 PM, Skin assessment revealed blisters on right foot, left upper back, and left lateral breast to under breast. Tx (treatment) initiated, and blisters will be evaluated by NP (nurse practitioner) [name redacted] next visit.A review of a Nursing-Weekly Skin Assessment completed 7/2/25, prior to transfer to the hospital on 7/3/25, revealed the resident's skin was intact with a wound/skin record that indicated scattered purpura right hand/wrist. A review of the wound consult dated 7/10/25, revealed Patient re-admitted to facility s/p (status post) hospitalization after been found outside after an unknown amount of time around lunch time slumped over in [their] w/c (wheelchair). Hospital notes report per EMS (emergency medical services) patient was found with AMS (altered mental status) and a temperature of 104.1 degrees Fahrenheit. dehydration, possible CVA, leukocytosis. Cardiac was consulted and patient was admitted for further evaluation and management. Staff ask to evaluate for open bullous formation (fluid filled blisters) noted to the left breast and intact serous (clear, pale yellow, watery fluid) blister of the right 1st and 2nd MTP (metatarsophalangeal) (connective tissue between foot and toes) toes. The wound assessment included Wound:1, Location: Left Breast, Primary Etiology: Burn-2nd Degree. Wound:2, Location: right 1st and 2nd MTP toe dorsal aspect, Primary Etiology: Burn-2nd degree. The assessment indicated Sunburn of second degree.A review of the Nursing-Weekly Skin Assessment completed 7/16/25, revealed skin was intact with a wound/skin record that indicated reddened face, scattered blisters on right upper foot, blisters left breast, large blister LUB (left upper back).On 10/31/25 at 9:51 AM, the surveyor interviewed CNA #3 who was assigned to Resident #1. CNA #3 stated she worked for an agency but has worked consistently at the facility since January 2025 and was familiar with Resident #1. CNA #3 explained the resident just recently was on hospice so that morning the hospice aide had provided care. CNA #3 added that the resident required total care but was able to feed themselves. CNA #3 also stated that the resident sometimes could start to say words but then went to gibberish and having a conversation or talking with the resident was very difficult. CNA #3 stated she was able to figure out if the resident wanted something through gestures or pointing. CNA #3 added the resident loved to go outside in the sun, so if the resident saw through the window the sun was out, they would want to be outside and there was a patio on the second floor that was easy to get to. CNA #3 also stated that the resident could not get to the patio by themselves and would have to be taken in the wheelchair outside and brought back in by staff.On 10/31/25 at 10:00 AM, the surveyor interviewed the Licensed Practice Nurse /Unit Manager (LPN/UM #1) who stated there were residents who liked to go out on the second-floor patio and there was now a log to complete when residents went outside. LPN/UM #1 also stated Resident #1 loved to go out on the patio in the sun, only when it was a nice, warm, sunny day. LPN/UM #1 added that she was made aware of the 7/3/25 incident with Resident #1 afterwards because she was not at the facility. On 10/31/25 at 10:13 AM, the surveyor interviewed the Assistant Director of Recreation (ADR) who stated that there were some activities outdoors in good weather that her department was responsible for but there was more than one outside area, and residents could go to those areas when they wanted. The ADR stated that she was aware of what happened to Resident #1 in July, but Resident #1 was not attending at an outdoor activity. The ADR added that during outdoor activities the activity staff was responsible for being aware of resident sun exposure, providing sunscreen and hydration. The ADR stated she had signage that would be posted on all doors that went outside when there was a heat advisory during summer months to make staff, visitors and residents aware. The surveyor with the ADR observed a sign which indicated SUMMER HEAT PRECAUTIONS IN EFFECT, DRINK FLUIDS, STAY OUT OF SUN and another sign Summer Heat Precaution In Effect, Please be sure to USE SUNSCREEN if you are going outside in the sun. All Nursing stations has sunscreen for resident use. On 10/31/25 at 10:20 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she had been DON since May of 2025. The DON also stated she was aware of the occurrence with Resident #1 and the AA had completed the Reportable Event Record/Review that was sent to the New Jersey Department of Health (NJDOH) and completed the investigation. The DON added that CNA #1 was still employed but CNA #2 was no longer employed at the facility.On 10/31/25 at 11:07 AM, the surveyor interviewed the AA who stated that the normal process when a resident was taken outside was to make the primary nurse and assigned CNA aware that the resident was outside, and it was the responsibility of the CNA assigned to the resident to check on them. The AA stated that prior to 7/3/25, the patio door on the second floor during the spring and summer was open from 8:00 AM until 8:00 PM, An alarm would sound only if a resident with a wander guard went outside. The AA stated CNA #2 was unwilling to give a written statement or sign a transcription of her verbal statement. The AA added that CNA #2 was unaware Resident #1 was outside, and that the resident had no medications due during that time. The AA also stated that CNA #2 was assigned to Resident #1 and should have made rounds by 2 PM on all her assigned residents to make sure the basics were completed such as changing residents that needed to be changed, providing water and accounting for their residents. The AA added that CNA #2 left her assignment at 3:00 PM and acknowledged that CNA #2 neglected to monitor the resident. The AA also stated that a visitor with Resident #2 had gone out to the second-floor patio on 7/3/25 at approximately 3:20 PM, and that was how the staff was notified that Resident #1 was slumped in their wheelchair on the patio. On 10/31/25 at 1:07 PM, the surveyor interviewed CNA #1 via telephone. CNA #1 primarily spoke another language and had an interpreter with her on the phone. CNA #1 stated she had worked at the facility for approximately five (5) months and explained prior to July that when a resident was brought to the outside patio and you were not the assigned CNA, you should communicate to the nurse or the assigned CNA to let them know the resident was outside. CNA #1 added that if any of her assigned residents were outside, she was responsible for checking on them every 30 minutes to see if they wanted to come back in, needed water or needed to use the bathroom. CNA #1 also stated that it was the responsibility of the CNA to apply sunscreen, check if they wanted sunglasses or a hat. CNA #1 stated that she remembered the incident with Resident #1 in July because she had brought the resident to the outside second floor patio after they finished lunch in the dining room at approximately 12:50 PM and then she went to lunch. CNA #1 added that the patio was not far from the dining room, approximately 3 to 5 feet. CNA #1 stated she forgot to communicate to the nurse or assigned CNA. CNA #1 stated I made a big mistake. CNA #1 also stated that the resident had a water cup with them and thought they could get their own water. CNA #1 also stated she had not applied sunscreen because she placed the resident in the shade because it was a hot day. CNA #1 added that the resident could apply sunscreen by themselves but did not have any outside.On 10/31/25 at 2:05 PM, the surveyor interviewed the AA who stated that water coolers were provided on the patio and signs regarding Summer Heat Precautions were on the doors to the outside all summer until after approximately the second week in September. The AA added that it was the responsibility of the staff, usually the CNA, to apply sunscreen and provide hydration if a resident was unable to do it by themselves. The AA also stated that prior to 7/3/25, there was no policy regarding residents being outdoors.On 10/31/25 at 3:50 PM, the surveyor interviewed the AA who stated Resident #1 was a maximum assist with transfers and could self-propel in a wheelchair short distance but getting in and out of the door to the second-floor patio would be challenging. The AA also stated that she thought Resident #1 would be able to get water from the cooler. The AA acknowledged that Resident #1 should have been monitored. The AA was unable to answer to the clothing Resident #1 was wearing on 7/3/25, or a skin assessment prior to being transferred because 911 was called immediately and the resident was sent out to the hospital.The facility submitted an acceptable Removal Plan (RP) indicating what actions the facility implemented post incident to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include; 15-minute checks were implemented on all outdoor areas (patio, courtyard, entrance) for 72 hours, checks recorded on log sheets. Notifications to NJDOH, Ombudsman Office and facility administrative staff were sent. Patio keypad was changed from opening from 8:00 AM to 8:00 PM to locked. All employees at the facility were educated on Resident Safety/Heat Advisory. CNA #1 received inservice/education on Resident Safety and CNA #2 received inservice/education on Resident Safety, knowing your assigned resident's whereabouts, making rounds on assigned residents and received a 3-day suspension. A facility wide inservice on the new Outdoor Resident Policy was initiated with Resident Safety/Updated Log Sheets and camera installation on the patio was completed. In addition, 30-minute checks remain on all outdoor areas recorded on log sheets.The facility self-corrected their non-compliance on 7/11/25. The surveyor verified the implementation of the RP on-site on 10/31/25 during a continuation of the survey.NJAC 8:39-4.1(a)(5)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) ensure that washed utensils were dried in a manner to prevent contamination from foreign substances and potential for the development of food-borne illness; b.) maintain the kitchen equipment in a sanitary manner to prevent microbial growth; c.) store, label and date potentially hazardous foods to prevent food borne illness; and d.) ensure bottled drinking water supply was stored in a sanitary manner at least six inches from the floor. This deficient practice was evidenced by the following:On 9/11/2025 at 9:08 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following:1. Near the washing area, dinner knives, forks, and teaspoons contained in perforated plastic flatware containers being air-dried by a standing fan with dust build-up at the back grills. The FSD stated that the fan was cleaned the previous night. 2. Manual can opener blue plastic slide bar insert with heavy buildup of blackish unidentified substance. A staff member handed the clean blade and stem to the FSD who reassembled the parts together. The FSD stated that they could not clean the blue plastic insert, so they ordered a new one to come in.On 9/12/2025 at 8:48 AM, the surveyor toured the first-floor pantry with Registered Nurse/ Unit Manager (RN/Um #1) and observed the following:1. Reach-in refrigerator freezer without an internal thermometer. Six cups of ice cream were observed inside. RN/UM #1 stated that there used to be a thermometer inside the freezer. 2. Reach-in refrigerator contained an unlabeled and undated chicken soup in a covered Pyrex container. The surveyor also observed an undated box of 2 cannoli and box of 2 puff pastries. On 9/17/2025 at 8:30 AM, the surveyor observed the following in the hallway near the kitchen:1. Three 5-gallon jug water containers inserted horizontally inside blue plastic crates which were in direct contact with the floor. The mouthpiece up to the neck part of the containers were [NAME] out of the crates exposed to any activity on the floor. The crates were observed to have heavy buildup of dirt and dust. The FSD stated the water jugs should not be there, and they will be relocated. A review of facility-provided undated policy titled General Sanitation of Kitchen did not address proper drying of utensils.A review of facility-provided procedure dated 3/22/2024 titled Can Opener Cleaning Instructions included the following: 5. Take out blue holding block. Wash, rinse, and sanitize.A review of facility provided policy dated 12/15/2024 titled Dating and Labeling Policy included the following: All . food otherwise stored outside their original containers, must be labeled and dated at the time it was put in the container. The label must include the item description, the date stored, opened date and the use by date.A review of facility-provided policy dated 2/3/2024 titled Food Storage Policy and Procedure did not include proper storage of water containers. N.J.A.C. 8:39 - 17.2 (g)

Based on observation, interview, review of medical record and pertinent facility documentation, it was determined that the facility failed to a.) provide residents with appropriate products for hand hygiene during mealtime identified in 2 of 3 dining room observations (1st floor Tea [NAME] and the Main dining rooms) and b.) implement and maintain a resident with stage 3 pressure ulcer wound on Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes identified in 1 of 1 resident (Resident #114) reviewed for pressure ulcer, to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of infection control practice. This deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html Reference: Enhanced Barrier Precautions are indicated for residents known to be colonized or infected with an MDRO deemed novel or targeted by the CDC. When Contact Precautions do not otherwise apply, or when the resident has an indwelling medical device or wound. https://www.nj.gov/health/cd/documents/topics/hai/EBP_in_Nursing_Homes_Algorithm.pdf 1.(a) On 09/12/2025 at 11:38 AM, Surveyor #1 observed dining for lunch on the 1st floor Tea [NAME] dining room. The Assistant Activities Director (AAD) provided the residents in the dining room with lemon-scented moist towelettes for hand hygiene. The lemon-scented moist towelettes were alcohol free. During an interview with Surveyor #1 on 09/12/2025 at 11:50 AM, the AAD stated that the lemon-scented moist towelettes are what the facility uses to provide hand hygiene for residents prior to meals. During an interview with Surveyor #1 on 09/15/2025 at 12:35 PM, the Infection Preventionist (IP) stated that the facility provides towelettes scented with lemon to residents during mealtimes. She further stated that she was unsure whether the towelettes contain alcohol. During an interview with Surveyor #1 on 09/16/2025 at 1:10 PM, the Assistant Licensed Nursing Home Administrator (ALNHA) stated that lemon-scented moist towelettes are currently used by the facility to provide hand hygiene for residents prior to meals. She also stated that the facility plans to purchase alcohol-based hand wipes in the future for resident use. A review of a facility policy dated 05/06/2025 titled, Resident Health Program, revealed that, An active Resident Health Program is maintained as part of the overall Infection Control Program of the facility, under the direction of the Infection Control Committee and supervised by the Infection Control Coordinator. Educate resident on proper hand hygiene which includes washing hands with soap and water, utilizing alcohol-based sanitizer rub and to utilize the wipes that are provided with meals. b.) On 9/15/2025 at 11:45 AM, Surveyor #2 observed residents for lunch meal service in the Tea [NAME] dining room. A total of 17 residents occupied 6 of 11 tables in the dining room. The surveyor observed Helping Hand (HH) staff and Certified Nursing Assistant (CNA #1) assist residents wipe their hands using lemon-scented moist towelette packs before eating lunch. HH stated to this surveyor that the towelettes were the only supplies they use to clean the residents' hands before meals. On 9/16/2025 at 1:10 PM, during an interview with the survey team, the ALNHA stated that the lemon-scented moist towelettes are currently used by the facility to provide hand hygiene for residents prior to meals. They also stated that the facility plans to purchase alcohol-based hand wipes in the future for resident use. 2.) On 9/11/2025 at 10:46 AM, the Surveyor #2 observed Resident #114 in bed. The resident was using a low-air loss type of mattress. There was no signage for EBP inside and outside the room. No Personal Protective Equipment (PPE) supplies were immediately available near the room. On 9/12/2025 at 9:29 AM, the surveyor observed Resident #114 in bed. There was no signage for EBP inside or outside the room. No PPE supplies were immediately available near the room. On 9/16/2025 at 10:00 AM, the surveyor observed the resident's sacral wound treatment by Licensed Practical Nurse (LPN #1). LPN #1 wore gloves but did not wear any protective gown throughout the wound treatment process. The surveyor asked LPN #1 if they should have used a gown during the wound treatment. LPN #1 stated that since there was no sign that the resident was on EBP along the doorway, they did not wear the gown. The surveyor reviewed the electronic medical record (EMR) for Resident #114. A review of the Resident Face Sheet (an admission record) reflected the resident was admitted to the facility with diagnoses which included stage 3 pressure ulcer of the sacral region (a type of wound that develops over the tail bone area due to prolonged pressure) and malnutrition. A review of the most recent comprehensive Minimum Data S (MDS), an assessment tool dated 7/23/2025, indicated that the resident had no unhealed pressure ulcer. A review of the physician orders as of 9/5/2025, included the following treatment orders: Clean sacral wound with NSS (normal saline solution), apply Manuka honey ointment, and cover with CDD (conventional dry dressing). A review of the comprehensive person-centered care plan revealed a focus for actual skin impairment with the following interventions: Maintain adequate nutrition, position with pads to prevent pressure and offload affected area, wound consult, wound treatment, and wound healing supplement as ordered. On 9/16/2025 at 11:22 AM, during an interview with the survey team, the Director of Nursing (DON) stated that the EBP process entailed the staff use of gown and gloves during high-contact activities like wound care for residents with medical devices and wounds. A review of facility-provided undated policy titled Enhanced Barrier Precautions included under Policy: . Enhanced Barrier Precautions (EBP) are an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus (a bacteria) and MDROs. The policy also included under Overview: 3.) EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization, and infection or colonized with an MDRO. N.J.A.C. 8:39 - 19.4 (a)

Based on observation, interview, review of electronic medical records (EMR) and other pertinent facility documentation it was determined that the facility failed to document non-pharmacological interventions to manage a resident's behavior prior to administration of psychotropic medications. This deficient practice was identified for 1 of 5 residents (Resident #37) reviewed for unnecessary medications and was evidenced by the following:Review of the resident Face Sheet (admission summary) indicated that Resident #37 was admitted to the facility with the diagnoses that included but was not limited to dementia with other behavior disturbance, anxiety disorder, hypothyroidism and hypertension.Review of the quarterly Minimum Date Set (MDS) an assessment tool that facilitates a resident's care dated 8/15/25, indicated that Resident #37 had short and long-term memory deficits and was severely impaired with decision making. The MDS also indicated that the resident required moderate assistance with activities of daily living and exhibited no behaviors.On 9/11/2025 at 11:15 AM, the surveyor observed Resident #37 sitting quietly in the hallway in front of the nurse's station. The resident was in no distress, clean and dressed appropriately. The resident was unable to be interviewed due to cognitive deficits.On 9/12/2025 at 10:22 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that Resident #37 required assistance with washing and dressing. She also stated that resident was confused and required assistance with tray set up but was able to feed themselves. She stated that the resident did not have behaviors that she was aware of. On 9/12/2025 at 10:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #37 was confused and required supervision and direction. She stated that the resident sundown's (a period of increased confusion, agitation, and behavioral changes that often occurs in the late afternoon and evening in people with dementia) and paces the hallways at times in the wheelchair. She explained that the resident was redirected with guiding, food and toileting and that the resident required Xanax (antianxiety medication) at times due to being restless, yelling and trying to stand up. She stated that the resident did not listen when pacing and did not come back when asked by staff members. She stated that the resident was given a Xanax but not all the time. The LPN continued to add that the staff would try to bring the resident to activities, but the resident would sometimes not participate. On 9/12/2025 at 10:34 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manage (LPN/UM) who stated that Resident #37 had confusion and was very calm in the morning but restless in the afternoon and early evening. She stated that the resident paced in the wheelchair and usually a staff member would have to sit with the resident. She said that staff would sometimes just let the resident pace or that the activities department would try to read with the resident. She also added that activities department would take the resident outside, provide snacks and have the resident fold clothes. She explained that the psychiatrist saw the resident on 7/9/25 and started the resident on the psychotropic medication Zoloft for the restlessness. She stated that the antianxiety medication Xanax was only ordered for 14 days until the Zoloft could get into the resident's system. Review of the psychiatrist consultation dated 7/9/25, indicated that the nurses stated that Resident #37 was having episodes of increased anxiety, restlessness and frequently trying to stand up especially after dinner. The psychiatrist indicated that the resident was having no signs or symptoms of depression or anxiety at that time, however, was seen in the early morning hours and staff and family had reported increased anxiety occurred in the afternoon after dinner. The psychiatrist recommended starting Sertraline (Zoloft) 25 mg one tablet at bedtime for anxietyThe surveyor reviewed the physician's orders dated 7/9/25 for Sertraline (Zoloft) 25 mg one tablet at bedtime for anxiety.Review of the progress notes prior to the start date of Zoloft of 7/9/25, revealed that there was no documented behavior nor were there interventions documented regarding non-pharmacological interventions to manage behaviors such as agitation, pacing, or wandering or standing from the wheelchair. There was also no behavior monitoring documented after the medication Zoloft was administered.Review of the Interdisciplinary Care Plan (ICP) revealed that there was a ICP dated 5/12/25, with the focus on Dementia. There were no resident specific interventions to demonstrate how the facility was managing the resident's dementia. The interventions included the following: Use simple words or instructions. Maintain a safe environment. Offer choices of two items. Evaluate medication regimen.Review of the Interdisciplinary Care Plan (ICP) revealed that there was a ICP dated 7/23/25 with a focus on behavior expression such as wandering, non-compliance with safety education, not utilizing the call bell and standing without assistance. There were no resident specific interventions documented on the ICP to demonstrate how the facility was managing these behaviors. The interventions included the following: Document in the progress notes the intensity, duration or frequency of the behavior. Notify the physician immediate changes in behavior. Encourage participation in activities. Encourage participation in activities of daily living. Orient to surroundings. Administer medications as ordered by the physician.Review of the Physician's orders (PO) dated 8/27/25 indicated that Zoloft was increased to 50 mg one tablet every day at bedtime.Review of the PO dated 8/27/25 reflected an order for Xanax 0.25 mg every 12 hours as needed for 14 days for anxiety disorder.Review of the psychiatric medical evaluation dated 9/3/25, indicated that Resident #37 had the diagnoses of anxiety and dementia. The psychiatrist lists the behaviors as anxiety, restlessness, trying to stand up from the wheelchair and wandering looking for their daughter. The psychiatrist documented that these behaviors occurred after dinner. The psychiatrist indicated that the antidepressant medication Zoloft 25 mg was being given to the resident for anxiety and restlessness. The documentation also indicated that the resident was to be given Xanax 0.25 as needed for 14 days for anxiety on 8/27/25 and discontinued on 9/10/25. There were no documented interventions on the behavior ICP or dementia ICP that specifically addressed behaviors such as wandering, pacing, trying to stand up from the wheelchair prior to administration of psychoactive medications.On 9/12/2025 at 11:06 AM, the surveyor interviewed the activities assistant director (AAD) who stated that new residents were assessed within 5 days of admission, quarterly and annually. She stated that these assessments were important to perform to assure that all residents activities need, wants and interest were reviewed. She added that these assessments assured that residents psychosocial needs were met. She explained that Resident 37 was encouraged to participate in sensory group activities which were held at 1:30 PM every day. This activity included music, story time, domestic chores such as folding. The AAD stated that she was not aware that the resident had sundowning issues in the evening hours and was not sure if the staff were supposed to let her know. When the surveyor asked the AAD if the nurse should have told her that the resident was a sundowner or had specific behaviors in the evening, she stated that she wasn't sure. She stated she only had access to the progress notes and didn't have access to the care plan. She stated that the Social Worker (SW) was taking care of updating the care plan because the Director of SW was out on leave. She stated that if the resident was experiencing behaviors later in the day, then it would have been important to have a ICP with interventions that were specific for the resident at the time of the day to address the behaviors. On 9/12/2025 at 11:18 AM, the surveyor interviewed the Director of Social Services (DSW) who stated that if Resident #37 was experiencing behaviors such as sundowning, pacing or wandering, the staff should have been trying non-pharmacological approaches to the behaviors before trying psychotropic medications. The SW reviewed the activities notes and admitted that there was no documentation regarding the residents' behaviors or any specific activities that were being offered to the resident to manage the behaviors. The surveyor asked the SW regarding dementia care plans and activities care plans and the SW stated that all resident specific interventions related to behaviors should have been addressed in the ICP. The DSW confirmed that there were no non-pharmacological interventions addressed in the resident's care plan for the listed behaviors. On 9/12/2025 at 12:10 PM, the surveyor interviewed the DSW, Director of Nursing (DON) and Assistant Administrator (AA) who all confirmed that there were no documentations in Resident #37's medical record that indicated non-pharmacological interventions were initiated prior to start of psychotropic drugs. The SW also confirmed that the ICP did not address activities or resident specific intervention for the dementia care plan.On 9/16/2025 at 10:09 AM, the surveyor interviewed the LPN/UM who reviewed the progress notes in the presence of the surveyor and agreed that there were no nursing notes prior to 7/9/25 which addressed resident specific behaviors or attempted interventions to manage the behaviors before starting the resident on the psychotropic medication Zoloft. She confirmed that there should have been documented non-pharmacological approach to effectively manage the resident's behavior of agitation or wandering. She also agreed that the resident's care plan did not address any non-pharmacological interventions that were attempted before starting the psychoactive medication Zoloft. The LPN/ UM confirmed that there was no documentation in the MAR for behavior monitoring before starting the resident on a psychoactive medication or after the resident started on a psychoactive medication. She stated that they dropped the ball on that one.On 9/16/2025 at 12:45 PM, the surveyor interviewed the medical director (MD) who stated that it was nursing 101 that the nursing staff would try non-pharmacological interventions in an attempt to manage behaviors prior to starting the resident on a psychotropic medication. The facility policy dated 4/21/25 and titled, Psychotropic Drugs indicated that it was the facility policy that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive a gradual dose reduction, behavior interventions, unless clinically contraindicated. The policy specified that the IDT will implement non-pharmacological approaches designed to meet the individual needs of each resident by way of a personalized care plan. The facility policy dated 4/21/25 and titled, Dementia Care Planning indicated that the facility would provide person-centered, dignified and safe care for residents living with dementia. All residents with dementia will have a comprehensive care plan developed, implemented and reviewed regularly. Care planning would include a personal history and interest, communication strategies, environmental modifications, triggers and calming techniques, nutritional and hydration support and medication review and management. The policy also indicated that the facility would use non-pharmacological interventions as a first line management of behavior issues. The facility would provide meaningful engagement and activities tailored to cognitive levels and interest. Document all interventions and updates.N.J.A.C. 8:39-27.1(a)

Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to accurately code a resident's oxygen (O2) administration on the quarterly Minimum Data Set (MDS) an assessment tool for 1 of 24 residents (Resident #9) reviewed and was evidenced by the following:Review of the Face Sheet (admission summary) indicated that Resident #9 was admitted to the facility with the diagnoses that included but was not limited to pneumonia (respiratory infection) and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) an assessment tool that facilitates a resident's care dated 8/15/25 indicated that Resident #9 scored an 8/15 on the Basic Interview for Mental Status (BIMS) which indicated moderate impairment of cognition. The MDS also reflected that Resident #9 required moderate assistance with all aspect of activities of daily living. The MDS did not reflect that the resident was being administered O2.On 9/11/2025 at 10:50 AM, during initial tour, the surveyor observed Resident #9 lying in bed on O2 at 2 liters by way of (via) nasal cannula (tubing that delivers O2 through the resident's nares). The surveyor was unable to interview the resident at this time because the resident was sleeping. The surveyor did not observe that the resident was short or breath or having difficulty breathing.The surveyor reviewed the residents EMR which revealed the following information:A review of the physician's orders (PO) dated 5/27/25, reflected a PO to administer O2 at 2 liters via nasal cannula as needed (prn) for pulse oximetry (measures amount of O2 in the blood) less than 91% (percent) on room air or visible shortness of breath. A review of quarterly MDS with an assessment reference date of 8/15/25, reflected that the resident was not administered O2. The surveyor reviewed the nursing progress note date 8/14/25 which indicated that the resident in fact was administered O2 at 2 liters. On 9/17/2025 at 9:50 AM, the surveyor interviewed the MDS Registered Nurse (MDS/RN) Coordinator who explained that the resident's quarterly MDS dated [DATE], had a look back was to 8/2/25. The MDS/RN confirmed that the documentation in the progress notes indicated that the resident received O2 on 8/14/25. The MDS Coordinator stated that the MDS had to be modified to include that the resident was on O2 at the time the MDS was completed. The MDS/RN stated that this was an error in documentation.A review of the facilities undated policy titled, MDS Coordinator Policy indicated that the Resident Assessment Instrument (RAI) assist skilled nursing facility staff to consistently and accurately gather information regarding residents' strength which provides the foundation for an individual interdisciplinary plan of care. The MDS Coordinator conducts a comprehensive assessment of residents to determine their healthcare needs, functional ability and psychosocial status. To ensure that the MDS is accurately completed to reflect each resident's clinical status.N.J.A.C 8:39-33.2 (d)

Based on observation, record review, interview, and review of pertinent facility documentation, it was determined that the facility failed to implement a comprehensive, person-centered care plan (CPCCP) for pain that was consistent with professional standards of practice and included measurable objectives and timeframes to meet a resident's medical needs. This deficiency was identified for 1 of 1 resident (Resident #129) reviewed for pain.This deficient practice was evidenced by the following: On 09/11/2025 at 10:42 AM, the surveyor observed Resident #129 in their bedroom, lying in bed with the head of the bed elevated to approximately 45 degrees. The resident reported having undergone surgery on their lower right leg on 09/04/2025, including a skin graft (a medical procedure where healthy skin is removed from one area of the body and replaced to another area) for a painful wound in that area. The resident stated that he/she had received pain medication at approximately 6:00 a.m. and were planning to ask the nurse for additional medication for their lower right leg later. According to the admission record, Resident #129 was admitted to the facility with diagnoses including, but not limited to, atherosclerosis with ulceration to right lower leg (a condition where narrowed or blocked arteries have poor blood flow, resulting in formation of open sores), and pain in right leg. A review of Resident #129's annual Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 07/22/2025, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of Section J: Health Conditions revealed that the resident receives as-needed pain medication and non-medication interventions for pain management. A review of Resident #129's physician orders (PO), dated as of 09/09/2025, included the following PO for oxycodone 5 milligrams (mg) tablets by oral route every 6 hours as needed for severe pain, and PO dated 09/10/2025 for acetaminophen extra strength 500 mg tablet give 2 tablets (1000 mg) by oral route every 6 hours as needed for moderate pain and acetaminophen 325 mg give 2 tablets (650 mg) by oral route every 4 as needed for mild pain. Resident #129 did not have a Comprehensive Person-Centered Care Plan (CPCCP) for pain to review. During an interview with the surveyor on 09/15/2025 at 12:10 PM, the Assistant Licensed Nursing Home Administrator stated that Resident #129 was admitted to the hospital from the facility in 08/2025 and returned on 09/09/2025. She stated that the resident had a CPCCP for pain prior to hospitalization, but she was not sure why a CPCCP for pain was not in place upon the resident's return. She acknowledged that the resident should have had one in place. The facility was unable to provide a policy regarding the development of a CPCCP. NJAC 8:39-11.2(b)

Based on observation, interview and review of medical records and other pertinent facility documentation it was determined that the facility failed to update and revise a resident's Interdisciplinary Care Plan (ICP) to accurately reflect the care for 1 of 24 residents (Resident #2) and was evidenced by the following: Review of the Face Sheet (admission summary) indicated that Resident #2 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease, heart failure and diabetes mellites (DM).Review of the quarterly Minimum Date Set (MDS) an assessment tool that facilitates a resident's care dated 8/4/2025, indicated that Resident #2 had a score of 8/15 on the Brief Interview for Mental Status (BIMS) which indicated that the resident had moderate cognitive impairment. The MDS reflected that the resident required maximum assistance with activities of daily living.On 9/11/2025 at 10:54 AM, the surveyor observed Resident #2 sitting in the dayroom. The resident was very pleasant and well dressed. The surveyor observed that the resident had edema (swelling) of the lower extremities and was wearing compression stockings (stocking that manage circulatory issues and swelling). The resident was interviewed at the time and was unable to provide the surveyor details about the compression stocking. The surveyor reviewed the residents electronic medical record which revealed the following information:Review of the Physician's Order (PO) dated 1/29/2025, reflected an order to apply knee high (compression stocking) in the AM and remove at night (hs).Review of the Treatment Administration Record (TAR) for September 2025, reflected that the nurses were signing the TAR that they applied the compression stocking in the AM and removed them at hs.Review of the PO dated 12/10/2024, reflected that the resident was ordered the antidiuretic medication Furosemide 20 mg 1 (one) tablet daily and then subsequently discontinued. Review of the Resident #'2 Comprehensive Interdisciplinary Care Plan (ICP) dated 3/02/2020 and reviewed 8/4/2025, reflected that Resident #2 had decreased cardiac output and would be free of complications such as edema, fluid overload and shortness of breath. The ICP indicated that the resident was still on the medication Furosemide and there was no documentation that the resident was to wear compression stockings for edema management.On 9/15/2025 at 10:35 AM, Resident #2 was observed lying in bed. The resident was sleeping at this time, and the surveyor was unable to interview. The resident had compression stockings on the bilateral lower extremities. The surveyor interviewed the primary care Certified Nursing Assistant (CNA) who stated that compression stockings were applied every morning and removed at night for edema of the lower extremities.On 9/15/2025 at 10:54 AM, the surveyor interviewed the primary care Licensed Practical Nurse (LPN) who stated that Resident #2 had non-pitting (indentation) edema of the lower extremities and that the edema was chronic (persisting for a long time). She reviewed the resident's ICP in the presence of the surveyor and confirmed that the ICP reflected that the resident was on an antidiuretic medication even though there were no orders for diuretic medications. The LPN also stated that the compression stockings should be on the ICP as an intervention to reduce the resident's edema. She explained that the residents ICP should be resident specific to describe a resident's condition in real time. The LPN added that the Unit Manager was responsible to update residents ICPs. The LPN reviewed the resident's ICP and stated that the compression stocking should be a part of the ICP, and that the resident was not on a diuretic medication since starting on hospice.On 9/15/2025 at 11:06 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who reviewed Resident #2's ICP and confirmed that the compression stockings should be documented on the ICP and that the ICP should have been updated to reflect that. She also confirmed that the diuretic medication should have been removed from the ICP. On 9/17/2025 at 9:24 AM, the surveyor interviewed the Assistant Licensed Nursing Home Administrator and the Director of Nursing who both confirmed that the ICP should have been revised and updated to include the resident's compression stockings and discontinuation of the diuretic medication Furosemide. The undated facility policy titled, Interdisciplinary Care Plans indicated that the care plan shall be designed to meet the resident's medical, nursing and psycho-social needs as identified in the comprehensive assessment. The ICP will be periodically reviewed and revised after each resident's annual assessment, quarterly review and upon significant change in condition. The care plan shall also be updated as warranted by a change in medication or treatments or other changes in condition.NJAC 8:39-11.2(i)

Based on record review, interview, and pertinent facility documentation, it was determined that the facility failed to ensure that the resident's environment was free of possible hazards. This deficiency was identified in 1 of 2 residents (Resident #128) reviewed for accidents.This deficient practice was evidenced by the following: On 09/15/2025 at 11:20 AM, the surveyor reviewed the facility's accident investigation for Resident #128's near-fall incident that occurred on 10/11/2024. The identified contributing factor was a broken right halo bar (a safety and mobility device attached to the resident's bed) that failed to lock into place. Measure to prevent recurrence was notifying the maintenance department. On 09/15/2024 at 11:30 AM, the surveyor reviewed the facility's Housekeeping and Maintenance Request Forms for the period of 09/2024-10/2024. Logs showed two work requests for loose halo bars submitted by nursing: one on 09/25/2024 and another on 10/18/2025. However, there was no maintenance request submitted or completed on 10/11/2024 for Resident #128's halo bar following the near-fall incident out of bed. According to the admission record, the resident was admitted to the facility with diagnoses including, but not limited to, Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks) and muscle weakness. A review of the resident's Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 10/30/2024, included a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating severe cognitive impairment. The resident's comprehensive care plan, dated 09/18/2024, identified a focus area noting a high risk of falls and the need for preventative measures to reduce the likelihood of falls. During an interview with the surveyor on 09/15/2025 at 12:10 PM, the Assistant Licensed Nursing Home Administrator stated that Resident #128's halo bars were used as safety devices to help prevent falls and assist with mobility and repositioning in bed. She was unsure why maintenance did not complete a facility-wide audit of halo bars after Resident #128's near-fall incident, which involved the halo bars, to ensure all were functioning properly, noting that the maintenance director is no longer employed at the facility. A review of a facility policy dated 04/21/2025 titled, Quality of Life, revealed that, All staff shall care for our residents in a manner and in an environment that promotes maintenance and enhancement of each resident's quality of life. Environment - safe, comfortable, clean, orderly, home-like, appropriate linens, sound levels, ventilation, lighting, and proper care of personal belongings. NJAC8:39-27.1(a)

Based on observation, interview, review of electronic medical records (EMR) and other pertinent facility documentation it was determined that the facility failed to document the administration of oxygen (O2) and failed to document the administration of O2 on the resident's Interdisciplinary Care Plan for 1 of 1 resident (Resident #9) reviewed for respiratory care and was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a 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. Review of the Face Sheet (admission summary) indicated that Resident #9 was admitted to the facility with diagnoses that included but were not limited to pneumonia (respiratory infection) and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) an assessment tool that facilitates a resident's care dated 8/15/2025 indicated that Resident #9 scored an 8/15 on the Brief Interview for Mental Status (BIMS) which indicated moderate impairment of cognition. The MDS also reflected that Resident #9 required moderate assistance with all aspect of activities of daily living.On 9/11/2025 at 10:50 AM, during the initial tour, the surveyor observed Resident #9 lying in bed on oxygen (O2) at 2 liters by way of (via) nasal cannula (tubing that delivers O2 through the resident's nares). The surveyor was unable to interview the resident at this time because the resident was sleeping. The surveyor did not observe that the resident was short or breath or having difficulty breathing.The surveyor reviewed the residents EMR which revealed the following information:A review of the physician's orders (PO) dated 5/27/2025, reflected a PO to administer O2 at 2 liters via nasal cannula as needed (prn) for pulse oximetry (measures amount of O2 in the blood) less than 91% (percent) on room air or visible shortness of breath. A review of the Medication Administration Record (MAR) dated 9/11/2025, revealed that there was no documentation that the resident was administered O2 at 2 liters. The surveyor also reviewed the nursing progress notes dated 9/11/2025 and there was no documentation that the resident was administered O2.On 9/15/2025 at 11:25 AM, the surveyor observed Resident #9 in the room lying in bed sleeping and received O2 at 2 liters via nasal cannula. The resident was not able to be interviewed at that time.On 9/15/2025 at 11:42 AM, the surveyor interviewed the Registered Nurse (RN) who explained that she was new to the facility and that her previous nursing experience was from the acute care setting. The RN accompanied the surveyor to the resident's room and confirmed that the resident was being administered O2 at 2 liters via nasal cannula. The surveyor reviewed the MAR in the presence of the RN and the RN admitted that the O2 was not signed out in the MAR that the resident was receiving O2. The RN stated that she was not familiar with the LTC regulations and did not know that the nurses were responsible to sign out in the MAR that the resident was administered O2. She also stated that she worked on 9/12/2025 and that the resident was short of breath and required the PRN O2 on that day. She admitted that she applied the O2 as ordered by the physician, however, did not sign it out on the MAR when she administered the O2 on 9/12/2025.The surveyor reviewed the resident's MAR and progress notes dated 9/12/2025 and 9/15/2025, which revealed that there was no documentation that the resident received O2.Review of the Interdisciplinary Care Plan did not reveal that Resident #9 was being administered O2.On 9/15/2025 at 11:42 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated that if a resident was on O2 all the time that was considered continuous and would require a physician's order. She added that if Resident #9 had a PO for prn O2, that would indicate that the resident would only be administered the O2 if the resident needed it. The RN explained that Resident #9 was currently being treated for pneumonia and needed the O2 at this time. She explained that the resident had a prn order for O2, and the nurses should be signing the O2 out on the MAR if the resident was administered O2. The RN/UM reviewed the MAR in the presence of the surveyor and confirmed that there were no nurse's signatures documented on the MAR that the resident was being administered O2. The RN/UM also reviewed the residents ICP and confirmed that there was no documentation on the care plan that the resident was on O2 continuously or intermittently.On 9/17/2025 at 9:25 AM, the surveyor interviewed the Director of Nursing (DON) who stated that if a resident was prescribed O2 that the O2 should have been care planned and that the nurses were responsible to sign out the O2 on the MAR when administered.On 9/17/2025 at 9:25 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the administration of O2 should have been care planned for Resident #9 and that the nurses were responsible to sign out the O2 when it was administered to Resident #9.The facility policy dated 4/21/25 and titled, Oxygen Administration indicated that documentation details of emergency, resident condition, oxygen administered, SpO2 testing and the residents' response to therapy.The facility undated policy titled, Interdisciplinary Care Plans indicated that the care plan shall be designed to meet the resident's medical, nursing and psycho-social needs as identified in the comprehensive assessment and will include measurable time frames. The care plan shall also be updated as warranted by a change in medications or treatments or other changes in condition. The resident's care plan should address needs or care and be appropriate to the individual.NJAC 8:39-19.4(a)

Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to a.) develop an individualized comprehensive assessment and Care Plan (CP) with resident specific interventions to address dementia care, and b.) follow the facility policy for dementia care. This deficient practice was identified for Resident #37, 1 of 1 resident reviewed for dementia care and was evidenced by the following:Review of the resident Face Sheet (admission summary) indicated that Resident #37 was admitted to the facility with diagnoses that included but were not limited to dementia with other behavior disturbance, anxiety disorder, hypothyroidism and hypertension.Review of the quarterly Minimum Date Set (MDS) an assessment tool that facilitates a resident's care dated 8/15/2025, indicated that Resident #37 had short and long-term memory deficits and was severely impaired with decision making. The MDS also indicated that the resident required moderate assistance with activities of daily living and did not exhibit behaviors.On 9/11/2025 at 11:15 AM, the surveyor observed Resident #37 sitting quietly in the hallway in front of the nurse's station. The resident was in no distress, clean and dressed appropriately. The resident was unable to be interviewed due to cognitive deficits.On 9/12/2025 at 10:22 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who told the surveyor that Resident #37 required assistance with washing and dressing. The CNA also stated that Resident #37 was confused. She explained the resident required assistance with tray set up but was able to feed themselves and did not have behaviors that she was aware of. On 9/12/2025 at 10:27 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #37 required supervision and direction due to the resident's confusion. She stated that the resident had sundowning (a period of increased confusion, agitation, and behavioral changes that often occurs in the late afternoon and evening in people with dementia) and paced the hallways at times in the wheelchair. She explained that the resident was redirected with guiding, food and toileting. She stated that the resident required Xanax (antianxiety medication) at times due to being restless, yelling and trying to stand up. She stated that the resident was given a Xanax but not all the time. She stated that the staff would try to bring the resident to activities, but the resident at times would not participate. On 9/12/2025 at 10:34 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manage (LPN/UM) who stated that Resident #37 had confusion and was very calm in the morning but restless in the afternoon and early evening. She stated that the resident paced in the wheelchair and that they usually had to have a staff member sit with the resident. She stated that the activities department would try to read with the resident, take the resident outside, sit with the resident, provide snacks or they would let the resident fold clothes as a diversion.Review of the Interdisciplinary Care Plan (ICP) revealed that there was a ICP dated 5/12/2025 with a focus on Dementia. There were no resident specific interventions to demonstrate how the facility was managing the resident's dementia or behaviors associated with dementia. The interventions included the following: Use simple words or instructions. Maintain a safe environment. Offer choices of two items. Evaluate medication regimen.Review of the psychiatric medical evaluation dated 9/3/2025, indicated that Resident #37 had diagnoses of anxiety and dementia. The psychiatrist lists the behaviors as anxiety, restlessness, trying to stand up from the wheelchair and wandering looking for his/her daughter. The psychiatrist documented that these behaviors occurred after dinner. There were no resident specific interventions documented on the ICP to address triggers or calming techniques used to manage or address the resident's dementia or behaviors associated with dementia. There were no person-centered interventions documented that specifically addressed these behaviors such as sundowning, wandering, pacing, trying to stand up from the wheelchair. On 9/12/2025 at 11:06 AM, the surveyor interviewed the activities assistant director (AAD) of the recreation department who stated that new residents were assessed within 5 days of admission, quarterly and annually. She stated that these assessments and reviews were important to perform to assure that all residents activity needs, wants and interests were reviewed to assure that the residents were getting their psychosocial needs met. She stated that Resident #37 was encouraged to participate in sensory group activities which was held at 1:30 PM every day. This activity included music, story time and domestic chores such as folding. The AAD stated that she was not aware that the resident had sundowning issues and was not sure if the staff were supposed to let her know. When the surveyor asked the AAD if the nurse should have told her that the resident was a sundowner or had specific behaviors in the evening, she stated that she wasn't sure. She stated that she only had access to the progress notes and didn't have access to the ICP. She stated that the Social Worker (SW) was taking care of updating the care plan updating and the Director of Social Work was out on leave. She stated that if the resident was experiencing behaviors later in the day, then it would have been important to have a ICP with interventions that were specific for the resident at the time of the day to address the behaviors. On 9/12/2025 at 11:18 AM, the surveyor interviewed the Director of Social Services (DSW) who was employed in the facility for 11 years. The DSW stated that if Resident #37 was experiencing behaviors such as sundowning, pacing or wandering the staff should have been trying non-pharmacological approaches to manage the behaviors. The SW reviewed the activities notes and admitted that there was no documentation in the progress notes or on the Dementia ICP regarding the residents' behaviors or any specific activities that were being offered to the resident to manage the behaviors. The surveyor asked the SW regarding dementia care plans and activities care plans and the SW stated that all resident specific interventions related to behaviors should have been addressed in the CP. On 9/12/2025 at 12:10 PM, the surveyor interviewed the DSW, Director of Nursing (DON) and Assistant Administrator (AA) who all confirmed that there were no documented interventions on the ICP to address activities or resident specific behavior interventions in the dementia care plan.On 9/16/2025 at 10:09 AM, the surveyor interviewed the LPN/UM who reviewed the ICP in the presence of the surveyor and stated that they dropped the ball on that one and there were no documented interventions to address the resident specific behaviors. The facility policy dated 4/21/2025 and titled, Dementia Care Planning indicated that the facility would provide person-centered, dignified and safe care for residents living with dementia. All residents with dementia will have a comprehensive care plan developed, implemented and reviewed regularly. Care planning would include a personal history and interest, communication strategies, environmental modifications, triggers and calming techniques, nutritional and hydration support and medication review and management. The policy also indicated that the facility would use non-pharmacological interventions as a first line management of behavior issues. The facility would provide meaningful engagement and activities tailored to cognitive levels and interest. Document all interventions and updates.N.J.A.C 8:39-45.1(a)

Based on interview and review of pertinent facility documents, it was determined that the facility failed to a.) ensure the Infection Preventionist (IP) was present for quarterly Quality Assurance and Performance Improvement (QAPI) meetings, and b.) included as a member of the Quality Assessment and Assurance (QAA) Committee. This deficient practice was identified by the following: On 09/15/2025 at 12:35 PM, the surveyor interviewed the IP who stated that she had worked at the facility for the past two and a half years in her current role and had never attended a QAPI meeting. She reported that she provided infection control information to the Director of Nursing (DON), who presented it during the QAPI meetings. On 09/17/2025 at 10:14 AM, the surveyor interviewed the Assistant Licensed Nursing Home Administrator (ALNHA) who stated that the IP did not attend QAPI meetings and was not a member of the QAA committee. The Director of Nursing (DON) presents infection control information during the QAPI meetings. On 09/16/2025 at 12:02 PM, the surveyor reviewed the facility's 2025 quarterly QAPI attendance sheets for meetings that were held on 01/28/2025, 04/25/2025, and 07/29/2025, as well as the list of QAA committee members. The Infection Preventionist (IP) did not attend any of the QAPI meetings and was not listed as a member of the QAA committee. A review of a facility policy dated 04/01/2025 titled, Quality Assurance and Performance Improvement (QAPI), revealed that, It is the policy of [NAME] Garden to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. NJAC 8:39-33.1(a)(b)

Based on interviews, record reviews, and a review of pertinent facility documentation, it was determined that the facility failed to consistently implement an Antibiotic Stewardship Program (ASP), a program designed to improve clinical outcomes and reduce harm by promoting the appropriate use of antibiotics and monitoring their use, in collaboration with the facility's consultant pharmacist and medical director. This deficiency was identified in 1 of 1 resident (Resident #44) reviewed for antibiotic use.The deficient practice was evidenced by the following: On 09/15/2025 at 1:00 PM, the surveyor reviewed the facility's monthly antibiotic roster for 08/2025, which is used to monitor all residents receiving antibiotics. The roster, provided by the Infection Preventionist (IP), did not include Resident #44, who had received intravenous (IV) (a method that allows the medication to enter the bloodstream quickly and work faster) antibiotics during 08/2025. According to the admission record, Resident#44 was admitted to the facility with diagnoses including, but not limited to, infection following a procedure at the surgical site on the lumbar spine, and Methicillin-Resistant Staphylococcus Aureus (MRSA) infection (a type of bacteria that causes infections and is resistant to many common antibiotics). A review of Resident's #44 admission Minimum Data Set (MDS), an assessment tool used to facilitate care management, dated 08/06/2025, included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Further review of Section 0: Special Treatments, Procedures, and Programs revealed that the resident had received IV medication. Resident's #44 comprehensive care plan, dated 07/28/2025, included a care area indicating that the resident was receiving IV antibiotic therapy for an MRSA wound infection. A review of Resident #44's Physician Orders (PO), dated 08/03/2025, included an order for cefazolin 2 grams in 50 milliliters of dextrose intravenous piggyback (IV medication diluted in a carrier fluid to treat bacterial infections), to be infused by IV every 8 hours for a total of 142 doses. During an interview with the surveyor on 09/15/2025 at 12:35 PM, the Infection Preventionist (IP) stated that, as part of her daily infection control tasks, she keeps detailed records for each resident receiving antibiotics, including the type of infection, lab results, start and end dates, and the prescribed antibiotic. She stated that she was not sure what specific criteria the facility uses to diagnose infections and would need to follow up to determine that information. She further stated that she is not familiar with established clinical criteria used to identify infections in long-term care facilities. During an interview with the surveyor on 09/16/2025 at 11:20 AM, the Assistant Licensed Nursing Home Administrator stated that she was unsure of the clinical criteria the facility used to identify infections. She also indicated that if Resident #44 had received IV antibiotics, the resident should have been included on the 08/2025 monthly antibiotic roster. During an interview with the surveyor on 09/16/2025 at 11:32 AM, the facility's Pharmacist Consultant stated that the facility uses the Situation, Background, Assessment, Recommendation (SBAR) form as the primary tool for tracking and managing antibiotic usage. During an interview with the surveyor on 09/16/2025 at 12:58 PM the facility's Medical Director stated that the facility uses the Situation, Background, Assessment, Recommendation (SBAR) form as the primary tool for tracking and managing antibiotic usage. A review of the facility's policy dated 03/28/2025, titled, Antibiotic Stewardship Policy, revealed that, It is the policy of the facility to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The facility is committed to improving antibiotic prescribing practices and reducing inappropriate antibiotic use. A monthly infection control report will be completed, including both a quantitative and qualitative rationale for why the antibiotic was needed, the outcome of its effectiveness in treating the infection, and any associated adverse side effects. N.J.A.C. 8:39-19.4(a)

Based on interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure the Infection Preventionist (IP) actively performed responsibilities in accordance with the facility designated role implementing programs and activities to prevent and control infections.The deficient practice was evidenced by the following: During an interview with the surveyor on 09/15/2025 at 12:35 PM, the IP stated that she was not sure what specific criteria the facility used for diagnosing infections and would need to follow up to determine that information. She further stated that she is not familiar with established clinical criteria used to identify infections in long-term care facilities. The IP also reported that she is not involved in the facility's water management or treatment plan, explaining that those responsibilities are handled by the maintenance department. Additionally, she stated that she does not conduct regular surveillance in the kitchen or laundry areas and only enters those areas if she needs something. During an interview with the surveyor on 09/16/2025 at 11:20 AM, the Assistant Licensed Nursing Home Administrator stated that she was unsure what clinical criteria the facility used to identify infections. She further stated that the IP does not conduct surveillance in the kitchen or laundry areas. Instead, she does weekly rounds throughout the facility every Monday with the Maintenance Director. A review of the facility's policy dated 03/28/2025, titled, Infection Control Rounds, revealed that, the objective of infection control round is to evaluate compliance with infection control policies and procedures throughout the facility, and data collected during rounds shall be utilized for educating staff and improving resident care and facility practices. NJAC 8:39-19.1(b)

Based on interview and record review, it was determined that the facility failed to ensure that the pneumococcal vaccination was offered to all residents upon admission to the facility to prevent incidence of pneumonia for 1 of 5 residents (Resident # 87) reviewed for immunization administration. This deficient practice was evidenced by the followingDuring the initial tour of the facility on 09/11/2025 at 10:21 AM, Resident #87 was observed seated in a wheelchair in their bedroom. A review of Resident #87's admission Record revealed that the resident was admitted to the facility with diagnosis which included, but were not limited to, displaced fracture of the left lower leg and encounter for orthopedic aftercare.A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 7/22/2025, included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS identified under Section O that the Pneumococcal Vaccine was offered but declined. A review of Resident #87's Immunization Consent form, dated 7/16/2025, identified under Pneumonia Vaccine: (checked) I do want [resident name] to be given the pneumonia vaccine. When the surveyor requested a printed copy of Immunization form, it was observed that a handwritten year was entered into the line that stated: [Blank] has received the Pneumonia previously on 2024, which was not identified in the electronic medical record. A review of Resident #87's Nursing Immunization Record form, created on 7/16/2025 and completed on 7/2/25, identified under Pneumonia Vaccine: Is the resident's Pneumococcal vaccination up to date? and Yes is checked. On 9/16/2025 at 9:18 AM, during an interview with the surveyor, the Infection Preventionist (IP) advised that she was responsible for overseeing the immunization consents. When asked for documentation of Resident #87 pneumococcal vaccination, the IP responded that the resident was admitted for short term rehabilitation and that the pneumococcal vaccine is only admitted to long term care residents. On 9/12/2025 at 9:54 AM, during an interview with the surveyor the Director of Nursing (DON) confirmed that all residents, both long term care and short-term rehabilitation should be offered the pneumonia vaccine and that it was one of the questions asked during admission. On 9/12/2025 at 11:26 AM, during an interview with the surveyor the DON, in the presence of the Licensed Nursing Home Administrator confirmed that all residents, both long term care and short-term rehabilitation should be offered the pneumonia vaccine.A review of the undated facility provided document Prevention and Control of Nosocomial Pneumonia Pneumococcal Vaccine revealed the following: The facility shall offer the pneumococcal vaccine to every resident upon admission who has not had the vaccine unless medically contraindicated or refused by the resident [.] Consent or refusal for the initial and second shall be signed by the resident or family member after receiving documented education on the risks and benefits of the vaccination.NJAC 8:39-19.4 (h) (i)

Based on interview, review of the Nurse Staffing Report and the PB&J (Payroll Based Journal) report and other facility documentation, it was determined that the facility failed to ensure there was sufficient nursing staff on a 24-hour basis to provide nursing care to the residents. This deficient practice was evidenced by the following: During the initial tour on 04/23/2024 at 10:30 AM, Resident #32 was just getting morning care. Resident #32 said, They are short of nurses and aides all the time, especially on weekends. On 04/23/2024 at 10:30 AM, Resident #72 stated that they do not have enough aides on the weekends. Resident #72 also stated that he/she did not receive their bed bath yesterday due to being short staffed. During the Resident Council Meeting on 04/24/2024 at 10:00 AM, 3 of 5 Residents reported there is not enough staff, especially at night. Resident #77 said, It seems like they go on break, everyone goes on break. 1. For the 2 weeks of Complaint staffing from 07/30/2023 to 08/12/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 1 of 14 evening shifts, and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -07/30/23 had 8 CNAs for 114 residents on the day shift, required at least 14 CNAs. -07/30/23 had 7.5 total staff for 114 residents on the overnight shift, required at least 8 total staff. -07/31/23 had 11 CNAs for 113 residents on the day shift, required at least 14 CNAs. -08/01/23 had 11 CNAs for 112 residents on the day shift, required at least 14 CNAs. -08/02/23 had 10 CNAs for 112 residents on the day shift, required at least 14 CNAs. -08/03/23 had 9 CNAs for 112 residents on the day shift, required at least 14 CNAs. -08/04/23 had 9.5 CNAs for 112 residents on the day shift, required at least 14 CNAs. -08/05/23 had 8.5 CNAs for 115 residents on the day shift, required at least 14 CNAs. -08/06/23 had 10.5 CNAs for 115 residents on the day shift, required at least 14 CNAs -08/07/23 had 9 CNAs for 115 residents on the day shift, required at least 14 CNAs. -08/08/23 had 9 CNAs for 115 residents on the day shift, required at least 14 CNAs. -08/09/23 had 10 CNAs for 115 residents on the day shift, required at least 14 CNAs. -08/09/23 had 10.5 total staff for 115 residents on the evening shift, required at least 11 total staff. -08/10/23 had 10 CNAs for 118 residents on the day shift, required at least 15 CNAs. -08/11/23 had 9.5 CNAs for 118 residents on the day shift, required at least 15 CNAs. -08/12/23 had 9.5 CNAs for 116 residents on the day shift, required at least 14 CNAs. 2. For the 2 weeks of staffing prior to survey from 04/07/2024 to 04/20/2024, the facility was deficient in CNA staffing for residents on 12 of 14 day shifts, deficient in total staff for residents on 2 of 14 evening shifts, deficient in CNAs to total staff on 2 of 14 evening shifts, and deficient in total staff for residents on 1 of 14 overnight shifts as follows: -04/07/24 had 10 CNAs for 110 residents on the day shift, required at least 14 CNAs. -04/08/24 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/09/24 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/11/24 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/12/24 had 7 CNAs for 108 residents on the day shift, required at least 13 CNAs. -04/13/24 had 7.5 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/14/24 had 8.75 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/14/24 had 10.5 total staff for 107 residents on the evening shift, required at least 11 total staff. -04/14/24 had 4.5 CNAs to 10.5 total staff on the evening shift, required at least 5 CNAs. -04/15/24 had 9 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/16/24 had 9 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/17/24 had 10 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/18/24 had 11 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/19/24 had 9 CNAs for 107 residents on the day shift, required at least 13 CNAs. -04/19/24 had 9 total staff for 107 residents on the evening shift, required at least 11 total staff. -04/19/24 had 6 total staff for 107 residents on the overnight shift, required at least 8 total staff. -04/20/24 had 7.75 CNAs to 16.25 total staff on the evening shift, required at least 8 CNAs. During an interview with the surveyor on 04/26/2024 at 09:45 AM, Registered Nurse (RN#1) said, We are challenged a lot for staff, and we have call outs. We try to have at least 1 desk nurse on the weekend as back up for call out. Also, if you call out on weekend you have to make it up. During an interview with the surveyor on 04/26/2024 at 11:02 AM, Certified Nursing Assistant (CNA #1) said, We are always short. We have 3 aides today and I have like 19 residents. When asked how is staffing on weekends, CNA #1 said I work every other weekend and we are always short on weekends. When asked how many aides you should have, CNA #1 replied, we are supposed to have eight (8) aides but may have same as today. There are no hospice aides to help on weekends. During an interview with the surveyor on 04/29/2024 at 10:15 AM, the Staffing Coordinator said she was aware of the minimum staffing requirements for CNA's which is 1 to 8 residents for 7-3 shift, 1 to 10 for 3-11 shift and 1 to14 for 11-7 shift. When asked if the facility meets those requirements, the staffing coordinator said, No. A review of the Facility Assessment last updated 2/15/23 revealed the following: Under 2. Facility Staffing Plan section: Nursing Day Shift 7a-3p 1st floor 1 Unit manager & desk Nurse 3 Nurse 7 CNA's Avg. census:56 Nursing Evening Shift 3p-11p Supervisor 2 Nurses 7 CNA's Avg. Census: 56 Nursing Night Shift 11p-7a Supervisor 2 Nurses 4CNA's Avg. census: 56 2nd Floor Nursing Day shift 7a-3p 1 Unit Manager& Desk Nurse 3 Nurses 8 CNA's Avg. Census:59 Nursing Evening Shift 3p-11p Desk Nurse 3p-7p 2 nurses 7 CNA's Avg. Census: 59 Nursing Night Shift 11p-7a 2 nurses 5 CNA's Avg. Census:59 During an interview with the surveyor on 04/29/2024 at 01:11 PM, the Director of Nursing (DON) was asked what the facility staffing plan is for the 1st and 2nd floor. The DON replied with the following: 1st floor 7a-3p shift 1 desk nurse, 1 Unit Manager (UM), 3 nurses and 5-7 CNA's pending census. 3p-11p shift Nurse 12-hour shifts and there are 3 until 7PM then goes to 2 nurses at 7PM, 5-6 CNA's pending census. 11p-7a shift 2 nurse 1 supervisor and 4 CNA'S. 2nd floor 7a-3p shift 1 desk nurse 1 UM 3 nurses and 7 CNA'S. 3p-11p shift Nurse 12-hour shifts and there are 3 until 7PM then goes to 2 nurses at 7PM, and 6 CNA'S. 11p-7a shift 2 nurses, 1 supervisor, 4 CNA'S. The surveyor asked if this is daily, including weekends? The DON replied, No, we don't have UM's on the weekends, but we do have a desk nurse. When asked are you meeting this plan, the DON replied No. NJAC 8:39-5.1(a), 27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On [DATE] from 09:23 to 10:04 AM, the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the dry storage room on a middle shelf a quarter pan contained (7) bottles of Smucker's Breakfast syrup. (6) bottles had a best if used by date of [DATE]. The FSD removed the expired syrups from storage. 2. In the walk-in freezer on a middle shelf a plastic bag contained frozen hash brown potatoes. The product inside the bag was covered in ice. The bag had no dates. The FSD removed the frozen hash browns to the trash. On a lower shelf a box contained frozen French fries. The bag of French fries was opened and exposed to the air. The FSD removed the bag of French fries to the trash. A review of a facility policy titled Dating and Labeling Policy, Est: 12.22. revealed: All Cambro (An insulated container for keeping food or drink hot), plastic wrapped, or and foods otherwise stored outside their original containers, must be labeled, and dated at the time it (sic) put into its container. The label must include the item description, the date stored and the use by date. All items are to be dated with an expiration date of 5 days unless otherwise specified. All kitchen staff are responsible for labeling items as they are opened and stored as they work. All dates and labels are monitored and verified at the end of each service day by the Prep cooks and Cooks on duty to ensure items have been dated properly, used by their Use-By-Date, or discarded if necessary. NJAC 18:,d+[DATE].2 (g)

Based on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notices for 2 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #32 and Resident #73). This deficient practice was evidenced by the following: The surveyor reviewed the SNF (Skilled Nursing Facility) SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #32. The SNFBPNR indicated the residents last covered Medicare day was 02/29/2024 and the resident remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was given to Resident #32. When the surveyor requested a copy, the Administrator in Training (AIT) provided the surveyor with a copy of Resident #32's signed Admission Agreement. The surveyor reviewed the SNF (Skilled Nursing Facility) SNF Beneficiary Protection Notification Review (SNFBPNR) completed by the facility for Resident #73. The SNFBPNR indicated the residents last covered Medicare day was 02/29/2024 and Resident #73 remained in the facility. The SNFBPNR further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage Form CMS-10055 was given to Resident #73. When the surveyor requested a copy, the AIT provided the surveyor with copy of Resident #73's signed Admission Agreement. During an interview with the surveyor on 04/24/2024 at 12:32 PM, the AIT said this comes up every year at survey as we use section 5 of the admission agreement as the SNFABN. When the surveyor asked the AIT do you use the CMS -10055 form, the AIT said no. Historically we only use the admission agreement. The surveyor reviewed the form with the AIT, and she said yes, I know about that form. We are waiting to see if we are told to change our practice. During a follow-up interview with the AIT on 04/24/2024 at 12:41 PM, the AIT clarified that we are waiting to see if it ever came up with survey and that we are not able to utilize this (admission agreement). Every survey we are questioned but it never comes up as an issue. NJAC 8:39-4.1(a)(7)

Based on observation, interview, and review of the medical record and other facility documentation, it was determined that the facility failed to follow a physician order for weekly weights on 1 of 3 residents reviewed for nutrition. This deficient practice was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 regimes 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. According to the Face Sheet, Resident #54 was admitted to the facility with diagnoses including but not limited to: Encounter for surgical aftercare following surgery on digestive system and Major depressive disorder. On 04/24/24 at 11:47 AM, Resident #54 was observed seated in the dining room eating lunch. Resident #54's lunch consisted of a mechanical soft diet that included roasted turkey, grilled zucchini, stuffing, gravy, cheesecake, juice, protein shake, and high protein jello. A review of the Resident Physician Orders with a start date of 3/19/2024 revealed a physician order for Weekly weights on Monday before breakfast or any intake. A review of the Medication Administration Records (MAR) for the months of March 2024, and April 2024, showed the physician order for weekly weights. The blocks for March 25, 2024 and April 15, 2024 were blank. There was no documentation to indicate that the weights had been completed as ordered. A review of the Electronic Medical Record (EMR), in the weight section, there was no documentation of the weight for the aforementioned. During an interview with the surveyor on 4/29/24 at 9:48 AM , Licensed Practical Nurse (LPN #2) said that weights are usually done by the Certified Nursing Assistants (CNA) at 6 AM prior to breakfast. We (the nurses) would let the aides know who is popping up for weights. If they were to refuse weekly weights the Unit Manager would be notified and then it is replotted for the next morning. During an interview with the surveyor on 4/29/24 10:10 AM, Unit Manager/Licensed Practical Nurse (UM/LPN ) revealed that weekly weights are done on Mondays between 7 AM and 3 PM. It is done for 4 (four) weeks after the resident is admitted , then monthly. The dietician will review the weight. If there is no stop date (on the physician order), the weights should continue. UM/LPN also stated that nursing usually weighs the resident and the weight should be documented in the resident's Medication Administration Record (MAR). During the interview the UM/LPN accessed Resident # 54's electronic medical record and stated, Yeah, he/she's weekly (weights) since 3/19. The UM/LPN confirmed that the MAR was blank for 3/25/24 and 4/15/24. The UM/LPN replied yes when asked, is it fair to say that if there is no documentation, the wt (weight) was not done. During an interview with the surveyor on 4/29/24 at 1:08 PM, the Director of Nursing (DON) revealed that the CNAs are usually tasked to weigh the residents and it is the nurses responsibility to make sure the task is delegated to the CNA. The DON continued to say that due to staffing challenges, the nurses weigh the residents and the weight should be documented in the MAR. The DON further stated, there should be documentation if the resident refuses to be weighed. A review of a the facility policy titled Weight Monitoring, undated, under the procedure for monitoring weights section revealed Weekly weights will be done when ordered by the physician, recommended by the Dietician, or as a nursing intervention. A review of a facility policy titled Physician's Orders, undated, under the note section revealed Each Physician order shall be executed by the nursing, Dietary, Social Work, Activities, Rehab, or Pharmacy service as appropriate in accordance with professional standards of practice. If the order cannot be carried out within 24 hours, the reason for this must be documented in the medical record and the Physician notified. NJAC 8:39-27.1(a)

Based on observation, interview, and review of the medical record and other facility records, it was determined that the facility failed to consistently assess or measure SPO2 (blood oxygen saturation) for a resident with an order for PRN (as necessary) supplemental oxygen use. This deficient practice occurred for 1 of 4 residents (Resident #46) reviewed for respiratory care. This deficient practice was evidenced by the following: On 04/23/2024 at 11:05 AM, the surveyor observed an oxygen concentrator against the wall in Resident #46's room. The oxygen concentrator was not observed to be in use and according to nursing staff Resident #46 didn't use it (oxygen) regularly. According to the Resident Face Sheet Resident #46 was admitted with diagnoses including but not limited to: Chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long term respiratory symptoms and air flow limitation), acute respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), and congestive heart failure (when your heart can't pump enough blood to provide your body with the blood and oxygen it needs). A review of the most recent Minimum Data Set (MDS), an assessment tool, dated 1/30/2024, revealed a Brief Interview for Mental Status score of 4/15, indicating severely impaired cognition. According to Section J Resident #46 did not have shortness of breath. Section O did not indicate that Resident #46 received oxygen therapy. A record review for Resident #46 was initiated on 4/23/2024 at 1:53 pm and continued 4/24/2024 upon arrival to the facility. The medical record included the following physician order: Administer O2 at 2 Liters per minute via nasal cannula PRN (as necessary) for spO2 less than 91% room air or visible shortness of breath. Start Date: 4/24/2024. On 04/25/2024 at 09:55 AM the surveyor reviewed the electronic medical record (EMR) for Resident #46. The March 2024 Medication Administration Record (MAR) revealed that Resident #46 had the following order: Administer O2 at 2 Liters per minute via nasal cannula PRN (as needed) if oxygen drops below 92% Start Date: 06/02/2023 03:21 PM. There is no evidence on the March 2024 MAR to indicate that the facility was monitoring SPO2 for Resident #46. The surveyor then requested a copy of SPO2 monitoring for March/April 2024. In addition, the surveyor requested from the facility Director of Nursing (DON) copies of the MAR and Treatment Administration Record (TAR) for the following: March/April 2024 and June 2023. On 04/25/2024 at 11:05 AM the surveyor spoke with facility DON. The surveyor asked if Resident #46 only had SPO2's for the dates of 4/24 and 4/25/2024 and no SPO2's for the previous 23 days of April 2024. The DON then proceeded to go into Resident #46's EMR to bring up Resident #46's SPO2's for March 2024. The DON was unable to find any SPO2's for the month of March 2024 in the electronic health record. The surveyor utilized the EMR to get SPO2 monitoring from 6/3/2023 up to 4/25/2024. The following results were obtained: Oxygen Saturation 94 % 06/03/2023 08:00 am Administration Record Oxygen Saturation 97 % 06/03/2023 10:05 pm Administration Record Oxygen Saturation 98 % 06/04/2023 08:42 am Administration Record Oxygen Saturation 93 % 06/05/2023 12:18 am Administration Record Oxygen Saturation 97 % 06/05/2023 01:01 pm Administration Record Oxygen Saturation 97 % 06/06/2023 12:02 am Administration Record Oxygen Saturation 97 % 06/06/2023 09:26 am Administration Record Oxygen Saturation 94 % 06/06/2023 11:48 pm Administration Record Oxygen Saturation 96 % 04/24/2024 08:04 am Administration Record Oxygen Saturation 96 % 04/24/2024 08:42 pm Administration Record Oxygen Saturation 94 % 04/25/2024 01:15 am Administration Record Oxygen Saturation 95 % 04/25/2024 08:00 am Administration Record There was no documented spO2 from 06/07/2023 until 04/24/2024 when a new order for PRN O2 was written on 4/24/2024. At the time of entrance to the facility on [DATE], Resident #46 had an active order from 6/2/2023 for the following: Administer O2 at 2 Liters per minute via nasal cannula PRN if oxygen drops below 92% Start Date: 06/02/2023 03:21 PM. On 04/26/2024 at 09:56 AM, the surveyor conducted an interview with the 1st Floor Unit Manager/Registered Nurse (UM/RN). The surveyor asked the UM/RN what is the facility policy for the use of PRN oxygen? The UM/RN replied, I think everybody has an order for PRN oxygen for SPO2 less than 91% or visible shortness of breath. We do vitals every shift for subacute residents, and we do vitals for long term resident's weekly unless otherwise stated. The surveyor asked UM/RN if Resident #46 was considered long term care. UM/RN stated, yes, he/she is. We put him/her on vitals recently because he/she had issues with their breathing, but they are fine now. The UM/RN further mentioned we do vital signs weekly and of course we can see when he/she is short of breath. According to the facility policy titled Pulse Oximetry, undated, the procedure section revealed that All residents on oxygen use must have a Pulse Oximeter check. Residents on continuous oxygen will have their Pulse Oximeter check every shift, and for PRN, will have a Pulse Oximeter check at 9:00 p.m. daily. In addition, the facility Oxygen Administration policy revealed that All orders for oxygen therapy, either continuous or PRN, shall also have an order for pulse oximetry tests (SPO2) at least once daily, but more often if appropriate for the resident's condition and need for use of oxygen therapy. See Policy: Pulse Oximetry. On 04/30/2024 at 09:58 AM,the surveyor interviewed the facility Director of Nursing (DON). The DON explained to the surveyor that During COVID we were checking everyone's symptoms. We actually changed our policy to reflect the new guidance after COVID. We revised the policy (Pulse Oximetry) on May 11, 2023. Up until that point the policy did include checking the SPO2 daily at 9 PM. That was my predecessor's policy. On 04/30/2024 at 10:57 AM, the surveyor conducted an interview with the facility DON. The surveyor explained to the DON that Resident #46 had an order dated 6/2/2023 at 3:21 PM for the following: Administer O2 at 2 Liters per minute via nasal cannula PRN if oxygen drops below 92% Start Date: 06/02/2023 03:21 PM. The surveyor explained that there is no order to check for shortness of breath. The order specifically stated to apply oxygen at 2 liters per minute via nasal cannula PRN if oxygen drops below 92%. The DON agreed that the physician order from 6/2/2023 up until changed on 4/24/2024 would require checking the residents pulse oximetry to assess if it was 92% or less and provide oxygen if necessary. The DON stated, Yes, I understand now that it has a number parameter and would need to be measured as the order is written. NJAC 8:39-27.1(a)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to a) change respiratory equipment tubing in a manner to prevent the spread of infection for 1 of 4 resident's (Resident #33) and b) properly store a nasal cannula (tube used to deliver oxygen to a person) in accordance with facility policy and not properly store a nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) and nebulizer equipment according to facility policy for 1 of 4 residents (Resident #91) reviewed for respiratory care. This deficient practice was evidenced by the following: A) During the initial tour of the 2nd floor on 04/23/2024 at 09:53 AM, Surveyor #1 observed resident #33 sleeping in bed. Resident #33 was receiving oxygen at 3 liters per minute (lpm) via nasal cannula. Surveyor #1 observed the nasal cannula tubing with a piece of tape attached to the tubing and dated 04/12/2024. According to the Admission Record, Resident #33 was admitted to facility with diagnoses including but not limited to: Chronic Obstructive Pulmonary Disease (COPD) (refers to a group of diseases that cause airflow blockage and breathing-related problems) and Pneumonia (refers to infection in your lungs caused by bacteria, viruses, or fungi). According to the most recent Minimum Data Set (MDS), an assessment tool dated 02/08/2024, Resident #33 had a Brief Interview for Mental Status score of 09/15 indicating moderately impaired cognition. A review of the Physician Orders with active orders as of 03/28/2024 revealed a physician order to administer O2 (oxygen) at 3 liters per minute (lpm) via nasal cannula continuous for chronic obstructive pulmonary disease. The Physician Orders also included a physician order to change and date O2 and nebulizer tubing weekly, every week on Saturday at 7:00pm - 7:00am. On 04/25/2024 at 11:07 AM, Resident #33 was observed in bed sleeping in no distress. Resident #33 was receiving oxygen at 3 lpm via nasal cannula. Surveyor #1 observed the nasal cannula tubing which revealed it was dated 04/12/2024. On 04/26/2024 at 10:31 AM, Surveyor #1 observed resident #33 in bed sleeping. Resident #33 was receiving oxygen at 3 lpm via nasal cannula. Surveyor #1 observed the nasal cannula tubing which revealed it was dated 04/12/2024. During an interview with Surveyor #1 on 04/26/2024 at 10:45 AM, Licensed Practical Nurse (LPN #1) was asked how often oxygen tubing gets changed. LPN #1 responded, The oxygen tubing is to be changed every week and as needed. Surveyor #1 asked who is responsible to change the oxygen tubing. LPN #1 said the nurse on the overnight (7 pm - 7am) shift. Surveyor #1 then asked should the tubing remain on the oxygen concentrator past seven days. LPN #1 stated, No, it should be changed weekly as ordered. During an interview with Surveyor #1 on 04/29/2024 at 09:52 AM, the Unit Manager/Licensed Practical Nurse (UM/LPN) said oxygen tubing is to be changed weekly on Saturdays by the overnight nurse. When asked should the tubing remain on the oxygen concentrator past seven days, the UM/LPN said no it should be changed weekly. During an interview with Surveyor #1 on 04/29/2024 at 1:19 PM, the Director of Nursing (DON) said that the respiratory tubing gets changed every Saturday on the overnight shift. The DON went on to say that oxygen tubing should not remain on the oxygen concentrator past the seven days for infection control purposes. 40039 B. On 04/23/2024 at 10:26 AM, during the initial tour of the facility, Surveyor #2 observed Resident #91 seated in their wheelchair in their room. Surveyor #2 observed an oxygen concentrator machine next to the bedside table behind Resident #91, and the nasal cannula draped was over the trash can next to Resident #91's bed with the nasal cannula inside the trash can. The oxygen concentrator was turned on at the time and was set at 2 liters per minute. In addition, observation of the bedside table revealed a humidifier mask lying on top of bedside table attached to a nebulizer machine. The humidifier mask was exposed while not in use with face side facing up. When asked by Surveyor #2 , Resident #91 agreed that he/she utilized oxygen to help them breathe. According to the Resident Face Sheet, Resident #91 was admitted to the facility with diagnoses including but not limited to: Pneumonia, sepsis (blood infection), acute respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), chronic obstructive pulmonary disease (a type of progressive lung disease), and fever. A review of the most recent MDS, an assessment tool, Resident #91 had a Brief Interview for Mental Status score of 11/15, indicating moderate cognitive impairment. According to Section I, Resident #91 had active diagnoses of chronic obstructive pulmonary disease and respiratory failure. Section O indicated that Resident #91 received continuous oxygen therapy. A review of the Physician's Orders, revealed the following orders for Resident #91: 1. Maintain O2 (oxygen) at 2LPM (liters per minute) continuous. Every Day at 7:00 am - 7:00 pm; 7:00 pm - 7:00 am. Original order date: 03/12/2024. 2. Duoneb (medication used to help open the airways in your lungs) 0.5 mg (milligrams) - 3 mg (2.5 mg base)/3 ml (milliliters) solution for nebulization. Inhale 3 ml by nebulization route 3 times per day. Every Day at 9:00 am; 1:00 pm; 5:00 pm. Original Order Date: 03/12/2024. A review of the April 2024 Medication Administration Record (MAR) for Resident #91 revealed that Resident #91 received continuous oxygen on 4/23/2024 at 7:00 am to 7:00 pm and a nebulizer treatment on 4/23/2024 at 9:00 am, as indicated by nursing documentation. During an interview with Surveyor #2 on 04/30/2024 at 09:38 AM, Registered Nurse (RN#3) assigned to Resident #91, was asked if it was facility practice to allow a resident's nasal cannula to be suspended in the trash can and to allow a nebulizer mask to be exposed when not in use. RN#3 responded, He/she constantly plays with his/her stuff. They are on continuous O2 so it should not be off. But it shouldn't have been in the trash can for sure. I'll have to talk to him/her. Surveyor #2 then asked if the nebulizer mask should be left exposed when not in use. RN #3 stated, The nebulizer mask when not in use should be covered for infection control. During an interview with Surveyor #2 on 04/30/2024 at 10:03 AM, the DON stated, The nebulizer mask should be bagged between uses for infection control purposes. It is the responsibility of the nurse or helping hands staff can assist. A review of a facility policy titled Oxygen Administration undated, revealed under the heading NOTE: 6. Infection control procedures shall be followed: No oxygen cannulas or tubing touching the floor. Nasal cannulas shall be changed weekly or more often, if necessary. Cannulas, masks, or other respiratory equipment will be covered by plastic bags when not in use. NJAC 8:39-19.4(k)

Based on interview and record review, it was determined that the facility failed to investigate an unwitnessed fall which resulted in a fracture. The resident, Resident #5, complained of pain, was unable to stand, and informed staff of a fall but staff did not follow the facility's policy for reporting and investigating the incident in a timely manner. The fall, which occurred on the morning of 6/4/11 was not investigated until the evening of 6/6. The resident was sent to the hospital on 6/6 for an evaluation secondary to left hip pain and was diagnosed with [REDACTED]. During the initial tour on 10/3/11, the nurse unit manager stated that Resident #5 was alert but confused and had a history of [REDACTED]. The surveyor reviewed the medical record on 10/4 and observed nursing notes from 6/4 and 6/5/11 which indicated that Resident #5 complained of pain in the left hip and leg area. The resident told staff at that time that she had a fall. There was no evidence that staff investigated the fall or informed Administrative staff of the unwitnessed fall. The resident continued to experience pain and complained of being unable to stand but services were delayed for 2 days before the resident was sent to the hospital for an evaluation. The surveyor reviewed the facility's Abuse Prohibition Policy which included a section titled "Recognizing Signs and Symptoms of Abuse/Neglect." The section for signs of physical abuse included fractures of questionable origin. The policy stated further that all suspected violations were to be reported to a supervisor and that the Director of Nursing and/or the Administrator will be notified immediately. The protocol included the "Procedures For Investigating Injuries of Unknown Origin" which stated that the nurse would immediately assess the resident and attempt to determine the cause of injury and document the date, time and location of the reported incident. An incident report was to be completed at that time and signed and dated statements from all personnel related to the incident were to be obtained. The physician was to be notified immediately. The policy also indicated that notification to the appropriate regulatory agency would be determined. The surveyor interviewed the Assistant Administrator on 10/5/11 at 2 p.m. who stated that she had been informed of the incident the evening of 6/6/11 when the resident was sent out to the hospital. The investigation was started immediately. The Assistant Administrator stated that the nursing staff did not follow the facility's policy and procedure for investigating an injury of unknown origin. The surveyor interviewed the Administrator on 10/6 at 2 p.m. regarding reporting an unwitnessed fall resulting in a fracture. The Administrator stated that they followed the guidelines provided to the facility from the State. The surveyor reviewed the document on 10/7 and noted that the document was an older version of the guidelines for reporting to the State. Refer to F309. NJAC 8:39- 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to treat a resident in a timely manner who complained of pain. Nursing staff failed to fully assess the resident after the resident stated she had fallen, failed to follow-up with a physician, and failed to provide pain medication while documenting resident complaints of pain. The resident complained of a fall the morning of 6/4/11 and was sent to the hospital with a fractured pelvis the evening of 6/6/11. This deficient practice was evidenced for 1 of 24 residents, Resident #5, and findings were as follows: During the initial tour on 10/3/11, the nurse unit manager stated that Resident #5 was alert but confused, able to make her needs known and had had a fall with a resultant fracture. The surveyor observed the resident at 1:30 p.m. seated in the Day Room in a wheelchair with an attached alarm. The surveyor reviewed the resident's medical record on 10/4/11 and observed a nursing note dated 6/4/11 at 2 p.m. which stated: "Res. c/o (complained) pain to left hip unable to stand. Stated I fell sometime ago and got myself up. No visible injury noted no collaboration to the claims. Tylenol given. Ate 80% of lunch vomited undigested foods medium size. Call out to Dr (name) covering. Awaiting response." A nursing note dated 6/5 at 7:30 p.m. stated "Each time resident turned she moaned. Tylenol given." A 6/5 note at 1 p.m. indicated the resident denied pain and stated "pain on movement only." On 6/6 at 11:30 a.m. a nursing note stated "C/o pain lower legs from sitting up in bed." It was not until 8 p.m.on 6/6 that a nursing note indicated that a call was placed to the physician for a c/o of left hip pain and the resident was transferred to the hospital for evaluation. The resident was admitted with a fractured pelvis. At the time of the transfer the nurse completed a full body assessment. This assessment noted that the resident was unable to lift the leg off the bed and that the resident grimaced with pain. When the nurse lifted the leg, Resident #5 yelled out in pain. The resident was unable to flex the left foot or bear weight on the left side. The resident was medicated with Tylenol at that time. The surveyor reviewed the resident's comprehensive assessment of 4/29/11 which indicated that prior to the fracture, while the resident required assistance with transfers and ambulation, she was able to ambulate with a walker with assistance and independently ambulate in a wheelchair. When interviewed on 10/6 at 1:25 p.m., the Assistant Administrator stated that the administrative staff were unaware of the incident until the evening of 6/6/11 and a full investigation was started immediately. The surveyor reviewed the investigative report which indicated that the resident had an unwitnessed fall on the morning of 6/4 at which time the resident complained of pain. Neither an initial full body assessment or an incident report were generated. While a call was placed to a covering physician, the reason for the call was for vomiting. A follow-up call to the physician was not done when the doctor failed to call back. The nursing 24 hour report (3 p.m. - 11 p.m.) indicated that the morning shift reported resident had hip pain. The 24 hour report for the 11 p.m. - 7 a.m. shift stated : "Still complains of pain and does not want to get up per CNA since she claims she can not stand up." The 24 hour nursing report for 6/5/11 (7 a.m. - 3 p.m.) reported that Resident #5 c/o "not feeling well" and Tylenol was given as per a standing order. The report also indicated that while the resident denied pain, she also stated she experienced discomfort the entire shift and pain upon movement only. The 11 p.m. - 7 a.m. shift noted that Resident #5 still refused to get up for morning care. On 6/6/11, the 24 hour report (7 a.m. - 3 p.m.) stated that the resident c/o of "not feeling well yesterday. Will call MD. Refused to get out of bed this a.m." The information regarding pain and refusing to get out of bed were not written in the medical record nor was there evidence that the physician was called on 6/5/11. According to a statement from the nursing staff on 6/4, the "story of the fall was not collaborated by the roommate" and that "there was no way she could have fallen and got up from the floor." A statement taken by the Social Worker on 6/7 from Resident #5's alert and oriented roommate indicated that Resident #5 had wheeled herself into the bathroom and was later observed by the roommate on the floor with her head by the bathroom door. Both residents yelled and an aide helped the resident up and back into bed. The roommate stated that a nurse did not come and evaluate the resident after the fall occurred. The surveyor reviewed the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident had a physician's orders [REDACTED]. The resident also had an order for [REDACTED]. Refer to F226. NJAC 8:39- 27.1(a)