Every finding on record at Seacrest Rehabilitation and Healthcare Center

Based on observation, interviews, and record review, it was determined that the facility failed to maintain food service and hydration station equipment in a clean and sanitary manner. This deficient practice was evidenced by the following:On 12/15/25 at 9:35 AM, during a tour of the kitchen with the Food Service Director (FSD), the surveyor observed the following:The top of the steamer was visibly soiled with food debris and splashes. The FSD acknowledged the finding and stated that, per facility policy, the steamer top should be cleaned when visibly soiled. The gas oven was observed with splashes of grease and burnt food particles on interior surfaces. The FSD acknowledged the finding and stated that, per facility policy, the oven should be cleaned when visibly soiledOn 12/16/25 at 8:56 AM, during a tour of the third-floor's hydration station, and nourishment and dining rooms with the Activities Aide (AA), the surveyor observed the following:Review of the temperature log for the nourishment room refrigerator revealed a missing temperature entry and employee initials for the evening monitoring on 12/15/25. The AA acknowledged the finding and stated that refrigerator temperatures should be checked and documented daily during both the morning (AM) and evening (PM) shifts.The hydration station water pitcher was observed to be undated and contained cloudy water. The AA acknowledged the findings and confirmed that the water pitcher should have been dated, and the water should be clear.On 12/18/25 at 9:46 AM, the surveyor interviewed the FSD who acknowledged that the steamer and oven, like other kitchen equipment, should be cleaned weekly and whenever visibly soiled and dirty, and that the staff should have cleaned the equipment. The FSD also stated that hydration station water pitchers and should cleaned, dated, and filled with fresh water daily. The FSD further stated that when the water appears cloudy, the cause is unknown, and it presents a safety hazard. On 12/18/25 at 12:12 PM, the surveyor interviewed the Regional Food Service Director (RFSD) who confirmed that kitchen equipment should be maintained in a clean sanitary manner and that the hydration station water pitchers should be dated and contain clear water. The RFSD further stated that it is important to clean the pitcher and change the water daily to prevent contamination and reduce the risk of foodborne illness.Review of the facility's Sanitization policy, dated 2001, indicated that the food service area is to be maintained in a clean and sanitary manner and that all utensils, counters, shelves, and equipment are to be kept clean and sanitized using heat or chemical sanitizing solutions.Review of the facility's undated Labeling Food and Date Marking policy indicated that labeling and dating food products helps identify what the items are, when they were prepared, and how long they can be safely stored.NJAC 8:39-17.2(g)

Based on record review, interview, and review of facility documentation, it was determined that the facility failed to ensure that 1 of 24 Registered Nurses (RN # 1) maintained a valid license or multistate privilege to practice in the State of New Jersey in accordance with the Nurse Licensure Compact (NLC) 60-day residency rule. The deficient practice was evidenced by the following: A review of the employee file for RN # 1 revealed that she was hired on 8/14/2025.The file included a New Jersey Driver's License issued on 01/17/2025, which listed a primary residential address in New Jersey.A review of RN # 1's employment application, signed on July 21, 2025, also listed a primary residential address in New Jersey.The licensure documentation in the file consisted of a multistate Registered Nurse license from the State of Florida, issued on 4/21/2025, with an expiration date of 4/30/2027. The address listed on the license revealed another New Jersey residential address that was different than the one on her New Jersey Driver's License. A review of Nurse Licensure Compact (NLC) rule 402.2 revealed that a multistate licensee who changes their primary state of residence to another party state shall apply for a multistate license in the new party state within 60 days.As RN # 1 had established primary residency in New Jersey as of 01/17/2025 but continued to practice under a Florida multistate license past the 60-day requirement, she was not properly licensed to practice in New Jersey.On 12/18/2025 at 11:03 AM, during an interview with the surveyor, the Human Resources (HR) Manager stated that RN # 1 was a per-diem employee and that there was no knowledge of any address change for her.The HR Manager confirmed that RN # 1's residential address on file was in New Jersey and that no Florida address could be found in the employee's paper file.On 12/18/2025 at 11:40 AM, during an interview with the surveyor, the Director of Nursing (DON) confirmed that RN # 1 was an active employee and was scheduled to work in the facility.A review of the facility policy titled Licensure, Certification, and Registration of Personnel revealed that the facility conducts license verification in accordance with current federal and state laws.N.J.A.C. 8:39-5.1(a)

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) obtain physician orders for oxygen (O2) therapy before administering continuous oxygen, b.) monitor and document O2 levels while administering continuous oxygen, and c.) ensure that a resident's Interdisciplinary Care Plan (ICP) accurately reflected and guided the Resident's respiratory care needs in accordance with professional standards of nursing practice.This deficient practice was identified for 1 (one) of 6 residents (Resident #25) reviewed for Oxygen and was evidenced by the following: During the initial tour of the facility on 12/15/2025 at 10:39 AM, the surveyor observed Resident #25 lying in bed in their room. The resident was receiving O2 a rate of two liters per minute (2 LPM) via nasal cannula (NC), [tubing that delivers oxygen through the nostrils] with humidification (a process that adds moisture to the air) in use.A review of the admission Record (admission summary) dated 6/1/25 reflected that Resident #25 was admitted to the facility with diagnoses which included but were not limited to: Non-ST Elevation (NSTEMI) Myocardial Infarction (a condition that affects blood flow of the heart thereby reducing oxygen to heart) and pulmonary hypertension (high blood pressure in the lungs which causes shortness of breath). A review of the quarterly Minimum Data Set (MDS), an assessment that facilitates the management of a resident's care, dated 12/8/25, indicated that Resident #25 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, meaning the Resident's cognition was intact. The Order Summary Report (OSR), dated as of 12/16/25, did not include physician orders for O2 therapy including O2, O2 tubing, NC, or humidification. Additionally, the OSR revealed no physician orders to monitor oxygen levels, despite Resident #25 being administered O2 via NC at 2 LPM.A review of the Treatment Administration Record (TAR) for December 2025, revealed no documentation indicating that Resident #25 was receiving continuous O2 therapy. Additionally, the TAR did not reflect that the Resident's O2 levels were being monitored. Review of the Progress Notes (PN) revealed a nurse's note dated 12/12/25 at 2:03 PM revealing that Resident #25 was receiving O2 at 2 LPM via NC. This finding was supported by the Nurse Practitioner's PN dated 12/12/25 at 12:20 PM, which indicated that Resident's O2 level was 93% and confirmed that the Resident was receiving O2 at 2 LPM.A review of the O2 saturation levels (measures the percentage of oxygen in the blood), for December revealed that Resident #25's O2 level ranged from 93% to 97% on room air. No O2 measurements were documented after 12/8/25. On 12/17/25 at 9:31 AM, the surveyor interviewed the Licensed Practical Nurse (LPN)/Unit Manager (UM), who confirmed that Resident #25 was receiving O2 at 2 LPM via NC and O2 tubing with humidification without a physician's orders. The LPN/UM stated that The resident should have had physician orders for O2, O2 tubing, humidification, and monitoring O2 levels. The LPN/UM also acknowledged that the Resident's ICP should have included a problem focus with interventions to guide the Resident's care while receiving continuous O2 therapy. During the interview, the surveyor asked the LPN/UM to accompany her to Resident #25's room to assess the resident's O2 level, which was measured at 99%. The UM agreed that it was important to assess the resident's oxygen levels every shift to ensure that the O2 level is maintained within acceptable limits.On 12/17/25 at 9:40 AM, the surveyor interviewed the LPN/Infection Preventionist (IP), who confirmed that Resident #25 should have had physician orders for oxygen therapy, including weekly changes of O2 tubing and humidifier for infection prevention purposes. The LPN/IP further stated that The resident should have had a care plan in place that addressed their O2 needs and that the Resident's O2 levels should have been monitored while receiving O2 therapy.On 12/18/25 at 12:10 PM, the surveyor interviewed the Director of Nursing (DON), who acknowledged that the nurses should have obtained physician orders for O2 therapy before administering O2 including orders to monitor the Resident's O2 levels every shift. The DON also confirmed that the Resident's ICP should have been updated to reflect the O2 therapy.The DON further explained that monitoring O2 levels is essential to ensure that the Resident's O2 is maintained within recommended levels. When asked what nurses are expected to do if a resident does not have a physician order for O2 therapy, the DON stated, nurses are expected to contact the physician and obtain the order.The DON further explained that monitoring oxygen levels is essential to ensure that the resident's oxygen saturation is maintained within recommended levels. When asked what nurses are expected to do if a resident does not have a physician order for oxygen therapy, the DON stated, Nurses are expected to contact the physician and obtain the order.Review of the facility's policies revealed the following:1. Physician Orders policy, updated January 2025, indicated that licensed nurses will obtain, document and provide care and services in accordance with orders received from the physician. 2. Oxygen Administration policy, dated 2001, indicated that the purpose of this procedure was to provide guidelines for safe oxygen administration. The preparation outlined the following:a.) Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. b.) Review the Resident's care plan to assess for any special needs of the resident. 3. Care Plans, Comprehensive Person-Centered policy indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physician psychosocial and functional needs is developed and implemented for each resident.N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications and medical supplied were stored safely, securely, and in accordance with professional standards. The facility failed to ensure that a resident did not self-administer medications without a physician's order, evaluation, and care plan, and failed to store medications in a locked area. Additionally, the facility failed to ensure medical supplies were maintained for use by having expired supplies in 1 of 2 medication storage rooms inspected under the Medication Storage task. The deficient practice was identified for 1 of 1 residents (Resident # 38) reviewed for medication storage and 1 of 2 medication storage rooms inspected. The deficient practice was evidenced by the following: A review of Resident # 38's diagnoses revealed a fracture of unspecified part of neck of left femur (a break in the upper part of the thigh bone), chronic obstructive pulmonary disease (a group of lung diseases that make it hard to breathe), and acute respiratory failure with hypoxia (a sudden condition where the lungs cannot get enough oxygen into the blood). A review of physician's orders for Resident # 38 revealed an order for Albuterol Sulfate HFA inhalation Aerosol Solution, 2 puffs inhaled orally every 6 hours as needed for wheezing. A review of Resident # 38's individualized care plan initiated on 11/16/2025 revealed a goal to mitigate the risk for respiratory complications and infections. A review of Resident's # 38 Electronic Medical Record revealed there was no physician's order for the self-administration of medications and no care plan for self-administration. On 12/15/2025 at 10:12 AM, the surveyor observed an inhaler and a nasal spray on Resident # 38's bedside table. At that time, Resident # 38 told the surveyor that she [NAME] the medications from home and was allowed to have them. On 12/16/2025 at 9:43 AM, during an interview with the surveyor, the Interim Unit Manager Registered Nurse (UMRN) stated that the facility keeps a record of which residents can self-administer medications in the physician's orders, care plan, and Minimum Data Set (MDS). The UMRN further stated that the process for a resident to self-administer medication requires speaking with the physician, obtaining a physician's order, an evaluation for self-administration, and an updated care plan. The UMRN confirmed that medications considered for self-administration, such as nasal sprays and rescue inhalers, should be stored at the bedside only if properly labeled and was unsure if they could remain at the bedside. On 12/18/2025 at 12:00 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that inhalers or nasal sprays should not be left at a resident's bedside. The DON further stated that if a resident is able to self-administer, the medical record must contain a physician's order, and evaluation, and a care plan. The DON confirmed that even if a resident is cleared to self-administer, the medications should be stored in a locked drawer in the bedroom. A review of the facility's policy titled Medication Storage revealed that the administrator will provide an appropriate and safe medication storage area for the storage of medications that are not self-administered by the resident. A review of the facility's policy titled Administering Medications revealed that residents may self -administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determining that they have the decision-making capacity to do so safely. N.J.A.C. 8:39-29.4(h) On 12/15/2025 at 12:29 PM the surveyor in the presence of a Licensed Practical Nurse (LPN)# 2, observed 3 Hypodermoclysis kits with an expiration date on 10/01/2025 in the third-floor medication storage room. LPN # 2 said we don't use them much, but no, expired ones should not be in here, and she removed them from the medication room to dispose of them. During an interview on 12/18/2025 at 12:31 PM with the surveyor the Director of Nursing (DON) said there should not be any expired items in the medication rooms because you don't want to give residents expired medications. Facility failed to provide a policy. N.J.A.C 8:39-29.4 (g)

Based on observation, interview, record review, and review of pertinent facility documents it was determined that the facility staff failed to ensure that respiratory equipment was stored in a manner that prevented contamination, in accordance with infection prevention and control standards for 1 of 6 residents reviewed for oxygen. (Resident # 57). The deficient practice was evidenced by the following: On 12/16/2025 at 09:32 AM during the initial tour the surveyor observed Resident # 57's continuous positive airway pressure (CPAP) machine (a machine that gently blows air throw a hose and mask to help a person breath while they sleep) mask laying on the night stand open to air.A review of Resident # 57's admission Record revealed the resident was admitted to the facility with but not limited to Chronic Respiratory Failure with Hypoxia (low levels of oxygen in your body), Chronic Obstructive Pulmonary Disease (a group of lung conditions that cause breathing difficulties), and Obstructive Sleep Apnea. (a sleep disorder where a person stops breathing repeatedly during sleep.)A review of Resident #57's Medication Administration Record (MAR) revealed a physician's order to provide new patient bedside bag weekly for CPAP.During an interview on 12/17/2025 at 10:21 AM with the surveyor, the Licensed Practical Nurse (LPN) #1 said that all respiratory equipment should be stored in a labeled plastic bag when not in use for proper infection control. During an interview on 12/17/2025 at 11:42 AM with surveyors, the infection preventionist (IP) said that tubing and masks should be stored in a bag when not in use. The IP also said tubing, bag and masks should be changed weekly and should not be stored open to air on top of the nightstand.A review of a facility provided policy titled Cleaning and Disinfection of BiPAP/CPAP devices Between Residents revealed, Store clean BiPAP/CPAP device in an area where there is low risk of contamination between uses. NJAC 8:39-19.4 (k)

Based on observation, interview, and record review it was determined that the facility failed to ensure a pain management regimen was followed in accordance with physician orders. This deficient practice was identified in 1 of 2 residents reviewed for pain (Resident #12).This deficient practice was evidenced by the following:On 12/15/25 at 11:22 AM, during the initial tour of the facility Resident #12 was observed in the room and said they feel good.On 12/16/2025 at 1:06 PM, Resident #12 was observed in the room and told the surveyor that he/she felt good, that they receive pain medication and said that their pain was controlled.A review of Resident #12's admission Record (an admission summary) reflected that Resident #12 was admitted to the facility with diagnoses which included but were not limited to arthritis and low back pain.A review of the Annual Minimum Data Set (MDS), an annual summary, dated 12/02/2025 indicated the resident had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired. Review of Section J, titled Health Conditions, revealed that the resident had a pain assessment completed. It reflected that the resident received routine pain medication.The surveyor reviewed Resident #12's physician orders which reflected, on 05/26/2025, an order for Hydrocodone-Acetaminophen Tablet 5-325 milligrams [MG] (a narcotic pain reliever), one tablet every four hours as needed for moderate pain related to presence of a left artificial knee joint (four to six on the one to ten numeric pain scale), Tramadol HCl Oral Tablet 50 MG (narcotic pain reliever) one tablet every six hours as needed for mild pain related to presence of left artificial knee joint (one to three on the one to ten numeric pain scale) and Acetaminophen 325mg (pain reliever), give two tablets by mouth every six hours as needed for pain. A review of the Medication Administration Record (MAR) for November and December 2025 reflected that Resident #12 received tramadol 50mg on 11/25/2025 at 1:20 PM for a pain level of four, on 12/4/2025 at 9:05 PM for a pain level of four, and on 12/14/2025 at 8:27 PM for a pain level of five. Resident #12 received acetaminophen 325mg two tablets on 11/4/2025 at 7:08 PM for a pain level of four, 11/26/2025 at 05:29 PM for a pain level of five and on 12/02/2025 at 8:46 PM for a pain level of five. The November and December MAR reflected that Resident # 12 did not receive the Hydrocodone-Acetaminophen Tablet 5-325 MG according to the physician order.On 12/16/2025 at 9:53 AM, the surveyor interviewed the Registered Nurse (RN) who cared for Resident #12 regarding the pain regime. The RN stated that the facility used a numeric pain scale of one to ten. The surveyor and the RN reviewed the pain medication orders for Resident #12. The RN acknowledged that Resident #12 received pain medication outside of the physician ordered parameters. On 12/17/2025 at 12:17 PM, the surveyor interviewed the LPN Unit Manager regarding pain scale. The LPN stated they used a numeric scale, one to three for mild pain, four to six for moderate pain and seven to ten for severe pain. The Unit Manager reviewed the November and December 2025 MAR for Resident #12 and acknowledged the tramadol and acetaminophen were given outside of the parameters ordered by the physician. The surveyor reviewed the facility provided policy titled, Pain Assessment and Management dated April 2025, reflected that the purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident goals and needs, and address the underlying causes of pain. The surveyor reviewed the facility policy titled, Administering Medications with a reviewed date of April 2019. The policy stated that medications are administered in accordance with prescriber orders and validate physician ordered parameters prior to medication administration. NJAC-8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that 1.) Physician-ordered treatments were administered as scheduled and 2.) proper hand hygiene and infection control practices were maintained during wound care. This deficient practice was identified for 1 of 1 resident (Resident # 22) reviewed for wound care and skin integrity.The deficient practice was evidenced by the following:A review of the Electronic Medical Record (EMR) for Resident # 22 revealed a physician's order dated 11/24/2025 for wound care to clean skin tears on bilateral arms with wound cleanser and apply xeroform and an abdominal dressing with Kling wrap daily and PRN (as needed).A review of the admission 5-Day Minimum Data Set (MDS; an assessment tool) dated 12/15/2025 revealed Resident # 22 had a diagnoses including muscle wasting and atrophy, unspecified convulsions, and anxiety disorder.A review of the individualized care plan initiated on 11/24/2025 revealed a focus of I have impaired skin integrity [related to] poor skin integrity with an intervention to Administer treatments as ordered and monitor effectiveness.On 12/15/2025 at 10:19 AM, the surveyor observed Resident # 22 in bed with dressings on both forearms dated 12/14/2025.On 12/16/2025 at 11:07 AM, the surveyor observed Resident # 22 in bed with dressings on both forearms still dated 12/14/2025, which indicated the daily treatment ordered for 12/15/2025 had not been performed.On 12/16/2025 at 11:09 AM, the surveyor observed Register Nurse (RN # 1) prepare to perform the dressing change for Resident # 22.At that time, RN # 1 brought the wound cart into the room and the surveyor observed there was no alcohol-based hand rub (ABHR) on the cart.RN # 1 donned gloves and moved the resident's bedside table but did not change his gloves or perform hand hygiene after touching the table and before initiated wound care.RN # 1 then removed the soiled dressings that were dated 12/14/2025.After removing the soiled dressings, RN # 1 removed his gloves and donned new gloves without performing hand hygiene.RN # 1 proceeded to apply xeroform and clean dressings to the wounds.After the application was complete, RN # 1 removed his gloves and did not perform hand hygiene before concluding the task.On the same date at 11:15 AM, during an interview with the surveyor, RN # 1 stated that hand hygiene should be performed before and after contact with the resident. When asked when gloves should be changed, RN # 1 stated he did not know the exact answer but changed them whenever he felt they were contaminated.On 12/18/2025 at 12:00 PM, during an interview with the surveyor, the Director of Nursing (DON) said staff should change gloves when they remove the dressing, perform hand hygiene, and reapply gloves. The DON confirmed that RN # 1 should not have brought the treatment cart into the resident's room during the treatment.A review of the facility's policy titled Wound Treatment revealed under Steps in the Procedure that staff are to Perform hand hygiene and put on clean gloves, Remove soiled dressing, and Remove gloves and perform hand hygiene before putting on clean gloves to apply the new treatment.N.J.A.C. 8:39-27.1(a)

Based on observation, interview, and record review it was determined that the facility failed to initiate an individualized care plan (ICP) for residents a.) that was incontinent of bladder and bowel and b.) identified with contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) and limited range of motion (ROM). This deficient practice was identified for 2 (two) of 30 residents (Resident #14 and #126) reviewed for comprehensive Individual Care Planning (ICP) and implementation and was evidenced by the following: 1. On 12/15/2025 at 09:40 AM during initial tour of the facility the surveyor observed Resident # 95 in bed and they asked if surveyor # 1 could find someone to change his/her brief. A review of Resident # 95's admissions record revealed that, Resident # 14 was admitted with but not limited to fracture of the lower end of right radius, (broken wrist) and rhabdomyolysis (a condition where muscle tissue breaks down rapidly and releases its contents into the bloodstream). A review of Resident #95's admission Minimum Data Set (MDS; an assessment tool) dated 11/03/2025 revealed under section H that Resident # 95 was occasionally incontinent of bladder and frequently incontinent of bowel. A review of the current Care Plan (CP) for Resident #95 revealed no focus or intervention for incontinence or incontinence care. During an interview on 12/17/2025 at 10:427AM with surveyor #1 the Unit Manager Registered Nurse (UMRN) said that residents with any incontinence should have a focus for that on their care plan. When asked if Resident #95 should have a focus for incontinence the UMRN replied, yes, but I see that it's not here. During an interview on 12/18/2025 at 12:31 PM with surveyor # 1, the Director of Nursing (DON) replied, yes when asked if incontinence should be reflected in a care plan. The DON said it was important, so staff are aware of the care residents needed. A review of a facility provided policy titled, Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. 2.) On 12/15/2025 at 9:51 AM, the Surveyor observed Resident #126's with left elbow maintained in a flexed position, and the fingers on the left hand were bent toward the palm. Resident #126 was not wearing orthotic device (device is applied to the body to modify or control skeletal structure or function), such as a splint or brace on the left arm or hand. When the surveyor asked the resident if they could move the left elbow or fingers of the left hand, the resident stated No. On 12/16/2025 at 9:19 AM, the surveyor again observed Resident #126 during breakfast. The resident was eating with the right hand, while the left arm remained flexed and positioned close to the body with the fingers bent toward the palm. The resident denied pain or discomfort but was unable to provide details regarding the care of the left arm. The resident appeared pleasant. The surveyor reviewed the resident's Electronic Medical Record (EMR) which revealed the following: Review of the admission Record (AD-admission summary) indicated that Resident #126 was admitted to the facility with the diagnoses which included but was not limited to; cerebral infarction (stroke), hemiplegia (paralysis) and diabetes mellitus (DM). Review of the quarterly Minimum Data Set (assessment that facilitates resident care) dated 9/25/25, reflected that Resident #126 scored a 5 out of 15 on the Basic Interview for Mental Status (BIMS) which indicated severe cognitive impairment. The MDS further identified impaired functional range of motion (ROM) of one upper extremity on one side of the body. Review of the Interdisciplinary Care Plan (ICP) revealed no documented care or goals addressing care of the resident's left elbow or left hand related to limited ROM or contracture. Review of Occupational Therapy (OT) Evaluation and Plan of Treatment dated 7/1/2024-7/28/24 indicated that Resident #126 had left sided hemiplegia affecting the non-dominant side of the body. The evaluation documented impaired limited ROM of the left shoulder, left elbow, left wrist and left hand, with functional limitations due to contracture impacting grasp and release and use of assistant device. On 12/16/2025 at 9:22 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who explained that Resident #126 required total assist with all activities of daily living (ADLs). The CNA further stated that the resident was paralyzed on the left side and required two-person assist for pivot transfers to the wheelchair (W/C). The CNA explained that the resident previously used a brace to the left arm, but the resident refused to continue wearing it and was resistant to wearing a hand roll (a rolled cloth or specialized device placed in a patient's hand to maintain finger extension, keep the thumb in opposition, and prevent painful finger curling (flexion contractures), preserving the hand's functional ability for grasping and promoting comfort). The surveyor could not locate any documentation in the EMR that verified that the resident refused to wear orthotics to the left arm or hand. The surveyor reviewed the residents ICP which did not contain a limited ROM or contracture focus with interventions or goals related to Resident #126's left arm or hand. The ICP also did not contain documentation that indicated Resident #126 refused to wear assistant devices or orthotics to the left arm or hand. On 12/16/2025 at 9:34 AM, the surveyor interviewed the Director of Rehab (DOR) who stated that Resident #126 received OT from 12/22/24 to 2/28/24 for ADLs. The DOR further added that Resident #126's initial evaluation for OT was done in 2024. He stated that on 7/1/2024 the resident was admitted to the facility with impairment/contractures to left upper extremity wrist, forearm and elbow. On 12/17/2025 at 8:30 AM, the surveyor interviewed the DOR who stated that Resident #126 was evaluated by the Occupational Therapist (OT) 12/16/25, after surveyor inquiry and the resident was ordered a splint for the left elbow and hand due to limited ROM. On 12/17/2025 at 8:39 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was familiar with Resident #126 care. The LPN stated that the resident had left sided weakness and used the right leg and arm. She stated that the resident was alert and informed the nurses of basic needs like pain, hunger or thirst. She stated that the resident could not provide detailed events due to confusion. The LPN stated that Resident #126 had limited ROM since admission to the facility and did not think the contractures have worsened. She explained that the resident did not use orthotics to the left elbow or hand, however, should have a ICP to address the contracture and limited ROM of the left elbow and hand. The LPN reviewed the ICP in the presence of the surveyor and confirmed that a ICP was not developed to address the contractures nor were there documented interventions or goals to prevent the contractures from getting worse. On 12/17/2025 at 9:05 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who confirmed that a ICP should have been developed with goals and interventions to address Resident #126's contracture and limited ROM of the left hand and elbow. He explained that interventions would include preventive measures to ensure that the contracture of the left elbow did not worsen or did not cause the resident discomfort. The surveyor viewed Resident #126 Medication Administration Record (MAR) which reflected that the resident did not have complaints of pain. On 12/17/2025 at 9:53 AM, the surveyor interviewed the OT who explained that Resident #126 was screened every quarter. She stated that Resident #126 was screened on the following dates: 9/24/25, 8/14/25 and 4/15/25, 4/11/25. She stated the resident's functional level did not change and there were no new contractures. OT stated that upon evaluation of 12/16/25 the residents' fingers were in a resting, curled position, however, were not contracted and were able to fully extend. She stated that the resident was admitted with the left elbow contracture. She did confirm that there should be ongoing interventions in place to prevent the contractures from deteriorating. On 12/19/2025at 9:41 AM, the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) both agreed on the importance of ensuring that ICPs be developed with preventative interventions and goals for residents with impaired ROM. A review of the facility policy dated 2001 and titled, Care Plans, Comprehensive Person-Centered indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. NJAC 8:39-27.1 (a)

Based on interview, record review, and review of pertinent facility documents it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to guide the planning and management of care for all residents. This deficient practice was identified for 1 of 19 residents (Resident #9) reviewed for MDS accuracy and was evidenced by the following:A review of the admission Record (admission summary) reflected that Resident #9 was admitted to the facility with the diagnoses which included but was not limited to; depression and schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with those of a mood disorder (depression or mania), where psychotic symptoms occur even without mood episodes)).A review of the quarterly Minimum Data Set (MDS; an assessment tool) dated 9/23/2025 indicated that the resident completed a Basic Interview for Mental Status (BIMS) with a score of 3 (three) out of 15, reflecting severe cognitive impairment. Despite the score, the MDS indicated that the resident exhibited no behaviors during this assessment reference period.On 12/15/2025 at 9:55 AM, the surveyor observed Resident #9 confused and wandering into other resident rooms. The staff were observed redirecting the resident successfully. A review of the Interdisciplinary Care Plan (ICP) indicated that the resident had behaviors such as wandering, refusing medications and physical behaviors during care.A review of the Progress Notes (PN) dated 6/5/25 at 12:11 PM, a gradual dose reduction (GDR) of the antipsychotic medication Seroquel was initiated. The resident's dosage was reduced from Seroquel 25mg one time a day to 12.5 mg once daily.A subsequent PN dated 6/26/25 at 14:16 PM (2:26 PM) authored by the Psychiatrist, indicated that resident was having increased behaviors since the GDR of Seroquel. The medication Seroquel was increased to 25 mg daily.Review of the annual MDS dated [DATE] under Section N-Medications, indicated that the resident had not undergone a GDR. However, review of the medical records confirmed that a GDR was attempted on 6/6/25, and was later determined to be contraindicated on 6/26/25, which occurred three days after the assessment reference date.Additionally, a review of the annual MDS dated [DATE] revealed a coding inaccuracy regarding whether a GDR had been attempted. The MDS indicated that a GDR was not attempted, however documentation confirmed that a GDR was attempted on 6/6/25.On 12/17/2025 at 12:09 PM, the surveyor interviewed the Licensed Practical Nurse Minimum Data Set coordinator (LPN/MDS #1) who stated that the MDS coordinator gathers information to complete the MDS by resident interview, by reviewing electronic medical records and by communication with the direct care staff. LPN/MDS #1 stated that the MDS was an assessment that helps to facilitate a resident's care and that an accurate assessment ensured that the resident received the best care possible for a quality of life.LPN/MDS #1 stated that LPN/MDS #2 completed the 6/23/25 and 9/23/25 MDS assessments and was currently on leave from the facility and therefore could not be interviewed at this time. LPN/MDS #1 further stated that the Director of Nursing (DON) signed the MDS after completion by the LPN. She stated that the DON was a Registered Nurse and signs the MDS for completion only, not for accuracy. LPN/MDS #1 stated that the LPN/MDS #2 may have been confused with the dates; however, she was unable to explain why Section N of the MDS was inaccurately coded on 6/23/25 and 9/23/25.The Resident Assessment Instrument (RAI- federally mandated framework used in long-term care facilities) section Z0400: Signature of persons Completing the Assessment indicated that the person signing the attestation must review the information to assure accuracy of information. The job description of the MDS coordinator indicated that it was the of responsibility of the MDS coordinator to inform all assessments team members of the requirements for accuracy and completion of the resident assessments (MDS).NJAC 8:39-33.2(a)

Based on interview and record review, it was determined that the facility failed to ensure that medications were administered in accordance with prescriber orders by failing to administer an intravenous (IV) antibiotic within the required timeframe. This deficient practice was identified for 1 of 1 resident (Resident # 3) review for medication administration.The deficient practice was evidenced by the following:A review of Resident # 3's diagnoses revealed but were not limited to, acute osteomyelitis (a sudden and painful infection of the bone) of the left ankle and foot, bacteremia (the presence of harmful bacteria in the bloodstream), and a Methicillin-resistant Staphylococcus aureus (MRSA) infection (a type of staph bacteria that is very difficult to treat because it is resistant to many common antibiotics).A review of a physician's orders located in the Electronic Medical Record dated 12/2/2025 revealed an order for Daptomycin (an antibiotic) Intravenous Solution Reconstituted 430 milligram to be administered intravenously one time a day at 18:00 (6:00 PM) for osteomyelitis.A review of the facility's Medication Audit Report revealed that the Daptomycin IV was administered outside of the facility's designated one-hour window on the following dates:On 12/2/2025, the 18:00 dose was administered at 20:26 (8:26 PM).On 12/5/2025, the 18:00 dose was administered at 20:01 (8:21 PM).On 12/10/2025, the 18:00 dose was administered at 19:51 (7:51 PM).On 12/12/2025, the 18:00 dose was administered at 21:14 (9:14 PM).On 12/18/2025 at 9:44 AM, during an interview with the surveyor, the Interim Unit Manager Registered Nurse (UMRN) stated that the antibiotic should be administered at six, with a window of one hour before and one hour after the scheduled time.The UMRN further stated that if a medication is going to be late on more than one occasion, the nurse should notify the doctor and Infectious Disease (doctors who specialize in treating illness caused by germs like bacteria and viruses) to ask for a schedule change.The UMRN confirmed that there was no indication in the progress notes that the nurse had contacted the physician regarding the late administrations.On 12/18/2025 at 12:00 PM, during an interview with the surveyor, the Director of Nursing (DON) stated that medications should be given within their administration times, which is defined as one hour before and one hour after the scheduled time.A review of the facility's policy titled, Administering Medications revealed that Medications are administered in accordance with prescriber orders, including any required time frame. The policy further indicated that Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.N.J.A.C. 8:39-29.4(a)

Complaint #'s: NJ428767 and NJ428770Based on record review, interviews and document review, the facility failed to protect one of four residents Resident (R) #5 from an accident hazard. Specifically, Certified Nurse Aide (CNA) #1 pushed R5 in a wheelchair without leg rests causing R5's legs to become trapped underneath the wheelchair, which resulted in the fracture of R5's left femur. This failure caused unnecessary pain and resulted in R5 requiring surgery to repair the left femur fracture. Findings include:Review of R5's Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R5 was admitted to the facility in 06/2022 with diagnoses of Parkinson's Disease and Alzheimer's Disease. Review of R5's Care Plan Report initiated 07/11/2024 included under Focus: I have an ADL [Activity of Daily Living] Self Care Performance Deficit r/t [related to] Cognitive Impairment, [NAME] process, Impaired Balance. Under Goal' included I will be at reduced risk for complications of self care performance deficient and impaired mobility daily through the review date. In addition, under Interventions included: Encourage me to participate in ADLs to the fullest extent possible. AMBULATION: I am non-ambulatory. Review of R5's Progress Notes located under the Progress Note tab in the EMR dated 06/06/25 at 8:27 AM indicated, Acetaminophen Tablet 325 MG [milligrams] Give 2 tablet by mouth every 6 hours as needed for General Discomfort.pt [patient] c/o [complains of] left knee pain. Review of R5's Progress Notes dated 06/06/25 at 12:26 PM, the nurse documented, left knee noted swollen and patient c/o left knee pain vitals taken stable APN [Advanced Practice Nurse] made aware new order for xray [sic] and ultrasound. PRN [as needed] Tylenol given with good effects. Lidocaine patch applied to left. Will continue to monitor [sic]. Continued review of R5's Progress Note dated 06/06/25 at 3:21 PM, the APN documented, . new onset L [left] knee pain. Per staff, the pain started today. Nursing noted unilateral swelling to the lower extremities. The pt reports pain with movement and palpitation. No recent hx [history] of trauma to the area. Bruising suggests fx [fracture]. Review of the Radiology Note located under the Progress Note tab in the EMR dated 06/07/25 at 1:32 PM, indicated, .There is a complex comminuted fracture of the distal femur with impaction and angulation. [Name of doctor] notified via [by] phone, order received to send to ER [emergency room] for evaluation. Review of the Progress Note indicated R5 was admitted to the hospital on [DATE] with the diagnosis of left femur fracture. The Progress Note Nurses Note dated 06/07/25 at 9:02 PM and Nurses Note dated 06/12/25 at 4:00 PM indicated, .Surgery in [sic] left lower extremity. Review of the Physician Progress note dated 06/13/25 at 1:26 PM indicated, .[R5] underwent a surgical fixation on 6/9. Review of On the Spot Education - Coaching provided by the facility and dated 06/07/25 at 8:00 AM indicated under the section .Description of Issue/Education (What was observed): CNA [CNA1] pushed resident in w/c [wheelchair] [,] and legs got caught beneath w/c wheel; no leg rests utilized. Under the Correct Action section of this training indicated, Re-educated on utilizing leg rests when propelling residents who normally self-propel. Re-educated on proper transfers, if a resident's leg gets caught beneath w/c or any other type of mobility issues in which the resident says ouch, stop and inform the primary nurse immediately. This form was signed by CNA1 and Assistant Director of Nursing (ADON)1. During an interview on 11/24/25 at 6:14 PM, ADON1 stated, we thought this was an injury of unknown origin. When we interviewed [name of CNA1], she stated that she pushed [R5] into the dining room on 06/05/25, and [R5] said, Ouch. ADON1 stated CNA1 asked [R5] if they were okay, and the resident stated that they were. When asked if CNA1 had the leg rest on or off the wheelchair when she was pushing R5 into the dining room, ADON1 stated, I believe that her statement was that after [R5] said ouch [,] [CNA1] turned the wheelchair around. When asked if CNA1 should have used leg rests on the wheelchair when pushing a resident. ADON1 stated, Yes, she should have put the leg rests on the wheelchair. This resident usually is able to self-propel [themself] around the building, so that is the reason why the leg rests were not already on the wheelchair. During a phone interview on 11/25/25 at 12:34 PM, Licensed Practical Nurse (LPN) 4 stated, I don't recall ever being notified about [R5] legs getting caught underneath the wheelchair. If this happens, the CNAs are to report this to the nurse as soon as possible so that we can assess the resident. During a phone interview on 11/25/25 at 12:41 PM, CNA1 stated, I was wheeling [R5] back to the dining room [,] and I felt the resident's legs stop the wheelchair. I looked, and the resident said ouch, but they usually say that a lot. I asked [R5] if they were okay, and the resident said they were, so I wheeled the resident into the dining room. Asked if the leg rests were on or off the wheelchair when she [CNA1] was pushing the wheelchair. CNA1 replied, No, I didn't have them on the wheelchair. CNA1 was asked if she reported [R5] saying ouch to anyone when it happened. CNA1 stated, No, I didn't because the patient was able to tell me that he/she was okay. During a phone interview on 11/25/25 at 12:50 PM, CNA2 stated, I got report from the day shift aide [CNA1] on 06/05/25, but nothing was reported about [R5] having anything unusual happening on her shift. [CNA1] offered to take [R5] back to their room and put the resident to bed, so I said, 'Okay.' In a few minutes, she [CNA1] came back to get me because she said she couldn't get [R5] back to bed by herself. One person can usually help [R5] back to bed with no problems. CNA2 further stated that when I walked into the patient's room, I noticed [R5] wasn't as verbal as usual, and I said to [CNA1] I don't think [R5] is feeling well tonight. [CNA1] said to me that she would tell the nurse about this. The shift got busy [,] and as I passed [CNA1] in the hallway, I briefly asked if she had told the nurse, and she [CNA1] said yeah. I don't know if she did or not, but there was a difference in [R5]. CNA2 was asked if [R5] ever complained of pain or acted like they were in discomfort when having to be assisted to bed. CNA2 stated, [R5] really didn't say anything. During an interview on 11/25/25 at 12:57 PM, LPN5 stated, [R5] was lying in bed most of the day on 06/06/25. [The resident] wasn't moving much. When I pulled [R5] sheet back and saw [the resident's] knee and mid-thigh, I knew something was wrong. [R5] left knee was swollen more than usual [,] and there was a bruise down the middle of [the resident's] leg from mid-thigh to right above [the] knee. I notified the APN, and she ordered an x-ray. I don't know of any incident or a report of an incident that would have caused [R5] to get a fracture. During a phone interview on 11/25/25 at 1:06 PM, Registered Nurse (RN)1 stated, I don't recall [R5] having a fall or anything occurring for him/her to get a fracture. During a phone interview on 11/25/25 at 1:15 PM, the Medical Director was informed of the details of the On the Spot Education - Coaching form dated 06/07/25 by ADON1. When asked if a resident with Parkinson's Disease and Alzheimer's Disease could have sustained a femur fracture when pushed in a wheelchair without using a leg rest, the Medical Director stated, It is a possibility that this could have caused the fracture due to the muscles being rigid at times, and if the wheelchair was being pushed. During an interview on 11/25/25 at 1:45 PM, the Director of Nursing (DON) was asked about the findings of the investigation into R5's femur fracture. The DON stated, We began doing interviews, and when [CNA1] was asked if anything happened to R5 when she was taking care of the resident, CNA1 stated that during her 7-3 shift on 06/05/25, she was propelling [R5] back into the dining room after toileting the resident. [CNA1] stated the resident's legs dropped down and got pulled back underneath the wheelchair. The resident had said ouch, and the resident does say that a lot. [CNA1] said she stopped and readjusted [R5's] legs and took him/her into the dining room. When asked if the leg rests were on the wheelchair, the DON stated, When ADON1 was getting her to show her what happened, we found out that [CNA1] did not have leg rests on the wheelchair. When asked whether the CNAs should have leg rests on the wheelchair when propelling a resident, the DON stated, Yes, most definitely so we can prevent accidents from occurring. The DON was also asked to provide the facility's policy and procedure on wheelchair safety when propelling a resident. The DON stated she would have to look for one because she was not sure that the facility had a policy for this. The Administrator provided a Falls Risk Managing policy and stated this was all that the facility had. NJAC 8:39-27.1 (a)

Complaint #: NJ2666455Based on interview and policy review, the facility failed to provide educational materials to residents and/or resident representatives so that they could make an informed decision in regard to be administered the Coronavirus Disease (COVID-19) vaccine. This failure had the potential for all 145 residents in the facility who are the vulnerable population to be exposed to and have a greater chance of these residents contracting COVID-19.Interview with Health Department (HD)1 on 11/24/25 at 2:50 PM to discuss the COVID outbreak at the facility. HD1 confirmed during the call that the facility had kept the local Health Department (LHD) updated daily identifying which residents were positive for COVID and whether residents had received the COVID vaccine. During the conversation, it was discussed that the facility had a 9% COVID vaccination rate. HD1 did not explain during the call how this percentage was calculated.During an interview on 11/24/25 at 12:30 PM, the Infection Preventionist (IP) stated, . I haven't been able to give residents the COVID-19 vaccine because we don't have the educational materials for the year 2025-2026. The only one we have is for the previous year. The IP confirmed that no resident in the facility has been offered or given the COVID-19 vaccines. When asked if he had reached out to the facility's pharmacy or the LDH if they had the appropriate educational materials for the COVID-19 vaccine, the IP stated, No, I haven't. The Health Department (HD)1 was contacted on 11/25/25 at 10:21 AM and asked if the facility had requested educational materials to give to the residents and /or resident representatives so they could make an informed decision on whether or not to take the COVID-19 vaccine. HD1 stated, I am not aware if the facility has reached out to us about this. During an interview on 11/25/25 at 1:15 PM, the Medical Director stated that the facility has not given any COVID-19 vaccines to the residents because they do not have the appropriate educational materials to give to the residents and/or their representatives. The Medical Director stated, No, I wasn't aware of this, and it is very important for residents and/or resident representatives to have the educational materials so that they can give informed consent. During an interview on 11/25/25 at 1:45 PM, the Director of Nursing (DON) stated, I know on admission, the admitting nurse will ask if they know if they have had the COVID-19 vaccine.We will also check the state website to see which vaccine the resident has received and when. The residents have to have this [education material] so they can make an informed decision to take it or not.Review of the facility's policy Coronavirus Disease (COVID-19) - Vaccination of Residents dated August 2025 indicated, .Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. The resident or representative is provided the most current vaccine information statement (VIS) prior to the vaccine administration. Current VIS for all recommended vaccines are available at: http://www.cdc.gov/vaccines/hcp/vis/index.html .NJAC 8:39-19.4(a)

Complaint #: NJ428748Based on interview, record review, and review of the facility's policy, the facility failed to ensure nurses completed narcotic mediation counts to maintain accountability for three of four residents' narcotic medications (Resident (R) 7, R8, and R9) out of 13 sampled residents. This failure had the potential for R7, R8, and R9's narcotic medications being diverted.Findings include:Review of the facility's undated policy titled, Documenting Controlled Substances revealed, I. c. Sign the appropriate area when removing from the count. II.d. Each liquid narcotic must be entered on a separate page. Description of liquid must be documented.V. Shift Count. a. Performed by an oncoming and off going [sic] nurse. b. Examine both front and back of the card and page to verify count.Review of the facility's policy titled, Controlled Substance Prescriptions, dated 11/2021 revealed, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations.Review of the facility's policy titled, Controlled Substance Storage, dated 11/2021 revealed, Policy. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures.B. Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications.C. Controlled substances that require refrigeration are stored within a locked box within the refrigerator.D. A controlled substance accountability record is prepared by the pharmacy/facility for all schedule II, III, IV, and V medications including those in the emergency supply.E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented on the shift change form.1. Review of R8's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility in 04/2018 with diagnosis of anxiety disorder.Review of R8's Order Summary Report located in the resident's EMR under the Orders tab revealed an order dated 09/17/24 for lorazepam oral concentrate (a scheduled IV controlled substance) give 0.5 milliliters (ml) by mouth every 6 hours for anxiety.Review of R8's untitled controlled drug record provided by the facility revealed on 01/05/25 at 6:00 PM there were 10 ml on hand when one dose of lorazepam was administered leaving 9.5 ml remaining. On 01/06/25 at 12:00 AM one 0.5 ml dose was administered leaving 9.0 ml. On 01/06/25 at 6:00 AM one dose was administered leaving 8.5 ml on hand. Continued review of R8's controlled drug record revealed on 01/06/25 at 2:00 PM it was documented Count Adjusted.6.0 ml. There was no documented evidence that the medication was administered to the resident after 11/06/25 at 6:00 AM when the amount available was 8.5 ml which indicated a 2.5 ml deficit.Review of Licensed Practical Nurse (LPN)3's written statement dated 01/06/25 and located in the facility's investigation provided by the facility revealed Narcotics. When I counted the cart this A.M. with [LPN1's Name], she told me that the lorazepam for [R8's Name] was low. The book [controlled drug record] was 8.5 ml and 6.0 [ml] was in the bottle. The count was correct when I last worked on 1/3 [01/03/25] and counted out with the supervisor.Review of LPN2's written statement dated 01/06/25 and located in the facility's investigation provided by the facility revealed Ativan [lorazepam] in refrigerator was not counted during med [medication] count upon coming on shift or going off [shift]. [I] did not observe count being off during med pass. The Director of Nursing (DON) documented on the statement Spoke with [LPN2] who stated she did count with [LPN1] at 11P [11:00 PM] and [Registered Nurse (RN) 2] at 3pm [3:00 PM]. She did not count Ativan in fridge [refrigerator] but did give it at 6pm [6:00 PM] and count was correct.Review of LPN1's written statement dated 01/07/25 and located in the facility's investigation provided by the facility revealed 1/5/25 the count for the refrigerated Ativan was not counted. 1/6/25 Monday morning I realized the count was off by 2.5 ML. I reported it to the oncoming nurse and UM [unit manager]. This unfortunate incident happens to [sic] often without [sic] a discrepancy. I can only say for myself.it a time issue. This will never happen again.Review of untitled meeting documentation dated 01/07/25 at 3:00 PM and located in the facility's investigation provided by the facility revealed the meeting was with LPN1 and included the facility's Administrator and DON. Continued review revealed .When asked if she completed a count for the liquid Ativan, [LPN1] answered 'No.' When asked why not, [LPN1] said 'Because.cutting corners,' and further stated that it's 'never really done.' When asked how she administered the liquid Ativan, [LPN1] stated that she gives 0.5 at 12am & 6am. When asked if she brings the bottle to the bedside, [LPN1] stated that she does not bring the bottle to the bedside, but instead, draws it up in the medication room and leaves the bottle there. When asked what the procedure is for administering the narcotics, [LPN1] stated that sometimes she forgets to log in/sign out the narcotic and waits until later to do the count. She noticed the count was different in the morning after the 2nd dose. She stated that she is not the only one who does that, and that it's a 'bad habit.' .During an interview on 11/25/25 at 11:00 AM, the DON stated when LPN3 reported the missing lorazepam, she immediately directed the Assistant Director of Nursing (ADON) to go and complete a full narcotic audit of all medication carts and refrigerators starting with the third floor where LPN1 worked. During the audit, the ADON identified two other residents' narcotic medications with discrepancies. The DON stated the LPN1 was the off going nurse and admitted to discovering the lorazepam deficit. The DON stated LPN1 first stated she reported this to a Certified Nursing Assistant (CNA); however, she did not report this to another nurse or a nurse supervisor. The DON also stated during the investigation they determined LPN3 did not observe the refrigerated lorazepam to verify the count but signed off that she did.2. Review of R7's undated admission Record, located in the EMR under the Profile tab revealed the resident was admitted to the facility in 04/2024 with diagnoses of dementia, generalized anxiety disorder, and depression.Review of R7's Order Summary Report located in the EMR under the Orders tab revealed an order dated 12/17/24 for tramadol HCI (a scheduled IV controlled substance) 50 milligrams (mg) by mouth every 12 hours as needed for pain.Review of R7's untitled controlled drug record provided by the facility revealed the first date on the control drug record was 12/19/24 with a beginning count of 28 tablets. Continued review of the controlled drug record revealed on 01/06/25, the record reflected 11 tramadol tablets were on hand, and one tablet was signed out by LPN1, documented it was administered by mouth and that 10 remained. LPN1 did not put the time the medication was signed out.Review of LPN1's written statement dated 01/07/25 and located in the facility's investigation provided by the facility related to R7's missing medication bingo card revealed, I [LPN1] have no knowledge for sure if the bingo card was in the narc [narcotic] drawer since we count by numbers and pt's [patients/residents] names. I did not admin [administer] tramadol to [R7]. I gave him/her [NAME] [Tylenol] 650 mg.Review of untitled meeting documentation dated 01/07/25 at 3:00 PM and located in the facility's investigation provided by the facility revealed the meeting was with LPN1 and included the facility's Administrator and DON. Continued review revealed When asked if she administered the tramadol to [R7], [LPN1] said 'No,' that she only administered Tylenol.[DON] then advised that [another nurse] administered the Tramadol at 10PM, then signed it over to [LPN1] and now the entire card of Tramadol is missing. [LPN1] stated that she doesn't know what happened to it, and that 'I'm used to looking at names, not numbers.' [DON] stated that even though [R7] is only to be given the Tramadol PRN [as needed], [LPN1] had signed it out multiple times, and asked why. [LPN1] stated that it was because she 'borrowed it' to administer to [another resident who was out]. [DON] reminded [LPN1] that she should not be 'borrowing' narcotics.When asked if she [LPN1] was taking the narcotics, or bringing them home, [LPN1] responded, 'No. I get my own pain management.' .3. Review of R9's undated admission Record, located in the EMR under the Profile tab revealed the resident was admitted to the facility in 04/2023 with diagnosis of unspecified inflammatory spondylopathy in the lumbar region of the spine.Review of R9's Order Summary Report located in the resident's EMR under the Orders tab revealed an order dated 11/01/24 for hydrocodone-acetaminophen oral tablet 7.5/325 mg, one tablet by mouth every six hours as needed for pain for four days.Review of R9's untitled controlled drug record provided by the facility revealed on 11/02/24 LPN1 made the first entry showing the resident received 10 hydrocodone tablets. Continued review of the controlled drug record revealed on 11/06/24 at 3:15 AM, LPN1 documented eight tablets on hand, documented administered one by mouth leaving seven tablets on hand.Review of LPN1's written statement dated 01/07/25 and located in the facility's investigation provided by the facility related to R9's hydrocodone medication being destroyed by LPN1 revealed, I have no knowledge the card [was] missing. I signed it out and when I went to chart in the computer the order was dc'd [discontinued] and I wasted the tab [tablet]. No witness due to being the only nurse on the floor.Review of untitled meeting documentation dated 01/07/25 at 3:00 PM and located in the facility's investigation provided by the facility revealed the meeting was with LPN1 and included the facility's Administrator and DON. Continued review revealed, .[LPN1] admitted that she did sign out the Vicodin [hydrocodone], but it was discontinued so she wasted it. When asked where, [LPN1] stated 'I don't know.' When asked if [LPN1] wasted the Vicodin with a witness, [LPN1] stated, 'I'm always by myself.' [DON] advised that she could either call another nurse in the building to come to the unit, or wait until the day shift nurses arrive on the unit fir [sic] their 7am shifts.Review of the facility's undated investigation Conclusion and located in the facility's investigation provided by the facility revealed Upon completion of the investigation, it was deemed that due to the evidence collected and statements and action made by [LPN1] that the narcotics were diverted by [LPN1]. The facility immediately started re-education to the nurses on proper narcotic counting and documenting narcotics administered in the narcotic binders. [LPN2] was educated and disciplined for failing to count with [LPN1] at 11pm on 1/5/25. We had initiated a narcotic accountability sheet that states the quantity of narcotics that are passed on to the oncoming nurse from shift to shift in addition to the current narcotic counting process in place. [LPN1] was terminated from employment with [facility name] based on these findings. The DEA] Drug Enforcement Agency], BON [Board of Nursing], and local PD [police department] were notified of the findings of our investigation. It was deemed that the diversion did not affect any residents. During an interview on 11/25/25 at 11:00 AM, the DON stated when LPN3 reported the missing lorazepam, she immediately directed the Assistant Director of Nursing (ADON) to go and complete a full narcotic audit of all medication carts and refrigerators starting with the third floor where LPN1 worked. During the audit, the ADON identified two other residents' narcotic medications with discrepancies. The DON stated the LPN1 was the off going nurse and admitted to discovering the lorazepam deficit. The DON stated LPN1 first stated she reported this to a CNA; however, she did not report this to another nurse or a nurse supervisor. The DON also stated during the investigation they determined LPN3 did not observe the refrigerated lorazepam to verify the count but signed off that she did. Continued interview revealed LPN1 stated she destroyed seven hydrocodone tablets; however, no one witnessed the destruction, and the medication bingo card was never located. The DON stated their investigation yielded that LPN1 diverted the medications, and she was terminated. The DON further stated not only did LPN1 state that she destroyed narcotics without a witness, but it was also identified LPN3 did not count the liquid lorazepam as she documented.During an interview on 11/25/25 at 12:45 PM, the DON stated it was her expectation that the nurses would count all narcotic medications and document by signing the controlled record books. The DON also stated it was her expectation LPN3 would not have signed that she visualized the liquid lorazepam count. The DON further stated it was important nursing practices and the facility's policy be followed related to residents' narcotic medications to ensure residents were receiving the mediations as ordered and to prevent diversion. NJAC 8:39-27.1(a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/29/2024 from 09:28 AM to 09:48 AM the surveyor accompanied by the Regional Food Service Director (RFSD), observed the following in the kitchen: 1. In the walk-in refrigerator there was raw fish wrapped in plastic wrap with a use by date of 7/28/2024. The RFSD removed the fish and stated, That should have been removed. 2. In the walk-in freezer there was a bag of frozen pork with a use by date of 7/10/2024 and three bags of frozen corned beef with a use by date of 5/6/2024. The RFSD removed the items and stated, They should have all been removed. 3. In the prep refrigerator there were 11 salad plates on two trays wrapped in plastic wrap with no label or date, and 2 pitchers of what the RFSD identified as iced tea with no label and no date. The RFSD removed the items and stated, They were made today but they should be labeled and dated. On 08/01/2024 at 12:30 PM during an interview with the surveyor, the Licensed Nursing Home Administrator (LNHA) replied No when asked if food that is after their use by date should still be in the freezer and refrigerator. A review of the facility provided policy Food Receiving and Storage with a revised date of November 2022 revealed under the Policy Statement that, Food shall be received and stored in a manner that complies with food handling practices. The policy also revealed under section Refrigerator/Freezer Storage that, All foods stored in the refrigerator or freezer are covered, labeled and dated (use by) date. N.J.A.C. 8:39-17.2(g)

Based on observation, record review, and review of pertinent facility documentation, it was determined that the facility failed to consistently monitor and document behaviors of residents on psychotropic medications per the physician's orders and the resident-centered Care Plan. This deficient practice was identified for 2 of 7 residents (Resident # 105 and # 117) reviewed for behaviors and was evidenced by the following: 1.) On 07/29/24 at 10:13 AM, the surveyor observed Resident # 105 in the third-floor unit day room. Resident # 105 was holding a blanket; their eyes were closed, and the resident did not respond to the surveyor when the surveyor greeted the resident. On 08/01/24 at 8:12 AM, the Certified Nursing Assistant (CNA) stated she did care for Resident # 105 too often and was not sure of the resident's behaviors. On 08/01/24 at 8:18 AM, the Registered Nurse Unit Manager (RN UM) stated Resident #105 had behaviors of verbally yelling at staff during care. She stated the resident would have behavior charting documented every shift and was seen by psychiatry. The RN UM stated there should never be blank areas on any Medication Administration Record (MAR) or Treatment Administration Record (TAR). A review of the Admission Record revealed that Resident # 105 was admitted with diagnoses which included but were not limited to; delusional disorders, depression, unspecified mood disorder, and dementia. A review of the Order Summary Report active orders as of 08/01/2024, included but were not limited to; an order dated 03/06/2024, for Depakote Sprinkles 125 mg (milligram) give 2 capsules by mouth two times a day related to unspecified mood disorder; dated 02/28/2024, for Escitalopram 10 mg give 1 tablet by mouth one time a day for depression; dated 04/26/2024, Seroquel 25 mg give 1 tablet by mouth at bedtime for unspecified mood disorder. There was an order dated 07/12/2024, Behaviors/Intervention monitor for paranoia, delusions, restlessness, sleeplessness, withdrawal with intervention codes may include . 1. Redirection 2. Direct supervision 3. Activity 4. Toilet 5. Food/fluid offered 6. Position change 7. Other intervention (specify in progress notes) 8. Medication every shift for behavior management. A review of the resident-centered, on-going care plan included but was not limited to the following: A focus area for the use of anti-anxiety medication, initated 04/21/2023 with an intervention to observe for effectiveness and side effects initiated 04/21/2023. A focus area for the use of anti-depressant medication, initated 02/28/2024 with interventions to observe for effectiveness and side effects, and to monitor/document/report to physician ongoing s/sx (signs/symptoms) of depression unaltered by antidepressant medication, or worsening s/sx of depression initated 02/28/2024. A focus area for the use of anti-psychotic medication r/t (related to) behavior management, depression, initated 03/03/2024 with interventions to observe for effectiveness and side effects, and to report to nurse possible medication side effects . initated 03/03/2024. A focus area of being resistive to care related to anxiety, dementia, initiated 03/05/2024 with interventions to allow the resident to make decisions initated 03/05/2024; encourage participation initated 03/05/2024; provide consistency in care initated 03/05/2024; and to provide 1:1 emotional support when needed initated 03/14/2024. A review of the TARs revealed the following: Dated March 2024, an order dated 03/03/2024, Monitor for changes in behaviors every shift. The TAR revealed two blank areas where monitoring was not documented as being completed. Dated April 2024, Monitor for changes in behaviors every shift. The TAR revealed one blank area where monitoring was not documented as being completed. Dated June 2024, Monitor for changes in behaviors every shift. The TAR revealed three blank areas and two shifts marked NO which indicated the monitoring was not documented as being completed. The TAR legend and codes did not include NO. Dated July 2024, Behaviors/Intervention monitor for paranoia, delusions, restlessness, sleeplessness, withdrawal and include intervention codes. Five shifts documented behaviors but failed to document any interventions. Nine shift documented X which indicated the monitoring was not documented as being completed. The TAR did not list X in the codes or legends. 2.) On 07/30/24 at 9:52 AM, the surveyor observed Resident # 117 in the third-floor unit day room holding a stuffed dog and having the dog jump on the table. The resident smiled when the surveyor spoke to them but did not respond. On 07/31/24 at 10:18 AM, the surveyor observed Resident # 117 in the day room sitting in a wheelchair at a table with other residents. The CNA was assisting the resident with looking at pictures. The CNA stated that the resident was easy to redirect when they get upset and likes to keep the stuffed dog with them. A review of the Admission Record revealed Resident # 117 had diagnoses which included but were not limited to; major depressive disorder, mood disorder, anxiety, and dementia. A review of the Order Summary Report included an order dated 06/12/2024, Clonazepam 0.5 mg related to anxiety; dated 11/15/2023, Escitalopram 10 mg for depression; and dated 06/05/2024, Quetiapine 50 mg related to mood disorder. There was an order dated 02/22/2024, Behaviors/Intervention Monitor for (verbal or physical agitation) ie: screaming, calling out, combativeness; Intervention Codes . 1. Redirection 2. Direct supervision 3. Activity 4. Toilet 5. Food/fluid offered 6. Position change 7. Other intervention (specify in progress notes) 8. Medication every shift for behavior management. A review of the resident-centered, on-going care plan included the following: A focus area for the use of anti-depressant medication, initated 11/15/2023 with interventions observe for effectiveness and side effects, monitor/document/report to physician ongoing s/sx of depression unaltered by antidepressant medication, or worsening s/sx of depression, and report to nurse possible medication side effects initiated 11/15/2023. A focus area for use of anti-psychotic medication r/t behavior management, initiated 02/19/2024 with interventions to observe for effectiveness and side effects, and report to the nurse possible medication side effects initiated 02/19/2024. A focus area of having the potential to demonstrate verbally abusive behaviors related to Dementia, . poor impulse control, and will interfere in other residents personal space, initiated 02/22/2024. Interventions included intervene before agitation escalates, guide away from source of distress, engage in conversation, if resident is still aggressive, approach later , initiated 02/22/2024. A focus area for use of anti-anxiety medication r/t anxiety disorder, initiated 02/19/2024 with interventions to observe for effectiveness and side effects, offer to have someone sit with resident when anxious, provide quiet space and reduced stimuli, and report to nurse possible medication side effects initiated 02/19/2024. A review of the TARs revealed Behaviors/Intervention monitor for (Verbal or Physical Agitation) ie: screaming, calling out, combativeness with Intervention Codes . 1. Redirection 2. Direct supervision 3. Activity 4. Toilet 5. Food/fluid offered 6. Position change 7. Other intervention (specify in progress notes) 8. Medication every shift for behavior management. The TARs documented the following: Dated March 2024, 36 shifts left blank where monitoring was not completed. One shift marked N where monitoring was not completed. Two shifts marked X where monitoring was not completed. The TAR legend and codes did not include X or N for the # (number) of behaviors exhibited. Dated April 2024, 39 shifts left blank where monitoring was not completed. Four shifts marked X where monitoring was not completed. The TAR legend and codes did not include X. Dated May 2024, 44 shifts left blank where monitoring was not completed. Ten shifts marked X or N where monitoring was not completed. The TAR legend and codes did not include X or N for the # of behaviors exhibited. Dated June 2024, 41 shifts left blank where monitoring was not completed. Four shifts marked X or N where monitoring was not completed. The TAR legend and codes did not include X or N for the # of behaviors exhibited. Dated July 2024, 11 shifts left blank where monitoring was not completed. Eight shifts marked X where monitoring was not completed. The TAR legend and codes did not include X. On 08/01/24 at 8:47 AM, the Director of Nursing (DON) stated behavior monitoring was completed and documented on every shift. She stated that there should not be any blank areas because that indicates it was not done. On 08/02/24 at 10:42 AM, the Assistant Director of Nursing (ADON) reviewed the TARS with the surveyor. The ADON acknowledged that X means it was not done. The ADON further stated that the documentation on the TARs should have been done according to the code on the orders and not an X. A review of the facility provided policy, Charting and Documentation revised July 2017, included but was not limited to; Policy Statement The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 6. To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records. A review of the facility provided policy, Behavioral Assessment, Intervention and Monitoring revised March 2019, included but was not limited to; Policy Statement 2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. 5. Residents will have minimal complications associated with the management of altered or impaired behavior. Assessment 2. As part of the comprehensive assessment, staff evaluate . a. the resident's usual patterns of cognition, mood and behavior; c. the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers. 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition . 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Causes Identification 1. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition . Management 10. When medications are prescribed for behavioral symptoms, documentation will include: . h. monitoring for efficacy and adverse consequences . NJAC 8:39-27.1(a)

Based on observation, interview, record review and review of facility documentation, it was determined that the facility failed to ensure a resident's oxygen delivery system was stored to protect it from the environment. This deficient practice was identified for 1 of 2 residents (Resident #118) reviewed for oxygen use and was evidenced as follows. On 07/29/2024 at 10:29 AM, the surveyor observed Resident #118 in a high back wheelchair (w/c) in the third-floor unit day room. Resident #118 had a portable oxygen tank on the back of the w/c and was wearing a nasal cannula (n/c) as an oxygen delivery system. On 07/30/2024 at 12:49 PM, the surveyor observed Resident #118 again in the third-floor unit day room. Resident #118 was not wearing a n/c. The surveyor observed the back of the w/c with the portable oxygen tank. The oxygen tubing and n/c delivery system were wrapped around the top of the portable oxygen tank. The n/c was exposed to the environment and not in any protective container. A review of the electronic medical record (EMR) for Resident #118 revealed an Admission Record with diagnoses which included but were not limited to; Chronic Obstructive Pulmonary Disease (COPD - a group of persistent respiratory symptoms that damage the lungs), Dementia, and pneumonia. A review of the Admission Minimum Data Set (MDS) an assessment tool used to facilitate resident care dated 07/05/2024, documented the resident scored 09 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #118 used oxygen therapy. The Order Summary Report revealed a physician's order dated 07/12/2024, for Oxygen at 2 L (liters)/ Minute via Nasal Cannula as needed for SOB (shortness of breath) or SP02 (peripheral capillary oxygen saturation) of 92 percent or below as needed. A review of the resident-centered, on-going resident Care Plan included a focus area of altered respiratory status . and included an intervention to administer respiratory treatments. On 07/31/2024 at 10:12 AM, the surveyor observed Resident #118 in the third-floor unit day room. The resident was wearing the n/c oxygen delivery system, but the oxygen concentration was set at 0.5 L/minute. The Registered Nurse Unit Manager (RN UM) was at the nurse's desk and was asked to come and observe the oxygen. The RN UM acknowledged that the oxygen tanks was set at the wrong concentration and also observed there was something wrong with the portable oxygen tank. The RN UM removed the n/c from the resident. The resident took the n/c and placed it under their w/c cushion. The portable oxygen tank was changed for a new one. At that time, the RN UM was asked about how the n/c should be stored when not in use. The RN UM stated that the n/c should be kept in a plastic bag to protect it from getting dirty. The surveyor showed the RN UM the n/c not in a protective bag on 07/30/2024. The RN UM acknowledged that was not the correct way to store the n/c. A review of the facility provided policy, Oxygen & Nebulizer Use-Infection Control adopted August 2021, included but was not limited to; Purpose. The purpose of this procedure is to guide prevention of infection associated with oxygen administration. Steps in the Procedure . 8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. On 08/01/2024 at 12:30 PM, the above information was provided to the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). No additional information was provided by the facility. NJAC 8:39-19.4(c), 27.1(a)

Based on observation, interview, record review and review of pertinent facility documentation it was determined that the facility failed to provide appropriate and sufficient care based upon current standards of practice and the resident's care plan by specifically having a urinary catheter drainage bag in contact with the floor and unsecured to the bed frame and failing to document urinary outputs on the treatment administration record (TAR) as ordered. The deficient practice was identified for 1 of 1 residents (Resident #73) investigated for Urinary Catheter or UTI (Urinary Tract Infection). The deficient practice was evidenced by the following: A review of Resident # 73's Minimum Data Set, an assessment tool dated 7/12/2024 located in the Electronic Medical Record revealed he/she had an indwelling urinary catheter. A review of Resident # 73's Electronic Medical Record (EMR) revealed that he/she was diagnosed with but not limited to muscle wasting and atrophy and urinary tract infection. A review of Resident # 73's physician's orders located in the EMR revealed that he/she had orders to measure urinary outputs. A review of Resident # 73's Care Plan located in the EMR revealed a focus that Resident # 73 had an indwelling urinary catheter related to retention initiated on 07/11/2024. The focus revealed an intervention to, Monitor/record/report PRN [as needed] s/sx [signs and symptoms] UTI [Urinary Tract Infection]: pain, burning, blood tinged urine, cloudiness, no output . The intervention was initiated on 07/11/2024. A review of Resident # 73's Treatment Administration Record located in the EMR revealed an order to measure urinary output every shift, document output in mls [milliliters]. The order had a start date of 07/11/2024. The following dates and times were blank revealing no urinary output in milliliters: 7/12/24 - Night 7/13/24 - Evening, Night 7/15/24 - Night 7/18/24 - Evening 7/19/24 - Night 7/20/24 - Evening 7/22/24 - Evening 7/26/24 - Night 7/29/24 - Night On 07/30/2024 at 8:25 AM while touring the unit, the surveyor observed Resident # 73 in bed. At that time, the surveyor observed the urinary catheter drainage bag in contact with the floor. The plastic securement hook was not attached to the bed frame. On 08/01/2024 at 12:29 PM, during an interview with the Director of Nursing (DON), the surveyor asked if a resident had an indwelling urinary catheter, how should the drainage bag be secured when the resident is in bed. The DON replied, .It should be hooked to the non-moveable portion of the bed. Further, the surveyor asked should the drainage bag be in contact with the floor. The DON replied, No. Lastly, the surveyor asked if a resident has an order to measure urinary outputs, would you consider it administered if the Treatment Administration Record is blank. The DON replied, No. A review of the facility policy titled, Catheter Care, Urinary revised August 2022 revealed under Infection Control that, 2. Be sure the catheter tubing and drainage bag are kept off the floor. Also, the policy revealed under, Input/Output that, 2. Follow the facility procedure for measuring and documenting input and output. NJAC S 8:39-27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to provide treatment and care to address the resident's positioning needs that were in accordance with professional standards of practice that were based on the comprehensive assessment, person-centered care plan and the resident's choice. The deficient practice was identified for 1 of 4 residents reviewed for Position and Mobility. The deficient practice was evidenced by the following: On 07/29/2024 at 10:30 AM during the initial tour, the surveyor observed Resident # 115 in the hallway in his/her wheelchair. He/she had a white, leg splint observed on his/her left leg. The splint was located outside of his/her pants. On 07/30/2024 at 11:57 AM, the surveyor observed Resident # 115 in the hallway in his/her wheelchair. He/she had a white, leg splint observed on his/her left leg. The splint was located outside of his/her pants. On the same date at 12:45 PM, the surveyor observed Resident # 115 in his/her wheelchair in the day room eating lunch. He/she had the white, leg splint observed near the left ankle. The splint was located outside of his/her pants. A review of the physician's orders located in Resident # 115's Electronic Medical Record (EMR) did not reveal an order for Resident # 115 to wear a splint. A review of Resident # 115's diagnoses located in the EMR revealed that he/she had diagnoses of but not limited to cerebral vascular accident (stroke) and hemiplegia (unspecified affecting left nondominant side (paralysis on one side of the body). A review of Resident # 115's Care Plan located in the EMR revealed that he/she did not have a care plan focus or intervention for the splint. On 07/30/2024 at 1:26 PM during an interview with the surveyor, Licensed Practical Nurse (LPN) # 1 said that Resident # 115 chooses to wear the splint on his leg. She said that it was from a prior hospital admission. Another review of Resident # 115's Care Plan revealed a new intervention that revealed, I wear a brace to the left lower leg when out of bed. The intervention was initiated on 07/30/2024 after the surveyor's original review of the Care Plan. Another review of Resident # 115's physician's orders revealed a new order that revealed, Apply left leg brace in the morning and remove in the evening every day and evening shift. The order was added on 07/30/2024 at 20:31 (8:31 PM). On 07/31/2024 at 9:32 AM during an interview with the surveyor, Unit Manager Licensed Practical Nurse (UMLPN) # 1 replied, No, I have no reason. Going through the chart, it was on [his/her] chart from the previous stay and I do know he wears it. when the surveyor asked if there was a reason the order and care plan were input yesterday. The UMLPN # 1 replied, The day he arrived. One hundred percent. when the surveyor asked when the brace should have been ordered and care planned. On 08/01/2024 at 12:29 PM during an interview with the Director of Nursing (DON), the surveyor asked if a resident entered the facility and chose to use a leg splint or brace, should there be an order and care plan for it. The DON replied, Yes. Further, the surveyor asked when the order and care plan should be initiated. The DON replied, Upon arrival of the brace. It should be care planned and an order to be put in. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered with a revised date of March 2022 revealed under, Policy Interpretation and Implementation that, 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. A review of the facility policy titled, Range of Motion (ROM) Devices dated March 2022 revealed under Procedure that, 2. When a ROM device is to be utilized, the primary physician or consulting physician will provide orders specifying the type of device, the frequency of application, and the duration of application. a. If applicable, the physician's order will specify the don and doff times for the deice to be applied and removed. and 6. The resident's care plan will include measurable goals and objectives as well as resident-specific interventions for the use of ROM devices. NJAC S 8:39-27.1 (a)

Based on interview, record review, and review of facility documentation, it was determined that the facility failed to complete and transmit a death in facility Minimum Data Set (MDS) an assessment tool, for 1 of 1 resident (Resident # 16) reviewed for MDS record over 120 days old. The deficient practice was evidenced by the following: A review of the Admission Record revealed Resident # 16 was admitted with diagnoses which included but were not limited to; hypertension (elevated blood pressure) and atherosclerotic heart disease (a build up of fats in the walls of the arteries causing narrowing). A review of the progress notes revealed a note dated 05/21/2024 at 16:24 (4:24 PM), the resident was noted sitting in their wheelchair and was nonresponsive. The resident was taken to their room and was noted without a pulse and no respirations. Resident # 16's code status request was for no resuscitation and no hospitalization . The resident was pronounced dead at 4:15 PM. A review of the MDS' revealed that there was no MDS completed or transmitted to depict Resident # 16's death in the facility. On 08/01/24 at 8:35 AM, during an interview with the surveyor, the MDS Coordinator was asked about Resident # 16's death in the facility. The MDS Coordinator acknowledged it had not been completed or transmitted but should have been completed and transmitted timely. The MDS Coordinator stated it was important to keep the resident information accurate. A review of the facility provided MDS Coordinator Job Description undated, included but was not limited to; Purpose The primary purpose of your job position is to conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this Center. Care Plan and Assessment Function ensure that a complete resident assessment is conducted within fourteen days of a significant change in the resident's condition. A review of the facility provided policy, MDS Completion and Submission Timeframes revised October 2023, included but was not limited to; Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted . in accordance with current federal and state guidelines. On 08/01/2024 at 12:30 PM, the above concern was addressed with the facility administrative team. The facility had no additional information to provide. NJAC 8:39-11.2

Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to identify, document, and transmit on the Minimum Data Set (MDS) an assessment tool used to facility resident care, a resident's diagnosis of skin cancer. This deficient practice was identified for 1 of 27 residents (Resident # 72) reviewed for MDS. This deficient practice was evidenced as follows: On 07/29/2024 at 9:47 AM, the surveyor observed Resident #72 self-propelling in their wheelchair (w/c) around the third-floor unit. The surveyor observed the resident had multiple red sores on their face. On 07/31/2024 at 12:52 PM, the Licensed Practical Nurse (LPN) stated that Resident # 72's sores were skin cancer lesions. The LPN further stated that the resident had this diagnosis and sores for three years. A review of the Admission Record documented diagnoses which included but were not limited to; dementia, rosacea (chronic skin condition that causes redness, flushing, bumps, and visible blood vessels on the face), personal history of malignant melanoma of the skin dated 10/21/2021, and unspecified skin changes. A review of the resident-centered, on-going care plan included a focus area of impaired skin integrity r/t (related to) skin lesions and dermatitis r/t skin cancer. A review of the Annual MDS dated [DATE], included Section M1040 D. Open lesion(s) other than ulcers, rashes, cuts (e.g. cancer lesions) and had a documented response of No. A review of the Weekly Skin Check dated 12/19/2023, within the 7 day look back period of the Annual MDS, documented Resident # 72 had open lesion other than ulcer to the face and right ear. A review of the MDS dated [DATE], included Section M1040 D. Open lesion(s) other than ulcers, rashes, cuts (e.g. cancer lesions) and had a documented response of No. A review of the Weekly Skin Check dated 01/31/2024, within the 7 day look back period of the MDS, documented Resident # 72 had an open lesion other than ulcer skin cancer lesion to ear. A review of the MDS dated [DATE], included Section M1040 D. Open lesion(s) other than ulcers, rashes, cuts (e.g. cancer lesions) and had a documented response of No. A review of the Weekly Skin Check dated 07/09/2024, within the 7 day look back period of the MDS, documented Resident # 72 had an open lesion other than ulcer of the left ear. On 08/01/24 at 8:38 AM, during an interview with the surveyor, the MDS Coordinator stated that she would obtain her resident information from areas such as the progress notes, the staff, the medication and treatment administration records, and skin checks. She further stated that skin cancer on the face should have been documented on the MDS to reflect accurate care of the resident. A review of the facility provided MDS Coordinator Job Description undated, included but was not limited to; Purpose . to conduct and coordinate the development and completion of the resident assessment in accordance with the requirements of this state and the policies and goals of this Center. Care Plan and Assessment Function included but was not limited to; ensure all members of the assessment team are aware of the importance of completeness and accuracy . On 08/01/2024 at 8:30 AM, the above concern was presented to the facility administrative team. On 08/02/2024 at 9:47 AM, the administrative team acknowledged the concerns with the MDS accuracy but had no additional information to provide regarding Resident # 72. NJAC 8:39-11.1, 11.2