Every finding on record at Shore Pointe Care Center

Based on interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for 2 of 29 residents (Resident #22 and #51) reviewed for accurately coding the MDS according to the Resident Assessment Instrument (RAI - used to assess and care plan residents).The deficient practice was evidenced by the following: 1.On 5/28/26 at 10:51 AM, during initial tour, Resident #22 was observed in their room in their bed. Resident #22 stated they were a smoker, and they could smoke up to five times a day at (9am, 11am, 1pm, 3pm, and 6pm). They further stated that the facility holds onto their cigarettes until it was time to smoke. On 5/29/26 at 9:55 AM, the surveyor reviewed a list of smokers provided by the facility. Resident #22 was identified as a smoker. The surveyor reviewed the electronic medical record (EMR) for Resident #22. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; chronic obstructive pulmonary disease (incurable lung disease that blocks airflow and makes it hard to breathe). A review of the most recent annual Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. A further review in Section J, Health Conditions, the question for tobacco use was marked as no, which meant Resident #22 was assessed as a non-smoker. A review of the Smoking – Safety Screen dated 2/3/26, included in the section IDTC Decision, that the resident is approved as a candidate to participate in smoking activity while in the facility. It also included in the section team decision, that the resident was safe to smoke with supervision. A review of the Smoking Assessment's dated 5/7/25 and 11/7/25, included in the section titled frequency, that the resident smoked 2 – 5 times a day. Further review included in the section titled smoking comments, that the resident would continue to smoke with supervision. A review of the resident's smoking contract revealed the resident signed a smoking contract on 1/30/26. On 6/2/26 at 10:53 AM, the surveyor interviewed the MDS Coordinator (MDSC) who stated that they were responsible for completing the annual MDS's. He stated that when completing an annual MDS resident assessment he received information from each department's assessment and the 7 day look back. The MDSC verified that section J1300 for Resident #22 was checked off as no for tobacco use. He confirmed that the resident did use tobacco and stated, It's my mistake. I should have triggered the resident as a smoker. I will fix it right now. On 6/2/26 at 11:10 AM, the surveyor interviewed the Activities Aide who stated that the resident would usually come out to smoke depending on how they were feeling that day. The Activities Aide confirmed the resident smokes with supervision. On 6/3/26 at 12:50 PM, the surveyor made the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) aware of the above concerns. On 6/4/26 the facility had no further information to provide. 2. On 5/28/2026 at 10:59 AM, during initial tour, the surveyor observed Resident #51 in their room sitting on their bed. Resident #51 stated they smoked and that the facility kept their cigarettes and lighter until it was time to smoke, which was 5 times daily. On 5/29/2026 at 9:27 AM, the surveyor observed Resident #51 outside smoking. On 5/29/26 at 10:00 AM, the surveyor reviewed a list of smokers provided by the facility. Resident #51 was identified as a smoker. On 5/29/26 at 10:02 AM, the surveyor reviewed the EMR which revealed: A review of the admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; arthritis, depression, anxiety and bipolar disease (a mental health condition characterized by significant mood swings). A review of the admission MDS dated [DATE], indicated that the resident had a BIMS score of 15 out of 15, which indicated intact cognition. A further review in Section J, Health Conditions, the question for tobacco use was marked as no, which meant Resident #51 was assessed as a non-smoker. A review of the Smoking assessment dated [DATE], indicated that Resident #51 smoked 2 – 5 times daily. A review of the individualized comprehensive care plan (ICCP) revealed a focus area initiated 1/3/26, which indicated that Resident #51 wished to smoke at the facility. Interventions included: smoking evaluation, encourage resident to comply with smoking policy, notify resident of interest in smoking cessation, and remind resident of designated smoking times and location. On 6/02/2026 at 10:53 AM, the surveyor interviewed MDSC who stated that he was responsible for completion of the MDS. He explained that when completing an MDS assessment he reviewed information from each department's assessments for the look back period (7 days for tobacco use). He confirmed that section J1300 was coded no for tobacco use. He confirmed that tobacco use should have been coded yes for this resident, that it was missed, and that he would correct it right now. On 6/3/26 at 12:50 PM, the surveyor made the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) aware of the above concerns. On 6/4/26 the facility had no further information to provide. A review of the facility provided policy, Policy - MDS 3.0 Completion, implemented 10/1/25, included: Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI (Resident Assessment Instrument) specified by the State. Care Plan Team Responsibility for Assessment Completion: Interdisciplinary Responsibility for Completion of MDS section c. Persons completing part of the assessment must attest to the accuracy of the section they completed. Coding of Assessment a. Follow the guidelines in Chapter 3, of the RAI Manual, Version 3.0 for coding the assessment. A review of the facility provided policy MDS Completion Guidelines, date revised 1/2/26, included, Purpose: To ensure Minimum Data Set (MDS) assessments are completed accurately, timely, and in accordance with CMS regulations, RAI Manual guidelines, New Jersey Department of Health requirements, and federal reimbursement and quality reporting standards. Policy: The facility will complete all MDS assessments, Care Area Assessments, care plans, and related documentation within federally mandated timeframes to support accurate resident assessment, quality of care planning, reimbursement, and regulatory compliance.Staff will: Utilize the current CMS Resident Assessment Instrument (RAI) Manual and coding guidelines. Ensure assessments accurately reflect the resident's status during the applicable look back period. NJAC 8:39-33.2 (d)

Based on observation, interviews, record review and facility documents, it was determined that the facility failed to timely revise individual comprehensive care plans (ICCP) for 2 of 29 residents (Resident #2 and #15) reviewed for ICCP.This deficient practice was evidenced as follows: 1.On 5/29/2026 at 10:10 AM, the surveyor observed Resident #2 with their eyes closed in the room, in a reclining chair. The surveyor reviewed the electronic medical record (EMR) for Resident #2. A review of the admission Record (AR-an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; Alzheimer's Disease, unspecified (a brain disorder that slowly destroys memory and thinking skills), dementia in other diseases classified elsewhere with behavioral disturbance (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions) and dysphagia, unspecified (difficulty swallowing). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 3/31/26, revealed the resident had a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was severely cognitively impaired. Further review of the MDS revealed the resident was complete care for activities of daily living, had a feeding tube, and was receiving insulin. A review of the ICCP revealed a focus of has a risk for aspiration R/T (related to) dysphagia presents with a swallowing dysfunction. Revised on: 5/26/2026 with an intervention of Diet: Jevity 1.5 (a standard form of nutrition) 1 can bolus QID (four times a day)/flush with 125 ml (milliliters) water before and after feeding, Date Initiated: 12/03/2024. Further review of the ICCP did not reveal a focus of diabetes or the resident was receiving insulin. A review of the Physician Order Summary Report (OSR) revealed the following physician orders (PO): Enteral Feed Order one time a day Administer Glucerna (a form of nutrition specifically for people with diabetes) 1.2 ml @ (at) 62mL/hr (hour). Order Date 3/23/2026. Further review of the OSR revealed multiple POs from 3/23/2026 until present, continuing the Glucerna with adjustments to the formula and monitoring. NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 0 - 200 = 0 Units Call MD if BS <70 or >500. subcutaneously before meals and at bedtime for diabetes beforelunch-Order Date 2/20/2026 On 6/02/2026 at 12:42 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who stated he was Resident # 2's assigned nurse. He stated the resident was a diabetic, received Glucerna, and received finger sticks (blood sugar checks). He stated care plans should include things that included medical diagnoses, receiving insulin, tube feeding, and the type and rate of the feeding. He stated the nurses and the unit manager were responsible for updating the care plans. LPN #1 accessed the EMR in the presence of the surveyor. He was unable to locate a care plan for diabetes or insulin. At that time, Licensed Practical Nurse/Unit Manager (LPN/UM #1) joined the interview. She reviewed the care plan in the EMR and stated Resident #2 was receiving Jevity. The surveyor asked LPN/UM #1 to review the POs. She confirmed the resident was receiving Glucerna and stated she (the dietician) never updated the care plan with order. LPN/UM #1 continued to review the care plan and confirmed Diabetes or insulin was not on the care plan. She stated there should have been a care plan for Diabetes. The surveyor asked who was responsible to make sure the care plan was updated, LPN/UM #1 stated I am. She stated the purpose of the care plan was for the care of patients, to make sure everything gets completed. On 6/2/2026 at 1:02 PM, the surveyor met with the Director of Nursing (DON) and the Regional DON (RDON). The DON stated the purpose of the care plan was to ensure everyone's needs were being met, a screen shot of what is being done. She stated care plans should be updated the minute a change was made. When asked if care plans should be accurate, the DON responded Yes. The DON accessed the resident's EMR in the presence of the surveyor, and stated the resident was care planned for receiving Glucerna and confirmed it had been updated today (after surveyor inquiry). She also confirmed that a care plan for diabetes was updated today by LPN/UM #1. The RDON confirmed the care plan for Jevity was discontinued today by LPN/UM #1. On 6/3/2026 at 12:50 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, and the RDON were made aware of the above concern. 2.On 5/28/26 at 10:51 AM, during initial tour, the surveyor observed Resident #15 walking in the hallway towards the nurse to receive their medication. During a conversation with the surveyor, the resident stated that they were on hospice but was no longer on hospice by their choice. The surveyor reviewed the EMR for Resident #15. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; personal history of malignant neoplasm of pancreas (pancreatic cancer), malignant neoplasm of rectum (rectal cancer), gastro-esophageal reflux disease without esophagitis (stomach acid flows back up into the esophagus and causes heartburn), and essential (primary) hypertension (high blood pressure). A review of the significant change Minimum Data Set, dated [DATE], indicated the resident had a BIMS score of 11 out of 15, indicating moderately impaired cognition. A further review of section O special treatments, procedures, and programs revealed that Resident #15 was on hospice care while a resident. A review of the individualized comprehensive care plan (ICCP) included a focus area with a revision date of 3/17/26, receiving hospice services for diagnosis metastatic colon cancer. The ICCP interventions included encourage nutritional intake and use supplements as appropriate, facilitate hospice visits, hospice staff to visit to provide care, assistance, and/or evaluation, and no invasive procedures. A review of the Order Summary Report included the following physician orders (PO): A PO, dated 3/17/26, hospice eval and treat. A PO, dated 3/18/26, hospice eval and treat diagnosis of malignant neoplasm of colon. A PO, dated 5/1/26, discontinue hospice. On 6/2/26 at 1:12 PM, the surveyor interviewed the LPN #2, who stated care plans were completed upon admission and that the unit manager would update the care plan with any changes. She then stated the care plan would include the following focus areas: pain, colostomy care, falls, wounds and hospice status. LPN #2 confirmed that Resident #15 was no longer on hospice and was taken off at the beginning of May. She acknowledged that the residents care plan should have been updated when the resident's hospice was discontinued. On 6/2/26 at 1:22 PM, the surveyor interviewed LPN/UM #2, who stated care plans were usually completed and updated by the unit manager. She further stated that care plans were updated during the care plan meetings. She stated that if there was a change in the resident's care or condition the care plan would be updated immediately. She also stated that the importance of the care plan was for the resident's care. LPN/UM #2, in the presence of the surveyor, confirmed Resident #15's care plan had a focus area for hospice and was not updated when hospice was discontinued. LPN/UM #2 then stated that it was an error and that the care plan should have been updated. On 6/3/26 at 10:57 AM, the surveyor interviewed the Director of Nursing (DON), who stated that care plans were updated when there was any change in the resident's care and quarterly. The DON confirmed that the resident's care plan should have been updated when there was an order to discontinue hospice. The DON further stated that it was the responsibility of the unit manager, DON, and Assistant Director of Nursing (ADON) to update the care plans. The DON stated the importance of care plans were to make everyone aware of the resident's needs and their plan of care. The DON then stated that the residents care plan should have been updated immediately. On 6/3/26 at 12:50 PM, the DON, Licensed Nursing Home Administrator (LNHA), and Regional DON (RDON), in the presence of the survey team, were made aware of the above concerns. On 6/4/26 the facility had no further information to provide. A review of the facility's policy Care Plan Revision and Update Policy reviewed on 1/2/2026, revealed Purpose: To ensure that each resident's comprehensive care plan accurately reflects current needs, goals, preferences, risks, strengths, and interventions and is revised promptly when changes in condition or circumstances occur. Policy: The facility will develop, review, revise, and update resident care plans in accordance with federal and state regulations. Care plans shall be individualized and designed to assist the resident in attaining or maintaining the highest practicable physical, mental and psychosocial well-being.Care plan revisions: The care plan shall be reviewed and updated whenever there is: a significant change in condition, new diagnosis or treatment.nutritional concerns or weight changes. Physician recommendation or order change. NJAC 8:39-11.2 (i)

Based on observation, interview, and record review, it was determined that the facility failed to follow a Physician's Order for continuous oxygen (O2) in accordance with professional standards of practice for 1 of 1 residents, (Resident #112), reviewed for respiratory care.The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 5/28/26 at 9:59 AM, the surveyor observed Resident #112 in bed awake with the O2 concentrator (a medical device that provides supplemental oxygen by filtering air) turned off and against the wall. The O2 nasal cannula tubing (a flexible medical tube that connects an oxygen source to a delivery device, allowing supplemental oxygen to reach the patient safely and effectively) was in a bag on top of the concentrator. The resident stated, I'm not feeling good today. The resident was not wearing oxygen. On 5/29/26 at 11:28 AM, the surveyor observed Resident #112 sitting in a wheelchair in the room, not wearing oxygen. The O2 concentrator was against the wall and turned off. The O2 nasal cannula tubing was in a bag on top of the concentrator. The resident stated I'm feeling better today. I use the oxygen when I'm in bed.The electronic medical record for Resident #112 was reviewed.A review of the admission Record (an admission summary) revealed diagnoses that included but were not limited to; respiratory failure (a medical condition where the respiratory system cannot adequately supply oxygen to the blood or clear carbon dioxide from the body), pneumonia (an infection that inflames the air sacs in one or both lungs), and dementia (a decline in memory, language, problem-solving, and other thinking skills).A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 3/8/26, revealed a brief interview for mental status (BIMS) of 7 out of 15, which indicated the resident's cognitive function was severely impaired.A review of the resident's individual comprehensive care plan (ICCP) included a focus area initiated 3/3/26; at risk for changes in breathing patterns and/or respiratory distress related to diagnosis of congestive heart failure (CHF- a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time). Interventions included; administer medications/O2 per physician's order and monitor vital signs as needed.A review of the Order Summary Report (OSR) included the following physician orders (PO):A PO dated 3/3/26 Oxygen 2L (liters per minute) via nasal cannula continuously; every shift related to respiratory failure.A PO dated 3/4/26 Evaluate lung sounds. Notify medical provider of changes from baseline, document in progress notes every shift.A PO dated 3/25/26 Daily vital signs 7-3 every day shift.A review of Resident #112's May 2026 Medication Administration Record (MAR) revealed an order for Oxygen 2L via nasal cannula continuously every shift. The order was signed by nursing staff on both 5/28/26 and 5/29/26 day shifts, indicating the O2 was in place.On 5/29/26 at 12:43 PM, the surveyor interviewed the registered nurse (RN#1), who stated Resident #112 was admitted with continuous O2, but was now stable. RN#1 also stated that staff would document vitals but not a note regarding oxygen.On 6/2/26 at 10:19 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who stated the nurses have to supervise the residents on O2 and they know it should be continuous if ordered. The ADON also stated the nurses could contact the doctor if the resident was taking the O2 off and the vitals were stable to do an O2 challenge or change the order to as needed (PRN).On 6/3/26 at 12:51 PM, the surveyor presented the above concerns to the Licensed Nursing Home Administrator, the Director of Nursing, and the Regional Director of Nursing.No additional information was provided.A review of the facility provided Oxygen Administration and Safety policy, updated on 1/2/26, revealed Policy: The facility shall provide oxygen therapy only upon the order of a licensed practitioner and shall ensure oxygen is administered safely and effectively to meet the resident's assessed needs . 1. Physician's Orders-Oxygen shall be administered only upon the order of a physician, nurse practitioner, or physician assistant. Orders shall include flow rate, delivery device, frequency, and clinical indication. 2. Assessment and Monitoring .Changes in condition shall be reported promptly. NJAC 8:39- 27.1 (a)

Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure professional standards of nursing practice were followed by a.) clarifying a physician's order to accurately document the dosage calculation prior to administering a medication, (Vitamin B 12), for one (1) of seven (7) residents, (unsampled Resident #19), b.) ensuring observation of the administration of a medication (Polyethylene Glycol 3350) to one (1) of seven (7) residents, (unsampled Resident #89), and c.) accurately documenting medication administration for two (2) of seven (7) residents, (unsampled Resident #89 and Resident # 95). The deficient practices were identified for one (1) of three (3) nurses observed during the medication administration observation.The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On [DATE] at 8:23 AM, the surveyor observed the Registered Nurse (RN #1) preparing to administer five (5) medications which included two (2) tablets of Vitamin B12 500 micrograms (MCG) to unsampled Resident #19. RN #1 stated the physician's order (PO) on the electronic medication administration record (EMAR) indicated 1000 MCG of Vitamin B12 was to be administered and she had 500 MCG tablets in her medication cart, so she was administering two (2) tablets. RN #1 added the Vitamin B 12 tablets were an over-the-counter house stock (OTC-HS) medication.On [DATE] at 8:35 AM, the surveyor observed RN #1 administered five (5) medications which included two (2) tablets of Vitamin B12 500 MCG to unsampled Resident #19. Upon returning to the medication cart, RN #1 electronically signed for the administration of one (1) tablet of Vitamin B 12 1000 MCG on the EMAR.On [DATE] at 9:30 AM, the surveyor interviewed RN #1 who acknowledged she had signed for the PO that reflected one (1) tablet of 1000 MCG of Vitamin B 12 was administered. RN #1 stated she did not think the facility had Vitamin B 12 1000 MCG tablets and was allowed to make the dose. RN #1 added the PO should have been changed.On [DATE] at 10:39 AM, during the reconciliation review of the medication administration observation, the surveyor reviewed the Order Summary Report for unsampled Resident #19 which revealed a PO with a start date [DATE] for Vitamin B12 oral tablet 1000 MCG (micrograms) (Cyanocobalamin) Give 1 tablet by mouth one time a day for Vitamin B12 Deficiency.There was no documentation in the nursing progress notes indicating the physician was notified of the actual dosage calculation administered.On [DATE] at 11:53 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated nurses were to administer medications as ordered by the physician. UM/LPN explained if a PO indicated one tablet of 1000 MCG and there were 500 MCG tablets then the physician was to be called, and the PO clarified for the administration of two (2) tablets of 500 MCG. The UM/LPN added she recently reviewed POs for Vitamin D and called the physician to clarify the dosage of Vitamin D tablets the facility had as OTC-HS.On [DATE] at 8:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated the PO must match the medication that is being administered. The DON added if there was a PO for a OTC-HS dose that was not available then that dose could be obtained from the provider pharmacy or central supply could order it. A review of the facility In House Stocked Meds provided by the UM/LPN revealed Vitamin B 12 was on the list with a dose of 1000 MCG. There was no listing for the 500 MCG tablets.On [DATE] at 1:01 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON and Regional DON. The DON stated RN #1 should know the correct procedures for med pass.A review of Clinical Competency Validation report for RN #1 on Medication Administration: Oral provided by the DON, dated [DATE] and [DATE], completed by the ADON indicated RN #1 had met the requirement for Verifies medication order on Medication Administration Record (MAR) with medication label for correct drug, dose, route, time, special considerations and expiration date. If discrepancies, notifies physician/advanced practice provider (APP) and/or pharmacy, if indicated. and passed successfully.A review of a Medication Pass Observation for RN #1 provided by the DON, dated [DATE] and completed by the Consultant Pharmacist indicated the Correct drug, correct amount, correct dosage form administered was observed.A review of the current facility policy Medication Administration and Documentation provided by the DON revealed the purpose is to ensure medications are administered and documented safely, accurately and in accordance with physician orders, professional standards of practice, CMS (Centers of Medicare and Medicaid Services) requirements, and applicable state regulations. In addition, the policy revealed the procedure included administering medications as ordered and documentation requirements were to be complete, accurate, and timely. 2. On [DATE] at 8:58 AM, the surveyor observed RN #1 enter unsampled Resident #89's room with six (6) medications in a medication cup and a four (4) ounce cup of water mixed with 17 grams (GM) of Polyethylene Glycol 3350 (PEG3350) powder mixed in the water. RN #1 placed the 4-ounce cup on the overbed table in front of the resident near their breakfast tray. The resident was unable to follow directions from RN #1 to take the medications. RN #1 then removed the medication cup with the six (6) medications from the resident's hand and stated she was going to try to administer the medications later. RN #1 left the four (4) ounce cup with the PEG3350 on the overbed table with the resident.On [DATE] at 9:30 AM, the surveyor interviewed RN #1 who stated unsampled Resident #89 was able to take the four (4) ounce cup with PEG3350 by themselves. RN #1 added she should have watched the resident drink the four (4) ounces of water with the PEG3350.On [DATE] at 11:47 AM, the surveyor interviewed RN #1 who stated she had returned to unsampled Resident #89 to administer the medications that they had not taken during the medication administration observation but was unable to speak to the time. In addition, RN #1 was unable to speak to whether the resident had taken the four (4) ounces of water with the PEG3350 and stated, Let me go check. The surveyor, with RN #1, went to unsampled Resident #89's room. The resident was not in the room and the overbed table was empty. There was no documentation in the progress notes regarding any issue with the medication administration for unsampled Resident #89.On [DATE] at 11:53 AM, the surveyor interviewed the UM/LPN who stated she thought unsampled Resident #89 could take their own medications but would need supervision. The UM/LPN also stated no medications were allowed to be left at the bedside.On [DATE] at 8:46 AM, the surveyor interviewed the DON who stated there were no residents that were allowed to have medications left with them. The DON explained the nurses were not to leave a medication at a resident's bedside.On [DATE] at 1:01 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), DON and Regional DON. The DON stated RN #1 should know the correct procedures for med pass.A review of Clinical Competency Validation report for RN #1 on Medication Administration: Oral provided by the DON, dated [DATE] and [DATE], completed by the ADON indicated RN #1 had met the requirement for Stays with patient until the drug has been swallowed. and passed successfully.A review of a Medication Pass Observation for RN #1 provided by the DON, dated [DATE] and completed by the Consultant Pharmacist indicated the RN #1 had met the requirement Resident observed to ensure medication swallowed. 3. On [DATE] at 9:25 AM, the surveyor observed RN #1 administer seven (7) medications to Resident #95. Upon returning to the medication cart, RN #1 stated her computer had died and would have to plug it in. The surveyor observed the computer screen was dark with a notice Battery officially low. RN #1 stated she was unable to sign for the administration of Resident #95's medications at that moment.On [DATE] at 10:39 AM, during reconciliation of the medication administration observation, the surveyor reviewed Resident #95's EMAR which revealed the seven (7) medications observed by the surveyor as administered had not been signed. In addition, the surveyor reviewed unsampled Resident #89's EMAR which revealed a 9:00 AM medication (Amlodipine) (a medication used for high blood pressure) that had not been observed during the medication administration was signed as administered with blood pressure results documented. There were no other signatures for the seven (7) medications observed as prepared which included the PEG3350.On [DATE] at 11:43 AM, the surveyor interviewed RN #1 who stated she had not yet had the time to document the administration of Resident #95's medications that were administered at 9:25 AM. RN #1also stated she had returned to unsampled Resident #89 to administer the medications that they had not taken during the medication administration observation but was unable to speak to the time. RN #1 acknowledged Amlodipine had been signed as administered for unsampled Resident #89 and had not signed for any other morning medications. RN #1 again stated she had not yet had the time and was signing the EMAR then.On [DATE] at 11:53 AM, the surveyor interviewed the UM/LPN who stated medications were to be signed immediately after administration and if there was a problem then documentation would be noted such as a refusal or if there was a problem and then the physician would be notified. The UM/LPN explained if a computer died there were extra laptops available as well as she could use her own computer if she needed to login and document. The UM/LPN added there was also a computer at the nursing station.On [DATE] at 8:46 AM, the surveyor interviewed the DON who stated medications were to be signed immediately after administration. The DON explained the nurses had access to extra chargers and there were backup laptops so if one was not working they could get another to sign for medication administration.On [DATE] at 10:42 AM, the surveyor reviewed the EMARs for Resident #95 and unsampled Resident #89. The morning medications had been signed as administered. There was no nursing progress notes regarding any issue with medication administration for either resident.A review of a Medication Admin Audit Report for Resident #95 revealed administration times for the morning medications by RN #1 were after 11:46 AM on [DATE].A review of a Medication Admin Audit Report for unsampled Resident #89 revealed administration times for the morning medications by RN #1 were after 11:44 AM on [DATE].On [DATE] at 1:01 PM, the survey team met with the LNHA, DON and Regional DON. The DON stated RN #1 should know the correct procedures for med pass.A review of a Medication Pass Observation for RN #1 provided by the DON, dated [DATE] and completed by the CP indicated the RN #1 met the requirement Medication signed for immediately after administration.A review of the current facility policy Medication Administration and Documentation provided by the DON revealed Document administration immediately after the medication is given. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observations, interviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure infection control practices were implemented by performing appropriate hand washing technique to prevent the spread of infection in accordance with accepted national standards and Centers for Disease Control and Prevention (CDC) guidelines, during the medication administration observation for one (1) of three (3) nurses observed while administering medications to four (4) residents, (Unsampled Residents #19, #50, #89 and Resident #95).The deficient practice was evidenced by the following: According to the CDC Guideline for Hand Hygiene in Health-Care Settings, dated October 25, 2002, indicates when washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. On 6/2/26 between 8:23 AM and 8:35 AM, during the medication administration observation, the surveyor observed Registered Nurse (RN #1) prepare and administer seven (7) medications to unsampled Resident #19 in their room. RN #1 checked the name band of unsampled Resident #19 prior to administering the medications.On 6/2/26 at 8:37 AM, after unsampled Resident #19 was administered their medications, the surveyor observed RN #1 perform hand hygiene at the sink in the resident's room. RN #1 used a paper towel to turn the faucet handles on and left the towel on the sink ledge. RN #1 applied soap to her hands and lathered for 5 seconds, then put her hands under the running water for 10 seconds and using the paper towel on the sink ledge turned off the faucet handles and using the same paper towel, obtained additional paper towels from the towel rack to dry her hands.On 6/2/26 between 8:39 AM and 8:58 AM, continuing with the medication administration observation, the surveyor observed RN #1 prepare medications for unsampled Resident #89. RN #1 checked the arm band of unsampled Resident #89 and gave the resident a medication cup containing six (6) medications and put a four (4) ounce cup containing a medication on their overbed table near the breakfast tray. The resident was unable to follow directions from RN #1 to take the medications. RN #1 then removed the medication cup from the resident's hand and stated she was going to try to administer the medications at a later time. On 6/2/26 at 9:00 AM, the surveyor observed RN #1 use a drug buster on another medication cart to dispose of unsampled Resident #89's medications and then returned to her medication cart. There was no observation of hand hygiene.On 6/2/26 between 9:06 AM to 9:07 AM, continuing the medication administration observation, the surveyor observed RN #1 prepare and administer one (1) medication, Peridex 30 milliliters (a medicated mouthwash), to unsampled Resident #50. RN #1 placed the medication cup with the Peridex on the resident's overbed table. The unsampled Resident #50 requested the Peridex be administered in the bathroom with the door closed and RN #1 accompanied the resident with the overbed table into the bathroom.On 6/2/26 at 9:13 AM, after RN #1 came out of unsampled Resident #50's bathroom, the surveyor observed RN #1 go to the nursing station bathroom to wash her hands. The surveyor observed RN #1 use a paper towel to turn the faucet handles on and left the paper towel on the sink ledge. RN #1 applied soap to her hands and lathered for 5 seconds, then put her hands under the running water for 15 seconds and using the paper towel on the sink ledge turned off the faucet handles and obtained additional paper towels to dry her hands by touching the towel rack handle.On 6/2/26 between 9:14 AM and 9:28 AM, during the medication administration observation, the surveyor observed RN #1 prepare medications for Resident #95 and took the medications into the resident's room, raised the head of the bed for the resident to take the medications and then lowered the bed after the administration was completed. Then, the surveyor observed RN #1 perform hand hygiene at the sink in the resident's room. RN #1 used a paper towel to turn the faucet handles on and left the paper towel on the sink ledge. RN #1 applied soap to her hands and lathered for 5 seconds, then put her hands under the running water for 10 seconds and using the paper towel on the sink ledge turned off the faucet handles and using the same paper towel, obtained additional paper towels from the towel rack to dry her hands.On 6/2/26 at 9:30 AM, the surveyor interviewed RN #1 who stated she had been inserviced on the correct technique for hand washing by the Assistant Director of Nursing (ADON). The surveyor asked RN #1 to review the correct technique for hand washing, RN #1 stated I can't remember. RN #1 could not speak to the appropriate method or timeframe for hand washing.On 6/2/26 at 11:53 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) regarding the correct hand washing technique. The UM/LPN explained she would wet her hands and apply soap and lather for 20 seconds outside of the water stream by either counting or singing the song Happy Birthday three times and scrub her nails. The UM/LPN added she would then put her hands under the stream of water in a downward facing manner and making sure not to touch anything. UM/LPN also stated she would then use a paper towel that was already hanging from the towel rack to dry her hands and use another paper towel to turn off the faucet handles. The UM/LPN added she would not touch anything with her bare hands and the paper towels had to be dry paper towels because a wet paper towel could have bacteria and the dry paper towel was considered clean. The UM/LPN also stated inservices were provided on infection control practices by the ADON and Infection Preventionist (IP).On 6/3/26 at 10:01 AM, the surveyor interviewed the IP/LPN in the presence of the DON. The IP/LPN explained the proper procedure for hand washing hands was to wet hands first then lather for at least 20 seconds outside of the water and then rinse. The IP/LPN added nurses should not touch the faucet with clean hands and should use paper towels to dry hands and turn off the faucet with a paper towel.A review of a Hand Hygiene Competency Validation for RN #1 provided and completed by the Director of Nursing (DON) dated 3/19/26 indicated the nurse was competent for hand hygiene with soap and water. A review of Clinical Competency Validation reports for RN #1 provided by the DON, dated 3/12/26, 3/13/26, 3/15/26, 3/19/26, completed by the ADON indicated RN #1 had met the requirement for performs hand hygiene or cleanses hands and passed successfully.A review of a Medication Pass Observation for RN #1 provided by the DON, dated 5/26/26 and completed by the Consultant Pharmacist indicated there was a technique error for not performing hand washing (alcohol based hand rub or soap and water per facility policy) between every resident even if patient contact was not made. An In-Service Sign-In Sheet was also provided and completed by the DON for Med Pass Education signed by RN #1 as the attendee for a presentation which included but not limited to must wash hands in between residents.A review of the current facility policy Medication Administration and Documentation provided by the DON revealed Perform hand hygiene before and after medication administration and between residents.A review of the current facility policy Hand Hygiene Guidelines provided by the DON revealed all staff shall perform hand hygiene in accordance with current infection prevention standards, CDC guidelines, and facility procedures. In addition, the policy indicated the procedure for hand hygiene with soap and water included: 1. Verify sink areas are supplied with soap and paper towels. 2. Turn on the faucet and regulate water temperature. 3. Wet hands and apply sufficient soap to cover all surfaces. 4. Vigorously rub hands for a minimum of 20 seconds. 5. Rinse thoroughly while keeping fingertips pointed downward. 6. Dry hands and wrists completely with paper towels. 7. Discard paper towels in an appropriate waste receptacle. 8. Use a clean paper towel to turn off the faucet. The policy also indicated to perform hand hygiene before and after resident contact and before handling medications. NJAC 8:39-19.4 (a)(b)(n)

Based on observation, interviews, and a review of medical records and pertinent facility documents on 11/12/25, it was determined that the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering behaviors, who eloped from the facility on 10/29/25. The deficient practice was identified for 1 of 5 residents reviewed for elopement (Resident #2). During the survey, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 483.25 (d)(2) F 689, as the facility failed to provide adequate supervision to a severely cognitively impaired resident (Resident #2) with a known history of wandering behaviors who eloped from the facility on 10/29/2025. Registered Nurse (RN) #1 who was assigned to Resident #2 last observed the resident at approximately 4:45 p.m. on 10/29/2025. At approximately 5:05 p.m. Resident #2's assigned Certified Nurse Aide, (CNA) #1 went to the resident's room and observed the resident was not in there. CNA #1 then initiated a search for the resident in the dining room, and the resident was not found. At that time, CNA #1 alerted all staff and informed them that Resident #2 could not be located. A Code Gray (elopement/missing person code) was initiated, and staff members proceeded to search for the resident. The local police contacted the facility at approximately 5:45 p.m. and informed them that they found Resident #2 in a nearby town. The police returned Resident #2 to the facility at 6:00 p.m. The facility assessed Resident #2 with no injury. The facility's failure to provide the adequate supervision to a severely cognitively impaired resident with history of wandering behaviors and at risk for elopement and eloped, posed a likelihood of serious harm, injury, impairment or death. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began 10/29/25 at approximately 4:45 p.m. when resident was last seen by staff in the facility. The facility Administration was notified on 11/12/25 at 4:17 p.m The facility submitted an acceptable Removal Plan (RP) on 11/13/25 3:34 p.m The surveyor verified the implementation of the RP during the continuation of the onsite survey on 11/17/25 at 1:32 p.m. The evidence was as follows:A review of the facility's policy, undated, Elopements and Wandering Residents included: Policy This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.Policy Explanation and Compliance Guidelines 1. Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless.2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering . d. Adequate supervision will be provided to help prevent accidents or elopements.The Facility Reportable Event record (FRE) dated 10/29/2025, which the facility submitted to the New Jersey Department of Health (NJDOH) revealed that on 10/29/2025, at approximately 7:00 PM, Resident #2 exited the facility without staff knowledge and returned safely. Also, when the resident returned to the facility, they exhibited increased agitation, refused skin assessment and stated, This is not my home, I did not want to stay here. Resident #2 was transferred to hospital due to aggressive behavior. A review of an untitled facility document dated 10/29/2025 revealed the following:On 10/29/2025, Resident #2 was last seen on the nursing unit at approximately 4:45 p.m., by Registered Nurse (RN) #1, who was assigned to the resident. At approximately 5:05 p.m. Resident #2's assigned Certified Nurse Aide (CNA) #1 went to the resident's room and observed the resident was not in their room. CNA #1 then initiated a search for the resident in the dining room, and the resident could not be found. At that time, CNA #1 alerted all staff and informed them that Resident #2 could not be located. A Code Gray (elopement/missing person code) was initiated. The staff performed an extensive search of the entire facility premises. It was determined that Resident #2 was missing. The local police contacted the facility at approximately 5:45 p.m. and informed them that they found Resident #2 in a nearby town. The police returned Resident #2 to the facility at 6:00 p.m. The facility assessed Resident #2 with no injury. However, Resident #2 exhibited increased agitation and was sent to the hospital for evaluation. On 11/14/2025 at 2:48 p.m., the surveyor requested and received a copy of the Police Officer's Report from the town the resident was found. The report dated 10/29/25 8:27 p.m., indicated the following: Around 5:19 p.m., Resident #2 knocked on the passenger window of their police vehicle that was parked in (name of town) which was approximately 3 miles away from the facility and approximately one hour away by walking. The police report stated that Resident #2 appeared confused and stated to the police that they were trying to find where they lived but the resident was unable to provide the address. The police looked through the resident's cell phone and was able to find the facility she eloped. A review of CNA #1's statement revealed that Resident #2 was last seen on the unit before dinner. CNA #1 stated that CNA #2 was the person that took Resident #2's dinner tray to the resident's room and left the food there. CNA #1 stated that at 5:15 p.m., she went to check on Resident #2 in their room and noticed the dinner tray was in their room, but the resident was not there. CNA #1 stated that she then went to the day room to look for Resident #2, but the resident was not there either. CNA #1 then alerted the other staff members on duty and a search was initiated by looking from room -to- room, and in the other two units (West and East wing) in search of the resident. A review of RN #1's statement revealed that she was informed around dinner time that Resident #2 was not in their room or in the dining room. RN #1 then checked the hall and other residents' rooms because she knew Resident ##2 sometimes went into other residents' rooms. RN #1 stated that at 5:26 p.m., the Supervisor informed staff that Resident #2 was not in the building and that the search for the resident continued.On 11/12/2025 at 10:25 a.m., the surveyor conducted an interview with Licensed Practical Nurse (LPN #1) who was the Unit Manager on 10/29/25. LPN #1 stated: nurses and CNAs, we all eyeball the residents who wander, and staff would place a resident on the 24-hour staff-to-staff communication report if the resident showed exit seeking. LPN #1 stated that Resident #2 liked to wander and would pace by the nurse's desk and on the unit LPN #1 stated the facility is not sure how Resident #2 exited the building because all the doors were locked. On 11/12/2025 at 12:30 p.m., the surveyor conducted a telephone interview with Registered Nurse (RN #1) who was assigned to care for Resident #2. RN #1 stated that she last saw Resident #2 around 4:45 p.m. at the nurse's station. On 11/12/2025 at 11:05 a.m., the surveyor conducted an interview with CNA#1, who was assigned to Resident #2. CNA #1 stated the last time she saw Resident #2 was in the dining room before dinner. CNA #1 stated that she left the floor briefly to go to the human resources and returned to the unit at approximately 5:05 p.m. CNA #1 stated that she looked in the dining room but did not see the Resident #2, she then went to their room and noted the dinner tray on the table. CNA #1 stated she returned to the dining room to look for the resident and did not see them there and she alerted the assigned nurse. On 11/12/2025 at 11:45 a.m., the surveyor conducted an interview the receptionist. The receptionist stated that the lobby door has a code to allow people to enter and exit the facility, and that the front entrance door gets locked after 8 p.m. The receptionist stated she did not see Resident #2 leave the facility through the front door on 10/29/25.The surveyor conducted a telephone interview with Registered Nurse (RN #1) who was assigned to care for Resident #2. RN#1 stated she last saw Resident #2 around 4:45 PM at the nurse's station. On 11/12/2025 at 12:45 p.m., the surveyor conducted an interview with the Director of Nursing (DON) who stated that upon admission Resident #2's risk score for wandering was a 9, meaning Resident #2 was at moderate risk for wandering. The DON further stated that staff should be eyeballing Resident #2, and that the facility did not place the resident on 15-minute checks because they were not considered exit seeking. The surveyor asked what type of risk assessments are done for residents with wandering behaviors. The DON stated: We do not do elopement risk, just wandering risk and that a wandering care plan should have been in place not elopement care plan. The DON also stated that Dietary and Housekeeping staff were interviewed regarding Resident #2's elopement on 10/29/2025 and they could not recall seeing the resident leave the facility. The surveyor interviewed the Licensed Nursing Home Administrator (LNHA) on 11/12/25 at 12:45 p.m., who stated that Resident#2 was not an elopement risk but should have been considered a wanderer. LNHA stated that the resident's care plan as elopement was wrong because wandering and elopement are not the same, and that while elopement involves exit seeking, wandering involves going into other people's rooms. LNHA further stated that facility has not been doing elopement risk assessment, just wandering risk. The surveyor reviewed the medical record for Resident #2. According to the admission Record (AR) face sheet, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Unspecified Dementia, Mood Disturbance Anxiety and Alzheimer's Disease.According to the Minimum Data Set (MDS), an assessment tool dated 10/25/2025, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated the resident was severely cognitively impaired. According to Resident #2's Wandering Risk Scale assessment with an effective date of 10/25/2025, Resident #2 had a Wandering Risk Scale of 9, which indicated Resident #2 was at risk to Wander.A review of Resident #2's Care Plan (CP) with an initiated date of 10/27/2025, under Focus revealed that Resident #2 was at risk for Elopement related to Alzheimer's/Dementia. The goal of the CP was that Resident #2 will not leave the facility unattended. The CP interventions included: engage in activities/tasks to keep occupied, engage resident in diversional activity, monitor behavior and attempt to determine pattern/frequency, redirect to an appropriate area and provide supervision when resident exhibiting exit seeking behavior. A review of the Progress Note (PN) dated 10/27/2025 at 7:56 a.m. revealed that Resident #2 was alert with confusion and that the resident stayed awake on and off and wandered into other rooms. A review of PN dated 10/27/2025 at 10:31 p.m. revealed that Resident #2 was experiencing some difficulty adjusting to facility because they were new, have history of confusion, forgetfulness, wandering and had trouble with sleep. An acceptable Removal Plan (RP) was received on 11/13/2025 at 3:34 p.m., indicating the actions the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice to include:1. Identification of Residents Affected or Likely to be Affected:The facility maintained the following actions to address the citation and prevent any additional residents having the potential to be affected by the deficient practice. Immediately upon identification of the missing Resident #2, all residents were visually checked to be sure they were safe and all staff facility wide were informed to check all residents to ensure safety. A complete head count of residents was conducted, and all other residents were accounted for:DON/Designee immediately, on 10/30/25 conducted an audit to review the residents at risk of elopement assessments.DON/Designee conducted a full house audit on 11/12/25 for residents at risk for elopement with review and revision of the care plans. This included implementation of interventions consistent with the residents' needs, goals and care plans to reflect current risk of elopement. The residents were monitored Q 30-minutes when noted in the common areas such as dayroom, dining rooms, and attending activities. The facility has now increased the monitoring to Q 15-minute monitoring Q shift.DON/Designee on 10/29/25 immediately re-educated license and non-license staff on the Elopement Policy and Procedure.At risk residents for elopement are identified with a discreet visual indicator listed under special instructions in the residents EMR (Electronic Medical Records) on 11/12/25.Facility Educator/Director of Nursing 10/29/25 immediately reviewed and revised the elopement binders located on each unit and front entrance with the resident's profile picture in color.All exits, windows, and keypads were checked and functioning. Facility Administrator/Director of Maintenance changed all the keypad codes on 10/30/25. 2. Actions to prevent Occurrence/RecurrenceThe facility took the following actions to prevent an adverse outcome from reoccurring: Facility added monitoring rounds every 15 minutes for identified high-risk residents to maintain safety on 11/12/25. Audit monitoring tool sheets will be completed by direct care staff and completion reviewed by the DON/Designee.Facility implemented a new protocol for Family/Vendors/Visitors to sign in upon entering and sign out prior to exiting the facility on 10/29/25.Director of Maintenance conducted a full house audit of the keypad doors and windows noted secured, and functioning on 10/30/25.The facility Director of Maintenance, Director of Housekeeping, and the Administrator will maintain the keypad codes. Director of Maintenance will revise the schedule for changing keypad codes, making changes more frequent to monthly to the exit doors located at the end of the units.Visitor Communication Signage is located at the vestibule alerting visitors and staff to monitor the surroundings prior to entering the lobby to ensure the safety of the residents 10/29/25.Facility Educator provided mandatory re-education for staff (nursing, direct care, dietary, housekeeping, maintenance, and department heads) on elopement prevention, supervision, and emergency response on 10/29/25. Ongoing training will be provided with any staff on all shifts or vacations prior to the start of the next schedule shift.Facility Educator will continue to incorporate the Elopement prevention training into new hire orientation and annual education.Facility Educator provided mandatory training on the new implementation of identifying residents at risk for elopement under special instructions in the residents EMR (Electronic Medical Records) on 11/12/25.Facility Administrator conducted QAPI Ad Hoc (Quality Assurance and Performance Improvement) meeting with the Interdisciplinary Team on 10/30/25 to review the residents at risk for elopement care plans, interventions and elopement assessments.Quarterly X 2 elopement drills will be conducted to reinforce emergency response.Monthly X 6 months review of elopement risk assessments by the interdisciplinary team will be conducted and revised as needed.A QAPI (Quality Assurance and Performance Improvement) has been initiated to report on the above monitoring and auditing procedures. Results of the audits and findings, if any, will be presented to the monthly QAPI (Quality Assurance and Performance Improvement) meeting for review and revised as deemed appropriate. Monitoring/Auditing and reporting will continue for a minimum of three months.The surveyor verified the implementation of the RP on-site survey and determined that the immediacy for F 689 was removed as of 11/17/25 at 1:32 p.m.NJAC 8:39-27.1(a)

Based on observations, interviews, record review, and review of facility documents, it was determined that the facility failed to prevent unintended insidious (gradual but with harmful effects) weight loss of 31.5 pounds (lbs.) in one year from 1/3/24 through 1/1/25, and significant weight losses to include a 14 lb./10.5% loss in 6 months from 4/2/24 through 9/2/24; a 15 lb./11.2% loss in 6 months from 5/5/24 through 10/1/24; a 6.5 lb./5.6% loss in 1 month from 11/1/24 through 12/3/24; and an additional 4 lb. loss from 12/3/24 through 1/1/25; which was also a 16.5 lb./13.4% loss in 6 months from 8/1/24 through 1/1/25. The facility failed to prevent and address these weight losses in a timely manner, which included the failure to a.) ascertain (to find out) food preferences, b.) implement fortified foods (foods that are nutrient dense in calories and protein), c.) provide culturally appropriate alternate meal options d.) implement and monitor weekly weights, and e.) consistently monitor intake and record consumption of a physician prescribed supplement. In addition, the facility relied on cultural food brought in by family when they visited approximately once a month as a nutritional intervention. This deficient practice was identified for 1 of 5 residents (Resident #67) reviewed for weight loss. The evidence was as follows: A review of an undated facility policy Weight Management and Intervention Procedure, reflected that the interdisciplinary team would strive to prevent, monitor and intervene when a resident experienced an undesirable weight loss. It also included that a 5% weight loss in a one-month time frame was considered significant and a 10% loss within six months was considered significant and a weight loss greater than 10% in six months was considered severe. In addition, it reflected that the registered dietitian (RD) would review residents' weights by the 15th of each month and the team would discuss and analyze negative trends and interventions at the monthly weight meetings. A review of an undated facility policy Nutritional Procedure, reflected that all residents should receive appropriate nutrition tailored to their individual health needs and food preferences for overall health and quality of life. Nutritional assessments should include a resident's dietary habits, preferred foods, favorite meals and traditional foods from their cultural background. It also reflected that staff should report any changes in eating habits and weights to the RD promptly. In addition, it included to maintain accurate and current records of all assessments, care plans, and residents' food preferences. A review of an undated facility policy Interdisciplinary Care Planning Protocol, reflected that dietary should include an overview of their assessments of the residents needs and problems, which should be specific and individualized. On 1/03/25 at 12:46 PM, the surveyor observed Resident #67 in their room. There was an untouched lunch tray on the overbed table. On 1/06/25 at 12:20 PM, the surveyor observed the resident lying in their bed. Upon inquiry, the Certified Nurse Aide (CNA #1) stated that the resident refused lunch and that an alternate was usually offered; however, there were no culturally appropriate alternate meals available. On 1/07/25 at 12:21 PM, the surveyor observed the resident lying in their bed and there was no lunch tray in the room. Upon inquiry, the Licensed Practical Nurse (LPN #1) stated that the resident no longer ate well and the physician recently increased a supplement from three to four times a day, and also prescribed a medication to stimulate the appetite. On 1/08/25 at 12:15 PM, two surveyors observed the resident lying in their bed. At that time, the surveyor interviewed the Assistant Activities Director (AAD), who stated that the resident's daughter visited the resident every three to four weeks and brought in cultural foods. In addition, she stated that the daughter visited on Saturday and the resident ate very little but did drink the soymilk brought by the daughter. The AAD stated that ever since the resident had COVID-19, the resident lost their sense of taste and therefore appetite. She also added that she knew the resident liked marinated beef and did not like pork. In addition, she added that the resident enjoyed their supplements, and liked juice. The Activities Director entered the resident's room as well and translated in the resident's native language. Resident #67 confirmed that they enjoyed and completed supplements, soy milk when brought by the daughter and enjoyed juices. The resident stated that they preferred beverages and not food due to loss of taste. The surveyor reviewed the medical record for Resident #67. A review of the resident's Admission Record (an admission summary) included diagnoses not limited to; hypertensive, heart and chronic kidney disease with heart failure. A review of the quarterly Minimum Data Set, an assessment tool used to facilitate the management of care dated 12/3/24, reflected a Brief Interview for Mental Status score of 5 out of 15 which indicated severe cognitive impairment. It also reflected the resident had a significant weight loss not on physician-prescribed weight-loss regimen. A review of the resident's comprehensive care plan reflected a nutrition care plan initiated 12/22/20. The focus reflected that the resident had weight loss related to diuretic use, advanced age and poor meal intake. It also included that in 8/2024 and 9/2024, they had gradual weight loss, in 11/2024, the resident had gradual weight loss and a significant weight loss over six months, in 12/2024, the resident had a significant weight loss over a one- and six-month period of time, and in 1/2025, the resident had a significant weight loss over three and six months. The goals initiated on 12/22/20, included that the resident would maintain their weight with no significant weight changes and would consume at least 75% of meals and supplements. Interventions included to Encourage family to bring food/snacks, which was initiated on 6/12/23, by the facility RD and provide House Supplement 237 ml four times a day, this intervention was revised on 1/2/25, by the facility RD. A review of the Order Summary Report (OSR) reflected the following physician orders (PO): A PO dated 8/9/23, for Glucerna (a supplement with less sugar) 237 milliliters (mls) twice a day; A PO dated 2/2/24, for Glucerna three times a day and record amount; A PO dated 3/22/24, for House Supplement NSA (no sugar added) three times a day; A PO dated 6/26/24, for House Supplement NSA (no sugar added) three times a day; A PO dated 12/3/24, for House Supplement four times a day for supplement for poor appetite; and A PO dated 12/27/24, for a Regular diet; A PO dated 12/27/24, for House Supplement four times a day. A review of the Medication Administration Record (MAR) reflected the above PO dated 6/26/24. Further review of the MAR for the dates 6/27/24 through 8/1/24, reflected the House Supplement was administered three times a day (09:00 AM, 2:00 PM, 09:00 PM) with a check mark; however, there was an X marked for the amt (amount consumed) row, which did not quantify the amount of supplement consumed. The surveyor reviewed the weight record in the electronic medical record (EMR) which did not include weekly weight monitoring. Weights documented were as follows: 1/3/24 139 lbs. 2/2/24 135.5 lbs. 3/7/24 132.5 lbs. 4/2/24 134 lbs. 5/5/24 134 lbs. 6/5/24 128.5 lbs. 7/1/24 128 lbs. 8/1/24 124 lbs. 9/2/24 120 lbs. 10/1/24 119 lbs. 11/1/24 118 lbs. 12/3/24 111.5 lbs. 1/1/25 107.5 lbs. The Director of Nursing (DON) provided the surveyor with documentation that Resident #67 was discussed at a monthly weight meeting on 11/6/24, for a 16 lb./11.9% weight loss over six months. Interventions/Notes reflected the weight loss was expected due to diuretic use (a medication used to increase the production of urine, helping the body to get rid of excess fluid), the age of the resident and that the resident preferred food from the family. In addition, the resident's weights were discussed at a weight meeting dated 12/9/24, for a 6.5 lb./5.5% loss over one month and a 17 lb./13.2% loss over six months. Interventions/Notes reflected the weight loss was undesired, but that the resident was on a diuretic with improved edema (fluid retention); had poor intake of meals but good intake of supplements. At that time, there was a recommendation to increase the supplement from three to four times a day. Further review of the residents OSR, reflected a PO for the diuretic Furosemide 20 milligrams (mg) one tablet once a day with a start date 3/11/23 through 1/7/25. There was also no PO for a multivitamin and mineral supplement. A review of the resident's meal tickets dated 1/7/24, for breakfast, lunch and dinner included whole milk not soy milk, no fortified foods and a Korean Meal, for lunch and dinner. It also included hot cereal at breakfast (not fortified hot cereal) and a four-ounce cranberry juice (not a calorically dense Nutritional Juice.) A review of the resident's progress notes from 5/1/24 through 1/8/25 reflected the following documentation: -Physician Progress Note Narratives reflected the resident had mild bilateral (both sides) edema on 7/18/24 at 4:23 PM and 8/19/24 at 12:27 PM. -Physician Progress Note Narratives reflected the resident had improved bilateral edema on 9/6/24 at 10:29 AM and on 10/25/24 at 1:50 PM. -CRNP [Nurse Practitioner] Progress Note Narratives reflected the resident had trace edema on the following dates and times: 5/9/24 at 1:54 PM, 5/13/24 at 1:35 PM, 5/30/24 at 10:52 AM, 6/27/24 at 11:46 AM, 7/2/24 at 11:22 AM, 7/24/24 at 11:48 AM, 8/1/24 at 1:35 PM, 8/15/24 at 2:00 PM, 8/16/24 at 11:21 AM, 8/20/24 at 1:36 PM, 8/28/24 at 4:42 PM, 9/4/24 at 11:21 AM, and 9/13/24 at 11:46 AM. -Nursing Progress Note's reflected the resident had trace edema on 6/20/24 at 1:11 PM and 9/20/24 at 7:43 PM. A review of multiple progress notes from the Physician, Nurse Practitioner, and Nurse reflected no documented evidence that the resident had more than mild or trace edema. A Dietary progress note dated 2/2/24 at 11:54 AM, reflected the resident's weight was 135.5 lbs. which was a gradual undesired loss. It further reflected the resident was not a big breakfast eater. In addition, the RD noted that nursing informed her that the resident had good consumption of foods brought by the family, had poor to fair consumption of facility food and took 100% of the supplement Glucerna 237 ml twice a day. The RD would recommend increasing the Glucerna to three times a day. A quarterly Nutritional assessment dated [DATE] at 8:55 AM, reflected the resident's weight was 132.5 lbs. which was a gradual undesired loss. It also included the residents usual body weight/goal weight at 135-145 lbs. and that the resident's meal intake met 26-100% of their estimated nutritional needs. It further reflected that the resident had poor intake of facility meals, but had good consumption of food and snacks brought by the family when they visited. A quarterly Nutritional assessment dated [DATE] at 11:13 AM, reflected the resident's weight was 128.5 lbs., which was a gradual undesired loss and now their usual body weight/goal weight was 130-140 lbs. It reflected the resident's meal intake met 26-100% of the resident's estimated nutritional needs. It further reflected that the resident had poor intake of facility meals but had good consumption of food brought by the family. The RD notes the resident had trace edema and that she would continue to monitor the residents weights and intake. A Dietary progress note dated 8/2/24 at 11:05 AM, reflected the resident's weight was 124 lbs. which was a gradual undesired loss. The RD further documented that the resident had good consumption of food brought by the daughter per a translator and had good intake of supplements and preferred to drink them at medication pass times. The RD indicated she would continue to monitor the resident's weight and intake of meals and supplements. An annual Dietary note dated 8/30/24 at 8:50 AM, reflected the resident's weight was 124 lbs. The note reflected the resident received Vitamin C, Vitamin D and folic acid (but not a complete vitamin/mineral supplement). The RD further documented that the resident had good consumption of food brought by the daughter about once a month per a translator and had fair to good intake of supplements as per staff. The RD indicated she would continue to monitor the resident's weight and intake of meals and supplements. A Dietary progress note dated 11/1/24 at 3:18 PM, reflected the resident's weight was 118 lbs. which was a gradual weight loss over one month and a significant weight loss over six months (16 lbs./11.9%). The RD documented that the loss was expected due to an improvement of edema as per a progress note dated 10/25/24. In addition, it reflected that the resident had poor intake of facility meals since the resident enjoyed foods brought by the daughter and was consuming 100% of the House Supplement NSA three times a day. A quarterly Nutritional assessment dated [DATE] at 12:42 PM, reflected the resident's weight was 118 lbs., which was a gradual weight loss over one month and a significant weight loss over six months (16 lbs./11.9%). The assessment now indicated that the resident's usual body weight/goal weight fluctuates. The RD documented that the loss was expected due to an improvement of edema as per a progress note dated 11/15/24. It reflected the resident's meal intake met 26-100% of the resident's estimated nutritional needs. It further reflected that the resident had poor intake of facility meals since the resident enjoyed foods brought by the daughter. In addition, it reflected the resident had fair to good consumption of the House Supplement NSA 237 ml three times a day. A Physician Progress Note Narrative dated 12/2/24 at 3:03 PM, reflected the resident had improved bilateral edema, check TSH (thyroid stimulating hormone, which is a test to check thyroid function), monitor weights and intake, RD to follow up. A Nursing Progress Note dated 12/2/24 at 3:21 PM, reflected the resident had a poor appetite and the resident's physician and daughter were notified. A Nursing Progress Note dated 12/2/24 at 8:12 PM, reflected the resident refused dinner but consumed 100% of the House Supplement. A Nursing Progress Note dated 12/3/24 at 11:29 AM, reflected the RD and speech therapist were notified of the resident's poor appetite. A Dietary note dated 12/3/24 at 12:35 PM, reflected that the resident's weight was 111.5 lbs. which was an undesired significant weight loss of 6.5 lbs./5.5% over one month and 17 lbs./13.2% over six months. It reflected that edema improved and that as per the staff the resident's meal consumption was less than 25% and sometimes refused meals but consumed 100% of the supplements. The RD indicated that she would increase the supplements from three to four times per day and continue to monitor weights and intake of meals and supplements. A Dietary note dated 12/25/24 at 9:54 AM, reflected the resident continued to have poor intake of facility meals and enjoyed food brought by family when they visited. Also, per nursing, the resident was taking the supplements well which was increased to four times a day on 12/3/24 (which was not evidenced in the OSR or MAR). The RD also documented that the resident did not have a history of diabetes and therefore requested the diet be liberalized to a regular not a diabetic diet and the same for the supplements. A Dietary note dated 1/2/25 at 11:47 AM, reflected the resident's weight was 107.5 lbs. which reflected a gradual four pound weight loss over one month, a significant weight loss of 11.5 lbs./9.7% over three months and a 20.5 lb./16% significant weight loss over six months, all of which were undesired. The RD included that on 12/27/24, the diet was liberalized to regular, and the supplement was changed to a regular House Supplement 237 ml to four times a day. She included that the resident had variable intake of facility meals and enjoyed food brought by the family. Intake of supplements was 100% and that nursing requested the physician order a medication to stimulate the appetite. In addition, it reflected the RD would continue to monitor the resident's weight and intake of meals and supplements. There was no documented evidence that the RD implemented interventions related to the residents insidious and significant weight changes since the 2/2/24, Dietary progress note until December 2024 (10 months later). A Nursing Progress Note dated 1/1/25 at 12:40 PM, reflected the resident did not eat breakfast or lunch and only consumed the House Supplement in the morning and at lunch. In addition, the resident's daughter and physician were notified. A Nursing Progress Note dated 1/3/25 at 9:16 PM, reflected the resident had a poor appetite and consumed 25% of their meals. A Nursing Progress Note dated 1/5/25 at 3:40 PM, reflected the physician ordered a medication to stimulate the appetite for Resident #67. A Nursing Progress Note dated 1/7/25 at 3:21 PM, reflected the resident refused lunch despite two attempts. The resident did consume 90% of the House Supplement and the resident's daughter and physician were notified. On 1/07/25 at 1:07 PM, the surveyor interviewed the RD in presence of survey team. She stated that she was aware that the resident had weight loss but was not sure of the details. She stated that there were no alternate Korean meals available if a resident refused a meal; there was only American items available. The RD stated that if a resident was not eating, she would order supplements. She stated a House Supplement was either Ensure Plus or Boost Plus. The RD acknowledged that she should have tried foods first. The RD stated that when she obtained food preferences, she relayed that information to the kitchen and ensured the resident received them via meal rounds. The RD stated that the family brought in food; however, she could not speak to how often or what foods. In addition, she stated that the facility had fortified foods which were calorically dense and served as a nutritional intervention to abate and/or reverse unplanned weight loss. She could not answer why fortified foods were not tried for Resident #67; such as Super Cereal as that was a calorically dense hot cereal that could have replaced the hot cereal the resident received each morning. In addition, the RD could not answer why she did not try a calorically dense juice to replace the resident's regular juice which the resident enjoyed. Furthermore, she could not answer why the resident was not ordered a multivitamin and mineral supplement since their meal intake was inadequate. The RD stated she would have to get back to the surveyor regarding what interventions she put into place for the resident's weight loss which was now significant. She could not answer why the resident was not placed on weekly weights for closer monitoring. On 1/09/25 at 9:52 AM, the survey team met with the administrative team: the DON, the Regional DON, the Assistant DON (ADON), the Licensed Nursing Home Administrator (LNHA) and the Regional LNHA. The LNHA stated the RD would not be available for a follow up interview since she had an emergency. The administrative team acknowledged that residents and families were made aware that the always available meal substitute items were from the American menu and acknowledged that residents on the Korean unit received American breakfast. The administrative team stated that the residents supplement was changed from Glucerna to Ensure Plus on 12/3/24. The LNHA stated that his expectation was that the RD would have identified weight losses and the causation, update food preferences, reassess, implement interventions and follow up. The DON stated she could not answer whether the RD did this for Resident #67. She provided the surveyor with documentation that the resident was discussed at the November and December 2024 monthly weight meetings. She also stated that the resident should have been on weekly weights for closer monitoring. The Regional LNHA stated that when he spoke to the RD, she stated that she had interviewed the resident, but did not document the conversations. In addition, he stated that the RD indicated that the family provided cueing at meals which increased the resident's meal consumption. Furthermore, he acknowledged that if the resident's family was visiting every three to four weeks, the facility could not rely on food brought from home or the family member cuing as nutrition interventions. The ADON stated that the physician was aware of the weight loss and ordered an appetite stimulant medication on 1/5/25. The LNHA stated that the resident's weight losses should have been addressed by the RD or Consultant RD, and that he was ultimately responsible to ensure the RD had addressed the weight losses appropriately. A review of the Korean units four-week menu cycle reflected that one meal choice was available for lunch and dinner. A review of a recipe for the fortified food Super Cereal, reflected that a portion size of this hot cereal would have provided 511 calories and 11 grams of protein. A review of an unsigned and undated job description for Dietitian, reflected that job responsibilities included but were not limited to; provide substitute foods of similar nutritive value to resident's who refuse foods served, interview residents or family members as necessary to obtain diet history, participate in maintaining records of the residents food likes and dislikes, visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc., involve the resident's/family in planning dietary objectives and goals for the resident, and assist in developing diet plans for individual residents. NJAC 8:39-11.2(e)(2), 17.1(c), 17.4(a)(1), 27.1(a)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's Registered Dietitian (RD) reviewed and approved the menus (American and Korean) for nutritional adequacy and in accordance with nationally accredited standards, and b.) residents received care planned and physician ordered fortified foods for 3 of 3 residents (Resident's #41, 71 and 118) reviewed for food. The deficient practice was evidenced by the following: 1. On 1/2/25 at 9:46 AM, two surveyors toured the kitchen with the Food Service Director (FSD), the Regional RD and the Assistant Licensed Nursing Home Administrator (ALNHA). At that time, the FSD stated that the facility followed a three-week cycle menu (a menu prepared in advance which was repeated after three weeks). On 1/2/25 at 10:38 AM, the surveyor met with the facility Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Assistant DON (ADON). At that time, the LNHA informed the surveyor that their East Wing was the unit where their Korean population resided. On 1/2/25, the FSD provided the surveyor with a copy of the American three-week cycle menus dated 12/22/24, 12/29/24 and 1/5/25. In addition, he provided the surveyor with a copy of menu extensions (listed portion sizes and substitutions based on physician prescribed diets) for week three dated 12/29/24 and week one dated 1/5/25. These extensions indicated that residents should be served a four-ounce portion of milk for lunch and dinner. Furthermore, the FSD provided the surveyor with copy of the undated Korean four-week cycle menus, which did not include beverages or the breakfast meal. None of the seven menus provided were signed and dated by the RD to ensure they were reviewed for adequacy. On 1/3/25 at 11:06 AM, the surveyor met with six residents for the resident council meeting. Six of six residents stated that sometimes they received food items on their trays that did not match the meal ticket (with listed meal items and preferences). On 1/7/25 at 1:07 PM, the surveyor interviewed the RD, in the presence of the survey team. The RD stated that the Food Service Department developed the American menus and she looked at them for nutritional adequacy by ensuring there was a protein, starch and vegetable. The RD stated that she chose to be more clinical and did not really get involved with the menu extensions. At this same time, the RD stated that she was unaware of who developed the Korean menus, nor did she know who reviewed and approved them to ensure they were nutritionally adequate. On 1/7/25 at 2:14 PM, the surveyor interviewed the FSD, who stated the RD reviewed the American menus for adequacy and signed them; however, no one reviewed the Korean menus for nutritional adequacy. On 1/8/25 at 9:26 AM, the surveyor interviewed the FSD, in the presence of a second surveyor. The FSD provided the surveyor a Diet Manual (the 7th Edition), dated 2018 for review. The Diet Manual of the Dietetics in Health Care Communities of New Jersey (Compiled by a Committee of RD's) included the purpose of the Regular diet was to provide a variety of foods to meet nutritional needs of individuals. The Diet Manual further reflected that This diet is nutritionally adequate in all nutrients when planned according to Dietary Reference Intakes, established by the Food and Nutrition Board; Institute of Medicine, USDA Dietary Guidelines for Americans 2015-2020. These are consistent with the USDA Dietary Guidelines for Americans 2020-2025. It included that an eight-ounce portion of milk should be served at lunch and dinner. On 1/8/25 at 12:33 PM, the surveyor observed the lunch trays on both the Korean wings and the North wing (American menu). The surveyor observed the trays on both wing with four-ounce portions of milk which was reflected on the menu. On 1/9/25 at 9:52 AM, the survey team met with the Regional LNHA, LNHA, DON, Regional DON and the ADON. The Regional LNHA stated that the menus should have been reviewed by the RD or the consultant RD for nutritional adequacy. He further acknowledged that the menus were not reviewed by an RD for this building. The LNHA stated he was ultimately responsible. 2. On 01/02/25 at 11:31 AM, the surveyor observed Resident #41 in bed, awake and alert. The resident offered no concerns or complaints. On 1/08/25 at 11:04 AM, the surveyor interviewed the resident in their room. The resident stated that they disliked fish but enjoyed shellfish (shrimp) and did not like meat other than chicken. A review of the Admission Record (an admission summary) reflected Resident #41 had diagnoses that included but were not limited to; hypertension (high blood pressure), dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (lung disease that block airflow and make it difficult to breathe.) A review of the quarterly MDS (Minimum Data Set), a tool to facilitate the management of care dated 12/6/24, reflected a Brief Interview of Mental Status (BIMS) score of 9 out of 15, which indicated an impaired cognition. A review of the comprehensive care plan included a Nutrition care plan initiated on 5/9/23, which included to honor the resident's food preferences as needed and to provide fortified (provided additional calories and protein) pudding four ounces twice a day. A review of the Medication Review Report reflected a physician's order (PO) dated 12/2/24, for a four-ounce fortified pudding twice a day. A review of the Nutritional assessment dated [DATE], reflected the resident disliked fish, including tuna but liked shrimp. In addition, the RD noted she recommended fortified pudding twice a day to prevent weight loss. A review of the list of labeled snacks the FSD provided to the surveyor on 1/2/25, did not include fortified puddings for the resident. A review of the resident's breakfast, lunch and meal tickets dated 1/7/25 did not include fortified pudding twice a day or the food preferences of disliking fish but liked shellfish (shrimp) and did not like meat other than chicken which the resident verbalized to the surveyor on 1/8/25. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/9/25, did not include fortified pudding twice a day. A review of the resident's breakfast, lunch and dinner meal tickets for 1/10/25, included fortified pudding twice a day after multiple surveyor inquiries. 3. On 01/02/25 at 11:38 AM, the surveyor observed Resident #71 in their room sitting in a chair, awake and alert. The resident offered no concerns or complaints. A review of the Admission Record reflected Resident #71 had diagnoses that included but were not limited to; hypertension, moderate protein-calorie malnutrition, and chronic obstructive pulmonary disease. A review of the quarterly MDS dated [DATE], reflected a BIMS score of 7 out of 15, which indicated a severely impaired cognition. A review of the comprehensive care plan included a Nutrition care plan initiated on 1/26/21, which reflected to provide fortified pudding at lunch and dinner - preferred vanilla. A review of the Medication Review Report reflected a (PO) dated 9/3/24, for a four-ounce fortified pudding twice a day preferred vanilla as available. A review of the Nutritional Assessment (quarterly) dated 11/7/24, reflected the resident received fortified pudding twice a day. A review of the list of labeled snacks the FSD provided to the surveyor on 1/2/25, did not include fortified puddings for the resident. And a review of the resident's breakfast, lunch and meal tickets dated 1/7/25, did not include fortified pudding twice a day. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/9/25, did not include fortified pudding twice a day. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/10/25, included fortified pudding twice a day at lunch and dinner after multiple surveyor inquiries. Furthermore, it did not reflect the resident's preference for vanilla. 4. On 1/2/25 at 11:13 AM, the surveyor observed Resident #118 sitting in a wheelchair in the day room with their eyes closed. On 1/3/24 at approximately 12:40 PM, the surveyor observed the resident eating lunch in the dayroom. The pureed meal intake was approximately 25% completed and when the surveyor inquired if the resident was hungry or had an appetite, the resident shook their head no. A review of the Admission Record reflected they had diagnoses that included but were not limited to; unspecified dementia, dysphagia and depression. A review of a significant change MDS dated [DATE], reflected the resident had a short- and long-term memory problem with moderate impairment of cognitive skills for daily decision making. A review of the comprehensive care plan included a Nutrition care plan initiated on 2/9/24, which reflected to honor the resident's food preferences which included lactose free milk, disliked tomatoes but liked tomato sauce and hot sauce. A review of the Order Summary Report reflected a PO dated 8/31/24, for a super mashed potatoes at lunch and dinner two times a day. A review of the RD progress note dated 8/23/24, reflected the resident was lactose intolerant and would be provided lactose free milk per the resident's preference. A review of the RD progress note dated 9/9/24, 9/25/24, 10/2/24, 10/15/24, and 12/6/24 reflected the resident recieved super mashed potatoes at lunch and dinner. A review of the list of the resident's breakfast, lunch and meal tickets dated 1/6/25, did not include super mashed potatoes for lunch and dinner or the noted preferences. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/9/25, did not include super mashed potatoes for lunch and dinner. A review of the resident's breakfast, lunch and dinner meal tickets dated 1/10/25, included super mashed potatoes for lunch and dinner after multiple surveyor inquiries. Furthermore, it did not reflect the residents' preferences for lactose free milk, disliked tomatoes but liked tomato sauce and hot sauce. On 1/7/25 at 1:07 PM, the surveyor interviewed the RD in the presence of the survey team. The RD stated when she recommended a resident to receive fortified food, she would give that request in writing to the nurse via a diet slip and nursing then contacted the physician for a PO. Then nursing sent a diet slip to the FSD. She then stated the Electronic Medical Record (EMR) was linked to the Food Service software program which automatically populated the information to the resident's meal tickets. The RD also stated that when she updated residents' food preferences, she provided that information to the FSD via a diet slip and when she conducted meal rounds, she ensured the residents received the accurate items. During this same interview, the surveyor reviewed the meal tickets and labeled snacks for Resident #41, #71 and #118. She could not speak to why Resident #41's food preferences related to fish nor the PO for fortified pudding twice a day was not provided. She acknowledged the same for Resident #71. Furthermore, she stated she had just mentioned this yesterday to the kitchen. She stated when she was in the kitchen during the tray line process (items are placed on the trays in accordance with the resident's diet order, menu, food and beverage preferences and POs for fortified foods), she observed that the fortified pudding was not listed on Resident #71's meal ticket. In addition, the RD stated I just told them to add it; however, she could not speak to who them was and why she did not follow up. The RD also acknowledged that Resident #118's food preferences and PO for super mashed potatoes for lunch and dinner were not listed on the meal tickets. The RD stated that in relation to these discrepancies, she would get on that right away. The RD stated that she had no formal way to ensure recommendations she made for a fortified food PO and/or updated food preferences for residents were carried out and accepted. On 1/7/25 at 2:14 PM, the surveyor interviewed the FSD. He stated that the facility's EMR was linked to the FS software program and when there was a new or readmitted resident or a change in diet or supplements, it automatically populated to the kitchen software program. In addition, he stated that he also received a diet slip (written communication) from the RD or nursing, when the resident had a change in food preferences and that would be added or changed manually in the FS software system. On 1/9/25 at 9:52 AM, the LNHA stated to the survey team that the RD had an emergency and would be unavailable for any follow up interviews. In addition, he acknowledged that he would have expected the RD to follow up on her recommendations and to have an audit and follow up system in place. A review of an undated facility Job Description for the Dietitian included the following responsibilities: -Ensure that menus are maintained and filed in accordance with established policies and procedures. -Visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc. -Assist in planning regular and special diet menus as prescribed by the attending physician. -Review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders. -Develop, implement, and maintain and ongoing quality assurance program for the Dietary Department. A review of an undated facility policy Nutritional Procedure, reflected that all residents should receive appropriate nutrition tailored to their individual health needs and food preferences for overall health and quality of life. In addition, it included to maintain accurate and current records of all assessments, care plans, and residents' food preferences. A review of an undated facility policy Interdisciplinary Care Planning Protocol, reflected that dietary should include an overview of their assessments of the residents needs and problems, which should be specific and individualized. NJAC 8:39-17.1 (b), 17.2 (a), 17.4 (a) (1) (3) (e)

Based on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure the designated Infection Preventionist (IP) was dedicated solely to the infection prevention and control program (IPCP) from 8/9/24 and ongoing. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health Executive Directive No 20-026-1 dated October 20, 2020, revealed the following: ii. Required Core Practices for Infection Prevention and Control: Facilities are required to have one or more individuals with training in infection prevention and control employed or contracted on a full-time basis or part-time basis to provide on-site management of the Infection Prevention and Control (IPC) program. The requirements of this Directive may be fulfilled by: a. An individual certified by the Certification Board of Infection Control and Epidemiology or meets the requirements under N.J.A.C. 8:39-20.2; or b. A Physician who has completed an infectious disease fell owship; or c. A healthcare professional licensed and in good standing by the State of New Jersey, with five (5) or more years of Infection Control experience. iv. Facilities with 100 or more beds or on-site hemodialysis services must: 1. Hire a full-time employee in the infection prevention role, with no other responsibilities and must attest to the hiring no later than August 10, 2021. On 1/07/25 at 11:07 AM, the surveyor interviewed the Infection Preventionist (IP), who indicated that she was also the acting Unit Manager on the North wing since August 2024. When asked how she splits her time, she stated that she usually spends an hour to an hour and half each day on her IP duties and the majority of her days is spent on her UM duties. She also stated that she felt it was enough time. Review of facility provided job description for Infection Control Preventionist, revised 5/10 included: Position Summary: The IP Nurse takes the management lead over infection Prevention of the facility by directing and supervising and coordination of all services and assist the DON/ADON with the managerial and clinical activities of units assigned. Position Action Form, provided by the facility, dated 8/9/24, reflected that previous Unit Manager's last day of work was 8/9/24. On 1/08/25 at 03:06 PM, the surveyor interviewed the VP of corporate clinical, who stated that the IP is a part time position, and that the acting UM position was temporary. She also stated that the IP/UM was up to date on everything, both her IP and her UM duties. She has a desk nurse to assist her with the UM work. When asked if eight hours was enough for IP? The VP of corporate clinical stated she was not sure why the IP/UM said that as it is a 20 hour position and she is well aware of that. On 1/09/25 at 09:53 AM, the surveyor interviewed the Director of Nursing, who stated the IP was up to date with infection control and the building was not affected negatively. NJAC 8:39-19.1(b)

Based on observation and interview, it was determined that the facility failed to maintain the residents' environment and living areas in a sanitary and homelike manner. This deficient practice was identified for 2 of 6 residents (Resident #90 and Resident #125) having lunch in the East Unit Sunshine Room in wheelchairs or recliners and 1 of 2 residents (Resident #124) utilizing overbed tables. This deficient practice was evidenced by the following: 1.On 1/02/25 at 11:10 AM, the surveyor observed Resident #90 out of bed, in a recliner in the Sunshine Room. A bead [NAME] activity center was noted on an overbed table in front of the resident. The resident was noted with closed eyes. No distress was noted. On 1/06/25 at 12:07 PM, the surveyor observed facility staff sitting next to Resident #90 in the Sunshine Room providing verbal cues/assisting as needed with lunch. The surveyor observed Resident #90's recliner with dried brown substances on sides of recliner. A review of the admission record reflected that Resident #90 had diagnoses included but not limited to; dementia and diabetes. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, dated 11/13/24, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. On 1/07/25 at 12:05 PM, the surveyor observed Resident #90 in the Sunshine Room. The resident's recliner was observed with dried brown substances on the sides of recliner. When the Unit Manager was asked about it, she stated that's a hospice chair and another staff member present in the room at that time stated, the resident spits all the time. 2. On 1/06/25 at 12:08 PM, the surveyor observed Resident #125 in the Sunshine Room. The resident was being assisted with lunch by a staff member. The surveyor observed Resident #125's wheelchair with dried brownish, white substances on the resident's left wheel of the wheelchair. A review of the admission record reflected that Resident #125 had diagnoses that included but not limited to; dementia and hyperlipidemia (high cholesterol). A review of the most recent quarterly MDS, dated [DATE], reflected that the resident had a BIMS score of 3 out of 15, indicating severely impaired cognition. On 1/07/25 at 12:05 PM, the surveyor observed Resdient #15 in the Sunshine Room. The surveyor observed the wheelchair with dried brownish, white substances all over the left wheel of the wheelchair. The surveyor showed the wheelchair to the Unit Manager, who stated she would text housekeeping and they'll come do it right after lunch. 3. On 1/02/25 at 11:13 AM, the surveyor observed Resident #124 in a wheelchair in the Sunshine Room. The resident was doing a large piece puzzle. A review of the admission record reflected that Resident #124 had diagnoses that included but not limited to; dementia and diabetes. A review of the most recent quarterly MDS, dated [DATE], indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severely impaired cognition. On 01/07/25 at 12:12 PM, the surveyor interviewed the Unit Manager, who stated there was a schedule for wheelchair and recliner cleaning. She also stated housekeeping usually does them and that they were just cleaned in the last 2 weeks. She further stated that if the chairs were dirty, we tell them (housekeeping) and they clean them as soon as possible. On 1/08/25 at 8:18 AM, during observation of tube feeding administration, the surveyor observed Resident #124's bottom of their overbed table with multiple dried brownish spots. The Licensed Practical Nurse (LPN) stated that housekeeping was in charge of cleaning overbed tables. The LPN acknowledged that the overbed table bottom was not clean. On 1/08/25 at 9:06 AM, the surveyor interviewed a housekeeper, who stated she cleans the bathroom first, then the room, including the overbed table. The Director of Housekeeping (DH) joined the interview and stated they generally clean five wheelchairs and recliners a week. He explained in the nice weather they are taken outside and cleaned with the power washer. He went on to explain that now (winter) it's harder, and they are taken into the shower room to clean. On 1/08/25 at 10:12 AM, the surveyor conducted rounds with the DH. The DH acknowledged Resident # 90's recliner with the brownish substances on the side and stated, that's a rental chair. When asked if they clean rental chairs, he stated they do. The DH acknowledged Resident #125's wheelchair with the brownish substances on the left wheel. The DH acknowledged Resident #124's overbed table with brownish substances on the bottom and stated, I'll have them scrape that. A review of facility provided policy Wheelchair and Geri Chair Cleaning, undated, included: Policy: The policy for this facility and the Environmental Services Director is to ensure the scheduling of each chair for cleaning at least once a month. Schedule: Weekly wheelchair schedule is as follows: Monday, East Wing, Rooms 100 through 131 A review of facility provided cleaning calendar for January 2025 showed one room for each wing on each day ex. [DATE] has rooms [ROOM NUMBER]. On 1/09/25 at 9:53 AM, the surveyor interviewed the Regional Licensed Nursing Home Administrator, who stated that regarding wheelchair cleaning they typically follow the policy on the schedule and adjusted it on a as needed basis. He also stated that they listen to the residents and pay attention to details, to make sure everyone is in a safe and comfortable environment. He further stated that if they observe a chair that needs cleaning, they follow policy, but sometimes the needs of the building overrule. The chairs are cleaned on an as needed basis. N.J.A.C. 8:39-31.4(a)(c)(f)

Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report and initiate an investigation for an injury of unknown origin in accordance with their abuse and neglect policy until surveyor inquiry. This deficient practice was identified for one (1) of one (1) resident reviewed for abuse (Resident #47), and was evidenced by the following: On 1/2/25 at 10:44 AM, the surveyor observed Resident #47 in bed. The resident had a line down the bridge of their nose with a reddish/brown colored marking and a dried scab. The surveyor attempted to interview the resident but the resident was not responding to the surveyor. On 1/3/25 at 9:00 AM, the Director of Nursing (DON) provided the surveyor with two investigations for Resident #47 from August 2024 and October 2024. The DON verified that there were two investigations in the past six (6) months and no other investigations. A review of the two investigations for Resident #47 revealed that there was no investigation regarding a marking on the resident's nose. On 1/3/25 at 12:54 PM, the surveyor interviewed the Certified Nursing Assistant (CNA#1), who stated that she had worked at the facility for less than two months and was familiar with Resident #47. CNA#1 stated that she had cared for the resident yesterday but that another CNA (CNA#2) had fed the resident that day. CNA#1 added that she had seen a mark on the resident's nose and thought it was always there. CNA#1 also stated that she had not told anyone regarding the mark on the resident's nose. On 1/3/25 at 12:59 PM, the surveyor interviewed CNA#2, who stated that she had started working at the facility yesterday and had cared for Resident #47 that morning. CNA#2 stated that she had seen the mark on the resident's nose but thought the staff already knew about it and had not told anyone. On 1/3/25 at 1:01 PM, the surveyor interviewed the acting Unit Manager/Infection Preventionist/Licensed Practical Nurse (UM/IP/LPN), who stated that she was unaware of a mark on Resident #47's nose. At that time, the surveyor with the UM/IP/LPN, observed Resident #47 in their room in bed. The UM/IP/LPN acknowledged that there was a marking on the resident's nose that looked like a scratch. The UM/IP/LPN was able to interview the resident in the presence of the surveyor. The resident shook their head yes when asked if there was a scratch on their nose. The UM/IP/LPN asked the resident how the scratch occurred, and the resident stated, I was trying to make it shiny. The UM/IP/LPN stated that a risk management report would have to be completed. The UM/IP/LPN added that the CNAs were to report any skin issues to the nurses and thought maybe the medication nurse was aware. The UM/IP/LPN could not speak to why the CNAs or nurse had not reported to her the scratch on Resident #47's nose. The surveyor reviewed the medical record for Resident #47. A review of the Admission Record revealed diagnoses of but not limited to; schizophrenia (a disorder that affects ability to think, feel, and behave clearly) and an unspecified mood (affective) disorder. A review of the most recent quarterly comprehensive Minimum Data Set, an assessment tool used to facilitate the management of care dated 12/11/24, reflected the resident had a brief interview for mental status score of 12 out of 15, indicating that the resident had a moderately impaired cognition. A review of the resident's individualized plan of care (IDPC) revealed a focus area Resident #47 has an ADL (activities of daily living) deficit related to: [They] requires assistance with ADL's in transfers, dressing, bed mobility, bathing/showering, toileting, eating and mobility. With an initiated date of 6/13/22 and revised date of 12/10/24. Another focus area Resident #47 has an alteration in skin integrity and requires EBP (enhanced barrier protection-gown and glove use during high contact procedures) 1. Sacrum, 2. 10/09/24-DTI (deep tissue injury) Right lateral Fifth Toe. with an initiated date of 10/25/23 and revision date 12/31/24. A review of the resident's Body Check assessments dated 12/3, 12/6, 12/12, 12/17, 12/20, 12/26, 12/27 for December 2024 revealed that there were no new identified areas that were previously identified. On 1/6/25 at 12:45 PM, the DON provided the surveyor with an investigation titled Self-inflicted report for the unwitnessed scratch on Resident #47's face that was completed on 1/3/25 at 1:17 PM by a Registered Nurse (RN#1). The report included an unwitnessed incident description of Alerted by CNA that resident has a scratch on [their] nose. Resident stated to this writer My nose was itchy I did scratch myself. In addition, the report included employee statements from 1/2/24 and 1/3/24. The employee statements indicated that they had not seen a mark on the resident's nose except for the statements of CNA#1 and CNA#2 that included that they had seen a mark. On 1/6/25 at 12:47 PM, the surveyor interviewed the Licensed Practical Nurse (LPN#1) who stated that she was familiar with Resident #47. LPN#1 also stated that the resident speaks slowly and sometimes does not respond to unfamiliar faces. LPN#1 introduced Resident #47 to the surveyor and left the room. On 1/6/25 at 12:57 PM, the surveyor interviewed Resident #47, who stated that they had scratched their nose and that the nurse put medicine on it. The resident was unable to speak to when they had scratched their nose but felt that their nails were short enough and felt safe in the facility. On 1/7/25 at 9:15 AM, the surveyor interviewed the UM/IP/LPN who stated that CNA#2 was training with CNA#1 on 1/3/25. On 1/7/25 at 10:17 AM, the Assistant Director of Nursing (ADON) provided the staff education that was completed for CNA#1 and CNA#2. A review of the staff education for CNA#1 revealed a Zero Tolerance for Abuse and neglect undated form describing What is Abuse? signed by the CNA#1. In addition, a Resident Abuse quiz dated 12/10/24 completed by CNA#1 with a question All injuries or conditions below can suggest physical abuse except: A. Bruises, B. A runny nose, C. A broken bone, D. Burns and the CNA#1 correctly answered, B. A runny nose. A review of the staff education for CNA#2 revealed a Zero Tolerance for Abuse and neglect undated form describing What is Abuse? signed by the CNA#2. In addition, a Resident Abuse quiz dated 1/2/25 completed by CNA#2 with a question All injuries or conditions below can suggest physical abuse except: A. Bruises, B. A runny nose, C. A broken bone, D. Burns and the CNA#2 correctly answered, B. A runny nose. On 1/8/25 at 9:38 AM, the surveyor interviewed the ADON who stated that she reviewed Abuse training with all new employees and explains to report any skin impairments to the nurse immediately. The ADON also stated that usually a new orientee CNA will work alongside a seasoned CNA. The ADON could not speak to why CNA#1 who had worked at the facility approximately less than two months was training CNA#2. The ADON added that she thought CNA#1 and CNA#2 had worked as CNAs prior to coming to the facility. On 1/8/25 at 9:56 AM, the surveyor interviewed RN#1, who verified that she was the medication nurse and had completed the Self-inflicted report for Resident #47 on 1/3/24 and wrote the description Alerted by CNA that resident has a scratch on [their] nose. Resident stated to this writer My nose was itchy I did scratch myself. RN#1 stated that she was told by CNA#2 about the scratch on the resident's nose after surveyor inquiry. RN#1 added that she had not seen the scratch prior to CNA#2 making her aware. RN#1 acknowledged that she had spoken to the resident after the UM/IP/LPN was in the resident's room with the surveyor. Further review of the resident's medical record revealed that there was no Body Check assessment completed from 12/27/24 until after surveyor inquiry. On 1/8/25 at 12:09 PM, the surveyor interviewed the UM/IP/LPN, who stated that body checks were performed on shower days and Resident #47 had a shower schedule of Tuesday and Friday. The UM/IP/LPN stated that on 12/31/24 the resident had a bed bath completed and could not speak to why there was no Body Check form completed. The UM/IP/LPN stated that a body check was to be performed on shower days whether the resident received a bed bath or even refused to be bathed. The UM/IP/LPN added that on 1/1/25 the resident was seen by a physician for a wound consult. On 1/8/25 at 2:37 PM, the survey team met with the facility administrative team. The DON stated that staff were to report to a nurse immediately any time there was a new skin impairment on a resident. The DON added that an investigation was completed, and the CNAs were educated to report immediately any skin issues. A review of the facility policy dated 3/18/2024 Prohibition of Resident Abuse & Neglect provided by the Licensed Nursing Home Administrator revealed Any witness, alleged, or suspected violations involving mistreatment, neglect or abuse. Including injuries of an unknown source and misappropriation of resident property, MUST BE REPORTED IMMEDIATELY TO THE EMPLOYEE'S SUPERVISOR. NJAC 8:39-4.1(a)(5), 13.4(c)(ii), 27.1(a)

REFER to F759 Based on observation, interview, and record review, it was determined that the facility failed to follow acceptable professional standards of clinical practice by borrowing a medication (Lidocaine 4% patch) from another resident's supply. The deficient practice was identified for one (1) of three (3) nurses observed during medication administration for one (1) of six (6) residents, (Resident #122). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 1/3/25 at 8:59 AM, during the morning medication administration pass, the surveyor observed Registered Nurse (RN#1) at the door of Resident #122's room with the medication cart. RN#1 stated that she was about to administer the resident's eye drops and patches. RN#1 showed the surveyor the container of eye drops and two (2) packages of Max Strength Aspercreme with 4% Lidocaine pain relief patch (a topical patch used for pain relief) that was on the resident's overbed table. The RN#1 stated that the resident had physician's orders (PO) for the Lidocaine patches to be applied to two (2) different sites, the right shoulder and the left shoulder. Upon returning to the medication cart, RN#1 showed the surveyor the electronic medication administration record (EMAR) which revealed a PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to left shoulder topically one time a day for pain and remove per schedule. In addition, another PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to right shoulder topically one time a day for pain and remove per schedule. After RN#1 acknowledged that she had administered the wrong strength of Lidocaine, she stated that Resident #122 had no Lidocaine patches in the medication cart and she had to borrow both Lidocaine patches from another resident. RN#1 then showed the surveyor a box of Max Strength Aspercreme with 4% Lidocaine pain relief patch labeled by the provider pharmacy for an unsampled resident that she had removed the two Lidocaine 4% patches to use for Resident #122. The surveyor reviewed the Order Summary Report for the unsampled resident and verified that there were active physician's orders (PO) with a start date of 11/13/24 for Lidocaine External Patch 4% (Lidocaine) Apply to left knee topically in the morning for pain and remove per schedule and Lidocaine External Patch 4% (Lidocaine) Apply to lower back topically in the morning for pain and remove per schedule. On 1/3/25 at 10:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that she was responsible for nursing staff education. The ADON stated that nurses were not allowed to borrow any medications from another resident. The ADON stated that Lidocaine 5% patches were provided by the provider pharmacy and if the 5% patch was not available then the nurse would have to call the provider pharmacy to see why the medication was not available and the nurse would also have to call the physician for a follow up order as to what she should do. The ADON also stated that the facility had Lidocaine 4% patches as a house stock over the counter medication meaning that the facility had stock available for any resident that had a PO. The ADON added that some residents do get the Lidocaine 4% patches from the pharmacy if the insurance paid for them. The ADON stated that she would have to look into why the Lidocaine 5% was not available. On 1/3/25 at 1:27 PM, the surveyor interviewed the ADON who stated that she was unsure why the Lidocaine 5% patches were not available for Resident #122, but the nurse should not have borrowed Lidocaine patches from another resident. On 1/6/25 at 12:12 PM, the surveyor, with the Director of Nursing (DON), reviewed the EMAR for Resident #122. The DON explained that the RN#1 had not signed that she administered the Lidocaine 5% patches to the left and right shoulders because RN#1 had realized she had applied the wrong strength and had obtained a one-time PO for the 4% patch. The DON added that there should be documentation indicating what RN#1 had done. The DON stated that the nurses were not to borrow medications but was unsure if there was a policy. A review of the resident's nursing progress notes dated 1/3/25 at 11:36 AM completed by RN#1 revealed Notified MD for lidocaine patch. New ordered received and carried out. On 1/6/25 at 12:45 PM, the surveyor interviewed the DON, who stated that there was no policy regarding borrowing of medications. On 1/6/25 at 2:16 PM, the surveyor interviewed the Consultant Pharmacist (CP), via the telephone, who stated that she had been the CP for a while. The CP stated that the nurses cannot borrow any medications from another resident. The CP added that if the Lidocaine 5% patch was not available then the nurse should have called the physician for a follow-up order as to what to do. The CP added that she tells the nurses during her inservices and medication passes that they cannot borrow medications and that can lead to a medication error. NJAC 8:39-11.2(b), 29.2(a)(d), 29.3(5)(6)

REFER to F658 Based on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the morning medication administration observation on 1/3/25, the surveyor observed three (3) nurses administer medications to six (6) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.4%. The deficient practices were identified for one (1) of six (6) residents, (Resident #122), that were administered medications by one (1) of three (3) nurses that were observed. The deficient practices were evidenced by the following: On 1/3/25 at 8:59 AM, during the morning medication administration pass, the surveyor observed Registered Nurse (RN#1) at the door of Resident #122's room with the medication cart. RN#1 stated that she was about to administer the resident's eye drops and patches. RN#1 showed the surveyor the container of eye drops, and two (2) packages labeled Max Strength Aspercreme with 4% Lidocaine pain relief patch (a topical patch containing Lidocaine used for pain relief) that were on the resident's overbed table. RN#1 stated that the resident had physician's orders (PO) for the Lidocaine patches to be applied to two (2) different sites, the right shoulder and the left shoulder. At that time, the surveyor observed RN#1 open each Lidocaine 4% patch package and wrote the date on the patch and then applied one patch to the left shoulder and one patch to the right shoulder. The surveyor obtained one of the empty Lidocaine 4% patch packages for review. RN#1 then spoke to Resident #122 in the resident's language. The surveyor observed the resident smiling and lifted both elbows halfway up in the air and then back down. RN#1 translated for the surveyor and stated that the resident had said that they felt that the pain was improving. Upon returning to the medication cart, RN#1 showed the surveyor the electronic medication administration record (EMAR) which revealed a PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to left shoulder topically one time a day for pain and remove per schedule. In addition, another PO dated 9/29/24 for Lidocaine External Patch 5% (Lidocaine) Apply to right shoulder topically one time a day for pain and remove per schedule. The surveyor then showed RN#1 the empty package of the Lidocaine patch which revealed the strength of 4%. RN#1 acknowledged that the Lidocaine 4% patches that she had applied to each site was not the 5 % strength that was ordered. The RN#1 stated, I gave the wrong amount. (ERROR #1 and ERROR #2) The surveyor reviewed the medical record for Resident #122. A review of the Admission Record revealed diagnoses that included, but not limited to, dementia and a history of falling. A review of a comprehensive quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 11/27/2024, reflected the resident had a brief interview for mental status (BIMS) score of five (5) out of 15, indicating that the resident had a severely impaired cognition. A review of the Order Summary Report revealed two active PO's with a start date of 9/30/24 for Lidocaine External Patch 5% (Lidocaine) Apply to left shoulder topically one time a day for pain and remove per schedule and Lidocaine External Patch 5% (Lidocaine) Apply to right shoulder topically one time a day for pain and remove per schedule. On 1/3/25 at 10:47 AM, the surveyor interviewed the Assistant Director of Nursing (ADON), who stated that she was responsible for nursing staff education. The ADON stated that Lidocaine 5% patches were provided by the provider pharmacy and if the 5% patch was not available then the nurse would have to call the provider pharmacy to see why the medication was not available and the nurse would also have to call the physician for a follow up order as to what she should do. The ADON stated that the Consultant Pharmacist (CP) had provided information on Med Pass and would provide a med pass that was completed for RN#1. On 1/3/25 at 12:11 PM, the ADON provided the surveyor with a completed medication pass for RN#1 and an inservice on Medication Pass that had been completed for the nurses. The ADON stated that she was aware RN#1 did not have Lidocaine 5% patches for Resident #122 and thought RN#1 had called the physician. A review of a Medication Pass Observation dated 3/25/24 for RN#1 completed by the CP revealed that there were no errors observed and that the correct drug, correct amount, correct dosage form was administered during that medication pass observation. A review of the Inservice Log dated 9/25/24 for Med Pass completed by the CP revealed that RN#1 was in attendance. On 1/3/25 at 1:27 PM, the surveyor interviewed the ADON, who acknowledged that she spoke with RN#1, and she had administered the wrong dose of Lidocaine patch to each site. The ADON added that the physician was called and allowed the Lidocaine 4% patches. The ADON added that there may have been a problem with insurance and was unsure why the Lidocaine 5% patches were not available. On 1/6/25 at 12:12 PM, the surveyor, with the Director of Nursing (DON), who stated that she was unaware that the surveyor had shown the RN#1 the strength of the two patches that had been applied on the resident's shoulders was not 5% as ordered. The DON verified that there was a medication error report being completed. On 1/6/25 at 2:16 PM, the surveyor interviewed the CP via the telephone who stated that she had been the CP for a while. The CP stated that the nurse cannot interchange 4% Lidocaine patches for the 5% Lidocaine patches and that the nurses must follow the PO for the correct strength. The CP added that if the Lidocaine 5% patch was not available then the nurse should have called the physician for a follow-up order as to what to do. The CP also stated that she had completed medication observations with some of the nurses and reviewed the instructions with them. In addition, the CP stated that she had also provided the facility with a handout that she used for the inservices. A review of the Medication Pass handout that was reviewed during the Med Pass inservice by the CP on 9/25/24 revealed that for accuracy the rights of med pass included ensuring the right dose. In addition, the handout indicated Medication checked against the MAR/eMAR before administering. On 1/8/25 at 2:37 PM, the survey team met with the administrative team. The DON questioned that the error that occurred for the strength of Lidocaine be considered one error due to being the same medication. The DON acknowledged that the Lidocaine 5% patch had POs for applications to two different sites and was considered two opportunities for the medication nurse to follow the correct medication pass procedures for assuring that the right dose was administered. A review of the facility undated policy for Medication Administration provided by the DON had not reflected procedures for ensuring the administration of the correct dosage. NJAC 8:39-11.2(b), 29.2(d)

Based on observations, interviews, and record review it was determined that the facility failed to ensure that staff wear the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP)(designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) to address the risk for infection transmission, in accordance with the facility policy and acceptable standards of infection control practice. This was observed for 2 of 3 unsampled residents (Resident #99 and #Resident #106) reviewed for EBP on 2 of 2 units (North Unit and East Unit) and was evidenced by the following: 1. On 1/03/25 at 07:58 AM, during incontinence rounds with the Acting Unit Manager / Infection Preventionist (UM/IP) on the North Unit, the surveyor observed the UM/IP approach unsampled Resident #99 who was lying in bed. The UM/IP donned gloves, asked permission to check the resident's brief, the resident granted permission. The UM/IP pulled down Resident #99's pants, opened the brief, pulled down the front of the brief, and allowed the surveyor to observe that the brief was wet, but not saturated and the pants were dry. After the surveyor's observation, the UM/IP then pulled up the front of the brief, refastened the brief, and pulled the resident's pants up. The UM/IP then removed her gloves and performed hand hygiene. On the way out of the room, the surveyor observed an EBP sign which indicated gloves and a gown were required for High-Contact Resident Care Activities. Examples of High-Contact Resident Care Activites listed on the sign included changing briefs or assisting with toileting. The surveyor questioned the UM/IP about the sign, and she stated that the resident was on dialysis so therefore on EBP. When asked about wearing a protective gown, theUM/IP stated that she should've had a gown on. On 1/03/25 at 08:46 AM, the UM/IP approached the surveyor to clarify that she had not worn a gown because she was just checking the brief, she was not changing the resident. She further stated that if the resident had been soiled, she would have then donned the required PPE for EBP. A review of the admission record reflected that Resident #99 had diagnoses that include but not limited to; end stage renal disease on dialysis. A review of the interdisciplinary care plan revealed an intervention dated 4/1/24 for Enhanced Barrier Precautions for Infection Prevention: Perform hand hygiene, don gloves and gowns during high contact resident care. 2. On 1/03/25 at 08:12 AM, during incontinence rounds with the East wing Unit Manager (UM), the surveyor and UM entered the room of unsampled Resident #106 to find a Certified Nursing Assistant (CNA) performing care on the resident. The incontinent brief was clean and dry and the CNA stated she had already changed the brief. The CNA noted to be wearing gloves and no protective gown. EBP sign was noted on the wall over the bed. When asked at that time, the UM stated the CNA should have been wearing a gown for care. On 1/03/25 at 12:05 PM, the CNA stated to the surveyor that this morning she was done with providing care and had to step out of the to get a brief so that's why she did not had a gown on when observed earlier. When the surveyor asked her what she did with that brief that she went out of the room for, the CNA stated she then put the clean brief on the resident and did not need a gown at that time. On 1/03/25 at 12:11 PM, the surveyor observed the garbage can in Resident #106's room. There was noted garbage present in the can, no blue gown was noted in garbage. A review of the admission record reflected that Resident #106 had diagnosis that include but not limited to; diabetes. A review of the physician orders included an order dated 12/17/24 for EBP related to a sacral area wound. A review of the interdisciplinary care plan revealed an intervention dated 12/13/24 for enhanced barrier precautions related to sacral wound: Staff to perform hand hygiene, don gown and gloves before performing high-contact resident care. On 1/08/25 at 03:02 PM, the surveyor interviewed the Corporate Clinical Nurse, who stated that the UM/IP was only checking the brief of Resident #99, she had no intention of performing any high contact with the resident. She just opened the brief, she did not provide care. On 1/08/25 at 03:02 PM, the surveyor interviewed the Director of Nursing (DON), who stated the CNA should have been wearing a gown to put a clean brief on Resident #106. Review of facility provided policy Enhanced Barrier Precautions included: Policy Statement: Gateway Care Center is committed to ensuring the safety of patients, visitors and healthcare personnel (HCP) by implementing effective measures to prevent the transmission of Multi Drug Resistant Organisms (MDROs) within our facility. This policy outlines the procedures for identifying, managing, and controlling MDRO infections and colonization, including the implementation of Contact Precautions, with targeted gown and glove use during high contact resident care activities. Scope: EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Procedures: For residents for who EBP are indicated, EBP is employed when performing the following high-contact resident care activities: o bathing/showering o transferring o providing hygiene o changing linens o changing briefs or assisting with toileting o dressing o device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator o wound care: any skin opening requiring a dressing NJAC 8:39-19.4(a)(2)(c)

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities that meet either of the following conditions: (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128 A(a)(6) of the Act. (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76 (d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes: (1) Within 30 days - (i) A change of ownership; (ii) Any adverse legal action; or (iii) A change in practice location. (2) All other changes in enrollment must be reported within 90 days. Prior to the survey, the surveyor accessed the facility's website which listed the facility's name as Shore Point Care Center at the address listed for the registered name Gateway Care Center. On 1/2/2025 at 9:10AM, upon arrival to the facility, the surveyor observed a facility sign and the name on the building written into the stone overhang in the front of the build that read, Shore Point Care Center. That name did not correspond with the CMS licensed, approved name and provider registered name Gateway Care Center. On 1/2/2025 at 10:38 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the Assistant DON for entrance conference. The LNHA and the DON provided the surveyor with their business cards with the name of Shore Pointe Care Center on each card. The LNHA stated the facility has been working as Shore Points Care Center for just under 3 years. He further stated that licensing (state department) was aware of this. The surveyor requested a copy of the facility's license. A review of the facility provided license revealed the New Jersey Department of Health Division of Certificate of Need & Licensing issued a license to Gateway Care Center LLC (Limited Liability Company) was licensed to operate Gate Care Center, effective 11/1/2024, Expires 10/31/2025, issued: 9/23/2024. On 1/2/2025 at 02:07 PM, the surveyor requested the NJ approved license and the application for the name change to CMS from the LNHA. On 1/3/2025 at 9:05 AM, the LNHA informed the surveyor that he had requested the name change information from his corporate office. On 1/6/2025 at 11:00 AM, the LNHA provided a copy of the alternate name documentation to the surveyor. A review of the document revealed a document from the NJ Department of the Treasury. On 1/6/2025 at 12:24 PM, the surveyor met with the LNHA and the Regional LNHA (RLNHA) and requested documentation that the New Jersey Department of Health Division of Certificate of Need was notified and the form 855B to CMS was completed. At that time, the RLNHA stated it wasn't done. On 1/6/2025 at 12:57 PM, the surveyor met with the LNHA, who stated we do not have form 855 B, it (the name change) was intended for marketing purpose. He stated the facility will start operating under Gateway Care Center. On 1/6/25 at 1:24 PM, the surveyor met with the RLNHA, who stated he spoke with corporate and we are going to function under Gateway Care Center; the sign will be changed back to Gateway. NJAC 8:39-5.1 (a)

Complaint NJ #165453; 159439; 156933; 164687 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain a clean, comfortable, homelike environment for the residents. This deficient practice was identified on 3 of 3 nursing units, (the 100, 200, and 300 units) and was evidenced by the following: On 09/21/23 at 12:54 PM, in room [ROOM NUMBER], the surveyor observed that the window in the resident's room had a portable air conditioning unit which had a piece of cardboard surrounding the cylinder that was positioned outside of the window. The cardboard was observed to be bent, exposing outside air. On 09/22/23 at 8:50 AM, on the 300 unit, the surveyor was standing in Resident #104 and Resident #149's room and observed a small black bug flying around the room. A Certified Nursing Assistant (CNA) was also in the room at the time of the surveyor's observation. The surveyor asked the CNA if she saw the bug and the CNA did not respond to the surveyor. Resident #104 told the surveyor to go look in the bathroom. The surveyor entered the resident's bathroom and observed approximately 30 small black spots that appeared to be dead bug carcasses throughout the walls in the resident's bathroom. Resident #104 told the surveyor that the black spots on the walls were bugs that he/she had killed. On 09/22/23 at 9:55 AM, the surveyor observed a large horizontal picture hanging on the wall in between rooms [ROOM NUMBERS]. The picture was crooked with the left-hand side of the picture frame hanging lower than the right. At 10:56 AM, the surveyor observed on the 200 unit, a crooked picture of a [NAME] hanging on the wall to the left of the nurse's station. The right-hand side of the picture frame was hanging lower than the left. At 11:20 AM, in room [ROOM NUMBER], the surveyor observed a blue piece on masking tape on the plastic molding next the sink. The plastic molding was observed peeling up from the floor. Further observations in the room included black scratches and indentations on and in the wall between the sink and the bathroom. The surveyor further observed black horizontal scratches in the wall to the left of the resident's bedroom door and a small rectangular hole in the wall. At 11:26 AM, in room [ROOM NUMBER], the surveyor observed that the edges of the wall surrounding the heating and air conditioner unit were not flat, exposing an opening around the upper left area of the heating and air conditioner unit. The wall above the heating and air conditioning unit was painted a light brown and the surrounding wall was a white color. Further holes, indentations and scratches were observed on the wall under the window next to the heating and air conditioner unit. In addition, the walls to the resident's room were bare. There was one picture on the resident's wall to the right of the television. At 11:35 AM, the surveyor observed that the wood doors to the entrance of the main dining area on the 200 unit were scratched and chipping on the edges, bottom section, and in between the door closure, leaving exposed and chipped, lighter colored wood present. On 09/26/23 at 8:33 AM, in room [ROOM NUMBER], the surveyor observed a hole in the wall to the right of the bathroom door, above the gray plastic molding on the floor. At 9:32 AM, on the 100 unit, the surveyor observed in the hallway by the kitchen entryway, the bottom portion of the wall under the grab bar between the maintenance shop and shower room, had a thick yellowish-brown colored wall covering that was peeling from the wall. In addition, the surveyor observed that the plastic, grey colored molding was peeling up from the bottom of the wall. There was a crack, observed to the right of the wall by the maintenance door, leaving an open, exposed area. On 09/27/23 at 10:22 AM, on the 300 unit, the surveyor observed scratches and indentations on the bottom half of the door into the main dining/activity room on the unit. The scratches and indentations were black against the yellow painted door. At 10:24 AM, on the same unit, in the main dining/activity room the surveyor observed under the dry erase board, that the wallpaper was peeling from the wall throughout and at the edges. At 10:49 AM, the surveyor interviewed the Housekeeping Director (HD) who stated that the Maintenance Department was responsible for fixing holes in the walls, spackling, and painting. The HD further stated that the housekeeping department was responsible for the cleanliness of the common areas and resident rooms. He explained that housekeeping staff were supposed to go into the resident's rooms, clean, dust, and wash the curtains in the resident's rooms. The HD stated that the hallways were swept, mopped, and the handrails were routinely wiped and cleaned. The HD stated that if his staff saw dead bugs throughout a resident room or bathroom, the expectation would be for staff to clean the area, remove the bugs, and disinfect the area. At 11:17 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manger (LPN/UM) on the 100 unit who stated that the holes in the walls were a problem which were usually caused by the resident's wheelchairs knocking into the walls. The LPN/UM further stated that when she identified that there was a hole in the resident's wall, she would notify Maintenance to patch up the hole. At 11:25 AM, in room [ROOM NUMBER], the surveyor observed to the left of the entryway door, black scratches, and indentations throughout the wall. Yellow paint was observed surrounding the black scratches. In addition, the plastic molding that was touching the floor and the wall was observed to be slightly peeling from the wall. At 11:35 AM, the surveyor made a second observation of room [ROOM NUMBER] and observed in the window to the left, a portable air conditioning unit that had a piece of cardboard surrounding the cylinder that was positioned outside of the window. The cardboard was observed to be bent, exposing outside air. At 11:42 AM, the surveyor interviewed the Maintenance Director (MD) who stated that the maintenance department was currently working to fix the holes in the walls throughout the facility and was in the process of spackling and painting. The MD told the surveyor that in the past, the building had flooring concerns, so the facility was working to fix the resident's environment based on priority and safety. On 09/29/23 at 10:12 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility was committed to making the facility comfortable for the residents and his staff were focused on the cleanliness of the furniture, air quality, and safety of the building for the resident's. The LNHA told the surveyor that he implemented a program called, Guardian Angel Rounds in which the facility staff had assigned rooms to monitor, so they could focus on maintaining a clean, comfortable, homelike environment for the residents. A review of the Housekeeper's Job description dated 4/20, indicated, Under the close direction of the Director and/or Supervisor is responsible to perform designated cleaning duties, routine housekeeping and preventative maintenance services in an efficient manner. A review of the Director of Environmental Services (Housekeeping Director) Job description dated 4/20, indicated, The position of Environmental Service Director is to plan, organize, develop, and direct the overall operation of the Environmental Services Department in accordance with current federal, state and local standards, guidelines and regulations, our established policies and procedures, as may be directed by the Administrator. The HD's Job Description further included, Keep abreast of current federal and state regulations, economic conditions, as well as professional standards, and make recommendations on changes in the department's policies and procedures to the Administrator to assure the facility's continued ability to provide a clean, safe comfortable environment for its residents, visitors, and staff. A review of the Director of Building Management Services (Maintenance Director) Job Description, revised 3/11, indicated the MD was to, Ensure the overall operations of the Building Maintenance is operated based on the facility's policy and procedures as regulated by Department of Health and Federal Standards. A further review of the Job Description indicated that the MD was, Responsible for contract vendors providing a variety of repair, maintenance or building management services for buildings and property, which may include medical waste management and recycling. Assist in ensuring the effective maintenance of property including building infrastructure and exterior grounds, and efficient administration management through establishment of quantitative and qualitative controls. Participates in Quality Rounds to inspect and evaluate the physical condition of the facility including residents' rooms, bathrooms, solariums, dining rooms, laundry area, grounds and Parking lots. Demonstrate knowledge of State & Federal regulations specific to Maintenance Services. A review of the facility's Environmental Policy annually reviewed 2023, indicated, Our facility is committed to providing person-entered care to our residents, prioritizing their comfort, independence, and personal needs and preferences. We believe that a homelike environment can significantly improve the quality of life for our residents Therefore, we have established the following environmental policy: 1. Cleanliness and order: We maintain cleanliness and order at all times to promote a healthy and safe living environment for our residents We are committed to providing our residents with the best possible care in a safe, comfortable, and homelike environment. NJAC 8:39-31.4(a)(f)

Complaint NJ#: 159439; 165453 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to maintain an effective pest control program. This deficient practice was identified on 2 of 3 nursing units, (the 200 and the 300 unit), for 4 of 29 residents, (Resident #17, #64, #104 and #149), reviewed for concerns related to pests, and by 5 out of 6 alert and oriented residents during the Resident Council meeting. This deficient practice was evidenced by the following: On 09/21/23, the surveyor toured the 200 unit and observed dead insects on the floors in rooms [ROOM NUMBERS]. At 11:16 AM, on the 200 unit, the surveyor observed a fly on Resident #17's forehead. At that time, the resident stated that the facility had, quite a few flies. Resident #64, the roommate, told the surveyor that the facility supposedly fumigated a couple of days ago. The surveyor asked if the residents had seen bugs in their rooms since. Both residents told the surveyor that they stayed mostly in their room and had only seen flies and not roaches. On 09/22/23, the surveyor observed the dead insect still on the floor in resident room [ROOM NUMBER]. That same day the surveyor observed additional dead and living insects in rooms [ROOM NUMBERS]. On 09/21/23 at 11:41 AM, the surveyor toured the 300 unit and interviewed Resident #104 in his/her room. The resident stated that he/she had issues with bugs, namely flies, and roaches. The resident stated that he/she had flies frequently land on his/her lunch tray and had taken pictures to prove it. Resident #104 then showed the surveyor the pictures he/she had taken on their cell phone which corroborated the resident's interview. The resident then pointed and showed the surveyor a plastic, plug-in night light with fragrance. Insects were observed throughout the plug-in light. The surveyor saw three roaches stuck on the sticky material on the plug-in light fixture. The resident asked the surveyor to show it to a staff member. At 11:47 AM, the surveyor showed the 300 unit Licensed Practical Nurse/Unit Manger (LPN/UM) the resident's plug-in light fixture. The LPN/UM stated that Resident #104 mentioned to her approximately a week ago that there were bugs in his/her room and pest management came to the facility on e day last week to resolve the issue. The LPN/UM told the surveyor that the residents should not have bugs in their rooms. At 12:03 PM, the surveyor interviewed Resident #149, the roommate of Resident #104 in the main dining room on the 300 unit. The resident stated that he/she had seen a bug scurry off their roommate's meal tray, they told the staff, and someone came in and sprayed to get rid of the bugs about a week ago, but there were still bugs. On 09/22/23 at 8:50 AM, the surveyor was standing in Resident #104 and Resident #149's room and observed a small black bug flying around. A Certified Nursing Assistant (CNA) was also in the room at the time of the surveyor's observation. The surveyor asked the CNA if she saw the bug and the CNA did not respond to the surveyor. Resident #104 told the surveyor to go look in the bathroom. The surveyor entered the resident's bathroom and observed approximately 30 small black spots that appeared to be dead bug carcasses throughout the walls in the resident's bathroom. Resident #104 told the surveyor that the black spots on the walls were bugs that he/she had killed. On 09/27/23 at 10:40 AM, the surveyor conducted the Resident Council Meeting. Five out of the six alert and oriented residents stated that they had seen flies in their rooms for a few weeks. Three out of the six stated that they had seen roaches. The residents told the surveyor that the pest control company had recently come to the facility. On 09/26/23 at 11:53 AM, the surveyor interviewed the CNA on the 300 unit who stated that she had worked at the facility since January 2023. The surveyor asked the CNA if he had seen bugs around the facility and the CNA responded, Not really. The surveyor further asked the CNA if residents had complained to him of bugs being in their rooms and the CNA nodded his head up and down indicating yes. The CNA told the surveyor that he didn't remember how many residents had complained. The CNA stated that if a resident complained to him about pests, he would let the nurse know and the nurse would inform the housekeeping and maintenance department. On 09/26/23 at 12:24 PM, the surveyor interviewed the CNA on the 200 unit who had worked at the facility for [AGE] years. The CNA stated that she had seen pests or bugs in and around the facility about three weeks prior. The CNA further stated since then, the pest company had come into the facility and she had not seen any pests. On 09/27/23 at 10:35 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) on the 200 unit who stated that she had seen bugs on the unit from time to time throughout the past year such as ants, crickets, and roaches. The LPN told the surveyor that if she saw pests on the unit, she would have notified the housekeeping department and the housekeeping department would have contacted the pest control company. The LPN further stated that the pest control company came to the facility about a week ago, had sprayed and since then she noticed that there were less bugs. On 09/27/23 at 10:51 AM, the surveyor interviewed the Housekeeping Director (HD) who stated that the pest control company came weekly to the facility. The HD stated that if the staff observed a pest, they would document in the pest control logbook which was located on every unit, the staff would notify him, and he would then call the pest control company. The surveyor asked the HD if he had seen any pests. The HD stated that he had seen, a few fruit flies in the resident's rooms because they were leaving out food. The surveyor further questioned the HD about the time frame that the pests had been observed throughout the facility and the HD could not specify a time frame. The HD told the surveyor that the facility recently entered into a contract with a new pest control company about a week or two ago and they had performed, a deeper spray of the facility to rectify the pests that were in the facility. The HD stated that if his staff saw dead bugs throughout a resident room or bathroom, the expectation would be for staff to clean the area, remove the bugs, and disinfect the area. At 11:44 AM, the surveyor interviewed the Maintenance Director (MD) who stated that there was a pest control book behind every nurse's station and the nurses were supposed to write down what they saw and the location into the book and the pest company would come in and take care of the issue. The MD told the surveyor that the facility had a company that was coming in before and they weren't really on top of stuff, so that contributed to the pest problem. The MD explained that the facility hired a new company about one to two months ago and that had seemed to help. The MD stated that officially the roaches started in the 100 unit and gradually spread throughout the facility. He further stated that he and his staff were, really on top of it due to resident concerns. The MD told the surveyor that the facility identified that some of the pests were related to resident food storage, so the facility educated the residents about proper food storage and provided them with plastic containers to put their food in. The surveyor reviewed the 300-unit Pest Special Service Record (PSSR) from 03/01/23 to present which revealed the following: 03/01/23 - Roaches in breakroom and at nurse's station. The PSSR indicated that the technician came to the facility on [DATE] and 03/13/23. 03/29/30 - Roaches in room [ROOM NUMBER]. The PSSR indicated that the technician came to the facility on [DATE]. 04/17/23 - Mice in kitchen, doors, and halls. The PSSR indicated that the technician came to the facility on [DATE]. 04/26/23 - Roaches in the kitchen. The PSSR indicated that the technician came to the facility on [DATE]. 05/01/23 - Bugs crawling at nurse's station. The PSRR indicated that the technician came to the facility on [DATE]. 05/17/23 - Gnat's in the bathroom. No specific bathroom specified. The PSSR did not reveal a technician signature. 07/28/23 - Mouse in room [ROOM NUMBER]. The PSSR did not reveal a technician signature. The surveyor reviewed the 200-unit PSSR from 02/13/23 to present which revealed the following: 02/13/23 - Roaches all over. The PSSR indicated that the technician came to the facility on [DATE]. 03/03/23 - Roaches all over. The PSSR indicated that the technician came to the facility on [DATE]. 04/24/23 - Roaches in rooms 200 - 218. Lots of roaches. The PSSR indicated that the technician came to the facility on [DATE]. 06/05/23 - Roaches in drawer of room [ROOM NUMBER]B. The PSSR indicated that the technician came to the facility on [DATE]. The technician signed the PSSR approximately one month before the problem was documented in the PSSR. 06/07/23 - Roaches 200 - 219 in the rooms and hallways. The PSSR indicated that the technician came to the facility on [DATE]. 06/19/23 - Roaches 211A. A lot of roaches. The PSSR indicated that the technician came to the facility on [DATE]. 08/11/23 - Roaches and flies on the unit, nurse's station and in rooms [ROOM NUMBER]. The PSSR indicated that the technician came to the facility on [DATE]. 09/10/23 - Cockroaches A lot at the nurse's station. The PSSR did not reveal a technician signature. A review of the facility's Pest Control Policy and Procedure dated 08/31/23, indicated that the facility would maintain an effective pest control program and, This facility maintains an on-going pest control program to ensure that the building is kept free of insect and rodents. On 09/29/23 at 10:09 AM, the facility's Regional Registered Nurse (R/RN) stated that the pest problem was identified by the facility prior to the survey team entering the facility and the facility had recently switched pest control companies to help rectify the situation. The R/RN further stated that the facility would resolve the issue in its entirety and systematically. NJAC 8:39-31.5

Based on observation, interviews, and review of medical record it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for a resident's personal preference to wear a specific urinary collection device (leg bag) during the day while the resident was out of bed. This deficient practice was identified for 1 of 29 residents reviewed, (Resident #25) and was evidenced by the following: On 09/21/23 at 11:19 AM, during tour the surveyor observed the resident sitting up in his/her wheelchair in their room. The resident was interviewed at this time and stated that he/she had an indwelling urinary catheter. The resident stated that he/she wore a leg bag (urine collection storage bag) during the day and a urinary drainage storage bag at night that hung on the resident's bedframe. According to the Admission Record, Resident #25 was admitted to the facility with the diagnoses which included but was not limited to: heart failure, history of urinary tract infections (UTI), benign prostatic hyperplasia (enlarged prostate), and obstructive uropathy (obstructed urinary flow and can be either structural or functional). According to the significant change in status Minimum Date Set (MDS), an assessment tool utilized to facilitate care dated 08/17/23, indicated that the resident had moderate cognitive impairment, required extensive assistance with activities of daily living and had an indwelling urinary catheter (device inserted into the bladder to drain urine). On 09/21/23 at 12:26 PM, the surveyor reviewed the resident's medical record and the Care Plan (CP) did not indicate that the resident wore a leg bag during the day. Based on record review the resident had not had a UTI since 2017. On 09/27/23 at 11:00 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who stated that he had been employed in the facility for approximately 9 (nine) months. The CNA stated that the resident required extensive assistance with care and had a urinary catheter. He added that Resident #25 was continent of the bowel and was able to be toileted. He stated that the resident wore a urinary leg bag (collection device that holds urine, can be concealed under clothing, and may assist with optimizing independence with activities of daily living during the day). He added that the leg bag was applied during morning care. He stated that he had to disconnect the drainage bag and hook up to the leg bag. The CNA stated that he wiped the end on the drainage bag connector with disinfectant wipes and then attached the leg bag. He stated that the drainage bag was thrown away daily and a new bag urinary drainage bag was obtained daily. He stated that he knew the resident and that was why he knew that the resident wore a leg bag during the day. He stated that he did not document that the resident wore a leg bag during the day. On 09/27/23 at 11:05 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #25 had an indwelling urinary catheter. The LPN reviewed the physician orders and reviewed the Care Plan in the presence of the surveyor and revealed that there was no documentation that indicated that the resident utilized a urinary leg bag during the day nor that the drainage tubing to the leg bag was changed daily during the day. He stated that there should be documentation on the Care Plan related to the resident's personal preference on wearing a leg bag during the day, however, he could not find the documentation in the resident's medical records. The LPN stated that he had only been employed in the facility for one month and was not familiar with the process of who was responsible to assure that the resident had a leg bag applied during the day but would find out the information. On 09/27/23 at 11:16 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM) who stated that Resident #25 wore a urinary leg bag during the day and had a regular drainage bag applied at night. The surveyor asked the LPN/UM where it was documented in the resident's medical record that the resident had a preference to wear a urinary leg bag during the day. The LPN/UM stated that it should be documented on the resident's CP. The LPN/UM reviewed the residents CP in the presence of the surveyor and admitted to the surveyor that there was no documentation on the CP or in the resident's medical record that indicated that the resident had the preference to wear a urinary leg bag during the day. The LPN/UM stated that it would have been important to document the resident's preference on the CP so that the staff knew what care was to be provided for the resident and what the resident's preference was. On 09/29/23 at 10:38 AM, the surveyor interviewed the Director of Nursing who stated that any personal preference the resident had should have been addressed on the CP. The facility policy dated 02/2023 and titled, Cleaning of the foley and applying the leg bag-Urine Collection Device indicated that application of the leg bag was required to be documented on the resident's Care Plan and CNA assignment sheet. The facility undated policy titled, Care Plans indicated that residents would have comprehensive person-centered comprehensive care plans. NJAC 8:39-11.2 (d)

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to complete an incident report, after a resident sustained an injury in the facility. This deficient practice was identified for 1 of 3 residents reviewed for skin issues (Resident #28), and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated Title 45. Chapter 11. New Jersey Board of Nursing Statutes 45:11-23. Definitions b. The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribe by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen. Human response means those signs, symptoms and processes which denote the individual's health need or reaction to an actual or potential health problem. On 09/21/2023 at 10:56 AM, the surveyor observed Resident #28 sitting in a wheelchair next to their bed. The resident was and alert and oriented to person, place, and time. The surveyor observed Resident #28 with an undated bandage on the right shin area. Resident #28 stated that they developed the wound by accidentally hitting their shin on the bedframe. Resident #28 indicated that the wound/injury occurred approximately two weeks ago and that they still had pain in the area. According to the Admission Record Resident #28 was admitted to the facility with the following but not limited to diagnoses: Peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), pressure ulcer, anemia (a condition in which the blood doesn't have enough healthy red blood cells), hemiplegia and hemiparesis affecting the left dominant side (weakness), polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on the body, featuring weakness, numbness, and burning pain). According to the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate care dated XX/XX.XX, Resident #28 had a Brief Interview for Mental Status score of 15/15, indicating intact cognitive status. A further review of Section G - Functional Mobility of the MDS, indicated Resident #28 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #28 required limited assist with transfers and was an independent eater. Section I - Diagnoses of the MDS revealed that Resident #28 had active diagnoses of hemiplegia/hemiparesis, polyneuropathy, and absence of left leg above the knee. Section M - Skin Conditions revealed Resident #28 had an open lesion(s). A review of the Order Summary Report, dated 08/01/23 - 08/31/23, Resident #28 had the following physician order: Cleanse [sic] right anterior lower leg with nss [normal saline solution, a mixture of sodium chloride and water], apply bactroban [an antibiotic that prevents bacteria from growing on your skin] adaptic [a dressing designed as a primary wound contact layer for use in the management of dry to heavy exuding, partial and full-thickness chronic wounds] with ABD pad [a pad essential for controlling bleeding and preventing contamination of large wounds] and wrap with kerlix [bandage rolls that provide fast-wicking action, superior aeration, and excellent absorbency] qd [every day]. A review of the Order Summary Report, with active orders as of 09/28/23, revealed the following physician order: Cleanse [sic] right anterior lower leg with nss apply santyl [an ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas] ABD pad and wrap with kerlix qd every day shift. A review of the Medical Record revealed the following progress note, dated effective date: 08/18/2023 14:04: Seen by [name redacted] DNP [doctor of nursing practice], wound care. Right posterior heel resolved to nursing. Left lateral arm skin tear 1.0 x 0.5 x 0.2 and left arm 3.0 x 1.0 x 0.2 bacitracin [an antibiotic cream/ointment] and cover daily proximal left lateral arm 2.0 x 1.3 x 0.2 bacitracin daily and cover right anterior lower leg 3.5 x 4.0 x 0 bactroban adaptic abd pad and wrap with kerlix qd. According to Resident #28's comprehensive care plan, Resident #28 had a care plan Focus of: [Resident name redacted] has alteration in his/her skin integrity R/T (related to) fragile skin condition upper and lower extremities manifested by skin tears, created on 03/31/23 and revision on 09/12/23. Interventions included, 8/18/2023 Administer wound treatment as prescribed MD [medical doctor], wound consult. Revision on: 8/30/2023. On 09/27/23 at 11:10 AM, the surveyor requested any incident/accident reports for Resident #28 for the past 90 days from the facility Director of Nursing (DON). On 09/28/2023 at 09:24 AM, the surveyor conducted an interview with the Registered Nurse (RN) assigned to Resident #28 on that shift. The surveyor asked the RN when an accident/incident report should have been completed for a resident who sustained an injury. The RN explained, Usually they are filled out on the date of incident. The surveyor asked the RN if an accident/incident report should have been completed and if the resident was cognitively intact and was able to explain how the injury occurred. The RN responded that she would still have filled out an incident report if a cognitively intact resident told her what happened because the skin was opened. The RN further stated that she would have also written a progress note that described what happened. On 09/28/2023 at 10:43 AM, the DON told the surveyor that there was only one incident/accident report for Resident #28 on 08/18/23 related to an abrasion to Resident #28's left buttock. The DON stated that there was not an accident/incident form completed on 08/18/23 related to Resident #28's right lower anterior leg injury. The surveyor asked the DON if an accident/incident form should have been completed for the right lower leg anterior injury Resident #28 sustained and in what time frame. The DON stated, An accident/incident report should be filled out within 24 - 48 hours of the incident, I would say. I would fill out an incident report for any skin tear, yes. The DON further explained, An incident report should have been filled out for Resident #28 because [gender redacted] had an injury to his/her shin. The nurse should have documented it in a progress note. The family should have been notified and the care plan should have been updated, as well. On 09/28/2023 at 12:38 PM, the facility DON provided the surveyor with documentation that revealed Resident #28 sustained a right lower anterior extremity injury on 8/18/2023. The DON further acknowledged that the nurse who observed and obtained a physician's order for the treatment of the right anterior lower leg injury failed to fill out an accident/incident report. On 09/29/2023 at 9:01 AM, during a meeting with the facility administration, the Licensed Nursing Home Administrator stated that after the fact, the facility created the incident and accident report for Resident #28. The facility's DON explained that the main purpose of doing the incident and accident report was so that everyone knew there was an incident and there was a full investigation that was reviewed to rule out abuse and neglect for the resident. The DON did not mention implementing interventions to prevent future accidents as part of the facility's incident/accident investigative process. The surveyor reviewed a facility policy titled Accidents and Incidents - Investigating and Reporting, date: 5/18/2023. The following was revealed under Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and results reported to the appropriate department manager and the Administrator. The following was revealed under Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of accidents or incidents as appropriate. N.J.A.C. 18:39-27.1(a)

Complaint NJ: 165453, 163618 Based on observation, interview, review of the medical record and review of other facility documentation, it was determined that the facility failed to provide dependent residents with routine and appropriate incontinence care, specifically by applying double briefs. This deficient practice was identified for 1 of 6 residents observed for incontinence care, (Resident #71) and was evidenced by the following: On 09/27/2023 at 8:47 AM, the surveyor performed a care tour of the 200 unit with the Licensed Practical Nurse/Unit Manager (LPN/UM). At 08:55 AM, Resident # 71 gave permission to the surveyor and the LPN/UM to observe his/her adult brief. The surveyor observed that Resident #71 had two green colored briefs on. The briefs were dry. At that time the LPN/UM confirmed that Resident #71 had two briefs on and said, I am sorry. On 09/27/2023 at 9:01 AM, the surveyor interviewed the assigned Certified Nursing Assistant (CNA) who confirmed she was assigned to Resident #71. When asked when the last time incontinence care was provided for Resident #71 the CNA said, When I come in, I start rounds. I was a little late today and I started rounds and then breakfast came so I stopped to pass trays and feed residents. She said not yet when the surveyor asked if she had provided incontinence care for Resident #71. The surveyor then asked the CNA how many briefs a resident was to wear, and the CNA replied, one. On the same date at 9:03 AM, the LPN/UM said, It was probably night shift when asked who would have put double briefs on this resident. On 09/27/2023 at 12:51 PM, the surveyor placed a telephone call to the 11:00 PM -7:00 AM assigned CNA on 09/26/2023 and left a message requesting a call back. The 11:00 PM - 7:00 AM CNA did not return the surveyor's call. The surveyor reviewed the medical record for Resident #71. According to the Admission Record, Resident # 71 was admitted to the facility with diagnoses including but not limited to: epilepsy, unspecified dementia, personal history of Traumatic Brain Injury (TBI). A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/29/2023, that revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score 10/15 indicating Resident #71 had moderately impaired cognition. The MDS further revealed Resident #71 was dependent for toileting and required staff assistance of one person. The MDS also indicated Resident #71 was incontinent of bladder and bowel. A review of Resident #71's Care Plan (CP) revealed a focus area with an initiated date of 05/31/2022, [Resident name] had an ADL (Activities Daily Living) deficient related to TBI. He/She requires total assistance with ADL's. Under the Goal section [Resident name] will maintain current level of participation without farther{sic}[further] decline through the next review dated. Interventions included but were not limited to Resident #71 required total assist x one by staff with toileting with a Date Initiated: 05/31/2022. A further review of the CP with an initiated date of 05/31/2022, revealed Resident #71 was at risk for alteration in skin integrity R/T B&B (bladder and bowel) incontinence and decreased mobility. Under the Goal section with an initiated date of 05/31/2022, Resident's skin integrity would remain intact within the next review date. Interventions included call physician with any concerns. Preventative skin care, lotion to dry skin, Zinc oxide after each inc (incontinent) episode. On 09/28/2023 at 8:39 AM, the surveyor interviewed the assigned CNA who stated that the facility incontinence policy was to check the resident every two hours and change the resident if needed. The CNA told the surveyor that the staff would have offered the bathroom if the resident could have used the bathroom and ambulated. The CNA further stated, Just one brief is to be on a resident and never to put two briefs on a resident. The CNA added that the aides were responsible to provide incontinence care. On 09/28/2023 at 9:22 AM, the surveyor interviewed the Director of Nursing (DON) who was asked what the facility's incontinence policy was. The DON replied that they do preventative care and use barrier cream for each incontinence care. They (residents) should be checked every two hours. Some residents were changed every two hours. Some residents were alert and would tell you and then care was provided as needed. When asked by the surveyor if CNAs were to apply double briefs on residents, the DON said, Not at all. The DON went on to say that not unless the resident was awake, alert and oriented x3 with a BIMS score of eleven out of fifteen and the residents asked to be able to wear double briefs. We would have an IDCP (Interdisciplinary Care Plan) meeting and would decide if a double brief was appropriate for them. The DON said that is not good when the surveyor reviewed the observation for Resident #71. The DON also said They (staff) will be disciplined, not good, it shouldn't happen. On 09/29/2023 at 09:05 AM, the surveyor interviewed the [NAME] President of Clinical Services (VPCS) who stated that the 11:00 PM - 7:00 AM CNA was educated along with the rest of the staff and was disciplined. The VPCS went on to say this could lead to skin breakdown and possibly could lead to infections, and all sorts of skin issues. A review of an facility policy reveiewed 2023, titled Bowel and Bladder Incontinence did not address the use of double briefs. NJAC 8:39-27.2(h)

Based on observation, interview, and record review, it was determined that the facility failed to provide prescribed nutrition to a resident totally dependent on a tube feeding which resulted in a significant weight loss. This deficient practice was identified for 1 resident, Resident #5, of the 2 residents reviewed for the care of tube-fed residents. Resident #5 had a weight loss of 18% between 12/2012 and 1/2013, and a weight loss of 13% between 3/2013 and 4/2013. Findings are as follows: During the initial facility tour on 4/18/13 at 9:40 a.m., the Unit Manager (UM) told the surveyor that Resident #5 received the tube feeding (TF) formula [MEDICATION NAME] 1.2 via a gastrostomy tube at the rate of 50 milliliters (ml) per hour for 18 hours. The UM stated that the feeding "goes up at 2 p.m. and comes down at 8 a.m." According to the UM, Resident #5 did have a recent weight loss. On 4/19/13 at 8:30 a.m., the surveyor observed Resident #5 in bed. The surveyor observed the resident to be thin with contractures of both upper and lower extremities. A feeding pump was positioned next to the resident's bed, however, it was turned off and no formula was hanging on the pump. During an interview at 9:30 a.m., the Certified Nursing Assistant (CNA) told the surveyor that the TF had been hanging when she came on duty at 7 a.m., but it was taken down "between 8 and 9 o'clock." On 4/22/13 at 8:50 a.m., the surveyor observed Resident #5 in bed receiving care from the CNA. Again, the feeding pump was positioned next to the resident's bed, but there was no formula on the pump. The CNA told the surveyor that the TF "always comes down at 8 o'clock." The surveyor reviewed the medical record on 4/22/13. The Medication Administration Record (MAR) for 4/2013 indicated that the staff signed their initials when the TF was started at "2p" and when the TF was taken down at "8A." There was no documented evidence on the MAR that the facility staff monitored the actual volume of formula Resident #5 was receiving. The surveyor reviewed the Nutrition Progress Notes (NPN) dated 12/10/12 that indicated that Resident #5 weighed "117#(pounds)" and was receiving [MEDICATION NAME] 1.0 cal at 50 milliliters (ml)/hour for 18 hours. This would provide the resident with 900 calories per day. The NPN dated 1/18/13 indicated that Resident #5 weighed "96#" which was assessed as an "18%" weight loss in 1 month. At that time, the TF formula was changed to [MEDICATION NAME] 1.2 cal at 50 ml/hour for 18 hours, providing the resident with an additional 180 calories per day. The NPN further indicated that the resident's weight loss "is not desirable." The NPN dated 2/10/13 indicated that Resident #5 weighed "102#" and the resident's weight gain of 6% was assessed as "desirable." There was no change in the TF recommendations at that time. Review of the Weight/Vital sign Record indicated a "March" weight of 94 pounds for Resident #5. The resident was re-weighed and the result was 91.8 pounds. There was no corresponding NPN for March, and the TF recommendations remained the same. Review of a Universal Transfer Form dated 3/29/13 indicated that Resident #5 was in the hospital from 3/21-3/29/13 with a [DIAGNOSES REDACTED]. Review of the NPN dated 4/2/13 indicated that Resident #5 weighed "89#." The dietitian's documentation indicated that the "previous rate" of TF was restarted although the resident's weight had declined by "13%" in 1 month. According to the NPN, the current TF "should cause a slow, gradual" weight increase over 1 month's time which would be "desirable." On 4/22/13 at 2:10 p.m., the surveyor observed that Resident #5 was in bed, however, the TF had not yet been started. The feeding pump digital display in the resident's room indicated that the resident only received 580 ml (696 calories) of [MEDICATION NAME] 1.2 since 2 p.m. on 4/21 and not the 900 ml (1080 calories) recommended for a desired weight gain. On 4/23/13 at 8 a.m., the surveyor observed Resident #5 in bed with [MEDICATION NAME] 1.2 infusing at a rate of 50 ml/hour. Approximately 300 ml remained in an "open-system" formula bag hanging on the pump. The digital display on the pump indicated that the resident received 683 ml at this time. The CNA in the resident's room told the surveyor that the feeding always comes down "about now." A Licensed Practical Nurse (LPN) administering medications at that time outside of the resident's room reviewed the MAR and told the surveyor "it comes down now." At 8:35 a.m., the surveyor returned to the resident's room. Resident #5 was out of the room in a wheelchair being assisted by the CNA. The feeding pump digital display indicated that Resident #5 received a total of 691 ml (829 calories) and not the 900 ml (1080 calories) assessed as needed for a desirable weight gain. During an interview on 4/23/13 at 10:05 a.m., the UM told the surveyor that there was no documented accountability to ensure that Resident #5 received the amount of formula as recommended by the RD and as prescribed by the physician. During an interview on 4/23/13 at approximately 10:15 a.m., the Registered Dietitian (RD) told the surveyor that the TF recommendations were written to reflect what time the formula was started and what time the formula was stopped. The RD stated "I haven't started writing recommendations to say 'until total volume infused'." The RD further acknowledged that there should be accountability for how much formula Resident #5 was actually receiving. During an interview on 4/24/13 at 12:25 p.m., the facility Administrator stated that Resident #5's significant weight loss "was not desirable." NJAC 8:39-27.1(a)

Based on observation, interview and record review it was determined that the facility failed to provide necessary treatment and monitoring of a resident at high risk for pressure ulcers. Resident #14 was at high risk for pressure ulcers and was found on 3/18/11 with an open area (no description or measurement) requiring treatment and re-evaluation. There was no evidence of a re-evaluation or continued intervention and the resident subsequently developed a Stage III pressure ulcer on 4/11/11. This deficient practice was observed for 1 of 5 residents, Resident #14, on the sample for pressure ulcers. Evidence was as follows: Resident #14 was readmitted from the hospital with [DIAGNOSES REDACTED]. On that same date the MDS evaluation indicated "skin is free of breakdown this quarter. Continue plan of care." The facility Skin Risk Assessment form, dated 2/10/11 for Resident #14 indicated the resident was at high risk for pressure ulcers related to immobility, incontinence, mental status and nutritional status. According to the Nurse's Notes, on 3/18/11 at 3 p.m., the physician was made aware of the area identified on the left inner thigh by the groin. There was a new order to cleanse the area with normal saline and apply [MEDICATION NAME] twice a day and apply dressing for 10 days then reevaluate." According to the facility Treatment Administration Record (TAR) for March, 2011, the treatment to the left groin was signed as done from 3/18/11 until 3/28/11. There was no other description of this area and no staging or measurements. There was no indication that the left groin area was re-evaluated. The facility Body Assessment form for March, 2011, which was to be filled out weekly per facility policy, was as follows; 3/8/11-skin intact, 3/15/11-skin intact, 3/22/11-skin intact, and on 3/29/11-skin impaired. According to the resident care plan dated 10/26/10, pressure ulcers were addressed based on the residents high risk; goal was for the resident to be free of skin breakdown. There was no interventions documented on the careplan regarding the identified skin breakdown and treatment on 3/18/11. The Nurse's Notes do not include documentation of the resident's skin condition after the 3/18/11 note about the left groin area. On 4/11/11 at 8:45 p.m., it was documented that the resident had breakdown on the left inner perineal area measuring 2.5cm. X 1.75cm. X 1.8 cm deep and was a Stage III. A new order was written at that time to cleanse left perineal area with normal saline, apply santyl and loosely pack with border gauze twice daily for 14 days. On 4/11/11 a careplan was initiated and interventions identified regarding the discovery of the Stage III area of the left gluteal fold. On 4/13/11, the Wound Care Consultant was notified to see Resident #14 and documented that "staff reported a re-opening of left ischium/inner gluteal area now stage 3...this ulcer is recurrent." The weekly skin assessment was not signed as completed on 4/5/11 or 4/26/11 on the 3-11 shift. The Body Assessment form for April, 2011 was not completed for 4/4/11 or 4/11/11 (day of Stage III discovery), and on 4/18/11 it was documented that Resident #14 had a stage III wound in the inner left perineal area. On 4/20/11, the quarterly note indicated that "Patient has Stage III to left inner gluteal and being treated....followed by wound specialist - will continue plan of care." The surveyor discussed this issue with the Administrator, Director of Nurses and Assistant Director of Nurses on 5/16/11 at 2:45 p.m. and they stated that the pressure sore was in an area that "could easily be missed." NJAC 8:39-27.1(a)(e)