Every finding on record at Skilled Nursing at Fellowship Village

Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner, b) maintain proper food storage in a clean, safe and sanitary manner and c) maintain kitchen garbage in a clean, safe and sanitary manner, and free from pests as evidenced by the following:On 3/30/26 at 9:37 AM, in the presence of the Food Service Director (FSD), the surveyors observed the following in the kitchen:The can-opener blade had areas missing and a congealed orange residue in the top left corner. The FSD acknowledged the blade had not been changed and it could cause potential harm to the residents. She further stated that the can opener blade and shaft are washed daily through the high temperature wash machine.Cutting boards (4 green and 8 white plastic) were observed to have deep etching and black /brown discoloration on them. The FSD acknowledged the surveyor concerns and stated, they do go through the high temperature wash machine, she could not identify what the discoloration was on the cutting boards.In the dry storage area, 2 storage containers (sugar and white rice) were noted to have the scoops in the product instead of on the hook within the container. The FSD acknowledged the scoops were stored incorrectly and stated that correct storage helps to prevent infection and cross contamination.In the freezer the surveyor observed multiple frozen food items that were not sealed or stored in containers with tight fitting lids. The unsealed food (vegetable burgers, okra, pumpkin, macadamia cookies, and link sausage) was open to air, frost and pollutants. The FSD acknowledged they should be sealed after opening to prevent frost, poor food quality and cross contamination of food products.During the tour of the kitchen the surveyor observed 6 trash cans without appropriate covers on them (1 at the employee wash sink, 2 in the food prep area,1 in the cook area, and 2 at the dirty tray line). The FSD acknowledged the surveyor's concerns.On 4/1/26 at 3:12 PM, the survey team met with Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist (IP), Regional Director of Nursing (RDON) and [NAME] President of Clinical Operations (VPCO). The LNHA acknowledged the surveyor's concerns and stated that the equipment should be cleaned, maintained and lidded to prevent injury or cross contamination. He further stated the freezer food should be sealed to prevent food quality issues, food borne illnesses and cross contamination of products.On 4/2/26 at 9:37 AM, the surveyor interviewed the Resident District Manager (RDM), who stated that the can-opener blade should be changed regularly to ensure safety for the residents and ensure that no metal fragments entered the food. He further stated that the cleaning of equipment should be hand scrubbed and then put through the high temp wash machine to prevent food borne illness and maintain safe and sanitary environment for the staff and residents. The RDM acknowledged the surveyor's concerns and agreed they were not done according to facility policy.A review of the manufacturer guidelines for the can opener, provided by the FSD, revealed; recommended supplies .cleaning brush.procedures.2) The can opener can be taken to the three compartments sink to be disassembled, washed, rinsed and sanitized.Note; Blade and gear should be checked monthly for wear. If gear appears to be worn or sharp grooves appear in blade, they should be replaced. This will reduce the risk of can slivers entering the food product.A review of the Food and Supply Storage dated 5/95 and revised 1/24, revealed; dry storage. hang the scoop.scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop.NJAC 8:39-17.2(g)

Based on observations, interviews, record review, and review of facility provided documents, it was determined that the facility failed to provide medically related social services for a resident who transitioned in care from rehabilitation to long term care (Resident #16). This deficient practice was identified for 1 of 1 long term care (LTC) residents reviewed for social work services and was evidenced by the following:On 3/30/26 at 10:38 AM, during the initial facility tour, the surveyor observed Resident #16 in their room with the door open. Resident #16 stated they fell and got injured, needed rehabilitation, and then added, I've been here forever. Resident #16 stated they used to live in an apartment and wished they could return. On 3/31/26 at 10:26 AM the surveyor observed Resident #16 sitting in their room, waving for the surveyor to come in. Resident #16 stated they preferred to stay in their room and chose not to socialize with other residents. Resident #16 stated they did not know if the facility had a social worker (SW) or not and could not recall discussing their plan of care, including their transition to long term care, with anyone. On 4/1/26 at 9:46 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the decision to transition a resident to long term care was made by the resident and their doctor after their rehabilitation was finished. The DON stated the doctor made notes in the resident's chart, and the Social Worker (SW) made notes in care plan meetings. The DON stated the SW saw LTC residents quarterly and for any concerns, and care plans were reviewed quarterly and for any changes in the residents' needs. The DON, in the presence of the surveyor, reviewed the Electronic Medical Record (EMR) for Resident #16 including a SW note dated 1/9/26 that included the sentence, Discontinue treatment plan. The DON stated, I don't know why she wrote that. I don't know what that means. The DON, in the presence of the surveyor, searched the EMR for additional SW notes from 2025 or 2026 and was unable to locate any. On 4/1/26 at 11:45 AM, during an interview with the surveyor, the SW stated, I don't counsel, I just do social work. The SW stated that she met with families for decision making and discharge planning and was familiar with Resident #16 who she saw once a week to talk, because the resident was a homebody. The SW, in the presence of the surveyor, reviewed the EMR for Resident #16. The SW acknowledged she could not locate documentation of conversations with Resident #16 or their family in the EMR at this time and would get back to the surveyor. The surveyor reviewed the EMR and hybrid paper chart for Resident #16, which revealed the following: A review of the census tab in the EMR reflected Resident #16 had been in their current room for approximately a year and a half. A review of the admission Record (an admission summary) revealed Diagnoses which included but were not limited to; repeated falls and depression. A review of the Minimum Data Set, a resident assessment and care screening tool, dated 3/27/26, reflected a Brief Interview for Mental Status score of 15 out of 15 which indicated the resident was cognitively intact. A review of the individual comprehensive care plan (ICCP) reflected a focus area initiated on 6/26/24, cancelled on 1/9/26, which revealed that support was needed to facilitate a safe discharge plan to return home. The associated interventions included to assist and encourage the client/representative to identify any barriers or concerns regarding needs and a safe discharge, and to provide support to the client/representative for reaching goals and developing a safe discharge plan. The responsible staff assigned to that intervention was SW. The surveyor was unable to locate other current or active focus areas or interventions assigned to the SW. A review of Evaluations titled Care Plan Conference Interdisciplinary Team Summary (care plan meeting summary) reflected a quarterly care plan meeting summary with date and time of meeting entered as 2/26/25 at 11:31AM, signed by the SW on 4/1/26 after surveyor inquiry; A Other care plan meeting summary with date and time of meeting entered as 12/1/25 at 6:00 AM, signed by the SW on 4/1/26 after surveyor inquiry; A quarterly care plan meeting summary with date and time of meeting entered as 4/1/26 at 3:10AM, signed by the SW on 4/1/26 with an effective date and time of 4/1/26 3:09PM, after surveyor inquiry. A review of the Progress notes reflected a plan of care note with effective date and time of 1/9/26 8:56 AM which contained the note text, Resident is now a LTC (long term care) resident in [facility redacted] LTC neighborhood. Discontinue treatment plan; A Social Service note with an effective date and time of 4/1/26 8:03 PM, after surveyor inquiry, reflected the note text, Reflective summary on ongoing Discussions: Social work has had ongoing involvement with resident. On 4/1/2026 at 3:11 PM, the Licensed Nursing Home Administrator, the DON, the Infection Preventionist, the [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were made aware of the above concerns. No additional information was provided. The surveyor reviewed the facility provided job description for Social Worker dated 2023 reflected the SW would contribute to and/or direct/delegate contribution of social services goals and approaches to the comprehensive care plan. The Social Worker would encourage residents/responsible parties to participate in the development of their care plan, and invite them to care plan meetings accordingly. The Social Worker will accurately and completely document social service actions and interactions in each resident's medical record. NJAC 8:39-27.1(a); 39.4

Based on observations, interviews, record review, and review of pertinent documentation, it was determined that the facility failed to obtain consent to ensure that the residents did not receive an unnecessary medication for 2 of 5 residents reviewed for unnecessary medications, (Resident #10 and #61).This deficient practice was evidenced by the following:1.) On 3/30/2026 at 10:10 AM, the surveyor observed Resident #10 in bed with the TV on. The resident greeted the surveyor but was unable to hold a conversation. On 3/31/2026 at 11:50 AM, the surveyor observed Resident #10 lying in bed. An empty juice cup with a straw was observed on the overbed table. The resident greeted the surveyor and asked when lunch was coming. The surveyor had observed staff in the hallway delivering lunch trays and made Resident #10 aware. The surveyor asked Resident #10 if they were in any pain or discomfort, the resident responded that they were fine and that they were not interested in talking. The surveyor reviewed the medical records for Resident #10. A review of the admission Record, an admission summary, revealed that Resident #10 had diagnoses which included, but were not limited to; anxiety disorder (a mental health condition involving persistent, excessive fear or worry that interferes with daily life, exceeding normal stress), unspecified dementia (symptoms of cognitive decline—such as memory loss, confusion, or personality changes—are present, but the underlying cause cannot be definitively identified), depression (a common, serious mood disorder characterized by persistent sadness, loss of interest, and low energy, severely affecting daily life for at least two weeks), and unspecified psychosis (symptoms like hallucinations, delusions, or disorganized behavior that disrupt functioning but do not meet the full, specific criteria for disorders such as schizophrenia or bipolar disorde) not due to a substance or known physiological condition. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/7/2025, included that the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated that the resident had severe cognitive impairment. Further review of the MDS, revealed that the resident was dependent on staff for activities of daily living (ADLs) and received psychoactive medications (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). A review of the Individual Comprehensive Care Plan (ICCP) included a focus area, dated 11/9/2025, that the resident was taking Risperdal, an antipsychotic medication (a type of psychoactive medication specifically used to manage psychosis (hallucinations, delusions), schizophrenia, bipolar disorder, and severe agitation by balancing brain chemicals like dopamine and serotonin), and had a potential for adverse reactions due to the medication. Interventions included monitoring for adverse effects of antipsychotic medications and to report mood or behavioral changes and treat them as ordered if they occurred. Other interventions included psychiatry and psychology consultations as needed. Another focus area, dated 11/9/2025, included that the resident was at risk for falls related to confusion, incontinence, and psychoactive drug use. Interventions included anticipating and meeting the resident's needs, and to promptly assist if needed. A focus area, dated 1/8/2025, included that the resident used antidepressant medication. Interventions included monitoring for side effects and reporting them. A review of the Order Summary Report (OSR), included the following physician orders (PO): A PO, dated 10/28/25, for: Risperdal Oral Tablet (Risperidone), give 0.25 mg by mouth two times a day for psychosis. A PO, dated 8/12/2025, for: Effexor XR Oral Capsule Extended Release 24 Hour 150 MG (Venlafaxine HCl), give 1 capsule by mouth one time a day for depression. A PO, dated 11/1/2025, for: Complete Weekly Psychotropic documentation on Saturday on 7-3 shift. List medications in note. Choose antipsychotic/antianxiety or Mood meds/sedative/hypnotic (Venlafaxine, Risperidone), every day shift every Saturday. On 3/31/2026 at 1:50 PM, the surveyor requested Resident #10's pharmacy medication regimen review and the initial consent for psychotropic medications from the Director of Nursing (DON). On 4/1/2026 at 11:12 AM, the surveyor completed review of the requested material. During review the surveyor observed that in the resident's admission packet was a form titled Consent for use of Psychoactive Medication Therapy which included the resident's original admission date in 2024, and was filled out with the resident's information, the psychoactive medications to be used, and that the proposed course was for prolonged treatment; but the form was not signed until 3/31/2026, the date of surveyor inquiry. On 4/1/26 at 12:22 PM, the surveyor interviewed Registered Nurse (RN) #1, who stated that residents receiving psychoactive medications were monitored for behaviors and had them documented weekly in their respective charts. RN #1 stated that monitoring was done to observe for any adverse medication reactions and to observe if the medications were effective for the resident. She then stated that when starting a new psychoactive medication, a psychological evaluation was done beforehand by the provider. Asked whether a consent form should be used for psychoactive medications, the RN responded that the facility confirms consent during the admission with a form in the admission packet and that the importance of informed consent was to inform a resident or caretaker of the risks versus benefits of a medication. When presented with Resident #10's Consent for use of Psychoactive Medication Therapy form the RN acknowledged that it was signed the previous day 3/31/2026 by her and another nurse when they received consent over the phone and that it was previously unsigned. On 4/1/26 at 12:39 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) #1. RN/UM#1 stated that providers would order psychoactive medications, and nursing would monitor any adverse effects. She stated that every psychotropic medication had a weekly monitoring attached to it where behaviors or adverse effects would be charted every week and then reviewed by the providers. The RN/UM#1 stated that consent was to be obtained upon admission for residents with psychoactive medications, even if the resident was already on the medication, as a consent to continue giving the medication at the facility. When presented with Resident #10's Informed Consent for Psychoactive Medications form, RN/UM#1 acknowledged that the form was part of the resident's admission packet; that the informed consent was signed on 3/31/26 after surveyor inquiry and that every resident should have had the form completed during their admission. On 4/1/26 at 1:38 PM, the surveyor interviewed the Director of Nursing (DON) regarding informed consent of psychoactive medications. The DON stated that even if a resident was admitted with a psychoactive medication, the facility would review it with them or their representative to make sure they understood the risks versus benefits. She then stated that written or verbal consent would be obtained during admission for a continuation, or before starting a new psychoactive medication ordered by a provider for existing residents. The DON acknowledged that Resident #10's Informed Consent for Psychoactive Medications was signed on 3/31/26, after survey inquiry, and was left blank during the resident's original admission. On 04/01/2026 at 3:18 PM, the surveyor presented the above concerns with psychoactive medication consent to the Licensed Nursing Home Administrator (LNHA) in the presence of the DON, Assistant DON, and Regional Director of Clinical Operations. The LNHA acknowledged the surveyor's concerns and then stated that the initial consent should be completed during admission. 2.On 3/30/2026 at 9:36 AM, during the initial tour, the surveyor observed an oxygen in use sign on the door frame of Resident #61's door. The resident was in a reclining chair wearing oxygen (O2) via a nasal canula (NC) at 2l (liters) per minute (min). The resident stated, so far the care is good. The surveyor reviewed the electronic medical record (EMR) for Resident #61 A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; dementia, unspecified (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life), Chronic Obstructive Pulmonary Disease (COPD- a progressive, treatable lung disease—often including emphysema or chronic bronchitis—that restricts airflow and makes breathing difficult), unspecified congestive heart failure (CHF-a condition that occurs when the heart cannot pump blood efficiently to meet the body's needs) and Type 2 Diabetes Mellitus (DM2-a condition in which the body has trouble controlling blood sugar). A review of the admission Minimum Data Set, an assessment tool dated 3/20/26, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the resident was receiving oxygen, insulin and an antidepressant. A review of the individual comprehensive care plan revealed a focus of client is admitted for SA (subacute) care .due to respiratory distress, DM2 and CHF, date initiated 3/13/2026. Further review revealed a focus of use antidepressant medication (Remeron) r/t (related to) Depression, date initiated 3/21/2026 and an intervention of educate [name redacted]/family/caregivers abouts risks, benefits, and the side effects and/or toxic symptoms of anti-depressant medication, date initiated 3/21/2026. Further review of the ICCP did not reveal a focus or intervention of wearing oxygen or of receiving insulin. A review of the Order Summary Report revealed the following POs: - Mirtazapine Oral Tablet 15 MG (Remeron) Give 1 tablet by mouth one time a day for depression start 3/13/2026, 9:00 PM, discontinued 3/15/26. -Mirtazapine Oral Tablet 15 MG (Remeron) Give 1 tablet by mouth at bedtime for depression start 3/15/2026, 9:00 PM. A review of the March 2026 Medication Administration Record (MAR) revealed the above-mentioned POs had been documented as completed as ordered from the date of orders. A review of the progress notes revealed a Nurse's Note on 3/13/2026 at 4:33 PM.admission packet was reviewed with resident.call made to [identifiers redacted] will be here tomorrow to sign all necessary documents. Further review did not reveal any additional documentation regarding the admission packet. On 3/31/2026 at 12:13 PM, the surveyor reviewed the paper chart for Resident # 61 which revealed a two page Consent for use of Psychoactive Medication Therapy there was no information filled out. In the area of: Statement of Consent: there was no I Do or I Do Not consent to the use of: line was left blank. The signature lines from the resident, the resident representative (RR) or the nurse completing the form were blank. The area Telephone Consent was left blank. On the first page of the admission packet there was a post it note that read.spoke with [identifier redacted] will be here tomorrow to sign all necessary documents.On 3/31/2026 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, who was Resident #61's assigned nurse. She stated when a new admission comes, she started the new admission paperwork, but the Registered Nurse (RN) completed the assessment, the medication review and the care plan. LPN #1 stated she had written the post it note on the front of the packet. LPN #1 stated that it was endorsed to the next shift that the RR was coming in the next day to complete the paperwork. She had acknowledged the paperwork should have been completed but it was not. On 4/1/2026 at 12:39 PM, the surveyors interviewed RN/UM #1, who stated any medication that the resident was started on at the facility, she would review it with the RR. She stated in the admission packet there was a consent form for psychotropic medications started upon admission. She stated, yes, we still get consent for a medication that they (the resident) were taking prior to admission. RN/UM #1 stated it was important to make sure family is aware, this patient is getting this psychotropic. She stated every resident that comes to the facility, especially taking psychotropics, they have to make sure the family was in agreement, even if it was over the telephone. RN/UM #1 accessed the EMR for Resident #61 and acknowledged the resident was started on Mirtazapine on admission. She stated we missed it; the whole packet (admission packet) was not signed. She stated, for some reason that was missed. On 4/1/2026 at 1:39 PM, the surveyors interviewed the Director of Nursing (DON), who acknowledged Resident #61's Consent for use of Psychoactive Medication Therapy that was included in the admission packet should have been completed but it was not. She stated they should review medication with them (the resident) making sure they understood why they were taking the medication. She added it could be written or verbal consent, but it should be documented. On 4/1/2026 at 3:11 PM, the Licensed Nursing Home Administrator, the DON, the Infection Preventionist, the [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were made aware of the above concerns. No additional information was provided. A review of the facility's policy Psychotropic Medication Use revised 10/30/25, revealed Policy: Our community is committed to protecting residents' rights to be free from abuse, neglect, exploitation, and unnecessary chemical restraints.Definitions: Psychotropic Drug: a medication that affects brain activity, including antipsychotics, antidepressants, anti-anxiety drugs, and hypnotics.5. Informed Consent: Residents or their legal representatives must be informed of: Purpose of medication, Benefits and risks.Consent must be document in the medical record prior to initiation of or changes in psychotropic medication therapy.8. Psychotropic Medication Initiation and Changes: Prior to initiating or increasing a psychotropic medication, the resident, family and/or resident representative must be informed of the benefits.9. Documentation: Medical records must include: Diagnosis justifying medication use and changes. N.J.A.C. 8:39-27.1 (a)

Based on interviews, review of the facility's policy, and other pertinent facility documents, it was determined that the facility failed to implement their abuse policy to a.) complete a background check for 1 out of 65 employees (Employee #4) and b.) complete refence checks for 1 out of 65 employees (Employee #5). This deficient practice was identified for newly hired employees reviewed since last survey of 11/4/2024.This deficient practice was evidenced by the following:On 3/30/26 at approximately 9:40 AM, during the entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA), all newly hired employee files for active and inactive employees from 11/4/24 to the current date.A review of the employee personnel files revealed the following:For Employee #4, a Homemaker with a date of hire (DOH) 5/5/25, there was no evidence of a background check prior to the start of employment.For Employee #5, a Certified Nursing Assistant (CNA) with a DOH 8/26/25, there was no evidence of reference checks prior to the start of employment. On 4/1/26 at 3:11 PM, the LNHA and Director of Nursing (DON) were made aware of the above concerns regarding background checks and reference checks for newly hired employees.On 4/2/26 at 11:29 AM, the surveyor interviewed the Senior Human Resources Journalist, LNHA and Human Resources Recruiter (HR Recruiter). The HR Recruiter stated that they normally receive two references checks prior to hire. She stated that if they could not get in contact with a reference resource, they would document the attempt in their employee file. She further stated that background checks were completed prior to the employees' first day of hire. She then stated the importance of completing background checks and reference checks was to ensure there was no criminal history and to ensure they were a viable candidate to work with the senior population at the facility. On 4/2/26 at 10:16 AM, the survey team met with the LNHA and the DON. The LNHA stated that the facility had no additional information to present for the above concerns. A review of the facility's Selection and Hiring Policy policy, revised 11/1/24 revealed.all applicants must meet minimum qualifications and complete recruitment process, including: provision of employment and personal references.successful completion of criminal background check.new hires generally may not begin work until references are received and verified.all offers of employment are conditional upon successful completion of pre-employment requirements, which may include: criminal background checks and reference verification.background checks will be conducted after a conditional offer is made. Screenings includes, at minimum, criminal history, employment references, and credential verification.A review of the facility's Employment History Checks: policy, revised 11/1/24 revealed.the goal of this policy is to provide a consistent approach to conducting reference checks on prospective employees, current employees, certain volunteers and contractors.it is necessary to contact previous employers or volunteer organizations of an applicant to obtain information about the individual's training, experience, knowledge, skills, and abilities and verify his or her job history.employment references will be conducted on all candidates after a conditional offer or employment has been extended. Human resources is responsible for coordinating and completing all reference checks.prior to making an offer of employment, at least two references will be obtained, two of which will be supervisory references, including the top candidate's current supervisor whenever possible.A review of the facility's P & P: Abuse Prevention policy, undated revealed .all potential employees will be screened for a history of abuse, neglect or mistreating residents according to the following guidelines .reference checks will be performed by H/R using info screen and telephone verification. Copies are kept in the personnel file. This is done on all employee applications before a decision is made to hire the employee. Criminal background checks are performed by an outside vendor on all potential applicants. Results are kept in the file . NJAC 8:39-9.3(b)

Based on record review, interview, and facility policy review, the facility failed to ensure a written copy of the baseline care plan was completed and provided to the resident and/or resident representative (RR) within 48 hours of admission for 1 of 20 sampled residents (Resident #61) reviewed for baseline care plan. This deficient practice was evidenced by the following:On 3/30/2026 at 9:36 AM, during the initial tour, the surveyor observed an oxygen in use sign on the door frame of Resident #61's door. The resident was in a reclining chair wearing oxygen (O2) via a nasal canula (NC) at 2l (liters) per minute (min). The resident stated, so far the care is good.The surveyor reviewed the electronic medical record (EMR) for Resident #61A review of the admission Record (an admission summary) revealed the resident was admitted to the facility with diagnoses which included but were not limited to; dementia, unspecified (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life), Chronic Obstructive Pulmonary Disease (COPD- a progressive, treatable lung disease-often including emphysema or chronic bronchitis-that restricts airflow and makes breathing difficult), unspecified congestive heart failure (CHF-a condition that occurs when the heart cannot pump blood efficiently to meet the body's needs) and Type 2 Diabetes Mellitus (DM2-a condition in which the body has trouble controlling blood sugar). A review of the admission Minimum Data Set (MDS), an assessment tool dated 3/20/26, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the resident was receiving oxygen, insulin and an antidepressant. A review of the individual comprehensive care plan (ICCP) revealed a focus of; client is admitted for SA (subacute) care .due to respiratory distress, DM2 and CHF, date initiated 3/13/2026. Further review revealed a focus for the use of antidepressant medication (Remeron) r/t (related to) Depression, date initiated 3/21/2026, with an intervention to educate [name redacted]/family/caregivers abouts risks, benefits, and the side effects and/or toxic symptoms of anti-depressant medication, date initiated 3/21/2026. Further review of the ICCP did not reveal a focus or intervention for using oxygen or for receiving insulin.A review of the progress notes revealed a Nurse's Note on 3/13/2026 at 4:33 PM,.admission packet was reviewed with resident.call made to [identifiers redacted], will be here tomorrow to sign all necessary documents. Further review did not reveal any addition documentation regarding the admission packet. On 3/31/2026 at 12:13 PM, the surveyor reviewed the paper chart for Resident # 61 which revealed a two page Client's Baseline Care Plan Summary Client's Name [identifier redacted] Date: 3/13/2026, no other information was filled out. There was no signature from the resident, the RR or the nurse completing the form. On the first page of the admission packet there was a sticky note that read.spoke with [identifier redacted] will be here tomorrow to sign all necessary documents. On 3/31/2026 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, who was Resident #61's assigned nurse. She stated that when a new admission comes, she started the new admission paperwork but the Registered Nurse (RN) completed the assessment, the medication review, and the care plan. LPN #1 stated the care plan should include diagnoses, medications such as insulin or breathing treatments. LPN #1 reviewed the paper chart for Resident #61 stated she had started the admission packet for the resident. At that time, she reviewed the baseline care plan and acknowledged that it was not completed. She stated she had written the sticky note on the front of the packet. LPN #1 stated that it was endorsed to the next shift that the RR was coming in the next day to complete the paperwork. She had acknowledged the paperwork should have been completed but it was not. On 3/31/2026 at 12:49 PM, the surveyor interviewed the RN/Unit Manager (RN/UM) #1, who stated she usually reviewed the new admission medications and completed the baseline care plan. She stated the resident or RR usually did not sign the base line care plan on admission, but they would usually sign it during the care plan meeting which was usually around day 5 of the admission. RN/UM #1 stated that a baseline care plan should be completed within 24 hours of admission and should include diagnoses, falls, skin, pain and COVID status. She stated the purpose of a care plan was the plan of care, what we are going to do if the patient needs things. At that time, RN/UM #1 reviewed Resident #61's paper chart, in the presence of the surveyor. She acknowledged the baseline care plan was not completed and it was not signed but should have been. On 3/31/2026 at 1:09 PM, the surveyor interviewed the Director of Nursing (DON), who stated baseline care plans were completed by the admitting nurse under supervising UM. She stated the UM reviewed the baseline care plan with the resident and if the resident was unable to sign, it would be reviewed with the RR. At that time, she reviewed the admission packet with the surveyor and acknowledged the baseline care plan was not completed and was not signed by the resident, RR or verified by the nurse. On 4/1/2026 at 12:39 PM, during a follow up interview, RN/UM #1 stated the whole admission packet was not completed or signed. She stated, for some reason that (the admission packet) was missed. On 4/1/2026 at 3:11 PM, the Licensed Nursing Home Administrator, the DON, the Infection Preventionist, the [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were made aware of the above concerns. A review of the facility policy P&P Baseline Care Plans revised 10/30/25, revealed Policy.will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.1. The baseline care plan will: a be developed within 48 hours of a resident's admission.3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative.5. A supervising nurse/nurse designee is responsible for providing the written summary of the baseline care plan to the resident and representative.6. The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided.7. If the summary was provided via telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident/representative. NJAC 8:39-11.2(d)

Based on observations, interviews, record review and review of facility provided documents, it was determined that the facility failed to update the Individualized Comprehensive Care Plan (care plan) for 2 of 20 sampled residents (Resident #7 and #16) reviewed for care planning. This deficient practice was evidenced by the following: 1. On 3/30/26 at 9:59 AM, during an initial tour, the surveyor observed Resident #7 sitting in their room with the door open. Resident #7 stated they can't swallow right so they had surgery. The surveyor observed a capped feeding tube (a medical tubing inserted directly into the stomach delivering nutrition, fluids and medications) on the resident's abdomen which extended from under their shirt. Resident #7 stated they received meals (liquid nutrition), water, and medication through the feeding tube. Resident #7 stated they were also able to enjoy their favorite drink, coffee, in the morning, after being taught how to swallow it safely by speech therapy. Resident #7 stated the coffee had to be thick, and he had to swallow a few times after each sip but enjoyed it. The surveyor reviewed the Electronic Medical Record (EMR) and hybrid paper chart for Resident #7. A review of the admission Record (an admission summary) reflected diagnoses which included but were not limited to; dysphagia (difficulty or inability to swallow) and gastrointestinal hemorrhage (stomach/intestinal bleeding). A review of the Speech Therapy (ST) communication/diet recommendation form reflected .initiate pleasure feeds. signed by the ST and the receiving nurse, followed by the dates 3/12/26 and 3/13/26. A review of the physician's orders reflected an order dated 3/13/26 for Regular diet. Mechanical soft texture, Nectar/mildly thick consistency for diet. Pleasure feedings on request only. A review of the March 2026 Medication Administration Record (MAR) included the order for pleasure feedings initiated on 3/13/26, with entries signed for day, evening, and night shifts each shift from 3/13/26 up to and including 3/31/26. A review of the individual comprehensive care plan (ICCP) included a focus area of admission for aspiration (something other than air getting into the airway, such as food or water) .with an associated intervention to follow safety precautions as ordered, NPO (nothing by mouth) status, date initiated 2/16/26. Another focus area for nutrition revealed the resident was a nutrition/hydration risk related to NPO status, tube feeding dependency, and persistent dysphagia. Interventions included: NPO, provide bolus feeding.five times daily. date initiated 2/19/26. 2. On 3/30/26 at 10:38 AM, during an initial tour, the surveyor observed Resident #16 sitting in their room with the door open. Resident #16 stated they had a fall and received rehabilitation at the facility. The surveyor observed the resident moving their arms and legs, sitting and standing without assistance. Resident #16 stated that the nurse brought medications and the kitchen provided meals, but otherwise they took care of themselves including dressing, bathing, and other activities of daily living. The surveyor reviewed the EMR and hybrid paper chart for Resident #16. A review of the admission Record reflected diagnoses which included, but were not limited to; repeated falls, and muscle weakness. A review of the ICCP included a focus area initiated on 6/26/24 which revealed that the resident was admitted for SA (subacute) care for ambulation (movement) due to s/p (status post) fall. The associated interventions included the following which were initiated 10/4/24; [brand name redacted] cervical collar on at all times for every shift, for protection, and Sling to RUE (Right Upper Extremity) on at all times- may remove for skin checks and ADLs (Activities of Daily Living) every shift. A review of the physician's orders including active, discontinued, and completed orders reflected a discontinued order for cervical collar with start date 5/17/24, discontinued on 10/23/24, and a discontinued order for sling to RUE with start date of 6/26/24, and discontinued on 10/23/24. On 3/30/26 at 10:25 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1 who stated that Resident #7 had a feeding tube for nutrition and medicine. LPN #1 added that Resident #7 also received pleasure feeds (small amounts of preferred foods or liquids consumed while following precautions, to improve quality of life) based on the recommendation from speech therapy and doctor's orders. On 4/1/26 at 9:46 AM, the surveyor interviewed the Director of Nursing (DON) who stated a resident's care plan was initiated by the nurse upon admission and updated as the resident's condition changed. She stated the care plans were reviewed by the clinical team at least quarterly (every 3 months). On 4/1/26 at 11:31 AM, the surveyor re-interviewed LPN #1 who stated she had been the nurse for Resident #7 and Resident #16 for a few months. LPN #1 in the presence of the surveyor, reviewed the care plan for Resident #7. LPN #1 acknowledged the care plan reflected the resident's NPO status but did not reflect the pleasure feeds initiated on 3/13/26. LPN #1, in the presence of the surveyor, then reviewed the care plan for Resident #16. She acknowledged that Resident #16 did not have a cervical collar or arm sling, and maybe those were old items on the care plan. LPN #1 stated that she attended care plan meetings and updated care plans when she knew something had changed with a resident. LPN #1 stated that Resident #16 hadn't changed so she had no reason to review or update their care plan. She stated that if she was not the one who changed the resident's orders, she was not the one who updated the care plans and would have to ask around to see who updated them. On 4/1/2026 at 3:11 PM, the Licensed Nursing Home Administrator, the DON, the Infection Preventionist, the [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were made aware of the above concerns for Resident #7 and #16. A review of the facility policy and procedure titled Care Plans - Updating for Status Changes revised 10/24/25, revealed the following Policy Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised or updated as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan . c. The care plan will be updated with the new or modified interventions accordingly. d. Care plans will be modified as needed by the Nurse and, or other, designated team member. h. The Director of Nursing provides oversight of the care plan process by prioritizing with the team the review of all residents experiencing a change in status to ensure care plans have been promptly updated to reflect current resident needs. NJAC 8:39-11.2

Based on observations, interviews, review of the medical record and other facility documents, it was determined that the facility failed to obtain a physician's order for a wrist splint and/or brace. This deficient practice was identified for 1 of 1 resident reviewed for Activities of Daily Living (Resident #70), and was evidenced by the following:On 3/30/26 at approximately 9:36 AM, the surveyor observed Resident #70 in bed with a resident representative (RR) in the room. The resident was wearing a left wrist brace. The RR stated to the surveyor that they took the brace off to wash the resident's left hand. The RR also stated that the left wrist had no function and needed support to keep it straight. The surveyor observed a blue brace on the windowsill of the room. The RR stated that the blue brace went on the left arm at night to keep it straight. The surveyor reviewed the electronic medical record (EMR) and the hard chart for Resident #70. A review of the admission Record (an admission summary) revealed diagnoses that included but were not limited to; muscle weakness, cognitive communication deficit (a condition where underlying cognitive impairments disrupt a person's ability to communicate effectively), and dermatitis (a common skin condition that causes irritation, itching, rash, or blisters). A review of the Order Summary Report (OSR) did not reveal a physician's order for a splint/brace to the left hand/wrist/arm or for a placement/removal schedule.A review of the Minimum Data Set (MDS), an assessment tool dated 3/19/26, revealed a Brief Interview for Mental Status of 14 out of 15 which indicated no cognitive impairment. Further review of the MDS indicated that the resident had impairment on one side, upper extremity.A review of the Individualized Comprehensive Care Plan (ICCP) dated 3/20/26, did not reveal any focus area or intervention for the use of a left arm/wrist/hand splint.A review of the Occupational Therapy (OT) Plan of Care signed 3/20/26, revealed Musculoskeletal System Assessment Left Upper Extremity (LUE) Range of Motion (ROM).Wrist=impaired; patient did not tolerate testing, wearing splint with wrist in neutral position with forearm supination.A review of the Progress Notes (PN) revealed a provider follow up note dated 3/27/26 which included .Moves extremities, left hemiparesis. LUE weakness.contracture: Continue brace, OT.Patient with risk for skin breakdown.On 4/1/26 at 9:00 AM, the surveyor interviewed the Registered Nurse/Charge Nurse (RN/CN) who stated the brace to Resident #70's left arm was there upon admission, the resident wore it at all times, and the staff removed it to check for skin integrity. The RN/CN stated the resident's left arm was flaccid (limp). The RN/CN stated if the resident felt itching or discomfort, staff removed the brace for a while. The RN/CN stated, It should be used at all times, that arm is contracted. She added, There is no order for that brace. I don't think it is care planned. The RN/CN continued, I have to ask physical therapy. On those kinds of splints or a brace the physical therapist would assess it and then let us know if they needed it or not. The doctor would also put in an order. We usually add it to the care plan. On 4/1/26 at 9:48 AM, the surveyor interviewed the Physical Therapist (PT), who stated that typically OT assessed braced. The PT further stated Resident #70 has only had the wrist immobilizer when I've worked with [them]. I haven't seen anything about a second brace. We would talk to nursing about it if, they have a piece of equipment .to get the appropriate order to use during therapy. On 4/1/26 at 11:18 AM, the surveyor interviewed the OT, who stated Resident #70's wrist brace came over with the resident from the hospital and OT had been looking at their arm positioning. The OT stated, We haven't established a wearing schedule. The OT further stated It (the wearing schedule) was not something that we assigned and had not been established yet. I thought the wrist brace was a doctor's order. The resting hand splint was the one we set a goal to look at. The OT described the process upon admission was if a resident was supposed to sleep with a brace, OT would have the resident wear it during the daytime while therapy was there. Then if the resident tolerated wearing the brace, therapy would write a recommendation for the brace to be worn at night. She stated they would give it (the recommendation) to the charge nurse to enter an order for the resident. The OT stated therapy would do training for the staff after the order was entered. The OT stated, We wouldn't give (a resident) something if we weren't confident, it wouldn't cause skin breakdown.On 4/1/26 at 1:16 PM, the surveyor interviewed the Director of Nursing (DON) who stated therapy should enter the order for a brace or splint after their evaluation and nursing would approve it. The doctor could also write the order, but nursing usually got it (the order) from therapy. If a resident had a brace or splint upon admission, the admitting physician would accept that order until therapy saw the resident.On 4/1/26 at 3:11 PM, the Licensed Nursing Home Administrator, the DON, the Infection Preventionist, the [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were made aware of the above concern. A review of the facility provided Splint/Brace Use policy, undated, revealed it was the policy of the community to ensure that all splints, braces, and orthotic devices were assessed, applied, monitored, and documented in a manner that promotes resident safety, maintains functional ability, and complies with all applicable federal and New Jersey regulations. The procedures indicated. All splints/braces must have a valid order from a licensed provider including: type and location of device, clinical indication, wearing schedule (on/off times), precautions or contraindications. Documentation must include: provider order, assessment findings, care plan interventions, application/removal times, monitoring results, resident tolerance and response, education provided. NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures to ensure that a resident's urinary catheter drainage bag was stored properly for 1 of 1 resident reviewed for urinary catheter (Resident #35) and was evidenced by the following: On 3/30/2026 at 9:56 AM, during the initial tour, the surveyor observed Resident #35's urinary catheter drainage bag attached to the handrail in the bathroom with the end of the uncapped tube tip on the floor. The surveyor also observed two signs in the bathroom, one on the wall above the toilet and the other on the side of the cabinet in the bathroom which stated, Please refrain from discarding Urinary collection bags!On 3/30/2026 at 11:59 AM, the surveyor observed Resident #35's same undated urinary catheter drainage bag attached to the handrail in bathroom with the end of the uncapped tube tip on the floor.On 3/30/2026 at 12:10 PM, the surveyor accompanied the Registered Nurse (RN) to Resident #35's bathroom and observed the undated urinary catheter drainage bag with the uncapped tip on the bathroom floor. When the surveyor asked the RN what the process was for urinary catheter care, the RN stated, the process is if the resident has an order for a [name redacted] bag, the drainage bag is used at night when the resident is in bed. The nurse gets the bag and dates it prior to putting it on the resident. In the morning, before the resident gets out of bed, the leg bag is put on, and the bedside drainage bag is emptied and bagged and kept in the bathroom. The RN confirmed the urinary catheter drainage bag tip was on the floor. The RN stated the urinary catheter drainage bag tip should not have been on the floor for infection control. The RN stated the Certified Nursing Aide (CNA) should have put the urinary catheter drainage bag in a plastic bag. When the surveyor asked the RN about the undated urinary catheter bag, the RN stated that the nurse that put the urinary catheter drainage bag on the resident during the 3:00 PM-11:00 PM shift should have dated the urinary catheter drainage bag, so the staff would know when it was due to be changed.On 3/31/2026 at 9:59 AM, during an interview with the surveyor, the CNA who was assigned to Resident #35 and provided care to the resident on 3/30/26 during the 7:00AM - 3:00 PM shift, stated she removed the night bag (urinary catheter drainage bag), washed it, and hung it on the handrail by the toilet so it could be reused. The CNA stated she had washed the night bag before and hung it on the rail but did not remember how many times she had done it, and that it depended on how soiled the drainage bag was. The CNA stated the urinary catheter drainage bag looked new, so that was why she washed it with soap and water. The CNA acknowledged that she should have stored the urinary catheter drainage bag in a plastic bag for infection control.On 4/01/2026 at 10:03 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated the urinary catheter drainage bag should not have been hung there with the uncapped tip on the floor because it was an infection control issue. The IP further stated the CNA should have removed the urinary catheter drainage bag from the resident and discarded it as soon as she was finished taking care of the resident.On 4/01/2026 at 10:33 AM, during an interview with the surveyor, the Director of Nursing (DON) stated the urinary catheter drainage bag tubing tip should not have been on the floor because it was an infection control issue and once it touched the ground it was contaminated.On 4/01/2026 at 12:14 PM, during a follow up interview with the surveyor, in the presence of the DON, the IP stated that the signage that was posted in Resident #35's bathroom, was removed on 3/30/26. The IP further stated the signage, Please refrain from discarding Urinary collection bags! was not facility policy.The surveyor reviewed the medical records for Resident #35 which revealed the following:The Admissions Record (AR; an admission summary) reflected that Resident #35 was admitted to the facility, had diagnoses which included but were not limited to; retention of urine, Benign Prostatic Hyperplasia (BPH; causes the prostate to increase in size) with lower urinary tract symptoms, and obstructive and reflux uropathy (when urine can't flow either partially or completely through the ureter, bladder, or urethra due to some type of obstruction [blockage]).A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 01/13/2026, included the resident had a Brief Interview for Mental Status score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Further review of the MDS, reflected Resident #35 had an indwelling catheter (including suprapubic catheter .).A review of Resident #35's Order Summary Report revealed the following physician's order (PO):- Suprapubic Catheter 22 fr (French; size of catheter) care every shift for Suprapubic Catheter/BPH, date started 12/01/2025.-Bedside drainage bag to be applied when in bed every evening shift, date started 10/29/25.-Leg bag to be applied when OOB (out of bed) every day shift, dated started 10/29/25.A review of Resident #35's individual comprehensive care Plan (ICCP) revealed a focus of resident having infection that was difficult to treat related to (r/t) use of Suprapubic Catheter, date initiated 10/09/2025. Further review revealed a focus of the resident having an indwelling Suprapubic Catheter r/t to BPH, date initiated 10/16/2025. Further review of the ICCP did not reveal a focus or intervention for changing or disposing urinary drainage bag as per facility policy.On 4/1/2026 at 3:15 PM, the Licensed Nursing Home Administrator, the DON, the IP, the [NAME] President of Clinical Operations, and the Regional Director of Clinical Operations were made aware of the above concerns. A review of the facility policy P&P Appropriate Use of Indwelling Catheters - Skilled Nursing Catheter Indications/Intervention, revised on 1/30/2025, revealed it is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . Under Procedure: 6. Leg bags may be worn during the day but need to be removed and discarded, after which a new bedside drainage bag will be placed on the catheter at night.A review of the facility policy P&P Urinary Incontinence and Indwelling Catheter Indications/Intervention, revised on 09/22/2025, revealed Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice .A review of the facility policy Urinary Tract Infections (Catheter -Associated), Guidelines for Preventing, revised on 01/30/2025 revealed under Steps in the Procedure: 6. c. Do not place the drainage bag on the floor. NJAC 8:39 - 19.4(a)(5), 27.1(a)

Based on observations, interviews, record review, and review of other pertinent facility documents, it was determined that the facility failed to implement their policy to a.) ensure all eligible residents were educated on the benefits and potential side effects of the influenza and pneumococcal immunizations and b.) document in the medical record the residents' education and refusal of the influenza and pneumococcal immunizations. The deficient practice was identified for 3 of 5 residents reviewed for immunizations (Resident #61, #70 and #73.)This deficient practice was evidenced by the following:1. On 3/30/2026 at 9:36 AM, during the initial tour, the surveyor observed an oxygen in use sign on the door frame of Resident #61's door. The resident was in a reclining chair wearing oxygen (O2) via a nasal canula (NC) at 2l (liters) per minute (min). The resident stated, so far the care is good. The surveyor reviewed the electronic medical record (EMR) for Resident #61 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; dementia, unspecified (a mental disorder that can cause a person to lose the ability to learn, remember, think, solve problems, and make decisions), anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life), Chronic Obstructive Pulmonary Disease (COPD- a progressive, treatable lung disease—often including emphysema or chronic bronchitis—that restricts airflow and makes breathing difficult), unspecified congestive heart failure (CHF-a condition that occurs when the heart cannot pump blood efficiently to meet the body's needs) and Type 2 Diabetes Mellitus (DM2-a condition in which the body has trouble controlling blood sugar). A review of the admission Minimum Data Set (MDS), an assessment tool dated 3/20/26, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating the resident was cognitively intact. A review of the progress notes revealed a Nurse's Note on 3/13/12026 at 4:33 PM.admission packet was reviewed with resident.call made to [identifiers redacted] will be here tomorrow to sign all necessary documents. Further review did not reveal any additional documentation regarding the admission packet. A review of the immunizations tab in the EMR for Resident #61 revealed 2025-2026 Seqirus Fluad Influenza Vaccine 0.5mL marked as Refused by resident, and PCV 21 Pneumococcal vaccine marked as refused. On 3/31/2026 at 12:13 PM, the surveyor reviewed the paper chart for Resident #61 which revealed a Consent for Flu Vaccine-Resident declinations marked as refused, not signed by the resident; but the nurse signed it on 3/13/26. The Flu Vaccine Consent-Resident Representative was completely blank. The [Name Redacted] Pneumonia Vaccination Consent form had the Resident's Name: [Identifier Redacted-Resident #61's name was printed]; a check mark next to [Identifier redacted Resident #61s name] and the word verbally was printed next to Do not give consent; the Signature line was blank. Further review of the packet, revealed on the first page of the admission packet there was a post it note that read.spoke with [identifier redacted] will be here tomorrow to sign all necessary documents. On 3/31/2026 at 12:25 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) #1, who was Resident #61's assigned nurse. She stated when a new admission comes, she started the new admission paperwork which included assessed for vaccinations. LPN #1 reviewed the paper chart for Resident #61 stated she had started the admission packet for the resident. She stated she had written the post it note on the front of the packet. LPN #1 stated that it was endorsed to the next shift that the RR was coming in the next day to complete the paperwork. She had acknowledged the paperwork should have been completed but it was not. On 3/31/2026 at 1:09 PM, the surveyor interviewed the Director of Nursing (DON), who stated vaccines were assessed by the nurse and the nurse managers on admission and the Infection Preventionist (IP) reviewed them the next day. The DON reviewed the admission packet and acknowledge the vaccinations paperwork was not signed by the resident or verified by the nurse. 2.On 3/30/26 at 9:36 AM, the surveyor observed Resident #70 in bed with their eyes closed and with family members in the room. A review of both the electronic medical record (EMR) and hard chart for Resident #70 was conducted. A review of the AR reflected diagnoses that included but were not limited to muscle weakness; cognitive communication deficit (a condition where underlying cognitive impairments disrupt a person's ability to communicate effectively); and asthma. A review of the immunizations tab in the EMR for Resident #70 revealed Pneumococcal immunization refused by family on 3/19/26. Education provided, risk vs benefits discussed with family. A review of the admission Minimum Data Set (MDS), an assessment tool dated 3/19/26 revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated minimal or no cognitive impairment. A review of the Medication Administration Record (MAR) for Resident #70, revealed the nurse marked the physician order for Pneumovax as other-see note at 00:11 AM on 3/20/26. A review of the progress notes in the EMR showed a note refused. On 3/31/26 at 2:15 PM, the surveyor reviewed Resident # 70's hard chart on the 101 unit, which revealed a document titled [name redacted] Pneumonia Vaccination Consent that was blank. 3.On 3/30/26 at approximately 9:50 AM, the surveyor observed Resident #73 with a family member in the room. The family member was wearing a gown and gloves, and the resident was ambulating using a walker. No concerns were reported by the resident or the family member. Two staff members entered the room wearing gowns and gloves. The staff stated the resident was on contact precautions. A review of both the EMR and hard chart for Resident #73 was conducted. A review of the AR reflected diagnoses that included but were not limited to pneumonia, unspecified organism; unspecified dementia; and need for assistance with personal care. A review of the immunizations tab in the EMR for Resident #73 revealed 2025-2026 Seqirus Fluad Influenza Vaccine 0.5mL Refused by resident on 3/20/26. Education provided, risks/benefits discussed. A review of the admission MDS dated [DATE] for Resident #73 revealed a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. A review of the MAR for Resident #73 revealed the physician's order for Flu Vaccine marked drug refused on 3/20/26 at 19:33PM. On 3/31/26 at 2:15 PM, the surveyor reviewed Resident #73's hard chart on the 101 unit, which revealed a document titled Consent for Flu Vaccine-Resident, that was signed by the resident and by a witness on 3/20/26, with no consent or declination for the flu vaccine. The chart also contained a document titled Flu Vaccine Consent-Responsible Representative, that was signed by the representative and by a witness on 3/20/26, with no consent or declination for the flu vaccine. On 4/1/2026 at 3:11 PM, the Licensed Nursing Home Administrator, the DON, the Infection Preventionist, the [NAME] President of Clinical Operations and the Regional Director of Clinical Operations were made aware of the above concerns for Residents #61, # 70, and #73. No additional information was provided A review of the facility's policy Influenza (Flu)Vaccine Administration-Residents revised 6/12/23, revealed Policy: It is the policy of [name redacted] to strongly encourage and administer the annual influenza (flu)vaccine to its residents as essential protection against the Flu infection .The resident has the right to refuse the Flu vaccine. If the resident or representative refuses the Flu vaccination, the physician/NP/PA will be notified and attempt to reeducate the resident and encourage/strongly recommend receipt of the vaccination. A review of the facility's policy Pneumococcal Vaccine Administration revised 10/24, revealed Policy: It is the policy of [name redacted] to encourage and administer the Pneumococcal Vaccine to residents per Centers for Disease Control (CDC) recommendations as essential protection against Pneumococcal disease. Older adults are at greatest risk of serious illness and death related to Pneumococcal disease .The resident has the right to refuse the Pneumococcal Vaccine. An attempt will be made to encourage the vaccine through education about the benefits of the vaccine and the risks of not receiving it. As noted above, the Nurse will document education and any refusal of the Pneumococcal Vaccine in the MAR. The physician/APN/PA may also educate the resident. NJAC 8:39-19.4 (h) (i)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 7 (seven) residents during the medication observation pass (Resident #46). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual 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 07/12/23 at 9:40 AM, during the medication administration observation, the surveyor observed the Registered Nurse (RN#1) in the room of Resident #46. The surveyor observed RN#1 checking the resident's identification bracelet and informing Resident #46 that she will be administering the resident's medications. The surveyor observed the resident in bed and just finished eating breakfast. On 07/12/23 at 9:45 AM, the surveyor observed RN#1 preparing to administer five (5) medications to Resident #46 which included Metoprolol Succinate Extended Release (ER) 50 mg tablet (medication for lowering blood pressure), Potassium Chloride 20 MEQ ER tablet (potassium supplement), Eliquis 2.5 tablet (irregular heartbeat), Torsemide 10 mg tablet (medication for lowering blood pressure) and Rhopressa eye drops (medication for pressure in the eye). The surveyor observed RN #1 prepared the resident's medication and then brought it into Resident #46's room. At that time, Resident #46 asked RN#1 if she could split the Potassium ER 20 MEQ tablet in half since it was too big to swallow. The surveyor observed RN#1 take the medications to the medication cart and then scooped out the Potassium Chloride tablet and proceeded to crush Potassium ER 20 MEQ tablet. After crushing the tablet, RN#1 placed it into a medication cup and then added apple sauce. RN#1 then added the remaining tablets into the medication cup containing the crushed Potassium Chloride ER tablet and apple sauce. The surveyor stopped RN#1 prior to administering the medications and asked RN#1 if she can bring the medication cup outside of the resident's room. At that time, the surveyor interviewed RN#1 who stated that she crushed the Potassium ER 20 MEQ tablet because the resident complained that they were unable to swallow the whole tablet. The surveyor asked RN#1 if it was recommended to crush an extended-release tablet. RN#1 stated that an extended-release tablet should not be crushed and that when the resident complained that they were unable to swallow the tablet that she should have held the medication and contacted the physician for a recommendation. The surveyor reviewed the medical record for Resident # 46. A review of the Admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to hypertension (elevated blood pressure), glaucoma (pressure in the eye) and atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chamber of the heart). A review of the Admission Minimum Data Set, an assessment tool used to facilitate the management of care, dated 7/04/23, reflected that the resident's cognitive skills for daily decision-making score was 15 out of 15, which indicated that the resident was cognitively intact. A review of the July 2023 Physician Order Sheet (POS) revealed no physician order (PO) for medications to be crushed. Further review of the July 2023 POS revealed a PO dated 7/7/23, for Potassium Chloride ER Oral Extended-release 20 MEQ tablet give (1) tablet by mouth two times daily for supplement with food. A review of the July 2023 Electronic Medication Administration Record (eMAR) revealed an order dated 7/7/23, for Potassium Chloride ER Oral Extended-release 20 MEQ tablet give (1) tablet by mouth two times daily for supplement with food. A review of the Manufacturer's specifications for Potassium Chloride ER 20 MEQ revealed the following: To take each dose without crushing, chewing, or sucking the tablet. If those patients are having difficulty swallowing whole tablets, they may try one of the following alternate methods of administration: a. Break the tablet in half and take each half separately with a glass of water. b. Prepare an aqueous (water) suspension as follows: 1. Place the whole tablet (s) in approximately 1/2 glass of water (4-fluid ounces). 2. Allow approximately 2 minutes for the tablet (s) to disintegrate. 3. Stir for about half a minute after the tablet (s) has disintegrated. 4. Swirl the suspension and consume the entire contents of the glass immediately. 5. Add another 1 fluid ounce of water, swirl and consume immediately 6. Then, add an additional 1 fluid ounce of water, swirl, and consume immediately. On 07/12/23 at 10:20 AM, the surveyor interviewed the RN/UM#2 Unit Manager (UM) who stated that the resident's Potassium Chloride ER 20 MEQ tablet should not have been crushed because it was an extended-release tablet. The RN/UM#2 further stated that the facility called the resident's physician, and the order was changed after surveyor inquiry. On 7/13/23 at 1:30 PM, the surveyor discussed the above observations and findings with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON). There was no additional information provided. A review of the facility's policy for sub-acute/Skilled Nursing Household Medication Administration-General Guidelines dated 6/25/19, which was provided by the DON included the following, Cautionary information on the MAR or medication package/container (e.g., don't crush, shake well, give food on an empty stomach, etc.) is checked and adhered to prior to medication administration. Nurse personnel must contact the physician/Physician assistant (PA) and Advance Nurse Practitioner (APN) when there is a discrepancy based on the written order or for any questions related to cautionary information. NJAC 8:39-11.2 (b), 29.2 (d)

Based on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications for 2 of 2 medication room refrigerators inspected. This deficient practice was evidenced by the following: On [DATE] at 6:50 PM, the surveyor inspected the 2nd-floor medication room refrigerator in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an expired bottle of [MEDICATION(S)] eye drops that had an opened date of [DATE]. The surveyor interviewed LPN #1, who stated that the [MEDICATION(S)] eye drops were expired and belonged to a resident discharged from the facility. LPN #1 said that all expired and medications belonging to a discharged resident should have been removed from the medication refrigerator. On [DATE] at 7:15 PM, the surveyor inspected the 3rd-floor medication room refrigerator in the presence of LPN #2. The surveyor observed an expired Purified Protein Derivative (PPD) vial with an opened date of [DATE] and an opened Novolog pen that had an expiration date of [DATE] inside the medication refrigerator. The surveyor interviewed LPN #2, who stated that the PPD dated [DATE] was expired and should have been removed from the medication refrigerator. LPN #2 also noted that the expired Novolog pen was for a discharged resident and should have been removed from the medication refrigerator. A review of the Manufacturer's Specifications for the above medications indicated the following: 1. [MEDICATION(S)] eye drops, once opened, had an expiration date of 42-days 2. PPD vial, once opened, had an expiration date of 30-days 3. Novolog Insulin pen, once opened, had an expiration date of 28-days. On [DATE] at 3:15 PM, the surveyor met with the Licensed Nursing Home Administrator and the Director of Nursing (DON). The facility provided no further information. A review of the facility's policy for Storage of Medications dated [DATE] that the DON provided indicated the following: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exist. A review of the facility's policy for Disposal of Medications and Medication-Related Supplies dated [DATE] that the DON provided indicated the following: Medications are removed from the medication cart immediately upon receipt of an order to discontinued (to avoid inadvertent administration). Medications awaiting disposal or return are stored in a locked, secure area designated for that purpose until destroyed or picked up by pharmacy. NJAC: 8:,d+[DATE].4 (a) (h) (d)

Based on observation, record review and interview on 3/2/16 in the presence of facility management it was determined that the facility failed to maintain their duel temperature fan coils and commercial clothes dryers in a safe and optimal condition. This deficient practice was evidenced by the following: 1. On 3/2/16 from 10:45 a.m. to 12:35 p.m., the surveyor observed throughout the facility that the duel temperature fan coils had filters that were clogged and dirty in the following areas. Resident rooms: 104-105-111-120-125-128-130-141-142-146-147-148-149-150-155-161-163-164-167 and in resident room 131 the unit had no filter installed. Skilled Nursing Dining room: 8 of 8 duel temperature fan coil units. 2. At 12:30 p.m., the surveyor observed in the laundry dryer room that two commercial dryers had lint filters with an heavy accumulation of lint. The log provided indicated that the units were cleaned once a day only at the end of the shift. The amount of lint on the filters at the time of the survey indicated that the filters should be cleaned more often. The surveyor interviewed the Plant Operations Director at 11:30 a.m., and he stated that the units were clogged and dirty and will be changed as soon as possible. No filter maintenance log was provided at the time of the survey. NJAC 8:39-31.2(e) NJAC 8:39-31.4(b)

Based on surveyor's observation of the main kitchen, in the presence of the facility staff on 4/8/2015 at 9:25 a.m., it was determined that food preparation and storage areas were not maintained in a clean, sanitary and functional manner. Finding include: The surveyor observed the following which had an accumulation of blackened dust or /grease /burned food/ brown stains/rust stain; or did not have working parts: 1. The exterior of the small steamer 2. The exterior and interior of the two convection ovens which were stacked on top of each other 3. The interior of the surface of the hood over the stove 4. The exterior of the large grill 5. The exterior and interior of the two ovens which were stacked on top of each other 6. The exterior and interior of the two stacked ovens which were located on the other side of the hood 7. Three large fans inside the #1 walk-in refrigerator 8. Three large fans inside the # 2 walk- in refrigerator 9. The ceiling tiles in the dish machine room 10. One vent inside the dish machine room 11. Six knobs were missing from the six burner stove 12. Five knobs were missing from the large grill 13. One square vent was found to be broken, located in the middle of the dish room The faucet was observed to be leaking from the hand washing sink near the food preparation area. The paper towel was observed to be missing from the hand washing sink next to cook's area. The scoop was found resting inside the large container on the top of the brown rice. The food serving trays were observed to be cracked / chipped / and damaged all around the 4 sides and corners. The surveyor observed the following inside the dry storage room: The following items were stored higher than 18 inches: 1. Forty eight cans of tomato juice 2. One large box of medley cracker; 3. One large box of vanilla wafers cracker; 4. One large box of nips cheese crackers; 5. One large box of parchment paper; 6. Five large boxes of clear plastic saran wrapping paper; 7. Two large boxes of pink napkins; 8. Large stack of prefabricated boxes which can be converted into boxes; Four shelves were observed to be broken/damaged in side the storage room. Two large boxes of salad and spinach were stored higher than 18 inches inside the # 2 walk-in- refrigerator. The surveyor observed the following inside the Expo kitchen which is a small kitchen located next to the main dining room. Food was served directly to the resident from this kitchen: The surveyor observed that small fan inside the refrigerator was soiled and had an accumulation of dust. The thermometer was missing from the refrigerator. The stainless steel hand washing sink was visibly soiled. The tile wall above the sink and all around the counter, an approximately 3 inch area between the tile wall and stainless steel wall, had tiles missing and was visibly soiled with blackened dust, which was covered with clear epoxy glue. Additionally, two wooden sticks were also placed on each side of the counter underneath the epoxy glue. NJAC 8:39 - 31.4 (a)

Based on observation, interview and record review, it was determined that the facility failed to provide adequate supervision for 1 of 5 residents reviewed for falls, Resident #5, as evidenced by the following: The surveyor reviewed Resident #5's medical record on 4/9/15 and 4/13/15. According to the admission Face Sheet, the resident was admitted in 5/2014 with [DIAGNOSES REDACTED]. The 5/22/14 Admission and the 1/29/15 Quarterly Minimum Data Set (MDS) assessment tools indicated that the resident was non-ambulatory, required the extensive assistance of 2 people for transfers, and extensive assistance of 2 people for toileting. The balance assessments for the resident indicated that the resident was not able to steady herself without staff assistance when transferring from a sit to a stand position, when getting on and off the toilet, and for surface to surface transfers. The Interdisciplinary Team (IDC Team) determined that the resident was at risk for falls and implemented the following care plan interventions: keep call light in reach, respond promptly to requests for assistance, and bed and chair alarms. The resident had 4 falls since admission to the facility. The surveyor reviewed the fall investigations on 4/13/15 and 4/14/15 for these falls which occurred on 6/22/14, 10/28/14, 2/14/15 and 3/12/15. Following the fall on 10/28/15 the IDC Team added the intervention for 2 person assist for transfers. On 2/14/15 at 10:40 a.m. Resident #5 was placed on the toilet by the Certified Nursing Assistant (CNA). The CNA stood just outside the bathroom door. The CNA then left Resident #5 alone to respond to another resident's call for assistance. Resident #5 was found 5 minutes later on the floor in the bathroom. The resident had a reddened area on the left flank. Neuro checks were initiated. Pelvic and left hip x-rays were taken and showed no fractures. The surveyor observed the resident on 4/9/15 at 8:55 a.m. in a low positioned bed with eyes were closed. The call bell was in reach and bilateral floor mats were in place. The surveyor observed the resident on 4/14/15 at 11:45 a.m. seated in a wheelchair, conversing with the psychologist. There was an alarm on the wheelchair. The surveyor interviewed the resident's regular CNA on 4/14/15 at 11:55 a.m. The CNA stated that she has been assigned to the resident since admission. The CNA stated that she never leaves the resident unattended in the bathroom. The surveyor discussed the fall of 2/14/15 with the Director of Nursing (DON). The DON acknowledged that the resident should not have been left unattended in the bathroom and that the involved CNA had been counseled. The involved CNA is no longer an employee at the facility. NJAC 8:39-27.1(a)

Based on interview, observation and record review it was determined that the facility failed to accurately document on a medical record the resident's weight (wt.) for 2 months past admission. This deficient practice was noted for 1 out of 2 residents, Resident #10, reviewed for weight and evidenced by the following: On 4/8/15 at 9:40 a.m. the surveyor toured the facility with a unit staff member who informed the surveyor that Resident #10 was admitted to the facility with a documented wt. of 106 pounds (lbs.) but the resident's current wt. fluctuated between 164 and 165 lbs. The staff member felt that the admission wt. was incorrect. The surveyor reviewed the medical record for Resident #10 on 4/13/15 at 10:47 a.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident previously lived in the associated facility Assisted Living Residence prior to admission to this facility. The resident's weight recorded on admission to the skilled care unit 11/25/14 was 106.2 lbs. The resident had a documented height of 63 inches. The resident had documented weights (wts.) on 12/2/14 at 108.5 lbs., 1/7/15 at 108 lbs., and on 1/14/15 at 109 lbs. On 1/16/15 the resident's weight was recorded at 157.9 lbs. and a reweigh on the same day 1/16/15 at 160.4 lbs. On 1/21/15 the weight was documented at 110 lbs. On 1/22/15 the resident was reweighed by the Assistant Director of Nursing (ADON) and the previous wt. of 110 lbs. was crossed out. The ADON documented the corrected wt. as 162.7 lbs., and added a note to the crossed out wt. from the previous day 1/21/15 "1/22/2015 14:09, incorrect documentation." On 4/13/15 at 1:25 p.m. the surveyor reviewed the progress notes written by the dietician with the ADON. This dietician was no longer working for the facility at the time of the survey. The dietician's first progress note entered on 12/5/15 noted "ALU weight this writer has on file and in ALU chart in 167 pounds (#) in November 2014. Question accuracy of 108# wt., requested reweigh and weekly wts." The following note entered by the dietician on 1/1/15 "No wts noted in PCC (Point Click Care, the facility's medical recording computer system) since 12/5/-will continue to add weekly weight lists, nursing notified of missing wts." "Wts in ALU over last 6 months before admission to Skilled Nursing Unit (SNU) at 157-167# (noted 10# gain from October-November) ? accuracy of 108# wt. upon admission to SNU after hospital. ? " On 4/14/15 at 10:00 a.m. the Director of Nursing presented the facility's "Nutritional Status/Weight Monitoring Policy" to the surveyor. The section 3 Procedure states "All new admits and readmissions will be weighed on the admission day, then weekly for the 1st 4 weeks after admission, and then monthly there after unless physician order [REDACTED]./reweighs will be reviewed by the dietician and ADON or designee prior to documentation in the Medical record." The "Procedure for Taking Weights" section 3 states "The CNA (Certified Nursing Assistant) reports the weight to the ADON for logging in to PCC." On 1/14/15 at 9:40 a.m. the surveyor interviewed Resident #10's CNA who explained that the resident was transferred to the current room in January 2015. Prior to that, the resident was in a different room in the facility. The CNA explained that once the resident was transferred, the CNA was asked to perform numerous reweighs but the CNA said she was unaware of the rationale for these reweighs. N.J.A.C. 8:39-35.2(g)

Based on observation, interview and record review it was determined that the facility failed to properly transcribe a physician's order for pain medication. This deficient practice occurred for Resident #13, 1 of 14 residents reviewed for services that meet professional standards. The evidence was as follows: Resident #13 was admitted to the facility on [DATE] after a motor vehicle accident. The Resident was observed on 4/15/2014 at 9:50 a.m. during Medication Pass Observation. The surveyor observed the resident take the medications and tell the nurse that there was a patch on his/her chest area that needed to be removed after 12 hours. The surveyor heard the nurse tell the resident "I'll have to check the computer, I didn't see anything about that." The surveyor observed that there was a patch on Resident #13's sternum. At 9:55 a.m., the surveyor and the nurse reviewed the electronic Medication Administration Record [REDACTED]. At 10:10 a.m. the surveyor reviewed the medical record for Resident #13. An order was written on 4/14 (untimed) for a [MEDICATION NAME] Patch to be applied "QD and remove 12 hours later." The surveyor interviewed the Assistant Director of Nurses (ADON) who stated that "QD" dosing was for 9 a.m. unless otherwise written in the order. The surveyor was told by the ADON at this time that the nurse who entered the order into the E-MAR scheduled the pain patch to be administered at 7 p.m. rather than 9 a.m. as indicated on the physician's order. The surveyor was also told by the ADON that the E-MAR did not reflect that a nurse applied a patch at 7 p.m. on 4/14. And because the nurse did not sign out the [MEDICATION NAME] Patch she applied on 4/14 at 7 p.m., the electronic system did not trigger an order to remove it 12 hours later at 7 a.m. on 4/15. The surveyor observed the nurse remove the patch at 10 a.m., 3 hours later than it should have been removed. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that a facility Physical Therapist did not respond to a resident's complaint of pain when it was voiced. This deficient practice occurred for Resident #10, 1 of 13 residents reviewed for quality of care. The evidence was as follows: Resident #10 was admitted to the facility on [DATE] from the hospital after a fall. Resident #10 had the [DIAGNOSES REDACTED]. Resident #10 was first observed during the initial tour on 4/14/14 at 9:40 a.m. The surveyor observed Resident #10 walking out of his/her room with a walker and a Physical Therapist (PT). The surveyor heard the resident state to the PT "My back is killing me, I don't know if I can do the therapy." The surveyor observed the PT continue guiding Resident #10 down the hall toward the therapy room as she stated in response to the resident's report of pain, "Your back hurts because you are in bed too much." At 10:45 a.m. on 4/14 the surveyor along with the Assistant Director of Nurses observed Resident #10 walking with a walker in the hallway back to the room with the same PT. The surveyor asked the resident at that time if he/she was still having pain. Resident #10 stated "Yes, I do, thank you for asking." The PT continued to guide Resident #10 along and said "he/she has pain from lying in bed too much." At 10:55 a.m. on 4/14, the surveyor was told by the PT "I just told the nurse (Resident #10) was having pain." That was one hour and fifteen minutes after the resident was first heard by the surveyor to say to the PT on the way to therapy "My back is killing me, I don't know if I can do the therapy." The surveyor reviewed the medical record for Resident #10 on 4/15/14 at approximately 11 a.m. The record indicated on 3/31/14, the resident scored 4 out of a possible 15 on the "Brief Interview of Mental Status (BIMS)" assessment, indicating cognitive impairment. There was a physician's orders [REDACTED]. as needed for pain in the medical record. At approximately 10 a.m. on 4/17 the survey team interviewed the PT. A surveyor asked the PT when would she tell a nurse that a resident has complained of pain. The PT stated "If it's an Ortho (Orthopedic) resident, it will be addressed immediately." When the surveyor asked what if the resident was not an Ortho resident, the PT stated "It depends on the patient. In this case, in my professional judgement, I felt like maybe if he/she had exercise, he/she would be better." NJAC 8:39-27.1 (a)

Based on observation, interview and record review it was determined that the facility did not provide catheter care to prevent infection. This deficient practice occured for Resident #4, 1 of 1 residents with an indwelling catheter. The evidence was as follows: Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 4/14 at 9:48 a.m. during the Medication Pass Observation, the surveyor observed Resident #4 lying in bed. A Certified Nurse Aide (CNA) was at the bedside. The surveyor was told by the CNA that she had just removed Resident #4's urinary drainage bag and attached a leg bag for holding urine. At 9:50 a.m. the surveyor went into the bathroom in Resident #4's room. The surveyor observed the drainage bag hanging over a handrail and the tip of the tubing was touching the toilet bowl base. There was no cap on the end of the tubing. At 9:55 a.m. the surveyor interviewed the CNA who was caring for Resident #4 with regard to the urinary drainage bag. The surveyor was told by the CNA that she puts the drainage bag over the handrail that same way every morning and the next shift CNA would re-attach it to Resident #4's catheter. The surveyor reviewed the medical record for Resident #4 at 10:10 a.m. In the record was a Urologist's consult dated 3/27/14 which indicated a past medical history of [REDACTED].#4 was treated with antibiotics for bladder infections discovered on 10/30/13, 2/20/14 and on 3/10/14. At 10:20 a.m. the surveyor and the Assistant Director of Nurses (ADON) entered the bathroom of Resident #4's room. The ADON saw the manner in which the catheter drainage bag was stored and stated it should not be there like that and immediately put it in a trash receptable. The facility policy was received by the survey team on 4/14 at 11:30 a.m. The policy required that an end cap be applied to the tubing and it then be placed in a plastic bag for storage in the resident's bathroom. NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to revise fall interventions for a resident with multiple falls out of the chair. This deficient practice was identified for Resident #2, 1 of 5 residents reviewed and was evidenced by the following: During the initial unit tour on 4/14/14, the Assistant Director of Nursing (ADON), told the surveyor that Resident #2 was forgetful and had a history of [REDACTED].#2 on 4/16/14 that indicated Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's fall investigations showed the following: 0n 6/24/13, the resident slipped off the reclining chair and sustained an abrasion to the back of the head. On 7/25/13, the resident fell off the chair. On 12/19/13, the resident slipped off the wheelchair and on 3/30/14, Resident #2 slipped off the reclining chair. The surveyor reviewed the resident's fall interventions dated 3/8/13. There was no revision to the care plan to address the resident's falls related to sliding off the chair or the recliner. On 4/17/14 at 10:40 a.m., the surveyor went to the resident's room with the ADON and observed that there was no anti-slip device on either the wheelchair or the reclining chair. The surveyor asked the ADON how they addressed the resident's falls by way of slipping off the chairs. The ADON stated that they had hourly monitoring for the resident but had not addressed the slipping off the chair specifically. During interview with the facility administration at 1:45 a.m., the Clinical Director and the Director of Nursing stated that they implemented hourly monitoring for Resident #2 but had not addressed resident's slipping off the chair. NJAC 8:39-27.1(a)

Based on interview and observation, the facility failed to properly supervise medications by not locking the medication cart during the morning medication pass. This deficient practice was observed for 1 of 2 medication nurses and evidenced by the following: The surveyor observed the morning medication pass on 2/20/13. The medication nurse obtained medications for a resident at 9:15 a.m. from the medication cart which was located outside the resident's room. The medication nurse went into the resident's room without locking the medication cart. The medication nurse gave the resident the medications while the medication cart was not in view of the nurse. The medication nurse then proceeded to the resident's bathroom to wash his/her hands and could not visualize the medication cart. The medication nurse then returned to the medication cart and locked it prior to going to the next resident. The medication nurse obtained the medications for the next resident at 9:25 a.m. from the medication cart located outside the resident's room. The medication nurse went into the resident's room without locking the medication cart. The medication nurse gave the resident the medications while the medication cart was not in view of the nurse. The medication nurse then proceeded to the resident's bathroom to wash his/her hands and could not visualize the medication cart. The surveyor questioned the medication nurse upon return to the medication cart about not locking the medication cart. The medication nurse stated that s/he was not aware s/he had to lock the medication cart when the cart was right outside the room s/he was in. The locking of the medication cart and keeping it in visual contact ensured that no unauthorized persons (staff, visitors and/or residents) had access to a variety of medications including narcotics. This concern was discussed with administration on 2/21/13 at 2:50 p.m. and they indicated surprise because the pharmacy consultant had reviewed every medication nurse. N.J.A.C. 8:39-29.4(h)