Every finding on record at Tower Lodge Care Center

Based on observation, interview, and document review, it was determined that the facility failed to a) ensure potentially hazardous foods were stored and handled in a manner to prevent food-borne illness, b) the kitchen equipment was maintained in a clean and sanitary manner, and c) staff practiced appropriate hand hygiene and glove use to prevent contamination from foreign substances and limit the potential for the development a foodborne illness. This deficient practice affected all residents who resided at the facility and was evidenced by the following: On 04/16/26 at 8:28 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) present and observed the meal preparation in progress and observed a metal can opener was affixed to the table had food debris embedded on the blade, and the blue insert that held the can opener could not be removed by the staff, due to caked on, embedded dark colored debris. A Dietary Staff (DS) was then observed with very long fingernails that extended past all 10 fingertips, was not wearing gloves and was scooping gelatin into cups. The FSD informed the DS about the gloves and the DS proceeded to put gloves on without first washing hands. On 04/17/26 at 9:52 AM, the surveyor observed a large metal pot scrubbing pad in the kitchen by the pot sink washing area. The FSD acknowledged that the metal scrubbers were not supposed to be used due to potential shredding. On 04/20/26 at 8:38 AM, the surveyor entered the kitchen to review the food temperatures with the [NAME] and reviewed the food temperature log for the breakfast meal. The breakfast temperature log for 04/20/26 was blank, along with the temperature log for the 4/19/26 dinner meal. When asked about the food temperatures, the [NAME] stated, It's not filled out because I didn't get a chance to fill them out. When asked if the food temperatures were written down somewhere else, the [NAME] stated, No, and that she only took the food temperature of the oatmeal.At that time, the [NAME] was observed wiping down the counters and the tray line area after the breakfast meal, and the surveyor observed that a large metal sheet pan was resting over the top of a food preparation sink. The pan was partially covered with aluminum foil, and the surveyor observed raw chicken was exposed underneath, was not fully covered, and the pan was not labeled or dated. The surveyor asked the [NAME] to uncover the pan which exposed approximately 15 large pieces of chicken, and some with skin. The chicken was sitting in a red liquid which the [NAME] then poured into the prep sink, and the surveyor then asked what the chicken was for? The [NAME] stated, it will be prepped. The surveyor asked the cook to take the temperature of the chicken, and the [NAME] used a thermometer and placed it into a piece of the chicken and it read 59 degrees Fahrenheit (F). The surveyor asked why the chicken was 59 F and if 59F was acceptable? The [NAME] stated, No, but it wasn't sitting long. The surveyor then observed a package of pre-cooked pancakes, in a plastic bag that was rested on top of the toaster which was on the counter. When asked what that was, the [NAME] responded that they were pancakes, and they were on top of the toaster because she was cleaning. When asked if they were going to be discarded? The [NAME] stated, No, they were used at breakfast and she placed them there while she was cleaning. The surveyor then asked the [NAME] to take the temperature of the pancakes, and she inserted the thermometer and the temperature was 57 F.At that time, the surveyor observed the DS pick up a hair net outside of the kitchen that was on top of a cart, then she entered the kitchen and began placing individual condiments that were scattered on the tray line, into a container. When the surveyor asked the DS if she washed her hands, she stated, in the break room. When asked about touching the hair net before she entered the kitchen, she stated, oh and proceeded to wash her hands for 3 seconds under running water. The surveyor then asked how long she was supposed to wash her hands for, and she stated 20 seconds.On 04/20/26 at 8:58 AM, the surveyor exited the kitchen and informed the Licensed Nursing Home Administrator and FSD of the observations with the raw chicken and pancakes. The FSD stated the food should have been 40 degrees F when it was removed from the refrigerator, and not almost 60 degrees F, and he would discard the items.On 4/21/26 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), [NAME] President (VP) of Clinical, and the Regional Nurse Consultant to inform them of the above concerns.On 4/22/26 at 10:24 AM, the survey team met with the administration: LNHA, DON and Regional Nursing for further responses and no additional information was provided.A review of the Handling Refrigerated-Thawed Meat Prior to Cooking Policy revised January 24, 2026 revealed the following: Purpose: To ensure safe food handling practices and reduce the the risk of foodborne illness (e.g. Salmonella and Escherichia coli infection by controlling time and temperature exposure. 1. Approved Thawing Method: Meat, including chicken, must be thawed in a refrigerator at 41 F or below .The Hand Hygiene Policy- Dietary Department, undated revealed, revealed Procedure Dietary staff must wash hands: before starting work and before food preparation . after touching face, hair, body, or personal items, before putting on gloves and after removing them .Between handling different food items or tasks . Handwashing: Employees must follow this process: 1. Wet hands and wrists under warm running water. Apply soap. 2. Scrub vigorously for at least 20 seconds, including back of hands; between fingers .The Food Safety and Sanitation Policy Revised January 2026 revealed All local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department: Procedure: Food Storage: Food that is stored is protected from contamination and growth of any pathogenic organisms. b. Among the food protection measures that are performed by the food service department are: Foods are refrigerated and stored at or below 41 F.Perishable ingredients are refrigerated when they are not being used.NJAC 8:39-17.2 (g)

Based on observations, interviews, record review and document review it was determined that the facility failed to regularly provide a nourishing bedtime snack for the residents. The deficient practice was identified for 8 of 8 residents who attended a resident council meeting (Resident #2, # 4,# 7, #25 #,45, #46, #50,and Resident #53) and had the potential to affect all residents who resided in the facility, and was evidenced by the following: A review of the meal Tray Delivery Times provided by the facility on 04/22/26 at 11:15 AM, reflected the following: The meal tray delivery schedule included the following information: Meal trays for the [NAME] Unit were scheduled to be delivered for dinner at 5:09 PM and for breakfast at 8:14 AM, (indicative of a 15 hour and 5 minute time span between the two meals); Meal trays for the Pearl Unit were scheduled to be delivered for dinner at 5:20 PM and for breakfast at 8:20 AM (indicative of a 15 hours' time span between the two meals); Meal trays for the Emerald Unit scheduled time was not provided, however the breakfast trays were scheduled to be delivered for breakfast at 8:25 AM.On 4/17/26 at 10:35 AM, the surveyor conducted a Resident Council Meeting with eight alert and oriented residents who regularly attended the monthly resident council meetings and inquired regarding being offered a bedtime snack (HS) Snack. All 8 of 8 residents stated they were not offered a bedtime snack, and had not been aware that the facility should offer a bedtime snack. On 4/21/26 at 10:29 AM, the surveyor interviewed the Food Service Director (FSD) and inquired regarding bedtime HS snacks (HS) that were provided to the units. The FSD stated that HS snacks were delivered to the unit every evening and labeled HS snacks. The surveyor then asked about the PAR level to verify what was sent to the unit based on the facility census. The FSD stated, I don't have a par level for HS Snacks. The surveyor then inquired regarding the amount of HS Snacks sent to the units. The FSD then stated, 6-8 peanut butter and jelly sandwiches, 12 puddings, and some cookies. The current census was 55 and the amount of snacks did not equal the amount of residents.On 4/21/26 at 10:45 AM, the FSD accompanied the surveyor to the unit pantry, where we both observed 2 peanut butter and jelly sandwiches, 11 puddings, and some cookies on a container dated 4/21/26.On 4/21/26 at 11:40 AM, the surveyor interviewed a random Certified Nurse Aide (CNA)#1 and asked to show the surveyor where on the Task (CNA documentation of care) that HS Snacks offered would be documented. CNA #1 stated that she could not locate the documentation. On 4/21/26 at 12:00 PM, the surveyor then interviewed CNA #2 who worked both shifts, 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts, and inquired regarding where the documentation regarding HS snacks offered would be located. CNA #2 stated, The residents went to bed after dinner and no HS snack was offered. The CNA then stated, if they want a snack they should ask for it. The surveyor then asked CNA #2 if residents should be provided with a snack or, they had to ask for a bedtime snack and she did not respond. The above concerns were presented to the administrative staff on 4/21/26 and additional information was requested.On 4/22/26 at 7:50 AM, the surveyor returned to the pantry and observed 2 peanut butter and jelly sandwiches, 11 pudding cups, and a few cookies labeled 4/22/26.On 04/22/26 at 10:15 AM, the Director of Nursing (DON) stated in an interview the nurses signed on the medication administration record that snacks were being offered. A review of the residents list provided by the DON, reflected that all residents refused HS snacks.The DON did not address what CNA #2 stated that HS snacks were not offered because the residents went to bed after dinner, or the amount of snacks provided that did not cover the amount of residents in the facility. On 4/22/26 at 11:30 AM the facility provided a picture of the snacks delivered on 4/21/26. The list consisted of 6 peanut butter and jelly sandwiches, 11 pudding cups, some cookies, and nine ice cream cups. Based on the remaining snacks observed in the pantry on 4/22/26 at 7:50 AM, only 4 peanuts butter and jelly sandwiches were distributed. The 11-pudding cups and ice cream were observed still in the pantry, refrigerator/freezer along with the cookies. A review of the facility's policy, titled, Offer HS Snack and Documented Acceptance last revised, 5/2025 reflected the following:PurposeTo ensure residents are offered a bedtime (HS) snack and that acceptance of refusal is consistently documented.PolicyAll residents will be offered an HS snack as appropriate to their care plan and dietary needs.Nursing staff are responsible for documenting the resident's response to the snack offer by recording:Y (Yes)- if the resident accepts the snackN (No)-if the resident declines the snackDocumentation must be completed at the time the snack is offered to ensure accuracy.Expectation: Every HS snack offer must have a corresponding Y or N documented in the medical record.NJAC 8:39-17.4(b)

Based on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to have a system in place to ensure that contracted staff had the appropriate competencies and skills to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with standards of practice and individual resident care plans. This deficient practice had the potential to affect all residents who resided at the facility and was evidenced by the following: 1. On 4/16/26 at 1:24 PM, the surveyor reviewed the Resident Council Meeting Minutes for January, February and March 2026. The Resident Council Minutes dated 03/25/26, reflected the following: Residents were complaining about agency staff. Residents requested to have more regular staff and to not have agency workers at all. On 4/17/26 at 10:35 AM, during the Resident Council meeting conducted by the surveyor and attended by 8 alert and oriented residents, the residents were asked to elaborate on their concerns. All 8 of 8 residents stated that the facility could use more help. When asked to elaborate further, the residents stated the all services stopped after 4:00 PM on Friday. The residents stated, the agency staff do not care. The residents shared that the regular staff were frustrated as the agency staff were better compensated for doing a lousy job. The residents further stated that from 12:00 AM until the following day, the agency staff was not visible, and call lights would not be answered, and the residents stated that the staff would be observed in the lounge. The surveyor then followed- up with the Director of Nursing (DON) regarding the above concerns. The DON confirmed that he was aware of the concerns shared by the residents about the agency staff, and the facility was in the process of having more full-time staff hired to work at the facility. No additional information was provided.On 4/17/26 at 8:05 AM, a surveyor observed a nurse (Registered Nurse-RN) at a medication cart and he was wearing a hospital identification badge, not a facility identification badge. When inquired, he stated he was an agency nurse and was not provided with a facility identification badge, and it was his first time working at the facility. At 8:07 AM, the surveyor informed the DON about the RN who was wearing a hospital identification badge. The DON stated that the RN should not have been wearing the hospital identification badge, and then stated the staffing agency was responsible for providing an identification badge.On 4/17/26 at 8:10 AM, while standing in the hallway near the nurses' station, another surveyor was present and observed the same RN preparing medications at the medication cart. The RN removed the tablets from the bingo card, then placed the tablets first in his bare hand, then placed them into the medication cup. The surveyor approached the RN and inquired regarding the observed practice. The RN informed the surveyor there were no gloves available on the medication cart to use, but going forward, he would avoid touching resident medication with his bare hands. Around 8:18 AM, both surveyors returned to the hallway and observed the medication cart that the RN was preparing medications at, was ajar with the lock button popped out, and was unlocked in the hallway. The RN was not visible at either end of the hallway. The surveyors observed ancillary staff, including housekeeping staff, kitchen, activity staff along with the Assistant Director of Nursing (ADON) in the hallway. The surveyors remained at the medication cart, and at 10:24 AM, both surveyors observed the RN exit the last room at the opposite end of the hallway. The RN could not visualize the medication cart. The ADON also observed the unlocked medication cart ajar in the hallway. When asked the ADON if the RN had been educated on facility practice, the ADON stated, the nurse should know not to leave the medication cart open.On 4/17/26 at 8:25 AM, the surveyor interviewed the RN and inquired if the medication cart should be left open in the hallway. The RN stated, maybe it will be better for me to leave. On 4/17/26 at 8:45 AM the surveyor interviewed the DON and inquired if the RN had received any orientation on medication administration. The DON stated that the ADON reported the concerns regarding the medication cart left ajar and unlocked in the hallway. The DON stated the nurse was an agency nurse, and he stated he gave the nurse a brief orientation on the medication cart at start of the shift. The DON did not provide any documented evidence of an orientation for the RN.2. On 4/20/26 at 11:30 AM, the surveyor reviewed a fall incident report dated 8/22/25, for Resident #40. According to the Progress notes dated 8/22/25, the Certified Nursing Aide reported that she used the mechanical lift (Hoyer- a type of mechanical lift machine that is used to lift a resident in the air and used for transfer -and two staff are utilized for safety) to transfer Resident #40 from the bed to the wheelchair, and the CNA turned to turn off the water and the resident slid to the floor. The surveyor then requested the fall investigation for review. The facility provided one statement from the CNA, and a statement from the nurse who worked the unit for review. The DON completed the post fall assessment, and indicated that Resident #40 did not sustain any injuries. The facility did not further investigate if a second staff was present as required and failed to determine if the CNA acted alone for the Hoyer Lift transfer. The facility did not provide any training for the CNA prior to using the Hoyer Lift to transfer the resident, or after the fall to prevent further recurrence.On 4/21/26 at 8:51 AM, the surveyor conducted a telephone interview with the the CNA involved with the transfer. The surveyor asked the CNA who assisted her with the transfer. The CNA stated the nurse entered the room, but the resident was already on the floor. The CNA stated that she transferred the resident alone with the Hoyer Lift and the resident slid on the floor. The surveyor then asked the CAN, if she received any orientation from the facility regarding resident's care, she stated, No, she was not educated by a regular staff to familiarize herself with the residents.On 4/21/26 at 10:00 AM, the surveyor requested the CNA's file for review. The file was not provided. The surveyor interviewed the Director of Human Services/ Staffing Coordinator (HR/SC) and requested a competency evaluation for the CNA who transferred Resident #40 using the Hoyer Lift. The HR/SC stated that the CNA was agency staff, and she did not have her competency evaluation. She further stated that the facility required only a criminal background check and license verification from the agency, they did not request education.On 4/21/26 at 12:30 PM, the surveyor requested a competency evaluation for the CNA from the DON. The DON stated that he would get the file from the agency, along with the agency contract.On 4/22/26 at 9:52 AM, the facility provided the contract from the agency. The contract did not include the CNA's file. The Contract specified in paragraph E under Client Duties: Client acknowledges and accepts: Vii .Nurse Personnel are independent contractors providing Nursing Services directly to you. Personnel are not employees, agents, or legal representatives of you. If during the performance of any Nursing Services, you do not reasonably find the quality of the Nursing Services provided by the Nurse Personnel to meet your reasonable expectations, you are solely responsible for addressing quality concerns, including but not limited to intentional or unintentional dereliction of duties as determined in your sole discretion.The above concerns were presented to the facility administrative staff on 4/21/26 at 11:43 AM. On 4/22/26 at 10:45 AM, during the exit conference, the facility provided an orientation package that would be implemented in the future to verify agency staff had competencies completed prior to providing care to the residents. NJAC 8:39-27.1(a); 43.14(a)

Based on observation, interview and document review it was determined that the facility failed to ensure that the menu was followed, and recipes were utilized to ensure meals were provided in a consistent manner. The deficient practice was identified for 7 of 8 Residents who attended a resident council meeting and had the potential to affect all residents who resided at the facility.The evidence was as follows: On 04/17/26 at 10:35 AM, the surveyor conducted a resident meeting with eight residents in attendance. When asked about the meals, 7 of 8 residents stated the food quality was poor, the food was served cold and the meal trays would be left to sit in the hallway while staff were doing other things. One resident stated they have been living on sandwiches for the past six months because the food was not good.On 04/20/26 at 8:10 AM, surveyor observed the [NAME] Unit and asked the Certified Nurse Aide (CNA) assigned to the unit when the breakfast meal would arrive and the CNA stated 8:00 AM. At 8:12 AM, an open cart was delivered and the CNA stated she had all 10 resident meal trays to pass on the unit, and then immediately began passing the meal trays. No assistance from any other staff was provided. The 2nd to last meal tray was passed at 8:29 AM, and the surveyor removed the last tray to conduct a tray observation with the [NAME] present. The Meal Tray ticket for Resident #14 documented the following: Regular Texture, CCD (Controlled Carbohydrate) No Added Salt, Thin Fluid Diet. The following items were listed on the mal ticket:- 6 ounces of Oatmeal.- 1 Farmers Egg Bake (SQ 3x3)- Scrambled eggs were observed instead of an egg bake.- 4 ounces orange juice.- 8 ounces of skim milk.- 6 ounces coffee. -Breakfast Roll- 1 each was listed and was not on the tray -2 pieces of triangular shaped raisin toast was on the tray and was not listed on the ticket.-Diet jelly was listed on the tray and was not provided, regular jelly was provided.At 8:31 AM, when the surveyor showed the [NAME] the meal ticket and asked the [NAME] what was the Farmers Egg Bake? The [NAME] stated, I don't know, they just told me scrambled eggs.On 04/20/26 at 8:35 AM, a second surveyor observed the meal cart arrive on the Emerald Wing and Resident #31's meal tray was reviewed which was documented as a Low-Fat Diet on the meal ticket. A CNA was in attendance during the temperature check by the surveyor which revealed:- 4 ounces orange juice.- 6 ounces oatmeal.- 8 ounces skim milk. - 1 Pancake was on the tray and was not listed on the meal ticket.-1 Farmers Egg Bake (sq 3 x 3) and 1 -Breakfast Roll was listed on the meal ticket, and both were not provided on the the meal tray. The CNA confirmed that there was no egg bake or breakfast roll on the tray, and stated that was a pancake instead and stated, maybe they forgot to put the eggs on the tray. On 4/20/26 at 8:38 AM, during an observation in the kitchen with the Cook, the surveyor asked about the Egg Bake and asked to see the recipe. The [NAME] stated, I don't know what the hell the egg bake is, and she confirmed that she didn't have any recipes. When asked what the breakfast roll was, she stated, there was none, that was what the raisin toast was. When the surveyor reviewed the menu, and observed barbeque chicken for lunch, and vegetable barley soup for dinner and requested the recipes. The [NAME] stated I don't know if [the Food Service Director] has a recipe book, but I know how to cook. The [NAME] stated she had been cooking at the facility for 3 years and didn't use recipes. When asked the [NAME] if it was important to have recipes for consistency, the [NAME] stated there were four different cooks here, and everyone cooks differently. On 4/21/26 at 12:27 PM, the survey team met with the License Nursing Home Administrator (LNHA), DON, [NAME] President (VP) of Clinical, and the Regional Nurse Consultant, to inform them of the above concerns.On 4/22/26 at 10:24 AM, the survey team met with the administration: LNHA, DON and Regional Nursing for further responses and no additional information was provided.The Menus and Recipes Policy revealed Policy: Standardized recipes are used when preparing menu items. NJAC 8:39-17.4(a)2

Based on observation and interview it was determined that the facility failed to ensure meals were served at appetizing and palatable temperatures. The deficient practice occurred for 7 of 8 residents who attended a resident council meeting and for 2 of 2 test meals on 2 of 3 resident units (Ruby and Emerald) and had the potential to affect all residents who resided at the facility.The evidence was as follows: On 04/17/26 at 10:35 AM, the surveyor conducted a resident meeting with nine residents in attendance. When asked about the meals, 7 of 8 residents stated the food quality was poor, the food was served cold and the meal trays would be left in the hallway while staff were doing other things. One resident stated they have been living on sandwiches for the past six months because the food was not good. On 04/20/26 at 8:10 AM, the surveyor observed the [NAME] Unit and asked the Certified Nurse Aide (CNA) assigned to the unit when the breakfast meal would arrive and the CNA stated 8:00 AM. At 8:12 AM, an open cart was delivered and the CNA stated she had all 10 resident meal trays to pass on the unit, and immediately began passing the meal trays. No assistance was provided from any other staff to pass the meal trays. The 2nd to last meal tray was passed at 8:29 AM, and the surveyor removed the last tray and requested a replacement tray for the resident from a Dietary Staff that was present, and the [NAME] was also present during the observation. The Meal Tray ticket for Resident #14 documented the following: Regular Texture, CCD (Controlled Carbohydrate) No Added Salt, Thin Fluid Diet with the following food items and temperatures were taken by the surveyor. - 6 ounces of Oatmeal - 120 Fahrenheit (F).- 1 Farmers Egg Bake (SQ 3x3)- Scrambled eggs were on tray- 95 F.- 4 ounces orange juice- 48 F.- 8 ounces of skim milk- 56 F.- 6 ounces coffee - 120 F. At 8:31 AM, the surveyor asked the [NAME] what the hot food temperature should be when it reached the residents, she stated 179-186 F on the steam table and then stated it varied. The [NAME] then asked the surveyor how long the food was sitting out? The surveyor informed the [NAME] it was immediately served. The surveyor asked the cook if the last tray served to the resident should have a different temperature than the first tray and the [NAME] stated, No. Then the surveyor showed the [NAME] the meal ticket and asked what was the farmers egg bake? The [NAME] stated, I don't know, they just told me scrambled eggs. On 04/20/26 at 8:35 AM, a second surveyor observed the meal cart arrive on the Emerald Wing and the 2nd to last tray was passed at 8:45 AM (1 hour later) and the following meal temperatures were taken for Resident #31's meal tray which was a Low-Fat Diet. A CNA was in attendance during the temperature check by the surveyor which revealed: - 4 ounces orange juice- 48 F.- 6 ounces oatmeal- 117 F.- 8 ounces skim milk 54.7 F.- Pancake - 88.8 F.On 4/21/26 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, [NAME] President (VP) of Clinical, and the Regional Nurse Consultant to inform them of the above concerns.On 4/22/26 at 10:24 AM, the survey team met with the administration: LNHA, DON and Regional Nursing for further responses and no additional information was provided.A Food Temperature Policy, Revised February 2026 revealed under Procedure:1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F, or below 41 F for cold foods, and at or above 135 F for hot foods. 5. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to maintain temperatures at or below 41 F for cold foods and at or above 135 F for hot foods. 7. Food temperature of hot and cold food shall be recorded in the temperature book at the beginning of meal service. NJAC 8:39-17.4(a)2

Based on interview and record review, it was determined that the facility failed to issue the proper required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 1 resident (Resident #25) and the NOMNC for 2 of 2 residents (Resident #62 and Resident #63 ) reviewed for Beneficiary Notification. This deficient practice was evidenced by the following:On 4/17/26 at 11:23 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of residents who were discharged from the facility within the last six months from a Medicare covered Part A stay (helps cover the cost of skilled nursing facility care including rehabilitation services). The surveyor randomly chose three residents (one who remained in the facility and two who were discharged ) and requested copies of the Beneficiary Notices. On 04/20/026 at 12:52 PM, the Regional Social Worker (RSW) stated she called the previous Social Worker (SW), who resigned in March, and stated the notices were kept in a file in her drawer. However, the RSW was unable to locate the notices for the three residents that were requested. On 4/20/2026 at 1:39 PM, the surveyor interviewed the RSW regarding the procedure for the Beneficiary Notices. She stated that when a resident was ending their Medicare Part A stay, the Director of Rehabilitation (DOR) notified the SW of the last covered day. The SW would then have the notices signed either by the resident or the responsible party. On 4/21/26 at 9:51 AM, the RSW stated she had no further information to provide. On 4/21/26 at 12:27 PM, the Director of Nursing (DON), LNHA, [NAME] President of Clinical Services, and the Regional Nurse Consultant were notified of above concern.On 4/22/2026 at 10:12 AM, the facility provided no further information. NJAC 8:39-4.1a(8)

Based on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough investigation was completed and documented to determine the causal factor of injuries of unknown origin and to ensure that abuse or neglect had not occurred. This deficient practice occurred for 2 of 2 residents reviewed for injuries of unknown origin, Resident #40 who was identified with a swollen left index finger, and Resident #47 who was identified with a scab wound on the left abdomen area measuring 4 centimeters (cm) by 3 cm.The deficient practice was evidenced by the following:Refer to F689 1. On 4/20/26 at 11:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #40. The admission Face Sheet (an admission summary), revealed that Resident #40 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia severe, muscle weakness and aphasia following cerebral infarction (stroke).The annual Minimum Data Set (MDS), an assessment tool dated 03/17/2026 revealed that Resident #40 was severely cognitively impaired. Resident #40 received a score of 99 on the Brief Interview for Mental Status (BIMS). Resident #40 was totally dependent on staff for all Activities of Daily Living (ADLs).On 04/20/26 at 11:30 AM, the surveyor reviewed a progress note which revealed that on 7/18/25 at 7:00 AM, Resident #40 was found with a skin tear to the left hand which measured 3 centimeters. The Certified Nursing Aide (CNA) who cared for the resident revealed that when she entered the room at 7:00 AM, she observed bloody drainage on the pillow. The investigation report provided by the facility did not detail any follow-up interviews from any staff on any of three shifts that provided care to Resident #40, prior to the discovery of the unwitnessed injury. On 8/4/25 at 11:05 AM, Resident #40 was found with a swollen left index finger.The surveyor asked for any investigations for review. The facility did not provide any documentation from any caregiver for the dependent residents to determine the cause of Resident #40's injury prior to the identification on 8/3/25. On 4/21/26 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON) and inquired regarding the investigation process for all injuries of unknown origin. In the presence of the survey team, the DON stated that he would do a look back for 24 hours and collect statements from all who provided care to the residents. The DON could not provide any statement from all staff who provided care for Resident #40 on 07/17/25 and 08/03/25, and did not provide an identified cause of the injuries to ensure abuse and neglect had not occured.2. Resident #47 was admitted to the facility with diagnoses which included but were not limited to; Dementia in other diseases classified elsewhere, moderate with other behavioral disturbances, need for assistance with Personal Care, pain in unspecified knee, presence of right artificial knee joint and orthostatic hypotension.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/13/26, reflected that Resident #47 had a Brief Interview for Mental Status (BIMS) score of 10 out 15, which indicated moderately impaired cognition. A review of the comprehensive Care Plan (CP), provided by the facility on 4/19/26 at 10:58 AM, included a focus area for skin breakdown related to decreased mobility and incontinence. The care plan reflected also that Resident #47 was receiving antiplatelet ( to avoid blood clots) therapy medication and was at risk for side effects. The interventions were to assist as needed during transfer, paying attention to extremities to ensure they do not bump. Initiated 07/07/2025. Daily skin monitoring by CNA, notifying nurses of areas of concerns. Initiated 07/07/25.The surveyor reviewed all the progress notes and assessments for Resident #47 available in the medical record. A review of a nursing Progress Note dated 03/05/26 at 11:00 PM, revealed that Resident #47 was noted with bleeding on their first two toes. The physician and the resident representative was informed, and treatment initiated.Another nursing Progress note dated 03/24/26 timed 6:09 PM, revealed that Resident #47 reported to the Nurse Practitioner (NP) the presence of a wound to their left abdomen area. The NP described the wound as flat with some underlying black tissue. The NP ordered to apply bacitracin, cover with bordered gauze and to refer Resident #47 for wound care. The wound measured 4 centimeters (cm) x 3 cm. The facility was unaware of the wound prior to 3/24/26.Resident #47 was dependent on staff for care, no documentation of any redness from the staff prior to 3/24/26 when Resident #47 reported the concerns to the NP. On 4/21/26 at 8:40 AM, upon request for all documentation related to incidents for Resident #47, the DON provided the Incident Audit Report dated 3/24/26. There was no documentation that the staff who cared for Resident #47 were interviewed to determine a causal factor of the injury that occurred to Resident #47. The facility concluded that the wound was most consistent with unintentional friction.On 4/22/26 at 10:30 AM in the presence of the team, the DON stated that for all injuries of unknown origin he would investigate and collect statements from all staff involved with the resident's care. The facility did not provide any staff statement for review.A review of the facility's policy titled, Injury of unknown origin last revise 6/2025, revealed the following:Purpose: To ensure any injury of unknown origin is identified, reviewed, and addressed in a timely and appropriate manner to support resident safety and well-being.Policy: An injury of unknown origin is any observed injury where the cause is not immediately clear. All such findings will be taken seriously and reviewed to determine possible contributing factors.Procedure: The injury will be assessed promptly and documented, including size, location, appearance, and any statements made by the resident.The nurse will notify the physician and responsible party as appropriate. The interdisciplinary team may review the situation to determine if any patterns, risks, or care needs are identified.Interventions may be implemented based on findings to support resident safety.Investigation: An internal review will be completed, which may include:A brief investigation reportWitness statements, if applicableA CAN/staff statement or investigation report.Documentation will remain factual and objective, focusing on observed information. NJAC 8:39- 1. On 4/20/26 at 11:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #40. The admission Face Sheet (an admission summary), revealed that Resident #40 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia severe, muscle weakness and aphasia following cerebral infarction (stroke).The annual Minimum Data Set (MDS), an assessment tool dated 03/17/2026 revealed that Resident #40 was severely cognitively impaired. Resident #40 received a score of 99 on the Brief Interview for Mental Status (BIMS). Resident #40 was totally dependent on staff for all Activities of Daily Living (ADLs).On 04/20/26 at 11:30 AM, the surveyor reviewed a progress note which revealed that on 7/18/25 at 7:00 AM, Resident #40 was found with a skin tear to the left hand which measured 3 centimeters. The Certified Nursing Aide (CNA) who cared for the resident revealed that when she entered the room at 7:00 AM, she observed bloody drainage on the pillow. The investigation report provided by the facility did not detail any follow-up interviews from any staff on any of three shifts that provided care to Resident #40, prior to the discovery of the unwitnessed injury. On 8/4/25 at 11:05 AM, Resident #40 was found with a swollen left index finger.The surveyor asked for any investigations for review. The facility did not provide any documentation from any caregiver for the dependent residents to determine the cause of Resident #40's injury prior to the identification on 8/3/25. On 4/21/26 at 11:20 AM, the surveyor interviewed the Director of Nursing (DON) and inquired regarding the investigation process for all injuries of unknown origin. In the presence of the survey team, the DON stated that he would do a look back for 24 hours and collect statements from all who provided care to the residents. The DON could not provide any statement from all staff who provided care for Resident #40 on 07/17/25 and 08/03/25, and did not provide an identified cause of the injuries to ensure abuse and neglect had not occured.2. Resident #47 was admitted to the facility with diagnoses which included but were not limited to; Dementia in other diseases classified elsewhere, moderate with other behavioral disturbances, need for assistance with Personal Care, pain in unspecified knee, presence of right artificial knee joint and orthostatic hypotension.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/13/26, reflected that Resident #47 had a Brief Interview for Mental Status (BIMS) score of 10 out 15, which indicated moderately impaired cognition. A review of the comprehensive Care Plan (CP), provided by the facility on 4/19/26 at 10:58 AM, included a focus area for skin breakdown related to decreased mobility and incontinence. The care plan reflected also that Resident #47 was receiving antiplatelet ( to avoid blood clots) therapy medication and was at risk for side effects. The interventions were to assist as needed during transfer, paying attention to extremities to ensure they do not bump. Initiated 07/07/2025. Daily skin monitoring by CNA, notifying nurses of areas of concerns. Initiated 07/07/25.The surveyor reviewed all the progress notes and assessments for Resident #47 available in the medical record. A review of a nursing Progress Note dated 03/05/26 at 11:00 PM, revealed that Resident #47 was noted with bleeding on their first two toes. The physician and the resident representative was informed, and treatment initiated.Another nursing Progress note dated 03/24/26 timed 6:09 PM, revealed that Resident #47 reported to the Nurse Practitioner (NP) the presence of a wound to their left abdomen area. The NP described the wound as flat with some underlying black tissue. The NP ordered to apply bacitracin, cover with bordered gauze and to refer Resident #47 for wound care. The wound measured 4 centimeters (cm) x 3 cm. The facility was unaware of the wound prior to 3/24/26.Resident #47 was dependent on staff for care, no documentation of any redness from the staff prior to 3/24/26 when Resident #47 reported the concerns to the NP. On 4/21/26 at 8:40 AM, upon request for all documentation related to incidents for Resident #47, the DON provided the Incident Audit Report dated 3/24/26. There was no documentation that the staff who cared for Resident #47 were interviewed to determine a causal factor of the injury that occurred to Resident #47. The facility concluded that the wound was most consistent with unintentional friction.On 4/22/26 at 10:30 AM in the presence of the team, the DON stated that for all injuries of unknown origin he would investigate and collect statements from all staff involved with the resident's care. The facility did not provide any staff statement for review.A review of the facility's policy titled, Injury of unknown origin last revise 6/2025, revealed the following:Purpose: To ensure any injury of unknown origin is identified, reviewed, and addressed in a timely and appropriate manner to support resident safety and well-being.Policy: An injury of unknown origin is any observed injury where the cause is not immediately clear. All such findings will be taken seriously and reviewed to determine possible contributing factors.Procedure: The injury will be assessed promptly and documented, including size, location, appearance, and any statements made by the resident.The nurse will notify the physician and responsible party as appropriate. The interdisciplinary team may review the situation to determine if any patterns, risks, or care needs are identified.Interventions may be implemented based on findings to support resident safety.Investigation: An internal review will be completed, which may include:A brief investigation reportWitness statements, if applicableA CNA/staff statement or investigation report.Documentation will remain factual and objective, focusing on observed information. NJAC 8:39-27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure: a) adequate supervision was provided to a resident to prevent falls, b) consistently initiate new fall prevention interventions in response to falls, c) current care plan interventions to prevent accidents were consistently implemented. This deficient practice occurred for 2 of 2 residents (Resident #40 and #47) reviewed for falls and were identified as being at high risk for falls.Findings included: Refer to F610 1. On 4/16/26 at 9:21 AM, the surveyor toured the unit and observed Resident # 40 in a low bed with 1/2 siderails in place. The resident was awake but unable to communicate with the surveyor.On 4/16/26 at 11:53 AM, the surveyor observed Resident #40 sitting in the hallway near the facility entrance door. Resident #40 could not hold a conversation. On 4/16/26 at 12:40 PM, during an interview with the Certified Nursing Aide (CNA) who cared for Resident #40, she stated that Resident #40 did not engage in activities, the resident was placed at the entrance door for supervision.On 4/17/26 at 7:55 AM, the surveyor observed the resident in bed, the bed was in a low position, and the side rails were elevated.On 4/17/26 at 11:30 AM, the surveyor reviewed Resident #40's medical record which revealed the following: The admission face sheet (an admission summary) reflected that Resident #40 was admitted to the facility with diagnoses which included but were not limited to; Unspecified dementia severe with other behavioral disturbances, muscle weakness, Type 2 diabetes Mellitus. The Annual Minimum Data Set (MDS) dated [DATE], an assessment tool used by the facility to prioritize care, reflected that Resident #40 was severely cognitively impaired. Resident #40 scored 99 on the Brief Interview for Mental Status (BIMS) Normal Score (00-15).Review of Resident #40's Comprehensive Care plan provided by the facility on 04/19/26, revealed: A focus area: Risk for falls related to impaired mobility, impaired cognition, poor safety awareness. Initiated 01/09/22 and revised on 08/22/25. The goal was that Resident #40's risk for falls would be reduced, will remain free from injury. Initiated 01/09/22 last revised 04/01/26.The interventions included:Keep bed in lowest position. Initiated 01/09/22. Anticipate and meets Resident #40's needs. Initiated 11/14/21. Do not leave alone in bathroom. Initiated 01/09/22.Offer assist with toileting. Initiated 01/09/22.Bilateral leg rests to wheelchair. Initiated 4/15/25.Use Hoyer Lift with 2-person assist for transfer Initiated. 7/4/24.Monitor for decline in mobility and notify therapy for possible screen/ evaluation. Initiated 01/09/22. Keep room and walkways clean and clutter-free. Keep areas well lit. Keep call bell in reach, encourage use. Keep the items needed in reach. Initiated 01/09/22.Dycem (chair pad) to the wheelchair. Initiated 01/03/23.Ensure resident is wearing proper footwear, assist with dressing as needed. Offer nonslip socks when in bed. Initiated 01/09/22.The following incidents were documented in the Electronic Medical Record:The surveyor reviewed a nursing Progress note dated 4/13/25 which reflected that Resident #40 sustained a fall during transfer in the hallway. The resident was assessed and the interventions added after the fall was to have bilateral leg rests in place during transfer.Another nursing Progress note dated 08/22/25 timed 10:00 AM, reflected that Resident #40 sustained another fall following transfer. The nursing progress notes revealed that Resident #40 slid out of the wheelchair.On 04/20/26 at 9:30 AM, the surveyor requested all investigations, for Resident #40 for review from the Director of Nursing (DON).The surveyor further reviewed the medical record and observed that Resident #40 had 2 fall risk assessments dated 1/5/25 and 11/13/25.The Fall Risk Assessment on admission dated 01/05/22, reflected that the facility identified Resident # 40 as a high fall risk. Resident #40 received a score of 19. Fall Risk Total score of 10 or above represents High Risk.The Fall Risk assessment dated [DATE], Resident #40 received a score of (12) indicative of high fall risk. On 4/19/26 at 10:25 AM, the surveyor interviewed the Physical Therapist and requested the therapy screen for Resident #40. A review of the Physical Therapy Screen dated 8/22/25, revealed the following: Educated nursing staff on Hoyer transfer sequencing, to be performed by ADON/ DON (Assistant Director of Nursing). Continue to recommend 2-person for Hoyer Lift.On 4/21/26 at 8:52 AM, the surveyor conducted a telephone interview with the CNA involved with the transfer on 8/22/25 when the resident sustained a fall from the wheelchair. The surveyor asked the CNA to elaborate on the incident leading to the fall. The CNA stated that she used the Hoyer Lift (mechanical device used to safely transfer individuals with limited mobility) to transfer Resident #40 from the bed to the chair, the resident slid out during the transfer. The surveyor asked the CNA who assisted her with the Hoyer Lift, she stated the nurse entered the room, but the resident was already on the floor. The surveyor again asked the CNA who assisted her with the Hoyer lift transfer, she stated she did not have anyone in the room. The Surveyor asked the CNA if she received any orientation from the facility on how to care for the residents. She stated, no. The CNA further stated that she was not observed by the facility for care observations, or provided with any education related to the use of two persons with the Hoyer transfer as indicated in the resident's care plan intervention that was initiated 7/4/24.On 4/21/26 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who documented the statement regarding the fall of 8/22/25. Upon inquiry, the LPN stated that she did not assist with the Hoyer lift transfer. The LPN stated she was called to the room, and the resident was already on the floor, and only the agency CNA was present in the room.On 4/21/26 at 11:30 AM, the surveyor interviewed the DON regarding the fall with the Hoyer Lift. The DON stated that he could not remember what had happened. The surveyor then asked for the employee's file and any competencies that were completed following the incident with the Hoyer Lift. The DON stated that the CNA involved in the incident was an agency staff and he would provide the file in the morning.On 4/22/26 at 9:52 AM, the Licensed Nursing Home Administrator (LNHA) provided the signed contract from the agency. The CNA's file was not included. The agency signed contract indicated that the nursing staff were independent contractors, and the agency was not responsible for their performance. There was no employee file provided at the exit date. 2. On 4/17/26 at 10:30 AM, the surveyor observed Resident #47 sitting at the bedside in the wheelchair. The surveyor then inquired regarding what activities they liked. The resident informed the surveyor that there was nothing to do and they would like to go home. The surveyor then reviewed the medical record which revealed the following: Resident #47 was admitted to the facility with diagnoses which included but were not limited to; Dementia, need for assistance with Personal Care, pain in unspecified knee, presence of right artificial knee joint and orthostatic hypotension.A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 1/13/26, reflected that Resident #47 had a Brief Interview for Mental Status (BIMS) score of 10 out 15, which indicated a moderate cognitive impairment. A review of the comprehensive Care Plan (CP), provided by the facility on 4/19/26 at 10:58 AM, included a focus area for falls related to poor safety awareness, impaired vision and psychotropic medication use. Initiated on 07/07/25. The goal was that Resident #47 risk for falls will be reduced, Resident #47 will remain free from injury. Initiated on 07/07/25.The interventions included: Assist in participating in activities of choice. Escort/transport to activities as needed. Initiated 07/07/25.Offer/assist with toileting during care, before and after meals and activities and at bedtime. Initiated on 07/07/25.Hourly safety rounds. Initiated 09/02/25.Nurse to ensure CNAs offer toileting assist every 2 hours and as needed for fall prevention. Initiated 10/30/25.Nursing staff provide brief reassurance visits between hourly rounds to reduce impulsive behavior.Bed against the wall initiated 02/13/26.Added a beveled mattress to reduce risk of injury from potential roll-out. Initiated 02/13/26.Floor mat on exit (left) side of bed when in bed, be sure to remove from floor when not in bed, to prevent injury. On 4/17/26 at 10:50 AM, the surveyor requested from the Director of Nursing (DON) all investigations for Resident #47, along with any fall risk assessments and a timeline of Resident #47's falls. A review of the Fall Risk assessment dated [DATE], Resident #47 scored 16. On 11/13/25 Resident # 47 received a score of 12. Fall Risk, Total score of 10 or above represents high risk.On 04/17/26 at 12:51PM, the surveyor interviewed the Physical Therapist and requested the therapy screen for review. Based on the therapy screen dated 3/6/26, Resident #47 had a decline in ambulation and transfer. Resident #47 completed therapy on 4/10/26, however the facility was unable to provide restorative minutes as the facility did not have a restorative program ( a program to maintain functional status after therapy ends).On 4/20/26 at 11:00 AM, the DON provided the fall investigations and the Fall timeline for review.Resident #47 sustained 10 unwitnessed falls at the facility from 8/26/25 to 2/22/26. The resident sustained 3 falls in the bathroom, 9/2/25 at 1:30 PM, 11/14/25 at 1:00 PM, 1/15/26 AT 5:00 PM. The facility could not provide any documentation that any interventions were implemented, including supervision, to further prevent falls occurring while the resident was in the bathroom, and did not address specific toileting needs that may have been needed. There was no documentation Resident #47 had been provided or refused staff assistance to proactively offer and assist with toileting. There was no documented evidence provided by the facility to ensure the Care Plan interventions for toileting were implemented every 2 hours as needed per the Care Plan. On 8/26/25 at 7:10 PM, Resident #47 was found sitting on the floor in front of the wheelchair. Resident #47 stated that they were trying to transfer to bed.On 09/02/25 at 1:20 PM, Resident #47 sustained a fall in the bathroom. The resident stated that they were trying to sit back in the wheelchair and the wheelchair rolled back.On 09/02/25 at 4:00 PM, the spouse visited and found Resident #47 sitting on the floor. The fall incident report did not indicate when the resident was last observed, how long the resident had been on the floor, or when Resident #47 was last toileted.On 10/29/25 at 6:20 AM, Resident #47 was found on the floor. Predisposing factors: Ambulating without assistance. The incident report did not include the last time the resident was observed or provided with incontinence care.On 11/2/25 at 8:30 PM, Resident #47 sustained a fall during care. The Progress note reported that Resident #47 lost their balance.11/14/25 at 1:00 PM, Resident #47 was found on the bathroom floor. Resident #47 sustained a skin tear to the right elbow. On 02/08/2026 at 1:05 PM, the CNA found Resident #47 sitting on the floor. Interventions added, Scheduled reassurance checks. The Incident Report did not reflect when Resident was last observed and assisted with their needs.On 02/12/206 at 8:10 PM, CNA found Resident #47 on the floor. Resident #47 stated later that they hit their head. New Intervention: Beveled mattress added. On 02/22/26 at 5:30 PM, Resident #47 was found on their knees in the room. Open scab on bilateral extremities with bleeding noted by staff. There was no documentation in the Incident Report of when Resident #47 was last observed and assisted with needs. After the fall Resident #47 was assisted with care.There were no targeted interventions implemented based on the root causes of the multiple falls. On 04/21/26 at 12:27 PM, the survey team met with the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), Regional Nurse (RN) and the [NAME] President of Clinical Services (VPCS) and presented the above concerns. The RN stated that the facility was unable to provide an orientation file for the agency CNA who transferred the resident by herself with the Hoyer lift. On 4/21/26 at 1:30 PM, the surveyor asked the DON to provide documentation that staff were following the interventions documented on the care plan to prevent falls, such as reassurance checks, offering and assisting with toilet needs, and temporary increased emotional support, inquired regarding toileting needs. No documentation was provided. The causal factors for the falls were not identified. The facility did not provide any documentation regarding temporary emotional support and scheduled reassurance checks. The DON stated should have competencies completed before taking care of these residentsOn 04/22/26 at 10:12 AM, the survey team met with the facility staff for the exit conference and the RN informed the survey team that there were no competencies completed for the Hoyer lift for the agency CNA. A review of the facility Accident Incident policy last revised 11/8/2025, revealed the following:Policy: The facility staff will document all accidents and incidents or any unusual occurrences experienced by residents, employees, and visitors on an Incident/Accident Report in the Risk Management module in the computer system.All occurrences of incidents and accidents must be reported to the leadership team immediately following identification of the event to ensure timely assessment of the resident.Based on the findings of the clinical assessment conducted by the RN or physician, necessary measures will be taken to address the situation in accordance with accepted standards of practice and facility policies.The Director of Nursing or designee will investigate the incident and check the form for completeness.The facility's policy for Hoyer Lift last revised 02/01/2026, revealed the following:Policy: A Hoyer Lift will be used to lift and move contracted, spastic or heavy residents safely.Procedure #1 If a resident requires the use of hydraulic lift based on assessment, a minimum of 2 staff members are required to operate the lift. NJAC: 8-39-27.1 (a)

Based on observation, interview, record review and document review it was determined that the facility failed to ensure that a resident with a history of Urinary Tract Infections (UTI) received appropriate incontinence care to prevent further UTI's and provide appropriate care and services to restore continence and maintain resident dignity. This deficient practice was evidenced for 1 of 1 resident (Resident #61) reviewed for continence care and was evidenced by the following: On 04/16/26 at 11:34 AM, the surveyor interviewed Resident #61 about the care received at the facility and asked Resident #61 about rehabilitation and toileting care provided. Resident #61 stated, I cannot walk, I just go in my pants. Resident #61 stated I know when I have to go, it was a matter of getting out of bed. Resident #61 stated, now they were getting physical therapy. Resident #61 stated, I want to walk and stated that they were diagnosed with a UTI at the hospital, and I know that feeling when they have a UTI. Resident #61 stated that they knew when they needed to use the bathroom, sometimes staff would get impatient though and Resident #61 stated, I sit on it all day. When asked to elaborate, Resident #61 stated, pee and shit. Resident #61 also stated that there were 4 people in the room, the room was connected to another room who had also 4 other residents. (1 bathroom for 8 residents). On 4/16/26 at 11:49 AM, the surveyor observed Resident #61's room, the bed was next to the bathroom which was connecting both to 4 bedded rooms. There was no bedside commode in Resident #61's room. On 04/16/26 at 12:24 PM, the surveyor reviewed Resident #61's medical record. The admission Face Sheet, (an admission summary) revealed the resident had diagnoses with included but were not limited to; syncope, collapse, unspecified fall, unspecified fracture of second and third lumbar vertebrae. A review of the hospital admission notes dated 4/1/26 reflected that Resident #61 fell, hit their head and required transport to the emergency room for evaluation and treatment. During the admission for the fall with head injury, the assessment revealed that Resident #61's urine culture was positive for a UTI. Resident #61 was prescribed antibiotics for the UTI which was listed under Actual Hospital Problems. A review of the Order Summary Report revealed an order for PT (physical therapy), OT (occupational therapy), speech therapy screen, evaluation and treatment as indicated/needed; dated; 11/18/25. The skilled PT eval and treat 3-5 x/week for 12 weeks for therapeutic exercise, strengthening exercise, neuromuscular re-education, therapeutic activity, bed mobility training, transfer training, balance/coordination, gait training, modalities PRN (as needed) for ROM (range of motion/pain, patient/caregiver education and discharge planning was discontinued on 11/19/25. Speech evaluation completed. Recommend dysphagia therapy 2-3 times per week for six weeks for safe swallow strategies, therapeutic trials, patient/caregiver education, and discharge planning. Discontinued 11/20/25. The admission Minimum Data Set (an assessment tool) dated 11/25/25, revealed the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a moderately impaired cognition. Section GG for Functional Ability revealed the resident was dependent on staff for upper body dressing, lower body dressing, putting on/taking off footwear, for personal hygiene, and for toileting. The Toilet transfer section (the ability to get on and off a toilet or commode) was coded 09 for Not Applicable (not attempted or not performed). The section for Therapy Services (15 minutes a day for one or more days in the last 7 days) and Speech-Language Pathology Services and Physical Therapy was checked. The Bowel and Bladder Section H for Urinary and Bowel Continence Section of the MDS was coded 2 for Frequently Incontinent of urine and bowels. The Urinary Toileting Program section was coded 0 for a trial toileting program (e.g. scheduled toileting, prompted voiding or bladder training) has been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility. Bowel toileting program was coded 0 which indicated that there was No toileting program being used to manage the resident's bowel continence. Under Active Diagnosis (in the last 7 days): Urinary Tract Infection was coded. The 41-page Care Plan that included active and discontinued items revealed the following: Focus for Impaired functional status due to recent hospitalization for Cerebro -Vascular Accident (CVA-stroke), L2-L3 (Lumbar- mid back) fracture, Urinary Tract Infection, respiratory failure and endocarditis; Goal: Will show improvement in functional status evidenced by increased self-participation in ADLs (Activity of Daily Living), Initiated 11/19/25. The Interventions included: Interdisciplinary Care Team Collaboration to determine usual performance; PT (Physical)/ OT (Occupational Therapy) evaluation and treatment as ordered to improve functional status, Date Initiated: 11/19/25. Toileting Hygiene-Dependent x1: Helper does All of the activity; resident does none of the effort to complete the activity. There were no interventions to restore continence or related to a toileting program, or use of a commode. Another Focus Area for risk for falls due to decreased mobility, history of fall, incontinence, hypotension . Date Initiated 11/19/25 and Interventions included offer/assist with toileting during care, before/after meals and activities and at bedtime, Date Initiated: 11/19/25. A review of the Physician History and Physical effective 11/19/25, revealed under Current Diagnosis: CVA . Treatment Plan: 1. Recurrent Syncope . 12. Recurrent falls, gait instability- uses walker . 13 Recent UTI, 14. Urinary Incontinence; Plan: PT/OT . The surveyor reviewed the Progress Notes from the 11/18/25 admission through present and could not locate an Interdisciplinary Team (IDT) Note regarding Resident #61's plan of care. On 04/17/26 at 11:14 AM, the surveyor interviewed the Rehabilitation Director (RD), in the presence of the Speech Therapist (ST) in the rehabilitation department. The surveyor requested all the rehabilitation documentation for Resident #61 since admission. When asked about Resident #61, the RD stated that the resident had been here for a while and just came back from the hospital. The surveyor asked about the rehabilitation services provided to Resident #61. The RD stated that when Resident #61 was admitted in November 2025, they did not receive physical therapy services, because they were private pay. The RD further explained that when Resident #61 was admitted they were non-ambulatory, they were screened by therapy and the therapist determined that the resident would benefit from rehabilitation but they would have to pay for the services and the resident did not want to pay for it. When asked how the facility would know what the current functional status of the resident was, including what was required for the staff to transfer Resident #61 safely, the RD stated Resident #61 was not assessed for functional status, and all care and services, including how to toilet the resident would have been a nursing judgement. A review of the documentation provided by the RD revealed: A PT Evaluation and Plan of Treatment, electronically signed by the PT on 11/19/25 at 7:37 PM which revealed: Payer: Private Pay; Start of Care: 11/19/25 for the Certification Period 11/19/25 through 2/9/26. Initial Assessment/ Current Level of Function and Underlying Impairments: Current Referral: Reason for referral/current illness: Patient referred to PT due to new onset of hemiparesis and muscle weakness involving the left non-dominant side as a result of L1 (lumbar vertebrae) level injury, L2 (lumbar vertebrae) level injury and cerebrovascular diseases. Patient reported: Patient's health concerns/complaints: resident presents with decreased functional mobility, decreased motor control/left hemiplegia and s/p acute CVA and L1-L2 compression fracture. Prior Level of function: Prior device use= walker: Indoor Mobility (ambulation) = Independent. The PT Assessment Summary revealed: Reason for therapy: Clinical impressions/reason for skilled services: Based upon examination of patients body regions, systems and structures, patient presents with strength impairments, muscle tone limitations, motor control deficits, pain, unilateral weakness, balance deficits, decreased dynamic balance and decreased functional capacity and in consideration of history, personal factors, and functional limitations documented in this eval summary, patient requires skilled PT services to improve dynamic balance, improve tone in LE (lower extremities), increase functional activity tolerance, increase LE ROM and strength, minimize falls, promote safety awareness, facilitate independence with all functional mobility and facilitate discharge planning.On 04/20/26 at 11:44 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about Resident #61. The surveyor asked the LNHA if he was aware that Resident #61 did not receive therapy because they were unable to pay for it. The LNHA stated that he was not the LNHA at the time and stated, everyone gets equal rights. When asked if Resident #61 should have received the therapy that was ordered after the admission in November 2025, the LNHA stated they should have received therapy from day one. When asked the DON how Resident # 61's functional status was obtained, he stated, I thought [therapy] would evaluate and communicate their findings, and would inform the LNHA and the DON, that Resident #61 could beneficiate from therapy but could not pay for the services. When asked if the transfer status was important to know for safety, the DON stated, yes.On 04/20/26 at 1:15 PM, the surveyor interviewed the Corporate Social Worker (CSW) who stated the prior SW resigned and when asked about any IDT documentation regarding Resident #61's plan of care, the CSW stated there was supposed to be documentation for a meeting and would be located in the SW documentation. The facility was unable to provide documentation regarding an IDT meeting for Resident #61 plan of care.On 04/21/26 at 8:22 AM, the surveyor interviewed Resident #61's regularly assigned Certified Nurse Aide (CNA). The surveyor inquired regarding Resident #61's mode of transfer. The CNA stated, when Resident #61 was admitted , there was no documentation on how to proceed with their transfer. She had to use her judgement and enlist another staff to assist with the transfer. When asked if therapy, or nursing had ever informed her or documented the type of transfer Resident #61 required, she stated that they did not. When asked if any education was ever provided by therapy on the appropriate transfer for Resident #61, she stated no, it took a while for [Resident #61] to get therapy.On 04/21/2026 9:35 AM, the surveyor conducted a telephone interview, in the presence of the survey team, with the physician (MD) who completed Resident #61's initial History and Physical dated 11/19/25. The MD stated he completed the History and Physical in person and that he ordered PT/OT. When asked if the MD expected Resident #61 to receive the PT/OT, he stated, I expect Resident #61 to receive it if they needed it. The MD stated that Resident #61 was getting PT/OT in the hospital and prior to hospitalization, Resident #61 was using a rollator to aid with ambulation. When asked if the MD had been aware that Resident #61 did not receive PT/OT because they were unable to pay for it, the MD stated, that was weird that the resident did not get picked up for therapy because they could not pay for it. On 04/21/26 at 8:42 AM, the surveyor interviewed Resident #61 in the room. The surveyor asked if they had ever been informed that prior to transferring to the facility from the hospital they would not receive physical therapy unless they paid for it. Resident #61, stated, No, that was why I came here, for rehabilitation, because I have a problem with balance. When asked if they ever had a meeting about the plan for care, they stated maybe in the room and when asked what the plan was, they stated, the plan was for physical therapy. When asked if a toileting plan was ever set up to help them use the bathroom, they stated, No. I wear a diaper. When asked if it was a brief, they stated, and old fashioned thing baby's get, I feel like a baby, it doesn't catch all the pee, it goes down my legs. Resident #61 stated, I feel like a prisoner here. On 04/21/26 at 10:29 AM, the surveyor interviewed the Minimum Data Set (MDS) coordinator regarding the completed MDS for Resident #61. When asked if residents could not pay for rehabilitation, would they be able to receive it? The MDS stated everybody is supposed to be treated the same. When asked if someone who required therapy services did not receive it, she stated, they could decline and they can fall. When asked about how the functional status for Resident #61 was determined and coded in the MDS form. The MDS stated that the information for the MDS would be taken from the CNAs. The MDS Coordinator stated, she completed the MDS and Care Plans. When asked about how the care plan interventions were determined for toileting, and transfer status and who determined the information. The MDS stated therapy should have provided the recommendations for mobility and transfer. On 04/21/26 at 12:27 PM, the surveyor in the presence of the survey team, informed the Director of Nursing, Licensed Nursing Home Administrator, [NAME] President of Clinical Services and the Regional Nurse Consultant of the above findings.On 04/22/26 at 10:12 AM, the survey team conducted an exit conference with the facility administrative staff, the DON informed the survey team that a brief type incontinence pull ups were offered to Resident #61 but they were too tight. The facility did not provide any additional information related to any services to improve continence, or care or services for Resident #61. NJAC 8:39-5.1(b); 27.1(a)

Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that facility failed to ensure a resident received the appropriate pain management by accurately administering pain medications according to the physician's orders. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #61) and evidenced by the following:The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist.Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.On 4/17/26 at 8:16 AM, two surveyors observed Resident #61, who was alert and oriented and was observed in a scoop bed (specialized mattress with elevated sides). At that time, the surveyors interviewed Resident #61 who stated that they were admitted to the facility after having a bad stroke. Resident #61 further stated that the scoop mattress was uncomfortable and that they were experiencing pain and needed their Tramadol (pain medication). The surveyors alerted the resident's Certified Nursing Assistant (CNA) that the resident was requesting pain medication. The CNA stated that she would notify the resident's nurse.On 4/17/26 at 11:10 AM, the surveyor in the presence of another surveyor conducted a follow-up interview with Resident #61 regarding their pain. Resident #61 stated they were still in pain, and the nurse came and never administered the Tramadol. Resident #61 stated, it happens all the time, and they were still experiencing leg pain.After interviewing Resident #61, the surveyor reviewed the resident's electronic medication administration record (e-MAR) which revealed that the resident did not receive their Tramadol 50 Mg tablet and their schedule 9:00 AM Lidocaine 4% patches.On 04/17/26 at 11:45 AM, the surveyor interviewed the resident who stated that they still had not received their Tramadol. The surveyor also asked the resident if they received their Lidocaine patch. Resident #61 stated that the Lidocaine patch really helped with their pain. The surveyor then observed the resident reaching for their shoulder and they stated they were not sure if they were given a new patch of Lidocaine.On 4/17/26 at 11:55 AM, the surveyor interviewed the CNA who was informed by the surveyors at 8:16 AM regarding Resident #61's complaint of pain, and the CNA stated that after the surveyors informed her, she notified both nurses that Resident #61 needed their pain medication.On 4/17/26 at 12:00 PM, the surveyor observed a Licensed Practical Nurse (LPN#1) that checked to see if Resident #61 had their Lidocaine patch on their left shoulder. LPN #1 then acknowledged that the resident did not have the Lidocaine patch on their left shoulder (approximately 4 hours after the CNA was alerted of the resident's pain complaints). On 4/17/26 at 12:10 PM, the surveyor in the presence of LPN #1 reviewed Resident #61's e-MAR. LPN#1 acknowledge that the resident did not receive their Tramadol or Lidocaine 4% patches. She stated that the nurse covering the resident's nursing unit was an agency nurse and was behind at giving out resident medications. She stated that the resident received all their medications late. LPN#1 further acknowledged that the resident's CNA notified her that the resident was requesting their Tramadol. She further stated that she was working on the other unit and was in the middle of checking blood glucose levels, and thought the other nurse had administered the medication to Resident #61.On 4/17/26 at 12:50 PM, the surveyor interviewed the Registered Nurse (RN) who was Resident #61's nurse who acknowledged that he did not administer the resident's pain medication. He stated that he never worked at the facility before and was behind in administering medications. He further stated that he should have administered the resident's pain medications in a timely manner.A review of Resident #61's medical records revealed the following:A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included chronic pain syndrome (a condition where pain lasts for more than 3 to 6 months, often continuing long after an injury has healed), hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (one-sided bodily impairments caused by brain or spinal cord damage, commonly from stroke, tumor, or trauma), and unspecified fracture of third lumbar vertebra, subsequent encounter for fracture with routine healing.A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care, dated 02/25/26, reflected that the resident's cognitive skills for daily decision-making score was 14 out of 15, which indicated that the resident was cognitively intact. A review of the April 2026 Order Summary Report (OSR) and the April 2026 e-MAR revealed the following Physician's Order (PO):A PO dated 04/09/26 for Cymbalta Capsule Delayed Release Particles 60 MG (Duloxetine HCL), give 1 capsule by mouth one time a day for chronic pain management. Do not crush/chew/open capsule. Monitor for drowsiness/dizziness. Schedule administration time of 0900 (9:00 AM) which was signed as being administered. A PO dated 04/14/26 for Gabapentin Capsule 300 mg , give 1 capsule by mouth two times a day (nerve pain). May open capsules, sprinkle on food or mix in water. May cause drowsiness or dizziness. No Antacids within 2 hours. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to left knee topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to left shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to lower back topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to right shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/14/26 for Tramadol tablet 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain. Medication was not administered.Tylenol Arthritis Pain tablet Extended Release 650 mg (Acetaminophen ER) give 1 tablet by mouth two times a day. Do Not Crush. Do Not Exceed 3 Grams of APAP/24 hours from all sources give with Gabapentin. Schedule administration time of 0900 (9:00 AM) which was signed as being administeredA review of the April 2026 Medication Administration Audit Reports for 4/17/26 revealed the following:A po dated 04/09/26 for Cymbalta Capsule Delayed Release Particles 60 MG (Duloxetine HCL), give 1 capsule by mouth one time a day for chronic pain management. Do not crush/chew/open capsule. Monitor for drowsiness/dizziness. Scheduled time for 9:00 AM medication was administered at 11:33 AM A PO dated 04/14/26 for Gabapentin Capsule 300 mg , give 1 capsule by mouth two times a day (nerve pain). May open capsules, sprinkle on food or mix in water. May cause drowsiness or dizziness. No Antacids within 2 hours. Scheduled time for 9:00 AM medication was administered at 11:26 AMA PO dated 04/09/26 for Lidocaine External patch 4% Apply to left knee topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00 AM, medication was administered at 12:56 PMA PO dated 04/09/26 for Lidocaine External patch 4% Apply to left shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00 AM, medication was administered at 12:56 PM.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to lower back topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00 AM, medication was administered at 12:56 PM.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to right shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00AM, medication was administered at 12:56 PM.A PO dated 04/14/26 for Tramadol tablet 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain. Medication was not administered.Tylenol Arthritis Pain tablet Extended Release 650 mg (Acetaminophen ER) give 1 tablet by mouth two times a day. Do Not Crush. Do Not Exceed 3 Grams of APAP/24 hours from all sources give with Gabapentin. Schedule time was 9:00 AM, medication was administered at 11:32 AM.On 4/21/26 at 12:30 PM, the surveyor presented the above concerns to the facility administrative team which included the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), [NAME] President of Clinical Services, and the Regional Nurse Consultant.The facility did not provide any further pertinent information.The surveyor reviewed the facility provided policy titled Policy and Procedure on Pain Management, dated 2/2026. The policy did not reflect anything about the accurate use of pain scales or administering physician ordered pain medication.The surveyor reviewed the facility policy titled Pain Management, dated revised 4/05/25 and was provided by the DON which reflected the following: Policy- It is the policy of the facility [name redacted] to provide uniform method of assessing and documenting our resident's verbal and non-verbal complaints of pain and effectively treat residents with both chronic and/or acute pain. NJAC-8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed (a) to properly secure one of two medication carts and (b) to administered medications in a timely manner in accordance with professional standards of nursing practice for 1 of 1 residents reviewed for pain (Resident # 61).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.1) On 4/17/26 at 8:16 AM, two surveyors observed the resident, who was alert and oriented, and was observed in a scoop bed (specialized mattress). At that time, the surveyor interviewed Resident #61 who stated that they were admitted to the facility after having a bad stroke. Resident #61 further stated that the scoop mattress was uncomfortable and that they were experiencing pain and needed their Tramadol. The surveyor alerted the resident's Certified Nursing Assistant (CNA) that the resident was requesting pain medication. The CNA stated that she would notify the resident's nurse. On 4/17/26 at 8:18 AM, the surveyor observed a parked medication cart at the far end of the hallway by the nursing station (no residents in the vicinity) that was unlocked and unattended. The surveyor alerted the Assistant Director of Nursing (ADON) who confirmed the medication cart was open. In the presence of the ADON the surveyor was able to open all all the medication drawers, which exposed all medications inside the medication cart. The nurse did not return to the medication cart until 8:24 AM.At that time, the surveyor interviewed ADON who stated that the nurse should have locked the medication cart before leaving the cart unattended. The surveyor asked the ADON if the nurse who was from an agency was trained. ADON stated that he's a nurse and he should know not to leave the medication cart unlocked and unattended.On 04/17/26 at 8:24 AM, the surveyor interviewed the Registered Nurse (RN) regarding leaving his medication cart unattended and unlocked. The RN acknowledged that he should have locked the medication cart before leaving the medication unattended.On 4/17/26 at 11:10 AM, the surveyor in the presence of another surveyor interviewed the resident who stated that they were still in pain and never received their pain medication that was requested that morning. Resident #61 stated that they did not receive their Tramadol and that this happens all the time. Resident #61 stated that they still are experiencing leg pain.After interviewing Resident #61, the surveyor reviewed the resident's electronic medication administration record (e-MAR) which revealed that the resident did not receive their Tramadol 50 Mg tablet and their schedule 9 AM Lidocaine 4% patches.On 04/17/26 at 11:45 AM, the surveyor interviewed the resident who stated that they still have not received their Tramadol. The surveyor asked the resident if they received their Lidocaine patch. The surveyor observed the resident reaching for their shoulder and was not sure if they were given a new patch of Lidocaine.On 4/17/26 at 12:00 PM, the surveyor observed a Licensed Practical Nurse (LPN #1) checked to see if Resident #61 had their Lidocaine patch on their left shoulder. LPN #1 acknowledge that the resident had no patch on their left shoulder. The resident requested that the nurse apply their Lidocaine patch after they finished lunch.On 4/17/26 at 12:10 PM, the surveyor in the presence of LPN#1 reviewed Resident #61's e-MAR. LPN#1 acknowledge that the resident did not receive their Tramadol or Lidocaine 4% patches. She stated that the nurse covering the resident's nursing unit was an agency nurse and was behind at giving out medications. She stated that the resident received all their medications late. A review of Resident #61's medical records revealed the following:A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included chronic pain syndrome (a condition where pain lasts for more than 3 to 6 months, often continuing long after an injury has healed), hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side (one-sided bodily impairments caused by brain or spinal cord damage, commonly from stroke, tumor, or trauma), and unspecified fracture of third lumbar vertebra, subsequent encounter for fracture with routine healing.A review of the Quarterly Minimum Data Set, an assessment tool used to facilitate care, dated 02/25/26, reflected that the resident's cognitive skills for daily decision-making score was 14 out of 15, which indicated that the resident was cognitively intact.A review of the April 2026 Order Summary Report (OSR) and the April 2026 e-MAR revealed the following Physician Orders (PO):A PO dated 04/09/26 for Cymbalta Capsule Delayed Release Particles 60 MG (Duloxetine HCL), give 1 capsule by mouth one time a day for chronic pain management. Do not crush/chew/open capsule. Monitor for drowsiness/dizziness. Schedule administration time of 0900 (9:00 AM) which was signed as being administered. A PO dated 04/14/26 for Gabapentin Capsule 300 mg , give 1 capsule by mouth two times a day (nerve pain). May open capsules, sprinkle on food or mix in water. May cause drowsiness or dizziness. No Antacids within 2 hours. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to left knee topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to left shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to lower back topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to right shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/14/26 for Tramadol tablet 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain. Medication was not administered.A PO dated 04/14/26 for Tylenol Arthritis Pain tablet Extended Release 650 mg (Acetaminophen ER) give 1 tablet by mouth two times a day. Do Not Crush. Do Not Exceed 3 Grams of APAP/24 hours from all sources give with Gabapentin. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/10/26 for Cholecalciferol Oral tablet 25 mg, give 1 tablet by mouth one time a day for Vit D deficiency. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/10/26 for Dulcolax suppository 10 mg (Bisacodyl), insert 1 suppository rectally one time a day for constipation. For Rectal use only. Hold if loose stools. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/14/26 for Metoprolol Succinate ER oral tablet Extended Release 24-hour 25 mg, give 1 tablet by mouth one time a day for Atrial Fibrillation. Preferably with or immediately following meals. Do not Crush. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/10/26 for Multivitamin Adult Oral tablet, give 1 tablet by mouth one time a day for supplement. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/10/26 for Protonix tablet Delayed Release 40 mg, give 1 tablet by mouth one time a day for GERD. Do not Crush/Chew. May administer without regard to meals. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Apixaban tablet 5 mg, give 1 tablet by mouth two times a day for mitral valve thrombus. Caution may cause severe bleeding. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Lamotrigine ER tablet Extended Release 24-hour 100 mg, give 1 tablet by mouth two times a day for seizures. [NAME] Not Crush/Chew. Mat cause dizziness/drowsiness. Notify MD on 1st sign of rash. Hazardous destruction. Schedule administration time of 0900 (9:00 AM) which was signed as being administered.A PO dated 04/09/26 for Midodrine HCL 5 mg 1 tablet by mouth three times a day for hypotension. Hold for SBP (systolic blood pressure) more than 130. Avoid taking it within 4 hours of bedtime. Schedule administration time of 0900 (9:00 AM) which was signed as being administered. Blood pressure was plotted as 98/63.A review of the April 2026 Medication Administration Audit Reports for 4/17/26 revealed the following:A po dated 04/09/26 for Cymbalta Capsule Delayed Release Particles 60 MG (Duloxetine HCL), give 1 capsule by mouth one time a day for chronic pain management. Do not crush/chew/open capsule. Monitor for drowsiness/dizziness. Scheduled time for 9:00 AM medication was administered at 11:33 AM A PO dated 04/14/26 for Gabapentin Capsule 300 mg , give 1 capsule by mouth two times a day (nerve pain). May open capsules, sprinkle on food or mix in water. May cause drowsiness or dizziness. No Antacids within 2 hours. Scheduled time for 9:00 AM medication was administered at 11:26 AMA PO dated 04/09/26 for Lidocaine External patch 4% Apply to left knee topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00 AM, medication was administered at 12:56 PMA PO dated 04/09/26 for Lidocaine External patch 4% Apply to left shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00 AM, medication was administered at 12:56 PM.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to lower back topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00 AM, medication was administered at 12:56 PM.A PO dated 04/09/26 for Lidocaine External patch 4% Apply to right shoulder topically one time a day for pain relief external use only. Apply for up to 8 hours on and 8 hours off and remove per schedule. Schedule time was 9:00AM, medication was administered at 12:56 PM.A PO dated 04/14/26 for Tramadol tablet 50 mg, give 1 tablet by mouth every 12 hours as needed for moderate to severe pain. Medication was not administered.Tylenol Arthritis Pain tablet Extended Release 650 mg (Acetaminophen ER) give 1 tablet by mouth two times a day. Do Not Crush. Do Not Exceed 3 Grams of APAP/24 hours from all sources give with Gabapentin. Schedule time was 9:00 AM, medication was administered at 11:32 AM.A PO dated 04/10/26 for Cholecalciferol Oral tablet 25 mg, give 1 tablet by mouth one time a day for Vit D deficiency. Scheduled time for 9:00 AM medication was administered at 11:32 AM.A PO dated 04/10/26 for Dulcolax suppository 10 mg (Bisacodyl), insert 1 suppository rectally one time a day for constipation. For Rectal use only. Hold if loose stools. Scheduled time for 9:00 AM medication was administered at 11:32 AM.A PO dated 04/14/26 for Metoprolol Succinate ER oral tablet Extended Release 24-hour 25 mg, give 1 tablet by mouth one time a day for Atrial Fibrillation. Preferably with or immediately following meals. Do not Crush. Scheduled time for 9:00 AM medication was administered at 11:32 AM.A PO dated 04/10/26 for Multivitamin Adult Oral tablet, give 1 tablet by mouth one time a day for supplement. Scheduled time for 9:00 AM medication was administered at 11:32 AMA PO dated 04/10/26 for Protonix tablet Delayed Release 40 mg, give 1 tablet by mouth one time a day for GERD. Do not Crush/Chew. May administer without regard to meals. Scheduled time for 9:00 AM medication was administered at 11:32 AM.A PO dated 04/09/26 for Apixaban tablet 5 mg, give 1 tablet by mouth two times a day for mitral valve thrombus. Caution may cause severe bleeding. Scheduled time for 9:00 AM medication was administered at 11:32AM.A PO dated 04/09/26 for Lamotrigine ER tablet Extended Release 24-hour 100 mg, give 1 tablet by mouth two times a day for seizures. [NAME] Not Crush/Chew. Monitor dizziness/drowsiness. Notify MD on 1st sign of rash. Scheduled time for 9:00 AM medication was administered at 11:32 AM. A PO dated 04/09/26 for Midodrine HCL 5 mg 1 tablet by mouth three times a day for hypotension. Hold for SBP (systolic blood pressure) more than 130. Avoid taking it within 4 hours of bedtime. Blood pressure was plotted as 98/63. Scheduled time for 9:00 AM medication was administered at 11:32 AM.On 4/21/26 at 12:30 PM, the surveyor presented the above concerns to the facility administrative team which included the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), [NAME] President of Clinical Services, and the Regional Nurse Consultant. The facility did not provide any further pertinent information. NJAC-8:39-27.1 (a)

Based on observation, interview, record review and document review it was determined that the facility failed to ensure that a resident received physician ordered rehabilitation services as indicated and was not based on the ability to pay for the services. This deficient practice was evidenced for 1 of 1 resident (Resident #61) who had a history of falls, impaired functional status and was reviewed for rehabilitation services.The deficient practice was evidenced by the following: On 04/16/26 at 11:34 AM, the surveyor interviewed Resident #61 while they were seated in their wheelchair, about the care received at the facility and also asked about the high sided bed that was observed. Resident #61 stated it's awful, I have a bad back and it is bothering me. When asked if they knew why they had the scoop type bed, they stated they never told me. When asked if Resident #61 had any falls they stated, they fell in the room and had two stiches in their head and pointed to their head to show to the surveyor where the stitches were. When asked about what happened when they fell, Resident #61 stated they were in their room, did not recall what they were doing, slid out of the chair and hit their head on the floor. The surveyor asked Resident #61 about rehabilitation and toileting they stated, I cannot walk, I just go in my pants. Resident #61 stated I know when I had to go, it was a matter of getting out of bed. Resident #61 stated, now they were getting physical therapy. Resident #61 stated, I want to walk and confirmed that now that they were receiving therapy it was very much helping them. On 04/16/26 at 12:24 PM, the surveyor reviewed the medical record for Resident #61. The admission Face Sheet (an admission summary) revealed the resident had diagnoses with included but were not limited to; syncope, collapse, unspecified fall, unspecified fracture of second and third lumbar vertebrae. A review of the Order Summary Report revealed an order for PT (physical therapy), OT (occupational therapy), speech therapy screen, evaluation and treatment as indicated/needed; dated; 11/18/25. The skilled PT eval and treat 3-5 x/week for 12 weeks for therapeutic exercise, strengthening exercise, neuromuscular re-education, therapeutic activity, bed mobility training, transfer training, balance/coordination, gait training, modalities PRN (as needed) for ROM (range of motion/pain, patient/caregiver education and discharge planning was discontinued on 11/19/25. Speech evaluation completed. Recommend dysphagia therapy 2-3 times per week for six weeks for safe swallow strategies, therapeutic trials, patient/caregiver education, and discharge planning. Discontinued 11/20/25. The admission Minimum Data Set (an assessment tool) dated 11/25/25, revealed the resident scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated a moderately impaired cognition. Section GG for Functional Ability revealed the resident was dependent on staff for upper body dressing, lower body dressing, putting on/taking off footwear, for personal hygiene, and for toileting. Resident #61 was also coded as having a fall in the last month prior to admission/entry. The section for Therapy Services (15 minutes a day for one or more days in the last 7 days) and Speech-Language Pathology Services and Physical Therapy was checked. The 41-page Care Plan that included active and discontinued items revealed the following: Focus for Impaired functional status due to recent hospitalization for Cerebro Vascular Accident (CVA-stroke), L2-L3 (Lumbar- mid back) fracture, Urinary tract infection, respiratory failure and endocarditis; Goal: Will show improvement in functional status evidenced by increased self-participation in ADLs (Activity of Daily Living), Initiated 11/19/25. The Interventions included: Interdisciplinary Care Team Collaboration to determine usual performance; PT (Physical)/ OT (Occupational Therapy) evaluation and treatment as ordered to improved functional status, Date Initiated: 11/19/25. Another Focus revealed: Risk for falls due to decreased mobility, history of fall, incontinence, hypotension, psychotropic use, Peripheral Vascular Disease; Goal: Risk for falls with be reduced, will remain free from injury. Date Initiated: 11/19/25. Interventions included PT/OT evaluation and treatment as ordered to improve mobility; Date Initiated 11/19/25; Assist with transfers as needed, Date Initiated 11/19/25. A review of the hospital records for the 10/23/25 through 11/18/25 hospital admission revealed that Resident #61 reported to the emergency room physician that they fell at home after they became lightheaded after getting out of bed and walking approximately two feet and fell backwards and had persistent lower back pain. A physician progress note dated 11/18/25 at 14:26 [2:26 PM] revealed Plan: . Acute CVA . back pain, PT recommends rehabilitation . A review of the Physician History and Physical effective 11/19/25 revealed under Current Diagnosis Includes: CVA . Treatment Plan: 1. Recurrent Syncope . 12. Recurrent falls, gait instability- uses walker . 13 Recent UTI, 14. Urinary Incontinence; Plan: PT/OT . On 04/17/26 at 11:14 AM, the surveyor interviewed the Rehabilitation Director (RD), in the presence of the Speech Therapist (ST) in the rehabilitation department. The surveyor requested all the rehabilitation documentation for Resident #61 since admission. When asked about Resident #61, the RD stated that the resident had been here for a while and just came back from the hospital. The RD stated that Resident #61 wanted to get better and was on therapy. The surveyor asked about the rehabilitation services provided to Resident #61. The RD stated that when Resident #61 was admitted in November 2025, they were not therapy services, because they were private pay. The RD further explained that when Resident #61 was admitted they were non-ambulatory, they were screened by therapy and the therapist determined that the resident would benefit from rehabilitation services. The therapist included in her note that Resident #61 would have to pay for therapy services. The therapist notes did not reflect that the concerns with payment were discussed and explained to Resident #61. When asked how the facility would know what the current functional status of the resident was, including what was required for the staff to assist Resident #61 with mobility and transfer, the RD stated, Resident #61 was not assessed for functional status, and all care and services, including how to toilet the resident would have been a nursing judgement. The RD stated that now, since Resident #61 was Medicaid pending, they were evaluated /and being treated by therapy. The surveyor asked the ST if she knew if Resident #61 was cognitively intact and she stated Resident #61 was cognitively intact. When asked if the facility had a restorative program (staff work with residents to maintain functional ability) the RD stated they do not have a restorative program at the facility. When asked about falls the RD confirmed Resident #61 had unwitnessed falls since they were admitted to the facility. A review of the documentation provided by the RD revealed: A PT Evaluation and Plan of Treatment, electronically signed by the PT on 11/19/25 at 7:37 PM which revealed: Payer: Private Pay; Start of Care: 11/19/25 for the Certification Period 11/19/25 through 2/9/26. Initial Assessment/ Current Level of Function and Underlying Impairments: Current Referral: Reason for referral/current illness: Patient referred to PT due to new onset of hemiparesis and muscle weakness involving the left non-dominant side as a result of L1 (lumbar vertebrae) level injury, L2 (lumbar vertebrae) level injury and cerebrovascular diseases. Patient reported: Patient's health concerns/complaints: resident presents with decreased functional mobility, decreased motor control/left hemiplegia and s/p acute CVA and L1-L2 compression fracture. Prior Level of function: Prior device use= walker: Indoor Mobility (ambulation) = Independent. The PT Assessment Summary revealed: Reason for therapy: Clinical impressions/reason for skilled services: Based upon examination of patients body regions, systems and structures, patient presents with strength impairments, muscle tone limitations, motor control deficits, pain, unilateral weakness, balance deficits, decreased dynamic balance and decreased functional capacity and in consideration of history, personal factors, and functional limitations documented in this eval summary, patient requires skilled PT services to improve dynamic balance, improve tone in LE (lower extremities), increase functional activity tolerance, increase LE ROM and strength, minimize falls, promote safety awareness, facilitate independence with all functional mobility and facilitate discharge planning. A review of PT notes for Certification Period 1/8/26-3/31/26 (1.5 months after admission) for Payer: Medicare Part B: Current Referral: Patient re-referred to Pt status post insurance change for services due to new onset of hemiparesis . Reasons for Therapy: Patient presents with strength impairments, decreased dynamic balance, decreased functional capacity, paralysis.decreased functional limitations documented in this evaluation summary, patient requires skilled PT services. Goals: Increase Strength and to walk.A review of OT notes for Certification Period 1/6/26-3/29/26 Payer: Medicare Part B; Reason for Referral/Current Illness: status fall with lumbar fracture. ADLs were evaluated and Resident #61 required Substantial/Maximal assistance for Toileting, bathing, upper and lower body dressing, including putting on footwear. A review of Speech Therapy (ST) notes for Certification Period 1/8/26-3/31/26 Payer: Medicare Part B; Patient Goals: I'm ready for therapy. Current Referral: Reason for Referral/current illness: Resident admitted to this facility on chopped textures evaluated and denied by insurance. Patient with change of payor and re-evaluated for least restrictive/safest diet and possible diet upgrade.On 04/20/26 at 11:44 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) about Resident #61. The surveyor asked the LNHA if he was aware that Resident #61 did not receive therapy because they were unable to pay for it. The LNHA stated that he was not the LNHA at the time and stated, everyone gets equal rights. When asked if Resident #61 should have received the therapy that was ordered after the admission in November 2025, the LNHA stated they should have received therapy from day one. When asked the DON how Resident # 61's functional status was obtained, he stated, I thought [therapy] Resident #61 was evaluated by therapy but Resident #61 could not pay for therapy services. When asked if the transfer status was important to know for safety.On 04/21/26 at 8:22 AM, the surveyor interviewed Resident #61's regularly assigned Certified Nurse Aide (CNA). The surveyor inquired regarding Resident #61's mode of transfer. The CNA stated that she did not receive any directives from PT/Nursing, she had to use her clinical skills and enlist another CNA to assist with transfer. The CNA further stated that Resident #61 was currently able to stand and pivot. When asked if therapy, or nursing had ever informed her or documented the type of transfer Resident #61 required, she stated that they did not. When asked if any education was ever provided by therapy on the appropriate transfer method for Resident #61, she stated no, it took a while for [Resident #61] to get therapy.On 04/21/26 at 8:42 AM, the surveyor interviewed Resident #61 at the bedside. The surveyor asked if they were informed that prior to transferring to the facility from the hospital that they would not receive physical therapy unless they paid for it. Resident #61, stated, No, I came here for rehabilitation services, I have a problem with balance. When asked if the facility ever had a meeting about the plan of care, Resident #61stated maybe in the room and when asked what the plan was, Resident #61 stated, the plan was for physical therapy. On 04/21/2026 at 9:35 AM, the surveyor conducted a telephone interview, in the presence of the survey team, with the physician (MD) who completed Resident #61's initial History and Physical dated 11/19/25. The MD stated he completed the History and Physical in person and that he ordered PT/OT. When asked if the MD expected Resident #61 to receive the PT/OT, he stated, I expect Resident #61 to receive rehabilitation services, if they needed it. The MD stated that Resident #61 was getting PT/OT in the hospital and Resident #61 was using a rollator prior to admission. When asked if the MD had been aware that Resident #61 did not receive PT/OT because they were unable to pay for PT/OT services, the MD stated, that was weird that the resident did not get picked up for therapy because they could not pay for it. On 04/21/26 at 10:17 AM, the surveyor interviewed the resident who confirmed they were using a rollator ( wheeled, four-legged mobility aid) prior to their admission to the facility. On 04/21/26 at 10:29 AM, the surveyor interviewed the Minimum Data Set (MDS) coordinator regarding the completed MDS for Resident #61. When asked if residents could not pay for rehabilitation, would they be able to receive PT/OT services, The MDS Coordinator stated, everybody is supposed to be treated the same. When asked if someone who required therapy services did not receive it, she stated, they could decline and they can fall. When asked about how the functional status for Resident #61 was determined and coded in the MDS form. The MDS stated that the information for the MDS would be taken from the CNAs. The MDS stated she completed the MDS and Care Plans. When asked about how the care plan interventions were determined for toileting, and transfer status and who determined the transfer mode required based on the resident functional status, the MDS stated the recommendations should have provided by the therapist. On 04/21/26 at 12:27 PM, the surveyor in the presence of the survey team, informed the Director of Nursing, Licensed Nursing Home Administrator, [NAME] President of Clinical Services and the Regional Nurse Consultant of the above findings.On 04/22/26 at 10:12 AM, during the exit conference with the facility administrative staff, no additional information was provided. NJAC 8:39-5.1(b); 27.1(a)

Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, to accurately reflect the resident's status as of the Assessment Reference Date (ARD) for 1 of 5 residents reviewed (Resident #5).The deficient practice was evidenced by the following:On 4/16/2026 at 9:12 AM, the surveyor observed Resident #5 in bed lying on an air mattress and stated they wanted to rest.On 4/17/2026 at 2:45 PM, a review of the Electronic Medical Records (EMR) revealed diagnoses which included but were not limited to metabolic encephalopathy (reversible brain dysfunction caused by metabolic disturbances), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A review of the Significant Change Minimum Data Set (MDS an assessment tool to facilitate the plan of care) dated 3/20/26 revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15 indicating intact cognition; Section N-Medications of the MDS revealed no antipsychotic medication coded; Section O-Special Treatments, Procedures, and Programs revealed, Pneumonia (PNA) Vaccine offered and declined. A further review of the EMR under the Immunization Tab revealed: Prevnar20 (PNA) vaccine was offered and refused on 5/1/24 and 10/21/24; there was no documentation in 2025 or 2026 that PNA vaccine was offered or declined.On 4/20/2026 at 9:00 AM, the surveyor interviewed the Infection Preventionist/Assistant Director of Nursing (IP/ADON) regarding the resident's PNA vaccine, and she stated, the family was against vaccinations and was offered verbally last year but did not document that in the resident's medical records. The surveyor asked was the expectation to document refusals in the resident's medical records to show supportive documentation. The IP/ADON confirmed, I should have written on the progress note when they refused last year and have the family or resident signed a declination form. There was no supportive documentation found to support the MDS coding that PNA vaccine was offered and declined.A review of the physician order dated 3/10/26 revealed an order for Seroquel Tablet 50 MG (Quetiapine Fumarate-antipsychotic) Give 1 tablet by mouth two times a day for schizoaffective disorder. May cause dizziness/drowsiness avoid alcohol. A review of the March 2026 Electronic Medication Administration Records (EMAR) revealed Seroquel tablet 50 MG was administered for a total of 7 days (3/14/26-3/20/26) from the look back period of the Significant Change MDS ARD of 3/20/26.A review of the resident's Care Plans revealed: (Name Redacted) has potential for impaired cognition- short- & long-term memory loss related to diagnosis of dementia, status post recent hospitalization for metabolic encephalopathy BIMS 13/15, (Name Redacted) is AAO (awake, alert and oriented) with periods of forgetfulness/confusion, date initiated: 3/25/2026; Receiving psychotropic medication (s) 3/10/26 related to . diagnosis schizoaffective disorder .target behaviors.delusions, accusatory behaviors for Seroquel.On 4/20/2026 at 11:21 AM, the surveyor interviewed the MDS Coordinator/License Practical Nurse (MDSC/LPN), via cell phone, regarding the inaccuracy of the MDS for sections N and O. The MDSC/LPN confirmed, I missed the coding for Seroquel, it should have been coded, it was my data entry mistake. The surveyor asked her where she got the information that the PNA vaccine was offered, and she replied that she coded it according to the refusal in 2024. She confirmed, I guess I didn't look at the documentation, if it was offered in 2025 or 2026. It should have been offered . The MDSC/LPN stated she was going to correct the MDS to reflect PNA vaccine was not offered. On 4/21/2026 at 11:26 AM, the MDSC/LPN stated they don't have an MDS Accuracy policy, that they follow the RAI (Resident Assessment Instrument-a comprehensive, standardized system to assess a resident's functional, clinical and psychosocial status) manual.On 4/21/2026 at 12:27 PM, the survey team met with the License Nursing Home Administrator (LNHA), DON, [NAME] President (VP) of Clinical, and the Regional Nurse Consultant, to inform them of the concerns with MDS accuracy.On 4/22/2026 at 10:24 AM, the survey team met with the administration: LNHA, DON and Regional Nursing for further responses and no additional information was provided.NJAC 8:39-33.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control practices for the administration of medications for 2 of 2 nurses during the medication observation pass. The evidence was as follows:1. On 4/17/26 at 8:20 AM, during the medication observation pass, the surveyor observed a Registered Nurse (RN) remove out a bingo card (medication administration system for tablets) from a medication cart and popped out one tablet and placed it in his bare hands. The RN was then observed putting the tablet with his bare hands into a medication cup in preparation of administering a medication to a resident.At that time, the surveyor interviewed the RN who stated that he touched the medication with his bare hands because he had no gloves because he was unable to find a box on the medication cart. The RN further stated that going forward he will place medication directly into the medication cup. 2. On 4/17/26 at 08:47 AM, the surveyor observed a Licensed Practical Nurse (LPN) washing her hands after administering medications to a resident. The surveyor observed the LPN wet her hands and then added soap to her hands. She was then observed lathering her hands away from a stream of water for less than 5 seconds and was then observed placing her hands under the stream of water and lathering them for another 15 seconds before rinsing off her hands.At that time, the surveyor interviewed the LPN who acknowledge that she scrubbed her hands less than 20 seconds away from a stream of water. The LPN further stated that she should have scrubbed her hands away from a stream of water for 20 seconds.On 4/21/26 at 12:30 PM, the surveyor presented the above concerns to the facility administrative team which included the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), [NAME] President of Clinical Services, and the Regional Nurse Consultant.No further information was provided. A review of the facility's policy titled Hand Hygiene Policy which was dated 12/31/25, and was provided by the DON revealed the following: Handwashing with soap and water (required when hands are visibly dirty or after certain exposures):-Wet hands with water.-Apply soap and lather well.-Scrub all surfaces of hands for at least 20 seconds.-Rinse thoroughly under running water.-Dry with paper towel.-Use separate towels to turn off faucet. NJAC 8:39-19.4 (a) (1) (n) (2)

Based on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer residents the pneumonia (PNA) vaccination. This deficient practice was identified for 2 (two) of 5 (five) residents, (Resident # 2 and # 5), reviewed for vaccination status and was evidenced by the following:1. The surveyor reviewed Resident #2's medical record which revealed the following:On 4/16/2026 at 8:40 AM, the surveyor observed Resident #2 in their room, lying on an air mattress, eating breakfast, and stated she was receiving therapy.On 4/17/2026 at 11:02 AM, a review of the electronic medical records (EMR) revealed diagnoses which included but not limited to muscle weakness (generalized); personal history of (healed) traumatic fracture; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety.A review of the Modified Quarterly Minimum Data Set (MDS-an assessment tool to facilitate the plan of care) dated 3/2/26 revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. In Section O of the MDS-Special Treatments, Procedures, and Programs, revealed PNA vaccine was not offered.A further review of the EMR under the Immunization Tab revealed: Historical Pneumovax 23 was given on 3/7/2019; Prevnar 20 was refused on 11/12/24; no documentation in 2025 that PNA vaccine was offered or declined.On 4/20/2026 at 8:56 AM, the surveyor interviewed the Infection Preventionist/Assistant Director of Nursing (IP/ADON), regarding the process for PNA vaccines for residents. The IP/ADON stated that she was responsible for overseeing the vaccinations. She further stated that she did not offer the PNA vaccine to Resident #2 in 2025, missed it and should have been offered for protection, especially a place like this with a lot of bacteria. The IP/ADON also stated the regulation was to offer PCV20 after Pneumovax 23 and should be offered yearly if refused. 2. On 4/16/2026 at 9:12 AM, the surveyor observed Resident #5 in bed lying on an air mattress and stated they wanted to rest.On 4/17/2026 at 2:45 PM, a review of the EMR revealed diagnoses which included but were not limited to metabolic encephalopathy (reversible brain dysfunction caused by metabolic disturbances), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.A review of the Modified Significant Change MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. In Section O of the MDS-Special Treatments, Procedures, and Programs, revealed PNA vaccine was not offered.A further review of the EMR under the Immunization Tab revealed: Prevnar20 vaccine was offered and refused on 5/1/24 and 10/21/24; there was no documentation in 2025 that PNA vaccine was offered or declined.On 4/20/2026 at 9:00 AM, the surveyor interviewed the IP/ADON regarding the resident's PNA vaccine and she stated, the family was against vaccinations and was offered verbally last year but did not document that in the resident's medical records. The surveyor asked was the expectation to document refusals in the resident's medical records to show supportive documentation. The IP/ADON stated, I should have written on the progress note when they refused last year and have the family or resident signed a declination form.On 4/21/2026 at 12:27 PM, the survey team met with the License Nursing Home Administrator (LNHA), DON, [NAME] President (VP) of Clinical, and the Regional Nurse Consultant, to inform them of the concerns with PNA vaccines.On 4/22/2026 at 9:30 AM, the IP/ADON provided in response to the PNA vaccine concerns: Resident #2's Pneumococcal-PCV20 vaccine consent dated 4/17/26 and administered vaccine form dated 4/21/26 (after surveyor inquiry); and provided Resident #5's Pneumococcal vaccine declination form dated 4/21/26 (after surveyor inquiry). On 4/22/2026 at 10:24 AM, the survey team met with the LNHA, DON and Regional Nursing and no additional information was provided.A review of the facility policy titled, Pneumococcal Vaccine Policy, dated April 2026, revealed under Objective, To provide resident's protection against Pneumococcal Pneumonia. Under Procedure #7 revealed, Pneumococcal vaccine will be offered yearly to those residents who refuse. NJAC 8:39-19.4(i)

Based on observation, interview and record review it was determined that the facility failed to ensure a physician ordered diet for a resident with dysphagia was provided per physician order for 1 of 1 Resident (Resident #14) reviewed for therapeutic diet order. The evidence was as follows: On 04/20/26 at 8:29 AM, surveyor completed a test tray observation on the [NAME] Unit and requested a replacement tray for Resident #14 from a Dietary Staff (DS) that was present and the DS stated the diet was wrong as the resident came in over the weekend and the kitchen did not get the diet order.The Meal Tray ticket for Resident #14 documented the following diet: Regular Texture, CCD (Controlled Carbohydrate) No Added Salt, Thin Fluid Diet. One diet jelly was listed and one packet of regular jelly was on the tray, along with scrambled eggs (Farmers Egg Bake 3 x 3 was listed), oatmeal and two pieces of toasted raisin bread were observed on the tray. On 4/20/26 at 11:00 AM, the surveyor reviewed the medical record for Resident #14 which revealed a physician order, dated 4/17/26 at 12:25 PM for a CCD/NAS (controlled carbohydrate no added salt, chopped (Soft and Bite sized) texture. On 04/20/26 at 11:09 AM, the surveyor interviewed the Rehabilitation Director (RD) and showed her the meal ticket for Resident #14 and asked if the diet provided was correct. The RD showed the surveyor a Dietary Communication slip dated 4/17/26 and signed by the Speech Therapist for a Chopped Textures/ Thin Liquids Diet. The RD showed the surveyor where there was a signature on the sheet that confirmed the dietary department received the order the same day it was written. On 04/20/26 at 11:25 AM, the RD provided the surveyor with a Speech Therapy encounter note for Date of Service: 4/17/26. The note revealed Swallow Precautions in place. Resident seen in room in bed, repositioned head of bed for safe intake with regular texture lunch tray .Diet modifications to presidents plate for bite size bolus provided . adequate mastication and bolus manipulation noted. Change to chopped texture and Current Solids=Mechanical Soft/chopped textures. Asked the RD if toasted raisin bread was okay on the ordered diet and she stated, no. On 4/21/26 at 7:55 AM, the Corporate Nurse provided the Diet Orders Policy Revised February 2025 which revealed Policy: The facility will provide a liberalized therapeutic diet that takes into account the individual's clinical condition and preferences, when there is a nutritional indication .On 4/21/26 at 12:27 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Nursing, [NAME] President (VP) of Clinical, and the Regional Nurse Consultant to inform them of the above concerns.On 4/22/26 at 10:24 AM, the survey team met with the administration: LNHA, DON and Regional Nursing for further responses and no additional information was provided.NJAC 8:39-17.2(a)

Based on review of the Payroll-Based Journal (PBJ) Staffing Data Report, Nurse Staffing Reports, interview, and facility documentation, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 15 of 15 weekends reviewed. The deficient practice was evidenced by the following: A review of the PBJ staffing Data submitted for the 3rd quarter (April, May and June) of 2024 revealed the facility triggered for RN coverage for 8 consecutive hours/day. Further review revealed Infractions Dates: 04/06 (SA-Saturday); 04/07 (SU-Sunday); 04/13 (SA); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 04/28 (SU) 05/04 (SA); 05/05 (SU); 05/11 (SA); 05/12 (SU); 05/18 (SA); 05/19 (SU); 05/25 (SA); 05/26 (SU) 06/01 (SA); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/22 (SA); 06/23 (SU); 06/29 (SA); 06/30 (SU) A review of the facility provided staffing for the above-mentioned days did not reveal a registered nurse was scheduled for day, evening, or night shifts. On 09/15/24 at 8:55 AM, the survey team entered the facility. Licensed Practical Nurse (LPN) #1 assisted the survey team to the conference room. She stated there was another LPN (LPN #2) in the building. The survey team asked if there was a RN in the building, she confirmed that there was not. LPN # 1 stated the Director of Nursing (DON) was always available by phone. A review of the facility provided Nurse Staffing Report for the weeks of 9/1/24-9/7/24 and 9/8/24-9/14/24, did not revealed an RN was schedule for 9/7/24, 9/8/24, or 9/14/24. A review of the facility provided schedule for 9/15/24 did not reveal a RN was scheduled for the day, evening, or night shift. On 09/17/24 at 12:01 PM, during an interview, the DON stated that there was 1 other RN at the facility, but she was prn (as needed.) She then stated if she goes on vacation or takes a day off, the Regional Nurse Manager (RNM) would have to be in the facility. The DON stated she submitted the PBJ Staffing Reports and was aware that they (the facility) did not have a RN consistently on the weekends. She further stated she was on call 24 hours a day/7 days a week and comes in if she was needed. The DON stated the staff would call 911, if they needed to. At that time, in the presence of the surveyor, the DON reviewed the facility provided schedules for the above-mentioned weekends for the 3rd quarter. She confirmed that there was not an RN on the weekends. She then reviewed the Nurse Staffing Report for the weeks of 9/1/24-9/7/24 and 9/8/24-9/14/24 and confirmed that there was not a RN for 9/7 (SA), 9/8 (SU), or 9/14 (SA). On 09/17/24 at 1:27 PM, during a meeting with the Licensed Nursing Home Administrator (LNHA), the DON, the Infection Preventionist, and the RNM, the above concerns were presented. A review of the facility's Staffing Policy reviewed 4/2024, revealed: Goal: .goal is to provide adequate staffing to meet needed care and services for our resident population .Policy: .There will be at least one registered professional nurse on duty in the facility during all day shifts. (During a temporary absence, not to exceed 72 hours, the registered professional nurse may be on duty during the evening or night shift. NJAC 8:39-25.2(h)

Based on observation, interview, record review and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 9/16/24 at 9:46 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: In the food preparation area, the surveyor observed the following: - tan colored debris smeared on the surface of the door and on the door handles of standing refrigerator # 1, - brown colored substance on the clear plastic packaging which contained styrofoam plates, -brown colored substance on the microwave oven door and door handle which was easily lifted with the FSD's pen tip, -thick brown colored grease-like substance on 7 of 8 stove knobs, and brown thick grease-like substance on 1 of 2 oven handles. In the dry storage area, the surveyor observed the following: -tan colored debris smeared on the surface of the door and on the door handles of the produce standing refrigerator. The FSD stated that this equipment should be clean and could not explain what might have happened. During an interview on 9/16/24 at 1:00 PM, the surveyor brought the above concerns to the attention of the Administrator and Director of Nursing. A review of the facility's policy, Cleaning and Sanitation of Food Service Areas, Revised 8/4/2024, revealed: Policy: The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written and comprehensive cleaning schedule. Procedure: 1. The food service manager (or designee) will record all cleaning and sanitation tasks needed for the department. NJAC 8:39-17.2(g)

Based on observation, interview, record review and facility documentation it was determined that the facility failed to maintain professional standards of clinical practice by not notifying the physician of a weight discrepancy for 1 of 2 residents (Resident #38) reviewed for nutrition. 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 09/15/24 at 11:38 AM, during initial tour, the surveyor observed Resident #34 in bed. The resident did not have any complaints at that time. The surveyor reviewed Resident #34's electronic medical record (eMR). A review of the Admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; HTN (hypertension-high blood pressure), Congestive heart failure (CHF-a serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and a presence of a cardiac pacemaker (a small device that helps regulate a person's heart rate by sending electrical pulses to the heart.) A review of the admission Minimum Data Set (MDS), an assessment tool, dated 7/23/24, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS, revealed the resident was receiving a diuretic. (a water pill) A review of the Care Plan (CP) revealed: Focus: Potential for complications r/t (related to) impaired cardiac status, HTN, Pacemaker status, Date initiated 06/25/24 .Interventions: Administer diuretic medication as ordered. Monitor for adverse effects r/t diuretic med (medication) use (dizziness, muscle cramps, etc.), keep MD (Doctor of Medicine) informed of abnormalities, Date initiated: 06/25/24. Further review of the CP revealed: Focus: Resident is at risk for weight changes, fluid volume changes due to hx (history) CHF/edema (swelling caused by fluid trapped in your body's tissues), Date Initiated: 06/27/2024; Goal: Resident will maintain weight +/- (plus or minus) 1 to 5 lbs. Weight will increase no more than 5 lbs Date Initiated: 06/27/2024. Interventions: Monitor weighs per protocol Date Initiated 6/27/24. A review of the Resident's weights revealed the following: 7/29/2024 14:37 (2:37 PM) 159 Lbs (pounds) Mechanical Lift (a device designed to help caregivers move a person from a bed to a chair) 7/30/2024 13:57 (1:57 PM) 158.2 Lbs Mechanical Lift 7/31/2024 15:05 (3:05 PM) 134.6 Lbs Mechanical Lift 8/5/2024 16:26 (4:26 PM) 133.6 Lbs Mechanical Lift 8/15/2024 10:13 (10:13 AM) 136.0 Lbs Mechanical Lift A reviewed of the nutritional assessment dated [DATE] revealed: Weight is significant unplanned gain in 1 month PTA (prior to admission) .r/t fluids/ BLE (bilateral lower extremity) edema, planned loss is desirable, on Lasix (a diuretic medication) daily. A review of the electronic Medication Administration Record (MAR) revealed a check for the day shift weight on 7/31/24. Further review of the MAR Chart Codes/Follow up Codes revealed the check=administered. No other documentation was noted for that order. A review of the progress notes revealed: 7/29/2024 12:20 Nurses Note Note Text: Call received from Cardio office. Device interrogation show Heart Failure . Possible fluid accumulation. NP (Nurse Practitioner) notified. New order to increase Furosemide (diuretic) from 20 mg to 40 mg daily. Further review of the progress notes did not reveal a progress note that the physician was made aware of the weight difference from 7/30/24 and 7/31/24 of 23.6 Lbs. Further review of the progress notes revealed: 8/6/2024 16:25 (4:25 PM), Dietitian Note Note Text: Weight note- significant loss in 1 mo (month), mostly in 1 week, suspect mostly planned r/t diuresis of edema, on daily weights per CHF protocol. On 09/17/24 at 11:34 AM, the surveyor interviewed Licensed Practical Nurse (LPN) #1, who stated the aides do the weights, but the nurse enters the weights in the eMR. She stated that you should look at the previous weight and if there was a difference you should call the doctor for a certain weight gain. She stated that on the MAR it would be checked off that the doctor was called or there would be a progress note that the doctor was called. LPN#1 reviewed Resident # 34's eMR in the presence of the surveyor. She verified that she had entered Resident #34's weight on 7/31/24. She verified there was no progress note that the doctor was called. She further verified that there was no documentation on the MAR that the doctor was called. She then stated, Yes, a weight difference of that amount, the doctor should have been called and it should have been documented. On 09/17/24 at 12:01 PM, the surveyor interviewed with the Director of Nursing (DON), who stated if there was a weight discrepancy, she would expect a reweight to be done. The DON reviewed the eMR in the presence of the surveyor for Resident #34. She reviewed the resident's weights from admission and noted the weight on 7/30 of 158 Lbs and 7/31 of 134 Lbs. She stated, I would attempt a reweight to make sure it was right since there was such a significant change. I would call the doctor and alert the dietician. She reviewed the eMR and verified there was no documentation that the physician or the dietician was made aware of the significant weight difference. The DON stated, the doctor should have been made aware. On 09/17/24 at 1:27 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator (LNHA), the DON, the Infection Preventionist, and the RNM, the above concerns were presented. On 09/18/24 at 9:20 AM, during a meeting with the survey team, the LNHA, the DON stated the weight loss was expected but it was not expected within 24 hours. She stated that the resident should have been reweighed, the doctor notified and there should have been documentation. A review of the facility, Weight Policy revised 10/2023, revealed: Procedure 2. Residents with weight loss or at risk for weight loss. a. Review medications and/or changes to medication regime (i.e., diuretics); b. notify physician of weight loss/gain. 4. Medical Records, a. Nursing will document in the nurse's notes the communication between Physician, Dietitian, and other disciplines. A review of the facility's Scale Accuracy for Weighing of Residents revised 10/2023, revealed Purpose: The purpose of this verification is to assure accurate weights. Procedure: 2. If there is a significant change in the resident's weight, the resident will be reweighed to assure accuracy. 3. If there continues to be a significant change in the resident's weight, the ADON (Assistant Director of Nursing) or designee will be notified. NJAC 8:39-13.1(d)

Based on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 09/13/23 from 09:57 AM until 11:10 AM the surveyors, who were accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the first refrigerator a box of individual containers of cranberry juice had a typed label of 9/24 and a handwritten label of 8/24. The FSD stated he will throw them away just to be sure. 2. In the first refrigerator, there were two white cups of liquid with no label and no date. The FSD identified the cups as being lactose free milk. The FSD stated the cups should have been dated and that he will discard. 3. In the first refrigerator there were individual cups of cream cheese in an opened box with a received date of 6/22/23. The FSD stated they were good for three months. He stated we are close; he will dispose of them. 4. In the third refrigerator, strawberries that were labeled 9/14/23. The FSD stated they were received on 9/5/23 but he will throw them away. 5. On the spice rack, a salt free seasoning blend container had no label and no date. The FSD stated that spices should be dated when received and are good for usually 6 months. He stated he will discard. 6. In the first freezer in the storage room, an opened bag of breakfast muffins was labeled 9/24/23. The FSD stated that they are mislabeled, and he will get rid of them. 7. In the first freezer in the storage room, an opened bag of fish patties had no label and no date. The FSD stated he will discard the fish patties. 8.In the meat freezer there were chicken tenders and meatballs in separate bags with no labels and no dates. The FSD stated he will discard the items. 9. In the meat freezer there were veal patties and hamburger patties in separate bags with a hole in each bag with no labels and no dates. The FSD stated he will discard the items. 10. On the bottom shelf of the dry storage rack, there were coffee filters in an opened bag exposed and opened to the air. The FSD stated that they should be covered and that he would get rid of them. 11. A food service worker with short facial hair was observed with no beard guard. The FSD stated he will get him a beard guard. On 09/19/23 at 11:55 AM, the surveyors observed a food service worker with facial hair extending past his chin and another food service worker with short facial hair. The food service workers were not wearing beard guards. The FSD stated they should have something covering their facial hair. The surveyor reviewed the undated Sun Cups (juices) policy provided by the FSD. The policy reflected that juices upon delivery are to be labeled with the delivery date and thawed in the refrigerator. Juices not used within 10 days will be disposed of. The surveyor reviewed an undated and untitled policy provided by the FSD. The policy revealed that foods are labeled, dated, and put away promptly upon receipt. The surveyor reviewed the undated Employee Sanitary Practices policy provided by the facility Administrator. The policy reflected that all employees shall: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. NJAC 8:39-17.2(g)

Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to implement Transmission Based Precaution mitigation strategies in a timely manner to prevent the transmission of COVID-19. This deficient practice was identified for 25 of 25 residents (Residents #4, 5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24, 25,26,27 and #28) who were exposed to two known COVID-19 positive staff members on 3 of 3 nursing units; during a Covid-19 survey conducted on 1/6/2021 and was evidenced by the following: Part A. 1. On 1/6/2021 at 2:30 PM, the DON/IP provided the team team with a document titled: Timeline, dated 11/26/2020. Review of the Timeline date indicated that the facility became aware on 11/25/2020, that a Certified Nursing Assistant (CNA #1) who worked 11/23/20 on the 7 AM -3 PM shift; tested positive for COVID-19. The surveyors reviewed CNA #1's assignment and identified that on 11/23/20, CNA #1 had direct contact and provided care to 9 residents. Further review of the Timeline showed that the facility became aware on 11/30/2020, that a second CNA (CNA #2) who worked on 7 AM - 3 PM shift on 11/30/20 tested positive for COVID-19. The surveyors reviewed CNA #2's assignment and noted that on 11/30/20, CNA #2 had direct contact and provided care to 10 residents. The facility failed to identify these 10 residents and failed to place these residents on Transmission Based Precautions to mitigate the spread of [MEDICAL CONDITION]. The facility's failure to identify residents exposed to Covid-19 positive staff and implement strategies to prevent the spread of Covid-19 posed a serious and immediate threat to the safety and wellbeing of all non-ill residents (residents who were negative for Covid-19). This resulted in an Immediate Jeopardy (IJ) situation that began on 11/25/2020 when the facility was notified of the confirmed Covid positive CNA #1. The facility Administration was notified of the IJ on 01/06/2021 at 4:45 PM. The immediacy was removed on 01/07/2021, based on an acceptable Removal Plan that was implemented by the facility and verified by the surveyors during an on-site revisit survey conducted on 01/08/2021. The evidence was as follows: On 1/05/21 from 10:02 AM to 10:40 AM, the surveyors conducted entrance conference with the Director of Nursing (DON) who is also the Infection Preventionist (IP), the Licensed Nursing Home Administrator (LNHA) and a Corporate Registered Nurse (CRN). The surveyors inquired about the number of Covid-19 positive residents at the facility and were informed that the facility had 13 Covid-19 positive residents currently residing at the facility and 3 Covid-19 positive residents that had been sent out to the hospital. The DON/IP confirmed that all current Covid-19 positive residents had acquired the infection at the facility. When questioned about contact tracing, the DON/IP stated that they did not conduct contact tracing because it was the Local Health Department (LHD) that conducts contact tracing. Upon further inquiry during the entrance conference, the LNHA stated that they did contact tracing but did not document it anywhere. The LNHA stated that the facility did not implement Transmission Based Precaution (TBP) because the facility did not have Covid-19 positive residents at the time CNA #1 tested positive. The CRN, DON/IP and the LNHA stated again that they did not write down their discussions but that they talked about the Covid-19 positive CNAs during their morning meetings. The LNHA also acknowledged that the facility did not implement TBP in a timely manner. The DON/IP stated that the facility had three residents units - Emerald,(NAME)and Ruby Units. She added that the facility quarantined residents in place in their rooms for both Covid-19 positive residents and for Persons Under Investigation (PUI), which includes residents with potential exposure to Covid-19 positive staff. The DON/IP stated that the facility did not have the physical capacity to designate separate areas for Covid-19 positives residents and PUIs and that was why they quarantined in place as directed by their Local Health Department. During a follow-up interview with the Administrative team on 01/05/21 at 3:05 PM, the DON/IP stated that CNA #1 and CNA #2 worked everywhere throughout the facility. The surveyor questioned again if a facility -wide TBP was initiated after CNA #1 and CNA #2 tested positive. The DON/IP responded that they did not feel they needed to initiate TBP at that time. The LNHA stated that the first in-house COVID-19 positive resident (Resident #1) was in a private room, and that they initiated TBP for Resident #1 upon receipt of the resident's test results on 12/3/20. The LNHA further stated that they discussed as a team and felt that facility- wide TBP did not need to be initiated at that time. The surveyor then requested a timeline and any investigations they completed related to the 11/23/20 and 11/30/20 positive Covid-19 of two CNAs. Both the LNHA and the DON/IP stated that the facility was in constant communication with the LHD and that the LHD did not direct them to implement TBP. The DON/IP then handed the surveyor a line listing for staff and residents and the facility team members left the conference room. The facility did not provide any other document regarding contact tracing or time line during day one of the survey. Review of the facility's line listing reflected the following: As indicated by the symptom/testing onset date on the line list, the facility's current out break started on 11/23/2020, which was the day CNA #1 tested positive for Covid -19 and had symptoms of coughing and dizziness. The Line list also showed that CNA #2 tested positive for Covid-19 on 11/30/2020. Resident #1 who resided on Emerald Unit, tested positive for Covid-19 on 12/1/20. Resident #2 who resided on Emerald unit, tested positive for Covid -19 on 12/1/20. Resident #3 who resided on Ruby Unit, tested Positive for Covid-19 on 12/1/20. Resident #4 who resided on Emerald unit, tested positive for Covid-19 on 12/4/20. Resident #5 who resided on(NAME)unit, tested positive for Covid-19 on 12/4/20. Resident #6 who resided on(NAME)unit tested positive for Covid-19 unit on 12/4/20. The daily assignment sheets showed that CNA #1 worked on(NAME)on 11/23/20 and that CNA #2 worked on Emerald and(NAME)units on 11/30/20. The surveyor then conducted a full review of the daily assignment sheets. The assignment showed that CNA #1 worked on 11/23/20 on 7:00 AM to 3:00 PM shift on(NAME)unit and provided direct care to nine residents (Residents #5,6, 7, 8, 9,10, 11,12 ,13). The surveyor reviewed the 11/21/20 and 11/22/20 daily assignment sheet which was the 48 hour look back period that preceded CNA #1's positive test on 11/23/20. The Assignment sheet showed that CNA #1 worked 7:00 AM to 3:00 PM shift on(NAME) Ruby and Emerald units, and provided direct care for additional six residents for a combined total of fifteen residents (Residents #5, 6,7,8,9,10,11, 12,13,23,24,25,26,27 and #28) from 11/21/20 to 11/23/20. During a telephone interview with the DON/IP on 1/11/20 at 2:30 PM, she confirmed that CNA #1 worked on(NAME) Emerald and Ruby Units on 11/21/20, two days before she tested positive for Covid-19. Review of the 11/30/20 daily assignment sheet showed that CNA #2 worked the 7:00 AM to 3:00 PM shift on Emerald and(NAME)Units and cared for ten residents, (Residents #13, 14,15,16,17,18,19,20,21 and #22). Review of 11/28/20 and 11/29/20 daily assignment sheet which was the 48 hour look back period that preceded CNA #2's positive test on 11/30/20, showed that CNA #2 worked the 7:00 AM to 3:00 PM shift on 11/29/20, on Emerald and(NAME)units, and provided direct care for the same ten residents as on 11/30/20, (Residents #4,13,14,15,16,17,18,19, 20 and #21). The surveyor reviewed an email communication dated 12/7/2020, which was provided by the DON/IP. This communication reflected that the facility increased the cleansing of high touch areas. The surveyor interviewed the Director of Housekeeping (DH) on 1/5/21 at 1:25 PM. He stated that he started working at the facility approximately two and half weeks ago and that he did not know when facility-wide TBP was initiated. The DH also stated that he had not implemented new infection prevention interventions in the house keeping department since he started. He then provided the surveyor with a document titled: Housekeeping job description and stated housekeeping staff followed this job description daily. There was no indication on the document for an increased cleaning of high touch areas. During interview with CNA #2 on 1/5/21 at 1:20 PM, she stated that she was sent home after testing positive for Covid-19 and that she quarantined for 14 days following her positive test. She added that she returned to work on 12/21/20 and that facility-wide TBP was in place when she returned and that she did not know when TBP was initiated. The surveyor interviewed unit Licensed Practical Nurse (LPN #2) on 1/5/21 at 1:05 PM. She stated that they don full PPE (gown, gloves, N95 mask and face shield) when they provided care for all residents. She stated that she was not sure when TBP was started. On 01/6/21, at 10:50 AM, the surveyor went to the DON/IP's office to inquire about the requested documents. The DON/IP informed the surveyor that she was still typing up the information. The CRN stated that someone was completing the contact tracing on CNA #1 and CNA #2 and that they would provide the information shortly. On 1/6/2021 at 11:30 AM, the Corporate Registered Nurse (CRN) provided the surveyor with a typed document dated 1/7/2021, which reflected the following: 11/2/2020 met with all staff on 7-3 to make aware of 2 staff members testing positive for Covid19 12/6/2020 transmission based precautions were instituted for the entire building. Supplies were provided and in-servicing done with staff On 1/6/2020 at 2:30 PM. the CRN provided the survey team with a typed document titled: Timeline. The Timeline reflected that the facility were aware that CNA #1 was tested for Covid -19 on 11/23/20 and that the facility received the result of test on 11/25/20. The Timeline showed that the facility notified CNA #1 and the LHD. The document showed that LHD directed the facility to conduct weekly testing for two weeks. The Timeline also showed that the facility were made aware that CNA #2 tested positive for Covid-19 on 11/30/2020. The Timeline indicated that the facility notified CNA#2 and the LHD of the positive results. The Timeline showed that the facility were made aware of Resident #1's positive Covid -19 result on 12/3/2020. During interview on 1/5/2020 at 3:30 PM, the surveyor inquired about the interventions and preventive measure the facility implemented following their receipt of positive test results of Covid19 for CNA #1, CNA #2 and Resident #1. The LNHA stated that the facility purchased trash cans for isolation rooms, started fit testing of staff members for N 95 masks, and purchased extra blood pressure cuffs. The DON/IP stated that they tested residents weekly and that she informed the Local Health Department of the positive Covid-19 for CNA #1 and CNA #2. The DON/IP further stated that she was not be able to provide any documentation regarding facility -wide TBP. The DON reiterated that TBP was initiated on 12/06/2020. The LNHA insisted that the facility followed all the CDC/NJDOH guidance The facility did not provide an explanation for why they waited from 11/23/2020 to 12/6/2020 before implementing TBP in accordance with CDC/NJDOH guidelines. Review of Center for Disease Control and Prevention (CDC) guidance dated April 30, 2020 and titled; Responding to Coronavirus (COVID-19) in Nursing Homes indicated the following: The facility should identify which residents received care from a Health Care Professional (HCP) diagnosed with [REDACTED]. The guidance also reflected to maintain TBP on all residents on the units at least until there were no additional clinical cases for 14 days. Documentation on the facility' line list showed that CNA#1, who tested positive for Covid-19 on 11/23/2020, had symptoms of coughing and dizziness. The New Jersey Department of Health (NJDOH) guidance dated October 29, 2020 indicated that upon the facility's identification of Covid-19 positive staff and/or residents, priority actions should be taken including but not limited to: identify close contacts including 48 hours prior to symptom onset/date of specimen collection of associated case. The surveyor reviewed the facility's Outbreak Response Plan (OBRP) dated 9/23/2020. The OBRP indicated that the facility would implement all appropriate TBP to mitigate, reduce and or eliminate infection control concerns. Review of facility's Covid-19 Guidance Policy dated 03/2020 showed that the facility would follow any guidance from LHD/NJDOH/CDC, including following all updated guidelines. The IJ was identified on 1/6/2021, the LNHA, DON/IP and the CRN were notified of the IJ at 4:45 PM. A removal plan was accepted on 1/7/2021 which included that residents who were identified as having been exposed to a known Covid-19 positive person, would be placed on TBP. All licensed staff were re-inserviced on TBP. On 1/8/2021 at 10:31 AM, the surveyors toured all three units of the facility and verified through observations, interviews with facility staff, and review of in-service education and revised facility infection control policy; that the Removal Plan had been implemented. The implementation of the removal plan was verified on-site on 1/8/2021. Part B: F880 remains a deficiency, at a scope and severity level of a D based on the following: Based on observation, interview and record review, it was determined that the facility failed to follow appropriate infection control protocols regarding doffing of soiled isolation gown, in accordance with facility protocols. This deficient practice was identified for 1 of 2 nursing staff (LPN #1) observed for donning and doffing PPE and was evidenced by the following: On 1/5/2021 at 09:35 AM, the survey team entered the facility lobby and stood near the nurses' station for observation of staff on the units. At that time, the surveyor observed as LPN #1 walked out of room -1 and onto the hallway of the Emerald unit. Room-1 was situated not far from the nurses's station and the whole hallway was in clear view of the surveyors from the nurses' station. The surveyor noted that LPN #1 wore a yellow isolation gown as she walked past two other rooms down the hallway. LPN #1 then turned around and walked back to the front of room-2, doffed/removed the isolation gown and placed it in a dirty linen bin which was by the entrance of room-2. The surveyor noted that room-1's front entrance was covered with a clear plastic curtain while room-2 was not. At 09:40 AM, the surveyor invited LPN #1 to the lobby for an interview. When asked about the clear plastic curtain in front of room-1, LPN #1 stated that the facility quarantined Covid-19 positive residents in place in their rooms and that the rooms with clear plastic curtains housed Covid-19 positive residents. She also confirmed that the residents in room -1 were positive for Covid-19. When questioned about the protocol for removing used isolation gowns and other PPE, LPN#1 stated that there was no soiled linen bin in room-1 and that she did not know why there was no bin in room-1. She added that there should be a soiled linen bin in a Covid-19 positive room or right outside the room. At 1:56 PM, the surveyor interviewed LPN #1 again. She stated that she should not have worn the isolation gown outside the Covid-19 positive room and into the hallway. LPN #1 also stated that she should not have placed the used isolation gown into the bin in room-2. When asked if room -2 was a Covid-19 room, she stated that room-2 was not a Covid-19 room because Covid-19 precautions was discontinued for room-2 this morning( 1/5/2021.) She added that the residents in room-2 were recovered Covid-19 residents. During a follow-up interview with the Administrative team on 01/05/21 at 3:05 PM, the DON/IP stated that staff were required to wear full PPE (N95 mask, face shield or goggles, gown and gloves) prior to entering residents' rooms on the Covid Unit. The DON/IP added that staff were supposed to remove their gown and place them in the bin located inside the resident's room before exiting the resident's room. The DON/IP stated it was the responsibility of the nursing staff to make sure that all residents' rooms had bins for the used reusable gowns. At 11:10 AM, the surveyors inspected other rooms and noted that they had bins for soiled reusable gowns. At 1:20 PM, the surveyor interviewed CNA #2 who stated that staff were supposed to remove their gown in a resident's room and place it in the bin located in the resident's room or right outside the room. According to a document provided by the facility dated 12/7/2020, and titled In-service description: Transmission Based Precautions. Dirty disposable gowns should be doffed at the residents doorway, and placed in a plastic bag and into a garbage bin. An in-service document dated 12/4/2020, indicated that staff should follow the Transmission Based Precautions Guidelines. Another in-service document dated 12/11/2020 titled: procedure for using Non-disposable isolation gowns indicated that washable isolation gowns were to be removed properly before leaving the room, place them in a marked container inside the room, so they can be sent out for laundry. NJAC 8:39-19.4 (a)(b)(c)(d)

Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirement which affected the safety of all residents in the facility. The Administrator failed to a.) ensure the implementation of Transmission Based Precautions (TBP) in a timely manner to prevent the transmission of COVID-19 and b.) by not appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI). This placed 25 of 25 residents on 3 of 3 units at risk for Covid-19 Infection. This deficient practice was evidenced by the following: Refer to F880L as it pertains to the facility's failure to ensure the implementation of Infection Control Practices and Precautions during an identified COVID-19 outbreak. During the survey conducted on 01/06/20, the surveyors identified deficient practices concerning Infection Control related to the identification of residents who had been exposed to staff members with a known Covid-19 positive test results; and timely implementation of transmission-based precautions (TBP) for these residents. These deficient practices were identified on 3 of 3 nursing units. On 01/06/21 at 4:45 PM, the facility's LNHA was notified that an Immediate Jeopardy (IJ) situation was identified related to the facility not identifying residents as PUI after they were exposed to two certified nurse aides (CNAs) who tested positive for COVID-19. Additionally, the facility did not implement TBP for the residents who had been exposed to the two known COVID-19 positive staff members for the period of 11/23/2020 to 12/6/2020. On 01/07/21, the facility's removal plan was accepted. According to the removal plan, TBP were in place for all residents residing in the facility, staff were educated on the proper protocol of exposure and implementation of TBP, to prevent the spread of infection. On 1/8/2021 at 10:31 AM, the surveyors toured all three units of the facility and verified through observations, interviews with facility staff, review of in-service education and revised facility infection control policy; that the Removal Plan had been implemented. The implementation of the removal plan was verified on-site on 1/8/2021. A review of the Administrator's job description provided by the facility revealed the following: Responsibilities/Accountabilities included; Establishes, directs and is responsible for the overall operation of the Facility's internal and external activities; Works to ensure regulatory and corporate compliance, quality assurance, and the fiscal viability of the Facility; Responsible for the overall organization and management of the facility; Ensures compliance with all pertinent standards, regulations, and requirements; Ensures a safe residential living environment and reviews physical condition of facility through environmental rounds; Ensures proper resident care services; Ensures accurate documentation, implementation and compliance of all issues. On 1/05/21 from 10:02 AM to 10:40 AM, the surveyors conducted an entrance conference with the Administrative team (LNHA, DON/IP and CRN). The DON/IP informed the surveyors that there were 13 COVID-19 positive residents currently residing at the facility and there were three COVID-19 positive residents that had been sent out to the hospital. The DON/IP confirmed that all current COVID-19 positive residents had acquired the infection at the facility. The DON/IP then handed the surveyor a line listing for staff and residents. The DON/IP stated that the facility had three residents nursing units - Emerald,(NAME)and Ruby Units. She added that the facility quarantined residents in place in their rooms for both COVID-19 positive residents and for residents under observation for their potential exposure to COVID-19 positive staff members. The LNHA stated that the facility did not have the physical capacity to designate separate areas for COVID-19 positives residents and the PUIs. The DON/IP stated that everyone was required to wear a N95 mask and face shield when in the facility and that staff were supposed to don gown, N95 mask, eye shield and gloves prior to entering a resident's room because the entire facility was on Transmission Based Precautions. The surveyor reviewed the facility's line listing and noted that the current outbreak at the facility started on 11/23/2020 after a Certified Nursing Assistant (CNA #1) tested positive for Covid-19 while CNA #2 tested positive for Covid-19 on 11/30/2020. The surveyor then inquired about contact tracing and investigations regarding the two positive cases above. The LNHA stated that they talked about the positive Covid-19 cases in their morning meeting but did not document the discussion. The LNHA stated that the facility did not implement Transmission Based Precaution (TBP) because the facility did not have Covid-19 positive residents in the facility at the time CNA #1 tested positive. The LNHA and the DON/IP stated that they did not complete contact tracing and that they were in communication with their Local Health Department (LHD) and that LHD did not direct them to conduct contact tracing. The facility did not provide any documented evidence of contact tracing/investigation despite multiple requests made by the survey team on 01/05/2021. The surveyor then requested a timeline of events related to the 11/23/20 and 11/30/20 identification of the two COVID-19 positive CNAs. The CRN, DON/IP and the LNHA stated again that they did not document their discussions concerning the two Covid-19 positive CNAs During a follow-up interview with the Administrative team on 01/05/21 at 3:05 PM, the LNHA and the DON/IP stated that CNA #1 and CNA #2 worked everywhere throughout the facility. The LNHA and the DON/IP added that they did not feel as though they needed to initiate TBP in November 2020 when the CNAs tested positive for Covid-19. The LNHA stated that the first in-house COVID-19 positive resident (Resident #1) with an onset date of 12/1/20 was in a private room and TBP was initiated for Resident #1 upon receipt of the test results on 12/3/20. He had no explanation for why TBP was not initiated for all the residents that were exposed to CNA #1 and CNA #2. The LNHA further stated they discussed it as a team and felt that facility wide TBP did not need to be initiated at that time. The LNHA acknowledged that the facility did not implement TBP in a timely manner. On 01/06/21 at 10:50 AM, the surveyor requested additional information as to when they facility initiated TBP. The DON/IP responded that she was actively typing up a timeline as to when they initiated TBP and the CRN stated someone was in the process of completing the contact tracing. During a follow-up interview with the Administrative team on 01/06/21 at 12:00 PM, the DON/IP and the LNHA stated that residents were tested weekly and that they were in communication with the LHD. The LNHA stated that they initiated TBP on 12/06/20, which was eleven days after the facility was made aware that two staff members tested positive for Covid-19. The DON reiterated that facility wide TBP was initiated on 12/06/20. When the surveyor inquired about the policy and guidance the facility followed to address the new Covid-19 outbreak in the facility; both the LNHA and the DON/IP informed the surveyors that the facility followed both the CDC and the NJDOH guidance. The surveyor reviewed the April 30, 2020 CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes. Under the Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2 infected (COVID-19) HCP (health care professional) or Residents. The guidance instructed facilities to determine which residents received direct care from the HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. The guidance further revealed that if the HCP is diagnosed with [REDACTED]. The surveyor questioned the LNHA regarding interventions or changes that he implemented following the identification of in-house COVID-19 positive staff and residents. The CRN stated they monitored the 24-hour report, increased the monitoring of residents' vital signs, and monitored for respiratory issues. The LNHA stated that he purchased trash cans for isolation rooms, started fit testing of staff members for N 95 masks, and purchased more blood pressure cuffs. During a follow up interview with the CRN on 01/06/21 at 2:40 PM, the surveyors questioned her regarding the reason for deciding to initiate TBP on 12/06/20. The CRN stated she would have to speak with the DON/IP and would follow up with surveyors. Upon return, the CRN stated that the facility -wide TBP was initiated on 12/06/20 due to an increase in residents with Covid-19 type symptoms. During an interview with the Director of Clinical Services (DCS) on 01/08/21 at 12:30 PM, the DCS stated that she was from the facility's management company and that she consulted with the facility on infection control matters. The DCS added that she knew that DON/IP completed contact tracing but did not document it. The DCS further stated that the LHD did not instruct the facility staff to initiate TBP. The administrative team did not provide any information regarding how they identified and implemented TBP for the 25 residents who were exposed to the two CNAs that tested positive for Covid-19 on 11/23/20 and 11/30/2020. The surveyor reviewed the facility's 03/2020 COVID-19 Guidance Policy which indicated it was the facility's policy to comply with DOH (Department of Health), CMS (Center For Medicare & Medicaid Services) and CDC (Centers for Disease Control and Prevention) guidelines to contain any potential cases of COVID-19 and prevent spread of infection as much as possible. The policy also reflected that infection control protocol for outbreaks, including moving and cohorting ill residents, will be followed along with any guidance from the LHD, NJDOH (New Jersey Department of Health), and CDC. The policy further revealed that the facility would continue to follow updated guidelines from the CDC, LHD, NJDOH and CMS. There was no procedure documented on the policy regarding the steps that staff were to take regarding TBP upon identification of positive Covid-19 cases in the facility. On 01/05/21, the surveyor reviewed the facility's document titled, Outbreak Response Plan updated on 9/23/2020, provided by the CRN. The Outbreak Response Plan reflected that the facility would institute control measures to mitigate, reduce and/or eliminate infection control concerns. The control measures included, but not limited to, universal masking, isolation of ill residents, cohorting residents and all appropriate TBPs. On 01/05/21, the surveyor reviewed the facility's Infection Control General Policies, revised on 09/2020, provided by the CRN. The policy revealed that the facility's objective included to prevent the spread of communicable disease. The policy further revealed that it was the responsibility of the Administrator, through the Infection Control Committee, to ensure that all infection control policies and procedures are implemented and followed when necessary. On 01/06/21, the surveyor reviewed the facility's 09/2020 Isolation Precautions policy, provided by the CRN. The policy reflected that residents would be placed on appropriate isolation precautions as noted in the most recent state and federal guidelines. The surveyor reviewed the October 29, 2020 NJDOH guidance titled Testing in Response to a Newly Identified COVID-19 Case in Long-term Care Facilities (LTCF). Under the Identification of a COVID-19 case in LTCFs section, the guidance indicated that upon the facility's identification of a confirmed case of Covid-19 within the Long Term Care Facilities, they should take critical priority actions regardless of where the transmission event occurred. The guidance further reflected that the facility should take some steps when a new case of COVID-19 was identified at their facility, which included but was not limited to the following: Perform risk assessment to determine potential exposures and/or infection control breaches, determine any possible exposures the new case of COVID-19 may have had prior to diagnosis, and identify close contacts including 48 hours prior to symptom onset/date of specimen collection of associated case. The guidance described close contact as being within approximately six feet of a COVID-19 case for a prolong period of time, a cumulative total of 15 minutes or more over a 24-hour period starting from two days before illness onset. The guidance also indicated to quarantine close contacts for 14 days from last exposure and provide care using all COVID-19 recommended PPE. Under the Newly Positive HCP section, the guidance reflected that facility should take immediate action to ensure that further transmission did not occur. NJAC 8:39-27.1 (a)

# NJ 6387 Based on record review, it was determined that the facility failed to implement care plan interventions to provide for a resident's safety. As a result, the resident sustained [REDACTED]. The resident required an emergency room visit and sutures to close the [MEDICAL CONDITION]. This deficient practice was identified for 1 of 6 residents reviewed for falls, Resident #12, as evidenced by the following: The surveyor reviewed the medical record of Resident #12 on 8/27/13 at 11:00 a.m., which revealed that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of an "Unusual Occurrence Incident Report," dated 5/28/13, revealed that the resident fell from the wheelchair and sustained a head injury. The resident's Lap Stim tray had been removed at lunchtime, and was not re-applied by staff as per the care plan. On 5/28/13 Resident #12 fell out of the chair and sustained a laceration to the head requiring sutures and skin tears to both hands. Refer to F 323 NJAC 8:39- 11.2

#NJ 387 Based on observation, interview and record review, it was determined that the facility failed to apply a safety device to protect a resident from falling. This deficient practice was identified for 1 of 6 residents reviewed for falls and accidents, Resident #12. The resident fell and sustained a laceration to the head, requiring an emergency room visit and 7 sutures. The facility also failed to store cleaning chemicals in an area that was not accessible to residents. as evidenced by the following: 1. The surveyor reviewed the medical record of Resident #12 as a closed record on 8/27/13 at 10:00 a.m., which revealed that the resident had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of an "Unusual Occurrence Incident Report" provided by the facility dated 5/28/13, revealed that at 8:20 p.m., the resident was found in the hallway next to the nurses' station laying on his/her right side, with a laceration to the head, and skin tears on the right and left hands. The resident was sent to the hospital and required 7 sutures to close the head laceration. Review of the "Statement Summary" on the incident report revealed that on 5/28/13, the CNA asked the ADON if she should remove the lap tray when giving the resident his/her lunch tray. The CNA was advised to remove the tray as it was the policy to remove a restraint at meal time. The lap tray was removed and a lunch tray was placed on an over bed table in front of the resident. After lunch, the same CNA collected the lunch tray, but did not replace the lap tray. That afternoon, the Unit Manager ambulated with the resident, returned him/her to the wheelchair, repositioned the resident but did not reapply the lap tray. The incident report further indicated that multiple other staff members interacted with the resident on that date, as evidenced below: -The 7-3 nurse was seen taking the resident to administer medications with the lap tray off. -The Unit Manager DON responded to the chair alarm, repositioned the resident in the wheelchair and did not apply the lap tray. -The 3-11 nurse responded 5 times in a 45 minute period to the chair alarm prior to the fall but did not apply the lap tray. -The ADON was at the nursing desk and interacted with the resident with the lap tray off. The "Conclusion" of the investigation revealed that the fall was a direct result of the lap tray not being placed back on the resident after lunch despite multiple times staff responded to the chair alarm. All nursing staff were in-serviced on Restraint Safety, Accountability and Disciplinary Actions. 2. On 8/26/13 at 10:30 a.m., the surveyor observed the door to the laundry room to be open. The room was located at the end of the "Ruby" corridor, where residents resided. Upon entrance to the laundry room area, the surveyor observed an office to the right labeled "Housekeeping Office" which also had the door open. Inside the office was a filling cabinet with 3 spray bottles of cleaning solution on top. The bottles were labeled as follows: a.) H2 Orange concentrate 117 light duty cleaner. "Keep out of reach of children, hazardous to human and domestic animals. Caution- causes moderate eye damage. Harmful if swallowed, absorbed through the skin or inhaled." b.) H2 Orange Concentrate 117 heavy duty cleaner. This bottle had the same precautions as the previous cleaner. c.) Mega Builder Cleaner- "Warning, causes eye irritation, keep out of reach of children. Avoid contact with eyes." The surveyor noted during the time of the above observation, that no residents were present in the area. Upon further investigation and interview with the unit manager, the surveyor was informed that the residents who reside on the Ruby Unit were either bed-bound or used wheelchairs. A wheelchair resident would not have been able to reach the top of the filling cabinet to have access to the chemicals. NJAC 8:39-27.1 (a)