Arbor Glen Center

Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to retain health files for staff that were no longer employed with the facility for the timeframe required, for 2 of 20 new employee files reviewed. This deficient practice was evidenced by the following: On 12/1/25 at 10:14 AM, during entrance conference, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the medical files of the facility's 20 new hire employees since their last recertification survey. On 12/4/25 at 10:18 AM, the surveyor asked the LNHA for additional files for employees that were not given to the surveyor. The LNHA stated that the files were sent to storage if they were no longer employed with the facility and that she was calling to get the files. On 12/8/25 at 11:26 AM, the surveyor interviewed the Nurse Practice Educator (NPE) regarding process for health files. The NPE stated that when the staff member was no longer employed, she gave the file to human resources. On 12/8/25 at 1:00 PM, the surveyor notified the LNHA and Clinical Lead (CL) the concern that the facility could not provide 2 of the 20 medical files requested. On 12/9/25 at 12:00 PM, in the presence of the Director of Nursing (DON) and CL, the LNHA confirmed that she did not have the two medical files requested. The LNHA did not provide any additional information. N.J.A.C. 8:39-5.1 (a)

Based on observation, interview, review of the medical records, and other facility documentation, it was determined that the facility failed to; a.) provide adequate monitoring for the use of psychoactive medication for 1 of 5 residents (Resident #7), b.) review duplicate orders for the as needed (PRN) bowel regimen medications for 2 of 5 residents (Residents #7 and #35), and c.) review, clarify, and sequenced the PRN pain medications for 1 of 5 residents (Resident #7), reviewed for unnecessary medications. The deficient practice was evidenced by the following:
1.On 12/1/25 at 11:00 AM, Surveyor #1 (S #1) observed Resident #7 lying on bed, awake, and informed S #1 that they were at the facility for short term rehabilitation.
S #1 reviewed the medical records for Resident #7.
A review of the admission Record (AR, an admission summary) reflected that Resident #7 was admitted to the facility with the diagnoses which included but not limited to; unspecified sequelae of nontraumatic intracerebral hemorrhage (stroke), post traumatic stress disorder (PTSD) unspecified, restlessness and agitation, adjustment disorder with anxiety, and mood disorder due to known physiological condition with mixed features.
A review of the most recent comprehensive Minimum Data Set (cMDS), an assessment tool, with an assessment reference date (ARD) of 9/18/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. The MDS further reflected the resident received psychoactive medications (meds) which were antipsychotic and antidepressant, opioid (controlled medication), and routine and PRN pain meds.
A review of the November and December 2025 electronic Medication Administration Record (eMAR) revealed that the resident was on olanzapine (antipsychotic medication) oral tablet (tab) 5 mg (milligram), to give one tab by mouth at bedtime (HS) for mood adjustment disorder with mixed anxiety target behavior for delusions, hallucinations, and paranoia.
The above olanzapine order in the November and December 2025 eMAR was plotted at 9:00 PM (9 PM), signed by nurses as administered and no behavior was noted. There were no further documentation in the eMAR for other shifts that the behavior was monitored for use of antipsychotic medication (med).
A review of the November and December 2025 eMAR revealed the following orders for PRN pain meds:
-start date 9/30/25, acetaminophen 325 mg, give two tablets (tabs) orally every six hours PRN for mild pain.
-start date 9/30/25, oxycodone oral tab 5 mg, give one tab by mouth every six hours PRN for moderate to severe pain.
-start date 10/15/25, tramadol oral tab 50 mg, give one tab by mouth every six hours PRN for pain.
Further review of the above PRN pain meds revealed that the PRN tramadol had no indication of what kind of pain, it was not sequenced from other PRN pain meds.
A review of the November and December 2025 eMAR revealed the following orders for PRN bowel regimen meds:
-start date 9/9/25, Dulcolax suppository 10 mg, insert one suppository rectally every 24 hours PRN for constipation if no result from MOM (milk of magnesia).
-start date 9/9/25, miralax powder, give 17 gram by mouth every 24 hours PRN for constipation in 4 to 8 ounces (oz) of fluid if resident has not had a bowel movement (BM) in past 72 hours.
-start date 9/30/25, MOM suspension 400 mg/5 ml (milliliters), give 30 ml by mouth every 24 hours PRN for constipation give at HS if no BM in three days.
Further review of the above PRN orders revealed duplicate orders for constipation meds.
On 12/8/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), the Clinical Lead (CL; also known as the regional director), and S #1 notified the LNHA, DON, and CL of the above findings and concerns with regard to Resident #7's duplicate orders for bowel regimen meds, no adequate monitoring for antipsychotic med, and sequencing of PRN pain meds.
2. On 12/1/25 at 10:38 AM, Surveyor #2 (S #2) observed Resident #35 sitting in a chair, in their room watching TV. S #2 attempted to interview the resident, the resident answered yes or no but otherwise did not engage in a conversation. S #2 reviewed the medical records for Resident #35. A review of the AR reflected that Resident #35 was admitted to the facility with the diagnoses which included but not limited to essential hypertension (high blood pressure) and hypothyroidism (a condition when the thyroid does not produce enough hormones resulting in a lower metabolism).
A review of the most recent quarterly MDS, with an ARD of 10/10/25, reflected that the resident had a BIMS score of 3 out of 15, which indicated severe cognitive impairment.
A review of the resident's care plan (CP) dated 10/14/25, revealed a focus that reflects the resident was at risk for complications related to constipation.
A review of the resident's eMAR for December 2025, revealed orders that reflected:
MOM Suspension 400 mg/5 ml, give 30 ml by mouth every 24 hours PRN for constipation give at HS if no BM in 3 days -Start Date-1/3/25
MiraLax Powder (Polyethylene Glycol 3350) give 17 gram by mouth every 24 hours PRN for constipation in 4 to 8 oz of fluid-if resident has not had a BM in past 72 hours -Start Date-1/3/25
Further review of the above orders revealed duplicate orders for constipation meds with no indication of which to use first.
On 12/8/25 at 12:55 PM, the survey team met with the LNHA, ADON, the Clinical Lead (CL; also known as the regional director). S #2 notified the LNHA, DON, and CL of the above findings and concerns regarding Resident #35's duplicate as needed orders for bowel regimen meds and no indication of which to use first.
On 12/9/25 9:59 AM, S #2 interviewed the facility Consultant Pharmacist (CP) by phone. S #2 asked if they reviewed PRN orders for sequencing or clarification if duplicate instructions or insufficient indications such as pain scale. The CP stated yes, they would usually ask for a clarification of an order to sequence it if it was incomplete or to eliminate duplication.
On 12/9/25 at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON), and the CL, and the DON stated that the PRN bowel regimen meds were updated and that the PRN laxatives were updated with corrected directions. The LNHA stated that we contacted the CP who will do thte audits on PRN meds for proper sequencing, review duplicate orders, and to ensure the PRN meds were appropriate. The LNHA had no response with regard to antipsychotic med concern for Resident #7.
On 12/9/25 at 1:55 PM, the survey team met with the LNHA, DON, and CL for exit conference and there were no additional information provided by the LNHA.
A review of the facility's Consultant Pharmacist Provider Requirements, revised 3/1/11, the policy revealed under 2.4 Conducting routine med regimen reviews. The policy did not reflect anything specific about clarifying orders.
There was no policy provided regarding clarification of orders, duplicate orders or sequencing orders.
NJAC 8:39-27.1(a); 33.2(a)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 3 of 5 days in a prominent place within the facility readily accessible and visible to the residents and the visitors.This deficient practice was evidenced by the following: On 12/1/25 at 10:55 AM, Surveyor #1 (S #1) interviewed Registered Nurse/Unit Manager #1 (RN/UM #1) in unit 1 nursing station, who informed S #1 that the unit's census was 16, with two Certified Nursing Aides (CNAs) for 7:00 AM-3:00 PM (7-3) shift. On 12/1/25 at 11:08 AM, S #1 interviewed RN/UM #2, who informed the surveyor that the unit's census was 26 in unit 4, with three CNAs for 7-3 shift. On 12/1/25 at 2:14 PM, during team meeting of surveyors, S #1 reported that per RN/UM #1 there were two CNAs in unit 1 and RN/UM #2 there were three CNAS in unit 4. S #2 stated that there were three CNAs in unit 2. S #3 stated that there were three CNAs in unit 3. The total CNAs on 12/1/25 were 11. On 12/1/25 at 2:35 PM, S #1 observed the posted Nursing Home Resident Care Staffing Report (NHRCSR) in the reception area dated 12/1/25, census 98, and with 14 CNAs. A review of the 12/1/25 NHRCSR for Day Shift, included information: census 98 with 14 CNAs. A review of the facility's provided Daily Staffing Sheet dated 12/1/25, executed at 11:01 AM, included total CNAs on the schedule: unit 1 with 2 CNAs, unit 2 with 4 CNAs, unit 3 with 4 CNAs, and unit 4 with 3 CNAs with a total 13 CNAs. Further review of the above staffing reports, the total CNAs on 12/1/25 were 11 which did not match the posted 12/1/25 NHRCSR (14 CNAs) that was provided by the Receptionist, and the Daily Staffing Sheet (13 CNAs) that was provided by RN/UM #3. A review of the NHRCSR 12/2/25 Day Shift, census 99, with 12 CNAs, while the provided Daily Staffing Sheet of the LNHA for 12/2/25 executed 9:25 AM, unit 1 with 2 CNAs, unit 2 with 3 CNAs, unit 3 with 3 CNAs, and unit 4 with 3 CNAs for a total 11 CNAs. The NHRCSR and Daily Staffing Sheet f or 12/2/25 was inaccurate and did not match. On 12/8/25 at 6:47 AM, S #1 observed the posted sign for NHRCSR dated 12/8/25-Day Shift with census of 98 and total of 12 CNAs. On 12/8/25 at 6:50 AM, S #1 interviewed Licensed Practical Nurse #1 (LPN #1), who informed S #1 that census in unit 1 was 16 with 2 CNAs. On 12/8/25 at 6:54 AM, S #1 went to 2nd floor and met with LPN #2, who informed S #1 that she was the assigned nurse in unit 4 and half of unit 3. LPN #2 stated that she worked 11:00 PM-7:00 AM (11-7) and there were total of three CNAs in their shift who worked last night on the 2nd floor, one in each unit (unit 2, 3, and 4). A review of the provided Daily Staffing Sheet by the Director of Nursing (DON) revealed, 12/7/25 for 11-7 shift there were total of 5 CNAs with no call outs. The provided NHRCSR by the DON revealed that on 12/7/25 Night Shift (11-7) there were total of 7 CNAs. Both provided reports was inaccurate and did not match. On 12/9/25 at 10:17 AM, S #1 interviewed the Licensed Nursing Home Administrator (LNHA) regarding the facility's practice of NHRCSR posting and if she was aware of the requirement of the regulation. The LNHA stated that the Staffing Coordinator (SC) was responsible for posting the NHRCSR during weekdays and for the weekend I have to be honest I do not have anyone. She further stated that we have to train the Manager on Duty (MOD) for the weekends. She added that every center I worked, we correct the NHRCSR in the morning of Monday for that past weekend. The LNHA also stated, I have to be refreshed with the regulation for posting. S #1 notified the LNHA of the above concern with inaccurate staffing posting for three days of observation. On 12/9/25 at 11:56 AM, the survey team met with the LNHA, DON, and the Clinical Lead (CL), and the LNHA stated we will do an in service with the SC to ensure assignments were reconciled and matched. A review of the facility's Posting Staffing Policy that was provided by the DON, with a review and revised date of 8/7/23, revealed, in accordance with federal and state regulations, Centers will post the census, shift hours, number of staff, and total actual hours worked by licensed and unlicensed nursing staff who are directly responsible for patient care for each shift and on a daily basis. If a state requirement exists for posting staffing that is different from the federal requirement, both reports will be posted with an explanation of the differences.Process: .3. The posting should be: .3.3. Completed on a daily basis at the beginning of each shift; and 3.4 Adjusted either upward or downward if staffing changes. On 12/9/25 at 1:55 PM, the survey team met with the LNHA, DON, and CL for exit conference and there were no additional information provided by the LNHA. N.J.A.C. 8:39-41.2 (a)(b)(c)(d)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for soiled linens and waste to decrease the possibility of spreading infection. The deficient practice was observed during tour on 1 of 4 units. This deficient practice was evidenced by the following: On 12/8/25 at 11:17 AM, the surveyor observed with a Registered Nurse Unit Manager (RN/UM) the soiled utility room of Unit #1. The RN/UM stated the designated room was the only soiled utility room on the unit. The room had signage which indicated storage room and was secured with a keypad lock. Upon entering the room, the surveyor accompanied by the RN/UM observed on the front, right side of the room, one covered yellow colored bin with signage indicating only soiled diapers please; a large transport bin with a couple of clear plastic bags containing linen items; and three smaller covered garbage bins including one with signage labeled soiled gowns. The surveyor observed to the left side of the room, storage racks with containers and boxes; piled boxes and containers; including uncovered and exposed items. Visible items included recreation and decor items. The back right side of the room contained a large storage cabinet and cardboard items. The RN/UM stated that the soiled utility bins were previously kept in the shower room and were moved into the storage room. The RN/UM could not speak to why the soiled utility area was kept there and acknowledged that clean and soiled items should be stored in separate areas. On 12/8/25 at 11:23 AM the surveyor interviewed the Infection Preventionist (IP) about the soiled utility area. The IP stated she was not familiar with Unit #1's soiled utility area. The IP accompanied the surveyor to observe the room. The surveyor asked the IP about the storage of soiled items with stored, clean items in use and the facility's policy. The IP referred the surveyor to ask the LNHA who could speak to designated storage areas in the facility. On 12/8/25 at 12:35 PM, the surveyor interviewed a Certified Nurse Aide (CNA) assigned to work on Unit #1 who stated soiled linens including personal clothing items in plastic bags were placed in the soiled utility area in the storage room. The CNA further explained soiled diapers were also disposed in the designated bin in the soiled utility area. The CAN stated there were no other soiled utility areas on the unit. On 12/8/25 at 12:55 PM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), and the Clinical Lead (CL) of the concern regarding the designated soiled utility room on Unit #1 which also stored (clean) items used within the facility. There was no verbal response by the facility at this time. On 12/9/25 at 11:57 AM, the LNHA, the Director of Nursing (DON) and the CL met with the surveyors. The LNHA stated the soiled utility area would be moved from the storage room to keep it in a separate room away from non-soiled items. There was no additional information provided by the facility. The surveyor reviewed the facility's Soiled Linen Handling Policy with a last revised date of 3/1/2024, under Policy revealed: Centers/Communities will handle, store, and transport linen in a safe and sanitary method to prevent the spread of infection. The provided facility policies did not further address soiled utility and storage areas. N.J.A.C. 8:39-19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 2 medication carts observed on 1 of 1 medication storage areas observed in the facility. 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 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 [DATE] at 10:25 AM, the surveyor began to inspect selected medication (med) storage areas in the facility. The surveyor observed the following:The surveyor in the presence of Unit 4 Unit Manger (UM4) inspected the refrigerator used to store medications (meds) for the 2nd floor. The surveyor observed a plastic bag containing three bottles of liquid med Acetylcysteine, an inhaled med used to break up mucous in the lungs, two bottles were unopened, and one bottle was opened. The surveyor observed a date opened written on the open bottle that reflected a date of 11/25. The surveyor also observed the manufacturer labeling reflect the statement Warning: Discard opened containers after 96 hours, in bold print. The surveyor showed UM4 the bottle and asked if 11/25 was the date it was opened, and the UM4 stated yes. The surveyor asked UM4 if it was longer than four days (96 hours) that the bottle was opened. UM4 stated yes, they didn't notice it and it should be disposed. On the same date, at 10:37 AM, the surveyor, in the presence of the Registered Nurse assigned to the 1st floor medication cart (medRN). The surveyor observed, in the top drawer of medication cart (med cart), a plastic med cup with four white tablets (tabs), that had a white souffle cup on top with magnesium 400 mg (milligram) handwritten on it. The surveyor asked the medRN if they knew what the tabs were or where they came from. The medRN stated that they did not put them in the med cart and could not positively identify what the tabs were. The medRN stated that meds should not be stored that way and should be thrown out. On [DATE] at 12:55 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA), the Assistant Director of Nursing (ADON) and the Clinical Lead (CL) to discuss concerns. The surveyor asked if the Acetylcysteine should have been disposed prior to the surveyor discovery. The LNHA stated yes, it should not have been in the refrigerator. The surveyor asked if meds should be stored in original containers or other packaging from the pharmacy. The LNHA stated yes, meds should be in proper packaging until used. On [DATE] at 9:59 AM, the surveyor interviewed the facility Consultant Pharmacist (CP) by telephone. The surveyor asked the CP if they checked the storage areas and med cart during visits, and the CP stated yes, they do. The surveyor asked if the CP was familiar with Acetylcysteine and the expiration when opened. The CP stated yes, dispose after 96 hours, the facility should have disposed of the open bottle in time. The surveyor asked the CP if meds should be stored in med cups in the cart. The CP stated no, they should only be in original or appropriate containers, not left in any med cups or pre-poured for use. On [DATE] at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON) and CL, and the LNHA stated that staff were educated on expired meds, unlabeled meds and meds found outside of packaging. The surveyor requested a facility policy for Medication Storage and Labeling. The LNHA provided a form dated 6/2023 titled Medication Storage and Labeling. The form reflected, were meds.labeled in accordance with currently accepted professional principles. multi-dose vials which have been opened.should be dated and discarded.unless the manufacturer specifies a different.date for that opened vial. NJAC 8:39-29.4(d)(g)

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 2 of 21 residents (Residents #20 and #39) call bells were within reach, able to use to accommodate residents' needs, and follow facility's call light policy.This deficient practice was evidenced by the following:
1.On 12/8/25 at 11:01 AM, Surveyor #1 (S #1) in the presence of the Registered Nurse/Unit Manager #1 (RN/UM #1) entered Resident #39's room and both observed the resident lying in a low bed with a cane by their side. S#1 observed the resident's call bell wrapped up in a loop and clipped to the wall where the system was attached to the wall. The call bell was not within reach of the resident.
S #1 asked RN/UM #1 if the resident could reach the call bell, and she replied no they cannot. RN/UM #1 moved the call bell and placed it on the bed next to the resident and explained to the resident that it should stay where they can reach it if needed.
2.On 12/8/25 at 6:56 AM, Surveyor #2 (S #2) was accompanied by Registered Nurse/Unit Manager #2 (RN/UM #2) during incontinence round in unit 2. Both S #2 and RN/UM #2 observed Resident #20 was lying on bed, awake, and agreed for incontinence check. S #2 observed the call bell on the floor and not accessible to the resident. RN/UM #2 immediately picked up the call bell on the floor and clipped it into resident's bed. RN/UM #2 stated that the call bell should not be on the floor and acknowledged that it was not within reach.
On 12/8/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), the Clinical Lead (CL) for concerns above for Residents #20 and #39. S #1 asked if residents' call bells should always be within reach, and the CL stated yes, they should always be within reach.
On 12/9/25 at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON), and the LNHA stated that education was done immediately yesterday about call bells. The LNHA further stated that education provided was to ensure call bells were within reach of the residents.
A review of the facility's Call Lights Policy that was provided by the LNHA with a review and revision date of 7/15/25, revealed that patients will have a call light or alternative communication device at each patient's bedside.to allow patients to call for assistance when unattended.Process:.4. Staff will ensure the call light is within reach of the patient and secured as needed. 5. The call system will be accessible to patients while in their beds or other sleeping accommodations within the patient's room.
On 12/9/25 at 1:55 PM, the survey team met with the LNHA, DON, and CL for exit conference and there were no additional information provided by the LNHA.
NJAC 8:39-31.8 (c)(9)

Based on observation, interview, and review of facility documentation, it was determined that the facility failed to follow its Grievance/Concern Policy by failing to a.) thoroughly investigate a grievance filed by unsampled resident, b.) followed through the concerns of 1 of 1 resident during resident council meeting, and c.) notify the residents of the comprehensive resolution with regard laundry concerns identified during resident council meeting for 5 of 5 residents (Residents #23, #31, #42, #61, and #65). This deficient practice was evidenced by the following: On 12/2/25 at 10:00 AM, the surveyor reviewed the provided last three months Resident Council Minutes that was provided by the Licensed Nursing Home Administrator (LNHA) and revealed that on 10/14/25, there were seven members (residents) and two non-council members (Recreation Assistant and Food Service Director) in attendance. During the 10/14/25 Resident Council Meeting (RCM), Resident #23 had voiced concerns regarding the laundry process and clothing return. Further review of the 10/14/25 RCM revealed that there was an attached Departmental Response Form (DRF) for Resident #23's voiced concerns, and the response included in the DRF was that the Resident was given the facility's laundry process and reminded that the clothes were washed at the facility and delivered back to the appropriate resident in a timely manner. A review of the attached undated facility's Laundry Process revealed that all personal clothing items were to be collected by nursing staff and placed in the designated laundry chute (a vertical gravity-powered conduit designed to transport soiled linens from upper floors directly to a designated collection point, typically the laundry room) for cleaning. Once laundered, housekeeping staff will sort and return the cleaned items to the appropriate resident rooms. Housekeeping was responsible for labeling all personal clothing to ensure proper identification and return. Further review of the above facility's Laundry Process did not include information how often the personal clothing items were to be collected and returned in a week. On 12/4/25 at 10:33 AM, the surveyor met with Residents #23, #31, #42, #61, and #65 during RCM, and discussed the last three months council minutes. Resident #23 and Resident #65 informed the surveyor that the residents on 10/14/25 meeting wanted to know the laundry process because they were unsure of the pickup days and returned days for laundered personal clothing, and they were not provided a clear information, and was told that laundry was being picked up and it was downstairs. The five residents acknowledged that they were not satisfied with the resolution about the concerns with laundry services because they were not provided enough information. At that same time, Residents #23 and #65 both stated that there were times that their and other residents personal clothing were not picked up to be laundered for few days that was why they asked the facility's process for laundry. Resident #65 also added that other resident (who did not provide a name) had to use other resident's clothing because their clothing had not returned from laundry. All five residents confirmed that the concern with laundry still persisted and there were no definite answer as to how often the laundry pick up. All residents in the meeting thought that the laundry was being picked up every Monday and delivered back on Friday. Furthermore, Resident #65 stated that there was an incident also that they received other resident's clothes. Resident #65 further stated that they knew it was not their clothes because they saw other resident's name on the clothes provided to them. On 12/4/25 at 12:10 PM, the surveyor interviewed Certified Nursing Aide #1 (CNA #1), who informed the surveyor that it was CNAs responsibility to send the dirty clothes of the residents to laundry via chute but unaware how often they were being laundered. She further stated that at times other CNA forgot to send them down and when she saw them the following day she send them to the chute. On 12/4/25 at 12:15 PM, the surveyor interviewed CNA #2, who informed the surveyor that she thinks that the personal clothing of the residents were being laundered two times a week but unsure when. She further stated that she sent them to the laundry via chute. On 12/4/25 at 12:30 PM, the surveyor interviewed the Laundry Staff (LS), who informed the surveyor that she was the assigned staff for personal clothing of residents in the facility. The LS stated that personal clothing of residents were laundered at the facility daily except weekends and returned to the residents the same day. She further stated that it was the responsibility of the CNA to ensure residents soiled personal clothing were picked up and sent to laundry via chute. She added that it was her responsibility to sent it back to residents clean and that she hung them to residents' closet. On 12/4/25 at 12:35 PM, the surveyor interviewed the Director of Housekeeping (DH) in the presence of LS. The surveyor notified the DH of the above concerns of the residents regarding laundry pick-up and delivery. The surveyor also asked the DH and LS if there were issues about it. The DH informed the surveyor that he remembered one resident complained about missing clothes and when he went and check he found out that the file of dirty clothes were inside resident's room. The DH further stated that the CNA had forgot to send it for laundry and filed up that was why the resident thought the clothes were missing. On that same date and time, the surveyor asked the DH if grievance was filed on behalf of the resident who had concerns with missing clothes. The surveyor also asked who the resident was, CNA, and when it happened, and the DH stated that he was unable to remember the name of the resident, what unit, who was the CNA, and other details. The DH further stated that he did not fill out a grievance form about the resident's concern because they found the dirty clothes. He added that he was unsure if grievance form should have been filled out and that the Administrator was not notified. On 12/8/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), the Clinical Lead (CL; also known as the regional director), and they were notified of the above findings and concerns with regard to residents' grievance regarding laundry services. At that same time, the surveyor also notified of the concern that the provided binder for grievance did not include information provided by the DH about missing clothes and the dirty clothing filed by the unsampled resident and no grievance was formulated. The LNHA acknowledged it should have been filed as a grievance the concern of unsampled resident that the DH communicated to the surveyor. On 12/9/25 at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON), and the CL, and the LNHA stated that we are educating the activity personnel about the facility's procedure and revising the process in responding to problems or concerns brought up by residents. The LNHA also stated that education will be provided also with regard to on how to report grievance, resolution, managing the grievance process, and on how to respond. A review of the facility's Grievance/Concern Policy that was provided by the DON with a review and revision date of 10/15/24, revealed that the patient/resident has the right to voice grievances to the Center or other agency or entity that hears grievances.All patients and/or their representatives may voice grievances/concerns and recommendations for changes. Service location leadership will investigate, document, and follow up on all concerns and grievances registered by any patient or patient representative. Social Service personnel will serve as patient advocates in the grievance/concern process. The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process.receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility.Process:.1.1 The right to file grievances orally (meaning spoken) or in writing. On 12/9/25 at 1:55 PM, the survey team met with the LNHA, DON, and CL for exit conference and there were no additional information provided by the LNHA. NJAC 8:39-4.1(a) 14, 15, 35

Complaint # 406936Based on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 1 of 24 residents (Resident #98) reviewed for comprehensive care plans. This deficient practice was evidenced by the following: 1.On 12/9/25 at 9:04 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #98.A review of the admission Record (an admission summary) revealed that Resident #98 had diagnoses that included, but were not limited to; chronic kidney disease, peripheral vascular disease (a condition where blood vessels outside of the heart and brain become narrowed or blocked), hypertension (high blood pressure), and difficulty walking. A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an Assessment Reference date (ARD) of 8/12/24, indicated a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. In Section GG (Functional Abilities and Goals) of the MDS assessment indicated the resident needed substantial/maximal assistance with toileting hygiene. In Section H (Bladder and Bowel) of the MDS assessment, Resident #98 was coded as frequently incontinent and not on a toileting program. A review of the Care Area Assessment (CAA; a tool used to investigate issues triggered by MDS responses, to implement person centered care plans for residents) indicated a care plan (CP) for urinary incontinence (loss of bladder control) would be initiated. A review of the physician's order dated 8/24/24, indicated toilet before and after meal, before going to bed and as needed every shift for comfort care. A review of the resident's CP revealed there was no CP and interventions related to (r/t) the resident's urinary incontinence and/or toileting. On 12/9/25 at 10:16 AM, the surveyor interviewed the Director of Nursing (DON) in the presence of the Clinical Lead (CL) about care planning. The DON stated CP were initiated by the unit managers and the nurse supervisors. The DON explained ADL (activities of daily living) care including incontinence care and toileting were part of the basic CP for residents. At that time, the surveyor notified the DON and the CL of the concern that the MDS assessment was triggered for a CP to be initiated and there was no CP for urinary incontinence and/or toileting for Resident #98. The DON and the CL reviewed the resident's CP in the EMR and could not find a CP related to urinary incontinence and toileting. The DON stated the EMR would be reviewed to provide any additional information. On 12/9/25 at 11:57 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA), the DON, and the CL of the above concern that there was no CP r/t urinary incontinence and toileting for Resident #98. On 12/9/25 at 1:20 PM, the LNHA, the DON, and the CL met with the surveyors. The DON stated the CP had one intervention that included to support toileting, which was found in the Enhanced Barrier Precaution (EBP) CP. Review of the CP and intervention documented Protective Personal Equipment would be worn .to support toileting. There was no additional documentation r/t toileting or urinary incontinence care. The surveyor asked if the CAA of the MDS triggered for a CP to be done would it be expected for there to be documented in the resident's CP. The DON replied yes. There was no additional information provided to the surveyor. A review of the facility's Person-Centered Care Plan Policy with a last revised date of 10/24/22, under Policy indicated: A comprehensive, individualized CP will be developed within seven days after completion of the comprehensive assessment.and review and revise the CP after each [MDS] assessment.CP includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments.The interdisciplinary team, in conjunction with the patient and/or patient representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors r/t the effectiveness of the plan of care.Documentation will show evidence of.patient's goals and preferences.Development of care planning interventions for all CAAs triggered by the MDS; and Rationale for not care planning for a specific triggered CAA . NJAC 8:39-27.1(a)

Based on observation, interview and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 2 of 24 residents reviewed, Resident #9 and Resident #33.The deficient practice is 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.Surveyor #1 reviewed the electronic medical record (EMR) for Resident #33.
A review of the resident's admission Record (AR; an admission summary) reflected that the resident was re-admitted to the facility with diagnoses which included but not limited to, essential hypertension (high blood pressure) and major depressive disorder (a mood disorder causing persistent sadness, loss of interest and hopelessness that significantly impairs daily life).
A review of the Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 11/13/25, had a Brief Interview Mental Status (BIMS) score of 7 out of 15, which indicated the resident has severe cognitive impairment. Section I of the QMDS revealed section Psychiatric/Mood Disorder which reflected a diagnosis of Psychotic disorder (other than schizophrenia), and that the resident was not coded for schizophrenia or bipolar disorder.
A review of the resident's comprehensive Care Plan (CP), dated 11/21/25, revealed, under the focus area, entries reflecting, diagnoses of cognitive loss/dementia, psychiatric disorders and psychosis.
A review of the resident's Order Summary Report (OSR), revealed an order to monitor behaviors every shift for bipolar, orders for quetiapine, (an antipsychotic medication normally used to treat psychiatric disorders), that reflected an indication for use of dementia with psychotic features.
A review of the resident's progress notes (PN), revealed notes titled Care Plan Meeting (CPM). The most recent CPM reflected that the resident was being followed by psychiatry for depression and psychosis.
Further review of PN revealed chronic care management notes which were written by the resident's attending physician, otherwise known as physician progress notes (PPN). A PPN dated 11/15/25, reflected a diagnosis of schizoaffective disorder.
Further review of PN revealed psychiatric follow up notes (PFN) written by the psychiatric physician's assistant (PA) or nurse practitioner (NP). A PFN dated 11/5/25, written by the PA reflected a diagnosis of schizoaffective disorder in the notes and on an addendum to the note dated 11/6/25. A PFN dated 8/20/25, written by the NP reflected a diagnosis of schizoaffective disorder in the notes.
On 12/2/25 at 12:06 PM, S #1 interviewed the Psychiatrist PA by phone. The PA stated the they remember the resident. S #1 notified of the above concerns about the inconsistency with diagnoses for the resident in the notes and medical record. The PA stated that the resident did not have schizoaffective disorder and that they were doing a look back in the medical record and it was unclear, with no proof of it, but they were trying to simplify billing with codes in the addendum. The PA also stated they wanted to be sure the resident had an appropriate diagnosis for the medications that they were taking. The PA stated that they would clean up the notes on the next visit.
On 12/8/25 at 12:55 PM, the survey team met with the facility Licensed Nursing Home Administrator (LNHA), the Assistant Director of Nursing (ADON) and the Clinical Lead (CL), and S #1 notified the facility management about concerns with inconsistencies and discrepancies with diagnoses in the medical record and the resident's CP. S #1 asked if the CP should reflect the resident's current condition, including diagnoses, and the CL stated yes, the CP should match the resident's condition.
On 12/9/25 at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON) and CL, and the LNHA stated that the facility reached out to the Psychiatrist PA for correct and updated diagnoses and the diagnoses in the CP were what the resident was admitted with and were not updated when the Psychiatry made changes. The CL stated the CP was now updated after surveyor's inquiry.
A review of the facility's Person-Centered Care Plan Policy, revised 9/15/25, reflected under Comprehensive CP .5.1 The CP must be customized to each individual patient's preferences and needs .6.2 Reviewed and revised by the interdisciplinary team.as needed to reflect the response to care and changing needs and goals;.
2. On 12/2/25 at 9:30 AM, Surveyor #2 (S #2) requested from the LNHA for Resident #9's fall investigations.
On 12/2/25 at 12:36 PM, S #2 reviewed the EMR of Resident #9.
A review of the AR revealed that Resident #9 had diagnoses that included but were not limited to; syncope (fainting), fall, nasal fracture, heart failure, retention of urine, and urinary tract infection.
A review of the comprehensive MDS, with an ARD of 10/14/25, indicated a BIMS score of 10 out of 15, which indicated the resident had moderate cognitive impairment.
A review of the PN dated 10/24/25 indicated Resident #9 had a fall incident.
On 12/2/25 at 10:10 AM, the LNHA provided S #2 with Resident #9's fall investigations, which was a total of one fall incident.
A review of the fall investigation completed by the facility dated 10/24/25, the conclusion and summary of the investigation indicated the .Plan of correction/intervention to provide resident with toileting schedule.
A review of the resident's CP revealed there was no intervention r/t a toilet schedule being initiated for the resident.
On 12/4/25 at 9:42 AM, S #2 observed Resident #9 sitting in a wheelchair at their bedside, dressed in well fitted clothes. The resident was alert, and verbally responsive. A Certified Nurse Aide (CNA) was at the bedside supervising and conversing with the resident.
On 12/4/25 at 9:43 AM, S #2 interviewed the Registered Nurse (RN) who stated that the resident was a fall risk, and interventions were in place to prevent falls. The RN stated that they would sometimes provide one on one monitoring of the resident when Resident #9 tried to get up on their own; sit with the resident by nurses' station and provide an activity for the resident to do; and floor mats at the resident's bedside.
At that time, S #2 asked the RN if she recalled the resident's 10/24/25 fall and any interventions implemented after the fall. The RN stated she did not recall the details of the fall, or any interventions put into place after the event. S #2 asked about the resident's urinary continence and toileting, and the RN replied, Resident #9 was occasionally incontinent and asked staff to go to the bathroom. S #2 asked the RN if the resident was on a toileting schedule, and the RN replied the resident was not on a schedule; Resident #9 would say when they needed to go to the bathroom and nursing staff checked on the resident a few times on the shift to see if the resident needed to be toileted. The RN was not aware of a toileting schedule being part of the resident's CP. The RN stated the unit managers and nurse supervisors were responsible for initiating and updating CP.
On 12/4/25 at 9:59 AM, S #2 interviewed the RN Unit Manager (RN/UM) who stated after a resident's fall, an incident report was completed by the nurse which would be reviewed by the unit manager and the DON. The RN/UM explained an interdisciplinary team (IDT) meeting was then held for a root cause analysis, to determine why the fall happened, interview staff, and obtain statements. The RN/UM stated the IDT planned on what intervention would be implemented to prevent future falls. S #2 asked the RN/UM who reviewed and updated CP. The RN/UM replied, the nurses, and the unit managers would.
At that same time, the RN/UM confirmed Resident #9 was a fall risk and did have a fall event in October 2025. The RN/UM could not recall the details of the fall. S #2 asked if there were any interventions put into place. The RN/UM replied she was not sure and would have to check the EMR. The RN/UM stated it would be expected for interventions put into place after a fall event to be included in the resident's CP. S #2 asked the RN/UM if the resident was on a toileting schedule, and the RN/UM replied the resident was not on a toileting schedule, usually Resident #9 let the staff know when they needed to go to the bathroom, and when the resident got antsy the staff would take the resident to the bathroom.
On 12/4/25 at 10:09 AM, S #2 and the RN/UM were joined by the Clinical Lead (CL). S #2 notified the RN/UM and CL of the concern that Resident #9's 10/24/25 fall investigation indicated an intervention of a toileting schedule would be implemented and there was not documentation of the resident's CP being updated. The CL stated they would review and provide any additional information.
On 12/8/25 at 12:55 PM, S #2 notified the LNHA and the CL of the concern regarding the resident's CP not being updated after their fall incident as indicated.
On 12/9/25 at 11:57 AM, the LNHA, the DON, and the CL met with the surveyors. The LNHA stated the CP was updated after the surveyor's inquiry. The DON stated that at the time there was an overlap when the CP was reviewed. The DON further explained the CP should have reflected the new intervention but reflected the section GG assessment of the MDS done at the time of the review.
A review of the facility's Person-Centered Care Plan Policy with a last revised date of 10/24/22, under Practice Standards indicated: .7. Care plans will be.7.2 Reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments and as needed to reflect the response to care and changing needs and goals; and.7.3 Documented on the CP Evaluation Note.
NJAC 8:39-11.1; 11.2(h)(i); 27.1(a)

Complaint # 2682000Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to ensure that a resident received a physician's order for Librium in a timely manner or notify the physician that the ordered medicine was unavailable for additional orders for 1 of 24 sampled residents reviewed (Resident #63). This deficient practice was evidenced by: A review of Resident #63's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly interfering with daily life, work, and relationships), alcohol abuse (problematic pattern of alcohol use causing significant impairment or distress, diagnosed by 2 or more of 11 symptoms (like craving, tolerance, withdrawal, failing obligations, risky use, social problems) within 12 months, categorized as mild, moderate, or severe), and homelessness (the condition of not having a regular or adequate place to live). A review of Resident #63's comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated that Resident #63's cognition was intact. A review of Resident #63's Progress Notes (PN) included the following late entry general note with an effective date of 11/22/2025 at 11:17 AM, which included information that the resident asked the Registered Nurse (RN) if the nurse could provide an alcohol, and the RN explained the we cannot provide alcohol in the facility. The resident expressed to the RN their feeling as they were going to crack. The RN asked resident if they felt as if they were having withdrawal symptoms, they just kept expressing they were going to crack. The resident had a history of ETOH (ethanol, the intoxicating alcohol in beverages) abuse with 50 plus history, depression, and PTSD (post traumatic stress disorder), with an appointment with psychiatrist at [name redacted] on 11/26 at 9:30 AM. The RN notified the MD (medical doctor) in regard to resident's needs, with new order for one time dose of ativan to decrease anxiety and librium TID (three times a day). No further seeking of alcohol for the rest of the shift and will continue to monitor. Further review of Resident #63's PN included the following general note with an effective date of 11/23/2025 at 3:19 PM, which included the following: Nurse was called by Receptionist as patient (also known as the resident) was observed walking out of building. The resident wanted to get to a liquor store, both RNs followed and walked with the resident to try to get the resident re-enter the facility. The RN called the MOD (manager on duty) to contact the police, the police came and assisted the nurses to have resident re-entered the facility. The MOD, RN, and NP (Nurse Practitioner) had lengthy conversation with the resident in regards to ETOH addiction, medications (meds), and life in general. Awaiting Librium to start administering. NP will follow up with orders. A review of Resident #63's physician visit PN with an effective date of 11/23/25 at 12:00 AM, included the following: Meds: Ativan oral tablet (tab) 1 mg (milligram), give 1 tab by mouth as needed (PRN) for agitation/anxiety until 12/7/25 11:59 PM. Target behavior: Restlessness, nervousness and overly concerned about anything; ChlordiazePOXIDE HCl (hydrocholoride) capsule (cap) 10 mg, give 1 cap by mouth three times a day for ETOH withdrawal.resident experienced episode of wanting to drink today .they were pleasant but reported being triggered by memories of [name redacted] who passed away in front of them. Librium and ativan ordered.A review of Resident #63's November 2025 electronic Medication Administration Record (eMAR) included the following order Chlordiazepoxide HCl (Librium) cap10 mg, give 1 cap by mouth three times a day for ETOH withdrawal which had a start date of 11/22/25 10:00 PM (10 PM). Further review of Resident #63's November 2025 eMAR included that the medication (med) was not administered on 11/22/25 for the 10 PM dose, on 11/23/25 for the 6:00 AM (6 AM), 2:00 PM (2 PM) and 10 PM doses and on 11/24/25 for the 6 AM, 2 PM and 10 PM doses. A total of seven doses were not given. The eMAR indicated that on 11/25/25 the nurses signed that all three doses were given on 11/25/25. A review of Resident #63's eMAR notes for the reason chlordiazepoxide was not given included awaiting pharmacy delivery and not delivered for five of the seven missed doses. The remaining two doses indicated that the nurse called the pharmacy on 11/24/25 at 2:34 PM and at 9:10 PM meds not given, will be delivered by pharmacy tonight. A review of Resident #63's declining inventory sheet for Chlordiazepoxide HCL included, issue 11/23/25; date received 11/25/25. Further review indicated that on 11/25/25 only two doses were given not the ordered three doses, and the three doses that were signed for on the eMAR. On 12/4/25 at 9:11 AM, the surveyor interviewed the Sub Acute Rehab Unit Manager (SARUM) regarding Resident #63, and the surveyor asked the SARUM about the Librium order for Resident #63. The SARUM stated that the med was ordered that day and came a couple days later. On 12/4/25 at 9:38 AM, in the presence of the Licensed Nursing Home Administrator (LNHA), the DON stated that Resident #63 had a long history of depression and alcohol abuse. The DON also stated that the physician ordered Librium and Ativan as a stat (immediate) order. The surveyor asked the DON what the expectation was for a delivery of a med. The DON stated that there would be a 4-6 hour window but that they could not control delivery. The DON stated that the med was ordered on 11/22/25 and was administered on 11/25/25. The DON added that she did an in-service if a med was not available. The DON stated that she was not in the building [at the time] and that it was ordered and not delivered. On 12/4/25 at 1:39 PM, the surveyor called the pharmacy for information on Resident #63's order for Librium. On 12/8/25 at 12:49 PM, the surveyor received an email from the pharmacy which included the following:Librium was filled and attempted delivery on 11/24 (manifest that was posted). Med was then returned to pharmacy because [facility name redacted] could not produce the original script. Librium was redelivered on 11/25 11:30 PM. On 12/8/25 at 12:56 PM, the surveyor notified the LNHA and Clinical Lead (CL) the concern that Resident #63 order for Librium was not given for seven shifts and the physician was not notified for further orders. On 12/9/25 at 11:57 AM, in the presence of the DON and CL, the LNHA stated that education was provided regarding substance abuse. The DON stated that Resident #63's order for Librium was ordered by the NP on 11/22/25 but that the NP did not bring the physical prescription to the facility until 11/23/25. The DON added that when the pharmacy originally delivered the medicine, the facility did not have the physical prescription to give the pharmacy, and that the pharmacy could not leave the medicine and left the facility. The DON stated that the medicine was delivered on 11/25/25 at 1:37 PM. The surveyor asked what the expectation was if there was a delay in obtaining or administering an ordered med. The DON stated that the expectation was to notify the physician. She added that she had done an in-service of the staff and a QAPI (Quality Assurance Performance Improvement). The LNHA did not provide any additional information. A review of the facility's Medication Shortages/Unavailable Medications with a revised date of 10/1/18, included the following: Policy, when meds are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. N.J.A.C. 8:39-27.1 (a)

Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to complete post dialysis communication record assessments upon the resident's return from the dialysis center for 1 of one 1 resident, (Resident #6), reviewed for dialysis services, and consistent with professional standards of practice. 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 12/1/25 at 10:55 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of unit 1, who informed the surveyor that Resident #6 was at dialysis every Monday, Wednesday, and Friday (M-W-F). On 12/1/25 at 10:59 AM, the surveyor observed an enhanced barrier precautions (EBP) posted sign outside the resident's room, the resident was not inside the room. The surveyor reviewed the medical record of Resident #6. A review of the admission Record (an admission summary) documented that the resident had diagnoses that included but were not limited to, end stage renal [kidney] disease, type 2 diabetes mellitus with hyperglycemia (or high blood sugar, occurs when there is too much glucose in the bloodstream, often due to insufficient insulin or insulin resistance), and neuromuscular dysfunction of bladder (commonly referred to as neurogenic bladder, occurs when nerve damage affects bladder control, leading to issues with urine storage and release) unspecified. A review of the most comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 10/15/25, reflected a Brief Interview Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. A review of the December 2025 Order Summary Report included a physician's order dated 10/8/25, hemodialysis [name of dialysis center] M-W-F 2 PM (2:00 PM) chair time. On 12/2/25 at 11:49 AM, the surveyor asked the RN/UM about the resident's dialysis communication records. The RN/UM stated that the dialysis communication records were filed in the resident's chart. Both the surveyor and the RN/UM reviewed the resident's Hemodialysis Communication Records (HDCR) forms. The RN/UM informed the surveyor that the facility's process and standard of practice, the facility's morning nurse will prepare the HDCR form and fill up entirety the top part, then the form will be sent to the dialysis center which the middle part of the form will be filled out by the dialysis nurse, then when the resident returned at the facility, the nurse from the facility will fill out the bottom part of the form and ensure the form will be filled out entirely. At that same time, after both the surveyor and the RN/UM reviewed the HDCR forms, and there were days that the forms were not filled out thoroughly by the nurse when the resident returned to the facility. The RN/UM confirmed that the forms were not completed accordingly according to the facility's practice and should have been completed to include resident's vital signs and dialysis site assessment upon return to the facility for safety of the resident. A review of the HDCR form revealed the following information that were not thoroughly filled out, To be completed by Licensed Nurse post dialysis treatment:-Access site: boxes to be checked either for swelling, drainage, and pain.-AV shunt (an arteriovenous (AV) fistula, is a surgical connection between an artery and a vein, primarily used for hemodialysis access) only: boxes to be checked either for bruit and thrill (indicate + [positive] or - [negative] (Bruit and thrill are essential indicators of a properly functioning dialysis fistula, reflecting turbulent blood flow and ensuring effective dialysis treatment).-New orders from dialysis center: boxes to be checked for yes or no. On 12/2/25 at 12:00 PM, the surveyor observed Resident #6 lying on the bed with indwelling catheter hung on the below the right side of the bed with privacy bag. The resident informed the surveyor that they go to dialysis every M-W-F. On 12/2/25 at 12:05 PM, the RN/UM informed the surveyor that Resident #6 was cognitively intact and dialysis every MWF at 11:00 AM pick up time and return around 3-4 PM. On 12/8/25 at 10:54 AM, the surveyor reviewed the provided handwritten unit 1 Resident #6's HDCR list of nurses who had an incomplete post dialysis vital signs and assessment of dialysis access site and revealed that 3 of 8 incomplete HDCR forms were unable to locate documentation that the vital signs (provides critical information for assessing health status, detecting changes, and guiding clinical decisions) and dialysis access site assessment were done (for dates 10/17/25, 11/12/25, and 11/26/25). 1 of 6 Registered Nurse (RN) did not thoroughly complete the assessment post dialysis. On 12/8/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), the Clinical Lead (CL; also known as the regional director), and they were notified of the above findings and concerns with regard to residents' HDCR forms. On 12/9/25 at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON), and the CL, and the LNHA stated that 1:1 education was provided to the RN who did not thoroughly complete the post dialysis HDCR to include resident's vital signs and assessment of dialysis access site. A review of the facility's Hemodialysis: Graft and Fistula Care Policy that was provided by the LNHA, with a revision/review date of 11/14/25, revealed, center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility .Practice Standards: 1. Prior to a patient leaving the center for HD, a licensed nurse will complete the HDCR or electronic pre/post dialysis evaluation and send with the patient to their HD facility visit. 2. Following completion of the HD, the dialysis facility should complete and return the form and/or other communication to the Center with the patient. 3. Upon return of the patient to the Center, a licensed nurse will: 3.1. Review the certified dialysis facility communication; 3.2 Evaluate/observe the patient; and 3.3 Complete the post-hemodialysis treatment evaluation using the HDCR or electronic pre/post dialysis evaluation .5. Maintain the HDCR or state required form in the patient's medical record. On 12/9/25 at 1:55 PM, the survey team met with the LNHA, DON, and CL for exit conference and there were no additional information provided by the LNHA. N.J.A.C. 8:39-27.1(a)

Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain an effective pest control program in 1 of 1 kitchen observed. The deficient practice was evidenced by the following: During the initial tour on 12/1/25 at 9:51 AM, the surveyor observed the dual conventional oven that had a stove and a grill on top. The Food Service Director (FSD) stated the stove and grill on top were being used to cook residents' food. The FSD stated the dual ovens in the bottom do not get used for cooking. The surveyor did not observe any signage that the dual ovens in the bottom were out of order or not to be used. The surveyor opened the dual ovens and observed inside four strips of glue board traps with dead roaches. The surveyor observed inside the first oven five dead roaches on one glue board, and seven dead roaches on another. The surveyor observed the second oven, which had two dead roaches on one glue board and seven dead roaches on the other glue board. On that same date and time, the FSD stated, We have a roach problem since last month, the roach trap gets changed every Monday when the pest control comes. The surveyor asked when the glue boards were changed last and the FSD responded when the pest company came last. The surveyor then asked how long it had been that the dual ovens have not been working. The FSD responded that the ovens did not work for three years since the FSD was at the facility. The surveyor requested for all the Pest Control Services reports for the last three months. On 12/1/25 at 10:26 AM, the FSD informed the surveyor that the local health department most recent inspection was on 10/2/24. The surveyor requested for the most recent inspection report. On 12/1/25 at 11:51 AM, the District Manager provided the Pest Control services reports which revealed below:-On 11/11/24, glue boards for roaches in target areas-kitchen, dishwash area.-On 11/10/25, glue boards for cockroaches in target areas-kitchen, dishwash area, utility room and storage area. At that same time, the surveyor requested from the License Nursing Home Administrator (LNHA) all the Pest Control reports and treatments for the last three months. The District Manager also provided the local health department inspection report dated 10/2/2024, which revealed one dead cockroach in kitchen where grease trap was located; Contact pest control to address asap (as soon as possible). On 12/2/25 at 9:30 AM, the LNHA stated, the pest control was called yesterday on 12/1/25 to spray the kitchen. The LNHA provided additional Pest Control services reports which further revealed below:-On 9/8/25 in the kitchen area, minor roach activity was observed on glue boards.-On 9/22/25, minor roaches captured observed on glue boards, liquid application done on surrounding areas.-On 10/13/25 (three weeks later), roaches were found underneath the prep area sink, glue boards, and liquid application to surrounding areas.-On 10/27/25, roaches in the kitchen dishwasher area caught on glue boards, applied roach gel bait, and spot treated.-On 11/10/25, observed moderate captures of roaches on glue boards in the dishwasher area, applied gel bait, and replaced glue boards and spot treated.-On 12/1/25 (three weeks later), treated the kitchen area back by ovens where roaches were in glue board, applied gel bait, and treated cracks and crevices around stove area. On 12/2/25 at 11:44 AM, the surveyor interviewed the Maintenance Director (MD) regarding the issue with roaches in the kitchen since the last inspection of the local health department from October 2024. The MD responded that the Pest Control come bi-weekly and stated, he was not aware the roach problem started since last year. The surveyor asked who was responsible for Pest Control and he responded anyone can call the Pest Control Service. On 12/8/25 at 10:46 AM, the surveyor notified the LNHA of the above findings and concerns. The LNHA stated, I've not heard of this, roaches in the kitchen, until surveyor's inquiry. The LNHA also stated that the FSD did mention it to me about the no signage on the dual ovens and that the sign was placed for non functional oven after surveyor's inquiry. On 12/8/25 at 12:37 PM, the surveyor met with the LNHA in her office as per her request, in the presence of the District Manager. The surveyor asked the LNHA and the District Manager, if they read the reports of the Pest Control service in the past few months which revealed roach activities in the dishwater area, utility room, storage area, under the prep sink, and back ovens, the LNHA and District Manager did not responsd. The surveyor asked if the stove and the grill, on top of the dual ovens, were being used to cook residents' food and the District Manager confirmed, Yes. The District Manager also confirmed that there was no signage placed on the dual ovens to indicate not to use when the surveyor toured with him and the FSD. On 12/8/25 at 12:56 PM, the survey team met with the LNHA, the Clinical Lead (CL), and the surveyor notified them of the above findings and concerns since 10/2/24. On 12/9/25 at 11:57 AM, the survey team met with the LNHA, Director of Nursing (DON), the CL, and the LNHA stated that the provided Quality Assurance Evaluation completed by the District Manager for September of 2025, October 2025, and November 2025, which revealed no mention of the dual ovens not in working order. A review of the facility's Pest Control Policy dated 7/18/25, which revealed under Purpose, To ensure an environment free of insects and rodents. NJAC 8:39-31.5

Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain a clean, safe, and sanitary environment for a.) 2 of 2 dining areas, b.) 1 of 4 unit hallways, and c.) and 2 of 21 sampled residents (Residents #20 and #33) rooms. This deficient practice was evidenced by the following:
1.On 12/2/25 at 11:23 AM, Surveyors #1 (S #1) and Surveyor #2 (S #2) in the presence of the Registered Nurse/Unit Manager (RN/UM) observed the 2nd floor dining (also known as the activity room) area with 10 residents and one activity staff. The surveyors and the RN/UM observed the six heating system inside the grill with dried leaves, plastics, pieces of puzzles, papers, and grayish substances which the RN/UM confirmed that was accumulation of dust and should have been cleaned.
At that same time, the surveyors and the RN/UM observed there were multiple boxes of different kinds of puzzles on top of one of the heating system. The RN/UM stated that those different boxes of puzzles that the activity department were being used for residents' should not be stored on top of heating system and there should be no plastic and other materials inside the grill of the heating systems for safety reasons.
Furthermore, the surveyors and the RN/UM observed on the other side of the dining area cobweb on the ceiling and ripped wallpapers. The floor inside the dining area had blackish and grayish dried substances which the RN/UM confirmed and stated that she would notify the housekeeping department.
On 12/2/25 at 11:45 AM, S #1 interviewed the Director of Housekeeping (DH), who informed the surveyor that he was a contract from [name of company] and had been working in the facility for 5-6 months. S #1 notified the DH of the above findings and concerns, and he stated that the blackish grayish substances on the floor was due to the chemicals that were sprayed to clean the floor and was probably due to too much chemical made them sticked to the floor. He further stated that it was a germicidal spray and should not be like that.
On that same date and time, the DH stated that it was the responsibility of the housekeeper on the 2nd floor to ensure cleanliness, mopped, and sweep it daily. S #1 asked if there was an accountability log for daily cleaning of the dining area, and he said there was none. The surveyor asked for policy about environment, good housekeeping, and he said he would get back to S #1.
At that same time, the DH also stated that it was the responsibility of the maintenance department to maintain the heating system.
On 12/4/25 at 12:28 PM, S #1 interviewed the Director of Maintenance (DoM) regarding the above concerns, and he stated that it was the responsibility of the housekeeping department to ensure cleanliness of the heater, we do change the filter every three months.
2.On 12/4/25 at 12:23 PM, after the resident council meeting, S #1 observed the 1st floor dining room floor with blackish grayish substances and the chair stained with blackish substances.
3.On 12/8/25 at 6:56 AM, during incontinence round of S #1 and the RN/UM, both observed Resident #20's overhead metal light string was short. The RN/UM confirmed that the metal light string was approximately three centimeters long and it should not be like that. She further stated that she would notify the maintenance department to fix it.
On 12/8/25 at 12:55 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and the Clinical Lead (CL; also known as the regional director), and they were notified of the above findings and concerns with regard to environmental tour in 1st and 2nd floor dining rooms and Resident #20's light string.
On 12/9/25 at 11:56 AM, the survey team met with the LNHA, Director of Nursing (DON), and the CL, and the LNHA stated, about housekeeping issues, we did thorough cleaning yesterday and ceiling tiles changed yesterday. The LNHA also provided a blank copy of Dining Room Cleanliness Audit form that included floor swept and mopped, walls clean, horizontal surfaces clean, windows clean, and trash emptied as part of the audit tool which will be checked off either satisfactory or unsatisfactory, to include Managers signature and date. The LNHA confirmed that the audit tool was formulated after surveyor's inquiry.
4.On 12/1/25 at 9:16 AM, during initial tour, S #2 observed two air circulation vents in the ceiling of the Unit 2 hallway had an accumulation of gray/brownish substance on and inside.
On that same day, at 10:43 AM, S #2 observed, from the doorway of Resident #33's room, assorted trash and paper on the floor of the resident's room and on the bathroom floor.
On 12/1/25 at 11:00 AM, S #2 observed a ceiling tile with a large brownish stain outside the door of the ice room near the Unit 2 hallway. S #2 also observed a ceiling tile with a brownish stain near a doorway marked door 4 in the Unit 2 hallway.
On 12/8/25 at 12:55 PM, the survey team met with the LNHA, ADON, and CL, and S #2 showed the LNHA the photographs of the air vents and asked if they saw the accumulation and should it be there. The LNHA stated, no, it should not be like that. S #2 showed the LNHA the photographs of the ceiling tiles and asked of they should be that color, and the LNHA stated, no. S #2 showed the LNHA the photographs of the floor of Resident #33's room, that was taken at 10:43 AM, and asked if residents' rooms should look that way, and the LNHA stated no, the floors should be clean. The LNHA stated that a thorough cleaning was done on 12/8/25 and the ceiling tiles were replaced.
A review of the facility's Safe and Homelike Environment Policy that was provided by the LNHA, with a review and revised date of 11/14/25, revealed, the resident/patient has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting.Process:.1.1.1 This includes ensuring that the patient can receive care and services safely.and does not pose a safety risk.1.1.3.5 Perform other desired tasks such as turning a table light on and off.1.2 Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 1.2.1 Ensure that furniture and fixtures in common areas frequented by patients are accommodating of physical limitations of patients.
There were no additional information provided by the LNHA.
NJAC-8:39-31.2(e), 31.4(a)(b)(f)

Complaint # 406965Based on interviews and record review and review of pertinent facility documentation, the facility failed to ensure that the physician was notified in a timely manner of a resident's change in condition for 1 of 3 residents reviewed for transfer to the hospital (Resident #1). This deficient practice was evidenced by the following:On 11/10/25 at 9:30 AM, the surveyor reviewed Resident #1's closed medical record. A review of Resident #1's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; congestive heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs) chronic obstructive pulmonary disease (aka COPD, a group of lung diseases that cause airflow obstruction and breathing difficulties) and obstructive sleep apnea (a sleep disorder where the airway repeatedly collapses or becomes blocked during sleep, leading to pauses in breathing).A review of Resident #1's electronic Progress Notes (PN) included the following note written by the Unit Manager dated 6/30/25, which was listed as a late entry and times were not in chronological order: 8:00 am In bed asleep during rounds. Slow to respond. Would opens his/her eyes when called but would go back to sleep. VS:BP-159/85, P-97, T-97.9, O2 sat-91%. Seen by the Respiratory Therapist and assessed for respiratory status. O2 saturation monitored. Unable to be fed/eat for breakfast and lunch. Medication not given due to lethargy. O2 at 3L/min continuous. Head of bed elevated at all times. No respiratory distress noted. Kept comfortable. 1:30 pm- Daughter came in. She is very concerned of Resident #1's current status. Not able to eat and take his/her medication. She wanted Resident #1 to be sent back to the hospital for further evaluation. Resident #1's physician made aware and gave orders for the resident to be sent to ER for evaluation. daughter took Resident #1's personal stuff with her.2:15pm- Called ambulance for transportation.3:00 pm- Picked up by ambulance via stretcher with O2 at 3l/min. daughter made aware that Resident #1 was just picked up. will go to the ER2pm- daughter visited. Given update of Resident #1. daughter is very concerned.Further review of Resident #1's PN indicated that on 6/30/25 at 11:39 AM the nurse documented that 3 medications were not given because resident was not opening his/her mouth. Further review of Resident #1's closed medical record included the following notes written by the respiratory therapist dated 6/30/25:10:13 AM (Respiratory Treatment Note) RCP received patient in bed with oxygen via nasal cannula at 5LPM however patient was not wearing oxygen underneath his/her nose. Patient had nasal cannula on his/her head so patient was technically on room air. RCP did pulse oximeter check to find SpO2 was 67%. Patient lethargic and not responsive. RCP obtained oxygen tank and oxygen non-rebreather mask and placed oxygen non-rebreather mask on patient at 15LPM over nasal cannula at 5LPM. RCP adjusted nasal cannula and placed it underneath patient's nose with non-rebreather mask on top. RCP stayed in the room and obtained/monitored vitals. SpO2 increased to 98% while on non-rebreather. HR 85/min and RR 18/min. Patient lethargic and not responsive to questions/commands. Patient unable to do incentive spirometry at this time. RCP informed nursing manager and nurse of patient's condition. Nursing manager and nurse came in the room to monitor patient. RCP left the room and informed director of rehab regarding patient's condition. Speech therapist and occupational therapist also came in the room to assess patient and informed the director of Rehab regarding patient's condition.When RCP returned to check on patient approximately 5 minutes later RCP received patient on oxygen via nasal cannula at 5LPM. Nursing manager informed RCP that nurse removed non-rebreather. RCP rechecked vitals to find: SpO2 92%, HR 87/mi and RR 18/min on oxygen via nasal cannula at 5LPM. Patient stable at this time. Nursing supervisor and nurse are going to continue to monitor patient. 11:05 AM (Progress Note) Patient unable to do incentive spirometry Patient lethargic and not responsive. Unable to follow commands. Patient is on 5 liters of oxygen via nasal cannula. Nurse and nursing supervisor informed.On 11/10/25 at 10:05 AM, the surveyor interviewed the Registered Nurse/Supervisor (RN/S) regarding the process for a resident that had a change in condition and specifically an episode of desaturation and was lethargic and not taking medications. The RN/S stated that the resident would be placed on oxygen with a non rebreather mask and monitor the pulse oximeter. If the resident improved, then the resident would be monitored and the physician would be notified. The RN/S stated that if the resident did not improve then the resident would be sent immediately to the emergency room. The RN/S stated that if a resident was lethargic, she would assess the vital signs and blood sugar and notify the physician for additional orders and/or to be sent to the hospital for evaluation. On 11/10/25 at 10:23 AM, the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) regarding change in condition. The ADON/IP stated that an assessment would be done and put in interventions that nurse could perform. She added that the physician would be notified. The surveyor then asked specially about a resident that had a desaturation and was lethargic and not taking medications. The ADON/IP stated that the resident would be assessed, oxygen given and if the saturation was 95% or better then the resident would be monitored and the physician would be notified. She added that if the resident was not taking their medications then the physician would be notified. The ADON/IP stated that every intervention done would be documented in the computer. On 11/10/25 at 11:10 AM, the surveyor interviewed the DON regarding Resident #1. The DON stated that she started at the facility in August 2025 and could not speak to anything regarding Resident #1 since she was not employed while Resident #1 was at the facility. The surveyor asked the DON what the process for a change in condition was. The DON stated that the resident would be assessed and that the physician would be notified. The surveyor notified the DON of the concern that Resident #1 had an episode of desaturation and was lethargic and not eating breakfast and lunch and not taking medications and the physician was not notified for approximately 3 to 4 hours after the desaturation incident and after the resident's daughter came in and requested a transfer to the hospital. On 11/10/25 at 12:37 PM, in the presence of the DON, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the concern regarding Resident #1 that the resident had a desaturation incident around 10 or 11 am and was lethargic and not eating or taking medications and the physician was not notified until 1:30 PM. The DON stated that she reviewed the residents medical record and the resident may have had the oxygen tubing displaced and had a desaturation. She added that the resident was saturation level was brought up to 95% and that it was a change of condition and the physician should have been notified. The DON stated that she did not know if the nurse just documented the time as later than when the physician was really notified. The DON stated that the family requested the resident be sent to the hospital and the family's request was respected. The LNHA stated that the priority was to make sure the resident was stable and that the resident was stable when transferred. A review of the facility provided policy titled NSG122 Change in Condition: Notification of with a revised date of 7/1/24, included the following:PolicyA Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is:.A significant change in the patient's physical mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications);PurposeTo provide appropriate and timely information about changes relevant to the patient's condition. N.J.A.C. 8:39-27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00184015
Based on interviews, medical record reviews, and review of other pertinent facility documents on 03/06/2025, it was determined that the facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse between a Certified Nursing Assistant (CNA), Home Health Aide (HHA), and a resident (Resident #1). On 02/28/2025 at approximately 1:10 PM, Resident #1 verbalized that their skin was bruised due to rough handling by two staff members during transfer that morning. The accused CNA continued to care for residents with no additional supervision after 1:10 PM on 02/28/2025 and on 03/04/2025 before the facility's investigation was complete.
Interviews with the Director of Nursing (DON) on 03/06/2025 and Clinical Lead for New Jersey (CLNJ) on 03/07/2025 revealed that the facility did not conduct a thorough investigation into the abuse allegation. Interviews with the DON on 03/06/2025 and CLNJ on 03/07/2025 revealed that the facility did not follow its abuse policy.
The facility's failure to follow their abuse policy, thoroughly investigate, and remove the accused staff from duty after an accusation of physical abuse by staff placed all residents under the care of CNA #1 at risk for abuse. These failures created the likelihood of serious physical and emotional harm, or impairment, and resulted in an Immediate Jeopardy (IJ) situation.
The Immediate Jeopardy was identified and was reported to the DON on 03/06/2025 at 6:39 PM. The DON was presented with the IJ template that included information about the issue. The IJ began on 02/28/2025 and continued through 03/07/2025 when the facility submitted an acceptable removal plan.
On 03/13/2025, the surveyor verified the implementation of the facility's removal plan during an onsite revisit. The facility implemented their removal plan which included:
On 03/07/2025 Resident #1 was assessed by the Registered Nurse (RN) and no new injuries were observed.
On 03/07/2025 Resident #1 was interviewed by the RN Supervisor and felt safe at the center.
CNA #1 was placed on administrative leave on 03/07/2025 pending the outcome of the investigation.
Residents with Brief Interview for Mental Status (BIMS) scores of ten and above were interviewed to ensure that they felt safe and had not experienced or witnessed abuse. Residents that expressed concerns had an investigation initiated. This was completed on 03/07/2025.
Residents with a BIMS below 10 had head to toe skin checks completed. No new skin injuries were identified. This was completed on 03/07/2025.
The DON and Administrator were re-educated by the RN Market Clinical Lead on the abuse policy on 03/06/2025.
The Director of Social Work and Social Service Specialist were re-educated by the RN Market Clinical Lead on the abuse policy on 03/07/2025.
Staff that were currently employed were re-educated by the DON, Assistant Director of Nursing, Educator, non-clinical department heads, RN Supervisor and/or Market Clinical Advisor on the abuse policy on 03/06/2025 and 03/07/2025.
The Hospice Social Worker was re-educated by the RN Supervisor on the abuse policy on 03/07/2025.
This deficient practice was identified for 1 of 3 residents (Resident #1) and was evidenced by the following:
Review of the facility policy titled OPS [Operations] 300 Abuse Prohibition, with an effective date of 07/01/2013, a review date of 10/24/2022, and a revision date of 10/24/2022, PAGE: 1 of 8, under POLICY included, The Center will implement an abuse prohibition program through the following: Screening of potential hires;
Training of employees (both new employees and ongoing training for all employees);
Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of all incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations.
Under Federal Definitions: the policy revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Willful, as used in this definition of abuse means the individual must have acted deliberately not that the individual must have intended to cause injury or harm.
Under PROCESS this policy revealed, 6.1.2 The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation. The PROCESS section of the facility policy also revealed, 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following. 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse or neglect occurred and to what extent; and 7.7.4 interventions to prevent further injury.
A Facility Reportable Event (FRE) (document used by healthcare facilities to report incidents) was submitted to the New Jersey Department of Health (NJDOH) by the facility's DON. The FRE was submitted on 02/28/2025, with a Date of Event, of 02/28/2025 and a Time of Event of 1:10 PM. The FRE revealed that on 02/28/2025 at about 1:10 PM, Resident #1 verbalized that a bruise on their skin was caused by rough treatment by their assigned CNA during a transfer that morning. The FRE revealed that the following interventions were implemented after the event: skin assessment to check for bruising, family notification, physician notification, hospice nurse notification, and investigation initiated.
According to the admission Record (AR) Resident #1 was admitted to the facility with diagnoses which included but were not limited to sepsis, unspecified organism; metabolic encephalopathy; acute kidney failure, unspecified; type 2 diabetes mellitus without complications; unspecified systolic (congestive) heart failure; anemia, unspecified; and encounter for palliative care.
According to the Minimum Data Set (MDS), an assessment tool dated 12/26/2024, Resident #1 had a BIMS score of 8 out of 15, which indicated that Resident #1's cognition was moderately impaired. The MDS revealed that Resident #1 was dependent on helpers for self-care activities. The MDS also revealed that Resident #1 was dependent on two or more helpers to roll left and right, move from sitting to laying, move from laying to sitting, and move from sitting to standing.
A review of Resident #1's Care Plan (CP) initiated on 12/15/2024 revealed under Focus, that Resident #1 requires max assistance for ADL [activities of daily living] care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting [ .]. Under Interventions, Resident #1's CP included, Monitor for SOB [shortness of breath], fatigue and/or change in condition. Adjust ADL tasks accordingly and encourage resident/patient to pace him/herself during ADL activity. The CP interventions initiated on 12/15/2025 also revealed Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered and document effectiveness/side effects.
A review of Resident #1's Progress Notes (PNs) dated 02/28/2025 at 2:52 PM written by Licensed Practical Nurse (LPN) #1 revealed: Resident reported he/she was roughed up by the 2 CNA's during transfer with the total lift this morning. The resident complained of lower back pain for which he/she was medicated with good effect. Head to toe assessment done together with unit manager, no skin issues noted.
During a telephone interview on 03/06/2025 at 12:29 P.M., LPN #1 stated that she and Unit Manager (UM) #1 conducted a check of Resident #1's skin on 02/28/2025. LPN #1 stated that the skin check was performed because at approximately 1:00 P.M. Resident #1 complained of rough treatment during a transfer with a Hoyer Lift (a mechanical device that helps caregivers safely transfer patients with limited mobility. Hoyer is a brand name often used as a generic term to refer to any type of mechanical patient lift) that morning.
During the same interview LPN #1 stated that the CNA assigned to Resident #1 that day continued to care for the rest of her assigned residents, but Resident #1 was removed from the CNA's assignment. LPN #1 stated that if she became aware of an abuse accusation about a staff member, she would notify her manager. LPN #1 stated that if the UM was not present, she would change the assignment of the staff members accused of abuse.
During an interview on 03/06/2025 at 12:57 P.M., Home Health Aide (HHA) #1, who was also accused of rough treatment by Resident #1, stated that she routinely cared for Resident #1. HHA #1 stated that the last day she provided care to Resident #1 was 02/28/2025. During a follow-up telephone interview on 03/07/2025 at 12:46 P.M., HHA #1 stated that on 02/28/2025 she stopped caring for residents at 1:00 P.M., then was off for the weekend (03/01/2025 and 03/02/2025). HHA #1 stated that she did not perform resident care on 03/04/2025 because she went to the office for education. HHA #1 stated that she resumed care of residents on 03/05/2025 but was not assigned to Resident #1.
During an interview on 03/06/2025 at 1:14 P.M., CNA #1, who was accused of rough treatment by Resident #1, stated that Resident #1 was usually one of the residents assigned to her. CNA #1 stated that on 02/28/2025 she and a HHA provided morning care to Resident #1. CNA #1 stated that at that time Resident #1 requested to be manually lifted rather than placed in the Hoyer Lift. CNA #1 stated that it was the first time she knew of the resident complaining about the Hoyer Lift and other than that, Resident #1 was fine during morning care. CNA #1 stated that Resident #1 returned from activities at approximately 12:30 or 1:00 P.M. that day, made a complaint of rough treatment, and was then removed from CNA #1's assignment. CNA #1 further stated that she continued to care for other residents that day until she left work at 2:30 P.M.
A review of a facility document Witness Statement/Interview Documentation Form, completed by CNA #1 and dated 2/28/25 was reviewed. The document revealed: I was assigned to [Resident #1] this morning with [his/her] Hospice Aide. We attended to [him/her] around 10:30 A and put [him/her] in the wheelchair using the Total Lift. At about 1:10 the Unit Manager asked us to put [him/her] back on the bed to assess [his/her] skin. The Hospice Aide and I put [him/her] back in the bed using the lift we were instructed. After the Manager finished the skin assessment, she told us that the resident reported that we were [NAME] (rough) with her when we use the lift to get [him/her] up this morning.
During an interview on 03/06/2025 at 2:02 P.M., UM #1 stated that Resident #1 required total care. UM #1 stated that in the afternoon of 02/28/2025 she overheard Resident #1 say that his/her whole body was bruised. UM #1 stated that at that time she and LPN #1 conducted a full body assessment and did not observe any marks. UM #1 stated that the assessment was documented, and notifications were made to Resident #1's Physician and family. UM #1 stated that on 03/01/2025 Resident #1 had no injuries, and still had no injuries on the day this interview was conducted. During the same interview, UM #1 stated that HHA #1 had already left work for the day when Resident #1 made the accusations of rough treatment. UM #1 stated that Resident #1 was removed from CNA #1's assignment until she finished work at 2:30 P.M. that day.
UM #1 stated that the process after an abuse accusation was to complete an incident report, investigate, and make notifications. UM #1 stated that if the abuse accusation was substantiated the accused staff would have been sent home while the investigation was completed. UM #1 further stated that if it was determined that there was abuse, she would have suspended the CNA.
A review of the facility document Witness Statement/Interview Documentation Form, completed and signed by UM #1, dated 2/28/25 was reviewed. The document revealed: [Resident #1] was brought to the nurses station from activities around 1250p [12:50 P.M.]. I asked [him/her] to stay there for a few minutes til [until] I get [his/her] aide to put [him/her] in bed. At about 110pm [1:10 P.M.] resident alleged that [his/her] whole body is bruised because the CNAs were rough when they used the lift to get [him/her] up this morning. I then instructed the CNAs to put her back to bed to be assessed which they did.
During an interview on 03/06/2025 at 2:30 P.M. the DON stated that when residents made allegations of injuries or abuse, the facility staff responded right away. The DON stated that the process was to interview the resident, review the chart, and get statements from staff. The DON stated that if it was believed or there was a strong suspicion that there was possible abuse or neglect, the staff member would have been sent home for the duration of the investigation.
A review of CNA #1's electronic timecard revealed that CNA #1 worked on 02/28/2025 from 6:31 A.M. to 2:50 P.M. The timecard revealed that CNA #1 did not work from 03/01/2025 to 03/03/2025. The timecard further revealed that CNA #1 worked on 03/04/2025 from 6:34 A.M. to 2:29 P.M.
During the same interview the DON stated that after the accusation of rough treatment was made by Resident #1 on 02/28/2025, CNA #1 was not sent home and that in general she would have needed to check with the other residents assigned to a CNA who was accused of abuse. The DON stated that part of an investigation was interviews with other residents. The DON stated that interviews with other residents were not done. The DON stated that other residents in CNA #1's assignment were not interviewed because she determined that there was no abuse. The DON further stated that her investigation was completed on 03/04/2025 at 12:38 P.M. when she emailed a FRE follow-up to the NJDOH.
On 03/06/2025 at 4:28 P.M., a follow up interview was conducted with the DON regarding the facility policy OPS 300 Abuse Prohibition. The DON stated that the term removed from duty, in this policy meant sent home. The DON stated that the facility employee should have been sent home on the day they were accused of abuse. The DON further stated that there was no increased supervision of CNA #1 while she cared for other residents after the accusation of abuse was made against her.
Also, during the follow-up interview the DON stated that if the facility's abuse policy wasn't followed residents could be injured, have emotional distress, get withdrawn, and their physical wellbeing could suffer.
An interview was conducted with the CLNJ on 03/07/2025 at 11:22 A.M. The CLNJ stated that it was the expectation that an abuse investigation included: interview of the accused staff and other staff; an interview of the resident who made the accusations; and interviews of other residents.
During the same interview, the CLNJ stated that it was the expectation that an employee accused of abuse was immediately placed on leave meaning that they were removed from the premises while the investigation was continued. The CLNJ stated that an investigation was considered complete when the abuse is substantiated or is unsubstantiated. The CLNJ further stated that allowing the accused staff member to continue to care for other residents was not in line with the facility's abuse policy.
N.J.A.C.:8.39-4.1 (a) (5)

Based on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) was comprehensively evaluated and care planned to receive appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of one (1) resident (Resident #91) reviewed for mood and behavior.
This deficient practice was evidenced by the following:
On 8/01/24 at 10:01 AM, the surveyor observed Resident #91 resting in bed. The resident was alert, and verbally responsive. Resident #91 stated they liked to stay in their room and watch television. The resident verbalized no concerns.
A review of the facility provided matrix (a document used to identify important care categories for residents in the facility) revealed Resident #91 was indicated as having PTSD/Trauma.
The surveyor reviewed the electronic medical record of Resident #91 which revealed the following:
The admission Record (a summary of important information about the resident) revealed that Resident #91 had diagnoses that included, but were not limited to, depression, hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke) affecting the left side, and hypertension (high blood pressure). PTSD was not listed as a diagnosis for the resident.
A comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/11/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #91 scored a 9 out of 15, which indicated the resident had moderate cognitive impairment. Under Section I-Active Diagnoses, Psychiatric/Mood Disorder the resident was only coded for depression.
A Physician's Order (PO) dated 5/07/24 read, Dental, ophthalmology, podiatry, physiatry, psych,wound Obtain Consult as needed/indicated and treatment for patient health and comfort.
A PO dated 5/07/24 read, DULoxetine HCl Capsule Delayed Release Particles 60 MG (milligram) Give 1 capsule by mouth one time a day for depression.
A PO dated 5/07/24 read, Mirtazapine Tablet (tab) 7.5 MG Give 1 tab by mouth at bedtime for depression target behavior: verbalizing sadness.
A PO dated 5/30/24 read, Ativan Oral Tab 0.5 MG (Lorazepam) Give 1 tab by mouth at bedtime for anxiety target behavior: yelling to exhaustion.
A PO dated 6/26/24 read, SEROquel Oral Tab 50 MG (Quetiapine Fumarate) Give 1 tab by mouth at bedtime for psychosis target behavior: delusional paranoia.
A review of the Medication Administration Record for June 2024 and July 2024 revealed it did not address the resident's history of PTSD or any identified triggers.
A review of the resident's care plans (CP) revealed there was no CP that addressed PTSD.
On 8/06/24 at 11:23 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to care for Resident #91. The LPN stated staff were aware the resident had a history of PTSD. The LPN further explained the resident was apprehensive with care and anxious. The LPN stated the resident had since improved and there were no acute concerns with the resident. The LPN could not specify the resident's PTSD triggers that could cause resident to re-experience their original trauma. The LPN added that the resident did not currently exhibit any symptoms and was seen by the psychiatry team and a psychologist.
On 8/09/24 at 9:03 AM, the surveyor interviewed the Psychiatry Physician Assistant (PPA#1) who had examined the resident. PPA#1 stated that she completed the initial evaluation for Resident #91, screened for PTSD, and it was negative. She further explained review of the medical records did not include diagnosis of PTSD. PPA#1 stated PPA#2 who saw the resident at the end of May 2024, documented in their note that resident had a history of PTSD, and could not speak to PPA #2's documentation. PPA#1 stated that based on the resident's symptoms, the resident more than likely had a history of PTSD. PPA#1 further explained the resident exhibited symptoms that included being jumpy, anxious, and had a history of psychosis. PPA#1 acknowledged that PTSD was not a disorder that simply goes away, it could reoccur, and the resident should be monitored.
On 8/09/24 at 9:31 AM, the surveyor interviewed the Director of Social Services (DSS) who stated residents who were admitted into the facility were screened for PTSD/trauma. The DSS stated Resident #91 did not have a known diagnosis of PTSD prior to their admission and stated it was a family member who mentioned that the resident had a history of PTSD. The DSS stated the psychiatry team was notified to evaluate the resident. The DSS acknowledged if a resident was found with a history of PTSD the resident should be assessed and it should be CP.
On 8/09/24 at 9:48 AM, the surveyor interviewed the Director of Nursing (DON) about the above concerns. The DON acknowledged that a resident with a reported history of PTSD should be evaluated, and CP, as a unknown PTSD trigger may cause the resident to re-experience trauma.
On 8/09/24 at 11:54 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the DON about the concern of there not being a comprehensive interdisciplinary evaluation and CP for a resident identified with a history of PTSD. There was no additional information provided by the facility.
The surveyor reviewed the facility's policy Trauma Informed Care with an effective date of 5/01/24. Under Policy it read, Centers will provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.
Under Process it read: .4. The Center will collaborate with patient trauma survivors, and as appropriate, the patient's family, friends, the primary physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized CP interventions .6. The Center will identify triggers which may re-traumatize patients with a history if trauma .8. The Center will evaluate whether the interventions have mitigated (or reduced) the impact of identified triggers on the patient that may cause re-traumatization .
NJAC 8:39-27.1 (a), 28.1 (c)

Based on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behavior for the use of a psychotropic medication specifically a antipsychotic medication (used to manage psychosis, a mental disorder characterized by a disconnection from reality) by not having an order for behavior monitoring and indicating the target behavior on the resident's individualized care plan for one (1) of five (5) residents (Resident #36) reviewed for unnecessary medications.
This deficient practice was evidenced by the following:
On 8/06/24 at 9:44 AM, the surveyor observed Resident #36 seated upright in bed.
On 8/06/24 at 01:06 PM, the surveyor reviewed Resident #36's hybrid (a combination of paper, scanned, and computer-generated records) medical record.
A review of Resident #36's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), parkinsonism (a clinical syndrome and presenting with various neurodegenerative diseases, which manifest with motor symptoms such as rigidity, tremors, bradykinesia, and unstable posture, leading to profound gait impairment) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Resident #36's care plan (CP) included the following focus area:
At risk for complications related to the use of psychotropic drugs
Medication (med): Ativan (used to treat anxiety), Lexapro (used to treat certain mental/mood disorders such as depression and anxiety) Aripiprazole (an antipsychotic med which is also a psychotropic med, that helps treat several kinds of mental health conditions that balances the levels of dopamine and serotonin in the brain to regulate mood, behaviors and thoughts) for depression with anxiety with an initiated date of 7/13/2024.
The focus area included the following interventions:
Complete behavior monitoring flow sheet; Gradual dose reduction as ordered; Monitor for changes in mental status and functional level and report to MD as indicated; Monitor for continued need of med as related to behavior and mood; Monitor for side effects and consult physician and/or pharmacist as needed; Obtain psych evaluation as ordered.
A review of the psychiatric progress note dated 7/18/24 included the following:
History of depression treated with Lexapro and Abilify .Hallucinations (A perception of having seen, heard, touched, tasted, or smelled something that was not actually there) began about 3 weeks ago .
Clinical Signs & Target Symptoms:
Anxiety; depression; hallucinations
MONITORED PSYCH MEDICATIONS (with DIAGNOSES):
.Abilify (Aripiprazole) 5 mg (milligram) PO (by mouth) QD (daily) (adjunct depression (a constant feeling of sadness and loss of interest), psychosis .
Resident #36's CP did not indicate the target behavior of hallucinations to be monitored for the use of the anti-psychotic med Abilify (Aripiprazole).
A review of Resident #36's July and August 2024 electronic Medication Administration Record (eMAR) included the following order:
Aripiprazole (Abilify) Tablet 15 MG Give 7.5 mg by mouth one time a
day for Psychosis. With a Start Date of 7/19/2024. The order did not include a target behavior to be monitored.
Further review of the July and August 2024 eMAR did not include any additional order for behavior monitoring related to a target behavior for the anti-psychotic med. There was no documented evidence on the eMARs that a target behavior was being monitored. There was also no documented evidence that the resident was being monitored for the side effects of an anti-psychotic med.
There was no documented evidence in Resident #36's hybrid medical record that a target behavior was being monitored for the anti-psychotic med that Resident #36 was taking.
On 8/07/24 at 11:22 AM, the surveyor interviewed the Registered Nurse (RN) regarding the process for psychotropic and antipsychotic medications (meds) and behavior monitoring. The RN stated that the process was if a resident was manifesting a behavior or received a psychotropic med (mood altering meds) that they would monitor behavior with a target behavior (specific behavior that the resident exhibited). She added the behavior would be documented in the electronic medical record on the eMAR. The RN stated that a particular question what is the behavior and what is the intervention would populate on the screen and would need to be answered. The RN stated that the behavior monitoring was part of the med order. The RN stated that the behavior monitoring was used by the physician to order new meds or to reduce the dose of the med used. The surveyor then asked the RN to view Resident #36's eMAR. The RN confirmed that the eMAR did not have an order for behavior monitoring and that the med order did not have a target behavior to be monitored. The RN stated that there should have been an order for behavior monitoring which included a target behavior and that she did not know why it was not on the eMAR. The surveyor then asked if the target behavior should be included in the resident's CP. The RN stated that the unit manager would do the CP and that the target behavior should be on the CP.
On 8/07/24 at 11:38 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process for psychotropic and antipsychotic meds and behavior monitoring. The DON stated that for a resident that received psychotropic meds there would have to be an appropriate diagnosis that indicated the need for the med. The DON stated that a psych consult would be done to review the need for the med and then the physician would follow up. The DON stated that behavior monitoring would be in the electronic medical record on the eMAR. The DON stated that there should be a CP for psychotropic meds which would include monitor for side effects and a target behavior. The surveyor asked the DON what the importance of behavior monitoring was. The DON stated that the importance of behavior monitoring was to see if the target behavior had improved and to make sure the resident was not placed on an antipsychotic that was not really indicated and for a gradual dose reduction if not contraindicated.
On that same date and time, the surveyor notified the DON that Resident #36's CP did not have the target behavior listed for the use of the anti-psychotic med. The DON stated that the CP should have the target behavior.
On 8/07/24 at 12:17 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the DON the concern that Resident #36 did not have any documented behavior monitoring of the target behavior for the antipsychotic med and that there was no target behavior listed on the CP.
On 8/08/24 at 01:06 PM, in the presence of the survey team and LNHA, the DON stated that Resident #36 did not have behavior monitoring for psychotropic med and that it was corrected. The DON stated that the CP should have had the target behavior and that it was updated. The survey requested a policy regarding anti-psychotic and psychotropic meds and behavior monitoring.
On 8/09/24 at 9:01 AM, the DON stated that the facility did not have a specific policy for psychotropic or anti-psychotic meds. The DON stated that the facility only had a policy on Behaviors.
The facility did not provide any additional information.
A review of the facility provided policy titled, Behaviors: Management of Symptoms with a revision date of 7/01/24, included the following:
Policy
Patients exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the patient's behavior .
Based on the comprehensive assessment, staff must ensure that a patient:
-Who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; .
Staff will use non-pharmacological interventions as the first line of approach to managing challenging behaviors. Behaviors and interventions will be addressed in the CP .
Purpose
To identify, prevent, and manage behavioral symptoms by: .
Monitoring outcomes of CP interventions.
To minimize the use of psychotropic meds, including antipsychotics, for patients with behavioral symptoms and/or dementia.
Practice Standards
1. The Center utilizes the comprehensive assessment process to identify and assess a patient's mental and psychosocial status.
2. Staff will monitor for and document in the medical records any exhibited behavioral symptoms .
4. Implement individualized, person-centered, non-pharmacological interventions as the initial behavior mitigation strategy and update CP accordingly .
5. The Center will ensure that necessary behavioral health services are person-centered and reflect the patient's goals of care, while maximizing the patient's dignity, autonomy, privacy, socialization, independence, choice, and safety.
A review of the facility provided policy titled, Behavioral Health Care and Services with a revision date of 10/24/22, included the following:
Policy
Each patient/resident (hereinafter patient) must receive and the Center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a patient's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders
Practice Standards
1. Patients will be provided the necessary behavioral health care and services to include:
1.1 Ensuring that the necessary care and services are person-centered and reflect the patient's goals for care, while maximizing the patient's dignity, autonomy, privacy, socialization, independence, choice, patient rights, and safety; .
1.5 Ensuring that pharmacological interventions (medications) are only used when non-pharmacological interventions are ineffective or when clinically indicated.
N.J.A.C. 8:39-27.1 (a)

Based on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy for one of (1) of two (2) residents, (Resident #82), reviewed for hospitalizations.
This deficient practice is evidenced by the following:
On 8/01/24 at 10:39 AM, the surveyor observed Resident #82 lying on their bed while watching the television with an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). There was an Enhanced Barrier Precaution (EBP) sign outside the door.
The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #82.
The admission Record (or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), other retention of urine, anemia (low blood count) unspecified, type 2 diabetes mellitus without complications.
According to the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/16/24, revealed in Section C Cognitive Patterns a brief interview for mental status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact.
Further review of the MDS showed that there were four most recent Discharge Return Anticipated (DRA) MDSs, indicating that the resident was transferred to the hospital.
A review of the Progress Notes showed the following:
-On 5/05/24, Registered Nurse #1 (RN#1) documented that the resident was transferred to the hospital.
-On 5/14/24, RN#2 documented that the resident was transferred to the hospital.
-On 5/23/24, RN#3 documented that the resident was transferred to the hospital.
-On 7/05/24, a Licensed Practical Nurse (LPN) documented that the resident was transferred to the hospital.
On 8/05/24 at 8:36 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) regarding the resident's transfers to the hospital. The RN/UM stated that it was the responsibility of the Business Office Manager (BOM) to notify the responsible party (RP) of the resident about the bed hold.
On 8/05/24 at 9:06 AM, the BOM in the presence of the survey team informed the surveyor that she was responsible for the bed hold notification. The BOM provided a copy of the Bed hold Notice-Deliver Upon Transfer Policy with a revision date of 8/2022. She also provided a copy of the Bed Hold Notice of Policy & Authorization for the date 5/15/24 and confirmed that was all she had for the bed hold transfer notification of Resident #82.
On 8/09/24 at 8:12 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) of the above concern that there were no copies of the Bed Hold Notice of Policy & Authorization for dates 5/05/24, 5/23/24 and 7/05/24.
A review of the facility's Bed hold Notice-Deliver Upon Transfer Policy with a revision date of 8/05/22 that the BOM provided revealed:
Process: Prior to a resident's transfer out of the center to a hospital or for therapeutic leave, the staff member conducting the transfer out will provide both the resident and representative, if applicable, with the Bed Hold Policy Notice & Authorization form.
-Notice must be given regardless of payer.
-Resident copy is given directly to the resident prior to transfer and noted in the medical record.
-Representative copy can be delivered electronically via email/secure fax or hard copy via mail if the representative is not present at the time of transfer. (Must be done within 24 hours.) .
What does the Business Office do? .
-Keep a copy of the Bed Hold Policy Notice & Authorization form to monitor that the original is signed and returned within a reasonable time; and
-Place the signed letter in the resident's financial file when it is returned.
On 8/09/24 at 12:41 PM, the survey team met with the LNHA and Director of Nursing for the Exit conference. The facility management did not provide additional information and did not refute findings.
N.J.A.C. 8:39-5.1 (a); 5.2 (a)

3. On 8/05/24 at 12:06 PM, the surveyor reviewed the closed medical record for Resident #167 who no longer resided at the facility.
A review of Resident #167's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), neuropathy (a nerve condition that can lead to pain, numbness, weakness or tingling in one or more parts of the body) and chronic viral hepatitis C.
A review of Resident #167's Discharge Return Anticipated Minimum Data Set (DRAMDS) reflected that the resident did not have any pressure ulcers.
A review of the EHR indicated hospital records which included documentation that the resident was transferred from the hospital to the facility with an unstageable, necrotic sacral wound.
On 8/06/24 at 9:12 AM, the surveyor interviewed the DON regarding Resident #167's pressure ulcer. The DON stated that the resident had a wound when the resident was admitted to the facility. The surveyor then asked the DON to view the Resident #167's DRAMDS and that it was coded as no for unhealed pressure ulcer/injury.
On 8/06/24 at 11:45 AM, the DON stated that she spoke with the MDSC and that the MDS was not coded correctly. She added that the MDS would be corrected.
On 8/07/24 at 12:16 PM, in the presence of the survey team, the surveyor notified the LNHA and the DON the concern that Resident #167's DRAMDS was not accurate and did not contain the residents pressure ulcers. The DON stated that Resident #167's DRAMDS was modified (corrected).
On 8/08/24 at 12:52 PM, in the presence of the survey team, the DON stated that the facility did not have a policy for MDS. She added that the facility followed the RAI manual.
The facility did not provide any additional information.
N.J.A.C. 8:39-11.1, 11.2
Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for three (3) of 24 residents, Residents #23, 109, and 167, reviewed for accuracy of MDS coding.
This deficient practice was evidenced by the following:
1. The surveyor reviewed the electronic health record (EHR) of Resident #109 which revealed the following:
The admission Record (AR; a summary of important information about the resident) revealed that Resident #109 had diagnoses that included, but were not limited to, spinal stenosis (narrowing of the space around the spinal cord), osteoporosis (a condition which bones become weak and brittle), and hypertension (high blood pressure).
The most recent Discharge-Return Not Anticipated (DRNA) MDS assessment, under section A, A2105, Discharge Status it was coded that the resident was discharged to 4. Short-Term General Hospital.
A review of progress notes (PN) revealed the resident was discharged (d/c) on 7/18/24 to the community.
On 8/05/24 at 01:10 PM, the MDS Coordinator (MDSC) was not available for interview. The surveyor interviewed the Regional Clinical Reimbursement Manager (RCRM) who was responsible for overseeing the MDSCs. The surveyor discussed with the RCRM about the concern for the coding of the resident's d/c status. The RCRM stated she would review Resident #109's MDS assessment.
On 8/06/24 at 9:50 AM, the LNHA stated the RCRM reviewed the MDS assessment for Resident #109 and it was modified to reflect that the resident was d/c to the community and not to the hospital.
2. On 8/01/24 at 10:29 AM, the surveyor observed Resident #23 lying in their bed, alert and verbally responsive. Resident #23 stated they had wounds and received wound treatment from nursing staff. The resident further explained they had chronic non-pressure ulcers to both lower legs and a wound physician visited weekly to examine the wounds.
The surveyor reviewed the EHR of Resident #23 which revealed the following:
The AR revealed that Resident #23 had diagnoses that included, but were not limited to, peripheral vascular disease (a condition of narrowed blood vessels which reduce blood flow to the limbs), and non-pressure chronic ulcer of the left and right lower limb.
A Quarterly MDS assessment, dated 6/21/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #23 scored a 15 out of 15, which indicated the resident was cognitively intact.
Under section M, M1030, Number of Venous and Arterial Ulcers [ulcers caused by problems with blood flow] it was coded 0 to indicate that the resident had no venous and arterial ulcers.
A review of June 2024 wound consultant PN and wound assessment notes revealed the resident was being treated for venous ulcers to the lower extremities.
On 8/07/24 at 12:00 PM, the survey informed the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) of the above concerns of Residents #23 and #109. The surveyor requested the facility's MDS policy.
On 8/08/24 at 12:47 PM, the LNHA and DON met with the survey team. The DON acknowledged that the DRNA MDS assessment for Resident #109 was not coded accurately. The DON also acknowledged that the MDS assessment for Resident #23 was not coded accurately to reflect that the resident had venous ulcers and stated the MDS assessment was modified.
On that same date and time, the DON further stated that there was no facility MDS policy and the MDSC followed the Resident Assessment Manual (RAI) manual guidelines.
A review of the latest version of the Center for Medicare/Medicaid Services - RAI 3.0 Manual (updated October 2023), Chapter 3-page A-42, under A2105, Coding Instructions read: .Code 1, Home/Community: if the resident was d/c to a private home, apartment, board and care, assisted living facility, group home, transitional living, or adult foster care . Code 4, Short-Term General Hospital (acute hospital/IPPS): if the resident was d/c to a hospital .
A review of the latest version of the Center for Medicare/Medicaid Services - RAI 3.0 Manual (updated October 2023), Chapter 3-page M-31, under M1030, Coding Instructions read: .Enter the number of venous and arterial ulcers present .Enter 0: if there were no venous or arterial ulcers present.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) act upon the recommendations of the Urologist for one (1) of two (2) residents (Resident #82) reviewed for the care of urinary catheter and b.) ensure a resident's medication administration time was adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) for one (1) of one (1) resident (Resident #12), reviewed for dialysis, according to facility's policies and standards of clinical practice.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
1. On 8/01/24 at 10:39 AM, the surveyor observed Resident #82 lying on their bed while watching the television with an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine). There was an Enhanced Barrier Precaution (EBP; gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organisms] as well as those at increased risk of MDRO acquisition [example, residents with wounds or indwelling medical devices]) sign outside the door.
The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #82.
The admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), other retention of urine, anemia (low blood count) unspecified, type 2 diabetes mellitus without complications.
According to the quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/16/24, revealed in Section C Cognitive Patterns a brief interview for mental status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. Section H Bladder and Bowel revealed that Resident #82 had an indwelling catheter.
A review of the Inpatient Consult to Urology note that was uploaded on 5/17/24 to the resident's electronic medical records [in the documents], the date of the Consult Note was 5/15/24 revealed the reason for consult was BPH (benign prostatic hyperplasia; age-associated prostate gland enlargement that can cause urination difficulty) and urinary retention with assessment and recommendations to start Tamsulosin (or Flomax; a medication (med) that can treat an enlarged prostate (BPH).
There was no documented evidence that the resident's medical doctor (MD) was notified of the above recommendations on 5/15/24 Urology Consult and why the Tamsulosin med was not ordered.
On 8/07/24 at 9:11 AM, the surveyor interviewed the Director of Nursing (DON) regarding the resident's indwelling catheter. The DON informed the surveyor in the presence of the survey team that the MD ordered to remove the foley catheter and do voiding trial. The DON stated that the voiding trial failed and the resident was sent out to the hospital on 5/23/24 with diagnosis of Urinary retention.
On that same date and time, the DON stated that there was a Urology consultation done in the hospital dated 5/15/24 with recommendations to start on Tamsulosin. The DON further stated that she (DON) discussed the recommendations and Consult notes with the MD yesterday (8/06/24) and the MD ordered the med to be started.
At that time, the surveyor asked the DON why the recommendations on 5/15/24 were not acted upon until the surveyor's inquiry. The DON responded, I do not know why, it was not followed and relayed to the MD at that time. She further stated that it was an expectation that recommendations should have been relayed to the doctor and followed through promptly. The DON acknowledged that the 5/15/24 recommendations were not acted upon until almost three months after the surveyor's inquiry.
On 8/07/24 at 12:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The Surveyor notified of the above findings and concerns regarding Resident#82.
On 8/09/24 at 12:41 PM, the survey team met with the LNHA and DON for the Exit conference. The facility did not provide an additional information and did not refute findings.
2. On 8/01/24 at 9:42 AM, the surveyor observed Resident #12 sitting up on their bed. The resident was alert, and verbally responsive. The resident stated they went to dialysis every Tuesday, Thursday, and Saturday. Resident #12 further explained they left the facility to dialysis around 01:00 PM and returned from dialysis around 7:00 PM.
On 8/05/24 at 9:14 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #12.
The AR documented that the resident had diagnoses that included but were not limited to, end stage renal [kidney] disease, and anemia.
A qMDS with an ARD of 4/28/24, indicated the facility assessed the resident's cognition using a BIMS test, Resident #12 scored a 15 out of 15, which indicated the resident was cognitively intact.
A Physician's Order (PO) dated 01/30/24 read, Hemodialysis at [Dialysis Center Name] on TUESDAY-THURSDAY-SATURDAY Chair time at [time], Pick up by [Transport Company] at [time]. [Dialysis Center's address and phone number]
A PO dated 01/23/24 read, Vitamin D3 Oral Tablet 125 MCG (5000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for Supplement .
A review of the electronic Med Administration Record (eMAR) for July and August 2024 revealed:
The Vitamin D3 medication entry was scheduled be given daily at 1700 [5PM] and signed as administered by the assigned nurses.
A review of progress notes in July and August 2024 revealed on dialysis days it was documented that the resident returned from dialysis to the facility after 6 PM.
On 8/05/24 at 10:41 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who was assigned to care for Resident #12. The LPN stated med administration times should accommodate a resident's dialysis time. The LPN further explained meds could be given an hour before or an hour after it was scheduled to be administered. The surveyor reviewed the eMAR with the LPN and informed her the times the resident was documented as returning from dialysis. The LPN stated if the resident was returning after 6 PM, the med time for the Vitamin D3 med should be adjusted.
On 8/05/24 at 10:48 AM, the surveyor interviewed the Registered Nurse Unit Manager (RN/UM) who stated med times should be adjusted to accommodate dialysis times. The surveyor reviewed with the RN/UM the eMAR and nurse documentation of the resident's return time from dialysis. The RN/UM stated the Vitamin D med administration time had to be updated. The RN/UM further explained it would be expected that the nurse would hold the med and follow up with the physician to clarify the med scheduled time.
On 8/07/24 at 12:00 PM, the surveyor informed the LNHA and the DON of the above concerns. The DON stated it was expected for the med administration times to be adjusted to accommodate a resident's dialysis schedule. The surveyor requested any policies related to med scheduling for dialysis residents.
On 8/08/24 at 12:47 PM, the LNHA and DON met with the survey team. The DON stated the scheduled time for Resident #12's Vitamin D was clarified to be administered at a time the resident was not in dialysis. The DON further explained she was following with the assigned nurses on the evening shift about what happened. The DON stated the resident was coming back usually between 6-7 PM. The DON and LNHA stated there were no other policy besides the dialysis policy. The surveyor requested the facility's med administration policy.
The surveyor reviewed the facility provided policy Dialysis: Hemodialysis (HD- Communication and Documentation with a last revision date of 6/15/22. The provided policy did not address adjustment of med schedule to accommodate a resident's dialysis schedule.
The surveyor reviewed the facility provided policy Medication Administration General Guidelines dated 01/24. Under Procedure, Med Administration it read, 1. Meds are administered in accordance with written orders of the prescriber .
NJAC 8:39-11.2 (b); 27.1 (a); 29.2(d)

Complaint#: NJ#174298
Based on interviews, record review, and review of other pertinent facility-provided documentation, the facility failed to ensure a.) that the resident with injury of unknown origin received treatment and implemented an intervention according to comprehensive assessment and person-centered care plan in accordance with professional standards of practice, and facility's policy and procedure for one (1) of three (3) residents, Resident #165, reviewed for abuse.
This deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
A review of Resident #165's hybrid (combination of paper and electronic) closed medical records revealed the following:
The admission Record (an admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; repeated falls, unspecified dementia, and hypertension (high blood pressure).
The Physician's progress note dated 8/24/23 included, new onset area of ecchymosis near rt (right) eye pt (patient also known as resident) has no pain or recent injury improving.
A review of the Reportable Event dated 8/21/23 for Resident #165 showed documentation that included an investigation for an injury of unknown origin and reflected a description of the incident, a conclusion, and interventions. The documentation reflected that the injury was a bluish-purplish discoloration around the left eye. Additional documentation included but was not limited to witness statements, incident reports, and resident-specific care plans.
Further review of the 8/21/23 Reportable Event revealed Summary and Conclusion a description of the incident and a conclusion that reflected the facility findings for how the resident obtained the injury. The facility findings reflected that the resident received the injury while leaning or pushing their face on a bedside rail.
Attached to the 8/21/23 Reportable Event were five witness statements. There were none of the statements reflected any mention of side rails or the resident leaning on the side rails.
Furthermore, the hybrid medical records and Reportable Event on 8/21/23 showed that there was no documented evidence that the staff observed or noted that the resident used or leaned on side rails that had caused the bluish-purplish discoloration around the left eye.
The individualized Care Plan (CP) revealed:
1. Focus: at risk for falls (initiated 8/11/23): cognitive loss and lack of safety awareness. Interventions included: Ambulation assistance of one with a rolling walker and low bed position.
2. Focus: at risk for injury or complications related to (r/t) anticoagulation therapy medication: Aspirin and clopidogrel. Interventions included continue to provide supervision for safety, (initiated on 8/21/23).
3. Focus: resident exhibits or is at risk for alterations in comfort r/t acute pain, and chronic pain (initiated 8/11/23). Interventions included assist the resident to a position of comfort and utilizing pillows and appropriate positioning devices (initiated 8/11/23).
Further review of the CP showed that there was no focus CP and interventions were initiated for 8/21/23 injury of unknown origin to the left eye.
On 8/07/24 at 12:16 PM, the surveyor in the presence of the survey team met with the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) to discuss the above concerns with the incident of 8/21/23. The surveyor requested if there was any further information that could be provided that was pertinent to the resident care plans, witness statements, and investigations specific to side rails for the 8/21/23 incident and if the CP interventions should match and specifically address the incident.
On 8/08/24 at 12:47 PM, the surveyor in the presence of the survey team met with the DON and LNHA. The DON stated that the investigation concluded that ruled out a fall and the resident was observed leaning on the side rail. The surveyor asked the DON if there was a statement in the medical record. The DON stated she would provide one.
On that same date and time, the DON provided a copy of the resident's CP that reflected an intervention of pillows and positioning. The DON also provided a copy of the resident's CP with a focus that the resident was at risk for elopement r/t expressed a desire to leave the facility and diagnosis of dementia that included interventions to monitor the resident's location with visual checks at all times every shift that was initiated on 8/22/23.
At that time, the surveyor reviewed the provided CP interventions for pillow and positioning which showed that this intervention was initiated on 8/11/23, and the incident occurred on 8/21/23.
At that same time, the surveyor asked the DON if these visual checks were documented, if there was always an order for visual checks of location every shift, and how the staff knew what to do. The DON stated that there was no specific documentation, and there was no specific order. The DON stated that the staff, such as nurses, nurse aides, and therapy personnel should check periodically the resident while providing care or services, but no specific times or how many times per shift. The DON was not able to further specify how this intervention would be put in place and why it did not address the concern for the 8/21/23 injury of unknown origin.
On 8/9/24 at 12:00 PM, the surveyor met with the DON and LNHA in the presence of the survey team. No further documentation or pertinent information was provided.
A review of the facility-provided policy Person-Centered Care Plan with a reviewed/revised date of 10/24/2022, revealed the following:
Purpose:
To eliminate or mitigate triggers that may cause re-traumatization of the patient.
N.J.A.C. 8:39-27.1 (a)

Complaint #NJ160835
Based on interview, and record review it was determined that the facility failed to provide care and services consistent with professional standards of clinical practice for a resident with pressure ulcers. This deficient practice was identified in one (1) of four (4) residents, Resident #168, reviewed for pressure ulcer care and prevention.
The deficient practice was evidenced by the following:
On 8/05/24 at 12:19 PM, the surveyor reviewed the hybrid (paper and electronic) medical records for Resident #168.
The admission Record (a summary of important information about the resident) documented that the resident had diagnoses that included but were not limited to, dementia, and muscle weakness.
A quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 10/18/22, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. Resident #168 scored a 3 out of 15, which indicated the resident had severe cognitive impairment.
A review of the November 2022 Treatment Administration Record (TAR) for Resident #168 revealed:
A Physician's Order (PO) dated 7/15/22 read, Bilateral 1/4 rails as enabler for turning and repositioning while in bed. every shift. There were seven (7) of 90 entries not signed by the nurse and left blank.
A PO dated 9/06/22 read Moisture Barrier - apply every shift and as needed to peri-area and buttocks every shift for MASD (moisture-associated skin damage). There were seven (7) out of 90 entries that were not signed by the nurse and left blank.
A review of the December 2022 TAR for Resident #168 revealed:
A PO dated 7/15/22 read, Bilateral 1/4 rails as enabler for turning and repositioning while in bed. every shift There were six (6) of 93 entries not signed by the nurse and left blank.
A PO dated 9/06/22 read Moisture Barrier - apply every shift and as needed to peri-area and buttocks every shift for MASD. There were six (6) out of 93 entries that were not signed by the nurse and left blank.
A PO dated 12/01/22 read, Float heels while in bed on pillow every shift for intact blood blister to right heel ensure pillow is located underneath the ankles for proper usage. There were six (6) out of 93 entries that were not signed by the nurse and left blank.
A PO dated 12/01/22 read Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to right heel topically every shift for intact blood blister for 21 Days cleanse prior to application with H2O[water] + soap, air dry, leave open to air and elevated on pillow located underneath the ankles. There were five (5) of 63 entries not signed by the nurse and left blank.
A PO dated 12/19/22 read Low airloss mattress to bed every shift Settings ___Check settings and functions every shift. There was one (1) of 37 entries not signed by the nurse and left blank.
A PO dated 12/25/22 read, Apply skin prep to the right heel every shift every shift for Wound care On while on bed, off when out of bed. There was one (1) of 20 entries not signed by the nurse and left blank.
A PO dated 12/26/22 read Heel boot on left heel while in bed, monitor for placement. every shift on while on bed, off when out of bed. There was one (1) of 18 entries not signed by the nurse and left blank.
A PO dated 12/26/22 read Heel boot on right heel, monitor for placement every shift for Wound care. There was one (1) of 18 entries not signed by the nurse and left blank.
A PO dated 12/27/22 and was discontinued 12/27/22 read Apply non sting barrier on sacrum DTI (deep tissue injury) wound daily and PRN (as needed) every day shift. The entry of the order was not signed by the nurse and left blank.
A PO dated 12/27/22 read Apply skin prep on the left lateral calf DTI and cover with optifoam, change it daily and PRN every day shift. There was one of five entries not signed by the nurse and left blank.
A PO dated 12/27/22 and was discontinued 12/27/22 read Cleanse wound with normal saline, pat dry and apply zinc oxide and open to air daily and PRN every day shift. The entry of the order was not signed by the nurse and left blank.
A PO dated 12/28/22 and was discontinued 12/28/22 read Cleanse wound on sacral (DTI) area with normal saline, pat it dry and apply zinc oxide, open to air daily and PRN every day shift. The entry of the order was not signed by the nurse and left blank.
A PO dated 12/28/22 read, Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to Sacral wound topically every day shift for Sacral wound Cleanse wound with normal saline, pat dry and apply santyl to the slough area and cover with dry protective dressing. There was one (1) of 4 entries not signed by the nurse and left blank.
The surveyor reviewed progress notes (PN) for Resident #168.
A nurse PN dated 12/01/22 indicated the resident had a right heel wound.
A wound consultant PN dated 12/01/22, documented the resident was referred to the wound care team due to a new right heel DTI wound. The resident was examined, and wound care recommendations provided.
A nurse PN dated 12/19/22, documented the resident had a new left lateral (side of) calf DTI and sacral DTI. Additionally, the note documented the physician and family member was made aware and wound treatment orders carried out.
A wound consultant PN, dated 12/22/22, documented that the resident was seen and examined for a right heel DTI wound, new left lateral (side of) calf partial thickness DTI and new sacral partial thickness DTI wound. The wound consultant recommended wound care treatment orders.
A nurse PN dated 01/05/23 documented that the resident had a new left heel DTI wound.
A wound consultant PN, dated 01/05/23, documented that the resident was seen and examined for a right heel DTI wound, left lateral calf DTI, sacral DTI and new a new left heel partial thickness DTI. Additionally, the note documented poor wound prognosis related to the resident's medical complexity and contributing factors. The wound consultant recommended wound care treatment orders.
The surveyor reviewed incident reports provided by the facility.
An incident report, dated 12/01/22, for a new in-house wound of the right heel was reviewed. The report included wound description, assessment of wound, evaluation of resident status and environment, assessment of wound, staff statements, resident representative and physician notified, interventions to be implemented and conclusion.
There were no additional incident reports found for Resident #168.
On 8/08/24 at 12:10 PM, the surveyor interviewed a Licensed Practical Nurse (LPN) in the presence of the Registered Nurse Unit Manager (RN/UM) regarding wound care protocols. The LPN stated if a resident was found with a new wound, a change of condition, incident report would be initiated. The nurse would notify the physician, resident representative, the resident's treatment plan would be reviewed, the resident's care plan updated, and orders carried out as per the physician.
The RN/UM stated skin assessments were conducted weekly and the unit managers made rounds with the wound consultant who visited weekly. There was a skin/wound evaluation assessment that was to be completed weekly by the unit manager and the wound consultant notes were in the residents' medical records.
On 8/08/24 at 01:10 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor informed the DON and LNHA of the concern that there were no investigations found for the wounds the resident acquired in the facility after 12/01/22. The DON stated it was expected for an investigation to be completed when a resident was found with a facility acquired wound. The DON stated she was not the current DON at that time and would have to follow up to provide further information.
On 8/09/24 at 11:30 AM, the DON provided the surveyor with an incident report for the resident's left heel wound found on 01/05/23. The report dated 01/05/23 included the wound description, assessment of wound, action taken, evaluation of resident status and environment, resident representative and physician notified, interventions to be implemented and conclusion. The report listed staff who provided statements. There were no statements attached with the report.
The surveyor asked the DON if there were any reports for the sacral and left lateral calf DTI wound the resident acquired in December 2022. The DON stated she could not find any additional investigation reports for the resident.
On 8/09/24 at 11:54 AM, the survey team met with the LNHA and DON. The surveyor informed the LNHA and DON of the above concerns with no investigations for the resident's sacral and left lateral calf wound. The surveyor also discussed the concern for entries in the TAR that were not signed by the nurses and left blank, which included pressure relieving interventions and wound treatments. The DON stated it would be expected for the nurses to complete the TAR and sign whether a treatment was administered or not. The DON acknowledged if the entries are blank and not signed, then it was considered not done.
There was no additional information provided by the facility.
The surveyor reviewed the facility's policy Skin Integrity and Wound Management, with a review dated of 5/01/24. Under Policy it read: The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed.
Under Practice Standards it read: .
3. Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition.
4. Identify patient's skin integrity status and need for preventions or treatment interventions through review of all appropriate assessment information .
6. The licensed nurse will .6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change of condition .6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds .6.7 Notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments, as indicated .
7. Collaborate with the wound provider to review co-morbid conditions that may affect healing.
8. Notify physician/APP (advance practice provider) to obtain orders.
11. Review care plan and revise as indicated .
NJAC 8:39-27.1 (e)

Based on observation, interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to initiate an active care plan for smoking and complete the entire smoking assessment for one (1) of one (1) resident reviewed for smoking (Resident #24).
This deficient practice was evidenced by the following:
On 8/01/24 at 01:45 PM, the surveyor reviewed the facility provided list of smokers which reflected that Resident #24 was an independent smoker.
On 8/05/24 at 10:25 AM, the surveyor reviewed Resident #24's electronic medical record and revealed:
Resident #36's admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly), acquired absence of kidney (missing one kidney due to an injury or operation), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
The most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, revealed in Section C Cognitive Status Brief Interview for Mental Status (BIMS) score of 15 out of 15 which reflected that the resident's cognition was intact.
A review of Resident #24's Smoking Evaluation (an assessment used to evaluate if a resident was able to smoke independently or required supervision) dated 5/16/24, indicated under section E. Evaluation that Independent smoking is allowed. Further review indicated that in section F. Care Plan, the boxes for Focus, Goal, and any interventions were not checked. The Evaluation was not completed.
The individualized care plan did not indicate there was a care plan for smoking.
On 8/05/24 at 10:48 AM, the surveyor observed Resident #24 seated in a wheelchair outside in with another resident in the designated smoking area. The surveyor interviewed Resident #24 regarding the smoking process. Resident #24 stated that they had rules to follow and that the staff would keep the cigarettes and lighter.
On 8/05/24 at 10:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding the smoking process. The LPN stated that there was a designated area outside with scheduled times. The LPN stated that staff kept the cigarettes and lighter and would give it to the resident when they went to smoke and then collect them when they were finished. The surveyor asked if a resident that smoked would have a care plan for smoking. The LPN stated that they should have a care plan for smoking. The surveyor asked the LPN if Resident #24 smoked. The LPN confirmed that Resident #24 smoked.
On 8/05/24 at 11:00 AM, the surveyor asked the Unit Manager to print Resident #24's care plan. A review of the printed care plan reflected a care plan for smoking with a revision done by the UM on 8/05/24. The surveyor asked the UM about the care plan. The UM stated that the resident had stopped smoking and the care plan for smoking was resolved (no longer active and did not pertain to the resident at that time). She added that she just saw Resident #24 go outside to smoke today so she redid (unresolved to make active) the smoking care plan today.
The surveyor then reviewed Resident #24's care plan history which included the following:
Care plan for may smoke independently per smoking evaluation had a created date of 11/16/2023 and was revised on 11/30/2023 and 12/05/2023. The care plan was resolved on 2/16/2024. There was a revision which made the care plan active on 8/05/2024. There was no active care plan for smoking while the resident was on the facility's smoking list until after surveyor inquiry.
On 8/05/24 at 12:33 PM, the surveyor interviewed the Director of Nursing (DON) regarding the care plan for residents that smoked. The DON stated that residents that smoked should have a smoking care plan.
On 8/07/24 at 12:14 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and the DON the concern that Resident #24 did not have a care plan for smoking prior to surveyor inquiry and that the smoking assessment was not completed to include the section on care plan.
On 8/08/24 at 01:01 PM, in the presence of the survey team and DON, the LNHA stated that Resident #24's smoking care plan had been resolved and that they did not know how it happened. She added that the care plan should have been active and not resolved prior to 8/05/24. The LNHA stated that all the residents that smoked were audited and their evaluations were done and that they were checking the facility process.
The facility did not provide any additional information.
A review of the facility provided policy titled, Smoking with a revision date of 10/24/22, included the following:
2.3 The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke.
2.3.1 Patients will be re-evaluated quarterly and with a change in condition.
2.5 A care plan for patients who smoke shall include such elements as the need for supervision or physical assistance while smoking and safety devices that are needed, such as a smoking apron to prevent burns. The care plan will be updated as necessary.
A review of the facility provided policy titled, Person-Centered Care Plan with a revision date of 10/24/22, included the following:
6.1 The care plan must be customized to each individual patient's preferences and needs
7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals .
N.J.A.C. 8:39-27.1(a)

Based on the interview and review of pertinent facility documentation, the facility failed to have the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) present for one (1) of three (3) quarterly Quality Assurance Performance Improvement (QAPI) meetings. This failure had the potential to affect all 111 residents who currently live in the facility.
The deficient practice was evidenced by the following:
On 8/01/24 at 9:44 AM, the surveyor met with the LNHA and the DON during an Entrance Conference meeting. Both the LNHA and the DON confirmed that day census (total number of residents) of 111 with no bed hold.
On 8/01/24 at 12:09 PM, the LNHA provided the last three-quarters of QAPI sign-in sheets and revealed the following:
QAPI Attendance:
01/17/24=the Medical Director (MD), DON, and other Interdisciplinary Team (IDT) signed the QAPI Attendance sheet. There was no documented evidence in the sign-in sheet that the LNHA and the Infection Preventionist (IP) attended the meeting.
4/15/24=the LNHA, MD, DON, IP, IDT, and vendor representative signed the QAPI Attendance sheet.
7/17/24=the LNHA, MD, IP, IDT, and vendor representatives signed the QAPI Attendance sheet except for the DON. There was no documented evidence that the DON attended the meeting.
A review of the provided copy of the QAPI Meeting Calendar 2024 the LNHA revealed the following schedules:
01/17/24 Quarterly
4/17/24 Quarterly
7/17/24 Quarterly
10/16/24 Quarterly
On 8/07/24 at 12:00 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the above findings regarding the attendance in QAPI meetings where the LNHA and the IP were not present on 01/17/24 and the DON on 7/17/24.
On that same date and time, the LNHA stated that she was on vacation on 01/17/24 and also the IP was probably on vacation at that time. The LNHA further stated that on 7/17/24 the DON was on vacation which was why they were not present during the QAPI meetings.
On 8/09/24 at 8:09 AM, the LNHA provided a copy of the IP's timesheet for 01/17/24 and revealed that the IP worked from 8:00 AM to 4:30 PM. The LNHA stated that the IP worked on 01/17/24 and she did not know why the IP did not sign the Attendance sheet for QAPI.
A review of the facility's Center Quality Assurance Performance Improvement Process Policies and Procedures with a revision date of 10/24/22 that was provided by the LNHA revealed:
Process:
2. The QAA (Quality Assessment and Assurance) Committee:
2.1 Functions under the authority of the Administrator and the Governing Body is composed of:
2.1.1 Administrator,
2.1.2 DON,
2.1.3 MD,
2.1.4 IP, or designee,
2.1.5 Consultant Pharmacist (recommended,
2.1.6 Patient and/or family representatives (if appropriate),
2.1.7 Three (3) additional staff representatives including, but not limited to, department heads, certified nursing assistants (CNA), rehabilitation services, hospice, home health, etc.
2.2 Meets at least quarterly.
On 8/09/24 at 12:41 PM, the survey team met with the LNHA and DON for the Exit conference. The facility did not provide additional information and did not refute findings.
NJAC 8:39-33.1 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REPEAT DEFICIENCY
Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene practices for one (1) of two (3) staff (Housekeeper) and b.) follow transmission-based precautions (TBP) and enhanced barrier precautions (EBP) protocol to prevent the potential spread of infection for two (2) of two (2) residents (Residents #82 and #108) reviewed for infection control, in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy.
This deficient practice was evidenced by the following:
According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed:
Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications:
Immediately before touching a patient .
Before moving from work on a soiled body site to a clean body site on the same patient .
After touching a patient or the patient's immediate environment
After contact with blood, body fluids, or contaminated surfaces
Immediately after glove removal.
According to the CDC guidelines dated 4/02/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) included information for EBP when to use PPE (personal protective equipment) during high contact resident care activities.
Examples of high-contact resident care activities requiring gown and glove use for EBP include:
Dressing .
Providing hygiene
Changing linens .
Device care or use: central line, urinary catheter, .
Implementation
When implementing Contact Precautions or EBP, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this:
Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves)
For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves
Make PPE, including gowns and gloves, available immediately outside of the resident room .
Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education
Provide education to residents and visitors .
1. On 8/01/24 at 10:27 AM, the surveyor interviewed the unit 1 SA (subacute) Registered Nurse/Unit Manager (RN/UM). The RN/UM informed the surveyor that residents with indwelling catheters (or foley catheters), tube feedings, and wounds would be placed on EBP and staff were required to use PPE and perform hand hygiene before and after using PPE. She further stated that EBP protocol would be observed when performing direct care to the resident and the environment of the resident on EBP.
On 8/01/24 at 10:32 AM, the surveyor observed the Housekeeper (HK) came out of the toilet room from room [ROOM NUMBER] with gloves and a surgical mask. The HK immediately went to the cleaning cart which was parked in front of room [ROOM NUMBER] without removing used gloves and did not perform hand hygiene. There was a posted sign for EBP outside the door of room [ROOM NUMBER].
During an interview with the HK, the HK claimed that she cleaned the toilet room. Afterward, the HK went back to the room with the same gloves and wiped the nightstand table of room [ROOM NUMBER]D (the room near the door). Then, the HK went back to her cleaning cart and removed both used gloves, and donned (put on) a new pair of gloves without performing hand hygiene. There was no ABHR inside and outside the resident's room of 101.
At that time, the surveyor asked the HK what she should do after removing her gloves, and the HK did not respond. The surveyor then asked the HK why she did not perform hand hygiene after removing and putting on a new pair of gloves. The HK stated that she should use ABHR in between gloves. The surveyor also observed the HK was looking inside the resident's room for something, and the HK stated and confirmed that there was no ABHR within the area that was why she did not perform hand hygiene.
On 8/01/24 at 10:42 AM, the surveyor interviewed and notified the RN/UM of the above concerns regarding HK. The RN/UM stated that the HK should perform hand hygiene after removing gloves and before donning a new pair of gloves. She further stated that the HK should have removed her gloves after cleaning the toilet room prior to cleaning room [ROOM NUMBER]D's nightstand or immediate environment to prevent cross-contamination.
A review of the facility's Personal Protective Equipment Policy with a revision date of 4/15/23 provided by the LNHA revealed:
Process:
6. Gloves:
6.3. Change gloves after contact with each individual resident or after contact with contaminated articles.
6.4. Wash hands after removing gloves.
A review of the facility's Hand Hygiene with a revision date of 5/01/24 provided by the LNHA on 8/5/24 at 10:29 AM showed:
Policy:
The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves
Process:
1. Perform hand hygiene:
1.1. Before patient/resident care; .
1.3. After any contact with blood or other body fluids, even if gloves are worn; .
1.5. After contact with the patient's environment
2. On 8/01/24 at 10:39 AM, the surveyor observed Resident #82 lying on their bed, with an indwelling catheter (a catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine), while watching the television . There was an EBP sign outside the door.
The surveyor reviewed the hybrid (a combination of paper, scanned, and computer-generated records) medical records of Resident #82.
The admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension (elevated blood pressure), other retention of urine, anemia (low blood count) unspecified, type 2 diabetes mellitus without complications.
According to the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 7/16/24, revealed in Section C Cognitive Patterns a brief interview for mental status (BIMS) score of 14 out of 15 which indicated that the resident was cognitively intact. Section H Bladder and Bowel revealed that Resident #82 had an indwelling catheter.
A review of the Lab (laboratory) Results Report showed that RN/UM reviewed the report on 5/24/24 at 15:47 (3:47 PM) and showed that the urine cult (culture) colony ct (count) final report:
Colony count: 100,000+
Gram-negative rods
Extended Spectrum Beta Lactamase (ESBL)-Positive .
Contact precautions indicated.
According to the Order Summary Report (OSR) there was a physician order (PO) dated 5/24/24 for Bactrim DS Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth every 12 hours for UTI (urinary tract infection) until 06/01/2024.
A review of the antibiotic stewardship (antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by MDROs) binder provided by the LNHA showed that on May 2024 and June 2024 monitoring and tracking list, the resident was not listed for positive ESBL in urine.
Further review of the hybrid medical records revealed that there was no documented evidence that the physician was notified of the 5/24/24 ESBL positive results, no care plan (CP) nor PO for contact precaution.
On 8/07/24 at 9:11 AM, the Director of Nursing (DON) informed the surveyor in the presence of the survey team that the Infection Preventionist Nurse (IPN) was on vacation and would not be at the facility.
On 8/07/24 at 10:45 AM, the surveyor interviewed the RN/UM. The RN/UM informed the surveyor that as facility's practice and expectation, the nurse should notify the physician of the abnormal lab results and if it requires isolation like contact precautions according to the lab results, the facility will initiate the isolation, obtain a PO from the doctor of what kind of isolation, update the CP for isolation and document it in the electronic medical records.
On that same date and time, the surveyor notified the RN/UM of the above concerns and findings regarding Resident #82's positive ESBL in urine results, and the RN/UM had no response.
On 8/07/24 at 10:50 AM, the DON stated that after reviewing the resident's medical records, there was no PO for contact precaution for positive ESBL in urine and no CP initiated when the results came out on 5/24/24. The DON acknowledged and further stated that she was aware that there was no documented evidence that the physician was made aware of the lab results and that she (DON) met with the nurses about the above findings and concerns after the surveyor's inquiry.
On 8/07/24 at 12:00 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The Surveyor notified of the above findings and concerns regarding the HK. The surveyor also notified the facility management of the findings about Resident#82's ESBL in urine for TBP that the facility failed to identify, track, monitor, and/or report the infection on 5/24/24 and there was no documented evidence that the physician was made aware of the ESBL report on 5/24/24.
A review of the facility's Contact Precautions with a review date of 5/01/23 that was provided by the LNHA revealed:
Process: .
3. Instruct staff, patient and their representative, and visitors regarding Precautions and the use of PPE .
6.1. Notify the healthcare provided in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission; .
8. Once the patient is no longer a risk for transmitting the infection (i.e., duration of the illness and/or can contain secretions), discontinue precautions.
A review of the facility's Infection Prevention and Control Program Description Policy with a revision date of 6/07/21 that was provided by the LNHA showed:
The major activities of the program are:
1. Surveillance of Infections which includes ongoing monitoring to identify possible communicable diseases or infections before they can spread to others in the Center and to whom they should be reported.
2. Process Surveillance to review infection prevention and control practices directly related to patient care.
5. Report of Infection and Communicable Disease which includes routine monthly infection control reporting and specific Department of Health reporting according to state and local regulations .
7. Antibiotic Stewardship Program which includes antibiotic use protocols and a system for monitoring antibiotic use
Goals: The IPCP (Infection Prevention and Control Program) has been developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices, and guidelines to reduce the risk of transmission of infection or communicable diseases.The goals of the program are to:
1. Provide a safe, sanitary and comfortable environment;
2. Decrease the risk of infection to the patients and staff;
3. Monitor for occurrence of infection and communicable disease and implement appropriate control measures; .
3. On 8/01/24 at 10:45 AM, the surveyor observed Resident #108's room with a posted sign for Standard and Contact Precaution, and the resident was not inside the room.
On 8/01/24 at 10:51 AM, the surveyor interviewed the RN/UM who informed the surveyor that Resident #108 was out of the facility for the hyperbaric treatment (or hyperbaric oxygen therapy involves exposing the body to 100% oxygen at a pressure that is greater than normal, to heal properly) of the diabetic wound right foot and would be back around 2 PM. The RN/UM stated that the resident was on EBP due to a wound.
The surveyor reviewed the hybrid medical records of Resident #108 and revealed:
The AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to essential hypertension, type 2 diabetes mellitus with diabetic nephropathy, other acute osteomyelitis (an infection in a bone) right ankle and foot, gas gangrene (a rare bacterial infection that destroys blood cells and soft tissues), and acquired absence of other right toe(s).
According to the comprehensive MDS with an ARD of 7/24/24, revealed in Section C BIMS score of 15 out of 15 which indicated that the resident was cognitively intact.
Further review of the hybrid medical records revealed that there was no CP and nor PO for EBP.
On 8/09/24 at 8:12 AM, the surveyor notified the LNHA of the concern that there was no PO and CP for EBP.
On 8/09/24 at 8:27 AM, the RN/UM acknowledged that there was no PO and CP for EBP, and she further stated that should have been done.
On 8/09/24 at 12:41 PM, the survey team met with the LNHA and DON for the Exit conference. The facility did not provide additional information and did not refute findings.
NJAC 8:39-19.4(a)(1,2,5)(d)(g), 27.1(a)

Based on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 3 of 22 residents observed for infection control breaches, Resident # 95, #25 and #61.
This deficient practice was evidenced by the following:
1. On 8/11/22 at 9:05 AM, the surveyor observed the Unit 3 Licensed Practical Nurse (LPN3) prepare for the administration of medication to Resident #95. Prior to the administration of medication, LPN3 removed a device from her pocket, a Pulse Oximeter (Pulsox) (a noninvasive device placed on the fingertip which uses a light beam to estimate the oxygen saturation and pulse rate). The surveyor did not observe LPN3 sanitize the Pulsox prior to placing the device on the resident's finger. When LPN3 completed the Pulsox check, she placed the Pulsox back into her pocket.
The surveyor interviewed LPN3 in reference to the sanitation of a multi resident use device. LPN3 stated, I cleaned the Pulsox in the morning and put it in my pocket. LPN3 then removed the Pulsox from her pocket and cleaned the device with an alcohol swab.
Review of the facility Cleaning and Disinfecting policy and procedure indicated, Non-critical items are objects that do not come into contact with mucus membranes, but do come into contact with intact skin (e.g., blood pressure cuff, glucose meters, stethoscope, activity supplies, sensory manipulative, craft supplies). These items require cleaning between patient use. Number 5. of the facility Cleaning and Disinfecting policy and procedure indicated, Perform routine disinfection of items used in daily care practices with Environmental Protection Agency (EPA) registered disinfectant.
On 8/16/22 at 11:33 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Lead Registered Nurse who both stated that all multi use devices should be cleaned/sanitized before and after each use with a resident.
2. On 8/16/22 at 8:37 AM, the surveyor observed as the Registered Nurse (RN) and Nurse Practice Educator (NPE) performed tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) care including suctioning and changing of the inner cannula (a tube inserted inside the tracheostomy which acts as a liner) on Resident #25.
On 8/16/22 at 9:03 AM, the surveyor observed that the RN used a vital signs machine with a Pulsox, oral thermometer, and blood pressure cuff to take Resident #25's vital signs including oxygen saturation, pulse rate, temperature, and blood pressure.
On 8/16/22 at 9:05 AM, the surveyor observed that the NPE wheeled the vital signs machine out of Resident #25's room into the hallway and plugged the vital signs machine into an electrical outlet.
On 8/16/22 at 9:10 AM, the surveyor interviewed the RN and NPE. The surveyor identified that the vital signs machine including Pulsox, oral thermometer, and blood pressure cuff were never cleaned or disinfected after it was used on Resident #25 and before it was removed from the room and plugged into the electrical outlet in the hallway. The RN stated that she cleaned the vital signs machine before she used it on Resident #25 and that the NPE brought it out to charge in the hallway because it had a low battery.
On 8/16/22 at 11:33 AM, the surveyor expressed her concern to the LNHA, Regional Clinical Lead RN, Infection Control Nurse, and NPE. The Clinical Lead RN stated, that all devices used touching any part of a resident should be cleaned before and after use on a resident.
The facility policy, Cleaning and Disinfecting with a reviewed date of 11/15/21 indicated under the Practice Standards section 5.2 Multi-patient equipment must also be cleaned/ disinfected after patient use.
3. On 8/8/22 at 12:13 PM, during the initial tour, Resident #61 was observed in a right side-lying position in bed, with eyes closed.
A review of Resident #61's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to, Type 2 Diabetes Mellitus, Unspecified Dementia with Behavioral Disturbance, and Hypertension.
A review of the Significant Change in Status in the Minimum Data Set, an assessment tool used to facilitate care management dated 7/21/22, indicated a Brief Interview for Mental Status scored at 1 of 15, which indicated that the resident had severe cognitive impairment.
The surveyor reviewed the August 2022 Physician Order Summary, which reflected a Physician's order (PO) to cleanse the sacral wound with normal saline, apply medi-honey to the wound's base, pack the wound with silver alginate, and apply the dressing every day and evening shift for wound care. The same PO was also noted on the August 2022 electronic Treatment Administration Record (eTAR).
On 8/18/22 at 11:15 AM, the surveyor observed the Unit 2 Licensed Practical Nurse (LPN2) perform a wound treatment to a Stage 4 Pressure Ulcer to the sacrum of Resident #61. LPN2 was observed assisted by the Registered Nurse/Unit Manager (RN/UM) in the positioning of the resident during the treatment.
Upon entering the resident's room, the surveyor observed LPN2 and RN/UM introduce themselves and inform the resident of the wound treatment. LPN2 closed the curtain for privacy. The surveyor observed LPN2 and RN/UM putting on gloves without washing or sanitizing their hands. LPN2 and and RN/UM proceeded to position Resident #61 to the right side in bed.
The surveyor observed during that LPN2 wore the same contaminated gloves that she wore to reposition the resident during the treatment process. LPN2 wore the same contaminated gloves to cleanse the wound with saline, apply the medi-honey on a tongue depressor to the wound, then used a cotton-tipped applicator to apply silver alginate and packing (special technique for wound covering) the wound with a gauze sponge/bordered dressing.
On 8/18/22 at 11:44 AM, the surveyor interviewed the LPN2 and RN/UM about concerns observed during the wound treatment. They both acknowledged that hand hygiene should have been initiated prior to applying gloves and positioning the resident in bed. They further acknowledged that the LPN2 should have removed her gloves after cleansing the wound with saline, washed her hands, and applied new pair of gloves before proceeding to apply the medi-honey and packing the wound with silver alginate.
On 8/18/22 at 11:50 AM, the surveyor reviewed the facility's policy and procedure titled 13.4 Wound Cleansing in the presence of the LPN2 and RN/UM. Under Process: 11. Remove the soiled gloves and place in a plastic disposal bag. 12. Cleanse your hands. Apply clean gloves. 13. Apply the treatment/dressing as ordered.
On 8/18/22 at 12:36 PM, the surveyor informed the LNHA, Regional Clinical Lead RN, and Infection Control Nurse regarding the above concern. The Regional Clinical Lead RN stated that LPN2 and RN/UM should have initiated hand hygiene (washed their hands) prior to applying gloves and positioning the resident in bed. The Regional Clinical Lead RN further stated that LPN2 should have removed the gloves after cleansing the wound with saline, washed her hands, and applied a new pair of gloves before proceeding to apply the medi-honey and pack the wound with silver alginate.
NJAC 8:39-19.4 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to a.) accurately follow facility policy related to the wasting of contaminated medication, b.) ensure that physician ordered hold parameters were accurately followed, c.) accurately document the administration of an as needed (prn) controlled substance.
This deficient practice was identified for 4 of 24 residents reviewed for medication management (Resident #164, #95, #25 and #161), and was evidenced by the following:
1. On [DATE] at 8:42 AM, the surveyor observed the Unit 1 Registered Nurse (RN) prepare medication for administration to Resident #164. During the medication preparation the RN dropped Losarten 100-12.5 mg (an antihypertensive medication) on the contaminated medication cart. The surveyor observed the RN pick up the Losarten 100-12.5 mg tablet and throw it into the garbage receptacle attached to the medication cart.
The surveyor interviewed the RN after she completed the administration of medication to Resident #164. The RN stated that it's ok to throw the contaminated medication into the garbage attached to the medication cart because, if it's not a narcotic it can be put in the garbage.
2. On [DATE] at 9:05 AM, the surveyor observed the Unit 3 Licensed Practical Nurse (LPN) prepare medication for administration to Resident #95. During the medication preparation the LPN dropped Spironalactone 25 mg (an antihypertensive medication) on the contaminated medication cart. The surveyor observed the LPN pick up the Spironalactone 25 mg tablet and put it into the clean medication cup that was prepared for administration to Resident #95.
The surveyor interviewed the LPN after she completed the administration of medication to Resident #95. The LPN stated, If the medicine doesn't fall on the ground, we use the medication. I clean the top of the cart in the morning.
Review of the facility Disposal of Medication Waste policy with a reviewed date of [DATE] explained Medications for disposal include: Discontinued, expired or contaminated medications not returned to the pharmacy. Medications may be sent with the patient upon discharge, when applicable, donated, where applicable, or disposed of using a contracted medical waste service (e.g., Stericycle). Medications that cannot be returned to the pharmacy, discharged with the patient, or donated will be placed in medication disposal bins. Waste bins will be stored in the medication room or other secure medication storage area not accessible to patients.
On [DATE] at 11:27 AM, the Licensed Nursing Home Administrator (LNHA) stated that Drug Buster and SteriCycle (receptacles for properly discarding medication) are stored in the medication room and used to dispose of contaminated medications. The LNHA also acknowledged that medications that are contaminated are not to be administered to residents or thrown in the garbage accessible to residents.
3. On [DATE] at 1:38 PM, the surveyor observed Resident #25 in bed in a room where the resident was connected to oxygen (O2) via a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) mask along with a feeding pump that was turned off at the time.
The surveyor reviewed the medical records belonging to Resident #25. Resident #25 was admitted to the facility with diagnosis that included but were not limited Aphasia following Cerebral Infarction, Dysphasia following Cerebral Infarction, Gastrostomy, Tracheostomy and Essential Hypertension.
Review of the [DATE] electronic medication administration record (eMAR) presented a physician's order (PO) for Amlodipine Besylate 10 mg (1) tablet via percutaneous endoscopic gastrostomy feeding tube (peg tube) once a day for Hypertension Hold for Systolic Blood Pressure (SBP) less than (<) 140 with a start date of [DATE].
Review of the nurses entry documented on the eMAR from [DATE] to [DATE] revealed 5 days ([DATE] SBP 136, [DATE] SBP 126, [DATE] SBP 130, [DATE] SBP 128, [DATE] SBP 128) of Amlodipine Besylate 10 mg administered despite Resident #25's SBP measuring less than 140.
On [DATE] at 12:00 PM, the surveyor interviewed the Unit 1 Registered Nurse who stated that if the PO for a medication includes a parameter, you need to follow the order and hold the medication if it is not within the specified parameter.
On [DATE] at 2:00 PM, the LNHA stated that when there is a medication order that includes parameters, the administering medication nurse must evaluate to see if the medication should be administered or held. The LNHA could not provide any further information explaining why there was a discrepancy between the parameter ordered by the physician and the evaluation of the facility nurse as to administering the medication when the SBP was less than the level set by the PO.
4. On [DATE] at 1:22 PM, the surveyor observed Resident #161 behind a closed door to a private room in the facility. Resident #161 was noted in a room that had signage which affirmed that they were being quarantined. Review of the medical records for Resident #25 revealed there was documentation confirming that the resident was COVID positive.
The surveyor reviewed the medical records which belonged to Resident #161. Resident #161 was admitted to the facility with diagnosis that included but were not limited to Type 2 Diabetes Mellitus, Aftercare following joint replacement surgery, presence of left artificial knee joint and COVID-19 hospital acquired.
Review of the [DATE] eMAR presented a PO for Oxycodone HCL 5 mg (2) tablets every 8 hours as needed (prn) for severe pain with a start date of [DATE] and a discontinue date of [DATE]. There was another PO for Oxycodone HCL 5 mg (1) tablet every 8 hours prn for moderate pain (4-6) with a start date of [DATE] and a discontinue date of [DATE]. There was a third PO for Oxycodone HCL 5 mg (2) tablets every 4 hours prn for pain (7-10) with a start date of [DATE].
The surveyor reviewed all the nursing entries documented in the Controlled Medication Utilization Record (CMUR), a narcotic inventory sheet. The CMUR documented all the Oxycodone 5 mg tablets that were removed from inventory for the purposes of administering to Resident #161.
The surveyor cross referenced the nursing entries documented in the CMUR with the administration entries documented in the different orders for the Oxycodone 5 mg in the eMAR, matching up the inventory removal of the for Oxycodone HCL 5 mg with the documentation of administration to Resident #161. The surveyor found that there were several discrepancies. The surveyor found that the Oxycodone 5 mg signed by nursing on the CMUR as removed from the inventory had several missing entries by nursing as administered in the eMAR.
The CMUR documented 7 entries dated from [DATE] to [DATE] confirming (2) tablets of Oxycodone HCL 5 mg were removed from inventory each time (totals 14 tablets). The eMAR did not document that those 14 tablets of Oxycodone HCL 5 mg were administered to Resident #161.
The surveyor also found an additional physician's order for Oxycodone HCL 5 mg (1) tablet every 8 hours prn for severe pain with a start date of [DATE] and a discontinue date of [DATE]. The CMUR documented 2 tablets were removed a total of 3 times while the eMAR documented 1 tablet was administered to Resident #161 on those same dates and times by nursing.
In addition to this order for Oxycodone there was an additional order for Oxycodone HCL 5 mg (1) tablet every 8 hours prn for moderate pain (4-6) with a start date of [DATE] and a discontinue date of [DATE] which documented an administration date of [DATE] and a time of 2338 (11:38 PM) which was not entered in the CMUR.
On [DATE] at 2:00 PM, the LNHA stated that when administering narcotics, the nurse must sign the narcotic declining sheet as well as the eMAR documenting administration. No further information was relayed from the facility as to the reason for the discrepancy between the CMUR and eMAR.
NJAC 8:39- 29.4(b)2

Based on observation, interview and record review, it was determined that the facility failed to ensure a.) that a concentrator for a resident who was dependent on supplemental oxygen (O2) via a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) had the proper settings, b.) that the O2 supply for a resident who was dependent on supplemental O2 via a tracheostomy was connected properly and c.) that a resident who was dependent on supplemental O2 via a tracheostomy had a valid physician's order for O2 in place.
This deficient practice was identified for 1 of 2 residents reviewed with a tracheostomy (Resident #25), and was evidenced by the following:
On 8/9/22 at 1:38 PM, the surveyor observed Resident #25 in bed in a room where the resident was connected to O2 via a tracheostomy tube along with a feeding pump that was turned off at the time.
On 8/15/22 at 11:41 AM, the surveyor entered Resident #25's room and noted the O2 diluter attached to the oxygen and tracheostomy tube was set at 28 which corresponded to 5 liters per minute (LPM) of O2. The resident appeared comfortable without any difficulty breathing.
On 8/15/22 at 11:54 AM, the surveyor along with the Registered Nurse Practice Educator (NPE) observed the setting of the tracheostomy tubing diluter. The surveyor along with the NPE reviewed the physician's order for O2 which read, O2 at 28% via trach collar with inner cannula Shiley #6, leave O2 concentrator at 3 LPM. The NPE stated that the diluter was set incorrectly as it should be set for 3 LPM.
The NPE in the presence of the surveyor, evaluated the O2 concentrator which was set at 4 LPM. The NPE then attempted to adjust the O2 concentrator that was on the left side of the resident's bed, when she realized that the O2 tubing was disconnected from the O2 concentrator.
On 8/15/22 at 12:00 PM the NPE checked Resident #25's vitals which were: Heart Rate 109 O2 level 86 and Systolic Blood Pressure at 167/89. The NPE stated that the resident's O2 level should be at least be 92. The resident did not appear in any distress.
On 8/15/22 at 12:34 PM, the surveyor in the presence of two other surveyors interviewed the NPE along with the Registered Nurse (RN) who was responsible for Resident #25's care. The NPE agreed that the diluter for the Compressor was set wrong as well as the O2 concentrator, which was inaccurately set at 4 LPM and most importantly the tubing supplying the O2 to the compressor was disconnected from the concentrator. The NPE stated that it was the nurses responsibility to check that the settings were correct and that all tubings were connected. The RN did not have any additional comments.
The surveyor reviewed the medical record for Resident #25.
A review of the resident's Face Sheet (an admission record) reflected that Resident #25 was admitted to the facility with diagnoses that included but were not limited Aphasia following Cerebral Infarction, Dysphasia following Cerebral Infarction, Gastrostomy, Tracheostomy and Essential Hypertension.
A review of the August 2022 physician's order (PO) entry dated 8/4/22 documented, O2 at 28% via trach collar with inner cannula Shiley #6, leave O2 concentrator at 3 LPM.
A review of the nursing entries for the physician's order dated 8/4/22 and documented in the August 2022 Electronic Medical Administration Record (eMAR), Check O2 saturation every shift maintain saturation greater than 92% every shift. All nursing entries for saturation rates from 8/4/22 to 8/16/22 were documented as over 92%.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/10/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score (screen used to assist with identifying a resident's current cognition) of 11
out of 15, indicating that the resident had a moderately impaired cognition. A further review of the resident's MDS, Section O for Special Treatments and Programs reflected that the resident received Oxygen Therapy, Tracheostomy Care and Suctioning.
On 8/15/22 at 1:53 PM, the surveyor discussed the above issues with the Registered Clinical Lead Nurse (RNL). The RNL stated that the nurse should be checking the O2 settings and connections for any Tracheostomy resident anytime they walk into the room, at minimum once every shift.
On 8/16/22 at 2:15 PM, the surveyors met with the Director of Nursing (DON), the NPE and the Licensed Nursing Home Administrator (LNHA) who could not give any further information as to the discrepancies found with the O2 settings for Resident #25.
On 8/18/22 at 12:12 PM, the surveyors interviewed the Certified Respiratory Therapist (CRT) who stated that she educates the nursing staff on the care of a Tracheostomy resident. The CRT stated that she comes in initially to set up the resident when they are admitted from the hospital.
The surveyor informed the CRT that the tubing was disconnected from the O2 concentrator. The CRT responded that the resident was not getting any oxygen if the tubing was disconnected from the concentrator.
2. On 8/16/22 at 8:34 AM, the surveyor observed Resident #25 sitting up in bed wearing a tracheostomy mask over their tracheostomy. The surveyor observed that the tracheostomy mask was connected to an O2 concentrator and that the O2 concentrator was set to 5 LPM.
On 8/16/22 at 8:35 AM, the surveyor reviewed Resident #25's PO. The surveyor observed that Resident #25 had a PO for O2 at 28% via trach collar with inner cannula Shiley #6, leave O2 concentrator at 3 LPM.
On 8/16/22 at 9:10 AM, the surveyor interviewed the RN. The surveyor asked the RN how many LPM of O2 Resident #25 should receive. The RN stated that the O2 concentrator should be set to 5 LPM. The surveyor stated that the PO indicated that the O2 concentrator should be set to 3 LPM. The RN stated that the doctor came this morning and changed the order to 5 LPM.
On 8/16/22 at 9:50 AM, the surveyor noted that Resident #25 had a PO for O2 at 28% via trach collar with inner cannula Shiley #6, leave O2 concentrator at 5 LPM with a start date of 8/16/22 at 15:00 (3 PM). The surveyor also observed that the PO to keep the O2 concentrator at 3 LPM was discontinued on 8/16/22 at 8:46 AM.
On 8/16/22 at 12:23 PM, the surveyor interviewed the RN again about the PO and stated that the PO was not active until 3 PM. The RN stated that the Registered Nurse Unit Manager (RN/UM) changed the PO in the electronic medical record (EMR) this morning.
On 8/16/22 at 12:15 PM, the surveyor interviewed the RN/UM. The RN/UM stated that she put the order in at 8:46 AM and that she did not know why it was not active immediately.
On 8/18/22 at 12:12 PM, the surveyor interviewed the CRT. The surveyor stated that there was an interval on 8/16/22 where Resident #25 received O2 via tracheostomy mask to their tracheostomy with no active PO. The CRT stated that there should, always be an order.
On 8/18/22 at 12:34 PM, the surveyor expressed her concern to the LNHA, RNL, and Infection Preventionist Nurse (IPN).
On 8/22/22 at 11:45 AM the LNHA stated that when a new PO is put into their EMR that it does not become active until the next shift.
Review of the Oxygen Concentrator policy and procedure with a facility revision date of 6/15/22, documents, 1. Verify order. 10. Set liter flow per order 11. Attach prescribed oxygen delivery device. Apply oxygen delivery device to the resident.
Review of the Tracheostomy Care Policy and Procedure with a facility revision date of 7/15/21 documents, 2. Verify order.
NJAC 8:39-27.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to ensure the appropriate management of an enteral feeding formula. This deficient practice was identified for 1 of 5 residents reviewed for tube feeding (Resident #25), and was evidenced by the following:
On 8/9/22 at 1:38 PM, the surveyor observed Resident #25 in bed, in a room where the resident was connected to oxygen via tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe) tube along with a feeding pump that was turned off at the time.
On 8/15/22 at 11:07 AM, the surveyor observed Resident #25 in bed receiving tube feeding regulated by a pump. The surveyor noted that the feeding pump was set at 60 ml/hr with a total fed display of 1065 ml and 135 ml left to feed. The hanging bottle of Jevity 1.5 Cal had documented information written stating that it was hung on 8/14/22 and started at 4:00 PM at 60 ml/hr. The surveyor noticed that the hanging bottle of Jevity 1.5 Cal which originally contained 1000 ml, was almost completed.
On 8/15/22 at 11:30 AM, the surveyor noticed the 1st floor Registered Nurse (RN) enter Resident #25's room. The RN was carrying a new Jevity 1.5 Cal 1000 ml bottle when entering the resident's room.
On 8/15/22 at 11:41 AM, the surveyor entered Resident #25's room and noted that a new bottle of Jevity 1.5 Cal 1000 ml bottle was hung and attached to the resident's feeding pump. The surveyor noticed that the Jevity 1.5 Cal had documented information written on it stating that it was hung at 11:30 AM at 60 ml/hr. The surveyor noted that the feeding pump was now set at 65 ml / hr and showing a total volume fed of 1504 ml and a balance volume to be fed of 1184 ml.
On 8/15/22 at 11:54 AM, the surveyor noted that the Jevity 1.5 Cal tube feed pump was still set at 65 ml / hr. The pump was showing that 1517 ml was infused and 1171 ml was still programmed to be infused.
On 8/15/22 at 12:34 PM, the surveyor in the presence of 2 other surveyors interviewed the Registered Nurse Practice Educator (NPE) and the RN. Both the NPE and RN agreed that the pump feed setting was not correct and the NPE shut down the feeding system. The NPE stated that the nurse is responsible for setting the resident's pump for the tube feed. The RN stated that she only came in to change the feed when she heard the alarm of the pump sound off. The RN stated that she did not touch the pump.
The surveyor reviewed the medical record for Resident #25.
A review of the resident's Face Sheet (an admission record) reflected that Resident #25 was admitted to the facility with diagnosis that included but were not limited to Aphasia following Cerebral Infarction, Dysphasia following Cerebral Infarction, Gastrostomy, Tracheostomy and Essential Hypertension.
The surveyor reviewed the August 2022 physician's order entry dated 8/10/22 for Jevity 1.5 CAL to administer continuous via Pump 60 ml per hour until total volume 1200 ml reached supplying a total calorie amount of 1800. There was another physician's order dated 8/4/22 that specified that the Enteral Feed Up at 4PM Down at 12 Noon or until total volume is reach (1200).
A review of the August 2022 Medication Administration Record (MAR) reflected that the nurses were signing that the start time for the enteral tube feeding formula was 4:00 PM and the enteral tube feeding formula was stopped at 12 noon the following day. Further review of the MAR reflected that the nurses were documenting on the August 2022 MAR that the total volume of the tube feeding formula that was infused on a daily basis was 1200 ml.
A review of the resident's most recent quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/10/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score (screen used to assist with identifying a resident's current cognition) of 11 out of 15, indicating moderate cognitive impairment. Further review of the resident's MDS, Section K for Nutritional Status reflected that the resident received 51% or more of their nutrition through an enteral feeding program.
A review of the resident's weights did not reflect that the resident had a significant weight loss or gain since the need for enteral feeding began on 2/21/2022.
A review of the resident's comprehensive care plan dated 5/17/22 reflected a focus area that the resident required an enteral feeding to meet nutritional needs due to Dysphagia (difficulty swallowing) and CVA (Cerebrovascular Accident). The goal of the care plan reflected that the resident would tolerate safe enteral feedings without complications. The interventions included to flush and care for the resident's tube feeding per physician's order of Jevity 1.5 Cal at 60 ml/hr until 1200 ml.
A review of the facility's Enteral Feeding: Administration by Pump policy and procedure reviewed by the facility on 6/15/22 included, 1. Verify order: Order includes, but is not limited to: 1.5 Flow rate, total volume, and calories per 24 hours.
On 8/16/22 at 2:15 PM, the surveyors met with the Director of Nursing, the NPE and the Administrator who could not give any further information as to why Resident #25's feeding pump was set incorrectly.
On 8/18/22 at 11:32 AM, the surveyors interviewed the Registered Dietician (RD) who stated that she has been following Resident #25 since admission. The RD stated that Resident #25 has been stable over all. The RD informed the surveyors that Resident #25 has had a slight weight gain trend but the doctor isn't concerned.
The RD stated that the Jevity 1.5 should be hung at 60 ml/hr (ordered rate). The RD explained that the rate of 65 ml/hr and the additional amount infused, wouldn't impact the resident as it was only for a short period of time.
NJAC 8:39-27.1(a)

Based on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) in accordance with federal guidelines. This deficient practice was identified for 1 of 25 residents reviewed for resident assessment (Resident #1). This deficient practice was evidenced by:
On 8/17/22 at 1:30 PM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments.
The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed.
Resident #1 was observed to have a Discharge MDS with an Assessment Reference Date (ARD) of 5/13/22 and was due to be transmitted no later than 6/10/22. The MDS was not transmitted until 8/4/22.
According to the latest version of the Center for Medicare/Medicaid Services (CMS) - Resident Assessment Instrument (RAI) 3.0 Manual (updated October 2019) page 2-11 Discharge refers to the date a resident leaves the facility . The manual revealed on Page 2-17 A Discharge Assessment - return not anticipated (MDS) must be completed not later than discharge date + 14 days. The assessment must also be transmitted to the QIES ASAP system not later than the MDS completion + 14 days.
On 8/18/22 at 9:51 AM, the MDS Coordinator who was responsible for completing and submitting MDS assessments, confirmed that the Discharge MDS was not completed and submitted according to time sensitive federal guidelines.
On 8/18/22 at 12:34 PM, the surveyor informed the Administrator and the Clinical Lead Registered Nurse regarding the above concern. They did not provide any further information.
NJAC 8:39-11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident's call light was readily accessible for a resident who was dependent on staff for care. This deficient practice was identified for 2 of 25 residents reviewed for call bell/light (CBL), Resident #26 and #84, evidenced by the following:
1.) On 8/11/22 at 1:16 PM, the surveyor observed Resident #84's door closed. When the surveyor knocked on the door, the resident stated that she needed the nurse. The surveyor observed that the CBL was hanging toward the floor and out of reach for the resident. The surveyor asked the resident about the CBL. Resident #84 informed the surveyor that they didn't know that there was a CBL to use whenever they needed assistance. The surveyor handed the CBL to the resident. The surveyor observed Resident #84 press the CBL for assistance.
A review of the admission record for Resident #84 reflected that the resident was admitted to the facility with diagnoses which included but were not limited to Congestive Heart Failure, Atrial Fibrillation and Renal Failure associated with Renal Vascular Disease.
A review of the resident's significant change in status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 6/18/22, reflected that Resident #84 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. The MDS further reflected that the resident required extensive to total assistance with one staff assist in most areas of activities of daily living including transfers, bed mobility, eating and bathing.
2.) On 8/11/22 at 1:20 PM, the surveyor observed Resident #26's door closed. When the surveyor knocked on the door, the resident stated that they needed help. The surveyor observed that the CBL was under the pillow beside the side rails. The surveyor asked Resident #26 about the CBL, who then demonstrated the inability to reach it. The surveyor handed the CBL to the resident. The surveyor observed Resident #26 pressed the CBL to request for assistance.
At that time, a Licensed Practical Nurse (LPN), assigned to the resident, knocked and entered the resident's room stating, Why are all the call bell lights on now?
A review of the admission record for Resident #26 diagnoses which included but were not limited to Schizophrenia, Chronic Kidney Disease and Arteriosclerotic Heart Disease.
A review of the resident's quarterly MDS dated [DATE], reflected that Resident #26 had a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The MDS further reflected that the resident requires extensive to total assistance with one to two staff assist in most areas of Activities of daily living including transfers, bed mobility, eating and bathing.
A review of the facility's policy titled, Call Lights documented Staff will respond to call lights and communication devices promptly.
On 8/16/22 at 2:15 PM, the Administrator, and the Clinical Lead RN were made aware of the surveyor's observation. There was no further information provided.
NJAC 8:39-4.1(a)11; 31.1(b)

Based on observation, interview, record review, it was determined that the facility failed to maintain dignity during mealtime for a resident who needed assistance with eating. This deficient practice was observed for 1 of 25 residents reviewed, Resident #26 and was evidenced by the following:
On 8/8/22 at 12:25 PM, the surveyor observed Resident #26 in bed, eating lunch when she called the Certified Nurse's Aide (CNA) for assistance. The CNA entered the resident's room placing paper trash (removed from protected articles on the tray) ex. Straw paper covering) on top of the resident's meal tray. The surveyor further observed that the CNA was standing over the resident while feeding.
The surveyor interviewed the CNA on 8/9/22 at 12:30 PM, and specified that staff should be seated next to the resident while assisting them during feeding time.
Review of the admission record for Resident #26 documented diagnoses which included but were not limited to Schizophrenia, Chronic Kidney Disease and Arteriosclerotic Heart Disease.
The resident's quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 5/11/22, reflected that Resident #26 had a Brief Interview for Mental Status score of 8 out of 15, indicating moderate cognitive impairment. The MDS further reflected that the resident required set up help for meals.
A review of the facility's policy titled, Feeding a Patient/Resident indicated under #6. Sit in chair at eye level with the patient.
On 8/16/22 at 2:00 PM, the Administrator, and the Clinical Lead RN were made aware of the surveyor's observation. They both agreed that the CNA should be seated next to the resident when feeding.
N.J.A.C. 8:39-4.1(a)12