Based on observation, interview, record review, and review of pertinent facility documents, it was determined the facility failed to treat a resident with respect and dignity during podiatry care. This deficient practice was identified for 1 of 1 resident (Resident #243) reviewed. This deficient practice was evidenced by the following: On 6/26/25 at 10:52 AM, the surveyor observed Elder #243 (also known as Resident #243) was attending an activity with other six residents when the resident was pulled over to the side in the activity area by the Medical Assistant (MA) and the Podiatrist (physician). The surveyor observed the Podiatrist seated on a regular chair with gloves, Resident #243 seated on their wheelchair, and the MA with gloves. The Podiatrist attempted to remove the shoes of the resident in the open activity area with other residents and other facility staff around while the Podiatrist explained to Resident #243 that podiatry care will be provided. The resident declined and became agitated. On 6/26/25 at 10:55 AM, the surveyor immediately notified the Licensed Practical Nurse/Unit Manager (LPN/UM) of the above concerns and observations with the Podiatrist and the MA. The LPN/UM stated that they (Podiatrist and MA) should treat the resident inside a treatment room for privacy, and not in the activity area where people could see them. She further stated that she would talk to the Podiatrist and the MA. The surveyor reviewed the medical records of Resident #243, and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's disease unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate, and anxiety disorder unspecified. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 6/23/25, under Section C Cognitive Patterns reflected a brief interview for mental status (BIMS) score of 3 out of 15, which indicated that the resident's cognitive status was severely impaired. Section F Preferences for Routine & Activities revealed that favorite activities of the resident were coded 1, which reflected that it was very important to the resident. On 7/1/125 at 11:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The surveyor notified the LNHA and the DON of the above findings and concerns. On 7/2/25 at 11:40 AM, the survey team met with the LNHA and DON. The DON stated she spoke to the Director of Podiatrist and education was provided. On 7/2/25 at 1:15 PM, the surveyor in the presence of the Director of Recreation interviewed the Certified Nursing Aide (CNA). The CNA confirmed that Resident #243 was in the activity on 6/26/25, when the CNA observed the Podiatrist, and the MA took the resident from the activity session and sat within the area of the activity for podiatry consult. The CNA further stated that she also observed the surveyor at that time watching the activity and the Podiatrist. A review of the facility's Resident Dignity and Respect Policy dated 10/2001, that was provided by the DON, revealed, the facility staff will display respect for residents when communicating with, caring for, or talking about them as a constant affirmation of the resident's individuality and dignity as human beings . Procedure: 2. Schedules of daily activities allow maximum flexibility for residents to exercise choice about what they will do and when they will do it. 3. Medical and personal care is provided in a manner that maintains the privacy of their bodies and preserves their dignity . On 7/3/25 at 10:48 AM, the survey team met with the LNHA and DON, and there was no additional information provided by the LNHA and the DON. N.J.A.C. 8:39-4.1(a)(4,12,16,24), 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/26/25 at 10:52 AM, Surveyor #2 (S#2) observed Elder #243 (also known as Resident #243) was attending an activity with other six residents when the resident was pulled over to the side in the activity area by the Medical Assistant (MA) and the Podiatrist. S#1 observed that podiatry care was stopped after the resident declined to continue with podiatry care and became agitated. S#2 reviewed the medical records of Resident #243, and revealed: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's disease unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate, and anxiety disorder unspecified. A review of the most recent cMDS, with an ARD of 6/23/25, Section C Cognitive Patterns reflected a BIMS score of 3 out of 15, which indicated that the resident's cognitive status was severely impaired. Section N Medications revealed that the resident was taking an antipsychotic, antianxiety, and antidepressant meds. A review of the OSR revealed the following physician's orders (PO): -start date of 6/16/25, buspirone HCL (hydrocholoride) oral tab 10 mg, give 1 tab by mouth two times a day (2 x/day) for anxiety. -start date of 6/16/25, trazodone HCL oral tab 150 mg, give 1 tab by mouth one time a day (OD) for depression. -start date of 6/16/25, quetiapine fumarate oral tab 25 mg, give 1 tab by mouth three times a day (3 x/day) for Alzheimer's with behavioral disturbance. -start date of 6/17/25, escitalopram oxalate oral tab 5 mg, give 1 tab by mouth OD for depression. Further review of the medical records, revealed, there was no documented evidence that consent was obtained, or the RR was notified and agreed in writing when psychoactive meds (type of drug that interacts with the central nervous system, altering brain function and resulting in changes in awareness, thoughts, mood, and behavior. These meds can be used to treat various mental health conditions, including anxiety, depression, schizophrenia, and bipolar disorder) were ordered. On 7/1/25 at 9:16 AM, S#2 interviewed the Psychiatric Nurse Practitioner (PNP), who informed S#2 that she asked for a consent prior to starting the resident with a new psychoactive meds or if there will be a change in their psychoactive meds. The PNP stated that if the resident was cognitively impaired, she will ask for a consent from the RR. She further stated that she was unaware what happened when the resident was a new admit and had started psychoactive meds prior to PNP's consult who was responsible for obtaining a consent. On 7/1/25 at 9:30 AM, S#2 interviewed the LPN/UM regarding the process of obtaining a consent for psychoactive meds. The LPN/UM stated that there was no paper consent that the facility asked the resident or the RR to sign or obtained for use of psychoactive meds, when the resident was being admitted , it was the responsibility of the Psychiatrist to obtain a consent from the resident or RR via verbal consent and then document in their notes. S#2 then asked the LPN/UM when the resident admitted , was the Psychiatrist present or sees the resident immediately that day prior to administering the psychoactive meds, and the LPN/UM responded no. S#2 then asked the LPN/UM what happened, did the resident not take the meds because they must wait for the Psychiatrist to come to see them and call RR for consent. The LPN/UM confirmed that there was no documented evidence that the consent was obtained prior to administering the above psychoactive meds on 6/16/25 and 6/17/25, and that the PNP initial consult was on 6/25/25. On 7/1/125 at 11:56 AM, the survey team met with the LNHA and the DON. S#2 notified the LNHA and the DON of the above findings and concerns. On 7/3/25 at 10:48 AM, the survey team met with the LNHA and DON, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-4.1(a)2 Based on observation, interview, and record review, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving psychoactive medications (meds). This deficient practice was identified for 2 of 5 residents (Resident #124 and Resident #243), reviewed for unnecessary meds. This deficient practice was evidenced by the following: 1. On 6/26/25 at 11:46 AM, Surveyor #1 (S#1) observed Elder #124 (also known as Resident #124) in the bed sleeping with the Resident's Representative (RR) inside the room. On 6/26/25 at 3:00 PM, S#1 reviewed the medical records of the resident and revealed: A review of the admission Record (AR; an admission summary) reflected diagnosis which included but was not limited to; dementia in other disease classified elsewhere (loss of cognitive functioning), unspecified severity, with agitation, adjustment disorder with anxiety, and mood disorder. A review of the comprehensive Minimum Data Set (cMDS), an assessment tool which facilitates the plan of care, with an assessment reference date (ARD) of 6/8/25, revealed a Brief Interview of Mental Status (BIMS) score of 0 out of 15, which indicated that resident's cognition was severely impaired. A review of the resident's care plan (CP) revealed, the resident had impaired cognitive function or impaired thought processes related to (r/t) dementia; had anxiety r/t behaviors such as calling out, kicking and biting staff; and anti-psychotic (seroquel) use for mood disturbance; resident uses antidepressant r/t withdrawal and history of depression remeron 15 mg (milligram) half a tab. A review of the Order Summary Report (OSR), for psychotropic medication (med) orders were as followed: -ordered date 7/1/24, xanax oral tablet (tab) 0.25 mg (alprazolam), give 1 tab by mouth every 8 hours (hrs) as needed (PRN) for anxiety, until 7/3/2024 x 14 days. -ordered date 8/2/24, xanax oral Tab 0.25 mg, give 0.25 mg by mouth every 8 hrs PRN for anxiety, until 8/30/2024. -ordered date 9/23/24, xanax oral tab 0.25 mg, give 1 tab by mouth every 8 hrs PRN for anxiety, end date 9/23/24. -ordered date 9/23/24, xanax oral tab 0.25 mg, give 1 tab by mouth every 8 hrs PRN for anxiety for 60 days, end date 11/12/24. -ordered date 11/12/24, xanax oral tab 0.25 mg, give 1 tab by mouth every 8 hrs PRN for anxiety for 60 days, end date 11/26/24. -ordered date 1/27/25, xanax oral tab 0.25 mg, give 1 tab by mouth every 8 hrs PRN for agitation/restlessness, until 2/9/2025. -ordered date 1/31/25, xanax oral tab 0.25 mg, give 1 tab by mouth two times a day for anxiety, end date 2/28/25. -ordered date 3/25/25, xanax oral tab 0.5 mg, give 1 tab by mouth every 8 hrs PRN for anxiety, end date 3/27/25. -ordered date 4/18/25, seroquel oral tab 25 mg (quetiapine fumarate), give 1 tab by mouth one time a day for behavioral disturbances, discontinued (d/c) 5/9/25. -ordered date 4/19/25, seroquel oral tab 25 mg, give 0.5 tab by mouth two times a day for behavioral disturbances, d/c 5/9/25. -ordered date 12/10/24, remeron oral tab 15 mg (mirtazapine), give 0.5 tab by mouth at bedtime (HS) for depression, give 0.5 tab = 7.5 mg, end date 2/28/25. A review of the Psychiatry Nurse Practitioner (PNP) consult notes on 5/20/25, revealed, the resident with history of impulsive behaviors and anxiety. The other consult notes of PNP were dated 6/18/24 and 8/7/24. Further review of the resident's medical records revealed, there was no documented evidence that the above psychoactive meds consents were obtained prior to administration of meds. On 6/30/25 at 11:54 AM, S#1 interviewed the License Practical Nurse/Unit Manager (LPN/UM) in the [NAME] Unit, who stated that it was the PNP who obtain consents from the RR for use of psychotropic meds. The LPN/UM further stated, We do not use any consent form, I am not sure why we do not do that. On 7/1/25 at 11:30 AM, S#1 requested from the LPN/UM for any documentation that the RR gave consent for use of seroquel prior to administration including consents for any changes of dosages. On 7/1/25 at 12:21 PM, the Director of Nursing (DON) in the presence of the License Nursing Home Administrator (LNHA) stated, The process for psychoactive meds, the nurse will notify the RR prior to administering psychoactive meds, and the PNP will also notify the RR. The DON further stated that We should notify RR that there was a change in dosage and should be documented in progress notes (PN). The DON confirmed, We do not have an actual consent form for psychoactive meds. He further stated that the psychiatrist was at the facility twice a week. He added that whenever there was a new admit, We just continue what was from the hospital. The DON also stated the We should obtain a consent. Surveyor #2 (S#2) asked if the regulations were being followed by the facility, and the DON confirmed they were not following the regulations. On 7/2/25 at 12:00 PM, the Assistant Director of Nursing (ADON) was able to provide facility's documentation of RR's consent for use of psychoactive meds except for use of seroquel on 4/18/25 and 4/19/25. On 7/2/25 at 1:07 PM, S#1 requested from the DON to provide documentation that the RR was informed prior to administration of xanax on 7/1/24 (including seven orders of med changes), remeron on 12/10/24, and seroquel order changes for 4/18/25 and 4/19/25, and the DON stated that he would get back to S#1. On 7/3/25 at 9:29 AM, the ADON confirmed that the facility did not have documentation that consent was obtained from the RR for the above concern dates (4/18/25 and 4/19/25). S#1 asked the ADON, should consents had been obtained for psychotropic orders and med changes, and the ADON confirmed, We should have informed the RR. On 7/3/25 at 10:06 AM, S#1 interviewed the Licensed Practical Nurse (LPN) in [NAME] Unit, who stated that consent should have been obtained prior to administering psychoactive meds and notify the family of med changes. A review of the facility's Psychotropic Medications Policy dated 8/2019, that was provided by the DON, revealed, Consent: The resident or legal representative will be informed of any new prescribed psychotropic meds and/or changes to med. On 7/3/25 at 10:50 AM, the survey team met with the DON and Licensed Nursing Home Administrator (LNHA), and S#1 notified them of the above findings and concerns. S#1 asked what the expectation was for psychotropic med consent, and the DON stated, What we are doing right now, any changes or renewals we have to notify the RR and get consent even when we are holding the med like the Xanax, we still need to notify the RR. The LNHA stated, We are going to look at our process.

Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 1 of 35 residents (Resident #99) call bell was within reach and able to use to accommodate the residents' needs. This deficient practice was evidenced by the following: On 6/26/25 at 1:22 PM, while conducting the initial tour of the facility, the surveyor observed Elder #99 (also known as Resident #99) in their room, sleeping in a wheelchair (w/c), which was positioned next to the resident's bathroom. The surveyor observed the call bell cord on the resident's bed with the call bell device hanging between the mattress and footboard of the bed, and not within the reach of the resident if needed to use. The surveyor reviewed the electronic medical record (eMR) of Resident #99, and revealed the following: A review of the admission Record (an admission summary) reflected that the resident had diagnoses of but not limited fracture of right femur (a break in the thigh bone), type 2 diabetes (high blood sugar), and difficulty in walking. A review of Resident #99's comprehensive minimum data set (cMDS), an assessment tool, with an assessment reference date (ARD) of 6/12/25, reflected that the resident had a brief interview for mental status (BIMS) score of 8 out of 15, which indicated the resident had moderate cognitive impairment. Further review of the cMDS revealed under section GG that Resident #99 required substantial/maximum assistance or was dependent on a helper for self-care and mobility. A review of the resident's Care Plan (CP) dated 6/5/24, a document that lists risks, goals and interventions for an individual resident, revealed a focus that the resident was at risk for falls due to body weakness, impaired balance and limited mobility, and a focus that the resident decline in ability to perform activities of daily living (ADLs) and an intervention that the resident's call light was within reach. A review of the resident's Physical Therapy (PT) Evaluation and Plan of Treatment notes, revealed, a reason for referral that reflected but not limited to, new onset of decrease in strength, functional mobility, reduced ability to safely ambulate, and reduced balance. On 6/30/25 at 11:31 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the unit where Resident #99 resides. The surveyor asked the LPN how resident call bells should be placed. The LPN stated that call bells should always be within the resident's reach and clipped to a w/c if applicable. On 6/30/25 at 11:39 AM, the surveyor interviewed the LPN/Unit Manager (LPN/UM) for the unit where Resident #99 resides. The surveyor asked the LPN/UM about call bells, and the LPN/UM stated the call bells should be within reach of the resident depending on the resident ability. On 7/1/25 at 11:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) to discuss the above concerns. The surveyor asked the DON about call bell placement, and the DON stated that call bells should be within reach when the resident was in room and be able to activate it. The surveyor showed the DON and LNHA a picture of the surveyor's observation. The DON stated that the call bell placement was not acceptable. On 7/2/25 at 1:09 PM, the surveyor interviewed the Director of Therapy (DOT). The DOT stated that Resident #99 was currently on Skilled PT, and that the resident was not independent with ADLs. The facility provided no further pertinent information. A review of the facility's Call Bell Policy and Procedure, dated 11/28/24, the policy reflected, under 4. Procedure, Call Bell Use and Accessibility, Call bells must be placed within reach of each resident at all times. NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure accurate documentation of a Resident's advance directives (AD) for 1 of 5 residents, (Resident #99) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Elder #99 (also known as Resident #99), which revealed: A review of the admission Record (an admission summary) reflected that the resident had diagnoses of but not limited to; fracture of right femur (a break in the thigh bone), type 2 diabetes (high blood sugar), and difficulty in walking. A review of Resident #99's comprehensive minimum data set (MDS), an assessment tool, with an assessment reference date (ARD) of 6/12/25, reflected that the resident had a brief interview for mental status (BIMS) score of 8 out of 15, which indicated the resident had moderate cognitive impairment. A review of the personalized Care Plan (CP) dated 6/5/24, and the resident's baseline CP summary, neither which reflected any documentation of the resident's AD, code status or other resident wishes for life saving measures. A review of the resident's Social Services Resident assessment dated [DATE], did not reflect any documentation of the resident's AD, code status or other resident wishes for life saving measures. A review of the resident's Physician Order Sheet (POS), a listing of the resident's medication and medical orders, did not reflect any documentation of the resident's AD, code status or other resident wishes for life saving measures. A review of the resident's Physician Progress Notes (PPN), revealed a Physician's Note (PN), dated 6/24/25, that reflected the words Code Status with no other description. A review of the resident's paper chart, did not reveal any documentation of the resident's AD, code status or other resident wishes for life saving measures. Further review of the medical records revealed that there was no documented evidence that the resident or Resident Representative (RR) was educated on the AD process. On 6/27/25 at 11:22 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) for the unit that Resident #99 resided on. The surveyor asked the LPN/UM where the AD, code status or other resident wishes for life saving measures would be located and what the procedure was. The LPN/UM stated that it should be in the paper chart under the tab labeled Advance Directive and the procedure was to ask the resident or RR wishes and to provide education and related paperwork, and it should be followed up during the CP meeting. On 6/30/25 at 12:39 PM, the surveyor interviewed the Social Worker (SW) assigned to Resident #99. The surveyor asked the SW about the procedure for AD, code status or other resident wishes for life saving measures when residents were admitted . The SW stated that upon admission, if there were no related documents from the hospital or other facility, they will ask resident or family at a CP meeting, provide education and execute or amend the forms if necessary. The SW stated that nursing usually checks as well. On 6/30/25 at 1:20 PM, the surveyor reviewed Resident #99's electronic medical record (eMR). The eMR revealed, in the PPN, a Plan of Care Note (POCN) authored by the SW assigned to resident #99. The POCN reflected that it was a Late Entry, with an effective date of 6/11/25. Further review of the POCN revealed the day and time the note was created which reflected 6/30/25 at 12:54 PM. This reflected that the SW created and entered the note immediately after surveyor inquiry regarding Resident #99. The note reflected AD including POLST form reviewed. On 7/01/25 at 11:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss concerns. The surveyor asked the DON about the procedures for AD, code status or other resident wishes for life saving measures. The DON stated that Social Services or the nursing staff should communicate with the resident or RR on the wishes for AD life saving measures and it should be documented within 24 hours. The surveyor asked if documenting it as a late entry and back dating several weeks an expectation. The DON stated, no, it should not be back dated. The facility did not provide any further pertinent information. A review of the facility's Advance Directives and POLST (Provider Orders for Life-Sustaining Treatment, is a medical order that allows individuals with serious illnesses to specify their preferences for medical treatment during emergencies when they cannot communicate their wishes) Policy with a revised date of 7/2017, revealed the policy reflected under Procedure: 1. Prior to or upon admission to the facility, Social Services/Admissions will ask the resident/RR about existence of any AD .2. If the resident has an AD .will become part of the medical record. 3. If the resident does not have an AD, .Social Services .will provide .information N.J.A.C. 8:39-9.6(b)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a physician's order for as needed (PRN) psychotropic drug was limited to 14 days for 1 of 5 residents (Resident #66) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 6/26/25 at 11:16 AM, the surveyor observed Elder #66 (also known as Resident #66) sitting up in bed. A review of Resident #66'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 sudden and rapid decline in kidney function), encephalopathy (a broad term for any brain disease that alters brain function or structure) and psychosis (a mental state where a person loses touch with reality, experiencing symptoms like hallucinations, delusions, and disordered thinking). A review of Resident #66's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 6/10/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #66's cognition was severely impaired. A review of Resident #66's June 2025 electronic Medication Administration Record (eMAR) revealed a Physician order (PO) with a start date of 6/1/25, for lorazepam (medication (med) for anxiety) 0.5 mg (milligrams), give 1 tablet by mouth every 4 hours PRN for anxiety. Further review of the above PO did not have a stop date of 14 days. On 6/30/25 at 10:22 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) regarding an order for lorazepam PRN. The LPN stated that sometimes the order was a standing order (given on a set schedule) but for the most part it was PRN. The LPN also stated that usually the order for PRN was for 14 days the first time it was ordered. She added that if the resident did not use it then it would be discontinued and that if the resident used it then it would be renewed for 14 more days. On 6/30/25 at 10:27 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of Kaplan 1 unit regarding an order for lorazepam PRN. The RN/UM stated that lorazepam PRN was usually ordered for 14 days unless someone wrote the order for 30 days. She stated that it usually was for 14 days. The RN/UM stated that when it was a hospice recommendation it was usually for 14 days, unless it was specified for more than that. She stated that the regular physician was notified of the recommendation and then approve the order. On 6/30/25 at 10:38 AM, the RN/UM stated that she verified with the Director of Nursing (DON) and the lorazepam PRN order should be for 14 days. On 6/30/25 at 11:39 AM, the RN/UM stated that she spoke to the hospice provider and notified them that it should be only 14 days and then review if the resident still needed it. On 7/1/25 at 11:25 AM, the surveyor interviewed the DON regarding PRN order for lorazepam. The DON stated that for a new order of lorazepam PRN, it should be for 14 days. On 7/1/25 at 11:56 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #66's PRN order for lorazepam did not have a 14 day stop. The DON stated that the order was changed to 14 days. On 7/2/25 at 11:43 AM, in the presence of the LNHA, the DON stated that it was the hospice nurse that ordered the med and that after surveyor inquiry the order was changed to 14 days. He added that he spoke with the Director of hospice and that she was inservicing the hospice nurses. The DON stated that he was inservicing the facility nurses. The LNHA did not provide any additional information. A review of the facility's Psychotropic Medications and Gradual dose reductions, Psychotropic PRN orders Policy dated 11/2017, included the following: Procedure: In certain situations, psychotropic medications (meds) may be prescribed on a PRN basis, such as while the dose is adjusted, to address acute or intermittent symptoms, or in an emergency. However, residents must not have PRN orders for psychotropic meds unless the med is necessary to treat a diagnosed specific condition . The Table below explains additional limitations for PRN psychotropic (other than antipsychotic meds) . Type of PRN order: PRN orders for psychotropic Time Limitation: 14 days Exception: Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Required Actions: Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. N.J.A.C. 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #183210 Based on interview and record review, it was determined the facility failed to; a.) ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider, b.) provide and document an update to the resident and resident's representative (RR) about discharge planning to ensure sufficient preparation for a safe and orderly discharge from the facility, and c.) ensure completion of a physician's discharge summary and the physician was involved in the resident's discharge. This deficient practice was identified for 1 of 2 residents, (Resident #343), reviewed for discharge process. The deficient practice was evidenced by the following: On 6/30/25 at 9:19 AM, the surveyor reviewed the hybrid medical records (combination of electronic and paper medical records) of Elder #343 (also known as Resident #343). The resident had a facility-initiated discharge (d/c) and was no longer in the facility. A review of the admission Record (an admission summary) documented that the resident had diagnoses that included but were not limited to; type 2 diabetes, hypertension (high blood pressure), and mild cognitive impairment. A review of the quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference (ARD) date of 1/28/25, revealed a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. A review of the personalized care plan (CP) revealed that there was no documented evidence that the resident had a CP for discharge. A review of the Physician's progress note (PPN) dated 2/3/25, indicated the physician visited with the resident. The note further revealed documentation of the resident being very distressed about leaving [facility] and that the resident stated, there would be a decision from court on 2/6/25. There was no documentation in the PPN that the resident was being d/c to another facility on 2/4/25. There was no PPN by the physician after 2/3/25 in the hybrid medical records. A review of the Health Status Note (HSN) dated 2/4/25, with an effective time of 9:26 AM, by the Licensed Practical Nurse (LPN) documented the resident was transferred to the receiving facility in the morning and left the unit at 8:40 AM after eating breakfast. The note indicated the resident was stable and not distressed. A review of the HSN dated 2/4/25, with an effective time of 11:27 AM, by the Licensed Nursing Home Administrator (LNHA) documentation included the following: -The resident was transferred to the receiving facility this morning. -The resident and their RR were aware of upcoming d/c related to initial 30-day facility-initiated d/c since 7/31/24. -The resident appealed d/c and the adopted ruling of the resident's d/c to the receiving facility was finalized on 1/31/25. The had been sending all paperwork to the resident and the RR. The LNHA also provided all paperwork to the resident court was sending all paperwork to the resident and their RR. -The LNHA provided all paperwork to the resident this morning and the resident threw the paperwork on the floor. The LNHA documented that Copies sent to the [RR] instead. Transfer to [receiving facility] complete. A review of the HSN dated 2/4/25, with an effective time of 2:57 PM, by the LPN documented the physician was notified of the resident's d/c. There were no additional progress notes (PN) after the last above entry. A review of social services notes (SSN) revealed the last note was documented on 7/31/24, which indicated the Director of Social Services (DSS) and another social worker (SW) met with the resident to issue a 30-day facility-initiated d/c notice with a d/c date of 8/30/24, and their right to appeal the d/c and timeframe for their appeal to be filed. A Social Services Resident assessment dated [DATE], by a SW revealed no documentation related to awaiting court ruling or d/c status. There were no additional SSN or assessments after 1/28/25. A physician's order (PO) dated 2/4/25, and timed 9:19 AM, indicated Patient Transferred to [receiving facility]. A New Jersey Universal Transfer Form (NJUTF) to the receiving facility which was dated 2/4/25, and timed 8:40 AM. Under facility contact, a first name was written, no title or unit indicated. Attached documents checked off on NJUTF were face sheet, MAR [Medication Administration Record], medication reconciliation, POS [Physician Order Summary], diagnostic studies, and labs (laboratory). Further review of the medical records, including information from the PO dated 2/4/25, revealed, the PO was entered at 9:19 AM, after the resident left the facility at 8:40 AM, as seen on the 2/4/25 HSN of the LPN. A review of the paper medical records revealed the following: On 6/30/25 at 10:49 AM, the surveyor interviewed the LPN about Resident #343's d/c. The LPN confirmed the resident's d/c was facility-initiated and the resident did not want to leave. The surveyor asked if the resident's physician was aware prior to the resident's d/c. The LPN replied yes, the physician was. The surveyor asked about the morning the resident was d/c. The LPN stated Resident #343 was in their wheelchair and transported by staff to the lobby to be picked up by ambulance transport. The surveyor asked the LPN for resident d/c, if they were usually brought downstairs to be picked up by transport. The LPN replied that usually transport comes to the unit to pick up the resident and that the Director of Nursing (DON) instructed staff to bring the resident downstairs for d/c after breakfast. The LPN further stated the resident was aware that they were being brought downstairs for d/c and Resident #343 was cooperative. The surveyor asked the LPN if the resident had any belongings and the LPN stated the resident did not have many belongings, their belongings stayed in the room and was not sure what happened after. On 6/30/25 at 11:05 AM, the surveyor interviewed a Registered Nurse/Unit Manager (RN/UM) about Resident #343's d/c. The surveyor asked the RN/UM when the resident and RR were made aware of their d/c to another facility on 2/4/25. The RN/UM stated I'm not sure. The RN/UM could not recall when they were made aware, and the SW would have further information. The surveyor asked if the physician was aware resident would be d/c on 2/4/25. The RN/UM stated the physician was aware of the d/c. On that same date and time, the surveyor asked the RN/UM about the day the resident was d/c. The RN/UM stated the resident was eating breakfast in the dining room, and after they were finished with their meal a certified nurse aide (CNA) transported the resident to lobby for d/c to the receiving facility by ambulance transport. The surveyor asked if Resident #343 was made aware they were being d/c prior to being taken downstairs. The RN/UM stated the resident was aware that they were being taken to the lobby for d/c to another facility. The surveyor asked if the resident left with all their belongings. The RN/UM stated the resident did not leave with all of their belongings and could not speak to what happened since she did not pack the resident's belongings. On 6/30/25 at 11:30 AM, the surveyor interviewed the DSS about the resident's facility initiated d/c. The DSS stated that after multiple discussions with the resident and RR about non-payment and potential resolutions, the administration provided the resident with a 30-day d/c notice in July 2024. The DSS stated she discussed with the resident other facility options based on resident preferences, and the resident was referred to the receiving facility. The DSS further explained, Resident #343 appealed the facility's 30-day d/c notice which went to courts with a final decision report received at the end of January 2025. The DSS stated the Chief Executive Officer (CEO) and LNHA notified her that the resident would be d/c on 2/4/25. The surveyor asked if there was any documentation of the resident and RR being updated of the ruling after it was received and that the resident would be d/c on 2/4/25, and the DSS stated she would have to review to provide further information. At that same time, the surveyor asked the DSS about the day of d/c. The DSS stated she did not see the resident on day of d/c as she was not present during the d/c. The DSS recalled 1-2 hours after the resident left she did assist in supervising the packing and itemizing of the resident's belongings to ensure all items were accounted for to be sent to the resident. The surveyor asked if the physician was aware of the resident's d/c. The DSS replied yes but nursing would have more information. The DSS stated there were no concerns with the resident's d/c on 2/4/25. The surveyor requested from the DSS supportive documentation related to the resident's facility-initiated d/c, the physician d/c summary and any d/c documentation for the resident's d/c to the receiving facility. On 6/30/25 at 12:07 PM, the DSS provided a folder which included the following: a timeline of the resident's facility initiated d/c and other documentation about the court proceedings and a final agency decision by the Department of Human Services which was dated 1/31/25, and adopted the initial decision based on initial 30 day d/c notice dated 7/31/24. The timeline of the d/c indicated the resident and RR were made aware on 1/31/25 of ruling and resident to be d/c to receiving facility on 2/4/25. The DSS was unable to provide documented evidence that the facility had a meeting or notified the resident or the RR of the actual d/c on 2/4/25. On 6/30/25 at 1:06 PM, the surveyor interviewed the LNHA who stated on 1/31/25, the day the facility received the ruling he personally let the resident and RR know the resident would be d/c on 2/4/25, and resident did not want leave. The LNHA stated the day of the d/c the resident was brought to the lobby by a CNA and the LNHA met with the resident to explain again that they would be d/c to the receiving facility. The LNHA further explained he provided Resident #343 copies of the papers, the ruling paperwork, and the resident threw them on the floor. The LNHA stated he mailed the paperwork to the RR. At that time, the surveyor notified LNHA of the concern there was no physician d/c summary in the resident's medical record, no d/c summary documentation for the receiving facility, and no documentation of update to resident and RR about the resident's d/c on 2/4/25. The LNHA acknowledged there should be a physician d/c summary even for unplanned d/c and documentation about the resident's d/c. On 7/1/25 at 9:06 AM, the DON provided a physician d/c summary (PDS) for Resident #343 after surveyor's inquiry. The surveyor asked the DON where the PDS was located. The DON stated the facility received the PDS from the physician's office. The DON acknowledged the information was not in the resident's medical record. On that same date and time, the surveyor asked the DON about a d/c summary, and any additional documentation related to the resident's d/c to the receiving facility. The DON stated that resident's being transferred to another facility copies of medical record documentation would be sent with them and the nurses would complete a summary in the electronic medical record for a d/c. The DON stated he would follow up to provide additional information. On 7/1/25 at 9:44 AM, the Medical Records/Registered Nurse (MR/RN) provided email documentation between the SW and the receiving facility contact which included medical record documentation. The surveyor asked the MR/RN if there would be any documentation in the resident's medical record of a d/c summary, communication with the receiving facility, and notification to resident and RR about d/c. The MR/RN stated the NJUTF was in the paper medical record and the DSS emailed to the receiving facility the resident medical record documentation. The MR/RN further explained residents being transferred to another facility, the needed information would be sent with resident to the receiving facility at time of d/c. There was no additional information provided at this time. On 7/1/25 at 11:40 AM, the surveyor further reviewed the PDS provided by the DON which revealed the physician documented 6/30/25 Asked to complete d/c summary .I was made aware of d/c after the fact though I was aware that there were court proceedings. On 7/1/25 at 11:56 AM, the surveyor notified the LNHA and the DON of the concern with Resident #343's PDS which was not in the medical record. The DON acknowledged it would be expected for a PDS to be in the resident's medical record. The surveyor notified facility management of the physician's documentation in the DPS of being aware after the fact of the resident's d/c although aware of court proceedings. The DON and LNHA stated that the physician was aware that Resident #343 would be d/c to another facility after the ruling was received. The LNHA added that the physician may not have been aware of the specific date. The DON stated that staff spoke with the physician. The surveyor informed the facility management also that the nurses' note that indicated the physician was notified of the resident's d/c was dated and timed after the resident had been d/c from the facility. There was no further response by facility management at this time. At that same time, the surveyor notified the DON and LNHA of the concern that there was no documentation in the resident's medical record regarding communication of d/c to the receiving facility. The LNHA and DON stated the DSS emailed documentation to the receiving facility. The surveyor acknowledged the provided emails provided however there was no documentation in the resident's medical record of any d/c summary documentation which would have included information sent to the receiving facility, medication reconciliation completed by or with the physician, and plan of care; there was no verbal response at this time and facility to provide information Furthermore, the surveyor notified the LNHA and the DON regarding the concern there was no documentation in the medical record of the resident/RR was made aware on 1/31/25, that the resident would be d/c on 2/4/25. The surveyor requested any documentation to the resident/RR were made aware on 1/31/25, that resident would be d/c on 2/4/25. The LNHA stated that they would check and that he primarily communicated directly with the resident and with the RR verbally via phone. On 7/1/25 at 7:58 AM, the LNHA provided the surveyor a copy of his HSN entry on 2/4/25. The LNHA stated all he could show was that he documented resident and family have been aware of upcoming transfer and further stated .I know it does not specify 2/4/25 . The LNHA stated he documented provided all paperwork which would include about d/c. On 7/2/25 at 11:40 AM, the LNHA and the DON met with the survey team. The DON stated we have in the electronic medical records for nurses to complete a d/c summary which includes instruction and education regarding d/c. The DON stated the nurse did not complete the d/c summary. The DON stated in-service education was initiated to staff to ensure completion of a d/c summary. There was no additional information provided by facility management. A review of the facility's Discharge and/or Transfer of Resident Policy dated October 2001, revealed under Policy: .It is imperative that all transfers and actions taken are documented in the resident's medical record . Under Procedure revealed: . 7. When transfer or d/c is to outside facility or community setting, preparation may include . 7.4 information on date, time, and method of transportation to the new facility/community setting . 7.5 addressing adjustment issues related to transfer/discharge . A review of the facility's Discharge Documentation Policy with a last revised date of February 2013, under Policy revealed: Pertinent information will be documented in the clinical record at the time of d/c from the [facility]. Under Procedure of the policy revealed: . 2. Closed records will contain a concise summary of pertinent medical nursing and social information to reflect the resident's status at the time of d/c and to insure that contents comply with applicable state and federal regulations and accepted professional practice standards . 5. The d/c summary should be complete and signed by appropriate disciplines . NJAC 8:39-4.1; 27.1 (a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to update and revise a comprehensive care plan, specifically discontinue a care plan when a medication was discontinued, in a timely to manner for 1 of 38 residents (Resident #66) reviewed. This deficient practice was evidenced by the following: On 6/26/25 at 11:16 AM, the surveyor observed Elder #66 (also known as Resident #66) sitting up in bed. A review of Resident #66'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 sudden and rapid decline in kidney function), encephalopathy (a broad term for any brain disease that alters brain function or structure), and psychosis (a mental state where a person loses touch with reality, experiencing symptoms like hallucinations, delusions, and disordered thinking). A review of Resident #66's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 6/10/25, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated that Resident #66's cognition was severely impaired. A review of Resident #66's comprehensive care plan (CP) included the following focus area: The resident uses anti-anxiety medications (meds) xanax r/t (related to) anxiety disorder with an initiated date of 1/20/25, with the following intervention of administer anti-anxiety meds as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT (every shift). Further review indicated the following: 2/19/25 Readmit, cont. CP (continue care plan) Readmit 3/26/25, cont. CP Readmit 4/24/25, cont CP Readmit 5/2/25, cont CP A review of Resident #66's Order Summary Report (physician's orders) did not include a physician's order (PO) for the anti-anxiety medication (med) xanax. Further review of the electronic medical record included a PO for xanax that was discontinued (d/c) on 3/5/25. On 6/30/25 at 11:27 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of Kaplan 1 unit regarding CP. The RN/UM stated that after a resident was readmitted after after a hospitalization, the CP was reviewed and any changes were added or deleted. The surveyor asked the RN/UM to review Resident #66's CP. The RN/UM stated that the resident had been hospitalized a few times. The RN/UM confirmed that Resident #66's CP for xanax was still active and that it should not have been. The RN/UM confirmed that the PO for xanax was d/c on 3/5/25, and that the CP should have been revised. On 7/1/25 at 11:26 AM, the surveyor interviewed the Director of Nursing (DON) regarding Resident #66's CP. The DON stated that the CP would be revised for new medications (meds) or when a med was d/c. The DON stated that Resident #66's CP should have been revised and the xanax CP should have been removed. On 7/1/25 at 11:57 AM, the surveyor notified the Licensed Nursing Home Administrator (LNHA) and DON the concern that Resident #66 had a CP related to xanax and the resident had not received xanax since 3/5/25, and the CP had been reviewed after returning from a hospitalization in March 2025, April 2025, and May 2025. On 7/2/25 at 11:44 AM, in the presence of the LNHA, the DON stated that Resident #66's CP related to xanax was d/c after surveyor's inquiry. The LNHA did not provide any additional information. A review of the facility's Care Plan/Comprehensive person centered care planning Policy with a revised date of 12/2017, included the following: Policy: A comprehensive person centered CP shall be developed for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing and psychosocial needs. Procedure: 1. The interdisciplinary assessment team, in coordination with the resident and their representative (sponsor), develops and maintains a comprehensive person centered CP for each resident. 2. The comprehensive person centered CP has been designed to: The CP address the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline 4. CPs are revised as changes in the resident's condition dictate. Reviews are made at least quarterly. N.J.A.C. 8:39-11.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received care consistent with professional standards of practice, by failing to identify a duplicate physician order and following the provider's recommendations, for 1 of 5 residents, (Resident #70), reviewed for pressure injury. The evidence was as follows: 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 6/26/25 at 10:30 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) in the [NAME] unit nursing station. The LPN/UM informed the surveyor that Elder #70 (also known as Resident #70) had a facility acquired pressure injury to the sacrum, and she was unsure what stage, and would get back to the surveyor. She further stated that the resident was on tube feeding (TF). On 6/26/25 at 10:43 AM, the surveyor observed Resident #70 lying on air mattress with oxygen via nasal cannula attached to a concentrator at 2 LPM (liters per minute) and TF infusing at 80 ml/hr (milliliters/hour) with container of glucerna at 800 ml left in the container hung on a pole. The surveyor reviewed the medical records of Resident #70, and revealed: The admission Record (an admission summary) revealed that the resident was admitted to the facility with the following medical diagnoses that were not limited to; Parkinson's disease without dyskinesia (refers to the condition where individuals experience the symptoms of Parkinson's but do not exhibit the involuntary movements often associated with long-term treatment, particularly with levodopa), without mention of fluctuations, cognitive communication deficit, and dysphagia (difficulty in swallowing) unspecified. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/21/25, revealed a brief interview for mental status (BIMS) score of 0 out of 15, which reflected that the resident's cognition was severely impaired. A review of the sacrum pressure injury wound timeline that was provided by the Director of Nursing (DON) revealed that the resident's facility acquired wound was identified on 1/15/24, healed on 3/12/24, re-opened on 12/23/24 as unstageable (a type of wound that cannot be accurately assessed due to the presence of necrotic tissue or eschar, making it difficult to determine the depth and extent of tissue damage) wound, healed on 2/24/25, and re-opened at stage 3 (pressure ulcers are characterized by full-thickness skin loss, potentially extending into the subcutaneous tissue, resembling a crater, and requiring immediate medical attention for proper treatment and healing) on 6/21/25. A review of the wound consultation report, date of service 6/24/25, and was electronically signed by the Wound Doctor (WD) on 6/29/25, revealed the following: -stage 3 pressure ulcer (also known as pressure injury) to sacrum with measurements of 0.8 (length) x 0.8 (width), x 0.2 (depth) by centimeters, with minimum amount of serous (a clear to yellow fluid that leaks out of a wound. It's slightly thicker than water. This type of wound drainage is a normal part of your body's healing process), and tissue exposed subcutaneous. -Treatment Recommendations: the plan for the pressure ulcer was to cleanse the area with normal saline (NS). Primary Dressing: honey (medical grade) gel Secondary Dressing: gauze, bordered foam dressing. This treatment will be done daily and as needed (PRN) until discontinued (d/c) . -WD comments: the resident presented with reopened stage 3 pressure injury to their sacrum .No signs or symptoms of infection .d/c prior wound care orders, please see new recommendations. A review of the Order Summary Report (OSR), with current physician orders (PO) revealed the following: -a PO with a start date of 10/30/23, apply periguard (use to treat skin irritations associated with incontinence or as part of a comprehensive prevention program) post hygienic wash every day and evening shift for skin prevention. - a PO with a start date of 10/30/23, apply periguard (use to treat skin irritations associated with incontinence or as part of a comprehensive prevention program) post hygienic wash every shift for pericare. -a PO with a start date of 2/5/25, zinc oxide external paste 20%, apply to sacrum topically PRN for wound prevention, apply every incontinence care. - a PO with a start date of 2/5/25, zinc oxide external paste 20%, apply to sacrum topically every shift for wound prevention. -a PO with a start date of 6/22/25, medihoney wound/burn dressing external gel apply to sacrum topically every day shift for wound care, cleanse sacrum with NS, pat dry, and over with optifoam (advanced wound care products designed for effective management of various types of wounds) daily. The above PO were transcribed to the electronic Treatment Administration Record (eTAR) for June 2025. Further review of the above medical records revealed that there was no documented evidence that the facility staff identified the duplicate orders for periguard and as to why the recommendation of the WD to d/c previous treatment orders to the sacrum were not followed. On 7/1/25 at 8:48 AM, the surveyor interviewed the Registered Nurse (RN) regarding Resident #70, and the RN informed the surveyor that he was the assigned nurse of the resident. The RN stated that the resident was cognitively impaired, and on EBP (Enhanced Barrier Precautions; a set of guidelines aimed at preventing the transmission of infections in healthcare settings, particularly for patients (or residents) with chronic wounds) due to TF and wound. The surveyor notified the above concerns regarding the duplicate orders for periguard and the recommendations of the WD to d/c previous orders to the sacrum. The RN stated that the orders should have been clarified. He further stated that he would call the Physician to clarify the orders. On 7/2/25 at 10:44 AM, the surveyor notified the DON of the above concerns regarding duplicate orders and not following the WD's recommendations, and the DON stated that the recommendations of the WD should have been followed. On 7/2/25 at 11:40 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The DON stated that the resident's wound treatment orders were reviewed and we are auditing now any duplicate orders, and in service provided to staff and practitioners. A review of the facility's Consultants Policy dated 10/2001, that was provided by the DON, revealed . the facility uses outside resources to furnish specific services provided by the facility . Procedure: 5. Consultants provide the administrator with written, dated, and signed reports of each consultation visit. Such reports contain the consultant's: a. Recommendations; b. Plans for implementation of his/her recommendations; c. findings; and d. plans for continued assessments . 6. Consultant recommendations will be reviewed and ordered by the attending physician . A review of the facility's Pressure Ulcer and Protocol Policy with a revised date of 2/2024, that was provided by the DON, revealed . the nursing department will collaborate with all members of the care plan (CP) team .The CP team will ensure that an assessment, Plan of Care, implementation and evaluation of that plan is in place for each resident . Interdisciplinary Team Members: 1. Assess resident's potential for development of pressure ulcer, utilizing protocol criteria. 2. Reviews triggers for pressure ulcer and initiates interventions. Pressure Ulcer Committee: will assure that system for identifying residents at risk is implemented. Will assure that plan is in place for each resident as risk for developing pressure sore or with a pressure sore present . A review of the facility's Documentation and Charting Policy with a revised date of 11/2017, revealed .#8. Medication (med) Administration-Documentation pertaining to med administration may include date, time started, and time stopped, rate of flow, route, and rationale .Upon receipt of a new med order, nursing and physician must review the patient's current med and clarify all duplicate orders . On 7/3/25 at 11:55 AM, the survey team met with the LNHA and DON for an exit conference and there was no additional information provided by the LNHA and DON. NJAC 8:39-27.1 (a,e)

Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure a.) the physician's orders (PO) were clarified with regard to duplicate orders for fluids (Resident #132) and b.) the PO to obtain and monitor weight was followed (Resident #168). This deficient practice was identified for 2 of 38 residents reviewed. This deficient practice was evidenced by the following: 1. On 6/26/25 at 10:58 AM, Surveyor #1 (S#1) observed Elder #132 (also known as Resident #132) seated in a wheelchair (w/c) with other residents in the activity area while watching tv with music. S#1 reviewed the medical records of Resident #132, and revealed: A review of the resident's face sheet or admission Record (AR; an admission summary), reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; other Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with agitation, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy (eye condition caused by diabetes that can lead to vision loss and blindness if not managed properly) without macular edema bilateral, and chronic kidney disease stage 3 (characterized by a moderate decrease in kidney function) unspecified. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 4/14/25, revealed in Section C: Cognitive Patterns, a brief interview for mental status (BIMS) score of 0 out of 15, which reflected that the resident's cognitive status was severely impaired. A review of Resident#132's Order Summary Report (OSR), included an active PO, and revealed the following: -start date of 5/6/24, increase by mouth fluids to 240 cc (cubic centimeter; is a unit of measure for fluid volume. One cc is equivalent to one milliliter) four times a day (QID). -start date of 8/17/24, increased by mouth fluids every shift for hydration. A review of the electronic Medication Administration Record (eMAR) revealed that the above PO for increase fluids were transcribed and signed by nurses daily as administered. On 7/1/25 at 11:56 AM, the survey team met with Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and S#1 notified the LNHA and the DON of the above findings and concerns for duplicate orders of Resident #132's fluids and the order with no specific amount of how much increase fluids to be given every shift. On 7/2/25 at 11:40 AM, the survey team met with the LNHA and DON. The DON stated that the duplicate orders for fluids we discontinued (d/c) order the one with no specific amount. A review of the facility's Documentation and Charting Policy with a revised date of 11/2017, revealed .#8. Medication (med) Administration-Documentation pertaining to med administration may include date, time started, and time stopped, rate of flow, route, and rationale .Upon receipt of a new med order, nursing and physician must review the patient's current med and clarify all duplicate orders . On 7/3/25 at 11:55 AM, the survey team met with the LNHA and DON for an exit conference and there was no additional information provided by the LNHA and DON. 2. On 6/27/25 at 10:21 AM, Surveyor #2 (S#2) observed Resident #168 seated in a w/c in their room. S#2 interviewed the resident's representative (RR), who stated that Resident #168 had a stroke, still had a gtube (medical device used to deliver nutrition, fluids, and medications directly to the stomach when a person cannot consume enough by mouth) but was not using it for feeding at this time. A review of Resident #168's AR reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; cerebral infarction (also known as an ischemic stroke, is a condition where a part of the brain is deprived of blood flow, leading to tissue damage or death), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), and cognitive communication deficit (communication difficulties stemming from impairments in cognitive processes like attention, memory, and reasoning, rather than primary language or speech problems). A review of Resident #168's comprehensive MDS, reflected a BIMS score of 6 out of 15, which indicated that Resident #168's cognition was severely impaired. A review of Resident #168's Nutrition/Dietary Progress Note included the following dated 5/22/25: Met with Resident #168 and RR today regarding bolus TF (tube feeding). They were requesting to d/c TF at this time as resident had been eating well on a chopped, thin liquids diet. Resident reports being afraid to eat too much while on TF for fear of gaining too much wt (weight) .Recommend d/c TF at this time - continue with manual water flushes as ordered and start wts 3 x/week (three times a week). Will monitor PO (by mouth) intake and wts and make any new recommendations accordingly. A review of Resident #168's June 2025 electronic Treatment Administration Record (eTAR) included the following physician's order: 3 x week weights every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday). Further review of the June 2025 eTAR revealed blanks on 6/13/25, 6/16/25, 6/18/25, 6/25/25, and 6/30/25. The blanks indicated that the order was not followed on those dates to obtain wts. On 7/1/25 at 11:07 AM, S#2 interviewed the Licensed Practical Nurse (LPN) regarding process for weighing residents according to physician's order. The LPN stated that residents have a physician's order may be to weigh monthly, weekly or more and that it was documented in the eTAR. She added that the Certified Nursing Assistant would be notified to obtain the weight and they would tell us the weight and we would document it. The LPN stated that if the resident was out of the facility we would pass it to the next shift to obtain. She added that if the resident refused it would be documented. At that same time, S#2 showed the LPN Resident #168's eTAR which had the five blank weights in the month of June. S#2 asked if there should be documentation of the reason why the weight was not obtained. The LPN stated there should be documentation. She added that the resident needed a hoyer lift (a mechanical device designed to safely transfer individuals with limited mobility from one place to another) to be weighed and that if the weight was not obtained when the resident was taken out of bed or placed back in bed then the weight could not be obtained. She added the resident does not stand up. The LPN stated that she just left it blank if the weight was not obtained. On 7/1/25 at 11:13 AM, S#2 interviewed the Registered Nurse/Unit Manager (RN/UM) of Kaplan 1 regarding weights. The RN/UM stated that weights were obtained usually monthly before the 5th of the month. She added that some elders (residents) were weekly, daily or 3 times a week. The RN/UM stated that some also refused to be weighed. S#2 asked the RN/UM if the refusal should be documented. The RN/UM stated that it should be documented if refused. At that same time, S#2 asked the RN/UM to view Resident #168's June 2025 eTAR. The RN/UM confirmed that there were five days that the ordered weights were left blank and stated that it should not be blank. On 7/1/25 at 11:23 AM, S#2 interviewed the DON regarding weights. The DON stated that weights were what the order was which meant it could be monthly or weekly. S#2 notified the DON of the five dates in June for Resident #168 that were blank for the weights 3 times a week. The DON stated that the weights should be filled out and that the importance was to track. The DON confirmed that the five dates were blank. On 7/1/25 at 11:58 AM, S#2 notified the LNHA and DON the concern that Resident #168's order for 3 times a week weights had five dates that were blank for June 2025. On 7/2/25 at 11:45 AM, the DON stated that for the five blanks there were two different nurses that left the blank and that the nurses were inserviced. The DON stated that all nurses were being inserviced to fill in the weights on the eTAR. The LNHA did not provide any additional information. A review of the facility's Weight: Resident Policy dated 11/2001, included the following: Policy Each resident will be weighed on admission, weekly for four weeks, and at least one time monthly between the 1st and 5th of the month, unless otherwise ordered by the physician. admission weights will be taken by the Nursing Assistant and reported to the Licensed Nurse. Residents requiring weekly weights as determined by the Nurse or Dietician or physician will also be recorded in the weight book located on each unit. Procedure 1. All residents will be weighed according to a schedule on each unit. 2. All residents on weekly weights will be weighed on the same day each week 8. The same equipment will be used for consistent weights. The lifter scale will be used for all residents unless wheelchair or upright scale is more appropriate. N.J.A.C. 8:39-27.1(a)

Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the facility staff documented the oxygen treatment provided according to the physician's order for 1 of 2 residents, (Resident #70), reviewed for respiratory care, according to standards of clinical practice and facility's practice and policy. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 6/26/25 at 10:43 AM, the surveyor observed Elder #70 (also known as Resident #70) lying on air mattress with oxygen (O2) via nasal cannula (n/c) attached to a concentrator at 2 LPM (liters per minute). The surveyor reviewed the medical records of Resident #70, and revealed: The admission Record (an admission summary) revealed that the resident was admitted to the facility with the following medical diagnoses that were not limited to; Parkinson's disease without dyskinesia (refers to the condition where individuals experience the symptoms of Parkinson's but do not exhibit the involuntary movements often associated with long-term treatment, particularly with levodopa), without mention of fluctuations, cognitive communication deficit, and dysphagia (difficulty in swallowing) unspecified. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 4/21/25, revealed a brief interview for mental status (BIMS) score of 0 out of 15, which reflected that the resident's cognition was severely impaired. A review of the Order Summary Report (OSR), with current physician orders (PO) revealed a PO with a start date of 12/14/23, O2 at 2 LPM via n/c as needed (PRN) for SOB (shortness of breath), keep O2 sat (saturation) at 90 and above. The above PO were transcribed to the June 2025 electronic Treatment Administration Record (eTAR). Further review of the PO revealed that there was no documented evidence in the June 2025 eTAR that the nurse signed the PRN O2 when the surveyor observed O2 was in use on 6/26/25 at 10:43 AM. On 7/1/25 at 8:48 AM, the surveyor interviewed the Registered Nurse (RN) regarding Resident #70's O2 use. The RN informed the surveyor that he was the assigned nurse of the resident, the resident was cognitively impaired, and on O2 PRN. On that same date and time, the RN acknowledged that on 6/26/25, when he arrived at 7:00 AM (7 AM) for his 7 AM-7:00 PM (7 PM) shift, the resident was on O2. He further stated that it was the 7 PM-7 AM shift who administered the O2, and that he received the resident with O2. The RN also confirmed that he should have signed the eTAR on 6/26/25, that the resident was on O2 at that time. On 7/2/25 at 10:44 AM, the surveyor notified the Director of Nursing (DON) of the above concerns regarding the eTAR was not signed when the surveyor observed the resident with O2 on 6/26/25 at 10:43 AM. On 7/2/25 at 11:40 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and DON. The DON stated that the two nurses (RN and the Licensed Practical Nurse) who did not sign the eTAR on O2 use were provided education and they were disciplined. On that same date and time, the DON provided the surveyor a copy of the RN and Licensed Practical Nurse's Employee Disciplinary Notices with the reason for infraction, that included date, location, specific rule, policy that was violated . Above nurse did not log in O2 order on eTAR 6/26/25. A review of the facility's Documentation and Charting Policy with a revised date of 11/2017, that was provided by the DON, revealed .only authorized personnel or individuals may provide documentation in the clinical record which includes the medical plan of treatment, assessments, interventions, responses to care and treatment by multiple health care providers . Procedure: 1. The following individuals are authorized to record data in the clinical record: 1.1. Physicians, Licensed nurses . 8. Medication (med) Administration: documentation pertaining to med administration may include: date, time started, and time stopped, rate of flow, route, and rationale; name of the person administering the O2; frequency and duration of the treatment; resident's tolerance to the treatment and reasons for PRN administration On 7/3/25 at 11:55 AM, the survey team met with the LNHA and DON for an exit conference and there was no additional information provided by the LNHA and DON. NJAC 8:39-11.2(b); 25.2(c)4; 27.1(a)

Based on interview and record review, it was determined that the facility failed to ensure that the primary physician, responsible for supervising the care of a resident, wrote, signed and dated physician progress notes monthly or at least every 60 days with alternating Nurse Practitioner visits to indicate a review of the resident's total program of care, including medications and treatments. This deficient practice was identified for 1 of 38 residents (Resident #5) reviewed. The deficient practice was evidenced by the following: On 7/2/25 at 9:05 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #5. The admission Record (an admission summary) documented that Resident #5 had diagnoses that included but were not limited to; chronic kidney disease, chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems), type 2 diabetes mellitus, and atrial fibrillation (an irregular and often very rapid heart rhythm). A review of the progress notes (PN) revealed: On 1/2/25, Nurse Practitioner #1 (NP#1) visited the resident and wrote a Physician PN (PPN). On 1/31/25, Primary Physician #1 (PP#1) visited the resident and wrote a PPN. On 4/6/25, a NP#2 wrote a PPN and visited the resident for acute complaint of cough with changes in appetite. On 4/15/25, PP#2 visited the resident and wrote a PPN. On 5/23/25, PP#3 visited the resident and wrote a PPN. There was no PPN found in the eMR for February 2025 and March 2025 to indicate a review of the resident's program of care and a visit with the resident by the primary physician group. A review of the orders in the eMR, did not indicate orders were reviewed and signed electronically. On 7/2/25 at 10:08 AM, the surveyor reviewed the paper medical record chart of Resident #5, which revealed there were no PPNs documented. On 7/2/25 at 10:10 AM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) about the PPNs and physician visits for Resident #5. The RN/UM stated that Resident #5's PP was originally PP#1 and was changed to PP#3 who belonged to that same medical group. The RN/UM further explained there were different physicians in the medical group and one NP who visited residents from the group. The RN/UM reviewed the paper chart and confirmed there were no PPNs documented. The RN/UM reviewed the eMR and confirmed there were no February 2025 and March 2025 PPNs by the primary medical group. The RN/UM stated the physicians visited frequently especially the NP and would follow up to provide any additional information. On 7/2/25 at 12:07 PM, the surveyor notified the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) of the concern that there were no PPNs by the primary medical group found for Resident #5 in February 2025 and March 2025. On 7/3/25 at 8:25 AM, the DON provided the surveyor with a PN by NP#2. The note was dated 2/14/25 and indicated reason for visit as comprehensive physical exam and review of chronic conditions. The PN was not in the resident's medical record and had a print date of 7/3/25 8:08 AM. On 7/3/25 at 10:48 AM, the LNHA and the DON met with the survey team. The DON stated there was no physician visit for Resident #5 in March 2025. The DON stated an audit of all resident charts for physician visits and notes was initiated. The LNHA stated that the resident was originally under the care of PP#1 and services were changed to PP#2 during that month and believed that was the reason the visit for that time was missed. The surveyor requested the facility's policies for physician visits and notes and a copy of the resident's physician orders (PO) from March 2025. On 7/3/25 at 11:44 AM, the DON provided the surveyor the policies for physician monthly orders and physician services. The DON also provided a March 2025 physician orders summary which also had two signature lines at the end. One signature line indicated Physician which was blank and unsigned. The other signature line indicated Signature: which was signed and dated 3/1/25. The surveyor asked the DON who signature was on the document. The DON could not identify who signed the PO summary and that he was trying to determine who it was. There was no additional information provided. A review of the facility's Physician Services Policy, dated October 2001. Under Procedure revealed . 2. Physician services include, but are not limited to . b. A medical evaluation of the resident and review of orders for care and treatment . c. Resident diagnoses and plan of care . e. Written and signed orders for diet, care, diagnostic tests and treatment of resident's health records . The policy did not address frequency of physician visits or PPN documentation. A review of the facility's Physician Monthly Orders Policy with a last revised date of March 2015, the policy did not address physician visits or PPN documentation. NJAC 8:39-23.2 (b), (d)

**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 all medications were administered without error of 5% or more. During the medication observation conducted on 7/2/25, the surveyor observed 5 nurses administer medications to 5 residents. There were 27 opportunities, and two errors were observed which resulted in a medication error rate of 7.41%. This deficient practice was identified for 1 of 5 residents, that was administered by 1 of 5 nurses and was evidenced by the following: Reference: According to the manufacturer's specifications for Humalog (insulin Lispo) instructions for use included: Step 6. To prime, turn the know to select 2 units. Step 7. Hold the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Reference: According to the manufacturer's specifications for Toujeo (insulin glargine) instruction for use included: Step 3. Always do a safety test before each injection, to ensure pen is ready for use and avoid underdosing or no dosing upon administration. Step 3A. Select 3 units by turning the dose selector until the dose pointer is at the mark between 2 and 4. Step 3B. When insulin comes out of the needle tip, the pen is working [image of insulin pen with needle pointed upward] On 7/2/25 at 7:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications (meds) for Elder #132 (also known as Resident #132). The meds included the following: -Insulin Lispro [NAME] KwikPen injector (Humalog [NAME]) 100 unit/milliliter (ml) inject 38 units subcutaneously (sc) one time a day before breakfast for diabetes mellitus (DM) with hyperglycemia (high blood sugar).The order was started on 11/23/24 and scheduled for administration at 7:30 AM. -Insulin Glargine Solostar (Toujeo) 300 unit/ml solution pen-injector, inject 18 units sc one time a day for DM in the morning. The order was started on 11/23/24 and scheduled for administration at 8:00 AM. At 8:08 AM, the surveyor observed the LPN turned the knob of the Humalog [NAME] pen, walked over to the opened lid garbage attached to the medication (med) cart and primed (removing a small amount of med to remove air bubbles from the needle and cartridge and ensures the pen is working; air bubbles rise to the top when pointed upward due to gravity) the Humalog with the needle pointed downward into the garbage receptacle. The surveyor was unable to observe if any liquid was expelled. At that time, the surveyor observed the LPN set the dial of the Humalog [NAME] pen to 30 units. At 8:10 AM, the surveyor the LPN turned the knob of the Toujeo pen, walked over to the opened lid garbage attached to the med cart and primed the Toujeo with the needle pointed downward into the garbage receptacle. The surveyor was unable to observe if any liquid was expelled. At 8:17 AM, the LPN confirmed he was ready to administer the meds prepared for Resident #132 and crossed the resident's threshold. At that time, the surveyor stopped the med pass and reviewed the insulin pen cartridges with the LPN. At 8:18 AM, during an interview with the surveyor the LPN confirmed the air spaces that displaced the dosed of the Humalog and Toujeo. The LPN also stated that he should have primed upward so the air pushed the gaps upward. On 7/2/25 at 10:47 AM, during a meeting with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the surveyor discussed the concern regarding the med pass observation for Resident #132 wherein the Humalog [NAME] and Toujeo were primed downward with visible gaps when turned upward. At that time, the DON stated that the expectation for injectable administration was that it must be primed properly. On 7/2/25 at 11:40 AM, during a meeting with the survey team and the LNHA, the DON stated that education was provided to the staff. A review of the facility's Medication Administration Policy, dated/revised 4/2014, included that the purpose of the policy was to ensure efficient, accurate administration, optimal effectiveness of meds ordered and ensure safety of residents . A review of the July 2025, Insulin Pen Administration education provided to staff, reflected section 2. Prime the pen by dialing a few units and injecting it into the air upwards to remove any air bubbles. N.J.A.C. 8:39-29.2 (d)

2. On 6/26/25 at 10:52 AM, Surveyor #2 (S#2) observed Resident #243 was attending an activity with other six residents when the resident was pulled over to the side in the activity area by the Medical Assistant (MA) and the Podiatrist. The surveyor observed the resident declined and became agitated during the podiatry care consult. S#2 reviewed the medical records of Resident #243, and revealed: A review of the AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; Alzheimer's disease unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate, and anxiety disorder unspecified. A review of the most recent comprehensive Minimum Data Set (MDS), with an ARD of 6/23/25, Section C: Cognitive Patterns reflected a BIMS score of 3 out of 15, which indicated that the resident's cognitive status was severely impaired. Section N: Meds revealed that the resident was taking an antipsychotic, antianxiety, and antidepressant meds. A review of the Psychiatric Nurse Practitioner's (PNP's) initial consult notes dated 6/25/25, revealed diagnosis and plan that included but not limited to start Ativan (also known as lorazepam; used for short-term relief of symptoms of anxiety disorders in adolescents and adults) 0.25 mg by mouth BID (2x/day)/PRN (as needed) x 14 days for agitation and aggression with a stop date of 7/9/25. A review of the OSR revealed the following PO that included but not limited to, with a start date of 6/27/25, lorazepam oral tab 0.5 mg, give 0.5 tab by mouth 2x/day for aggression/agitation. The above PO of lorazepam was transcribed to the June 2025 eMAR, plotted for 8:00 AM and 5:00 PM, and were signed by nurses as administered from 6/28/25 through 6/30/25. Further review of the medical records revealed that there was no documented evidence as to why the plan for lorazepam PRN on the 6/25/25 PNP's consult notes were not followed. On 7/1/25 at 9:16 AM, S#2 interviewed the PNP regarding the 6/25/25's initial consult notes. The PNP informed the surveyor that her recommendation was to start Resident #243 with lorazepam 0.25 mg tab BID PRN for 14 days, with a stop date on 7/9/25. The PNP confirmed that she ordered PRN and not as a standing order for lorazepam. She further stated that she was notified by the facility after surveyor's inquiry that was why she was at the facility today to call the Resident's Representative (RR) to explain the changes. On 7/1/25 at 9:30 AM, S#2 interviewed LPN/UM#2 regarding the concern with the order for lorazepam. LPN/UM#2 stated that the PNP's recommendations should have been clarified at that time because the order was not clear. S#2 then asked LPN/UM#2 if that was considered a med error, and she responded yes that was considered a med error. On 7/1/125 at 11:56 AM, the survey team met with the LNHA and the DON. S#2 notified the LNHA and the DON of the above findings and concerns. S#2 asked the LNHA and the DON if that was considered a med error, and the DON responded yes. The DON further stated that the med error investigation was initiated after surveyor's inquiry. A review of the facility's Medication Error Policy dated 7/2018, that was provided by the DON, revealed .1. nursing supervisors/nurses/consultant pharmacists will identify med errors. Nursing will correct errors as quickly as possible and take appropriate action .3. QAPI (Quality Assurance Performance Improvement) coordinator or DON will identify trends of med errors, i.e .transcription error . On 7/3/25 at 10:48 AM, the survey team met with the LNHA and DON, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-11.2(b), 29.2(d) Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) follow a physician's order for medications with a parameter and acceptable professional standards of practice for 1 of 6 residents, (Resident #166), reviewed with medication parameters and b.) follow and clarify the recommendations of the provider with regard to antianxiety medication for 1 of 5 residents, (Resident #243), reviewed for unnecessary medications. 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 casefinding, 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 casefinding; 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 (S#1) reviewed the electronic medical records (eMR) of Resident #166. A review of the admission Record (AR; an admission summary) revealed that Resident #166 had diagnoses that included but were not limited to; peripheral vascular disease (a disorder of the blood vessels outside the heart that affects blood flow to the limbs, hypertension (high blood pressure), and difficulty walking. A review of the quarterly Minimum Data Set (MDS), assessment tool used to facilitate management of care, with an assessment reference date (ARD) of 6/12/25, had a Brief Interview Mental Status (BIMS) score of 15 out of 15, which indicated the resident had no cognitive impairment. A review of the Order Summary Report (OSR), reflected a physician's order (PO) dated 4/16/25, an order for midodrine HCL (hydrocholoride) (a medication (med) used to increase low blood pressure) oral tablet (tab) 2.5 mg (milligram), give 1 tab by mouth three times a day (3x/day) for orthostatic hypotension (a decrease in blood pressure on standing); hold for SBP (systolic blood pressure) above 110. The med was scheduled to be given to the resident at 8:00 AM, 12:00 PM and 6:00 PM. A review of the May 2025 electronic Medication Administration Record (eMAR) revealed that the midodrine order was marked as administered for 10 doses when the resident's blood pressure (BP) was recorded as above 110. A review of the June 2025 eMAR revealed that the midodrine order was marked as administered for 13 doses, between 6/1/25-6/27/25, when the resident's BP was recorded as above 110. On 6/30/25 AM at 11:10 AM, S#1 interviewed Licensed Practical Nurse/Unit Manager #1 (LPN/UM#1) where Resident #166 resides. S#1 asked LPN/UM#1 if hold parameters for BP should be followed and verified by the nursing staff if a med was going to be held or given. LPN/UM#1 stated that the staff should read and understand the PO and follow it. On 6/30/25 at 11:27 AM, S#1 interviewed the Licensed Practical Nurse (LPN) assigned to the unit where Resident #166 resides. S#1 asked the LPN about holding BP medications (meds) when there was a parameter. The LPN stated that the order should be followed even if the BP was only off by one or two points. On 7/1/25 at 11:56 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) and S#1 asked the DON the procedure for giving meds with holding parameters. The DON stated that the staff should take and record the BP immediately before administering the med and follow the PO appropriately. A review of the facility's Medication Administration Policy, revised 4/2014, the policy did not reflect any information related to administering meds with holding parameters. There was no further pertinent information provided by the LNHA.

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide a sanitary environment for residents, staff, and the public by failing to keep the garbage container area free of garbage and debris and failed to have a closed cover over the opening of 2 of 2 garbage containers. This deficient practice was evidenced by: On 6/27/25 at 12:30 PM, the surveyor toured with the Assistant Director of Dining Services (ADDS), who was covering for the Food Service Director (FSD), the garbage/refuse areas and observed the following: 1. #1 regular garbage dumpster, open with no cover, garbage overflowing, not bagged, ice cream container on top. 2. #2 cardboard boxes dumpster, overflowing with cardboard boxes, and not covered. 3. areas around the two dumpsters with debris, garbage on the ground, and four used disposable gloves noted on the ground. At that same time, the ADDS confirmed that the dumpsters should be covered and the ground area free from garbage due to risks of pests. The ADDS stated, They will pick up the dumpsters today. On 6/30/25 at 10:21 AM, the second observation with the ADDS, of the #1 and #2 dumpsters were observed uncovered, garbage bags tied but overflowing in both dumpsters; used gloves noted on the ground. The ADDS stated, When it overflows, it gets too tight to cover it, they should be picking it up today. It should be covered and no gloves on the ground. On 6/30/25 at 1:27 PM, the ADDS showed the surveyor a picture of dumpster #1 covered with a lid and with bags of sealed garbage were on top of the lid. The surveyor asked the ADDS if that sealed garbage should be on top of the lid and the ADDS confirmed, Nothing should be on top of the dumpster lids. We will fix that now. On 7/1/25 at 9:10 AM, the Licensed Nursing Home Administrator (LNHA) informed the surveyor that he was made aware by the ADDS about the surveyor's concerns. The LNHA stated that there should be no garbage on top of the lids. The LNHA also confirmed that the dumpsters were not covered, with overflowing garbage, and grounds had debris of disposable gloves. He further stated that the dumpsters get picked up every Friday by a company and he told the team that if they were filled before the pickup date, that they need to be replaced earlier. On 7/1/25 at 11:56 AM, the survey team met with the Director of Nursing (DON) and the LNHA regarding the above concerns and findings. The LNHA stated, We are discussing with the company to make sure there's room to accommodate all the garbage that needs to be disposed. A review of the facility's Garbage Disposal Area Policy and Procedure, dated 1/13/25, revealed .Collection and Removal-Garbage must be removed from the building at least daily or more often as needed . NJAC 8:39-19.3(a)(c), 31.5(a)1,2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 4 of 10 staff (1 Certified Nursing Aide, 1 Registered Nurse, 1 Provider, and 1 Medical Assistant) and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 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 information on how to safely remove PPE: There are a variety of ways to safely remove PPE without contaminating your clothing, skin, or mucous membranes with potentially infectious materials .Remove all PPE before exiting the patient room .discard to appropriate receptacle . 1. On 6/26/25 at 10:40 AM, the surveyor observed Elder #70's (also known as Resident #70's) room was closed with posted sign outside the room for Enhanced Barrier Precautions (EBP; are infection control measures designed to reduce the transmission of multidrug-resistant organisms (MDROs) in healthcare settings, particularly in nursing homes) and PPE box outside the door with ABHR, gloves, gown, and mask. The surveyor then observed a staff came out of resident's room with gloves on, walked in the hallway while removing used gloves, discarded the used gloves inside his uniform pocket, and pushed the linen cart away from Resident #70's room. At that time, the surveyor interviewed the staff, who informed the surveyor that he was a Certified Nursing Aide (CNA) and confirmed that he came out of Resident #70's room. The CNA also confirmed that he came out of the resident's room with gloves and discarded the used gloves inside his uniform pocket. The surveyor asked why he did not perform hand hygiene after doffing (removing) off gloves, and the CNA did not respond. Afterward, the CNA proceeded to go to Resident room [ROOM NUMBER] (RR#275 without performing hand hygiene. The surveyor immediately notified the Licensed Practical Nurse/Unit Manager (LPN/UM) of the above findings and concerns. The LPN/UM stated that the CNA should have performed hand hygiene, and she would talk to the CNA. On 7/1/25 at 8:48 AM, the surveyor interviewed the Registered Nurse (RN) regarding Resident #70's oxygen (O2) use. The RN informed the surveyor that Resident #70 was cognitively impaired, on as needed (PRN) O2, tube feeding (TF), and nebulizer (neb). The RN stated that the resident was also on EBP due to TF and wound. At that same time, the surveyor observed the RN did not follow the posted sign to perform hand hygiene prior to entering the resident's room. Inside Resident #70's room, the surveyor observed the RN opened the resident's nightstand table drawer and showed to the surveyor the resident's neb mask with a tape wrapped around the tubing, dated 6/25/25. The RN informed the surveyor that the neb mask was being changed weekly. 2. On 6/26/25 at 10:52 AM, the surveyor observed the Podiatrist and the Medical Assistant (MA) with gloves in use in the hallway of recreation area while providing care to Resident #243. The surveyor observed the podiatry care was not completed, and Resident #243 returned to activity with other residents. On that same date, the surveyor observed the Podiatrist and the MA walked away from the recreation area of the Seidan unit, and proceeded to the other unit with the same gloves. On 6/26/25 at 10:55 AM, the surveyor immediately notified the LPN/UM of the above concerns and observations with the Podiatrist and the MA, and the LPN/UM stated that gloves should not be used in the hallway. She further stated that she would talk to them (Podiatrist and the MA). On 7/1/25 at 9:46 AM, the surveyor interviewed the Infection Preventionist Nurse (IPN). The surveyor notified the IPN of the above findings and concerns. She stated that she was made aware of the concern with the CNA, and that the CNA should not dispose the used gloves in his uniform pocket. She further stated that as per EBP instructions in the posted sign, all staff should perform hand hygiene before entering and prior to exiting the room. The IPN also stated that the instructions were, if staff had to provide direct care to residents on EBP, including residents with TF and wound, staff must perform hand hygiene, donned (put on) PPE, doffed PPE including gloves, and immediately perform hand hygiene prior to exiting the room. On that same date and time, the IPN stated that she was also made aware of the concern with the Podiatrist and the MA. She further stated that as per facility practice, there should be no gloves in the hallway, treatment of the provider should be done in the treatment room. A review of the facility's Hand Hygiene and Glove Use Policy dated January 2021, that was provided by the DON, revealed .the facility utilizes the CDC guideline for hand hygiene in healthcare settings . 2. The essential hand hygiene indications can be summarized by the five moments for hand hygiene: a. before touching an elder (also known as resident) . d. after touching the elder e. after touching the elder's environment . 5. Alcohol based hand sanitizer is the preferred method for cleaning hands in the healthcare setting . d. This method can be chosen for the following indications: i. Upon entry and exit from all elder's rooms . iv. Before putting on and after removal of gloves. v. Gloves are removed and hand hygiene is to be performed prior to moving on to an another activity . A review of the facility's EBP posted sign revealed .Everyone must: clean their hands, including before entering and when leaving the room .Do not wear the same gown and gloves for the care of more than one person. On 7/2/25 at 11:40 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The DON stated that staff observed with gloves in the hallway was a no, no and that education was provided to the CNA, RN, Podiatrist, MA, and all other staff education was ongoing. On 7/3/25 at 10:48 AM, the survey team met with the LNHA and DON, and there was no additional information provided by the LNHA and the DON. NJAC 8:39-19.4(a)(1,2)

Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to a.) obtain written consent and b.) ensure documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization and the administration of an influenza (flu) vaccine for 1 of 5 residents, (Resident #132), reviewed for immunizations. This deficient practice was evidenced by the following: On 6/26/25 at 10:58 AM, the surveyor observed Elder #132 (also known as Resident #132) seated in a wheelchair with other residents in the activity area while watching tv with music. The surveyor reviewed the medical records of Resident #132, and revealed: A review of the resident's face sheet or admission Record (an admission summary), reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; other Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with agitation, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy (eye condition caused by diabetes that can lead to vision loss and blindness if not managed properly) without macular edema bilateral, and chronic kidney disease stage 3 (characterized by a moderate decrease in kidney function) unspecified. A review of the most recent quarterly Minimum Data Set (qMDS), an assessment tool, with an assessment reference date (ARD) of 4/14/25, revealed in Section C: Cognitive Patterns, a brief interview for mental status (BIMS) score of 0 out of 15, which reflected that the resident's cognitive status was severely impaired. A review of the electronic record, under immunization tab, revealed that the flu vaccine was received on 10/1/24, and education was not provided. The note section was blank. A review of the October 2024 electronic Medication Administration Record (eMAR) revealed that the Licensed Practical Nurse (LPN) administered the flu vaccine to the right deltoid (also known as the 'common shoulder muscle'). Further review of the medical records revealed, there was no documented evidence that the Resident's Representative (RR) was notified prior to administering the flu vaccine. There was no documented evidence that education was provided regarding the benefits and risks of immunization and administration of flu vaccine. On 7/1/25 at 9:25 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) regarding Resident #132's immunization records. The LPN/UM informed the surveyor that the that consent should be obtained, and education provided to the resident or if the resident was cognitively impaired the RR will receive the education for the vaccines that will be administered prior to administering the vaccine. Upon review of the resident's paper chart, both the surveyor and the LPN/UM observed a blank vaccination consent form, and the LPN/UM stated that the initial consent was probably with the Infection Preventionist Nurse (IPN). On that same date and time, the LPN/UM reviewed the resident's electronic medical record, and the LPN/UM stated that the immunization tab which showed that the flu vaccine was administered to the resident on 10/1/24. The surveyor then asked why the education part was answered no. The LPN/UM stated that there should be a documentation that education provided, and the consent was obtained to whom because the resident was cognitively impaired. The LPN/UM confirmed that the progress notes (PN) that was documented by the LPN did not include information that education was provided, and consent was obtained from the RR. On 7/1/25 at 9:46 AM, the surveyor interviewed the IPN. The IPN informed the surveyor that it was the responsibility of the admitting nurse to obtain the consent for immunizations. She further stated that annual required flu vaccine verbal consent will be obtained and documented in the immunization tab or PN. She also stated that education provided with regard to the vaccine will also be documented in the PN, and if the resident was cognitively impaired, it will be provided to the RR the consent and education prior to administering the vaccine. At that same time, the IPN was unable to provide documented evidence that consent was obtained, and education was provided to RR prior to administering the 10/1/24 flu vaccine. On 7/1/25 at 11:56 AM, the survey team met with Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), and the surveyor notified the of the above findings and concerns. A review of the facility's Influenza Vaccination Policy with a revised date of 10/2022, that was provided by the DON, revealed .all residents will be screened to determine eligibility of influenza vaccine and will be offered unless contraindicated . Further review of the provided Influenza Vaccination Policy revealed that there was no information about consent and education to provide to the resident and/or RR. On 7/3/25 at 11:55 AM, the survey team met with the LNHA and DON for an exit conference and there was no additional information provided by the LNHA and DON. NJAC-8:39-19.4(h)(i)

2. On 6/26/25 at 10:58 AM, Surveyor #2 (S#2) observed Resident #132 seated in a wheelchair with other residents in the activity area while watching tv with music. S#2 reviewed the medical records of Resident #132, and revealed: A review of the resident's AR reflected that the resident was admitted to the facility with a diagnosis that included but was not limited to; other Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, with agitation, type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy (eye condition caused by diabetes that can lead to vision loss and blindness if not managed properly) without macular edema bilateral, and chronic kidney disease stage 3 (characterized by a moderate decrease in kidney function) unspecified. A review of the most recent quarterly MDS, with an ARD of 4/14/25, revealed in Section C: Cognitive Patterns, a BIMS score of 0 out of 15, which reflected that the resident's cognitive status was severely impaired. A review of the eMR, under immunization tab, revealed that the COVID-19 vaccine was received on 5/8/25, and education was not provided. The notes section was blank. A review of the October 2024 electronic Medication Administration Record (eMAR) revealed that the Licensed Practical Nurse (LPN) administered the COVID-19 vaccine to the left deltoid (also known as the 'common shoulder muscle'). Further review of the medical records revealed, there was no documented evidence that the Resident's Representative (RR) was notified prior to administering the COVID-19 vaccine. There was no documented evidence that education was provided regarding the benefits and risks of immunization and administration of flu vaccine in a manner the RR could understand. On 7/1/25 at 9:25 AM, the surveyor interviewed Licensed Practical Nurse/Unit Manager#2 (LPN/UM#2) regarding Resident #132's immunization records. LPN/UM#2 informed the surveyor that the that consent should be obtained, and education provided to the resident or if the resident was cognitively impaired the RR will receive the education for the vaccines that will be administered prior. Upon review of the resident's paper chart, both S#2 and LPN/UM#2 observed a blank vaccination consent form, and LPN/UM#2 stated that the initial consent was probably with the IPN (Infection Preventionist Nurse). On that same date and time, LPN/UM#2 reviewed the resident's eMR, and she stated that the immunization tab which showed that the COVID-19 was administered to the resident on 5/8/25. LPN/UM#2 stated that there should be a documentation that education provided, and the consent was obtained from the RR because the resident was cognitively impaired. LPN/UM#2 confirmed that the PN that was documented by the LPN did not indicate the information that education provided, and consent was obtained from the RR. On 7/1/25 at 9:46 AM, S#2 interviewed the IPN. The IPN informed S#1 that it was the responsibility of the admitting nurse to obtain the consent for immunizations. She further stated that annual required COVID-19 vaccine verbal consent will be obtained and documented in the immunization tab or PN. She also stated that education provided with regard to the vaccine will also be documented in the PN, and if the resident was cognitively impaired, it will be provided to the RR the consent and education prior to administering the vaccine. At that same time, the IPN was unable to provide documented evidence that consent was obtained, and education was provided to RR prior to administering the 5/8/25 COVID-19 vaccine. On 7/1/25 at 11:56 AM, the survey team met with the LNHA and the DON, and the surveyor notified the of the above findings and concerns. A review of the facility's Infection Control: COVID-19 Vaccination Policy dated 4/21/23, that was provided by the DON, revealed . Policy and Procedure: -COVID-19 vaccinations will be offered to all staff and residents (or RR if they cannot make health care decisions) per CDC and/or NJDOH (New Jersey Department of Health) guidelines unless such immunization is medically contraindicated . -All staff and residents/RR will be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks consistent with CDC . -All staff and residents/RR will be offered the opportunity to ask questions about the risk and benefits of vaccination . Documenting COVID-19 Vaccine: -The facility will maintain documentation for all residents and staff on COVID-19 vaccination. -for residents, the information will be documented in their medical record. -The information to be documented includes: -The staff person, resident or RR was provided education regarding the benefits and potential risks associated with COVID-19 vaccine. -Whether the staff, resident/RR consented to the vaccine. NJAC 8:39-5.1(a), 19.4 (a) Based on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to a.) administer a resident a coronavirus-19 (COVID-19) vaccine after consent was given, for 1 of 5 residents, (Resident #85), and b.) ensure all residents and/or resident representatives must be educated on the COVID-19 vaccine the facility offered, in a manner they can understand for 2 of 5 residents reviewed for immunizations (Resident #86 and Resident #132). The deficient practice was evidenced by the following: 1. Surveyor #1 (S#1) reviewed the hybrid medical record (electronic and paper) of Elder #86 (also known as Resident #86), and reveled: A review of the admission Record (AR; an admission summary), documented that Resident #86 was recently admitted and had diagnoses that included but were not limited to; dementia, acute respiratory failure (when the lungs can't release enough oxygen to the blood), and hypertension (high blood pressure). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date of 6/9/25, indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating that the resident had moderate cognitive impairment. Section O of the MDS reflected that the resident was not up to date with the COVID-19 vaccine. A review of the most recent Comprehensive Care Plan (CCP), did not reveal any information related to vaccinations. A review of the immunizations listed in the electronic medical record (eMR) revealed documentation for a COVID-19 booster 2025, dose which indicated the resident refused. Additional review revealed the refusal was dated 4/29/25. A review of the hard copy chart revealed there was a Consent/Refusal Vaccination Form dated 4/29/25 that reflected refusal of COVID-19 vaccine. A Consent/Refusal Vaccination Form dated 6/4/25, signed by the resident's power of attorney (POA) (responsible party) that reflected consent to administer COVID-19 vaccine. Further review of the hybrid medical record, revealed, there was no documented evidence that the resident received the COVID-19 vaccine after the POA consented and signed the vaccination form on 6/4/25. On 7/2/25 at 10:15 AM, S#1 interviewed Licensed Practical Nurse/Unit Manager #1(LPN/UM#1) for the unit where Resident #86 resides. S#1 asked LPN/UM#1 how consent or refusal of vaccines was documented. LPN/UM#1 stated that the documentation would either be in the hard copy chart with a form or some information may be in eMR. S#1 asked about Resident #86 vaccination status, and why the resident did not get any vaccines in the period between the consent and present. LPN/UM#1 stated that they would have to clarify why the eMR states refused but there was a form with consent given in the chart. On 7/2/25 at 11:54 AM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). S#1 asked the DON about Resident #86's COVID-19 vaccination status, the earlier refusal document dated 4/25/25, then an approval by the POA dated 6/4/25, and why there was no further documentation of administration of the vaccine or education being provided between the 6/4/25 approval and present. Further review of Resident #86's EMR revealed a Health Status Note (HSN) located in the resident's Progress Notes (PN). The HSN, dated 7/2/25, authored by LPN/UM#1, reflected a phone call with the resident's POA to clarify the 6/4/25 consent. The HSN further reflected documentation claiming the POA made a mistake on the 6/4/25 form and they did not want the resident to get the vaccine. The eMR also revealed in the immunization section a new entry dated 7/2/25, marked as refusal of COVID vaccine, education provided, with comments reflecting that the POA does not want it given. On 7/3/25 at 10:51 AM, the survey team met with the LNHA and the DON stated that Resident #86's COVID vaccination status was clarified with the resident's POA. The DON acknowledged that it was clarified after surveyor's inquiry. The LNHA did not provide any further pertinent information.

**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 provide pharmaceutical services in accordance with professional standards to assure accurate dispensing and administration of Resident #132's insulin. This deficient practice was identified for 1 of 5 residents, that was administered by 1 of 5 nurses. Reference: According to the manufacturer's specifications for Humalog [NAME] KwikPen, instructions for use included: Each turn of the dose knob dials (0.5) ½ unit of unit. Administration of 0.5 to 30 units in a single injection. A dose more than 30 units required more than one injection. The evidence was as follows: On 7/2/25 at 7:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications (meds) for Elder #132 (also known as Resident #132) that included: -Insulin Lispro [NAME] KwikPen injector (Humalog [NAME]) 100 unit/milliliter (ml) inject 38 units subcutaneously (sc) one time a day before breakfast for diabetes mellitus (DM) with hyperglycemia (high blood sugar). The order was started on 11/23/24 and scheduled for administration at 7:30 AM. At 8:23 AM, the, the surveyor observed the LPN set the dial of the Humalog [NAME] pen to 30 units, pointed the pen upward and pressed on the injector which expelled liquid from the cartridge. At 8:17 AM, the LPN confirmed he was ready to administer the meds prepared to Resident #132 and crossed the resident's threshold. At 8:24 AM, the surveyor observed the LPN administer 30 units of Humalog [NAME] Pen to the resident followed by another 8 units at the same area. At 8:26 AM, the LPN informed the surveyor that he had questioned the order for Humalog [NAME] Kwik pen that did not allow for a one-time needle puncture administration, as opposed to the current order that required two needle puncture sc (under the skin) administration each time the Humalog was administered. The LPN stated he was told that was the resident's order for some time. The surveyor reviewed the medical record for Resident #132. A review of the admission Record (an admission summary) reflected that Resident #132 was admitted to the facility with diagnoses that included type 2 DM. A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, with an assessment reference date (ARD) of 4/14/25, reflected the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. Section I: Active diagnosis included: Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and DM. A review of the Order Summary Report included an active physician's order for -Insulin Lispro [NAME] Kwik Pen injector (Humalog [NAME]) 100 unit/ml inject 38 units sc one time a day before breakfast for DM with hyperglycemia. The order was started on 11/23/24. A review of the progress notes did not reflect a clarification was made for the Humalog [NAME] KwikPen by the nurses. On 7/2/25 at 11:40 AM, during a meeting with the survey team, the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA), the surveyor discussed the concern regarding Resident #132's Humalog [NAME] Kwik Pen to that required two needle puncture under the skin for each time the Humalog 38 units was administered and the concern why the pharmacy dispensed the [NAME] pen instead of the regular pen that allowed for a one-time administration, the nurses that administered the medication without documented clarification and the consultant pharmacist that did not report the irregularity to the facility. On 7/2/25 at 11:40 AM, the surveyor left a message for the Consultant Pharmacist (CP). On 7/2/25 at 12:40 PM, the surveyor called the provided pharmacy and was left on hold by the pharmacy technician. On 7/2/25 at 1:07 PM, the CP stated the resident's regimen was complicated and was not familiar that the Humalog [NAME] KwikPen max dose of 30 units for each administration. On 7/2/25 at 1:30 PM, during a follow-up interview with the surveyor, the DON stated he reached out to the pharmacy provider and the concern was escalated to the provider's quality assurance department. At that time, the DON confirmed and acknowledged that the Humalog [NAME] KwikPen was not the appropriate choice for the resident who received another injectable insulin doses. A review of the facility's Medication Administration Policy, dated/revised 4/2014, included that the purpose of the policy was to ensure efficient, accurate administration, optimal effectiveness of meds ordered and ensure safety of residents . The LNHA did not provided further information. NJAC 8:39-27.1 (a)

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain kitchen sanitation practices as well as store, and label in a manner intended to prevent the spread of food borne illness. This deficient practice was evidenced by the following: On 6/26/25 at 9:46 AM, the surveyor in the presence of the Dietary Supervisor (DS), who was covering for the Food Service Director (FSD), observed the following during the initial kitchen tour: 1. Large mixing machine with mashed potato residue. The DS confirmed the surveyor's observation and stated that it should have been cleaned yesterday as scheduled and after each use. The Dietary Aide Staff (DAS) confirmed that it was not used that morning and was used yesterday. 2. #1 dairy grill with moderate grease build up on front bottom of the grill. The DS stated, The buildup is grease, I do not know when that was cleaned, we clean every day if they clean on top, it should be cleaned inside too. 3. #2 meat grill with thick, heavy grease build up on top and under the front of the grill. The DS stated, It was not used yet this morning, it should have been cleaned yesterday. 4. Refrigerator #1 for meat with 1 box of chicken opened in a bag not labeled or dated. The DS confirmed that the box of chicken should have been labeled and dated once opened. 5. Refrigerator #3 for produce with 1 bag of carrots, onions, carton of mushrooms, cucumbers, sweet potatoes, basil, apples opened and not dated. The DS stated, I don't know when they were opened. 6. Storage room ice cream freezer with buildup of heavy frost all around the inside of the freezer. The DS stated that the ice freezer was defrosted two days ago and it should not be this way, I have to discard everything in there now. 7. second (2nd) ice cream freezer with freezer heavily frosted and no thermometer in the freezer. The DS and a DAS confirmed that there was no thermometer in the freezer and there was a frost buildup. The DS stated, It was defrosted two days ago, we have to throw out food now too. 8. Storage room with 4 dented cans, about half an inch to an inch (potatoes, peach, pear, tomato paste cans). The DS confirmed and stated, They get checked every day, the four dented cans should have been separated. The DS spoke to staff who checked the cans that morning and stated the staff missed the four cans that were dented. There were no accountability cleaning logs for the following: large mixing machine, #1 dairy grill, #2 meat grill, refrigerator#1, refrigerator#3, storage ice cream freezer, 2nd ice cream freezer, and storage room. The surveyor asked the DS how did the staff know when to clean kitchen equipment if there were no accountability cleaning logs. The DS stated that the ovens were cleaned daily and deep cleaned every Saturday. The DS further stated that the Supervisors were in charge of ensuring that they were cleaned. The DS also confirmed that there was no accountability (or log) for cleaning the identified areas of concerns. The DS was unable to respond when asked when the meat grinder, slicer machine, ovens and ice machine were cleaned last. On 6/27/25 at 11:26 AM, during the second kitchen tour with the Assistant Director of Dining Services (ADDS), who was covering for the FSD. The surveyor reviewed with the ADDS all the findings and concerns from previous day and confirmed that, Dining Supervisor had mentioned all the concerns above. The ADDS stated that there was no accountability logs for cleaning since COVID-19, and I do not know why. On 6/30/25 at 1:27 PM, the ADDS provided the surveyor with the Daily Morning Kitchen Sanitation Audit form completed on 6/30/25, after surveyor inquiry. The ADDS stated, We stopped using this form, it's been a long time, I don't know why. On 7/1/25 at 11:56 AM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) regarding the above concerns and findings. On 7/2/25 at 10:00 AM, the FSD stated that they were unsure when the facility had stopped using the accountability logs for cleaning and maybe January or February of this year. It must have fell through the cracks. A review of the facility's Kitchen Equipment Cleaning Policy and Procedure, Storage and Usage of Dry Goods; Kitchen Equipment Cleaning Policy and Procedure, dated 8/3/24, revealed .Cleaning Frequency Guidelines: Ovens and stovetops-daily and weekly deep clean; Refrigerators/freezers-weekly, spills cleaned ASAP (as soon as possible); Slicers/mixers/blenders-after each use; Ice machines-weekly and per manufacturer. Responsibilities: Kitchen Supervisor/Dietary Manager: Maintain cleaning logs . A review of the facility's Food Storage Policy and Procedure, dated 12/13/24, revealed .Shelving and Rotation-Damaged or bulging cans must be removed immediately and reported. Labeling and Inspection-All incoming canned goods must be inspected for dents, rust or swelling. Inventory and Stock Control-Discard cans that are expired, unlabeled, or compromised in integrity . A review of the facility's Food Storage-Refrigerators and Freezers Policy, dated 12/29/23, revealed .Labeling and Dating-All prepared and opened food items must be labeled with date opened/prepared . There was no additional information provided by the LNHA. NJAC 8:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the medical record, and other facility documents, it was determined that the facility failed to ensure a resident received a restorative nursing program in accordance with his/her preference. This deficient practice was identified for 1 of 1 resident reviewed for restorative nursing (Resident #41), and was evidenced by the following: On 07/28/21 at 10:59 AM, the surveyor interviewed Resident # 41 who stated that he/she enjoyed therapy, however it was discontinued after the resident's maximum potential was reached. The resident stated that he/she received restorative care, which was stopped at least two weeks ago without explanation. The resident stated that participation in the Restorative Nursing Program (RNP) was his/her preference. A review of the resident's medical record reflected the following: A review of the resident's admission Record reflected an admission date of 2/5/2021 and diagnoses included but were not limited to, osteoporosis and an unspecified fracture of the sacrum. A review of the quarterly Minimum Data Set (MDS) dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 15, which reflected an intact cognition. It further reflected that the resident required limited assistance with one-person physical assistance for walking in the resident's room, corridor, and on the unit. A review of the resident's Task List Report reflected Nursing Rehab instructions dated 3/12/2021, to walk the resident 100-200 feet, or as tolerated with a rolling walker and supervision every day on the day shift and as needed during the night and evening shifts. This task was assigned to a Restorative Nursing Assistant. A review of the Task history for July 2021, which is an accountability tool for the resident's restorative ambulation, reflected the resident received restorative ambulation six out of 31 days (7/1/21, 7/6/21, 7/8/21, 7/9/21, 7/13/21, and 7/14/21). A review of the resident's individualized comprehensive Care Plan, reflected the resident enjoyed physical therapy, should be encouraged to participate in the restorative program as much as possible and assist as needed. It also reflected that the resident should be involved in the development and implementation of the care plan. On 07/30/21 at 12:40 PM, the surveyor interviewed the resident's assigned Certified Nursing Assistant (CNA) who stated that she has not seen the Restorative Aide (RA) walk the resident in over a week and was not sure if the RA was on a different floor or on vacation. On 08/02/21 at 10:40 AM, the surveyor interviewed the resident's RA who stated that he also worked as a CNA on another floor. He stated that the resident was able to walk independently 100-200 feet with a rolling walker and he keeps a wheelchair behind him/her in case of fatigue. The RA stated that the accountability for the restorative program should be documented in the Nursing Rehab Task section in the electronic medical record (EMAR). The surveyor reviewed the Nursing Rehab Task section with the RA who acknowledged that 7/14/21 was the last time the restorative program was provided in the month of July. At 10:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who manages the RNP. She stated that there were three RAs in the building, who also worked as CNAs. The LPN also stated that the restorative program was done once a day, however the RAs can be reassigned to work in a CNA capacity, in which case the resident would miss the RNP for that day. The surveyor reviewed the Nursing Rehab Task with the LPN, who acknowledged that 7/14/21, was the last time the RNP was provided. She stated that, most likely that was the last time they received therapy. The surveyor inquired if anyone alerted the resident that the RNP would not be provided for a period of time. The LPN stated that she was not sure if anyone alerts the resident why therapy was missed. At 11:00 AM, the surveyor observed the resident walking with the RA. The resident stated, I am happy that restorative resumed. On 08/03/21 at 10:50 AM, the surveyor had a follow up interview with the LPN, who stated that when an RA is reassigned to a CNA assignment, The resident does not receive their restorative therapy that day and there is no documentation about the missed session. She also stated that it was her responsibility to schedule the RNP and communicated missed sessions to the therapy department. At 1:30 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) to discuss the above concern for Resident #41. The DON acknowledged that the resident did not receive the RNP for an extended period during the month of July. The DON also acknowledged that the RAs were at times reassigned to CNA assignments. He also stated that there was no back up plan to provide the RNP when this occurred. On 08/04/21 at 10:40 AM, the surveyor interviewed the Director of Rehabilitation in the presence of the survey team. She was unaware that the resident was on the RNP per resident preference. She also stated that despite the resident not receiving the RNP consistently in the month of July, the resident had not declined. At 1:30 PM, the survey team met with the LNHA and the DON. They acknowledged that it was the resident's preference to participate in the RNP, which was not provided consistently during the month of July. A review of the facility policy Restorative Nursing with a revised date of 6/2012, reflected It is the philosophy of the Jewish Home at Rockleigh to promote each resident to his/her optimal level of physical, mental and psychosocial function and independence by the utilization of specialized restorative techniques. Restorative nursing care is an integral part of overall nursing care. Restorative nursing care should be designed to assist each resident to achieve or maintain the highest possible degree of function, self-care and independence. A review of the Day Shift Supervisor job description signed 5/17/21, reflected that this nursing staff member was Responsible for overseeing and implementing Restorative Nursing Program. NJAC 8:39 4.1 (a)

Based on observation, interview, and record review, it was determined that the facility failed to follow an Incident/Accident Report (I/A Report) Final Disposition Interventions for Rehabilitation (Rehab) alert with regards to fall incidents for 1 of 4 elders (residents) (Resident #267), according to the 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 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. On 7/29/21 at 10:58 AM, the surveyor observed Resident #267 during a musical activity with a bump on the left side of the forehead. On 8/2/21 at 11:39 AM, the Registered Nurse/Unit Manager (RN/UM) informed the surveyor that Resident #267 was cognitively impaired, required extensive assistance with activities of daily living (ADLs), with disruptive behavior, currently on hospice care, and was at risk for falls. The RN/UM stated that the resident was hospitalized due to a recent fall and recently re-admitted from the hospital's behavioral unit due to disruptive behavior. She further stated that the responsible party of the resident was able to observe the resident's behavior without regard to safety during hospitalization. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Alzheimer's Disease, atrial fibrillation (which causes the heart to beat much faster than normal), encounter for palliative care, personal history of COVID-19, major depression, and unspecified fall subsequent encounter (history of fall). A review of the 6/2/21, Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate the management of care, indicated a Brief Interview for Mental Status (BIMS) score of 4, which reflected that the resident's cognition was severely impaired. The QMDS indicated that the resident had two or more fall incidents and was on hospice care. A review of the 5/31/21 and 6/9/21 I/A Report fall incident showed that the Final Disposition Interventions which included Rehab Alert was not followed. On 8/3/21 at 1:35 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON), and were made aware of the above concerns. The DON stated that the facility had a Fall Team that meets routinely and will get back to the surveyor for further information. On 8/4/21 at 9:49 AM, the DON and the Registered Nurse/MDS Coordinator met with the surveyors. The DON informed the surveyors that the intervention on 5/31/21 and 6/9/21 fall incidents for Rehab Alert were not followed. The DON indicated that even though the resident was on hospice, the resident should have been seen by therapy as part of the fall intervention within 48-72 hours. The DON further stated that there was no negative impact on the resident and no decline in function. He indicated that the resident was on therapy from 6/17/21 through 6/29/21. A review of the Physical Therapy (PT) Plan of Care provided by the DON indicated that the resident was on Skilled PT from 6/17/21 to 6/29/21. The reason for the referral for Skilled PT on 6/17/21 showed that the resident was noted by nursing to be more alert and for rehab to determine the appropriate level of mobility and ambulation tolerance for setting up of the restorative nursing program. On 8/4/21 at 10:13 AM, the Physical Therapist/Rehab Director (PT/RD) informed the surveyors that as a standard of practice, the Rehab Department receives fall reports during morning meetings from the Unit Managers and via email, then the rehab department will screen the resident, provides recommendations if therapy is needed. The PT/RD stated that the rehab screen is completed within 24-48 hours. The PT/RD could not speak to why Resident #267 was not seen for two fall incidents dated 5/31/21 and 6/9/21 when a Rehab alert was part of the interventions. A review of the facility Falls Policy and Procedure provided by the DON with a revised date of 7/2019 indicated, In the event a resident falls: #4. An A/I Report and Investigation Report will be completed by the nurse, prior to the end of the shift in which the fall occurred. #9. The resident's fall will be reviewed by the IDC Team (or partial team) within seventy two (72) hours. The Team will consider causal factors contributing to the fall, such as: decline in function, environmental factors, change in medical status (i.e. infection), medications, etc. an IDC note will be written in the clinical record, to document this review. The IDC Team may make recommendations for appropriate interventions, evaluation and screens to be implemented. On 8/4/21 at 1:18 PM, the survey team met with the LNHA, the DON, and there was no additional information provided. NJ 8:39-11.2 (b)

Based on observation, interview, and other review of other facility documents, it was determined that the facility failed to maintain kitchen sanitation in a manner to prevent the spread of food borne illness. This deficient practice was evidenced by the following: On 7/28/2021 at 10:43 AM, the surveyor toured the kitchen with the Food Service Director (FSD), in the presence of another surveyor. The following was observed: 1. The dairy walk-in refrigerator was noted with a buildup of a white substance, which was able to be rubbed off, on four shelves of the green epoxy racks. The FSD stated that the white substance was most likely spillage. 2. The produce walk-in refrigerator was noted with a buildup of a brown/blackish fuzzy substance on two fan covers. One shelf of the green epoxy wire rack had a buildup of a blackish sticky substance, that was able to be rubbed off. In addition, the dunnage rack near the door also had a buildup of debris. 3. The walk-in freezer had a large buildup of frost around the condenser pipe area as well as frozen liquid particle on the ceiling. 4. The dairy single tank dish washing machine was observed, unable to reach a final rinse temperature of 180 degrees Fahrenheit (F). This was acknowledged by the FSD, who stopped the use of the dish machine. The Dietary Aide stated that he did not notice the temperature had dropped below 180 degrees F, and further stated that the final rinse temperature was 180 degree F this morning before the machine was in use. The temperature log for the dairy dish machine was reviewed, which reflected a final rinse temperature recorded at 180 degrees F that morning. The FSD informed the surveyors that the facility had another dish machine available for ware washing. 5. There was a plastic tube connected to the end of the water faucet between the kettle and the tilted braiser, which had a yellowish/rust colored buildup and a small portion on the open end was able to be dislodged. 6. There were two steamer gaskets observed to be in disrepair. 7. The plastic covered dairy deli slicer was observed with some debris on the base of the machine. The FSD stated that when the deli slicer was covered it indicated that the slicer should have been cleaned and sanitized. 8. The meat dish air drying racks were observed with wet nesting on the inside of two roasting pans and four full sized 1/3 pans. Review of the facility policy How to Operate the Dish Machine, dated 5/2013, indicated that the person assigned to the loading position fills the dishwasher with hot water by closing the door and pressing start. The rinse cycle should be 180 degrees F. The gauges should be checked frequently. In addition, the policy indicated that the supervisors and employees should visually check the dish machine daily for monitoring. Review of the facility policy How to Clean the Slicer, dated 5/2013, Indicated that To keep the slicers clean, prevent the spread of germs and cross contamination. Cross contamination occurs if the slicer isn't cleaned between each use. Review of the facilities Pot Washing and Drying Competency Checklist, with a review date of 8/1/2014, indicated that 10. Allow all washed and sanitized items to air dry vertically on the clean pot rack. 11. Check to see that all pans are draining properly and are not stacked with water in between. NJAC 8:39-17.2(g)