Care One At King James

F-F0800 revealed that the Residents Affected - Some Staff Assessment of Daily and Activity Preferences was left blank. The Brief Interview for Mental Status section revealed the resident scored 03 out of 15 which indicated the resident was severely cognitively impaired. A Care Plan Focus for Activities initiated 12/30/24 revealed, Enjoys activities such as music, crafts and television. The Goal is Will actively participate in independent activities of choice daily, Date Initiated: 12/30/2024, Target Date: 01/12/2025. The Interventions included, Assist to transport to and from activities of choice, Date Initiated: 12/30/2024, Provide supplies/materials for leisure activities as needed/requested, Date Initiated: 12/30/2024. The Activity Evaluation, singed by the AD on 12/30/24 documented that the the Language Spoken was English, and speech was Clear. The Activity Evaluation revealed;ed the following Current Interests: Crafts/Arts/Hobbies, Music, TV Program Viewing Radio, Talking and Conversing, Spending Time Outdoors, Watching Movies and Favorie Movie section was left blank, and Parties and Social Events.

On 01/08/25 at 11:45 AM, the surveyor interviewed the AD regarding if there was any documentation regarding resident attendance in activities. The AD stated that only for the Long Term Care Residents, and not for the activity program attendance for the sub-acute residents and Resident #26 was considered sub-acute. The surveyor asked were there any sensory type programs developed for cognitively impaired residents. The AD could not provide the survey team with any sensory type activity programs or activities that were scheduled for the residents who were cognitively impaired. The surveyor asked the AD about Resident #26 activities since the resident only spoke Spanish and the Care Plan did not document any Spanish activities and the Activity Evaluation indicated the resident spoke English. The AD stated that she must have gotten the information from somewhere else. The AD was unable to provide any information on Resident #26 being provided activities in their native language or related to their cognitive status.

38079

b) On 01/05/25 at 7:26 AM, Surveyor #2 was touring Section 3 unit and observed Resident #24 sleeping on their right side in bed. Surveyor #2 observed a very large activities calendar by the unit day room and a large television in the unit day room. The large activities calendar failed to include the times or locations of the activities.

On 01/06/25 at 11:49 AM, Surveyor #2 observed Resident #24 in their room watching television.

On 01/07/25 at 9:26 AM, Resident #24 was observed in bed sleeping on their right side.

On 01/07/25 at 9:27 AM, the direct care Certified Nursing Assistant (CNA) stated that often Resident #24 was independent but needed prompting. He stated Resident #24 did come of the room and liked to watch television and sports.

On 01/08/25 at 9:45 AM, Resident #24 was observed in the unit day room watching television with other residents. There were no activities going on at that time. Resident #24 next self-propelled off the unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 A review of Admission Record revealed that Resident #24 was admitted to the facility with diagnoses which included but were not limited to; bipolar (a mental illness characterized by extreme mood swings), dementia, Level of Harm - Minimal harm or and muscle weakness. A review of the annual Minimum Data Set (MDS) an assessment tool used to potential for actual harm facilitate care dated 10/26/24, included but was not limited to; a Brief Interview for Mental Status (BIMS) of 04 out of 15 indicating severe cognitive impairment; Section D Mood revealed 0 never for social isolation; Residents Affected - Some Section F Preferences for Customary Routine and Activities documented it was 1 Very Important to go outside, participate in religious services and 2 Somewhat Important to listen to music, be around animals, keep up with the news; a review of the resident-centered care plan included but was not limited to; wandering through facility - attempts to minimize excess stimulation and provide supervision during recreation programs, indicators of depression/sadness - attempt to involve in activities respecting choice and preferences dated 12/22/20, and Prefers not to attend group activities prefers independent activities such as watching television, wheeling around facility and engaging in conversation with staff and residents - encourage participation in activities of interest dated 08/07/21. A review of the facility provided most recent Activity Evaluation was dated 01/28/2024 and not filled out. A review of the January 2025 Individual Participation Record revealed codes to be used to record resident activity. The form included A=active, P=passive, R=refused, W=leaves and returns, I=individual, and O=off unit. The form included 21 categories of activities and noted that Resident #24 was marked A in four categories inconsistently. There were no other codes entered to indicate if the resident was a passive observer or was invited and refused activities.

On 01/08/25 at 11:49 AM, the Activities Director (AD) was in the conference room with two surveyors and stated that if a resident participated in an activity, there would not be documentation. She further stated there was no documentation if a resident was offered or refused to participate. When asked if the resident was offered should their form include an R for refused, the AD stated you are right, it is not done. I don't have an answer for that. The AD stated Resident #24 liked to go to music events and live music, but it was not documented anywhere that the resident was invited to any of those types of activities.

A review of the facility provided policy, Activity Programs revised 2018, included but was not limited to; a. to support the well-being of residents and to encourage independence and community interaction; 5. designed to encourage maximum individual participation and . individual resident's needs; 9. All activities are documented in the resident's medical record. 13. residents are encouraged . to participate in scheduled activities.

A review of the facility provided policy, Group Programs and Activities Calendar revised June 2018, included but was not limited to; 3. Residents are encouraged to participate in all group activities, especially those best suited for their interests and physical, mental, and emotional needs.

The Activity Director Job Descrtiption revealed: The primary purpose of your job description is to plan, organize, develop and direct the overall operation of the Activity Department in accordance with current federal, state, and local standards, guidelines and regulations, our established polices and procedures, and as may be directed by the Aedministrator an d/or Activit Consultant, to assure that on on-going program of activities is designed to meet in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

The above concerns were discussed with the facility administration on 01/08/2025, and the facility had no additional information to provide.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 NJAC 8:39-7.2; 7.3

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27193 Residents Affected - Some 38079

Based on observation, interview, and review of pertinent documents it was determined that the facility failed to ensure a system was in place to inspect the emergency crash carts (ECC) for expiration dates and placement. This deficient practice was identified on 3 of 3 Resident Sections (1,2,3) and was evidenced by

the following:

On [DATE REDACTED] at 12:17 PM, Surveyor #1 and Surveyor #2 were on Section 1 unit. The Automatic External Defibrillator (AED) was located in a cabinet on the wall. Across from the AED, the ECC was located. At that time, the Licensed Practical Nurse Infection Preventionist (LPN IP) was on the unit.

Surveyor #2 inspected the ECC and found it was locked. There were items on top of the ECC which included

the checklist. A review of the ECC checklist revealed the following items were not documented as having been checked: AED, suction machine, suction canister, Intravenous (IV) kit, back board, flashlight with batteries, extension cord, oxygen tank, gloves, [name redacted] suction tube, oral airway, and isolation gowns. Surveyor #2 observed a resuscitation bag hanging on the ECC which was not included in the checklist and there were no instructions on the checklist.

The LPN IP stated that the checklist should be checked and signed daily and that there was no reason why it was not. He further stated the facility did not have a policy or procedure for inspecting the ECC.

On [DATE REDACTED] at 7:48 AM, Surveyor #2 observed the ECC and checklist on Section 3. The LPN stated the process was for the staff to make sure everything is there. She stated the pharmacy replaces supplies but did not know who was responsible to check expiration dates. A review of the ECC checklist revealed a lock number for the lock on the cart and lines through the rest of the items. There were no instructions on the checklist.

On [DATE REDACTED] at 9:02 AM, the Licensed Nursing Home Administrator (LNHA) stated there was no policy and procedure for staff to use to check the ECC. The LNHA acknowledged that the staff were signing the bottom of the checklist but there was no procedure for them to follow regarding what to check for.

On [DATE REDACTED] at 9:18 AM, Surveyor #2 was on Section 1 and observed the Registered Nurse (RN) Supervisor by the ECC. The RN Supervisor stated that there was no policy, and she could not inform the surveyor what

the staff would be checking for. The RN Supervisor further stated without a policy there was no way for sure to know who was responsible. She lastly stated that the ECC should be checked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 On [DATE REDACTED] at 10:30 AM, Surveyor #3 was on Section 1 and observed the RN opening the ECC. Surveyor #3 inspected the ECC along with the RN. It was noted that the resuscitation bag hanging on the top of the cart Level of Harm - Minimal harm or was dated [DATE REDACTED] and had expired [DATE REDACTED]. Inside the ECC, it was noted that two IV insertion kits had potential for actual harm expired [DATE REDACTED]. The RN revealed that the facility had to check and ensure the emergency cart was locked only and that once a month the 11 PM - 7 PM shift staff would open and check the items inside the Residents Affected - Some emergency cart.

On [DATE REDACTED] at 11:00 AM, Surveyor #2 inspected the ECC on Section 2. The ECC was locked, and the checklist was on top. There were no instructions on what to inspect for on the checklist. The checklist had a lock number and line through all items and did not include inspection of the resuscitation bag.

On [DATE REDACTED] at 1:43 PM, the facility administration was made aware of the concerns.

On [DATE REDACTED] at 10:00 AM, the facility administration informed the survey team that they were still waiting on a policy and procedure for the ECC. The facility informed the survey team that they did create a new ECC checklist. When reviewed, it was noted that the new list did not include inspection of the resuscitation bag.

NJAC 8:,d+[DATE REDACTED].1; 29.4

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 31654

Residents Affected - Many Based on observation, interview and document review it was determined that the facility failed to failed to maintain the kitchen environment and equipment in a sanitary and properly functioning manner to prevent potential contamination and or the spread of potential food borne illness. This deficient practice was evidenced by the following:

On 01/07/25 at 9:51 AM, the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following:

1. The metal baffles that were inside of the exhaust hood, and above the cooking battery, were visibly soiled with black debris in the slats of the baffles. There was visible grease and grime located on the bottom of the baffles and there was grease type droplets affixed to the opposite inside of the hood. At that time the surveyor interviewed the FSD who confirmed the findings and the surveyor asked the FSD if there was a cleaning schedule to remove and clean the baffles. The FSD state I am working on a cleaning schedule. The nozzles of the fire suppression system in the hood was also observed covered in a grease like substance.

2. The surveyor proceeded to wash hands in the only hand washing sink in the kitchen. The sink water out of

the hot faucet felt cold. The surveyor asked the FSD to take the temperature with the facility's calibrated thermometer. The FSD held a thermometer under the running hot water and the thermometer was 74 degrees Fahrenheit. There was a sign affixed above the hand washing sink that revealed: All Employees Must Wash Hands Before Returning to Work, and Wet hands with hot water with a temperature between 90 and 110 degrees Fahrenheit. The surveyor asked the FSD if it was okay if the water was below the required temperature to wash the hands. The FSD stated the cold water won't take off bacteria.

3. Under a stainless steel table opposite of the cooking area the insulated tray lids were stacked with food covering side open and unprotected under a visibly soiled stainless steal table.

The Cleaning Policy, undated, provided by the Liscensed Nursing Home Administrator revealed: 2. Surfaces must be cleaned with a sanitizing agent /solution . 4. Grid panels in the fire suppression hood over the stove will be removed and run through the dish machine once a month.

NJAC 8:39-17.2(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 48423 potential for actual harm Based on observation, interview, and review of pertinent facility documents, it was determined that the facility Residents Affected - Some failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a) follow Contact isolation precautions for a resident who was on Transmission Based Precautions (TBP) (Resident #42), b) ensure that resident's indwelling urinary catheter drainage bag was stored properly for 1 of 1 resident reviewed for urinary catheter (Resident #47), and c) perform hand hygiene during meals according to the facility policy. This deficient practice occurred on 2 of 3 resident units (Section 1 & 2) and was evidenced by the following:

1. On 1/5/24 at 7:19 AM, during the initial tour, the surveyor observed a Contact Precaution signage and personal protective equipment (PPE; equipment (gowns, gloves, masks, etc. worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) bin hanging on Resident #42's door. The surveyor observed that the signage indicated Everyone must: Put on gloves before room entry. Put on gown

before room entry.

On 1/6/25 at 12:36 PM, the surveyor observed a Certified Nursing Assistant (CNA) in Resident #42's room.

The CNA was not observed wearing a gown and gloves while in the resident's room as the sign on the door indicated. At that time, the surveyor conducted an interview with the CNA upon exiting Resident #42's room.

The CNA confirmed that she was not wearing a gown and gloves upon entering Resident #42's room. The CNA stated it was important to put on PPE before entering a Contact precaution room to protect oneself from what the resident had. The CNA stated, I just went to drop off the lunch tray and I did not have to put on PPE. After reading the posted signage, the CNA further stated they (the unit manager [UM]) told us we have to put on a gown and gloves when we are feeding a resident. I wasn't feeding the resident. I just went to drop off the tray and came out. Later, the CNA stated, I should have put it on as per the signage.

At 1/6/25 at 12:43 PM, during an interview with the surveyor, the Licensed Practical Nurse/ Unit Manager (LPN/UM) stated the Contact precaution signage meant that gown and gloves were to be worn at all times and anytime you walked into the Contact isolation room. The LPN/UM stated it was important to put on gown and gloves to protect self and the residents. The surveyor notified the LPN/UM of the above-mentioned

observations and the LPN/UM stated that the CNA should have had the gown and gloves on before she entered Resident #42's room.

The surveyor reviewed the medical records for Resident #42 which revealed the following:

The Admission Record (AR, admission summary) reflected that the resident was admitted to the facility, had diagnoses which included but were not limited to Crohn's disease (a chronic [long duration and generally slow progression] inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition), irritable bowel syndrome (a common condition that affects the stomach and intestines), ulcerative colitis (an inflammatory bowel disease, that causes irritation, inflammation, and ulcers

in the lining of your large intestine (also called your colon), and major depressive disorder.

The Order Summary Report (OSR) indicated a physician order Contact isolation every shift for HSV-1 (a viral infection that causes genital and oral herpes) with a start date of 12/23/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/9/25 at 9:37 AM, during an interview with the surveyor, the Infection Preventionist (IP) stated it was important to utilize PPE before entering the Contact precaution room for infection control. The IP Level of Harm - Minimal harm or acknowledged that the CNA should have worn PPE upon entry and when she delivered the lunch tray. potential for actual harm

A review of the facility provided Employee In-Service Education dated 5/1/24, Topic: Infection Control: Hand Residents Affected - Some Washing, PPE, EBP, Donning & doffing revealed that above mentioned CNA attended.

A review of the facility provided Job Responsibilities for Certified Nursing Assistant (CNA) under Duties and Responsibilities included: Follow established infection prevention and control procedures.

A review of the facility policy titled Isolation - Categories of Transmission-Based Precautions (TBP) revised 9/22 included under Policy Statement: TBP are initiated when a resident develops signs and symptoms of a transmissible infection and is at risk of transmitting the infection to other residents. Under Policy Interpretation and Implementation 5a.) The signage informs the staff of the type of CDC (centers for disease control and prevention) precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room.

2. On 1/5/25 at 8:13 AM, during initial tour, the surveyor observed Resident #47 watching TV in their bed. Resident had a urinary drainage bag placed on bedframe to their left side of the bed.

On 1/6/25 from 11:58 AM through 1:25 PM, the surveyor observed Resident #47 in bed. At that time, the surveyor observed resident's urinary drainage bag resting on the floor. The drainage bag was not secured to

the bedframe.

At 1:29 PM, during an interview with the surveyor, the CNA stated if a resident has a urinary catheter. The CNA stated the drainage bag would be below the bladder and secured on the frame of the bed (bedframe).

The CNA stated if she observed a urinary drainage bag on the floor, she would notify resident's nurse. The surveyor then accompanied the CNA to resident #47's room and both observed resident's urinary drainage bag on the floor. The CNA donned PPE and picked up resident's urinary drainage bag and secured on the bed frame. The CNA stated she would notify resident's nurse and change the privacy bag.

On 1/6/25 at 1:57 PM, during an interview with the surveyor, the LPN stated the urinary bag would be placed

on a hook on the bedframe, so it doesn't touch the floor for infection control. The LPN further stated if the urinary bag touched the floor or was on the floor, she would notify resident's physician and get an order to change the bag.

On 1/6/25 at 2:07 PM, during an interview with the surveyor, the LPN/UM stated the urinary drainage bag would be placed on the bed frame and it should not touch the floor due to risk of infection. The surveyor notified of the above-mentioned observations and concern regarding resident's urinary bag between the time of 11:58 AM - 1:50 PM.

The surveyor then reviewed the medical records for Resident #47 which revealed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The AR reflected that the resident was admitted to the facility, had diagnoses which included but were not limited to type 2 diabetes mellitus with other circulatory complications, history of falling, obstructive and reflux Level of Harm - Minimal harm or uropathy (when urine can't flow (either partially or completely) through your ureter, bladder, or urethra due to potential for actual harm some type of obstruction [blockage]).

Residents Affected - Some A review of the resident's most recent comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 11/7/2024 included the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident's cognition was moderately impaired. Further review of MDS, Section H for bladder and bowel reflected Resident #47 had an indwelling catheter.

A review of the OSR indicated a physician order, dated 11/08/24 for Insert #16fr (size of catheter) 10 cc (milliliters) [Name redacted] catheter.

A review of Resident #47's care plan included the following focus area with an initiated date of 11/26/2024: Use of indwelling urinary catheter related to disease process secondary to obstructive uropathy.

On 1/8/25 1:44 PM, the survey team met with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The surveyor notified of the above-mentioned concerns.

On 1/9/25 at 9:37 AM, during an interview with the surveyor, the IP stated urinary bags should be secured on

the bedframe. The surveyor mentioned Resident #47's urinary bag concerns to the IP. The IP further stated, There is no excuse. It (urinary drainage bag) shouldn't be on the floor.

A review of the facility provided Employee Competency Assessment for Catheter Care, Urinary, dated 7/15/24, did not reflect any comments or concerns for the CNA.

A review of the facility policy titled Catheter Care, Urinary revised 8/22 included under Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor.

27193

3. On 01/06/25 at 11:49 AM, the surveyor reported to the subacute Unit to observe the lunch meal. The surveyor observed a Certified Nursing Assistant (CNA) approaching the dietary cart, picked up a tray, delivered the tray to Resident #58, assisted with setting up the resident. Posted signage was observed on

the door to caution staff to wash hands prior to enter and exiting the room, and to wear Personal Protective Equipment during care.

The CNA then exited the room without performing hand hygiene. The CNA then went to the dietary cart picked up another meal tray, delivered the tray to another resident on Enhanced Barrier Precaution without washing their hands first.

On 01/06/25 at 1:30 PM, the surveyor interviewed the CNA who stated that she entered the room, delivered

the tray and did not perform any care to the resident. The surveyor then showed to the CNA the signage posted at the door, and the CNA did not have any comment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 At that time the surveyor reviewed the Electronic Medical Record (EMR) for Resident # 58 was admitted to

the facility with diagnoses which included but were not limited to, muscle weakness, immunodeficiency, Level of Harm - Minimal harm or aftercare following joint replacement surgery. Resident #58 had a wound to the left leg and was placed on potential for actual harm Enhanced Barrier precautions.

Residents Affected - Some On 01/07/25 at 1:45 PM, the surveyor interviewed the Infection Control Nurse who stated that all staff had been educated on Infection Control Prevention.

On 1/9/25 at 10:41 AM, the survey team met with the LNHA, and DON for the Exit Conference, and facility management did not provide any additional information and did not refute the findings.

NJAC 8:39-19.4(1,2), 27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 315087 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315087 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Careone at Middletown 1040 State Route 36 Atlantic Highlands, NJ 07716

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48782 potential for actual harm Based on observations and interviews between 01/08/2025 and 01/10/2025 in the presence of the Residents Affected - Many Maintenance Assistant (MA), Regional Director of Maintenance (RDOM) and Senior Regional Director of Maintenance (SRDOM), it was determined that the facility failed to ensure that the resident call bell system properly functioned .This deficient practice had the potential to affect all residents and was evidenced by the following:

An observation on 01/09/2025 at 10:14 AM revealed, when the call bell was tested for room [ROOM NUMBER], it did not send a signal of activation to the nurse's station on unit 3. The call bell annunciator was showing an ERROR CONNECTIVITY signal at the desk.

An observation at 10:22 AM revealed, when the call bell was tested for room [ROOM NUMBER], it did not send signal of activation to the nurse's station on unit 3.

Upon further investigation, The SRDOM push the cord on the annunciator in and stated that the cord was not all the way in.

An observation at 11:01 AM revealed, when the call bell was tested for room [ROOM NUMBER], it did not send signal of activation to the nurse's station on unit 2.

Upon further investigation, the RDOM noticed that the annunciator at the nurse's station was unplugged and not powered on. The RDOM proceeded to plug the annunciator in and power it on.

The facility's Administrator was informed of the deficient practices at the Life Safety Code exit conference on 01/10/25 at 12:30 PM.

N.J.A.C 8:39-31.2 (e)

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