Mohawk Meadows

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

reported because Resident #13 was no longer at the facility.C.) On 08/15/25 at 11:37 A.M., the surveyor interviewed Resident #11 who reported an allegation of verbal abuse between Resident #14 and themself.

On 8/15/25 at 02:09 P.M., the surveyor notified the DON and LNHA of an allegation that Resident #14 verbally abused Resident #11.According to the AR face sheet, Resident #14 was admitted to the facility with diagnoses which included were not limited to; Type 2 diabetes mellitus with hyperglycemia (chronic metabolic disorder where the body doesn't properly use insulin, leading to elevated blood sugar levels), essential hypertension (elevated blood pressure), and alcohol abuse.A review of the MDS dated [DATE REDACTED], revealed Resident #14 BIMS score of 15/15 which indicated that Resident #14's cognition was intact.On 08/18/25 at 11:57 A.M., the surveyor interviewed the DON and LNHA together. The DON stated that based

on the context of the investigation and interview regarding verbal abuse between Resident #11 and Resident #14, the DON did not believe this allegation had to be reported to the NJDOH.A review of the facility's policy titled Abuse, Prevention and Prohibition Program dated revised 06/27/23, included the following information under Reporting/Response:D. The facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime.i. Immediately, but no later than 2 hours after forming the suspicion or belief if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, law enforcement, and the Ombudsman (if applicable per state regulation).ii. No later than 24 hours after forming

the suspicion or belief if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, law enforcement, and the Ombudsman (if applicable per state regulations).NJAC 8.39-9.4

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mohawk Meadows

1 O'Brien Lane Lafayette, NJ 07848

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

review of the June 2025 Progress Notes (PNs) did not include documentation regarding the treatment orders administration.On 08/18/25 at 11:49 A.M., the surveyor interviewed the Registered Nurse (RN), who stated that the treatments were always signed out on the TAR after administering the treatments to the residents. The RN further stated it was important to sign out the TAR to document whether the resident had received the treatment. The RN also stated that there was not supposed to be any blank spaces on the TAR according to the facility's policy.On 08/18/25 at 11:57 A.M., the surveyor interviewed the Director of Nursing (DON) in the presence of the Licensed Nursing Home Administrator (LNHA). The DON stated that the nurses should sign on the TAR whether a treatment was administered or not. The DON stated if a resident refused a treatment, the nurse was to code it appropriately on the TAR and write a progress note. The DON further indicated that there should not be any blank spaces on the TAR.A review of the facility policy titled Nursing Documentation dated 07/2025 revealed under Purpose, Documentation in nursing is a key factor in our role and responsibility as patient care advocates. Under General Guidelines (in Nursing Documentation), When to Chart: 1. Record nursing actions and individual responses as soon after they occur as possible.NJAC 8:39-23.2 (a),27.1(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mohawk Meadows

1 O'Brien Lane Lafayette, NJ 07848

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

C39051/IQBased on interviews, medical record review, and other pertinent facility documentation on 08/14/25, 08/15/25, and 08/18/25 it was determined that the facility failed to obtain a physician's order (PO) for the resident's (Resident #11) bilevel positive airway pressure (BiPAP) machine (a non-invasive ventilation therapy that uses a machine to deliver pressurized air to a patient through a mask). This deficient practice was identified for 1 of 14 residents reviewed (Resident #11).The deficient practice was evidenced by the following:A review of the Electronic Medical Record (EMR) was as follows:According to

the admission Record (AR) face sheet, Resident #11 was admitted to the facility with diagnoses which included but were not limited to; acute and chronic respiratory failure with hypoxia (medical condition where

a part of the body, or the entire body, is deprived of an adequate oxygen supply at the tissue level), benign neoplasm (an abnormal growth of tissue in some part of the body) of brain, acute and chronic respiratory failure with hypercapnia (excessively high levels of carbon dioxide (CO2) in the blood), and chronic obstructive pulmonary disease with (acute) exacerbation (a condition involving constriction of the airways and difficulty or discomfort in breathing).A review of the Minimum Data Set (MDS), an assessment tool dated 08/07/25, Resident #11 had a Brief Interview of Mental Status (BIMS) score of 11/15, which indicated Resident #11's cognition was moderately impaired.A review of Resident #11's care plan (CP) included a focus area initiated 11/08/24, that the resident was at risk for signs and symptoms of respiratory distress due to COPD and a history of smoking. Intervention includes to administer BiPAP as ordered.A review of Resident #11's progress notes (PN) revealed that Resident #11 has been using a BiPAP machine since 11/12/24.A review of Resident #11's Order Summary Report (OSR), revealed no order for BiPAP until 05/16/25.On 08/18/25 at 11:54 A.M., the surveyor interviewed a Registered Nurse (RN) who worked on Resident #11's unit. The RN stated that she would ensure that a resident who had a BiPAP had an order for

a BiPAP. The RN further stated that if she saw a resident with respiratory equipment but not an order for it,

she would call the doctor for an order as it would be regarding a resident's breathing.On 08/18/25 at 11:57 A.M., the surveyor interviewed the Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) together. The surveyor asked the DON what her expectations were for staff regarding a resident and their respiratory equipment such as oxygen or a BiPAP. The DON stated that expected her staff to have obtained an order for a resident's respiratory interventions.At that time, the surveyor presented the DON and LNHA with the receipt for Resident #11's BiPAP dated 10/2024, and then Resident #11's order for BiPAP dated 05/16/25. The LNHA stated that Resident #11 came to the facility with the BiPAP machine and that there should have been an order for it.A review of the facility's policy titled Physician Orders last revised 08/01/17, revealed under Policy: Nursing Department will verify that physician orders are complete, accurate and clarified as necessary, and that resident receives their medication timely. N.J.A.C. S 8:39-27.1

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet