**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that two residents (Resident (R) 2 and R65) out of 32 sampled residents' Minimum Data Set (MDS) assessments were completed and transmitted in a timely manner. Findings include: Review of Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, version 1.181, dated 10/23 revealed, Chapter 2: Assessments for the Resident Assessment Instrument, 2.6: Required OBRA Assessments for the MDS .RAI OBRA-required assessment summary for quarterly assessment .MDS completion date (Z0500B) no later than assessment reference date (ARD) + 14 calendar days .Transmission date MDS completion date + 14 calendar days. 1. Review of R2's Face Sheet under the Profile tab in the electronic medical record (EMR) indicated that R2 was admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI) and paraplegia. Review of R2's quarterly MDS assessment under the MDS tab in the EMR with an ARD of 03/02/24 revealed MDS completed on 03/21/24 and submitted on 04/02/24. Review of the MDS Summary under the MDS tab in the EMR, dated 03/02/24, revealed Completed MDS on 03/21/24 and accepted on 04/02/24. Review of the Assessment History under the MDS tab in the EMR, dated 03/02/24, revealed Quarterly assessment batched and accepted on 04/02/24. 2. Review of R65's Face Sheet under the Profile tab in the EMR indicated that R65 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, major depressive disorder (MDD), and mood disorder. Review of R65's quarterly MDS assessment under the MDS tab in the EMR with an ARD of 03/01/24 revealed MDS completed on 03/20/24 and submitted on 04/02/24. Review of the MDS Summary under the MDS tab in the EMR, dated 03/01/24, revealed Completed MDS on 03/20/24 and accepted on 04/02/24. Review of the Assessment History under the MDS tab in the EMR, dated 03/01/24, revealed Quarterly assessment batched and accepted on 04/02/24. During an interview on 04/11/24 at 1:40 PM, the MDS Assistant (MDSA) confirmed that neither assessments were completed and submitted within the appropriate timeframe. NJAC 8:39-11.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that five of 12 residents (Resident (R) 17, R19, R61, R128 and R297) reviewed for side rails had a comprehensive care plan developed that addressed the use of side rails of 32 sampled residents. Findings include: Review of facility's undated policy titled, Comprehensive Person-Centered Care Plans, revealed [name of the facility] will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. A plan of care is something that describes in an easily accessible way the services and support being provided and should be put together and agreed with the person through the process of care planning and review. 1. Review of R17's Face Sheet under the Profile tab in the electronic medical record (EMR) indicated that R17 was admitted to the facility on [DATE] with a diagnosis including multiple sclerosis (MS), generalized muscle weakness, and ataxia (impaired balance or coordination). During an observation and interview on 04/08/24 at 10:30 AM, R17 was sitting up in her bed with bilateral half side rails in the up position. During this observation, R17 stated that she used the side rails for turning. At 12:15 PM, R17 was sitting up in bed eating lunch with upper half bilateral side rails in the up position. During further observation on 04/10/24 at 6:30 PM, R17 was in bed with upper half bilateral side rails in the up position. Review of R17's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/24 indicated a Brief Interview for Mental Status (BIMS) was 15 out of 15, which indicated R17 was cognitively intact. Review of R17's Care Plan's under the EMR Care Plan tab, dated 09/09/22, revealed no evidence of a side rail care plan or side rails as an intervention. 2. Review of R19's Face Sheet under the Profile tab in the EMR indicated that R19 was re-admitted to the facility on [DATE], with a diagnosis including difficulty walking, muscle weakness, arthritis, fracture of right humerus, and unsteady gait/balance. During initial tour observation on 04/08/24 at 10:00 AM, R19 was in bed asleep with her upper half bilateral side rails in the raised position. Review of R19's undated Care Plan under the EMR Care Plan tab, revealed no evidence of a side rail care plan or side rails as an intervention. 3. Review of R61's Face Sheet under the Profile tab in the EMR indicated that R61 was admitted to the facility on [DATE] with a diagnosis of dementia, pain in left shoulder, and history of falling. During an observation on 04/08/24 at 10:05 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. Further observation on 04/11/24 at 9:00 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. Review of R61's Care Plan under the EMR Care Plan tab, dated 05/31/21, indicated no evidence of a side rail care plan or side rails as an intervention. 4. Review of R128's Face Sheet under the Profile tab in the EMR indicated that R128 was re-admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness, restless leg syndrome (RLS), dementia, and difficulty walking. During the initial observational tour of the facility on 04/08/24 at 10:00 AM, R128 was laying in her bed with bilateral half side rails in the up position. At 12:00 PM, R128 was sitting up in her bed with bilateral half side rails in the up position. Review of R128's Care Plan under the Care Plan tab in the EMR, dated 07/11/23, indicated no evidence of a side rail care plan or side rails as an intervention. 5. Review of R297's Face Sheet under the Profile tab in the EMR indicated that R297 was admitted to the facility on [DATE] with a diagnosis of fracture left femur. During observation on 04/08/24 at 10:20 AM, R297 was in bed, with bilateral half side rails in the up position. At 12:20 PM, R297 was sitting up in her bed, eating lunch with bilateral half side rails in the up position. During further observation on 04/10/24 at 10:00 AM and 6:37 PM, R297 was in her bed with bilateral half side rails in the up position. Review of R297's Care Plan under the Care Plan tab in the EMR, dated 01/10/24, indicated no evidence of a side rail care plan or side rails as an intervention. During an interview on 04/10/24 at 3:45 PM, the Assistant Director of Nursing (ADON) confirmed that R17, R19, R61, R128, and R297 did not have a side rail care plan. NJAC 8:39-11.2(e) thru (i) NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and facility policy review, the facility failed to attempt to use appropriate alternatives prior to installing bed rails; failed to assess the residents for the risk of entrapment from the bed rails; failed to review the risks and benefits of the bed rails with the resident or resident representative; and failed to obtain informed consent prior to installation or use of the side rails of 11 of 11 residents (Resident (R) 17, R19, R61, R128, R297, R6, R23, R54, R57, R196, and R197) reviewed for accident hazards of 32 sampled residents. Findings include: Review of facility's undated policy titled, Side Rail Assessment, revealed Purpose: 1. Every resident will be assessed for the need for side rails upon admission or re-admission. 2. When side rail usage is determined to be necessary and side rails meet the definition of a restraint whether to restrict movement for safety, a physician's order should be obtained, and the side rail should be addresses as an approach to a problem/need on the resident's plan of care. 3. The need for side rails will initially be determined upon admission by the admitting nurse, conferring with the resident and family members. Physical and mental status, resident wishes and history will all assist in determining initial side rail usage. 4. A screening form will be used to assist in determining the need of rationale for side rail usage. A new screen may be indicated by functional ability changes as noted by the Minimum Data Set (MDS). 5. The resident or family representative will be asked to sign a consent form upon admission. If after the screening process, bed rail usage changes or at any time thereafter, the family representative will be notified. Review of facility provided documentation titled, Side Rail Screen, revised 08/15, revealed Patient Name: __Unit: __Room number: __1. Is the patient ambulatory? 2. Is the patient comatose or semi-comatose? 3. Does the patient have alteration in safety awareness? 4. Does the patient have a history of frequent falls? 5. Does the patient have difficulty moving in bed? 6. Does the patient have difficulty sitting on or moving to the side of the bed? 7. Does the patient have difficulty with balance or poor trunk control? 8. Does the patent take any medication that would require an increase in safety precautions? 9. Is the patient currently using side rails for independent positioning or to assist with positioning? 10. Has the patient asked to have the side rails raised while in bed? Alternate to Side Rails: 1. Frequent toileting 2. Reminders to use call bell 3. Restorative care to enhance independence 4. Other: Yes/No (circle) Side rails are indicated to: 1. Provide safety 2. Promote independence of positioning of transfers 3. Fulfill resident's request Yes/No (circle) Side Rails are not indicated at the present time. Yes/No (circle) Evaluation will continue to determine the appropriateness. Comments: __Side Rails Utilization: __One __Both __1/2 Rail __3/4 Rails Signature: __ Date: __ 1. Review of R17's Face Sheet under the Profile tab in the electronic medical record (EMR) indicated that R17 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), generalized muscle weakness, and ataxia (impaired balance or coordination). Review of R17's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/24 indicated a Brief Interview for Mental Status (BIMS) was 15 out of 15, which indicated R17 cognitively intact. During an observation and interview on 04/08/24 at 10:30 AM, R17 was sitting up in her bed with bilateral half side rails in the up position. During this observation, R17 stated that she used the side rails for turning. At 12:15 PM, R17 was sitting up in bed eating lunch with upper half bilateral side rails in the up position. During further observation on 04/10/24 at 6:30 PM, R17 was in bed with upper half bilateral side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails: 1/3 left and right. Review of Assessments under the Evaluation tab in the EMR indicated no evidence of a side rail assessment. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or alternatives prior to side rail use. 2. Review of R19's Face Sheet under the Profile tab in the EMR indicated that R19 was re-admitted to the facility on [DATE], with diagnoses including difficulty walking, muscle weakness, arthritis, fracture of right humerus, and unsteady gait/balance. During initial tour observation on 04/08/24 at 10:00 AM, R19 was in bed asleep with her upper half bilateral side rails in the raised position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails as enabler 1/3 to left and right. Review of Assessments under the Evaluations tab in the EMR indicated no evidence that R19 had an assessment for side rails. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or alternatives prior to side rails being used. 3. Review of R61's Face Sheet under the Profile tab in the EMR indicated that R61 was admitted to the facility on [DATE] with diagnoses of dementia, pain in left shoulder, and history of falling. During an observation on 04/08/24 at 10:05 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. During further observation on 04/11/24 at 09:00 AM, R61 was sitting up in her bed with bilateral half side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails 1/3 to left and right. Review of Assessments under the Evaluations tab in the EMR indicated no evidence of a side rail assessment. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or alternatives prior to side rails being used. 4. Review of R128's Face Sheet under the Profile tab in the EMR indicated that R128 was re-admitted to the facility on [DATE] with diagnoses of generalized muscle weakness, restless leg syndrome (RLS), dementia, and difficulty walking. During the initial observational tour of the facility on 04/08/24 at 10:00 AM, R128 was lying in her bed with bilateral half side rails in the up position. At 12:00 PM, R128 was sitting up in her bed with bilateral half side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails: 1/3 as enabler for left and right. Review of Assessments under the Evaluations tab in the EMR indicated no evidence of a side rail assessment. Review of Consent under the Miscellaneous tab in the EMR indicated no evidence of a side rail consent and/or no evidence of alternatives completed prior to side rails applied. 5. Review of R297's Face Sheet under the Profile tab in the EMR, indicated that R297 was admitted to the facility on [DATE] with a diagnosis of a fracture left femur. During observation on 04/08/24 at 10:20 AM, R297 was in bed, with bilateral half side rails in the up position. At 12:20 PM, R297 was sitting up in her bed, eating lunch with bilateral half side rails in the up position. During further observation on 04/10/24 at 10:00 AM and 6:37 PM, R297 was in her bed with bilateral half side rails in the up position. Review of Order Summary Report under the Orders tab in the EMR, dated 04/10/24, indicated Side rails 1/3 as enabler to left and right. Review of Admit/Readmit Screener under the Evaluations tab in the EMR, dated 01/09/24, indicated both side rails were used; however, no evidence of an indication why the side rails were being used. Further review revealed no evidence of alternatives prior to side rails being applied. Review of Consent under the Miscellaneous tab in the EMR indicated no consent and/or alternatives prior to side rails being applied. During an interview on 04/10/24 at 3:45 PM, the Assistant Director of Nursing (ADON) indicated that all beds had 1/3 side rails, and these side rails were built into the bed. She stated that side rails were used for bed mobility and/or positioning. She indicated that side rails should have been assessed quarterly during the care conference; however, they were only being assessed upon admission and/or re-admission. The ADON confirmed that R17, R19, R61, R128, and R297 did not have side rail consent, quarterly side rail assessments, and/or alternatives prior to side rail usage. 6. Review of R6's quarterly MDS with an ARD of 12/20/23 revealed she had a BIMS score of 9 out of 15 indicating she had moderately impaired cognition and she required substantial assistance with bed mobility. Review of R6's physician orders located in the Orders tab of the electronic medical record (EMR) revealed she had a physician's order for 1/3 side rails as enabler with a start date of 07/28/23. Review of the Admit/Readmit screener, dated 07/27/23, under the Evaluation tab of the EMR revealed she used half side rails on both sides of the bed to promote independence with bed mobility. R6's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During an observation on 04/09/24 at 8:57 AM and on 04/11/24 at 7:37 AM, R6 was observed in bed with one-third side rails in the up position on the top of the bed. 7. Review of R23's quarterly MDS with an ARD of 03/04/24 revealed she had a BIMS score of 15 out of 15 indicating she was cognitively intact. Review of R23's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 10/20/23. Review of the Admit/Readmit screener, dated 07/27/23, under the Evaluation tab of the EMR revealed she used half side rails on both sides of the bed. R23's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During an observation on 04/09/24 at 8:58 AM, 9:54 AM, and 5:05 PM and on 04/11/24 at 7:37 AM, R23 was observed in bed with one-third side rails in the up position on the top of the bed. 8. Review of R54's admission MDS with an ARD of 03/07/24 revealed she had a BIMS score of 6 out of 15 indicating she was severely cognitively impaired and required substantial/maximal assistance with bed mobility. Review of R54's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 09/29/24. Review of the Admit/Readmit screener, dated 2/29/24, under the Evaluation tab of the EMR revealed the resident used half side rails on both sides of the bed for safety and to promote independence with bed mobility. R54's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observations on 04/08/24 at 10:45 AM, 1:33 PM; on 04/09/24 at 6:53 PM; on 04/10/24 at 10:26 AM; and on 04/11/24 at 6:15 AM and 7:39 AM, R54 was observed in bed with one-third side rails in the up position on the top of the bed. 9. Review of R57's quarterly MDS with an ARD of 02/07/24 revealed she had a BIMS score of 14 out of 15 indicating she was cognitively intact, and she required partial assistance with bed mobility. Review of R57's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 12/22/23. Review of the Admit/Readmit screener, dated 12/21/23, under the Evaluation tab of the EMR was blank for the use of the side rails. R57's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observation on 04/09/24 at 8:58 AM and on 04/11/24 at 7:38 AM, R57 was observed in bed with one-third side rails in the up position on the top of the bed. 10. Review of R196's admission MDS with an ARD of 03/29/24 stated she had a BIMS score of 10 out of 15 indicating she had moderate cognitive impairment and she required supervision or touch assistance with bed mobility. Review of R196's physician's orders in the Orders tab of the EMR revealed she had a physician's order for 1/3 side rails as enabler with a start date of 03/24/24. Review of the Admit/Readmit screener, dated 03/23/24, under the evaluation tab of the EMR revealed she used two half side rails to promote independence with bed mobility. R196's EMR was reviewed in its entirety and was absent documentation to show what alternatives were attempted prior to the use of the side rails, documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observation on 04/09/24 at 6:52 PM, R196 was observed in bed with one-third side rails in the up position on the top portion of the bed. 11. Review of R197's admission MDS with an ARD of 03/25/24 revealed she had a BIMS score of 15 out of 15 indicating she was cognitively intact, and she required supervision or touch assistance with bed mobility. Review of R197's physician's orders in the Orders tab of the EMR, revealed she had a physician's order for 1/3 side rails as enabler with a start date of 03/21/24. Review of the Admit/Readmit screener, dated 03/21/24 and located under the Evaluation tab of the EMR revealed she used two half side rails to promote independence with bed mobility. R197's EMR was reviewed in its entirety and was silent for documentation to show what alternatives were attempted prior to the use of the side rails and for documentation to show the risks and benefits of bed rails was reviewed with the resident or resident representative, or that informed consent was obtained prior to installation of the 1/3 side rails. During observations on 04/08/24 at 10:51 AM and on 04/09/24 at 5:01 PM, R197 was observed in bed with one-third side rails in the up position on the top of the bed. On 04/08/24 at 10:51 AM the resident stated she only used the side rails to attach her phone cords and call cord to so she could reach them. During an interview on 04/10/24 at 4:00 PM, the ADON was interviewed, and the above records were reviewed with her. She was unable to find any information related to alternatives attempted prior to putting the side rails in place; or documentation to show the residents and/or the residents' representatives were informed of the risk and benefits prior to using the side rails. She stated they did not have consent for the use of the side rails for the above residents. NJAC 8:39-27.1(a)

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the dish washer sanitizer level was maintained at a level required to sanitize the dishes. This had the potential to affect 146 of 146 residents in the facility. Findings include: Review of the undated facility's policy titled, Dish Machine Policy and Procedure revealed it was the facility policy to test the chlorine level using test strips. According to the policy the chlorine level should be 50 to 100 PPM and should be tested at the start of running the dish machine. During an observation and interview on 04/08/24 at 9:52 AM, the Dietary Manager (DM) stated the dish washer was being used as a low temperature dish machine because the booster went out on 03/28/24. He stated the employee was using it to wash breakfast dishes. He tested the chlorine sanitizer level of the dish washer rinse water, and it tested zero (0) parts per million (ppm). He stated it was supposed to be testing at 50 to 100 ppm. The dish washer was ran and tested two additional times and each time the sanitizer level of the rinse water was zero ppm. The hose running from the bottle of sanitizer was examined while the dish washer was running, and the sanitizer was not running through the hose. During an observation and interview on 04/08/24 at 10:10 AM, Dietary Aide (DA) 1 was asked what he did prior to washing the breakfast dishes and he stated he checked the temperatures on the two thermometers located on the top of the machine and wrote the temperatures on the log that was hanging on the wall across from the dish washer. The log was examined and did not contain an area to document the chemical level of the chlorine. The DM was present and verified the chlorine level was not being documented. DA1 was asked if he checked the chemical level, and he did not appear to understand so the container of test strips was handed to him, and he opened the container took out half the strips and threw them into the dishwasher tank. The strips did not change color again indicating there was no chlorine in the rinse water. The DM was present during the observation and verified the employee did not understand how to check the chlorine level of the sanitizer. Review of the manufacturer's information posted on the back of the gallon bottle of Santec Three sanitizer used to sanitize the dishes for the dish washer stated to prepare sanitizing solution to an initial concentration of 100 ppm available chlorine. The instructions stated the chlorine level must be tested and adjusted periodically to ensure the available chlorine did not drop below 50 ppm. During an observation and interview on 04/09/24 at 9:15 AM the level of the chlorine sanitizer was checked in the rinse water of the dish washer, and it was 50 ppm. The DM provided documentation titled Cleanslate Kitchen Service Report, dated 04/08/23 and timed 2:30 PM. According to the report the professional technician came to the facility to complete a preventative maintenance call. The report revealed he recalibrated the sanitizer on the dish machine and made sure chemicals were at the right levels. The DM stated that the service technician from Cleanslate told him the tubing was clogged and he replaced the tubing and rearranged/recalibrated the sanitizer and now it was running at 50 to 100 PPM. He stated that he retrained staff, and he produced a new log for them to record the chemical level of the sanitizer. NJAC 8:39-17.2(g) NJAC 8:39-19.7(d)

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility staff failed to ensure that resident's were free from verbal abuse for 1 of 30 residents reviewed for abuse, (Resident #93). This deficient practice was evidenced by the following: On 11/15/2021 at 10:17 AM, the surveyor was standing at the nurses station on the Maple unit. A staff member, later identified as a Certified Nursing Assistant (CNA #1), was in the lobby area of the unit with a resident, later identified as Resident #93. The surveyor heard CNA #1 say to the resident You don't shake your soda you weirdo. At approximately 10:35 AM, the surveyor reported this to the Administrator and Director of Nursing (DON). The DON said this was not appropriate. The Administrator said he would immediately go and start an investigation. A review of the medical record revealed Resident #93 was admitted to the facility with diagnoses including but not limited to; Cerebral Infarction (Stroke) and dementia. According to the Minimum Data Set (MDS) an assessment tool, dated 10/1/2021, Resident #93 had a Brief Interview for Mental Status score of 11/15, indicating Resident #93 had moderately impaired cognition. During an interview with the surveyor on 11/15/2021 at 11:30 AM, the administrator said CNA #1 would be writing a statement and meeting with the DON and then be sent home. The Administrator also said he had reported this to the New Jersey Department of Health (NJDOH) and the Office of the Ombudsman. During an interview with the surveyor on 11/16/2021 at 08:04 AM, the DON said that CNA #1 was still suspended and admitted it was improper to call the resident a weirdo and didn't mean it. The DON went on to say CNA #1 thought it was a joke and the DON believed it was seriously not appropriate to say this. The DON again said CNA #1 knew she was wrong. The DON further stated that on interview Resident #93 didn't recall the CNA calling he or she a weirdo and did not want to get the aide in trouble. A review of the facility investigation revealed a handwritten statement, dated 11/15/2021 at 10:20 AM and signed by CNA #1. The statement indicated that Resident #93 started to shake the can of soda and she said to the Resident, Don't shake the can you weirdo, your gonna make it explode everywhere. A review of a summary of investigation revealed Resident #93 was interviewed by the Administrator and DON and did not remember the conversation and didn't hear the staff call him/her a weirdo. During an interview with the surveyor on 11/16/2021 at 11:45 AM, Resident #93 said no staff has been disrespectful to him/her and that the staff treats me good. Resident #93 said he/she did not recall the incident. A review of facility provided written material for the Understanding Abuse and Neglect education, undated, revealed under Section 2; Recognizing, Reporting and Preventing Abuse, Verbal Abuse includes talking disrespectfully A review of a facility provided policy titled Abuse Prevention with an initiated date of March 2013, revealed under Policy: The facility will not tolerate any form of resident abuse, neglect, or exploitation by staff members NJAC 8:39-4.1(a)(5)

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to provide care consistent with professional standards necessary to prevent the risk of an infection from developing during a wound care observation, on 1 of 3 residents investigated for pressure ulcers, (Resident #61). The deficient practice was evidenced by the following: On 11/10/2021 at 9:40 AM, during a wound care observation for Resident #61's left heel pressure ulcer, the surveyor observed the Unit Manager (UM) use a pair of scissors to cut and remove a wound dressing that revealed a date of 11/9. After cutting the dressing, the UM placed the scissors into her shirt pocket without cleaning them. On the same date at 9:51 AM, the surveyor observed the UM remove the scissors from her pocket and used them to cut calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven fiber). After cutting the calcium alginate, she applied it to the base of the pressure ulcer. The UM did not clean the scissors before cutting the calcium alginate. A review of the Quarterly Minimum Data Set (an assessment tool) dated 10/21/21, revealed Resident #61 had a pressure ulcer. A review of the Physician's orders revealed an order active from 8/17/21 to cleanse the left heel with normal saline solution, apply Santyl (medicine that removes dead tissue from wounds) and calcium alginate with a clean, dry dressing daily. A review of the care plan revised 10/6/21, revealed Resident #61 was at risk to develop complications related to infection such as dehydration, respiratory distress, pain, skin breakdown, weakness, and mental fog. The care plan further revealed a need to remain free from infection through the review date of 1/31/22. A review of the care plan revised on 10/21/2021, revealed Resident #61 had discoloration to the left heel. The care plan further revealed that Resident #61 wished to remain free from infection for the next 90 days through the review date 1/31/2022. During an interview with the surveyor on 11/10/2021 at 10:01 AM, the UM said she should have cleaned the scissors. A review of a facility policy titled Pressure Ulcer Prevention/Management Program initiated 3/2013 and revised 8/2020, did not address cleaning scissors during wound care. A review of an undated and untitled facility documentation provided by the Administrator on 11/16/21 at 10:28 AM, included steps of wound care procedures under the headings of Clean dressing of wound Preparation, Removing an old dressing, Cleaning and dressing the wound, After the procedure. There was no documentation to address cleaning of scissors during wound care. N.J.A.C. 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 food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/17/2021 from 11:19 AM to 12:09 PM the surveyor, accompanied by the Food Service Manager (FSM) observed the following in the kitchen: 1. Upon entry to the dish room, the surveyor observed the dietary aide (DA) loading the high temperature dish machine with racks of dirty dishes. The DA then proceeded to walk over to the clean side of the dish machine to unload cleaned and sanitized dishes. The surveyor asked the DA if she should handle the cleaned and sanitized dishes after handling the dirty dishes. The DA stated, I can't touch the cleaned dishes because I will cross contaminate. The DA then proceeded to go to the designated hand washing sink to perform hand hygiene. The DA was observed to turn on running water via the foot pedal. The DA then placed their hands under the running water for 5 seconds. The DA then turned off the running water via the foot pedal and proceeded to don a pair of disposable gloves with their hands still wet. The DA did not apply soap to their hands or perform vigorous hand washing for 20 seconds and the DA did not dry their hands before proceeding to don gloves. The DA then went to the cleaned and sanitized dishes that had just exited the high temperature dish machine. The surveyor interrupted the DA and asked them not to touch the cleaned and sanitized dishes with their gloved hands. The surveyor requested that the DA perform hand hygiene again before having contact with the cleaned and sanitized dishes. The DA then proceeded to doff their gloves and place them in the waste basket located at the designated hand washing sink. The DA then turned on the water via the foot pedal and wet their hands under running water. The DA then applied hand soap and proceeded to wash their hands vigorously under the running water for approximately 20 seconds. Upon the 20 second mark the DA had no noticeable soap lather on their hands as the running water had effectively washed the soap off. The DA then proceeded to turn off the water and dry their hands with a hand towel. The DA then attempted to don a new pair of gloves; however, the surveyor again questioned the DA whether they had performed hand hygiene according to the facility policy and procedure. The DA became agitated and walked away from the surveyor. On interview the FSM stated, She has been in-serviced on hand hygiene by foodservice and our infection control nurse. The surveyor reviewed the facility provided policy titled Hand Washing, copyright 2019. The following was revealed under the heading Procedure: 2. How to wash hands: a. Turn on the faucet using a paper towel to avoid contaminating the faucet. b. Wet hands and forearms with warm water (minimum 110 F) and apply an antibacterial soap. c. Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20-second hand washing procedure. Apply vigorous friction between the fingers and fingertips. Rinse with clean, running warm water. d. Rinse thoroughly. e. Dry hands with paper towel or use a hand blow dryer. f. Use the paper towel to turn the faucet off and open the door if needed, and then discard it. 3. Staff will be educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines. 4. Hand washing procedures will be posted by each hand-washing sink. The surveyor reviewed the facility provided Hand Washing Competency for the DA, dated 9/14/2021. Review of the competency revealed that the DA had successfully met the required hand washing competencies on 9/14/2021. N.J.A.C. 18:39-17.2(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/2/19 at 10:30 AM, the surveyor observed Resident #134 during resident council meeting. The surveyor reviewed Resident #134's medical records that revealed the following: According to the Resident Face Sheet, Resident #134 was admitted to the facility on [DATE] with a diagnoses that included Major Depressive Disease, Anxiety disorder and Chronic Obstructive Pulmonary Disease. The CPTS form dated 8/5/19 documented the following: Please comment on the effectiveness of Remeron 15 mg (milligrams) at bedtime since May 2019. The CPTS revealed documentation that a physician was notified and indicated to continue the medication. There was no comment from the facility about the effectiveness of Remeron. The CPTS form dated 9/9/19 documented the following: Regarding the comment made on 8/5/19: Please comment on the effectiveness of Remeron for appetite stimulation. The resident has been taking Remeron 15 mg's at bedtime since May 2019. The Pharmacy Consult was not addressed. The CPTS contained documentation by the physician that the medication was used only for appetite stimulation. There was no comment from the facility about the effectiveness of Remeron. The CPTS form dated 10/15/19 documented the following: Please comment on the effectiveness of Levocetirizine for allergies since 10/18. Regarding the comment made on 9/9/19: Please comment on the effectiveness of Remeron for appetite stimulation. The resident has been taking Remeron 15 mg at bedtime since May 2019. The Pharmacy Consult was not addressed. The CPTS documented that the physician was called and ordered to continue with Levocetirizine. There was no comment from the facility about the effectiveness of the Remeron. The CPTS form dated 11/4/19 documented the following: Regarding the comment made on 10/15/19: Please comment on the effectiveness of Levocetirizine for allergies since 10/18. The Pharmacy Consult was not addressed. There was documentation on the CPTS by the physician to discontinue the medication. The POF's from 8/2019 through 12/2019, revealed that the facility did not respond to the CP's request for a comment on the effectiveness for Remeron and Levocetirizine. The physician's Progress Notes from 8/29/19 through 11/29/19 revealed no documentation that the physician addressed the CPTS's dated 8/5/19, 9/9/19, 10/15/19 and 11/4/19. On 1/7/19 at 9:24 AM, the surveyor interviewed LPN UM #2 who stated she is responsible to call or fax the physician the CPTS's when she receives them, as well as, follow up with the physicians when they are in the facility. LPN UM #2 also reported that she was unsure why the physician did not respond to the CPTS's and was unable to offer an explanation as to why no one followed up. Based on interview and record review, it was determined that the facility failed to develop a policy outlining the time frames for responding to the Consultant Pharmacist (CP) recommendations and failed to respond to CP recommendations. This deficient practice occurred for 4 of 31 residents (Residents #37, #149, #134 and #119) reviewed. This deficient practice was evidenced by the following: 1. On 12/27/19 at 10:29 AM, the surveyor observed Resident #37 lying in bed. The surveyor reviewed Resident #37's medical records that revealed the following: According to the Physician's Order Form (POF), Resident #37 was admitted to the facility on [DATE] with a diagnoses that included Hypothyroidism. The Consultant Pharmacist Therapeutic Suggestion (CPTS) form dated 10/18/19 documented: The most recent TSH [Thyroid Stimulating Hormone] level was below therapeutic range (0.11); consider adjusting the dose of Levothyroxine. The resident has been taking levothyroxine 150 mcg [micrograms] since 1/19. The CPTS form dated 11/5/19 documented: Regarding the comment made on 10/18/2019: The most recent TSH level was below therapeutic range (0.11); consider adjusting the dose of Levothyroxine. The resident has been taking levothyroxine 150 mcg [micrograms] since 1/19. The Pharmacy Consult was not addressed. The CPTS forms dated 10/18/19 and 11/5/19 were signed and dated by the Nurse Practitioner on 12/2/19. The December 2019 monthly POF noted the resident's list of medications included Levothyroxine tablet 150 mcg, one tablet by mouth daily for Hypothyroidism. There was a physician's order dated 12/2/19 for a new order to discontinue the Levothyroxine 150 mg and start Levothyroxine 88 mcg by mouth daily. The Medication Administration Records (MAR's) from October 2019 through December 2019 revealed documentation that the resident continued to receive Levothyroxine 150 mcg daily from 10/19/19 through 12/2/19. The Interdisciplinary Progress Notes (IDPN) from 10/19/19 through 12/1/19 revealed no documentation that attempts were made to contact the physician regarding the CPTS's dated 10/18/19 and 11/5/19. 2. On 12/27/19 at 10:38 AM, the surveyor observed Resident #149 lying in bed. The surveyor reviewed Resident #149's medical records and noted the following: According to the Resident Face Sheet, Resident #149 was admitted to the facility on [DATE] with a diagnosis of Intraspinal abscess and Granuloma. The CPTS form dated 10/18/19 noted the following: The pharmacy cautionary warning recommends not exceeding 3 grams of acetaminophen daily from all sources. Presently 2 grams/day are being administered routinely, which if combined with PRN [as needed] orders could exceed recommended maximum dose. To avoid a potential issue consider decreasing the frequency of PRN Tylenol [acetaminophen] to once daily. The CPTS form dated 11/5/19 noted the following: While receiving routine OxyContin, consider the addition of a routine laxative to the drug regimen. The CPTS form dated 12/13/19 noted the following: The pharmacy cautionary warning recommends not exceeding 3 grams of acetaminophen daily from all sources. Presently 2 grams/day are being administered routinely, which if combined with PRN orders could exceed recommended maximum dose. To avoid a potential issue consider decreasing the frequency of PRN Tylenol to once daily and Regarding the comment made on 11/05/2019: While receiving routine OxyContin, consider the addition of a routine laxative to the drug regimen. The Pharmacy Consult was not addressed. None of the CPTS forms above revealed documentation that the physician was notified or addressed the pharmacist's recommendations. The December 2019 monthly POF and additional Physician's Order forms through 12/31/19 contained no documentation that the PRN acetaminophen order had been changed or that a laxative had been added to the drug regimen. The IDPN from 10/19/19 through 12/30/19 contained no documentation that attempts were made to contact the physician regarding the CPTS's dated 10/18/19, 11/5/19 and 12/5/19. On 12/31/19 at 10:22 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN UM #1) who stated, the Director of Nursing (DON) gives her the CP recommendations reports monthly, at which time she was responsible to ensure the recommendations are addressed and then returns the completed report to the DON. LPN UM #1 further stated that the CPTS's should be reported to the physician as soon as the report was received and should not take longer than a week for completion. LPN UM #1 was unable to offer an explanation as to why the CPTS's had not been reviewed with the physician or completed. 4. On 12/27/19 at 11:51 AM, the surveyor observed Resident #119 in bed watching television. The surveyor reviewed Resident # 119's medical records that revealed the following: According to the admission Record, Resident #119 was admitted to the facility on [DATE] with a diagnoses that included Insomnia and Anxiety. According to the CP Evaluation form, the CP performed Medication Regimen Review (MRR) on 9/10/19 and 10/18/19. The CP recommended that the timing for Wellbutrin SR 150 mg (Bupropion) be changed from 9:00 PM to either a morning or noon administration time due to the medication's potential for insomnia. The October 2019 POF indicated the resident's list of medications included an order for Bupropion (Wellbutrin) SR (sustained release) 150 mg tablet to be administered once a day for anxiety. The MAR's from September 2019 through October 2019 revealed that the order for Bupropion 150 mg SR was being administered at 9:00 PM. On 1/7/20 at 10:00 AM, the surveyor interviewed LPN UM #1 who stated that the physician would review all CP monthly recommendations and would respond immediately to the CP recommendations. LPN UM #1 stated that it was the nurses responsibility to reach out to the physician if they didn't respond to the CP recommendations. On 1/2/20 at 12:45 PM, the surveyor interviewed the DON who stated, that the staff call the physician right away with the CPTS's and this should be documented in the IDPN's. The DON also stated that the Unit Managers are responsible to follow up and complete all of the CP recommendations monthly and provide her with a copy of the report which she reviews for completeness. The DON confirmed that the CPTS's should have been addressed. When the surveyor requested a policy outlining the time frames for responding to the CP recommendations, the DON stated that there was no policy. On 1/6/20 at 12:36 PM, the surveyor interviewed the CP by telephone who stated she was unsure of what the time frames for completing the CP recommendations should have been. A review of the facility's policy titled Medication Regiment Reviews under #8 The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the physician directly to report information to the Physician, and will document such contacts. If the physician does not provide pertinent response, or Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or if the Medical Director is the Physician of Record-the Administrator. A review of the facility's policy titled, Medication Regiment Reviews did not indicate any time frames for responding to the CP recommendations. NJAC: 8:39-29.3 (a)1

Based on observation, interview and record review, it was determined that the facility failed to properly store, label and dispose of medications. This deficient practice was noted in 4 of 6 medication carts and 1 of 3 medication refrigerators inspected and was evidenced by the following: On 12/27/19 at 9:40 AM, the surveyor inspected the Cedar unit low-side medication cart in the presence of a Licensed Practical Nurse (LPN #1). The surveyor observed an opened bottle of Prostat that was not dated. The surveyor interviewed LPN #1 who stated that the bottle of Pro-Stat should have been dated when opened. On 12/27/19 at 9:45 AM, the surveyor inspected the Cedar unit medication refrigerator in the presence of LPN #1. The surveyor observed an opened bottle of Lorazepam solution that was not dated. The surveyor interviewed LPN #1 who stated the bottle of Lorazepam solution should have been dated when opened. On 12/27/19 at 9:50 AM, the surveyor inspected the Cedar unit high-side medication cart in the presence of LPN #2. The surveyor observed two opened Breo100 inhalers that were not dated. The surveyor interviewed LPN #2 who stated that the two Breo inhalers should have been dated when opened. On 12/27/19 at 9:55 AM, the surveyor inspected the Maple unit high-side medication cart in the presence of LPN #3. The surveyor observed two opened bottles of Pro-Stat solution that were not dated. The surveyor interviewed LPN #3 who stated that the two bottles of Pro-Stat should have been dated when opened. On 12/27/19 at 10:15 AM, the surveyor inspected the Pine unit medication cart #1 in the presence of LPN #4. The surveyor observed an unopened Lantus insulin pen that was not dated and was stored in the medication cart. The surveyor interviewed LPN #4 who stated that an unopened Lantus insulin pen should have been stored in the refrigerator. A review of Manufacturer's Specifications for the above medications revealed the following: 1. Pro-Stat bottle once opened had a 90-day expiration date. 2. Breo inhaler once opened had a 42-day expiration date. 3. Lorazepam oral solution once opened had a 90-day expiration date. 4. Unopened Lantus insulin pen should be stored in a refrigerator. A review of the facility's policy titled Medication Storage, under letter G. Medications will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. Under letter H. Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2-8 degrees Celsius (36-46 degrees Fahrenheit). If a medication label indicated to store in a Cool Place, the medication may be stored in the refrigerator unless specifically noted otherwise. Medications stored in the refrigerator are to be kept in a closed, separate container. The facility's policy provided to the surveyor by the Director of Nursing did not address dating of opened medications. NJAC: 8:39-29.4 (a) (h) and (d)