**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 1 of 5 residents, Resident #9, reviewed for immunization status. This deficient practice was by the following: Reference: A review of the CDC's Advisory Committee on Immunization Practices (ACIP) for Pneumococcal Vaccine Recommendations dated/last reviewed on 10/26/24, included the following. The CDC recommended administration of pneumococcal conjugate vaccine (PCV20 or PCV21) at least 1 year for all adults 50 years or older who have received PCV 13 only at any age. On 03/26/25 at 11:50 AM, the surveyor observed Resident #9, seated in the dining area with other residents while the staff prepared to serve lunch. The resident greeted the surveyor hello, then was observed looking around the room. The surveyor reviewed Resident #9's medical record. The admission Record (AR, admission summary) reflected that Resident #9 was admitted to the facility with medical diagnoses which included but were not limited to: diabetes mellitus (high blood sugar), congestive heart failure (decreased contractility of the hearts ability to pump blood and the inability to fill with blood properly in between beats) and asthma (a long-term condition that affects the airways in the lungs). Resident #9's most recent quarterly Minimum Data Set (qMDS), an assessment tool used to facilitate the management of care, dated 12/18/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out 15 which indicated the resident's cognition was severely impaired. Further review of the qMDS dated [DATE], under section O0300 A. Is the resident's Pneumococcal vaccine (PV) up to date? The response was marked 1, which reflected Yes. A review of the electronic Medical Record (eMR) under Immunization reflected Resident #9, last received Pneumovax on 11/18/22. The paper chart did not show the PV was offered, education was provided, or a declination had occurred. On 3/31/25 at 10:48 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that every year, each resident who was alert were asked/offered the PV, when appropriate. For residents who had impaired cognition, the resident's family or representative were asked on behalf of the resident for permission to administer the PV. The resident's offer, education or declination were documented in the paper chart and/or the electronic medical record (eMR). At that time, the surveyor and the RN/UM reviewed Resident #9's immunization record together. The RN/UM stated the resident's record reflected the resident received Pneumovax on 11/18/22. During the review of the resident's medical record (electronic and paper), the proof of offer, education, and declination were not found. The RN/UM stated she would review the records, look for the documents, and inform the Director of Nursing (DON). On 3/31/25 at 10:57 AM, during an interview with the RN/Infection Preventionist, (RN/IP) the surveyor requested the information of the guidelines that the facility followed for the PV. On 4/1/25 at 8:52 AM, during a meeting with the surveyor and the DON, the RN/IP stated that the facility followed the current CDC guidelines and offered PCV 20 to their residents. The RN/IP provided the surveyor PV declination for Resident #9 dated on 8/20/24 and 10/27/23. At that time, the surveyor discussed the concern with the RN/IP and the DON regarding the qMDS dated [DATE] that reflected the resident's PV was current. On 4/1/25 at 9:43 AM, during an interview with the surveyor, the Licensed Practical Nurse/ MDS Nurse (LPN/MDSN) stated she inputted information in the MDS while the MDS Coordinator (MDSC) checked the MDS data for completion and accuracy. The surveyor and the LPN/MDSN reviewed section O0300 of the qMDS dated [DATE] together. At that time, the LPN/MDSN confirmed and acknowledged that Resident #9's PV was not current, the submitted MDS section O0300 was inaccurate/incorrect and was signed by the MDSC On 4/1/25 at 10:12 AM, during an interview with the surveyor, the MDSC stated that his signature meant he checked the MDS for completion and accuracy. At that time, the MDSC stated that the data entered for section O0300 qMDS dated [DATE] was a typographical error. On 4/1/25 at 12:27 PM, during a meeting with the survey team, the Licensed Nursing Home Administrator, the DON and the ADON/IP, the surveyor discussed the concern regarding the Resident #9's inaccurate MDS for PV. A review of the provided facility policy for Minimum Data Set, dated /revised 7/2023 did not reflect the expectation that the submitted MDS were reviewed for accuracy prior to submission. A review of section Z0400 for the MDS dated [DATE], revealed that the person signing the MDS certified that the accompanying information accurately reflected the resident assessment information. No further information was provided. NJAC 8:39-33.2 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to a) reconcile, identify and remove three of the expired medication intravenous medication supply set (IV set) located in the bottom of a medication cart observed in 1 of 1 of the subacute unit; b) ensure the accurate execution of a Drug Enforcement Agency (DEA) Form 222 (a federal narcotic requisition form), to enable accurate reconciliation of controlled-dangerous substances (medications, with high potential for abuse and tracked with detail), which was identified in 1 of 1 form reviewed. This deficient practice was evidenced by the following: 1) On [DATE] at 11:53 AM, the surveyor began the inspection of the non-controlled portion of the medication cart in the subacute unit in the presence of the Registered Nurse (RN). The surveyor observed three expired IV set. The surveyor and the RN further examined the sealed IV sets which reflected a manufacturer expiration date of [DATE]. At that time, the surveyor interviewed the RN who stated the expired IV set should not have been on the cart because the medication could have permeated and leaked through the IV bag. The RN also stated that she did not have any residents using the IV set at that time and it was stored in the cart as an emergency supply. On [DATE] at 1:28 PM, the surveyor was provided copies of the pharmacy provider invoices that included listings for IV sets by the Director of Nursing (DON). At that time, in the presence of the survey team, the DON was asked to clarify that the expired IV set found was the item listed on the invoices provided. The DON stated she would conduct further research. On [DATE] at 11:25 AM, in the presence of the survey team, the DON stated the pharmacy provider was unable to provide documentation to reconcile the items on the invoice was the expired IV set. At 11:54 AM, the DON provided an email from the provider Pharmacist and the Unit Inspection conducted by the Consultant Pharmacist. A review of the facility provided email from the provider Pharmacist reflected that the Provider pharmacy conducted a unit inspection on [DATE]. A review of the facility provided Unit Inspection conducted by the Consultant Pharmacist (CP) dated [DATE], did not indicate an expired IV set was observed. At 1:26 PM, during a follow up interview with the surveyor, the DON stated that medical supplies were supposed to be checked for expiration and removed from active inventory. The pharmacy provider, CP and the nursing staff, missed it. The DON confirmed that all residents were checked, and determined no resident was scheduled to use the IV set at that time. A review of the facility provided policy Storage of Medication, revised on 11/22 included, under Procedures, section 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The nurse is responsible to check al supplies before using them. Upon receiving the medical supplies, staff will check the packaging slip and keep them in a binder. Pharmacy consultant, pharmacist and staff will check supplies at least monthly and will remove all expired supplies. 2) On [DATE] at 1:04 PM, a review of the facility's DEA Form-222 reflected on the reverse side instructions required by Title 21 Code of Federal Regulations Part 1305. Further review revealed the facility did not execute the following: Part 1. Purchaser Information 3. Enter the total number of line items ordered. 4 .Purchaser must make a copy of the order form for its records before mailing the original to the supplier. Order Form Number: 220405269 did not include the last line completed (bottom, left corner). The facility provided DEA Form-222 had a completed information for Part 4 Controlled Substance Shipment (to be filled out by the supplier). On [DATE] at 1:28 PM, the surveyor in the presence of another surveyor, discussed with the DON, the concern regarding the DEA Form-222. The DON stated the forms were new and was discussed with the medical director On [DATE] at 11:25 AM, in the presence of the survey team, the DON explained her process for executing the DEA Form-222. The DON stated she filled out the form and sent it to the pharmacy. At that time, The DON confirmed she did not make a copy of the DEA Form-222 before it was sent to the pharmacy. The provider pharmacy returned the form to the facility after they had filled out their portion. The DON stated she reconciled the DEA Form-222 with the items and the invoice received. At that time, the DON was unable to explain how the order form could be reconciled properly when a copy of the DEA Form-222 was not made and retained for its records prior to sending the form to the pharmacy. The DON informed the surveyors that moving forward she would retain a copy of the executed DEA Form-222 prior to sending to the pharmacy. A review of the facility provided policy Utilizing DEA form 222 for ordering CII medications for backup replacement revised 2/22 included, under procedures: Please send the original form to the pharmacy, a copy must be kept in your records for two years .Be sure to fill in Last line Completed. NJAC 8:39-19.4(a), 29.4(g), 29.7(c)

2. On 3/10/21 at 1:33 PM, in the presence of the UMRN, the surveyor inspected the second-floor medication storage room which contained the medication storage refrigerator. The medication storage refrigerator contained a clear plastic locked storage box which was located on the upper shelf inside the refrigerator and was able to be removed from the shelf as it was not affixed inside the refrigerator. There were no medications stored inside the clear plastic locked storage box. The UMRN stated that this was the narcotic storage box and was not sure why the clear plastic locked storage box was not affixed inside the refrigerator. On 3/10/21 at 2:15 PM, the surveyors brought the above concerns to the attention of the Administrator and the Director of Nursing. A review of the facility's policy and procedure for the storage of controlled substances. Under Policy Statement revealed the following: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal of s II and other controlled substances. NJAC 8:39- 29.4(b)2. Based on observation and interview it was determined that the facility failed to ensure that controlled substances were stored in a manner to prevent loss or diversion. This was found in 2 of 2 medication refrigerators. The deficient practice was evidenced by the following: 1. On 3/10/21 at 1:29 PM, the surveyor inspected the medication refrigerator in the medication room on the first floor in the presence of the Unit Manager, Registered Nurse (UMRN). Inside of the refrigerator there was a locked storage box that was attached to a removable shelf. The UMRN unlocked the storage box. The storage box contained an opened bottle of Ativan Concentrate (a sedative; controlled substance). The surveyor removed the shelf from the refrigerator with the locked box attached. The UM/RN acknowledged that the shelf was not permanently affixed within the medication refrigerator.

Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness, and c.) failed to discard expired nutritional supplements. This deficient practice was evidenced by the following: On 3/10/21 at 09:48 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed keys stored on a hook touching a cleaned whisk, the FSD stated that these keys should not have been stored with the whisk. 2. In the food preparation area, the surveyor observed grease-like brown colored particulates on the can opener. 3. In the food preparation area, the surveyor observed two ceramic plates stored on a shelf containing clean dishware, the two plates were soiled with black particles and a soiled napkin on top of one plate. The FSD stated that these plates should have been clean. 4. In the dry storage area, the surveyor observed a random sampling of dented cans which were in rotation for use. The surveyor observed the following: - A #10 sized can of sauerkraut with a 1/2 inch dent on the lower lip of the can, - A # 10 sized can of pineapples with a 1/4 inch dent on body of the can, - A # 10 sized can of peaches with a 1/2 inch dent on body of the can, - A # 10 sized can of garbanzo beans with a 1/2 inch dent on upper lip of the can, - A # 10 sized can of mushroom with a 1 inch dent on body of the can, - A # 10 sized can of butterscotch pudding with a 1/4 inch dent on body of the can, The surveyor reviewed the facility's policy titled, Storage of Utensils dated 8/15/2020. The policy indicated that utensils will be stored above the cooks table and ensure that they are sanitized and cleaned. The surveyor reviewed the facility's policy titled, Canned Food Free from Damages dated 1/1/2021. The policy indicated that the cooks and servers must inspect cans for damages before use and to remove any dented or damaged cans from service and place in designated damage area. 5. On 3/10/21 at 1:29 PM, the surveyor inspected the medication refrigerator, located on the first floor medication room, in the presence of the Unit Manager, Registered Nurse (UMRN). After inspecting the medication refrigerator, the surveyor observed that there were storage shelves in the medication room which held nutritional supplements. The surveyor counted 23 containers of a nutritional supplement that were honey thick liquid consistency with a best by date of 3/6/21. The UMRN acknowledged that the supplements were expired and said that there were no residents on the unit that were prescribed honey thick liquids. The surveyor asked the UMRN how often she checked the supply of nutritional supplements. The UMRN said she checked them monthly. She said she last checked the supplements on 3/1/21 but she must have missed them. On 3/10/21 at 2:15 PM, the surveyors brought the above concerns to the attention of the Administrator and the Director of Nursing. On 3/15/21 at 1:00 PM, the facility was not able to provide a policy regarding the storage of nutritional supplements. NJAC 8:39-17.2(g)