Based on observation, interview, and record review it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent potential urinary tract infections. This deficient practice was identified for 1 of 2 residents reviewed for indwelling urinary catheter (Resident #32), and was evidenced by the following: On 09/23/24 at 6:37 PM, the surveyor observed Resident # 32 in the room. At that time, the surveyor observed a used plastic bag tied to a handrail in the resident's bathroom. Inside the plastic bag was a used indwelling urinary catheter drainage bag dated 09/23/24. The urinary catheter drainage port was not capped, and was in direct contact with the plastic bag. On 09/24/24 at at 8:48 AM, the surveyor observed the resident resting in bed. The surveyor observed that the resident had an indwelling urinary Foley catheter (a flexible tube inserted into the bladder for urinary drainage) contained in a privacy bag and hung on the bedrail. On 09/24/24 at 12:06 PM, the surveyor observed Resident #32 sitting in a wheelchair at the bedside. The surveyor observed the Foley catheter drainage bag stored in a plastic bag in the bathroom. The drainage port was not capped. On 09/25/24 at 11:24 AM, the surveyor observed the Foley catheter drainage bag stored in a plastic bag in the bathroom, the drainage port was not capped. The Foley catheter drainage bag was dated 09/23/24. On 09/25/24 at 11:35 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) who provided Resident #32's indwelling catheter care. The CNA stated that prior to switching the leg bag to the catheter drainage bag, he would wash his hands, don (put on) gloves and gown, remove the leg bag and applied the Foley catheter drainage bag. The CNA did not indicate that the drainage port was to be disinfected prior to apply the leg bag. On 09/25/24 at 11:45 AM, the surveyor interview the Licensed Practical Nurse (LPN) assigned to the Unit. The LPN stated that the leg bag and the Foley catheter drainage bags were scheduled to be changed every Sunday. The LPN stated that when an indwelling urinary catheter drainage bag was not in use, staff were required to clean the bag of any residual urine and store the Foley catheter drainage bag in a plastic bag in the bathroom. The LPN further stated that the CNAs received training on how to store the bags/ drainage /leg bag. The surveyor then inquired specifically regarding the storage of the Foley catheter drainage bag. The LPN stated that the Foley catheter drainage bag must be cleansed of any residual urine and stored in a plastic bag in the bathroom. On 09/25/24 at 11:50 AM, the surveyor interviewed the LPN who cared for Resident #32. The LPN stated that Resident #32 had a suprapubic catheter (tube inserted into the bladder to facilitate urinary drainage). The LPN added that Resident #32 wore a leg bag during the day and a Foley catheter drainage bag at bedtime. The Foley catheter drainage bag would be stored in a plastic bag in the bathroom when not in use. The surveyor accompanied the LPN in the bathroom and we both observed the Foley catheter drainage bag in a plastic type basin, not in a plastic bag, and the drainage port was not capped. The Foley catheter drainage bag dated 9/23/24. The LPN confirmed that both bags were to be changed on Sunday and as needed. The LPN observed there was no cap on the drainage port, the LPN donned gloves and placed the Foley catheter drainage bag in the plastic bag. On 09/26/24 at 9:05 AM, the surveyor observed the resident sitting in a wheelchair in the room. The surveyor went to the bathroom and observed that the Foley catheter drainage bag was dated 09/23/24 and stored in a the basin in the bathroom, the drainage port was not capped. On 09/26/24 at 9:30 AM, the surveyor accompanied the Registered Nurse Supervisor (RN/SON) to the room and we both observed the Foley catheter drainage bag in the plastic bag with visible amount of urine, stored in the bassinet. The drainage port was not capped. The Foley catheter drainage bag was dated 9/23/24. That same day during an interview with Registered Nurse, Supervisor of Nursing (RN/SON), she stated that the Foley catheter drainage bag should be stored in a clean plastic bag and the drainage port should be capped to prevent infection. When inquired about how this information was communicated to the staff, the RN stated , in services education were provided to inform the staff of what needed to be done. On 09/24/24 at 11:30 AM, the surveyor reviewed the medical record for Resident #32. According to the admission Face Sheet, Resident #32 was admitted to the facility with diagnoses which included but were not limited to; unspecified Dementia, unspecified severity without agitation, benign prostatic hyperplasia with lower urinary tract symptoms and chronic kidney disease. The Annual Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 7/4/24, reflected that Resident #32 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated a moderate cognitive impairment. A review of the September 2024 Order Summary Report, revealed an order with an original date of 09/22/2023, to change the Suprapubic Catheter (SP) monthly on the 22nd of the month every night shift starting on the 22nd and ending on the 22nd every month for Preventative Care. Use size SP tube 22 French (diameter size), order dated 08/03/21. Have the Catheter leg bag on in AM, OFF at Bedtime two times a day. A review of the resident's individualized Interdisciplinary Care Plan (ICP) revised on 3/10/22, included a focus area that the resident had bladder elimination dysfunction: use of indwelling Suprapubic catheter related to Neurogenic bladder. The goal of the ICP included that the resident will not show no signs/ symptoms of infection. Will be free from catheter related trauma. Will not develop Urinary Tract Infection (UTI). Interventions of the ICP included catheter care daily and as needed. Monitor for signs and symptoms of infection. On 09/26/24 at 11:40 AM, the surveyor reviewed the facility's policy and procedure on Foley Catheter Insertion and Care last revised 07/2019. The policy included to maintain Universal Precautions throughout procedure. Perform all manipulations of Foley system as clean procedure. Wipe the end of the Catheter with an alcohol pad. Wipe the connector on the new bag with the second alcohol pad. Cleaning the drainage bag Wash your hands thoroughly with soap and water. Rinse the bag with soap and cool water. Do not use hot water because it can damage the plastic equipment. Cap after one hour and place in plastic bag for storage. Plastic storage bag is to be changed daily. Foley bags are to be replaced weekly. NJAC 8:39-19.4(a)5

Based on observation, interview, record review and review of facility documentation, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. This deficient practice was identified during the medication administration observation for 1 of 2 nurses, 2 of 4 residents (Residents #12 and #48), and for 27 opportunities. This resulted in two observed errors which resulted in a medication administration error rate of 7.41 % and was evidenced by the following: 1. On 9/24/24 at 9:34 AM, the surveyor conducted the medication administration and observed a Licensed Practical Nurse (LPN) preparing to administer nine (9) medications which included one Aspirin chewable 81 milligram (MG) tablet to Resident #12. The LPN stated that the Aspirin was an over the counter (OTC) house stock medication (stock bottles that the facility purchased for any resident that had a physician's order for the medication). On 9/24/24 at 9:56 AM, the surveyor observed the LPN administer the Aspirin chewable 81 MG tablet to Resident #12. On 9/24/24 at 10:57 AM, during reconciliation for the medication observation, the surveyor reviewed the Order Summary report which revealed an active physician's order (PO) with a start date of 1/5/23 for Aspirin Enteric Coated (EC)(a coating that allows the tablet to survive intact as it passes through the acidic stomach and dissolve in the small intestine to be absorbed) tablet delayed release 81 MG (Aspirin) Give 1 tablet by mouth in the morning for coronary artery disease (CAD) (a condition that happens when the coronary artery struggles to supply the heart with enough blood, oxygen and nutrients). On 9/24/24 at 11:31 AM, the surveyor, with the LPN, reviewed the electronic medication administration record (eMAR) at the medication cart. The eMAR revealed the same PO as above. The LPN stated that the PO was for Aspirin EC and was able to show the surveyor an OTC house stock bottle of Aspirin EC 81 MG tablets that were stored in the medication cart. The LPN then stated that she had administered Resident #12 the Aspirin chewable 81 MG tablet and realized that she should have administered Aspirin EC according to the PO. The LPN added that both were the same drug but one was EC and one was chewable. The LPN also stated that she was an agency nurse and was not usually on this medication cart. The LPN acknowledged that the PO specified EC and that she had administered the chewable formulation. (ERROR#1) The surveyor reviewed the medical record for Resident #12. A review of the admission Record revealed diagnoses which included, but were not limited to, dementia, gasto-esophageal reflux disease (heartburn) and atherosclerotic heart disease of native coronary artery (a disease of the coronary arteries having plaques of fatty material on their inner walls causing a struggle to supply the heart with enough blood, oxygen, and nutrients). On 9/25/24 at 8:32 AM, the surveyor interviewed the Consultant Pharmacist (CP) via the telephone who stated that the CP who had been servicing the facility was no longer employed but that he was the owner and could speak to any questions. The CP stated that the nurses were to follow the PO. The CP stated that the facility would have the records of any medication observations and in services that were completed. On 9/26/24 at 8:25 AM, the surveyor interviewed the Assistant Nursing Home Administrator (ANHA) who stated that the Infection Preventionist (IP) was the staff educator. The ANHA added that there were no medication administration observations completed for the LPN and would have to check if there were any in services completed. The ANHA added that the IP was covering for the Director of Nursing (DON) while the DON was temporarily not available. On 9/26/24 at 11:11 AM, the surveyor interviewed the IP who stated that she only completed medication administration observations if there was an issue or problem identified such as being late with medications. The IP added that the CP also did medication administration observations and in-services. On 9/26/24 at 11:28 AM, the surveyor interviewed the IP who stated that agency nurses were not observed for medication administration. On 9/26/24 at 11:31 AM, the surveyor, in the presence of the survey team, interviewed the ANHA and IP. The ANHA stated that the competency for agency nurses for medication administration was completed by the agency and would have to reach out to the agency for the records. On 9/26/24 at 11:43 AM, the surveyor was provided by the IP a Medication Pass in-service completed on 1/30/24 by the CP. A review of the Med Pass In-Service/Meeting sign-in sheet revealed that the LPN had not attended the in-service. A review of the in-service document used for the Medication Pass reflected the Five Rights which included but not limited to; 2. Right Medication: Review MAR for medication to be administered at the time ordered and Precautions. On 9/26/24 at 12:54 PM, the survey team met with the Licensed Nursing Home Administrator, ANHA and IP and reviewed the above concern. There was no further documentation provided. A review of the facility policy dated 2/23/2021 for Medication Administration Time provided by the ANHA revealed that the policy was for medications to be administered per physician order. In addition, the procedure reflected 11. Staff should verify each time a medication is administered that it is the correct medication, . 2. On 9/24/24 at 10:05 AM, the surveyor observed the LPN preparing to administer six (6) medications, which included one Glipizide Extended Release (ER) 5 MG tablet to Resident #48. On 9/24/24 at 10:09 AM, the surveyor observed the LPN address Resident #48 who was seated in a wheelchair in the hallway and explained to the resident that before they went to an activity that she wanted to administer the resident's morning medications. On 9/24/24 at 10:12 AM, the surveyor observed the LPN administer the Glipizide ER 5 MG tablet to Resident #48. On 9/24/24 at 10:17 AM, upon returning to the medication cart, the surveyor, with the LPN, reviewed the labeling on the package of the resident's Glipizide ER which revealed a sticker that specified Take this medication ½ hour before a meal. Read label carefully for how many times to take each day. The LPN stated that she was unsure when breakfast was served and could not speak to what time the Glipizide ER was to be administered. The LPN acknowledged that the time of administration on the eMAR was 8 AM. The LPN stated that she does go out earlier and tries to give medications before breakfast but was unaware of this medication. (ERROR#2) On 9/24/24 at 11:31 AM, the surveyor interviewed the LPN who stated that she was an agency nurse and was not usually on this medication cart. The LPN stated that she had administered insulin (a medication used to lower blood sugar) before breakfast but was unaware that the Glipizide had to be administered earlier. The LPN stated, I go down the line on my unit. The LPN explained that she went room to room with the eMAR administering medications in the morning. The surveyor reviewed the medical record for Resident #12. A review of the admission Record revealed diagnoses which included, but were not limited to, diabetes (a long-term condition where the body has trouble controlling blood sugar). A review of the Order Summary Report revealed a PO with a start date of 7/24/21 for Glipizide ER tablet Extended release 24 hour Give 5 MG by mouth in the morning related to Type 2 Diabetes Mellitus without complications. A review of the eMAR reflected the above PO with a time of administration of 0800 (8AM). On 9/25/24 at 8:32 AM, the surveyor interviewed the CP via the telephone who stated that the CP who had been servicing the facility was no longer employed but that he was the owner and could speak to any questions. The CP stated that the nurses were to follow the PO and any cautionaries associated with a medication. The CP stated that the facility would have the records of any medication observations and in-services that were completed. The CP further explained that cautionary warnings were usually on the eMAR as well as on the packaging of the medication and that the nurses should be looking at the cautionary information and following it. The CP added that if the cautionary information was only on the packaging, then it was still the responsibility of the nurses to follow the information. On 9/26/24 at 8:25 AM, the surveyor interviewed the ANHA who stated that the IP was the staff educator. The ANHA added that there were no medication administration observations completed for the LPN and would have to check if there were any in-services completed. The ANHA added that the IP was covering for the DON while the DON was temporarily unavailable. On 9/26/24 at 11:11 AM, the surveyor interviewed the IP who stated that she only completed medication administration observations if there was an issue or problem identified such as being late with medications. The IP added that the CP also did medication administration observations and in-services. On 9/26/24 at 11:28 AM, the surveyor interviewed the IP who stated that agency nurses were not observed for medication administration. On 9/26/24 at 11:31 AM, the surveyor, in the presence of the survey team, interviewed the ANHA and IP. The ANHA stated that the competency for medication administration was completed by the agency that the nurse was from and would have to reach out to that agency for the records. On 9/26/24 at 11:43 AM, the surveyor was provided by the IP a Medication Pass in-service completed on 1/30/24 by the CP. A review of the Med Pass In-Service/Meeting sign-in sheet revealed that the LPN had not attended the in-service. A review of the in-service handout for Medication Pass reflected the Five Rights included but not limited to 2. Right Medication: Review MAR for medication to be administered at the time ordered and Precautions. And 4. Right Time: Medication can be given 60 minutes before the time on MAR or 60 minutes after is considered correct, Exception medication to be given with regard to meals, either before meals (AC) or after meals (PC) need to be given as such. Further review of the in-service handout for Medication Pass reflected for Administration of Medication 7. All Cautionary labeling must be followed (separation from meds or food/fluid parameters.) On 9/26/24 at 12:54 PM, the survey team met with the Licensed Nursing Home Administrator, ANHA and IP and reviewed the above concern. There was no further documentation provided. A review of the facility policy dated 2/23/2021 for Medication Administration Time provided by the ANHA revealed that the policy was for medications to be administered following best practices. In addition, the procedure reflected 11. Staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route at the correct rate, at the correct time, for the correct resident, as set forth in Medication Administration Times Schedule. A review of the Medication Administration Times Schedule that was part of the policy, reflected that AC hours of administration were 7:30 AM, 11:30 AM and 4:30 PM. In addition, with meals hours of administration were 8:00 AM, 12:00 PM and 5:00 PM. Additionally, the facility policy for Medication Administration Time reflected 19. Follow manufacturer medication administration guidelines. A review of the manufacturer specifications for Glipizide ER revealed for Patient Information to Take Glipizide extended-release tablets by mouth, 1 time each day with breakfast or your first meal of the day. NJAC 8:39-11.2(b), 29.2(a)(d)

Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure staff: a) performed appropriate hand hygiene (HH) during meal delivery services and b) removed soiled gloves upon exiting a resident room to prevent the potential spread of infection. This deficient practice occurred on 2 of 3 units, for 1 staff observed on 1 of 3 units and was evidenced by the following: a) On 09/25/2024 at 8:13 AM, Surveyor #1 observed the breakfast meal trays being delivered to residents on the B unit. Surveyor #1 observed two Certified Nursing Aides (CNA) delivering breakfast to residents without first performing HH or offering residents the opportunity to clean their hands. On 09/25/2024 at 8:49 AM, CNA #1 stated that there were only 2 CNAs on the B unit and confirmed he should have washed his hands after each resident interaction to prevent the spread of infection. CNA #2 was assigned to observe the dining area with the residents. On 09/25/2024 at 9:40 AM, during an interview with Surveyor #1, the acting Food service Director (FSD) revealed that the facility kitchen did not have or provide anything on the meal trays for the residents to cleanse their hands with. On 09/25/2024 at 8:06 AM - 8:17 AM, Surveyor #2 observed the breakfast trays being delivered to residents on the A unit. Surveyor #2 observed CNA #3 deliver trays twice into the same room without any HH performed or offering the residents HH, CNA #3 then pushed the tray cart down the hall, and without first performing HH, delivered a tray into another resident room and did not offer the resident HH. Next CNA #3 exited the room, and without performing HH, obtained another resident breakfast tray, delivered it and assisted opening foods and setting the resident up to eat without offering the resident any HH. CNA #3 asked CNA #4 to assist her in repositioning a resident in another room without either CNA first performing HH and then CNA #3 began to assist the resident with eating without first performing HH. During the same meal delivery on A unit, CNA #4 was observed delivering a meal tray to a resident without first performing HH or providing the resident with HH. CNA #4 exited the room, did not perform HH, then delivered 2 more meal trays without performing HH or offering the resident HH. CNA #4 exited again without performing HH and then delivered another meal tray without providing the resident with HH. CNA #4 then assisted CNA #3 to reposition a resident without performing HH first or after positioning. On 09/25/2024 at 8:21 AM, CNA #3 stated the correct process was to stop resident care, wash our hands, and deliver the trays to the residents. When asked about HH, CNA #3 stated the residents would have their hands cleaned during morning care and that she should have used HH in between delivering trays to each resident but had no reason as to why she did not. On 09/25/2024 at 8:32 AM, CNA #4 stated the process was to take the trays to each resident room and set the resident up to eat. She stated the residents were provided hand hygiene before meals. When asked what was used or how this was performed, CNA #4 stated we don't use anything because the residents were cleaned up in the morning. CNA #4 did acknowledge she should have used HH in between delivering the meal trays to the residents and had no reason as to why she did not. A review of the facility provided Sign in Sheet dated August 2024, included but was not limited to; a topic of HH. The sign in sheet indicated that CNA #1 had not signed that he had attended the education. CNA #3 was not listed as part of the nursing staff. CNA #4 had signed and dated on 08/08/2024, that she had attended the HH education. b) On 09/25/2024 at 8:30 AM, Surveyor #1 observed a contracted laboratory technician (LT) enter a resident room on the B unit. The LT donned (put on) gloves, drew the resident's blood sample, and left the resident room while still wearing the soiled gloves. The LT was observed in the hallway with the same gloves on, then collected a specimen from the nurse and began arranging specimens collected on the nursing desk countertop, before placing them into a collection bag. On 09/25/2024 at 8:33 AM, the LT stated that he had not disposed of the soiled gloves prior to exiting the resident room, and stated I should have put them [soiled gloves] in the trash. A review of the facility provided Handwashing Pledge undated, included but was not limited to; It is recognized as the single most important means of preventing the spread of infection. I understand that the only cost to me is the time it takes to wash, and the benefit of this pledge is a reduction of cross infection in my facility. A review of the facility provided policy, Handwashing/Hand Hygiene revised August 2019, included but was not limited to; This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene . 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections . 5. Residents, visitors . will be encouraged to practice hand hygiene . 7. Use an alcohol-based hand rub or soap and water for the following situations: b. before and after direct contact with residents; . j. after contact with blood or bodily fluids; . l. after contact with objects in the immediate vicinity of the resident; . o. before and after eating or handling food; p. before and after assisting a resident with meals . NJAC 8:39-19.4(a), 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00163437 Based on observation, the interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to: a) ensure there was a physician's order and physician documentation regarding discharge for one (1) of three (3) closed medical records reviewed for discharge (Resident #117) and b) ensure a physician's order for a diet order of nectar thick consistency for one (1) of five (5) residents were followed during Medication Pass Observation of Resident#1. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 5/04/23 at 01:27 PM, the surveyor reviewed the closed medical record for Resident #117 and revealed the following: The admission Record (AR; or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; altered mental status (a change in mental function), hypertension (elevated blood pressure) and cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area). The Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/08/23, showed that the resident was discharged to the community (which includes private home/apt, board/care, assisted living, group home). A review of a Progress Note (PN) dated 12/08/23 showed a note written by nursing staff which included the following: Resident was discharged from the facility at approximately 02:45 PM, discharge papers with medication scripts were handed over to resident's responsible party. Further review of the electronic PNs showed a note written by the physician that included Resident #117's history and physical (H&P). The H&P did not include information about a plan for discharge. There was no other documentation written by a physician in the PN's. The Order Summary Report (OSR) dated 12/08/22, did not include a physician's order for discharge. A review of a copy of prescriptions written by the physician dated 12/07/22 did not include a physician's order for discharge. On 5/11/23 at 11:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) via phone, regarding the process of a resident's discharge. LPN #1 stated that the physician would usually write an order for discharge in the electronic medical record or would give a verbal order to the nurse and that the nurse would place the order in the electronic medical record. On 5/11/23 at 11:32 AM, the surveyor interviewed the Director of Nursing (DON) regarding the process of a resident's discharge and a physician's order for discharge. The DON stated that there would be a physician's order for discharge and that it would be in the order section of the electronic medical record. The surveyor then asked the DON if Resident #117 should have had a physician's order for discharge in the electronic medical record. The DON stated that there should be a physician's order for discharge. On 5/11/23 at 01:39 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Admissions and Marketing/Assistant Administrator (DoAM/AA) and DON, the findings that Resident #117's medical record did not include a physician's discharge order and physician's documentation regarding discharge. On 5/16/23 at 12:58 PM, in the presence of the survey team, DoAM/AA and DON, the LNHA confirmed that there was no physician's order for discharge for Resident #117 prior to surveyor inquiry. The surveyor asked the LNHA if there should have been a physician's order for discharge. The LNHA stated that there should have been a physician's order for discharge. She added that an order could be in the electronic medical record, or it could be handwritten and uploaded to the electronic medical record. On 5/17/23 at 12:01 PM, the DoAM/AA provided the survey team a Clinical Physician Order which included the following: Discharge to ALF (Assisted Living Facility). A review of the document indicated the note was created after surveyor inquiry on 5/16/23. 2. On 5/05/23, at 8:53 AM, the surveyor began the Medication Observation Pass for Resident #1. LPN #2 began to prepare the medication for the resident. At that time, the surveyor observed an order on the electronic Medication Administration Record (eMAR) that indicated the resident had a nectar thick order. On 5/05/23 at 9:10 AM, LPN #2 confirmed with the surveyor that she was ready to administer the medications to Resident #1. On 5/05/23 at 9:11 AM, during the medication pass observation for Resident #1, the LPN stated she had pre-prepared the resident's nectar thickened liquid that morning. At that time, LPN #2 identified the liquid that was in a covered Styrofoam cup on the resident's sink was the liquid she had prepared that morning. At that time, Resident #1 stated she added a tea bag in the Styrofoam cup. The surveyor observed the LPN was about to administer the medications to the resident. At that time, the surveyor stopped the medication pass for Resident #1 to check the liquid in the cup. LPN #2 removed the Styrofoam cup from the resident's room. At that time, the surveyor and LPN #2 reviewed the liquid within the Styrofoam cup. The LPN informed the surveyor that the liquid in the Styrofoam cup was not nectar thick consistency. The surveyor reviewed the medical records for Resident #1. The AR reflected the resident was admitted with medical diagnoses that included, chronic obstructive pulmonary disease, hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction affecting unspecified side, and gastro-esophageal reflux disease without esophagitis. The quarterly MDS dated [DATE], reflected the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated the resident had a fully intact cognition. Further review of the MDS under section K 0510 Nutrition approaches under subsection C. Mechanically altered diet - require change in texture of food or liquids (e.g., puree food, thickened liquids) indicated, yes. The OSR reflected the dietary order for No Added Salt diet, regular texture, nectar consistency with a start date of 12/29/21. Further review of the order summary report revealed an ST [speech therapist] recommendation: Thin/Free Water Protocol. Patient can be provided with regular thin water in between meals ONLY upon request and as tolerated. Adequate oral care and positioning OOB (out of bed) in wheelchair ONLY when provided with regular water with DIRECT SUPERVISION. Maintain aspiration precautions at all times and continue to monitor for aspiration (body temp; respiratory status). Medications to be provided with thickened Liquids. On 5/05/23 at 10:53 AM, during a follow up interview with the surveyor, LPN #2 informed the surveyor that she prepared a nectar thick liquid because she had an order for it. LPN #2 stated she used two (2) packets in a nine-ounce cup not filled to the brim and poured it into the Styrofoam cup. LPN #2 stated she was not sure why the liquid in Resident #1's room was not nectar thickened. The LPN #2 informed the surveyor that she did add ice into the resident's cup, and it may have changed the consistency. LPN #2 stated she should have double checked after mixing the liquid before placing the Styrofoam cup into the resident's room. On 5/10/23 at 12:04 PM, in the presence of the survey team, the DON, the LNHA and the DoAM/AA, the surveyor discussed the findings regarding the failure to follow the physicians order for nectar thickened liquid for Resident #1. On 5/11/23 at 12:07 PM, during an interview with the surveyor, the Rehabilitation Director (RD) stated Resident #1 was referred because the resident wanted an upgrade on their diet. The RD explained an upgrade/advance meant a less restrictive diet. On 5/11/23 at 12:08 PM, the surveyor and the RD reviewed the Speech Therapy Speech-language pathologist (SLP) Evaluation and Plan of Treatment. The evaluation reflected diagnoses that included dysphagia (swallowing difficulties). At that time, the RD stated that Resident #1's SLP recommended free water protocol with adequate mouth care and distant supervision. The RD clarified that medication must be administered with nectar thickened liquid. On 5/11/23 at 01:05 PM, the DON stated the resident was given instruction for free water protocol and in between meals. The DON also stated he had consulted with the consultant pharmacist and was told since the resident had order for free water protocol the nurse should have been able to administer the medication with thin liquid. The DON stated he would further research the order that indicated medication to be provided with thickened liquid. The DON informed the surveyors that education was given to LPN #2. A review of the facility provided policy titled, Discharge Policy & Procedure dated 2/15/23, included the following: POLICY It is the policy of this facility that residents will be assessed for their discharge goals, preferences and care needs to meet their goals. The assessment information will be used to develop a comprehensive discharge care plan .The care plan will be developed by the interdisciplinary team (IDT), including the resident's physician . OBJECTIVE OF THE DISCHARGE PLAN FACILITY POLICY The objective of the discharge plan policy and procedure is to provide a framework for the completion of relevant documents by the IDT and the residents and representative that will inform the discharge process and assist the resident to reach their discharge goals. The policy did not include information regarding physician order or documentation. A review of the facility provided policy titled, Discharge Planning-Physician's Responsibility dated 12/11/2020, included the following: I. POLICY: It is the policy of that the medical care of each resident is supervised by a physician who assumes the principal obligation and responsibility to manage the resident's medical condition, including transfer and discharge. II. STATEMENT: Physician involvement in nursing facilities is essential to the delivery of quality long-term care. Attending physicians should lead the clinical decision-making for patients under their care . III. Process and Procedure: .C. Physician responsibilities Physicians are responsible for deciding whether the patient is safe for discharge, creating the discharge plan in conjunction with the rest of the team, and communicating instructions to the discharge nurse or designated discharge personnel . To facilitate a patient's safe discharge from an inpatient unit, physicians should: a. Determine that the patient is medically stable and ready for discharge from the treating facility . Physician responsibilities may include: .Provide appropriate documentation and other information that may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; Give all orders needed at the time or prior to discharge from the facility . A review of the facility policy provided, Operational Manual, subject: Speech Therapy Policy revised/ reviewed 3/15/21 included under Procedure, B. The areas addressed by Speech therapist include, but are not limited to: 7. Diet consistency/textures A review of the facility policy provided, Nursing Policy Manual, subject Medication Administration dated 7/08 included under Policy: Medications are administered by licensed nurses per physician order, following all regulations and best practices. No further information was provided. NJAC 8:39-17.4 (a) 1(e), 27.1 (a)

Complaint # NJ00163437 Based on interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to document a discharge summary which included a recapitulation of the resident's stay and a final summary of the resident's status for one (1) of three (3) closed records reviewed for discharge (Resident #117). This deficient practice was evidenced by the following: On 5/04/23 at 01:27 PM, the surveyor reviewed the closed medical record for Resident #117 and revealed the following: The admission Record (or face sheet; admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; altered mental status (a change in mental function), hypertension (elevated blood pressure) and cerebral infarction (also known as a stroke refers to damage to tissues in the brain due to a loss of oxygen to the area). The Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/08/23, showed that the resident was discharged to the community (which includes private home/apt, board/care, assisted living, group home). A review of a Progress Note dated 12/08/23 showed a note written by nursing staff which included the following: Resident was discharged from the facility at approximately 2:45 PM, discharge papers with medication scripts were handed over to resident's responsible party. The Transfer/Discharge Report included Resident #117's diagnoses, last vital signs (included the date but not a time) and the date and time of discharge. The Transfer/Discharge Report did not include where Resident #117 was discharged to, a recapitulation of the resident's stay and the final status of the resident. The medical record revealed that there was no documented discharge summary which included the recapitulation of the resident's stay and a final summary of the resident's status. On 5/11/23 at 01:39 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Admissions and Marketing/Assistant Administrator (DoAM/AA) and Director of Nursing (DON), the findings that Resident #117's medical record did not include a discharge summary. On 5/16/23 at 12:48 PM, in the presence of the survey team, LNHA and DON, the DoAM/AA stated that Resident #117's physician left the medical practice and had not written a note but that another physician wrote a late entry. On 5/16/23 at 12:58 PM, in the presence of the survey team, DoAM/AA and DON, the LNHA confirmed that there was not a discharge summary written for Resident #117 until after surveyor inquiry. The surveyor then asked the LNHA if there should have been a discharge summary. The LNHA stated that there should have been a discharge summary. On 5/17/23 at 12:01 PM, the DoAM/AA provided the survey team a late entry Medical Progress Note which included a medical discharge summary. A review of the document indicated the note was created on 5/13/23, after surveyor inquiry. A review of the facility provided policy titled, Discharge Policy & Procedure dated 2/15/23, included the following: (2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services . 8. Discharge Summary a. A discharge summary will be completed upon discharge to include: a. A recapitulation of the residents stay in the facility (diagnoses, course of illness/treatment, therapy, lab, radiology and consultation reports) b. A final summary of resident status c. Medication reconciliation d. A post-discharge plan of care developed with the resident and resident representative. i. Location/Agency/Facility where resident will reside. ii. Arrangements for care, medications and services post-discharge. iii. Arrangements for follow-up communication post-discharge. A review of the facility provided policy titled, Discharge Planning-Physician's Responsibility dated 12/11/2020, included the following: I. Policy: It is the policy of that the medical care of each resident is supervised by a physician who assumes the principal obligation and responsibility to manage the resident's medical condition, including transfer and discharge . III. Process and Procedure: .C. Physician responsibilities Physicians are responsible for deciding whether the patient is safe for discharge, creating the discharge plan in conjunction with the rest of the team, and communicating instructions to the discharge nurse or designated discharge personnel . To facilitate a patient's safe discharge from an inpatient unit, physicians should: a. Determine that the patient is medically stable and ready for discharge from the treating facility . Physician responsibilities may include: .Provide appropriate documentation and other information that may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; . Provide pertinent medical discharge information within 30 days of discharge or transfer of the patient. N.J.A.C. 8:39-35.2(d)(16)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a) expired medications were removed from the electronic emergency (back-up) supply for 1 (one) of 1 (one) back up machine, b) prescription medication for unsampled Resident #267 was removed from active inventory after being discontinued on October 2022, c) prescription medications were labeled, dispensed, and accounted, for 1 (one) of 2 (two) medication rooms inspected and 1 (one) of 3 (three) medication carts inspected. 21 CFR 1306.24(b) If the prescription is filled at a central fill pharmacy, the central fill pharmacy shall affix to the package a label showing the retail pharmacy name and address and a unique identifier, (i.e. the central fill pharmacy's DEA registration number) indicating that the prescription was filled at the central fill pharmacy, in addition to the information required under paragraph (a) of this section. 21 CFR 205.50(a)(3) a) Facilities. All facilities at which prescription drugs are stored, warehoused, handled, held, offered, marketed, or displayed shall: Have a quarantine area for storage of prescription drugs that are outdated, damaged, deteriorated, misbranded, or adulterated, or that are in immediate or sealed, secondary containers that have been opened . The deficient practice was evidenced by the following: 1. On 5/05/23 at 12:31 PM, the surveyor and the Registered Nurse/Unit Manager (RN/UM) entered the medication room for the E wing (subacute unit). Located within the same medication room was the electronic back-up machine. At that time, the RN/UM stated that the supervisors on all shifts were responsible to monitor the inventory and did not have a written accounting that the task was being completed. On 5/05/23 at 12:37 PM, the RN/UM, in the presence of the surveyor began the cycle count for the back-up machine. The back-up machine had locked drawers that opened once the nurse entered their credentials. Each drawer contained several medications. On 5/05/23 at 12:53 PM, the surveyor, in the presence of the RN/UM observed two Ciprofloxacin (antibiotic medication used to treat various bacterial infections) 200 milligram (mg)/100 milliliter (ml) 5 % dextrose (D5W) injection, USP. The medication was labeled with an expiration date of 01/31/23. On 5/04/23 at 12:56 PM, the RN/UM confirmed the two Ciprofloxacin for injection were expired since 01/31/23. A review of the PAR (minimum and maximum quantity limits that was set for a certain medication) of the Ciprofloxacin D5W 200 mg/100 reflected a quantity of 2 (two). At that time, during an interview with the surveyor, the RN/UM stated expired medications should not have been contained within the electronic back-up machine. The RN/UM stated expired medications would not have been effective to treat the resident. At that time, the RN/UM stated, I recognize that we do not have an audit list and that could have helped with the accountability. The RN/UM stated she would remove the expired medications, notify the pharmacy to pick up, replace the medication and inform the Director of Nursing (DON). 2. On 5/11/23 at 9:34 AM, the surveyor in the presence of the Registered Nurse#1 (RN#1) began the unit inspection for the medication room for the D wing (unit 2). On 5/11/23 at 9:48 AM, the surveyor, in the presence of RN #1, observed a bottle of Lactulose (medication for encephalopathy) labeled for unsampled Resident #267 commingled with the over the counter (OTC; house stock) medications. At that time, RN#1 could not explain why the labeled medication bottle for Resident #267 dated 10/07/22 was in the same medication cabinet commingled with the OTC medications. The surveyor reviewed the medical records for Unsampled Resident #267. The admission Record (AR; face sheet; admission summary) for Unsampled Resident #267 reflected the resident was admitted with diagnoses that included acute on chronic systolic (congestive) heart failure, cognitive communication deficit, and cerebral infarction (stroke). The Clinical Physician Orders for Unsampled Resident #267 reflected that Lactulose Solution had a start date of 10/07/22 and an end date of 10/12/22. A review of the Census List for Unsampled Resident #267 revealed the resident was discharged to the hospital on [DATE]. On 5/11/23 at 9:56 AM, during an interview with the surveyor, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated discontinued medications should have been returned to the pharmacy provider for the resident to receive credit. On 5/11/23 at 10:02 AM, the LPN/UM stated the discontinued medication should have been separated from all the OTC medications in active inventory to avoid medication errors, We can't use someone else's medications and resident should receive the credit. 3. On 5/11/23 at 10:02 AM, the surveyor in the presence of RN#1 continued the inspection of the medication room and observed the following: -three sealed bottles of Lactulose with no pharmacy provider label -one box of Ondansetron (medication used to treat nausea and vomiting) 4 mg, quantity of thirty tablets with pharmacy provider label. At that time, during an interview with the surveyor, the RN/UM stated the pharmacy should not have sent prescription medications without a label. We do not know who the medications were indicated for, and this is not safe for the residents. On 5/11/23 at 10:22 AM, the surveyor began the medication cart inspection for the A and B wing (unit 1) in the presence of the Licensed Practical Nurse (LPN). On 5/11/23 at 10:31 AM, the surveyor observed an unlabeled box of Ondansetron 4 mg Oral Disintegrating tablets that contained 23. At that time, during an interview with the surveyor, the LPN stated that prescription back-up medications were also known as house stock. She further informed the surveyor that the Ondansetron was a house stock medication that they used. At that time, the LPN/UM explained the process for removal of back-up medications, we take out the dose of what we need for the resident. The LPN stated we should not have an unlabeled medication in our active inventory because medication error and drug diversion could occur. The LPN informed the surveyor that she would immediately remove the medication from the medication cart and give it to the RN/UM. On 5/11/23 at 01:05 PM, in the presence of the survey team, the DON, the Licensed Nursing Home Administrator (LNHA) and the Administrator in Training (AIT), the surveyor discussed the concerns regarding the expired medication, unlabeled medications and discontinued medication. At that time, the LNHA stated she followed up with the pharmacy provider. She stated that the pharmacy provider assured her that the expired medication would not show as available and would not be dispensed from the electronic back-up machine. At that time, the LNHA, presented an electronic mail (email) correspondence between her and the provider pharmacy. The email reflected that the electronic back-up machine was checked for outdated medications monthly and inventoried every 90 days. The individual tasked with the responsibility to was terminated in March. The correspondence further revealed that the expired medication in the machine was automatically quarantined and unavailable for removal. The LNHA acknowledged that the expired Ciprofloxacin D5W from 01/31/23 should have been removed. On 5/16/23 at 01:23 PM, the DON presented an email correspondence between him and the pharmacy provider. The email reflected that the Lactulose was a back-up supply and was labeled with the location on a different medication room. The pharmacy provider acknowledged that a unit dose medication would be best for the back-up supply and the bottles would be replaced with the unit dose medication. At that time, the DON and the LNHA stated that the medication that belonged on the back-up supply should have been in the same medication room and that they should have been informed. Both acknowledged it should not have been in a separate unit. On 5/17/23 at 11:40 AM, during a follow up interview with the surveyor, in the presence of the survey team, the DON stated that the previous medical director had ordered Ondansetron from a different pharmacy provider on 11/12/21 as a house stock. The DON stated the Ondansetron should not have been there. It should have been returned to the pharmacy or discarded. It was missed by nursing, the supervising nurses, and the consultant pharmacist (CP). On 5/17/23 at 11:54 AM, during an interview with the surveyor, in the presence of the survey team, the DON, LNHA and AIT, the CP stated that the unlabeled medications in a different unit from the back-up machine commingled with active OTC inventory was not inappropriate. The CP also stated the discharged resident's medication should have been removed and was overlooked. A review of facility policy provided; Medication Storage revised/reviewed 8/01/22 included under Policy: It is the policy that back up medication shall be kept in the [name redacted] provided by [name redacted]. A review of facility policy provided, Medication Storage in the Facility 2023 Edition included under section 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without closures are immediately removed from stock, disposed of according to the procedures for medication destruction and reordered from the pharmacy, if current order exits [exists]. NJAC 8:39-29.4 (c) (f) (g) (h)

Based on the interview, record review, and review of the facility provided documents, it was determined that the facility failed to: a) follow up and act upon the Consultant Pharmacist's (CP's) recommendations for one (1) of 18 residents reviewed for Medication Record Review (MRR), Resident #118 and b) identify medication irregularity during the monthly MRR of the CP for one (1) of five (5) residents reviewed for unnecessary medications, Resident#120. This deficient practice was evidenced by the following: 1. On 5/02/23 at 11:08 AM, the surveyor observed Resident #118 seated in a wheelchair inside their room while watching television. The surveyor reviewed Resident #118's medical records. The admission Record (AR or face sheet; an admission summary) showed that the resident was admitted to the facility with diagnoses that included type two diabetes mellitus without complications (abnormal or elevated blood sugar level), essential hypertension (elevated blood pressure), and orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down). The admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, with an Assessment Reference Date (ARD) of 4/12/23 showed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated that the resident's cognition was moderately impaired. The April and May 2023 electronic Medication Administration Record (eMAR) revealed a physician order (PO) dated 4/24/23 for Midodrine (medication that can treat a kind of low blood pressure that causes severe dizziness and fainting) 12.5 mg (milligram) to give one tablet by mouth every eight (8) hours (hrs) as needed (PRN) for hypotension hold for SBP (systolic blood pressure; the first number) more than 130. According to the 5/02/23 CP MRR for Resident#118, the CP recommended to change the PRN Midodrine to be given if SBP is less than 100 and obtain an order to check SBP every 8 hrs to determine if the order should be administered. Further review of the medical records and the eMAR showed that the above recommendation to change the parameter of Midodrine to SBP less than 100 was followed and was transcribed to May 2023 eMAR. The recommendation to obtain an order to check SBP every 8 hrs was not followed. On 5/05/23 at 9:48 AM, the surveyor interviewed the Licensed Practical Nurse (LPN). The LPN informed the surveyor that the CP comes once a month to review the MRR of residents at the facility, and reports are submitted via email to the Director of Nursing (DON), and then the DON will give it to the Registered Nurse/Supervisor (RN/S) to follow up the recommendations and call the doctor. On 5/10/23 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator (LNHA), Director of Admissions & Marketing/Assistant Administrator (DoAM/AA), and DON and were made aware of the above findings. On 5/11/23 at 8:56 AM, the surveyor interviewed the RN/S in the presence of the survey team. The RN/S informed the surveyor that it was the facility's practice, policy, and procedure that the CP review resident's MRR every first week of the month, then a couple of days the written reports were sent via email to the DON. The RN/S stated that the DON will provide a copy to the RN/S, then the RN/S initiate to act upon the CP's recommendations, if it was not completed, it will then be delegated to the nurses in the unit and/or to the afternoon Nursing Supervisor. The RN/S further stated that the following day if the CP's recommendations were not completed, the RN/S will continue to follow up on the remaining recommendations that were not done. At that same time, the surveyor showed and notified the RN/S of the 5/02/23 CP's recommendation to obtain an order for SBP every 8 hrs was not followed. The RN/S stated that she was not sure who took care of the recommendations and why the recommendation for Resident #118 was not followed. On 5/11/23 at 01:03 PM, the survey team met with the LNHA, DoAM/AA, and the DON. The DON stated that he investigated what had happened and why the CP's recommendation on 5/02/23 was not followed. The DON further stated that it was the Registered Nurse (RN) who followed up on the CP's recommendation for a Midodrine order for SBP and the reason why the RN did not follow the recommendation to obtain an order for every 8 hrs to check SBP because all residents in the subacute where the resident was located had a standing order for vital signs check every shift. On that same date and time, the surveyor asked the DON what time every shift was plotted and the every 8 hrs plotted in the eMAR. The DON stated that every shift has no specific time and usually vital signs are checked during the first med pass at 8:00 AM for the 7-3 shift and 4:00 PM for the 3-11 shift. The DON further stated that every 8 hrs means it is 6:00 AM, 2:00 PM, and 10:00 PM. In addition, the DON stated that the RN should have called the doctor and obtained an order for every 8 hrs. Furthermore, the DON acknowledged that the CP's recommendation was not clear and should have been clarified as well. 2. On 5/02/23 at 11:16 AM, the surveyor observed Resident#120 laying on the bed with the head of the bed elevated. The resident informed the surveyor that he/she had a cancer diagnosis and with variable pain in the abdomen area that nurse administers pain medication. The resident further stated that he/she was satisfied with their pain medication regimen. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included Secondary malignant neoplasm of the liver and intrahepatic bile duct (type of liver cancer), secondary malignant neoplasm of the unspecified lung (type of lung cancer), anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), essential hypertension, unspecified abdominal pain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormones). The 5/05/23 Comprehensive MDS (CMDS) revealed a BIMS score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The CMDS reflected that the resident received PRN pain medications, with occasionally moderate pain for the last five (5 days). A review of the April and May 2023 eMAR revealed the following orders: 1. PO dated 4/28/23 at 1751 (5:51 PM) for Acetaminophen 325 mg to give 2 (two) tabs by mouth for a total of 650 mg every 4 (four) hrs PRN for mild pain. 2. PO dated 4/30/23 at 1530 (3:30 PM) for Oxycodone HCL (hydrochloride) oral 5 (five) mg to give one tab by mouth every 4 hrs PRN for mod-severe (moderate-severe) pain. 3. PO dated 5/02/23 at 1015 (10:15 AM) for Morphine Sulfate (concentrate) oral solution 20 mg/ml (milligram/milliliter), give 0.25 ml by mouth every 3 (three) hrs PRN for pain. The order for Morphine Sulfate was updated on 5/03/23 at 0645 (6:45 AM) to give 0.25 ml by mouth every 4 hrs PRN for pain. Furthermore, the above orders for PRN pain medications for April and May 2023 showed that the PRN Oxycodone was administered on 4/30/23 and 5/01/23 and the PRN Morphine was administered on 5/02/23, 5/03/23, 5/04/23, and 5/05/23. A review of the 5/02/23 MRR of the CP showed that there were no recommendations comments. In addition, the 5/02/23 at 1842 (6:42 PM) Progress Notes of CP in the electronic medical record revealed that MRR was completed. On 5/05/23 at 9:48 AM, the surveyor interviewed the LPN. The LPN stated that the resident was able to make needs known to staff, was constantly in pain, and was on multiple pain medication regimens as standing order and PRN. The LPN further stated that the physician and the responsible party were aware of the resident's condition. At that same time, the LPN informed the surveyor that there were times when the CNA will have to call the nurse to assess the resident because the resident had pain when repositioning. The LPN stated that even during morning rounds, the LPN noticed that the resident with a facial grimace and PRN pain medication being offered and the resident will decline. On that same date and time, the surveyor notified the LPN of the findings with regard to PRN pain medication Morphine with no indication of what level of pain to administer. The LPN stated that there should be a proper sequencing of PRN pain medications and it was probably an oversight on their part. She further stated that the CP should have pick up the irregularity and reported it to CP's monthly MRR. The LPN indicated that she will call the physician regarding the PRN Morphine order. On 5/10/23 at 12:32 PM, the survey team met with the LNHA, DON, DoAM/AA and were made aware of the above findings. On 5/11/23 at 8:56 AM, the surveyor interviewed the RN/S. The RN/S informed the surveyor that residents with multiple PRN orders for pain medications should have a sequenced order for mild, moderate, and severe pain, and it was the nurse's responsibility to clarify and obtain that order from the physician according to the facility's practice and policy. The RN/S stated that it was also the CP's responsibility to identify those irregularities and document and report it in the written MRR. She further stated that the nurse and the CP should have identified those sequencing irregularities for PRN Morphine for pain. A review of the facility's Medication Regimen Review (MRR) Policy that was provided by the LNHA with a revised date of January 2018 included that the CP performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. MRR also involves reporting findings with recommendations for improvement. MRR activities include but are not limited to evaluating medication orders to determine that the resident's orders represent optimal therapy for that individual that includes PRN orders that include indications for use. Recommendations are acted upon and documented by the facility staff and/or the prescriber. On 5/17/23 at 12:10 PM, the LNHA provided her phone with CP on the other line to discuss the PRN Morphine findings in the presence of the survey team. The CP stated that you are right, the Morphine should have been clarified and identified in the 5/02/23 MRR. The CP further stated that the nurse should have identified the irregularities as well. NJAC 8:39-29.3 (a)(1)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a) properly label and date the opened bulk dry food items and b) maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a foodborne illness. This deficient practice was evidenced by the following: On 5/03/23 at 12:33 PM, during the second day tour of the kitchen, the surveyor and General Manager/Food Service (GM/FS) observed the following in the basement food storage area: 1. In the basement#1 refrigerator, the surveyor observed four (4) crates of 4oz (ounces) whole milk, one gallon of 2% milk, four boxes of individual creamers, six (6) crates of 2% 4oz milk. The inside bottom floor of basement#1 refrigerator had dried and liquid white substance residue covering almost half of the refrigerator. During an interview, the GM/FS informed the surveyor that the white substance was milk. The GM/FS stated that the refrigerator should be cleaned once a week and maintained to be clean. He further stated that there was no accountability log for the weekly cleaning of the basement#1 refrigerator. 2. In the dry storage room, the surveyor observed the unlabeled covered bin with black plastic inside with noticeable white and brown substances around it and papers at the bottom of the container. In addition, inside the container were two (2) opened bulky bags of sugar and flour with no date opened and a use-by date. At that time, the GM/FS informed the surveyor that as per facility policy and protocol, all opened food items must have a label, date opened, and use-by date. Furthermore, the GM/FS picked up and showed to the surveyor labels that were on the bottom of the container which revealed that three (3) out of four (4) labels that fell off were for the flour with dates: 4/15/21 (date open) and use by 6/25/21, 9/23/21 (date open) and use by 11/23/21, and 4/11/23 (date open) and use by 7/11/23. The other label was for the sugar with dates: 4/13/21 (date open) with use by 7/13/21. Furthermore, the GM/FS stated that the bag of sugar and flour contained 50 lbs (pounds) each and both had approximately 25 lbs remaining in each bag. He further stated that he did not know why the bag of sugar had no appropriate label. He acknowledged that the container of sugar and flour was not clean, with dust and residues of both flour and sugar visibly seen because of the black plastic. On 5/05/23 at 10:05 AM, the surveyor interviewed the GM/FS. The GM/FS informed the surveyor that according to their previous policy about the bulk items and following the 2017 Food Code, bulk sugar and other bulk food items once opened, should have an open date and use by date because, after two years, the sugar crystallized. The GM/FS stated that opened bulk flour and sugar should have been placed in a separate covered container with a label outside the container. On that same date and time, the GM/FS stated that in the process of receiving the delivery of milk every Monday, the Executive Chef (EC) who receives delivery should remove the old milk stock, clean and sanitize the reach in refrigerator (basement#1 refrigerator), check the new delivered milk temperature, then store the newly delivered milk. He further stated that it was a major oversight for me. A review of the undated facility's Bulk Product Procedure Policy that was provided by GM/FS included that all bulk products must have a receiving date upon delivery; once the product is open, it must be transferred in a clean and sanitized container labeled with product name, date opened, use by date (follow manufacturer's guideline), and employee initials; and products: bulk flour, bulk sugar, bulk rice, and bulk thickener. A review of the undated facility's Cold Storage Refrigeration and Freezers Cleaning and Sanitizing Policy that was provided by the GM/FS included that the reach-in Refrigerator and Freezer are weekly. On 5/10/23 at 12:32 PM, the survey team met with the Licensed Nursing Home Administrator, Director of Nursing, and Assistant Administrator and were made aware of the above findings. NJAC 8:39-17.2(g)

Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to maintain the necessary respiratory care and services for residents who were receiving oxygen (O2) treatment according to standards of practice. This deficient practice was identified for three (3) of three (3) residents (Resident #10, #31, and #120) reviewed for respiratory care. This deficient practice was evidenced by the following: 1. On 5/02/23 at 10:06 AM, the surveyor observed Resident #10 seated in a wheelchair in their room. The surveyor observed a nasal cannula (n/c; consisting of two hollow prongs projecting from a hollow face piece) O2 tubing attached to an O2 concentrator in Resident #10's room. The n/c O2 tubing was in a clear plastic bag and was dated 4/24/23. On that same date and time, the surveyor interviewed Resident #10. Resident #10 stated that he/she would use the O2 at night and that he/she had a problem with breathing after he/she had COVID-19. Resident #10 then added that he/she tried not to use it [oxygen] the during day. The surveyor reviewed the medical records of Resident #10. The resident's admission Record (AR; or face sheet, an admission summary) reflected that the resident was admitted to the facility with diagnoses that included Type 2 Diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), atrial fibrillation (an irregular and often very rapid heart rhythm) and history of COVID-19 (a highly contagious respiratory disease). A review of the 3/31/23 Quarterly Minimum Data Set (QMDS), an assessment tool used to facilitate care management, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. The QMDS did not indicate that the resident was on oxygen. The Order Summary Report (OSR) dated 5/11/23, revealed an order for 02 at 2 (two) Liter via n/a as needed for SOB (shortness of breath). Further review of the OSR showed that there was no order for O2 tubing change. The resident's personalized care plan did not reflect that the resident was on 02 and there were no interventions for respiratory care for the use of PRN (as needed) 02. On 5/03/23 at 02:10 PM, the surveyor interviewed Licensed Practical Nurse#1 (LPN #1) regarding the process for storing and changing 02 tubing. LPN #1 stated that the 11-7 staff change the 02 tubing once a week and put it in a bag and label it with the date. At that same time, the surveyor showed LPN #1 the picture of Resident #10's 02 tubing that was observed on 5/02/23. LPN #1 confirmed that the 02 tubing should have been changed on 5/01/23. The surveyor asked LPN #1 if the staff documented when the 02 tubing had been changed. LPN #1 stated that she was not sure if it was documented. She further stated that there was no order on her shift (7-3) but that she would check if there was an order on the other shift. On 5/08/23 at 11:18 AM, the surveyor interviewed the Infection Preventionist (IP) regarding the process for storing and changing 02 tubing. The IP stated that the 02 tubing should be changed every week on the 11-7 shift and that when it was not in use that the 02 tubing should be in a plastic bag. She added that there should be an order and that it was documented in the electronic Treatment Administration Record (eTAR). On 5/10/23 at 12:38 PM, in the presence of the survey team, the surveyor notified the Licensed Nursing Home Administrator (LNHA), Director of Admissions and Marketing/Assistant Administrator (DoAM/AA) and Director of Nursing (DON), the findings about the 02 tubing. On 5/11/23 at 01:14 PM, in the presence of the survey team, LNHA and DoAM/AA, the DON stated that Resident #10 had a PRN order for 02 and that the next change was to be done on 5/01/23 but that the nurse acknowledged that they forgot. The DON added that changing the 02 tubing was a standard of practice and that the order had not been in the eTAR but that the facility was going to change the policy to reflect changing the 02 tubing in the eTAR and in the careplan. A review of the facility provided policy titled, Oxygen Use with a revised date of 8/08 included the following: 4. Nasal cannula, mask, tubing, humidifier bottles are all single resident use items and are changed and dated weekly and only used for one resident. 2. On 5/02/23 at 10:28 AM, the surveyor observed in Resident #31's room, a suction machine that contained a disposable suction canister that had approximately 175 milliliters of clear fluid in it. Attached to the canister was a suction tubing with a yankauer tip (an oral suctioning tool) attached to the other end of the tubing. The yankauer tip was laid on the top of the dresser. There was no protective covering over the yankauer to keep it clean. There was a bottle labeled sterile water for inhalation, next to the suction machine, which was dated 4/15/23. On that same day at 11:50 AM, the surveyor interviewed Resident #31 who was seated in a wheelchair in their room. Resident #31 stated that he/she had bronchitis and had been in the hospital recently and had phlegm (mucus, thicker than normal due to illness or irritation, coughed up from the respiratory tract) that was being suctioned. Resident #31 was not sure when was the last time the suction machine was used. The surveyor reviewed the medical records of Resident #31 and showed the following: The resident's AR reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing), asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing) and Type 2 diabetes mellitus. The 4/25/23 QMDS revealed a BIMS score of 10 out of 15, which indicated that the resident's cognition was moderately impaired. The OSR dated 5/11/23, revealed an order for suction machine at bed side-suction resident as needed for seizure precautions. On 5/03/23 at 02:16 PM, the surveyor interviewed the LPN #1 regarding the process for the suction machine equipment. LPN #1 stated that the equipment should be in a bag and if it is used the disposable portion should be discarded. She added that a new setup should be available for use. The surveyor asked LPN #1 the reason Resident #31 had the suction machine at bedside. LPN #1 stated that Resident #31 was on seizure precautions and that was the reason the suction machine was at the resident's bedside. The surveyor then showed LPN #1 a picture of the observed suction machine and disposable equipment. LPN #1 confirmed that the used disposable suction equipment should not have been left there and that it should have been discarded. On 5/08/23 at 11:19 AM, the surveyor interviewed the IP regarding the process for the suction machine equipment. The IP stated that the disposable suction equipment could be used for a week. She further stated that the yankauer tip should be stored in a plastic bag. On 5/10/23 at 12:39 PM, in the presence of the survey team, the surveyor notified the LNHA, DoAM/AA and DON the above findings about the improper storage of the disposable suction equipment. On 5/11/23 at 01:16 PM, in the presence of the survey team, LNHA and DoAM/AA, the DON stated that Resident #31 had been transferred to the hospital on 4/15/23 and the resident came back to that room on 4/28/23. The DON further stated that when the resident came back to the room a new suction machine and equipment was brought to the room and the nurse forgot to take out the old machine and used disposable suction equipment. At that same time, the surveyor asked the DON what the process was for the disposable suction equipment after it was used. The DON stated that the yankauer tip should be discarded right away [after use]. He added that it should all be in a bag and when not being used. A review of the facility provided policy titled, Suctioning with a revised date of 10/94, included the following: PURPOSE: To provide guidelines to help prevent nosocomial infections associated with suctioning and to decrease the spread of infections. PROCEDURE: .8. If using a multi-use bottle of sterile distilled water for source of water for flushing, mark bottle with resident's name, date, and your initials. Discard twenty-four (24) hours after opening or if contamination is suspected MISCELLANEOUS: .11. When suction equipment is designated for a particular resident for extended use, suction connecting tubing and suction collecting canister need not be discarded on a regular schedule, but should be cleaned and flushed as necessary when secretions are present. If the suction connecting tubing becomes visibly soiled with secretions that will not flush, new tubing may be attached. The suction collection canister should be emptied and cleaned daily and changed or decontaminated as necessary. 12.Disposable suction collecting canisters must be discarded after single resident use. The policy did not contain information about suction yankauer tip. 3. On 5/02/23 at 11:16 AM, the surveyor observed Resident#120 laying on the bed with the head of the bed elevated. The surveyor observed that the resident had O2 in use at 4LPM (four liters per minute) via a n/c attached to an O2 wall with a humidified water bottle. At that same time, the resident stated that he/she had cancer and started on O2 use when he/she was hospitalized . The resident was not aware of how much O2 he/she should be on and stated I am comfortable right now with my O2. The resident's AR reflected that the resident was admitted to the facility with diagnoses that included Secondary malignant neoplasm of the liver and intrahepatic bile duct (type of liver cancer), secondary malignant neoplasm of the unspecified lung (type of lung cancer), anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues), essential hypertension (elevated blood pressure), unspecified abdominal pain, and hypothyroidism (when the thyroid gland does not produce enough thyroid hormones). The 5/05/23 Comprehensive MDS (CMDS) revealed a BIMS score of 12 out of 15 which indicated that the resident's cognitive status was moderately impaired. The CMDS reflected that the resident was on O2. A review of the April and May 2023 OSR revealed that there was an order dated 4/28/23 for O2 at 2 (two) liter via n/c PRN for SOB. There was no order for care of n/c tubing. The above order for PRN O2 was transcribed to the April and May 2023 eTAR. The April 2023 eTAR showed that the PRN O2 was signed as administered by the nurse on 4/29/23 at 0000 (midnight). The May 2023 eTAR reflected that there were no nurses' signatures that showed that the PRN O2 was administered. A review of the Progress Notes (PN) revealed that nurses documented on the following dates and times that the resident was on O2 use via n/c: 4/29/23 at 04:32 (4:32 AM) 4/30/23 at 18:47 (6:47 PM) 5/01/23 at 20:58 (8:58 PM) 5/02/23 at 04:40 (4:40 AM) 5/02/23 at 13:16 (01:16 PM) 5/02/23 at 21:11 (9:11 PM) 5/03/23 at 05:52 (5:52 AM) The personalized care plan did not reflect that the resident was on O2 and there were no interventions for respiratory care for the use of PRN O2. On 5/05/23 at 8:59 AM, the surveyor observed the resident seated on the bed with 2LPM via n/c. On 5/05/23 at 9:01 AM, the surveyor interviewed the assigned Certified Nursing Aide (CNA). The CNA informed the surveyor that it was the nurse's responsibility to take care of Resident #120's O2. She further stated that the resident was on continuous O2 since the resident was admitted to the facility because the resident was unable to breathe well without O2. On 5/05/23 at 9:48 AM, the surveyor interviewed Licensed Practical Nurse#2 (LPN#2). LPN#2 informed the surveyor that the staff nurse initiates the baseline care plan, and the nursing supervisors review and revise the care plan. LPN#2 stated that the O2 care plan should be part of the baseline care plan and care plan should include respiratory care like how often the O2 n/c to be changed, which in the facility, is once a week at 11-7 shift on a Saturday. On that same date and time, LPN#2 stated that for residents with an order for PRN or routine O2, the nurse must sign in the electronic Medication Administration Record (eMAR) or eTAR that it was administered and provided. She further stated that the care for n/c and change of n/c tubing must be signed in the eTAR. At that time, LPN#2 informed the surveyor that Resident #120 was alert and oriented to self, place, and people, with some confusion. LPN#2 stated that the resident required total assistance with activities of daily living (ADL), with incontinence, and pending hospice admission. She further stated that the resident was on O2 since admission at 2LPM. LPN#2 acknowledged that on 5/02/23 she was the assigned nurse of the resident and that the resident was on O2 but was unable to remember if she noticed that the O2 was at 4LPM at that time. LPN#2 further stated that you're maybe right, about the 5/02/23 O2 observation of the resident at 4LPM. She indicated that a family member visited on that day and probably, changed the amount of O2. In addition, LPN#2 stated that she should have signed the eTAR when the PRN O2 was administered and that there should have been a care plan for O2, and an order for n/c tubing care and changes according to the facility practice and policy. On 5/10/23 at 12:32 PM, the survey team met with the LNHA, DON, and DoAM/AA and were made aware of the above findings. On 5/11/23 at 01:03 PM, the survey team met with the LNHA, DON, and DoAM/AA. The DON informed the surveyor that according to LPN#2 on 5/02/23 the religious representative and a family member visited the resident and LPN#2 was not sure who changed it to 4LPM. Furthermore, the DON stated that there was no care plan and accountability for the nurse to change the n/c tubing. The DON further stated that the electronic medical record for the care plan did not have a pre-set O2 care plan and that he was not aware of how to modify it for him to be able to add O2 as part of the care plan. He acknowledged that there should be an order for n/c tubing care and a change in the eTAR. A review of the facility's Care Plan: Baseline and Comprehensive Policy dated 02/23/21 that was provided by the DON included that the facility will develop and implement a baseline care plan, followed by a comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. A review of the facility's Oxygen Use Policy revised 8/08 that was provided by the DON included that patients will be assessed for the need for respiratory services as part of the nursing assessment process; oxygen delivery via nasal cannula or mask will observe universal (standard) precautions; nasal cannula/mask/tubing/humidifier bottles are all single resident use items and are changed and dated weekly and only used for one resident; monitor resident for the effectiveness of oxygen administration and document in the medical record; and when oxygen is no longer required by the resident, dispose of all tubing, cannula, humidifiers, and clean/disinfect equipment. On 5/17/23 at 12:03 PM, the survey team met with the LNHA, DoAM/AA, and DON, and there was no additional information provided by the facility team. NJAC 8:39-11.2 (e)(1)(2)