**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that residents were served their meals in a manner that promotes respect and dignity during lunch. This deficient practice was identified for 6 out of 10 unsampled residents who were not served their meals at the same time and for 1 of 1 resident (Resident #40) who also experienced a significant delay in meal service delivery in the [NAME] 500 Dining Room. This deficient practice was evidenced by the following: On 11/6/24 at 12:03 PM, the surveyor observed residents who were seated in the [NAME] 500 Dining Room who awaited meal service. On 11/6/24 at 12:09 PM, the surveyor observed that the food cart was delivered to the nursing unit and staff had begun to pass out trays to residents in their rooms. On 11/6/24 at 12:18 PM, the surveyor observed that three (3) of ten (10) residents were served lunch and had begun to eat while seven (7) other residents waited for their lunch. On 11/6/24 at 12:29 PM, the food cart was placed in front of the dining room. On 11/6/24 at 12:30 PM, Resident #40 sat at a small table with an unsampled resident who ate their meal in front of the resident. At that time, the staff had begun to move four (4) residents, including Resident #40, away from the tables where other residents were already eating. On 11/6/24 at 12:32 PM, the 4 residents were served beverages while they awaited meal delivery. On 11/6/24 at 12:34 PM, the Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated that the resident's food cart was not there yet and that the other residents were served from the first food cart. The LPN/IP stated you can not put a resident in front of someone eating a meal and that was why she moved the residents because it was a dignity issue. On 11/6/24 at 12:46 PM, the LPN/IP stated that the food cart arrived. Resident #40's tray was still not available on the food cart and that she would get the resident's meal tray. The resident was the only resident in the dining room who had not yet received their meal tray and was seated in the presence of three (3) other unsampled residents who were served and ate their meals in his/her presence. On 11/12/24 at 2:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated he would not expect to see one (1) resident eating in front of another resident for both their dignity and their resident rights. A review of the facility's undated Resident Dining-Protocol included: .No resident should be eating their meal until all residents at the specific location have their trays. NJAC 8:39-4.1(a)12

Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to implement their new hire policy to ensure reference checks were completed. This deficient practice was identified for 4 of 10 employee files reviewed (Employee #1, #6, #8, and #10) and was evidenced by the following: A review of the employee files for reference check reflected the following: Employee #1, a Licensed Practical Nurse (LPN), with a date of hire of 8/6/24, did not have a reference check on file. Employee #6 a Certified Nurse Aide (CNA), with a date of hire of 1/24/24, did not have a reference check on file. Employee #8, a CNA, with a date of hire of 10/30/24, did not have a reference check on file. Employee #10, a Registered Nurse (RN) with the hire date of 7/29/24, did not have a reference check on file. On 11/12/24 at 1:03 PM, the surveyor interviewed the Human Resource Director (HRD), who stated two (2) references were done on every employee. The HRD stated we will not hold back an employee if we have not received all the references, but will continue to call the references and hope they respond. The HRD then stated if they were unable to contact the references, they asked the employee for additional references. A review of the facility's undated New Hire Employee References/Physicals - Protocol, included, 1. Upon hire the facility will request for 3 references. 2. The facility will reach out to all references and before their start date. NJAC 8:39-4.1(a)5

Complaint #: NJ172932 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) a resident-to resident altercation for 1 of 4 residents (Resident #310) reviewed for abuse. This deficient practice was evidenced by the following: On 11/8/24 at 11:46 AM, the surveyor reviewed Resident #310's closed medical record. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: Alzheimer's Disease, dementia, major depressive disorder, unspecified mood [affective] disorder, persistent mood [affective] disorder, post-traumatic stress disorder (PTSD), insomnia, cognitive communication deficit, and generalized anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 2/25/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred one to three days during the review period. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 2/20/24 that the resident's room was changed. Further review of the ICCP included a focus area, dated 2/24/24, that the resident had the potential to be verbally aggressive (cursing) related to dementia. Interventions included: staff to intervene before agitation escalates; guide resident away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. A review of the Progress Notes (PN) included a Nurses Note (NN), dated 2/19/24 at 11:23 PM, which revealed Resident #310 was walking down the hallway and began cursing at another resident. The NN further revealed Resident #310 charged at the other resident, but the nurse was able intervene before Resident #310 made contact with the other resident. According to the NN, the nurse had to bring Resident #310 down to the floor to refrain them from causing any harm to themselves or other residents, and that 911 was called for the resident to be sent to crisis at the hospital. Further review of the PN included a Room Change Notification note, dated 2/20/24 at 1:45 PM, which indicated Resident #310 had a room change to a different nursing unit. A review of the Psychiatry Evaluation (psych eval), dated 2/26/24, revealed the resident was seen for an initial evaluation. Further review of the psych eval included the resident was sent to crisis on 2/19/24 for agitation and aggression, and that the resident admits he/she continued to experience anxiety, depression, and mood swings. The psych eval also included recommendations from the psychiatrist to adjust Resident #310's psychiatric medications. On 11/8/24, the surveyor requested all Facility Reportable Events (FRE) for Resident #310, but the facility was unable to provide a FRE for the resident-to-resident altercation that took place on 2/19/24. On 11/12/24 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #3 who stated resident-to-resident altercations were reportable events and that the state has to be aware of the people fighting. On 11/12/24 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated resident-to-resident altercations were reported to the state. On 11/12/24 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated a resident-to-resident altercation could be verbal or physical. The DON further stated verbal altercations were reported to the physician and the resident's family. When asked whether Resident #6's resident-to-resident altercation on 2/19/24 should have been reported to the NJDOH, the DON stated she was unsure. A review of the facility's Abuse Investigation and Reporting policy, revised January 2023, included, All alleged violations involving abuse, neglect, exploitation, or mistreatment will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: . The State licensing/certification agency responsible for surveying/licensing the facility. Further review of the policy included, The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. NJAC 8:39-5.1(a)

Complaint #: NJ172932; NJ172314 Based on interview, record review, and review of facility documents, it was determined that the facility failed to conduct a thorough investigation for a.) a resident-to-resident altercation, and b.) an injury of unknown origin. This deficient practice was identified for 2 of 4 residents (Resident #6 and #310) reviewed for abuse, and was evidenced by the following: 1.) On 11/8/24 at 11:46 AM, the surveyor reviewed Resident #310's closed medical record. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: Alzheimer's Disease, dementia, major depressive disorder, unspecified mood [affective] disorder, persistent mood [affective] disorder, post-traumatic stress disorder (PTSD), insomnia, cognitive communication deficit, and generalized anxiety disorder. A review of the comprehensive Minimum Data Set (MDS), an assessment tool, dated 02/25/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) which occurred one to three days during the review period. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 2/20/24 that the resident's room was changed. Further review of the ICCP included a focus area, dated 2/24/24, that the resident had the potential to be verbally aggressive (cursing) related to dementia. Interventions included: staff to intervene before agitation escalates; guide resident away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. A review of the Progress Notes (PN) included a Nurses Note (NN), dated 2/19/24 at 11:23 PM, which revealed Resident #310 was walking down the hallway and began cursing at another resident. The NN further revealed Resident #310 charged at the other resident, but the nurse was able intervene before Resident #310 made contact with the other resident. According to the NN, the nurse had to bring Resident #310 down to the floor to refrain them from causing any harm to themselves or other residents, and that 911 was called for the resident to be sent to crisis at the hospital. Further review of the PN included a Room Change Notification note, dated 2/20/24 at 1:45 PM, which indicated Resident #310 had a room change to a different nursing unit. A review of the Psychiatry Evaluation (psych eval), dated 2/26/24, revealed the resident was seen for an initial evaluation. Further review of the psych eval included the resident was sent to crisis on 2/19/24 for agitation and aggression, and that the resident admits he/she continued to experience anxiety, depression, and mood swings. The psych eval also included recommendations from the psychiatrist to adjust Resident #310's psychiatric medications. On 11/8/24, the surveyor requested all incident reports for Resident #310, but the facility was unable to provide an incident report or investigation for the resident-to-resident altercation that took place on 2/19/24. On 11/12/24 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #3 who stated when there was a resident-to-resident altercation, the residents were immediately separated. LPN #3 further stated that any staff present on the unit during the altercation should complete a written statement. LPN #3 added that it was important to thoroughly investigate resident-to-resident altercations to document the resident's behavior and determine how the facility could better handle the resident's behavior. On 11/12/24 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated when there was a resident-to-resident altercation, the residents were immediately separated, the aggressor was sent to crisis if needed, and an incident report was completed. LPN/UM #1 further stated that the importance of the incident report was so the investigation could be initiated and so that nothing gets missed. LPN/UM #1 added that resident-to-resident altercations had to be thoroughly investigated to prevent further incidents and to maintain the safety of residents and staff. On 11/12/24 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated a resident-to-resident altercation could be verbal or physical. The DON further stated for a physical altercation, the nurse should complete an incident report, but for a verbal altercation, the nurse would only need to write a NN. When asked if a verbal altercation resulting in a resident being sent to crisis would require an incident report, the DON verified that an incident report should be completed. At that time, the surveyor informed the DON of the missing incident report for Resident #310's resident-to-resident altercation on 2/19/24, and the DON confirmed that an incident report should have been completed. The DON added that it was important to thoroughly investigate resident-to-resident altercations to prevent future occurrences. 2.) On 11/6/24 at 9:57 AM, the surveyor observed Resident #6 lying in bed. On 11/6/24 at 1:22 PM, the surveyor reviewed the medical record for Resident #6. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: dementia, Alzheimer's Disease, major depressive disorder, schizophrenia, nondisplaced intertrochanteric fracture of left femur (left hip fracture), and unspecified fall. A review of the quarterly Minimum Data Set (MDS), an assessment tool used, dated 4/3/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had one fall. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 3/20/24, that the resident had a left hip fracture related to a fall. Interventions included: anticipate and meet needs, be sure call light is within reach, and modify environment as needed to meet current needs. A review of the PN included an Alert Note (AN), dated 3/4/24 at 11:06 PM, which revealed the resident had two falls (one witnessed and one unwitnessed) without injuries. Further review of the AN revealed the resident was confused at baseline, vital signs were normal, and the resident was assessed from head to toe. Further review of the PN revealed documentation that the resident had no complaints of pain or discomfort post fall on the following dates: On 3/5/24 at 3:24 PM On 3/5/24 at 7:28 PM On 3/6/24 at 7:11 AM On 3/6/24 at 3:28 PM On 3/6/24 at 9:07 PM On 3/7/24 at 4:40 AM A review of a Nurse Practitioner Progress Note, dated 3/6/24 at 9:30 AM, revealed the resident had two falls recently but had no recall of the falls and remained pleasantly confused. Further review of the PN included a NN, dated 3/19/24 at 2:20 PM (15 days after the falls on 3/4/24), revealed the resident complained of pain in the left leg when moved up or when sitting up in the wheelchair. Further review of the NN revealed an order for an x-ray of the left hip and knee was obtained. A review of a NN, dated 3/20/24 at 2:13 PM, revealed the resident's x-ray results showed a fracture and the resident was sent to the hospital for further evaluation. A review of a NN, dated 3/27/24 at 10:23 PM, included the resident returned from the hospital post left hip surgery. On 11/8/24, the surveyor requested the complete investigation related to Resident #6's injury of unknown origin on 3/19/24. On 11/12/24 at 9:00 AM, the facility provided the surveyor with a copy of the Facility Reportable Event (FRE) for Resident #6's injury of unknown origin which revealed the following: On 3/4/24, the resident was found on the floor next to his/her bed laying on the floor mat. Resident was confused at baseline, however did not complain of any pain. On 3/19/24, the resident informed staff that he/she was having pain in his/her left leg when being moved and sitting in the wheelchair. An x-ray was ordered for the left hip and knee. On 3/20/24, the x-ray came back positive for a left hip fracture and the resident was sent to the hospital. The FRE did not include an incident report for the injury of unknown origin and the investigation did not include statements from staff for the shifts leading up to the resident's hip fracture on 3/19/24. On 11/12/24, the surveyor requested the incident report for the 3/19/24 injury of unknown origin, however the facility was only able to provide an incident report for the resident's falls on 3/4/24. On 11/12/24 at 11:50 AM, the surveyor interviewed LPN #3 who stated any injuries of unknown origin were reported immediately to the supervisor and all staff assigned to the resident for the three days prior would have to complete a written statement. LPN #3 further stated that it was important to thoroughly investigate an injury of unknown origin to find out where it came from and to rule out abuse. On 11/12/24 at 12:03 PM, the surveyor interviewed LPN/UM #1 who stated when there was an injury of unknown origin, the facility would launch a full investigation and obtain statements from all staff assigned to the resident in the past 72 hours. LPN/UM #1 further stated that it was important to thoroughly investigate an injury of unknown origin to ensure nothing else is going on that is preventable, such as a fall or abuse. On 11/12/24 at 12:50 PM, the surveyor interviewed the DON who stated when there was an injury of unknown origin, an incident report was completed, and statements were obtained from the nurses and certified nursing assistants going back 72 hours. At that time, the surveyor informed the DON of the missing incident report and statements for Resident #6's injury of unknown origin on 3/19/24, and the DON confirmed that there should have been an investigation into whether something happened to the resident between the 3/4/24 falls and the fracture on 3/19/24. The DON further stated that statements should be obtained to rule out abuse. A review of the facility's Management and Reporting of Resident Incidents policy, revised September 2016, included, When an accident or incident occurs to a resident, an investigation is conducted to determine any/all factors contributing to the incident, analyze the cause and effect, and to identify and implement interventions in an effort to prevent or minimize future occurrences. Further review of the policy included, If an injury of unknown origin has been identified, the Unit Manager will communicate with shift supervisors to ensure that staff from the previous 2 shifts who provided care for that resident are interviewed and give statements. A review of the facility's Abuse Investigation and Reporting policy, revised January 2023, included, If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. Further review of the policy included, The individual conducting the investigation will, as a minimum: . Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. NJAC 8:39-4.1(a)(5)

Based on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization. This deficient practice was identified for 1 of 1 resident (Resident #2) reviewed for hospitalization and was evidenced by the following: On 11/6/24 at 10:01 AM, the surveyor observed that Resident #2 was not in their room. On 11/7/24 at 12:00 PM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: chronic obstructive pulmonary disease (COPD, a condition that makes it difficult to breathe), acute respiratory failure, and tobacco use. A review of the resident's comprehensive Minimum Data Set (MDS), an assessment tool, dated 4/4/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident's cognition was intact. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 9/26/24, that the resident had COPD related to smoking. Interventions included: monitor for signs/symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis (a bluish color of the skin or lips), somnolence (sleepiness/drowsiness). Notify medical doctor of changes. A review of the Progress Notes (PN) included a Nurse's Note (NN), dated 5/6/24 at 5:56 AM, which included that the resident was admitted to the hospital for pneumonia. Further review of the PN included a Social Services (SS) note dated 5/6/24 at 2:57 PM, which indicated that a Bed Hold Notice was placed in the resident's room as the resident was his/her own responsible party and had no Power of Attorney. On 11/8/24 at 8:35 AM, the surveyor interviewed the Director of Social Services (DSS) who stated that she sent out the Bed Hold Notices and the nurses notified the resident's representative of the hospitalization. On 11/8/24 at 12:33 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he was responsible for the notification of the State Long-Term Care Ombudsman and agreed to furnish the notification. On 11/12/24 at 8:42 AM, the LNHA stated that a former employee who worked in medical records was responsible to notify the Ombudsman and there was no record of facsimile (fax) confirmation to confirm notification. A review of the facility's undated Ombudsman Notification of Transfer-Protocol included: At the beginning of each month the facility will establish a list of all residents that were sent out to the hospital for the previous month. The facility will electronically fax a sheet to the local NJ Ombudsman Office containing the following: Resident Name, Date of transfer, Was voluntary or involuntary (facility initiated), What hospital the resident was transferred to, Reason for transfer. These sheets will be saved along with the fax confirmation. NJAC 8:39-4.1(a)3

2.) On 11/8/24 at 12:25 PM, the surveyor reviewed the closed electronic medical record (EMR) for Resident #309. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: muscle wasting and atrophy, other abnormalities of gait (a person's manner of walking) and mobility and vascular dementia. A review of the admission Minimum Data Set (MDS), an assessment tool, dated 1/24/24, included the resident had a Brief Interview Mental Status score of 3 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident has one (1) fall with injury since admission. A review of the individualized comprehensive care plan (ICCP) included a focus area, dated 1/23/24, that the resident was a high risk for falls related to confusion, gait/balance problems, and unaware of safety needs. All interventions for that focus area were dated 1/23/24. A review of the Progress Notes (PN) included a Nurses Note (NN), dated 1/26/24 at 4:08 PM, which revealed the resident was found on the floor by a Certified Nursing Assistant (CNA). Further review of the NN revealed safety measures were put into place. Further review of the ICCP did not include any new interventions related to the resident's fall on 1/26/24. A review of the incident report (IR), dated 1/26/24 at 4:00 PM, revealed Resident #309 had an unwitnessed fall and was found lying on the floor. The IR did not indicate whether the resident's ICCP was updated to include the new interventions related to the fall. On 11/12/24 at 11:46 AM, the surveyor interviewed LPN #4 who stated that that the care plan was updated by the Unit Manager (UM). She stated she was unsure if was it was updated after each fall since the UM was responsible for updating the care plans. On 11/12/24 at 11:55 AM, the surveyor interviewed LPN/UM #2 who stated that the previous Director of Nursing (DON) wanted the nurses to update the care plans all at once after the Interdisciplinary Team (IDT) meeting which was every couple of days. She then stated the current DON wanted the care plan to be updated immediately after each incident. On 11/12/24 at 12:05 PM, the surveyor interviewed the DON in the presence of the Licensed Nursing Home Administrator (LNHA) who stated the nurses, MDS, UM, social services and dietary were all responsible for creating the care plan related to the specific issues. She stated that the care plan was updated after the IDT reviewed the incident and updated the interventions accordingly. The DON confirmed there should be interventions in place after each fall to prevent additional falls. On 11/12/24 at 12:12 PM, the surveyor interviewed the LNHA in the presence of the DON who stated they had issues with the previous DON and the care plans was one of the issues. The LNHA stated that anything that occurred the care plan should be updated accordingly and specialized to the individual residents. He further stated that the expectation was for the care plan to be updated to include interventions after each fall. On 11/13/24 at 1:57 PM, in the presence of the survey team both the LNHA and DON acknowledged there were no interventions in place for Resident #309 after the 1/26/24 fall and that there should have been interventions put into place after each fall. A review of the facility's Falls - Clinical Protocol policy, revised June 2022, included, the staff and physician will identify pertinent interventions to try to prevent subsequent falls. A review of the facility's Care Planning - Interdisciplinary Team policy, revised December 2023, included, A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). NJAC 8:39-27.1(a) Complaint NJ#: 171267 and 173863 Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to revise a resident's individual comprehensive care plan after a resident fall for 2 of 3 residents (Resident #87 and #309) reviewed for accidents. This deficient practice was evidenced by the following: 1.) On 11/6/24 at 9:51 AM, the surveyor observed staff providing care to Resident #87 in his/her room. On 11/6/24 at 12:34 PM, the surveyor reviewed the medical record for Resident #87. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: vascular dementia, muscle wasting and atrophy, and other abnormalities of gait and mobility. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 8/7/24, included the resident had a Brief Interview for Mental Status score of 1 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had one fall with injury since the prior assessment. A review of the individualized comprehensive care plan (ICCP) included a focus area, dated 4/15/24, that the resident had an actual fall or was at risk for falls related to new and unfamiliar environment, deconditioning and weakness, cognitive impairment, and poor safety awareness. All interventions for that focus area were dated 4/15/24. A review of the Progress Notes (PN) included a Nurses Note (NN), dated 6/11/24 at 2:29 PM, which revealed a nurse witnessed the resident fall while the resident was walking around the nurses' station. Further review of the NN revealed the resident fell on his/her left side, was holding his/her left shoulder, and had a bruise under his/her left eye. The NN further included the Nurse Practitioner was notified and an order for a left shoulder x-ray was obtained. Further review of the ICCP did not include any new interventions related to the resident's fall on 6/11/24. A review of the incident report (IR), dated 6/11/24 at 2:05 PM, revealed Resident #87 was observed agitated at the nurses' station and staff attempted to redirect the resident without success. The IR further revealed a nurse witnessed the resident fall on his/her left side and the immediate action taken was the Nurse Practitioner was notified and an order for a left shoulder x-ray was obtained. The IR did not indicate whether the resident's ICCP was updated to include new interventions related to the fall. A review of the Supervisor Fall Incident Investigation, dated 6/11/24, revealed the section New Interventions/Recommendations was not filled out and was left blank. On 11/12/24 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #3 who stated that if a resident fell, the nurse should update the resident's ICCP as soon as possible. LPN #3 further stated it was important to update the ICCP with new interventions to prevent future falls. On 11/12/24 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that if a resident fell, the interdisciplinary team would meet to update the resident's ICCP. LPN/UM #1 further stated that it was important to update the ICCP with new interventions to prevent further injuries. On 11/12/24 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if a resident fell, the interdisciplinary team or nursing staff would update the resident's ICCP as soon as possible to prevent additional falls. At that time, the surveyor informed the DON that Resident #87's ICCP was not updated with new interventions after the resident's fall on 6/11/24, and the DON confirmed that the ICCP should have been revised to include new interventions after the fall.

Complaint #: NJ172314 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to complete an incident report and thoroughly investigate a resident's fall for 1 of 3 residents (Resident #87) reviewed for accidents. This deficient practice was evidenced by the following: On 11/6/24 at 9:51 AM, the surveyor observed staff providing care to Resident #87 in their room. On 11/6/24 at 12:34 PM, the surveyor reviewed the medical record for Resident #87. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: vascular dementia, muscle wasting and atrophy, and other abnormalities of gait and mobility. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 8/7/24, included the resident had a Brief Interview for Mental Status score of 1 out of 15 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident had one fall with injury since the prior assessment. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 4/15/24, that the resident had an actual fall or was at risk for falls related to new and unfamiliar environment, deconditioning and weakness, cognitive impairment, and poor safety awareness. Interventions included to be sure that the call bell and personal items were within reach, encourage a clutter free environment, and bed in the lowest position at all times except during care. A review of the Progress Notes (PN) included a Nurses Note (NN), dated 3/22/24 at 3:05 PM, revealed the nurse was notified that Resident #87 fell in the physical therapy gym and was observed lying on the floor face down. Further review of the NN revealed the resident had swelling to his/her right eye and was sent to the hospital for further evaluation. On 11/12/24 at 11:30 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a copy of the fall packet for Resident #87's fall on 3/22/24. The fall packet consisted of a statement from the nurse, a statement from a therapy staff member, and a copy of the NN, dated 3/22/24 at 3:05 PM. The fall packet did not include an incident report with details of the incident, nor did it include an investigation detailing potential causes of the fall, interventions to prevent reoccurrence, or evidence that the fall was reviewed by the interdisciplinary team. On 11/12/24 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #3 who stated that if a resident fell, there was a fall packet the nurse would complete which included completing an incident report. On 11/12/24 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that if a resident fell, there was a fall packet the nurse would complete which included an incident report. LPN/UM #1 further stated it was important to complete a thorough investigation of a resident's fall to develop interventions and maintain the safety of the resident. On 11/12/24 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated that if a resident fell, the nurse should complete an incident report and investigation. At that time, the surveyor informed the DON of the missing incident report and investigation for Resident #87's fall on 3/22/24 and the DON confirmed that an incident report and investigation should have been completed at the time of the fall. A review of the facility's Falls - Clinical Protocol policy, revised June 2022, included, The staff will evaluate and document falls that occur while the individual is in the facility . and, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. A review of the facility's Management and Reporting of Resident Incidents policy, revised September 2016, included, When an accident or incident occurs to a resident, an investigation is conducted to determine any/all factors contributing to the incident . and, The nurse will complete all sections of the incident/accident report including, when possible, the resident's account of the event. Further review of the policy included, All falls and/or significant incidents will be reviewed by the Interdisciplinary Team after the morning departmental meeting on the first business day following the incident. NJAC 8:39-27.1 (a)

Complaint #NJ176585 Based on interview, record review, and review of facility documents, it was determined that the facility failed to follow standard operational procedures in accordance with the facility policy for a resident with weight loss of five pounds or more for 1 of 5 residents (Resident #304) reviewed for nutritional status and was evidenced by the following: A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: anemia (a lack of healthy, red blood cells), dysphagia (difficulty swallowing) unspecified, major depressive disorder, recurrent without psychotic features, generalized anxiety disorder, muscle wasting and atrophy (to waste away), not elsewhere classified, muscle weakness, and tobacco use. A review of the resident's annual Minimum Data Set (MDS), an assessment tool, dated 7/12/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed the resident was 68 inches tall and weighed 149 pounds and had not experienced a weight (wt) loss of five percent (5%) or more in the last month or loss of 10% or more in the last six months. Further review of the MDS revealed that the resident was ordered a therapeutic diet. A review of the resident's individual comprehensive care plan (ICCP) included a focus area of: I have a nutritional problem or potential nutritional problem. Interventions included: Monitor/record/report to medical doctor as needed signs/symptoms of malnutrition: Emaciation (abnormally thin), Cachexia (weakness and wasting of the body), muscle wasting, significant weight loss: 3 pounds in 1 week, greater than (>)5% in 1 month, >7.5% in 3 months, >10% in 6 months, Provide and serve diet/supplement as ordered. A review the Order Summary Report (OSR), included the following physician orders (PO): A PO, dated 8/28/24, for Carb Consistent Diet Regular texture, thin liquids. A PO dated 8/28/24, for Boost Glucose Control (dietary supplement) one time a day record % consumed, may substitute with facility equivalent. A PO dated 8/28/24 to weigh monthly every day shift every 1 (one) month (s) starting on the 1st for 10 day (s) for weight. Start date 9/1/24. A PO dated 8/28/24 to Obtain resident's weight weekly x 4 (four) post admission every day shift every Wednesday for Baseline for 4 weeks. Obtain resident' weight weekly x 4 post admission beginning 1 week post admission (Start date 9/4/24, End Date 10/2/24). A review of the Progress Notes (PN) included a Nutrition/Dietary Note dated 4/9/24 at 12:05 PM, which included .Skin intact per nursing. No current labs to review continues on controlled carbohydrate diet (CCD) with boost glucose control supplementation. Intake is variable. Food preferences updated frequently. Observed resident skip lunch at times to not miss his/her smoke break. March weight 163.9# suggesting a 4.5% gain x 1 (one) month, stable x 3 (three) and 6 (six) months. continue (cont.) to monitor and encourage intake, monitor meds, labs, weights and skin. Follow quarterly and as needed (PRN). Further review of the PN included a Nutrition/Dietary Note dated 7/23/24 at 10:27 AM, which included July monthly weight continues to trigger for weight loss x six (6) months. Currently stable x 1 month cont. to monitor. Discussed with resident, encouraged stable weight. A review of the Weights and Vitals Summary revealed the following: 12/5/23 169. (pounds - lbs) (wheelchair) 1/12/24 166.5 lbs. (wheelchair) 2/8/24 156.9 lbs. (wheelchair) 2/15/24 157.6 lbs. (wheelchair) 3/11/24 163.9 lbs. (wheelchair). There was no reweigh to confirm a 6.3 lb. weight gain. There was no documented weight for April 2024. 5/10/24 153.4 lbs. (standing) 6/12/24 152.9 lbs. (wheelchair) 7/10/24 148.9 lbs. (wheelchair) 8/4/24 151.8 lbs (wheelchair) 8/14/24 156.4 lbs. (wheelchair) 8/21/24 158.6 lbs. (wheelchair) 8/29/24 156.9 lbs. (wheelchair) 8/30/24 163.7 lbs. (wheelchair) 9/9/24 160.5 lbs. (wheelchair) On 11/8/24 at 8:49 AM, the surveyor interviewed the Registered Dietician (RD) who stated that the resident was independent with choosing meals, and ordered out. The RD stated that the resident dropped weight and the rationale for the weight loss was never explained. The RD stated that the resident was ordered supplements and his/weight fluctuated. The RD stated that in December we met and discussed food preferences and the resident only wanted soup and sandwiches due to an upset stomach. The RD stated that the resident was ordered Pepcid (used for Gastrointestinal Reflux Disease, a condition that caused acid reflux). The RD further stated that in January of 2024 the resident weighed 166.5 lbs. Then in February there was a 6 % weight loss in one month, a significant weight loss, and was 156.9 lbs and a re-weight was 156 lbs. The RD stated that the resident was starting to dislike the food. The RD stated that Boost Glucose Control was ordered daily in addition to a selective menu. The RD stated that the residents meal intake was not documented unless the resident was ordered a calorie count. the RD stated that the resident skipped meals to attend smoking breaks. The surveyor asked the RD why in April of 2024 the resident's weight was not recorded under the Weights and Vitals Summary? The surveyor also asked why there was no documented reweigh to confirm a 6.3 lb. weight gain that was recorded when the resident's weight fluctuated from 157.6 lbs. on 2/15/24 to 163.9 lbs. 3/11/24? The RD stated that she did not know why it was not done. The RD stated that the recorded weight loss from 163.9 lbs. on 3/11/24 to 153.4 lbs. on 5/10/24 was not considered significant because there was no recorded weight in April to trend x one month, so I trended x three months which was considered stable. The RD stated that no changes were made. The RD stated that nothing needed to be done. The resident was not actively losing significant weight. The RD stated that there was no special accommodation made for smoking. The RD stated that the resident was told to have their meal and then go out and smoke. On 11/8/24 at 10:29 AM, the surveyor interviewed the Certified Nursing Assistant (CNA) #3 who stated that resident smoking breaks were scheduled after meals. CNA #3 stated that she documented the amount of food consumed in the Plan of Care (POC) and alerted nursing if the resident was not eating. On 11/8/24 at 10:51 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that smoking breaks were scheduled around 9:30 AM and 1:30 PM, after lunch. LPN/UM #1 stated that she was unaware of any resident skipping meals to accommodate smoke times as the smoke breaks were usually scheduled after meals. LPN/UM #1 stated that in April our scale may have had a missing battery because weights were not usually missed. On 11/8/24 at 11:56 AM, the surveyor interviewed the Director of Nursing (DON) who stated that she noticed when she started working here in July that there were complaints of the scales not working and the weights were not obtained at one point. On 11/12/24 at 1:45 PM, the surveyor interviewed the DON who stated that the nurse, unit manager and the dietician were responsible to ensure that monthly weights were done. A review of the facility's policy, Weight Taking and Recording revised 3/28/23, included: .Monthly weights will be taken for each resident and will be recorded in the weight record sheet provided by the dietician. Monthly weights are due by the 5th of each month. Reweights are due by the 8th of each month. All weights should be recorded in the individual's medical record by the 10th of each month. Any weight changes of 5 (five) lbs +/- or more since the last weight assessment will require a reweight confirmation. The dietician will review individual weight trends over time. Negative trends will be evaluated by the interdisciplinary team, whether or not the criteria for significant weight change has been met. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month-5% weight gain or loss is significant b. 3 months-7.5% weight gain or loss is significant c. 6 months-10% weight gain or loss is significant. NJAC 8:3927.2(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure an as needed (PRN) psychotropic medication was prescribed with a 14-day duration and re-evaluated for continued use for 1 of 5 residents (Resident #39) reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 11/6/24 at 10:20 AM, the surveyor observed Resident # 39, awake and alert, lying in bed with a family member at the bedside. The resident's spouse stated that the resident has been depressed and had started on Zoloft (anti-depressant) medications and has been getting seen by psychiatry doctor. On 11/7/24 at 8:50 AM, the surveyor observed Resident # 39 lying in bed awake and alert with their breakfast tray on the over bed table. No behaviors observed at that time. On 11/7/24 at 11:58 AM, the surveyor reviewed the medical record for Resident # 39. A review of the admission Record, an admission summary, revealed that Resident #39 was admitted to the facility with diagnoses which included: dementia, cerebral infarct (a stroke), generalized anxiety disorder, and major depressive disorder. A review of Resident #39's quarterly Minimum Data Set (MDS), dated [DATE], included the resident had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated the resident's cognition was moderately impaired. The MDS further revealed that the resident was on an anti-anxiety medication and refused to respond to the mood interview. A review of the resident's individual comprehensive care plan (ICCP), included a focus area, dated 3/25/24, of I have anxiety. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. The surveyor reviewed the residents November active physician's orders (PO) which reflected that Resident # 39 was on the following psychoactive medication: A PO, dated 9/9/24, for Ativan Oral tablet 1 milligram (mg) (Lorazepam) give 1 mg by mouth every 8 hours as needed for anxiety, hold/monitor for lethargy. NO STOP DATE. A review of the September, October, and November 2024 Medication Administration Record (MAR) did not reveal a stop date for the Ativan PO. A review of the Psychiatry Note, dated 9/9/24, revealed that resident continued with mood swings, agitation, irritability, anxiety, and restlessness. Both the resident and the wife agreed to prn (as needed) Ativan be restarted for the time being. The psychiatric Advance Practice Nurse (APN) recommended to start Ativan 1 mg every 8 hours prn (as needed, anxiety x 14 days (hold/monitor for lethargy). A review of the Consultant Pharmacy (CP) recommendations, dated 9/16/24 and 10/25/24, revealed the CP recommended that duration must be specified for PRN psychoactive medications. First order limited to only 14 days, but if rationale documented by prescriber to continue order, then next duration may be longer, i.e. 30, 60, or 90 days. Please update order for Ativan per CMS regulations. On 11/13/24 at 11:51 PM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #2) who stated that a new order for Ativan should have a 14 day stop date. The surveyor and LPN/UM #2 reviewed the CP recommendations and LPN/UM #2 stated that she had called the attending doctor who stated that the Ativan could be continued but she did not document in the Electronic Medical Record or update the PO. LPN/UM #2 further stated that she knew that the Ativan needed a 14 day stop date but was unaware that after the 14 days, the Ativan needed a rationale and a duration date. On 11/13/24 at 12:21 PM, the Director of Nursing (DON), in the presence of the Licensed Nursing Home Administrator (LNHA), stated that the Ativan should have had a 14 day stop date and then a note with the rationale for the medication to be extended with a 30, 60, or 90 days stop date. A review of the facility's Psychotropic Medication Review policy, dated October 2017, included that orders for PRN psychotropic medications will be time limited (no more than 14 days) and only for specific clearly documented circumstances. A review of the undated facility's Pharmacy Consult Review- Clinical Protocol policy, included that consultant pharmacist submits admission reviews and monthly reviews, these should be completed promptly and filed in the review binder, and the completed pharmacy consult shall be reviewed by the DON. NJAC 8:39-27.1(a) NJAC 8:39-29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to a.) clarify and transcribe a Physician's Order (PO) for carrot hand splints (a type of splint that provides a barrier between the fingers and the palm to prevent injury to the palm from finger contracture) to the both hands, and b.) follow a physician's order for the application of a carrot hand splints to both hands, and c.) document in the Treatment Administration Record (TAR). This deficient practice was identified for 1 of 1 resident (Resident #91) reviewed for positioning and mobility and was evidenced by the following: On 11/6/24 at 10:21 AM, during the initial tour, the surveyor observed Resident #91 awake and alert, lying in bed with bilateral hands bent towards the chest and both hands clenched in a fist position without carrot hand splints in both fists. The surveyor observed two (2) orange carrot shaped hand splints lying on the overbed table. On 11/7/24 at 9:03 AM, the surveyor observed Resident # 91 awake and alert lying in bed, with both hands clenched in a fist position without carrot hand splints in both hands. The surveyor observed 2 orange carrot shaped hand splints lying on the overbed table. Resident # 91 stated that they used the carrots sometimes but just did not want them on at this time. On 11/8/24 at 10:02 AM, the surveyor observed Resident # 91 awake and alert lying in bed, with both hands clenched in a fist position without carrot hand splints in both hands. The surveyor observed 2 orange carrot shaped hand splints lying on the overbed table. On 11/8/24 at 9:08 AM, the surveyor reviewed the medical record for Resident #91. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: spastic quadriplegic cerebral palsy, muscle wasting, and epilepsy. A review of the quarterly Minimum Dats Set (MDS), an assessment tool, dated, 10/10/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident's cognition was severely impaired. Further review of the MDS revealed the resident dependent in all activities of daily living and mobility. A review of the resident's individual comprehensive care plan (ICCP) included a focus area, dated 7/13/24, that the resident had contractures and weakness and a decline in functional mobility. Interventions included: bilateral carrot hand splints to hands for contracture management at all times except for routine care and skin checks. A review of Resident # 91's Occupational Therapy (OT) Discharge summary, dated [DATE], revealed recommendations to donn (apply) carrot splints in bilateral (B/L) hands at all times, except during care with skin checks. A review of the Order Summary Report (OSR) included a physician's order (PO), dated 8/22/24, to donn B/L hand carrot splints, at all times, except during care. A review of the August, September, October, and November 2024 Treatment Administration Record (TAR) did not reveal a corresponding PO to donn B/L hand carrot splints, at all times, except during care. A review of Resident #91's Progress Notes (PN) did not reveal any documentation that the B/L hand carrot splints, at all times, except during care were applied as ordered. The PN did not reveal any documentation of the resident's refusal of the hand splints. On 11/9/24 at 10:04 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #4) who stated that Resident # 91 required total care and used positioning wedges for repositioning the resident in bed. CNA #4 stated I do not apply the carrot splints; I think therapy does that. I was not taught how to use the carrot hand splints. On 11/9/24 at 10:14 AM, the surveyor interviewed the Registered Nurse (RN#2) who stated that Resident # 91 only uses wedges and pillows for repositioning but does not use any splints for contractures. At that time, the surveyor and RN #2 reviewed the active TAR and RN #2 confirmed there was no PO on the TAR for B/L carrot hand splints. On 11/9/24 at 10:18 AM, the surveyor interviewed the Assistant Director of Rehabilitation (ADoR) and the Director of Rehabilitation (DoR). The ADoR stated that Resident #91 was discharged from OT services on 8/21/24 with recommendations to donn B/L hand carrot splints, at all times, except for hygiene care. The DoR stated that the therapist would enter the therapy recommendations PO into the electronic medical record (EMR). At that time, the surveyor reviewed the PO for the carrot hand splints with the ADoR and the DoR. The DoR confirmed that the PO was entered into the EMR incorrectly, without directions and never transferred to the TAR. The DoR further stated that the importance of the B/L hand splints were for contracture and skin integrity management. On 11/9/24 at 10:18 AM, the surveyor interviewed the Licensed Practical Nurse Unit Manager (LPN/UM #2) who stated that when therapy recommended a positioning or splint device, the therapist would enter the PO into the EMR. LPN/UM #2 confirmed that the PO for the hand splints were entered incorrectly and were not transferred to the MAR or TAR. LPN/UM #2 stated that the importance of the B/L carrots hand splints were to prevent contractures. On 11/9/24 at 10:18 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the therapist entered the PO for splints into the EMR and the nurse would acknowledge the PO. The DON acknowledged that the PO were entered incorrectly in the EMR. The DON further stated that it was important to follow the recommendation for the B/L carrot hand splints and document in the TAR to prevent skin damage and contractures. On 11/12/24 at 3:12 PM, surveyor reviewed the concern with the Licensed Nursing Home Administrator (LNHA). A review of the undated facility's Splints- Clinical policy, included that splints should be in [the EMR] as order under the TAR. A review of the facility's Resident Mobility and Range of Motion policy, revised March 2024, included that residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. A review of the facility's Physicians Order policy, revised January 2022, revealed that the purpose of the policy is to ensure all physician orders are complete and accurate. The policy also included that treatment orders will include the following: a description of the treatment, including the treatment site. NJAC 8:39-27.1 (a)

Complaint #: NJ174562 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) adjust medication administration times to accommodate for scheduled dialysis times, and b.) obtain a physician's order to monitor dialysis fistula sites (surgical connection between an artery and vein) for bruit and thrill (sound and vibration which indicates good blood flow in a dialysis fistula). This deficient practice was identified for 2 of 2 residents (Resident #9 and #306) reviewed for dialysis and was evidenced by the following: 1.) On 11/6/24 at 10:09 AM, the surveyor observed that Resident #9 was not in their room. On 11/7/24 at 10:30 AM, the surveyor reviewed the medical record for Resident #9. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: end stage renal (kidney) disease and dependence on renal dialysis. A review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 9/28/24, included the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 8/6/24, that the resident needed dialysis related to renal failure and that the resident went to dialysis on Mondays, Wednesdays, and Fridays with a chair time (appointment time) of 5:10 AM. Interventions included: Monitor/document/report to the physician as needed of any signs/symptoms of infection to the dialysis access site, such as redness, swelling, warmth, or drainage. The ICCP did not include any interventions to schedule medications around the resident's scheduled dialysis times, or to monitor the resident's dialysis fistula site for bruit and thrill. A review of the Order Summary Report (OSR), dated as of 11/12/24, included the following physician orders (PO): A PO, dated 12/30/23, for hemodialysis on Mondays, Wednesdays, and Fridays with a chair time of 5:10 AM and a pickup time of 4:50 AM. A PO, dated 12/30/23, to monitor the left arm fistula for signs and symptoms of infection or bleeding every shift. A review of the November 2024 Medication Administration Record (MAR) included the following PO: A PO, dated 12/30/23, for Protonix delayed release 40 mg (milligrams) one tablet by mouth in the morning for GERD (reflux) which was scheduled to be administered at 6:00 AM. A PO, dated 12/30/23, for Hydralazine 100 mg one tablet by mouth every eight hours for hypertension (high blood pressure) which was scheduled to be administered at 6:00 AM. A PO, dated 5/20/24, for Clonidine 0.3 mg one tablet by mouth every eight hours for hypertension which was scheduled to be administered at 6:00 AM. A review of the November 2024 Treatment Administration Record (TAR) did not include a PO to monitor the resident's dialysis fistula site for bruit and thrill. A review of the Pharmacy Consultant's Comments Report for the previous six months revealed a recommendation, dated 5/24/24, to please be sure that medication times are changed to accommodate resident's dialysis times. On 11/12/24 at 11:50 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) #3 who stated dialysis residents received their medications before they left for dialysis and that if a medication was scheduled to be administered during dialysis, the nurse should notify the physician to see if the medication administration time could be adjusted to accommodate the resident's dialysis schedule to prevent missed doses of medication. At that time, LPN #3 further stated that there should be a PO for the nurse to monitor a resident's dialysis fistula site for bruit and thrill to ensure the fistula site was working. LPN #3 reviewed Resident #9's PO and confirmed that the resident did not have an order for the nurse to monitor the resident's fistula site for bruit and thrill. On 11/12/24 at 12:03 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated dialysis residents' medication administration times were scheduled around their dialysis times to prevent missed doses, and that if there was a conflict in medication time and dialysis time, the nurse should reach out to the physician to change the medication times. LPN/UM #1 reviewed Resident #9's PO and confirmed the resident had medications scheduled for 6:00 AM on days the resident would be at the dialysis center. At that time, LPN/UM #1 further stated that there should be a PO for the nurse to monitor a resident's dialysis fistula site for bruit and thrill to ensure the site was patent. LPN/UM #1 reviewed Resident #9's PO and confirmed the resident should have had a PO for the nurse to monitor the resident's fistula site for bruit and thrill. On 11/12/24 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated dialysis residents' medication administration times should be scheduled either before or after their dialysis times to prevent missed medication doses. The DON further stated that there should be a PO for nurses to monitor residents' dialysis fistula sites for bruit and thrill to ensure there were no complications with the site. At that time, the surveyor informed the DON of Resident #9's medication administration times that were scheduled during the resident's dialysis times, and that Resident #9 did not have a PO to monitor for bruit and thrill. The DON stated the nurse should have contacted the physician to reschedule the medication administration times, and there should have been a PO to monitor the fistula site for bruit and thrill. 2. On 11/7/24 at 12:51 PM, the surveyor reviewed the closed medical record of Resident #306. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included: acute osteomyelitis (bone infection), right ankle and foot, anemia (a low number of red blood cells) in chronic kidney disease, dependence on renal dialysis (a procedure to remove waste products and excess fluid when the kidneys stop working properly). A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool, dated 5/27/24, included that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that the resident's cognition was intact. Further review of the MDS revealed the resident received dialysis while a resident at the facility. A review of the resident's individual comprehensive care plan (ICCP) included a focus area dated 5/24/24, which indicated that the resident had a nutritional problem related to presents for right ankle wound; prior medical history diabetes mellitus (DM), end stage renal (kidney) disease (ESRD) on hemodialysis (HD - a method of dialysis treatment), hypertension (HTN- high blood pressure). Interventions included: provide early/late trays as needed on dialysis days Tuesday, Thursday, Saturday), monitor weights as ordered and monitor before and after (pre/post) HD weights. A review of the Order Summary Report (OSR), dated 5/23/24, revealed there was no PO for the resident to attend HD, and there was no order to monitor the resident's dialysis fistula site for function both prior to and after dialysis treatments. Further review of the OSR revealed an order dated 5/23/24 to obtain resident's weight on shift of admission and then on day shift x 2 (two) days. Every day shift for baseline for 2 (two) days. A review of the Progress Notes (PN) included a Medical Doctor/Doctor of Osteopathic Medicine (MD/DO) Admission/readmission Note dated 5/24/24 at 6:35 PM, Addendum: ESRD on hemodialysis with Hyperkalemia (elevated potassium level) HD via right arm arteriovenous fistula (AVF). Further review of the PN included a Nurse's Note (NN), dated 5/29/24 at 9:12 PM, which included that the resident was leaving for dialysis tomorrow morning and requested to have hot cereal and coffee before he/she leaves for treatment. There was no documented evidence within the PN that detailed the resident's care and assessment both prior to and after dialysis treatments. On 11/8/24 at 9:17 AM, the surveyor interviewed the Registered Dietician (RD) who stated that the resident went to dialysis on Tuesday, Thursday and Saturday and received an early breakfast tray. The RD stated that the residents were weighed weekly for the first month x 4 and then monthly. The RD stated that dialysis obtained a pre and post dialysis treatment weight on dialysis days. The RD stated that there was a sheet that the nurses filled out that were maintained in the resident's closed record. The RD further stated that the resident weighed 111 pounds and she had no concerns because she communicated with dialysis. A review of the resident's Treatment Administration Record (TAR) revealed that the resident was weighed on 5/23/24 and weighed 111 pounds. There were no other documented weights within the resident's electronic health record. On 11/8/24 at 11:08 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #1 who stated that the resident went to dialysis on Tuesday, Thursday and Saturday mornings. LPN/UM #1 reviewed the resident's medical record in the presence of the surveyor and stated that there was no order for the resident to receive dialysis. LPN/UM #1 further stated that there was usually an order that specified the scheduled days and chair times but I am not seeing it. LPN/UM #1 stated that the facility communicated with the dialysis center via a Communication Sheet that required the resident's vital signs (blood pressure, pulse, heart rate, respirations, and pulse oximetry rate (measured the amount of oxygen in the blood via a probe placed on the finger), medications received, if the resident ate, and the resident's condition before they left the building. The surveyor requested to view the resident's Communication Sheets at that time. On 11/12/24 at 1:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated that the Communication Log for HD should have been maintained but neither the resident's weights or the Communication Sheets were found, but they should have been documented. On 11/13/24 at 1:59 PM, the surveyor interviewed the DON who stated that she phoned the dialysis center and confirmed that the resident's pick up time was likely 8:15 AM and his/her dialysis time was at 9:45 AM. The DON stated that there should have been an order for the resident to go to the dialysis center with the time and location included, an order to check the resident's dialysis fistula site for bruit and thrill, an order for the resident's weights and vital signs. The DON stated that the orders were not in the resident's medical chart. The DON stated that without orders, you can not assess the resident's fistula for complications. The DON stated that if ordered, the orders would have been reflected upon the resident's TAR. The Licensed Nursing Home Administrator (LNHA) was present at that time. On 11/13/24 at 8:52 AM, the DON provided the surveyor with copies of the Dialysis Communication Forms that she reportedly obtained from the dialysis center via fax that were dated 5/25/24, 5/28/24, 5/30/24, and 6/1/24. The DON confirmed that the Dialysis Communication Forms should have been accessible within the resident's closed record. The surveyor reviewed the forms which revealed that the facility failed to document the type of access the resident the resident had for dialysis treatment and any medications that were administered prior to his/her dialysis appointments on any of the forms in the space provided. A review of the facility's Medication Administration policy, revised July 2016, included, Medications must be administered in a timely manner and in accordance with physician's orders, and, Medications may not be prepared in advance and must be administered within one hour of the prescribed time. A review of the undated facility's Pharmacy Consultant Review policy, included, Consultant pharmacist submits admission reviews and monthly reviews, and, These should be completed promptly and filed in the review binder. A review of the facility's Dialysis Care policy, revised January 2023, included, All residents receive dialysis treatment will have their access site checked Q shift [every shift] and document on the MAR. Check the following: a. For Peripheral access, AV [arteriovenous] Graft, or AV Fistula: Check bruit and thrill . A review of the facility's Hemodialysis policy, revised January 2023, included, The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding and complications. NJAC 8:39-11.2(b) NJAC 8:39-27.1(a) NJAC 8:39-29.2(a)(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #NJ174562 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure palatable temperature of food for 1 of 1 lunch meal served on 1 of 2 units ([NAME] 600). This deficient practice was evidenced by the following: On 11/7/24 at 10:52 AM, the surveyor conducted a meeting with the Resident Council which included five residents (Residents #9, #3, #48, #64, and #81). Four of the five residents informed the surveyor that the food was not served hot and was described as cool on both nursing units. On 11/12/24 at 11:10 AM, the surveyor observed the [NAME] who calibrated (process to make sure the instrument is taking an accurate temperature reading) a thermometer to 32 degrees Fahrenheit (F) before he proceeded to obtain food temperatures from the steam table. The [NAME] failed to document the food temperatures after he obtained them from the steam table. On 11/12/24 at 11:42 AM, the surveyor observed the Assistant Dining Director (ADD) as she left the kitchen with Food Cart #1 and delivered it to the [NAME] 600 Unit where the nursing staff awaited meal delivery. On 11/12/24 at 11:52, the last meal tray was passed. On 11/12/24 at 11:53 AM, the ADD obtained food temperatures from a pureed tray using a calibrated thermometer which included: pureed tuna 123 F, mashed potatoes 125 F, pureed bread 132 F, and pureed peas 119 F. The ADD stated that all food temperatures should have been above 140 F. On 11/12/24 at 11:57 AM, the ADD obtained food temperatures from a regular tray which included: tuna melt 122 F, sweet peas 119 F, and rice 113 F. On 11/12/24 at 12:03 PM, the surveyor interviewed the ADD who stated that we could have done better on the timing of the meal distribution. The ADD stated that the facility had plate warmers that were not presently utilized due to the food being served on paper products while the dish machine was out of service. The ADD further stated, We handled it if the residents stated that the food was not warm enough. On 11/12/24 at 2:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility had complaints of cold food and addressed it with the residents. A review of the undated facility's Hot Foods policy, included: The kitchen will assure that hot foods are held so that all parts of the food meet current temperature regulations for hot holding. Procedure: 1. Potentially hazardous foods must be held and served at 135 F or above (or at the temperature dictated by local health regulations). Dietary staff records temperatures of hot foods on the service line immediately prior to service. Dietary staff follows standard corrective procedures for hot foods not at the appropriate temperatures. Dietary staff will serve all hot foods at 135 F or above . NJAC 8:39-17.4(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a 14-hour span of time between the dinner and breakfast meal times. This deficient practice was identified for 5 of 5 residents (Residents #9, #33, #48, #64, and #81) interviewed during a meeting with the Resident Council and was evidenced by the following: On 11/7/24 at 10:30 AM, the surveyor conducted a resident council meeting with five (5) awake, alert, and oriented residents. During the meeting, 5 out of 5 residents stated that snacks were kept in the pantry and were not accessible during the evening shift to the residents. One resident stated, If we don't like our dinner, then we are hungry and need a snack at night. On 11/12/24 at 10:49 AM, the surveyor interviewed the Assistant Dining Director (ADD) who stated that there was a snack book on the nursing units with a list of all residents who received snacks. The ADD stated that she was unable to provide the surveyor with any documented evidence of snack delivery to the nursing units. A review of the facility's Cart Delivery Log revealed that on 11/11/24 the [NAME] 6, Cart 5 dinner meal was delivered to the unit at 5:42 PM and on 11/12/24 the [NAME] 6, Cart 5 breakfast meal was delivered to the unit at 8:35 AM, a duration of 14 hours and fifty-three minutes. On 11/12/24 at 12:27 PM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 who stated that during the day snacks were available and included extra sandwiches. LPN/UM #2 stated that snacks were offered to different residents in between meals. LPN/UM #2 stated that the kitchen brought up a tray of snacks that were labeled for specific residents and the supervisor signed for it and handled it. LPN/UM #2 stated that there was no book on the unit that identified which residents received snacks. On 11/12/24 at 12:37 PM, during an inspection of the pantry on the [NAME] 600 Unit in the presence of LPN/UM #2 the surveyor noted that there were no snacks available for distribution in the pantry cupboards or refrigerator. LPN/UM #2 stated, Snacks are usually in here. On 11/12/24 at 12:43 PM, the surveyor interviewed the Certified Nursing Assistant (CNA) #6 during an inspection of the [NAME] 500 Unit Pantry, who stated that snacks were delivered to the nursing unit between 5:00 PM and 6:00 PM and consisted of sandwiches, graham crackers and fruit cups. CNA #6 stated that the snacks were not usually labeled. CNA #6 stated that the residents usually asked for snacks. When asked how she knew what to give the residents if the snacks were not labeled, CNA #6 stated residents who were on a pureed diet were given apple sauce or pudding. On 11/12/24 at 2:51 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility addressed snack distribution monthly at Resident Council to confirm receipt of snacks. The surveyor asked how the facility accounted for residents who could not speak for themselves and did not attend Resident Council, the LNHA stated that the supervisor went around and offered snacks. The LNHA further stated that snacks should be available in the pantry with a bare minimum of cookies, crackers and cereals. The surveyor then informed the LNHA that there were no cookies, crackers or cereals observed during the inspection of the [NAME] 600 Pantry. NJAC 8:39-17.2(f)(1)(i-ii)

Complaint NJ #'s: 170567 and 171267 Based on interview, and review of pertinent facility documentation, it was determined the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: 1.) Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio (s) were effective on 02/01/2021: One (1) Certified Nurse Aide (CNA) to every eight (8) residents for the day shift. One (1) direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff members shall be CNAs, and each direct staff member shall be signed in to work as a CNA and shall perform nurse aide duties: and One (1) direct care staff member to every 14 residents for the night shift, provided that each direct care staff member shall sign in to work as a CNA and perform CNA duties. A review of New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Reports (AAS-11 and AAS-12) for the 11/20/2024 Standard survey revealed the following: A review of the Nurse Staffing Report for the following weeks provided by the facility revealed the following: 1. For the 3 weeks of Complaint staffing from 01/21/2024 to 02/10/2024, the facility was deficient in CNA staffing for residents on 15 of 21 day shifts, and deficient in total staff for residents on 1 of 21 evening shifts as follows: -01/21/24 had 8 CNAs for 103 residents on the day shift, required at least 13 CNAs. -01/22/24 had 8 CNAs for 103 residents on the day shift, required at least 13 CNAs. -01/23/24 had 11 CNAs for 103 residents on the day shift, required at least 13 CNAs. -01/27/24 had 8 CNAs for 101 residents on the day shift, required at least 13 CNAs. -01/28/24 had 6 CNAs for 101 residents on the day shift, required at least 13 CNAs. -01/29/24 had 10 CNAs for 101 residents on the day shift, required at least 13 CNAs. -01/30/24 had 11 CNAs for 101 residents on the day shift, required at least 13 CNAs. -01/30/24 had 9 total staff for 101 residents on the evening shift, required at least 10 total staff. -01/31/24 had 9 CNAs for 101 residents on the day shift, required at least 13 CNAs. -02/01/24 had 10 CNAs for 101 residents on the day shift, required at least 13 CNAs. -02/02/24 had 10 CNAs for 101 residents on the day shift, required at least 13 CNAs. -02/03/24 had 7 CNAs for 101 residents on the day shift, required at least 13 CNAs. -02/04/24 had 10 CNAs for 105 residents on the day shift, required at least 13 CNAs. -02/05/24 had 8 CNAs for 104 residents on the day shift, required at least 13 CNAs. -02/08/24 had 10 CNAs for 104 residents on the day shift, required at least 13 CNAs. -02/10/24 had 10 CNAs for 102 residents on the day shift, required at least 13 CNAs. 2. For the 2 weeks of staffing prior to survey from 10/20/2024 to 11/02/2024, the facility was deficient in CNA staffing for residents on 10 of 14 day shifts and deficient in total staff of residents on 1 of 14 overnight shifts as follows: -10/20/24 had 8 CNAs for 107 residents on the day shift, required at least 13 CNAs. -10/21/24 had 10 CNAs for 105 residents on the day shift, required at least 13 CNAs. -10/23/24 had 12 CNAs for 105 residents on the day shift, required at least 13 CNAs. -10/25/24 had 11 CNAs for 105 residents on the day shift, required at least 13 CNAs. -10/26/24 had 9 CNAs for 105 residents on the day shift, required at least 13 CNAs. -10/27/24 had 8 CNAs for 105 residents on the day shift, required at least 13 CNAs. -10/27/24 had 5 total staff for 105 residents on the overnight shift, required at least 7 total staff. -10/28/24 had 10 CNAs for 105 residents on the day shift, required at least 13 CNAs. -10/31/24 had 12 CNAs for 105 residents on the day shift, required at least 13 CNAs. -11/01/24 had 12 CNAs for 105 residents on the day shift, required at least 13 CNAs. -11/02/24 had 12 CNAs for 106 residents on the day shift, required at least 13 CNAs On 11/12/24 at 1:31 PM, the surveyor interviewed the Staffing Coordinator (SC) who stated that she was aware of the staffing ratios and that most of the facility's callouts occurred on the weekends. On 11/13/24 at 1:47 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated, No staffing is perfect, I feel pretty confident about our staffing. He stated that they offered bonuses to the in-house staff and a full-time schedule for the agency staff. A review of the facility's Staffing policy dated revised September 2023, included, 1. Facility will develop and implement a written staffing plan that provides an adequate number of qualified direct-care staff to meet the resident's needs. 2.) The facility was deficient for Registered Nurse staffing as submitted for the 2 weeks of AAS-12 staffing from10/20/2024 to 11/02/2024. For the week of 10/20/24 Required Total Staffing Hours: 302.25 -10/20/24 had 272 actual staffing hours, for a difference of -30.25 hours. -10/26/24 had 280 actual staffing hours, for a difference of -22.25 hours. For the week of 10/27/24 Required Total Staffing Hours: 305.50 -10/27/24 had 256 actual staffing hours, for a difference of -49.5 hours. A review of the facility's Staffing policy, dated revised September 2023, included, Facility will ensure qualified employees will be scheduled to meet operational requirements and the needs of the residents. Refer to F550D, F678J and F684G NJAC 8:39-5.1(a); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency Based on observations, interview, and record review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 11/6/24 from 9:46 AM to 10:50 AM, the surveyor observed the following in the kitchen in the presence of the Dining Director (DD): 1. The DD demonstrated use of the high temperature dish machine. The DD stated that the facility used a booster for the dish machine to reach the required rinse temperature of 180 degrees Fahrenheit (F) but sometimes the booster does not work so we always use a chemical sanitizer. The surveyor requested to see the dish machine temperature/sanitizer log. A review of log, Low Temp Dish Machine Temperature Log and PPM (Parts per Million) Log (LTDMTL/PPM) revealed that the dish machine log was not filled in on 11/5/24 prior to the dinner meal and on 11/6/24 the lunch meal was pre-filled in for the lunch meal which had not yet been served. When the surveyor questioned why the form was already filled in the DD stated that the Dietary Manager (DM) had accidentally filled it in. Further review of the LTDMTL/PPM indicated that the required wash standard temperature was required to be 120 F or greater and the PPM were required to be 20-100 PPM. The values filled in on the form for the breakfast, lunch, and dinner meals on 11/1/24 through 11/6/24, with the exception of the dinner meal on 11/5/24, indicated that the wash temperature was 165 at all meals, and the PPM was 180. At that time, The Food Service Manager (FSM) pushed a tray of dirty dishes into the dish machine to demonstrate function. The surveyor watched the three gauges on the front of the dish machine which reflected the wash tank temperature, rinse tank temperature, and the final rinse (which had 180 F printed over the gauge for reference). The tray was processed through the dish machine and none of the three gauges moved as the tray moved through the wash, rinse, and final rinse cycles to reflect temperature of the dish machine at each cycle and remained fixed in place. The wash cycle temperature remained at 116 F, the rinse cycle temperature remained at 0 F, and the final rinse cycle temperature remained at 202 F. The DD told the FSM to run a second tray through the dish machine and the gauges did not move. The DM was present and stated that the gauges were working last night. The surveyor asked why he had not documented the temperature readings at the dinner meal he stated, The gauges were not moving this morning. The surveyor asked why both the breakfast and lunch values were filled in if the gauges had not moved? The DM confirmed that he had not notified maintenance of the issue as required. At the bottom of the LTDMTL/PPM it instructed the user to: Notify supervisor immediately if temperatures are below the standard. The DD then proceeded to demonstrate the sanitizer level by running a tray through the dish machine, collecting water in a bowl, and dipping a test strip into the water and then compared the color of the test strip to a legend on the side of the test strip container. The surveyor requested to see the test strip container and noted that the test strips expired on September 1 2024. The DD stated that he did not know that there was an expiration date on the test strips. The DD then proceeded to hand the surveyor a second container of test strips which had expired in November of 2023. The surveyor noted that the PPM that were completed on the form all indicated a value of 180, which did not coincide with the expected values of (20-100) on the log. The DM then stated that Monday, 11/4/24, was the last time that he saw the gauges working. He stated that he did not document the sanitizer level because there was no space provided on the form to record the sanitizer level. The DM stated that the value recorded in the space provided for PPM, referred to the temperature gauge that was on the booster beneath the dish machine. The DD stated that he could not say that everything that was washed in the dish machine was sanitized. He further stated, The dish machine is out of service. The DD further stated that he would order the test strips now and have the technician come out to the facility today to service the dish machine. 2. On the lower shelf, second shelf, and third shelf of a four-tiered drying rack, wet nesting (a build up of bacteria caused by stacking wet dishes) was evident as water dripped from the shelves above. The DD stated that a six inch shallow pan, and a two inch perforated strainer that were on the second shelf from the top, had both moisture and wetness between them when pulled apart. On the third shelf from the top, six inch chafing pans were stored inside of one another and had water beaded up on the outside, outer edges, and in between the chafing pans. The DD stated that wet nesting was identified. The DD stated that wet nesting harbors bacteria. At that time, the surveyor noted that the flooring in front of the drying rack was heavily soiled with dirt, debris, and food particles. The DD stated that staff were required to clean the floor after the meal service. 3. On the third shelf from the top of a four-tiered pot rack, the surveyor observed wet nesting between three sheet pans. There were three two-inch hotel pans that were wet nested together over top of the sheet pans. On the second shelf from the top, multiple sheet pans were wet nested inside of one another. The DD stated that they must have collapsed. The DD confirmed that wet nesting was present. 4. In the galley of the kitchen, the surveyor observed an oven that was heavily soiled with debris. The DD stated that the oven was not in use. The DD stated that the inside of the oven was cleaned two months ago and the burners on the top of the stove were cleaned nightly. 5. In the galley of the kitchen, the grill was heavily soiled with a thick layer of yellow liquid and solid matter on the top, front, and on the shelf beneath the grill which had a thick layer of yellow, orange, and brown liquid and dried matter on it. The DD stated that the grease trap was cleaned daily. When the DD pulled out the grease trap, a thick layer of yellow and white solid food matter was present, around a yellow, brown, and orange liquid with a thick layer of black charring was noted. 6. In the galley of the kitchen, a deep fryer had a very thick layer of food particles present in the dark colored oil within the fryer. The DD stated that they cooked 300 hash browns today. The DD stated that they cleaned the deep fryer every three days. At that time, the surveyor asked to see the cleaning schedule. The DD stated, I have no cleaning schedule. He further stated, We communicate with each other. 7. The ice machine had a service date of 4/11/24. The DD stated that the ice machine was serviced quarterly and should have been serviced in August. The DD stated that he was not sure why it was not done. 8. On an eight top burn stove, the left front burner was heavily coated with food debris. The DD stated that it was cleaned nightly, but was hard to clean. The DD stated that it depended who was working and who cleaned up. The DD further stated, Some cooks are [NAME] than others. 9. Inside of a new steamer there were multiple rags and gloves stored inside. When the surveyor asked why flammable items should not be stored within the steamer he stated, It is dirty. 10. Inside of a dual convection oven, there was a thick build up of black matter and food debris. the DD stated that he cleaned it last on 9/1/24. The DD stated that it should have been cleaned monthly. There was food cooking in the oven at the time. The DD stated that management should have ensured that it was cleaned. The DD stated that he thought that it was burned on food, which does not contaminate the food that was cooked in the oven. The DD stated, We could do a better job, it is not dirty, it is forty years old. 11. In walk-in refrigerator #2, on the third shelf from the top of a four-tiered wired rack, a ten pound box of bacon was partially opened with the plastic opened and exposed the bacon to air. The DD stated that the plastic should have covered the bacon. 12. In the walk-in freezer, there was no light. The surveyor used a flash light to perform the inspection. The DD stated, it needed a light bulb. 13. In walk-in refrigerator #1, there was a twenty pound container of hard boiled eggs that was opened, and was not dated with an opened date or a used by date. The DD stated that the eggs were kept for one week after opening. The DD stated that the container should have been dated when opened. 14. In the dry storage area, a six pound container of peaches was dented in the can rack. The DD stated that it was probably dropped and placed in the rack. 15. In the milk box, a sealed five pound container of cottage cheese, had an expiration date of 10/16/24. The DD stated that it should have been removed when we had a milk delivery yesterday. During an interview with the surveyor on 11/06/24 at 12:39 PM, the Licensed Practical Nurse/Infection Preventionist (LPN/IP) stated that the DM should have informed us that the dish machine gauges were broken and addressed it immediately. The LPN/IP stated that it was an issue if the dishware were not properly cleaned. The LPN/IP stated, How would you track chemical sanitizer level if it were not on the form? The LPN/IP stated the temperature log should not have been filled in if the gauges were not working. The LPN/IP stated, It is a big issue because it throws everything off. The LPN/IP stated that if the chemical sanitizer strips were expired, they were not accurate, or not up to date. The LPN/IP stated that the dish machine must be fixed. On 11/7/24 at 9:04 AM, the surveeyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the vendor determined that there was a problem with the dish machine thermometer (temperature probe) and was scheduled for repair tomorrow. The LNHA stated that the facility would continue to serve meals on paper products until the repair was completed. On 11/12/24 at 8:33 AM, during a follow-up interview the LNHA stated that the facility continued to serve meals on paper products due to the dish machine being out of service. The LNHA stated that he expected the thermometer probe to be installed today. On 11/12/24 from 10:49 AM to 11:42 AM during a follow-up visit to the kitchen, the surveyor observed the following in the kitchen in the presence of the Assistant Dining Director (ADD): 1. During the tray line observation, the [NAME] doffed his gloves after he obtained food temperatures. The [NAME] then proceeded to go to the hand washing sink where another employee washed their hands and placed his hands beneath the running water and rubbed them together for eight seconds, dried his hands before he donned gloves. 2. The ADD was observed in the galley of the kitchen with long strands of hair protruding from her hair net bilaterally. The ADD then proceeded to assist with the tray line. 3. A Dietary Aide (DA) was observed with a hairnet that covered only the back of her that was pulled up on top of her head. the DA wore a head band to cover the middle section of her head. The front of portion of the DA's hair was not covered as she assisted in the tray line assembly and covered plates of food with domed lids. When interviewed at that time, the DA stated that her hair net probably slipped up. The ADD was present and stated, Is mine out too? The ADD then proceeded to push the long strands of hair (bangs) back into her hair net bilaterally. During a later interview with the surveyor on 11/12/24 at 12:06 PM, the ADD stated that hair was to be kept covered so that it did not get into the food and also for infection control purposes. At that time, the ADD stated that when the [NAME] doffed his gloves, he should have rinsed his hands, applied soap, and washed his hands for 20 to 30 seconds or bacteria could build up on the hands and food may be under the finger nails. The ADD stated that hand hygiene should be performed properly so that nothing gets in the food and for both your protection and the residents. The ADD stated that the [NAME] should have waited for the other person to finish at the hand washing sink before he washed his hands. The ADD further stated, that he should have washed his hands for 20-30 seconds. On 11/12/24 from 12:32 PM to 12:37 PM, the surveyor observed the [NAME] 600 Nourishment Room in the presence of Licensed Practical Nurse/Unit Manager (LPN/UM) #2. 1. In the refrigerator, A 64 ounce container or prune juice was opened and was not dated. LPN/UM #2 stated, This is trash because it is not dated. She then proceeded to discard the container of prune juice. 2. In the freezer, a frozen dinner was marked with initials and Do not touch. LPN/UM #2 stated that it should have been dated and properly labeled with the resident's name and date. 3. An ice scoop was stored in a wall mount that was not self-draining. There was brown matter in the base of the wall mount and the ice scoop was in direct contact with the water that pooled in the bottom of the wall mount. LPN/UM #2 looked inside the wall mount and stated that the ice scoop was contaminated. On 11/12/24 from 12:43 PM to 12:48 PM, the surveyor observed the [NAME] 500 Nourishment Room in the presence of Certified Nursing Assistant (CNA) #6 until LPN/UM #1 arrived. 1. An ice scoop was stored in a wall mount that was not self-draining. The ice scoop was in direct contact with the water that pooled in the bottom of the wall mount. LPN/UM #3 stated that it was an infection control issue if the ice scoop mount were not self-draining and were placed in the ice machine. 2. On the top shelf inside the door of the refrigerator, a large amount of dried brown matter was noted. On 11/12/24 at 1:32 PM, the surveyor interviewed the ADD who stated that the kitchen management was responsible for the nourishment rooms. The ADD stated that if the ice scoop mount were not self-draining it could get bacteria on the scoop and if it were used to scoop ice, germs may spread. The ADD further stated that resident's food may be kept in the refrigerator for up to three days and should be labeled with the resident's name and date. The ADD stated that if the item was not labeled and dated, then it had to go into the trash. The ADD further stated that the refrigerator should be cleaned every two to three days. The ADD further stated that there should have been a maintenance log on the outside of the ice machines. The ADD further stated that they must have gotten wet. The ADD stated that the facility maintained the outside of the ice machine and a company maintained the inside. The ADD was unsure of the frequency that the inside of the ice machine was cleaned. On 11/13/24 at 1:55 PM, the surrveyor interviewed the LNHA who stated that he performed walking rounds in the kitchen the Friday (11/15/24), prior to survey and had concerns with the facility's cleaning schedule. In a later interview with the LNHA in the presence of the survey team on 11/13/24 at 4:15 PM, the LNHA stated that the dish machine repair was delayed due to receipt of the wrong part and was scheduled for repair tomorrow. A review of an undated facility's,Dishwashing (mechanical) policy included: .High Temp (Wash 150 degrees F, Rinse 180 F). Low Temp (Wash 120 degrees F, Rinse 120 degrees F). Must use a chlorine test strip after each use using a 50 parts per million (PPM) solution. FSD (Food Service Director) or designee will spot check and log temperature and PPM reading prior to each usage. A review of the facility's Sanitation policy #506, revised 8/1/18, included: The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive, cleaning schedule. Cleaning and sanitation tasks for the kitchen will be recorded. Tasks will be assigned to be the responsibility of specific positions. Frequency of cleaning for each task will be defined A cleaning schedule will be posted. Employees will be trained on the cleaning schedule and how to perform duties. Employees will be trained on the cleaning schedule and how to perform duties. Employees will initial and date tasks when completed. A review of the facility's Pot Washing and Air-Drying Policy revised May 2021, included: .Air dry all clean and sanitized pots and wares .Pots and Pans must be stored in such a way as to allowthetotal [sic.] air-drying process to be achieved. Once air dried, all pots and pans must be stored inverted (upside down). All pots and pans must be dry to the touch and sight prior to being put into production and/or properly stacked/stored together. A review of the facility's Labeling and Dating System Protocol policy revised 10/20/24, included: Follow manufacturers expiration date on all un-opened product .All fresh and frozen foods must be dated with the date it was received into the kitchen unless it has a Purveyor shipping label on it. Make sure to not date over or cover up the manufacture's expiration date on the product. Day 1 (one) is first day of labeling.Hard boiled eggs, 3 (three days) . A review of an undated facility's Dating and Labeling Policy included: .Discard all foods that expire immediately. A review of the facility's Ice Machine policy revised 3/28/24, included: Ice machine will be cleaned monthly following the manufacturers instructions for cleaning, disinfecting, draining, and sanitizing Ice machine will be serviced bi-annually . A review of an undated facility's Dented Can Policy included: Identify all unacceptable dented cans Place all dented cans on a designated shelf marked Dented Cans. A review of the facility's Floor Cleaning policy revised 11/10/23, included: The staff will properly sweep and mop the floor to ensure cleanliness . A review of the facility's Hairnets policy revised 3/28/24, included: All food handlers are required to wear effective hair restraints that cover all exposed body hair. Hair restraints must effectively prevent contact with food, clean food service equipment, utensils and food contact surfaces. A review of the facility's Hand Hygiene policy revised 10/27/22, included: The facility considers hand hygiene the primary means to prevent the spread of infections. Practicing hand hygiene is a simple and effective way to prevent infections Soap and water for the following situations: .Immediately after removing gloves .Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds . NJAC 8:39-17.2(G), 19.4

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff implemented facility policies and procedures to ensure a.) residents were provided with care and services to achieve their highest practical wellbeing and, b.) the minimum State staffing requirements were met. This deficient practice was identified for and 2 out of 2 nursing units, and was evidenced by the following: Refer to F678, F684, F688, F698, F725, F804, F809, and F812 A review of the Administrator's job description provided by the facility revealed the following: The Administrator's primary purpose is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guideline, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to the residents at all times. Duties and Responsibilities included but not limited to: plan, develop, organize, implement, evaluate, and direct the facility's programs and activities. Meet with department directors to discuss use of departmental policies and procedures and establish a rapport in and among departments so that each can realize the importance of teamwork. Review the facility's policies and procedures periodically, at least annually and make changes as necessary to assure continued compliance with current regulations. Assure that an adequately number of appropriately trained professional and auxiliary personnel are on duty at all times to meet the needs of the residents. Assure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. During the entrance conference on 11/6/24 at 9:55 AM, the LNHA stated that he was the LNHA from January 2023 to August 2023 and returned back to the facility in October of 2023 and the Director of Nursing (DON) started at the facility in July of 2024. 1.) On 11/07/24 at 11:25 AM, the surveyor reviewed the closed medical record of Resident #103. A review of the Progress Notes (PN) and interviews with the licensed nursing staff revealed that on 9/27/24 at 4:30 AM, the Certified Nursing Assistant (CNA #1) found Resident #103 who was a full code (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating in accordance with the Basic Life Support (BLS) for Healthcare Providers) unresponsive and reported it to the Licensed Practical Nurse (LPN #1) who began performing cardiopulmonary resuscitation (CPR). LPN #1 did not call 911 and did not notify the Registered Nurse (RN #1) until 5:50 AM of the resident's code. RN #1 did not perform CPR or call 911 and pronounced Resident #103 deceased at 5:55 AM. On 11/13/24 at 1:13 PM, the surveyor interviewed the DON who stated that she did not do an investigation and did not question the time lapse from then CNA #1 found the resident unresponsive at 4:30 AM and notified LPN #1, to LPN #1 notifying RN #1 at 5:50 AM. The DON stated that she did not focus on the time and just asked RN #1 about CPR and why 911 was not called. The DON stated that she was just screaming and angry. The LNHA who was present stated that, RN #1 thought that it was an ethical issue to keep CPR going. On 11/13/24 at 2:38 PM, the surveyor interviewed the Medical Director (MD) who stated that when there was a code blue and someone stopped breathing who was a full code, he would expect whoever was in the building to call the nursing supervisor, do Basic Life Support (BLS) and call 911. EMS came to the facility with Advanced Cardiac Life Support (ACLS- protocols beyond BLS, to treat cardiac emergencies such as cardiac arrest with CPR, airway management, and/or the use of an AED). The Medical Director stated that EMS took over the care of the resident and pronounce them if indicated. The Medical Director stated that he was notified of the scenario and clearly, 911 should have been notified. 2.) A review of the April and May 2024 Physician's Order Sheet (POS) and Treatment Administration Record (TAR) did not include any physician's order (PO) for the new right shin skin tear until 5/16/24. The PO was started 23 days after the initial treatment was ordered on 4/23/24. On 11/12/24 at 10:37 AM, the surveyor and the Licensed Practical Nurse/Unit Manager (LPN/UM#1) reviewed the Progress Notes, the PO, the ICCP and the weekly skin assessments in the electronic medical record (EMR). LPN/UM #1 confirmed that she had entered the 4/23/24 PO in the EMR and it should have been for the right shin skin tear and not the sacral wound. LPN /UM#1 confirmed that a treatment order for the right shin skin tear was not on the POS or the TAR until 5/16/24. LPN/UM#1 further stated that on 5/16/24, when the right shin skin tear had worsened, a skin assessment should have been completed. After reviewing the Progress Notes, LPN/UM#1 could not recall if the Hospice Nurse had notified her about the right shin skin tear between April to May 2024. On 11/13/24 at 1:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that he was made aware of Resident # 305's right shin wound infection by the Hospice Nurse and by the local ombudsman. The LNHA stated he could not remember the exact date, but it was when the resident was still in the facility. 3.) On 11/8/24 at 9:08 AM, the surveyor reviewed the medical record for Resident #91. A review of Resident #91's Progress Notes did not reveal any documentation that the bilateral (B/L) hand carrot splints, at all times, except during care were applied as ordered. The Progress Notes did not reveal any documentation of the resident's refusal of the hand splints. On 11/9/24 at 10:18 AM, the surveyor interviewed the Director of Nursing (DON) who stated that the therapist entered the physician's order (PO) for splints into the electronic medical record (EMR) and the nurse would acknowledge the PO. The DON acknowledged that the PO were entered incorrectly in the EMR. The DON further stated that it was important to follow the recommendation for the B/L carrot hand splints and document in the Treatment Administration Record (TAR) to prevent skin damage and contractures. On 11/12/24 at 3:12 PM, surveyor reviewed the concern with the Licensed Nursing Home Administrator (LNHA). 4.) On 11/7/24 at 10:30 AM, the surveyor reviewed the medical record for Resident #9. A review of the individual comprehensive care plan (ICCP) included a focus area, dated 8/6/24, that the resident needed dialysis related to renal failure and that the resident went to dialysis on Mondays, Wednesdays, and Fridays with a chair time (appointment time) of 5:10 AM. Interventions included: Monitor/document/report to the physician as needed of any signs/symptoms of infection to the dialysis access site, such as redness, swelling, warmth, or drainage. The ICCP did not include any interventions to schedule medications around the resident's scheduled dialysis times, or to monitor the resident's dialysis fistula site for bruit and thrill. A review of the November 2024 Treatment Administration Record (TAR) did not include a PO to monitor the resident's dialysis fistula site for bruit and thrill. A review of the Pharmacy Consultant's Comments Report for the previous six months revealed a recommendation, dated 5/24/24, to please be sure that medication times are changed to accommodate resident's dialysis times. On 11/12/24 at 12:50 PM, the surveyor interviewed the Director of Nursing (DON) who stated dialysis residents' medication administration times should be scheduled either before or after their dialysis times to prevent missed medication doses. The DON further stated that there should be a PO for nurses to monitor residents' dialysis fistula sites for bruit and thrill to ensure there were no complications with the site. At that time, the surveyor informed the DON of Resident #9's medication administration times that were scheduled during the resident's dialysis times, and that Resident #9 did not have a PO to monitor for bruit and thrill. The DON stated the nurse should have contacted the physician to reschedule the medication administration times, and there should have been a PO to monitor the fistula site for bruit and thrill. 5.) A review of the Nurse Staffing Report for the following weeks provided by the facility revealed the following: For the 3 weeks of Complaint staffing from 01/21/2024 to 02/10/2024, the facility was deficient in CNA staffing for residents on 15 of 21 day shifts, and deficient in total staff for residents on 1 of 21 evening shifts. For the 2 weeks of staffing prior to survey from 10/20/2024 to 11/02/2024, the facility was deficient in CNA staffing for residents on 10 of 14 day shifts and deficient in total staff of residents on 1 of 14 overnight shifts. On 11/13/24 at 1:47 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated, No staffing is perfect, I feel pretty confident about our staffing. He stated that they offered bonuses to the in-house staff and a full-time schedule for the agency staff. 6.) On 11/7/24 at 10:52 AM, the surveyor conducted a meeting with the Resident Council which included five residents (Residents #9, #3, #48, #64, and #81). Four of the five residents informed the surveyor that the food was not served hot and was described as cool on both nursing units. On 11/12/24 at 11:42 AM, the surveyor observed the Assistant Dining Director (ADD) as she left the kitchen with Food Cart #1 and delivered it to the [NAME] 600 Unit where the nursing staff awaited meal delivery. On 11/12/24 at 12:03 PM, the surveyor interviewed the ADD who stated that we could have done better on the timing of the meal distribution. The ADD stated that the facility had plate warmers that were not presently utilized due to the food being served on paper products while the dish machine was out of service. The ADD further stated, We handled it if the residents stated that the food was not warm enough. On 11/12/24 at 2:56 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility had complaints of cold food and addressed it with the residents. 7.) On 11/7/24 at 10:30 AM, the surveyor conducted a resident council meeting with five (5) awake, alert, and oriented residents. During the meeting, 5 out of 5 residents stated that snacks were kept in the pantry and were not accessible during the evening shift to the residents. One resident stated, If we don't like our dinner, then we are hungry and need a snack at night. On 11/12/24 at 2:51 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the facility addressed snack distribution monthly at Resident Council to confirm receipt of snacks. The surveyor asked how the facility accounted for residents who could not speak for themselves and did not attend Resident Council, the LNHA stated that the supervisor went around and offered snacks. The LNHA further stated that snacks should be available in the pantry with a bare minimum of cookies, crackers and cereals. The surveyor then informed the LNHA that there were no cookies, crackers or cereals observed during the inspection of the [NAME] 600 Pantry. 8.) On 11/6/24 from 9:46 AM to 10:50 AM, the surveyor, accompanied by the Dining Director (DD) toured the kitchen and it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. On 11/7/24 at 9:04 AM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA) who stated that the vendor determined that there was a problem with the dish machine thermometer (temperature probe) and was scheduled for repair tomorrow. The LNHA stated that the facility would continue to serve meals on paper products until the repair was completed. On 11/12/24 at 8:33 AM, during a follow-up interview the LNHA stated that the facility continued to serve meals on paper products due to the dish machine being out of service. The LNHA stated that he expected the thermometer probe to be installed today. On 11/13/24 at 1:55 PM, the surveyor interviewed the LNHA who stated that he performed walking rounds in the kitchen the Friday (11/15/24) prior to survey and had concerns with the facility's cleaning schedule. On 11/13/24 at 1:44 PM, the surveyor interviewed the LNHA in the presence of the DON and the survey team who stated that the role of the Administrator was to oversee the operations of the facility to ensure they are following the regulations for the skilled nursing facility. He further stated to ensure the residents were taken care of and had a home like environment. The LNHA stated that he was a resource for the staff, assisted and initiate any concerns with grievances from the family or residents and to be an advocate for the staff and the residents. On 11/13/24 at 1:56 PM, the LNHA acknowledged the concerns that were brought to his attention in the presence of the DON and the survey team. NJAC 8:39-9.2(a); 9.3(a); 27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint# NJ166308 Based on observation, interview, and review of facility documentation on 1/5/24, it was determined that the facility failed to consistently serve hot foods at acceptable temperatures to the residents. This deficient practice was observed for 2 of 2 test trays on two different units ([NAME] 5 and [NAME] 6) and evidenced by the following: On 1/5/24 at 11:57 AM, the surveyor, in the presence of the Dietary Director (DD), observed the server at the steam table calibrate the digital thermometer before taking the temperatures of the prepared foods. The surveyor recorded the temperatures of the prepared foods on the steam table prior to service at 12:00 PM and the temperatures were as follows: Cheesesteak - 200 degrees Peppers/onions - 201 degrees French fries - 165 degrees Ground meat - 193 degrees Pureed vegetables - 188 degrees Mashed potatoes - 176 degrees Pureed French fries - 165 degrees Ground vegetables - 195 degrees Ground hash browns - 189 degrees On 1/5/24 at 12:20 PM, the surveyor, in the presence of the DD, followed the cart to the [NAME] 6 unit. The cart left the kitchen at 12:20 PM and arrived on the unit at 12:25 PM. The surveyor observed the Certified Nursing Assistants (CNA) and other facility staff, pass out the prepared food trays immediately to resident rooms on the lower end of the unit. The DD, in the presence of the surveyor, took the temperatures of the last test tray in the cart with a calibrated thermometer and they were as follows: Cheesesteak: 120 degrees Peppers/onions: 124 degrees French fries: 130 degrees During an interview with the surveyor on 1/5/24 at 12:38 PM, the DD stated he would expect the prepared food temperatures to be at least 140 degrees before being served to the residents. The DD stated if prepared food temperatures were found to be below 140 degrees, he would document it. The DD also stated he would not serve the food to the residents and provide another prepared food tray that was at the proper temperature. The DD further stated it is important to serve the prepared foods at the right temperature because the food would be in the danger zone, which meant bacteria could build up and the residents could get sick. On 1/5/24 at 12:45 PM, the surveyor, in the presence of the DD, followed a second food cart to the [NAME] 5 unit. The food cart arrived on the [NAME] 5 unit at 12:49 PM. The surveyor observed the CNAs, and other facility staff, pass out the prepared food trays to the resident rooms. The CNAs and the dietician started to serve the prepared food trays when they ran out of coffee cups at 1:00 PM. The dietician stated she couldn't serve the remaining eight prepared food trays to the residents until all items were on the trays, which included the coffee cups. At 1:10 PM the coffee cups arrived on the unit and tray service was resumed. The DD, in the presence of the surveyor, took the temperatures of the last test tray in the cart with a calibrated thermometer and they were as follows: Cheesesteak - 118 degrees French fries - 124 degrees Peppers/onions - 113 degrees During an interview with the surveyor on 1/5/24 at 1:23 PM, the Licensed Nursing Home Administrator (LNHA) stated issues with proper food temperatures were identified in the resident council meetings. The LNHA stated there were food temperature complaints from the residents about hot food being served cold. This happened sometimes during the breakfast meal and lunch meal. When this occurred, the food trays were removed and discarded. The LNHA further stated proper food temperatures were important because of safety concerns and the food would not be appetizing, to the residents. Review the facility policy titled; Food Temperatures under the Policy section, revealed Foods will be cooked, cooled, held, reheated, and stored at the proper temperature to minimize the growth of pathogenic bacteria that may result in foodborne illness. Temperatures of food will be monitored to ensure safety. Under the Procedure section, revealed under 4. All hot food items must be cooked to appropriate internal temperatures and held at a temperature of a least 135 degrees Fahrenheit; and 6. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the holding and serving process. NJAC 8:39-17.4 (a)2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to protect the confidentiality of a resident's health related information. This deficient practice was identified for 1 of 4 residents observed during medication pass (Resident #78), and was evidenced by the following: On 7/21/23 at 9:00 AM, during the medication pass observation on [NAME]-5 nursing unit, the surveyor observed the Licensed Practical Nurse (LPN) walk away from the medication cart leaving the Medication Administration Record (MAR) for Resident #78 opened to full view. The MAR was displayed on a fixed laptop attached to the top of the medication cart located in the hallway. The medication cart was locked, but the LPN was not near the cart. At that time, the Staff Educator/LPN (SE/LPN) walked up to the medication cart and acknowledged the open MAR, and closed the screen removing Resident #78's health information from view. The LPN did not return to the medication cart and left the building. On 7/21/23 at 9:01 AM, the surveyor interviewed the SE/LPN who confirmed that the MAR should not have been left opened. No residents or visitors were near the opened MAR at the time of the observation. The surveyor then reviewed the MAR for Resident #78 which included the following information: the resident's name, date of birth , medical diagnoses, allergies, diet, and medications. On 7/27/23 at 9:32 AM, the Executive Director in the presence of the Licensed Nursing Home Administrator (LNHA), Acting Director of Nursing (ADON), Regional Registered Nurse, SE/LPN, and survey team acknowledged that personal identifying health information should not be left on the computer screen for other's to view. A review of the facility's Medication Storage- Med Cart policy dated 6/2020 included .during medication pass, the MAR will be closed when not being accessed by the nurse so that information is not visible or accessible to unauthorized individuals NJAC 8:39 - 4.1(a)(18)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) implement care plan interventions of bilateral floor mats for a resident with a history of falls and b.) develop a care plan for a resident who received nebulizer treatments. This deficient practice was identified for 2 of 25 residents reviewed for comprehensive care plans (Resident #62 and #85), and the evidence was as follows: 1. On 7/24/23 at 10:05 AM, the surveyor observed Resident #85 receiving morning (AM) care. At that time, the surveyor did not observe any floor mats in the room. The surveyor reviewed the medical record for Resident #85. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in September of 2022 with diagnoses which included Alzheimer's Disease, major depressive disorder, history of falls, syncope (fainting or passing out) and collapse, unspecified fracture of right femur (thigh bone) subsequent encounter for closed fracture with routine healing. A review of the most recent quarterly Minimum Data Set (MDS), and assessment tool dated 6/12/23, reflected the resident had a brief interview for mental status (BIMS) score of 5 out of 15, which indicated a severely impaired cognition. A review of the quarterly MDS dated [DATE], reflected in Section J. Heath Conditions, included the resident had one fall with no injury and one fall with injury (except major) which included skin tears, abrasions, lacerations, and superficial bruises since admission to the facility. A review of the resident's individualized comprehensive care plan (ICCP) included a focus area initiated on 9/12/22, for the resident had actual fall(s) and was at risk for falls related to new and unfamiliar environment, deconditioning and weakness, cognitive impairment, and poor safety awareness. Interventions included fall mats to both sides of the bed at all times when resident is in bed; check for placement every shift. A further review of the ICCP included a focus area initiated on 2/28/23, for ensure my floor mats are in place to both sides of bed for my safety. Interventions included to check placement of fall mats every shift. A review of the Order Summary Report dated active orders as of 7/26/23 included a physician's order (PO) dated 1/27/23, for floor mats to both sides of bed for safety when resident is in bed. Check placement every shift. On 7/24/23 at 1:00 PM, the surveyor received the requested investigations from the Executive Director (ED), and the surveyor reviewed the unwitnessed incident reports dated 1/19/23 and 2/14/23 reflected the following: Dated 1/19/23, included care plan interventions related to this incident included bilateral fall mats. Dated 2/14/23, included the resident was found on the floor, assessed, and found a right below the knee abrasion measuring 0.3 x 0.1. A review of the Supervisor Fall Incident Investigation dated 2/14/23, reflected if fall [was] from bed, was [the] bed in [the] lowest position? Yes and was mat on [the] floor? No. A review of the Treatment Administration Record (TAR) from 1/27/23 to 7/25/23 included physician's orders for floor mats to both sides of bed for safety when resident is in bed and check placement every shift was signed as administered. On 7/24/23 at 10:19 AM, the surveyor interviewed the Certified Nursing Assistant (CNA #1) who stated she was not that familiar with Resident #85, but she knew that the resident was nice. CNA #1 stated she was unsure if the resident was a fall risk. On 7/25/23 at 09:55 AM, the surveyor interviewed CNA #2 who stated that she was the aide for Resident #85 today (7/25/23). CNA #2 stated that the resident was a fall risk as she knew the resident could not stand by themselves and that the resident could only stand and pivot. The surveyor asked if the resident had floor mats, and CNA #2 replied, I did not see any floor mats today (7/25/23). She explained she only had the resident twice and was unsure if the resident was supposed to have floor mats as she was not normally on the [NAME]-5 nursing unit or on that end of the unit. On 7/25/23 at 10:09 AM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that today (7/25/23) was her first day back to the facility in years. LPN #1 stated that she was not familiar with Resident #85, and that she was just making her way to see the resident to administer the medications. LPN #1 stated she was unsure if the resident was supposed to have floor mats. At that time, LPN #1 looked in the electronic medical record (EMR) and stated the resident had a PO for floor mats. On 7/25/23 at 10:11 AM, the surveyor observed Resident #85 lying in bed waiting for the CNA to get him/her dressed and out of bed (oob). The resident stated he/she was feeling pretty good today (7/25/23). At that time, the surveyor did not observe any floor mats in the room. On 7/25/23 at 10:17 AM, the surveyor interviewed LPN #2 who stated Resident #85 had a history of falls and believed that the resident had floor mats on the floor. She stated that the resident was non wear bearing and was a one person assist to the wheelchair. On 7/25/23 at 11:10 AM, the surveyor still did not observe floor mats anywhere in the resident's room. On 7/26/23 at 8:57 AM, the surveyor observed Resident #85 oob in the hallway in front of their room. At that time, the surveyor did not observe floor mats anywhere in the room. On 7/26/23 at 9:02 AM, the surveyor interviewed CNA #3 who stated that she was the regular aide for Resident #85 and that the resident was a complete care. CNA #3 stated that Resident #85 was a fall risk and was not allowed in the room by themselves when oob. She further stated that when the resident was in bed, the bed had to be in the lowest position. When asked was there any other fall risk interventions? CNA #3 stated when she started with the resident on the [NAME]-6 nursing unit, the resident had floor mats but now since the resident moved to [NAME]-5 nursing unit, she had not seen the floor mats. CNA #3 stated that if she knew the resident was supposed to have them, then she should inform the nurse. CNA #3 stated that she only worked the 7:00 AM to 3:00 PM shift, but when she gets the resident oob there are no floor mats while the resident was in the bed. On 7/26/23 at 9:08 AM, the surveyor re-interviewed LPN #2 who stated that the resident had floor mats, but was not sure where they were. The surveyor asked did staff have to sign in the TAR for the floor mats being in place, and she responded yes. At that time, the surveyor and LPN #2 went into the resident's room to look for the floor mats. The LPN looked all around in the resident's room and stated she did not see the floor mats, but stated they was there before. The surveyor asked LPN #2 the last time she saw the floor mats, and she was unable to confirm the last time she seen them. On 7/26/23 at 9:14 AM, the surveyor interviewed Unit Manager/Licensed Practical Nurse (UM/LPN #1) regarding the floor mats having a PO and on the care plan. UM/LPN #1 stated that she just completed an audit on Monday 7/24/23, on which residents had floor mats, and that Resident #85 was not on her list for having floor mats. She stated that the resident changed rooms on 2/17/23 from [NAME]-6 to [NAME]-5 nursing unit. At that time, the surveyor and UM/LPN #1 looked in the EMR at the PO and confirmed the floor mats to bilateral sides. When asked should the nurses sign for the floor mats if they were not in place, UM/LPN #1 responded that the nurses should not be signing if the floor mats were not in place. She explained when they were signing off on it, it meant that the floor mats were in place. She then stated, obviously they were not in place and that was incorrect documentation. UM/LPN #1 stated the care plan painted a picture of the resident needs and it included what we hope to do for them and the goals for that resident. She stated that if staff saw that the resident needed floor mats and they were not in place, then they should have informed the supervisor, maintenance or housekeeping to get them. On 7/26/23 at 9:27 AM, the surveyor interviewed the Acting Director of Nursing (ADON) who stated that Resident # 85 should have had the floor mats while in bed, and that they just placed them in the room after surveyor inquiry. The ADON stated the importance of following the PO was because it was for the care of the resident as well as for their health and safety. She stated that the care plan was a quick snapshot of the care that the resident needed, and that it was important to follow and update as things changed to reflect what the care should be. The ADON stated that at one point, Resident # 85 had the floor mats and was unsure of when they disappeared and what happened to them. The ADON stated again that the floor mats were now in place, but acknowledged the floor mats should have been in place since there was a PO and it was care planned. The ADON stated that staff should not be signing for them if they were not in place because if they did not do it then they should not be documenting that they were there. She stated that if the staff seen there was no floor mats and needed to obtain them, they could inform the maintenance department. On 7/27/23 at 9:01 AM, the surveyor observed the bilateral floor mats in place for resident #85 after surveyor inquiry. On 7/27/23 at 9:03 AM, the Staff Educator/Licensed Practical Nurse (SE/LPN) in the presence of the Licensed Nursing Home Administrator (LNHA) and the surveyor stated that staff must follow the PO and care plan. She stated that it was important to follow them because it was for the resident's safety, and it showed how to care for the resident. She further stated that nurses should be signing every shift that the floor mats were in place. The SE/LPN explained that signing in the EMR indicated that the floor mats were actually there and that the order and care plan was in place. The SE/LPN acknowledged that staff should not be signing for them if the floor mats were not in place. She stated that if staff knew the resident needed the floor mats and did not see them, they should have contacted any supervisor, and they would be able to get the floor mats. When asked if the floor mats were ordered and care planned for after the January 2023 fall should they have been in place during the second fall in February 2023, the SE/LPN replied, yes, if it was ordered and care planned. On 7/27/23 at 9:07 AM, the LNHA in the presence of the SE/LPN and surveyor stated that staff should be following the PO and care plan because it was for the safety of the resident. He further stated that the care plan was resident center as it indicated the individualized care of the resident and to ensure that they were getting their specific care. The LNHA stated that it was missed and that the floor mats should have been in place. The LNHA stated that staff should be not signing in the EMR if the floor mats were not in place. He stated that staff should only be signing if they are in place. The LNHA acknowledged that staff should be following the PO and the care plan. On 7/28/23 at 9:42 AM, the SE/LPN in the presence of the LNHA, the ED, the Regional Nurse and the survey team acknowledged that staff should be following the PO and the care plan. 2. On 7/20/23 at 10:08 AM, the surveyor observed the Resident #62 in bed with covers over his/her head. There was a nebulizer machine (a machine that delivers aerosol medication) on the side table with connected tubing that was dated 7/18/23. The tubing was connected to a dry nebulizer mask/medication cup that was resting on the side table. There was a cell phone resting next to the nebulizer; a urinal containing yellow urine sitting near the nebulizer; a cup of applesauce resting near nebulizer mask/medication cup, and a brown paper bag resting near the nebulizer mask/medication cup. The surveyor reviewed the medical record of Resident #62. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in June of 2023 with diagnoses which included acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), streptococcus pneumonia, acute pulmonary edema (a condition caused by excess fluid in the lungs), interstitial pulmonary disease (disease that causes scarring in the lungs), and pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), type 2 diabetes mellitus (DM) with diabetic neuropathy (nerve damage that occurs with diabetes.) A review of the July 2023 Order Summary Report included a physician's order dated 6/23/2023, for albuterol sulfate inhalation nebulization solution 0.63 milligram per 3 milliliters (mg/ml); 1 vial inhale orally via nebulizer four times a day for shortness of breath (SOB). A review of the July 2023 Medication Administration Record (MAR) reflected the above physician's order and was documented as administered. A review of the resident's individualized comprehensive care plan (ICCP) did not include a focus area, goals, or interventions for a nebulizer. On 7/21/23 at 9:44 AM, the surveyor interviewed CNA #4 who stated it was the first time that she cared for the resident, and she received a verbal report from the previous CNA, and a paper report from the nurse as to the type of care the resident required. On 7/25/23 at 11:38 AM, the surveyor interviewed the Registered Nurse (RN) caring for Resident #62 who stated an ICCP was a plan for the resident's specific needs that was created by the admission nurse when the initial assessment was done. The RN stated that an ICCP can change and be updated and that a nebulizer should have been on an ICCP, but that she had not seen many ICCPs. On 7/25/23 at 12:26 PM, the surveyor interviewed UM/LPN #2 who stated that an ICCP was the bible for the resident and that it would tell the entire team how to care for the resident. UM/LPN #2 stated that nursing, social worker, therapists, CNA, dietician, MDS Coordinator, and the LNHA all had access to the ICCP and could have updated it. UM/LPN #2 stated the ICCP may not have specifically contained a nebulizer, but may have said respiratory equipment or treatment. On 7/25/23 at 1:04 PM, the surveyor interviewed the ADON who stated an ICCP was a picture of the care that the resident received, and that any discipline would have been able to access the ICCP and would have known what kind of care the resident required. The ADON stated that the admission nurse started the basic ICCP and then the unit manager oversaw it to ensure it was updated. The ADON stated that she would have expected to see a nebulizer on the ICCP with a respiratory diagnosis on the goals and a nebulizer under the interventions. On 7/25/23 at 1:45 PM, the surveyors met with the Administration team and informed them the nebulizer was not on Resident #62's ICCP. At this time, the surveyor inquired with the Administration team if a nebulizer was ordered, where would the surveyor expect to see documentation, and no one from Administration answered. The surveyor then inquired where else in the medical record a nebulizer would have been documented, and he ADON stated that a nebulizer should be on the ICCP under a medical reason that included an intervention of a nebulizer. The LNHA then stated an ICCP was a plan specific to the resident's care and needs. The Staff Educator/LPN confirmed that the nebulizer should have been on the ICCP. A review of the facility provided Care Planning Process and Care Conference policy dated reviewed 7/2023, included .all resident/patient care and interventions must be carried out per the Care Plan . A review of the facility provided Falls Prevention and Management policy dated reviewed 6/2023, included Fall Injury Prevention - Post fall: assess the resident and immediately implement appropriate measures to prevent injury. a. examples may be, but not limited to: .low bed, perimeter mattress, fall mats, positioning devices in bed/chair . A review of the facility provided Physician Orders, Verbal and Telephone policy dated reviewed 6/2023, included .to secure physician orders for care and services for residents .physician orders will include the medication, treatment and or care requiring physician orders .update care plan as necessary based on physician orders . NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ165640 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise comprehensive care plans in a timely manner for a.) two residents (Resident #59 and #67) with significant weight loss and b.) a resident (Resident #45) with a change in bowel and bladder status. This deficient practice was identified for 3 of 25 resident reviewed for revision of comprehensive care plans (Resident #45, #59, and #67), and the evidence was as follows: 1. On 7/18/23 at 12:14 PM, the surveyor observed Resident #59 seated in their wheelchair watching television. Resident #59 reported that they had an unintentional weight loss due their dislike of the facility's food. The surveyor reviewed the medical record for Resident #59. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in January of 2020, with diagnoses which included dysphagia (difficulty swallowing) following cerebral infarction (disrupted blood flow to the brain). Resident #59 was readmitted in April of 2023 with a diagnosis of aspiration pneumonia (a condition where food and/or liquid enters the airways or lungs instead of being swallowed). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 4/18/23, reflected a brief interview for mental status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A review of the resident's current Order Summary Report included the following physician's orders (PO): A PO dated 6/7/23, regular diet: mechanical soft (ground meat) texture. A review of the Progress Notes included a Nutrition Dietary note dated 5/9/23 at 10:53 AM, which indicated that the resident was recently hospitalized and returned with weight loss. The May monthly weight was 112.5 pounds that suggested a 10% loss times one month. The resident returned from the hospital on a downgraded diet of puree/nectar thick liquids following a diagnosis of aspiration pneumonia. The resident was ordered health shakes three times a day, Prostat (liquid protein supplement) twice a day, and required feeding assistance due to weakness and encouragement. A review of an additional Nutrition Dietary note dated 6/8/23 at 11:04 AM, identified Resident #59 had a significant change. This weight suggested 3.6% loss times one month and 15.5% loss times six months. The resident was continued on Speech Therapy (ST) services and the diet was upgraded to mechanical soft/ground yesterday (6/7/23). A review of the individualized comprehensive care plan (ICCP) included a focus area revised on 4/27/23, that the resident had a nutritional problem or potential nutritional problem related to stroke, dysphagia [ .] 4/21/23-4/26/23 with aspiration pneumonia and sepsis, high aspiration risk, malnutrition, noncompliance. Interventions included diet as ordered (Refer to Physician's Order Sheet for current) diet type: regular; diet texture: puree; allowance: oatmeal cream pie, bananas per Speech Therapy; supplement: health shakes and Prostat. Upon further review of Resident #59's ICCP it did not include their change in condition regarding the significant weight loss and corresponding interventions, including correct diet and level of need. On 7/21/23 at 8:46 AM, the surveyor observed Resident #59 independently eating breakfast. The surveyor observed that the resident's meal ticket identified them as a Feeder. The surveyor reviewed the Daily Assignment Binder which did not identify the Resident as a Feeder for 7/21/23, but the surveyor did observe the resident's name on [NAME]-5 nursing unit's Feeder List. On 7/21/23 at 8:52 AM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who confirmed that the resident was mostly independent and did not require assistance with feeding. CNA #1 reported that the resident required additional assistance approximately four months ago, but did not need assistance any further. CNA #1 confirmed the resident's name on the [NAME]-5 nursing unit's Feeder List and meal ticket that identified the resident as a Feeder. When asked who was responsible for updating these lists CNA #1 responded, the Registered Dietitian (RD). On 7/21/23 at 9:12 AM, the surveyor interviewed Director of Rehabilitation (DOR), in the presence of the resident's Speech Therapist (ST), who confirmed that Resident #59's diet was upgraded to mechanical soft diet, and they did not need to have any type of supervision. When asked who was responsible for updating the meal ticket and the unit Feeder List the ST responded, the RD. On 7/24/23 at 10:48 AM, the surveyor interviewed the RD who confirmed that she was responsible for updating the care plan. The RD reported that the Food Service Director or herself were responsible for updating the meal tickets. When asked how nutritional interventions were put into the place, the RD responded that the care plan was updated, and nursing would be advised through communication. The surveyor inquired how often the care plan should be updated. The RD confirmed that the care plan should be updated to reflect any changes, including significant weight change and that Resident #59's diet should have been identified as chopped. On 7/25/23 at 10:17 AM, the surveyor interviewed the Acting Director of Nursing (ADON) who confirmed that Resident #59's care plan was not a comprehensive personal care plan for nutrition since it did not include the trending weight loss with the corresponding dates and the correct diet. On 7/26/23 at 1:17 PM, Regional Registered Nurse #1, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse #2, ADON, Executive Director, Staff Educator, and the survey team, confirmed that Resident #59's care plan was not comprehensive since did not include the trending weight loss and the interventions that were put into place. 2. On 7/18/23 at 11:10 PM, the surveyor observed Resident #67 seated in a wheelchair in the dining room being pushed to a table. The surveyor reviewed the medical record for Resident #67. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in December of 2019, with diagnoses which included chronic kidney disease and diabetes. A review of the most recent significant change MDS dated [DATE], reflected a BIMS score of 14 out of 15, which indicated a fully intact cognition. According to the Swallowing/Nutritional Status (Section K) Resident #67 was identified as having a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. A review of the current Order Summary Report included the following physician's orders (PO): A PO with start date of 6/21/23, regular diet: chopped texture, thin consistency. A review of the Progress Notes included a Nutrition Dietary note dated 5/8/23 at 7:53 AM, which indicated that the resident triggered for weight loss of 4.6% times one month, and 12.5% times six months. The note further indicated that the resident has had multiple medication changes due to increased behaviors. The resident was started on weekly weights. An additional Nutrition Dietary note dated 5/18/23 at 10:50 AM, included May weight of 139.5 pounds, which suggested a 4.6% loss times one month and 12.5% times six months. The resident was continued on weekly weights and Boost Glucose Control (a nutritional supplement) three times a day to encourage additional supplementation. A Nutrition Dietary note dated 5/25/23 at 8:40 AM, included that the resident continued to show ongoing loss with medication adjustments. A Nutrition Dietary note dated 6/13/25 at 10:40 AM, included that the resident weights continue to trend downward times two-three months. The June weight was identified as 127 pounds that suggested a nine-pound loss times one month and Prostat (liquid protein supplement) twice a day and Nurse Practitioner (NP) would review medications for possible appetite stimulant as medically appropriate. A Nutrition Dietary note dated 7/18/23 at 10:02 AM, included that the resident's weight was 126.2 pounds that suggested stable weight times one month and 18% loss times six months. Speech Therapy had downgraded diet texture. The resident's medications continued to be adjusted due to behaviors, and trends were continued to be monitored. A review of the individualized comprehensive care plan (ICCP) included a focus area revised on 12/7/21, that the resident had a nutritional problem or potential nutritional problem related to [diagnosis of] bipolar disorder, diabetes, non-compliant with therapeutic diet. Interventions included diet as ordered (Refer to Physician's Order Sheet for current) diet type: carbohydrate controlled diet, no added salt; diet texture: regular; liquid consistency: thin liquids. Upon further review of the ICCP, it did not include the resident's change in condition regarding the significant weight loss and corresponding interventions, including correct diet. On 7/24/23 at 10:48 AM, the surveyor interviewed the Registered Dietitian (RD) who confirmed that they were responsible for updating the care plan. When asked how nutritional interventions are put into the place, the RD responded that the care plan was updated, and nursing would be advised through communication. The surveyor inquired how often the care plan should be updated. The RD confirmed that the care plan should be updated to reflect any changes, including significant weight change. The RD reported the Resident #67's care plan had been updated to reflect chopped diet, but confirmed that it was updated after the surveyor brought it to the facilities attention. On 7/25/23 at 10:17 AM, the surveyor interviewed the Acting Director of Nursing (ADON) who confirmed that Resident #59's care plan was not a comprehensive personal care plan for nutrition since it did not include the trending weight loss with the corresponding dates and the correct diet. On 7/26/23 at 1:17 PM, Regional Registered Nurse #1, in the presence of the Licensed Nursing Home Administrator (LNHA), Regional Registered Nurse #2, Executive Director, Staff Educator, and survey team, confirmed that Resident #67's care plan was not up to date and comprehensive, since weight loss should have been updated, including trending weight loss and the interventions that were put into place. 3. On 7/25/23 at 9:30 AM, the surveyor observed Resident #45 lying in bed. The resident stated that he/she depended on staff to change his/her incontinence briefs. The surveyor reviewed the medical record for Resident #45. A review of the admission Record face sheet reflected the resident had diagnoses which included muscle wasting and atrophy, transient ischemic attack (mini stroke), and muscle weakness. A review of the admission Bowel and Bladder assessment dated [DATE], included the resident was continent of bowel and bladder. A review of the resident's admission MDS dated [DATE], included the resident had a BIMS score of 14 out of 15, which indicated the resident's cognition was intact. Further review of the MDS included the resident was always continent of bowel and bladder. A review of the resident's most recent quarterly MDS dated [DATE], included the resident was occasionally incontinent of bowel and bladder. A review of the resident's Bladder Continence record for the month of 4/2023, indicated the resident was incontinent of bladder. A review of the resident's Bowel Continence record for the month of 4/2023 indicated the resident was incontinent of bowel. Review of the resident's individualized comprehensive care plan (ICCP) included a focus area last revised 11/24/22, the resident was continent of bowel and/or bladder with interventions that included to report episodes of incontinence to nurse. On 7/25/23 at 10:25 AM, the surveyor interviewed CNA #2 who stated Resident #45 was incontinent of bowel and bladder and wore incontinence briefs. CNA #2 further stated that the resident called for assistance when he/she needed to be changed. On 7/25/23 at 1:00 PM, the surveyor interviewed the Registered Nurse (RN) who stated Resident #45 was alert and oriented, but confused at times. The RN further stated the resident was incontinent of bowel and bladder, and called for assistance when he/she needed to be changed. On 7/26/23 at 9:27 AM, the surveyor interviewed the Unit Manager/LPN (UM/LPN) who stated Resident #45 was incontinent of bowel and bladder and wore incontinence briefs. The UM/LPN further stated that resident's care plans were initiated upon the resident's admission to the facility and revised any time there is a need for updates. The UM/LPN explained that the care plan was revised by each department depending on the care plan focus area, and that there was no time frame for revising the care plan. On 7/26/23 at 11:23 AM, the surveyor interviewed the Assistant MDS Coordinator (AMDSC) who stated that each month, the MDS department provided each department with a calendar of which residents were due for their comprehensive or quarterly MDS assessments. The AMDSC further stated that each department knew which care plans were due to be reviewed and revised based on that calendar. The AMDSC explained that a resident's care plan should be revised as soon as there was a change in the resident's condition, however, if it is missed, it should be revised during the next quarterly review when the resident was due for an MDS assessment. The AMDSC stated that the importance of a care plan was to guide the staff on how to care for the resident and she verified that Resident #45's care plan should have been revised to reflect the resident's incontinent status. On 7/26/23 at 12:04 PM, the surveyor interviewed the ADON who stated that resident care plans were initiated on admission, and should be revised any time there was a change in the resident's condition. The ADON further stated the care plan should be revised during the quarterly review, however, if there was a change in condition, it should be revised within 24 hours. The ADON stated the importance of a care plan was it, tells providers and staff how to take care of that resident. The ADON then verified that Resident #45's care plan should have been revised when the resident had a change from being continent to incontinent of bowel and bladder. A review the facility provided Weight Assessment and Interventions policy that was last reviewed April 2023, included .if a weight loss meets the definition of significant, the Dietitian should discuss with the Interdisciplinary Team if a significant change MDS is necessary; care plan interventions will consider: severity of change; medical diagnosis; [Activities of Daily Living] status; medications; psychological status; family input; resident preferences; and input from direct care givers A review the facility provided Care Planning policy that was last reviewed July 2017, included .include such initial needs/problems such as [Activities of Daily Living], falls, skin tears, risk for skin breakdown, nutritional status, behaviors, pacemaker, anticoagulants, psychotropic medication use, etcetera. Include a care plan related to the resident's primary diagnosis .the interdisciplinary team will meet within 21 days of admission, readmission, when a change of condition occurs, and annually to develop the comprehensive, resident centered plan of care for each resident .when the problem, goal, approach or target date is change or resolved, it is indicated on the care plan .resident care and interventions must be carried out per the Care Plan (example adaptive equipment, such as braces, restraints, dentures, hearing aids) . Review of the facility's Care Planning Process and Care Conference policy, dated revised 7/03/23, included .care plan development, renewal and revision will be based on the results of the resident assessment .the interdisciplinary team will meet within 21 days of admission, readmission, when a change of condition occurs and annually to develop the comprehensive, resident centered plan of care for each resident . NJAC 8:39-27.1(a)

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) perform complete and accurate skin assessments for visible facial injuries and b.) develop and implement an individualized comprehensive care plan with interventions for a resident's behavior of excoriating their skin. This deficient practice was identified for 1 of 3 residents reviewed for mood and behavior (Resident #80) and was evidenced by the following: On 7/18/23 at 11:02 AM, the surveyor observed Resident #80 in bed wearing a hospital gown. The surveyor observed a wound on the jaw on the left side of the resident's face. The resident stated to the surveyor he/she liked to pick at the scabs on their skin; that the nurse did not treat or bandage the area, but that would be a good idea. The surveyor reviewed the medical record for Resident #80. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in October 2021, with diagnoses which included major depressive disorder, generalized anxiety disorder, and obsessive-compulsive disorder (OCD). A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 6/8/23, reflected that the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which indicated an intact cognition. A review of the most recent Psychiatric Progress Note dated 6/26/23, indicated the resident had diagnoses of depression, anxiety, and insomnia and that under clinical signs and target symptoms for anxiety and depression. The note did not include scratching. A review of the Certified Nurse Aide (CNA) daily task report for July 2023, for Skin Observation: Document new skin areas identified, report all findings to the nurse, from 7/14/23 until 7/26/23, the CNAs did not document the resident had any scratches, red areas, discoloration, skin tears, or open areas identified. A review of the Weekly Skin Check report dated 7/24/23, the nurse indicated that the resident had no opened areas or marks on their skin. A review of the individualized comprehensive care plan (ICCP) revised 5/23/23, reflected a focus area for opened skin areas with interventions which included continue all other preventive skin care measures as ordered. The ICCP did not include the resident's open skin area on their jaw or the resident's scratching and picking of their skin behavior observed by the surveyor and confirmed by the resident. On 7/19/23 at 12:54 PM, the surveyor interviewed Resident Representative (RR #1) for Resident #80 who was visiting the resident. RR #1 stated he/she did not visit often, but had been visiting weekly for about a month because RR #2 who came more regularly was unavailable. When asked about the wounds on the resident's face, RR #1 stated they had seen the resident picking at their skin, but the wound was new, he/she had not seen the wound last week when they visited. When asked if this was a behavior the resident regularly exhibited, RR #1 stated he/she was unsure. On 7/20/23 at 12:42 PM, the surveyor observed the resident in bed, staff had just brought in the resident's lunch tray. The surveyor observed the wound on the resident's left jaw line had begun to scab over and was approximately the size of a quarter. On 7/24/23 at 11:53 AM, the surveyor observed the resident in bed with wounds on their left jaw which appeared to be the same as the previous observation. The surveyor again asked the resident about their facial wound, and the resident stated the wound had been there a few weeks now, and again stated he/she liked to pick at their skin. The resident further stated neither the nurse nor the aides asked him/her about the wounds on his/her face, and they did not treat the skin with any salve or cream or bandage it in any way. On 7/24/23 at 12:34 PM, the surveyor interviewed the resident's Certified Nursing Aide (CNA) assigned for the day who stated she had washed and dressed the resident that day, brushed their hair and had performed mouth care. The CNA stated part of washing a resident's body was to check the body fully and ensure there was no breakdown of their skin; make sure there were no markings or bruising. The CNA stated she had not observed any skin breakdown on the resident's body or face today. On 7/24/23 at 12:44 PM, the surveyor interviewed the resident's Registered Nurse (RN) who stated the resident had a history of depression and had been in a funk lately. The RN stated the resident had a behavior, that he/she had a small wound on their cheek that the liked to pick at. The RN stated the resident had been diagnosed with OCD and stated to the nurse that he/she had exhibited this picking behavior most of their life. The RN stated nursing had been putting a bandage on the site, but the resident kept removing the bandage. The RN then stated the wound care team had been notified to evaluate the resident's skin about two weeks ago. The RN could not find if an evaluation had been done by the wound care team. The RN further stated he had checked the resident's face today, and that it looked better today than it had last week. When the surveyor along with the RN reviewed the electronic medical record (EMR) for the resident, there were no physician's orders (PO) for a treatment to the resident's cheek, or an order to apply a bandage either. The RN stated that was because the band-aid was just a barrier to picking. On 7/24/23 at 12:59 PM, the surveyor along with the RN entered the resident's room where RR #2 was visiting. On 7/24/23 at 1:02 PM, the surveyor interviewed RR #2 who stated the resident had been picking their skin for ages. RR #2 also stated the resident had a history of depression, OCD, and anxiety, and in the past, he/she had brought in bandages to cover the wound, but the resident continued to remove them and pick at their skin. On 7/25/23 at 10:31 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated when a resident was admitted to the facility, there was a skin assessment completed. The nurse assessed for any wounds, skin discoloration, bruises, or unusual skin issues including rashes. The CNAs every day when performing daily care, again checked for skin issues and notified the nurse if they observed an irregularity. The UM/LPN stated nurses then performed a weekly skin assessment usually completed on the resident's shower day, and if a skin issue was identified, then an incident report would be generated to determine the cause, and the family and the physician would be notified. The UM/LPN stated if new orders were obtained if needed, the wound care team would be notified if needed as well. The UM/LPN stated the resident was pleasantly confused and had a history of depression, but did not have behaviors that she was aware of. The UM/LPN stated that 7/24/23, was the first time someone had made her aware of the wound on the resident's face, and after she had been made aware, the resident's family and physician were notified; new orders for treatment were obtained; and the wound care team had been contacted to do an evaluation. On 7/25/23 at 1:16 PM, the surveyor interviewed the facility's Registered Nurse/Wound Nurse (RN/WN) who stated nurses should do weekly skin assessments and the CNAs when providing daily care were supposed to report any new skin alterations. On 7/25/23 at 1:23 PM, the surveyor and the RN/WN together entered the resident's room to visualize the resident's face. The RN/WN stated she believed the wound was more of a skin tear or a mechanical injury. The RN/WN stated she had been informed by nursing that the resident had been picking at the skin. The RN/WN stated both the nurse and the CNA should have assessed the resident and reported a new skin change. The RN/WN stated that if the resident was picking at their skin and causing a skin tear, then there should be a care plan for that behavior with interventions put in place. On 7/25/23 at 1:37 PM, the surveyor re-interviewed the resident's RN who acknowledged both himself and the CNA should have recognized the resident's wound on their jaw and made an assessment and documented the wound. The RN further acknowledged the resident's care plan should have been updated to include the wound on the resident's jaw as well as the resident's behavior of picking at their skin, that they had dropped the ball and spent a lot of time putting out fires. On 7/25/23 at 1:42 PM, the surveyor re-interviewed the UM/LPN who stated a care plan was a bible for the resident, it included everything you needed to know to care for the resident and the goals that were set for the resident. The UM/LPN acknowledged the resident's care plan should have been updated for the current wound on the resident's jaw as well as the resident's behavior of picking at their skin. On 7/25/23 at 1:55 PM, the surveyor interviewed the Acting Director of Nursing (ADON) who stated nurses were required to assess a resident's skin weekly and the CNA daily usually during morning care. The ADON stated if the CNA noticed a skin alteration, they needed to make the nurse aware, and the physician was contacted, and new orders obtained if necessary, and the care plan needed to be updated to include the skin alteration. The ADON confirmed the resident's care plan should have been updated to reflect the actual skin breakdown as well as the skin picking behavior. On 7/27/23 The survey team met with the facility Administration which included the ADON who stated a skin assessment should have been completed as soon as the skin was broken, and the care plan should have been updated to reflect the wound on the resident's jaw as well as the behaviors of picking. The ADON further stated the resident had been evaluated by the wound care Nurse Practitioner, the resident's primary physician was notified, and new orders were obtained to cleanse the resident's left jaw with normal saline, apply triple antibiotic ointment and cover with a band-aid, and the care plan had been updated for skin injury and picking behaviors. A review of the facility's Weekly Skin Observation-Licensed Staff policy dated and reviewed 4/2023, included . the facility will complete a weekly wound observation of resident. This observation includes a head-to-toe visualization of the resident's skin . A review of the facility's Care Planning policy dated and revised 7/2017, included that .the facility will develop a comprehensive, resident centered care plan for each resident . based upon the results of the resident assessment . NJAC 8:39-27.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure all medications were administered without an error of 5% or more. During the medication observation on 7/21/23, the surveyor observed three (3) nurses administer medications to four (4) residents. There were 35 opportunities, and three (3) errors were observed which calculated a medication administration error rate of 8.5%. This deficient practice was identified for 1 of 4 residents (Resident #65) that were administered medications by 1 of 3 nurses. The deficient practice was evidenced as follows: On 7/21/23 at 9:13 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #65 which included, Bactrim [DS] (double strength; an antibiotic), Depakote [DR] (delayed release; a mood stabilizer). At this time, the LPN stated the resident took their medications crushed in applesauce and proceeded to crush the medications and placed them into applesauce. The LPN then proceeded to enter the resident's room to administer the medications. At this time, the surveyor asked the LPN to hold the medications and step outside the resident's room. Upon returning to the cart, the surveyor reviewed the Medication Administration Record (MAR) with the LPN. The MAR revealed a physician's order (PO) for Bactrim DS 800-160 milligram (mg) tablet; give one tablet by mouth one time a day, and a PO for Depakote DR 125 mg capsule; give one capsule by mouth three times a day, and a PO for Depakote DR 250 mg capsule; give one capsule by mouth three times a day. The surveyor asked the LPN if these medications could be crushed, and the LPN stated no, delayed release tablets should not be crushed. The LPN confirmed she needed to call the physician to clarify the orders. (ERROR #1, #2 and #3). On 7/21/23 at 9:33 AM, the LPN and surveyor went to the nurse's station on [NAME]-6 nursing unit. The Staff Educator/LPN confirmed that the above medications could not be crushed, and she needed to call the resident's physician for clarification. The surveyor reviewed the medical record for Resident #65. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility May of 2020, with diagnoses which included dysphagia (difficulty swallowing), major depressive disorder, and anxiety. A review of the Order Summary Report included the following physician's orders: A PO dated 5/23/20, may crush mediations unless contraindicated. A PO dated 6/2/21, for Bactrim DS 800-160 mg tablet; give one tablet by mouth one time a day. A PO dated 7/11/23, for Depakote oral Delayed Release 125 mg capsule; give one capsule by mouth three times a day. A PO dated 7/11/23, for Depakote oral Delayed Release 250 mg capsule; give one capsule by mouth three times a day. On 7/27/23 at 9:37 AM, the survey team met with the facility administration including the Acting Director of Nursing (ADON) who acknowledged that both Bactrim DS and Depakote DR should not be crushed. A review of the facility provided Medication Administration/Disposition policy dated reviewed 6/2023, included .nurses will have access to a current Drug Handbook for reference of medications if necessary . NJAC 8:39-11.2(b); 29.2(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly label opened multi-dose medications, b.) ensure that out of date medications were removed from the medication carts where other current in use medications were stored, and c.) maintain proper temperature ranges for the medication refrigerators. This deficient practice was identified for 2 of 4 medication carts and 2 of 2 medication refrigerators on 2 of 2 nursing units ([NAME]-5 and [NAME]-6) and was evidenced by the following: 1. On 7/25/23 at 11:47 AM, the surveyor inspected the [NAME]-5 nursing unit medication cart identified as Cart 3 & 4, in the presence of Licensed Practical Nurse (LPN #1). There was an opened multi-dose insulin lispro pen that was not labeled with an opened date. The date on the bag for the insulin lispro pen was 6/1/23. There was a second opened multi-dose insulin lispro pen that was labeled with an opened date of 5/29/23. When asked about the two insulin pens, LPN #1 stated she was not sure how long the pens were good for after opening and would give the insulin pens to the Unit Manager. On 7/25/23 at 12:01 PM, the surveyor inspected the [NAME]-5 nursing unit medication cart identified as Cart 1 & 2, in the presence of LPN #2. There was an opened multi-dose inhaler (Incruse Ellipta) that was not labeled with an opened date. The date on the box for the inhaler was 04/22, and there were instructions on the inhaler box to discard six weeks after opening. LPN #2 acknowledged the inhaler was no longer good and removed it from the medication cart. 2. On 7/25/23 at 12:13 PM, the surveyor inspected the [NAME]-6 nursing unit medication room in the presence of the Registered Nurse (RN). Upon opening the medication refrigerator, the internal temperature was 48 degrees Fahrenheit (F), and there was clear liquid dripping from the freezer section of the refrigerator onto sealed plastic bags of medications. The RN stated the night shift (11:00 PM to 7:00 AM) nurse was responsible for checking the refrigerator temperatures. According to the refrigerator temperature log for July 2023, the temperature was not recorded that morning (7/25/23). On 7/25/23 at 12:42 PM, the surveyor inspected the [NAME]-5 nursing unit medication room in the presence of Unit Manager/LPN (UM/LPN #1). Upon opening the medication refrigerator, there were two thermometers; one in the door and one on a shelf inside the refrigerator. The door thermometer had a temperature of 34 F, and the shelf thermometer had a temperature of 32 F. UM/LPN #1 stated she was unsure what the temperature inside the medication refrigerator should be. On 7/25/23 at 12:45 PM, the surveyor interviewed UM/LPN #1 who stated that insulin pens and inhalers should be labeled on the bag, box, or actual medication device, and were good for 30 days after opening. UM/LPN #1 also stated that the medication refrigerator temperature should be between 36 F and 46 F. On 7/25/23 at 12:55 PM, the surveyor interviewed UM/LPN #2 who stated nurses dated the actual insulin pen upon opening and it was good for 28 days. UM/LPN #2 further stated that nurses dated the actual inhaler upon opening and followed the directions on the label to determine when to discard the inhaler. When asked about the medication refrigerator, UM/LPN #2 stated she was unsure of the temperature range, but if the refrigerator was out of range, the nurse was expected to move the medications into a different refrigerator and notify maintenance. UM/LPN #2 further stated that medications should be kept at the correct temperature to ensure efficacy. On 7/26/23 at 12:04 PM, the surveyor interviewed the Acting Director of Nursing (ADON) who stated that multi-dose medications should be labeled with the opened date on the actual device (pen/inhaler). The ADON further stated that insulin pens were good for 28 days after opening and inhalers were good for 14 to 21 days after opening depending on the specific inhaler. The ADON stated that all nurses on the medication carts were responsible for checking the medication cart for out-of-date medications because expired medications may not be as effective. The ADON then verified the insulin pen and inhaler should have been labeled with an opened date on the actual device in case the bag or box was misplaced, and that they should have been discarded when they were past their use-by date. When asked about the medication refrigerator temperatures, the ADON was unsure what the proper temperature range was, but stated that if the refrigerator was out of range, the nurse was expected to call maintenance to prevent the medications from losing their effectiveness. A review of the manufacturer recommendations, provided by the facility, for insulin lispro pens, dated revised 4/2020, included .throw away the [insulin lispro] pen you are using after 28 days, even if it still has insulin left in it . A review of the manufacturer recommendations, provided by the facility, for the Incruse Ellipta inhaler, dated revised 6/2019, included .discard Incruse Ellipta 6 weeks after opening the foil tray . A review of the facility provided Insulin Pens) policy, dated 2/4/22, included .once opened, insulin pens may be stored in med carts and must be labeled with Date Opened' and using manufacturer recommendation for number of days for room temp storage, Discard Date . A review of the facility provided Inhalants and Nebulizer Medications policy dated 10/2017, did not include a policy related to dating inhalers upon opening or when to discard inhalers. A review of the facility provided Medication Storage policy dated revised 3/2021, included .the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . A review of the facility provided Medication Refrigerator Temperatures Monitoring dated reviewed 2/2023, included .any deviation from acceptable range (36-46 degrees F) will result in the medications being moved to another refrigerator and a work order sent to Maintenance Department for repair . NJAC: 8:39-27.1(a); 29.4(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ#: 164425 Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure safe and appetizing temperatures of food for 4 of 4 entree meals observed during 1 of 1 meal observations (breakfast). This deficient practice was evidenced by the following: On 7/21/23 at 10:35 AM, the surveyor conducted a Resident Council meeting which included nine residents (Resident #2, #21, #43, #47, #66, #100, #103, #104, and #564). All nine residents informed the surveyor during the meeting that all meals served at the facility were cold, and that the facility did not offer to warm up cold food. Resident #21 stated if you asked staff to warm up your food, staff gave you an attitude. The residents stated that food will sit on the floor for at least ten minutes before staff will start to pass out meal trays. All nine resident confirmed the food tasted terrible and they wouldn't even give to their dogs. On 7/25/23 at 7:11 AM, the surveyor informed the Food Service Director (FSD) they wanted to observe the breakfast meal for the day including food temperatures. The surveyor asked the FSD to calibrate two digital thin probe thermometers in their presence; which the FSD completed using an ice bath, and the thermometers reached 32 degrees Fahrenheit (F). On 7/25/23 at 7:49 AM, the surveyor asked the FSD and the Registered Dietitian (RD) what the minimum temperature should be for hot food and what the maximum temperature should be for cold food. The RD stated hot food should be at 135 degrees Fahrenheit (F) or above, which the FSD agreed, and the FSD stated cold food should be 41 F or below. At this time, the surveyor observed the FSD using one of the thermometers calibrated to 32 F and took the following temperatures for the breakfast meal: Scrambled eggs 161 F Pureed eggs 166 F Pureed sausage 162 F Pureed bread 158 F Oatmeal 189 F Gravy 189 F Toast 123 F Ground sausage 154 F Chopped sausage 144 F Biscuits 174 F Pancakes (alternative regular meal) 197 F Fried eggs 137 F Cheese omelet 145 F Fat free milk 53 F; the Regional FSD put additional ice on top of the milk in the basin. Fat free lactose milk 54 F; the Regional FSD put additional ice on top of the milk in the basin. Yogurt 60 F; the Regional FSD put ice on top of the yogurts in the basin. On 7/25/23 at 8:02 AM, the surveyor observed the first plate of food [NAME]-6 nursing unit be plated. The surveyor observed the facility utilize a plate warmer, a device used to heat the plates prior to serving, and plastic insulated domes and bases. On 7/25/23 at 8:19 AM, the Dietary Aide informed the surveyor that the first cart for [NAME]-6 was completed and ready to leave the kitchen. At this time, the surveyor informed the FSD that they would like to the obtain a temperature on the floor of the first resident's trays that plated which included a regular meal, alternative regular meal, pureed meal, and chopped meal. On 7/25/23 at 8:25 AM, the first meal cart arrived on [NAME]-6 nursing unit. On 7/25/23 at 8:29 AM, the first resident's meal tray was served and the FSD obtained the following meal temperatures from the test trays: Regular meal texture: Scrambled eggs 132 F Biscuit 120 F Oatmeal 140 F Coffee 109 F Fat free milk 63 F Whole milk 61 F Orange juice 35 F Alternative meal texture: Pancake 125 F Pureed meal texture: Pureed eggs 123 F Pureed bread 124 F Pureed sausage 124 F Chopped meal texture: Chopped eggs 132 F Chopped biscuit 126 F At this time, the FSD confirmed all the food and beverages besides the orange juice and oatmeal were not at acceptable temperatures. The cold food was above 41 F, and the hot foods were below 135 F. On 7/25/23 at 8:40 AM, the surveyor accompanied by the FSD inspected the milk walk-in refrigerator and observed the ambient temperature was at 35 F. The FSD obtained a temperature of a fat free milk located inside the walk-in refrigerator and the temperature was 41 F. The surveyor asked the FSD if the residents had ever complained of cold food, and the FSD confirmed this past Resident Council meeting, residents complained of cold food. The FSD stated the facility offered residents a new plate of food versus reheating the food, and the facility used heated plates and insulated dome lids and bases to maintain temperature. On 7/25/23 at 11:45 AM, the surveyor asked Resident #564 and an Unsampled Resident how their breakfast was that morning, and both residents stated breakfast was not good. Both residents stated they were served eggs for breakfast that were cold. On 7/25/23 at 9:32 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Acting Director of Nursing (ADON), Executive Director, Staff Educator, Regional Registered Nurse, and survey team acknowledged that the sampled test trays were not at acceptable temperatures. The LNHA stated hot food should be at 135 F or above, and cold food should be at 41 F or below. The LNHA stated that kitchen staff took the temperatures of each meal on the tray line in the kitchen, and test trays on the floor were not consistently being done. A review of the facility provided Cold Foods Policy dated revised 5/8/22, included .potentially hazardous foods must be held and served off tray line or dining room service at 41 degrees Fahrenheit or below . A review of the facility provided Food Temperatures policy dated revised 6/2022, included all hot food items must be cooked to the appropriate internal temperatures, held and served at a temperature of at least 135 .all cold food items must be maintained and served at a temperature of 41 F or below; temperatures should be taken periodically to assure hot foods stay above 135 F and cold foods stay below 41 F during the portioning, transporting and delivery process until received by the individual recipient; foods should be transported as quickly as possible to maintain temperatures for delivery and service . NJAC 8:39-17.4(a)(2)

3. On 7/19/23 at 11:29 AM, the surveyor observed Resident #62 lying in bed with the sheet covering his/her head. The resident responded when spoken to and said he/she was okay and recovered their head with the sheet. The surveyor reviewed the medical record of Resident #62. A review of the admission Record face sheet (an admission summary) reflected that resident was admitted to the facility in June of 2023 with diagnoses which included acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), streptococcus pneumonia, acute pulmonary edema (a condition caused by excess fluid in the lungs), interstitial pulmonary disease (disease that causes scarring in the lungs), pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), and type 2 diabetes mellitus (DM) with diabetic neuropathy (nerve damage that occurs with diabetes.) A review of the July 2023 Order Summary Report included a physician's order (PO) dated 6/16/23, for atorvastatin calcium oral tablet 80 milligrams (mg); give 1 tablet by mouth at bedtime for hyperlipidemia (HLD). A review of the corresponding July 2023 Medication Administration Record (MAR) revealed blanks on 7/10/23 at 9:00 PM for the administration of the atorvastatin calcium. A review of the July 2023 Order Summary Report included a PO dated 6/16/2023, for insulin glargine subcutaneous solution pen-injector 100 unit/milliliters (unit/ml); inject 6 units subcutaneously at bedtime for DM. A review of the corresponding July 2023 MAR revealed blanks on 7/10/23 at 9:00 PM for the insulin glargine. A review of the July 2023 Order Summary Report included a PO dated 6/16/2023, for tamsulosin hydrochloride (HCL) oral capsule 0.4 mg; give 1 capsule by mouth one time a day for urinary retention. A review of the corresponding July 2023 MAR revealed blanks on 7/10/23 at 5:30 PM for the tamsulosin HCL. A review of the July 2023 Order Summary Report included a PO dated 6/24/2023, for Lasix oral tablet; give 60 mg by mouth two times a day related to chronic diastolic congestive heart failure. A review of the corresponding July 2023 MAR revealed blanks on 7/10/23 at 5:00 PM for the Lasix. A review of the July 2023 Order Summary Report included a PO dated 6/16/2023, for insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml; inject as per sliding scale ., subcutaneously three times a day for DM before meals. A review of the corresponding July 2023 MAR revealed blanks on 7/10/23 at 5:00 PM for the insulin lispro. A review of the July 2023 Order Summary Report included a PO dated 6/23/23, for albuterol sulfate inhalation nebulization solution 0.63 mg/3 ml; 1 vial inhale orally via nebulizer four times a day for SOB (shortness of breath). A review of the corresponding July 2023 MAR revealed blanks on 7/10/23 at 5:00 PM and at 9:00 PM. A review of the July 2023 Order Summary Report included a PO dated 6/16/2023, for mupirocin external ointment 2%; apply to left foot diabetic wound topically two times a day for diabetic foot wound. Cleanse with normal saline solution (NSS); apply mupirocin, cover with a wet-to-dry dressing. A review of the corresponding July 2023 Treatment Administration Record (TAR) revealed blanks on 7/7/23 at 5:00 PM, 7/9/23 at 9:00 AM, 07/10/23 at 5:00 PM, 7/14/23 at 9:00 AM, 7/16/23 at 5:00 PM, and 7/19/23 at 5:00 PM for the mupirocin. On 7/25/23 at 11:38 AM, the surveyor interviewed the Registered Nurse (RN) who cared for the resident. The RN stated that once the physician's orders were entered into the electronic medical record (EMR), that the order would show up on the MAR. The RN stated that she would not expect to see blank spots because that would mean that the medication was not administered. At this time, the surveyor with the RN reviewed Resident #62's July 2023 physician's orders with the corresponding MAR and TAR, and the RN acknowledged the blanks. On 7/25/23 at 12:26 PM, the surveyor interviewed UM/LPN #1 who stated that once the physician's orders were entered into the EMR, that the order would show up on the MAR. UM/LPN #1 stated that the nurse signed the MAR each time a medication was given and if there was a blank spot, that it meant an omission of a medication and that she expected to see a follow up progress note in the EMR. At this time, the surveyor with UM/LPN #1 reviewed Resident #62's July 2023 physician's orders with the corresponding MAR and TAR, and UM/LPN #1 acknowledged the blanks. The surveyor with UM/LPN #1 reviewed the July Progress Notes, and UM/LPN #1 acknowledged that she did not see any progress notes that would have explained why there would be blank spaces on the MAR and TAR. UM/LPN #1 stated, If it is not signed, it is not given. On 7/25/23 at 1:04 PM, the surveyor interviewed the Acting Director of Nursing (ADON) who stated that when the nurse administered the medications, that they signed their initials in the block on the MAR, and that there would be a drop-down box for the nurse to document the reason the medication was not given. The ADON stated that if a block was empty on the MAR, that it meant that the medication was not administered, and that it was important to fill out the MAR correctly for accountability of what medications the resident received. On 07/25/23 at 1:45 PM, the surveyors met with the Administration team who were made aware of the blanks on the resident's MAR and TAR. On 7/26/23 at 1:33 PM, the surveyor in the presence of the survey and Administration teams, interviewed the LNHA who stated that on the MAR and TAR, initials in the blocks meant that a medication was administered. The LNHA further stated, if it was not documented, it didn't happen, and that all of the blocks on the MAR should have been filled in. 4. On 7/19/23 at 11:36 AM, the surveyor observed Resident #79 seated in a wheelchair in the common area. The resident was alert, calm, and quiet and wore a wander guard on his/her right ankle. The surveyor reviewed the medical record of Resident #79. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in June of 2022 with diagnoses which included type 2 diabetes mellitus (DM), hypertension, Alzheimer's disease, and pneumonia. A review of the July 2023 MAR revealed a PO with start date 6/28/2023, for donepezil HCL oral tablet 5 mg; give 1 tablet by mouth at bedtime for dementia. The MAR revealed blanks on 7/10/23 at 9:00 PM. A review of the July 2023 MAR revealed a PO with start date 6/28/2023, for melatonin oral tablet 3 mg; give 2 tablets by mouth at bedtime for insomnia. The MAR revealed blanks on 7/10/23 at 9:00 PM. A review of the July 2023 Medication Review Report included a PO dated 4/11/2023, for Humalog subcutaneous solution 100 unit/ml (insulin); inject as per sliding scale: ., call if blood sugars less than 60 or greater than 400 ( <60 or >400), subcutaneously two times a day for DM. A review of the corresponding July 2023 MAR revealed blanks on 7/10/23 at 4:00 PM for the Humalog. A review of the July 2023 MAR revealed a PO with start date 6/28/2023, for Risperdal oral tablet 0.5 mg; give 0.5 mg by mouth two times a day for psychosis. The MAR revealed blanks on 7/10/23 at 5:00 PM. A review of the July 2023 MAR revealed a PO with start date 4/12/2023, for divalproex sodium oral capsule delayed release sprinkle 125 mg (an anticonvulsant); give 1 capsule by mouth three times a day for mood stabilizer, hold if lethargic. The MAR revealed blanks on 7/10/23 at 9:00 PM. A review of the July 2023 MAR revealed a PO with start date 6/22/2023, for hydralazine HCL oral tablet 10 mg; give 1 tablet by mouth three times a day for high blood pressure, hold if systolic blood pressure (SBP) less than 140. The MAR revealed blanks on 7/10/23 at 9:00 PM. On 7/25/23 at 11:38 AM, the surveyor interviewed the RN who cared for the resident. The RN stated that once the physician's orders were entered into the electronic medical record (EMR), that the order would show up on the MAR. The RN stated that she would not expect to see blank spots because that would mean that the medication was not administered. At this time, the surveyor with the RN reviewed Resident #79's July 2023 physician's orders with the corresponding MAR and the RN acknowledged the blanks. On 7/25/23 at 12:26 PM, the surveyor interviewed UM/LPN #1 who stated that once the physician's orders were entered into the EMR, that the order would show up on the MAR. UM/LPN #1 stated that the nurse signed the MAR each time a medication was given, and if there was a blank spot, that it meant an omission of a medication, and that she expected to see a follow up progress note in the EMR. At this time, the surveyor with UM/LPN #1 reviewed Resident #79's July 2023 physician's orders with the corresponding MAR and UM/LPN #1 acknowledged the blanks. The surveyor with UM/LPN #1 reviewed the July Progress Notes, and UM/LPN #1 acknowledged that she did not see any progress notes that would have explained why there would be blank spaces on the MAR. UM/LPN #1 stated, If it is not signed, it is not given. On 7/25/23 at 1:04 PM, the surveyor interviewed the ADON who stated that when the nurse administered the medications, that they put their initials in the block on the MAR, and that there would be a drop-down box for the nurse to document the reason the medication was not given. The ADON stated that if a block was empty on the MAR, that it meant that the medication was not administered, and that it was important to complete the MAR correctly for accountability of what medications the resident received. On 7/25/23 at 1:45 PM the surveyors met with the Administration team who were made aware of the resident's blanks on the MAR . On 7/26/23 at 1:33 PM, the surveyor in the presence of the survey and Administration teams interviewed the LNHA who stated that on the MAR, initials in the blocks meant that a medication was administered. The LNHA further stated, if it was not documented, it didn't happen, and that all of the blocks on the MAR should have been filled in. A review of the facility's Medication Administration/Disposition policy dated revised 7/1/23 included . Medications must be administered in accordance with the written physician's order . and the individual administering the medications must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication . A review of the facility provided Medication Administration Treatment Guidelines policy dated October 2017, included .treatments would be administered in a safe and accurate manner . the nurse would document was done by initialing on the electronic medical record . A review of the facility provided Physician Orders, Verbal and Telephone policy dated 7/1/23, included the policy intent was to secure physician orders for care and services for residents as required by state and federal law .treatment orders will include specific treatment ordered and reason or purpose. Unclear or incomplete written orders will be reviewed with the physician and any clarification will be documented . the facility would confirm accuracy of physician orders based on facility guidelines when monthly orders and recaps are due to be renewed. A review of the facility policy, Medication Administration/Disposition, last date revised 7/1/23, revealed Procedure .medications must be administered in accordance with the written physician order(s), including any required time frame .if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and use the corresponding code on the EMAR to indicate the medication was not given and the reason for not administering; the individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones; as required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. the date and time the medication was administered .the signature and the title of the person administering the drug. NJAC: 8:39-27.1(a); 29.2(d) 2. On 7/21/23 at 9:13 AM, the surveyor observed LPN #4 preparing to administer medications to Resident #65. The surveyor observed LPN #4 pour three (3) 25 microgram (mcg) tablets vitamin D3 capsules into a medication cup. At that time, the surveyor asked LPN #4 to review the Medication Administration Record (MAR). The MAR reflected a physician's order (PO) dated 6/27/22, for vitamin D3 75 mcg tablet; give one tablet by mouth one time a day for deficiency. LPN #4 and the surveyor reviewed the label on the bottle of vitamin D3 which indicated each tablet of vitamin D3 was 25 mcg. The LPN acknowledged that she should contacted the physician to clarify the above order. The surveyor reviewed the medical record for Resident #65. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in May of 2020, with diagnoses which included vitamin D deficiency, generalized anxiety, hypertension (high blood pressure). A review of the Order Summary Report included a PO dated 6/27/22, for vitamin D3 75 mcg tablet; give one tablet by mouth one time a day for deficiency. On 7/21/23 at 9:01 AM, the surveyor accompanied by LPN #4 interviewed the Staff Educator/LPN who confirmed that LPN #4 cannot substitute three vitamin D3 25 mcg to equal 75 mcg if the physician's order was for one 75 mcg tablet of vitamin D3. The Staff Educator/LPN stated the nurse should have called the primary care physician to clarify the order if the facility only had 25 mcg tablets of vitamin D3 and not the 75 mcg tablets. On 7/27/23 at 9:32 AM, the Executive Director in the presence of the LNHA, ADON, Staff Educator/LPN, RRN #2, and the survey team confirmed nurses should administer medication per physician's order; if the facility did not have the dosage ordered, they should call the physician. Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed a.) to clarify a physician's order from 10/2/21 until 7/26/23 for dentures; b.) to apply and remove ace wraps (compression bandage) as ordered by the physician; c.) administer vitamin D3 in accordance to a physician's order; and d.) document on the Medication Administration Record and Treatment Administration Record for residents in accordance with professional standards of practice. This deficient practice was identified for 4 of 25 residents reviewed for professional standards of practice (Resident #62, #65, #66, and #79). 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 case-finding, 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 case-finding; 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 7/24/23 at 11:47 AM, the surveyor observed Resident #66 sitting up in bed. The surveyor interviewed the resident who stated that the facility's nursing staff left ace wraps on his/her legs for a couple days the week of 7/17/23 (could not give specifics dates that the ace wraps remained on) and did not take them off at night causing him/her to have wounds on their lower extremities. The surveyor inquired from the resident as to how often the resident was supposed to wear the ace wraps and the resident indicated that he/she was supposed to have the ace wraps applied in the morning and removed at night. The resident stated that he/she had a history of cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) and wounds of the lower extremities. The surveyor asked the resident if he/she told the nursing staff that the ace wraps needed to be removed at night, and they stated that it was their job to know, so he/she was not going to remind them. The surveyor asked the resident if he/she reported the incident to the administration, and they could not provide the surveyor with any names of the administration that he/she told. The resident then stated that Licensed Practical Nurse (LPN #1) was aware of what happened and could provide the surveyor with more details. The surveyor reviewed the medical record for Resident #66. The admission Record face sheet (an admission summary) reflected the resident was admitted to the facility in February of 2020 with the diagnoses which included lymphedema (swelling due to build-up of lymph fluid in the body), osteoarthritis, peripheral vascular disease (poor circulation) and wound on right lower leg. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 6/27/23, reflected that the resident had a brief interview for metal status (BIMS) score of 15 out of 15, which indicated a fully intact cognition. A further review indicated that the resident required complete to extensive assistance with activities of daily living (ADLs). A review of the Treatment Administration Record (TAR) for July 2023, included a physician's order dated 9/22/22, for ace wraps to be applied in the morning (AM) and removed at night (PM) for the diagnoses of lymphedema. A further review revealed there were blanks for the corresponding order on 7/9/23, 7/16/23, and 7/19/23 that included no nurses signatures. On 7/9/23, there was no nurse's signature on the TAR that indicated that the ace wraps were applied. On 7/16/23 and 7/19/23, there were no nurses' signatures on the TAR that indicated that the ace wraps were removed. A further review of the TAR included a physician's order dated 10/2/21, to left bottom partial on in the AM and out in the PM and a right bottom partial on in the AM and remove per schedule. The physician's order did not specify what a partial was or where it should be put in. The physician's order was unclear. On 7/24/23 at 11:54 AM, the surveyor interviewed LPN #1 who stated that she had been employed through Agency staffing and had been coming to the facility for approximately one year, and she was very familiar with Resident # 66. LPN #1 revealed that there had been occasions when she came in during the morning hours, and found that the resident's ace wraps had not been removed from the night before. She stated that it did not happen all the time, but occasionally occurred. LPN #1 stated that on 7/20/23, she had observed that there was blood on the resident's sheets, and then observed that the resident had open wounds on their bilateral lower extremities. She stated that resident already had scabs on their bilateral lower extremity, and it appeared as though the scabs had come off, so she put in a would consultation order, and notified the Nurse Practitioner (NP). She then added that the resident had a lengthy history of cellulitis and scabbed areas of the lower extremities. She explained that on the morning of the 7/20/23, the resident did not have the ace wraps on when she came into apply the ace wraps, and noticed there was blood on the sheets. LPN #1 stated that she called the NP who was in the building, and requested for her to come to the unit to see the resident's reopened wounds. LPN #1 stated that she performed the treatment to the resident's wound prior to applying the ace wraps. At this time, the surveyor in the presence of LPN #1 reviewed the resident's July 2023 TAR, and the surveyor questioned LPN #1 regarding the blanks in the signature section of the TAR. LPN #1 stated that she did not know why there were blanks in the TAR for 7/9/23, 7/16/23 and 7/19/23, and she would go and find out. LPN #1 then returned after a couple minutes and stated that she checked with the Regional Registered Nurse (RRN #1) regarding the blank areas on the signature section of the TAR, and that RRN #1 informed her that a blank in the signature section of the TAR meant that the nurse did not sign the TAR that they had completed the treatment as ordered by the physician. The surveyor reviewed the NP's Clinical Note dated 7/20/23 at 10:37 AM, which indicated that the resident had fragile skin on his/her legs and frequent wound issues. The NP documented that the wounds were very shallow, looked like abrasions with dry scabs on top, no signs of infection and local care was ordered. On 7/24/23 at 12:19 PM, the surveyor interviewed LPN #2 who stated she had worked at facility through Agency staffing and was familiar with Resident #66. LPN #2 stated that she had worked day shift and evening shift on 7/22/23 and day shift on 7/24/23. LPN #2 stated that she went to see Resident #66 on day shift 7/22/23, and Resident #66 told her that he/she did not get his/her legs wrapped with the ace wrap anymore because he/she had wounds on his/her legs. LPN #2 continued to explain that the resident told her that staff had left the ace wraps intact to his/her legs for a couple days without taking them off. LPN #2 stated that she did not report what the resident told her because the resident indicated that the issue was being taking care of. On 7/24/23 12:30 PM, the surveyor interviewed Certified Nursing Assistant (CNA #1) who stated that she had been employed on the day shift since May. She stated that she had observed maybe twice since employment that Resident #66 still had ace wraps on in the morning when she came in. She stated that the ace wraps were never left on days in a row. She explained that she would let the nurse know when this happened. She continued to add that the resident recently expressed concerns that the ace wraps were left on overnight on 7/19/23, because when she came in on 7/20/23, the ace wraps were still on the resident's legs. She stated that she reported the resident's concerns to the nurse. The surveyor continued to review the medical record for Resident #66. A review of the July 2023 TAR which included a physician's order which indicated the following: please ace wrap legs from toes to below knee, on in the AM and off at night one time a day for lymphedema and remove per schedule. According to the TAR, the ace wrap was to be applied at 9:00 AM and removed at 5:59 PM. The surveyor reviewed the TAR and there were blanks in the signature slots for 7/9/23, which indicated that the ace wraps were not put on and on 7/16/23 and 7/19/23, which indicated that the ace wraps were not removed as ordered by physician. A review of the Progress Notes included a Clinical Nurses' Notes (CNN) dated 7/16/23 at 10:42 AM, which indicated that the nurse went into the resident's room and noted that the ace wraps were still on the resident and not removed the previous night; the resident requested to have them removed. On 7/25/23 at 9:44 AM, the surveyor interviewed Unit Manager/LPN (UM/LPN #1) who stated that Resident #66 was cognitively intact and was very particular regarding his/her care. She stated that the resident required extensive assistance of one staff member and had chronic issues regarding lymphedema and wounds of the lower extremities. She continued to add that the resident had chronic small openings of the lower extremities which opened, drained, resolved, and then reopened. UM/LPN #1 continued to add that Resident #66 had a physician's order for ace wraps that were to be applied during the day and removed at night. She stated that when the nurse performed a treatment, they signed the TAR to indicate that the treatment was performed. She revealed that if the signature slot was blank, then it indicated that the treatment was not performed. She also stated that when a nurse obtained a physician's order the order, they should include specific directions including times, frequency, indications, and diagnoses. UM/LPN #1 confirmed that the treatment order for Resident #66 was not signed out on the TAR on 7/9/23, 7/16/23, and 7/19/23, which indicated that the treatment was not completed as ordered. At this time, the surveyor and UM/LPN #1 reviewed the treatment physician's orders, and UM/LPN #1 confirmed that the treatment physician's order dated 10/2/21, for left bottom partial on in the AM and out in the PM was an incomplete order and should be more specific. She also confirmed that the treatment physician's order in the TAR dated 10/2/21, which indicated right bottom partial on in the AM and remove per schedule was an incomplete order. UM/LPN #1 stated that they needed to be clarified. On 7/25/23 at 10:14 AM, the surveyor interviewed LPN #3 who stated that she worked day shift on 7/16/23, and noticed that Resident #66 still had ace wraps applied to their bilateral lower extremities. LPN #3 stated that the wraps should have been removed the night before, and when she removed the ace wraps, the resident's skin was intact. She continued to explain that the resident had openings on their lower legs on and off. LPN #3 stated the resident's skin on his/her legs was very thin, sensitive, and dry but had improved over time. She confirmed that when a nurse did not sign the TAR, then it meant that the treatment was not done. LPN #3 also confirmed that the treatment physician's orders dated 10/2/21, that indicated left bottom partial on in the AM and out in the PM was an incomplete order, and should be more specific. LPN #3 also confirmed that the treatment order in the TAR dated 10/2/21, which indicated right bottom partial on in the AM and remove per schedule was an incomplete order. On 7/25/23 at 11:40 AM, the surveyor interviewed the Acting Director of Nursing (ADON) who confirmed that if a nurse did not sign the signature slot on the TAR, then it meant that the nurse did not complete the treatment. The ADON stated that nurses should always document on the TAR to indicate whether a treatment was completed or not. The ADON also confirmed that the treatment orders dated 10/2/21, that indicated left bottom partial on in the AM and out in the PM was an incomplete order, and should be more specific. She also confirmed that the treatment physician's order in the TAR dated 10/2/21, which indicated right bottom partial on in the AM and remove per schedule was an incomplete order. The ADON confirmed both physician's orders needed clarification and correction. On 7/26/23 at 1:19 PM, the surveyor interviewed the facility's RRN #1 who stated that if the signature section slots in the TAR were blank, it indicated that the treatment was not performed, You would not be able to tell if the treatment was done or not. On 7/26/23 at 1:33 PM, the Licensed Nursing Home Administrator (LNHA) was interviewed in the presence of the survey team, and the LNHA stated that if it was not documented, it was not done regarding signature slots on the Medication Administration Record (MAR) and TAR. On 7/27/23 at 9:32 AM, the Executive Director in the presence of the LNHA, ADON, Staff Educator/LPN, RRN #2, and survey team confirmed the blanks in the July 2023 TAR, and stated that the facility clarified the incomplete treatment physician's orders which were for the resident's dentures. The Executive Director confirmed the treatment physician's orders should have been clarified by the nurse at the time the orders were given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) properly dispose of a medication that fell on a contaminated surface and was previously cited during last standard survey and b.) ensure mediation was not left unattended at a resident's bedside. This deficient practice was identified for 1 of 4 residents reviewed during medication pass observation (Resident #13), and was evidenced by the following: On 7/21/23 at 8:39 AM, the surveyor during medication pass observation observed the Licensed practical Nurse (LPN) on [NAME]-5 nursing unit prepare medication for administration for Resident #13 which included two (2) 1000 milligram (mg) capsules of fish oil (a supplement) and one ampule (vial) of ipratropium-albuterol inhalation solution 0.5-2.5 mg (a medication used to treat symptoms of lung disease). During the preparation of the medications, the LPN dropped the fish oil capsules on the contaminated medication cart. The surveyor observed the LPN pick up the fish oil capsules, and throw them away into the garbage receptacle attached to the medication cart. The LPN then finished preparing the medications and entered the resident's room. The LPN administered the oral medications and then opened the canister on the nebulizer mask and poured in the ipratropium-albuterol solution into the chamber. The resident was in the middle of eating their breakfast so the LPN stated to the resident she would wait to give them their mediations until they had finished eating. She then proceeded to take the nebulizer, containing the medication, and placed it in the resident's bedside table drawer and returned to the medication cart to prepare medications for Resident # 13's roommate. On 7/21/23 at 8:52 AM, the surveyor interviewed the LPN who stated that fish oil was not a controlled substance and did not require disposal in a dedicated disposal container with another nurse as witness. When the surveyor questioned the safety of disposing of a medication in the garbage receptacle, the LPN stated she supposed someone could take the mediation out and consume it. The surveyor then asked the LPN if she should leave the nebulizer mask that contained mediation in the bedside table and the LPN stated, it was okay because the resident could not get out of the bed, and that she was had not left the room. On 7/21/23 at 9:01 AM, the surveyor interviewed the Staff Educator/LPN who stated that all medications should be disposed of properly in the dedicated disposal container which could be located on each unit in the medication room. The Staff Educator/LPN stated there should also be a container on each mediation cart, and proceeded to open the medication cart on the [NAME]-5 nursing unit that serviced Resident #13's room which revealed a drug disposal container, and acknowledged the LPN should not have discarded the fish oil in the garbage receptacle attached to the mediation cart. The Staff Educator/LPN then stated that a nurse should never have left medication in a nebulizer chamber and walk away, even to attend another resident in the same room; that leaving a mediation at bedside was never okay. On 7/27/23 at 9:39 AM, the Acting Director of Nursing (ADON) in the presence of the Licensed Nursing Home Administrator (LNHA), Staff Educator/LPN, Regional Registered Nurse, Executive Director, and survey team who confirmed that for safety reasons, there should never be medications left at a resident's bedside and medications should be disposed of properly in the designated disposal container and not in the garbage. At this time, the LNHA acknowledged that the facility was previously cited for disposing of medication in the garbage receptacle and not the drug buster during the facility's last standard survey. A review of the facility provided Medication Administration/Disposition policy dated revised 7/1/23, included .disposition should prevent diversion and/or accidental exposure . The policy did not address leaving medications unattended at a resident's bedside . A review of the facility provided Drug Buster policy dated last reviewed 6/2023, included .place medication into the Drug Buster container, invert and swish the bottle twice, replace the cap . A review of the facility provided Hand Held Nebulizer/Small Volume Nebulizer policy dated last reviewed 3/2023, did not include leaving medications unattended at the bedside. NJAC 8:39-29.4(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to serve residents a nourishing snack when there was more than a fourteen-hour span of time between the dinner and breakfast mealtimes. This deficient practice was identified for 10 of 10 residents sampled for bedtime snacks (Resident #2, #21, #43, #45, #47, #66, #100, #103, #104, and #564), and was evidenced by the following: During initial tour of the facility on 7/18/23 at 11:58 AM, Resident #45 informed the surveyor that he/she felt there was a long-time span between dinner and breakfast meals. The resident continued that he/she should receive breakfast around 8:00 AM, but usually received breakfast around 8:30 AM or 9:00 AM. On 7/21/23 at 10:35 AM, the surveyor conducted a Resident Council meeting which included nine residents (Resident #2, #21, #43, #47, #66, #100, #103, #104, and #564). All nine residents informed the surveyor during the meeting that bedtime (HS) snacks were not offered every night; they were given leftover sandwiches or crackers that the kitchen had sometimes around 8:00 PM. All nine residents stated it would be nice if the facility automatically provided each resident with a HS snack because the meals were terrible. The residents all confirmed dinner was served between 5:00 PM and 6:00 PM, and breakfast was served between 8:00 AM and 9:00 PM. The surveyor reviewed the Cart Delivery Log provided by the facility upon entrance conference, which indicated the first dinner cart was served to [NAME]-6 nursing unit at 5:00 PM, and the first breakfast cart was served to [NAME]-6 nursing at 7:45 AM. This was a fourteen-hour and forty-five minutes time span between dinner and breakfast. On 7/24/23 at 11:10 AM, the surveyor interviewed the Registered Dietitian (RD) who stated the facility did not have designated snack times throughout the day, including evenings. The RD stated the kitchen will send snacks to the nursing units at night, but not every resident was provided with a snack. When asked what a nourishing snack was, the RD responded snacks could be anything from cookies to graham crackers, juice, anything the resident wanted to eat, there was no definition of a nourishing snack or what would be considered a sufficient snack at night. On 7/25/23 at 7:13 AM, the surveyor interviewed the Food Service Director (FSD) who stated that residents could request throughout the day sandwiches, graham crackers, cookies, and chips. The FSD stated at night, the kitchen brought to the nursing units sandwiches, ice cream, cookies, milk, and yogurt, that was kept in a refrigerator on the nursing unit. The FSD stated snacks were available upon request only, residents were not automatically served a snack. The FSD confirmed the first dinner cart was served at 5:00 PM, and the first breakfast cart was served at 7:45/7:50 AM. On 7/25/23 at 10:09 AM, the surveyor interviewed the Certified Nursing Aide (CNA) who stated she worked on all three nursing shifts; day, evening, and night. The CNA stated that residents' snacks for the evening were provided as their dessert on their dinner meal tray, and the aide documented in the CNA Task section of the electronic medical record how much dessert the resident ate. The CNA stated the time indicated on the CNA Task was not necessarily the time the resident ate the snack; it was time the CNA completed their documentation which could be at the end of their shift. The CNA stated that after dinner, the kitchen brought to the floor additional food of sandwiches, juice, yogurt, cookies, and chips that were placed in the refrigerators on the nursing units if a resident requested a snack. The CNA stated usually during the night shift (11:00 PM to 7:00 AM) some residents requested food to snack on. The CNA confirmed there were no HS snacks provided to each resident, snacks were only provided upon request. On 7/25/23 at 10:17 AM, the surveyor interviewed the Acting Director of Nursing (ADON) who stated in the nursing unit pantries, the kitchen stored juice, soda, crackers, and cookies that residents could ask for. The ADON stated at nighttime, she thought there were labeled snacks for resident who were diabetic, and any resident who wanted a snack at night could request one. The ADON stated an HS snack was considered at hour of sleep and not the dessert on the dinner meal tray. The ADON stated she did not think everyone received a HS snack, but she would follow-up. At this time, the surveyor requested a copy of the CNA Task for HS snacks for the past thirty days for the nine residents from the Resident Council meeting plus Resident #45. On 7/25/23 at 12:40 PM, the surveyor reviewed the HS Snack Task reports from the past thirty days for the ten requested residents. The reports indicated that none of the residents consistently received a HS snack. The reports also indicated that staff were documenting at times HS snacks were consumed in the 4:00 PM, 5:00 PM, and 6:00 PM hours. On 7/27/23 at 9:32 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the ADON, Executive Director, Regional Registered Nurse, Staff Educator, and survey team acknowledged all residents were not being served a HS snack, that staff were provided to residents at night upon request only. At this time, the ADON stated and the LNHA confirmed, that a nourishing snack was considered food that contained protein such as a sandwich, yogurt, fruit, nuts, and not just a cookie or a bag of chips. A review of the facility provided ADL Care; Dining - Snacks policy dated reviewed 2/2023, included the Food Service will provide between meal snacks for prescribed patients/residents three times daily based on their individual nutritional needs; snacks will be delivered to the nursing units labeled with resident's name. In addition, the unit will be stocked with bulk food items for residents as needed . The policy did not include all residents will receive a nourishing HS snack if the time span between dinner and breakfast meal was greater than fourteen hours. NJAC 8:39-17.2 (f)(1)(i-ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation, b.) ensure respiratory equipment was kept in a clean and sanitary condition and stored properly to reduce the risk of infection, and c.) follow appropriate infection control practices and perform hand hygiene as indicated during a medication pass. This deficient practice was identified on 1 of 2 nursing units ([NAME]-6) for 1 of 3 residents reviewed for respiratory care (Resident #62) and for 2 of 4 residents reviewed for medication pass (Residents #13 and #78.) This deficient practice was evidenced by the following: 1. On 7/19/23 at 12:06 PM, the surveyor observed Certified Nursing Aide (CNA #1) who approached the covered food cart, removed a tray and entered Resident room [ROOM NUMBER]. CNA #1 placed the food tray on the bed side table (BST) of the resident in bed A; removed the plate cover and placed it on the bed; removed the lid from the coffee cup; unwrapped a straw and placed it into the foil cover of the apple juice; and moved the BST closer to the resident. CNA #1 then went directly with no observed hand hygiene to the resident in bed B bed, and assisted the resident with position in bed by using the bed remote to elevate the head of the bed, and moved the BST in front of the resident. CNA #1 then performed hand hygiene using alcohol based hand rub (ABHR) when she exited the room. CNA #1 returned to the food cart, and removed a tray and entered Resident room [ROOM NUMBER]. CNA #1 placed the food tray on the BST of the resident in bed B; removed the plate cover and placed it on the bed; removed the lid from the coffee cup; opened the napkin and tucked it into the resident's neckline; and moved the BST closer to the resident. CNA #1 then went directly with no observed hand hygiene to the resident in bed A, and grasped the white foam cup and the clear plastic cup on the BST and moved them closer to the resident; then moved the BST closer to the resident. The resident then picked up his/her white foam cup. CNA #1 then performed hand hygiene using ABHR when she exited the room. CNA #1 returned to the food cart, removed a tray and entered Resident room [ROOM NUMBER]; and placed the tray on the BST of the resident in bed A. No hand hygiene was observed after serving the resident their tray. CNA #1 again returned to the food cart, removed a tray and placed it on the BST of the resident in room [ROOM NUMBER] bed A. CNA #1 then moved the BST closer to the resident; removed the food cover and placed it on the bed; reached down to the floor to pick up a black folded item and placed it on the bed; moved the resident's shoes away from the resident's feet; and moved the BST closer to the resident. CNA #1 then went directly with no observed hand hygiene to the resident in room [ROOM NUMBER] bed B, and moved the BST closer to the resident. CNA #1 then performed hand hygiene using ABHR when she exited the room. When CNA #1 entered the hallway, she retrieved a yellow wet floor sign and placed it over a spill in the hallway. CNA #1 then went directly with no observed hand hygiene to the food cart; removed a tray and placed it on the BST of the resident in room [ROOM NUMBER] bed B. On 7/19/23 at 12:32 PM, the surveyor interviewed CNA #1 who stated that when the food cart arrived on the unit, that the staff checked the meal ticket to ensure the tray was correct; they poured coffee if requested; they delivered the tray to each resident; cleaned the resident's hands; and then returned to the cart to retrieve the next tray. CNA #1 acknowledged that she did not perform hand hygiene correctly and stated, I was moving fast. CNA #1 acknowledged that she should have performed hand hygiene between each resident; when she touched the items on the floor; and when she touched the wet floor sign. CNA #1 stated that it was important to perform hand hygiene correctly to prevent cross contamination. On 7/19/23 at 12:42 PM, the surveyor interviewed Licensed Practical Nurse (LPN #1) who stated that before the trays were served, that the resident's hands were sanitized with wipes and that when the food cart arrived on the unit, the staff ensured that the food matched the ticket; staff served coffee or tea; and they set up or fed the resident their meal if needed. LPN #1 stated that during meal pass, hand hygiene was performed before the trays were passed out, and ABHR was used before leaving the resident's room. The surveyor informed LPN #1 of CNA #1's tray pass observation, and LPN #1 acknowledged that CNA #1 did not perform hand hygiene correctly; that she should have used ABHR before caring for each resident and after she touched anything on the floor. LPN #1 stated it was important to perform hand hygiene correctly to prevent cross contamination of germs, fluids, or dirt. On 7/19/23 at 1:02 PM, the surveyor interviewed Unit Manager/LPN (UM/LPN) who stated that during meal time, staff used hand wipes on the residents and then washed their own hands prior to serving the food trays. She then stated that ABHR should have been used with each tray that was touched, between each resident, and when staff exited the resident's room. The surveyor informed the UM/LPN of CNA #1's tray pass observation, and the UM/LPN acknowledged that CNA #1 did not perform hand hygiene correctly, and stated that it was important for infection control that she used hand sanitizer between each resident and after touching the wet floor sign. On 7/20/23 at 11:10 AM, the surveyor interviewed the Acting Director of Nursing (ADON) who stated that when the food cart was delivered to the unit, the CNA removed a tray; reviewed the meal ticket and delivered the tray; helped the resident with set up if needed; then sanitized their hands when they exited the room. The ADON stated during meal pass, hand hygiene should have been done before a tray was removed from the cart and before exiting the resident's room. The surveyor informed the ADON of CNA #1's tray pass observation, and the ADON acknowledged that CNA #1 did not perform hand hygiene correctly, and stated that she should have performed hand hygiene prior to touching the resident's tray, in between residents, when retrieving items from the floor, and after touching the wet floor sign. The ADON stated that it was important to perform hand hygiene correctly to prevent passing germs and for infection control. On 7/25/23 at 1:45 PM, the Licensed Nursing Home Administrator (LNHA) met with the survey team, and was made aware of the tray pass observation on the [NAME]-6 nursing unit on 7/19/23. On 7/26/23 at 1:29 PM, the Regional Registered Nurse (RRN) met with the surveyors, and was made aware of the tray pass observation on [NAME]-6 nursing unit on 7/19/23. RRN confirmed that hand hygiene should have been performed between caring for each resident in the room, when touching inanimate objects, and prior to passing the food trays. A review of the facility document Summary Report of Meeting/In-Service dated 7/10/23, 7/11/23, 7/12/23, 7/13/23, and 7/18/23, included Subjects covered: Employees must wash their hands: before and after contact with each resident, even if gloves are worn. Before eating, drinking, or handling food .CNA #1 signed and dated the in-service on 7/11/23. 2. On 7/20/23 at 10:08 AM, the surveyor observed Resident #62 in bed with covers over his/her head. There was a nebulizer machine (a machine that delivers aerosol medication) on the side table with connected tubing that was dated 7/18/23. The tubing was connected to a dry nebulizer mask/medication cup that was resting on the side table. There was a cell phone resting next to the nebulizer, a urinal containing yellow urine sitting near the nebulizer, a cup of applesauce resting near nebulizer mask/medication cup, and a brown paper bag resting near the nebulizer mask/med cup. On 7/20/23 at 10:42 AM, the surveyor heard humming sounds from the resident's room. Upon entering, the surveyor observed the nebulizer running with the connected tubing under the sheet that was covering the resident's head. On 7/20/23 at 11:27 AM, the surveyor observed the nebulizer machine on the resident's side table. The tubing was connected to a dry nebulizer mask/medication cup that was resting on the table and touching the wall. The surveyor reviewed the medical record for Resident #62. A review of the admission Record face sheet (an admission summary) reflected that the resident was admitted to the facility in June of 2023 with diagnoses which included acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), streptococcus pneumonia, acute pulmonary edema (a condition caused by excess fluid in the lungs), interstitial pulmonary disease (disease that causes scarring in the lungs), and pleural effusion (buildup of fluid between the tissues that line the lungs and the chest.) A review of the July 2023 Order Summary Report revealed a physician's order dated 6/23/2023, for albuterol sulfate inhalation nebulization solution 0.63 milligram (mg) per 3 milliliters (ml) (albuterol sulfate); 1 vial inhale orally via nebulizer four times a day for shortness of breath (SOB). A review of the corresponding July 2023 Medication Administration Record (MAR) reflected the above physician's order and was documented as administered. On 7/21/23 at 09:19 AM, the resident was observed lying in bed, alert, watching television. The surveyor interviewed the resident who acknowledged that the nebulizer was theirs, and that it was used each day. The resident stated, The nurse sets it up, she puts the stuff in it, and she puts it on my face and tightens it. The resident stated that when the medication was finished, that the nurse took the mask off and that sometimes he/she would have turned the machine off. The surveyor inquired as to who put the mask on the table, and the resident stated, I guess she does. I don't, she does all that. The surveyor inquired as to who cleaned the mask, and the resident stated, They don't clean it. It don't really need to be cleaned, maybe just the part on my nose. On 7/21/23 at 9:50 AM, the surveyor interviewed the Registered Nurse (RN) that was caring for Resident #62, who stated that the resident received a nebulizer breathing treatment twice on her shift. The RN stated that each resident had their own nebulizer and that prior to the medication being administered, she washed the mask with water, let it air dry then put the medication in the medication cup for administration. The RN stated that when the medication was completed, she washed the mask out, dried it and placed it in a plastic bag for cleanliness. At 9:54 AM, the surveyor accompanied the RN to the resident's room and observed the nebulizer mask/medication cup unbagged and resting on the side table. The RN acknowledged that it was the resident's nebulizer that was used, and it was not stored correctly. The RN stated that the nebulizer mask/medication cup needed to be stored in a plastic bag, and then she picked up a plastic bag from the floor. The RN stated that she would get a new plastic bag and a new nebulizer mask/medication cup because it was not properly covered which was important for sanitary reasons. The RN removed the mask and tubing from the resident's room. On 7/21/23 at 10:01 AM, the surveyor interviewed the UM/LPN who stated that it was the nurse's responsibility to obtain the resident's nebulizer, date the tubing and mask/medication cup, and to change the tubing and mask/medication cup weekly or when dirty. The UM/LPN stated that when the nebulizer treatment was completed, that the mask was washed with soap and water; air dried on a paper towel; and then when dried, it was stored in a plastic bag. The surveyor discussed with the UM/LPN the nebulizer observations, and reviewed photographs of the resident's nebulizer taken on 7/20/23 and 7/21/23. The UM/LPN acknowledged that the nebulizer mask/medication cup was not stored correctly, and stated that it was important after the mask was cleaned that it should have been stored in a bag to prevent infection. On 7/21/23 at 10:14 AM, the surveyor interviewed the ADON who stated that the nurse was responsible for obtaining the nebulizer and tubing with the mask, ensuring the medication was administered, disconnecting and turning off the nebulizer, placing the mask in a bag when completed. The ADON stated the nebulizer mask was cleaned after a treatment with a disinfectant wipe and stored in a plastic bag. The surveyor discussed with the ADON the nebulizer observations and reviewed photographs of the resident's nebulizer taken on 7/20/23 and 7/21/23. The ADON stated the nebulizer mask was not stored correctly and that it should have been cleaned and placed in a labeled and dated plastic bag. The ADON stated, I wouldn't have left it on the table, I would put it in a bag and store it in the drawer. The ADON stated it was important to clean and store the nebulizer mask/medication cup correctly for infection control. On 7/21/23 at 10:43 AM, the surveyor interviewed the Staff Educator/LPN (SE/LPN) who stated that the nurses were responsible for obtaining the nebulizer and mask, changing the mask and tubing weekly, and storing the mask in a plastic bag that was labeled with the resident's room number and name. The SE/LPN stated that once a nebulizer treatment was administered, the nurse removed the mask and rinsed the medication cup and if the mask was visibly soiled, it would have been thrown away. The SE/LPN stated that if the mask was not soiled, it would have been reconnected to the tubing and stored in a plastic bag. The surveyor discussed with the SE/LPN the nebulizer observations and reviewed photographs of the resident's nebulizer taken on 7/20/23 and 7/21/23. The SE/LPN confirmed that the nebulizer mask/medication cup was not stored correctly and that it was important for infection control to make sure that the mask/medication cup were stored in a plastic bag after they were cleaned. 3. On 7/21/23 from 8:39 AM through 8:57 AM, the surveyor during Medication Pass observation of LPN #2 made the following observations: LPN #2 prepared medication for Resident #13 wearing a pair of gloves, and observed the resident in bed eating breakfast. LPN #2 administered the resident's oral medications wearing the same pair of gloves, but placed the resident's nebulizer treatment in the resident's bedside table to administer after the resident finished eating. LPN #2 then removed her gloves and without performing hand hygiene, proceeded to her medication cart to prepare medications for Resident #13's roommate (Resident #78). LPN #2 donned (put on) a new pair of gloves without performing hand hygiene, and removed Resident #78's medication from her cart and placed it into a medication cup. LPN #2 then proceeded into the resident's room wearing the same gloves, and administered the medication to Resident #78. LPN #2 then proceeded back to Resident #13's bedside table wearing the same gloves, and retrieved the nebulizer mask from the drawer and applied it to Resident #13's face. LPN #2 then proceeded out of the resident's room wearing the same gloves, and removed the gloves at the medication cart and did not perform hand hygiene. On 7/21/23 at 8:57 AM, the surveyor interviewed LPN #2 who acknowledged she should have changed her gloves and performed hand hygiene between caring for Resident #13 and Resident #78, and confirmed not doing so was an infection control issue. On 7/21/23 at 9:01 AM, the surveyor interviewed the Staff Educator/LPN who stated nurses must perform hand hygiene between caring for each resident to prevent infection. On 7/26/23 at 12:21 PM, the surveyor interviewed the facility's Infection Preventionist/LPN (IP/LPN) who stated LPN #2 should have removed her gloves and sanitized her hands, before proceeding to care for another resident. On 7/27/23 at 9:39 AM, the survey team met with the facility Administration which included the ADON who confirmed that hand hygiene must be performed between caring for each resident to prevent infection. A review of the facility provided Hand Hygiene policy revised 10/27/22, included . alcohol-based hand rub is the preferred method for routine hand hygiene. Use alcohol-based hand rub .for the following situations: .before and after direct contact with residents; before preparing or handling medications; immediately after removing gloves; after contact with a resident's intact skin; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . A review of the facility provided Food and Nutritional Services policy dated last date revised of 7/18/23, included .staff must wash hands prior to delivering the next tray if they have handled room items or Resident clothing . A review of the facility provided Hand Held Nebulizer/Small Volume Nebulizer policy dated revised date 3/2020, included .store nebulizer equipment in a storage bag . NJAC 8:39 - 19.4(a)(m)(n); 27.1 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain multi-use food-contact surfaces in a manner to prevent bacterial growth; b.) store potentially hazardous foods to prevent food-borne illness; c.) cool potentially hazardous foods in a manner to prevent food-borne illness; d.) maintain kitchen equipment in a sanitary manner; and e.) maintain cold food items to prevent food-borne illness. This deficient practice was evidenced by the following: 1. On 7/18/23 at 11:03 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed along the tour, the meat walk-in refrigerator's door was left ajar. The surveyor and FSD proceeded into the walk-in refrigerator and observed the ambient temperature to be 55 degrees Fahrenheit (F). The FSD stated refrigerators should be maintained at 41 F or below, and cold food should be held at 41 F or below. At this time, the FSD calibrated two thin probed digital thermometers in an ice bath to 32 F. The surveyor requested and observed the FSD obtain food temperatures from the following items: Hot dogs 50 F; the FSD stated the kitchen staff just returned the hot dogs to the walk-in refrigerator after preparing for lunch, and the surveyor observed hot dogs on the tray line. Bowl of marinated chicken breasts 55 F. The chicken was dated 7/18/23, and the FSD stated [NAME] #1 just prepared the chicken breasts at 10:30 AM. Whole eggs 48 F Baked potatoes 57; dated prepared 7/17/23. Sliced cooked peppers and onions 48 F; dated prepared 7/17/23. Pureed rice 49 F; dated prepared 7/17/23. A review of the Cadbury Refrigerator/Freezer Temperature Log for July 2023, indicated that the meat walk-in refrigerator was observed at 38 F that morning. A further review of the log indicated all the temperatures were within normal range for the month. On 7/18/23 at 11:30 AM, the surveyor interviewed [NAME] #1 who stated he marinated the chicken at 9:00 AM that morning. On 7/18/23 at 1:38 PM, the surveyor with the FSD conducted a follow-up inspection of the meat walk-in refrigerator and observed the ambient temperature of the walk-in refrigerator was 50 F. At this time, the FSD calibrated two thin probed digital thermometers in an ice bath to 32 F, and the surveyor observed the FSD obtain the following temperatures: Hot dogs 50 F Chopped chicken 42 F Whole eggs 49 F The FSD stated she had placed the marinated chicken in the walk-in freezer to cool down. On 7/19/23 at 10:03 AM, the surveyor interviewed the Regional FSD who stated Maintenance was in the kitchen yesterday repairing the meat walk-in refrigerator, and discovered an ice accumulation on the condenser unit that was at least an inch thick. The Regional FSD stated there should be no ice accumulation on the condenser because it could interfere with the refrigerator becoming the appropriate temperature of 41 F. The Regional FSD stated the facility removed all food from the walk-in refrigerator yesterday. The surveyor observed the walk-in refrigerator was emptied, and the ambient temperature was 38 F. 2. During initial kitchen tour on 7/18/23 at 11:03 AM, the surveyor in the presence of the FSD observed the meat walk-in refrigerator's door was open, and the ambient temperature was 55 F. At this time, the surveyor observed a full deep hotel pan filled to just below the rim of chicken soup labeled as prepared 7/18/23. On 7/18/23 at 1:38 PM, the surveyor with the FSD conducted a follow-up kitchen inspection of the meat walk-in refrigerator. The surveyor observed the ambient temperature at 50 F. At this time, the FSD calibrated two thin probed digital thermometers to 32 F in an ice bath. The surveyor observed the same full hotel pain of chicken soup labeled prepared 7/18/23, on a shelf that was observed earlier that morning at 11:03 AM. The surveyor requested the FSD obtain a temperature of the chicken soup which was 99 F. On 7/18/23 at 1:45 PM, the surveyor interviewed the Lead [NAME] in the presence of the FSD who stated she made the chicken soup that morning at 7:30 AM, and it was done cooking at 9:00 AM. The Lead [NAME] stated she transferred the chicken soup into a full deep hotel pan at 9:15 AM, covered and labeled it, and placed it in the meat walk-in refrigerator by 9:30 AM. The Lead [NAME] stated the soup was at 190 F when cooked, but she did not monitor the temperature when she placed the soup in the walk-in refrigerator or during the cooling process. The Lead [NAME] stated the facility did not take temperatures or document the temperatures during the cooling process. The FSD confirmed this, that the only temperature logs the kitchen maintained was for food on the tray line. On 7/18/23 at 1:50 PM, the surveyor asked the FSD and the Regional FSD if the kitchen had a hazard analysis and critical control points (HACCP) plan (management system in which food is safely addressed through the analysis and control of biological, chemical, and physical hazards from raw material production, procurement and handling, to manufacturing, distribution and consumption of the final product). The FSD was unaware of a HACCP plan the Regional FSD also stated he was unsure if the facility used a HACCP plan; that the facility did not record time and temperatures of cooked foods, that the chicken soup should never have been saved. The Regional FSD stated the facility had two hours to bring the temperature of the food down to 70 F and an additional four hours to bring the temperature down from 70 F to 41 F. The Regional FSD stated this could be accomplished with the use of ice baths. The FSD and Regional FSD acknowledged that from the Lead Cook's interview that the soup was in the meat walk-in refrigerator for about four and a half hours, was observed in the walk-in refrigerator at 11:03 AM, and the temperature did not reach 70 F which according to the Regional FSD should occur in two hours. On 7/19/23 at 10:03 AM, the Regional FSD informed the surveyor that the facility was now utilizing a HACCP plan, which they were not prior to surveyor inquiry. The Regional FSD provided the surveyor with a HACCP Food Chill Time and Temperature Log which indicated to place all food in a shallow three (3) inch or less depth pan and label with the expiration date of three days from production. Food may be uncovered during the cooling process however once temperature is reached must be covered. Ice paddles should be used to cool liquids. Chill food from 140 F to 70 F within two hours or less and chill food from 70 F to 41 F in an additional four hours or less. If food is not chilled within limits rapidly reheat to 165 F and begin chill process again; if second attempt fails discard food and document. 3. On 7/19/23 at 10:10 AM, the surveyor in the presence of the FSD conducted a follow-up kitchen tour and observed the following: On a storage rack eight large yellow, five large white, ten large blue, six large red, six large brown, and five large green cutting boards all deeply pitted and discolored black and brown. The FSD stated cutting boards were changed every three months or sooner if needed because food could become stuck in the pits and grooves and cross-contamination and bacterial growth could occur. The FSD confirmed these cutting boards should not be in use. The ice cream reach-in freezer contained an accumulation of ice build-up and discoloration. The FSD and Regional FSD confirmed there should be no accumulation of ice. The FSD stated that the ice cream reach-in freezer was cleaned weekly, but was unable to provide any documentation to verify. 4. On 7/19/23 at 10:35 AM, the surveyor in the presence of the FSD observed on a cooling rack three deep full hotel pans covered in foil labeled 7/18/23 and use by 7/21/23. The FSD stated they were sliced apple that were from a can that [NAME] #1 used to prepare apple cobbler. At this time, the surveyor in the presence of the FSD interviewed [NAME] #1 who stated he opened the cans of sliced apples yesterday, poured the apples into the pans, added sugar and cinnamon to them, covered the pans and dated, and left on the cooling racks to make today. [NAME] #1 stated he did not refrigerate the canned apples after opening; he was unaware that the canned apples needed to be refrigerated after opening. The FSD at this time stated she was unsure if the canned apples needed to be refrigerated after opening. On 7/19/23 at 10:40 AM, the surveyor in the presence of the FSD interviewed the Regional FSD who stated canned food needed to be refrigerated after being opened. The FSD stated the apples were supposed to be for apple cobbler today, and she could not speak to why they were not refrigerated. At this time, the FSD used a digital thin probed thermometer calibrated to 32 F in an ice bath to obtain a temperature of the sliced apples, which was 81 F. On 7/19/23 at 10:51 AM, the surveyor re-interviewed the Regional FSD who stated he was usually in the facility once a week to offer support to the FSD. The Regional FSD stated once canned food items were opened, they needed to be refrigerated for food safety because of bacterial growth in the temperature danger zone. The Regional FSD stated he noticed the apple on the cooling rack this morning and informed [NAME] #1 to discard, but the cook did not. On 7/19/23 at 10:56 AM, the surveyor interviewed [NAME] #1 who stated yesterday afternoon at some time, opened the canned apples to prepare apple cobbler for Friday's dessert that he was planning on finishing preparing today (Wednesday). [NAME] #1 stated he makes a cake that goes on top of the apples that he [NAME], and these apples were never baked yesterday; just removed from the cans and cinnamon and sugar was added. [NAME] #1 stated no one told him to start preparing the apple cobbler yesterday, that he was getting some of the baking done yesterday for the menu. A review of this week's menu reflected that apple cobbler was the dessert for Friday's dinner. On 7/20/23 at 9:24 AM, the surveyor interviewed the [NAME] President of Dining Corporation who stated the facility did not have a preparation policy or procedure, that the facility used the meal tracker production sheets that indicated what was needed for each meal, but there was no policy or procedure for when to start preparing a menu item. 5. On 7/25/23 at 7:44 AM, the surveyor observed the breakfast meal tray line. The surveyor observed the residents' meal trays stacked on the tray line, and observed thirty-two meal trays with the plastic finish chipped off exposing metal and other tray fibers. At this time, the FSD had the Dietary Aide remove the chipped resident meal trays and discarded all thirty-two trays. The FSD acknowledged that the trays were not safe to use because the chipped plastic could get in a resident's meal and bacterial growth. On 7/25/23 at 7:49 AM, the surveyor observed the FSD using a digital thin probed thermometer calibrated to 32 F in an ice bath obtained the following temperatures of cold food items on the tray line: Fat free milk 53 F Fat free lactose milk 54 F Yogurt 60 F The FSD acknowledged that cold food should be at 41 F or below. On 7/25/23 at 8:40 AM, the surveyor and the FSD conducted an inspection of the milk walk-in refrigerator and observed the ambient temperature was 35 F. At this time, the FSD used a calibrated digital thin probed thermometer and obtained the temperature of a fat free milk which was 41 F. On 7/27/23 at 9:32 AM, the Licensed Nursing Home Administrator (LNHA) in the presence of the Acting Director or Nursing (ADON), Executive Director, Staff Educator, and Regional Registered Nurse acknowledged that cold food should be stored and maintained at temperatures 41 F or below, refrigerators should be maintained at 41 F or below, the facility should be cooling foods according to the HACCP plan that was not in place prior to surveyor inquiry, kitchen refrigeration and freezer equipment should be maintained without ice accumulation, discolored and pitted cutting boards should not be used as well as chipped resident meal trays, and canned food needed to refrigerated after opening. A review of the facility provided Cold Foods Policy dated revised 5/8/22, included potentially hazardous foods must be held and served off tray line or dining room service at 41 degrees Fahrenheit or below .food that is cooked then chilled to 41 degrees Fahrenheit must be tracked through our Corporate HACCP Logging Tool .HACCP Memo hot foods must be cooled down within two hours to 70 degrees Fahrenheit and the cooled to 41 degrees Fahrenheit within the next four hours for a total of six-hour process. A review of the facility provided Food Temperatures policy dated revised 6/2022, included all hot food items must be cooked to the appropriate internal temperatures, held and served at a temperature of at least 135 all cold food items must be maintained and served at a temperature of 41 F or below . A review of the facility provided Reporting Equipment/Maintenance Needs Policy dated 3/2020, included FSD or Designee will identify equipment or maintenance needs daily or as needed . A review of the facility provided Cutting Board Safety and Usage Policy dated revised 3/2022, included .if any deep grooves, cracks, severe discoloring, or fading occurs, they must be discarded and not used. NJAC 8:39-17.2(g)

Based on observation, interview, and record review, it was determined that the facility failed to consistently document in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). This deficient practice was identified for 1 of 5 residents (Resident #61) reviewed for unnecessary medications and 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 or potential physical and emotional health problems, through such services as case finding, 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 case finding; 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. According to the admission Record, Resident #61 was admitted with a medical diagnosis that included but was not limited to syringomyelia and syringobulbia (a neurological disorder that affects the spinal cord), sepsis (the body's reaction to a severe infection), major depressive disorder and anxiety disorder. A review of the Order Summary Report dated 08/01/22-10/14/22 and August 2022, September 2022, and October 2022 MARs and TARs for Resident #61 revealed that there was no documentation to indicate that the medications and treatments were administered as ordered on the following dates and times: Gabapentin Capsule (used for nerve pain) 400 milligram (MG); give one capsule by mouth every eight hours. Ordered 08/26/22. 06:00 AM-09/07/22 02:00 PM-09/25/22 10:00 PM-09/04/22, 10/04/22 Heparin Sodium (Porcine) Solution (used to prevent blood clots) 5000 Unit/Milliliter (ml) inject one ml subcutaneously every eight hours. Ordered 08/26/22. 06:00 AM-09/03/22, 09/07/22 02:00 PM-09/07/22, 09/25/22 10:00 PM-09/04/22, 10/04/22, 10/10/22 Vital signs Q (every) shift every shift. Ordered 08/26/22. Evening - 10/05/22 Weekly skin checks on shower days in the afternoon every Monday and Thursday. Ordered 08/29/22. 02:00 PM - 10/06/22 Apply house barrier cream to peri area with each incontinence episode and as needed every shift. Ordered 08/26/22 Day - 08/30/22, 10/06/22, 10/08/22 Night - 09/02/22 Float heels above bed surface (when in bed) using pillows and wedges every shift. Ordered 08/26/22 Day - 08/30/22, 10/06/22, 10/08/22 Night - 09/02/22 Heel boots (right/left/bilateral at all times every shift. Ordered 08/26/22. Day - 08/30/22, 10/06/22, 10/08/22 Night - 09/02/22 Low bed in lowest position at all times, except during care. Check for bed position every shift. Ordered 08/26/22. Night - 09/02/22, 10/06/22, 10/08/22 During an interview with the surveyor on 10/14/22 at 1:15 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that the nurse was to administer a medication or treatment and then signed that the medication or treatment was administered in the MAR, and TAR. The LPN/UM added that if the medication or treatment was not signed, it was not given. During an interview with the surveyor on 10/17/22 at 1:50 PM, the Director of Nursing (DON) stated if the MAR or TAR had blanks (no initials indicating the medication or treatment was administered), that meant the medication or treatment was not administered or the nurse forgot to sign the medication or treatment. The DON further stated that she expected the nurse to sign the MAR and TAR once an order was administered, or the nurse would write a note in the progress notes about why the medication or treatment was not administered. A review of Resident #61's progress notes for October 2022 did not reveal any documentation of the medications or treatments not being administered on the above dates. A review of the facility's policy titled Medication Administration, reviewed 01/2022, revealed the individual administering the medication will record in the resident's medical record the signature and title of the person administering the drug. A review of the facility's policy titled Medication Administration Guidelines-Treatments, reviewed in October 2017, reflected that the nurse will document the treatment was done by initialing on the EMAR (Electronic Medical Administration Record). NJAC 8:39-29.2(d)

Based on observation, interview, and record review, it was determined that the facility failed to follow an active physician's orders to apply bilateral heel boots. This deficient practice was identified for Resident #61, 1 of 2 residents reviewed for position and mobility, and was evidenced by the following: During the initial tour on 10/05/22 at 11:49 AM, the surveyor observed Resident #61 lying in bed, awake and alert. The surveyor observed two light blue heel boots lying directly on the bedside nightstand. On 10/06/22 at 12:03 PM, the surveyor observed Resident#61 lying in bed with bed covers over his/her feet, unable to observe heels. The surveyor observed two light blue heel boots lying directly on the bedside nightstand. On 10/07/22 at 12:55 PM, the surveyor observed Resident #61 lying in bed with the bed covers over his/her feet. The surveyor observed two light blue heel boots lying directly on the bedside nightstand. The surveyor interviewed Resident #61, who stated they did not have anything on their feet. Resident #61 said they had not been wearing the heel booties and added, I want it. According to the admission Record, Resident #61 was admitted with a medical diagnosis that included but was not limited to: syringomyelia and syringobulbia (a neurological disorder that affects the spinal cord), sepsis (the body's reaction to a severe infection) and muscle wasting and atrophy. A review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected that the Resident #61 was cognitively intact, required limited assistance of two people for bed mobility, was non-ambulatory and was identified as being at risk for developing pressure ulcers. The MDS reflected that the resident did not have a pressure ulcer at the time of the MDS assessment. According to the 09/23/22 Braden Scale, an assessment tool used to predict the risk for pressure sore development, the facility identified Resident #61 as a 15 and at risk for developing a pressure sore. A review of Resident #61's October 2022 Physician Order Sheet (POS) reflected an 08/26/22 physician's order for heel boots (right/left/bilateral) every shift. A review of the October 2022 Treatment Administration Record (TAR) revealed the corresponding 08/26/22 physician's order for heel boots (right/left/bilateral) at all times. The October 2022 TAR further revealed that the nurses had initialed that the heel boots were applied as ordered for the day shift on 10/05/22 and 10/07/22. The October 2022 TAR did not show documentation that the heel boots were applied on the 10/06/22 day shift. During an interview with the surveyor on 10/11/22 at 11:52 AM, the Certified Nurse Assistant (CNA) assigned to Resident #61 stated that the resident was supposed to wear heel boots but had refused them today. The CNA said she would inform the nurse if the resident refused the heel boots but had not informed the nurse yet. The CNA added that the nursing assistants usually applied the heel boots. The CNA further stated that it was important for the resident to wear heel boots to prevent skin breakdown. During an interview with the surveyor on 10/11/22 at 12:07 PM, the Licensed Practical Nurse (LPN #1) stated that he had been Resident #61's nurse for the last two days on the day shifts. LPN #1 indicated that Resident # 61 required total assistance for mobility and had not gotten out of bed in the last two days. LPN#1 further stated that he was unaware of any devices or splint interventions in place to prevent skin breakdown for Resident # 61. LPN#1 added that if a resident refused treatment, he would document the refusal in the TAR and inform the doctor and the family. LPN #1 further stated that Resident #61 had not declined any medications or interventions while under his care for the last two days. During an interview with the surveyor on 10/13/22 at 10:05 AM, the LPN Unit Manager (LPN/UM) stated that the CNA or nurse would apply the heel boots as ordered. If a resident refused a treatment, the nurse would document the refusal on the TAR and write a progress note. If the resident continued to refuse treatment, then the nurses would inform the doctor and family. The LPN/UM further stated that Resident # 61 had a tendency to refuse the heel boots as ordered. A review of Resident #61's October TAR, in the presence of the LPN/UM, confirmed that the nurse had documented on the TAR on the day shift for 10/5/22 and 10/7/22, indicating the heel boots were applied as ordered. During an interview with the surveyor on 10/14/22 at 9:48 AM, the Director of Nursing (DON) stated that the heel boots could be applied by either the CNA or the nurse, but it was the nurse who would document in the TAR that the heel boots were applied. The DON further stated that if a resident refused a treatment, the nurse would document the refusal in the TAR, notify the doctor and write a progress note. The DON stated that it was important to apply the heel boots as ordered to prevent skin breakdown. A review of Resident #61's progress notes for October 2022 did not reveal any documentation that the resident had refused the heel boots as ordered until after the surveyor inquiry on 10/11/22. A review of Resident #61's Care Plan did not reveal that the resident had refused the heel boots until after the surveyor's inquiry on 10/11/22. A review of the facility's policy titled Risk Assessment and Prevention- Wound, reviewed 4/2022, indicated that interventions to manage pressure included but were not limited to: off-load heel pressure. The policy did not specify the interventions of heel boots. A review of the facility's policy titled Medication Administration Guidelines-Treatments, reviewed in October 2017, reflected that the nurse would document that the treatment was done by initialing on the EMAR (Electronic Medical Administration Record). NJAC 8:39-27.1(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to properly dispose medications for 1 of 5 residents (Resident #29) during medication administration. This deficient practice was identified for 1 of 3 nurses observed during medication administration on 1 of 2 units ([NAME] 6) and was evidenced by the following: On 10/11/22 at 8:59 AM, the surveyor observed Licensed Practical Nurse #1 (LPN #1) during the medication administration for Resident #29. LPN #1 dispensed the following medications for Resident # 29 as ordered: 1. Apixaban (a blood thinner) 5 milligram (mg) give one tablet by mouth every 12 hours for CVA (stroke). 2. Furosemide (a diuretic) 20 mg give one tablet by mouth two times a day for bilateral lower leg edema. 3. Ferrous Sulfate Tablet 325 mg (65 mg Ferrosol iron) give one tablet by mouth one time a day for anemia. The surveyor observed LPN #1 attempt to administer the above medications that were crushed in applesauce to Resident #29 three times and Resident #29 refused all the medications three times. LPN #1 stated that he would discard the medications and try again later. The surveyor observed LPN #1 discard the dispensed crushed medications into the trashcan located on the medication cart. At that time, the surveyor interviewed LPN #1 who stated, if the medications were not crushed, I would use a [medication disposal system] but since the medications were crushed in applesauce, I can just throw them out in the trash. During an interview with the surveyor on 10/13/22 at 10:48 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that nurses should discard refused medications in the [medication disposal system] and that medications were not to be discarded in the trash. During an interview with the surveyor on 10/14/22 at 09:48 AM, the Director of Nursing(DON), in the presence of the survey team, stated that if a resident refused medications, the dispensed medications were to be discarded in the [medication disposal system] located in the medication storage room. The DON further stated that it was important to dispose medications correctly because the medications could get into the waste and soil and contaminate everyone. Review of the facility's policy titled Medication Administration, reviewed 1/2022, revealed that if medication was dispensed and the resident refuses, medications would be destroyed using the [medication disposal system]. NJAC 8:39-29.4(i)